GPs Urged to Review HRT Treatment After New Cancer Evidence

Peter Russell

September 02, 2019

GPs were urged to review the use of hormone replacement therapy (HRT) with female patients following new evidence suggesting that the risks of breast cancer from treatment persist for longer than previously thought.

A meta-analysis of participant data in The Lancet from the Collaborative Group on Hormonal Factors in Breast Cancer found that some excess risk of breast cancer with systemic HRT persists for more than 10 years after stopping.

The study found that for women of average weight in developed countries, 5 years of use, starting at age 50 years, would increase breast cancer incidence at ages 50 to 69 by about:

  • One in every 50 users of oestrogen plus daily progestogen preparations

  • One in every 70 users of oestrogen plus intermittent progestogen preparations

  • One in every 200 users of oestrogen-only preparations

The absolute risk associated with 10 years of use starting at age 50 would be about twice as great, the University of Oxford scientists concluded.

Magnitude of risk depended on the duration of previous use, with little excess following less than 1 year of HRT use, they found.

The Medicines and Healthcare products Regulatory Agency (MHRA) said that:

  • Prescribers of HRT should inform women who use or are considering starting HRT of the new information about breast cancer risk at their next routine appointment

  • HRT should only be prescribed to relieve post-menopausal symptoms that are adversely affecting quality of life

  • HRT use should be regularly reviewed to ensure it is used for the shortest time and at the lowest dose

  • Current and past HRT users should be reminded of the importance of being vigilant for signs of breast cancer and encouraged to attend breast screening when invited

Blood Pressure Treatment Update

Treatment for hypertension should be considered for patients at a lower cardiovascular disease (CVD) risk threshold than previously recommended, NICE (the National Institute for Health and Care Excellence) confirmed.

In final guidance, it said antihypertensive drugs should be offered to people aged under 80 with a diagnosis of stage 1 hypertension who have an estimated 10-year risk of CVD of 10% or more.

This was a reduction from the 20% CVD risk threshold for treatment recommended in NICE's 2011 guideline.

However, it made no change to the 140/90mmHg and above level used to define hypertension.

Other changes included in the update covered monitoring, drug treatment, and identifying who to refer for same-day specialist review.

In 2015, hypertension was reported to affect around 13.5 million adults, and contributed to 75,000 deaths, making it by far the biggest preventable cause of death and disability in the UK through CVD. 

The clinical management of hypertension accounted for 12% of visits to primary care, and up to £2.1 billion of healthcare expenditure.

Over the last decade, average blood pressure in England fell by around 3 mmHg systolic, while the proportion of adults with untreated high blood pressure decreased, NICE said.

However, it noted that in 2014, Public Health England's Tackling high blood pressure: From evidence into action , called for further measures to reduce average blood pressure by 5 mmHg through improved prevention, detection, and management.

Dapagliflozin Recommended for Type 1 Diabetes

In final guidance, NICE recommended dapagliflozin (Forxiga, AstraZeneca) in combination with insulin as an option for treating type 1 diabetes in adults with a body mass index of at least 27 kg/m2, when insulin alone did not provide adequate glycaemic control despite optimal insulin therapy.

It said patients would be eligible providing that:

  • They were on insulin doses of more than 0.5 units/kg of body weight/day

  • They had completed a structured education programme that was evidence-based, quality-assured, and delivered by trained educators

  • Treatment was started and supervised by a consultant physician specialising in endocrinology and diabetes

Appraisers said that clinical trial evidence showed small improvements in HbA1c levels, weight loss, and very small improvements in quality of life, when dapagliflozin plus insulin was compared with placebo plus insulin.

Ovarian Cancer Drug for CDF

NICE recommended olaparib (Lynparza, AstraZeneca) for use within England's Cancer Drugs Fund (CDF) as an option for the maintenance treatment in adults of BRCA mutation-positive, advanced, high-grade epithelial ovarian, fallopian tube or primary peritoneal cancer that had responded to first-line platinum-based chemotherapy.

Final guidance noted that there were currently no maintenance treatments available for the condition in these circumstances.

It said that although early trial evidence suggested that olaparib delayed disease progression, there was currently insufficient evidence to show whether people having the treatment lived longer than those who did not.

Inclusion in the CDF would give more time for further data to be collected, an appraisal committee concluded.

Cerebral Palsy

Adults with cerebral palsy should be considered for referral to a multidisciplinary team (MDT) in cases where their ability to carry out usual daily activities has deteriorated or when they might be affected by a procedure being considered.

In draft guidance, NICE said an MDT, experienced in the management of neurological impairments, was better able to identify a person's needs and understand how those needs might change over time than non-specialist healthcare professionals.

They were also better placed to advise on specialist treatment options, it said.

A consultation on the draft quality standard runs until 30th September 2019.

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