Interesting Article in NY Times Nov. 13 Health

tbtam

To all -

We live in an imperfect world. Drugs are imperfect, studies are imperfect, data is imperfect.Until we have perfection, we need to live, and I need to practice medicine, using the data that are available to us

 Any time you study two variables together, such as breast cancer and birth control pills, you will, by statistical chance, find a certain number of associations.  Some are weak, some are strong. Some are consistently found across almost all studies. Others pop up only sporadically and are discounted. Others, like the association between pills and breast cancer, occur only in subsets of subjects, and not in all studies, but enough that they give us pause.

 And yet, despite the fact that the pill is probably THE most studied drug in history, the data on breast cancer risk remains unclear. One could argue that this alone suggests a lack of association - after all this research, if it's not clear, the association is either not there, or, more likely, exists only in a small subset of women yet to be identified. One of these days, we will have genetic testing in every drug study that will tell us who the folks are who are going to have adverse events, and thus we'll know just who should avoid taking that drug. Until then, this is what we have to deal with. 

Oral contraceptives are not risk free. Neither is crossing the street. What women need to do is decide what risks they are willing to accept in return for a given benefit.  My job as their doc is to try to keep them as informed as possible so together we are working with the best data available to us at the time we are making a decision. 

Peace,

Margaret Polaneczky, MD 

revkat

swimangel -- I don't mean to be contrary, but you've made the statement several times about the first thing all doctors ask is were you on oral contraceptives, and no one asked me that. They asked about age at first menstrual period, number of pregnancies and children, and how long did I breastfeed.

The problem with observational studies on humans is that there are so many variables that it becomes difficult to control. For example, are women on OC more likely to exercise than women not? Do they eat differently? Are they more likely to have other underlying hormonal issues? It's a tough job to tease out what the really important variables are.

AnnNYC

I'm happily surprised to see Dr. Polanecky's replies!

Swimangel, I think you made a great point about all the history information collected by all doctors... ideally it could be a great resource for study, although unfortunately it's probably unlikely in this country.  I do think something like that idea is involved in Dr. Susan Love's "Army of Women" project.  The thing is that, to be really useful, that information would have to be collected in some standardized way -- for example, a history/intake checklist for women newly diagnosed with breast cancer, where every woman would answer the same questions in the same format, about OC use, drinking, smoking, diet, exercise, periods, etc.  As it is now, that information is usually gathered by the doctor asking questions and writing down answers -- a doctor might not ask about OC (as revkat experienced), or might write down "3 alcoholic drinks a day" when the patient said "about 3 drinks a week" (as I experienced with my otherwise wonderful breast surgeon!).

Anyway, I think the simple point that many women are in fact taking a "cancer preventative" in the form of OC to reduce risk of ovarian cancer is an interesting addition to the NYT article -- and the weighing of the possible increased risk of BC versus reduced risk of ovarian cancer with birth control pills parallels the need to weigh risks/benefits in deciding whether to take Tamoxifen or Raloxifene to prevent BC.

A commenter on the Times comment page also brought up prophylactic bilateral mastectomy (BPM) being chosen by some BRCA+ women -- that's another "cancer preventative" measure taken by some of "the public."

That made me think of the number of women who choose bilateral mastectomy when dx'd with BC in one breast -- wasn't there some "health economics" paper a year ago decrying the rise of this "drastic choice"?  So many of these medical writers seem to have the attitude that patient choices are stupid!  Last night, I read through all those NYT comments -- I thought lots of them really expressed very well the thoughtful reasons for patient choices!