Re: WHI - HRT and Colorectal Cancer
From: art fougner, md (evsono@pipeline.com)
Fri Mar 5 13:24:46 2004
TJ
the problem with ALL HRT studies is that we are still unsure whether the
treatment groups and the control groups are similar or representative of
the larger population. Developments in genetics suggest that
predispostion to various disease states vary greatly among apparently
similar groups. recognizing and comparing apples and apples has become
more difficult. all these studies will need to be redone to reach
conclusions generating more light than heat. My wife started taking HRT
after a discussion with her gyn and then with me - after one week, she
stopped and said, "this is no damn good." A year later, WHI filled the
news. She never lets me forget.
additionally thanks for actually obtaining the MRI case report that i
could not.
art
At Fri, 5 Mar 2004, Terrence.Jones@kp.org wrote:
>
>This is a multipart message in MIME format.
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>
>My son was reading on the way to school today, and asked what the word
>"inane" meant. Lessee, one half of 72 is 36 advanced colon cancers (in the
>placebo group). And three fourths of 43 is 32 advanced cancers (in the
>treatment group). I'm sorry, what was Your point? Maybe You were trying to
>conclude that HRT protects against early stage colon cancer, but not
>advanced? Or maybe You were implying that the numbers are too small, and
>cross-over too great, to conclude anything, when constricted by an
>intention to treat model. Or maybe that confounding by surveillance versus
>presentation with symptoms was not reported? Aside from the issue of
>biologic plausability - "I don't care about mechanisms" (to quote an
>epidemiologist from HERS, at Her presentation to the Ninth Annual Congress
>on Women's Health and Gender-Based Medicine) - there's an inherent flaw,
>when comparing the number of angels on Your pinhead to another's, when You
>don't "do the math". Not an "opinion", tho I did the calculations in my
>head - so they "could be wrong". Oh, and while on the topic of inane - the
>article You cited regarding MR findings in "Gravid Uterine Dehiscence"
>(Abd Imag 20:486-88, Au: Hamrick-Turner) was a single case report from a
>center using a scanner with a pelvic coil, involving an early second
>trimester Patient with bleeding, secondary to a percreta, thru the prior
>scar. Unfortunately, it was not germane to Lynn's case. But thanks, as
>always, for offering Your unique perspective to the list. Regarding WHI
>and bills of goods - try keeping in mind the comment from Dr. Simon (GWU)
>from NAMS 11/03 -- "One must be extremely careful about extending both the
>benefits and the risks seen here beyond the population in which they were
>assessed." Try, tho he might, the sleeping chads still lie. tj
>
>evsono@pipeline.com (art fougner, md)
>Sent by: ob-gyn-l@obgyn.net
>03/04/2004 01:23 PM
>Please respond to ob-gyn-l
>
> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.n t>
> cc:
> Subject: Re: WHI - HRT and Colorectal Cancer
>
>especially disconcerting is the finding that the cancers found in those
>patients using HRT were more advanced. i still can't help feeling that
>ob-gyn's may have been sold the proverbial bill (pill?) of goods.
>
>definitely just my opinion - i could be wrong.
>
>art
>
>At Thu, 4 Mar 2004, Jay Kulkin wrote:
>>
>>This is my whole issue with the reduction of colo-rectal ca in women
>taking
>>hormone therapy. The paradigm has changed with the recommendation for
>>screening colonoscopy at age 50. Colon cancer should be reduced by early
>>polypectomy like cervical cancer was by the pap/colpo/LEEP etc. I sure
>won't
>>be recommending HRT/ERT for colon cancer reduction.
>>
>>--
>>Jay M. Kulkin, MD MBA FACOG
>>Women's Institute For Health PC
>>975 Johnson Ferry Road
>>Suite 460
>>Atlanta, Georgia 30342
>>Ph: 404.832.0300
>>Fax: 404-832-0070
>>http://www.wifh.com
>>
>>>>>----- Original Message -----
>>From: "art fougner, md" <evsono@pipeline.com>
>>To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@dns.obgyn.net>
>>Sent: Thursday, March 04, 2004 1:53 PM
>>Subject: Re: WHI - HRT and Colorectal Cancer
>>
>>> "The frequency of bowel examinations was not defined by the protocol.
