Podcast Episode 12: Oncology and the perimenopause and menopause with consultant medical oncologist, Dr Rebecca Bowen

On this episode of the Newson Health Menopause Society podcast, host Lauren Redfern is joined by Consultant Medical Oncologist Rebecca Bowen. Together, Lauren and Rebecca discuss the decision-making process involved when patients diagnosed with breast and gynaecological cancers are considering using HRT. Rebecca helps to explain the factors that both patients and clinicians need to consider when approaching treatment and helps to dispel common misconceptions surrounding cancer risk. Rebecca helps to clarify that whilst some patients may not realistically be able to use HRT due to their particular diagnosis, each patient is different and should be treated as an individual. She highlights the importance of integrated approaches to clinical care, outlining how communication between Oncologists, General Practitioners and Menopause Specialists, can help to empower patients to make informed decisions about the best course of treatment that is right for them.

Rebecca Bowen is a Consultant Medical Oncologist specialising in breast and gynaecological cancers. She works at one of the very few oncology clinics in the country that integrates menopausal treatment into their care.

Podcast Transcript:

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multi-disciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research collaborations across specialities and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:05] At 39, Caroline was diagnosed with breast cancer. After finding two small lumps, Caroline sought treatment and was told that these lumps were in fact tumours. Already grade three, Caroline was facing a fairly aggressive struggle, including chemotherapy, radiation and eventually a full mastectomy. A mother of two, Caroline, describes how her life became a hurried blur of appointments as she navigated her treatment alongside caring for her children. The chemotherapy was gruelling and Caroline describes how she felt that at times she might not get through it. On top of this, treatment stopped Caroline’s periods and she began experiencing menopausal symptoms. Caroline describes how at the time she thought she was just experiencing cancer induced anxiety, but that long after her chemo had finished, she continued to suffer both mentally and physically. Her symptoms were explained away as unwelcome hangovers from cancer treatment, and she explains that before having cancer, she barely knew anything about the menopause – only negative scare stories about HRT. In her own words, Caroline says, “I was a functioning wreck. By that I mean I kept going, kept working, being a mum, a wife, a daughter and friend. But inside I was a hollow, self-loathing and anxious version of myself. I’ve always been an outgoing, sociable and spontaneous lover of life, but I didn’t recognise myself anymore. The hardest part was not feeling like a good enough mum – the double whammy of breast cancer and menopause. Apart from the impact of having an induced menopause, I came to normalise the physical problems. I ached in my joints, felt cold and often exhausted, experienced a strange ringing in my ears. I had dry eyes, throat and mouth problems, IBS, the list goes on”. During this time, Caroline started reading about HRT and was surprised to find that someone in her position – that is to say, someone that had undertaken treatment for an estrogen receptor positive tumour – could actually still consider using HRT. Her decision to begin using HRT under the care of her clinician is described by Caroline as “without a doubt one of the most important decisions of my life”, and that “HRT gave me back what my cancer treatment took away. Nine years ago, I thought my life was over. But now I know that life is here for the living”.

Lauren Redfern [00:03:22] Sharing Caroline’s story in this way highlights how the onset of menopausal symptoms following an invasive period of treatment can be exhaustive and create prolonged periods in which one’s quality of life can be severely impacted. Regardless of this, however, there is still a certain level of controversy surrounding the use of HRT amongst those that have undergone treatment for cancer. Here to discuss the important topic of oncology and menopause with me today is Dr. Rebecca Bowen, a consultant medical oncologist specialising in both breast and gynaecological cancers. Hi, Rebecca, thank you so much for chatting with me today. Could I just ask you to start by please, introducing yourself to those listening and telling us a little bit more about the work that you do?

