Breast Cancer Drop May Just Mean Fewer Detected Cases

Dec. 15, 2006— -- Researchers have broached another possibility today to account for the decline in breast cancer rates, and it's not good news.

A day after the announcement of research citing the drop in women undergoing hormone replacement therapy as the chief reason for a steep drop in breast cancer cases, some experts suggest that just as many women may have breast cancer, they just aren't getting screened for it.

"We have been aware for several years that the number of radiologists who specialize in mammography have been decreasing, and that there are places in the United States where women have difficulty getting access to mammography," writes Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society, in a blog released after the announcement on the society's Web site.

"If mammography use has reached a peak and is now decreasing, we may actually be diagnosing fewer cancers when they can be most effectively treated. If you don't get a mammogram, you don't diagnose a cancer."

Dr. Michelle Warren, medical director of Columbia University's Center for Menopause, Hormonal Disorders, and Women's Health, calls the current availability of mammography in the United States "a crisis."

"The reimbursement for mammography has sunk so low and the risk is so great -- the most common malpractice suit is failure to diagnose breast cancer -- that centers have either stopped doing them or do so few that there is a three- to six-month wait," she says.

"I have a patient I saw yesterday who just made an appointment for the end of April. So declining mammography may well be contributing."

Interpreting the Results

The research linking the decline in HRT to the drop in breast cancer came from the M.D. Anderson Cancer Center in Houston and was discussed at a breast cancer conference in San Antonio Thursday. It was based on a recent report by the National Cancer Institute that showed a 7 percent drop in new cases of breast cancer between July 2002 and August 2003.

The drop corresponds with the results of the 2002 Women's Health Initiative study, which suggests the link between HRT and breast cancer. Millions of women quit HRT after the news.

But now some experts say the apparent downturn in breast cancer incidence may not be a downturn at all. Instead it may mean that just as many women have breast cancer, but fewer women get screened for it.

Women on HRT Worried

Others say that while an overall drop in breast cancer incidence may exist, attributing the decrease to a decline in HRT alone may not be accurate.

But by citing HRT decline as the direct cause, experts worry the public is getting the wrong message. Specifically, they say, women still taking the hormones or who have in the past may panic.

"I talked to patients last night in California, and this news is making them nervous," says Dr. Marisa Weiss, president and founder of the consumer information Web site breastcancer.org. "For people who got off this therapy, they're feeling reinforced that they made a good decision. But for those who chose to stay on it, they're experiencing anxiety."

"I received about 15 calls from patients this morning," says Dr. Katherine Sherif, director of the Drexel Center for Women's Health at Drexel University College of Medicine in Philadelphia. "What I have told them is that three years is too short of a time to measure the effects of a drug on breast cancer.

"Cancers take decades to develop, and conversely, withdrawing hormones could not result in a decrease in breast cancer in three years -- it's actually absurdly short."

Exploring the Ramifications

And the impact of the news could be felt beyond HRT. There are also concerns that patients may panic over other therapies using estrogen. The nation's leading organization for reproductive medicine issued a statement this morning in response to the breast cancer study.

"Patients undergoing IVF [in vitro fertilization] as recipients and receiving cryopreserved embryos do receive estrogen in doses and formulations similar to HRT patients but for a very short period of time," says Dr. Steve Ory, president of the American Society of Reproductive medicine, in the statement.

"It is not clear that it is at all relevant to the current controversy," the statement continues. "Previous studies that have looked at fertility therapy -- but not specifically recipients and cryo patients -- have generally provided reassuring data."

Another concern is that many of the experts who have commented on the study have not yet had a chance to read the research. Instead, says Dr. Donnica Moore, president of the Sapphire Women's Health Group, experts have commented only on news releases that summarize the research.

Moore, who says she has not yet obtained a copy of the research, says this could result in the public receiving inadequate information on the validity of the link between HRT and breast cancer.

"I'm in no way an apologist for HRT," Moore says. "But there are many, many factors involved here, and the vast majority of women with breast cancer have never touched an estrogen pill.

"Like most surprising scientific studies, this research raises more questions than answers," says Moore.

HRT -- Still a Factor?

Experts note, however, that although they believe the results of the latest study may be questionable, previous research does show a link between HRT and breast cancer.

"It makes sense to look at reduction in HRT use as one of the potential contributing factors," says Lillie Shockney, administrative director of the Johns Hopkins Avon Foundation Breast Center. "It has been hoped that with the announcement several years ago of its link to breast cancer that it would be less frequently prescribed, especially for high-risk women."

"I suspect there is indeed some positive benefit from the decreased emphasis on combination HRT, which years from now will in fact contribute to a true decline in the incidence of breast cancer," Lichtenfeld writes in his blog. "I do not believe the sudden drop in breast cancer incidence is because 11 percent of breast cancers in some of the postmenopausal women have suddenly disappeared and no longer exist."