How do you approach menopausal hormone therapy for breast cancer survivors?

Highlights

• Early trials on menopausal hormone therapy were stopped due to an increased risk of cancer recurrence, even with short-term use.
• For high-risk patients, physicians should prioritize non-hormonal interventions to manage specific menopausal symptoms before considering any hormonal therapies.
• Both combination estrogen-progestin and estrogen-only hormone therapies are associated with an increased risk of developing breast cancer.
• If hormonal therapy is deemed necessary for severe symptoms, consider limiting its use to less than seven years to mitigate risk.
• A thorough physician-patient conversation is essential to weigh the quality-of-life benefits against the personal risk of breast cancer recurrence.

Article

The Enduring Contraindication: Navigating MHT in Breast Cancer Survivors

Menopausal hormone therapy (MHT) for breast cancer survivors presents a significant clinical challenge, balancing the potential for profound quality-of-life improvement against the risk of cancer recurrence. The prevailing standard of care remains one of extreme caution, rooted in historical data and reinforced by contemporary risk-benefit analyses. A thorough, individualized discussion is paramount, prioritizing non-hormonal interventions before considering MHT, even in cases of severe symptomatology.

The Foundational Evidence for Caution

The current reluctance to prescribe MHT in this population is largely informed by pivotal trials from the 1990s. Dr. Ashley Davenport, a medical oncologist, emphasizes that these studies demonstrated an increased rate of recurrence among breast cancer survivors who received hormone therapy, even for a short duration. "Although the rates were higher in hormone positive breast cancer patients, there still was a slight increase in hormone negative patients, and these trials were actually stopped early," Dr. Davenport states. This historical context is critical for framing patient discussions, as it underscores that the concern is based on direct evidence of harm in a similar patient population. Clinicians must guide patients in understanding how these older, yet foundational, studies may apply to their individual circumstances.

"these trials were actually stopped early." Dr. Ashley Davenport

A Framework for Risk Assessment and Shared Decision-Making

For any patient considering MHT, particularly those with a personal or strong family history of breast cancer, a structured risk assessment is the essential first step. Dr. Anastasia Martynova, also a medical oncologist, describes her approach as a "long conversation" centered on quantifiable risk. "If their risk is high, let's say they're more than 20% risk of breast cancer, I counsel them extensively and recommend to do any possible non-hormonal intervention," she explains. This data-driven approach helps ground the shared decision-making process. Dr. Martynova notes that the relative risk of breast cancer with MHT increases by approximately 25%, a significant consideration for any patient, but especially for one already at high risk. She also clarifies a common patient misconception, stating that studies show "combined therapy does increase the risk of breast cancer and as well as the monotherapy estrogen."

"The actual combined therapy does increase the risk of breast cancer and as well as the monotherapy estrogen." Dr. Anastasia Martynova

Prioritizing Symptom-Specific, Non-Hormonal Therapies

Given the risks, a "non-hormonal first" strategy is the cornerstone of managing menopausal symptoms in breast cancer survivors. This requires a granular approach that targets the patient's most bothersome symptoms. Dr. Martynova provides a clinical model for this strategy: "Let's say the main symptoms is hot flashes. So maybe we can try something else like SSRI or other medication and not hormonal. Or the main symptom is vaginal dryness. Then we'll go through all the non-hormonal options before we proceed with hormonal therapy if needed." By deconstructing the patient's menopausal experience and applying targeted non-hormonal treatments, physicians can often achieve significant symptom relief and improve quality of life without introducing the risks associated with systemic hormones.

Limiting MHT Use in Exceptional Circumstances

In rare cases where refractory, severe symptoms dramatically impair a patient's quality of life and non-hormonal options have failed, MHT may be considered after extensive counseling. Even in this scenario, a time-limited approach is crucial. Dr. Martynova advises that if MHT is ultimately pursued, she would "definitely limit its use to less than seven years." This recommendation is based on observational data suggesting that the most significant rise in breast cancer risk occurs after seven to ten years of continuous hormone therapy. This harm-reduction strategy acknowledges the patient's severe distress while placing a clear boundary on the duration of exposure to minimize the potential for recurrence.

"I will definitely limit its use to less than seven years." Dr. Anastasia Martynova