Risk of menopause during the first year after breast cancer diagnosis

American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer

PURPOSE

To update the 2000 ASCO guidelines on the role of bisphosphonates in women with breast cancer and address the subject of bone health in these women.

RESULTS

For patients with plain radiographic evidence of bone destruction, intravenous pamidronate 90 mg delivered over 2 hours or zoledronic acid 4 mg over 15 minutes every 3 to 4 weeks is recommended. There is insufficient evidence supporting the efficacy of one bisphosphonate over the other. Starting bisphosphonates in women who demonstrate bone destruction through imaging but who have normal plain radiographs is considered reasonable treatment. Starting bisphosphonates in women with only an abnormal bone scan but without evidence of bone destruction is not recommended. The presence or absence of bone pain should not be a factor in initiating bisphosphonates. In patients with a serum creatinine less than 3.0 mg/dL (265 mumol/L), no change in dosage, infusion time, or interval is required. Infusion times less than 2 hours with pamidronate or less than 15 minutes with zoledronic acid should be avoided. Creatinine should be monitored before each dose of either agent in accordance with US Food and Drug Administration (FDA) labeling. Oncology professionals, especially medical oncologists, need to take an expanded role in the routine and regular assessment of the osteoporosis risk in women with breast cancer. The panel recommends an algorithm for patient management to maintain bone health.

CONCLUSION

Bisphosphonates provide a supportive, albeit expensive and non-life-prolonging, benefit to many patients with bone metastases. Current research is focusing on bisphosphonates as adjuvant therapy. Although new data addressing when to stop therapy, alternative doses or schedules for administration, and how to best coordinate bisphosphonates with other palliative therapies are needed, they are not currently being investigated.

Phytoestrogens: Potential Benefits and Implications for Breast Cancer Survivors

Phytoestrogens are a group of plant-derived substances that are structurally or functionally similar to estradiol. There has been much interest in the potential role of phytoestrogens in cancer prevention and treatment of estrogen-deficient states. This review summarizes the evidence for phytoestrogen risks and benefits relevant to the breast cancer survivor, including prevention of a second primary breast cancer or metastatic disease, reduction in menopausal symptoms, and interactions with tamoxifen. Epidemiological data suggest a breast cancer protective role for phytoestrogens, and there is some supporting clinical data, but they are far from conclusive. In addition, there is some evidence that genistein, the most prevalent isoflavone in soy, can stimulate estrogen receptor-positive (ER+) breast cancer growth and interfere with the antitumor activity of tamoxifen at low levels. Given current knowledge, women who have ER+ tumors should not increase their phytoestrogen intake. Several studies suggest an inhibitory effect on ER- breast cancer cell growth, and it may be reasonable for women with ER- tumors to safely consume soy and possibly other phytoestrogens. However, the optimal amount and source are not clear. More research is needed to clarify the role of phytoestrogens in breast cancer prevention and in treating estrogen-deficient diseases in women who have had breast cancer.

Counting the costs of treatment: the reproductive and gynaecological consequences of adjuvant therapy in young women with breast cancer

As the mortality rate from breast cancer decreases, the issues facing breast cancer survivors are becoming increasingly important. Survivors of all ages may face physical and psychosocial consequences of their diagnosis and treatments. However, the long-term fertility and menopause-related side-effects of adjuvant therapy uniquely affect younger premenopausal breast cancer survivors. This article provides an evidence-based overview of the reproductive and gynaecological impact of breast cancer therapy for premenopausal women diagnosed with breast cancer. The physical and psychosocial implications of premature menopause are presented. Strategies for preserving fertility in selected patients are also discussed. Recent clinical trials strongly indicate that premenopausal women with oestrogen receptor positive tumours should receive endocrine therapy. The increased use of endocrine therapies in younger women raises important questions regarding patient information needs and treatment decision-making.

