1: For many years, the long-entrenched standard practice for postmenopausal women was hormone replacement therapy or HRT.
Then, in 2002, the Women’s Health Initiative Study (WHI) published the results of a large clinical trial. The research involved thousands of older women and analyzed the health outcomes of women taking HRT versus those who did not.
“The study reported a 24 percent relative increase in the risk of breast cancer among a subset of women taking HRT,” Peter Attia writes in his powerful book Outlive: The Science and Art of Longevity.
“Headlines all over the world condemned HRT as a dangerous, cancer-causing therapy,” he notes. “All of a sudden, on the basis of this one study, hormone replacement treatment became virtually taboo.”
2: A 24 percent risk increase sounds frightening.
“But nobody seemed to care that the absolute risk increase of breast cancer for women in the study remained minuscule,” Peter observes.
“Roughly five out of every one thousand women in the HRT group developed breast cancer, versus four out of every one thousand in the control group, who received no hormones.
“The absolute risk increase was just 0.1 percentage point,” Peter writes. “HRT was linked to, potentially, one additional case of breast cancer in every thousand patients.”
3: What was the result of this slight increase in risk?
“Menopausal women would potentially be subject to hot flashes and night sweats, as well as loss of bone density and muscle mass, and other unpleasant symptoms of menopause,” Peter writes. “Not to mention a potentially increased risk of Alzheimer’s disease.”
Our current model of practicing medicine, Peter labels Medicine 2.0, “would rather throw out this therapy entirely, on the basis of one clinical trial, than try to understand and address the nuances involved.”
Peter believes there is a different approach, which he calls Medicine 3.0. This approach considers the study’s results while also understanding its limitations and biases.
“The key question that Medicine 3.0 asks,” Peter writes, “is whether this intervention, hormone replacement therapy, with its relatively small increase in average risk in a large group of women older than sixty-five, might still be net beneficial for our individual patient, with her own unique mix of symptoms and risk factors.”
Additional question#1: “How is she similar to or different from the population in the study?”
Answer: Most of the women in the study were many years out of menopause. So, how applicable are the findings of this study to women who are in or just entering menopause?
Additional question #2: “Is there some other possible explanation for the slightly increased risk with the specific HRT protocol?
Answer: “A deeper dive into the data suggests that the tiny increase in breast cancer risk was quite possibly due to the type of synthetic progesterone used in the study, and not the estrogen; the devil is always in the details.”
Yet, despite the tiny increase in absolute risk, Peter writes, “was deemed to outweigh any benefits.”
More tomorrow.
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Reflection: Do I have any family members or friends fighting a difficult medical prognosis? What assumptions are we making?
Action: Consider alternate paths.
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