Dr Rebecca Bowen [00:04:07] Hi, Lauren. Thank you very much for inviting me to talk with you today. So, as you say, I’m an oncologist and I specialise in women’s cancers, so I treat breast cancer, but also ovarian cancer, endometrial and cervix cancer. So the women that I see and I’ve been treating over a number of years, will often experience either an early menopause due to their surgical treatment or, as you’ve described with our first case, due to medical and often but not always, reversible menopause symptoms due to the chemotherapy and others will have gone through the menopause or be going through the menopause but have to take endocrine treatments, Tamoxifen, letrozole, anastrozole, which essentially cause a ‘menopause-plus’ in terms of symptoms, by taking out that last little bit of estrogen or blocking it such that menopause symptoms can be exaggerated. And this is all done, of course, to try and reduce the chance of the cancer coming back or in the setting of metastatic incurable disease to try and keep a woman as well as possible for as long as possible. But it was very obvious as I was working that there was a complete lack of resource for this particular group of women. There’s been an awful lot of work from a number of different people trying to promote menopause and the treatment in the general population. But as you pointed out, it is still quite a tricky area – the combination of menopause in the context of cancer. Even within breast cancer, breast cancer is a group of different diseases, some of which are hormone sensitive, where we know there can be an advantage to blocking estrogen. So we have to be very careful when we’re considering pros and cons with replacing estrogen. And others where the disease was never sensitive to hormones that women might have thought that they couldn’t consider hormone replacement simply because they had a breast cancer. I think we also have to remember there are different types of hormone replacement therapy and trying to find the best type to suit the individual according to their symptoms and according to their need is actually crucial. So I don’t think it’s simply saying ‘it’s okay for everyone to take or use HRT’. It’s about what is this individual person’s risk as best we can determine, although the data are poor, what are their main symptoms and how can we best address those and what are the risks to not addressing their menopause? What are the long term risks if we don’t replace hormones and making it possible for women to make their own decision about what they want to do.

Lauren Redfern [00:06:27] Yeah, and I think that’s sort of interesting from the perspective the story I shared with Caroline, obviously, for her, her symptoms are highly debilitating and she talks about how introduction of HRT is really life changing and lifesaving. And I suppose for yourself as a consultant, I suppose it’s about working with patients to make those decisions and understanding the relative risk-benefit ratio.

Dr Rebecca Bowen [00:06:50] Yes, and I’m very lucky where I work. We were able to get a Macmillan grant a few years ago to set up a clinic, so that I work alongside another oncologist, a nurse specialist and a menopause specialist and we run clinics together. So patients will see two or three of us, at least in each clinic, so that we can have that discussion about what their risks may be. Are they on a treatment that we can change or stop? And sometimes, you know, symptoms are worse with one hormone treatment for breast cancer than others. And it can simply be a discussion with their oncologist, do I need to continue with this? Can I stop? And sometimes simply discontinuing it because the benefit is now minimal, can make a big difference to the symptoms and we don’t even need to be replacing hormones. Other times it’s ‘can I safely take or use vaginal estrogens because my vaginal symptoms are bad?’ and the answer is often yes. And if so, how do we use it and what’s the best way of doing that? And so it is very much about looking at the individual, the individual person, their symptoms, their circumstance and the cancer that they’ve had treated or are being treated for. And sometimes it is a combination of things and the anxiety and the distress are a manifestation of their cancer diagnosis, treatments and concern about recurrence, as much as the symptoms of the menopause. So it’s never straightforward, but a very interesting clinic that we run, which I hope has been very helpful for a lot of women.

Lauren Redfern [00:08:13] No, I mean, it’s fascinating to me because I think we kind of talk quite broadly about HRT as a broad category, but also cancer as a broad category. And I wondered if we could break that down a little bit, because, I mean, you mentioned there – and it is important to emphasise – obviously, there are different types of cancer which will obviously impact your relative risk of using HRT. And I wondered if you could help us just kind of break that down into what things you’ll be thinking about as a consultant when you are treating a patient with, say, breast or gynaecological cancers when thinking about HRT, use of HRT.

