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Dr. Susan Love's Hormone Book - - - - - - - - - - T A B L E++T A L K Is it possible to pack a nutritious brown bag lunch? Share your tips and tricks in the Mothers area of Table Talk - - - - - - - - - - R E C E N T L Y Turning the tables on Terry Gross Don't complain. Don't explain. Don't call me Mom Are we there yet? Nursing death BROWSE THE MOTHERS WHO THINK HOT FLASH ARCHIVES - - - - - - - - - - Mamafesto
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ASK DR. LOVE | PAGE 1, 2
Last month, the New York Times ran a story about the drugs Tamoxifen and Raloxifene, and reported that they might not only delay breast cancer, but -- Tamoxifen particularly -- possibly prevent it. What is your take on these two drugs? The effects of Tamoxifen were only studied over four and a half years. There's some evidence -- or concern -- from the literature that after five years the cells may become resistant to the drug and we may in fact see an increase in risk for breast cancer. There are also other downsides. It can cause endometrial cancer as well as phlebitis and pulmonary embolism. So if you look at the deaths in the study written about in the New York Times, in the placebo group there were five deaths from breast cancer. In the Tamoxifen group there were five deaths -- three from breast cancer and two from pulmonary emboli. So it's not actually decreasing death, it's just shifting one disease to another. I'm not sure that's the way we want to do prevention. On Tamoxifen, if you don't die from one thing, you'll die from another. It's not preventing, it's merely changing what you die from. Isn't there any good news here? It's interesting that we've shown that a drug can have some effect in terms of prevention. I think that part of it is good. I'm not sure this is the drug that we want to use. With Raloxifene, the data is only two-year data, so it's much too soon to know whether it really does prevent breast cancer. It's not as good a drug for osteoporosis as estrogen; it's not as good on cholesterol as estrogen and it causes hot flashes. As is often the case, the first drugs of a new genre are not always perfect. Maybe we'll do better. But I would like to see us not use drugs for prevention. I think there are safer ways to do prevention. Such as? Exercise will decrease breast cancer, osteoporosis, heart disease, colon cancer and Alzheimer's -- and you feel morally superior. A diet that's low in fat and high in fruits and vegetables really makes a difference. Not smoking -- almost all premature heart disease is in smokers. We tend to go directly to drugs as a mode of prevention and don't emphasize that the foundation has got to be lifestyle changes. If you still need to add drugs on top of that -- for example, people who are very high risk for something -- then that's a different matter. As I read through your book, I got a little frustrated, because it seems if a woman wants to eliminate some of the less pleasant aspects of menopause and prevent osteoporosis, then she risks breast and endometrial cancer. It seems there's no winning. It's not like we're going to prevent death entirely last time I checked. So what people really want is to reduce and prevent suffering and disability. There was a very interesting study that came out in the last month or two in the Journal of the American Medical Association. They looked at three factors in people at middle age: weight, smoking and exercise. If you had maintained a healthy weight, didn't smoke and exercised, then you reduced the disability at the end of your life by six years. I don't think we care whether we live to 87 or 86. We don't want to suffer. We don't want to be disabled. I think that's what a lot of this is about: getting rid of premature, early death and getting rid of suffering and disability. The way to do that is first with lifestyle changes, and then, only in those people who really still need it, you consider whether you want to add drugs. So when do you recommend hormone treatment? It depends on the woman. When the symptoms are really interfering with the quality of women's lives and they don't feel like they can deal with it, then short-term use for three to five years is reasonable. For prevention, I don't think we have the data to recommend it universally, so women are going to have to look at their own situations -- what they're at risk for, what scares them, what their lifestyle issues are -- and make their decisions based on that. The other issue that is important to remember is that this is not a one-time decision. You're making the best decision you can for the moment and this stuff is changing every two weeks. So all you can do is make the best decision you can make for right now and reevaluate as things change. I think sometimes women get this notion that this is a big life-and-death decision and if you choose wrong, you die, and if you choose right, you live. It's just not. This is prevention. You're talking about preventing something you may or may not get down the road. We make prevention decisions all the time. We decide whether to put our seat belts on or not. You decide whether to eat that extra piece of chocolate cake. At the end of the "Breast Book," you talk about wanting to eradicate breast cancer so your daughter's generation won't have to worry about it. How will this happen? I think what we really need is a pap smear kind of thing. With the pap smear you've got levels one, two, three, four, five. And five is cancer and four is precancer. Two and three are somewhere in the middle there. What we need to do is find breast cancer when it's at two or three, just like with pap smears. Then you go in and get fixed. We'll just fix it before you ever get the cancer. And I think that's going to happen in the next four or five years. That's what I'm working on now -- research that's going to lead to that approach. I don't think surgery and radiation and chemo are the answers. We just need to prevent it. So perhaps it's premature to look at Tamoxifen and drugs like that as the hope, but there is hope. The optimism isn't unfounded? Oh yeah. I think that even drugs like Tamoxifen or Raloxifene offer some hope. I don't think drugs are the answer to all life's problems, but for women who are very high risk or maybe have precancerous conditions, to take them for five years now may make sense for them. I'm not against any of these things. I'm just against this notion that everybody should be on drugs forever. But there certainly are people for whom that may be a choice. And I think we're going to have better and better choices, because breast cancer is a moving target.
Weigh in on menopause and hormone treatment in the Science and Health area of Table Talk.
Small mercies Awaiting surgery to remove a lump, I'm thinking not about losing a breast but about having them.
A positive side effect Visiting my breast surgeon has become as pleasant as a lunch date. Almost.
Saving the breast Progress is being made and money is being spent, but women still need to "make some noise" if they're going to win the war on breast cancer.
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