Archive for breast cancer
Hormone Replacement Therapy has been both embraced and vilified over the last decade and more. It was once considered the magic potion to keep women young, until the Women’s Health Initiative published some of its’ findings in 2002.
The WHI raised significant concerns regarding the safety of HRT in terms of breast cancer and cardiovascular health. This large study seemed to indicate an increase of breast cancer with HRT users, as well as an increase in stroke and heart attacks. Use of HRT has plummeted, and many women have suffered through the menopausal transition too afraid to ask for relief from their providers.
In a turn of attitude, new recommendations have been released in the UK. British researchers have re-analyzed much of the WHI data, as well as data from the Million Women’s Study; and found that some of the conclusions were possibly faulty. This has also been an increasing thought of researchers in the US.
To summarize possible misconceptions from the WHI, the slight increase risk of cardiovascular events with use of HRT was mostly confined to women who started HRT after the age of 60. HRT is felt to inflame cholesterol plaque which had formed in the years following menopause. Starting HRT at the time of menopause is not felt to increase risk of heart attacks or strokes in low risk patients. A Danish study actually showed a lower risk of heart events when started early following menopause.
There still remains concerns shared by all menopausal researchers regarding the association between breast cancer and prolonged HRT use. A slight increased risk after 5 years of use of estrogen and progesterone has been seen in many studies. Use of estrogen alone has shown no increase in risk and in some instances a decreased risk. The problems with estrogen use alone is the increased risk of uterine cancer, a risk well known and studied extensively. Therefor, estrogen use alone for menopausal women is confined to women who have had a hysterectomy.
The current recommendations of the UK is to individualize the decision to take or not take HRT for your menopausal symptoms; rather than follow a blanket guideline recommendation. It is also recommended to consider HRT if your menopausal symptoms are significantly interfering with your life. The decision regarding HRT safety for you will depend on your personal history of cardiovascular health, as well as your family history of this and of cancer.
Here is how I think of HRT use. If should and can be considered if:
- You are significantly impacted by menopausal symptoms in terms of mood swings, hot flashes, insomnia, muddled thinking and fatigue.
- You are having difficulty with your work and daily chores because of these symptoms
- You do not have a personal history of female cancers (breast, ovarian, uterine,vaginal), and possibly colon cancer (there is a genetic link)
- You do not have a strong family history of any of these cancers ie. no mother, sister, daughter
- No strong family history of heart disease ie. no family members had stroke, heart attacks, blood clots before the age of 50-55
- You have never had a heart attack, stroke, blood clot of any kind and you had no problems with hormonal birth control use if ever used
- Use of non equine estrogen (no premarin) and natural progesterone in low risk situations described above can usually be safely used for up to 5 yrs.
- Use of estrogen patch and prometrium (natural progesterone) is felt to be safest combination, and I recommend tapering off in 3-5 years.
- If you have had a hysterectomy for non cancerous reasons like fibroid, heavy menses; then estrogen patch alone is usually safe for 5-8 yrs but I recommend tapering off by 10 yrs.
- If you are going to use HRT, I feel regular mammograms are a must. It is not the perfect screening tool but it is the best we have at this point. If you are going to do something that may increase your risk of developing a problem, you would be wise to screen for that problem and catch it early.
I am an advocate for HRT use in the safe and proper setting. I used it myself for 2 years at the onset of menopausal symptoms and it helped me cope with hot flashes, sleep deprivation and fatigue. My menopause came early, 45 yrs old, and took me completely by surprise! I tapered off when the findings of WHI came out because of the initial concerns this study raised; even though I am at low risk for cancer and cardiovascular illness. My own journey since then has focused on controlling symptoms though healthy diet and exercise, time for relaxation to promote sleep, and occasional use of herbs to help with sleep. After 10 yrs and more, I still get hot flashes but they are mild.
Every women’s journey through menopause is different. We have some similarity of symptoms, but the degree to which symptoms affect us are variable as is our ability to cope. Thus the need for an individualized approach!
It seems that almost weekly, there is a new study or analysis of a study questioning or extolling the virtues of breast cancer screening. Several decades ago, the medical community was repeatedly encouraging women to get breast cancer screening, all in an effort to lower the death from breast cancer. Treatments were admittedly severe with total mastectomy, radiation therapy causing severe side effects, and harsh chemotherapy.
Breast cancer treatments have come a long way since then, and many women are successfully treated for breast cancer without disfiguring surgery or devastating radiation and chemotherapy. We may be tempted to attribute this improvement of treatment with earlier detection, and that may be the case for many women.