Dr Rebecca Bowen [00:08:47] Okay. So we start with breast cancer and the different types of breast cancer. Firstly, we’ll be looking at, as I mentioned before, is is this a hormone receptor positive breast cancer? About 80% of breast cancers will be estrogen receptor/progesterone receptor positive. And so these are the women who will get some benefit from the use of hormone blocking treatments. The question then will be well what was the risk of that cancer? Was it caught early? Was it a low grade? Were there lymph nodes involved? What was the size of the cancer? And that gives us an indication of what the actual benefit of the treatment is. It may be that the benefit is very small and simply stopping it is the best thing that we can do for that individual. For other people, they may have a much larger, more aggressive tumour with a lot more lymph node involvement where the risk of recurrence is higher, and we want to try and keep them on a hormone treatment and it’s about adding in things to try and minimise symptoms and side effects to keep them on the treatment so that they get the benefit. We often, in the curative setting, will be recommending Tamoxifen for 5 to 10 years, depending on risk and tolerability and aromatase inhibitors for 5 to 7 years, again according to risk and tolerability. So it will then depend on where the patient is in their treatment pathway. Have they only recently had a cancer diagnosis? Are they only recently embarking on their hormone treatment? Can we switch it? Is there one that suits them better? Can they stop it?

Dr Rebecca Bowen [00:10:06] Then there’ll be women that come to the clinic who are 15, 20 years out, where we’re very much less concerned about the risk of recurrence – although with hormone receptor positive cancers, unfortunately, these are the ones that can relapse sometimes 15, 20, 25 years later. So we do need to be aware of that, but we’d be much less concerned about that and can be more optimistic with a patient and encouraging for their use. Then we’d be looking at what type of HRT do we need to use and as I mentioned before, what are their worst symptoms? Having a menopause factsheet where they can fill out the questionnaire, gauging the severity of the symptoms is really very helpful. Are there non-hormonal treatments that we can use, pregabalin can be very helpful for a lot of our patients. We use that with good effect, particularly in women who are needing to continue treatment. Can we use non-hormonal vaginal preparations or hormonal vaginal preparations, or do we need to be replacing systemically? If so, we’re tending to use transdermal estrogen in some form or another and if they have a uterus were tending to use micronised progesterone, where the data about breast cancer risk is less clear and we believe these are safer products to use. So again, it’s trying to make the best and safest option for the patient, but acknowledging the fact that our data that we have are unfortunately slightly flawed and don’t take account for all these individualities. So I think as oncologists we’re very used to discussing risk with patients and risk and benefits when talking about chemotherapy. So it’s a natural conversation for us, the data, though, are perhaps not as good as we have with some of our anti-cancer drugs.

Dr Rebecca Bowen [00:11:43] And then you’ve got the gynae cancer side of things. And again, that’s quite a mixed bag. So we’ll have some very young patients having treatment for cervix cancer who may have had early ovarian failure as a result of surgery or as a result of chemo radiotherapy. These women desperately need to have hormone replacement therapy. They don’t tend to have estrogen receptor positive cancers. They need to have their bone health, their cardiac health, their brains protected by HRT. So we really do need to make sure that these women are on systemic HRT. Then we’ve got women with ovarian cancer and most women with ovarian cancer will present to you in their sixties and seventies. But the lower grade ovarian cancers they can present slightly earlier and will often use in that context hormone-blocking treatments again. So it’s about, is the cancer hormone receptor positive, as some will be. If so, do we want to try something non-hormonal first? But for a lot of these women, it will not be about having gone through an early menopause and needing to be very careful about bone health. It’s about being careful about the risks of menopause, but mainly looking at their symptoms.

Dr Rebecca Bowen [00:12:49] And then with the endometrial patients as well, we need to be looking at their risks, their risks to cancer, making sure that they’ve got good lifestyle advice, maintaining a healthy weight, not smoking, alcohol, all of these other risks to cancer. If they’ve had their disease safely removed, then absolutely can we consider hormone replacement therapy. Most of those women will have had their womb removed. So we’re simply looking at estrogen replacement. But it’s again, it’s about discussing it with the individual. I think probably a lot of the worst symptoms that we see are in the women who’ve gone through a sudden menopause with a surgical menopause or a sudden menopause because they have been given chemotherapy when they’re pre- or perimenopausal and then they are having endocrine treatments. And increasingly we’re using drugs like Zoladex and Leuprorelin which block ovarian function on for several years after their chemotherapy. So they’re being maintained in a menopausal state for much longer. So this group often suffer a lot more and we need to be very mindful of that.

