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Chlebowski RT, Aragaki AK. Long-term breast cancer incidence trends by mammography, obesity, and menopausal hormone therapy. Breast Cancer Res Treat 2024; 203:121-124. [PMID: 37728692 DOI: 10.1007/s10549-023-07113-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/24/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Over the past half century, the annual age-adjusted breast cancer incidence in the USA has fluctuated, potentially influenced by changes in mammography screening, obesity, and menopausal hormone therapy. As the relative contributions of these factors on breast cancer incidence have not been resolved, we assembled reliable sources of year-to-year changes in mammography, obesity, and hormone therapy to graphically display their relationship to breast cancer incidence through 50 years. METHODS Year-to-year trends were assembled: for mammography from the Center for Disease Control National Health Interviews; for hormone therapy from the Collaborative Group on Hormonal Factors in Breast Cancer report; for obesity from the NCD (Non-Communicable Diseases) Risk Factor Collaboration; and for breast cancer for US women 50-64 years of age from Surveillance, Epidemiology, and End Results (SEER) registry findings. RESULTS Increases in age-adjusted breast cancer incidence trend from about 1982 to 2002 track both mammography and hormone therapy use but not obesity. However, the sudden decrease in breast cancer incidence in 2003, subsequently sustained at a lower incidence level, only tracks the parallel reduction in hormone therapy use. CONCLUSION The sustained reduction in hormone therapy use from 2003 provides a plausible explanation for most of the lower breast cancer incidence seen in US postmenopausal women during the last two decades. The strong observational study obesity association with higher breast cancer risk is not reflected in breast cancer incidence trends.
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Affiliation(s)
- Rowan T Chlebowski
- The Lundquist Institute, 1124 W. Carson Street, Torrance, CA, 90502, USA.
| | - Aaron K Aragaki
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Mossavar-Rahmani Y. Commentary on the Women's Health Initiative: Over 30 Years of Contribution to Nutrition and Dietetics. J Acad Nutr Diet 2023:S2212-2672(23)01700-8. [PMID: 38048877 PMCID: PMC11144259 DOI: 10.1016/j.jand.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Yasmin Mossavar-Rahmani
- Division of Health Behavior Research and Implementation Science, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.
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Bluming AZ, Hodis HN, Langer RD. 'Tis but a scratch: a critical review of the Women's Health Initiative evidence associating menopausal hormone therapy with the risk of breast cancer. Menopause 2023; 30:1241-1245. [PMID: 37847875 PMCID: PMC10758198 DOI: 10.1097/gme.0000000000002267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
ABSTRACT Use of menopausal hormone therapy (HT) fell precipitously after 2002, largely as a result of the Women's Health Initiative's report claiming that the combination of conjugated equine estrogen (CEE) and medroxyprogesterone acetate increased breast cancer risk and did not improve quality of life. More recently, Women's Health Initiative (WHI) publications acknowledge HT as the most effective treatment for managing menopausal vasomotor symptoms and report that CEE alone reduces the risk of breast cancer by 23% while reducing breast cancer death by 40%. Their sole remaining concern is a small increase in breast cancer incidence with CEE and medroxyprogesterone acetate (1 per 1,000 women per year) but with no increased risk of breast cancer mortality. This article closely examines evidence that calls even this claim of breast cancer risk into serious question, including the WHI's reporting of nonsignificant results as if they were meaningful, a misinterpretation of its own data, and the misleading assertion that the WHI's findings have reduced the incidence of breast cancer in the United States. A generation of women has been deprived of HT largely as a result of this widely publicized misinterpretation of the data. This article attempts to rectify this misunderstanding, with the goal of helping patients and physicians make informed joint decisions about the use of HT.
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Affiliation(s)
- Avrum Z. Bluming
- Department of Medicine, Keck School of Medicine, University of Southern California, San Diego, CA
| | - Howard N. Hodis
- Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, San Diego, CA
| | - Robert D. Langer
- Department of Family Medicine and Public Health, University of California, San Diego, CA
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Prentice RL. Diet and Chronic Disease Research in the Women's Health Initiative. J Acad Nutr Diet 2023:S2212-2672(23)01690-8. [PMID: 38000690 PMCID: PMC11109020 DOI: 10.1016/j.jand.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023]
Abstract
The Women's Health Initiative (WHI) has been a major contributor to diet and chronic disease research among postmenopausal US women over its 30+ year history (1993 to present). The WHI program included full-scale randomized trials of a low-fat dietary pattern high in fruits, vegetables, and grains, and of calcium and vitamin D supplementation, each with designated primary and secondary chronic disease outcomes. The history of these trials will be briefly reviewed here, along with principal findings that included evidence for breast cancer-related benefits for each of the 2 interventions. In recent years, WHI investigators have developed an active research program in nutritional biomarker development and in the application of these biomarkers in WHI cohorts, among various other nutritional epidemiology uses of WHI observational study resources. The intake biomarker work, which primarily relies on blood and urine metabolomics profiles, lends support to the low-fat dietary pattern trial results, and supports chronic disease benefits of higher carbohydrate diets more generally, especially through the fiber component of carbohydrate.
