Estrogen Replacement Therapy for Ovarian Cancer Survivors
Estrogen Replacement Therapy for Ovarian Cancer Survivors
Abstract & Commentary
Synopsis: Postoperative estrogen replacement therapy did not have a negative influence on the disease-free survival and overall survival of ovarian cancer survivors.
Source: Guidozzi F, Daponte A. Cancer 1999;86: 1013-1018.
Guidozzi and daponte have reported a prospective, randomized trial in which 130 patients younger than 59 years with invasive epithelial ovarian cancer were randomized to receive continuous, oral conjugated equine estrogen via estrogen replacment therapy (ERT) or no supplementation (non-ERT). All patients were followed prospectively for a minimum of 48 months. The purpose of the study was to determine whether postoperative ERT had a negative influence on the disease-free survival and overall survival. Three patients in the ERT group and two in the non-ERT group were lost to follow-up, so 59 and 66 were finally analyzed in their respective groups. Nine patients originally randomized to ERT refused or stopped their supplementation, whereas five in the non-ERT group commenced taking estrogens. A total of 32 recurrences occurred in the ERT group and 41 in the non-ERT group. The median disease-free survival was 34 vs. 27 months, respectively, whereas overall survival was 44 vs. 34 months, respectively, for the two groups. The differences in disease-free survival and overall survival between the two groups were not statistically significant. Guidozzi et al concluded that postoperative ERT did not have a negative influence on the disease-free survival and overall survival of ovarian cancer survivors.
Comment by David M. Gershenson, MD
More than 70% of epithelial ovarian cancers have already spread beyond the ovaries at diagnosis, and the recurrence rate for women with advanced stage disease is high, with a five-year survival rate of no better than 20%. Fear of recurrence is a common phenomenon among women with ovarian cancer, and they are naturally anxious about anything that may increase their risk of recurrence. Women who are postmenopausal or who undergo bilateral oophorectomy in the premenopausal age group have the same incidence of menopausal symptoms as women without ovarian cancer. The use of ERT in this patient population has been controversial. Although I know of no scientific evidence that ERT increases a woman’s risk of recurrence from ovarian cancer, the link between ERT and endometrial/breast cancers has been extrapolated to other "women’s cancers." Many physicians do not believe that a woman with a diagnosis of any gynecologic malignancy, including ovarian cancer, should ever receive ERT. In fact, epidemiological studies have not found a significantly increased risk of ovarian cancer in women who have taken ERT. Reports have shown either no increased risk or nonsignificantly elevated risks.
In the present study, Guidozzi et al found no differences in disease-free survival or overall survival between ERT and non-ERT patients. However, there were only 59 and 66 evaluable patients in the two arms of the study, and I am concerned about the possibility of an underpowered study leading to a type II error. Guidozzi et al do not discuss statistical concerns in their paper. Nevertheless, until information to the contrary is forthcoming, I continue to believe that the decision about ERT for women with ovarian cancer is personal. My own bias is that the potential benefits outweigh any deleterious effects.
Which of the following statements is true?
a. ERT increases the risk of recurrence in ovarian cancer patients two-fold.
b. ERT increases the risk of recurrence in ovarian cancer patients five-fold.
c. ERT decreases the risk of recurrence in ovarian cancer patients by 50%.
d. The influence of ERT on risk of recurrence in ovarian cancer patients is unknown.
e ERT has no negative or positive influence on recurrence in ovarian cancer patients.
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