If you were alarmed by the recent New York Times article, “Breast Cancer Seen as Riskier with Hormone,” you’re not alone. The day it came out, my computer crashed with hundreds of emails from worried women wanting clarification, validation, and the straight scoop, all summed up in one question: “What does this mean?”
It means a few things. It means we have some additional data from an old study that mostly confirms our knowledge that hormones can increase the risk of occurrence and the severity of breast cancer. But it also means that we need to take our morning news with a dose of perspective. The alarmist media we associate with politics these days seems to be spreading to medicine. And as in politics, this report is not what you’d call fair and balanced. Now that I’ve had a few days to read and discuss the findings with other experts in the field, I am certainly less alarmed than the average reader of the Times.
Here’s the straight story.
The Women’s Health Initiative (WHI) is the most rigorous study into the impact of hormone therapy on the cardiovascular health of post menopausal women. The latest followup of WHI Secondary Outcomes was just published in the Journal of the American Medical Association. And, I might add, released to the media several days before it reached practicing physicians.
As with the initial findings, this follow-up report confirms a slight—and I do mean slight—increase in the incidence of breast cancer in women on combined continuous estrogen plus progestin therapy (PremPro), as compared to women who were given no hormone therapy at all (the placebo group). The absolute numbers: 385 cases of breast cancer in the hormone treatment group versus 293 cases in the control group, out of a total of 16,608 women.
The original study did not report separately on breast cancer deaths. In this new WHI data, there were 25 deaths related to breast cancer in the hormone treated group and 12 deaths from breast cancer in the placebo group, from the start of the study (November 15, 1993) through this most recent review (August 14, 2009).
So we’re talking 2.6 deaths on hormone treatment versus 1.3 deaths on no treatment, per 10,000 women per year.
That’s really only one more woman who developed breast cancer. Per 10,000—ten thousand—women.
Not exactly a headline grabber, is it?
Many critics of the WHI still argue that the interpretation of the latest observational data—now 17 years out from the start—is plagued by an important flaw: at the start of the study, the median age of the participants was 63, more than a decade past the average age of menopause. Older women were chosen because, the reasoning went, they wouldn’t have menopausal symptoms and as a result would be less likely to know if they were on the hormonal medications or the placebo.
The median age of these women now is well over 70. Increasing age is known to be one of the most significant risk factors in the development of breast cancer. So in terms of gauging the risks of hormone therapy, findings for older women—already at risk for breast cancer based on age alone—has been extrapolated to the treatment of much younger women.
Even so, we need to give the WHI study its due. Over the years, it has clearly shown that postmenopausal hormone therapy has risks and rewards. From this data, we’ve learned that hormone therapy shouldn’t be used to prevent coronary artery disease or decrease heart attacks and strokes. And it’s clear that no woman should use it as a specious attempt to avoid aging, to keep a youthful complexion, or from an inappropriate fear that menopause will ruin her life.
On the other hand, there are times when hormone therapy can be appropriate. Women with severe symptoms of menopausal syndrome are few, but for them, it’s hard to look at anti-depressants and sleeping pills as the only recourse. I do feel that women who are not functioning and who find that they are “themselves again” with hormone therapy deserve the option of short-term therapy without constant anxiety from overblown headlines.
Bottom line: Women who have significant menopausal symptoms should evaluate the risks and benefits of hormonal treatment with their health care providers. If they choose to use systemic hormone therapy, they should use the lowest dose for the shortest period of time consistent with their needs. In the meantime, maybe what we need is a health advisory for media headlines. The media need news that will alarm their readers, and they need to be the first with the scoop on the bad news of the moment. They are not as concerned with balance as they should be, nor are they concerned with the anxiety and fear that their lead sentences will produce in their readers. Maybe the New York Times should have a black-box warning around these alarming health articles: “Check With Your Doctor Before Reading This.” And keep your speed dial on 911.