>>> Self-administered questionnaires or structured telephone interviews
>were
>>> used every six months to monitor the frequencies of rectal examination,
>>> fecal occult-blood testing, sigmoidoscopy and colonoscopy (asked as one
>>> question), and barium enema examination. Information concerning the
>>> duration and severity of vaginal bleeding was also collected every six
>>> months. Symptoms of bloating or gas, constipation, diarrhea, and
>>> abdominal pain or discomfort were ascertained at base line and after
>one
>>> year. With the exception of the above-mentioned practices, the
>>> participating clinical centers did not provide comprehensive health
>>> care. Decisions regarding the workup related to the diagnosis of
>>> colorectal cancer were made almost exclusively by the women's own local
>>> physicians."
>>>
>>> http://content.nejm.org/cgi/content/full/350/10/991
>>>
>>> art
>>>
>>> At Thu, 4 Mar 2004, Jay Kulkin wrote:
>>> >
>>> >What % of dx women had screening colonoscopy since all were over 50?
>>> >JK
>>> >Jay M. Kulkin MD MBA FACOG
>>> >Women's Institute For Health PC
>>> >975 Johnson Ferry Road
>>> >Suite 460
>>> >Atlanta, GA. 30342
>>> >ph: 404-832-0300
>>> >fax: 404-832-0070
>>> >http://www.wifh.com
>>> >
>>> >This email may contain confidential or proprietary information which
>may
>>be
>>> >legally privileged. If you are not the named recipient, you should
>>> >immediately delete it from your computer system.
>>> >
>>
>>>>>> >>----- Original Message -----
>>> >From: "art fougner, md" <evsono@pipeline.com>
>>> >To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@dns.obgyn.net>
>>> >Sent: Thursday, March 04, 2004 8:47 AM
>>> >Subject: GYN: WHI - HRT and Colorectal Cancer
>>> >
>>> >> Estrogen plus Progestin and Colorectal Cancer in Postmenopausal
>Women
>>> >>
>>> >> Rowan T. Chlebowski, M.D., Ph.D., Jean Wactawski-Wende, Ph.D.,
>Cheryl
>>> >> Ritenbaugh, Ph.D., M.P.H., F. Allan Hubbell, M.D., M.S.P.H., Joao
>>> >> Ascensao, M.D., Ph.D., Rebecca J. Rodabough, M.S., Carol A.
>>Rosenberg,
>>> >> M.D., Victoria M. Taylor, M.D., M.P.H., Randall Harris, M.D.,
>Ph.D.,
>>> >> Chu Chen, Ph.D., Lucile L. Adams-Campbell, Ph.D., Emily White,
>Ph.D.,
>>> >> for the Women's Health Initiative Investigators
>>> >>
>>> >> ABSTRACT
>>> >>
>>> >> Background Although the Women's Health Initiative (WHI) trial of
>>> >> estrogen plus progestin in postmenopausal women identified more
>overall
>>> >> health risks than benefits among women in the hormone group, the use
>of
>>> >> estrogen plus progestin was associated with a significant decrease
>in
>>> >> the risk of colorectal cancer. We analyzed features of the
>colorectal
>>> >> cancers that developed and their relation to the characteristics of
>the
>>> >> participants.
>>> >>
>>> >> Methods In the WHI trial, 16,608 postmenopausal women who were 50 to
>79
>>> >> years of age and had an intact uterus were randomly assigned to a
>>> >> combination of conjugated equine estrogens (0.625 mg per day) plus
>>> >> medroxyprogesterone acetate (2.5 mg per day) or placebo. The main
>>> >> outcome measures were the incidence, stages, and types of colorectal
>>> >> cancer, as determined by blinded central adjudication.
