The Dr Louise Newson Podcast - 051 - Breast Cancer & Menopause - Dr Tony Branson & Dr Louise Newson

Episode Date: June 9, 2020

In this podcast, Dr Louise Newson talks to Dr Tony Branson, a consultant oncologist who specialises in giving cancer treatments to women. Dr Branson and Dr Newson discuss the menopause in women who have had breast cancer in the past and the various ways of managing symptoms. Some women also experience menopausal symptoms as a result of their hormone treatment and Dr Branson shares some advice on how to manage this. This podcast also covers what risk means regarding taking HRT with a history of breast cancer and reasons why some women still choose to take HRT despite having breast cancer in their family or having had it themselves in the past. Dr Tony Branson's Three Take Home Tips: Whoever you see (hopefully a specialist) make sure to ask about your options. You may be able to stop your hormone treatment for a short time and see how you are. If that helps and you are considering HRT - find someone that will have a reasonable discussion with you about the relative risks and benefits, instead of just saying "no you can't!" Don't take no for an answer! Be clear with your healthcare professional about what really matters to YOU. 

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I'm very excited to have with me a male guest, which is quite unusual in my series, but I'm really excited to have Dr Tony Branson, who's a doctor who specialises in cancer medicine in Newcastle. So welcome to the podcast, Tony. Thank you. Nice to be here.

Ah, so before we get started, could you just tell me just a bit about your background and what you do and how you've managed to get to where you've gone over the last few years? Yes, well, I've been working in Newcastle for all of my consultant career, which started quite a long time ago back in the late 80s. And when I first started, I used to treat all sorts of cancer. And then as time has gone by, we've tended to specialize on, cancer sites and I now treat predominantly breast cancer. And that's very common, isn't it,

breast cancer? It's one of the most common cancers that we see, yes. So when I was at medical school in the 80s, I was taught one in 12 women that was their lifetime risk and then when I was qualified it was one in 11 and now some studies I read is one in eight, one in seven. So it's become more common, hasn't it? It has indeed. It's hard to say. It's hard to say, but it's probably due to the ageing population more than anything else. And it's one of those cancers that thankfully the treatment has advanced and changed. And so the majority of women who've had breast cancer actually have a very good long-term outlook, don't they, in their lives?

Yes, certainly. I mean, certainly since I've been working in the field, the proportion of patients who go on to live normal length lives without any further cancer has gone up considerably. and even for those whose cancer sadly recur, the length of time that this can be kept under control has now runs into years for a large number of. Which is absolutely wonderful, and it must be obviously so rewarding for you as a cancer doctor,

but also clearly for the patients, their families. And one of the things that we're both interested in and what I want to talk about in this podcast is looking at women's health beyond their breast cancer because obviously as a menopause doctor, I see a lot of women who will go through the menopause naturally. because they're living longer because of their breast cancer, which is great, but also a lot of the drugs that they're given that block the effects of estrogen on the breast

can lead them to go into an earlier menopause. So I see a lot of women who are struggling, and we've had lots of conversations over the last year or so since I met you about the whole quality of life issues and what can be done, because the menopause isn't just about symptoms, of course, it's about risks. and as a lot of people who are listening know that women who are menopausal have an increased risk of heart disease. And we know that women who have had breast cancer, actually the commonest cause of death is heart disease, isn't it? Not from their breast cancer.

So we need to look at helping their symptoms, but their future health, don't we? Yes, that's true. I mean, I think there are two elements. One clear is their future health from other conditions that may have been made more probable by the treatment. The other side of it is how they actually feel. And I'm to say, I'm reminded of a statement made by a fortunately late, but also great oncologist called Robert Buckman, who said it's no good making people better if they don't feel better.

