In the news: HRT and breast cancer

In the wake of the cancellation of the Women's Health Initiative study results and the subsequent abandonment of HRT by many women, a number of articles were published reporting that breast cancer diagnoses fell following the massive refusal of many doctors to prescribe HRT and abandonment of HRT by women frightened by the headlines that assured them that taking HRT would give them breast cancer. Here are some:

In the wake of this furor these articles raised, many doctors argued against prescribing HRT (again) and many frightened women were asking if they should give up HRT. But are these first, frightened responses the whole story? Are they a sound reason to make a complex, health-affecting decision that will have real consequences no matter which way we choose to act? It's good you're asking.

First of all, let's look at what was really found. Before WHI, Premarin was the single most-prescribed pharmaceutical in the US. That's a lot of users. Studies tell us that 30% of previous HRT users quit following WHI, resulting in a 7% drop in breast cancer diagnoses in the following year. Now, it takes a fair amount of time for breast cancer to grow to diagnosable size, and until it's big enough to diagnose, we don't know it's there. So there could be just as many cancers out there, only without the HRT, they're growing more slowly. Only long term data will tell us whether those cancers not seen in that single year of sampling truly never happened or were only postponed. Right now all we have is a correlation in time of two items—not enough, in any serious research context, to prove anything. If the reverse correlation had been observed, that breast cancer cases rose sharply in that year, there would be an outcry—wholly justifiably—for more testing to establish causation. Conceptualizing this report conclusion as "no HRT = no breast cancer" is simply invalid science.

What we also know from other studies is that a substantial number of these women who quit later went back on HRT of a different kind, when they found that their unmet hormone needs were more personally daunting on a day-to-day basis than their cancer risks, but we don't know what place they occupy in this finding. What we also don't know is the quality of life of the remaining women, and how their risks of other forms of mortality will play out. Remember: studies on topics like this focus on only one factor, and give the impression that there is a only dichotomy between certain death and total health in the study choices, when in fact we know that many cancers are early caught and treated, and many risks of low hormone status can be as deadly as cancers. For example, the risk of colon cancer, a much more frequent killer than breast cancer, was lowered more than breast cancer risk was raised, and yet where is this statistic in all of the furor? This is a simplistic discussion, then, that ignores real-world complexity.

We don't know how many of those 30% of HRT-using women who quit as a result of WHI were in natural meno as opposed to surgical and how many of them were taking HRTs in excess of their needs. We don't know what other measures they took to fight breast cancer as well as to maintain their health: breast cancer is reduced by several hours a week of exercise more than the extent to which it is raised by HRT use. How many of the women taking HRT are living healthier lifestyles, something we learn more about every year, that may be making a difference in those cancer rates?

Hormone exposure risks are proportional: we who are taking just enough to meet our non-fertile needs and who have no ovarian production are, remember, aiming at creating a situation much like that of a woman in natural meno who is able to meet her own needs: a potentially much lower exposure level than a woman in natural meno who may be taking a larger-than-needed HRT dose long after her need for it may have waned (many women in natural meno need HRT to ease them through perimenopause, not for their needs in menopause once they are stable). So if we continue taking HRT at our present minimal level, we're not all that different from the women in natural meno who don't take HRT. The arm of WHI that studied women in surgical menopause taking estrogen alone showed a slight decrease in breast cancer rates, and that may well speak as much to this incremental HRT use as the specific HRTs they did or did not use.

Remember too, this furor over WHI does not take into account another recent study that indicates that in terms of long term survival, women who have no ovaries and take no HRT have a 70% all-cause higher mortality rate than women who do take HRT. That means that women without HRT turn out, decades later, to die earlier than women who took HRT, even though they die from all sorts of things. If we combine these two studies (and pay no attention to any other quality of life aspects of using HRTs), then, we can predict a shorter life but a reduced (not eliminated, or in fact not even reduced by much) breast cancer risk. Sound good to you? It does to many doctors, because as they may see it, they would be actively contributing to the cancer but the mortality isn't something they deal with as an entity in itself: they only treat illnesses, not life. It's kind of like your health insurance company: they'll most often go for the short term fiscal savings on the expectation that by the time long terms effects happen, you'll be somebody else's problem.

