Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Prescribing Menopausal Hormone Therapy in Breast Cancer Survivors
Unlock the complexities of menopausal hormone therapy for breast cancer survivors in this episode of the Speaking of Women's Health podcast. Join Host Dr. Holly Thacker and her esteemed guest, Dr. Holly Pederson, as they navigate the intricate world of genetic testing and its crucial role in guiding treatment decisions.
Dr. Pederson, a leading expert in the field, emphasizes the importance of revisiting genetic tests conducted before 2013 to ensure breast cancer survivors receive the most informed care. They explore the advancements in genetic science and discuss the layers of genetic risk, revealing how these insights can revolutionize both treatment and screening practices.
Their conversation further examines the challenges faced by elderly women considering hormone replacement therapy. This episode offers a thoughtful reflection on the unique considerations for breast cancer survivors, especially those with BRCA mutations, and the importance of individualizing patient care.
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I am back in the Sunflower House for a new episode in Season 3 with a guest we've had before, dr Holly Peterson, and we are going to talk about prescribing menopausal hormone therapy for breast cancer survivors. And we've had a lot of discussion about genetics in the past breast cancer, genetics, hormone therapy, breast cancer survivors but we're going to specifically talk about the use of hormone therapy Now. Dr Peterson is a professor of medicine at the Cleveland Clinic Lerner College of Medicine here in Cleveland, ohio, and she is a board-certified internist and the former director of the medical breast program at the Cleveland Clinic, where she actually essentially founded this program, and she serves as a professor of medicine and she's actively involved in very interesting clinical research and has a co-appointment in the Lerner Research Institute and has a co-appointment in the Lerner Research Institute.
Speaker 1:Dr Peterson graduated Phi Beta Kappa from the University of California, santa Barbara, in biochemistry and molecular biology, and then she completed both an internship and a residency at the University of California, san Francisco, where she earned the distinction of Alpha Omega. Alpha Additional education includes clinical genetics fellowship at the Cleveland Clinic in 2008 and the City of Hope course in cancer genetic risk assessment in 2017. She has served on the prestigious National Comprehensive Cancer Network, risk Reduction and Genetic Committees and she speaks nationally and internationally with a specific focus on the management of women and high-risk patients for breast cancer genetics, and she's also developed an internal fellowship for training medical breast clinicians, a program which she helped create. Welcome, dr Peterson, it's great to have you on the podcast again, thank you so much for having me back.
Speaker 2:I really appreciate it on the podcast.
Speaker 1:again, thank you so much for having me back. I really appreciate it.
Speaker 2:So we have so many similarities. You know I wanted to mention something. I just wanted to mention something. I listened to your Highlights of the Year podcast and it was just fabulous recently about all of your podcasts. I think it's just great that you're doing this and raising awareness about so many different issues. Just because I have to say something about genetics. You know the guidelines are becoming complicated and really most women who develop breast cancer should look into genetic testing. That's sort of you know. Unless you're over 65 and qualify for genetic testing based on previous guidelines, all women should really investigate it, and so I wanted to kind of make that a little bit more clear for women. And if you were tested before the fall of 2013, the testing has improved drastically, so come on back. Just had to throw that in, I'm sorry.
Speaker 1:Yes, no, no. That is very important and we've made that point, and I always like to go back and look when I'm seeing patients in the clinic, because a lot of people can't exactly remember when they had the testing, and I think it's important. Even though it's uploaded electronically, people should really keep their hard copies, I think, because they may move and change and we're expecting, of course, continued advances in this very important field. I was just going to say, going over your bio, we have so many similarities, not just our first name and our similar age, and that we have three adult, wonderful children both.
