The role of hormone replacement therapy in women with a previous diagnosis of breast cancer and a review of possible alternatives

Venlafaxine Hydrochloride for the Treatment of Hot Flashes

OBJECTIVE:

To review the literature evaluating venlafaxine for the treatment of hot flashes.

DATA SOURCES:

Clinical literature accessed through MEDLINE (1966–August 2002), PubMed, Harrison's Online, and references of reviewed articles. Key terms used were venlafaxine, Effexor, hot flashes, and vasomotor symptoms.

DATA SYNTHESIS:

Not all patients experiencing hot flashes are candidates for traditional hormonal therapy. Nonhormonal alternatives have long been explored, but conflicting evidence of efficacy exists.

CONCLUSIONS:

Venlafaxine is an effective nonhormonal alternative for relief from uncontrolled hot flashes.

Randomised controlled trial comparing hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors: a pilot study

OBJECTIVES

To compare the efficacy of hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors, and to evaluate the feasibility of conducting a clinical trial comparing a drug with a complementary or alternative method (CAM).

DESIGN

Prospective randomised trial.

SETTING

Breast health centre of a tertiary care centre.

PARTICIPANTS

15 women with a personal history of breast cancer or an increased risk of breast cancer who reported at least one daily hot flash.

INTERVENTIONS

Gabapentin 900 mg daily in three divided doses (control) compared with standardised hypnotherapy. Participation lasted 8 weeks.

OUTCOME MEASURES

The primary endpoints were the number of daily hot flashes and hot flash severity score (HFSS). The secondary endpoint was the Hot Flash Related Daily Interference Scale (HFRDIS).

RESULTS

27 women were randomised and 15 (56%) were considered evaluable for the primary endpoint (n=8 gabapentin, n=7 hypnotherapy). The median number of daily hot flashes at enrolment was 4.5 in the gabapentin arm and 5 in the hypnotherapy arm. HFSS scores were 7.5 in the gabapentin arm and 10 in the hypnotherapy arm. After 8 weeks, the median number of daily hot flashes was reduced by 33.3% in the gabapentin arm and by 80% in the hypnotherapy arm. The median HFSS was reduced by 33.3% in the gabapentin arm and by 85% in the hypnotherapy arm. HFRDIS scores improved by 51.6% in the gabapentin group and by 55.2% in the hypnotherapy group. There were no statistically significant differences between groups.

CONCLUSIONS

Hypnotherapy and gabapentin demonstrate efficacy in improving hot flashes. A definitive trial evaluating traditional interventions against CAM methods is feasible, but not without challenges. Further studies aimed at defining evidence-based recommendations for CAM are necessary.

TRIAL REGISTRATION

clinicaltrials.gov (NCT00711529).

Vaginal oestrogen therapy after breast cancer: is it safe?

The increasing number of breast cancer patients who suffer from menopausal symptoms is mainly due to the extensive use of adjuvant treatments in the younger women. Both short and long-term side effects of oestrogen deficiency may severely impact on the quality of life of these women and should not be underestimated. Hormonal treatments are contraindicated in breast cancer survivors mainly due to the concern that dormant micrometastases may be stimulated to grow. Alternative non-hormonal remedies are now available to alleviate symptoms and to prevent chronic diseases associated with oestrogen deficiency. Urogenital atrophy is an important consequence of oestrogen deprivation that can be effectively treated by vaginal estrogens, although systemic absorption occurs with conventional doses. Preliminary data suggest that much lower doses of vaginal estrogens can alleviate urogenital atrophy without influencing serum estrogenic levels. Further research is warranted to confirm whether vaginal estrogens are safe in symptomatic breast cancer patients who are non-responsive to alternative treatments.

