In 2002, the landmark Women’s Health Initiative Study reported that the long-term use of hormone replacement medications, consisting of two female hormones in pill form, was associated with a 26% increase in the relative risk of breast cancer (among other serious diseases as well, I might add). More recently, the Centers for Disease Control has reported a significant and unprecedented decrease in the incidence of breast cancer diagnosed in 2003. Other large scale public health studies, most notably from California, have also subsequently confirmed that a significant decrease in the incidence of breast cancer appears to be ongoing in the wake of the dramatic reduction in the use of hormone replacement therapy medications since the Women’s Health Initiative Study initial results were published in 2002.
But doubts persist in the minds of some who still will not accept any linkage between hormone replacement therapy and the risk of breast cancer, despite very solid data recently showing that the greatest reduction in the incidence of breast cancer has been for the type of breast cancer that is known to respond to the female hormones estrogen and progesterone. Indeed, it was about 5 years ago that I sat down and wrote a book that reviewed and analyzed decades-old (and more recent) scientific data that presaged the findings of the Women’s Health Initiative Study, and that unequivocally linked lifetime exposure to estrogen with a woman’s risk of developing breast cancer. The 5 decade monopoly of a single pharmaceutical company over the hormone replacement therapy “business,” and that company’s little-known history of sponsoring what amounted to disinformation campaigns about the safety of these medications is an important backdrop to the larger issue of hormone replacement therapy and cancer risk, and one that was extensively covered in my book as well. While the traditional print publishing industry has always been somewhat capricious and opaque, even to many publishing insiders, I was still not prepared for some of the responses that I received from major publishing house editors (most of them women). Many of these editors accused me of having some sort of intrinsic bias against hormone replacement therapy, and several implied, or overtly stated, that I must somehow have the misogynistic goal, as they saw it, of depriving women of the most effective available treatment for their menopausal symptoms. Taken aback that my efforts to educate women (and men) about a known—and preventable—risk factor for the most common cause of cancer in American women (and the second most common cause of cancer death in women, after lung cancer) were somehow perceived by publishing house editors as being “anti-women,” I shelved the project in disgust….
A new study in the journal Breast Cancer Research takes a look at recent trends in breast cancer incidence among minority women in the US, in the aftermath of the research findings that I have already mentioned, but which were based upon the study of predominantly American women of European descent. This study is important not only because it shines the light of clinical research upon ethnic minority women in the US, but because it also evaluated recent trends in breast cancer incidence according to sub-types of breast cancer, and in particular, hormone-responsive and non-hormone-responsive breast cancers.
Using the largest prospectively compiled cancer database in the US, the Surveillance, Epidemiology, and End Results (or “SEER”) cancer registry, the study’s authors analyzed SEER data from 1992 through 2004, and assessed the incidence of breast cancer among women from the following ethnic subgroups: Asian/Pacific Islander, Hispanic, African-American, and non-Hispanic White. Tumor hormone sensitivity status, tumor size, and other important tumor factors were also specifically analyzed.
The findings of this study are fascinating, and further implicate recent breast cancer incidence trends with changing trends in the prescribing of hormone replacement therapy following the 2002 release of the Women’s Health Initiative Study results. Specifically, the study found that the overall incidence of breast cancer declined significantly during the period of study in Asian/Pacific Islander (by 8.5%) and Hispanic women (by 2.9%), and was essentially unchanged in African-American women. These results are in comparison to the 14.3% decrease in the incidence of breast cancer noted, during the same period, for non-Hispanic white women. When the authors then looked at the trends for the incidence of non-hormone-responsive tumors in this same population of women with breast cancer, the findings were striking. The incidence of non-hormone-responsive breast cancers rose significantly among African-American women (26.1%) and Hispanic women (26.9%), who were already less likely to use hormone replacement medications than non-Hispanic white women before 2002, and who are even much less likely to use such medications now.
Taken as a whole, this study shows a trend towards fewer breast cancers in American women from minority ethnic groups, albeit not as pronounced as has been recently observed among non-Hispanic white women. At the same time that overall breast cancer incidence is declining in at least two groups of minority women (and is stable in a third group), the incidence of non-hormone-responsive breast cancers, which are not affected by hormone replacement therapy drugs, is increasing among the two ethnic minority populations of women that rarely use hormone replacement therapy drugs in the wake of the Women’s Health Initiative Study’s 2002 report.
