Breast Cancer and Menopause
Think back to your PRE-menopause days. If someone told you they could trigger menopause for you, you’d hardly have jumped at the chance, right? But that’s exactly what many cancer survivors younger than 50 – or even younger than 40 – experience.
Each year in the U.S., almost 50,000 women younger than 50 are diagnosed with invasive breast cancer. Nearly 10,000 of them are younger than 40. During chemotherapy, women may have irregular menstrual cycles, amenorrhea (disappearance of menstrual periods), menopausal symptoms or be thrown into actual menopause. Menopause may be immediate or delayed, permanent or temporary when triggered by chemotherapy.
I reached out to the Yale Cancer Center and spoke to Dr. Erin W. Hofstatter, Assistant Professor of Medicine (Medical Oncology); Co-Director, Genetic Counseling Program, and Dr. Elena Ratner, Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences, to shed some light on issues of concern to my readers. They graciously provided me with philanthropy of their knowledge!
Dr. Hofstatter flatly responded, “I am a huge fan.” More and more data shows that this 3-D mammography cuts false-positives and call-back rates, and is picking up a few extra cancers per 1,000 women screened. It is a small amount of extra radiation compared to the usual 2-D mammogram, but is well worth it since it reduces call-backs and need for diagnostic mammograms (which are a lot more radiation than a screening 2-D mammo).
Genetic Testing For BRCA1 and BRCA2
Dr. Hofstatter noted that about 5 percent of breast cancer patients test positive for the BRCA1 and BRCA2 genes associated with the disease. However, the likelihood of testing positive for a woman with breast cancer depends on how old she is, if she is of Ashkenazi Jewish heritage, and what type of breast cancer she has. All these women have a slightly higher chance of testing positive. Here are some stats on the chances of women with breast cancer testing positive:
- Non-Ashkenazi Jewish woman with breast cancer at any age: 1 in 50 -2 percent
- Non-Ashkenazi Jewish woman with breast cancer <age 40: Less than 10 percent
- Ashkenazi Jewish woman with breast cancer at any age: 10 percent
- Ashkenazi Jewish woman with breast cancer <40: 30-35 percent
- Woman of any descent any age with triple negative breast cancer: roughly 10-20 percent
I asked Dr. Ratner what her thoughts were on the new research on Ashkenazi Jews and BRCA1 and BRCA2. The study recommends routine screening for the BRCA1 and BRCA2 genes for all women of Ashkenazi Jewish descent – even without a family history. Her research actually deals in gene mutation. She said she thinks it is very reasonable for women of Ashkenazi descent to be tested. Knowing your genetic mutations and what predisposes us to cancers is beneficial so that we can actually be proactive about it.
Dr. Ratner explained that the standard care options for women who carry the gene vary depending on the medical history of each patient. However, it is recommended that you add an MRI and sonogram – alternating at six-month intervals for breast cancer screening. For ovarian cancer screening, usually it is a pelvic (vaginal) ultrasound done every 12 months and a blood test CA-125 done every 6-12 months.
Breast Cancer Treatment Options
Research is also continuing on surgical treatment of breast cancer. Dr. Hofstatter shared her analysis of a recent JAMA study on the survival benefit of a double mastectomy in treating unilateral breast cancer. “Many women diagnosed with a breast cancer believe that getting a bilateral mastectomy will help them to improve their chances of curing the cancer and will make them live longer,” she said.
“The truth is, once the cancer has developed, the long-term risk of the cancer to someone’s health is the same no matter what surgery they choose. In other words, the chances that their cancer will recur at a later time are the same regardless of the surgery they choose. If a woman chooses bilateral mastectomy, she should understand that the purpose of that type of surgery is to prevent a second, new breast cancer in the future. For most women, the chances of developing another new breast cancer is .5 – 1 percent per year. I completely understand why a woman might want to be aggressive about her surgical options, and I always think it should be a patient’s choice. However, I fear women are ‘going under the knife’ without truly understanding the risks and benefits of the procedure. If anything, this JAMA study supports the idea that breast conservation is a safe option both in the short term and long term for most women.”
Breast Cancer After-Care Protocol
I was wondering what the “best practice” is now for breast cancer survivors and the length of time they will need to take drugs like Aromasin/Exemestane. Many women email me that they were originally told five years; however, it seems that the protocol is changing to 10 years.
According to Dr. Hofstatter, just how long women must be on these drugs is up for debate. She said she feels that the new standard will likely be 10 years. For pre-menopausal women, she said, 10 years of Tamoxifen has been proven to be better than five years. No data yet definitively says that 10 years of an aromatase inhibitor is best, but the guidelines are saying to “consider it” in all patients who have completed five years.
“The BCI Index is designed to help doctors and patients decide the length of treatment. This test takes the original tissue from the cancer and sends it to the company, which studies gene expression of several different genes in the particular woman’s tumor. Based on these results, a statistical report is produced that estimates the possible benefit from extended therapy.”
Dr. Hofstatter predicts that the clinical use of the BCI will increase over the coming years, and will likely become a new standard.
Treatment for DCIS
I asked Dr. Hofstatter what the recommended protocols are for women with ductal carcinoma in situ (DCIS). She said DCIS is still officially considered a breast cancer, but is non-invasive. This means, by definition, it cannot spread outside the breast, and therefore cannot be life-threatening. Women are typically treated for DCIS-type cancer with radiation and surgery, and oftentimes anti-hormonal agents that carry side effects. But some people are suggesting that this is “overkill” and that the treatment is worse than the disease. Some suggest that we should leave DCIS alone, not call it a cancer, and instead consider it a “high-risk lesion.” This debate will go on for years.
What we do know, she said, is that, while many DCIS lesions lie dormant and harmless for many, many years, there are others that do invade and become dangerous. We do not fully understand which DCIS lesions are which, so it becomes hard to pick and choose which patients need everything and which don’t. The bottom line is that women should talk with their doctors about their particular DCIS lesion, and decide which therapies are best for them. Sometimes, surgery with either radiation or anti-hormone pills is acceptable.
Treatment of Menopausal Symptoms
At Yale, Dr. Hofstatter is studying the use of Remifemin (estrogen-free black cohosh) in early-stage breast cancer, specifically DCIS, to see if a few weeks of Remifemin taken before surgery can reduce cell proliferation in areas of DCIS.
For breast cancer survivor Vicky, Remifemin was just what the doctor ordered. “I am 48 now and was treated at 35 for stage 1b breast cancer with surgery, chemo, radiation and Tamoxifen,” she said. “Hot flashes started full on for me … and I immediately went on Remifemin…. The hot flashes are about 98 percent gone.”
Dr. Elena Ratner said that women like Vicky, whose menopause was triggered by treatment for breast cancer, are the hardest to help. Their tumors have hormonal receptors, and even a minuscule amount of estrogen could grow their tumors.
Ironically, estrogen therapy is often prescribed to relieve menopausal symptoms in non-breast cancer patients. For example, local estrogen therapy (LET) is often used to treat vaginal atrophy (dry vagina). While Dr. Ratner acknowledges that LET has a very low systemic absorption, she said many oncologists discourage its use in breast cancer patients. She further recommends vaginal moisturizers as a viable option for these women. She noted that even testosterone can convert to estrogen in the body, so this is not an option for women with breast cancer.
And, while estrogen protects bone health, for breast cancer patients Dr. Ratner prescribes two 600mg doses of calcium twice a day with vitamin D, plus cardio and low weight-bearing exercise.
Many of these young breast cancer patients also hope to start a family, but toxic treatments such as chemo can adversely affect their fertility. Dr. Ratner stresses the importance for women and their providers to discuss fertility prior to their treatment. Some chemotherapy will not affect fertility in the long fun but others may.
I am so grateful for the generosity of these wonderful experts at the Yale Cancer Center. Knowledge is power!
Suffering in silence is OUT! Reaching out is IN!