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Dr. Len's Cancer Blog

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Lance Armstrong, Texas, and Cancer Research

by Dr. Len May 18, 2007

One of the things I enjoy most about what I do is the frequent unpredictability of my day.  I frequently say that when I wake up in the morning, I never know what the day will hold, or what city I will be sleeping in that night.

 

Today is no exception.

 

I am currently attending a meeting of our national board of directors in Austin, Texas.

 

Yesterday, I was approached by one of my Texas colleagues and asked if I could help out with some legislation currently before the Texas state senate this morning.

 

The bill (HJR90), which would authorize $3 billion for cancer prevention and research ($300 million a year for the next ten years) had passed the Texas House of Representatives, and was currently “in process” in the state Senate.  It had run into some roadblocks, and there was a hearing pending for Friday afternoon.  If it passes the legislature, it goes to the Texas voters as a constitutional amendment authorizing the funding for this momentous effort.

 

I indicated I would be glad to help out, and then received a phone call indicating that I would be participating in a news conference in the morning.  The lead attraction: Lance Armstrong, a Texan and someone who had committed himself to support this legislation and get it passed.

 

The press conference occurred as scheduled, showcasing the legislation and the many legislators and others who had made their own personal commitments to helping fund the cancer research that will help us continue our efforts to prevent and treat cancer over the next decade.

 

I have heard Lance speak last year at the annual meeting of the American Society of Clinical Oncology, and I have seen him several times on various television shows that deal with the issues of cancer and cancer survivorship.  I have never had the opportunity to meet him in person.

 

He is obviously an articulate and passionate spokesperson on these topics, and his commitment to supporting cancer research and survivorship efforts is legendary. 

 

His story is well known, but nothing prepares you to see him up close and personal, take a measure of his commitment and his intensity, and understand that this is obviously a very personal and very important mission for him.

 

So what do you say when you have a brief quiet moment with one of the most recognized and admired people in the country, if not the world?

 

You think about him as a person, and from my perspective, the battle that he fought to overcome a disease that could have led to a different outcome.

 

But that moment also brought back another memory for me, one that was much more personal and much more intense.  It is a memory of the way things were, and a memory of what can be.  It is a memory of a miracle.

 

When I started my cancer training in 1972, I was at a National Cancer Institute facility in Baltimore. 

 

We did cutting edge research in cancer, both in the lab and in the clinic.  We treated patients with lymphoma, leukemia, sarcoma and some solid tumors such as lung cancer and colorectal cancer.

 

We also treated (usually) young men with testicular cancer, the type of cancer that afflicted Lance Armstrong.

 

We had little to offer these young men.  If they had a certain type of testicular cancer called seminoma, we at least had a shot of helping them live.  But for the other types of testicular cancer, there wasn’t much to offer.

 

The memory that came to my mind this morning was of a young man who had one of the non-seminomatous types of testicular cancer.  This young man had widespread disease, and it wasn’t responsive to chemotherapy.  The disease was spreading rapidly—which was frequently the case with these types of cancers.

 

I remember being the physician on call in the intensive care unit one Sunday, spending hours by this young man’s bedside, trying to do something—anything—to save his life.

 

But there was nothing we could do.  The disease would progress, and all the supportive care, the ventilators, the antibiotics, the medications, the chemotherapy would make no difference.

 

The young man eventually died, as would several others that year who had the same type of cancer.  It was heartbreaking, and maybe a bit more so because many of us who cared for him could relate to him in some way given the fact that we were young men as well.

 

And then there was a research report.  It described a new drug called cis-platinum.  The drug was discovered because someone in a laboratory noted that bacteria died when exposed to an electric current from a platinum electrode.

 

The researchers took that observation and worked with it.  They found that the platinum compound was responsible for what happened, and then they learned that it worked as a cancer treatment drug in animal systems.

 

And, then, they learned that the drug they produced was exquisitely effective in the treatment of testicular cancer.

 

Suddenly, young men who would have died were living.  We treated some of those young men, and followed the clinical research that was developing around the country with close interest.