Lauren Redfern [00:13:52] I mean, I think that’s interesting that you bring that up, because one thing I actually wanted to ask you was from my own sort of interest in preparing for this podcast and also, I suppose generally, what I found is it seems like there’s far less data available on use of HRT amongst patients with ovarian, endometrial and cervical cancers. And I wondered what your thoughts are on this regarding that, and how we can ensure that these cancers are also considered when we’re discussing cancer in the broadest terms and HRT? Because it’s interesting there that you mentioned, actually the menopausal symptoms may be prolonged a lot longer, that there may be, you know, greater symptom issues. So, yeah, I’m just I’m curious to hear your thoughts on that.

Dr Rebecca Bowen [00:14:31] I think it is likely multifactorial. Breast cancer, of course, is unfortunately a very common disease.

Lauren Redfern [00:14:35] Yes.

Dr Rebecca Bowen [00:14:36] Ovarian cancer is a much less common disease. And unfortunately, women get breast cancer often a lot earlier. And it’s not uncommon for women to be developing breast cancer in their forties, whereas it’s very uncommon for women to develop ovarian cancer in their forties. So I think there’s funding issues to do with breast cancer research where there’s historically been less in gynae cancer research. The population groups, so a lot of women with gynae cancers will have gone through their menopause, symptoms may well have settled, they may have had HRT and no longer be using it, and now they have their cancer. When you look at the data which are predominantly from breast cancer about women using hormone treatments, Letrozole, Tamoxifen, the rates of failure or treatment discontinuation is somewhere in the order of about 25% to 30%. And these are women in trials who are motivated to continue. So I think when you bear that in mind, there’s this group that clearly do struggle a lot, but equally to the 60 to 70% of women actually manage their treatment very well. And so we will see a lot of women who seem to take these hormone tablets without seemingly any side effects at all. So it is a huge spectrum. And it may be if someone has already gone through their menopause, they’re less disturbed by their treatment than if they are premenopausal, perimenopausal. I should say that it is something that as a research group in gynae cancer, we are very interested in looking to do more research and the NCRI, the National Cancer Research Institute, gynae group are keen to try and look into doing more research into menopause and gynae cancers to try and redress that balance of a data lack.

Lauren Redfern [00:16:13] Which is great. I mean, I think I wanted also to ask you if you could talk us through a little bit, I guess, your day to day work within the clinic that you operate in, because it seems like something really amazing happens there, which is you have consultants from different specialities kind of working together and something that I’m sort of been interested in and exploring a bit in this podcast is every healthcare professional I seem to speak to, a big take home message is we really need to get clinicians working together and existing in conversation.

Dr Rebecca Bowen [00:16:41] Yes.

Lauren Redfern [00:16:42] And it’s really sad, actually, because I think really in looking at this field, what you can see is ideally you need to have menopause specialist, oncologists and also, you know, GP’s working in conversation. So I’m curious to hear how I suppose the clinic that you operate within manages to make that work, but also any thoughts that you have for how we can create that best practice? You know, if we don’t have a specialist clinic that’s operating in that way.

Dr Rebecca Bowen [00:17:08] You know, hospitals and trusts and GP practices will work slightly differently. So our sort of model may not exactly fit all. We currently run 1 to 2 clinics a month, I think waiting list wise we could do with running 2 to 3 at least, but we have in the room at any one time at least an oncologist, a menopause specialist and a nurse specialist in with the patient. We will often have others who are interested in learning. So most clinics they’ll be one of our local GPs or GPs around who are keen to learn more about the menopause. And so we’ve started by seeing all, all women that are referred within our area who’ve had a diagnosis of cancer or who are at high risk of cancer and wanting to consider HRT or who are struggling with their treatments. I think moving forward, sort of three plus years on into our service, the idea would be to be educating more and more of the surgeries. And I think we’re seeing that now with each woman that we see, we’ll send out information with links to useful websites and Breast Cancer Now, for example, have a good booklet on managing breast cancer in the menopause. So these things are given to the patient, but we’re also feeding back to the GPs so that we’re seeing perhaps more of the patients who are particularly problematic. And we’re able to advise on the patients who are having treatments that we can manipulate sometimes earlier and then seeing them back in the menopause clinic only if they’re still having problems. I think it’s difficult to get the funding always to set up a new service, but it really does work I think best, where we are both in the same, or all in the same room at the same time. You also need to have people to signpost and refer on to. We’re very lucky to have a very good counselling service. Where here you, local to where I work, where patients can self-refer for help after a breast cancer or actually a cancer diagnosis, not just breast cancer, for group sessions and 1 to 1 sessions, which is hugely important. Menopause or otherwise, you need CBT services if possible. Yes, patients can be self-taught, but we have access to a cancer psychologist, so you need to be able to also accept where one’s own expertise ends and where you need to be able to refer on for extra help.