Speaker 1:AOA and both founding a really kind of innovative interdisciplinary women's health kind of having the vision to see that different fields need to come together for the benefit of the female patient. And so kudos to you and all of your expertise, and hopefully we'll have some time to talk about your recent award and some of your recent research. And I know that this podcast is primarily for any woman or any person anywhere who wants to listen, and it's free. You can hit, subscribe or follow anywhere you follow podcasts, but we do have a lot of physicians and nurses and clinicians who do tune in, so sometimes we go to some higher level things, but I think it's a benefit for everyone. So I wanted to say congratulations. I understand that you have retired from clinical practice, but not academic practice. Is that right?
Speaker 2:Yes, I'm still doing research and education, thank you.
Speaker 1:And that is so important. But certainly if there's any listeners that want to come to the medical breast program, we have several people available, including a lot of protégés and people that have trained under Dr Peterson, so I think that is so important. So, before we talk about our major that's a great program.
Speaker 2:You know, I was just going to say the medical breast program. You know it provides diagnostics, personalized team and the team is wonderful and they continue on with clinical practice. But I'm currently myself not practicing.
Speaker 1:And I wondered if you wanted to talk a little bit about Karis Eng. Dr Karis Eng, an MD PhD. She was certainly my son Stetson Thacker. Dr Stetson Thacker, who's been on our podcast, who's a PhD in molecular medicines mentor, and I know she was a mentor to you and so many people and she passed last year.
Speaker 2:It was a rough year. We lost both Dr Joseph Crow, who founded the Breast Center, in February another medical giant and Dr Karis Eng in October. Both too soon and very, very sad losses. But you know, for personally and professionally they were outstanding mentors and teachers, and scientists and physicians and scientists and physicians.
Speaker 1:Yes, dr Crow I stood by him and Dr Alice Rim, in charge of our breast imaging, in 2002 when we opened our Center for Specialized Women's Health and really expanded upon not just having breast services but having other specialty services. And Dr Eng has won so many national awards and made so many original discoveries, so it's really quite a legacy, and we certainly have, don't? We have the world's leading experience in nipple sparing, mastectomy and reconstruction.
Speaker 2:We do you know, our genetic and genomic program is really unparalleled and the Breast Center, with its multidisciplinary approach, has really been on the cutting edge in many fields and certainly in the field of nipple-sparing mastectomy. We probably have the largest single institution experience in the world, you know, demonstrating the safety of nipple sparing mastectomy even in very high risk patients.
Speaker 1:And such wonderful outcomes.
Speaker 1:And I even have some patients who volunteer to come in and see other patients who are thinking about this, to actually in the exam room give them a little look about how wonderful the cosmesis is.
Speaker 1:So I think that for women who have to deal with breast cancer, so many of them can live completely full lives, not miss a beat.
Speaker 1:The therapies are so much more targeted, outcomes are improving and many women who are young women go on and have children, and women who don't want to have further children or are past that stage in life or interest can move into midlife and beyond and expect to have the same type of life as other women. And so, since in the last 15 plus years we've had increasing research that shows that menopausal hormone therapy is really the thing that we offer to midlife women that extends life and reduces disease burden, and I've always been a proponent of just because you might have been unlucky enough to have severe problems maybe needing an organ transplant, maybe having cancer, maybe having had a heart attack or serious blood clots, yeah, or vascular problems that those women shouldn't be further denied other common therapies. So that gets us into using menopausal hormone therapy in breast cancer survivors, something I've done for essentially my whole career, but I think it's catching on a little bit more, and I wanted you to talk about it from your breast perspective.
Speaker 2:You know I mean breast cancer is the most common cancer in the United States and worldwide, aside from skin cancer, and the good news is is that treatments are improving and mortality is improving in all different types of breast cancer. And it's important to remember that breast cancer is not just one disease. It's a group of entirely different diseases that have entirely different rates of recurrence and patterns of recurrence and methods of treatment and methods of surveillance. But what we do know we know a couple of things and you bring to light very important points is that we have more and more survivors and we have more and more young survivors. And we also know that most women who have breast cancer don't die from breast cancer. They actually are more likely to die from cardiovascular disease or stroke.
