Is the Race for the Cure Giving You a Heart Attack??

A couple of weeks ago I stepped out of my apartment building, headed to a shift in the E.R.– and found myself adrift in an ocean of Pink. A bead of cold sweat formed on the back of my neck. Race for the Cure supporters had amassed near Central Park. As is their custom, even their pets were wrapped in declaratory fuchsia. I considered slipping back inside– was there anything I could use for camouflage? But I knew it would be futile: even my most metrosexual shirt is a sort of very pale champagne pink at best… nothing that would mark me a true believer. I moved cautiously between them, head down, softly repeating the words “brick wall, brick wall,” lest they read my thoughts. Surely my scrubs would keep me safe: “I left my pink ribbon at the hospital!,” I could say. Images of Donald Sutherland from Invasion of the Body Snatchers filled my head, his hand raised– “J’accuse!” Somehow I made it to the parking garage… but it was small comfort. I knew this was only the beginning.

Breast Cancer Awareness month is upon us.

It used to just be Breast Cancer Awareness Week, but the Pink Ribbon feeds and grows… now all of October has been consumed. In case you couldn’t tell,

the Pink Ribbon stresses me out a little.

Don’t stone me! I’m not anti-women. I’m PRO-women. I’m in favor of women living long, healthy lives. And certainly I am aware that those who Race for the Cure are using their free time to contribute to a worthy cause–and exercising to boot! They deserve my admiration. Yet the Pink Ribbon still keeps me up at night. Here’s why: The more women fixate on breast cancer, the more they fear estrogen. And women’s Fear Of Estrogen is killing them by the tens of thousands. Most of the women who come to me to discuss estrogen replacement therapy, have managed to overcome their Fear Of Estrogen. But so many women never make it that far; their F.O.E. holds them back.

And here is the result:

(The above article is from July 2013 and can be read here.)

My kingdom for a red ribbon!

What women really need are more red ribbons: Heart Disease Awareness Month. In fact there is such a thing, but no one knows about it. It’s in February. There’s no “Race for the Heart.” Yet each year, while we ignore it, heart disease quietly kills eight times as many women as breast cancer.

And therein lies the rub:
It’s not that pink ribbons are bad. Obviously they aren’t. But they get a LOT of attention. And when women focus solely on breast cancer, they tend to really worry about whether they should use estrogen– and many of them avoid HRT.

That’s a big problem– because estrogen cuts the risk of heart disease in half– and heart disease kills eight times as many women as breast cancer.

In other words:

Avoiding estrogen therapy due to fear of breast cancer is like
jumping in front of a bus to avoid a bicycle.

…which is why the Pink Ribbon stresses me out. For many women, it represents fear more than it does hope. And that fear can lead them to the wrong health decisions. What I’m going to show you is this: if you are a woman at menopause, starting HRT is at least three times more likely to save your life than it is to give you breast cancer. Hopefully that got your attention– so let’s get into the nitty-gritty!

FIRST, A WORD FROM DENMARK:

Here is a quick review of the analysis I wrote looking at the Danish HRT study published last year (that news outlets completely ignored): The Danish Osteoporosis Prevention Study was a prospective, placebo controlled trial of HRT (using bio-identical estradiol, no less!) that included 1000 women. Two years before that study was published, the Endocrine Society (as mainstream a group of docs as you can find!) reviewed ALL studies on HRT, and published a 66 page report. One of their findings was particularly astounding:

Menopausal Hormone Therapy was associated with a 40% reduction in mortality in women in trials in which participants had a mean age below 60 yr or were within 10 years of menopause onset.

Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement. JCEM July 1, 2010 vol. 95 no. 7 Supplement 1

That’s right, they said that women on HRT had a 40% lower risk of death, as long as they started within ten years of menopause! Is that really possible? Well, the Danish trial results were published two years later, so the Endocrine Society had not seen those results– so let’s take a look. The Endocrine Society criteria fit the participants in the Danish trial: they were all within ten years of menopause onset. And sure enough: over the ten years of the Danish study, 15 women died—but in the control group (women who did NOT take HRT), 26 women died! HRT lowered their mortality rate by 42%, right in line with what the Endocrine Society review predicted back in 2010.

KICKSTART MY HEART

How can HRT be so beneficial?? By knocking out cardiovascular disease. Their risk of heart attack and stroke decreased—in fact it decreased a LOT. As Dr. Raffaele pointed out in his analysis of the study,

These Danish women had over a 50 percent reduction in combined heart attacks, heart failure and death. Remarkably this reduction started to accrue very soon after initiation of therapy.

By the way, there was also no increase in breast cancer (or any other cancer). It’s a great illustration of what I’m trying to say: HRT is much more likely to save your life than it is to give you breast cancer.

But enough hypotheticals: What’s YOUR risk?

