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

Highlights

• Older studies show that menopausal hormone therapy increases the risk of breast cancer recurrence, even with short-term use.
• Clinicians should recommend non-hormonal options tailored to specific symptoms before considering hormone therapy in high-risk patients.
• Both combined estrogen-progestin and estrogen-only therapies are shown to increase the risk of breast cancer.
• For patients with severe symptoms, consider limiting the use of hormone replacement therapy to less than seven years.
• A thorough patient discussion is crucial to weigh quality-of-life benefits against the potential risks of hormone therapy.

Expert Insights

A Cautious and Individualized Approach to MHT

Navigating the use of menopausal hormone therapy (MHT) in breast cancer survivors presents a significant clinical challenge, demanding a careful balance between alleviating debilitating menopausal symptoms and mitigating the risk of cancer recurrence. The decision-making process is complex, underscored by historical data and the need for a highly individualized, patient-centered discussion. Both the quality-of-life benefits and the potential harms must be weighed meticulously.

The Foundation of Caution: Historical Trial Data

The prevailing reluctance to prescribe MHT to breast cancer survivors is rooted in critical studies from the 1990s. Dr. Ashley Davenport, a breast oncologist, emphasizes that this data remains central to the conversation. "Those studies showed an increased recurrence among patients who received hormone replacement therapy, even for a short period," she notes. Dr. Davenport highlights that while the increased rates were most pronounced in hormone-receptor–positive patients, a small increase was also observed in the hormone-receptor–negative cohort, leading to the early termination of the trials. Her clinical takeaway is that any patient considering MHT must have a thorough discussion with their physician about these specific studies and the demonstrated risks before initiating treatment.

Risk Stratification and Shared Decision-Making

For breast oncologist Dr. Anastasia Martynova, the dialogue begins with acknowledging the profound impact MHT can have on quality of life. However, this is immediately followed by a careful risk assessment. "If there is a risk of breast cancer—especially a family history or a calculable high risk—we need to discuss that carefully," she states. For women whose estimated risk exceeds 20%, Dr. Martynova engages in extensive counseling. She quantifies the risk, noting that MHT is associated with approximately a 25% relative increase in breast cancer risk, a substantial figure for an individual already at elevated risk. This framework positions the final decision as a collaborative one, where the patient must consciously accept the potential risk in exchange for symptom relief.

"The risk of breast cancer with hormone replacement therapy is increased—about a 25% relative increase—so it raises risk substantially for an individual." Dr. Anastasia Martynova

Prioritizing Symptom-Specific, Non-Hormonal Interventions

A cornerstone of the modern approach is to exhaust non-hormonal options before considering MHT. Dr. Martynova advocates for a strategy tailored to the patient's primary complaints. "We review the specific symptoms: for example, if the main symptom is hot flashes, we might try an SSRI or another non-hormonal medication; if the main symptom is vaginal dryness, we go through all non-hormonal options first," she explains. This methodical, symptom-driven approach ensures that hormonal therapy is reserved for cases where alternative treatments have failed to provide adequate relief from severe symptoms.

Nuances in Hormonal Therapy Selection and Duration

Should the clinical scenario necessitate MHT despite the risks, several key considerations remain. Dr. Martynova addresses a common misconception regarding the safety profile of different MHT formulations, clarifying that "studies show that both combined therapy and estrogen alone can increase breast cancer risk." If a patient with extremely severe symptoms opts for MHT, she advises limiting its duration. "I would limit its use to less than seven years," she recommends, "because rises in breast cancer are typically seen after seven to ten years of hormonal therapy." This counsel provides a practical risk-mitigation strategy for the small subset of survivors for whom the benefits of MHT are deemed to outweigh the potential harms.

"I would limit its use to less than seven years because rises in breast cancer are typically seen after seven to ten years of hormonal therapy." Dr. Anastasia Martynova