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Affiliation(s)
- Ross L Prentice
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Biostatistics, University of Washington, Seattle, Washington.
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Lee W, Carlson JJ, Basu A, Veenstra D. Quantifying the value of older adult-specific clinical trials: Post-lumpectomy irradiation among older adults with early-stage breast cancer. J Geriatr Oncol 2023; 14:101487. [PMID: 37075565 DOI: 10.1016/j.jgo.2023.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/26/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Although there is increasing interest in conducting cancer clinical trials in older adults, the benefit of such trials is unclear. We aimed to quantify the real-world clinical and economic effects of two phase 3 trials (CALGB 9343 and PRIME II) which showed that post-lumpectomy radiation therapy (RT) improves loco-regional recurrence but makes no improvement in overall survival among older women with early-stage breast cancer (ESBC). MATERIALS AND METHODS We developed a health-transition model to quantify the incremental clinical and economic outcomes between scenarios with vs. without older adult-specific trial results from a societal perspective between 2004 and 2018. The transition probabilities in the model were mainly derived from the 10-year results of CALGB 9343. The total number of the affected patient population in the US and the change in the probability of omitting post-lumpectomy RT due to the CALGB 9343 and PRIME II results were derived from a retrospective analysis of the SEER registry data for patients with ESBC. Sensitivity analyses were conducted to calculate the 95% credible interval (CR) of the incremental clinical and economic outcomes between the two scenarios. RESULTS Between 2004 and 2018, 32,936 (95% CR: 31,512, 34,357) fewer patients received post-lumpectomy RT among those aged 70 years or older diagnosed with ESBC in the US and there was a decrease cost of $419 M USD (95% CR: -$238 M, -$689 M) in scenarios with vs. without older adult-specific trial results. The difference in projected life years (1083 years, 95% CI: -2542, 7985) and QALYs (866 years, 95% CI: -2561, 7780) were not significant. At a willingness-to-pay threshold of $100 k/QALY, the probability of older adult-specific trial results generating a positive net monetary benefit was 98%. DISCUSSION The CALGB 9343 and PRIME II trial results were associated with a substantial cost-saving in the US society. Our results suggest that older adult-specific clinical trials that demonstrate no survival benefit of an intervention in older adults could be correlated with a significant monetary benefit. Further case studies are needed for different types of older adult-specific trials to understand the value of older adult-specific trials comprehensively.
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Affiliation(s)
- Woojung Lee
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA.
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - David Veenstra
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
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Chlebowski RT, Aragaki AK. The Women's Health Initiative randomized trials of menopausal hormone therapy and breast cancer: findings in context. Menopause 2023; 30:454-461. [PMID: 36727752 DOI: 10.1097/gme.0000000000002154] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE AND OBJECTIVE The menopausal hormone therapy (MHT) association with breast cancer has been controversial for more than 40 years. Most recently, findings from cohort studies have been discordant compared with those from the Women's Health Initiative (WHI) randomized trials. In cohort studies, both estrogen therapy and estrogen plus progestin were associated with higher breast cancer incidence. In contrast, in the WHI randomized trials, findings for estrogen plus progestin are concordant with cohort study reports, whereas estrogen therapy significantly reduced breast cancer incidence. In addition, concerns have been raised regarding the WHI findings from both trials. In this report, we briefly summarize findings for MHT on breast cancer from cohort studies and the WHI randomized trials. The report focus is addressing, point-by-point, concerns raised regarding the WHI findings. METHODS For cohort studies, we relied on the latest findings from (1) the meta-analysis of the Collaborative Group on Hormonal Factors in Breast Cancer and (2) the Million Women's Study. To identify commentaries and editorials, "Menopause" and "Climacteric" were searched from 2002 to present; PubMed and Google Scholar were searched for commentaries, editorials, and breast cancer, MHT, estrogen, conjugated equine estrogen, estradiol, "hormone replacement therapy," and "HRT." DISCUSSION AND CONCLUSIONS Thirty commentaries challenging WHI findings were identified. All were reviewed, and issues needing response were identified. Findings from the meta-analysis from the Collaborative Group on Hormonal Factors in Breast Cancer and the Million Women Study were summarized and compared with finding in the two WHI randomized trials evaluating estrogen therapy and estrogen plus progestin. Based on the randomized clinical trials, estrogen therapy, for women with prior hysterectomy, decreases breast cancer incidence and mortality. In contrast, estrogen plus progestin increases breast cancer incidence, which persists through two decades. Women considering estrogen plus progestin use for vasomotor symptoms should understand the breast cancer risk.
