1. Breast Cancer Risk with Menopausal Hormone Use Jackie Bouillon Advisor: Dr. Robert Hadley Spring 2007

2. The HRT Controversy HRT was standard of therapy for menopausal symptoms for years HRT was standard of therapy for menopausal symptoms for years In early 2000’s positive view of HRT was changed with the results of WHI and HERS studies In early 2000’s positive view of HRT was changed with the results of WHI and HERS studies Showed association between HRT and increased risk for breast cancer, heart attack, stroke Showed association between HRT and increased risk for breast cancer, heart attack, stroke

3. Summary of HRT and Factors Associated with Breast Cancer Factors leading to worse prognosis Factors leading to worse prognosis Adiposity Adiposity Smaller body size and HRT use Smaller body size and HRT use Long term unopposed estrogen use (>15 yrs) Long term unopposed estrogen use (>15 yrs) Combined estrogen- progesterone regimens Combined estrogen- progesterone regimens Positive hormone tumor status (ER+/PR+) Positive hormone tumor status (ER+/PR+) Higher tumor grade Higher tumor grade Factors that do not lead to worse prognosis HRT use if overweight (no additional increased risk) Short-term unopposed estrogen use (<15 yrs) Negative hormone receptor tumor status (ER+/PR- or ER-/PR-)

4. HRT After Breast Cancer What about HRT for women with a history of breast cancer? What about HRT for women with a history of breast cancer? Very controversial issue Very controversial issue Typically HRT is avoided by women with prior breast cancer diagnosis for fear of recurrence Typically HRT is avoided by women with prior breast cancer diagnosis for fear of recurrence Most observational studies suggest that HRT does NOT increase breast cancer recurrence and mortality in women with a prior diagnosis Most observational studies suggest that HRT does NOT increase breast cancer recurrence and mortality in women with a prior diagnosis

5. HRT After Breast Cancer First 2 randomized controlled trials were stopped prematurely after showing an increase in recurrence with HRT use First 2 randomized controlled trials were stopped prematurely after showing an increase in recurrence with HRT use HABITS Trial: rate of recurrence significantly higher with HRT use HABITS Trial: rate of recurrence significantly higher with HRT use Stockholm Trial: no associated increase in recurrence with HRT use Stockholm Trial: no associated increase in recurrence with HRT use

6. Why the Disparity in the Results? HABITS Trial HABITS Trial Participants had higher grade lymph node involvement Participants had higher grade lymph node involvement Majority of women used combined HRT; small percentage used unopposed estrogen Majority of women used combined HRT; small percentage used unopposed estrogen Stockholm Trial Participants had lower grade lymph node involvement Majority of women used unopposed estrogen or combined in which progesterone was taken for short intervals

7. Conclusions More clinical trials needed before can make conclusions about HRT after breast cancer More clinical trials needed before can make conclusions about HRT after breast cancer Providers need to be aware of the factors associated with increased breast cancer risk Providers need to be aware of the factors associated with increased breast cancer risk Providers need to work with each patient individually to assess her need for HRT and risk factors to determine if HRT is appropriate Providers need to work with each patient individually to assess her need for HRT and risk factors to determine if HRT is appropriate