Strategies for managing breast cancer risk after the menopause

Postmenopausal women in Western societies are conscious of breast cancer as a potential cause of death and ill health, which they wish to avoid with the advice of their doctors. Yet many factors that predispose women to the development of cancer will have been laid down before the menopause, in their genetic makeup or during their adolescent years. Even in middle age it is important to take account of the intrinsic level of risk, and to give women advice tailored to their own individual risk level. This results from their family history, previous diseases such as benign breast disease, and previous treatment for breast cancer or Hodgkin's disease. For those at the highest level of risk, strategies will include regular screening, prophylactic mastectomy, and the use of chemoprevention agents, such as tamoxifen. These women should avoid hormone replacement therapy (HRT) and control their menopausal symptoms and osteoporosis through the use of other agents now available - venlafaxine for menopausal symptoms and bisphosphonates for osteoporosis. Raloxifene is an agent under trial that may be valuable for breast cancer control as well as for osteoporosis. Women at standard population risk will require less robust preventive strategies, which will include screening and lifestyle modification. Their decisions regarding HRT should now be modified by recent evidence of associated risks. Recent studies show that tibolone causes less mammographic density and has a lower relative risk of breast cancer than combined estrogen/progestogen preparations. There is limited evidence that controlling obesity, participating in exercise and adopting a diet low in fats and high in fruit and vegetables will alter risk at this age. These precautions will, however, reduce the risk of other diseases common in this age group, such as hypertension, heart disease, stroke, and type 2 diabetes mellitus. Alcohol, even in small amounts, is a risk factor for breast cancer. Given the cardioprotective effect of moderate alcohol intake, advice on alcohol must reflect the individual relative risk of cardiovascular disease and breast cancer. Personal risk assessment is relevant for all women. Screening and a healthy lifestyle are worthwhile approaches for all, with the more aggressive approaches such as chemoprevention and prophylactic surgery reserved for those who have substantially elevated levels of risk. Once the menopause has passed, screening is probably the most effective evidence-based tool for breast cancer control by early diagnosis.

The association between nocturnal hot flashes and sleep in breast cancer survivors

This study examined the relationship between objectively measured nocturnal hot flashes and objectively measured sleep in breast cancer survivors with insomnia. Twenty-four women who had completed treatment for non-metastatic breast cancer participated. All were enrolled in a study of cognitive-behavioral treatment for chronic insomnia. Nocturnal hot flashes and sleep were measured by skin conductance and polysomnography, respectively. The 10-minute periods around hot flashes were found to have significantly more wake time, and more stage changes to lighter sleep, than other 10-minute periods during the night. Nights with hot flashes had a significantly higher percentage of wake time, a lower percentage of Stage 2 sleep, and a longer REM latency compared to nights without hot flashes. Overall, hot flashes were found to be associated with less efficient, more disrupted sleep. Nocturnal hot flashes, or their underlying mechanisms, should be considered as potential contributors to sleep disruption in women with breast cancer who report poor sleep.

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.

Breast cancer and post-menopausal hormone therapy

From the introduction of post-menopausal hormone replacement therapy (HRT) there has been great concern that HRT could possibly increase the risk of breast cancer. Prolonged exposure to endogenous oestrogens undeniably increases the risk of breast cancer. Questions that are important and until now only partly answered, are the following. Are oestrogens tumour promoters, as they induce mitosis, lead to proliferation and, therefore, accelerated growth of clinically occult pre-existing tumours? In addition to this, are they genotoxic mutagenic carcinogens, or could they initiate tumours by way of accumulation of incessant DNA-replication damage mechanism? Opinions vary as to the effect of the addition of a progestogen. There is a multitude of different progestogens which could bind with differing affinity to progesterone receptor PR-A or PR-B, and which have different physiological functions via differential gene regulation. The action of a progestogen on the oestrogen-induced cellular mitotic activity could be synergistic or antagonistic (by different pathways: oestrogen receptor downregulation, activating of metabolic pathways within the breast or stimulation of apoptosis)? Over 60 observational studies and two randomized trials provide evidence that the small but significant increase in risk appears with long-term current post-menopausal hormone use. The addition of a progestogen does not decrease the risk as seen with oestrogens alone and might increase the risk further. It is not clear whether there is a difference in risk with sequentially combined versus continuously combined HRT. Many questions nevertheless still remain. Is the risk increase limited to lean women only? What about risk-modifying factors such as alcohol use and a positive family history for breast cancer? Are tumours detected under HRT less aggressive, is there a better prognosis and is the mortality not increased while morbidity is? And is HRT contraindicated for women with a positive family history for breast cancer or in those women who have been treated for breast cancer? And finally, are there alternative options for these women?

