The Dr Louise Newson Podcast - 138 - Explaining what the evidence shows to offer choice to women after breast cancer, with Avrum Bluming

Episode Date: February 8, 2022

Medical oncologist, Dr Avrum Bluming makes a welcome return to the podcast this week to re-visit the hot topic of menopause hormone therapy after breast cancer. Avrum has spent decades studying the research on the benefits and risks of HRT in women with a history of breast cancer and is passionate about giving women clear, evidence-based information that dispels myths and combats the misinformation that has unnecessarily frightened women and clinicians for over 20 years. In discussion with Dr Louise Newson, Avrum clearly explains what his recent review of the literature reveals about the safety of HRT and the benefits it brings for your future health. The experts highlight the gender disparities that are commonplace in how women with cancer are treated with regard to their hormones compared to men, and they also discuss the importance of patient-centred medicine and giving women choice. Avrum’s 3 tips for women interested in exploring their menopause treatment options after breast cancer: Speak to your oncologist. Tell them about your menopause symptoms, ask to discuss the possibility of starting HRT and have a conversation about the benefits and risk for you individually. When it is available, take Avrum’s article that will be published in the ‘Cancer’ journal in May/June 2022, and show it to your oncologist and GP. Don’t accept a dismissal of your views – engage them in discussion. ‘Oestrogen Matters’ (2018, published by Little Brown) is a book co-authored by Avrum that is for women and clinicians, including a chapter on HRT after breast cancer, and it is heavily referenced to show all the evidence behind the information given. Links to Avrum Bluming’s upcoming journal article will be published on the balance-menopause.com website when it is released.

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. Today I'm very excited, delighted and thrilled to introduce back to the studio today, Avram Blooming, who hopefully a lot of you have heard a previous podcast we did together.

Avram is an emeritus clinical professor of medicine at the University of Southern California and he's also master of the American Colleges of Physicians, which he's going to say what that means because that's quite a mouthful, but it's a real honor that he was awarded. So I'm very honored to have you here today, Avram. It's incredible. I am honored as well. So, and today on the podcast, we're really going to concentrate talking about breast cancer and women's choices following breast cancer. Okay. I think first it's important to recognize that as human beings, we are risk averse. If we're given the option of a good gain with an associated risk,

we will almost always decide in favor of avoiding the risk, even if it means not getting the gain. And in the world we currently live in, most of the benefits of HRT have now been endorsed, not just by people like you and me and other medical practitioners, but by the Women's Health Initiative, which is responsible for the dramatic decline in HRT that we've seen over the last 20 years. And the benefits include reduced risk of cardiovascular disease and reduced hip fractures and improved cognition and obviously avoiding the symptoms of menopause and even longevity. And it's very important to note, and I think I sent you this, there was a paper by one of the senior investigators of the Women's Health Initiative,

that was just published last month, Rowan Schlabowski, that says that we have missed the fact that even though we thought that women who took combination hormone replacement therapy had an increased risk of breast cancer, we omitted stating that they don't have an increased risk of death from breast cancer. And in fact, estrogen decreases the risk of breast cancer when given alone and improves longevity. And we can talk about whether their thought,

that the combination increases the risk of breast cancer is still valid. There are articles that you've seen that I've seen that say it's no longer valid. So even for women without any history of breast cancer, the movement is clearly in the direction of let's look at the benefits and stop waving this red risk flag of breast cancer, which is a false red flag. Okay, having said that, we then have to look at what about women who have had breast cancer? And as you know, you and I can both talk indefinitely on this subject. So cut me off anytime you want to.

I've just finished a literature review of giving hormone replacement therapy, either estrogen or the combination, to women with a history of breast cancer, to see what it tells us. And what I found is there are 25 primary studies in the medical literature of giving hormone replacement therapy to women with a history of breast cancer. Of the 25, one has reported an increased risk of recurrence. The one is called the Habits trial. And as you know, Habits is an acronym for hormones after breast cancer.

