Quality of Life and Hormone Replacement Therapy in BRCA12 Mutation Carriers following a Risk Reducin

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Quality of Life and Hormone Replacement Therapy
in BRCA1/2 Mutation Carriers following a Risk
Reducing Salpingo-Oophorectomy (RRBSO). An
Evidence Based Review. Mary Shanahan Nurse
Co-Ordinator Familial Cancer Centre
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Clinical Research Fellowship

• Identify issue of clinical significance
• Evidence to answer the question

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Background

• Hereditary breast/ovarian cancer syndrome
• BRCA 1/BRCA 2 germline mutations
• High lifetime ovarian cancer risk (1065)
• Breast Cancer Risk - 80

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Mutation Carrier Family
Breast cancer dx 50
Breast cancer dx 36
Jane 38
Ovarian cancer dx 45
Breast cancer dx 37
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Ovarian Cancer / Risk Management

• Ovarian cancer often advanced stage at diagnosis
  
• Long-term survival is poor, primarily due to late
  stage at diagnosis
• Options for ovarian cancer risk management
• Screening ineffective (Evans, 2008)
• Surgery removal of fallopian tubes and ovaries
  (Risk reducing bilateral salpingo-oophorectomy)

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Surgery
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Current Practice

• Follow up of mutation carriers
• Focus on psychosocial issues
• Dissemination of genetic information
• Ongoing cancer risk management
• Post RRBSO Management
• Not coherent
• No specific specialist/speciality is
  responsible
• No established guidelines for management
  of acute and
• long-term effects

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Literature

• Databases
• CINAHL PUBMED GOOGLE SCHOLAR COCHRANE
  Database,
• and references of original articles .
• Key Words
• Prophylactic oophorectomy, menopause,
• hormone replacement therapy,
• osteoporosis

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Quality of Life
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Quality of Life
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Sexual functioning

• Decrease in sexual functioning
• Problems vaginal dryness
• painful intercourse
• libido decrease
• Management
• Systemic HRT not always effective.
  Madalinska et al, 2006
• Local estrogen systemic absorption may
  be a problem
• Replens gel just as effective as local
  estrogen. Bygdeman et al 1995
• Androgen testosterone

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Hot Flushes /Flashes
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Hormone Replacement Therapy
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Hormone Replacement Therapy

• Complex decision
• Uptake of HRT in this population is low
• Uptake related to
• physician advice
• severity of symptoms
• information they found themselves
• Reason for deciding against
• connection between breast cancer and
  HRT. Tiller et al, (2001)

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Osteoporosis/Risk Factors

• Early menopause
• Oestrogen withdrawal
• Decrease in bone mass (fracture risk )
• Bone loss 2-3 fold greater than in women on
  natural menopause. Hadjidakis et al, 1999.
• Cigarette smoking
• Low levels of Vitamin D/Calcium
• Lack of exercise
• Bone mass measurement Dexa scan

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Osteoporosis Prevention Key findings

• HRT - Preserves bone mass
• WHI trial fracture rate lower by 24 in HRT
  cohort compared to placebo.
• Exercise - slows bone loss
• Aerobic/Resistance /Walking / -more effective
  when compared to no exercise. Boniauti et al,
  2002.
• Exercise maintains bone mineral density -3 yr
  longitudinal study in early post menopausal
  women.
• 
  Engelke et al, 2006

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Calcium /Vitamin D

• Calcium requirements change at menopause
• Increased bone resorption / intestinal
  absorption decreases
• Vitamin D affects
• calcium absorption,
• very little in foods
• insufficient exposure to sun
• Australian levels low. Shrapnel et al
  (2006).
• Use of Calcium or calcium in combination with
  vitamin D supplementation to prevent fractures
  and bone loss in people aged 50 years and older
  a meta analysis Tang et al, 2007.

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Summary

• Research limited on acute and long term effects
  of premenopausal RRBSO.
• No specific guidelines on hormonal/non hormonal
  management in HBOC
• Recommendations based on research breast cancer
  survivors /natural menopause

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Recommendations

• Acute symptoms
• Accurate cancer risk assessment presurgery
• Preparation pre-surgery
• honest discussion about symptoms
• Management options
• Management of symptoms-non pharmocological
• Systemic HRT
• Bone Health
• Available specialists with an interest in
  menopause and its management

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Future Plans

• Imperative need for research into needs and
  ongoing clinical management of this group
• Peter Mac study underway -needs assessment
• Overview of management options post BSO
• Acute menopause symptoms
• Osteoporosis prevention