While some who still do not see a link between hormone replacement therapy and breast cancer have proposed that a recent (and small) decrease in the number of mammograms being performed can somehow explain the unprecedented decline in breast cancer now being observed throughout North America (where, not coincidentally, the risk of breast cancer is among the highest in the world), the findings of this new study do not mirror recent trends in mammography when broken down by ethnicity. The findings of this new breast cancer study do, on the other hand, generally parallel the ongoing trends in the use of hormone replacement therapy drugs in postmenopausal women. Perhaps it’s time for me to dust off that old manuscript and have another look at it….
DOES HEALTH INSURANCE IMPROVE HEALTH?
A high-impact issue in the current Presidential primary election is that of health insurance in America. In the richest and most technologically advanced nation on the planet, an estimated 47 million US citizens have no comprehensive health insurance, and millions more have utterly inadequate coverage. At the same time, the increasingly older (and retired) population in the US is placing extraordinary demands upon the current healthcare system, such that the enormous healthcare entitlement systems currently in place for the elderly and for the poor (Medicare and Medicaid, respectively) are predicted to be operating in the red within the near-term future. Another related area of heated debate is the “cost-per-outcome” ratio within the current American healthcare system. Despite spending more, on a per capita basis, for healthcare than almost any other country in the world, the clinical outcomes of this exorbitantly expensive healthcare system are no better than those being achieved, and at less cost, in many other developed countries (in fact, several countries, notably in Scandinavia, actually have better health outcomes in several important public health areas). It is no wonder, then, that health insurance, and healthcare issues in general, have taken on such prominence in the ongoing election. Employers, Government, and the public at large all have enormous stakes in the future of healthcare and health insurance in the United States.
A new study, just published in the Journal of the American Medical Association, evaluated the apparent improvement in the health of previously uninsured patients who, upon reaching age 65, became eligible for Medicare coverage. Using patient survey data from the very large Health & Retirement Study, this research study compared more than 5,000 older adults who were continuously insured with more than 2,200 older adults who were frequently or continuously uninsured between the ages of 55 and 64, and who subsequently enrolled in Medicare coverage upon reaching the age of 65. All participants in this study completed questionnaires describing changes in their health arising after the age of 65, including trends related to their mobility, agility, pain, symptoms of depression, and cardiovascular health.
When compared with the group of continuously insured older adults, previously uninsured older adults reported significant improvement in their health after acquiring health insurance through Medicare, and these improvements were especially pronounced in those patients with preexisting diabetes or cardiovascular disease. In this particular group of patients, they reported improvements in their overall health, as well as in the specific areas of mobility and agility, although there was no significant change noted with respect to the symptoms of depression between the two groups of patients. By the time they reached the age of 70, the self-reported disparity between the two groups of patients, in terms of six different parameters of health that were evaluated in this study, had been reduced by 50% among those patients who were previously uninsured. In effect, within 5 years of acquiring health insurance through Medicare, the previously uninsured patients experienced a 50% improvement in their health, as defined by this study, when measured against the self-assessments of the continuously insured group.
This is a very interesting and potentially provocative study, despite its fundamental limitation of relying upon patient self-reporting to collect data. Nobody would doubt that people with comprehensive health insurance, and all of the preventive care options that come with such insurance, are likely to remain healthier than those without any health insurance. But the inevitable—and some say imminent—collision between the monstrous (and growing) costs associated with Medicare and other major Government-funded entitlement programs, on the one hand, and the increasing age of our population, on the other hand, will force a day of reckoning much sooner than later. Although this particular study relied upon the subjective self-assessment of patients (and not upon objective clinical outcomes data), it certainly adds substantial weight to the argument for some sort of universal comprehensive health insurance in our 21st Century society. How (and by whom) such universal comprehensive healthcare coverage will be funded is, of course, a trillion dollar question.
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity.
Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center
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Copyright 2008. Robert A. Wascher, MD, FACS. All rights reserved.
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