Is it safe? and they conclude that there is an increased risk of recurrence among women who are given hormone replacement therapy after a diagnosis of breast care. That's one out of 25. The other 24 do not show any increased risk of recurrence. And in fact, some show a decreased risk of recurrence and improved longevity, decreased mortality. So it's important to look at that one, the Habits study. And Habits is the only one that's quoted by many reviewers. And Habits is a randomized prospective study. It's not double-blind, but it's randomized perspective. And that's why everybody says, well, this is the one we have to pay attention to because it's randomized.

Well, there are three other randomized studies, and they don't show any increased risk of recurrence. So it's important to look at habits and see what we can learn from it. First, although it was randomized, the particular hormones used were left up to the individual practitioners. In addition, it wasn't one institution. It was a variety of institutions around Sweden who participated in the study. Fair enough. If you're going to do a study of hormone replacement therapy and breast cancer survivors, it's very, very important to be sure that at the time women enter the study, they have no evidence of recurrent breast cancer. Well, they say none of them had evidence of recurrent breast cancer, but there was no imaging study of the breast.

that was required before entry into the study, and the recurrences that they found increased among women who got the hormones were only localized or contralateral breast cancer, which are also localized. There was no increased risk of distant metastases. There was no increased risk among women whose primary breast cancer included involved lymph nodes, which would be the group we would think would have the highest risk. And there was no increased risk of breast cancer deaths in this study. They proposed to do a study of 1,300 women over five years. And what they found is after two years, not five years, because they found this increased risk of local recurrence, they stopped the study. And when they stopped the study, they only had a little over 400

women, not 1,300 women. It's important to note that the difference that they found is of 221 women, randomized to hormones. 39 of the 221, that's 18 percent, had a local recurrence or or a contralateral tumor. Of the 221 in the control arm, 17 or 8% had a local recurrence. The difference between 17 patients and 39 patients is 22 patients. Those 22 patients have yielded a practice guideline that prevents millions of women who are survivors of breast cancer from getting hormone replacement therapy. And by the way, they operated on the principle of intent to treat, which means that even within their groups, the women randomized to hormone replacement therapy didn't all get hormone replacement therapy. In fact, 11 of them chose not to take hormone

replacement therapy, but they were calculated as if they had, and 43 of the women who were randomized to receive nothing took hormone replacement therapy. And with that, there was still a 22 person difference in recurrences, which were not lethal recurrences. They were local or contralateral recurrences, and I'm not diminishing the importance of that. I don't want women to get local or contralateral tumors, but they didn't die of their tumors. And they had a much better life and some of them lived longer. And that's one of 25 studies, 24 showed no increased risk of recurrence. So in addition to the 25 studies, I found 18 studies that reviewed the studies that were already published. So these were analyses, not primary studies. And of the 18,

the only study that any of them cite that reports an increased risk of recurrence is the habit study. Oh, my God. And to show you where our minds are, of the 18 reviews, 15, include, well, there's really no harm in giving hormones. Three, including one that I wrote the letter about that was just published a few days ago by Pogio and Al from Italy, says, well, there's an increased risk of recurrence. Well, wait a minute. They include the Habits study. They include two other studies that don't show an increased risk of recurrence.

and they include one study by Kenamine, which is a study of tibolone. Well, tibolone is in estrogen or progesterone. It's a form of progestin, but it has no known effect on either the breast or the uterus, and to include that as part of an analysis of hormone replacement therapy, especially since the number of patients in that study was 75% of the total number that this review article reviewed, and conclude that hormones are dangerous is disingenuous at best. It's dishonest at worst. And there were two other review studies that misquote the results.

They misquote the results. And that's going to be in an article that I'll be publishing in May on this review that I've done of the totality of the literature that I could see. That's amazing. I mean, there's so many words that I want to. to use our room because we try, don't we, as physicians, as healthcare professionals, to practice evidence-based medicine. But sometimes the evidence isn't clear. Sometimes it is clear, but it's ignored. And there's a lot of bias in everything that we do, isn't there? And this area of medicine is something

that affects so many people. So when I was at medical school in the 80s, one in 12 women had breast cancer. We're now in 2022 and the most recent figures are about one in seven. So it's become far more common, but since I graduated from medical school, the use of HRT has declined since 2002 since the WHOI study. So, I mean, you were saying only 5% of women in the USA take HRT, around 14% of women in the UK take HRT who are menopausal. So HRT can't be causing all the breast cancers, can it? Because it's so common yet so few women take HRT. That's important to state that the overwhelming majority of women who develop breast cancer never took HRT and the overwhelming majority of women who take HRT never get breast cancer.

