This dissertation to answer the research question (Why HRT is prescribed for menopausal women despite the risk of breast cancer?) was carried out as mentioned in the methodology section using the literature review methodology. The selected studies were appraised with the critical appraisal tools by the Public health resource Unit. The methodology of literature review had well assisted to review all the studies in the perspective of the other and divulge meaningful evidence and information which in a single study capacity would have been otherwise unnoticed. The Critical appraisal tools have assisted to review all the studies comprehensively to ensure there validity, reliability and applicability so that the result could be generalized to all the menopausal women population. The studies which have been reviewed were conducted in various settings with participants from all types of study population hence the results are a wholesome reunion of the existing predisposing factors with the associated risk of HRT in the incidence of breast cancer.
ANSWER TO THE RESEARCH QUESTION
Every doctor has the relief of the patient of utmost importance while prescribing a treatment and every treatment is meant to bring relief. And treatment has dose schedules, administration guidelines and perhaps side-effects which are generally explained by the doctor. But unlike other medicines there is a lot of unrest around the use of HRT though the associated risk when evaluated with other factors is not high.
Keeping the results and conclusions derived from these studies in the present and elements for further research in front, it is seen that HRT does have benefits.
These associated benefits with use of HRT according to this study are:
1) Use of HRT decreases the risk of death overall (Sellers et.al,1997) (Sener et.al, 2009) and is associated with recurrence, metastasis-free survival and better overall and disease-free survival than HRT nonusers in the univariate analysis irrespective of the start of menopause (Sener et.al , 2009) (Bonneir et.al, 1998)
2) HRT does not increase the risk of breast cancer when administered to women for whom other risk factors have been excluded (Tzingounis et.al, 1996).
2) There is an inverse relationship between HRT and mortality due to coronary heart disease, stroke and cancers other than breast (Sellers et.al, 1997)
4) Use of HRT gives fewer locally advanced cancers and smaller and better-differentiated cancers compared to non-users (Bonneir et.al, 1998).
5) HRT is a favourable prognostic factor for breast cancer. (Bonneir et.al, 1998)
6) Use of HRT counteracts the increased incidence of breast cancer with the lower incidence of other tumors. (Olsson et.al, 2001)
7) Long term HRT use has a favorable effect against colorectal and endometrial cancer. (Writing Group for the Women’s Health Initiative Investigators, 2002) (Corrao et.al, 2008).
8) Use of trans-dermal HRT compared to the oral use of HRT is associated with lesser risk of breast cancer (Million women study collaborators, 2003) (Corrao et.al, 2008) which is presumed by the WHI, 2002.
However these benefits depend on many other inter-connected factors of duration of use, age of the menopausal woman, past personal history of HRT used, family history related to breast cancer, dose of the HRT administered and type of HRT regime prescribed.
These same factors affect the element of risk as well in the following way.
1) Risk of breast cancer may be increased with HRT use for duration of 5 years or less in women with family history of breast cancer (Sellers et.al,1997) (Olsson et.al, 2001).
2) Increased risk of breast cancer after prolonged use of HRT (Olsson et.al, 2001) (Sellers et.al, 1997) (Corrao et.al, 2008) (Sellers et.al, 1997) (Olsson et.al, 2001). This risk increased with increasing duration of use and decreased with time and reached at baseline with 5 years time. (Ewertz et.al, 2005) (Million women study collaborators, 2003)
3) Higher risk in current users than in past users which was greater for combined therapy than for other oral types of HRT (Million women study collaborators, 2003).
4) Women who used combined estrogen and progestin HRT regime are at increased risk of breast cancer (Stahlberg et.al, 2004) (Million women study collaborators, 2003) and Oral HRT use for long term had a higher risk of breast cancer than trans-dermal use of HRT (Corrao et.al, 2008).
5) Increased risk of breast cancer with current use of HRT in women of 50 years of age and above which increased with increased use. No increased risk in women between the ages of 40-49 (Ewertz et.al, 2005) (Million women study collaborators, 2003).
6) The risk of breast cancer increased in women who were current HRT users and had used OC in the past. (Lund et.al, 2007)
7) HRT users developed breast cancer at a younger age than non HRT users (Sener et.al, 2009).
According to the synopsis of the issues and factors derived it can be concluded that there are benefits associated with use of HRT which mutually depend on the risk factors. And this is the reason why HRT is prescribed for menopausal women despite the risk of breast cancer. And these will again depend on gynecologist judgment and patients level of knowledge and awareness (2006).
To bring the optimal benefit with minimally associated risk, HRT could be prescribed to menopausal women for lesser duration which the studies present as 5 years. This duration which could be disputable and the age of the women also has to be considered with the link of different effects of HRT in different age groups would again depend on the individual gynecologist’s judgment and the patient’s compliance for regular follow up and mammographic screening.
An attempt has been made to clear the otherwise existing dilemma of prescribing HRT or not but this again depends on many other factors which are most importantly the patients follow up and the doctors perception of the associated prescribing strategies. However more research is needed as within the limitations of this dissertation though it is possible to conclude that there are benefits associated with the use of HRT despite the risk of breast cancer; it is not possible to chalk out an effective prescribing strategy. And to bring any considerable changes a prescribing strategy and better patient compliance for follow-up would be needed.
These total results, conclusions and opinions from the studies have presented some principle elements which could guide through the dilemma of prescribing HRT to yet another menopausal woman.
1) It is evident that duration has a role to play in the increase of the foresaid risk of breast cancer and that there is no risk with the use of HRT in the past.
2) A lot would also depend on the gynecologist or the physician’s prescribing principles. It would be needed by them to follow some guiding factors like evaluating high-risk and low-risk women, family history and previous history of Oral Contraceptives which would vary for each patient.
3) A regular follow-up and timely check up as mentioned would help to catch otherwise unnoticeable breast changes.
4) Another factor which needs to be pursued for future research and studies is the type of HRT regimes. In routine HRT is prescribed orally hence less is known about other methods of administration which could perhaps assist in reducing the risk.
5) It would also be helpful to find if there is a link with the BMI and use of HRT. Generally obesity is linked to many diseases and unhealthy conditions and this would help to categorize women into high or low risk group.
This dissertation has tried to bring up some associating factors which could help to extract the optimal benefits with lesser risk. This systematic approach has helped conduct this dissertation so as to answer the research question. However research in healthcare is never ending and is expanding every day (Aveyard, 2010). New studies with various designs are being conducted around this topic as I write my dissertation which will bring in more new opinions and evidences which will form base for yet another dissertation or study tomorrow to help develop a successful prescribing strategy.