Saturday, 24 June 2017

Hormone replacement therapy and breast cancer/heart risk.

   When I started practice, way back in the dark ages, many women were on long term hormone replacement (HRT) therapy for years.  It was regarded as some sort of 'elixir of life' which protected its users from many of the consequences of growing older, including heart disease, vaginal atrophy, vascular instability resulting in hot flashes, palpitation and generally feeling unwell.  I believed then, as I do now, that it is appropriate to use HRT for a time in woman, who are symptomatic, where there is no contraindication.  In 2002, in a study called the Women's Health Initiative (WHI) the estrogen-progestin trial was stopped early as a result of an initial results press release citing an increase in breast cancer and increase of heart attacks in the treated group. Now Dr. Robert Langer, the lead investigator in the study states the report was written in secret by a small group of study executives and resulted in "misinformation and hysteria". Langer further stated that the study results were not statistically significant for breast cancer or cardiac harm, that there was some increase in venous blood clots but there was a reduction in hip fractures.  He states the study results were not adjusted for pre-existing diseases or treatments and that there was an unusually low rate of breast cancer in the placebo group(The controls).  Further, he states that the trial was designed to focus on long term hormone therapy to prevent chronic disease in women over the age of sixty, but the results were generalized to younger women on short-term therapy for menopause.  Later analysis of the study data showed that these younger women had an absolute risk of twelve (12) adverse events per ten thousand women (10,000), less than a third of the risk noted among women of age seventy to seventy-nine, as well as fewer cancers, fractures and deaths from any cause compared to the placebo group.
Langer states the press release favoured "fear and sensationalism over science".  
   Medical consensus has come around to supporting short-term hormone therapy for symptomatic menopausal women, though as a result of the bad press many doctors are apprehensive to prescribe it. Some specialists are more strongly in favour of prescribing HRT and a study published in 2013 estimated as many as 91,610 American women died prematurely between 2002 and 2012 as a result of avoiding estrogen therapy.
   In practice, my policy was to treat symptomatic woman with hormone replacement therapy after sharing as much information as we had at the time, if they wished to proceed despite the possible minimal risks.  Many had such severe symptoms and such severe an effect on  their quality of life that they were in absolutely no doubt in opting for treatment.   When their symptoms resolved we tapered the treatment as tolerated.  Of course continued careful observation is of prime importance but until the answers are all in, informing the patients as accurately as possible of what appears to be the minimal risks of symptomatic short term treatment and allowing the patient to decide whether to proceed or not would seem to be the appropriate approach.   Long term treatment is inappropriate with the current state of knowledge

No comments:

Post a Comment