Newsflash: Estrogen only joins “avoid long-term hormone therapy use” recommendations
How many times does one need to get hit over the head before they have that “ah-ha” moment?
That’s pretty much the party line when it comes to hormone replacement therapy, or HRT. I’ve been writing about HRT since I started this blog. And I have been reading study after study that ultimately come to the same conclusion: long-term use of any hormones is unsafe.
I know that there are naysayers out there who don’t want to believe. Even the International Menopause Society continues to dispute the link between combined hormones and breast cancer. Yet, I wholeheartedly believe in free will and choice, informed decision-making needs to lead the way when it comes to your health.
And so, in the latest wrench to be thrown into the HRT argument, researchers from Brigham and Women’s Hospital in Boston, reporting from the annual American Association for Cancer Research meeting, that the longer that any hormone replacement is used, regardless of whether or not it is estrogen plus progesterone or estrogen alone, the higher the risk for developing breast cancer.
Did you read that?
Lead researcher Wendy Y Chen is quoted in the Association’s newsrelease as saying that while it’s “already been confirmed that patients shouldn’t be undergoing estrogen plus progesteron hormone therapy for the long term,” (you can read about that here), “what we found is that people should also be careful about longer-term use of estrogen-alone [hormone therapy].”
Chen and her team evaluated data collected during the Nurses Health Study over a period of 28 years. They found that of the 121,700 women who took part in the study who were between the ages of 30 and 55 in 1976, and used combined hormones for 10 to 14.9 years, had an 88% higher risk of developing breast cancer than women who did not use HRT. Moreover, this risk increased to more than two-fold in women using it up to almost 20 years. And although the risk was comparatively lower for women who used estrogen only, they still had an 22% increased risk for up to 14.9 years and a 43% increased risk for up to 20 years compared to non-users.
Importantly, when the researchers restricted the population to the same that was observed in the Women’s Health Initiative study (i.e. healthy, active postmenopausal women ages 50 to 79 with an intact uterus), they observed a decline in breast cancer risk among women who used estrogen only therapy for less than five years but continued to observe an increased risk among women currently using estrogen fo 15 to 20 years.
Chen emphasizes that the data do not demonstrate an increased risk for dying from, although they continue to study this particular factor for additional clues.
So, what’s the upshot?
Long-term use of any kind of hormone therapy, estrogen alone or in combination with progesterone, significantly increases the risk for developing breast cancer. Is this increased risk worth a decline in hot flashes, night sweats, mood swings and vaginal dryness? Only you can decide.
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Breast cancer: is your environment placing you at risk?
Last week, the Institute of Medicine (IOM) issued a new report on breast cancer and you will want to take note of their recommendations.
Entitled “Breast Cancer and the Environment, a Life Course Approach,” the goal of the undertaking (which was sponsored by Susan G. Komen fo the Cure) was to examine how a woman’s genes interact with her environment outside of her DNA to increase breast cancer risk. For the purposes of this report, environment was defined broadly to encompass all non-inherited factors, including:
- How a woman might grow/develop throughout her lifetime (including body fat, abdominal fat, weight gain as an adult)
- what she eats and drinks (alcohol consumption, use of supplements)
- Physical, chemical and microbial agents encountered (e.g. dyes, BPA, parabens, tobacco smoke, metals, dioxins, pesticides, industrial chemicals)
- her participation in physical activity
- Social and cultural practices
- Any medical treatments or interventions (e.g. combination hormone therapy, oral contraceptives, radiation)
Although research has long focused on the potential interaction between breast cancer and the environment, rarely has it concluded in determining or explaining preventive actions that a woman might take to counteract risk. That’s why I wanted to share some of the key findings on Flashfree.
First a bit of context:
Breast cancer, like many adult cancers is believed to develop as a result of accumulating damage to cells and tissues caused by internal and external factors. According to researchers, timing is everything. In other words, it is possible that a woman’s susceptibility to developing breast cancer increases at key periods during her life; this means when she is exposed to various contributing factors may be important. Overall, girls born in the U.S. have a 12% risk of developing invasive breast cancer sometime during the lives and among White women who are currently age 50 , 24 out of 1,000 can be expected to receive a diagnosis within the next 10 years; this figure declines slightly in women who belong to other ethnicities, including Black women (22 out of 1,000), Asian women (20 out of 1,000) and Hispanic women (17 out of 1,000).
