Many women who choose not to take estrogen make that decision based on their fear of cancer. The Gallup survey referred to earlier revealed that in response to the following question: âœTo the best of your knowledge, what is the leading cause of disease-related death for women over 50?â The most-frequent answer (33 percent) given by the women surveyed was breast cancer, with heart disease running a close second (31 percent). However, heart disease is actually number one, killing eight times more women than breast cancer each year, yet it appears that it is breast cancer that we most fear. (Heart disease will be discussed in Chapter 9.) The relationship between cancer and estrogen therapy needs to be carefully examined before we attempt to answer the specific questions about cancer that are asked at the programs.
A slim, free publication from the National Cancer Institute, What You Need to Know About Breast Cancer (for your copy, write to the National Cancer Institute, 9000 Rockville Pike, Building 31, Room 10A24, Bethesda, MD, 20892), describes clearly what cancer is and how it grows. It explains that there are one hundred types of cancer currently known, among which are several kinds of breast cancer. The characteristic that is common to all cancer diseases is that abnormal cells proliferate and destroy tissues in the body.
The American Cancer Society indicates that in 1991, approximately 175,000 American women got breast cancer and that 44,500 died as a result of it. It is easy to understand why these facts strike fear in the minds of women. Yet there is more that we need to know. Let me cite a perfect example of the effect of educating yourself about the real facts of the cancer/estrogen conflict.
One woman caught me in the hotel lobby after a program. âœI wonder if I could talk to you for a few moments. I have such a need to tell you how I feel about this estrogen and breast cancer situation. I know you’re not a physician,â she said, âœyou made that perfectly clear during your presentation. But please let me tell you how I feel, because I think it may help other women and, besides, I really can’t go home and sleep tonight without getting this off my chest. No pun intended,â she laughed.
It is these kinds of conversations that let me know what women actually glean from the information presented at the programs and how they really feel about the changes that occur in midlife. âœI’m happy and eager to listen,â I assured her as we sat down together.
âœMy grandmother died of breast cancer,â she began. âœShe was eighty-nine, had been overweight since she was in her sixties, and she was sedentary. My mother died at seventy. She had breast and bone cancer and a stress-filled life. From the time she was my age, fifty, she was overweight and she didn’t exercise. Mom’s sister, my aunt, had the same general body and life-style profile, only she had eight kids. She also died of cancer that was first found in her breast.
âœWhat a family history I have! But I figured I would escape cancer, because I was different. I’m a health-food nut and an exercise devotee, so I figured I could protect myself from following in the footsteps of the females in my family. That made me feel secure until my cousin, slim and in her forties, found a lump in her breast, which when biopsied was found to be malignant. She had a lumpectomy. Since then, getting breast cancer is always in the back of my mind. So I’ve been getting ready for menopause with a real chip on my shoulder.
âœI’ve already had a small noncancerous growth removed from my left breast and I’ve read everything cautioning someone like me, with a personal medical history and a family medical history like mine, against taking ERT. I felt pretty discriminated against and hostile, especially now when news reports of medical studies keep informing me that there are many diseases that estrogen will, or may, prevent as women age. Big deal, I thought.
âœI read everything I can get my hands on to try to understand the risks of breast and endometrial cancer for women who take hormone replacement therapy and I have felt cheated. Tonight turned that around for me. Now I know that if my menopausal symptoms are difficult for me and I’m given a choice, I can chose to take estrogen under careful medical supervision. I know now that I might be willing to take that gamble. Hallelujah!â
âœWhoa,â I said. âœBefore we go any further, tell me what brought you to that conclusion.â I wanted to make sure that she had accurately heard what was said at our program and that she was reacting to sound medical information.
She continued, âœThe doctor who was discussing cancer said that although there is some evidence that taking estrogen may increase the risk of developing breast cancer, it is a small risk compared to the fact that estrogen can help alleviate my symptoms, can prevent osteoporosis, and may even decrease the risk of heart disease. As I said, I’m getting ready to gamble.â
âœYou can only gamble if your physician agrees and if you’re willing to take the responsibility for seeing him or her at least twice a year, for having a mammogram once a year, and for learning and practicing breast self-examination once a month,â I cautioned.
âœI know that. Tonight’s information really made me feel great. It made me feel like I could take control of what’s happening to me. I just needed to tell you that now, instead of feeling like a victim, I feel empowered to make choices for myself.â
How could a single lecture turn this intelligent and articulate woman’s perceptions around so completely? It was simple. The program gave her the opportunity to learn the facts and to ask questions, and then to make a decision based on sound information.
It’s no wonder that there is so much confusion about ERT and breast cancer. An article in Consumer Reports (September 1991) stated that the actual data concerning the relationship between breast cancer and estrogen therapy are not definitive. Conflicting results are produced by important studies. A major survey, in which researchers at Vanderbilt School of Medicine analyzed twenty-eight of the ERT studies published over the last fifteen years, found no increased risk for breast cancer at all. These researchers concluded that âœthe combined results from multiple studies provide strong evidence that hormone therapy (at the current standard dosage) does not increase breast cancer risk.â
Compare this finding to The Nurses Cohort Study at Harvard, reported in the Journal of the American Medical Association (September 28, 1991). This ongoing prospective study (a study designed to gather data over a specified period of years) in which more than one hundred twenty thousand women reported, found that women who used estrogen in the past, but who no longer use it, return to the same risk of breast cancer as women who have never used estrogen. No increase in breast cancer was found in women who stopped ERT, even after taking it for ten years. But, the study found, a woman who is currently on ERT has approximately a 35 percent higher risk of developing breast cancer than a woman who does not use it, and that remains true no matter what dose of estrogen she is taking or for how long she has taken it. Further, a woman has a greater risk of getting breast cancer if her mother or sister have had it in which case the risk is doubled. Additionally, these investigators indicate that estrogen may not actually cause cancer, but may cause the growth of an existing tumor. This could actually be helpful news, because it could mean that an undetected tumor would not stay hidden and could be treated at an early stage.
Most of the doctors surveyed are inclined to agree that if there is an increased risk of breast cancer with ERT, it is very, very small, perhaps from one to one and a third in one thousand women per year. Yet breast cancer affects one in every nine women in the United States over their lifetimes. According to Dr. Morris Notelevitz’s article in Menopause Management, a professional medical journal, âœWhile the incidence of breast cancer does not appear to be menopause-related, it is known to increase with age.â
Clearly there is a need for medical guidelines in determining the safety of hormone therapy in postmenopausal patients with breast cancer or with a family history of breast cancer. Two of the potential major risk factors for ERT are breast and endometrial (uterine) cancer. Women at the educational programs submit an extremely large number of question-cards about these concerns, but their questions basically fall into the ten areas covered by the questions in this chapter.