A 37-year-old woman was found to be positive for the BRCA mutation after being treated with chemotherapy, mastectomy, and radiation therapy for breast cancer. She then underwent prophylactic oophorectomy and contralateral mastectomy. Within four months of the oophorectomy, her bone mineral density decreased 18%. (She is also on chronic low-dose prednisone for rheumatoid arthritis.) She has tried venlafaxine (Effexor) unsuccessfully for severe hot flushes that prevent her from getting a good night’s sleep. She does not smoke or have other risk factors for coronary disease. What is the risk of recurrent breast cancer in a BRCA-positive woman after bilateral mastectomy? Is there any evidence that low-dose HRT increases the risk?
—John Foster, MD, Taos, N.M.

The risk of this patient’s developing recurrent (i.e., metastatic) breast cancer depends on the same factors as a patient who does not undergo contralateral mastectomy. Those include the size of the primary tumor; number of involved lymph nodes; and estrogen, progesterone, and Her-2/neu receptor status. I would not recommend HRT, especially if the patient is receiving adjuvant anti-estrogen hormonal therapy.
—Michael J. Flamm, MD, assistant professor of clinical medicine, College of Physicians and Surgeons, Columbia University, New York City