Sexual dysfunction after treatment for gynaecologic and breast malignancies

PURPOSE OF REVIEW

This review summarizes current knowledge about the nature of sexual dysfunction in gynaecologic and breast cancers, highlighting recent publications on treatment effects and communication issues.

RECENT FINDINGS

In both gynaecologic and breast cancer, sexual dysfunction causes much distress to patients, from the time of diagnosis through to long-term follow-up. It appears that younger women in particular experience difficulties related to loss of reproductive function and relationship problems, plus more abrupt vaginal changes, than older women. Chemotherapy has been shown to be associated with short and long-term effects on sexual functioning and quality of life in breast cancer, and it is anticipated that this would extend to gynaecologic cancers also. The addition of endocrine treatments to chemotherapy in breast cancer appears not to affect levels of sexual functioning, although this may depend on the age of the woman. Sexual self-schema appears to be an important concept in predicting sexual dysfunction. Communication with women about sexual issues is vital, but evidence suggests this is lacking.

SUMMARY

We are beginning to understand more about the sexual implications of different treatments and to identify factors which predict sexual dysfunction. More research is still required to identify how sexual dysfunction is affected in different groups of women and how best to help women who experience sexual difficulties. Recent findings suggest that there is a need to increase communication and support about sexual issues.

Estrogen replacement therapy for menopausal women with a history of breast carcinoma: results of a 5-year, prospective study

BACKGROUND

Women with a history of breast carcinoma generally have been advised to avoid estrogen replacement therapy (ERT). The validity of this approach has been scrutinized and debated in recent years, and reassessment through appropriate clinical trials has been suggested.

METHODS

The authors conducted a prospective clinical trial to assess the safety and efficacy of prolonged ERT in a group of menopausal women with localized (Stage I or Stage II) breast carcinoma and a minimum disease free interval of 2 years if estrogen receptor (ER) was negative or 10 years if ER status was unknown. For 5 years, the authors followed 77 trial participants and 222 other women with clinical and prognostic characteristics comparable to those of the trial participants. Overall, 56 women were on ERT, and 243 women were not on ERT. The association of ERT with skeletal and lipid changes was assessed in the randomized trial participants. The effect of ERT on the development of recurrent or new breast carcinoma and other carcinomas was analyzed both in the trial participants and in the overall group.

RESULTS

Patient and disease characteristics, such as tumor size, number of lymph nodes involved, ER status, menopausal status, and disease free interval were comparable for women who were on ERT and women who were not on ERT. These same parameters also were comparable for women who joined the trial and women who did not. ERT use was associated with modest lipid and skeletal benefits. The introduction of ERT did not compromise disease free survival. Two of 56 women on ERT (3.6%) developed a contralateral, new breast carcinoma. In the group that was not on ERT, 33 of 243 women (13.5%) developed new or recurrent breast carcinoma. There were no differences in the development of other carcinomas with respect to ERT.

CONCLUSIONS

ERT did not compromise disease free survival in select patients who were treated previously for localized breast carcinoma. Larger scale randomized trials are needed to confirm these findings.

Sexual functioning in breast cancer survivors

BACKGROUND

A growing body of evidence suggests that sexual dysfunction may be among the more common and distressing symptoms experienced by breast cancer survivors.

METHODS

This report reviews studies in which sexual functioning in breast cancer survivors has been investigated. Included are reports on the prevalence and nature of sexual difficulties, the relationship between specific breast cancer treatments and sexual difficulties, and the treatment of sexual dysfunction following completion of breast cancer treatment.

RESULTS

A review of the literature suggests a wide range of rates for the prevalence of sexual problems in breast cancer survivors. Factors that may affect prevalence rates include the methods used to determine prevalence and the demographic and medical characteristics of the patients studied. With regard to treatment effects, evidence suggests that breast cancer patients who undergo chemotherapy are at high risk for sexual dysfunction after treatment. In contrast, there is little evidence of a link between type of surgical treatment (eg, lumpectomy vs mastectomy) or treatment with tamoxifen and sexual functioning outcomes.

CONCLUSIONS

A growing body of evidence suggests that sexual problems can be a long-term side effect of breast cancer treatment. Oncology professionals should initiate communication about sexual difficulties, perform comprehensive assessments, and educate and counsel patients about the management of these difficulties.