Speaker 2:And in women who are long-term survivors of breast cancer, we have had a dogmatic approach in our multidisciplinary community to absolutely not consider systemic menopausal hormone therapy in a woman who's had a history of breast cancer due to concern, and it's largely based on theoretical concerns and not actual medical data.
Speaker 2:But we don't want to do any harm community in terms of hormone replacement following a breast cancer diagnosis.
Speaker 2:But this question is far from answered and I think that you know. It's just fascinating that you've been taking women individually, looking at their personal risk for developing a new cancer, their likelihood of being at risk for developing another cancer, looking at the type of cancer that they had, how they were treated, whether they responded well to treatment and how far out they are from their cancer. And you've made the decision, the judgment call, in those situations, with a woman understanding all of those factors, she may choose, when she exhausts non-hormonal methods of, you know, controlling menopausal symptoms, to consider hormonal menopausal hormone therapy, to consider hormonal menopausal hormone therapy, and it really has. You've been a trailblazer in this field. In fact, there was a recent study published by Dr Cheryl Kingsberg at UH, who dida survey of oncologists and oncology patients and actually found you know, in the real world about 15% of breast cancer survivors in that cohort were currently taking systemic menopausal hormone therapy. So you're not alone, and hopefully you will be less alone as time goes on if we're able to answer these types of questions.
Speaker 1:It's so interesting because I think that it's twofold why there's been this hesitancy. Well, it's probably threefold. One, I think women tend to be more anxious, and so if the patient's projecting anxiety and the physician or the clinical team wants to do no harm, they pull back. So part of it is the woman. I think a second part of it has to do with subtle ageism, in that we accept risk for younger women, for instance with hormonal contraceptives which have a higher rate of blood clot, and then we accept like hardly any risk or zero risk with menopausal hormones, and everything has a risk Driving to your doctor's office has a risk. So this misunderstanding of risk, absolute and relative risk is another factor, and the fact that we allow younger women who have more life to live, to undergo therapies if they want to control their reproductive life, prevention of pregnancy. But then at menopause, if you've lived long enough to lose your hormones, we say oh, too bad, too bad, suffer. And so I think that's a big problem. And young women who've had breast cancer after their treatment they can go on and get pregnant if they want to. And that's way higher levels, much higher levels than what we would ever do for menopause. And so I think, having more of this perspective and also understanding that the average man who's older than a woman, who's post-menopausal, has more estrogen than she has. How is that fair? That's how I got involved in this field, Because I just thought it was so unfair.
Speaker 1:And you're listening to the Speaking of Women's Health podcast. I'm your host, Dr Holly Thacker, the Executive Director of Speaking of Women's Health. I'm at the Center for Specialized Women's Health and I run our Specialized Women's Health Fellowship. And I am speaking to special guest. Dr Holly Peterson, who founded our Medical Breast Program, is a medical breast high-risk breast cancer expert and has done some cutting-edge research. And we're talking about safety, risk benefits, alternatives, exceptions to menopausal hormones. I want to talk a little bit more, first about risk assessment and your recent research. Tell me about that combined risk score and what your research found and how it's one of the top 10 advances in genomic medicine.
Speaker 2:Well, you are so funny. I just love the way your brain works. I mean, you've brought up at least 15 topics in that little blurb there. But you know, when you're talking about risk, you need to assess your own risk and we'll talk about that but you need to also, whenever you attend a medical visit, look at the risks of doing something and look at the risks of not doing something, because that's actually relevant here.