Now let’s get away from statistics and talk about YOU specifically:

When my patients express concern about breast cancer, I show them this handy National Cancer Institute risk assessment tool. Go to that site and calculate your five year risk of getting diagnosed with breast cancer. (Seriously, go ahead!) Most of you will find that your 5-year risk is about 1.3%. You can also go to this other site and calculate your ten-year risk (on average, about 2%). So now you have a baseline: you know what the chances are that you will develop breast cancer in the next 5-10 years. (Probably lower than you thought.) But what if you go on hormone replacement? How much will it increase that risk?? The answer lies somewhere between ‘not at all’ and ‘not much’– but I will give you specific numbers. In the Danish study, HRT did not increase breast cancer at all. But I’m not trying to trick you– almost all HRT studies that use synthetic progestins (instead of progesterone) DO show a small increased risk of breast cancer. I think the reason this Danish study did not increase the risk of breast cancer is that they only used the synthetic progestin ten days a month instead of every day. So let’s take the most pessimistic view possible— let’s say we look at studies where HRT did increase the risk of breast cancer. I’m STILL saying that if you are 50 years old and take HRT for ten years, over those ten years HRT is three-and-a-half times more likely to save your life than it is to give you breast cancer.

SHOW ME THE MONEY!

What we really need is an apples-to-apples comparison: What is the ten-year risk of breast cancer for a 50 year old woman who is not on HRT? Answer: about 1.4%, according to this site. So, if you follow 1000 women who are age 50, about 14 of them will get diagnosed with breast cancer by the time they turn 60. And what is the ten-year risk of death (from any cause) for a 50 year old woman? Based on this website from the American Academy of Family Physicians, if you track a thousand 50-yr-old women, 42 will die before they reach 60. So now we some useful data: For every thousand women who are 50 years old, over the next ten years,

  • 14 will get diagnosed with breast cancer,
  • and 42 will die (from all causes: heart attack, stroke, cancer, you name it).

But what if those same thousand women start taking HRT? Remember the Endocrine Society statement: .

Menopausal Hormone Therapy was associated with a 40% reduction in mortality in women in trials in which participants had a mean age below 60 yr or were within 10 years of menopause onset.

Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement. JCEM July 1, 2010 vol. 95 no. 7 Supplement 1

A 40% reduction in death! So look at those 42 women who would have died before age 60: If they use HRT, 40% of them will live! 17 more women will live because those thousand women used HRT. And what about breast cancer? Over that same ten years, will HRT cause some of those women to be diagnosed with breast cancer? Well, according to the large Danish study, the answer is “no.” But according to the WHI study, which is what your mainstream endocrinologist tends to look at, over those ten years,

In women starting estrogen within 5 years of menopause, attributable risk [of breast cancer] would be 2.59 cases per 1000 women per 5 years if the WHI data is used for calculations; a relatively small excess risk.

Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement. JCEM July 1, 2010 vol. 95 no. 7 Supplement 1. For this paragraph the authors referenced Am J Epidiol 167:1407-1415

So in those same 1000 women, over ten years you might see 5.2 extra cases of breast cancer. Not breast cancer deaths, just breast cancer diagnosis. And not invasive breast cancer per se, but any type. (By the way, that quote is from the same 2010 Endocrine Society review of all HRT studies, in case you think I’m cherry-picking my sources.)

FINALLY, SOME HARD NUMBERS!

So there you have it: Giving HRT to 1000 women at menopause and continuing for ten years

  • will save 17 lives,
  • but might [if you use the WHI data, which used non-bioidentical progestin] cause 5.2 extra cases of breast cancer (some of which are non-invasive).

17 lives saved, vs 5.2 cases of breast cancer: I stand by my statement that
HRT is over three times more likely to save your life than it is to give you breast cancer.

But I actually think YOUR numbers are even BETTER than that! Why not check out your own personal risk of taking HRT??
[expandsub1 title=”To find out the numbers for YOU specifically, click here!” trigclass=”references”] I think the breast cancer rates listed above are actually pretty aggressive. The Endocrine Society also found that [based on the WHI study, which used Provera instead of progesterone] you might have a 3% increase in your RELATIVE risk of breast cancer per year, if you were starting HRT within a few years of menopause. Meaning, if you went to this handy National Cancer Institute risk assessment tool and found that your five-year risk of breast cancer (without being on HRT) is, say, 1.3%, then:

  • Your risk of breast cancer– and that of all other women with your same risk characteristics– is 1.3%, or 13 chances in 1000 of getting breast cancer in the next 5 years.

Call that your baseline risk of “1”, meaning equal to all of your peers who have your same characteristics filled in on the NCI website. Now you start HRT. What happens to your risk?

After 1 year, your relative risk increases by 3%, meaning it is now 1.03 relative to your peers.
After 2 years, it is another 3%, or 1.061
After 3 years, 1.0927 After 4 years, 1.12551
After 5 years, 1.15927
So after 5 years, instead of a risk of 13 chances in 1000, you have a risk of 13 x 1.15927, or 15.07 chances in 1000. So your risk increased by 2.07 chances in 1000, which is even less than the “2.59 cases per five years per thousand women” mentioned above! [/expandsub1]

Do you see now why I’m troubled when I’m surrounded by pink ribbons, but no one is wearing “heart disease ribbons”?
And so I say again: avoiding estrogen due to fear of breast cancer, is like jumping in front of a bus to avoid a bicycle. So, this coming Breast Cancer Awareness Month, go ahead: wear your Pink Ribbon proudly. But maybe… would you consider putting a little red ribbon next to it? Over your heart?
Do it for the women you love.

Leave a Reply

Your email address will not be published. Required fields are marked *