And I'm certainly aware that a number of the patients I've treated have been rid of their cancer, but have been left with really very troublesome symptoms and simply don't feel better. And I think this is what's key, isn't it? And certainly, as you know, I expose myself to lots of women, either directly through my clinic or indirectly through social media. And time and time again, I hear women who are struggling because with the low estrogen levels, it can affect obviously our brains and cause symptoms such as low mood and brain fog and memory problems. But also stiff joints, people can push on weight because of the metabolic changes that occur. People can have really miserable. quality of lives. And I think more and more when I talk to women who have had any type of cancer, obviously they have very fortunate and happy and lucky to be alive. But then they say, I have all these symptoms and I don't know where to go and get help. And it can be very difficult sometimes

to know also if they're tired. Is that because of their treatment or is it because of their menopause? And that can be difficult as well, aren't it? Indeed. And I mean, certainly the proportion of patients who are on hormone modifying treatments as part of their breast cancer regimen, these are treatments that are given to reduce the risk of cancer returning, do have a number of symptoms. And it is quite often difficult to tease out whether these are due to the treatment or maybe another condition. And certainly my practice, where patients are conveying significant symptoms is to get them to stop taking these treatments for a shortish period of time, usually six weeks or so, and see how they feel.

And some of them will say, well, I don't feel any different. And at least you can then say, well, your symptoms are unlikely to be due to the tablets you're taking. And other people will say that they feel wonderful. They feel so much better. And then there's a decision to be made, really. And for some of them, they may say, yeah, I feel much better. but I'm really concerned about the risk of not continuing to take this treatment.

And one can discuss with them the magnitude of that risk, but that risk is not one which they feel happy to face, so they may go back to taking the tablets. Or maybe try them on a different medication, which might suit them better. Others may say, well, you've told me what the level of benefit in terms of risk reduction is. And it's usually quite modest. It's not a huge amount, single figure percentage in terms of, over 10 years.

And they say, well, actually, I'd rather take that risk and feel well than deal with that risk and not feel well. Yes, and I think that's very interesting, isn't it? And I think there's certainly, obviously, there's the aromatase inhibitors which really block estrogen throughout the body in quite a dramatic way. And then there's drugs such as tamoxifen, which have interesting roles in the body, don't they? Because they can affect estrogen in a negative and positive a way depending on whereabouts in the body. And a lot of women I speak to have been told they have to take these drugs, sometimes five years, sometimes 10 years. And they're not told anything different. And then they don't know who to see when they experience symptoms.

I saw someone recently in my clinic who had a very small cancer diagnosed by breast screening about eight years ago. And she was told she had to take her rheumatase inhibitor for 10 years. And her husband actually got in touch with my husband because they know each other and said, my wife's not how she used to be. She's hobbling like an old woman. She's stopped exercising. She's miserable. She keeps getting urine infections. The whole family are worried and we don't know what to do and my husband said, well, it would be her hormones. So she said, what do you mean? And so we had a discussion and I said to well, why don't you just stop for six weeks like you say and then maybe you could think about tamoxifen, we'll speak to your oncologist and we can do it

very. And I just got an email this afternoon actually from her to say, I feel so much better already and my consultant has agreed I'm going to try to moxophan but my joints aren't as stiff so I'm walking 20,000 steps a day and I'm walking with my daughter and it's lovely but I think women are you know as patients we want to do the best for our future health don't we and so just to hear from you to say a six week drug holiday is not really going to make any big difference is it in long-term outcome was certainly stubbing for six weeks has not significantly increased the risk of of the cancer coming back and I actually say to people, look, I have to say that if, God forbid, your cancer came back during the six weeks it was going to you anyway.

Yes. Part of the problem is probably a doctor mindset in that we're there, so we feel, to try and stop as many people dying from cancer as we possibly can or have their cancer come back. And certainly for many of us, you know, the worst thing that can happen is for somebody's cancer to return. Now, when you actually look at it a bit more sort of carefully, that's not necessarily, not necessarily the worst thing that could happen from the woman's point of view. And really what we need to do is to work with rather than on the patients who we see and to discuss things. And as I said, there are some patients who try stopping taking their adjuvant endocrine treatment feel much better,

I'm sorry, I've taken everything into account, I rather carry on. That's fine. That's fine. The other thing, you know, you mentioned, you know, aromatase inhibitors, yes, certainly. Significant joint pains are a problem for a proportion, probably about one in ten. Patients. Now, actually changing the aromatase inhibitor will quite often improve things, although they all have this as a side of it. But equally changing to tamoxy then may be very much better. Now, we use aromatase inhibits. We only use them in postmenopausal women that don't work in premenopausal women. We use those because there have been a number of large studies which show that they are a bit more effective, but not by a huge degree. Now, obviously, as a doctor, when I'm treating lots and lots of people, and that small difference will actually be a moderate number of women who would be okay.

