Major Study Gives Women More Guidance on Hormone Therapy During Menopause

Women who receive hormone therapy to help ease menopausal symptoms have an increased risk of breast cancer, which can persist long after they stop the therapy, a new study confirms.

The new review — which included data from 58 studies involving nearly 109,000 women from around the world — is the latest chapter in the ongoing story of these hormone therapies.

“Since the Women’s Health Initiative [study] identified in 2002 that women who took hormone replacement therapy were at an increased risk for the development of breast cancer, we have seen a marked decline in their use,” noted Dr. Lauren Cassell, a breast surgeon at Lenox Hill Hospital in New York City. She wasn’t involved in the new report.

“Patients who were on hormone replacement went off them [after the 2002 study], and physicians were more cautious in prescribing them,” Cassell said.

The new report, published Aug. 29 in The Lancet, “again reinforces that known increased risk, but more importantly, it identifies that the risk persists even after the therapy is stopped, and is affected by the length of time that the patient takes hormone replacement,” Cassell said.

The new analysis was performed by a global team of experts known as the Collaborative Group on Hormonal Factors in Breast Cancer. They pored over data from 58 studies conducted worldwide between 1992 and 2018. These studies included nearly 109,000 women with breast cancer, with an average age of 65 at diagnosis.

Half of the women had received hormone therapy for menopause, the researchers noted. The average age at menopause was 50 and the average age at starting hormone therapy was also 50. Women took hormone therapy for an average of 10 years, in current users, and for seven years in past users, the team said.

For women of average weight living in Western countries who have never used hormone therapy, the average risk of developing breast cancer between ages 50 to 69 was about 6.3 per 100 women, according to the study.

However, the risk rose for women who received hormone therapy, and the formulation used seemed key to an uptick in risk.

For example, for women who took treatments involving estrogen plus daily progestogen for five years, the rate of breast cancer was 8.3 per every 100 women. It was slightly lower for women taking estrogen plus intermittent progestogen — 7.7 per 100.

The rate was lower — but still elevated — for women who used an estrogen-only therapy: 6.8 cases per 100, the findings showed.

Duration of use mattered, as well. The rise in breast cancer risk was about twice as high for women who used hormone therapy for 10 years rather than five years, the study found.

Conversely, there was little increased risk of breast cancer after using any form of hormone therapy for less than a year, the researchers said.

One major finding was just how long hormone therapies left their mark for women who used the treatment for five years; any elevation in breast cancer risk didn’t fully subside until 15 years after stopping the therapy.

The findings suggest that all types of hormone therapy for menopause — with the exception of topical vaginal estrogens — are associated with an increased risk of breast cancer, the study authors said.

“Our new findings indicate that some increased risk persists even after stopping use of menopausal hormone therapy,” study co-author Valerie Beral, a professor at the University of Oxford in England, said in a journal news release.

The use of hormone therapy for menopause rose sharply in the 1990s, fell by half in the early 2000s and stabilized in the 2010s. Currently, there are about 12 million users in Western countries — about 6 million in North America and 6 million in Europe.

Ten years of use was once common, but about five years of use is now more likely, the researchers said.

Dr. Alice Police directs breast surgery at Northwell Health Cancer Institute in Sleepy Hollow, N.Y. Looking over the study, she said that as time goes by, research like this is giving women better guidelines on what is or is not safe when it comes to hormonal therapies.

For example, “we now know that topical vaginal creams do not increase the risk of breast cancer as they mostly work locally and absorption is minimal. This is great news for many women who depend on these therapies to prevent UTIs [urinary tract infections] and vaginal dryness,” Police said.

“We also know which medications, in what combinations, are the most dangerous,” she added. “For example, estrogen alone is safer than estrogen and progesterone together.”

For her part, Cassell said that, going forward, “oral hormone replacement therapy should be prescribed judiciously for patients who are having intolerable symptoms of menopause and understand the increased risk for breast cancer.”

That means, “the use of progesterone should be minimized and the length of the hormone replacement should be as short as possible,” Cassell said.

Source: HealthDay


Today’s Comic

U.S. Task Force Updates Breast Cancer Gene Testing Recommendations

Serena Gordon wrote . . . . . . . . .

Mutations in two genes — BRCA1 and BRCA2 — are known to significantly increase the risk of breast cancer, but experts have long debated which women should be tested for them.

New recommendations from the U.S. Preventive Services Task Force (USPSTF) may help clarify who can benefit most from a risk assessment test. Now, if a woman has a high risk, the task force is recommending that she see a genetic counselor and possibly be tested for the BRCA mutations.

“Breast cancer is very prevalent, but the BRCA founder mutations are rare, occurring in less than 1% of all women,” explained task force member Dr. Carol Mangione, a professor of medicine and public health at the University of California, Los Angeles.

Deciding whether to have a test for these mutations is “a complex decision with a lot of pros and cons to weigh,” she said. “Women who are known to be positive sign up for some pretty dramatic surgeries and medications.”

