Volume 176 - Issue 12
Safety of hormone replacement therapy after mastectomy
Author: Robert N Hitchins
Med J Aust 2002; 176 (12): 617-620. || doi: 10.5694/j.1326-5377.2002.tb04599.x
Published online: 17 June 2002
Published online: 17 June 2002
To the Editor: I agree with the assessment by Del Mar and colleagues of available data according to evidence-based guidelines on hormone replacement therapy (HRT) after mastectomy.1 As they note, these data are not definitive. Standard practice has been to avoid oestrogen use in women with a history of breast cancer.
Ours is an increasingly litigious society and courts make decisions according to different criteria than do scientists. In particular, precedent is very important to the law of tort, even if the scientific basis for the precedent is unproven.
For some years now, I have seen 100 or more new patients per year with recently diagnosed early breast carcinoma. By the time I see them, every single one already knows that:
anti-oestrogens are used in treatment of breast cancer; and
women are at least 30% more likely to develop breast cancer after five years of HRT.
Further, these women fear recurrence of breast cancer more than any other health problem.
Hence, I am concerned that the sound evidence-based conclusions reached by Del Mar and colleagues could be successfully challenged in court by a woman who developed recurrence of breast cancer while receiving HRT.
In addition to the costs and stress for the individual practitioner involved and other members of his medical indemnity organisation, such action would set back scientific enquiry into this important subject, possibly forever.
There is a wealth of well conducted research into non-oestrogenic management for menopausal symptoms. Lifestyle measures (clothing and activity) and dietary modifications (avoiding spicy foods, alcohol) have a role in well-being. Oral progestogens, clonidine, venlafaxine, black cohosh, and probably tibilone, all produce better outcomes than placebo.2 Evening primrose oil, pyridoxine, dong quai, Chinese herbs, progestogen and yam creams, and phytoestrogens do not work better than placebo.3 The last may actually be harmful. Advisory statements for general practitioners about oestrogen replacement therapy for managing menopausal symptoms after breast cancer should be prefaced with this information, as should any discussion with patients. I do prescribe oestrogens for distressing menopausal symptoms after breast cancer treatment, but only after several consultations to allow time for women to appreciate the uncertainties involved.
References
- Del Mar CB, Glasziou PP, Spinks AB. Safety of hormone replacement therapy after mastectomy. Med J Aust 2002; 176: 285.
- Davis SR. Menopausal symptoms after breast cancer. Australian Doctor 2002, 1 February. i1149912
- Eden J. Managing menopause after breast cancer. Proceedings of Annual Hormone Update and Education Day, Sydney: Sydney Menopause Centre, 16 February 2002.
- Del Mar CB, Glasziou PP, Spinks AB. Safety of hormone replacement therapy after mastectomy. Med J Aust 2002; 176: 285. 1
- Eden JA, Bush T, Bush N, et al. A case controlled study of combined continuous estrogen-progestin replacement therapy among women with a personal history of breast cancer. J Nth Am Menopause Soc 1995; 2: 67-72. 2
- Dew J, Eden J, Beller E, et al. A cohort study of hormone replacement therapy given to women previously treated for breast cancer. Climacteric 1998; 1: 137-142. 3
- Stoll BA, Parbhoo S. Treatment of menopausal symptoms in breast cancer patients. Eur J Cancer Clin Oncol 1989; 25: 1909-1913. 4
- Vassilopoulou-Sellin R, Asmar L, Hortobagyi GN, et al. Estrogen replacement therapy after localized breast cancer: clinical outcome of 319 women followed prospectively. J Clin Oncol 1999; 17: 1482-1487. 5
- Brewster WR, DiSaia PJ, Grosen EA, et al. An experience with estrogen replacement therapy in breast cancer survivors. Int J Fertil Womens Med 1999; 44: 186-192. 6
- Puthgraman K, Natrajan MD, Soumakis K, Gambrell RD. Estrogen replacement therapy in women with previous breast cancer. Am J Obstet Gynecol 1999; 181: 288-295. 7
- Del Mar CB, Glasziou PP, Spink A, et al. Safety of hormone replacement therapy after mastectomy. Med J Aust 2002; 176: 285. r1
- National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. Canberra: NHMRC, 1995. r2