>>> >>
>>> >> Results There were 43 invasive colorectal cancers in the hormone
>group
>>> >> and 72 in the placebo group (hazard ratio, 0.56; 95 percent
>confidence
>>> >> interval, 0.38 to 0.81; P=0.003). The invasive colorectal cancers
>in
>>> >> the hormone group were similar in histologic features and grade to
>>those
>>> >> in the placebo group but with a greater number of positive lymph
>nodes
>>> >> (mean ±SD, 3.2±4.1 vs. 0.8±1.7; P=0.002) and were more adva ced
>>> >> (regional or metastatic disease, 76.2 percent vs. 48.5 percent;
>>> >> P=0.004). In exploratory analyses, women in the hormone group with
>>> >> antecedent vaginal bleeding had colorectal cancers with a greater
>>number
>>> >> of positive nodes than women in the hormone group who did not have
>>> >> vaginal bleeding (3.8±4.3 vs. 0.7±1.5 nodes, P=0.006).
>>> >>
>>> >> Conclusions Relatively short-term use of estrogen plus progestin was
>>> >> associated with a decreased risk of colorectal cancer. However,
>>> >> colorectal cancers in women who took estrogen plus progestin were
>>> >> diagnosed at a more advanced stage than those in women who took
>>placebo.
>>> >>
>>> >> New England Journal of Medicine Volume 350:991-1004 March 4, 2004
>>> >>
>>> >> art
>>> >>
>>> >> --
>>> >> art fougner, md
>>> >> ich bin ein New Yorker
>>>
>>> --
>>> art fougner, md
>>> ich bin ein New Yorker
>>
>--
>art fougner, md
>ich bin ein New Yorker
>
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>Content-Transfer-Encoding: quoted-printable
>
><br><font size=2 face="sans-serif">My son was reading on the way to sc ool today, and asked what the word "inane" meant. Lessee, one ha f of 72 is 36 advanced colon cancers (in the placebo group). And three fou ths of 43 is 32 advanced cancers (in the treatment group). I'm sorry, what was Your point? Maybe You were trying to conclude that HRT protects agains early stage colon cancer, but not advanced? Or maybe You were implying th t the numbers are too small, and cross-over too great, to conclude anythin , when constricted by an intention to treat model. Or maybe that confoundi g by surveillance versus presentation with symptoms was not reported? &nbs ;Aside from the issue of biologic plausability - "I don't care about echanisms" (to quote an epidemiologist from HERS, at Her presentation to the Ninth Annual Congress on Women's Health and Gender-Based Medicine) there's an inherent flaw, when comparing the number of angels on Your pin ead to another's, when You don't "do the math". Not an "opi ion", tho I did the calculations in my head - so they "could be rong". Oh, and while on the topic of inane - the article You cited re arding MR findings in "Gravid Uterine Dehiscence" (Abd Imag 20:4 6-88, Au: Hamrick-Turner) was a single case report from a center using a & bsp;scanner with a pelvic coil, involving an early second trimester Patien with bleeding, secondary to a percreta, thru the prior scar. Unfortunatel , it was not germane to Lynn's case. But thanks, as always, for offering Y ur unique perspective to the list. Regarding WHI and bills of goods - try eeping in mind the comment from Dr. Simon (GWU) from NAMS 11/03 -- "O e must be extremely careful about extending both the benefits and the risk seen here beyond the population in which they were assessed." Try, t o he might, the sleeping chads still lie. tj</font>
><br>
><table width0%>
><tr valign=top>
><td>
><td><font size=1 face="sans-serif"><b>evsono@pipeline.com (art fougner md)</b></font>
