Joining FORCES is the FORCE newsletter with news, views and supportive information for individuals concerned about hereditary breast and ovarian cancer.
by Katrina Altersitz Wells
A question that is on the minds of almost every woman in the HBOC community as they weigh their ovarian cancer risk is the side effects of early menopause after oophorectomy, closely followed by the question of hormone replacement therapy (HRT) and its safety.
Andrew M. Kaunitz, MD, FACOG, NCMP, and Noah D. Kauff, MD, FACOG, took on the heavy burden of weighing the pros and cons of HRT for attendees at the 9th annual Joining FORCEs Against Hereditary Cancer conference. Both agreed that the biggest factor in treatment of postsurgical women, even those at high risk, is how they react to the surgery and how they feel. It's not for me to decide. It's for my patient to decide, Kaunitz said.
Kauff noted that much discussed factors, like protection from cardiovascular disease, may be less important than previously thought. He pointed out that HRT is not recommended for prevention of heart disease or improvement of cognitive function in the general population, so perhaps it should not be considered as such in the HBOC population. Instead, it should be used exclusively for the treatment of vasomotor symptoms of menopause (influences that cause blood vessels to constrict or dilate). I'm not convinced [oophorectomy] increases heart disease at all. We should not be taking HRT to protect against a risk that may not be real, Kauff said. I suggest they wait for symptoms to declare 3- 4 weeks after surgery.
Kauff admitted that he may be more conservative than others, and if a prophylactic mastectomy has not been performed, there is much more to consider. One group of women to whom I empirically offer HRT are those that already had prophylactic bilateral mastectomy, he said. If breast cancer risk is off the table due to mastectomy, it's reasonable to give hormone therapy until the age of natural menopause.
But Kaunitz presented data from three studies of HBOC women with intact breasts who took hormone therapy, which he felt shows this population can safely take HRT up to 5 years. One study (Rebbeck, et al., 2005) showed that risk-reducing oophorectomy further decreased the risk of breast cancer by 60% whether or not women used HRT; 2-3 years of HRT did not negate the beneficial effect of oophorectomy. Another study (Eisen, et al., 2008) "counterintuitively" found greater than a 40% reduction in breast cancer with hormone therapy. Yet another study (Domchek, et al., 2011) showed that HRT was not associated with increased risk of breast cancer, and in BRCA1 carriers, use of hormone therapy was again associated with a decreased risk of breast cancer, regardless of previous gynecologic surgery.
Up to 5 years of HRT use appears safe. Specifically in BRCA1 previvors, hormone therapy appears to reduce the risk of breast cancer, Kaunitz said. Previvors with intact breasts should not defer risk-reducing gynecologic surgery out of fear of symptoms related to surgical menopause.
Additionally, Kaunitz warned attendees against the use of unapproved hormonal options like compounded formulations or bioidentical hormones. Many physicians who prescribe and sell compounded hormone therapy also often charge for testing, he explained. While lucrative for prescribing physicians, the salivary tests taken to monitor the presence of compounded hormones do not correlate with blood levels.
Kaunitz encouraged attendees to find an educated physician for the menopausal journey. It is worth the effort to seek out well informed, up-to-date clinicians who involve their patients in choices regarding menopausal management, he said.
Kauff agreed, bringing it back to the real risks of ovarian cancer that women under the HBOC umbrella must weigh. We do not have an adequate ovarian cancer screening. Our only option is removal, he said. Salpingo-oophorectomy is when, not if, but we always have to remember we're dealing with two cancers. We shouldn't necessarily just prescribe hormone therapy without an indication. Treat it like any other drug where there are benefits and downsides.