Unfortunately, according to the statistics, one out of 8 women will develop this terrible disease in her lifetime. This is irrespective of whether she uses hormone replacement therapy / HRT.
This is a terrifying prospect. It is the principle reason many women choose to deny themselves the benefits of HRT. This may be true even when they are aware that HRT is instrumental in the protection of cardiovascular disease, by far the most frequent cause of death in menopausal women.
I recently attended a Mayo Clinic conference that dealt with the topic of of problem solving in hormone replacement therapy. The lecturer, an expert in the field and a staff physician at Mayo, related that although some studies showed a slight increase in the rate of breast cancer associated with estrogen use, just as many studies showed no relationship at all. His opinion was that estrogen did not cause breast cancer.
If this is so, why do some studies show even a slight increase in breast cancer?
One possible reason is what is called a "surveillance bias." This refers to the fact that we seem to follow women who use HRT more closely than those who do not. In order to obtain and continue HRT, a women is required to see a physician and return at regular intervals. Accordingly, women on HRT are more likely to have mammograms, physician breast examinations and to be instructed in breast self examination.
Women who are not HRT users, may not see their physicians as frequently, are less likely to undergo regular mammography, or be instructed in self breast examination.
It would be expected, given this increased surveillance that more cancers would be found in the HRT group. In addition, women in this group in whom cancers are discovered tend to have smaller, less aggressive tumors and are more likely to survive their disease.
If just as many studies show no increase in the rate of breast cancer, why don't we hear about them?
The principle agenda of the media, both print and visual, is to sell advertising. While we often hear that their purported purpose is to educate you, in almost all cases the profit motive prevails. Stories that talk about increased rates of cancer are perceived as having the potential of attracting more readers or viewers.
Given that I have this fear of breast cancer, should I use HRT?
Ultimately, this is a personal choice. The statistics show that women who use HRT are more likely to live longer and have a better quality of life. This is especially true in those women who have had an early menopause and/or had a hysterectomy. In addition, there is no consistent evidence that post menopausal estrogen use causes breast cancer. However, the continued perception that estrogen use increases the incidence of breast cancer precludes many women from using HRT. For these women this may be the right decision, as to live every day in constant fear would be untenable.
A Summary Of Some Of The Issues:
(1) Women who are hormonally deficient, especially those who have had their ovaries removed and are without the benefit of HRT are known to have higher rates of death from heart attacks, strokes and osteoporosis.
(2) The fear of a reoccurrence of breast cancer can be overwhelming and preclude any thought of using estrogen replacement.
(3) To the best of my knowledge there has never been a study that showed increased rates of reoccurrence of breast cancer associated with estrogen use in patients previously treated for early stage breast cancer.
(4) It is possible by using alternatives to estrogen such as tamoxifen (Nolvadex), raloxifene (Evista) and a bisphosphonate (Fosomax) and lifestyle changes, that the risk of these problems can be diminished.
(5) To the best of my knowledge there is no over the counter herbal preparation that is capable of preventing the long term negative health affects of hormone deprivation.
(6) Most physicians who are treating a woman with a history of treated early stage non metastatic breast cancer will discourage them from considering HRT. This is due to either being unaware that there is no evidence that it increases reoccurrence or mortality and/or a fear of becoming a malpractice target if the disease should reoccur.
Included below is a summary, or abstract of a study published in the American Journal of Obstetrics and Gynecology and an excerpt of medical education communication by Dr Rogerio Lobo, a physician, who is a highly regarded expert in menopause.
Estrogen replacement therapy in women with previous breast cancer.
Am J Obstet Gynecol 1999 Aug;181(2):288-95 (ISSN: 0002-9378) Natrajan PK; Soumakis K; Gambrell RD Jr [Find other articles with these Authors] Department of Physiology, Medical College of Georgia, Augusta, Georgia, USA.
OBJECTIVE: We sought to review the status of patients with breast cancer who were treated with estrogen replacement therapy and compare the results with those of nonestrogenic hormone users and women not treated with hormone replacement.
