hormone replacement therapy (HRT) in patients with breast cancer

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  • the prescription of HRT in patients with a history of breast cancer is controversial - seek expert advice before making a decision
      • 75% of breast tumours are oestrogen receptor-positive - for those patients who are oestrogen receptor-negative there may be a case for consideration of hormone replacement therapy (1) - however it is of note that HRT use itself can lead to an increased risk of breast cancer (see menu item)
        • NICE state..'HRT (including oestrogen/progestogen combination) should not be offered routinely to women with menopausal symptoms and a history of breast cancer. HRT may, in exceptional cases, be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed' (2)
      • tamoxifen is invariably given to women with a history of oestrogen receptor-positive breast cancer - although tamoxifen does have some oestrogenic effects there are not the same beneficial effects seen with respect to lipid profile and bone density as occur with the use of HRT. It is light of this, that 'many oncologists therefore believe that in certain circumstances, such as severe menopausal symptoms, HRT can be prescribed for patients on tamoxifen who are being treated for breast cancer (1)'

      • NICE state (2) :
        • regarding menopausal symptoms following management of early breast cancer:
          • discontinue hormone replacement therapy (HRT) in women who are diagnosed with breast cancer
          • HRT (including oestrogen/progestogen combination) should not be offered routinely to women with menopausal symptoms and a history of breast cancer. HRT may, in exceptional cases, be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed
          • tibolone or progestogens are not recommended for women with menopausal symptoms who have breast cancer
          • the selective serotonin re-uptake inhibitor antidepressants paroxetine and fluoxetine may be offered to women with breast cancer for relieving menopausal symptoms, particularly hot flushes, but not to those taking tamoxifen (2,5)
          • clonidine, venlafaxine and gabapentin should only be offered to treat hot flushes in women with breast cancer after they have been fully informed of the significant side effects
          • soy (isoflavone), red clover, black cohosh, vitamin E and magnetic devices are not recommended for the treatment of menopausal symptoms in women with breast cancer

      • NICE in the menopause guidance state (5):
        • offer menopausal women with, or at high risk of, breast cancer:
          • information on all available treatment options
          • information that the SSRIs paroxetine and fluoxetine should not be offered to women with breast cancer who are taking tamoxifen
          • referral to a healthcare professional with expertise in menopause

  • raloxifene is a selective oestrogen receptor modulator (SERM) that has anti-oestrogenic effects on breast and endometrial tissue and oestrogenic actions on bone, lipid metabolism and blood clotting
    • in postmenopausal women raloxifene decreases bone turnover and increases bone mineral density, reducing the incidence of vertebral fractures. Unlike tamoxifen, raloxifene does not cause endometrial hyperplasia or cancer, as demonstrated by endometrial monitoring with ultrasonography and biopsy during treatment
    • evidence suggests that raloxifene lowers total low-density lipoprotein cholesterol levels behaving like oestrogens, but does not increase high-density lipoprotein cholesterol levels
    • in randomised clinical trials on postmenopausal women with osteoporosis, raloxifene reduced the risk of newly diagnosed ER-positive invasive breast cancer by 76% during a median of 40 months of treatment
    • however, raloxifene does not alleviate early menopausal symptoms, such as hot flushes and urogenital atrophy, and may even exacerbate some of them
    • '.. raloxifene may be an alternative for the prevention of long-term effects of oestrogen deficiency (osteoporosis and heart diseases) in women with previous breast cancer not having hot flushes...' (3)

  • hot flushes experienced by breast cancer survivors present specific issues due to their frequency, severity and difficulty to treat
    • an algorithm of treatment propositions, documented by evidence-based medicine, has been proposed (4)
      • as randomized trials show that placebo-induced reduction of hot flushes frequency represents to 25 to 75%, non-pharmacological approaches selected by the patient should be preferred at first, to the exception however of phytoestrogens
      • first-line treatment for severe hot flushes should be, depending on each specific context, venlafaxine, paroxetine or gabapentin
      • prescription of progestin or of a menopausal hormone therapy should remain exceptional and limited to cases where all other treatments failed, after obtaining the patient's informed consent following exhaustive information (4)

Reference:

Last reviewed 02/2020

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