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Affiliation(s)
- Ross L. Prentice
- Ross L. Prentice is PhD, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA and Department of Biostatistics, University of Washington, Seattle, Washington 98195, USA
| | - Aaron K. Aragaki
- Aaron K. Aragaki is MS, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, 98109, USA
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Abstract
ABSTRACT Associations of estrogen-alone and estrogen plus progestin with breast cancer incidence and related mortality are reviewed from observational studies (The Collaborative Group on Hormonal Factors in Breast Cancer and The Million Women Study, 2019) and the Women's Health Initiative's (2020) two randomized trials evaluating conjugated equine estrogen alone, for women with prior hysterectomy or with medroxyprogesterone acetate. Findings are generally concordant for estrogen plus progestin use with both observational and randomized studies reporting higher breast cancer incidence. Findings are discordant for estrogen-alone use where, in the WHI randomized trial, a lower incidence and lower breast cancer mortality was seen. In contrast, in the observational studies, estrogen-alone use was associated with higher breast cancer incidence and higher breast cancer mortality. Although these discordant findings are difficult to fully reconcile, we conclude with a discussion of public health implications of the available evidence on menopausal hormone therapy and breast cancer.
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Chlebowski RT, Aragaki AK, Pan K. Breast Cancer Prevention: Time for Change. JCO Oncol Pract 2021; 17:709-716. [PMID: 34319769 PMCID: PMC8677965 DOI: 10.1200/op.21.00343] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/24/2021] [Accepted: 07/06/2021] [Indexed: 11/20/2022] Open
Abstract
Agency breast cancer prevention guidelines for other than hereditary cancers have not materially changed in 20 years; endocrine-targeted agents (then, tamoxifen; now, adding raloxifene and aromatase inhibitors) reduce good prognosis estrogen receptor (ER)-positive, progesterone receptor (PR)-positive cancers without reducing deaths from breast cancer. Across three tamoxifen placebo-controlled prevention trials (N = 23,360) begun almost 30 years ago, although there were 226 fewer breast cancer cases, there were nine more deaths from breast cancer in the tamoxifen groups. Following clinical advances, currently more than half of breast cancer cases are solved problems with extremely low risk of death. As endocrine-targeted agents commonly prevent these cancers, widespread implementation of current prevention strategies may not reduce deaths from breast cancer. Compared with other breast cancers, ER-positive, PR-negative cancers and triple-negative cancers have inferior survival (90.6% v 83.8% v 78.1%, respectively; P < .001). Against this background, in the Women's Health Initiative Dietary Modification randomized trial (N = 48,835), ER-positive, PR-negative cancers were statistically significantly reduced in the intervention group (hazard ratio, 0.77; 95% CI, 0.64 to 0.94) and deaths from breast cancer were reduced 21% (P = .02). In the Women's Health Initiative randomized, placebo-controlled trial evaluating conjugated equine estrogen (N = 10,739), ER-positive, PR-negative cancers were statistically significantly reduced in the intervention group (hazard ratio, 0.44; 95% CI, 0.27 to 0.74) and deaths from breast cancer were reduced 40% (P = .04). These findings suggest that reexamination of breast cancer risk reduction strategies and clinical practice is needed.
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Affiliation(s)
- Rowan T. Chlebowski
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | | | - Kathy Pan
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
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The Scientific and Cultural Journey to Ovarian Rejuvenation: Background, Barriers, and Beyond the Biological Clock. MEDICINES 2021; 8:medicines8060029. [PMID: 34201170 PMCID: PMC8228162 DOI: 10.3390/medicines8060029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
Female age has been known to define reproductive outcome since antiquity; attempts to improve ovarian function may be considered against a sociocultural landscape that foreshadows current practice. Ancient writs heralded the unlikely event of an older woman conceiving as nothing less than miraculous. Always deeply personal and sometimes dynastically pivotal, the goal of achieving pregnancy often engaged elite healers or revered clerics for help. The sorrow of defeat became a potent motif of barrenness or miscarriage lamented in art, music, and literature. Less well known is that rejuvenation practices from the 1900s were not confined to gynecology, as older men also eagerly pursued methods to turn back their biological clock. This interest coalesced within the nascent field of endocrinology, then an emerging specialty. The modern era of molecular science is now offering proof-of-concept evidence to address the once intractable problem of low or absent ovarian reserve. Yet, ovarian rejuvenation by platelet-rich plasma (PRP) originates from a heritage shared with both hormone replacement therapy (HRT) and sex reassignment surgery. These therapeutic ancestors later developed into allied, but now distinct, clinical fields. Here, current iterations of intraovarian PRP are discussed with historical and cultural precursors centering on cell and tissue regenerative effects. Intraovarian PRP thus shows promise for women in menopause as an alternative to conventional HRT, and to those seeking pregnancy—either with advanced reproductive technologies or as unassisted conceptions.