And by the way, getting pregnant after being treated for breast cancer has no negative prognostic effect on the outcome of your breast cancer. And by the way, taking in vitro fertilization has no. effect on the prognosis of breast cancer. And that's very important because the levels of estrogen in women who are pregnant are so much higher, aren't they, than the levels that women who take HRT. So, you know, I think sometimes with medicine, we're on this sort of hamster wheel where we're very, very busy and we learn by rote and we just sort of go through what we've been taught. And we don't have the luxury sometimes of being able to take a step back and review the literature. But also, we don't

sometimes, when I say we, I'm saying a lot of healthcare professionals, including myself, sometimes get so wrapped up with the risks or the worry that we forget about what patients want as well. And so I really sad lots of reasons in my work, the stories I hear in my clinic and social media and so forth. But one of the stories that really I find very sad is these women, so one in seven women, and the majority of them now who've had breast cancer have good life expectancy, don't they? It's a disease where the majority do very well. And actually, the majority of women who've had breast cancer in the past don't actually die from their breast cancer. They die from heart disease or dementia. And so a lot of women are given treatments that block their

hormones, which might be a temporary menopause. Sometimes they're advised to have their ovaries removed and therefore they won't have any hormones. And then a lot of women, because they live so much longer, we'll then enter a natural menopause. So I think, I don't know if I'm right here, but the majority of women who've had breast cancer in the past will become menopausal at some stage, and a lot of them will be menopausal earlier. With a reported 90% curate of newly diagnosed breast cancer, that means that over several years, 1.4 million women in the United States alone will be entered into the breast cancer survivor's population. and unless the guidelines are changed,

will be denied even a discussion of hormone replacement therapy. Yeah, we did a survey just to some of our patients recently, and the vast minority had ever been involved in any discussion about menopause or their treatment. And so a lot of women I speak to think that their symptoms are related to their chemotherapy or their treatment that they had in the past, like the brain fog or the bone pains or whatever, Some of the symptoms are due to their estrogen blocking treatments, such as aromatase inhibitors,

because it's squeezing every bit of estrogen out of their body. But a lot of women, like you say, are just told, well, you can't have HRT, end of. And a lot of women I speak to actually have vaginal symptoms. So they have vaginal dryness or soreness or irritation. Sometimes that means they can't wear under clothes or they can't sit down because the pain's so severe or they get recurrent urinary symptoms. Yet these women are told they can't even have vaginal, which is localised estrogen.

So people are so scared. Whereas my patients, I'm never going to stop them rock climbing or skydiving or driving very fast if they want to. So it just doesn't quite seem right, Avram. Well, I think there are two issues. The first is the one we started with at the beginning, which said that if you want to prevent people from doing something, frighten them. And people are inherently risk averse. What we now know is that women who take hormones, not breast cancer survivors, but the general

population of women who take hormones have a 50% reduced risk of heart disease, a 50% reduced risk of hip fracture, a probably reduced risk, although there haven't been any randomized studies, of cognitive decline. And they live an average of 3.3 years longer. And yet, they don't want to go near hormones because of just the environment. that you're talking about. If we think for a minute, what would the situation be like

if we were talking about men and not women? Of course you laugh because it is so preposterous that we seem to be almost plotting against women's well-being. And that's so unfair. Do you think men would tolerate

hot flashes, difficulty sleeping, loss of sex drive, forget trying to get an erection. And by the way, if you do have sex, it's going to be painful, increased risk of heart disease, increased risk of bone fracture, and you prevent them from taking something that you know can treat that, just get out of the way. Men won't allow that. No. And I think women thinking about breast cancer as well, I've got a very good friend who's an oncologist, and he does a lot of work for men who have prostate cancer. And as you know,

some people, not all, but some of men who have had prostate cancer have hormone blocking treatment. And he was saying to me recently, oh, we've reduced a lot of men only have three years of treatment rather than five because the symptoms are so severe, the long-term health risks are so severe of blocking their hormones, so we've reduced it. Whereas a lot of women I see now are telling me that they're told they have to not take five years of hormone blocking drugs, but 10 years. And there's so much that's wrong. That's his gender disparity. There's no doubt. about it. The more I do this work, the more I think it definitely is some sort of female suppression. But why is it that we worry about men who have hormone-blocking drugs after prostate cancer,