Speaker 2:You mentioned that estrogen is the most effective therapy for menopausal symptoms. We do know that women who undergo early surgical menopause or early iatrogenic menopause Maybe what that means is we cause the menopause, maybe by either surgery or chemotherapy, but those women we know are at risk for early cardiovascular disease and accelerated osteoporosis, amongst other things. And so young women who undergo iatrogenic menopause at an early age are certainly at higher risk of those issues. And so, while we need to worry about estrogen per se but that's debatable and we'll talk about that we also need to be cognizant that these young women should have estrogen in their bodies and we may be contributing to cardiovascular disease and osteoporosis by withholding it in some situations. Now, in terms of risk assessment young women really just a risk assessment is just to look at their family history very carefully and look for red flags. That might be a sign of, you know, of hereditary syndromes, but also just of being at higher risk for breast cancer. The things that we can all do are achieve and maintain our ideal body weight and limit alcohol consumption. But if there's a family history of early breast cancer, say, you know, under the age of 50, or ovarian or pancreatic cancer at any age metastatic prostate cancer, multiple primary breast cancers, male breast cancer, as you brought up, Ashkenazi, Jewish ancestry as there may be a one in 40 chance of carrying a BRCA mutation, women need to be inherently aware that they may be at much higher risk than another woman. Now that doesn't necessarily mean that they would not be eligible for hormone therapy, for hormone therapy, either contraceptive or menopausal, but a woman should know that she is at a baseline higher risk. When you talk about the combined risk score or a way to further substratify your risk the youngest women we really just ask about family history. Then, when women get a little bit older, say in their 30s, we can use mathematical models like the Tyra Kuzik model out of the United Kingdom to further estimate their risk using traditional risk factors.
Speaker 2:But what we've added to that is adding your own genetics into the mix, you know, because that's just a mathematical calculation, and what we've learned is that there are essentially three layers of genetic testing, if you will. There's the highly penetrant genes like BRCA1 and BRCA2 and PALB2. There's also in that group that are more rare CDH1, STK11, TP53, and P10. Those are all just alphabet soup, but those are the real bad genes and the most important of those are BRCA1, BRCA2, and PALB2. There's another level of genetic abnormality seen in moderate risk genes such as CHECK2 or ATM, and the risk that's conferred by those genes is similar to that of like. If you have a benign biopsy showing atypical hyperplasia, it's not as much of a red flag as you might see with someone who has triple negative breast cancer at age 35. That might be a sign of BRCA1. But many people carry these ATM and CHECK2 mutations. They're not uncommon and they may be causal.
Speaker 2:But what we've discovered is that there's a third level of genetics that's kind of like noise at the bottom.
Speaker 2:There's over 300 single nucleotide polymorphisms that have been linked to breast cancer, that are independently inherited from each parent, and so your complement of those 300 SNPs might be totally different from a sibling of yours, and that polygenic risk score, which is a weighted aggregate of the effects of those SNPs, which needs to be calibrated by ancestry, gets pretty complicated. That polygenic risk score, in combination with the mathematical risk model, can really help to further substratify women and what we found is that in looking at young Black women and young Hispanic women who develop breast cancer, lo and behold, 50 to 60% of those women had no family history of breast or ovarian cancer in a first or second degree relative, but their polygenic risk score was very different from even women who qualified for genetic testing and were also black or Hispanic but had negative genetic testing and didn't get cancer. So the ones who got breast cancer were very different in terms of the polygenic risk score from the ones who didn't get cancer and this may change our whole screening paradigm.
Speaker 2:Ultimately, you know, we may start looking at younger women and offering them not only genetic testing for the highly penetrant and moderately penetrant genes, but perhaps even in the future, offering this test to see what women might require more close surveillance, say with breast MRI. So that's really what my research pertains to, not so much with the question at hand with hormone in the breast cancer survivor, but it is important for that survivor to risk stratify. I think that that's one of the first things a practitioner has to think about when she's looking at a breast cancer patient who's contemplating hormone therapy is what is her level of risk? And you can't use the risk models with breast cancer patients because they're not designed for that.
Speaker 2:However, the polygenic risk score has been used experimentally in several studies and predicts the likelihood of developing a new cancer on the other side. That's been shown in three separate studies, and so the polygenic risk score can substratify risk in the general population within a gene. Say, if you had checked to, you can check your polygenic risk score to see whether you're higher or lower risk within that genetic group. It can be used to potentially identify low risk women in the long run, to potentially identify low-risk women in the long run, we're hoping. But it also can help newly diagnosed patients, not currently in the clinical setting but in the research setting, to identify their risk for contralateral disease. So it's very exciting technology. You're going to see it in all disease states. It's not just breast cancer, it's not just cancer. You're going to see it in heart disease, diabetes. These polygenic risk scores are going to help you to stratify your risk in a lot of different areas.