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The Women's Health Initiative Estrogen-alone Trial had differential disease and medical expenditure consequences across age groups. ACTA ACUST UNITED AC 2021; 27:632-639. [PMID: 32132440 DOI: 10.1097/gme.0000000000001517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Women's Health Initiative (WHI) randomized trial identified age differences in the benefit-risk profile of estrogen-alone (ET) use. The impact of WHI trial on disease-associated medical expenditures attributable to subsequent decreased ET utilization has, however, not been measured. Therefore, the objective of this analysis was to quantify the age-specific disease-associated medical expenditures attributable to reduced ET utilization after the WHI Hormone Therapy (HT) trials. METHODS Population-level disease counts and associated expenditures between 2003 and 2015 were compared between an observed ET-user population versus a hypothetical ET-user population assuming absence of the WHI HT trials, constructed by extrapolating ET utilization rates from 1996 to 2002 assuming pre-WHI HT rates would have continued without publication of the WHI HT trial data (2002-2004). Analyses were stratified by age (50-59, 60-69, and 70-79 years). Input data were extracted from Medical Expenditure Panel Survey and the literature. The primary outcomes were: ET utilization, chronic diseases (breast cancer, stroke, coronary heart disease, colorectal cancer, pulmonary embolism, and hip fracture) and disease-associated direct medical expenditures. RESULTS Over 13 years, the decline in ET utilization was associated with $4.1 billion expenditure for excess chronic diseases (37,549 excess events) among women in their 50s, compared to savings of $1.5 billion and $4.4 billion for diseases averted by lower ET utilization among women in their 60s (13,495 fewer events) and 70s (40,792 fewer events), respectively. CONCLUSION The decline in ET utilization had differential disease and expenditure consequences by age groups in the United States. These results are limited by the lack of inclusion of vasomotor symptom benefit and costs of alternative medications for these symptoms in the analysis.
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Machin N, Ragni MV. Hormones and thrombosis: risk across the reproductive years and beyond. Transl Res 2020; 225:9-19. [PMID: 32599096 DOI: 10.1016/j.trsl.2020.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/30/2022]
Abstract
Endogenous and exogenous hormones have significant effects on coagulation and may tip the hemostatic balance toward thrombosis. The endogenous hormonal changes in pregnancy and polycystic ovary syndrome, and exogenous hormonal contraception, menopause replacement, and transgender cross-hormone replacement may increase thromboembolism risk. Using the lowest effective dose is critical for prevention, but once thrombosis occurs, anticoagulation may be required, in some, long term. We review the relative risk of thrombosis in these conditions, risk factors, and anticoagulation treatment and prevention. Implementation of lowest effective hormonal therapies, thrombosis reduction strategies, and current anticoagulation management are critical for optimal patient outcomes.
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Affiliation(s)
- Nicoletta Machin
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania.
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Akhouri V, Kumari M, Kumar A. Therapeutic effect of Aegle marmelos fruit extract against DMBA induced breast cancer in rats. Sci Rep 2020; 10:18016. [PMID: 33093498 PMCID: PMC7581526 DOI: 10.1038/s41598-020-72935-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
Breast cancer is among most common form of cancer worldwide. It is also the major cause of death in female cancer patient around the world. Despite various therapeutic measures, it remains associated with high mortality rate. Aegle marmelos (L.) Correa has been extensively used in Indian medicine system Ayurveda, due to its various medicinal properties. However, there are very limited reports regarding its anticancer activity. Thus, the present research work has been aimed to study the anticancer activity of Aegle marmelos fruit extract on 7,12-dimethylbenz(a)anthracene (DMBA) induced breast cancer in rats. Female Charles Foster rats, 55-60 days old weighing around (150 ± 10 g) were used for the study and were induced DMBA (20 mg/mL dissolved in Olive oil) orally. After the development of breast tumors (about 0.5 cm), the rats were treated with Aegle marmelos ethanolic fruit pulp extract (200 mg/kg b.w./day) orally for 5 weeks and then volume of tumor was measured. Aegle marmelos treatment showed significantly reduced mammary tumor volume (P < 0.05), along with significant reduction (P < 0.0001) in the different serum biomarkers such as TNF-α level, serum malondialdehyde (MDA) level and glucose levels. Significant (P < 0.0001) improvement in both, the kidney and liver serum biomarker parameters were also observed after the treatment with Aegle marmelos ethanolic fruit pulp extract. From the entire study, taking everything into account it can be interpreted that Aegle marmelos ethanolic fruit pulp extract possesses anti-proliferative activity by suppressing the progression of breast tumors in rat model. The plant extract also possesses hepato-renal protective effect. Hence, it can be targeted as novel and safe anti-cancer drug against breast cancer.
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Affiliation(s)
| | | | - Arun Kumar
- Research Centre, Mahavir Cancer Sansthan and Research Centre, Patna, Bihar, 801505, India.