The researchers write that trying to “determine which environmental exposures may influence rates of breast cancer poses substantial challenge,” explaining that how breast cancer develops, where it originates and how it progresses are not entirely clear. They also emphasize that by solely focusing on exposure to these factors during adulthood, it is very possible that they are missing other critical windows earlier in a woman’s lifetime or while she is growing up, that could influence breast cancer risk later in life. Still, even without these missing pieces, they have made some key recommendations that a woman might take to reduce her risk for breast cancer from environmental exposures:
- Avoid inappropriate exposure to medical radiation, especially x rays and gamma rays (i.e. ionizing radiation)
- Avoid combination menopausal hormonal therapy unless medically appropriate (note that not only does this include HRT but also long term use of oral contraceptives)
- Avoid or end active smoking
- Avoid passive tobacco smoke
- Limit or eliminate alcohol consumption
- Maintain or increase physical activity (e.g. increasing specific exercise types or frequency or a combination of the two)
- Maintain weight or reduce overweight or obesity before menopause starts
- Limit workplace and general exposure to chemicals that have been linked to breast cancer
Importantly, some of these steps are not without risk or ramification. For example, avoiding exposure to radiation could result in a loss of clinical information that might be otherwise useful. Likewise, they point out that eliminating alcohol drinking could increase heart disease risk. And, increasing physical activity levels always raises the risk for injury.
The Committee who drafted the IOM report concluded that these steps are only the tip of the iceberg, and that there are still only limited opportunity for evidence-based preventive actions. Moreover, these steps are truly individualistic; what will work for one woman may not work for another. And, any risk reduction may be minimal at best. Still, it is heartening that researchers are starting to tease out how our environment affects our health, if not for us, then for our daughters and granddaughters. Ultimately, we need a better understanding of the relationship between breast cancer risk and environmental factors, of the changes that the breast undergoes through a woman’s lifetime, timing and windows of opportunity. Meanwhile, try to change the course of your life by changing the life of your environment. It can’t hurt.
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Wednesday Bubble: More on breast tenderness, hormone replacement and breast cancer
More bad news on the hormone replacement front: if you are taking estrogen (conjugated equine estrogen) with progestin (medoxyprogesterone) for menopausal symptoms and experience breast tenderness, you may want to think twice.
Frankly, this news isn’t exactly new. Because back in 2009, UCLA researchers reported similar findings in the Archives of Internal Medicine. These newer data, provided by the same researchers at UCLA’s Jonsson Comprehensive Cancer Center and published online in Breast Cancer Research and Treatment only add to the hormone risk fodder.
The researchers say that in their research, they’ve consistently run across data that suggest that “estrogen plus progestin compared to estrogen alone, have a more marked effect on breast tissue,” possibly due to more growth, leading to greater density. According to the lead study author, Dr. Carolyn Crandall “higher breast density (has been shown to be) associated with a higher risk of breast cancer,” adding that “in women with extremely dense breasts, the cancer risk can be four to six times higher than for women whose breasts are not dense.”
In this update, Dr. Crandall and her colleagues reviewed data from the Women’s Health Initiative, specifically focusing on reports of new breast tenderness. At the study’s start, almost 12% of women taking estrogen alone or estrogen in combination with progestin reported having breast tenderness. However, by the first year, women in the combination hormone therapy group reporting onset of breast tenderness after starting hormones had a 33% greater risk of developing invasive breast cancer compared with their peers who did not have breast tenderness. And while estrogen alone also increased the risk for developing breast tenderness, the effect was less than that of the combined hormones, especially since it did not lead to an increased breast cancer risk.
So, what to make of these new data? If you are taking HRT and develop breast tenderness, you need to speak to your health practitioner, assess your risks and make a joint decision as to whether or not the benefit of fewer menopausal symptoms is worth the risk of possibly developing an invasive form of breast cancer. And if you are not yet using hormone therapy, you may just want to step back and think twice.
Buyer beware: hormone therapy is a slippery slope with bumps, bruises and perhaps serious disease. Is it worth it? Only you can decide.
Read MoreShaken. Not Stirred.
I have been inspired by my friend Gini Dietrich’s weekly Gin and Topics posts over at Spin Sucks, so much so that I’ve decided to up the ante and bring back a Roundup-like feature to Flashfree (if you’re unfamiliar with the Roundup, think monthly highlight recaps. You can find them here.)
Shaken. Not Stirred is intended to highlight a few choice finds that I believe are worthy of mention in this space. They might not warrant an entire post, but they’ve shaken me up in one way or another to break (or pause, if you will) from our normally scheduled programming and deliver information in a format that is distinct from what you’ve come to expect. In that vein, this feature won’t appear on a regular schedule as I do believe that into every blog should flow a bit of the erratic; after all, that’s what keeps things lively, right?
So, without further ado… I bring you the Shaken. Not Stirred.
Bottom’s up!
