Tuesday, February 10, 2009

Breast cancer and hormone therapy

I believe that the most important influences driving our medical decision making process are our personal beliefs, both our worst fears and our fondest hopes. These belief systems are powered by our own medical histories, those of our family, the things that we read, and our personal experience. Sometimes my exam room is crowded to overflowing as Suzanne Somers argues with Dr. Susan Love in the corner as Dr. Andrew Weil tries to get a word in edgewise. Meanwhile my patient's mother and her best friend's cousin are lurking just behind her clamoring to add their opinions on the magazine articles spread out on the desk in front of us.

I would be foolish to discount these many voices; if they're important to my patient, they need to be a part of our discussion. I like to think my worst fears are highly informed ones, yet I am highly influenced by my family history of dementia and completely freaked out by the latest news on breast cancer and HRT in the latest issue of the NEJM(1). Here's the scoop:

The Women's Health Initiative randomized over 16,000 women to receive either combined postmenopausal hormone replacement therapy (Premarin plus Provera) or a look-alike placebo, then followed each group with regard to health outcomes, particularly the incidence of cardiovascular disease and breast cancer. The trial was abruptly halted in the summer of 2002 (what menopausal internist can forget that?) when it was clear that harm outweighed benefit with respect to heart attack, stroke, and breast cancer risk.

The study has come under attack for applying data obtained from a somewhat older group of women (average age 63) many of whom were overweight, hypertensive, diabetic, and smokers to a younger group of women just entering menopause and looking to improving their quality of life with HRT. Several studies, both trials concluded and some still underway suggest that, in fact, this latter group of 50-somethings may actually receive cardiovascular protection from the use of hormones particularly so-called bioidentical estrogen delivered in a non-oral fashion (such as via a skin patch).

I'm good with all that but note please that cardiovascular disease is not high on my to-worry list although I certainly recognize that many of my patients are at risk for same. And as losing my marbles is number one on my future frets, and estrogen is a top neuroprotective agent for aging female brains, I'm choosing to motor on with my HRT choices.

When the WHI data came out, some drug company or other provided me with graphics on this breast cancer thing. One thousand little grey female stick figures were lined up on the top of the page three of whom were colored orange. These unfortunate orange ladies were the number per year of new breast cancer victims in 1,000 post-menopausal ladies not on hormones. At the bottom of the page, another 1,000 skirted sticks queued up, 996 clad in grey and 4 in blue. You've got it: the blues were new cases of breast cancer per year in 1,000 post-menopausal hormone users. The absolute risk was huge; a 33% increase in breast cancer amongst hormone users but the relative risk small, namely one additional breast cancer per thousand users.

BUT...consider that 4th blue lady, her life turned upside down with biopsies, chemo, radiation, and a world of worry even though her chances of actually dying from that cancer are small. And if your worst fear is that cancer-induced world upheaval, then you will choose to discontinue therapy or never start it in the first place.

And now the doctors of the WHI bring us this new news to add to the evidence behind our worst fears, namely that the incidence of breast cancer which nearly doubled in the hormone users over the 5.6 years of the study decreased rapidly in the two years after the study coinciding with a marked drop in the use of combined hormones by the subjects. The busy slide at the top of this post illustrates this in the upsloping solid red line on the left which represents cancer incidence during the study and the soothing downward solid blue line on the right as fewer women got the bad news in the 2 years following the study's end. The black and white graph that follows is the interesting and contrasting data from a Scottish study that also notes the drop in hormone use over a similar time frame (the two plunging lines) but the more or less straight line at the top shows that Scottish women did not experience the drop in breast cancer rate with falling use of HRT.

Argh, what's an aging woman on hormones or contemplating their use to think? Estrogen is a growth-stimulating hormone, and thanks for the boost when it comes to bone, muscle, connective tissue, skin, vaginas, and brain. I love my brain power, I worry often about dementia, and I don't mind the youngish looking skin, so here's to hormones! But, breasts that aren't prepping to feed a developing babe don't like to be stimulated, and the more you goose your breast cells years after pregnancy is nothing but a distant memory, the more likely you are to stimulate a cancer. I don't want cancer, no not one bit, I know one woman who got cancer within 1 1/2 years of starting HRT, so to heck with hormones!

Well, Ms. Suzanne Somers staring out the cover of "The Sexy Years" like you just rolled out of a bed in which you were not alone, what is easy about this decision? Absolutely nothing. Per Dr. Morris Notelovitz, a venerable old menopausal researcher, every year a woman and her doctor should review her hormone therapy decision (and every other medical decision she makes per me!). If she is using HRT, why? If she is not using HRT, why not? What are the experts and your secretary's aunt saying? What do you believe is best for yourself?
(1)Cheblowski, RT et al. Breast Cancer after Use of Estrogen plus Progestin in Postmenopausal Women. NEJM. Volume 360:573-587 Feb. 5, 2009.


Anonymous said...

Dear Doctor,

Is the estrogen (only) patch safer to use (total hysterectomy)? In the case of a total hysterectomy, how long does a woman usually stay on HRT?

kenju said...

I was a WHI participant in Chapel Hill. I told them I would not take hormones and if I was put into the group that was - I would know it and stop them immediately. I had had prior problems taking hormone therapy and I wasn't about to do it again. Thank God I said that - since who knows which category I would have found myself in?

Mauigirl said...