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Prentice RL, Aragaki AK, Chlebowski RT, Zhao S, Anderson GL, Rossouw JE, Wallace R, Banack H, Shadyab AH, Qi L, Snively BM, Gass M, Manson JE. Dual-Outcome Intention-to-Treat Analyses in the Women's Health Initiative Randomized Controlled Hormone Therapy Trials. Am J Epidemiol 2020; 189:972-981. [PMID: 32314781 PMCID: PMC7443766 DOI: 10.1093/aje/kwaa033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/20/2019] [Accepted: 01/16/2020] [Indexed: 01/03/2023] Open
Abstract
Dual-outcome intention-to-treat hazard rate analyses have potential to complement single-outcome analyses for the evaluation of treatments or exposures in relation to multivariate time-to-response outcomes. Here we consider pairs formed from important clinical outcomes to obtain further insight into influences of menopausal hormone therapy on chronic disease. As part of the Women's Health Initiative, randomized, placebo-controlled hormone therapy trials of conjugated equine estrogens (CEE) among posthysterectomy participants and of these same estrogens plus medroxyprogesterone acetate (MPA) among participants with an intact uterus were carried out at 40 US clinical centers (1993-2016). These data provide the context for analyses covering the trial intervention periods and a nearly 20-year (median) cumulative duration of follow-up. The rates of multiple outcome pairs were significantly influenced by hormone therapy, especially over cumulative follow-up, providing potential clinical and mechanistic insights. For example, among women randomized to either regimen, hazard ratios for pairs defined by fracture during intervention followed by death from any cause were reduced and hazard ratios for pairs defined by gallbladder disease followed by death were increased, though these findings may primarily reflect single-outcome associations. In comparison, hazard ratios for diabetes followed by death were reduced with CEE but not with CEE + MPA, and those for hypertension followed by death were increased with CEE + MPA but not with CEE.
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Affiliation(s)
- Ross L Prentice
- Correspondence to Dr. Ross L. Prentice, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, P.O. Box 19024, Seattle, WA 98109-1024 (e-mail: )
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15
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Chlebowski RT, Aragaki AK, Anderson GL, Prentice RL. Forty‐year trends in menopausal hormone therapy use and breast cancer incidence among postmenopausal black and white women. Cancer 2020; 126:2956-2964. [DOI: 10.1002/cncr.32846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/22/2019] [Accepted: 10/21/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Rowan T. Chlebowski
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center Torrance California
| | - Aaron K. Aragaki
- Division of Public Health Sciences Fred Hutchinson Cancer Research Center Seattle Washington
| | - Garnet L. Anderson
- Division of Public Health Sciences Fred Hutchinson Cancer Research Center Seattle Washington
| | - Ross L. Prentice
- Division of Public Health Sciences Fred Hutchinson Cancer Research Center Seattle Washington
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Unger JM, Hershman DL, Till C, Tangen CM, Barlow WE, Ramsey SD, Goodman PJ, Thompson IM. Using Medicare Claims to Examine Long-term Prostate Cancer Risk of Finasteride in the Prostate Cancer Prevention Trial. J Natl Cancer Inst 2019. [PMID: 29534197 DOI: 10.1093/jnci/djy035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Investigators have used administrative claims to better understand cancer outcomes when a research question cannot feasibly be examined within a study. The Prostate Cancer Prevention Trial (PCPT) showed that seven years of finasteride reduced prostate cancer (PC) risk by 25% in men age 55 years or older. However, it was unclear whether the observed reduction in PC for finasteride participants would be maintained after finasteride discontinuation. Methods We examined PC diagnoses identified by PCPT study records and Medicare claims (finasteride = 9423, placebo = 9457). A Medicare-defined PC diagnosis algorithm was defined using diagnosis and procedure codes. Multivariable Cox regression was used to examine time to PC within prespecified follow-up windows (<6.5, 6.5-7.5, and >7.5 years) using time-dependent covariates interacting with intervention assignment to account for the PCPT protocol-specified end-of-study biopsy at seven years. All statistical tests were two-sided. Results Median follow-up using the linked database was 16 years. Overall, finasteride arm participants had a 21.1% decrease in the hazard ratio of PC (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.74 to 0.84, P < .001). The beneficial effect of finasteride in reducing the hazard ratio of PC was most pronounced in the first 7.5 years (HR = 0.71, 95% CI = 0.66 to 0.77, P < .001), consistent with the original study findings; after 7.5 years, there was no increased risk of PC for finasteride arm participants (HR = 1.10, 95% CI = 0.96 to 1.26, P = .18). Conclusions Finasteride provides a substantial reduction in PC through 16 years of follow-up. There was no strong evidence that the benefit of finasteride diminished after the end-of-study follow-up. Utilizing Medicare claims to augment PCPT follow-up illustrates how the novel use of secondary data sources can enhance the ability to detect long-term outcomes from prospective studies.
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Affiliation(s)
- Joseph M Unger
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Cathee Till
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Catherine M Tangen
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - William E Barlow
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott D Ramsey
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Phyllis J Goodman
- SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ian M Thompson
- Medical Center, CHRISTUS Santa Rosa Hospital, San Antonio, TX
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Seixas BV, Dionne F, Conte T, Mitton C. Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review. BMC Health Serv Res 2019; 19:560. [PMID: 31409369 PMCID: PMC6693163 DOI: 10.1186/s12913-019-4405-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries. METHODS We conducted a rapid review and a gray literature search to identify value assessment frameworks. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. In addition, we developed an interpretive classification system to make sense of existing approaches. RESULTS One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered. CONCLUSIONS The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite the predominance of cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not been sufficient to meet the needs of decision-makers. The use of multiple criteria has become more and more important, as well as the consideration of patient-reported measures. Considerations of costs are not always explicit and consistent.
