It was a stunning assertion: hormone replacement treatment, or HRT as it is more popularly known, is generally safe for breast cancer survivors.
This was the opinion of influential GP and activist Dr. Louise Newson, who appeared on ITV’s This Morning earlier this month. Phillip Schofield had questioned her whether patients who had survived cancer and were experiencing menopausal symptoms could receive the hormone treatment.
Dr. Newson, who operates a private clinic specializing in menopausal treatment, seems to imply that, contrary to what many of us have been told, we could.
I use the pronoun “we” because I have had breast cancer. twice, to be exact My cancer treatment, which included surgery, radiotherapy, chemotherapy, and other medicines, threw me into early menopause at the age of 40. Consequently, Dr. Newson’s statement captured my attention. It also made me uncomfortable.
My breast cancer, like 75 percent of all breast cancers, was fueled by the female sex hormone estrogen. The good news is that these are among the most curable tumors available today.
There are highly effective medications, such as tamoxifen and letrozole, that prevent cancer from growing by blocking the hormones that reach it. The tablets are typically administered after surgery and chemotherapy to prevent the disease from returning.
Initially, I was prescribed tamoxifen, but when my cancer returned in 2019, I needed a more decisive treatment: my ovaries were surgically removed and I was switched to letrozole.
This indicates that there is no estrogen in my body, giving me the highest chance of survival. Since three years ago, I have been cancer-free. The disadvantage has been so-called medical menopause. And the situation was dire. My night sweats were so severe that I frequently awoke believing I had soiled myself, and deep sleep became impossible.
My bicycle riding was incredibly unpleasant. Without estrogen, the skin might become dry and prone to ripping, as it helps maintain the delicate tissues of the labia and vagina. I learned this lesson the hard way.
Then there was a decline in libido. My newlywed status had a profound effect on my sexual life. The issues persisted for years.
I would have liked it if HRT had been an option, and I still do, as I still experience menopausal symptoms. Doctors often advise people like me against it, and for good reason: it can increase the risk of recurrence of breast cancer.
As you can see, HRT works by increasing estrogen levels. This is an excellent treatment for otherwise healthy women experiencing menopause-related symptoms owing to lowering estrogen levels. However, it is understandable why breast cancer patients with estrogen-driven cancers, such as myself, would be advised to avoid it.
Dr. Newson had a quite different opinion. We lack sufficient evidence to determine if it is safe or hazardous. The majority of research indicates that it is neutral or safe,’ she said on This Morning, adding with a smile, ‘Oestrogen was once used to cure breast cancer.’
Thus, may she be correct? Are people with breast cancer avoiding HRT when they could benefit safely from it?
Before I respond, I should clarify that my curiosity is both personal and professional. I was a breast cancer surgeon before I became a breast cancer patient. A few years ago, at the age of 45, I was forced to resign since the surgery to remove my breast and lymph nodes impacted the way my shoulder moved, rendering me unable to operate properly.
I began blogging about my experiences while receiving treatment, and eventually co-wrote The Complete Guide To Breast Cancer. Today, I’m focused on disseminating evidence-based information to individuals in similar circumstances as mine. And I’ve known for some time that there is a tiny but rising number of specialists who, like Dr. Newson, feel that many women with breast cancer can take HRT.
They communicate their opinions on social media and at conferences, and politicians also listen to them: Alongside MP Carolyn Harris, Dr. Newson has been a significant presence at campaign events attended by celebrities such as Penny Lancaster, and Patsy Kensit, and Davina McCall.
They have done a great deal of good by getting people, including men, to talk about menopause, by getting menopausal information added to the National Curriculum, and by supporting workplace adjustments to better support women experiencing symptoms. Like myself, their objective is to empower women. They argue that menopause should not be a taboo topic and that no one should feel embarrassed to address physical changes. I completely agree.
I concur with their assessment of how cancer specialists communicate the effects of medical menopause with patients, or lack thereof.
Before my diagnosis, when I was a surgeon, I told patients that tamoxifen could produce a few hot flushes or a touch of vaginal dryness, and that was that. In retrospect, this was tragically insufficient. Women deserve better.
Regarding the safety of HRT for breast cancer patients like myself, I believe Dr. Newson and her colleagues have gotten the message incorrect.
In a brochure aimed at breast cancer patients and available at balance-menopause.com, she and another menopause specialist GPs Dr. Melanie Martins and Dr. Jenni McCracken write: ‘It is likely that you have been advised you cannot use HRT… However, there is a dearth of high-quality studies in this area, and the dangers of HRT for breast cancer survivors are unknown.
Some research indicates that using HRT after breast cancer can potentially be advantageous.
It is essential to recognize that this is not the conventional medical viewpoint. The British Menopausal Society, the Royal College of Obstetricians and Gynecologists, and the Society for Endocrinology issued a consensus statement earlier this year to improve menopause care.