yet we don't seem to worry about the future health of these women who have hormones blocked and then the others who will become menopausal and then not allow their own hormones back? And incidentally, the link between testosterone and prostate cancer is considerably strong. than the link between estrogen and breast cancer. And the data that we have right now suggests that estrogen reduces the risk of breast cancer. And although you and I can banter about this, I think it's important to realize that neither of us, nor is anybody certain of what all this means. And Carlo Rovelli is an Italian physicist, a quantum physicist, who is the easiest quantum physicists to read, and I read everything he writes. And he wrote, the search for knowledge

is not nourished by certainty. It is precisely the openness of science, its constant putting of current knowledge in question that guarantees that the answers it offers are the best so far available. And that's what we're trying to do without being didactic. Yeah. And I think that's so important. And I think it's, but it's also looking, people forget the pathophysiology, but they also forget the basic biology of estrogen. And when I say estrogen, I mean estradiol, which is our natural estrogen that we produce when we're still ovulating and how anti-inflammatory it is in the body. And it can do amazing things. And that's why we know women who take HLT for many years have a reduced risk of different types of cancers, don't they? And also, like you say, a reduction in risk of death from breast cancer. because it can actually induce something called apoptosis, which is program cell death.

It can modulate the way our immune cells work, which is very good for fighting infections, but it's also very good for reducing disease as well. And it used to be used as a treatment for breast cancer, didn't it, many years ago? It was the first treatment we had besides surgery, yes. And it had a 44% response rate when high-dose estrogen was used. And so what people who are opposed to HRT, and I specifically identify them as people who are less than open-minded, say is, well, those are high doses. But low-dose estrogen would be dangerous. Well, Craig Jordan is the father of tamoxifen.

And he found that when women become resistant to tamoxifen, many of them become sensitive to low-dose estrogen in its ability to control their breast cancer. We still have a lot to learn, but absolute statements have no place in this discussion. Yeah, which is so important. And then the other thing just to really touch on is testosterone, obviously, is another female hormone. We produce even more testosterone than estrogen before the manopause or when we're younger. And there is some work to suggest that women who've had breast cancer and take testosterone actually don't increase their risk further.

That's true. but there, and here we get into selective citing of literature, there were articles that suggest that testosterone might be a risk. It's not a clear picture. And so it's just important to tread very carefully through this minefield of data and share what you know with your patient looking at benefits and risks so that the best possible decision is reached between the two of you. Yeah.

I think that's so important. So before the nice guidance came out for menopause, so before 2015, I was a GP seeing lots of women for all sorts of reasons, but obviously menopause are women as well. And I would never, ever, ever have given HRT to women who've had breast cancer. And then I set up my clinic. I became a specialist. And I remember about three weeks after I started, this gorgeous lady came in to see me. And she'd had breast cancer and she wanted some HRT. And I was there on my own thinking, oh my goodness, what do I do? What do I do? So she'd had a hysterectomy a long time ago, so she only wanted a bit of estrogen. And she said to me, look, Dr. News and I had breast cancer eight years ago. In those eight years, I have really struggled, but I've given up my job because I can't work. My husband's left me. We had lots of arguments because my mood was so bad. We weren't having any sex.

The sex we had was so painful. And my life is really miserable. I've put on two stone and weight. I'm only 61. I do not know how I'm going to end the rest of my day. some of my friends take HRT and they really feel better and got more energy and motivation and so forth. But I've been told no by every single doctor, including my breast surgeon and my oncology team. I was wondering if you could help me. So I was there thinking, and I didn't know