The fertility- and menopause-related information needs of younger women with a diagnosis of breast cancer: a qualitative study

The use of chemotherapy and endocrine therapies in the treatment of pre-menopausal women carries with it reproductive and gynaecological implications which younger women may find both unpleasant and discordant with plans for childbearing. This study aims to investigate the fertility- and menopause-related information needs of younger women with a diagnosis of early breast cancer. A retrospective qualitative methodology was chosen. Twenty-four women aged between 26 and 45 years at diagnosis participated in focus group interviews and telephone interviews. Many women thought that the information they had received in the past about fertility and menopausal symptoms was either insufficient or unavailable. Some women felt that, while information on fertility and menopause issues had not been paramount at the time of diagnosis, it became increasingly important after diagnosis. Participants spoke about the need to revisit or review fertility- and menopause-related information with their doctors during the course of treatment. Many women believed that information about fertility should be given prior to or during treatment decision-making, and that information related to the management of menopausal symptoms should be delivered during or after treatment when menopausal symptoms begin. Consultation with a fertility and/or menopause specialist-rated as the most preferred mode of receiving fertility- and menopause-related information. Clinical implications are drawn from the results of this study to assist clinicians and researchers to improve their communication with younger patients about the fertility- and menopause-related side effects of breast cancer treatment.

The effect of cytotoxic chemotherapy on female fertility

Nurses are now primarily responsible for the provision of patient information, and the administration of an escalating number of cytotoxic agents. This paper aims to provide nurses with key information concerning the adverse effects of cytotoxic chemotherapy on the reproductive system of women of childbearing age. The provision of information on gonadal function and fertility is vital, particularly with the increase in the survival of women treated for cancer, and the trend towards women starting a family later in life. Gonadal toxicity of the various cytotoxic agents, disruption of the menstrual cycle, premature menopause, avoidance of pregnancy, chemotherapy in pregnancy, and fertility prospects post-chemotherapy are addressed in this paper.

Menopause after breast cancer: a survey on breast cancer survivors

Due to the younger age and the ever wider use of adjuvant chemotherapy and antiestrogens, menopausal symptoms are a frequent cause of concern for breast cancer patients.

OBJECTIVES

To determine the prevalence of menopausal symptoms, and to explore the attitudes toward Hormone Replacement Therapy (HRT) or other treatments and the willingness to take oestrogen in breast cancer patients.

METHODS

A questionnaire-based survey on 250 breast cancer patients treated and followed-up at our department. Of them 144 (Group A) were in postmenopause and 106 (Group B) were in premenopause at time of diagnosis.

RESULTS

Adjuvant therapy with tamoxifen or tamoxifen plus chemotherapy is associated with a significant worsening of menopause-related symptoms of women belonging to Group A. These women are more concerned about risk of breast cancer recurrence than about risk of osteoporosis (P=0.05) and heart disease (P=0.006). Seventy-eight percent are against the use of HRT; only 22% would consider taking HRT mainly for vasomotor symptoms relief and osteoporosis prevention. The incidence of vasomotor and dystrophic symptoms is significantly higher in women belonging to Group B treated with chemotherapy and/or hormonotherapy as compared with postmenopausal women (P<0.000 and P=0.02, respectively). Premenopausal women are more concerned about risk of breast cancer recurrence than older women (P=0.09) and at the same time are significantly more worried about the impairment of the quality of life due to adjuvant therapy (P=0.005). Younger women are more prone to consider HRT than postmenopausal women (P=0.05). Sixty-six percent are against HRT use, and 34% would consider taking HRT to alleviate vasomotor and dystrophic symptoms and to prevent osteoporosis.

CONCLUSIONS

Breast cancer survivors are interested to treatments that may improve their quality of life, but fear of HRT persists among these women and their doctors, despite new evidence suggesting the low probability of detrimental effects.

Ovarian ablation in the adjuvant treatment of premenopausal and perimenopausal breast cancer

BACKGROUND

Ovarian ablation has been employed in the treatment of breast cancer for many decades and, more recently, its value as an adjuvant treatment for premenopausal women with early-stage disease has been clearly demonstrated. This review examines the different methods of achieving ovarian ablation and assesses the relevance of ovarian suppression as a treatment aim.

METHODS

Medline searches were used to identify recent key articles relating to the adenoma-carcinoma sequence. Further relevant articles were obtained by manual scanning of the reference lists of selected papers.