It is a big dilemma indeed. I am (finally) menopausal but am not having any severe symptoms so don't take HRT. If I were having severe symptoms that were disrupting my life, I would.

I would not take HRT to prevent heart disease or dementia.

Re: the dementia concern, try curcumin. Supposedly it seems to prevent dementia. (For instance, in India where everyone eats so much curry - which curcumin is in - hardly anyone gets Alzheimer's). Plus we've been giving it to my MIL who has Alzheimer's and I swear she has improved.

Anonymous said...

Here is the short version from an expert (Margaret Gedde) that I trust:
'The WHI study arm that used horse estrogen was stopped because this treatment increased breast cancer. The arm of the study that used horse estrogen alone did not increase cancer and was not stopped. This shows that medroxyprogesterone a chemical found in nature was the problem.WHI did not study bioidentical hormone replacement or natural hormone balancing. Many feel that the results would have been very different- significant benefits of therapy would have been seen- if properly monitored and individualized bioidentical hormone therapy had been studied.
The connection between lifetime estrogen and breast cancer is a solid statistic, but it doesnt explain why the highest rate of breast cancer occurs after menopause, when women no longer make estrogen. If estrogen causes cancer, shouldnt the highest rate be in menstruating women? It may be the balance of estrogen and progesterone is sthe important factor. How estrogen is metabolized may also be importanat. Natural hormone balancing reestablishes healthy hormone balance and metabolism.
Some cancers are fed by specific hormones. The hormone did not cause the cancer, but it could encourage the cancer to grow., so persons with certain cancers may chose to avoid hormone supplementaltion. However, healthy , balanced hormones create a environment that helps the body destroy cancers, along with lifestyle choices(diet, exercise,etc).If you have breast, uterine or prostrate cancer, the decision of whether to supplement wsith hormones should be made after considering all the ways you can support your body's healthy defenses, and after thoughtful discussion with your doctor. In all cases, use only bioidentical hormones and carefully monitor your therapy and results.

Can your doctor name the 9 major hormones and neurotransmitters, known to cause depression when their levels are low? If she can, then that do's a gem! (Tip: Prozac is NOT one of them!)

Why genetics is NOT destiny! Find out what your body needs to be well, even if your mother or other relatives suffered for years from problems you are showing signs of.
If someone tells you- get used to it---DONT BELIEVE THEM!

Also, DR. Paley, you are concerned about dementia, these concerns about having/getting what your mom had or died of , are very common.... please go to www.emofree.com and read the how to free manual and apply this techinique to your thoughts, feelings, symptoms.... because it works to remove the excess feelings, and is healing some in many cases.... this IS OUTSIDE the medical protocol 'BOX', however some doctors are using it now because of its obvious benefits and healing... it is proving itself....Prove it to yourself, it will be worth your time....really.
Please check it out for yourself...
Also, you may be interested in knowing the asian medicine treats dementia, and they use Lotus Leaf for high cholesterol, to regulate hyperlipid conditions.... some think is related to dementia....
However, with the knowledge I have dementia, diabetes, menopause, thyroid, and other illnesses are directly related to yin (kidney/adrenal) deficiencies, and the only ones rebuilding/supporting kidneys etal, are the chinese medicine....

This is free advice, because you are in need, and I feel like passing it forward.....
Please go to www.emofree.com and check it out... YOU and your patients will be glad for it.... I would have a poster with the site listed in my waiting room, if it were me...... take care wpf

Anonymous said...

Margaret Gedde is MD and PHD

Anonymous said...

I sometimes wonder what women did before HRT was even a possibility. I am too lazy/unskilled to see if anyone has studied this, but many millions of our ancestors didn't have access to this therapy. I'm assuming this as I have no idea when HRT was first discovered. Maybe a great number of our forebears died from infections, childbirth, etc. before they even hit menopause, but surely not all. What were the causes of death (and conditions of cognitive function) of those who survived for a couple of decades past menaopause. Anecdotally, I can tell you that my grandmother - in-law (born in the 1880s) lived to be 93 and died from a fall down some stairs caused by failing eyesight. My own grandmother also born before 1900 lived to be 84 and died from pneumonia. Neither one of these women had cancer, cognitive deficiencies or heart problems. So, I guess what I'm wondering is whether HRT is really a step forward for women at all.

femail doc said...

Thank you all for your interesting comments.
Anon#1: Evidence from the WHI and other studies suggest that therapy with estrogen alone carries a lot less breast cancer risk than the combination approach.
KJ: Did you end up in the WHI Observational Study?
MG: I agree, no HRT specifically to decrease cardiovascular or dementia risk. And I agree too on curcumin; I've taken it twice daily for a couple of years (ever since the published observation that curcumin dissolved beta-amyloid protein in the test tube.
WPF: What a lot of interesting info, and much of it sneaking into conventional wisdom insofar as Premarin and Provera and their negative influence on the WHI outcomes. (and that is why I don't prescribe those a bit). Thanks for dementia tips.
Anon the last: Many women did not live past menopause even into the last century, so what to do about it was not a consideration. Then as now, there were any number of persons dubbed the 'remarkable elderly' who sailed into old age straight-spined and clear-headed way past meno- or andro-pause. I don't think hormones promote quantity of life, but no doubt in some cases they promote quality. It's not forever, it's not for everybody, and it's no substitute for healthy living.