For example, women with a BRCA mutation might have both breasts removed to prevent cancer from developing.

“In women who don’t have an increased risk [of a BRCA mutation], the potential harms outweigh the benefits of testing,” Mangione said.

The latest USPSTF recommendations for BRCA testing were published Aug. 20 in Journal of the American Medical Association.

So who should have that initial risk assessment?

According to the task force, it is appropriate for women with a personal or family history of these cancers:

  • Breast
  • Ovarian
  • Fallopian tube
  • Peritoneal (the tissue lining the abdomen).

Women with an ancestry linked to BRCA mutations, such as those of Ashkenazi Jewish descent, should also have a risk assessment, the task force said.

Other groups that may have an increased risk of a BRCA mutation due to ancestry include some African-Americans, Mexicans, Nigerians, and people from India, according to an editorial published Aug. 20 in JAMA Network Open. Its lead author is Dr. Padma Sheila Rajagopal of the University of Chicago.

Depending on the results of a risk assessment, a woman may not end up having genetic counseling or testing. It’s also possible that a woman may have genetic counseling and then decide BRCA testing would not benefit her.

The task force said some women don’t need a risk assessment. These include women who don’t have a family history of the four cancers or an ancestry associated with BRCA mutations.

Dr. Len Lichtenfeld, interim chief medical officer of the American Cancer Society, said BRCA testing is a “very real” issue. “These recommendations may start a needed discussion, but we can do much better,” he said, calling the task force’s approach “conservative.”

He noted that it didn’t address BRCA testing in men, who can also get breast cancer (rarely) and other BRCA-related cancers.

Lichtenfeld also was concerned that the USPSTF didn’t address direct-to-consumer testing. A number of companies offer BRCA testing online. But these tests might not be as well-controlled as a medical test, so the findings might not be accurate.

“A woman might get tested and have a mutation that isn’t discovered by the online test,” Lichtenfeld said.

Mangione said the over-the-counter genetic tests are still new and the task force didn’t have enough evidence to make a recommendation. Still, she noted, “With an OTC test, you don’t know what you’re getting, and a positive test could create quite a bit of alarm.”

Lichtenfeld also took issue with the recommendation that every woman with a high risk based on her doctor’s risk assessment should then see a genetic counselor before testing.

“The recommendations are relying on genetic counselors, but too few are available. This recommendation will restrict access to screening for some women,” he said.

According to Rajagopal’s editorial, the United States has fewer than 700 cancer-specific genetic counselors available.

Source: HealthDay


Today’s Comic

Soy Foods Linked to Fewer Fractures in Younger Breast Cancer Survivors

A new paper in JNCI Cancer Spectrum, published by Oxford University Press, is the first study to find that diets high in soy foods are associated with a decreased risk of osteoporotic bone fractures in pre-menopausal breast cancer survivors.

Breast cancer is the second most common cancer among women in the United States, with 1 in 8 women diagnosed with it during their lifetime. Many treatments for breast cancer can cause premature menopause and decrease bone mineral density. This leads to a higher incidence of osteoporosis-related fractures among survivors compared to healthy women in the same age range, and yet many factors connected to this increase in fracture risks are understudied.

Researchers here studied the impact that BMI, exercise, and soy food consumption had on bone fracture rates among breast cancer survivors. The study used data from the Shanghai Breast Cancer Survival Study of 5,042 newly diagnosed breast cancer survivors between the ages of 20 and 75. Researchers collected detailed information at enrollment, including cancer diagnosis and treatment history, medication use, dietary habits, exercise and other lifestyle factors. About 52% of women in the study were postmenopausal. Patients then had follow-up visits at 18 months, and 3, 5, and 10 years after their diagnosis to update exposure and outcome information.

Throughout the 10-year study period, 3.6% of survivors reported an osteoporotic bone fracture. Higher soy intake was associated with a 77% reduced risk of osteoporotic fractures in younger women, and exercise showed a significantly reduced risk of fractures among older women.

Consistent with prior studies, the extended use of tamoxifen, a drug that is prescribed for breast cancer patients showed a 37% reduced risk of fractures in the overall study population. Tamoxifen is a selective estrogen receptor modulator, or SERM, that causes an increase in bone mineral density. Soy based foods, which are rich in isoflavones, provide a natural SERM.

“The menopausal transition is known to be a period of high risk for bone loss, and given the relative scarcity of data related to fracture risk among younger women with breast cancer, this study marks an important contribution to this body of literature,” said the paper’s lead author, Evelyn Hsieh. “Our findings, in particular regarding the protective effects of soy food consumption provide novel insight into how future interventions can be best tailored to different risk groups.”

Source: Science Daily

Breast Cancer and DDT: Timing of Exposure May Matter

Exposure to high levels of the pesticide DDT increases breast cancer risk — but when the cancer surfaces depends on when women first came in contact with the chemical, researchers say.

