Regular readers of this column are already well informed about the known risks associated with taking hormone replacement therapy (HRT) to relieve the symptoms of menopause. With the results of the landmark Women’s Health Initiative Study (WHIS), and similar studies, clearly implicating combination HRT with an increased risk of breast cancer, heart disease, stroke, dementia, and other serious illnesses, physicians and their patients are, increasingly, taking a more conservative approach to dealing with the unpleasant symptoms that often accompany the onset of menopause.
Among women who have previously been diagnosed with breast cancer, the risk of developing a recurrence of their cancer, and new breast cancers as well, is known to be higher than for women of otherwise average breast cancer risk, and with no prior history of breast cancer.
until now, there has not
been a great deal of research data looking specifically at the added
any, of taking HRT after a prior diagnosis of breast cancer, although
experts believe that HRT is almost certainly a risk factor for breast
recurrence (i.e., in addition to the development of new cancers in the
breast). Now, a new
study, from multiple
university medical centers in
The results of this study were quite striking. Among the 221 women taking HRT, just over 22% of these women were estimated to develop recurrent breast cancer after an average of 5 years of follow-up. Among the 221 women who did not take HRT, only 8% went on to develop a recurrence of their previous breast cancer at 5 years. This represents a nearly two-and-a-half fold increase in the risk of breast cancer associated with the use of HRT and, with respect to the natural history of breast cancer recurrence, within a rather short period of time as well. In fact, because the risk of recurrent breast cancer appeared to be so high in the group of women taking HRT, this research study was prematurely halted in 2004 (just as the WHIS was prematurely terminated in 2002) , and the women taking HRT were warned about the apparent increased risk of breast cancer recurrence associated with taking HRT.
multiple other previous studies have shown, and as I and other breast
experts have warned for years, the use of HRT (and combination HRT in
particular) appears to have significantly contributed to the
gradual rise in the annual number of breast cancer cases diagnosed in
United States since the mid-1960s, when HRT became especially popular
U.S. and in other western countries around the world.
The striking and unprecedented recent decline
in the annual incidence of breast cancer in the
The results of this new study are completely consistent with what we now know about the molecular biology of estrogen and progesterone (the primary female sex hormones), and their stimulatory effects on the proliferation of breast cancer cells (the overwhelming majority of breast cancers, especially in women aged 50 and older, have chemical receptors for these sex hormones, which stimulate these cancer cells to grow and divide). My advice to all women, and especially to women with a prior history of breast cancer, is to avoid HRT drugs, period. This has been my consistent recommendation for the past 20 years, based upon clinical research and observations dating back to the 1930s. With the enormous amount of confirmatory data that has been subsequently published since 2004, I don’t appear to be the one with significant biases in this area….
ARTERY DISEASE: SURGERY
ARTERY DISEASE: SURGERY
A relatively common manifestation of peripheral arterial atherosclerotic disease (“hardening of the arteries”) is carotid artery stenosis. The carotid arteries supply most of the blood to the brain, and when they become clogged with atherosclerotic plaque and blood clots, bits of these materials can break off (or embolize) and lodge in the smaller arteries that feed the brain, causing temporary or permanent damage to the brain. These embolic complications of carotid artery disease are referred to as, respectively, transient ischemic attacks and strokes (the same vascular disease process occurs in the coronary arteries, and leads to heart attacks, or myocardial infarctions).
150,000 operations for
carotid artery stenosis are currently performed each year in the
A relatively recent innovation in the management of arterial atherosclerotic disease has involved the use of shunts, most of which can be placed through small, superficial incisions in the groin or arm, much as cardiologists and interventional radiologists have been doing for decades in order to perform x-rays studies of the arterial system (“angiography”), and more recently, to treat diseased coronary arteries with balloon catheters and stents. This minimally-invasive approach to atherosclerotic vascular disease has revolutionized the management of not only coronary artery disease, but also for aneurysms (abnormal dilation of atherosclerotic arteries) of the aorta (the largest artery in the body), and the large branch arteries that arise from the aorta to supply the lower extremities (the iliac and femoral arteries). However, given the potentially catastrophic complications (including death) associated with strokes, the use of balloon catheters and stents to treat narrowed areas of the carotid arteries has not advanced as rapidly as it has for other diseased arteries in the body.