 

Each year, the news became better and better as we learned how to use the drug most effectively.  Patients who would have died a quick, difficult death were suddenly living and thriving.

 

Suddenly, we had survivors.

 

Lance Armstrong is a survivor.  He is a survivor because someone in a laboratory made an observation and developed it into a more robust treatment.  He is a survivor because of one moment in research.

 

That is what I discussed with Lance this morning, the memory of what was and what is.  The memory of that young man in that bed in a small, simple ICU in Baltimore where all of our efforts couldn’t make a difference.

 

Lance Armstrong is a special person.  He is a survivor.  There are also millions of other survivors in this country, whom he represents every time he speaks.  Millions of survivors, some of whom are here today because some researcher somewhere had the ability to make an observation that made a difference.

 

The Texas legislation is a bold step in support of advancing the dream that we will be able to further diminish the suffering and burden of cancer in this country.  The American Cancer Society vigorously supports the efforts of the many special people and legislators in this great state who are making an effort to make a difference.  As I write this, I am sitting in the gallery of the Texas state senate, waiting to see if the legislators will move this legislation to a committee hearing and a vote.

 

As a physician, however, you can never forget that moment of a miracle.  My young patient didn’t have a chance for a miracle; Lance Armstrong is a miracle.

 

And, as many of us know, there are many miracles around us. 

 

Hopefully, by emphasizing our investment in prevention and research, there will be many more.

 

+++++++++++++

 

PS:  It's 8:30 PM in Austin, and we have just left the committee hearing.  The bill passed out of committee, and now goes on to the Texas Senate.  If it passes there with a 2/3 vote, it will go on to the citizens of Texas to vote for the funding.

 

This is truly a momentous bill and a momentous commitment by the legislators of this state to fund cancer research.

 

 

Filed Under:

Other cancers | Prevention | Research

Decline In Screening Mammograms Is NOT Good News

by Dr. Len May 14, 2007

The information about breast cancer keeps on coming.

 

We have witnessed a number of new research reports over the past six months that would have anyone interested in the subject of breast cancer reeling from the various—and at times conflicting—messages contained in these reports.

 

Now, we have another article published in the current issue of Cancer which shows that mammography rates have fallen precipitously from 2000 to 2005.

 

If you are a regular reader of this blog, you might be asking, “What’s new about that?”  After all, we have been discussing the various reports about the decreasing incidence of breast cancer and the decrease in screening mammography for some time.

 

In fact, this new study adds further strong confirming evidence that we are facing significant challenges when it comes to the early diagnosis of breast cancer.

 

This new report, which is authored by investigators from the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC), found that mammography screening rates dropped nearly 4% from 2000 to 2005.

 

This drop was found in many different groups of women, irrespective of age (see comment below), insurance, demographic factors, etc.

 

Of particular note was the drop in mammography screening in women between the ages of 50-64, who are generally the highest utilizers of mammography screening.  In this group, the decline was 6.8% over the 5 year time frame.

 

As I mentioned, we have been hearing a lot of information about breast cancer incidence and mammography rates over the past 6 months.  In fact, there have been concerns about these issues for some time.

 

In a report my colleagues released in January of 2006 in our journal CA: A Cancer Journal For Clinicians, there was a brief comment noting that there was accumulating evidence that mammography rates were dropping.

 

This past September, in our annual report to the nation, my colleagues (and other collaborators) reported a 4.8% decline per year in the incidence of breast cancer from 2000 to 2003. 

 

In my blog at that time, I noted that the decline could be due to the decrease in hormone replacement therapy or the decrease in the use of screening mammograms

 

Then, in December 2006, researchers made a presentation at a breast cancer conference in San Antonio that a detailed analysis of a national cancer database called SEER showed there was a declining incidence of breast cancer over roughly the same time period. 

 

The press stood up and took notice of that presentation, and there were numerous reports on the topic in the national media.

 

In late January 2007, the Centers for Disease Control and Prevention (CDC) reported that a nationwide telephone survey showed, for the first time, a significant decline in the use of screening mammography between 2000 and 2005.  The decline, reported to be 1.8% in women age 40 and over who reported having a screening mammogram sometime in the past two years, didn’t seem like much. 

