Hormone therapy and breast cancer: risk communication and the ‘perfect storm’

Abstract

Many factors are considered when a woman estimates her personal risk of breast cancer. Common to most decisions are four separate influences that have convinced the public and many health-care providers that breast cancer is the greatest concern for menopausal women and that menopausal hormone therapy (MHT) is generally responsible. Historically there have been well-documented situations in which big pharma and doctors have not put patient interests first. Conflicting reports about the safety of MHT and the media imperative to always increase readership by presenting a compelling scary story have created an underlying distrust of science, doctors, and MHT. Numerical and statistical illiteracy in the general population creates a situation where lotteries succeed despite astronomical odds and the risks of medical interventions are exaggerated by their description using relative, rather than absolute, risks. Finally, mammographic overdiagnosis contributing to improved breast cancer survival has contributed to the ‘popularity paradox’ (more screening – more enthusiasm) especially among survivors and advocacy groups. As a result, worry about breast cancer has overshadowed concern about cardiovascular diseases as the major cause of death and disability in the later years. The ongoing challenge for clinicians dealing with menopausal women is to bridge the gap in risk perception with evidence-based common-sense advice.

Chinese abstract

当女性在评估患乳腺癌的个人风险时会考虑很多因素。大部分决定的共同点是四个独立影响因素, 这些影响因素使公众和许多医务工作者确信, 乳腺癌是更年期女性最担忧的问题, 并且绝经期激素治疗（MHT）是其担忧的主要原因。从历史上看, 大型制药公司并未把病人的利益放在第一位, 这是有证可循的。关于MHT安全性争议的报道以及媒体为了增加读者而呈现引人注目、让人觉得恐怖的故事, 这些造成了大众对科学、医生和MHT的潜在的不信任。在普通人群中, 数字和统计方面的无知造成了这样的一种情况——医疗干预的风险被他们的相关描述夸大了, 但这不是绝对的, 并且出现的几率很低。最后, 乳腺钼靶的过度诊断有助于提高乳腺癌的存活率, 这促成了“最受欢迎的悖论”出现（照射越多-越有激情）, 尤其是在幸存者和倡导团体中。由于乳腺癌是造成老年人死亡和残疾的主要原因, 所以对乳腺癌的担忧已经远远超过了对心血管疾病的担忧。临床医生在治疗更年期女性时, 不断面临的挑战是用证据和常识性的建议来弥补风险认知方面的差距。

Keywords:

• Hormone replacement therapy
• breast cancer
• risk communication