Many advancements include identifying specific cell types and tailoring treatment towards that cell type. This is where some of the controversy has arisen. There’s one type of cancer, called DCIS (ductal carcinoma in situ) that many women have been treated for and perhaps unnecessarily so.
Specialists initially felt this cancer type was as potentially life threatening as any type of breast cancer you may think of. It turns out however that this type is unlikely to ever progress beyond a localized tumor. This has caused many studies and data crunching to evaluate whether mammograms have actually lowered the breast cancer death rate.
It is clear that the final answer is not in yet. I suspect a more stratified evaluation guideline will eventually emerge regarding when and how often to get mammograms, and how having a higher risk for this disease will change that testing algorithm. For now however we are stuck with getting yearly or bi-yearly mammograms. I cannot help but believe that in many circumstances, a mammogram can discover a cancer earlier than it otherwise would have been discovered. In so doing, treatment would theoretically be kinder and gentler than the mastectomies and blasting radiation and chemotherapy of the 70′s and 80′s.
An interesting new study has introduced the use of a modality that is still somewhat controversial within the conventional medical community. It has been considered an alternative testing strategy, but this study raises its value.link to study***
Thermoscans have been around for a while and utilize the heat of blood flow to look for areas of growth within breast tissue. It does not use radiation, but an infrared technology. A growing cancer requires a blood supply that is otherwise not present to that degree in normal breast tissue. There for, an increased heat signal could indicate a growth. This will hopefully become a more accepted screening method within the medical community as it may give different information from standard mammograms.
Regardless of your personal feeling regarding breast cancer screening, it is wise to speak with your provider about your risk factors and determine a schedule and modality that is safe and effective for you.
Mammograms are part of most women’s health screening if they are over 40. Mammograms are never enjoyed, often feared for the information they may give forth; but usually endured on a regular basis. Woman are often relieved, if not happy; when they get their letter stating everything is fine for another year at least. Until now, most women were not routinely told if their breast tissue was dense and may limit the sensitivity of mammogram screening.
Mammograms detect a cancer by evaluating the density of normal breast tissue, and looking for an area of higher density which may represent an area of growth. Normal breast tissue is usually not all that dense by the time we are menopausal, and this is a normal changing associated with age. Any area that appears more dense than most the surrounding tissue is then felt to be abnormal, perhaps suspicious for a cancer. This is one reason that mammograms in younger women are usually not very good at picking up a cancer, as the breast tissue in younger women is usually fairly dense.
There are some women that do maintain density in the breast tissue as they age. Estrogen is one of the causes of breast tissue density, so it stands to reason that late onset menopause can cause breast tissue to remain dense because of prolonged amounts of estrogen in the system. For the same reason taking HRT can also cause breast tissue density. This, in and of itself is not a problem; except for the fact that screening accuracy can be affected.
If you have dense breast tissue, and you are at increased risk for breast cancer; you may want to talk to your provider about different forms of breast cancer screening such as MRI or ultrasound of a specific lump or mass. It is now required in some states that a patient be informed if her breast tissue is dense enough to limit sensitivity of screening.
Mammograms continue to be a useful and sensitive screening tool for detection of breast cancer. Like anything though, it has its’ limitations. They may be painful and a dreaded event; and many specialist would point out the amount of over diagnosis that a false positive mammogram causes. It is up to you and your provider what you do for screening and how often this screening occurs.
The North American Menopause Society, NAMS, has recently released a new position paper on the use of hormone therapy during and following menopause. An analysis of several studies and data has shown that hormone therapy is not as dangerous or onerous as believed 10 years ago after the initial release of the Women’s Health Initiate study results.
The Women’s Health Initiative was designed to determine if HRT was cardioprotective; as well as to help determine if HRT caused an increase in breast cancer. This study was stopped prematurely due to an increase in cardiovascular events including stroke, heart attack and blood clots. Hormone therapy was quickly blamed for this increase in cardiovascular events, and consequently usage has plummeted.
You may be asking what is new about all this information?
Researchers have been continuing to analyze the data from this study, and have come to some conclusions which have helped guide NAM’s new position paper. This is what they have determined:
- Most cardiac events occurred in women over 60 who were placed on hormone therapy 10 or more years after menopause.
- Women who underwent hysterectomy and were placed on estrogen without progesterone had a lower rate of breast cancer, therefore taking estrogen for up to 7-8 yrs was not associated with increase risk of breast cancer.