 

At that time, I reported in my blog that those numbers were in fact substantial, and suggested through a crude analysis that thousands of breast cancers were present but not being diagnosed since fewer women were having screening mammograms.

 

Basically, if you don’t look for an early breast cancer, you won’t find it.

 

The problem is that if you don’t find breast cancer early through a screening mammogram, it will eventually grow into a more serious cancer which will be found later.  Then, the cancer has a greater chance of being larger.  It also has a greater probability of spreading to the lymph nodes under the arm, or worse yet, to other parts of the body. 

 

Each step along this path means a lower chance of cure.  It means that we are going backwards in our progress in the treatment of breast cancer, instead of going forward to improve the outlook for the thousands of women who are diagnosed with this disease every year.

 

To continue our review, this past April there was an article in the New England Journal of Medicine that reported further details of the December presentation. 

 

Now, the researchers noted, there was a steep decline in breast cancer diagnoses that began in 2002, almost immediately following a July report in the Journal of the American Medical Association that reviewed the harms of combination hormone replacement therapy (HRT) when used for the relief of symptoms in post-menopausal women.

 

These researchers suggested several reasons the drop in breast cancer diagnoses occurred, but came to the conclusion that, given the almost direct parallel drop in breast cancer and number of hormone prescriptions filled, that the decrease in hormone utilization was the primary factor.

 

Then, a couple of weeks ago, my colleagues at the American Cancer Society published a study which highlighted the fact that the decrease in breast cancer incidence actually started before the HRT warnings were sounded in 2002.

Although they concluded that there were multiple reasons for the decline in breast cancer diagnoses, another factor that had to be given serious consideration was the fact that, after many years of increasing utilization of screening mammography, perhaps there had been in fact a “plateau” effect given the high utilization of mammography by eligible women.

 

To support this conclusion, they cited survey data that showed that mammography utilization rates had remained stable at about 70% over several years, while the incidence of breast cancer had been declining.  They also noted that the decline was primarily confined to smaller breast cancers (less than 2 cm in size), and that the rate of regional spread to lymph nodes and the rate of women diagnosed with more advanced disease had remained stable.

 

So, if mammography continued at a “steady state” rate, the drop in incidence was most likely due to the fact that there were fewer breast cancers to be found.  Thus, a “plateau” in new diagnoses had been achieved.

 

What makes the current Cancer report stand out is that the survey to back up their observations that the rate of screening mammography was indeed falling was based on a more representative, nationwide, face-to-face interview process.  This approach is considered to be more accurate and representative of what is really going on in the United States with respect to several health behaviors.

 

The data is distressing since it shows a decline in screening mammograms that cuts across almost all ethnic, age, and other demographic groups.

 

My interpretation of these various studies, as reported several weeks ago and including the current report, is that there are likely several different factors responsible for the decline in breast cancer diagnoses.

 

Perhaps it is partially the plateau effect. 

 

Perhaps the difficulty in accessing quality, qualified mammography facilities is playing a role.

 

Perhaps decreased insurance coverage is playing a role.  We know from other studies that screening rates for several cancers are much lower in people who do not have health insurance, and who do not have access to quality, consistent primary care.

 

There probably is an impact from the decreasing use of combination HRT by postmenopausal women (recalling that the impact of HRT on the incidence of breast cancer was primarily in women who still had an intact uterus, and therefore were treated with combination HRT which included estrogen and progesterone.  Women who have had a prior hysterectomy--and are not at risk of uterine cancer from HRT—can take estrogen alone.  In that circumstance, the risk of breast cancer is not increased in a woman who is not known to be at increased risk of developing the disease).

 

The problem here is that stopping combination HRT may slow down the growth of a breast cancer, but probably does not make it go away completely.  If the growth is simply slowed, then many of those women will eventually discover that particular breast cancer—which is already in development--but at a later date.

 

The issue here is that the fall off in breast cancer diagnoses so soon after the decrease in HRT is not likely due to a real decrease in the initiation of new breast cancers.  That impact is relatively modest, and will take several years to have an impact on the rate of breast cancer incidence.

