Hormone replacement therapy is known to relieve symptoms of natural menopause. However, this treatment can also help women with breast cancer that are hormone-receptor positive. This means that the breast cancer cells in the body grow and respond to the presence of estrogen and progesterone.
So how exactly does hormone therapy treat estrogen-positive breast cancer? Women diagnosed with estrogen receptor (ER) positive breast cancer are prescribed medications that lower estrogen levels and stop them from stimulating the growth of cancerous cells. This therapy is a safe treatment for both premenopausal and postmenopausal women.
Menopause is a natural phase that occurs among women when their bodies, particularly the ovaries, stop releasing eggs and producing female sex hormones. The age at which this begins is usually between 45 to 55 years old. Because of the fluctuating levels of estrogen and progestin, a menopausal woman typically experiences different vasomotor symptoms such as hot flashes, night sweats, and vaginal dryness.
Young women or those who are yet to reach the menopause age can likewise experience menopausal symptoms when they get a hysterectomy. A hysterectomy is a surgical procedure that involves the removal of the uterus. There are various reasons why hysterectomies are needed, among them are prevention of endometrial cancer, ovarian cancer, and uterine prolapse.
Aside from the uterus, hysterectomies can also involve excision of the cervix, fallopian tubes, and ovaries. Usually, early menopause (also known surgical menopause) can come to women who have had their ovaries removed in an oophorectomy procedure.
An oophorectomy, or bilateral oophorectomy, is a known ovarian suppression treatment that can lessen breast cancer incidence among premenopausal women. Ovarian suppression is a preventive care for cancer that describes the shutting down or removal of ovaries. This can inhibit cancerous cells to develop as the amount of estrogen hormones produced by the ovaries is decreased.
High-risk women, those who have tested for the BRCA1 mutation gene linked to breast cancer or have a family history of the cancer, can also benefit from having their ovaries removed. It significantly decreases cancer risk by 50% especially if their ovaries were removed before menopause.
Premenopausal women who have had a hysterectomy are safe to take hormone therapy, particularly oestrogen medications. This helps balance their body’s estrogen levels to maintain its normal function up until they reach the natural menopause stage.
The most common type of menopausal hormone therapy is estrogen-only therapy. Taking unopposed estrogen therapy can combat side effects of a hysterectomy procedure such as osteoporosis and bone fractures. High estrogen levels are shown to have a direct effect on maintaining good bone health as they prevent the bones from breaking.
Conjugated equine estrogen and vaginal estrogen can also be taken to treat menopausal symptoms that may manifest in the vagina. Likewise, there are studies that show regulated estrogen therapy after a hysterectomy relieves menopause symptoms and significantly lowers risk of invasive breast cancer. However, long-term use (at least 10 years) of estrogen can start to pose risks of breast cancer and ovarian cancer.
On the other hand, there’s an increased chance of being diagnosed with metastatic breast cancer (advanced breast cancer) when taking combined HRT or estrogen-progestin therapy. This possibility increases the most during the first three years of taking combination therapy but it eventually decreases when a patient stops taking medications.
Find out more: Should Postmenopausal Women Having Undergone Total Hysterectomy Take Hormone Replacement Therapy?
Determining the type of treatment for breast cancer depends on what caused the cancerous cells to grow. Normally, cancerous cells develop in the lining of milk ducts within the breast (invasive ductal carcinoma) or in the lobules where milk is usually produced (invasive lobular carcinoma). These cells can accumulate over time, forming an obvious lump or mass which is a common symptom of breast cancer.
There are also cancer cells which are highly responsive to the hormones that are circulating in the body. These cells have receptors that can receive signals from estrogen and progesterone to promote their abnormal growth and spread in the body. Among the types of hormone-receptor cancers are:
Estrogen receptors are the most common hormone receptor that causes breast cancer. A study by the American Cancer Society reports that 2 out of every 3 breast cancer cases are hormone receptor positive. This is because estrogen is a dominant hormone that is responsible for most female traits. It can be found in the ovaries, adrenal glands, kidneys, and even fat tissues.
Among the common symptoms of ER-positive breast cancer are lumps surrounding the breast area, skin irritation or dimpling, breast swelling, nipple discharge, redness in the nipple or breast skin, and an increase in size of one or both of the breasts. Upon detecting these changes, a doctor may conduct an ultrasound or biopsy to confirm whether it is a form of hormone-receptor breast cancer.
On the other hand, a PR-positive breast cancer is induced by cells that are more responsive to progesterone. Progesterone is a steroid hormone found in the ovaries and it is essential in the development of breasts during puberty. It also assists in preparing the body for lactation and breastfeeding. It also shows symptoms that are similar to the ER-positive cancer type.
The hormone treatment of ER-positive breast cancer requires administration of anti-estrogens which work to either lower levels of estrogen or block the hormones from sending signals to the cancerous cells. These hormone medicines (usually oral HRT) can also slow down the acceleration of cancer cells from reaching the advanced stage or metastatic breast cancer.
There are different kinds of hormone medicines used for treatment of ER-positive breast cancer such as:
SERMs are estrogen blockers that attach themselves to the breast tissues so the hormone will not be able to affect the breast cancer cells to grow and multiply in the body. One of the most common estrogen blockers is Tamoxifen.
Tamoxifen targets the estrogen hormones specifically located within the breast, but can activate normal functions in other cells. This oral drug is prescribed for women with early-stage cancer and those who have had surgery for their invasive breast cancer. It lowers the chances of breast cancer recurrence and subsequently stops growth of the tumor in the body.
