Philip J. DiSaia, MD; Wendy R. Brewster, MD, PhD
University of California Irvine-UCI Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Chao Family Comprehensive Cancer Center, 101 The City Dr S, Orange, CA 92868.
To the Editors
Hormone replacement therapy reduces the risks of cardiovascular disease, osteoporosis, colon cancer, and Alzheimer disease among postmenopausal women; it also enhances the quality of life for many of these women. Should not the same benefits be extended to women who have survived breast cancer, or should we continue to adhere to an unsubstantiated belief that the use of hormone replacement therapy will exacerbate a preexisting breast neoplasm?
We have believed for some time that the benefits of hormone replacement therapy may outweigh the underlying risks. It has been our policy to counsel women who have survived breast cancer regarding these benefits and the potential risks and to prescribe hormone replacement therapy for those who decide in favor of it. In 1993 the outcomes of the first 77 such patients who accepted hormone replacement therapy were published.[1] A subset of 41 patients, matched 2:1 for age, stage, and socioeconomic control subjects by the Cancer Surveillance Program of Orange County, Calif, was later analyzed in this Journal.[2] No increased risk of recurrence was shown among the patients who received hormone replacement therapy. This report is a follow-up of the initial 77 patients, with data on an additional 130 patients.
Most of the patients in this series had early disease: 22 (10.6%) had carcinoma in situ, 96 (46.4%) had stage I disease, and 44 (21.3%) had stage II disease. All patients were accepted as candidates for hormone replacement therapy regardless of lymph node status, estrogen receptor status, or interval between diagnosis and initial consultation for hormone replacement therapy. Seventy-four percent of the patients had negative lymph nodes. Most patients received conjugated estrogens with a progestin, although a small fraction of the patients used estradiol patches. Recurrences have been found in 15 patients (7.8%), as follows: 12 with stage I, 1 with stage II, and 2 with stage III. Twelve of these patients are still alive. Eight of the patients with recurrent breast cancer had initial breast cancer tumors that were estrogen receptor positive, and 10 had negative lymph nodes. One hundred eighty-six patients (89.9%) are alive without recurrent disease. Analysis of the 15 patients with recurrence demonstrated that the interval between the onset of hormone replacement therapy and identification of recurrent breast cancer varied from 3 to 138 months. The median disease-free survival was 23 months (range, 4-139 months). No new lesions were found in the contralateral breast (Table 1). * 1 2
Table 1. Hormone replacement therapy among breast cancer survivors
This study is not sufficient to document the absolute safety of hormone replacement therapy in women previously treated for breast cancer. However, it does suggest that hormone exposure is not associated with widespread recurrences.
References
DiSaia PJ, Odicino F, Grosen EA, Cowan B, Pecorelli S, Wile AG. Hormone replacement therapy in breast cancer [letter]. Lancet 1993;342:1232.
DiSaia PJ, Grosen EA, Kurosaki T, Gildea M, Cowan B, Anton-Culver H. Hormone replacement therapy in breast cancer survivors: a cohort study. Am J Obstet Gynecol 1996;174:1494-8.