A new study from Harvard University, and several other collaborating U.S. medical centers, and just published in this week’s New England Journal of Medicine, provides important clinical data to suggest that minimally invasive carotid artery stenting may finally have become at least the equal of carotid endarterectomy, at least in highly selected patients. In this prospective randomized clinical study, a total of 334 patients with narrowed carotid arteries were randomized to either standard surgical treatment (i.e., carotid endarterectomy) vs. carotid artery stenting. The average follow-up of these patients was 3 years.
Altogether, almost 80% of the patients participating in this clinical trial were available for follow-up evaluation after 3 years. The bottom line: patients in both treatment groups experienced a statistically equivalent incidence of stroke, myocardial infarction and death (the average incidence of any of these three complications in both groups of patients, at 3 years, was 27%).
This study will likely be considered a landmark research trial regarding the optimal management of severe carotid artery stenosis, especially in patients who are considered to be at very high risk of complications following traditional surgical intervention. The use, in this study, of a special device designed to catch errant bits of clot and plaque that might be dislodged during placement of the stent very likely helped to achieve the excellent results reported in this high-quality research trial, and sets this study apart from some earlier studies that did not use such “anti-embolization” devices (and which often reported prohibitive stroke rates associated with carotid artery ballooning and stenting).
As a reminder to my readers, the risk factors most commonly associated with carotid artery atherosclerosis (and, indeed, with atherosclerosis throughout the body) include smoking, elevated cholesterol and fat levels in the blood, obesity, a sedentary lifestyle and high blood pressure. Given that an ounce of prevention is worth far more than a pound of cure when it comes to your health, if you currently have any of these risk factors, then please see your physician soon, and modify your lifestyle to eliminate (or control) these risk factors.
DRUGS & CANCER
DRUGS & CANCER
There continues to be a great deal of debate regarding the class of cholesterol-lowering drugs referred to as statins, and their effects (if any) on lowering the risk of developing certain cancers. In addition to their potent ability to reduce the levels of so-called “bad cholesterol” (LDL) in the blood, and to increase the levels of “good cholesterol” (HDL), most statins appear to have at least mild anti-inflammatory effects as well. (Chronic inflammation in the body has been linked both to the development of atherosclerotic narrowing of the arteries in our bodies as well as to the development of many cancers.) Multiple prior laboratory and clinical research trials have generated conflicting data regarding the effects of statin drugs on cancer risk, with some studies showing a reduction in the risk of at least certain types of cancer with prolonged statin use, and other studies showing no apparent cancer-prevention benefit at all.
newly published study, in The American
Journal of Medicine,
provides results that suggest, as other recent studies have, that there
actually be a small, but significant, cancer-prevention effect
at least some of the statin drugs.
After an average of 7 years of follow-up, this study determined that the high-dose statin users, when compared to patients not taking any statin drugs, experienced a 25% reduction in the likelihood of admission to a hospital with a new diagnosis of cancer. The low-dose statin users also appeared to experience a reduction in hospital admissions related to the diagnosis of cancer, with a more modest 11% reduction in the incidence of admissions for cancer. Unlike similar recent clinical studies that have shown that only prolonged statin use may be associated with a reduction in the risk of developing cancer, this particular study found that even relatively short durations of statin usage appeared to be associated with a reduced risk of being admitted to a hospital with a new diagnosis of cancer, especially among patients receiving higher doses of these medications.
This study offers some further encouragement to those who believe that at least some statin drugs may be associated with the incidental benefit of reducing the risk of cancer. However, I think that the jury is still out on this one, for now anyway. As with most retrospective studies based upon public health databases, there are many potential sources of bias in retrospective epidemiological studies such as this one. Unlike randomized, prospective controlled studies, which seek to control as many potentially confounding variables as possible up front, retrospective studies are far more prone to bias, which can lead to erroneous conclusions.
At this time, I would not recommend that anyone take a statin drug primarily to reduce their risk of cancer. However, if you are already taking a lipophilic statin for elevated cholesterol levels, then there is at least the possibility that you may be receiving an additional health benefit from your statin drug. Obviously, a prospective, randomized, placebo-controlled study of statins would have to be done to definitively answer the question regarding statins and cancer risk. Until such a study is performed, we cannot be completely certain that statins really do reduce the risk of cancer.
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.
Dr. Wascher's Archives:
4-6-2008: Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)
12-16-2007: Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality