Hormone Replacement in Breast Cancer Patients (HRT)

28. Have you prescribed hormonal replacement for breast cancer survivors in the past two years?

Patrick Borgen, MD

This is an issue of quality of life versus quantity of life. If you have someone who says, "Life just ain't worth living. I've got 80 hot flashes a day. I really desperately need some help. I've tried 52 medications." I certainly would put that patient on the lowest dose estrogen replacement therapy I could find.

29. 54-year-old woman diagnosed 18 months ago with a 1.8 centimeter IDC, ER/PR+, two positive nodes. Rx: chemotherapy, tamoxifen. The patient has severe hot flashes, unresponsive to multiple medical and alternative regimens, and a short trial of tamoxifen withdrawal. Your suggested management:

Patrick Borgen, MD

I don't think that there's any evidence out there concerning the safety of hormone replacement therapy in the face of an invasive Stage II breast cancer. I think that depending on how convinced you are that tamoxifen withdrawal would help, I would probably consider an aromatase inhibitor in this patient.

Andrew Seidman, MD

I try to exhaust many possibilities before discontinuing tamoxifen, particularly in women with node-positive disease. So, the use of a megesterol acetate, clonidine, and more recently, the use of venlafaxine, or Effexor, are all maneuvers that I will try before thinking about abandoning tamoxifen. The strategy of stopping tamoxifen for a few weeks to see if it makes a difference is also reasonable. And if this woman's history was that she had chemotherapy-induced menopause, that would be a real question as to how much of her symptoms were due to tamoxifen as opposed to her underlying menopausal status.

This is a quality-of-life issue, and here the key word is "severe" hot flashes. If indeed this has such an impact on her quality of life, it becomes sometimes necessary to discontinue tamoxifen, despite all efforts to try to continue it.

I'm not yet comfortable giving hormonal replacement therapy in this scenario. I think that it is a very appropriate subject of clinical trials.

30. 59-year-old woman diagnosed six years ago with a 1.8 centimeter IDC, ER/PR+, one node positive. Rx: chemotherapy. PMH:
hysterectomy, on HRT at the time of diagnosis. Patient has severe hot flashes. Your suggested management:

Patrick Borgen, MD

This is a very difficult case. And here's a situation where you're six years out, no evidence of disease, and her life is crippled with hot flashes. I think there's a role for selectively and cautiously trying HRT in these people. I don't know very much data about tamoxifen necessarily helping severe hot flashes. I think there are a lot of medicines out there that are gaining favor, like the SSRI inhibitors that you could try. But at some point, you may have to go back to HRT.

31. 52-year-old woman with breast biopsy demonstrating atypical hyperplasia three years ago but never had breast cancer. No family history. Gail model risk: five-year: 2.9%, lifetime: 22.4%. Patient is having severe hot flashes unresponsive to multiple medical and alternative medical regimens. Your suggested management:

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