- However, HRT started at time of menopause was associated with slightly higher risk of breast cancer than when started a few years post menopause.
- Women on estrogen therapy (ET) and estrogen/progesterone therapy(EPT) had lower rate of cardiovascular events when HRT was started at time of menopause, as opposed to several years post menopause.
- The types of estrogen and types of progesterone may influence risk of breast cancer and cardiac events.
What does this mean for you?
The recommendations suggest that you can expect the have your hormone therapy customized to your particular medical situation, including consideration for your risk for breast disease and heart disease.
For those of you who have had a hysterectomy, you could reasonably take your estrogen therapy for up to 7 years without significantly increasing your risk of breast cancer.
For those of you who still have a uterus, you would want to limit your use of HT for 3-5 years. After this, your risk of breast cancer increases.
The type of progesterone therapy may affect the risk of cardiovascular events. A natural progesterone, such as Prometrium, may have significantly less risk than synthetic progesterone, for both cardiovascular events and possibly breast cancer.
The route of delivery of estrogen may lessen the risk of HT. Topical estrogen, or estrogen patches may have less risk of thrombotic events; than oral estrogen.
Estrogen is the most effective therapy for vulva and vaginal atrophy, with topical vaginal cream, ring and suppositories being superior to oral estrogen.
Compounded Bio-identical hormones should only be used if an allergy to a component of federally approved estrogen or progestin hormone therapy exists. These compounded hormones have not been tested and may contain levels of hormones or ingredients that are harmful. For this reason, safety cannot be established as clinical trials proving safety have not been performed.
Hormone therapy can be very helpful when you are first experiencing menopausal symptoms. Now, with this statement paper, there is more guidance on safety of HRT use. Compounded Bio-identical Hormones are very popular, but their safety has not been establishes in the types of studies that this position paper discusses. There are many safe options for women that include patches, creams as well as pills; and this allows flexibility in dosing. This is is a form of customization.
This is information that you can use when you see your medical provider. Write in and share your own experience with HRT and whether or not it has helped, and even which preparation you used (your information is anonymous to our readers). It is through sharing information that we can enlighten one another about menopause and strategies to ease the common problems.
Another study has been published weighing in on the debate as to whether mammogram screening actually saves lives. In 2009, the US Prevention Services Task Force (USPSTF) published a statement regarding frequency and age for women to obtain mammograms. Much to the consternation of many groups in support of mammogram screening, routine screening to begin at age 40 was recommended against as it was felt that mortality was not improved by early detection of breast cancer.
Most of us do not like having mammograms, and we dread it every year that we go. We pray for that normal reading and become fearful when we get a “call back”, although most are for thankfully minor issues. How are we supposed to feel when an esteemed group such as the USPSTF states that not enough lives are saved to justify the money spent on screening between 40-50, or yearly screening between 50-60? How many of us know women who had a breast cancer discovered in their 40′s or early 50′s. Would this cancer have been larger, or spread to other areas if these women had waited for the “recommended” interval?
The data from this recent study was collated and analyzed in Sweden, involved 133,065 women over 7 years and these women were followed up after 29 years to assess incidence of disease and death. A 30% reduction of mortality was seen in this group, including women 40-50 screened every 2 years and women 50-75 screened on average every 33 months.
What these researchers found was that it took 1000-1500 mammograms to prevent one death from breast cancer.
So tell me, do you think that money is well spent?
I can think of many women off the top of my head, that I personally know, that I am very glad they had their mammograms in a timely fashion. I think their money was very well spent.
What are you doing about mammograms? Is your doctor recommending you get one yearly, every few years, or how often? Does he or she believe in the recent guidelines or do they think you should be screened more often? Anne weighs in with some advice for women in menopause.
What do you think? How should it be done for you? Join in our conversation here. You can find Mammogram guidelines at the National Cancer Institute, and the USPSTF
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A study is currently underway at Southern Methodist University, regarding the stress of breast cancer to women under 40 who contract a certain aggressive type. This type is called Triple Negative Breast Cancer, or non-hormonal breast cancer. It is very aggressive and typically strikes African-American women early in life, usually 30′s to early 40′s.
Cancer groups and researchers have closely studied the psychological effects of cancer in older women, but this younger group is smaller and not so well studied. It is easy for people to lump women with breast cancer into the same category as far as psychological concerns, but there are some very real differences.
Younger women with breast cancer are often mid-career. Taking time off is often not as accepted or understood, especially if a woman wants to keep her diagnosis a secret from co-workers. There are not as many cancer patients their age that they can talk with or gain a support from; women who have similar concerns. Because they are young, people have the perception they should be able to recover quickly and “get on with it”.