RESULTS AND CONCLUSION

Ovarian ablation has historically been achieved by surgical or radiological intervention. Although beneficial in premenopausal disease, these methods produce permanent ablation that results in a premature menopause, which may be associated with long-term adverse events. A series of trials have recently demonstrated the benefits of luteinizing hormone releasing hormone (LHRH) agonists, such as goserelin and leuprorelin, as adjuvant treatment for premenopausal hormone-sensitive disease. LHRH agonists produce a reliable suppression of ovarian oestrogen production of equivalent efficacy to adjuvant chemotherapy in hormone-sensitive disease. Effective ovarian suppression is marked by amenorrhoea, but studies have suggested that permanent amenorrhoea is not necessary to confer benefit in the treatment of early breast cancer. LHRH agonists therefore represent a beneficial therapeutic option for premenopausal patients with hormone-sensitive early disease.

Breast cancer in the very young patient: a multidisciplinary case presentation

A case is presented that exemplifies many issues and controversies in the diagnosis and treatment of breast cancer in the very young. This woman was 22 years of age at diagnosis; she initially underwent breast-conservation therapy and adjuvant chemotherapy, retained fertility, had a subsequent uncomplicated pregnancy and delivery, and 7 years later developed a local recurrence in the breast. The discussion addresses risk factors, diagnosis, and treatment of breast cancer in the young; the impact of treatment on fertility; implications regarding pregnancy, and the management of local recurrence after breast conservation.

Fertility preservation in breast cancer patients: IVF and embryo cryopreservation after ovarian stimulation with tamoxifen

BACKGROUND

Breast cancer chemotherapy commonly causes premature ovarian failure and infertility. Because increased estrogen levels are thought to be potentially risky in breast cancer patients, natural cycle IVF (NCIVF) has been used to preserve fertility and treat infertility in these women.

METHODS

Twelve women with breast cancer received 40-60 mg tamoxifen for 6.9 +/- 0.6 days beginning on days 2-3 of their menstrual cycle (15 cycles), and had IVF (TamIVF) with either fresh embryo transfer (six cycles) or cryopreservation (nine cycles). They were compared to a retrospective control group (n = 5) who had natural cycle IVF (NCIVF, nine cycles).

RESULTS

Cycle cancellation was significantly less frequent in TamIVF, compared with NCIVF (1/15 versus 4/9, P < 0.05). Compared with NCIVF, TamIVF patients had a greater number of mature oocytes (1.6 +/- 0.3 versus 0.7 +/- 0.2, P = 0.03) and embryos (1.6 +/- 0.3 versus 0.6 +/- 0.2, P = 0.02) per initiated cycle. TamIVF resulted in the generation of embryo(s) in every patient (12/12) while only three out of five patients had an embryo following NCIVF. Two out of six patients in TamIVF, and 2/5 in NCIVF conceived. One patient in the TamIVF group delivered a set of twins. After a mean follow up of 15 +/- 3.6 months (range 3-54), none of the patients had a recurrence of cancer.

CONCLUSIONS

Tamoxifen stimulation appears to result in a higher number of embryos and may provide a safe method of IVF and fertility preservation in breast cancer patients.

Hot flushes

Almost every woman and some men will encounter hot flushes during their lifetime. Despite the prevalence of the symptoms, the pathophysiology of hot flushes remains unknown. A decline in hormone concentrations might lead to alterations in brain neurotransmitters and to instability in the hypothalamic thermoregulatory setpoint. The most effective treatments for hot flushes include oestrogens and progestagens. However, many women and their physicians are reluctant to accept hormonal treatments. Women want non-pharmacological treatments but unfortunately such treatments are not very effective, and non-hormonal drugs are often associated with adverse effects. Results from recent studies showed that selective serotonin reuptake inhibitors and other similar compounds can safely reduce hot flushes. Moreover, the efficacy of these drugs provides new insight into the pathophysiology of hot flushes. In this critical review, we assess knowledge of the epidemiology, pathophysiology, and treatment of hot flushes.

