Deep, gut feeling

[Joan M]

I always had a strong feeling that the use of hormone replacement therapy would be eventually tied to breast cancer as shown in the article pasted below.

My perspective at the time about developing breast cancer was that removal of my ovaries due to a hysterectomy and replacement of estrogen with an synthetic hormone -- Premarin -- drastically changed my immune system, allowing the cancer to grow.

In 2000 I had a full hysterectomy and took Premarin for three years. in 2003 after being off the drug for about a week a mammagram showed two tumors in my left breast -- one dcis and one invasive. That year I was four months late on my annual mammogram. I had stage 2b breast cancer and 7 positive lymph nodes.

Here's the link the the article in the New York Time. I also the article below:

http://www.nytimes.com/2010/10/20/he...tml?ref=health

Joan


Breast Cancer Seen as Riskier With Hormone
By DENISE GRADY
Published: October 19, 2010

Hormone treatment after menopause, already known to increase the risk of breast cancer, also makes it more likely that the cancer will be advanced and deadly, a study finds.
Related
Health Guide: Breast Cancer
Women who took hormones and developed breast cancer were more likely to have cancerous lymph nodes, a sign of more advanced disease, and were more likely to die from the disease than were breast cancer patients who had never taken hormones.
The increased risks were relatively small and are not fully understood. But previous research has found that hormone treatment can cause delays in diagnosis by increasing breast density, making tumors harder to see on mammograms. Delayed diagnosis may increase the risk of death.
It is also possible that hormones may feed the growth of some breast cancers or the blood vessels that tumors need to grow and spread.
The treatment studied was the most commonly prescribed hormone replacement pill, Prempro, which contains estrogens from horse urine and a synthetic relative of the hormone progesterone.
Many doctors assume that women can safely take hormones for four or five years for menopause symptoms like hot flashes and night sweats, said Dr. Rowan T. Chlebowski, the first author of an article published this week in The Journal of the American Medical Association and an oncologist who treats breast cancer patients at the Harbor-U.C.L.A. Medical Center in Torrance, Calif.
“I don’t think you can say that now,” he said. “I know some people have to take it because they can’t function, but the message now is that you really should try to stop after a year or two.”
Dr. Chlebowski said it was not known whether there is any length of time for which these hormones can be taken without increasing breast cancer risk.
The new information comes from the continuing follow-ups with 12,788 women who were in the Women’s Health Initiative, a major federally financed study that compared women taking hormones with a group taking placebos. The study was halted in 2002, three years ahead of schedule, because researchers found that the hormones were causing small but significant increases in the risk of breast cancer, heart disease, strokes and blood clots in the lungs.
The 2002 study had a huge impact. Before it came out, there was a widespread belief that hormones would reduce women’s risk of heart disease and generally keep them youthful, sexy and healthy. For many, the study shattered that faith.
Six million American women had been taking hormones, but the number quickly fell by about half. The breast cancer rate also soon began to decrease, and many researchers attribute that to the drop in hormone use.
The new report increases the average follow-up time to 11 years from the original 5.6 years. It is the first report from the Women’s Health Initiative that includes death rates from breast cancer related to hormone use.
The researchers found small but significant increases in several harmful effects in women who took the hormones. As the study previously showed, women taking hormones are more likely to develop invasive breast cancer. Their rate of the disease was 0.42 percent per year, compared with 0.34 percent per year in the placebo group.
Among women with breast cancer, those who took hormones were more likely to have cancerous lymph nodes, a sign of more advanced disease — 23.7 percent, versus 16.2 percent in the placebo group.
More women who took hormones died from breast cancer — 0.03 percent per year, versus 0.01 percent per year in the placebo group. That translates to 2.6 deaths per 10,000 women per year among those taking hormones, twice the 1.3 deaths per 10,000 in the placebo group.
Among women who had breast cancer, those who took hormones also had a higher death rate from other causes — 0.05 percent per year, versus 0.03 percent per year. In other words, there were 5.3 versus 3.4 deaths per 10,000 women per year — 1.9 extra deaths in hormone users.
Dr. Chlebowski said that a report last year from the Women’s Health Initiative also found that although hormone treatment did not increase women’s rate of lung cancer, hormone use was linked to a higher death rate among women who had the cancer.
Another author of the new study, Dr. JoAnn E. Manson, a professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, said women should not take the hormones at all unless they really need them, for moderate to severe symptoms like hot flashes and night sweats that disrupt sleep and severely affect their quality of life.
At the same time, she said, the new information should not necessarily alarm women who have taken the hormones, because the new report found only one to two additional breast cancer deaths per 10,000 women per year among those taking hormones.
“The data suggest it is cumulative long-term use,” Dr. Manson said. “Women should avoid long-term use. I think that’s the bottom line.”
She said that women who want treatment should take the lowest possible dose that eases their symptoms.
Noting that many women are taking other hormone formulations in hope of avoiding Prempro’s risks, Dr. Manson said that little was known about the drugs and that more research was urgently needed.
She said more research was also needed to find out if women who took hormones early in menopause had the same risks as those who started the drugs later.
Pfizer, which makes Prempro, issued a statement saying it took the new findings seriously, but questioned the mortality figures.
An editorial accompanying the journal article said that the researchers had probably underestimated the increase in deaths from breast cancer due to hormone therapy, and that “with longer follow-up, the deleterious effect will appear larger,” even though the women are no longer taking the drugs.
The editorial writer, Dr. Peter B. Bach, a physician at Memorial Sloan-Kettering Cancer Center in New York, said that although the increase in cancer in the study might seem small, it becomes large when multiplied out over the population. He also questioned the advice being given to women, to consult their doctors about risks and benefits, and to take the lowest possible doses for the shortest possible time.
“The fallback is that doctors and patients should be deciding this on a one-to-one basis, weighing risks and benefits,” Dr. Bach said in an interview. “How do you do that when you don’t know what the risks are?”
He added, “If you care about preventing this disease and keeping women from suffering and dying from it, then it’s hard to look at these drugs and not have serious concerns about them being used, even for what are intended to be relatively short periods of time.”
This article has been revised to reflect the following correction:
Correction: October 19, 2010

