Lifestyle Choices

I have only roundabout evidence regarding HRT in breast cancer survivors. For example, we know that younger women who have had breast cancer and then go on to become pregnant, with the associated high levels of estrogen and progesterone, do not have a worse prognosis or earlier relapse of breast cancer than women who do not experience a pregnancy. If estrogen can theoretically stimulate breast cancer growth, why do I see breast cancer appear in older postmenopausal women who are not on HRT? This is a fairly frequent occurrence, and most of these cancers are hormone receptor positive, yet they are growing in an estrogen-poor environment. This seems to counter what we know about the environment that is conducive to breast cancer, but this is just another reminder of how much we do not understand about this disease.

In most cases, if a young premenopausal woman with hormone receptor positive breast cancer is given tamoxifen, the cancer will get smaller and regress. At the same time, the tamoxifen will cause the woman’s blood estrogen levels to increase. The cancer must have a higher affinity to tamoxifen than to estrogen in order for the drug to be effective. In spite of high estrogen levels, the tamoxifen works to kill the cancer. Is it then possible to give both HRT and tamoxifen together and get the benefits of each?

Doctors have prescribed this dual treatment in the United Kingdom without reported ill effects, but American oncologists have been very hesitant to do this routinely without longer experience to assess risk of recurrence. What is needed is a clinical trial comparing HRT versus HRT plus tamoxifen versus tamoxifen alone versus no hormonal treatment. Such a trial, unfortunately, would take large numbers of women, and some of these women would have to participate on a no-treatment arm, or protocol. That has yet to be done. Researchers are also diligently working on new SERMs that are less stimulatory to the uterus and may potentially relieve menopausal symptoms while maintaining the ability to kill cancer cells. If such a new drug is found, there will be no need to administer both HRT and tamoxifen.

Let’s put the theoretical data to work for us and look at what to do with the information at hand. Are the benefits of HRT for the breast cancer survivor adequate to outweigh the theoretical risks? This is obviously not an easy question, and each woman’s situation is quite different in regard to it. Some factors for you to consider are your

• risk of recurrence
• type of breast cancer (presence of lobular neoplasia and hormone receptors) risk of heart disease
• cholesterol and lipoprotein levels
• risk of osteoporosis
• bone mineral density
• risk of uterine cancer
• quality-of-life issues (libido, vaginal atrophy, hot flashes, depression, memory loss)
• risk of Alzheimer’s disease. (Some recent intriguing reports indicate that HRT may prevent Alzheimer’s. Although very preliminary, this new information perhaps should also be factored into the equation.)

I suggest you meet with your oncologist and discuss the risks and benefits of HRT in your individual situation based on the above factors. If you and your doctor make the joint decision that you take HRT, the question then becomes whether there is one preparation that is better than another.

Here again, we face the problem of lack of evidence and controlled studies as we make these decisions. The literature indicates that different estrogen preparations stimulate the ductal glandular tissue to varying degrees. Estradiol is much more stimulatory than estriol. The most commonly used preparation, Premarin, is primarily estriol and appears to benefit bones and lower cholesterol. The unanswered question is, What is the benefit of adding tamoxifen to HRT? For women who have a uterus, the addition of low-dose progesterone appears to protect against uterine cancer, but it may cancel the cardiovascular benefit.

A new SERM, raloxifene hydrochloride (Evista), has been approved in the United States for the treatment of osteoporosis. Raloxifene does not appear to stimulate the uterine lining, nor does it appear to stimulate breast glandular tissue to activate. Presently, it is being tested against tamoxifen as a breast cancer prevention therapy. Breast cancer survivors who have completed therapy and are concerned about osteoporosis and heart disease might consider raloxifene hydrochloride as an alternative to HRT. Unfortunately, raloxifene hydrochloride does not usually alleviate menopausal symptoms such as hot flashes and vaginal dryness. This is something you should discuss with your oncologist. As I mentioned earlier, the pharmaceutical industry is striving to produce the “perfect” SERM. Until then, one must weigh the risks and benefits of what is available.

With low estrogen levels, the lining of the vagina will thin and lack lubricating secretions. I believe it is safe and effective to use local estrogen in the form of vaginal suppositories or an estrogen- emitting ring that is inserted around the cervix. Discuss these preparations with your oncologist or gynecologist.

Possibly related posts: (automatically generated)
Hormone Replacement therapy after Breast Cancer continue…

• Hormone Replacement therapy after Breast Cancer
• Stress and Depression, how Family and Friends Can Help
• Genetic Risk and Breast Cancer part 3
• MOOD Hormones
• After Medical Treatment, Copying Fear of Recurrence
• Genetic Risk and Breast Cancer part 1
• Brain Amines: Lithium
• Complementary Therapy for Cancer? (Cholesterol)
• Scientific Skin Care from Hair to Scalp
• Just pregnant