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Affiliation(s)
- Brayan V Seixas
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, USA.
| | | | - Tania Conte
- Center for Clinical Epidemiology and Evaluation, Vancouver, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
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Basu A, Veenstra DL, Carlson JJ, Wang WJ, Branch K, Probstfield J. How can clinical researchers quantify the value of their proposed comparative research? Am Heart J 2019; 209:116-125. [PMID: 30638543 DOI: 10.1016/j.ahj.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 12/03/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA; The Departments of Health Services and Economics, University of Washington, Seattle, WA.
| | - David L Veenstra
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
| | - Wei-Jhih Wang
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
| | - Kelley Branch
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA
| | - Jeffrey Probstfield
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA
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Bentley C, Cressman S, van der Hoek K, Arts K, Dancey J, Peacock S. Conducting clinical trials-costs, impacts, and the value of clinical trials networks: A scoping review. Clin Trials 2019; 16:183-193. [PMID: 30628466 DOI: 10.1177/1740774518820060] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A significant barrier to conducting clinical trials is their high cost, which is driven primarily by the time and resources required to activate trials and reach accrual targets. The high cost of running trials has a substantial impact on their long-term feasibility and the type of clinical research undertaken. METHODS A scoping review of the empirical literature on the costs associated with conducting clinical trials was undertaken for the years 2001-2015. Five reference databases were consulted to elicit how trials costs are presented in the literature. A review instrument was developed to extract the content of in-scope papers. Findings were characterized by date and place of publication, clinical disease area, and network/cooperative group designation, when specified. Costs were captured and grouped by patient accrual and management, infrastructure, and the opportunity costs associated with industry funding for trials research. Cost impacts on translational research and health systems were also captured, as were recommendations to reduce trial expenditures. Since articles often cited multiple costs, multiple cost coding was used during data extraction to capture the range and frequency of costs. RESULTS A total of 288 empirical articles were included. The distribution of reported costs was: patient management and accrual costs (132 articles), infrastructure costs (118 articles) and the opportunity costs of industry sponsorship (72 articles). 221 articles reported on the impact of undertaking costly trials on translational research and health systems; of these, the most frequently reported consequences were to research integrity (52% of articles), research capacity (36% of articles) and running low-value trials (34% of articles). 254 articles provided recommendations to reduce trial costs; of these, the most frequently reported recommendations related to improvements in: operational efficiencies (33% of articles); patient accrual (24% of articles); funding for trials and transparency in trials reporting (18% of articles, each). CONCLUSION Key findings from the review are: 1) delayed trial activation has costs to budgets and research; 2) poor accrual leads to low-value trials and wasted resources; 3) the pharmaceutical industry can be a pragmatic, if problematic, partner in clinical research; 4) organizational know-how and successful research collaboration are benefits of network/cooperative groups; and 5) there are spillover benefits of clinical trials to healthcare systems, including better health outcomes, enhanced research capacity, and drug cost avoidance. There is a need for more economic evaluations of the benefits of clinical research, such as health system use (or avoidance) and health outcomes in cities and health authorities with institutions that conduct clinical research, to demonstrate the affordability of clinical trials, despite their high cost.
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Affiliation(s)
- Colene Bentley
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Sonya Cressman
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Kim van der Hoek
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Karen Arts
- 3 Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Janet Dancey
- 3 Ontario Institute for Cancer Research, Toronto, ON, Canada.,4 Department of Oncology, School of Medicine, Queen's University, Kingston, ON, Canada.,5 The National Cancer Institute of Canada Clinical Trials Group, Kingston, ON, Canada
| | - Stuart Peacock
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada.,6 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Bacak HO, Leblebicioglu K, Tanacan A, Beksac MS. Computerized hybrid decision-making system for hormone replacement therapy in menopausal women. Technol Health Care 2018; 27:49-59. [PMID: 30475776 DOI: 10.3233/thc-181235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The diversity of the results of different hormone replacement therapy (HRT) protocols and the fuzziness of the conclusions have caused problems in routine clinical practice. OBJECTIVE To develop an intelligent decision-making system for HRT specifically is appropriate as we use the abbrevation HRT in the background section in menopausal women in order to assist physicians. METHODS This study consisted of 179 peri- and post-menopausal patients who were admitted to Hacettepe University Hospital (between 1996 and 2001) with various menopausal complaints. Database variables used in this study were age, height, weight, menopause duration, clinical condition, HRT duration, and the laboratory test results. Our newly developed multiple-centered fuzzy clustering (MCFC) algorithm was applied to the medical data set to differentiate patient groups. Finally, a hybrid intelligent decision-making system was developed by combining knowledge-based algorithms and the MCFC algorithm results. RESULTS We have used Fuzzy C-means, K-means, Hard C-means, similarity based clustering, and MCFC algorithms on the medical data set and have determined that the MCFC algorithm is the most appropriate algorithm for our medical model. We have defined 5 clusters and 16 cluster centers. A diagnostic phrase was assigned to each cluster center by the physician and these clusters together with knowledge-based algorithms were used for the decision-making system. CONCLUSIONS We have developed a computerized hybrid decision-making system recommending HRT to peri- and post-menopausal women in order to assist and protect physicians.
