Your menopausal patient’s breast biopsy reveals atypical hyperplasia

How do you manage your patient’s increased risk of breast cancer?

In examining the answer to this management point, we need to first ask and answer, “How does ADH develop?” and “What is her risk of developing breast cancer?”

The development of invasive breast cancer is believed to involve a complex, multistep process. Initially, there is disruption of normal cell development and growth, with overproduction of normal-looking cells (hyperplasia). These excess cells stack up and/or become abnormal. Then, there is continued change in appearance and multiplication, becoming ductal carcinoma in situ (noninvasive). If left untreated, the cells may develop into invasive cancer.¹⁸ See TABLE 2 for the relative risk of a patient with ADH developing breast cancer.¹⁰

Now, we can address, “How do you manage this patient’s increased risk of breast cancer?”

TABLE 2. Relative risk of developing breast cancer

More frequent breast screening!

• Clinical breast exams twice per year
• Screening mammograms annually
• Screening tomosynthesis (These are additional digital screening views which provide almost a 3D view.)
• Screening breast ultrasound
• Screening breast MRI — if she has a 20% lifetime risk of breast cancer (family history or genetic predisposition) (TABLE 3).

TABLE 3. ACS guidelines for screening breast MRI

Careful consideration of medications

Since it is possible that estrogen may fuel the growth of some breast cancers, avoiding systemic menopausal HT may be safest.

Counsel her about strategies to reduce breast cancer risk

These include:

• Lifestyle changes, including weight loss, exercise, and avoiding excess alcohol intake.
• Preventive medications. Tamoxifen or raloxifene (Evista) can be used for 5 years. These medications block estrogen from binding to the breast estrogen receptors. Another option is an aromatase inhibitor, which decreases estrogen production.
• Risk-reducing (prophylactic) mastectomy.

Andrew M. Kaunitz, MD:
It is important to note that both of the SERMs just mentioned (tamoxifen and raloxifene), as well as aromatase inhibitors, may cause women to experience vasomotor symptoms. SERMS also increase the risk of venous thromboembolism.

Management approach for this patient

This patient has had her ADH surgically excised. She will remain at higher risk for breast cancer and should consider strategies to decrease her risk, including lifestyle changes and the possible initiation of medications such as tamoxifen or raloxifene. New screening modalities, such as tomosynthesis or breast ultrasound, may be used to screen for breast cancer, and she may be a candidate for alternating mammograms and MRIs at 6-month intervals.

For her vaginal dryness, over-the-counter lubricants and moisturizers may be helpful. If not, topical or vaginal estrogen is available (as creams, tablets, or a ring) and provides primarily local benefit with limited systemic absorption.

For her bothersome hot flashes, if lifestyle changes don’t work, nonhormonal therapies can be offered off label, such as effexor, desvenlafaxine, gabapentin, or any of the SSRIs—including those tested in large, randomized, controlled trials, such as escitalopram and low-dose paroxetine salt, at low doses.

Andrew M. Kaunitz, MD:
Sertraline seems to be more likely to cause sweating than other SSRIs.³ For this reason, I don’t prescribe sertraline off label to treat vasomotor symptoms.

If she is taking tamoxifen, however, SSRIs such as paroxetine should be avoided due to P450 interaction.

If her hot flashes remain persistent and bothersome, low-dose estrogen could be considered, with education about the potential risks, as she is already at higher risk for breast cancer.

Acknowledgment

The author would like to thank Andrew M. Kaunitz, MD, for his forward thinking in helping to establish this new series on menopause.