><br><font size=1 face="sans-serif">Sent by: ob-gyn-l@obgyn.net</font>
><p><font size=1 face="sans-serif">03/04/2004 01:23 PM</font>
><br><font size=1 face="sans-serif">Please respond to ob-gyn-l</font>
><br>
><td><font size=1 face="Arial"> </font>
><br><font size=1 face="sans-serif"> To: &nb p; Multiple recipients of list OB-GYN-L <ob-gyn-l@d s.obgyn.net></font>
><br><font size=1 face="sans-serif"> cc: &nb p; </font>
><br><font size=1 face="sans-serif"> Subject Re: WHI - HRT and Colorectal Cancer</font></ta le>
><br>
><br><font size=2 face="Courier New">especially disconcerting is the fi ding that the cancers found in those<br>
>patients using HRT were more advanced. i still can't help feeling th t<br>
>ob-gyn's may have been sold the proverbial bill (pill?) of goods.<br>
><br>
>definitely just my opinion - i could be wrong.<br>
><br>
>art<br>
><br>
>At Thu, 4 Mar 2004, Jay Kulkin wrote:<br>
>><br>
>>This is my whole issue with the reduction of colo-rectal ca in women t king<br>
>>hormone therapy. The paradigm has changed with the recommendation for< r>
>>screening colonoscopy at age 50. Colon cancer should be reduced y early<br>
>>polypectomy like cervical cancer was by the pap/colpo/LEEP etc. I sure won't<br>
>>be recommending HRT/ERT for colon cancer reduction.<br>
>><br>
>>--<br>
>>Jay M. Kulkin, MD MBA FACOG<br>
>>Women's Institute For Health PC<br>
>>975 Johnson Ferry Road<br>
>>Suite 460<br>
>>Atlanta, Georgia 30342<br>
>>Ph: 404.832.0300<br>
>>Fax: 404-832-0070<br>
>>http://www.wifh.com<br>
>><br>
>
>>>>>----- Original Message -----<br>
>>From: "art fougner, md" <evsono@pipeline.com><br>
>>To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@dns. bgyn.net><br>
>>Sent: Thursday, March 04, 2004 1:53 PM<br>
>>Subject: Re: WHI - HRT and Colorectal Cancer<br>
>><br>
>>> "The frequency of bowel examinations was not defined by the rotocol.<br>
>>> Self-administered questionnaires or structured telephone intervie s were<br>
>>> used every six months to monitor the frequencies of rectal examin tion,<br>
>>> fecal occult-blood testing, sigmoidoscopy and colonoscopy (asked s one<br>
>>> question), and barium enema examination. Information concer ing the<br>
>>> duration and severity of vaginal bleeding was also collected ever six<br>
>>> months. Symptoms of bloating or gas, constipation, diarrhea and<br>
>>> abdominal pain or discomfort were ascertained at base line and af er one<br>
>>> year. With the exception of the above-mentioned practices, he<br>
>>> participating clinical centers did not provide comprehensive heal h<br>
>>> care. Decisions regarding the workup related to the diagnos s of<br>
>>> colorectal cancer were made almost exclusively by the women's own local<br>
>>> physicians."<br>
>>><br>
>>> http://content.nejm.org/cgi/content/full/350/10/991<br>
>>><br>
>>> art<br>
>>><br>
>>> At Thu, 4 Mar 2004, Jay Kulkin wrote:<br>
>>> ><br>
>>> >What % of dx women had screening colonoscopy since all were o er 50?<br>
>>> >JK<br>
>>> >Jay M. Kulkin MD MBA FACOG<br>
>>> >Women's Institute For Health PC<br>
>>> >975 Johnson Ferry Road<br>
>>> >Suite 460<br>
>>> >Atlanta, GA. 30342<br>
>>> >ph: 404-832-0300<br>
>>> >fax: 404-832-0070<br>
>>> >http://www.wifh.com<br>
>>> ><br>
>>> >This email may contain confidential or proprietary informatio which may<br>
>>be<br>
>>> >legally privileged. If you are not the named recipient, you s ould<br>
>>> >immediately delete it from your computer system.<br>
>>> ><br>
>><br>
>