 

The immediacy of the HRT effect seen in the April report likely reflects other factors.  It was simply too quick.

 

What about the possibility that women simply aren’t seeing there doctors once they stop taking their hormones?  After all, if so many women were taking those medications, then they had to see their gynecologists or other primary care health professional at least once a year to get their prescriptions refilled.

 

And, we know from other studies, that the recommendation of a primary care health professional is probably the single most important stimulus for following cancer screening recommendations.

 

The logical conclusion is that if you don’t see your doctor, you don’t hear the recommendation to get a screening mammogram.

 

I noted in a previous blog discussing the May report that the decrease in breast cancer incidence, although almost universal in age-specific groups of women age 50 and older, was not so evident in women between the ages of 40 and 49.

 

In fact, in women between the ages of 40-44, there had been little if any decline in breast cancer incidence.  In women ages 45-49, the data suggested a much slower decline in breast cancer diagnoses beginning in about 1996.

 

The current paper shows a strikingly similar pattern.  In the 40-49 age group, the decline in mammography rates in the 40-49 year old age group was 0.7%.  This is still a concern, but much less than the corresponding drop in women ages 50-64, which was 6.8%.

 

My thoughts?  If you are 40-49, you are probably still seeing your gynecologist every year for your birth control pills and/or your cervical cancer screening test.  Along with that visit comes a recommendation to get a mammogram.

 

Once you are post-menopausal, and you are not taking HRT, then you don’t feel as compelled to see your doctor.  No visit, no recommendation for screening.

 

The highest rate of mammography screening in the current NCI report was a stunning 85.6% in 2005 for women who had seen their gynecologist in the past year.  (It had been 87.5% in 2000, so there was a decline of about 1.9%.)

 

For women who had not seen their gynecologist in the preceding 12 months, the data from 2000 showed that 59.6% of these women had a mammogram within the preceding two years.  In 2005, if a woman had not seen her gynecologist in the prior 12 months, only 54.6% had a screening mammogram.  That’s a fall off of 5%.

 

(What the data does not tell us is what percentage of women actually had visited a gynecologist during the preceding year.  I think it is also important to emphasize that this survey asked only about a mammogram in the prior two years.  The American Cancer Society recommends a screening mammogram every year, so I suspect the number who actually follow our recommendation is much less than these percentages, which is cause for additional concern.)

 

Why is this such a problem in my opinion?

 

Primarily, all of this information muddles the water so to speak when it comes to giving a clear, concise recommendation about what a woman needs to do to protect her health.

 

I call this state of affairs “clutter and clatter.” 

 

Experts with different, well-intentioned opinions about a problem give ordinary folks an excuse not to take action. 

 

Arguments over the effectiveness of mammography (including the recent pronouncements from a leading medical organization regarding mammograms in women ages 40-49), the impact of hormones, and whether there is a saturation effect from screening mammograms are examples of such messages.

 

These are serious issues, and each needs to be addressed.  But the end result is that we send mixed messages.  And the result is that lives are likely at risk.

 

Here is the way I look at this complex set of facts:

 

1) I believe that mammograms save lives. 

 

The American Cancer Society recommends that a woman at average risk should have a mammogram and clinical breast exam by a health care professional once every twelve months beginning at age 40. (Women at high risk should be aware of their unique situation, and the recommendations that apply to their particular circumstance.)

 

Why do I believe this?

 

Notwithstanding all of the academic arguments, the reality is that death rates from breast cancer have been declining since the early 1990s, despite a continuing increase—until recently—in the numbers of cases diagnosed every year.  And that decline, as reflected in the SEER database, includes women ages 40-49.

 

2) There may well have been a plateau effect from the “saturation” levels of mammography, as noted earlier.

 

3) I suspect that some women are in fact becoming complacent when it comes to getting a mammogram. 

 

Mammograms aren’t easy to get.  They require making an appointment, getting the test, and having some (or a lot of) discomfort.  They require a possible series of tests if there is anything suspicious on the mammogram (we call it “false-positive), which means more anxiety and concern.

 

If you have done this for a number of years, it becomes easy to skip a year or two and ignore the potential consequences.