you. I didn't have the luxury of knowing you at that stage, Avram. And I really didn't know what to do actually. But I felt she'd come a long way, actually. She'd traveled for three hours to come and see me. And I just said to her, look, there is no strong data either way. I actually don't know what to do. But let's talk through the worst case scenario is whether you take estrogen or not, your breast cancer might come back. And she said, but Dr. Newsom, I've had chemotherapy. I've had chemotherapy. I've had a mastectomy. I know how awful breast cancer treatment is. But I also know how awful my life is now. And I want anything I can do to improve it. I've tried antidepressants. I've tried clonidine. I've tried sage. I've tried acupuncture. I don't know what else I can do. So I said, well, look, I can give you some gel, some estrogen. gel, we can start with a very low dose. You are in control. You can have half a pump, a quarter of a pump, gradually increase, see how you feel. But you can stop at any time. And when you do stop, it will take a day or two to come out of your system. You're likely to have more estrogen in your body than you had eight years ago because you put on weight as well. And our

fat cells produce quite a nasty type of estrogen. So I'm prepared to take this risk if you're prepared to try. And so we had a very shared consultation. And she went away. with her jail and I just didn't sleep for weeks afterwards. I was very worried what I'd done. Anyway, she came back to see me three or four months later. She had lost a stone in weight. She had a massive smile on her face and she said, oh my God, I'm never coming off this. This is transformational. I'm so happy. I'm looking at a job now. I've now started dating someone. I cannot thank you enough. And my shoulders just probably went down about a foot because I thought, this is what medicine is about, actually. This is not textbook medicine.

This is a bit risky medicine, but actually it's about patient-centered medicine. And, you know, I've learned so much since that lady first came to seem, and I'm now very grateful for her teaching me, actually, how I can push boundaries a little bit and listen to the patients. As you know, I'm a medical oncologist. So I am the doctor who was responsible for catapulting many women into menopause. I use chemotherapy. that can induce menopause in many of the premenopausal women I saw. And when the women would complain to me, I would say, well, you're well, you're alive.

And, you know, basically deal with it. And I had to learn to listen to these women. I'm also a physician who counseled pregnant women who came to me with breast cancer, that they get an abortion. Because if estrogen is bad, we thought that pregnancy, while you have breast cancer is terrible. And many women followed my advice. And we now know that that's not true,

that pregnancy does not adversely affect the prognosis of breast cancer. So like you, I've been learning carefully, trying very carefully not to overstep what I know, but sharing what I know, both with peers like you and with the patients who come to me for advice. Which is pivotal. I remember a while ago you said to me really, you know, as healthcare professionals,

we're here as advocates for our patients. And I really strongly feel not just in women who've had breast cancer, of course not with every single patient I see. It very is crucial that they are put number one. And every consultation I have is different. And every need of a woman or a person is different as well. And their expectations are different.

And we now, as you know, have a lot of physicians that work with us in the clinic. And a lot of them are very scared and nervous about seeing their first breast cancer patient. And actually, a lot of women just come because they want to talk. They don't want to go away with a gel or whatever. They just want to know that there are options available to them, actually. And the door is open to them. And I think that's really crucial as well, isn't it? Perfect.

I couldn't agree more. So we need to do more work in this area, don't we have? And we really need to do a really good study. and I think women would really love to do it, actually, because they want to help others, and that's something that I'm hearing more and more, actually. Women who are suffering don't want others to suffer. But I think there's a lot of women who would be really keen to be in a study,

but we need to initiate something, don't we? As you and I have discussed, where do we go from here? You and I agree, and there are many people out there still the majority of practicing physicians who don't agree. And so what do we do? When you say the word study, obviously the gold standard for study is a prospective, double-blind, randomized trial, which means we have placebo pills or placebo gel. We have medicine, and women are randomized to receive either the controlled placebo or the gel. That is never going to work. We have 25 studies, at least three of them, did

that, and that's just not going to be repeated. We have all the information we're going to get. I can critique every study that's been done, but if 24 of the 25 show no increased risk of recurrence and no study shows an increased risk of metastatic recurrence and no study shows an increased risk of death, perhaps we can follow a less strict study. For example, Yes, women want to go on hormones, but we shouldn't just do it in an uncontrolled way. Let us follow all women who are put on this treatment after breast cancer. We should be able to amass huge numbers of women, even if it isn't controlled. We have very good control data.