Lauren Redfern [00:19:23] Yeah, I think I like to exist, and it’s interesting earlier with sort of talking about the risks and the benefits, I like to exist in that sort of dreamland fantasy world where we could have the best possible services and kind of think about how we could do that. But I think it’s lovely really what you’re describing there about these kind of multipronged approaches in which we know how to have a solid, positive referral system that works, I think, as well, because it can be I mean, it’s a really daunting prospect, I think you’ve sort of described in there just how many aspects exist within a diagnosis and how much support is actually needed that can’t simply exist on the, you know, for the responsibility of just the oncologist or just the menopause specialist that needs to be working collaboratively.

Dr Rebecca Bowen [00:19:59] Exactly.

Lauren Redfern [00:20:00] Whether we agree or disagree, I think we can safely say that for a lot of healthcare professionals, I think there is probably sort of a reticence to treat women with HRT should they have a history of cancer. So even as we’ve discussed earlier, if there’s been a prior history of cancer at a younger age, when you maybe are entering perimenopause and you go to speak to your GP about possibly starting HRT, if you have that history of cancer, there may be a bit of a stop moment from your GP to really just have a moment to go. Oh, okay. Is this appropriate?

Dr Rebecca Bowen [00:20:32] Which I think, by the way, is reasonable and I think it should be a thought.

Lauren Redfern [00:20:35] Absolutely.

Dr Rebecca Bowen [00:20:36] And so they can then request for the local oncologist their thoughts. Some women, it will be that they’ve had a treatment for a haematological condition, and you’re thinking more about the risks of HRT in terms of stroke or what have you, rather than a risk of breast cancer. Others, we might need to think a little bit more carefully because their breast cancer risk might be slightly increased. So I think for a GP it’s a very difficult position to be in. And I think a quick question to their oncologist or their breast team is a very reasonable thing to do.

Lauren Redfern [00:21:04] Yeah. I mean the ending to that was really going to ask you what advice you might be able to give to professionals on best practice on things you think they should consider when interacting with a patient with the history of cancer seeking HRT. Because I completely agree, I think that there needs to be obviously a certain amount of thought and care and consideration that goes into that. So really for any health care professionals listening who are coming across patients with a history of cancer, breast cancer, ovarian cancer, endometrial cancer, what they should be thinking about if they’re seeing a patient and what steps they could take if they’re unsure about whether it might be safe to prescribe HRT.

Dr Rebecca Bowen [00:21:40] Well, again, I think it’s very hard for the GP to be able to make the decision on the patient’s oncological treatment. And I we get a number of letters probably a week, asking about whether it’s okay to consider HRT and again, what sort of HRT might we… So I think from the GPs point of view, it’s about really knowing, which many already do, which of the safer forms of HRT to use, which ones would be best to use for patients where their risk might be slightly increased, looking at the patient’s symptoms. But yes, just double checking with the oncologist. If someone’s had a colorectal cancer and they’ve got no familial risk, someone’s had a haematological cancer, someone’s had a cervix cancer, actually, it’s probably absolutely fine to consider whichever HRT you think would be most appropriate for their symptoms, probably as well to double check with the treating centre where the patient is in their journey in treatment. If it’s a breast cancer or an endometrial or ovarian cancer, then that can be a quick discussion between the two. It’s not quite as good, obviously, as having the two in the or I should say the three in the room, the patient, the oncologist and the menopause specialist or the prescriber. But as a second best at least seeking that information to just clarify, I think is entirely reasonable. And I don’t think a GP should feel embarrassed to be asking. Far from it.