So that's why I would choose that. but for the individual to change from, say, letharazole to moxifan, the additional risk they get of their cancer coming back is minuscule. And if it makes their life much better, well, that's great. Then it's great. I mean, certainly we often in my clinic use the predict tool. I'm sure you've crossed it, which is an NHS. It's a free tool, isn't it, if you just Google NHS and predict.

And you can put in the type of cancer that patients had, what treatment, they've had and it gives you this lovely graph, doesn't it? And like you're saying, the percentage of benefit over time with each treatment. And you can see it's a very small, often, amount with the hormone treatment. They have another display, which is the Vycons, and you have little dots which represent all the patients who would be okay. I mean, what that demonstrates very clearly, which are some oncologists sort of grit our teeth a bit about, is the vast majority of women who are cured of breast cancer are cured by our surgical colleagues. Yes.

One of my oncologist colleagues said the most effective drug for breast cancer is called steel. You know, it's what we do bumps it up and I'm sure that women would say, yes, I want the best possible chance for men and create cancer. But, you know, you need to weigh these things in the balance. Somebody once said to me a long, long time ago when I was a medical student, you've got to realize that everything we do medically is a swap in one set of problems for another. And I guess the discussion is around whether it's a good swap or a bad swap. Absolutely. And we all make different choices, don't we? And so then that brings me on to

HRT, hormone replacement therapy, because clearly in my clinic I give a lot of HRT and recommend it to the majority of women because we know there are more benefits and risks for women because not only it improves symptoms, but reduces future risk of heart disease, diabetes, dementia, osteoporosis and so forth, which is fine for women who haven't had an estrogen receptor positive cancer. But then there's obviously the proportion of women that have. But before we talk about them, there's women who have had an estrogen receptor negative breast cancer that is different, isn't it? So are these women more able, if you like, to take HRT if they've had an estrogen receptor negative breast cancer? I think there's no doubt that the risk is very, very much less,

but we don't quite know whether there's any risk at all. And certainly the patient who has significant menopausal symptoms and have had a least receptor negative breast cancer, I'm pretty comfortable with them having HRT. I think the likelihood that they're going to have recurrence of their breast cancer as a consequence is extremely small. One has to say, I mean, there's a group of breast cancers which find us triple negative in the bay, negative for Eastern receptor, negative for progester receptor, and negative for another receptor for two. And a proportion of these cancers behave, one has to say, very, very bad,

with they're very high risk. And so, yes, I guess these patients are at significant risk of recurrence, and I really doubt that HRT would have any bearing on this. and if what short time they have left before their cancer occurs. And sadly, they may subsequently die from it. They're in misery because of their menopal symptoms. That seems rather cruel. Yes, absolutely.

And then with estrogen receptor positive cancers, you know, there's no good trials, isn't there? There's no study that categorically says women do worse, but there isn't a trial that says they categorically do better, is there? Well, I think that's correct. I mean, I think there's not really, really strong evidence one way or the other. There was a trial which was carried out, which was stopped prematurely, which suggested there was a significant increase in recurrence of cancer.

There's not actually a demonstrated increase of mortality. And there's been a subsequent trial, which again is small, which really hasn't even shown a significant increase in recurrence. So the fact of the matter is that we don't know. And I guess a lot of it's about our actually rather primitive understanding of the role of hormones in breast cancer. Yes. I think our efforts are treating breast cancer with hormones or a bit akin to trying to men watch with a hammer. And, you know, we say estrogen receptor positive, any estrogen cancer will grow like that.