 

This is not a good idea.

 

4) There is no question that the decline in the use of combination HRT is associated with a decline in breast cancer diagnoses.

 

This is probably due to two primary factors: a) the influence that HRT may have on the growth rate of an existing cancer, and b) the sad reality that women who are no longer taking hormones—primarily those in the 50-64 year old age group—aren’t seeing their gynecologists for regular annual exams.

 

I don’t think that the third factor—the influence of combination HRT on the primary development of a new breast cancer—has had time yet to have a real impact on the incidence of this disease.

 

3) The “saturation effect” notwithstanding, there has been a precipitous decline in the rates of screening mammograms, which means that fewer breast cancers are being discovered each year.  My personal estimates are that these cases are in the thousands.  These cases are not going away.  They are more likely not being discovered.

 

What this means is that we have a crisis approaching in the diagnosis, treatment and ultimately survival of women with breast cancer.

 

I am ordinarily not given to being an alarmist, but I know what breast cancer was like in the 1960s and 1970s before the widespread use of screening mammograms, and I don’t want to go back to the past to see the results of the future.

 

If my sense of the situation is correct, this crisis is going to lead over the next several years to an increased frequency of breast cancer diagnoses at later stages, which will translate into an increased number of deaths from this disease.  This is going to occur at a time when we should have been seeing an increase in the use of screening mammography, and a continued improvement in our ability to provide more women effective, life saving treatment with continued improvement in survival.

 

We are now well into the cycle from the time the first alarm bells were sounded over a year ago.

 

Now, we have overwhelming and convincing evidence that the gains we made (and needed to continue to make) in encouraging women to have an annual mammogram are slipping away at a significant rate.

 

The American Cancer Society is currently sponsoring a nationwide advertising campaign to encourage women to get a screening mammogram.

 

But all of the advertising in the world isn’t going to make much difference to women, unless they personally understand how important this test is for their health and their lives, and take the recommendation to get a screening mammogram every year to heart.

 

At a time when we need more action—to make certain quality facilities and trained radiologists are available, to be certain that financial considerations are never a barrier for a woman to be screened or treated for breast cancer, to be certain that women understand the importance of this test for their health—we are faced with increasing barriers, confusion and complacency.

 

There is no time like the present to renew your commitment to your health, to yourself, to your family, to those who love you, to those who know you.

 

The last thing I want to write several years from now is that I was correct in my prediction that breast cancer diagnoses at a later stage increased, and that ultimately breast cancer deaths increased.

 

The last thing I want to write was that we recognized the problem and did nothing about it.

 

That would be the saddest blog of all.

 

 

 

 

 

 

What REALLY Caused The Decrease In Breast Cancer?

by Dr. Len May 03, 2007

If you are interested in the topic of breast cancer, these past months have certainly provided you with a lot of information.

 

There have been articles on the decrease in the incidence of breast cancer, the effects of hormones on breast cancer, the decrease in the use of mammography for the early detection of breast cancer, and conflicting new recommendations on the value of screening mammography for women between the ages of 40-49.

 

For all the clutter and the chatter, it is nearly impossible to keep all of the information straight, and it is even harder to figure out what it all means to you or someone you love.

 

A new paper in the current issue of Breast Cancer Research written by my colleagues here at the American Cancer Society is not going to make the discussion any easier.

 

The paper discusses the relative impacts of hormonal replacement therapy vs. the decrease in mammography as the cause for the recently reported decline in newly diagnosed breast cancer cases.

 

In the current study, the researchers took a look at the incidence of breast cancer diagnoses in the United States from 1975 to 2003, analyzing all cases of breast cancer in women aged 40 and older.  The data was obtained from the SEER registry, a program that monitors the numbers of cancers diagnosed in nine areas around the country (these are the oldest registries in the program.  More recently, others have been added.  These registries are considered representative of the entire United States population).

 

My colleagues reported that they found “sharp decreases in estrogen-receptor positive (hormone sensitive) tumors” in women ages 50-69 during the study period.  They also found that small tumors—the kind that are found more frequently on mammograms than by clinical examination—decreased by 4.1% per year from 2000 through 2003.