This was done in part to address lingering suspicions among some physicians that HRT can induce breast cancer in healthy women.
While past data revealed a risk, a more recent study indicates that the benefits of a couple of years of HRT, if needed to address severe menopausal symptoms, are enormous and the risk of breast cancer is nearly nonexistent.
However, the statement also makes it plain that a woman with a history of breast cancer should not be given HRT, unless in “rare circumstances” where symptoms are severe and all other means of managing them have failed.
This is because HRT increases the chance of breast cancer recurrence in women with all types of breast cancer, regardless of whether the cancer is hormone-sensitive like mine or not.
This year, a meta-analysis of four big trials concluded that HRT considerably raised the recurrence risk of breast cancer. The authors suggested that alternative therapies to alleviate menopause-related symptoms should be proposed.
Yes, there are studies indicating that HRT is safe after breast cancer, but I have reservations about these.
One is that they only monitored people for six months to two years, whereas we know that breast cancer can recur decades later.
However, women with breast cancer who are considering HRT must be informed of the dangers and uncertainty involved. This was shown to Dr. Newson, and she concurred.
My other concern, which is shared by the vast majority of the medical community, is that the benefits of HRT are overstated. Currently, HRT is solely given for the treatment of menopause symptoms and, in rare cases, for the prevention of osteoporosis.
There has been much discussion about its ability to prevent heart disease, type 2 diabetes, and dementia. But the proof is simply absent. Some research has demonstrated potential, while others have yielded contradicting results.
Aside from being deceptive, overstating the case for HRT only causes anxiety for women with breast cancer, who have likely been informed by their physicians that the treatment is dangerous and therefore do not wish to take it. I asked my social media followers for their opinions on the matter, and I received a deluge of responses: ‘I feel afraid when I hear these claims – forced to take a chance, or I’ll be sick anyway,’ said one.
Another respondent stated, ‘It’s quite difficult to know what to do when listening to a GP on This Morning declare that HRT is safe for women with breast cancer, such as myself, when my oncologist advises I cannot have it. My mind is jumbled by all of this.
Many gave single-word responses. Afraid, robbed, angry, weak, disadvantaged, conflicted, depressed, helpless… It was never-ending.
And what about the notion that hormone replacement therapy is safe because estrogen was originally used to treat breast cancer? Once upon a time, estrogen was administered to patients with advanced breast cancer.
In a small number of postmenopausal women, the medication reduced the progression of the condition, but the side effects were unpleasant.
Appetite loss, nausea, and vomiting were problematic. A few unfortunate individuals experienced significant vaginal hemorrhage and incontinence, as well as heart failure.
Then, in the late 1970s, tamoxifen was introduced. It had a comparable effect in this patient population, but without adverse effects, and thus became the treatment of choice.
Later, it was discovered that the medication, which works by blocking estrogen in breast tissue, has significant benefits for women with breast cancer at an earlier stage. It reduces the chance of relapse by approximately 50% and increases overall survival by 30%.
Importantly, you cannot mix the early use of estrogen as a cancer treatment that prolongs life with HRT. They are two very distinct entities. And it would be dishonest to say that this is evidence that HRT is safe for breast cancer patients.
Do not misunderstand; I am not suggesting that women with breast cancer who are experiencing terrible menopause symptoms must “put up with it.”
There are effective alternatives to HRT. Antidepressants, blood pressure medications, and painkillers such as gabapentin can be used to treat hot flushes. Vaginal estrogen, which is available in many forms, can alleviate sexual pain without increasing the chance of cancer recurrence.
Some women may have such a low risk of recurrence that their cancer team deems it safe for them to discontinue taking tamoxifen or take a vacation from it to determine if this helps.
I tried acupuncture and hypnotherapy, both of which have been proved to be beneficial, coupled with regular exercise and alcohol reduction.
We know that exercise alone can significantly lower the chance of breast cancer recurrence, as well as protect against cardiovascular disease, osteoporosis, type 2 diabetes, etc.
Dr. Newson stated in a statement, “Some studies have demonstrated an increased risk of breast cancer recurrence associated with HRT, but no increase in mortality.”
Other research has demonstrated either a benefit or no risk or benefit. None of this research has been rigorous or well-designed, therefore all results cannot be interpreted accurately.
Some women report menopausal symptoms as being worse than cancer. They are eager to take HRT to improve their quality of life, and they are completely aware of the risks involved.
I cannot in good faith deny them this treatment as a physician. It is a matter of choice, and that is the most crucial factor for women.
On this final point, we are once again in agreement. I am well aware that there are breast cancer patients who are significantly impacted by menopause and who may want to take their chances.
Everyone must recognize, however, that the claim that HRT is generally safe for women with breast cancer contradicts expert medical opinion. I wish otherwise, but the fact remains.
