January 8, 2002
Hormone replacement therapy and cancer: Balancing safety and quality
of life
Women at risk
J. Garber, MD, MPH
"There has always been controversy about hormone replacement therapy," explains Judy Garber, MD, MPH, director of the Friends of Dana-Farber Cancer Risk and Prevention Clinic. "Since the WHI study came out, I have tried to reassure patients about what the study does, and does not, say."
Dr. Garber sees women who are considered to be at risk for breast cancer for any of several reasons. They may have a family history of breast cancer. They may have a premalignant lesion diagnosed through a biopsy, or perhaps they have a close relative who has just been diagnosed. She also counsels patients who have the BRCA1 or BRCA2 gene mutation, which sharply raises their chances for developing breast and ovarian cancer.
"Most of my patients choose not to take HRT because they are already at increased risk for breast cancer," says Dr. Garber. "However, for them the study had a surprising spin. They thought they were missing out on the protective effects of estrogen on the heart and blood vessels. Now they discover that perhaps they are not missing much.
"What can we learn from the study?" she asks. For one thing, new studies are needed to determine what in the HRT combination is causing the increased risk. For another, Dr. Garber says, it is all the more important to develop new drugs that relieve symptoms of menopause more safely.
"I also remind patients that there are other strategies, such as diet and exercise and certain medications, that can reduce cancer and heart disease risk as well as strengthen bones," adds Dr. Garber. "These are more important now."
D. Cramer, MD, ScD
Women who are at above-average risk for ovarian cancer also come to the Friends of Dana-Farber Cancer Risk and Prevention Clinic, and with regard to HRT, they face a different set of concerns than women who are susceptible to developing breast cancer. Although ovarian cancer risk was not assessed by the WHI study, Daniel Cramer, MD, ScD, a gynecologist and epidemiologist at Dana-Farber, says that HRT actually may protect women from this type of cancer.
"Rates of ovarian cancer rise at menopause because the hormones that stimulate the ovary to produce eggs are abnormally high at this time in response to an ovary that has lost its store of eggs," explains Cramer. HRT or birth control pills can interrupt this process, but "we must balance this strategy against the risk for breast cancer. Since the WHI study tells us that hormone replacement therapy increases the risk for heart disease and stroke, forms of HRT that are better for the heart, or used in combination with aspirin, should be considered."
Dr. Cramer underscores the importance of assessing menopausal symptoms and explaining to each woman her own risks and benefits. "If a patient is having symptoms, I tailor my recommendations to her case," he says. "For example, I may recommend HRT to a woman with a history of colon cancer and/or osteoporosis, even if it increases her risk for breast cancer."
Next page: Cancer treatment can cause early menopause