The Hippocratic Oath, the philosophical foundation of the practice of medicine, forbids doing harm. To interpret it simplistically, then, forbids prescribing HRT because of the potential harm of breast cancer. It does not mandate weighing risks and benefits or considering the harm done by withholding treatment (all of the effects of estrogen deficiency). The decision, helped along by the litiginous nature of US society, is clear when you accept that HRT has no benfits other than reducing hot flashes and vaginal atrophy (which are the only two "reasons" for prescribing it under the FDA approvals process, a process that fails to explore fully all of the potential actions of any compound). This is all part of why medicine is a poor fit for menopausal women's needs: because we need wellness, not treatment of an illness, we just don't fit this schema. But it's what we've got, and so we are going to be affected by these concerns.

One thing that's cropping up in quite a few discussions stimulated by these reports is the assurance that taking bioidentical HRTs can't possibly involve the risks identified in WHI, which used the oral synthetic HRTs Premarin and Prempro (Premarin plus Provera). While compelling-sounding, this is mostly just whistling in the dark. Breast cancer (and estrogen-receptor cancers in general) is undeniably affected by all types of estrogen exposure (including that in soy, black cohosh and the other phytoestrogens as well as environmental contaminants, by the way) and goes along with what we knew from other testing that predates it: lifetime hormone exposure does correlate to increased diagnosis (not development) of cancers. Some of them, such as the ones recently identified as occuring with, specifically, Estratest, seem to be more agressive than the usual, but overall, women taking HRTs have a better prognosis once diagnosed because they are typically diagnosed sooner thanks to the higher level of medical supervision and access involved in the prescribing and monitoring of HRTs. And these studies do not integrate any of the things we know can also lower breast cancer risk, such as daily exercise (have we mentioned that exercise lowers breast cancer risk to a greater percentage than any HRT has been found to raise it?), weight loss, and a lower-fat diet. So while we are bashing the media for an overly-simplistic response to one set of data, it's important not to fool ourselves with overly-simplistic consolations either.

In contrast to our present situation, let's spend a moment looking at prostate cancer. It's caused, directly, by testosterone and nearly all men are believed liable to develop it if they live long enough. But interestingly, no one argues that testosterone is unneeded (although physical or chemical removal of testosterone is the only known treatment for prostate cancer that escapes surgical or radiation treatment) and that all men should give it up at some point in their lives, even though removal of the testes would accomplish this readily. In fact, it's becoming increasingly common for aging men to have their testosterone supplemented so they don't feel a loss of virility as they age. Somehow, that's not the conceptual problem for doctors or male HRT users or the media that HRT and breast cancer poses for women, although it's certainly interesting *cough* to contemplate just why that might be.

The whole situation is one of simplistic reasoning, and that just doesn't mesh well with our own needs for wellness. All we can do is point to the one inescapable fact: what we are doing is asking to have our hormones supplemented to what a woman of menopausal years who is meeting her needs well on her own (which is, presumably, a lower-risk situation as the research presently defines it ) would have to work with. We're not, if we're doing it right, asking for incremental estrogen, such as was shown to be the risk in the non-surgical arm of WHI.

So yes, we are engaging in something that probably enhances our risks of breast cancer. We are also engaging in something that probably lowers our overall mortality. And we have other lifestyle options to lower those risks even more, if we're smart enough to embrace them. Where any woman will fall in the continuum of those statistics will be a matter of individual circumstance, the nature and particulars of which are very poorly understood at this time (although genetic marker studies are beginning to offer guidance in at least a few cases). All we can say is that no matter how much terror the one side of the equation holds (breast cancer risk), we do ourselves a disservice when we ignore the other side. There are no easy answers and no good predictive factors. It's a gamble, and that's why we also have to engage in careful monitoring and whatever else we can do to lower that risk on our own. We're all going to die of something, but another equally important question is how we are going to live until that happens. Not succumbing to simplistic revenue-generating media panic would be one good way to enhance our present quality of life.

Want to discuss this further? Got specific questions about what this means or doesn't mean for your own situation? The link to our discussion list is on the discussions page; you're welcome to join us there.