The following is a bit off the topic of cancer tests, but it goes along with the general theme of individualizing patient treatment.
In yet another long term follow up of the massive Women’s Health Initiative study, which included a randomization between placebo and hormone replacement therapy (“HRT,” with estrogen + progesterone), an increased incidence of breast cancer and increased breast cancer deaths are being reported.
What is being (erroneously) disseminated in the media is the following message: “Not only does prolonged use of hormone replacement therapy raise the risk of breast cancer, new research finds, but it also ups the risk for more severe forms of the disease and increases a woman’s chances of dying.”
This most recent WHI paper only looks at (1) breast cancer mortality and (2) all cause mortality after a diagnosis of breast cancer. It does not report all cause mortality! Therefore, it cannot be stated that HRT “increases a woman’s chances of dying.”
An earlier study published by the same authors showed a slight (non-significant) reduction in all cause mortality with HRT and a significantly decreased incidence of colon cancer and hip fractures.
The risk of death following hip fractures has been stated to exceed the risk of death following breast cancer in post menopausal women.
I watched and listened to the lead author (Dr. Rowan Chlebowski, who is a medical oncologist with the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center) on the PBS News Hour on October 19, 2010, and I read the JAMA editorial which accompanied the Chlebowski paper and I felt that both exhibited much greater certitude in discouraging HRT use than the data support.
Risks and benefits must be individualized. Thin post menopausal women, with physically active lifestyles, non-hyperdense breasts, low to negligible alcohol consumption, lack of family history, negative mammograms, low fat diets, no tobacco use, low risk of coronary artery disease, and severe osteopenia are at high risk for high lethality hip fractures, but at low risk for breast cancer, lung cancer, and thromboembolic disorders. Might not the risk benefit ratio of lower dose, transdermal HRT be favorable?
I just use the above as an example. The absolute risk magnitude of breast cancer attributable to HRT remains very low, and there other threats to health and happiness in post-menopausal women beyond breast cancer.
I understand that a continuing series of articles from this study is planned for the future. Were I a reviewer, I’d demand that all cause mortality data be published with each and every one of these forthcoming studies.
In an earlier, previously-reported study from the same authors, the risk of non-small cell lung cancer was cited as a possible complication of HRT. But the absolute magnitude of risk was very small, and was not close to being significant in the case of never smokers. As noted above, yet another prior study had shown a significant decrease in the incidence of colon cancer, in women receiving HRT, compared to placebo. Along with the substantial reduction in hip fractures.
Yet study authors, editorialists, and especially the media are now making it appear that prescription of HRT to post-menopausal women is virtually tantamount to malpractice. I strongly disagree with this position. HRT has a risk benefit ratio, along with everything else in medicine. And this risk benefit ratio is hugely different in different subsets of patients.
Which is why therapy should be individualized and why broad, one size fits all pronouncements and messages should be discouraged.
- Larry Weisenthal