Lauren Redfern [00:22:55] No, absolutely. And I think that’s exactly, I remember doing a podcast at the beginning of this series, really, where I was talking with Louise. One of the things that she was saying is actually, if you don’t know, it’s always important to ask the question and spend the time sort of just saying, you know, I need to clarify this for myself and really get support and help from the expert that knows that field best.

Dr Rebecca Bowen [00:23:14] And what I would say is I don’t necessarily know myself, you know, the data aren’t clear. And because breast cancers can be so very different and it is so very individual, I cannot say you should do X, Y and Z for breast cancer. I don’t think we can do that, and I don’t think we will ever be able to do that. It’s much more individualised and it should be. It should be about the patient.

Lauren Redfern [00:23:35] Absolutely. I wondered sort of my own selfish question, really. It’s such an interesting clinic that you’re working in, and I wondered if you could really tell us what interested you in the relationship between the field of oncology and menopause, specifically what you found interesting about it and what you yeah, what you enjoy about it?

Dr Rebecca Bowen [00:23:52] Well, as I said, because I treat women, I have very few male patients, and I do do an awful lot of work with hereditary risk, with BRCA mutations, but also with hormone treatments. It was a problem that I was encountering for an awful lot of my patients. When I first started working in Bath about 11 years ago, there was a sexual health doctor who ran a menopause clinic and she retired and there was nobody to refer to and for a number of years, where you had patients who were having less and less follow up with oncologists as our capacity reduced, and they were having more and more follow up with radiographers, which is fantastic in terms of safety, but not necessarily addressing the side effects of their treatment, long or short term. And it was a serious unmet need. And I managed to encourage a good friend of mine who was interested to become a menopause specialist and to come and work with us in the clinic. And actually, it’s one of the most rewarding things that I do, because we do see a lot of women have a really positive benefit from the interventions that we can do to help them. And it’s surprising. It’s not always just about replacing estrogen, you know, it’s sometimes just being listened to and heard and understanding that they’re not the only ones going through that and understanding what they can do and what to be worried about, not what to be worried about and where to ask, which makes a big difference. So it is rewarding.

Lauren Redfern [00:25:13] Yeah. And I suppose, as you say, kind of the experience of really treating every patient that you see as an individual and kind of figuring out a programme of treatment that works for them specifically to their history. I think sadly, actually, that’s all the time we have for our discussion today Rebecca and I just want to thank you for spending this time with me today. And I wanted to end by asking if there are any take-home messages you’d like to stress, whether that’s when it comes to the relationship between oncology, menopause and HRT, whether that’s about oncology generally, yeah if there’s any take home messages you’d like to stress from our discussion today.

Dr Rebecca Bowen [00:25:46] So I think in terms of advice to women who have had treatment for cancer and are thinking about HRT, I think it’s important to know that there is help out there, that menopause symptoms can be addressed and improved. Even if you have had a diagnosis of a cancer and even if you’ve had a diagnosis of hormone receptor positive breast cancer, it doesn’t mean that you can never have estrogen replacement. It’s just important to have the conversations with the right people and get help. I think also the enthusiasm for the sort of clinic that we’re running is getting bigger and there will be more clinics I hope soon. I think for the GPs, ask, and if they’re at all unsure, to ask.

Lauren Redfern [00:26:23] Yes, well that’s great and thank you so much for your time and we’ll speak again soon.

Dr Rebecca Bowen [00:26:28] Pleasure. Thank you.

Lauren Redfern [00:26:31] We would love for you to join our collective of professionals passionate about the menopause. Visit NHMenopauseSociety.org to become an associate, you will receive regular webinars and advice from our experts as well as opportunities to network and connect with the latest research from around the world. You can follow us on Twitter at @NHMenoSociety and don’t forget to tell your colleagues about the Newson Health Menopause Society.

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