Management of the menopause in cancer survivors

The consequences of premature menopause are of great importance to cancer survivors. Oestrogen replacement therapy (with and without added progestins) is the most extensively researched agent for the treatment and prevention of menopausal problems. While this may be appropriate for symptom control in patients with tumours that are not hormone responsive, patients with hormone dependent tumours will require safe and effective alternative treatments for menopausal symptoms. This paper will discuss both the short-term and long-term consequences of the menopause in cancer survivors and will also offer various management strategies.

American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for women with hormone receptor-positive breast cancer: status report 2002

OBJECTIVE

To conduct an evidence-based technology assessment to determine whether the routine use of anastrozole or any of the aromatase inhibitors in the adjuvant breast cancer setting is appropriate for broad-based conventional use in clinical practice. POTENTIAL INTERVENTIONS: Anastrozole, letrozole, and exemestane.

OUTCOMES

Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefit.

EVIDENCE

A comprehensive, formal literature review was conducted for relevant topics and is detailed in the text. Testimony was collected from invited experts and interested parties. The American Society of Clinical Oncology (ASCO)-prescribed technology assessment procedure was followed. BENEFITS/HARMS: The ASCO panel recognizes that a woman and her physician's decision regarding adjuvant hormonal therapy is complex and will depend on the importance and weight attributed to information regarding both cancer and non-cancer-related risks and benefits.

CONCLUSION

The panel was influenced by the compelling, extensive, and long-term data available on tamoxifen. Overall, the panel considers the results of the Arimidex (anastrozole) or Tamoxifen Alone or in Combination (ATAC) trial and the extensive supporting data to be very promising but insufficient to change the standard practice at this time (May 2002). A 5-year course of adjuvant tamoxifen remains the standard therapy for women with hormone receptor-positive breast cancer. The panel recommends that physicians discuss the available information with patients, and, in making a decision, acknowledge that treatment approaches can change over time. Individual health care providers and their patients will need to come to their own conclusions, with careful consideration of all of the available data. (Specific questions addressed by the panel are summarized in Appendix 3.)

VALIDATION

The conclusions of the panel were endorsed by the ASCO Health Services Research Committee and the ASCO Board of Directors.

Side effects of chemotherapy and combined chemohormonal therapy in women with early-stage breast cancer

The decision to receive chemotherapy or chemohormonal therapy involves careful consideration of both the potential benefits and possible risks of therapy. There are substantial short- and long-term side effects from chemotherapy. By convention, short-term side effects include those toxic effects encountered during chemotherapy, while long-term side effects include later complications of treatment arising after the conclusion of adjuvant chemotherapy. These side effects vary, depending on the specific agents used in the adjuvant regimen as well as on the dose used and the duration of treatment. There is also considerable variability in side effect profile across individuals. This review will focus on the short- and long-term toxicity seen with the most commonly used adjuvant chemotherapy and chemohormonal therapy regimens.

Impact of tamoxifen adjuvant therapy on symptoms, functioning, and quality of life

This article reviews the symptoms and everyday problems associated with tamoxifen adjuvant therapy and their impact on patients' quality of life. In addition, the purported toxic effects of tamoxifen therapy (e.g., premature menopause, weight gain, and depression) are discussed, and data are presented that refute claims of the toxicity of tamoxifen therapy. From randomized controlled trials of adjuvant therapy, we know that tamoxifen therapy increases the rate of hot flashes, night sweats, and vaginal discharge; however, in observational studies these symptoms do not have a statistically significant impact on patients' quality of life as measured by standardized, self-report questionnaires. The Breast Cancer Prevention Trial found no evidence of excessive rates of depression or clinically significant differences in sexual functioning between women receiving placebo and those receiving tamoxifen therapy. Although several serious medical risks from tamoxifen therapy exist (e.g., uterine cancer, blood clots, stroke, and cataracts), there are additional benefits from tamoxifen therapy in addition to an increase in disease-free survival rates and overall survival rates, including a decrease in contralateral breast cancer and fractures. Ultimately, the decision to receive tamoxifen therapy is a personal choice for each woman to make on the basis of the evidence of tamoxifen therapy's benefits and risks, along with her own motivation to receive therapy. When the benefits of such therapy are small, some women may choose to avoid treatment, but others may wish to try therapy to determine whether possible side effects are relevant. For women in whom the absolute survival benefits are large, there may be less difficulty in making this decision.