 

They reported that localized disease—that is, disease confined to the breast without spread to the adjacent lymph nodes or elsewhere in the body—declined by 3.1% during the same time period. 

 

The number of larger breast cancers and those diagnosed with more advanced stages of disease remained constant during that time.

 

Finally, in situ breast cancers—meaning those that are diagnosed before they actually invade the breast tissue—also were stable during this time period.

 

The researchers concluded that, based on their study, that these results were consistent with “saturation in screening mammography.” 

 

That means that after so many years of having screening mammograms available to women in the United States, there has now come a time when the new breast cancers are diagnosed with a “steady state” frequency as opposed to the situation where more women are getting screened and therefore more breast cancers will be diagnosed.

 

They also acknowledged that the large drop in newly diagnosed breast cancers between 2002 and 2003 which happened primarily in women ages 50-69, and were (again) predominantly estrogen receptor positive “may reflect the early benefit of the reduced use of hormone therapy.”

 

If it were only so simple.

 

The researchers were able to look at hundreds of thousands of breast cancer cases (about 450,000 to be exact).

 

They found that the decreases in breast cancer actually began long before the adverse effects of combination estrogen-progesterone hormone replacement therapy (HRT) were known.

 

The decreases in breast cancer in women less than 60 or more than 69 years old actually began in 1998 or 1999.  The authors further note that among women ages 60-69, almost all of the decrease occurred between 2002 and 2003.

 

[I emphasize combination hormone therapy, because that is where the risk is.  In women who have had a hysterectomy and were treated with estrogen alone as part of the large Women’s Health Initiative study (WHI), the risk of breast cancer in women at average risk of developing breast cancer actually showed a lower risk of developing the disease.]

 

When looking at the incidence of hormonally sensitive breast cancers—that is, those which were estrogen receptor positive—the researchers found they increased approximately 3% per year from 1990 to 2000, then decreased sharply between 2002 and 2003. 

 

In contrast, they wrote, tumors that were not hormone sensitive had been decreasing at the rate of 1.1% per year from 1990 to 2003.  There was a much larger drop in these cancers (4.8%) between 2002 and 2003.

 

As noted, the authors attributed much of the stabilization and then decrease in breast cancer incidence to a “plateau” effect of mammography.  Since, according to the studies they quote, screening mammography rates remained stable from 1999 to 2003, and the incidence of new breast cancers fell during that period, then the explanation must be that there were, in fact, fewer new cancers diagnosed.

 

They acknowledge that the decrease on hormone usage beginning in July of 2002 played a role in the decreased rates between 2002 and 2003, but also state that “the recent decrease in HRT use cannot account for the reduction in breast cancer incidence that occurred before 2002 or for the decreased incidence in women age 75 and older.”

 

Another study reported recently in the New England Journal of Medicine and discussed in this blog came to a somewhat different conclusion, claiming that after careful review those researchers concluded that much of the drop in breast cancer incidence between 2002 and 2003 and continuing through 2004 was the result of decreasing use of hormone therapy in post-menopausal women.

 

My colleagues’ paper agrees with that premise, but also says that you can’t ignore the fact that the rates actually started dropping prior to hormone withdrawal.  Hormones, therefore, are not the entire story.

 

So here is the distilled version of all these statistics:

 

1) The incidence of newly diagnosed breast cancers began to decrease in the late 1990s, prior to the recommendation that women use combined HRT only when absolutely necessary for symptom control.

 

2) There was an accelerated drop in new breast cancer cases between 2002 and 2003, likely influenced by the recommendations to decrease the use of combination HRT.

 

3) Not mentioned in the article was the observation contained in one of the illustrations contained in the published paper that the rate of breast cancers diagnosed in the 40-44 year old group has remained relatively stable over many years, and the rate of breast cancers diagnosed in women ages 45-49 appears to have been slowly decreasing since around 1996.  Neither of these groups have high numbers of women taking hormones.

