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IMS Menopause Live

Hormone replacement therapy in cancer survivors

25 January 2021

Summary

Improvements in oncology have led to an increased survival of cancer patients. Indeed, breast cancer patients live long enough to reach the natural age of menopause. In addition, in many of them, one of the main adverse effects of their received oncotherapy is premature ovarian failure caused by the cessation of gonadal function. Indicating menopausal hormone therapy (MHT) in these type of patients has become increasingly difficult as multiple clinical studies suggest an increased risk of recurrence and mortality with the use of MHT. The use of therapy must be supported according to oncological and endocrine factors, the oncotherapy received and the type of compound to be used: estrogen alone, estrogen plus progestogen and progestogen only, always balancing risk – benefit [1]. The pattern of expression of the estrogen receptor is not sufficient to predict the effect of estrogen or progesterone; since the biological effect depends on the tissue and type of tumor, the interaction with isoforms, growth factors, coactivators and corepressors.
Taking into account the aforementioned, MHT is chosen according to the type of cancer and its characteristics, risk factors of each patient and their preferences. In breast cancer survivors it is difficult to choose which is the best therapy, since according to the interpretation of the International Menopause Society "IMS", all hormonal therapy would be contraindicated. Hence, questions arise regarding molecules such as tibolone, the use of estrogens alone and local hormonal therapy, which could be considered according to the scenario of each patient and their history.

Commentary

The IMS guideline is clear in emphasizing that non-hormonal methods are preferred in receptor-negative or positive breast cancer survivors who have menopausal symptoms, and MHT is contraindicated. However, there is controversy in the literature in this regard: observational and case-control studies suggest that MHT does not increase disease recurrence [2,3]. Contrary to this, clinical studies such as the HABITS were suspended after 2.1 years because their results showed a higher risk of breast cancer recurrence (n = 434, 26 cases of recurrence in the MHT group compared to 7 cases in the group that did not receive MHT, hazard ratio [HR] 3.3) [4]. The 10-year follow-up results from the Stockholm trial also indicated an increased risk of breast cancer recurrence. In the study of Fahlen et al [5], a HR of 3.6 was detected for disease recurrence (n = 378, mean duration of MHT 26 months, recurrent rate among MHT users was 7.4% vs. non-users 2.1%) [5].

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