And I think you've mentioned or we've mentioned in the past that women are told that if they have Eastern receptor, cancer that their cancer is fed by estrogen well. I mean, it's an oversimplification, but an understandable. Yes, and I think, and I can understand where it's come from because we talk about receptor positive, but we have estrogen receptors on all, all ourselves practically, in our body. And so it doesn't mean that that's caused the cancer, and we know there are other reasons why women have cancer and especially breast cancer, there are lifestyle risks. So, for example, women who are overweight or women who drink alcohol, smokers, family history,

there's all sorts of reasons, aren't there? And it's not just every woman who takes HRT gets breast cancer. So we know it's not all about estrogen causing. And actually, when we look at the studies of women who take estrogen-only HRT, they seem to have a lower risk of breast cancer. And women, it seems to be the progestogen that stimulates something, the synthetic progestogens. So like you say, it's so simplistic, isn't it? It's so synthetic.

I mean, obviously, the greatest exposure to progesterone is with pregnancy. And women who have multiple pregnancies actually have a slightly reduced risk of breast cancer. Yes. But these children clearly has some role in the development of breast cancer, in about 100 times the number of women get breast cancer as men, and women who have a late onset of their periods and early menopause have a reduced risk of breast cancer. But on the other hand, the majority of women who have estrogen through their life do not get breast cancer. And quite understandably, anybody who gets into cancer always wants to know why it's happened.

And the difficulty is we know there are certain things which may increase the risk of it or little. and you've mentioned diet and obesity and alcohol and in other thoughts of cancer smoking. But there is a very big element which I'm afraid is, I'm not going to be too trite about it, but it's bad luck. Absolutely. And I do spend, certainly, when I was a junior doctor and managing women who have had breast cancer, and they feel so guilty and say, well, if a lot of it is, like you say, it is bad luck. And there's a lot of women who contact me and say, well, my mother had developed breast cancer, three weeks after starting HRT, therefore it was caused by the HRT.

And we know it doesn't, cancer doesn't happen overnight, does it? And, you know, and it's awful that these women have felt like that because there's nothing worse than punishing yourself about the past, which we can't change. I think you can say with absolute certainty, and there's not a lot you can say with absolutely certainty, is that somebody who got a breast cancer three weeks after starting HRT, the HRT had nothing to do with it. I mean, the intimate bit with HRT is, I mean, I see, A number of women who are diagnosed with breast cancer who've been on HRT.

And almost universally, they have been told at some stage, and a lot of them believe it, that the reason they got breast cancer was because they took HRT. Now, if you look at the studies about the risk of HRT and breast cancer, and if you take the sort of worst case scenario, no more than a quarter of women who've taken HRT or get breast cancer, have got it because of the HRT. So in other words, three quarters of them will have got it anyhow. So you can't say there isn't a risk. And as you've mentioned, there are some types of HRT which are probably very much less risky than others. But the risk is not enormous. And it needs

to be weighed against the benefits. Absolutely. And I think it's very hard, isn't it, when we talk about risk? Because even as a patient myself, if someone says to me you have a one in a thousand risk or a 200,000 risk, what does that mean to me as an individual? And we take risks in our life, don't we? The way we cross the road, the way we drive our car. We all take risks. And they're not always based on evidence. They're based on what we want to do with our lives. And this is very difficult, isn't it, sometimes in medicine when there isn't a black and white answer. And I spoke to a lady today, actually, in my clinic, who, she's a different lady, to lady I mentioned earlier, but she'd had a small cancer diagnosed in 19, no, 2012.

And she had been taking to moxophan for six years and had to stop because she was having side effects and felt better coming off it. But she was still having sweats all the time. She said every time she had a shower, she wants to go back in the shower. The joints were awful. Her brain, her memory concentration were terrible. And so she had decided, she's had a hysterectomy as well. So she just had a little bit of estrogen to top up.

And as you know, estrogen only is better than with a synthetic progestogen. And she was feeling amazing, but she'd gone back to the clinic and she was told off. She was told off because she'd only had to moxophofen for six years rather than 10 years. And then the doctor said, well, you can't take HRT. And she said, well, I've chosen that I want to. And he said, well, I'm really not very happy. And it's very hard for her as a patient, but she is very strong and she feels better. and she knows that the evidence is very unclear.

And I feel like as a doctor sometimes, we have to take a step back, don't we, and look at the woman as a whole rather than a woman who has a disease? Well, I agree, and I'm quite sad to hear that in lots of ways, but I'm not completely surprised. And patients are not there for our benefits. We're there for theirs.