A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial

BACKGROUND

Previous research indicates that younger women (i.e., <or= 50) with breast carcinoma experience greater emotional distress than older women (i.e., > 50) and that coping style is significantly related to the psychosocial adjustment of women with this disease. The purpose of this study was to evaluate through a randomized controlled trial the effectiveness of a problem-solving training intervention designed to empower women with breast carcinoma to cope with a range of difficulties when diagnosed in mid-life.

METHODS

The study population consisted of women aged 50 years or younger who had no prior history of breast carcinoma, were diagnosed with Stage I-IIIA tumors, and for whom a first course of chemotherapy had been initiated recently. The intervention consisted of two in-person and four telephone sessions with an oncology nurse who provided problem-solving skills training and informational materials to the women over a 12-week period. All subjects were assessed for physical and psychosocial adjustment through telephone and mailed surveys at baseline, at 4 -months, and at 8 months.

RESULTS

Of 183 eligible women, 164 participated (a 90% participation rate), 149 of whom completed the study (a 91% completion rate). The subjects had significantly lower unmet needs and better mental health at the 4-month assessment. The intervention significantly decreased the number and severity of difficulties experienced by women with average or good problem-solving skills at 8 months, but was not effective in alleviating or resolving the problems encountered by women with poor problem-solving skills, relative to the control group.

CONCLUSIONS

We conclude that this problem-solving therapy-based home care training intervention is an effective method of helping the majority of women with breast carcinoma to reduce the stresses associated with the diagnosis and treatment of cancer in mid-life.

Prevalence and treatment of menopausal symptoms among breast cancer survivors

Women diagnosed with breast cancer often experience early menopause secondary to treatment effects, yet physicians may be reluctant to prescribe hormone replacement therapy (HRT) because of the potential increased risk of recurrence. To assess the burden of menopausal symptoms, HRT use, and alternative treatments in recent breast cancer survivors, a population-based, case-control study was conducted among breast cancer survivors and age-matched controls. Wisconsin women 18-69 years old with a new diagnosis of breast cancer 8-11 months prior to interview (n = 110) and control subjects randomly selected from population lists (n = 73) responded to a standardized telephone questionnaire that elicited information on menopausal symptoms, estrogen and alternative therapies (prescription medications, vitamins, herbal preparations, soy products, acupuncture, chiropractic) used to alleviate symptoms. We used multivariate logistic regression to obtain odds ratios and 95% confidence intervals (CI) for symptoms of menopause, use of estrogen, and use of alternative therapies. Breast cancer survivors were 5.3 (95% CI 2.7-10.2) times more likely to experience symptoms, 25 (95% CI 8.3-100) times less likely to use estrogen, and 7.4 (95% CI 2.5-21.9) times more likely to use alternatives than controls. Soy, vitamin E, and herbal remedies were the most common alternative therapies reported by participants; use was greater in cases compared to controls. Most soy users reported increasing soy products specifically to reduce the chances of a diagnosis of recurrent breast cancer. Among cases, tamoxifen users (n = 62) reported a higher prevalence of symptoms and a higher prevalence of alternative treatments. This is the first population-based survey of menopausal symptoms and treatments that compares breast cancer cases with disease-free controls. Cases are both more likely to experience menopausal symptoms and less likely to use HRT than controls. Instead, cases treat menopausal symptoms with vitamin E and soy products, even though the safety and efficacy of these therapies are unproven. The increased use of soy products in this population has not been previously documented.