An earlier version of this article incorrectly described Dr. Peter B. Bach, writer of an editorial in The Journal of the American Medical Association. He is a physician at Memorial Sloan-Kettering Cancer Center, but he is not an oncologist.

[AlaskaAngel]

Hi Joan,

I'm glad you posted the study and your feelings about it. The study is a start in trying to understand the relationship of HRT and breast cancer.

It raises more questions.

1. How much does having had a hysterectomy affect the potential development of breast cancer -- and how much of a difference does leaving the ovaries in or taking them out at that time make?

2. Is ERT genuinely risky? Or is it the addition of progesterone to HRT that increases the risk? Or is the problem related to the use of a synthetic progesterone made from horse mare urine rather than a natural progesterone the basis for the problem?

3. As Dr. Manson asks, do women who take hormones early in menopause have the same risks as women who started the drugs later?

To find the answers, it takes having women actively put in the effort to push for the studies and to take part in them.

I had a hysterectomy and left my ovaries in, and was diagnosed a few years later, and I have never taken HRT... but my diagnosis was stage I. Was the difference in stage of diagnosis between yours and mine different because of the ERT, perhaps due to the question of increased breast density? (My breast density was also high and being pre- to perimenopausal at age 50 also made my diagnosis difficult.)

Until they can answer some of these questions the only thing they know is that HRT increases the risk.

A.A.

[Debbie L.]

Hi Joan and AA,

What I found most interesting about this study, or at least about the reports of it, is that it did not assume that estrogen is the culprit (we already suspect that), nor that "cycling" (as happens with HRT) is the culprit. As AA says, it asks intriguing questions about progesterone -- about what role it might play in angiogenesis, for example.

Plain estrogen, given to those without uteri, has so far not shown the same association with increased cancer incidence, nor with worse outcomes. There may be many useful clues to be found as we investigate why that might be so.

I think progesterone is made synthetically, not from horses -- that's premarin, isn't it? But it seems to me that the question of source (natural, synthetic, or from horse pee) as what's bad about these hormones is a smoke screen (and/or a profit-maker). We already KNOW that our own natural endogenous (made by our body) hormones influence breast cancer behavior, so why would we think "natural" exogenous (from outside the body) hormones would be safe?

And lastly, although no one seems to have any criticisms of this study's design or validity, it is worth noting that the actual differences are fairly small. Just as most women who did not take HRT did not develop breast cancer, most women who DID take HRT did not develop breast cancer, either. Yet probably all women who took HRT (or, like Joan, ERT) and got breast cancer attribute that to their hormone replacement use. I wish that I were clever enough with numbers to spit out the figure for the percent of those cancers (that occurred in women who used exogenous hormones) that could be attributed to that use.

There's a new acronym for HRT and I've already forgotten it (smile). "M" for menopause is in the name, 3 letters. The intent was supposedly to change the perception that menopause is a "disease" that needs treatment although it didn't seem that different to me. Anyone remember the new name?

Debbie Laxague

[Jackie07]

I was given one oral prescription and then two shots (Progestrone?)in the period of 3 months for infertility treatment. All I'd gotten were three uterine fibroids.

I was then given birth control pills to curb the growth of the three uterine fibroids starting at 2000. Three years later we discovered the cancer in my right breast. (The surgeon estimated the cancer had been growing for 2 1/2 years.) The first thing my gynecologist told me to do was to stop taking the birth control pills.

"Hormonal contraceptives (the pill, the patch, and the vaginal ring) all contain a small amount of synthetic estrogen and progestin hormones. These hormones work to inhibit the body's natural cyclical hormones to prevent pregnancy."
http://www.webmd.com/sex/birth-contr...-control-pills

I guess it's never a good idea to go against nature. My Mother was against the idea for me to try to get pregnant. She didn't think I could endure child birth - having had brain surgery. She ought to know since she's had six children (out of 7 pregnancies)

I was given Premarin for 'vaginal irritation' (because of atrophy) two years ago and quit using it after just 3 months because I felt something 'growing' in my scar line. The biopsy showed 'scar tissue', but I've never used it again. ('Replen' is safer and works just fine.)