So we need to share with them risks and benefits, the bits that we know about. And then the other side of the coin is what they, know about because I don't know until I'm told for any woman what the symptoms are like. Some people say, oh, I think they say, they don't bother me too much. It's better than central eating. Well, that's their view. Others say that my life is just not worth living. I don't judge that because I don't feel I can only take what they tell me. And it's interesting, this is this is a quality of life is a very interesting.

When I used to teach medical students, I would ask them to define it and get some very interesting bits. And it's interesting because we measure it, so it's theoretically objective. But of course, it's subjective. Yes. The best definition I heard of quality of life is how close your experiences come to your expectations. And so for some patients, what they expect is one thing, and they experience something very different. but some people will cope with symptoms because that's what they expect and they're comfortable with that but it's their own personal view and it's not for us as doctors to impose

you know our scientific belief as it were on top of that we can use our scientific knowledge to inform discretion yes and I think that's so true and I think one of the reasons that I'm so passionate if you like trying to help women is giving them a choice is obviously really important, but I had symptoms just for a few months and I had no idea how it was going to affect my brain before I had it. And, you know, I could not work as a doctor if I wasn't taking HRT. My memory had gone. My brain had gone. My concentration, my ability to function had really gone and my sleep pattern was all over the place. And so if someone said to me, actually, Louise, you will definitely get cancer and it will be breast cancer and he will die 10 years earlier.

actually I would still choose to take HRT and that's my personal choice and I'm not saying anyone else should even contemplate that. But actually I want to live a fulfilled life even if it's shorter and a lot of women say that to me. Whereas other women that you say don't have such severe symptoms and they might find by changing their lifestyle or trying an alternative, which obviously we would recommend in the first instance is enough for them. I've had some ladies who have such bad sweats. I give them a very low antidepressant which can help with the low sweats and that's transformed their lives and that's fine. But for women who are really struggling and we both know patients ourselves who have been suicidal because of the effects of low estrogen in their

brains and you know as you said to me once well the risk of death from suicide is 100% the risk of death from her taking HR2 with respect to her breast cancer will not be 100% and the hard decisions to make and we don't get taught this, do we in medical school or as part of our training? And we learn from our patients, I often do. We're led by what they want as well. I think that's right. I think people are being taught more about this and the concept of shared decision-making. I mean, we've gone from, and it still exists from the sort of paternalistic view,

you come to me with your problems, I tell you what you need to do about it, and you either do it or you go away and, you know, I won't speak to you. There is a risk with the patient choice where it's a sort of menu-based thing. We say these are the things you could do, you choose, because written between the lines of that is the thing that says, well, and if it all goes horribly wrong, then it's your fault. The proper way of doing it, in my opinion, is that you put together the scientific knowledge, which we have and the clinical skills that we have,

along with what matters most to the patient, and try and formulate a plan that achieves as much as a problem. in all those regards. So, you know, if a patient says, I've got a lump in my breast, and I don't want to have surgery, I'm going to get rid of it by the power of positive thought, then I can't have a shared decision to say that's okay, because I honestly believe it won't end well, that I will tell people that. If on the other hand, they say, look, you told me that if I have four months of chemotherapy and it's going to my hair fall out, I feel terrible, that that improves my chances of being alive in 10 years by 5%.

Frankly, that's not good enough. And I'm very happy to take that. I'm not happy. I'm willing to take that risk in order to avoid going through the process. That's okay. I mean, I've seen patients who've actually the benefit from chemotherapy and other drugs is much higher than that. And they still have no, I'm not going to have that, which is right.