“What we have learned is that timing really matters,” said lead author Barbara Cohn, from the California-based Public Health Institute.

“We know that if harmful exposures occur at times when breast tissue is rapidly changing, such as during puberty, they impact breast development in ways that can later result in cancer,” added Cohn.

The breast cancer diagnoses tended to occur about 40 years after exposure to DDT, her team concluded.

DDT was widely used in agriculture until it was banned in the United States in 1972, and banned in many countries in the 1970s. Many women and girls in the United States were exposed to the pesticide. The youngest of them are now reaching the age of increased breast cancer risk.

For this study, researchers looked at more than 15,500 women in California who participated in the institute’s Child Health and Development Studies for nearly six decades. Levels of DDT exposure were determined by analyzing stored blood samples taken from them between 1959 and 1967. The researchers analyzed data on breast cancer cases that occurred up until age 54.

All women who were exposed to high levels of DDT had an increased risk of breast cancer through age 54, the study found.

But those exposed to DDT before age 14, particularly in infancy and early childhood, were most likely to develop premenopausal breast cancer (before age 50). Those exposed after infancy were at increased risk of postmenopausal breast cancer (ages 50-54).

Among the specific findings:

  • DDT exposure during childhood and puberty (ages 3-13) was a risk factor for both premenopausal and postmenopausal breast cancer.
  • A doubling of DDT was associated with an almost tripled increased risk of postmenopausal breast cancer for those first exposed to the pesticide after infancy.
  • Women at increased risk for premenopausal breast cancer were first exposed to DDT in utero and during infancy through puberty, but not after age 14. The highest risk was associated with first exposure before age 3.
  • Women first exposed to DDT after age 14 only had an increased risk of breast cancer after menopause, and were not at increased risk for breast cancer before age 50.

“The research suggests that DDT affects breast cancer as an endocrine disruptor, that the period of time between first exposure and cancer risk seems to be around 40 years — and that other endocrine-disrupting chemicals could potentially simulate this kind of risk pattern,” Cohn said in an institute news release.

Considering the patterns observed, working backward to determine when a woman first came into contact with DDT could help aid early detection and treatment of DDT-associated breast cancer, Cohn added.

The study was published in the Journal of the National Cancer Institute.

Source: HealthDay


Today’s Comic

Healthy Lifestyle Lowers Odds of Breast Cancer’s Return

There’s more evidence that when a survivor of early stage breast cancer takes up healthy eating and regular exercise, the odds of the disease returning go down.

The key is sticking with such programs, said study lead author Dr. Wolfgang Janni.

Healthier lifestyles “might improve the prognosis of breast cancer patients if adherence is high,” said Janni, who directs obstetrics and gynecology at the University of Ulm in Germany. His team developed and implemented a new program to help keep those lifestyle changes on track.

The findings were presented at the annual San Antonio Breast Cancer Symposium.

In the study, Janni’s team tracked outcomes for nearly 2,300 early stage breast cancer patients who’d been treated with chemotherapy. Half of these cancer survivors were randomly assigned to two years of ongoing telephone-based, personalized healthy living advice. The other half (the “control” group) received standard, general advice on a healthy lifestyle.

Those in the personalized lifestyle intervention group were coached in areas such as improving their diet, reducing fat intake, and increasing physical activity.

After two years, people in the intervention group saw an average weight loss of 2.2 pounds, while those in the control group experienced an average weight gain of 2.1 pounds, the findings showed.

But the real difference was in cancer outcomes, Janni’s team said. The rate of disease-free survival among the nearly 1,500 patients who completed the lifestyle intervention was 35 percent higher than that of those who didn’t complete the program. And it was 50 percent higher than women who didn’t get the intervention at all.

The findings shouldn’t come as a big surprise, Janni said.

Prior research “has shown that obesity and low physical activity are associated with higher risks of developing breast cancer, as well as an increased risk of recurrence and reduced survival,” he noted in a meeting news release.

One U.S. expert agreed.

Many women who’ve survived breast cancer may feel helpless, but “it is great to be able to tell patients that, yes, there is something they can do to help prevent a recurrence,” said Dr. Alice Police. She is regional director of breast surgery at the Northwell Health Cancer Institute, in Sleepy Hollow, N.Y.

She said sometimes women need a little nudge, though, to stay healthy.

“This is a very specific and focused look at the issues and includes information on exactly how a program of diet and lifestyle changes should look and function,” Police said, “and that makes it very important.”

Dr. Lauren Cassell is chief of breast surgery at Lenox Hill Hospital in New York City. Looking over the new study, she agreed that the new program appears to have merit.

“By providing the patient with a systematic telephone lifestyle intervention program — which was not difficult to develop and implement — they were able to increase patient compliance and as a result improve outcomes,” Cassell said.

“I believe patients want to help themselves,” Cassell said. “Sometimes they just need a little extra support.”

Source: HealthDay