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Affiliation(s)
- H Ozge Bacak
- Department of Electrical and Electronics Engineering, Middle East Technical University, Anakara, Turkey
| | - Kemal Leblebicioglu
- Department of Electrical and Electronics Engineering, Middle East Technical University, Anakara, Turkey
| | - Atakan Tanacan
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Mehmet Sinan Beksac
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University Medical Faculty, Ankara, Turkey
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Feuerstein IM, Jenkins MR, Kornstein SG, Lauer MS, Scott PE, Raju TN, Johnson T, Devaney S, Lolic M, Henderson M, Clayton JA. Working Together to Address Women's Health in Research and Drug Development: Summary of the 2017 Women's Health Congress Preconference Symposium. J Womens Health (Larchmt) 2018; 27:1195-1203. [PMID: 30325292 PMCID: PMC6425923 DOI: 10.1089/jwh.2018.29019.pcss] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Historically, women have been underrepresented in clinical research, requiring physicians to extrapolate medical recommendations for women from clinical research done in cohorts consisting predominantly of male participants. While government-funded clinical research has achieved gender parity in phase-3 clinical trials across many biomedical disciplines, improvements are still needed in several facets of women's health research, such as the inclusion of women in early-phase clinical trials, the inclusion of pregnant women and women with physical and intellectual disabilities, the consideration of sex as a biological variable in preclinical research, and the analysis and reporting of sex and gender differences across the full biomedical research continuum. The National Institutes of Health (NIH) Office of Research on Women's Health and the Office of Women's Health of the U.S. Food and Drug Administration (FDA) cosponsored a preconference symposium at the 25th Annual Women's Health Congress, held in Arlington, VA in April, 2017, to highlight gains made and remaining needs regarding the representation of women in clinical research, to introduce innovative procedures and technologies, and to outline revised policy for future studies. Six speakers presented information on a range of subjects related to the representation of women in clinical research and federal initiatives to advance precision medicine. Topics included the following: the return on investment from the NIH-funded Women's Health Initiative; progress in including women in clinical trials for FDA-approved drugs and products; the importance of clinical trials in pregnant women; FDA initiatives to report drug safety during pregnancy; the NIH-funded All of Us Research Program; and efforts to enhance FDA transparency and communications, including the introduction of Drug Trials Snapshots. This article summarizes the major points of the presentations and the discussions that followed.
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Affiliation(s)
- Irwin M. Feuerstein
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland
| | - Marjorie R. Jenkins
- Office of Women's Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Susan G. Kornstein
- Department of Psychiatry and Institute for Women's Health, Virginia Commonwealth University, Richmond, Virginia
| | - Michael S. Lauer
- Office of Extramural Research, National Institutes of Health, Bethesda, Maryland
| | - Pamela E. Scott
- Office of Women's Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Tonse N.K. Raju
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Tamara Johnson
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Stephanie Devaney
- All of Us Research Program, National Institutes of Health, Bethesda, Maryland
| | - Milena Lolic
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Marsha Henderson
- Office of Women's Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Janine Austin Clayton
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland
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Nielsen MW, Bloch CW, Schiebinger L. Making gender diversity work for scientific discovery and innovation. Nat Hum Behav 2018; 2:726-734. [DOI: 10.1038/s41562-018-0433-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/18/2018] [Indexed: 11/09/2022]
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Abstract
The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.
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Shreibati JB, Manson JE, Margolis KL, Chlebowski RT, Stefanick ML, Hlatky MA. Impact of hormone therapy on Medicare spending in the Women's Health Initiative randomized clinical trials. Am Heart J 2018; 198:108-114. [PMID: 29653631 PMCID: PMC5901884 DOI: 10.1016/j.ahj.2017.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Randomized trials can compare economic as well as clinical outcomes, but economic data are difficult to collect. Linking clinical trial data with Medicare claims could provide novel information on health care utilization and cost. METHODS We linked data from Medicare claims of women ≥65 years old who had Medicare fee-for-service coverage with their clinical data from the Women's Health Initiative trials of conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) versus placebo and of CEE-alone versus placebo. The primary outcome was total Medicare spending during the intervention phase of the trial, and the secondary outcomes were spending on diseases hypothesized a priori to be sensitive to the effects of hormone therapy. RESULTS In the CEE+MPA trial, 4,557 participants ≥65 years old were included. Women randomly assigned to CEE+MPA had 4% higher mean Medicare spending overall ($45,690 vs $43,920, P = .08) but 0.5% lower spending for hormone-sensitive diseases ($3,526 vs $3,547, P = .07), with 73% higher spending for coronary heart disease (P = .045) and 122% higher spending for pulmonary embolism (P = .026). In the CEE-alone trial, 3,107 participants were included. Total spending among women randomly assigned to CEE was 3.3% higher ($75,411 vs $72,997, P = .16), and 1.7% higher spending for hormone-sensitive diseases ($5,213 vs $5,127, P = .57), but with 39% lower spending for hip fracture (p<0.03). CONCLUSIONS Menopausal hormone therapy increased spending for some diseases, but decreased spending for others. These offsetting effects led to modest (3%-4%), nonsignificant increases in overall spending among women aged 65 years and older.