My duty, I feel, is to make sure they do understand what the level of risk. this case, but it's not 100%. And as you, we just mentioned, you know, there are a few things that are 100%. Yeah, that's so true. And then there are some people who are on a drug such as Tamoxifen and then they take HRT

and some experts think that will be not work because that Tamoxone can block the effects of estrogen in some parts of the body, whereas other people think it's more protective because you've got an estrogen blocker, if you like, and then you're getting HR

And I think we don't have the real studies about that, do we? No, we don't. And I think there's some studies with tamoxifen and tibolone, which do show some the fact that actually the tumoxifen doesn't protect a great deal, but they're small. And I'm sorry, I can go back to the watch and hammer analogy. I just don't know. Yes, and some women feel more comfortable taking tomoxifen with HRT,

and others don't. So, again, it's, you know, the jury's out. And I think this is what I always say to patients, when doctors can't agree, it's because there's often not enough evidence. And we have to just, you know, take each case as an individual. And we should all be treated as an individual, whatever aspect of medicine we're managing. And people should feel confident. And the other thing I always say to people is if they do start HRT,

they're not signing up for a life sentence. They can stop it. They can try it for a few weeks sometimes, a bit like your drug holiday, analogy of stopping for six weeks. Often I will give HRT for six to 12 weeks and then they can review and some women say to me my goodness my quality of life is amazing. I'm back at work. I'm happy. This is how I want to live my life and I'm going to take that risk. Whereas other women say I don't feel much better and every day I worry because of what I'm doing so they stop it. And that's not going to worsen their overall prognosis really is it.

Another analogy actually goes along with that which again there is some other. but not strong evidence for, is that particularly with the rometease inhibitors, but taking them some of the time, but not all of the time. So having, say, three months taking them and then three months not taking them might be as effective as taking them all the time. And some people will find that much more tolerable than taking them the whole time. Now, I couldn't put my hand in my heart and say, I know this is just as good, that I could say there's a possibility that it is.

And it's not completely without some evidence about them. Which is very interesting. And also, we know that in the past, estrogen used to be a treatment, didn't it, for breast cancer? Well, I said when I was a medical student, I was taught by somebody, an oncologist, who said, and this was the days before we knew about Eastern receptor, that we didn't measure them,

that if you had somebody who'd got breast cancer that would spread, you could do any number of things. You could give them estrogen. You could give them to moxifene. You could give them. There was a drug called the minor glythamide, which was an early sort of a remitone, you could give them androgens. You could remove their adrenal glands. You could remove their pituitary gland. And whatever you did, you would get 30% of the patient's respond. The business of giving estrogen from breast cancer keeps sort of coming to the surface and going away again.

I think some of my younger colleagues have got very, very scared by that. And it's not something I've been a while, but again, it is sometimes something that will produce a response, as do progestogens. I mean, I've certainly had a lovely patient years and years ago who came to see me and had got spread of her cancer to a bone marrow and really wasn't about to. We couldn't give a chemotherapy. And I actually get treated her with a progestogen because there was some suggestion at that stage that stimulated the bone marrow. And she told me all about planning her funeral and that She really was sad she never get to New Zealand to see one of her children and she wouldn't see her first grandchild born. Anyhow, she did amazingly well.

We treated it with various other hormones. She actually went through the whole sort of cycle of them several times. And I got a post-cover from New Zealand and a picture of it. Oh, wow. So, you know, I mean, these are what are medically described as anecdotes, so they don't prove anything. Yeah, so we do, do we? And, you know, I was talking to a professor in America from Yale University recently, and he was saying there is some evidence that estrogen can induce apoptosis,

so program cell death in some cancer tissue, including breast cancer. So we don't know. And, you know, this is what we're trying to tease out, I suppose, in this podcast, is that we haven't got the answer, but what we have got is to try and help women who are suffering. And talking about suffering, just before we end, I see a huge number and speak to a vast number of women who have symptoms related to vaginaldriness and recurrent urine infections.

And vaginaldriness doesn't just cause pain on penitative sex. It can often cause discomfort sitting down or walking even, can't it? And we know about 70% of women who are menopausal would experience this symptom. And we know about 7% of women receive treatment, which is shocking in my mind. but a lot of women who have had breast cancer are told they can't have vaginal estrogen. And we know the insert with vaginal estrogen will say there's a risk of breast cancer and all sorts of risks of things that aren't true. Yet the general consensus is that the vaginal preparation, so either pezzary, rain or cream,