Been feeling great since hysterectomy/oophorectomy in January.

[Becky]

I can't remember the new name either. Also, Premarin (estradiol only) is from pregnant mare urine (hence the name - Pre Mar In) so I guess that's an easy way to remember.

I do feel that removing the ovaries prior to natural menopause does reduce the risk of cancer. This is evident in many of the BRCA studies as well as studies that evaluate ooph versus Lupron/Zoladex shots. I think in perimenopause (just my thoughts here), that although natural estrogens are waning, they are also spiking. There is not the natural ebb and flow as when you are truly premenopausal and not perimenopausal. I think this is also a dangerous time for women. However, as Debbie stated about HRT, most women don't get breast cancer. What I think happens is that hormones cause excitation in all women but some women (those that do get dcis or breast cancer) have some pre-pre-pre cancerous conditions present. These conditions are also excited but grow to cancer versus normal cells that can "just handle it". Hyperplasia (pre dcis) may get pushed to dcis and then cancer. Research is showing that even ERneg/PR neg cancers probably start to grow due to estrogen excitation even though they don't need it to grow. This research stems from the work done on BRCA 1+ women who primarily get triple negative cancers. The newest studies show that oophorectomy prior to menopause reduces the incidence of breast cancer in these women by (I think) 68%. Very impressive if you think about it since BRCA 1+ women have a lifetime chance of getting bc of 80%+.

I think HRT and the erratic period of perimenopause can cause minor changes to become major ones in women who have minor things going on (perhaps those of us like AA, Joan, Debbie, me - all in that age bracket) is what happened and the minor changes happened earlier due to environmental exposures on a genetically prone person. Who knows? We may never know but I like these discussions as it brings more clarity on the environmental factors (such as HRT, hormones and additives in food, pesticides and the like). We are exposed earlier than our parents were who did not have all these environmental influences at younger ages (for example, my mom got bc 6 months after me at age 72 - and it was not that bad - 9mm tumor, highly ER/PR). Perhaps without environmental exposures when I was younger - I too may have gotten the same kind at the same age (basically inferring that I would have gotten it anyway but I truly would have preferred getting it that way).

I am sure more will respond and we will have a lively conversation here!

[suzan w]

I took HRT for over 10 years (gasp!). I went through early menopause in my early 40's, as did my mother and sister. because my parents also both had osteoporosis my doc at the time (1991) felt I should take HRT to 'protect' my bones. I balked for a year and finally had a DEXA scan which showed I already had severe osteoporosis. With no family history of breast cancer I reluctantly started on HRT (estradiol, as I recall). When the Women's Health Initiative in 2002 ceased their study early I again worried about taking HRT...and again was told my risk was not breast cancer, but osteoporosis. Which. by the way worsened with each DEXA scan. FINALLY, in 2005, a new gyn, said WHAT???You have been taking HRT for HOW LONG???? STOP immediately!!! Why oh why did I not pay attention to that gut feeling all those years? Well, the next week my routine mammo told the tale...invasive lobular breast cancer. I was lucky it was caught early. I am so glad to see that the HRT issue is still making news. In my case I know deep down inside that HRT for 12 years was not a good thing. I listen to my gut feelings now. I have breast cancer to thank for that!!

[candlegranny]

wow! I had a hysterctomy at 31 yrs old. I lost one ovary and kept one. that was in 1985. I started taking HRT in 1991. i started with .625 premarin. took it for 10 yrs or better. It certalinly stopped all the hot flashes and sweats. then i stopped for a while but the hot flashes came back. I then took .325 the lowest dose available. I took that about 5 yrs then stopped and had no more problems. Now I am wondering if that contributed to my BC. my doctor said i needed it for my bones too. it was 6 of one and half dozen of the other. BC has never been in my family on either side so I figured I had nothing to worry about. Alzheimers runs in my family. I am taking care of my mother who suffers from AD. I prayed that i would never get that disease cause I could not see my children taking care of me... guess we need to be careful what we ask for! Bonita

[MJo]

I took HRT for 10 years. I wonder too if it contributed to my BC. I only took half of the prescribed dose because the regular dose made me sleepy. My tumor was small. I often wonder what would have happened if I had taken the regular dose.

[PatriceH]

I was on DepoProvera for about ten years for birth control. I wonder about that too

[Debbie L.]

Becky, your thoughts about the "erratic period of menopause" (oh, don't we know!) are really interesting to me. I'd never thought about that. Thinking, thinking . . . for example, although we wouldn't know it from this board, most breast cancer is detected in postmenopausal women (and it's more likely to ERPR+). We could hypothesize that it might begin during that time of erratic and wide hormone fluctuation, but not become detectable until women were truly menopausal. Just thinking aloud (atype) here but that could be another interesting link to the lower incidence of breast cancer in Japanese women. I believe that they are also far less likely to experience severe menopausal symptoms (but I'm relying on my memory in saying that so please correct me if you know differently). Hmm.

Debbie Laxague