 

4) Although a plateau effect of screening mammography may explain the decrease in the diagnoses of small breast cancers and the stable rates of breast cancers that are diagnosed with lymph node involvement or actual metastatic disease, another explanation could be that there is in fact a decrease in screening mammography rates.  That means the cancer is still there, but will not be detected before it can be felt by the woman or her health care professional.

 

Although one survey source quoted in the current paper does indeed show that 70% of white and African American women are getting regular mammograms, there is conflicting evidence from a recent report from the Centers for Disease Control and Prevention that the rates of mammography have declined from 2000 to 2005. 

 

In a prior blog, I estimated in a very rough, “back of the envelope” way that this could account for somewhere between 5760 and 8640 fewer breast cancers diagnosed in 2005 compared to 2000, if the 2000 screening rates had continued.  That number is not inconsistent with the findings of my colleagues’ research.

 

Those statistics represent a small—but very real—number of breast cancers that would not be diagnosed that year.

 

So, if there are in fact fewer mammograms being performed as recommended, fewer small breast cancers would be detected. 

 

It also means that if we follow this trend long enough, we will eventually start to see an increase in the numbers of breast cancers that are diagnosed, and perhaps even an increase in the number of women who are diagnosed with lymph node involvement or metastatic disease when they first come to the attention of their doctors.

 

As I have mentioned previously, breast cancers take years to develop.  They don’t disappear over night.  Combination HRT takes several years to influence the rate of breast cancer, and even then the data suggest that with (relatively) short term usage the effect is modest (although with longer term usage, as was the custom in years past, the effects may well have been greater).

 

What I am trying to say here is that the real impact of hormone withdrawal—that is, a decrease in the actual development of a new breast cancer--will take years to become evident after large-scale cessation of HRT, and even then the effect would be predicted to be relatively small.

 

Stopping HRT and/or not getting a mammogram does not make a breast cancer go away. 

 

It simply delays the inevitable in most cases (it is also likely that some of those cancers may continue to exist, but perhaps grow more slowly or not grow at all, and therefore never be a problem for a woman during her lifetime).

 

This is certainly not the end of the story.  In my personal opinion, it is just the beginning. 

 

This is not a story of “either/or,” but more likely “both.”

 

This is something that will take years of follow-up to sort out.  For now, the news is interesting, but in my opinion definite conclusions are premature and incomplete. 

 

So, if you are a woman you may be asking yourself, what does all this mean to me?  What should I do?

 

First, don’t forget to get your mammogram every 12 months.  The American Cancer Society remains firm in its recommendation that women at average risk of breast cancer get a mammogram every year beginning at age 40, along with a clinical breast examination by a health care professional.

 

Second, if you are post-menopausal and have not had a hysterectomy, discuss the pros and cons of combination HRT with your doctor.  If you MUST use HRT, then use the lowest dose for the least time possible. 

 

If you have had a hysterectomy, and are a candidate for estrogen replacement, discuss the benefits and risks of HRT carefully with your health care professional.  They are somewhat different compared to the combination forms of HRT.  The same advice applies regarding dose and length of treatment. 

 

Some women seem to be of the opinion that, with all of this discussion about decreasing breast cancer risk after withdrawal of HRT that they no longer have to get a mammogram, or they can get them less frequently.  They certainly won’t be seeing their doctors as often.

 

If I am correct that the breast cancers are still there but the opportunity for detection is delayed, you could be making a serious mistake by not continuing to get your mammogram every year.  It is simply not worth the risk.

 

This is one area of research interest that is not going to go away.  There is no right or wrong here.  Eventually, my research colleagues will show where the trends lead us.

 

Personally, I hope I am wrong. 

 

I hope this decline is real, that it is permanent, and that many fewer women will be diagnosed with breast cancer.

 

But, frankly, my personal opinion is that when it comes to breast cancer, detection delayed is a life-saving opportunity lost.

 

Not getting a regular mammogram—no matter whether you are 40 or 60 or older--is one gamble that I would not be willing to take.

 

++++++++++

 

I am trying to get this blog posted while sitting in an airport with a limited internet connection.  As a result, I have not been able to provide all of the appropriate links.  I will try to finish posting the links later today.

 

 

 

 

About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.

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