As I read about the study that SMU is conducting, I thought about one of my patients and her recent journey through diagnosis and treatment of breast cancer. Similar to the participants in this study, she is young and diagnosed with breast cancer. She is in the midst of a professional career and considered to be very good with her skills. She is also a single mother with her extended family some distance away. As she has moved through radiation and chemotherapy, she found herself profoundly tired and was struggling to keep up with the demands of her job. Initially, her supervisor and co-workers pitched in the help her with covering some of the more physically and mentally demanding parts of her job. Her treatment journey lasted longer than this accommodation however; and after 6 months or more, she was pushed to resume her full duties or lose her job. This would have resulted in loss of medical benefits and cancer treatment. As you can imagine, this was extremely stressful for her. Luckily for my patient, someone stepped in to help in a significant way. A supervisor in a different department who had a personal experience with breast cancer, created a position for this woman and she is happily employed and recovering from a year of cancer treatment and feeling that she is emerging from a dark tunnel.
My thoughts for people as I type are this:
Just because someone is young and looks healthy, they can still be profoundly sick.
If someone you have worked with who has always been a dependable co-worker, suddenly starts taking time off; think about the worst that could be going on. They might be dealing with something pretty bad.
If you have a friend, relative or co-worker who has breast cancer (or any cancer for that matter), give them positive affirmations daily if you can. Positive energy goes a long way to help people. Speak the words if you can, cancer patients of all ages need to hear words of encouragement.
Let us know your thoughts or experiences with this issue, add your comment to our website. We can all learn from each other.
A reader recently posted a question:
What do you do when your health requires you to stop taking your hormone therapy?
Many specialists would simply say, stop your medication and in essence, deal with it. Your gynecologist or family practitioner could no doubt offer more advice than that. My first advice would be to contact your regular provider to ask their advice on controlling symptoms.
The time of menopause is also the time of increase risk of stroke, heart attacks, cancers, and blood clots or DVT ( deep vein thrombophlebitis). Estrogen and progesterone can cause inflammation of blood vessel walls, thus helping to cause stroke, blood clots, and heart attacks. Estrogens can fuel a breast cancer or other cancers of the female organs. Since having one cancer places you at risk for any other cancer, it makes sense to discontinue estrogen for any cancer a woman may experience.
So what do you do when you are told to suddenly stop the therapy which is helping you feel sane and in control?
There are many other therapies which are safe and can help control symptoms, but first you must check with you provider. One thing which will be vital for controlling the symptoms of menopause is a healthy life style. Because of how food is metabolized during this time, it is important to limit foods high in sugar as this can lead to fatigue and sometimes fuel hot flashes. It is also important to limit caffeine and alcohol as these items can trigger hot flashes both daytime and nighttime. Alcohol also causes difficulty with sleep mostly due to the sugar content.
We all know a bad night sleeping can lead to
- fatigue, which leads to
- low energy and avoidance of exercise,
- leads to convenient food choices for comfort and ease of preparation.
- lack of sex drive
- difficulty concentrating
- all of the above leading to low self esteem and possibly depression over lack of control
How do you gain control of all this?
A diet high in antioxidants helps. This means fresh fruits and vegetables, brightly colored or deep leafy green. Consuming less sugar, caffeine, and alcohol. If you are sensitive, a diet low in dairy. If you are not sure how dairy sensitive you are, stop all dairy for 1-2 months and see how you feel. You may have more energy, less respiratory problems and skin problems. Exercise of any kind that gets your heart beating faster and uses your muscles in a way not normally used in your average day.
For medical help when the above measures are not enough, there is clonodine or effexor (low dose) which can help with hot flashes. There are sleep aids which are generally safe for short periods of time. Doing cross word puzzles or other memory type games can help some with “brain fog”, as does some low dose antidepressants if applicable. Herbal products should be used with extreme caution if they contain soy or black cohosh; these products can theoretically be irritating to blood vessel walls as they are estrogen like in their action.
There are measures you can take to control your symptoms, nothing may be as completely relieving as hormone replacement therapy. Talk to your medical provider to get advice targeted to your health situation. Then, write us back and let us know what worked for you! Share your successes with our readers.
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If you have been listening to the news over the past week, you most likely have heard of a recent article to be published regarding breast cancer and hormone therapy. This data comes from an extension study of women who participated in the Women’s Health Initiative, a study regarding effects of hormone therapy on women, which ended in 2002.
