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A multidisciplinary approach to managing menopausal symptoms in women with breast cancer.

B reast cancer is a major health concern and one of the biggest fears women have. Starting at age 50 years, the approximate age of menopause, roughly 1 in 40 women (2.5%) will be expected to develop breast cancer over the next decade of their life. As they survive each subsequent decade, this risk increases until they reach the age of 85 years, where one in nine women (11.1%) will be expected to develop breast cancer. Because the detection of breast cancer dramatically increases after menopause, many women with breast cancer have concurrent menopausal complaints, symptoms, and comorbidities. Furthermore, some treatments rely on antiestrogen therapies, which can worsen or induce menopausal symptoms. Despite the association and close link between women with breast cancer and menopausal symptoms, there is a paucity of data on this topic. Even in the general menopausal population, women frequently do not have their symptoms and concerns properly addressed. Some physicians take menopausal symptoms lightly and downplay the tremendous physical, emotional, and psychological stress that menopause can have on women. The results of the Women’s Health Initiative have added additional complexity, and the take-home message by some has been to deny hormonal therapy to all postmenopausal women. Because of this confusion, the need for a multidisciplinary approach to menopausal care has been heightened, yet may be questioned by some physicians. Postmenopausal women suffer tremendously from vasomotor symptoms, vaginal atrophy, sexual dysfunction, mood changes, and other less frequent symptoms. The lack of understanding for what postmenopausal women experience is underappreciated by some physicians. Despite this reality, some women are so negatively impacted, including a decreased quality of life, that they prefer taking medications that could have significant risks. They are willing to take the risk that an adverse effect, or complication, may arise as a means to improve their quality of life. Menopausal care is a specialty area in which providers can gain additional training as a North American Menopause SocietyYCertified Menopause Practitioner. Such training incorporates information about the workup and evaluation of menopause along with expertise in counseling about therapeutic options. Providers who do not have this certification may not be comfortable making appropriate recommendations in regard to the risks and benefits of hormonal therapy or other treatment options. A multidisciplinary approach to menopausal care is rare, but it has been described. When several conditions overlap, such as menopause and breast cancer, recommendations for treatment should come from experts, or groups of experts, in the field. Much of the work related to multidisciplinary approaches to cancer care stemmed from work in England and Wales described in the mid-1990s in the Calman-Hine report. Such a multidisciplinary approach to postmenopausal women with breast cancer is unique and clearly important. The care of postmenopausal women with breast cancer can be complicated, with overlapping disease processes, symptom complexes, medication adverse effects, and concomitant psychosocial dynamics. Subspecialists may not have the breadth of knowledge, whereas generalists may not have the depth or comfort in certain areas. The limitations in time, resources, and coordination also become key barriers. Hence, the report by Hickey et al in this issue is a welcome addition to the literature. Although their population is likely to have referral biases, there is a great deal of beneficial and interesting information. The clinic described is located in Western Australia. It was established in 2003 and serves a population of around 2 million people. They consult on approximately 7 new and 13 follow-up patients per week, with 30 and 20 minutes reserved for new and follow-up encounters, respectively. These evaluations are done by a gynecologist or general practitioner specializing in menopausal care. The patient is then seen for an additional 20 to 30 minutes by a clinical nurse specialist trained in menopausal care. A wide range of menopausal and psychological symptoms are assessed, and each patient is then presented and discussed at a monthly multidisciplinary team meeting. This meeting includes gynecologists, breast surgeons, an oncologist, an endocrinologist, a genetic counselor, and a dietician, along with mental health experts, research personnel, and medical students. Among the data presented, Hickey et al point out the percentage of women with bothersome symptoms. As in other populations of postmenopausal women, vasomotor symptoms are the most common, followed by others including decreased sexual desire, difficulty sleeping and fatigue, along with vaginal dryness. Nearly 20% of their women presented with bothersome symptoms greater than 5 years after the diagnosis of menopause. These data suggest that more women with breast cancer may have prolonged, and bothersome, menopausal symptoms than do the general menopausal population, where symptoms for most women resolve within 2 years. It is interesting to note that although 42% of the women were premenopausal at the time of breast cancer diagnosis, 29% reported chemotherapy-induced ovarian failure and another