- There’s a new kid in town and you may want to get to know him better. So you chat about him online with your other online pals, weigh his pros and cons. And then decide collectively whether or not to befriend him. That’s what the new patient portal Treato is doing. Only this time, the new kid is a medication you might be considering taking for your menopause-related depression and you’re not sure about its side effects. Can you find someone just like you to talk to about it, read/hear their experiences, obtain advice from a medical expert who might be weighing in and then make a more informed decision? Treato is doing just that in one consolidated location. Granted, I’ve not thoroughly vetted the site for accuracy and like any medical information that circulates on the web, ‘whatever is received’ requires vigilance on the part of the user. But I am a huge advocate of leveling the healthcare playing field and patients should be participating in their healthcare. Check it out. And let me know what you think.
- Who knew that weight loss could be so easy? One pair of Zaggora HotPants can help you zap away that unsightly cellulite. How? By incorporating “a comfortable bioceramic material that emits infrared rays to help wearers naturally and efficiently amp up weight-loss regimens. The shorts’ Celu-Lite technology smoothes thighs and other dimple-prone areas by galvanizing the skin’s internal zamboni to promote a deep warming of body tissues and promote lymphatic drainage. This process boosts sweating by up to 80% and aids in eliminating the toxins responsible for cellulite. Gotta give the company props for the term ‘internal zamboni’ but the reality is that nothing has been scientifically proven to rid the body of cellulite.
- Since we are on the topic of do’s and don’ts, why not end this week’s Shaken. Not Stirred with a bit of alcohol-related news? My guess is that many of you have seen the news about drinking and breast cancer and are as confused as I’ve been. My friend Elaine Shattner, over at Medical Lessons Blog, has done an excellent job distilling the facts down to ‘what you need to know,’ much better than I ever could have. Like me, Elaine (who is a trained oncologist, among other things) agrees that women no longer need to be stigmatized by their decisions, writing “Women, in my experience, are generally more vulnerable to the put-downs of others. And so my concern about the BC-alcohol link is that this will, somehow, be used, or have the effect of, making survivors or thrivers or women who haven’t even had breast cancer feel like they’re doing the wrong thing if they go to a party and have a drink. And then they’ll feel badly about themselves.” Do yourselves a favour: read this post.
And if you would, can you do me a favour and weigh in on Shaken. Not Stirred?
Yay, nay or meh?
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On breast cancer screening. Guest post by Dr. Elaine Schattner
Mammography screening. Should you? Or shouldn’t you?
A few weeks ago, I received a letter in the mail from the clinic where I get my mammography. Rather than the expected ‘all is fine,’ the clinic was requesting that I call to schedule another screening due to abnormal findings. Not only was this not the way that I wanted to receive news that something might be wrong, but, I opened the letter at 4 pm on a Friday afternoon, giving me little time to get over the initial shock and then get on the phone to see if I could learn a bit more before the clinic closed for the weekend.
Mammography screening has been in the news quite a bit over the past year, with lines being drawn between experts who say that screening doesn’t save lives and women who want their mammograms regardless of the facts. I happen to fall on the latter side of the aisle and while I suffered a lot of anxiety before I had a second screening, not knowing would have been even worse. (FYI – it turned out fine.)
Recently, my friend Dr. Elaine Schattner, a trained oncologist, hematologist, educator and journalist, wrote about a new review that I believe that every woman should read before deciding whether or not to have a mammogram. It puts some of the controversy into perspective and also provides a much more balanced viewpoint on the risk-benefit ratio. And rather than reinvent the wheel, I asked Elaine if I could re-run the post on Flashfree. Please share it far and wide; it’s important.
With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography.
The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem:
Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)
On screening:
The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained….
She breaks down the data for mammography by age groups:
For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There’s a consensus that screening isn’t appropriate for women with serious coexisting illnesses and a life expectancy of less than 5–10 years.
For those between the ages of 40–49, Warner challenges the revised 2009 USPSTF recommendationson several counts. She critiques those authors’ weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers:
…However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained.”
What I like about Warner’s analysis, besides its extreme attention to details in the data, is that she’s not afraid to, at least implicitly, assign value to a procedure that impacts a young person’s life expectancy relative to that of an older person.
She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).
The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.
In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history):
…Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There’s about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding.…
In my opinion (ES) this is key – that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.
About the author…Dr. Elaine Schattner is a trained oncologist, hematologist, educator and journalist who writes about medicine. Her views on health care are informed by her experiences as a patient with scoliosis since childhood and other conditions including breast cancer. Elaine is a Clinical Associate Professor of Medicine at Weill Cornell Medical College in New York City where she teaches part-time. Her blog, Medical Lessons, is geared towards dissecting and providing commentary on how healthcare news is comunicated in order to foster learning and help bridge the gap between patients and doctors.
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