Medical management of breast cancer: today and tomorrow

The medical management of invasive breast cancer has evolved based on the recognition that surgery alone was associated with few long-term cures. This Update will review the current status of breast cancer medical management in three areas: prevention in individuals with an elevated risk, adjuvant (postoperative) treatment of early breast cancer, and treatment principles in metastatic disease. Tamoxifen has emerged as a promising agent in the treatment of women at an increased risk for breast cancer and in those with in situ disease. However, the risks of treatment must be carefully weighed against the benefits in these cohorts of women with an excellent overall prognosis. This same principle can be applied to the use of adjuvant treatment in early invasive breast cancer, where the goal is cure. Adjuvant polychemotherapy is recommended in women considered at high-risk for relapse and death. In addition, women with hormone-sensitive breast cancer are offered adjuvant taxmoxifen. Nonetheless, there are some patients with low-risk disease or those with significant co-morbidities that are unlikely to benefit from adjuvant therapies and likely to sustain toxicities. The treatment goal in metastatic breast cancer is focused on palliation of symptoms as fewer than 10% of such patients achieve 5-year survival. However, novel targeted therapies are changing the treatment armamentarium and hold great promise. These new directions of treatment will be discussed as well as areas of controversy.

The impact on sexual functioning of chemotherapy-induced menopause in women with breast cancer

This article presents a comprehensive review and synthesis of empirical and conceptually based literature documenting the impact of chemotherapy-induced menopause on the sexual functioning of women with breast cancer. A literature search of the CINAHL, MEDLINE, and Psych Lit from 1980 to 1999 databases was undertaken. This literature was systematically assessed to determine key findings and conclusions. Two major themes were identified and are reported here: physical and psychological sequelae associated with altered sexual functioning. Recommendations and suggestions for further directions in research are identified.

The management of menopausal sequelae in patients with breast cancer

The use of chemotherapy and tamoxifen for young women with breast cancer results in premature menopause in a significant number of patients. Early menopause has serious vasomotor, psychological, genitourinary, cardiac and skeletal effects. Psychopharmacological and herbal preparations are widely used for the treatment of vasomotor symptoms. The incidence of psychological and depressive illness following the menopause in women with breast cancer is significantly higher than seen with the natural menopause. Targeting this population of patients for early diagnosis and psychiatric intervention is recommended. Local vaginal moisturising or oestrogen cream would help to alleviate some of the urogenital symptoms. Patients whose treatment included Anthracycline chemotherapy or radiation to the heart and those with a history of heart disease, should be monitored closely for latecardiac complications. Early menopause is the major risk factor for the development of osteoporosis. Weight bearing exercise, bisphosphonate or calcitonin therapy are all useful in treating osteoporosis. Should a woman with a history of breast cancer be given hormone replacement therapy is one of the most controversial issues in the oncology field. There are no published prospective randomised studies on the subject. The available data suggests an increase of 5% of breast cancer related events when hormone replacement therapy is given to women with breast cancer. However, in certain situations, this could be given after a detailed explanation and documentation. The patient and physician should balance the severity of symptoms against the increased breast cancer related events and the final decision should be left to the patient.

Estrogen replacement therapy after breast cancer: a 12-year follow-up

BACKGROUND

In the United States, estrogen replacement therapy (ERT) is discouraged in breast cancer survivors because of concerns that hormones may reactivate the disease. Because ERT can improve quality of life and decrease morbidity from osteoporosis and cardiovascular disease, however, this policy is increasingly being challenged.

METHODS

From February to August 1995, 607 breast cancer survivors were interviewed concerning ERT usage. Sixty-four patients indicated they received some form of ERT after their breast cancer diagnosis. Medical records for these patients were analyzed for disease stage, surgical treatment, adjuvant treatment, estrogen and progesterone receptor status, date of initiation of ERT, type of ERT, recurrence, and final outcome. Patients receiving ERT were followed prospectively.

RESULTS

Eight patients were excluded because they had used only vaginal cream ERT. The remaining 56 received ERT as conjugated estrogens, an estradiol patch, estropipate, or birth control pills. The median follow-up from diagnosis was 12.8 years (range, 4.7-38.9 years). The median time on ERT since diagnosis was 6.4 years (range, 1.0-20.9 years); 38% of the patients initiated ERT within 2 years of diagnosis. Estrogen receptors were positive in 28 (74%) of the 38 cases with available information. Pathological disease stage at time of diagnosis and treatment was 0 in 15 cases (27%), I in 27 (48%), and II in 14 (25%). Twenty-six patients (47%) received adjuvant chemotherapy or hormonal therapy. One local recurrence and one contralateral breast cancer occurred during the follow-up period (13.5 and 9.6 years, respectively), with no regional or distant recurrences, for a 15-year actuarial disease-free survival rate of 92.5%. There were no breast cancer deaths.

