Study finds important differences in the way clinicians understand and treat early menopause after breast cancer

Hormonal treatment for breast cancer causes menopause in over 80% of women in the first year of therapy, but now new research, published in the peer-reviewed journal Climacteric, has found that how these women are diagnosed and treated for menopausal symptoms can vary substantially according to which type of doctor a woman sees.

Treatment for breast cancer usually causes premenopausal women to suddenly enter the menopause. For these women symptoms are generally more severe, with an abrupt and early onset of menopause which impairs quality of life. In addition, if a woman has gone through the menopause then some breast cancer treatments, designed to block the effect of the hormone estrogen, can make the menopausal symptoms significantly worse. Up to 20% of breast cancer patients consider stopping their breast cancer blocking hormonal treatment because of severe menopausal symptoms, putting women at greater risk of breast cancer recurrence. Now a group of Australian researchers has produced new data showing how different doctors diagnose and treat menopausal symptoms. They found that there are significant differences in approach between different medical specialities, meaning that many women may not always be getting consistent treatment.

A team led by Professor Helena Teede (Monash University) sent out detailed questionnaires to 300 clinicians who work with breast cancer patients. 151 replied, including 35 endocrinologists, 36 oncologists, 35 gynaecologists, and 35 breast surgeons. 35 GPs also participated. The questionnaire presented case scenarios of women with breast cancer and asked doctors how they would diagnose and treat menopausal symptoms in these breast cancer patients. In many cases, the differences in how doctors responded were significant. For example:

• 43% of breast surgeons would consider prescribing HRT, which is generally considered as contraindicated in women with breast cancer, as opposed to only 17% of gynaecologists.
• 34% of breast surgeons would consider not treating what were presented as severe menopausal symptoms at all, compared with only 6% of endocrinologists or 11% of GPs who would not treat.
• Despite a lack of evidence of efficacy, and potential concerns around safety, around half of endocrinologists, gynaecologists, and breast surgeons considered recommending complementary or alternative medicine for menopausal symptoms, whereas only 9% of GPs considered this option.

The study also found that there were significant differences in how doctors decide whether a woman has entered the menopause. Absent menstrual cycles (amenorrhea) is the most common way to diagnose menopause, and was used by 86% of endocrinologists and 57% of GPs. However because of the effect of breast cancer treatments and rapid symptom onset in this population other diagnostic approaches are also used; for example all (100%) of the oncologists in the survey used blood FSH and estrogen concentration as diagnostic indicators, whereas only 46% used FSH and 9% used estrogen levels among GPs This approach of measuring hormone levels for diagnosis is not commonly used unless a woman has breast cancer, and even in this population this is just one factor which can be considered in diagnosing the menopause.

Perhaps surprisingly, the gender of the doctor also made significant differences to the diagnosis and treatment, with male clinicians more likely to prescribe no treatment, HRT, or complementary/alternative therapies than female clinicians.

Commenting on the findings, Professor Teede said:

"This is an exploratory study, which shows some encouraging results in terms of clinician awareness of menopause symptoms in this population. However, there were significant differences in approach to diagnosis and in treatment, depending on which type of clinician was responding. In addition, male doctors tended to diagnose and treat differently to female practitioners. Ideally consistency of practice and alignment with evidence based best practice is needed in this area. If not managed well, implications can include debilitating symptoms, and a negative impact on quality of life, with many women stopping important cancer treatment because of worsening menopausal symptoms.

We think this is the first study of its kind, so we need to confirm the results with larger studies in other countries. These initial findings point to the need for more awareness and education, for both affected women and doctors, and for more accessible widely understood guidelines. This work also suggests that a multidisciplinary approach to treating younger women with breast cancer is needed".