Meanwhile, Fareston, or toremifene, is another type of SERMs that is used to treat breast cancer for postmenopausal women. The most common side effects of SERMs are fatigue, vaginal discharge or atrophy and hot flashes, while rare side effects include blood clots, stroke, and endometrial cancer.
Aromatase inhibitors are hormone medications that completely stop estrogen production among postmenopausal women. Aromatase is a type of enzyme that can convert androgen (testosterone) to estrogen when the female body stops its normal production of the hormone.
These drugs work by prohibiting the aromatase enzymes from making estrogen so that they will not be able to influence the development of ER-positive cancer cells. There are three types of aromatase inhibitors namely Letrozole, Anastrozole, and Exemestane. They are usually taken orally once a day.
Patients taking these medications can experience muscle pain or joint stiffness as a side effect. Additionally, severe side effects of these inhibitors can include heart disease, bone loss or osteoporosis, and increased bone fractures.
ERDs function the same as selective estrogen receptor modulators where they block the effects of estrogen in the breast tissues. But unlike SERMs that only target the cells in the breast, the downregulators extend its anti-estrogen functions throughout the entire body. They can also lessen the amount of estrogen receptors, as well as tweak the shape of the breast cell receptors to prevent connecting of the hormones.
Fulvestrant (Faslodex) is the most common type of ERD for hormone replacement therapy. It is usually prescribed for postmenopausal woman with estrogen-receptor positive breast cancer and advanced stage cancer. Unlike SERMs and aromatase inhibitors which are taken orally, Faslodex is administered via intramuscular injections into the buttocks.
For the first month of treatment, a patient must receive shots that are two weeks apart followed by one injection every month. After receiving the ERD shot, a patient may experience side effects such as pain at the injection site, nausea, headache, and hot flashes.
Luteinizing hormones are essential in maintaining normal function of the female reproductive system. It is usually released in the anterior pituitary gland and it is responsible for fueling the ovaries to produce estrogen. It also stimulates production of egg cells during ovulation and progesterone to support pregnancy.
When used for hormone therapy, LHRHs generally stop the ovaries from working and producing estrogen. They are available via injections which are performed once a month for the duration of the hormone therapy. Zoladex (Goserelin) and leuprolide (Lupron) are common LHRH medications that can be taken in conjunction with other hormone therapy drugs for premenopausal women with early stage ER-positive breast cancer.
Women can take hormone therapy after receiving surgery to lessen the possibilities of breast cancer returning. This method is known as adjuvant therapy. It is also effective in destroying the cancerous cells that are left behind or to treat the cancer that has returned after the surgery.
Meanwhile, there are patients who’d want to take preventative measures and start hormone therapy before surgery and this is known as neoadjuvant therapy. It usually works by shrinking the size of the cancer tumor and killing the cells that have already spread.
The first step to starting hormonal therapy is to consult with an oncologist or licensed HRT provider to determine the right treatment plan that will work for you. There are many factors that can affect the type of HRT medicine that will be recommended such as the cancer stage, menopausal status, medical history (to know if you’re at risk for uterine cancer and ovarian cancer or blood clots), and bone density.
The period of how long a woman stays on hormone replacement therapy depends on whether they’re taking it before or after surgery, and the stage of the cancer they have. For example, postmenopausal women with early stage cancer and are taking HRT after surgery can stay on the treatment for 5 years.
Meanwhile, postmenopausal women with early-stage cancer and are taking HRT before surgery may be recommended to be on treatment for at least 3 to 6 months before getting the operation to remove cancer cells. And as for women with advanced stage cancer, they can take hormone therapy for as long as it takes to keep the cancer cells at bay. The doctor may recommend a new course of treatment when the cancer stops responding to the HRT.
Before or after starting hormone therapy, patients are presented with surgical options that they can take to avoid increased breast cancer risk. The surgery treatments available for hormone receptor-positive breast cancer are:
Lumpectomy is a procedure that requires the removal of cancer cells and abnormal tissues within the breast. It’s an invasive surgery involving making incisions over the area where lumps are felt to remove the tumor and surrounding irregular breast tissues.
A lumpectomy may also be referred to as breast-conserving surgery since it ensures that the entire breast is not affected. It is typically performed among women with early-stage cancer and may be supplemented with hormone therapy or radiation to prevent the cancer from coming back.
Mastectomy is a surgical procedure that involves total removal of the whole breast and its tissues to treat breast cancer. There are several types of mastectomy such as total mastectomy (excising breast tissues, areola, and the nipple), skin-sparing mastectomy (breast removal that preserves the skin), and nipple-sparing mastectomy (removal of tissues except for the nipple, areola, and skin).
Like HRT, chemotherapy is a less invasive treatment where patients are given anti-cancer drugs to kill cancer cells. They can be taken orally or administered via injections into the vein wherein they will directly traverse through the bloodstream to reach the estrogen-receptor cells.
Women can choose to undergo chemotherapy as a form of adjuvant therapy to remove leftover cancer cells from their surgery. It’s also effective as a neoadjuvant treatment to shrink tumors that are too big for surgery. In cases where the cells have scattered beyond the breast and underarm area, chemotherapy can also be used to treat them.
Both premenopausal and postmenopausal women with estrogen-receptor positive breast cancer are elligible for being treated with hormone replacement therapy. Before starting, they should get examined by medical professionals to determine the types of HRT medications that will work for their cancer stage.
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