are quite safe to women who've had breast cancer. Is that correct way of it? Would you agree with that? Yes, I would. I think it's fair to say that I probably get a letter from a genealiener. well, certainly several times a year with this question. And my response is always, no, there is no reason why they should not use this. And certainly, I used to take the view, it seems to be wrongly, that if you were on aromatase inhibitors, that wasn't such a good idea because they were actually do lower the level of these children circulating to a very low level. But certainly at a discussion I was at

that the UK breast cancer group some years back, certainly one of the medical oncologists who looked to this very thoroughly said no. There's no reason why patients on any form of treatment should not use topical estrogens for vaginal dryness. And as you say, it's a symptom that can really make a woman's life on that complete misery. Absolutely. And I think it's very important and it's really reassuring for you to hear that. And this is something we really need to get out to the wider community because I was talking to a breast cancer surgeon yesterday and she said she doesn't prescribe in the hospital, which is quite common. ask GPs to prescribe and she has says most of the GPs in her area refuse to prescribe it.

And that's because they haven't had the right education and knowledge. And I can understand because of the warnings that are associated when they try and prescribe. So this really, to me, needs to be changed with some urgency. But it's reassuring to know. I mean, certainly one of the things that I've been involved with mostly last year was rewriting all the breast cancer guidelines, the Northern Cancer Alliance, Because I unfortunately looked at them and thought, my God, I wish I hadn't. So I then landed myself with quite a lot of work.

But certainly in that, we say the top of these people are okay. Yes. We also say that hormone replacement therapy for women if her breast cancer does have risks. And these risks and benefits should be discussed with patients. It isn't a straightforward thing. And it isn't. I think, and I'm sure there are those amongst my colleagues who may feel that to give a woman who's had breast cancer, HRT is a bit like hitting them over the head with a hammer, but it isn't.

No, absolutely. And in fact, this lady I spoke, was telling you about earlier, who had started her HRT, her consultant said, well, why don't you just use vagina leisstrogen, and that will help? And she said that that wouldn't improve my other symptoms. It's not just about the dryness that I was experiencing. And this lady was finding it very uncomfortable to sit down and had stopped wearing trousers and close-fitting genes because of her discomfort. So it is important.

And I think if anybody who's listening is struggling in any way, then they should talk either to their doctor or to their nurse or anyone in the hospital. And there is help. And if people don't get help, the first person they speak to, then they should certainly keep trying. One of the possible sort of bright lights on the horizon is that as part of the cancer strategy that was produced by the working probably

while back was to change what we did after we treated patients and to stop just seeing them on a regular because we see them on a regular basis and we deal rather poorly with these symptoms. Whereas if we put them on a question where if they have problems, they seek help. And what I would like to see is that patients with endocrine problems would be seen in a clinic that specialised in that, which would have a number of advantages. One is that it would put them together with people with similar problems. And another is it would actually give an opportunity for some rather better research than we have already. And also, I think then it would probably take some of these questions out of the hands of people who may not really put them very high up the priority.

Absolutely. So there's a lot of work that needs to be done, but we can keep plugging away and hopefully change for the future. So before we finish, and I'm so grateful for your time today, it's been absolutely brilliant. could you just give us three take-home tips for women who perhaps have had breast cancer and are experiencing medical symptoms? And are there any tips that you would give them just to try and help? I think the first thing is whoever you see, and it really should be a specialist, that you ask about what the options are and the first options maybe to stop the treatment that you're having for a bit to see how you are. So that's a very straight, forward one. And then if that helps, the question is whether you restart or start something different.

And if you get to the end of the line in terms of non-hormonal bits and considering hormone replacement therapy to try and get somebody to have a reasonable discussion about the relative risks and benefits rather than the no, you can't do that. Yes. Don't take no for an answer. Yeah, definitely. And I think it's just so important that women should, supported because it can have a big impact obviously not just on their direct lives but anyone

around them as well so i think they need to be clear about what really matters to them because that's what's important not what really matters to their doctor it's what matters to them and if they take that as the starting point okay there's some people who not wanting their cancer to come back really matters as much as their medical and that's quite difficult but it's still that they are and it's That should be the starting point. Absolutely. So really good advice from a very experienced doctor. So thank you ever so much for joining me today, Tony.

Okay, lovely to talk to you. For more information about the menopause, please visit our website www. www.menopausedoctor.com.