Doc's comments spark heated debate: Have we been giving bad advice to patients with breast cancer?
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“Even if HRT is not the best option, there are a number of things you can do to still reduce your risk of cardiovascular complications." — Maryam Lustberg, MD, MPH, Chief of Breast Medical Oncology at the Yale Cancer Center
A clip from an episode of The Mel Robbins Podcast is making the rounds on Instagram, touting the benefits of hormone replacement therapy (HRT) in menopausal women.
In it, Marie Claire Haver, MD, an OB/GYN and menopause practitioner, says women with breast cancer are most likely to die from cardiovascular disease (CVD), not breast cancer. She also adds that estrogen, through HRT, is highly protective against CVD.
Dr. Haver's comment ignited a heated debate among breast cancer survivors and advocates, as those with a history of the disease are often advised against taking systemic HRT. []
“That's all great ... but it doesn't help us cancer survivors. So instead of dying of breast cancer I'm now higher risk of cardiovascular death. Great,” user @photonatalie posted. Another user, @robbiealeonard, added, “It is very unfair to we breast cancer survivors to post this snippet."
MDLinx reached out to two Yale Medicine physicians to get their take. Here’s what they said.
What are the benefits of HRT?
When it comes to the general population, there are benefits to post-menopausal hormone therapy, according to Mary Jane Minkin, MD, co-director of the Sexuality, Intimacy & Menopause Program at Smilow Cancer Hospital, Yale Medicine.
For example, HRT can protect bone density by reducing menopause-accelerated bone loss. [] HRT can also alleviate menopausal symptoms like hot flashes and night sweats. []
The consensus on the cardiovascular benefits is more controversial, says Dr. Minkin. Estrogen therapy may protect heart health in some women, especially for those who experience menopause early, before the age of 45, she says.[] [] In such cases, it does a good job of preventing atherosclerotic heart disease.
But what about women with breast cancer? It depends on the type of cancer. “Some women with early breast cancers may be candidates. Women who have a significant risk of recurrence may not,” says Dr. Minkin.
Two out of three breast cancers are hormone receptor–positive, according to the American Cancer Society, meaning hormones like estrogen can stimulate the growth of cancer cells. []
Hormonally driven tumors are treated with estrogen deprivation, explains Maryam Lustberg, MD, MPH, Chief of Breast Medical Oncology at the Yale Cancer Center.
That’s why HRT, which boosts estrogen levels, can stimulate the growth of cancer in people with a history of estrogen receptor–positive breast cancers, according to the National Cancer Institute. []
“The concern is that HRT would counteract the effects of these cancer therapies and elevate the future risk of recurrence,” Dr. Lustberg tells MDLinx.
Therefore, women who’ve been diagnosed with hormone-sensitive cancers are generally advised to stop taking HRT. []
Related: Sex hormone therapy may benefit women with long COVID, suggests new researchHow BC patients can protect their heart health
Dr. Lustberg says it’s true that CVD is the most common cause of mortality in women—regardless of whether or not they had breast cancer. []
This is due to multiple factors—some modifiable (like a sedentary lifestyle) and others that are non-modifiable (such as age).
She encourages those with breast cancer to have a conversation with their physician about the type of cancer they have—whether it’s hormonally driven or not—along with the stage of their disease and the risk of recurrence. Doing so will inform how they can lower their risk of CVD.
“Even if HRT is not the best option, there are a number of things you can do to still reduce your risk of cardiovascular complications,” says Dr. Lustberg.
Addressing modifiable risk factors—such as blood pressure, sedentary lifestyles, obesity, and metabolic health—can substantially lower their risk, even in the absence of HRT.
“With or without a history of breast cancer, women’s health concerns need to be better researched and personalized to take into account individual risk factors, symptom burden, and patient preferences,” Dr. Lustberg says.
Related: ctDNA: The next big leap in breast cancer care?