>>>>>> >>----- Original Message -----<br>
>>> >From: "art fougner, md" <evsono@pipeline.com> br>
>>> >To: "Multiple recipients of list OB-GYN-L" <ob-g n-l@dns.obgyn.net><br>
>>> >Sent: Thursday, March 04, 2004 8:47 AM<br>
>>> >Subject: GYN: WHI - HRT and Colorectal Cancer<br>
>>> ><br>
>>> >> Estrogen plus Progestin and Colorectal Cancer in Postmen pausal Women<br>
>>> >><br>
>>> >> Rowan T. Chlebowski, M.D., Ph.D., Jean Wactawski-W nde, Ph.D., Cheryl<br>
>>> >> Ritenbaugh, Ph.D., M.P.H., F. Allan Hubbell, M.D., M.S.P.H., Joao<br>
>>> >> Ascensao, M.D., Ph.D., Rebecca J. Rodabough, M.S., Carol A.<br>
>>Rosenberg,<br>
>>> >> M.D., Victoria M. Taylor, M.D., M.P.H., Randall Ha ris, M.D., Ph.D.,<br>
>>> >> Chu Chen, Ph.D., Lucile L. Adams-Campbell, Ph.D., mily White, Ph.D.,<br>
>>> >> for the Women's Health Initiative Investigators<br>
>>> >><br>
>>> >> ABSTRACT<br>
>>> >><br>
>>> >> Background Although the Women's Health Initiative (WHI) rial of<br>
>>> >> estrogen plus progestin in postmenopausal women identifi d more overall<br>
>>> >> health risks than benefits among women in the hormone gr up, the use of<br>
>>> >> estrogen plus progestin was associated with a significan decrease in<br>
>>> >> the risk of colorectal cancer. We analyzed feature of the colorectal<br>
>>> >> cancers that developed and their relation to the charact ristics of the<br>
>>> >> participants.<br>
>>> >><br>
>>> >> Methods In the WHI trial, 16,608 postmenopausal women wh were 50 to 79<br>
>>> >> years of age and had an intact uterus were randomly assi ned to a<br>
>>> >> combination of conjugated equine estrogens (0.625 mg per day) plus<br>
>>> >> medroxyprogesterone acetate (2.5 mg per day) or placebo. The main<br>
>>> >> outcome measures were the incidence, stages, and types o colorectal<br>
>>> >> cancer, as determined by blinded central adjudication.<br>
>>> >><br>
>>> >> Results There were 43 invasive colorectal cancers in the hormone group<br>
>>> >> and 72 in the placebo group (hazard ratio, 0.56; 95 perc nt confidence<br>
>>> >> interval, 0.38 to 0.81; P=0.003). The invasive c lorectal cancers in<br>
>>> >> the hormone group were similar in histologic features an grade to<br>
>>those<br>
>>> >> in the placebo group but with a greater number of positi e lymph nodes<br>
>>> >> (mean ±SD, 3.2±4.1 vs. 0.8±1.7; P=0.002) a d were more advanced<br>
>>> >> (regional or metastatic disease, 76.2 percent vs. 8.5 percent;<br>
>>> >> P=0.004). In exploratory analyses, women in the ormone group with<br>
>>> >> antecedent vaginal bleeding had colorectal cancers with greater<br>
>>number<br>
>>> >> of positive nodes than women in the hormone group who di not have<br>
>>> >> vaginal bleeding (3.8±4.3 vs. 0.7±1.5 nodes, =0.006).<br>
>>> >><br>
>>> >> Conclusions Relatively short-term use of estrogen plus p ogestin was<br>
>>> >> associated with a decreased risk of colorectal cancer. & bsp;However,<br>
>>> >> colorectal cancers in women who took estrogen plus proge tin were<br>
>>> >> diagnosed at a more advanced stage than those in women w o took<br>
>>placebo.<br>
>>> >><br>
>>> >> New England Journal of Medicine Volume 350:991-1004 &nbs ;March 4, 2004<br>
>>> >><br>
>>> >> art<br>
>>> >><br>
>>> >> --<br>
>>> >> art fougner, md<br>
>>> >> ich bin ein New Yorker<br>
>>><br>
>>> --<br>
>>> art fougner, md<br>
>>> ich bin ein New Yorker<br>
>><br>
><br>
>--<br>
>art fougner, md<br>
>ich bin ein New Yorker<br>
></font>
><br>
>
--
art fougner, md
ich bin ein New Yorker
