Shining the light on genitourinary syndrome of menopause in survivors of breast cancer

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Over 250,000 women will be diagnosed with breast cancer this year, 11% of them young women under the age of 44. Currently, there are over 3.3 million survivors of breast cancer, and the number is growing by 200,000 women per year.1 The vast majority of breast cancer survivors will suffer from genitourinary syndrome of menopause (GSM) as a result of their treatment, and yet most will go undiagnosed and untreated as Cook et al2 demonstrate in this issue of Menopause. It is time for us to do better!
Genitourinary syndrome of menopause is a result of estrogen deficiency associated with menopause and results in changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. Symptoms associated with GSM include dryness, pain with sexual activity, burning, irritation, impaired urinary function, and recurrent urinary tract infections. The prevalence of GSM increases with time from menopause. GSM affects more than 50% of midlife and older women, is associated with impaired sexual function, and has a negative impact on overall quality of life.3 GSM is an even more pervasive problem in breast cancer survivors. Gene mutation carriers (eg, BReast CAncer susceptibility gene 1 or BReast CAncer susceptibility gene 2) who undergo risk-reducing salpingo-oophorectomy (RRSO), abrupt chemotherapy-induced menopause, long-term treatment with aromatase inhibitors and tamoxifen, and extended survival are all associated with the development of GSM.4,5 First-line treatment for all women with GSM is over-the-counter nonhormonal moisturizers and lubricants, but these treatments are often inadequate, especially for women with severe GSM—often breast cancer survivors on aromatase inhibitors. For women without a history of breast cancer, who have failed to respond to over-the-counter products, local vaginal estrogen is the standard of care and is highly effective. But in women with a history of breast cancer, there is no accepted or evidence-based management algorithm, and the use of local vaginal estrogen remains controversial among clinicians caring for these women. None of the US Food and Drug Administration (FDA)-approved medications for treatment of dyspareunia and GSM are approved for use in breast cancer survivors.
In this issue of Menopause, Cook et al2 demonstrate that GSM remains under-recognized and undertreated in breast cancer survivors. In a chart review of 800 breast cancer patients treated in a survivorship clinic at M.D. Anderson, a large referral cancer center, only 279 (34.8%) patients had symptoms of vaginal atrophy documented. Those results stand in stark contrast to the high prevalence of GSM in this population. Of the 279 patients with symptoms, only 111 patients (40%) received any form of treatment or specialist referral. These results, from a specialized survivorship clinic at a large cancer center, document a woeful ascertainment of GSM and lack of treatment plans in these breast cancer survivors. It is likely that identification and treatment of GSM in survivors in settings other than a specialty survivorship clinic are substantially lower.
Why have we made such little progress in identification and treatment of GSM in survivors of breast cancer when we know it is highly prevalent, often severe, worsens with time without treatment, and negatively impacts sexual function and quality of life? Evidence suggests that lack of clinician education and training in sexual medicine, a reluctance of clinicians to ask patients sexual health questions, and a lack of consensus or an accepted management algorithm for GSM in breast cancer survivors all contribute.
As the number of breast cancer survivors has grown, and life expectancy has increased, the unmet medical needs of survivors has become more apparent. Survivorship clinics associated with cancer centers has become standard, and survivorship care plans are readily available to all clinicians caring for cancer survivors.

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