CONCLUSIONS

Use of ERT in a cohort of breast cancer survivors with tumors of generally good prognosis was not associated with increased breast cancer events compared with non-ERT users, even over a long follow-up period.

Goserelin (Zoladex)--its role in early breast cancer in pre- and perimenopausal women

Current standard adjuvant therapies for premenopausal women with early breast cancer include ovarian ablation by surgery or irradiation, chemotherapy and tamoxifen. The value of ovarian ablation in prolonging the survival of premenopausal patients with early breast cancer was clearly established by the analyses performed by the Early Breast Cancer Trialists' Collaborative Group in 1996. More recently, the value of ovarian suppression using the luteinizing hormone releasing hormone analogue goserelin as adjuvant therapy in pre-/perimenopausal women with early breast cancer has been confirmed in a series of studies involving over 8000 patients. The results from these studies provide evidence that goserelin, alone or in combination with tamoxifen, is at least as effective as cytotoxic chemotherapy in patients with hormone receptor-positive tumours and is effective when used after adjuvant chemotherapy. The use of goserelin in the management of early breast cancer presents an option which can avoid the side-effects experienced with cytotoxic chemotherapy and may offer unique benefits to premenopausal patients. The consolidation of these emerging results should help in defining the optimal role for goserelin in pre-/perimenopausal patients with early breast cancer.

The role of hormones in breast carcinogenesis: issues of relevance to female childhood cancer survivors

Breast cancer is the most common cancer among women in Western industrialized countries, and is an important potential second cancer to consider in young women who are survivors of childhood or adolescent cancers. This paper reviews the relationship between hormones and breast biology, cancer treatment factors that may increase or reduce the risk of breast cancer in female survivors of childhood cancer, the treatment of ovarian failure in these survivors, and the potential for preventive strategies in this population. The expanding numbers of female childhood cancer survivors increase the need for health care providers to understand the late health effects of treatments on reproductive health and breast cancer risk.

Fertility and the impact of systemic therapy on hormonal status following treatment for breast cancer

Issues of long-term toxicity from treatment for breast cancer, including the induction of premature ovarian failure, appear to be of increasing importance for breast cancer survivors. The incidence of treatment-related amenorrhea is related to patient age and to the treatment regimen. Whereas the induction of ovarian failure may be advantageous with respect to breast cancer outcome, it is not clear that there is any advantage to permanent menopause over reversible hormonal manipulations. In addition, menopause may be associated with a variety of adverse health effects. Although nonhormonal therapies are available to manage many of the consequences of menopause, avoidance of chemotherapy-related ovarian toxicity may provide the best prospects for fertility after treatment. Pregnancy after breast cancer is a realistic consideration for some breast cancer survivors and is not clearly detrimental to either the mother or her offspring.

Hormone replacement therapy and breast cancer

There is considerable evidence that the risk of breast cancer is related to ovarian function. However, the effect of postmenopausal hormone replacement therapy (HRT) on breast cancer risk continues to be debated in the absence of data from randomised controlled trials. Observational studies suggest that HRT probably promotes the growth of pre-existing breast cancers rather than initiating malignant transformation of breast epithelial cells but without exerting an obviously detrimental effect on disease-specific mortality. The controversy surrounding HRT and breast cancer has become additionally more complex as a result of the dilemma faced by clinicians advising women rendered oestrogen-deficient by breast cancer therapy. Whilst HRT is currently contra-indicated due to theoretical concerns that it will promote disease recurrence, its increasing, ad hoc prescription to symptomatic breast cancer patients has not been associated with an increase in disease recurrence. Large-scale randomised trials of HRT in healthy women and breast cancer survivors are now ongoing but it will be some years before useful clinical information becomes available. Until then, the limitations and biases implicit as a result of the design of observational studies must be borne in mind when interpreting such studies.