STUDY DESIGN: The study group consisted of 76 patients with breast cancer, including 50 using estrogen replacement for up to 32 years, 8 using nonestrogenic hormone replacement for up to 6 years and followed for up to 11 years, and 18 using no hormones for up to 10 years. In addition to estrogen use, 40 of the 50 hormone users were treated with androgens, usually in the form of implantation of testosterone pellets. Forty-five subjects were also given progestogens, usually megestrol acetate 20 to 40 mg for 10 to 25 days each month. The 8 nonestrogen hormone users were treated with various combinations of testosterone pellets, tamoxifen, and progestogens. Forty-two of the 50 estrogen users are still being treated in our clinic, as are 2 of the 8 subjects using nonestrogen hormone. Follow-up was done through the tumor registry at University Hospital, and those whose tumor records were not current were telephoned. RESULTS: Of the 50 estrogen users, 3 have died (a mortality rate of 6%), and the rest have been followed for 6 months to 32 years, with a mean duration of follow-up of 83.3 +/- 8.81 months. One of the 8 nonestrogen hormone users has died (a mortality rate of 12.5%), and the rest have been followed for 2 to 11 years, with a mean duration of follow-up of 72.0 +/- 5. 93 months. Six of the 18 women not using hormone replacement have died (a mortality rate of 33.3%), and the rest have been followed for 6 months to 10 years, with a mean duration of follow-up of 50.5 +/- 6.01months.
CONCLUSION: Estrogen replacement therapy apparently does not increase either recurrences or mortality rates. Adding progestogens may even decrease recurrences. Women with early breast cancer should be offered hormone replacement therapy after a full explanation of the benefits, risks, and controversies.
Women's Health Clinical Management - Volume 1
Menopause Management for the Millennium CME
Author: Rogerio A. Lobo, MD
HRT in the Context of Disease
An important issue is whether HRT can be prescribed for postmenopausal women who have been treated for cancers (eg, breast and gynecologic cancer) or who have autoimmune diseases (eg, systemic lupus erythematosus [SLE] and multiple sclerosis [MS]) or other diseases associated with aging (eg, osteoarthritis [OA] and Parkinson's disease [PD]) or other chronic conditions (eg, diabetes and epilepsy). No prospective studies with a large number of patients and a long treatment period have addressed this question.
It has been estimated that the number of breast cancer survivors in the United States may approach 2.5 million. Moreover, because breast cancer is being detected at an earlier age and adjuvant chemotherapy can cause ovarian failure, the number of women becoming menopausal at a younger age after breast cancer treatment is increasing. Given that the risk of suffering a recurrence will be low for a large percentage of these women, should they consider HRT? At least 1 prospective study of HRT after localized breast cancer indicates that HRT does not seem to increase breast cancer events. However, the most reasonable course of action for women who have been treated for breast cancer and who have menopausal symptoms is to treat the symptoms with alternative therapies. Diet and exercise are effective for prevention of CVD; weight training and the addition of bisphosphonates or SERMs (eg, tamoxifen and raloxifene) can reduce the risk for osteoporosis. Certain dosages of progestins can alleviate hot flushes, although many oncologists believe that use of any sex steroids is contraindicated. Nevertheless, in those breast-cancer survivors who choose HRT , the lowest effective doses should be used, and these women must be monitored carefully.
Doctor Nosanchuk is currently practicing medicine in Southeastern Michigan and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit, Michigan. For over 25 years Dr N has been an expert in the care and treatment of menopausal women. He is a founding member of the North American Menopause Society and is certified as a specialist in menopausal medicine. (See his Biography Page for more information). He has a special interest providing treatment to women whose lives have been altered by their menopause, hysterectomy, or both. Dr N is also writing a book for menopausal women and is available to lecture to women’s groups regarding menopausal issues.
To make an appointment with Doctor Nosanchuk, contact Sherri or Kris at 1-248-644-7200 from 10 AM - 6 PM M-F EST.
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