Estrogen replacement in surgical stage I and II endometrial cancer survivors

doi:10.1016/S0002-9378(96)70027-3

American Journal of Obstetrics and Gynecology

Volume 175, Issue 5, November 1996, Pages 1195-1200

https://doi.org/10.1016/S0002-9378(96)70027-3 Get rights and content

Abstract

OBJECTIVE: Our purpose was to evaluate our experience with estrogen replacement in women with a history of early-stage endometrial cancer and to determine whether it increased the risk for recurrence or death. STUDY DESIGN: A retrospective review was performed of 123 women with surgical stage I and II endometrial adenocarcinoma treated between 1984 and 1994; 62 had received estrogen replacement therapy after cancer therapy. Sixty-one women received no estrogen. Variables analyzed included age, parity, surgical stage, grade, depth of myometrial invasion, presence of intercurrent illnesses, duration of follow-up, and duration of estrogen replacement, if applicable. Outcome variables assessed included recurrence rate, time to recurrence, and disease-free interval. RESULTS: The estrogen replacement therapy group had earlier stage disease (p = 0.04) and less severe depth of invasion (p = 0.003); however, the total number of deaths in each group was not significantly different. The disease-free survival in the estrogen replacement therapy group did not differ significantly compared with those not receiving estrogen replacement therapy. The data are suggestive of improved disease-free survival in the estrogen replacement therapy group, which may be related to differences in age, stage, grade, and depth of invasion. The overall recurrence rate was 6.5%, with an overall death rate of 1.6%. CONCLUSIONS: There is no evidence to suggest that estrogen decreased the disease-free interval or increased the risk for recurrence in early-stage disease. (Am J Obstet Gynecol 1996;175:1195-200.)

Section snippets

MATERIAL AND METHODS

Patients with clinical stage I and II adenocarcinoma of the endometrium who underwent all or part of the primary treatment at the University of California Irvine Medical Center and Long Beach Memorial Medical Center Women's Hospital between January 1982 and January 1994 were identified. These patients were followed up by two of the authors (P.J.D. and M.B.) and were obtained from the tumor registry and cross-referenced by office charts. Exclusion criteria included advanced-stage disease

RESULTS

A total of 123 patients were identified during this interval; 62, or 50.5%, were found to be receiving estrogen replacement postcancer therapy. The remaining 61 (49.5%) patients received no estrogen and were used as controls. Of the 62 women receiving estrogen replacement, 33 (53%) received combination estrogen and progesterone therapy. Fifty-seven (92%) received oral conjugated estrogen therapy, 1 (2%) patient each used the estrogen patch or vaginal estrogen, and 4 patients (5%) used a

COMMENT

In our population of women with surgicopathologic early-stage adenocarcinoma of the endometrium the overall recurrence rate was 6.5%, with an overall death rate from disease of 1.6%. The overall survival of early-stage adenocarcinoma of the endometrium is consistent with reported survival rates.2, 3

The prescribing habits of the two authors most likely accounts for the selection bias, which is reflected in the differences between the control group and the estrogen replacement therapy group. One

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The limited data suggest that women with low-grade, early-stage endometrial cancer may consider systemic or topical estrogens. However, menopausal hormone therapy may stimulate tumor growth in patients with more advanced disease, and non-hormonal approaches are recommended. Uterine sarcomas may be hormone dependent, and therefore estrogen and progesterone receptor testing should be undertaken to guide decisions as to whether menopausal hormone therapy or non-hormonal strategies should be used. The limited evidence available suggests that menopausal hormone therapy, either systemic or topical, does not appear to be associated with harm and does not decrease overall or disease-free survival in women with non-serous epithelial ovarian cancer and germ cell tumors. Caution is required with both systemic and topical menopausal hormone therapy in women with serous and granulosa cell tumors because of their hormone dependence, and non-hormonal options are recommended as initial therapy. There is no evidence to contraindicate the use of systemic or topical menopausal hormone therapy by women with cervical, vaginal or vulvar cancer, as these tumors are not considered to be hormone dependent.
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Citation Excerpt :
The role of estrogens in provoking a recurrence after hysterectomy for EC is less clear and debated. Recently, a series of clinical trials reported that HRT should be considered even after treatment of EC, since HRT does not increase recurrence (Creasman et al., 1986; Lee et al., 1990; Chapman et al., 1996; Suriano et al., 2001; Ayhan et al., 2006; Barakat et al., 2006). In a retrospective study, Creasman et al. reported the results of 47 stage I endometrial cancer patients treated with conjugated estrogen (0.625 mg/dl or 1.25 mg/dl) by oral or vaginal routes: vaginal (34 patients), oral (7 patients), and both vaginal and oral (6 patients) estrogen (Creasman et al., 1986).
As growing of old women population, menopausal women will also increase: an accurate estimation of postmenopausal population is an essential information for health care providers considering that with aging, the incidence of all cancers is expected to increase. Hormone replacement therapy (HRT) has proven to be highly effective in alleviating menopausal symptoms such as hot flashes, night sweats, dyspareunia, sexual disorders, and insomnia and in preventing osteoporosis. According to preclinical data, estrogen and progesterone are supposed to be involved in the induction and progression of breast and endometrial cancers. Similarly, in epithelial ovarian cancer (EOC), the pathogenesis seems to be at least partly hormonally influenced. Is HRT in gynecological cancer survivors possible? The literature data are controversial. Many clinicians remain reluctant to prescribe HRT for these patients due to the fear of relapse and the risk to develop coronary heart disease or breast cancer. Before the decision to use HRT an accurate counselling should be mandatory in order to individualizing on the basis of potential risks and benefits, including a close follow-up. Nevertheless, we do believe that with strong informed consent doctors may individually consider to prescribe some course of HRT in order to minimize menopausal symptoms and disease related to hormonal reduction.
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^☆: From the Division of Gynecology Oncology, Department of Obstetrics and Gynecology, University of Kansas Medical Center,^athe Division of Gynecology Oncology, Department of Obstetrics and Gynecology,^band the Department of Medicine,^cUniversity of California Irvine Medical Center, and Women's Hospital, Long Beach Memorial Medical Center.^d

^☆☆: Reprints not available from the authors.

^★: 0002-9378/96 $5.00 + 0 6/1/75448

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Estrogen replacement in surgical stage I and II endometrial cancer survivors☆,☆☆,★

Abstract

Section snippets

MATERIAL AND METHODS

RESULTS

COMMENT

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