Lifestyle Choices

Hormone replacement therapy (HRT) is a major area of concern among women with a history of breast cancer. If you are in the crisis of a recent breast cancer diagnosis, the issue of HRT may seem relatively unimportant. However, as you get farther along and finish your treatment and proceed with your life, questions regarding HRT will certainly arise.

Much has been written on the issue of HRT in general. Less is known specifically about HRT for breast cancer survivors because doctors have been concerned about prescribing anything for their patients that may increase the risk of recurrent disease. However, new research suggests this traditional tendency not to prescribe HRT for breast cancer survivors needs to be reevaluated. But, along with this, I must say blanket statements regarding HRT are not appropriate. Each woman must consider the risks and benefits of HRT based on her personal situation. Each woman experiences menopause differently, with varying degrees of symptoms. Some women ease into menopause with little problem and without increased risk of osteoporosis or heart disease. The menopause experience for others is traumatic and can introduce increased chances of illness into their lives.

Although the procedure is controversial, the medical profession has endorsed allowing women to replace ovarian hormones with HRT once the ovaries begin to fail. Evidence and clinical experience indicate that the benefits outweigh the risks and expense of such therapy. Results from large, randomized studies of hormone replacement have recently revealed that the use of combination therapy with estrogen and progesterone does not give the heart and cardiovascular benefits I previously assumed. This may not be the case for estrogen alone, and there are still bone and quality of life benefits for most women taking HRT. However, I do not have evidence of the risks to women surviving breast cancer. Our concerns are based on speculation and anecdotal experience alone.

For most women, the question is the relationship between HRT and an increased risk of breast cancer. Does hormone replacement contribute to breast cancer? At least twenty-four different studies and two meta-analyses (combining similar small studies to give greater statistical power) fail to show a causal relationship between the two. Researchers found no difference in breast cancer incidence for those women taking HRT and those women who did not in studies that controlled mammographic screening. Before starting HRT, physicians often require their patients to get a baseline screening mammogram, and because women receiving HRT are under a physician’s surveillance, they are more likely to continue to get annual screenings. These women detect early cancer years before women not on HRT, who are less likely to get mammograms. If a researcher looks at breast cancer incidence over a short span of time, he/she may incorrectly conclude that HRT is responsible for an increased number of breast cancers when it is actually a case of early detection due to regular mammographic screening. Although there is no difference between women not taking HRT and those taking HRT for less than ten years, once the duration exceeds the ten-year mark, there is an increase in breast cancer incidence, but the numbers are small. There also appears to be anecdotal data that women with lobular neoplasia, either lobular cancer in situ (LCIS) or atypical lobular hyperplasia, may have an increased risk for recurrence with HRT. As I discussed previously, however, these women are at an increased risk regardless of hormone replacement usage.

Research has led us to conclude that low-dose HRT for less than ten years does not significantly contribute to the development of breast cancer in the general population. Does this apply to the population of women cured of breast cancer? Unfortunately, there are no studies to tell us this, and we do not know the answer. Our opinion is that for women with a high probability of cure, the benefits of HRT outweigh the risks.

How do you know you are cured, however? Unfortunately, there is no absolute way to know. I can give a statistical probability based on your cancer’s characteristics. If you are destined to relapse, it will usually happen in the first five years after diagnosis. Unfortunately, late recurrences do occur—rarely, though. I advise our patients that once treatment is complete, they should consider themselves cured and move on. Granted, they are never the same and there is that “gray cloud on the horizon,” but the cloud becomes smaller as time passes.

Women often ask, “But what if I’m not cured? Can HRT cause increased harm?” I don’t know the answer to this, either. Theoretically, HRT could stimulate cells that have escaped systemically and stimulate them to grow and appear more rapidly. On the other hand, if this were to happen, tamoxifen or one of the newer hormonal therapies should then make the cancer regress.

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