Endocrine treatments, such as Tamoxifen (TAM) and/or Aromatase inhibitors (AI), are the adjuvant therapy of choice for hormone-receptor positive breast cancer. These agents are associated with menopausal symptoms, adversely affecting drug compliance. Topical estrogen (TE) has been proposed for symptom management, given its' local application and presumed reduced bioavailability, however its oncological safety remains uncertain. The present systematic review, meta-analysis and expert panel review aimed to evaluate the strength of the available evidence on the risk of recurrence and mortality when TE is utilised in congruence with TAM or AI treatment, among BC survivors. Six databases and two prospective registers, were interrogated from inception to January 3rd, 2024. Search terms were Breast cancer AND Hormone replacement therapy AND topical/vaginal oestrogen AND recurrence/mortality. All study designs reporting the use vs. non-use of TE in breast cancer survivors receiving adjuvant endocrine treatment were included. Six observational studies were deemed eligible for inclusion. Sources of heterogeneity were explored using subgroup analysis by risk of bias, median follow-up period, node positivity and menopausal status. Trial sequential analysis was performed to quantify outcome reliability. A global expert panel was called to deliberate on the data, pinpoint areas of limited understanding, and determine the most important areas for future research. Risk ratio effect sizes (RR) and corresponding 95 % Confidence Intervals (CI) of breast cancer recurrence and mortality in survivors on endocrine treatment (TAM and/or AI) exposed to TE were reported. Expert panel appraisal of meta-analysis evidence with definition of current knowledge gaps and future research aims. In 38 050 female patients receiving adjuvant endocrine treatment, of whom 1805 had been exposed to TE, TE exposure of those on AI, did not increase all-cause mortality (RR 0.99 [95 %CI 0.58, 1.69], I² = 81 %, P = 0.96; moderate GRADE certainty). However, such exposure may convey an increased risk of recurrence (RR 2.51 [95 % CI 1.10, 5.72], I² = 9 %, P = 0.03; low-GRADE certainty). Exposure to TE during TAM did not increase either recurrence risk or all-cause mortality. Clinical factors such as lymph node positivity at the time of diagnosis and menopausal status and follow-up time appeared to be significant confounders. The use of TE does not appear to increase either recurrence or mortality risk among BC survivors treated with TAM. An increased recurrence risk, without an increase in mortality, cannot be ruled out when TE is used during AI.

Sentinel lymph node biopsy (SLNB) has been widely adopted in the management of early-stage gynaecological cancers such as endometrial, vulvar and cervical cancer. Comprehensive surgical staging is crucial for patients with early-stage ovarian cancer and currently, that includes bilateral pelvic and para-aortic lymph node assessment. SLNB allows the identification, excision and pathological assessment of the first draining lymph nodes, thus negating the need for a full lymphadenectomy. We systematically searched the MEDLINE, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases (from inception to 3 November 2022) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Our search identified 153 articles from which 11 were eligible for inclusion. Patients with clinical stage I–II ovarian cancer undergoing sentinel lymph node biopsy were included. Statistical analysis was performed in RStudio using the meta package, where meta-analysis was performed for the detection. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies C (QUADAS-C) tool. Overall, 11 observational studies met the predetermined criteria and these included 194 women. The meta-analysis showed that the detection rate of sentinel lymph nodes in early-stage ovarian cancer was 94% (95% CI of 86% to 1.00%). Significant heterogeneity was noted among the studies with Q = 47.6, p < 0.0001, I² = 79% and τ² = 0.02. Sentinel lymph nodes in early-stage ovarian cancer have a high detection rate and can potentially have applicability in clinical practice. However, considering the small number of participants in the studies, the heterogeneity among them and the low quality of evidence, the results should be interpreted with caution. Larger trials are needed before a change in clinical practice is recommended.

Hormone replacement therapy (HRT) remains the cornerstone of menopausal symptom management, effectively alleviating vasomotor symptoms and genitourinary syndrome, whilst mitigating long‐term risks such as osteoporosis. However, despite an increasing body of evidence on the relative safety of HRT, earlier studies that demonstrated an increased cancer risk have resulted in decades of controversy and reshaped clinical practice and public perception. Concerns around HRT are heightened in cancer survivors or those with strong family histories and genetic risks, and many clinicians remain reluctant to consider HRT due to the potential for promoting cancer. Globally, around 9 million women and an estimated 60 000 women in the UK under the age of 50 are diagnosed with cancer and will receive treatment that results in iatrogenic premature or early menopause or develop hormone‐related, menopause‐like, side effects, even if not rendered menopausal. Improvements in oncological management have resulted in significant benefits in cancer survivorship, and importantly, an increasing focus on quality of life. This article aims to comprehensively review the evidence and provide an overview for clinicians that can help guide discussions with patients regarding HRT risks and benefits, and promote shared, informed decision making.

Menopause following cancer treatment is an increasingly recognised component of survivorship yet remains under-addressed in clinical care. The aim of this review was to synthesise current evidence on menopause induced by cancer treatment, by bringing together current evidence on the underlying mechanisms, clinical manifestations, and management in the context of survivorship care. Evidence was evaluated from contemporary clinical studies, guideline recommendations, and emerging evidence across oncology and menopause research. Cancer treatment-induced menopause commonly results from surgical removal of the ovaries, follicular depletion from chemotherapy, and radiation-induced ovarian damage, and in some cases, it is chemically induced by gonadotrophin-releasing hormone agonists. The resulting symptom burden is often substantial, including vasomotor symptoms, mood disturbance, genitourinary syndrome, sexual dysfunction, fatigue, and cognitive difficulties that impair quality of life. In addition, premature or early menopause is associated with increased long-term health risks, including reduced bone density, cardiovascular disease, and adverse psychosocial outcomes, such as infertility and altered self-identity. Menopause symptoms can also overlap with treatment side effects, and management is often complex, requiring an individualised, multidisciplinary approach. Whilst hormone replacement therapy is effective, its use is limited by concerns regarding cancer recurrence in hormone-sensitive disease. As a result, non-hormonal and supportive strategies play a pivotal role in symptom management. Despite increasing recognition of the impact of menopause, there are few effective licensed therapies and access to specialist support and counselling is limited. Integrated menopause care that incorporates menopause management into oncology pathways offers a pragmatic approach, providing holistic, patient-centred strategies that balance long-term health risks with quality-of-life priorities. Lay summary: Cancer treatment, including surgery, chemotherapy, radiotherapy, or long-term therapies, can cause menopause, which is often sudden, resulting in severe symptoms that may overlap with treatment-related side effects. Menopause can therefore be complex to manage, and there may also be added concerns around promoting cancer recurrence. Menopause symptoms can include hot flushes, poor sleep, mood disturbance, vaginal dryness, reduced sexual well-being, fatigue, and problems with memory – these can all impact daily life. There may also be longer-term health impacts, including bone loss and cardiovascular disease. This review brings together current evidence to discuss why treatment-related menopause occurs and how it can be best managed. It highlights that, despite growing awareness, many cancer survivors do not receive adequate information, support, or treatment for these symptoms. As cancer survival improves, menopause care must become a central part of improved survivorship. Personalised approaches to menopause management have the potential to improve long-term health, well-being, and quality of life after cancer.