The Women’s Health Initiative was a study designed to study the effects of HRT on heart disease in post menopausal women. This study was stopped prematurely as it revealed an increase in stroke and heart attack in women taking estrogen and progesterone for menopausal symptoms. An increase in breast cancer was also seen, and it is some of this data which has been further analyzed.
Researchers have seen an increase in aggressive breast cancer which has already spread to lymph nodes, making it more advanced at time of diagnosis and therefor harder to treat. Additionally, the hormone therapy caused a decrease in sensitivity in screening, making it more difficult to detect on mammograms. The hormones used during this study was a pharmaceutical product called Prempro. There has been much discussion regarding this type of hormone preparation, versus synthetic and bio-identical hormones.
Careful analysis of the data indicates, however, that the increase in death from this aggressive type of cancer amounted to 2.6/10,000 women vs. 1.3/10,000 women not taking these medications. There was also an increase in death from all causes for women diagnosed with breast cancer who also had taken hormones replacement therapy, 5.3/10.000 vs 3.4/10,000. Still, if you are one of those women, it is a significant increase to you.
So what does one do when faced with the symptoms of menopause that are disruptive to your life.
As in anything, you weigh the risk against the benefit. It is important to discuss your risk factors with your medical provider and decide how beneficial or harmful HRT may be for you. There are also many preparations available now, however you should know that these medications have not been studied so no one can really say whether they are safer than Prempro or not.
Hormone Therapy can seem like a life saver when you are in the throws of menopause but be aware if its risks before you begin taking these medications. I myself felt that HRT helped me to cope with all the symptoms of menopause that I was struggling with, and I felt the risk of 2-3 years of therapy was worth it. I weighed that risk, with my family history; and committed myself to regular breast exams, mammography, and PAP smears.
Write in and tell us your stories of menopause and coping with symptoms; what you have or are taking to help as well as other strategies to deal with symptoms!
Researchers are active in trying to identify ways women can move through menopause comfortably and in the most healthy fashion for them. Often times interesting studies are published or mentioned in meetings that the experts convene to discuss topics, both in the US as well as abroad. A few of the interesting topics I found in last weeks news are as follows:
Why does menopause happen well before our elderly years?
Researchers in the social sciences have been wondering this also. In most other species, the female species quickly die after loosing their reproductive capacity. Not so in Killer Whales and Pilot Whales who appear to have a similar social system as humans in terms of timing of menopause and life expectancy. It has been noted that these species of whale become genetically close to those they live with and are invested in the survival of the group. In humans, we already have this situation in that we often live with our families. It is surmised that post menopause, we are there to help the younger of our group raise their young. This tradition is especially demonstrated in other cultures mentioned in previous posting /cultural attitudes and menopause. In many African and Mayan cultures, the elder women become the sages and the leaders of their communities.
Sex and menopause is always a topic of discussion among men and women alike.
A recent study of a small group of British women, recently published in Journal of Psychology looked at this issue. Surprisingly, they found that other factors besides hormonal issues impacted a menopausal woman’s sex life the most. These included but were not confined to decreased sex drive of partner, carry for elderly parents. It is felt by researchers that social and psychological issues influence sexual behavior more than biologic issues. What do you think of this and is this the case with you and/or your friends?
There is now a blood test that researchers feel can predict when menopause may happen for a woman. In a small study performed by the Shahad Behesh University of Medical Sciences in Tehran, Iran; 266 women aged 20-49 submitted blood samples of AMH (Anti-Mullerian Hormone) over a period of years. These women were part of a larger study of lipids and glucose begun in 1998. AMH is a hormone which is expressed in ovarian follicles and controls formation of primary follicles, thereby allowing only one follicle to develop monthly.It is only produced in small follicles and is felt to be a measure of ovarian follicle reserve. Certain levels were found to correlate with the onset of menopause, perhaps allowing women to consider when to start families in terms of work and career issues. Researchers at the above facility feel it may be a useful tool to help with family planning.
Another reason to take fish oil capsules is prevention of invasive ductal breast carcinoma. Recently published in the Journal of American Association of Cancer Research is a small study indicating protection of this form of breast cancer with regular use of fish oil supplements containing EPA and DHA. A 32% reduction of invasive ductal carcinoma was seen.
It is reassuring that research continues on menopausal issues, as much of a woman’s productive life can be after her reproductive life. It is interesting to read of research from different countries as it seems much the research in the US can be presumed to be driven by the pharmacology industry.