Drs. Gillian Hanley (left) and Janice Kwon (right) are recipients of the 2021/2022 Precision Health Catalyst Grant award for their project entitled “Precision Health Care to Improve the Quality of Life and Long-term Health of People Entering Premature Surgical Menopause”.
Read a summary of the project here.
“We aim to generate evidence…for example, an understanding of the complexity of prescribing appropriate Hormone Replacement Therapy (HRT), strategies and realistic expectations for patients and providers regarding the length of time and number of trials needed to find the appropriate HRT regimen.”
Can you tell us about the precision health research work in women’s health you’re collaborating on?
Among women with a BRCA1 or BRCA2 mutation, the lifetime risk of ovarian cancer is 35-36% and 13-23%, respectively, compared with a general population lifetime risk of 1.4%. There is no effective screening for ovarian cancer and therefore most women are diagnosed with advanced stage disease which is difficult to treat. Thus, primary prevention through risk-reducing bilateral salpingo-oophorectomy (RRBSO, removal of both ovaries and fallopian tubes) is offered and it reduces the risk of BRCA mutation-associated ovarian or fallopian tube cancers by 80% and all-cause mortality by 70%. However, RRBSO is offered between the age of 35 and 40 for women with BRCA1 mutations and between 40 and 45 years for those with a BRCA2 mutation, because ovarian cancer tends to occur at an earlier age in these women (40’s and 50’s respectively for BRCA1 and BRCA2). This is well before the average age of onset of natural menopause of 51 years. Thus, women with a BRCA mutation, or women who are otherwise at high risk for ovarian cancer, are destined to enter premature surgical menopause if they have this life-saving prevention strategy.
Premature surgical menopause negatively impacts quality of life in the short term, particularly through vasomotor symptoms, sleep disturbance and reduced sexual functioning. However, it also increases risk of cardiovascular disease (CVD), osteoporosis and bone fractures in the long-term. Evidence suggests that use of hormone replacement therapy (HRT) can mitigate some of the harmful effects of surgical menopause, and when the HRT regimen is ideal for the patient, it provides significant short-term benefits for quality of life.
Our previous research has examined uptake of HRT in young women across BC who undergo premature surgical menopause. We reported: 1) low rates of initiating use of HRT following premature surgical menopause (~60%); and, 2) low rates of sustained use of HRT (only 19% used HRT for more than 5 years). The newly launched Gynecologic Cancer Survivorship Clinic at Vancouver Coastal Health was designed to serve the BRCA1 and BRCA2 population through ongoing care, support, and HRT management of young women after premature surgical menopause. These patients all receive personalized guidance on use of HRT that is tailored to their age, symptoms, and personal medical history.
Ultimately, we aim to generate evidence from this clinic that can be more broadly useful around uptake and HRT management in other patient populations. For example, an understanding of the complexity of prescribing appropriate HRT, strategies and realistic expectations for patients and providers regarding the length of time and number of trials needed to find the appropriate HRT regimen. We hope these data can go a long way to improving long-term health in many patient populations who enter premature surgical menopause.
What results have you seen so far?
We have seen evidence that finding the appropriate HRT regimen can be very challenging and can involve up to six different changes to medication and dosages. It is rarely a one-size fits all approach, but with persistence and the willingness to adjust, patients can get considerable relief from their menopausal symptoms, and can regain quality of life that they thought they would never again have. We are eager to expand these learnings beyond this clinic, so that many patients in premature surgical menopause can benefit.
From your perspective, what do you think is exciting about the future direction of precision health?
Precision health is absolutely the way forward in gynecologic cancer, and many other areas of medicine. This clinic provides precision health to a group of patients who have surgical prevention for ovarian cancer because of a genetic mutation that dramatically increases their cancer risk. The fact that we can identify their increased risk, intervene to reduce their all-cause mortality risk by 70%, and then follow them to provide the specific care that they need to maintain their health, live as high quality a life as possible, and reduce their future risk for adverse health outcomes related to premature surgical menopause, is an example of a precision medicine success story. These patients are getting exactly what they need to stay cancer-free and healthy through the appropriate use of hormone replacement. Our work aims to learn from this clinic, and then to extend it beyond those who would qualify to be seen at this clinic, as there are many people who could benefit from precision medicine with hormone replacement. There is so much work being done in this area, and we hope to see a future where hormone therapy is used in a way that extends the health and wellbeing of everyone who needs it.
About Dr. Gillian Hanley
Dr. Gillian Hanley is an Associate Professor in the Department of Obstetrics and Gynaecology at the University of British Columbia. She is a Tier 2 Canada Research Chair in Population-Based Gynecologic and Perinatal Outcomes. Her research combines her interest in women’s health with her training in economics, health services research and epidemiology to answer questions related to gynecologic cancer, primarily ovarian cancer prevention and survivorship.
About Dr. Janice Kwon
Dr. Janice Kwon is a Professor in the Department of Obstetrics and Gynecology at UBC. Her expertise is in hereditary cancer syndromes and conducting cost-effectiveness analyses of testing criteria and risk-reducing interventions. She currently holds a Health Professional Investigator Award from Michael Smith Health Research BC.