Speaker 1:That is so interesting. Do you have any predictions about when you think that this will be more standard practice and recommended by the NCCN?
Speaker 2:So the validation studies date back to 2015. We really have had solid validation studies for a very long time, but the National Comprehensive Cancer Network, or NCCN, has concerns about which PRS to use. Some of them are not validated in different ancestries because these tests were originally developed and validated in Caucasian women of European descent and the risk of these different SNP alleles, the different SNP DNA pieces, the risk is different in different ancestries and so you have to account for that and not all of the tests do. The other issue is that many practitioners don't really understand how they would use this going forward, and until there are clear guidelines to help practitioners, help patients, make those decisions, we're not going to see it in clinical care. You know, maybe in about, if I were to guess, three years or so. Three years or so although clinically they are available but they're not recommended by governing bodies at this time.
Speaker 1:I have to say in my own experience, because years ago, I mean before, we understood the benefits of longevity with menopausal hormone therapy and post-Women's Health Initiative, when there was all this media on a scientific study but kind of non-scientifically communicated to the public, that caused a lot of anxiety where a lot of women threw away their hormone therapy. I would regularly do the Gale model or sometimes the Tyler Cusick model and calculate how long they had been on hormones. We even offered for a point in time breast ductal lavage to see if we saw atypical breast cells. To try to encourage women for chemo prevention, because there are agents that are approved. To try to encourage women for chemo prevention because there are agents that are approved to take to reduce your risk of being diagnosed with breast cancer without any evidence showing that it reduces death rates. But I found that kind of an unsatisfying type of practice because some of the highest risk women I identified were not interested in any kind of preventive treatment. And so I think on a population level yeah, for education.
Speaker 1:Like people, women I think, are usually pretty invested in having a pap smear to screen for early cervical cancer and I think more and more we're trying to get to that 80% threshold in adults over 45 to screen for colon cancer, colorectal cancer. I think most women are pretty accepting of the mammogram and breast imaging, which I know we have differences of opinion in imaging, just because I do see the problem of over diagnosis because then women don't want hormone therapy or they stop their hormone therapy. Like I've got a patient coming in who's past the age that we even do screening by the American Cancer Society, but she had to have her mammogram because she's so healthy, because she's been on hormones for 35 years and of course there's an abnormality, of course there's a biopsy, it's not cancer but you know she's at increased risk, which of course a woman of advanced age just age alone is at an increased risk. So when there's not really good understanding, I don't think amongst not just patients but people in the medical field about what that risk actually translates to. It causes so much anxiety.
Speaker 1:One thing that I do is, especially when I see a younger woman who's diagnosed with breast cancer, is there are younger women who are not prevented from having their own ovarian hormones, based on the type of cancer or it being estrogen negative. Or maybe they've undergone therapy that stopped their period for a while but then they resumed ovarian function and they continue to have their own hormones until the age of menopause. And then they go into menopause and then they think they can't have hormones, even though they just had it for the last 10 years. Or I see women who may be in menopause but they saved some embryos and they got pregnant because they wanted to be a mom. They had really high estrogen levels for nine months and felt terrific and then postpartum if their ovaries didn't start working again, which many times is the case. All of a sudden, horrible hot flashes and the women don't even want to accept local vaginal estrogen, which we offer to women, even undergoing active breast cancer treatments if needed. So I wondered if you had any perspective on that.
Speaker 2:On those next 10 questions. All right, I'm going to start with the sensitivity of screening mammography in elderly women. There have been no studies of mammography in women over the age of 75. And major radiologic associations like the American College of Radiology, because the sensitivity is so good when the density goes down, most of the you know of the prominent experts in that field feel that probably it's okay to continue mammography till 90.
