Course of Women Who Develop Breast Cancer While Receiving HRT

If estrogen stimulates the growth of malignant breast cells, one might be concerned that subclinical disease may be fueled by HRT and grow rapidly, resulting in a worse clinical outcome. We have no information on the outcome of recurrent disease in women who begin HRT after having been treated for breast cancer.

In the general population, however, the hypothesis that HRT could result in more aggressive disease has been the subject of several studies, all of which have provided reassuring evidence that the prognosis of women who are taking HRT when they are initially diagnosed with breast cancer is similar to, if not better than, the prognosis of women who are not receiving HRT when they are initially diagnosed with breast cancer.

HRT appears to beneficially influence the biological characteristics of breast tumors (Squitieri et al., 1994; Harding et al., 1996; Magnussom et al., 1996; Bonnier et al., 1998; Gapstur et al., 1999).

Breast tumors diagnosed in women receiving HRT behave less aggressively than other breast tumors (Holli et al., 1998; Bergkvist et al., 1989; Strickland et al., 1992), and overall mortality from breast cancer in women receiving HRT at diagnosis has been reported to be either unchanged (Yuen et al., 1993; Fowble et al., 1999; Hunt et al., 1990; Jernstrom et al., 1999) or improved (Willis et al., 1996; Schairer et al., 1999; Sellers et al., 1997; Hormone Foundation et al., 1998) compared to mortality in women not receiving HRT at diagnosis.

It is possible that the improved outcome of HRT recipients is due to a combination of a health-conscious lifestyle, including conscientious screening, plus a favorable effect of HRT on the biology of the disease.

Conclusions
Many menopausal women, including breast cancer survivors, experience mild and self-limited climacteric symptoms but, by virtue of their individual health profiles, are not at risk for heart or bone disease. For these women, no medical interventions are needed. Other women have an increased risk of heart disease or osteoporosis but not both. For some women, climacteric symptoms are overwhelming and overshadow all other considerations.

The therapeutic decisions in these various potential scenarios must be individualized.

At M. D. Anderson, we believe that appropriate nonhormonal measures should be carefully and vigorously explored as a first approach to relief of menopausal symptoms in breast cancer survivors. However, if climacteric symptoms or skeletal and cardiovascular morbidity compromise a patient's health or quality of life, estrogen use may be considered in the context of clinical trials or after thoughtful, individualized discussion.

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KEY PRACTICE POINTS