HRT should be considered for breast cancer survivors, review suggests

Women who have been treated for breast cancer should be supported to make an informed choice about whether to have hormone replacement therapy (HRT) for severe menopausal symptoms, a new review suggests.

Experts are calling for a move away from a ‘de facto ban of HRT’ and suggest breast cancer survivors with severe menopausal symptoms should be supported to make an informed ‘evidence-based’ decision about whether or not to have HRT.

Based on the most comprehensive review of evidence to date, an international panel of UK-based experts, including researchers from University College London (UCL), suggests that healthcare workers should consider HRT as a treatment option on a case-by-case basis, with full risk-benefit discussions and patient input.

The panel concludes that while systemic HRT, including tablets, patches and gels which affect the whole body, and carry some extra relapse risk for breast cancer survivors, the risk was minimal, and other treatment options, such as vaginal oestrogen used locally, can be used to treat urogenital symptoms safely.

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The findings are published in the journal Menopause and provide new insights into the risks and benefits of HRT for breast cancer survivors.

Breast cancer is the most commonly diagnosed cancer in women globally, and treatments are highly effective, but many women experience debilitating menopausal symptoms as a result of their treatment.

Current NICE breast cancer guidance advises that HRT should only be prescribed in ‘exceptional circumstances’, as conventional HRT raises oestrogen levels and may increase the risk of recurrence in oestrogen receptor-positive cancers, which make up 70 to 80 per cent of all breast cancer cases. Recently updated NICE guidance on menopause advises that vaginal oestrogen can be considered for genitourinary symptoms of menopause in some women with a history of breast cancer, but only if non-hormonal options prove unhelpful, and depending on their particular risk factors.

Using the Delphi method, a panel of clinicians, including GPs with a special interest in menopause care, oncologists, a radiologist, and patients with lived experience of breast cancer, contributed to an Expert Consensus Statement. The review included consideration of available data from clinical trials and observational studies assessing the role of HRT after breast cancer, examining both the use of locally effective vaginal hormones (vaginal oestrogen and vaginal dehydroepiandrosterone, DHEA) and systemic HRT (oestrogen, progesterone, and testosterone, that have effects throughout the body), in women with and without a history of breast cancer. Together, the panel created 38 statements summarising the key issues relating to HRT and breast cancer.

After considering the evidence, the experts conclude that vaginal oestrogen is safe to use in the treatment of genitourinary symptoms of menopause in breast cancer survivors because of minimal systemic absorption.

Systemic HRT can increase the risk of relapse in women with oestrogen receptor-positive breast cancer, especially within the first five to ten years after diagnosis. The evidence showed that 2.3 per cent of the general population of women aged 50 to 59 develop breast cancer in the five years after treatment. Combined oestrogen and progestin HRT increases the risk to 2.7 per cent, but oestrogen-only HRT decreases it to 1.9 per cent. Most of the increase in risk from use of HRT is from local relapse or a second breast cancer, which are usually fully treatable.

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Only a small proportion of this increase in risk is for the more dangerous ‘distant relapse’, where the cancer metastasises to another part of the body. For women with moderate-risk breast cancer, HRT increases the seven-year distant relapse rate from 5.8 per cent to 6.3 per cent and from 2.1 per cent to 2.3 per cent in women with low-risk disease.

The level of risk depends on a patient’s cancer profile, and those with low-to-medium risk breast cancer may benefit from systemic HRT, with patients accepting the risk to improve the day-to-day quality of their life. For 92.8 per cent of women with low-risk disease, evidence shows they will not experience a relapse. As a consequence, experts suggest that collaboration with healthcare workers is key, allowing patients to be involved in the HRT choices available to them.

Dr Sarah Glynne, first author of the study and a GP Menopause Specialist at the Portland Hospital, added: ‘As a panel of experts, the consensus was that we should move away from a de facto ban of HRT after breast cancer diagnosis towards a more nuanced, evidence-based discussion that respects each woman’s circumstances, values and preferences.’

The panel also recommends that breast cancer survivors considering HRT should be enrolled in a clinical trial, such as the proposed MENO-ABC trial, which will collect long-term data on outcomes including recurrence, mortality and quality of life.

Professor Jayant Vaidya, an author of the study from UCL, said: ‘Based on our analysis of the available evidence, we think that some women may consider it reasonable to take HRT after breast cancer, after recognising their own risk profile, if it meaningfully improves their quality of life.’

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He added: ‘What we really need now is a new clinical trial, such as the MENO-ABC trial, to accurately quantify the risks and benefits in light of modern diagnostic methods and treatments, so that women and their clinicians have the complete information they need to make an informed decision.’