Speaker 1:I know you're going to kill me, but don't, don't don't start now I want to, I want to address some of your other questions, so you know, and I think that's fine if women do that, but I just don't want them coming crying to me when they're told that they can't be on hormones anymore. And they have zero symptoms and we can't tell them that it's, that it's not a false positive.
Speaker 2:Yeah.
Speaker 1:Yeah.
Speaker 2:Yeah, you know, and there are fewer false positives in the older women but anyways let's return to our topic, which you know you. You know so much about the history of the women's health initiative study and what happened with that, and I'm going to try to summarize it in a brief way. But you know, when did you start at the clinic, holly I?
Speaker 1:joined the staff in 1990., 1990.
Speaker 2:Okay, I came in 1997.
Speaker 2:And so we were both really in on the beginning of all of this.
Speaker 2:You know, in the early 90s I think it was 1992 when the Women's Health Initiative study started you know, the largest study in women ever performed, $700 million or so where really the question was to answer whether menopausal hormone therapy reduced the risk of cardiovascular disease.
Speaker 2:And so, rather than choosing the appropriate age of women to really answer hormonal questions they included the majority of women were over the age of 60, smokers, overweight. They were really looking at a different question, and in 2002, the study was suddenly stopped because there were big media releases that there was a 26% increase in breast cancer risk with hormone replacement therapy, as it used to be called, and what they didn't talk about, as you mentioned initially, was the increase in absolute risk that that may confer to a woman. Risk at the age of 50 is 1.3% or 1.5% over the next five years. If she increases her risk over the next five years by 26%, she goes from a whopping 1.5% to a 1.7% or 8%, which most women will accept in terms of absolute increase in risk. If this had been explained in 2002, I don't think that we would be sitting and having this discussion in 2024. And, in fact, what they show- 2025,.
Speaker 1:We're in 2025.
Speaker 2:2025,. Oh no, you're going to send my checks back. No, so it's fascinating because in 1994, a paper was published saying estrogen replacement therapy in breast cancer survivors. It's time to look at this. This was in 1994. And many trials started looking at this question would it be okay to consider hormone replacement in breast cancer survivors? And unfortunately, most of those trials were stopped. When the Women's Health Initiative trial was stopped because everyone was nervous about continuing several prospective studies which failed to accrue the appropriate number of patients and really didn't answer the questions that they set out to answer, and we're now making clinical decisions without the data that we need. I think that the most important part of this question is that we need further study in this area, but what we do know is not as ominous as most people think, and I wanted to kind of go over that with you.
Speaker 2:So you know, one thing is that we allow women who have invasive breast cancer, that's estrogen sensitive, to stop their hormonal therapy, their endocrine therapy, their tamoxifen or aromatase inhibitor therapy, in order to have a baby and breastfeed. And that's a very high hormonal state to have a baby and breastfeed and that's a very high hormonal state. You were mentioning that. We allow them, you know that opportunity, or encourage it, following their treatment. We actually allow it in the midst of their treatment.
Speaker 1:And those women have been shown, yeah, to do.
Speaker 2:Well, you know. And the other group that you know is reassuring is the patients with the highly penetrant gene mutations, patients with BRCA1 and BRCA2, who are at very high risk when we recommend that they have their tubes and ovaries removed because there's no good screening for ovarian cancer. We have been giving routinely menopausal hormone therapy back to those women and have not shown an increased risk of breast cancer. Those are the highest risk women that you're going to find. Women who do not have a genetic mutation, who have survived breast cancer, have about a 0.4% per year chance of having another breast cancer develop, and so it's very, very low and most people don't realize that. But if they do have a genetic mutation, of course their likelihood, if they retain their breast tissue, is higher. But you know the treatments are better. Women are more likely to be cured of this disease.
