The hue and cry over hormones shows no signs of abating. Anti-estrogen crusaders are crowing that a huge study on hormone replacement therapy (HRT) proves the drugs raise the risks of breast cancer and heart disease. Beleaguered women who found relief from the torments of menopause through HRT say the dangers are overblown. In the end, the study spotlights an underappreciated medical axiom: There is no such thing as treatment without risk. And patients must figure out for themselves if the risk is worth taking.
Don't assume your doctor has the answer. Physicians may try to "First, do no harm," but those are difficult words to practice by, given that any two doctors may strongly disagree on exactly what causes harm. Where does that leave the patient? With another set of words to live by: "Know thyself."
Every medical study produces statistics that can have very different implications for the many than for the few, and a public health policy based on a nationwide cost-benefit analysis may ill serve a particular individual. Only by knowing one's own risk factors can a patient decide if a medical procedure is merited. Even then, the decision is often an educated guess.
It's not just menopausal women who must guess. It seems like common sense, for example, that everyone should be tested early and often for cancer. But a recent analysis of data on prostate-cancer screening found that 35% of men over 65 who underwent the standard PSA test ended up being treated unnecessarily. If left alone, it is unlikely these men would ever have experienced symptoms. Given that the treatment can cause impotence and incontinence, that sounds like a case against widespread PSA testing--unless you're one of the individuals whose life was saved by early detection.
A similar calculation must be made for HRT, which many women have taken for decades to prevent osteoporosis and heart disease, as well as to relieve the often severe symptoms of menopause. The large HRT study, conducted by the National Institutes of Health, came up with some scary-sounding figures. After observing 160,000 postmenopausal women for five years, researchers said those taking a combination hormone drug from Wyeth Pharmaceuticals (WYE
) called Prempro had a 29% higher risk of heart attack than those in the control group. They also had a 41% higher risk of stroke and a 26% increase in breast cancer risk.
However, the absolute risk of a woman developing these diseases in her lifetime increases only very slightly on HRT--and there is no increased risk in the first four years of the treatment. The study found that 8 more women per 10,000 per year developed breast cancer if they took the drug, an increased risk of less than 0.1%. Seven more women per 10,000 had heart attacks, and 8 more had strokes. On the plus side, there were 5 fewer hip fractures per 10,000 in the Prempro group and 6 fewer cases of colon cancer.
Those tiny percentage increases on heart and breast disease can add up to tens of thousands of additional cases when spread across the 6 million U.S. women taking Prempro. Still, "there is no need to panic," says Dr. Daniel E. Stein, a gynecologist at St. Luke's-Roosevelt Hospital Center in New York. "Every woman should realize that the absolute risks are very small, and speak to her physician."
Figuring out one's own risk is complicated but doable. Healthy women have a 1-in-8 chance of developing breast cancer in their lifetime. To calculate the odds for a particular woman, doctors can take a detailed family and lifestyle history, punch each factor into a computer program called a Gail model, and come up with a statistical ranking of the patient's chances. There are also ways to determine the risk of heart disease, osteoporosis, and colon cancer. However, no one can say "yes, you will develop breast cancer" or "no, you won't."
This lack of certainty will become more of an issue as new preventive therapies are developed. Researchers are testing a number of drugs meant to be taken for years by healthy people to prevent a range of diseases, including Alzheimer's, diabetes, and cancer--although they may never develop these conditions if left alone. "It is unrealistic to think we will come up with a medical treatment that will have no side effects," warns Dr. Freya R. Schnabel, chief of the Breast Surgery Div. at Columbia-Presbyterian Medical Center in New York. "We need to grow up a little bit about this."
Often, the benefits outweigh the risks. But only the person swallowing the pill can make that determination--not a doctor, not society, and not some stranger quoted on TV.
By Catherine Arnst
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