News of the first decline in breast cancer rates in 25 years, presented by researchers from the M.D. Anderson Cancer Center in Houston during a breast cancer conference in San Antonio, made front-page headlines on Friday. Between 2002 and 2003, the incidence of all types of breast cancer for women of all ages dropped 7 percent, while the number of cases of the most common form of cancer dropped 15 percent. The decline was most pronounced in women age 50-69. Since many breast cancers are estrogen sensitive, the connection between the decline in new breast cancers and the decline in hormone therapy use in 2002 is compelling.

WVFC turned to its resident medical expert, Dr. Patricia Yarberry Allen, a gynecologist affiliated with New York Presbyterian Hospital and director of the New York Menopause Center, for her thoughts on the data.

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This seems like very good news for women who have hoped that research will not only find a cure for breast cancer, but also find the causes.

It is reported that one-third of American women over age 50 had been on hormone replacement therapy and that about half stopped when the hormone replacement arm of the Women’s Health Initiative was halted prematurely in July 2002. Almost all women who stopped hormone therapy after this report did so because they did not want to pay the price quoted for hormone use in the WHI study: increase in breast cancer incidence, increase in blood clots, stroke and heart disease.

The North American Menopause Society, The American College of Obstetrics and Gynecology, and other organized medical and scientific bodies have dissected the WHI and found much to criticize. The average age of the enrolled participants in the WHI study was 59, they were asymptomatic, and the dose of hormone therapy — while standard for many patients at that time — was higher than the dose currently recommended.

However, informed scientists and physicians altered their recommendations for hormone use after the work of the WHI was evaluated. It is now recommended that women who have menopausal symptoms that can not be managed without hormone therapy entering the blood stream use the lowest dose of hormone therapy that will control symptoms for the shortest period of time possible. For practical purposes, this means that many doctors suggest the use of low-dose hormone therapy for 18 to 36 months and then encourage patients to try a hormone holiday.

Should a woman be worried if her doctor suggests hormone therapy? Generally, doctors don’t recommend hormone therapy in the way that patients would like to think that they do.

Patients come to the doctor with a list of symptoms and the doctor works with each patient to diagnose the cause of the symptoms and to choose the safest and most effective therapeutic options.

It is the patient who is suffering and it is the patient who receives the benefit and takes the risk for all therapy. So, options include life-style changes; weight management; what often amounts to a dramatic reduction in alcohol use; avoiding multi-tasking and learning to focus on each task intensely; managing hot flashes with common sense, layers of natural fiber clothing and lots of cold water; buying a sexy fan (I have a collection of 50!); and using local genital estrogen in combination with other therapies for a continued comfortable sex life.

Most patients understand that the symptomatic part of the menopausal transition is related more to hormonal fluctuations and that this period of time generally lasts from two to three years. If the patient chooses to use hormone therapy, most doctors will evaluate her family and personal history carefully for breast cancer risk along with risk of blood clots, heart attack and stroke. If the patient is not a suitable candidate for hormone therapy, then other therapeutic options can be addressed for each symptom.

How do women know what is best at this point? The bottom line is nothing has changed. There have been many studies over the years pointing to the relationship between hormone use for some period of time and the development of breast cancer. The news from Texas last week just underscores this point and gives hope to the many women who look forward to understanding the causes of breast cancer.

It is possible that estrogen cessation (following the reduction of hormone therapy) caused the remission of very early estrogen sensitive breast tumors. There are some animal models to suggest this. Obviously, there will not be any clinical trials in women who have biopsy-proven estrogen-sensitive small tumors, as such a study would entail giving one group estrogen to see if the tumors grow and withholding estrogen from the other group to see if the tumor goes away.

Women need to make a choice: Can the non-hormonal options make life manageable for them for the hormonal transition, or must they take hormone therapy in order to have a decent quality of life?

There is no magic except the magic of a thoughtful relationship with a caring health-care provider who will listen and work with the patient throughout the process.

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  • Dr. Pat Allen December 22, 2006 at 2:39 pm

    I am delighted to have a question about America’s health care system and the individual patient’s responsibility in getting the best care possible.
    I think this is a topic that should be addressed with a well thought out blog, not just a quick pre-Christmas response to a thoughtful comment. I promise to work on this and will urge readers to respond. I want to hear your voice.

    Reply
  • Gay Hartigan December 21, 2006 at 11:47 am

    As usual Dr. Allen is on target with the issues: Texas news release confirms studies of 4 years ago, women need to be in charge of their healthcare and HRT to alleviate symptoms of menopause is not a magic pill, even when it works to alleviate overt symptoms.
    Women need to educate themselves regarding the “system” of menopause, not just the obvious symptoms, but also the sometimes vague, subtle and gradual declines in our bodies. Treating menopause is a holistic effort, it is not a magic pill and definitely requires a “conversation” or two with a healthcare professional versed in this particular issue.
    I use the word “system” to describe the stage of development and the treatment because it isn’t one procedure, one pill or one doctor. It is a system that needs to be managed and monitored by yourself in conjunction with astute healthcare professionals.
    For me, a 55 year old who went through menopause at 48, the defining moment was a phsyician who kept demanding that I do ERT, while I was just as adamant about not taking it. My mother had had estrogen sensitve breast cancer (premenopause). Luckily I persevered, found Dr. Allen and so far am doing well. Her sensitive, astute work with me put me on a “system” of care.
    Her prescriptive options and supplements helped the obvious symptoms. Her excellent referrals for adjunctive treatment, whether dermatology, orthopedics, diet, Pilates, hematology or psychotherapy, all can be of assistance depending upon the individual needs. For me, her education regarding sex therapy and her referral for me to take a sex therapy course (I am a healthcare professional myself) not only enriched me personally, but also has steered me onto my next career choice.
    Hopefully my story will encourage women to take control of their healthcare, find the Pat Allens out there and then be your own strong advocate to do the work to be healthy in every respect. This can be an enriching process which women can use to give themselves a strong voice in their own hearts as well as in the world.

    Reply
  • Lisa December 20, 2006 at 1:48 pm

    Thanks for the common-sense summary of everything we’ve been reading the last few days. I just wish I could guarantee all doctors would take such a holistic approach to treatment.
    While the news is obviously good to have, I’m afraid that many women who have struggled to find a truly “caring health-care provider,” will be left with a, “Well, there’s not much you can do!”
    How do we change health care in this country so it’s focused on prevention and wellness and not just medication?

    Reply