Speaker 2:You know we do give estrogen. You know we allow high estrogen states like pregnancy, even in the midst of cancer treatment, and the BRCA population tolerates menopausal hormone therapy very well following their risk-reducing surgery, and we give it to the time of natural menopause in women who haven't had breast cancer. Perhaps we should be giving that longer, and that's another question that I have in terms of these women, but you brought up what about the woman with ER negative disease or breast cancer that does not express the estrogen receptor? Would it be okay, in those women who have invasive breast cancer that's estrogen negative, to consider hormone replacement therapy earlier? My argument is no. I want to go over the different types of breast cancer and their typical recurrence patterns and rates. Dcis or ductal carcinoma in situ, which is stage zero breast cancer, it's just stage zero the potential to well, I believe it's breast cancer, but that's a different.
Speaker 2:That's a different if you don't undergo radiation. There's about a 30% local recurrence rate and 15% and 50% of those are invasive. So it's hard for me to not classify it in the cancer you know category when you have invasive recurrences occurring 50% of the time. But anyways, distant recurrences are very rare less than 2%. So a woman who is several years out from a DCIS diagnosis, you know is very different from a woman who has has stage two ER positive disease, you know, who is in the midst of therapy and there's everything in between.
Speaker 2:So there's triple negative breast cancer and HER2 positive breast cancer which usually occur, recur, if they're going to recur in the first five years and typically in the first three years.
Speaker 2:And so a woman who's five years out from ER negative breast cancer or HER2 positive breast cancer, you know, is in a good place. We don't have data that hormone's okay, but we know that she's in a good place in terms of her breast cancer diagnosis. With estrogen sensitive, her2 negative breast cancer the tail for recurrence goes out much further and those women need to understand that they might have a recurrence completely unrelated to hormone replacement or no hormone replacement because of their original disease. But let me tell you something about ER negative disease that bothers me in terms of saying, oh, it must be okay because it doesn't contain estrogen receptors. Women with BRCA1 mutations who have triple negative breast cancer and have their ovaries removed in the first year have a markedly improved survival rate as compared to women with triple negative breast cancer and BRCA1 who have their ovaries removed much later, and that makes me worry a little bit.
Speaker 2:There's something, and it may not be the estrogen, but there's something about the absence of the ovary that is promoting better breast cancer survival, and so there's something about that that gives me pause about estrogen replacement right away.
Speaker 2:Now, you know, five years in it, you know, with a triple negative breast cancer it's a completely different discussion. But I don't think that one can just assume that if it's estrogen receptor negative, it's okay, because there are. There are just different things that we've found. For instance, there's an Amerindian snip that's found in the Hispanic population that is protective from breast cancer. What it does is it lowers estrogen levels and lowers breast density, but it prevents triple negative disease, you know. And so there's a lot about that that we don't understand, and so I do have a little hesitation where many people don't because of those issues. You know, a patient with DCIS or who's five years out from triple negative disease or HER2 positive disease, or a person who's ER positive, HER2 negative, who's doing very well and has a very low likelihood of recurrence and is five years out, you know, those are the patients I believe that we should start with and be talking to and be enrolling in clinical trials.
Speaker 1:So this has just been such an excellent discussion and we'll have to bring you back on Dr Peterson and maybe even have you guest host for me, because you call yourself the other Dr Holly, so that would be wonderful.
Speaker 2:Oh, I'd love to do that.
Speaker 1:It's great to get other perspectives of really experienced clinician scientists, scholars and leaders scientists, scholars and leaders. I would mention to our listeners who are physicians and clinicians that we have a section on speakingofwomenshealthcom under tools for physicians, including links to CME, including links to menopausalearningorg, where we have some lectures that you could view of a breast oncologist talking about the use of hormone therapy in breast cancer survivors, as well as heart disease and many other topics. So thank you to our listeners and to Dr Peterson for joining us on the Speaking of Women's Health podcast. Please subscribe on Apple Podcasts, spotify or tune in or wherever you listen. Share the podcast, give us a five-star rating and I hope you'll tune in for future episodes. Remember be strong, be healthy and be in charge. Thank you.