We know the prognosis of women at each stage of breast cancer, how they're going to do based on their their treatment and the characteristics of their tumor. And we can compare the outcome with the women who we follow. And what's required is an informed consent form so that your colleagues who are concerned about medical legal ramifications of giving hormones can share the risk with their patients and protect themselves legally. And it also requires some form that can be used that is relatively simple, but will allow follow-up of these patients on hormones, so they're not simply lost to follow-up. And that way, we can at least get more information while providing the service that you and I and many other people around the world are straining to do as

effectively as possible. Yeah. And certainly that's something we're going to work on, Avram, very kindly as part of our advisory board for the Menopause Society that we have just set up through my not-for-profit. And we have some amazing people, but we're having a steering group to go forward in this. And I'm hoping over the next few years we'll have a lot more to report back. Wouldn't it be nice? We've got to start somewhere and I'm very keen to really work this. And we've got some amazing people actually. Obviously, you're on this group, but we've got a breast surgeon, we've got a few other oncologists. We've got oncology nurse. And actually, We've got some other menopause specialists, but crucially, we've got a patient.

One of my patients is coming on the group as well who has had breast cancer and has fought to actually keep her HRT going. And she was suicidal about her HRT. So we need to learn from women as well. That's really important with any research we do. And you and I aren't holding hands in the wilderness, Louise. There are physicians around the world who feel as we do, even though they're. they're outnumbered, many of them, highly respected physicians in their own countries and in their

field, both primary care physicians, breast cancer surgeons, medical oncologists who really want to see this happen. Yeah, absolutely. And we'll make it happen because we're not going to stop. So I'm very grateful for your time today, Abram. Before we end, I always do three take-home tips. And so you can't be excluded from me asking those. And I know what's going to happen. We'll put out this podcast and women will contact you or me or they'll put out on social media to say, but that's easy for you to say that. I don't know how to get help. What shall I do? So are there three things that you would suggest that women who have had breast cancer in the past, you just want to explore options, including HRT, what they could do? Well, first speak to your medical oncologist.

Second, I told you I'm writing this article which will be published in the Cancer Journal in the May-June edition of this year. And anyone who wants a copy of that article can contact you or me. Yeah, we'll put it up. We'll put it out. As soon as it's out, we can circulate it. And bring it to your physician. And if your physician disagrees, instead of just dismissing you, discuss the disagreement. what is the concern? And both you and I are available, not to give specific advice over the phone,

but to provide whatever additional information any patient or physician wishes. As you know, I published a book three years ago called Estrogen Matters, and I really wasn't going to plug the book, but I can't not do that with that question. Estrogen Matters was written both for the lay audience and for medical practitioners. It is heavily referenced so that you don't take my word for it. Everything that's stated in that book, which talks about the benefits and downsides of hormones, including a chapter on HRT for breast cancer survivors, is referenced so that it can be challenged. And since it was published three years ago, and this is something, my parents would get pleasure from, and sadly, neither of them are alive, but I mention it just

because it gives me some pleasure. Amazon rates books by how well they are selling, and they rate eight million books an hour. They follow eight million books, and they re-rate them every hour. And for the past three years, since this was published, Estrogen Matters has been rated in the top one-half of 1% of the 8 million books that Amazon carries, which means that people are reading it, doctors and patients, and we get calls from around the world, asking for more information, which we gladly supply, and one of our major information resources, Louise, is your website and obviously the information you post. And I have to mention that if I would write the book alone,

it would be very informative and heavily referenced and very dry and probably boring. And fortunately, I had a co-author, Carol Tavers, a social psychologist who is a rocket. And Carol makes the book so easy to read even funny in places. So it's called Estrogen Matters. It's published by Little Brown. Yeah, and we'll put a link to it in the notes at the end. And certainly we recommend, well, most of our patients have read it. And we now get to the stage where we recommend it certainly to our patients to have breast cancer. And they look, and they say, don't worry, I've already read it.

Whereas we're just around the time it came out. Obviously, they hadn't heard of it. So it's our Bible, and it's just fantastic for everyone. So I'm very grateful for your time today, Avram. And I hope I can invite you back with some more news and updates as to what we're getting up to behind the scenes. So thanks very much. It would be my pleasure. Thank you. Take care. For more information about the perimenopause and menopause, please visit my website, balance hyphen menopause.com, or you can download the free balance app, which is available to

download from the app store or from Google Play.