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Affiliation(s)
| | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA.
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Rodgers KM, Udesky JO, Rudel RA, Brody JG. Environmental chemicals and breast cancer: An updated review of epidemiological literature informed by biological mechanisms. ENVIRONMENTAL RESEARCH 2018; 160:152-182. [PMID: 28987728 DOI: 10.1016/j.envres.2017.08.045] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/28/2017] [Accepted: 08/29/2017] [Indexed: 05/20/2023]
Abstract
BACKGROUND Many common environmental chemicals are mammary gland carcinogens in animal studies, activate relevant hormonal pathways, or enhance mammary gland susceptibility to carcinogenesis. Breast cancer's long latency and multifactorial etiology make evaluation of these chemicals in humans challenging. OBJECTIVE For chemicals previously identified as mammary gland toxicants, we evaluated epidemiologic studies published since our 2007 review. We assessed whether study designs captured relevant exposures and disease features suggested by toxicological and biological evidence of genotoxicity, endocrine disruption, tumor promotion, or disruption of mammary gland development. METHODS We systematically searched the PubMed database for articles with breast cancer outcomes published in 2006-2016 using terms for 134 environmental chemicals, sources, or biomarkers of exposure. We critically reviewed the articles. RESULTS We identified 158 articles. Consistent with experimental evidence, a few key studies suggested higher risk for exposures during breast development to dichlorodiphenyltrichloroethane (DDT), dioxins, perfluorooctane-sulfonamide (PFOSA), and air pollution (risk estimates ranged from 2.14 to 5.0), and for occupational exposure to solvents and other mammary carcinogens, such as gasoline components (risk estimates ranged from 1.42 to 3.31). Notably, one 50-year cohort study captured exposure to DDT during several critical windows for breast development (in utero, adolescence, pregnancy) and when this chemical was still in use. Most other studies did not assess exposure during a biologically relevant window or specify the timing of exposure. Few studies considered genetic variation, but the Long Island Breast Cancer Study Project reported higher breast cancer risk for polycyclic aromatic hydrocarbons (PAHs) in women with certain genetic variations, especially in DNA repair genes. CONCLUSIONS New studies that targeted toxicologically relevant chemicals and captured biological hypotheses about genetic variants or windows of breast susceptibility added to evidence of links between environmental chemicals and breast cancer. However, many biologically relevant chemicals, including current-use consumer product chemicals, have not been adequately studied in humans. Studies are challenged to reconstruct exposures that occurred decades before diagnosis or access biological samples stored that long. Other problems include measuring rapidly metabolized chemicals and evaluating exposure to mixtures.
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Affiliation(s)
- Kathryn M Rodgers
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Julia O Udesky
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Ruthann A Rudel
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Julia Green Brody
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
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Schiebinger L, Klinge I. Gendered Innovation in Health and Medicine. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:643-654. [PMID: 30051412 DOI: 10.1007/978-3-319-77932-4_39] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Excellence in research requires careful attention to sex and gender analysis. The Gendered Innovations project, initiated in 2009, develops state-of-the-art methods of sex and gender analysis for basic and applied research. This chapter reviews recent developments in cardiovascular disease for (1) analyzing sex, (2) analyzing gender, and (3) policy initiatives.
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Affiliation(s)
| | - Ineke Klinge
- Horizon 2020 Advisory Group for Gender, European Commission, Brussels, Belgium
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Speich B, von Niederhäusern B, Schur N, Hemkens LG, Fürst T, Bhatnagar N, Alturki R, Agarwal A, Kasenda B, Pauli-Magnus C, Schwenkglenks M, Briel M. Systematic review on costs and resource use of randomized clinical trials shows a lack of transparent and comprehensive data. J Clin Epidemiol 2017; 96:1-11. [PMID: 29288136 DOI: 10.1016/j.jclinepi.2017.12.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/05/2017] [Accepted: 12/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Randomized clinical trials (RCTs) are costly. We aimed to provide a systematic overview of the available evidence on resource use and costs for RCTs to support budget planning. STUDY DESIGN AND SETTING We systematically searched MEDLINE, EMBASE, and HealthSTAR from inception until November 30, 2016 without language restrictions. We included any publication reporting empirical data on resource use and costs of RCTs and categorized them depending on whether they reported (i) resource and costs of all aspects at all study stages of an RCT (including conception, planning, preparation, conduct, and all tasks after the last patient has completed the RCT); (ii) on several aspects, (iii) on a single aspect (e.g., recruitment); or (iv) on overall costs for RCTs. Median costs of different recruitment strategies were calculated. Other results (e.g., overall costs) were listed descriptively. All cost data were converted into USD 2017. RESULTS A total of 56 articles that reported on cost or resource use of RCTs were included. None of the articles provided empirical resource use and cost data for all aspects of an entire RCT. Eight articles presented resource use and cost data on several aspects (e.g., aggregated cost data of different drug development phases, site-specific costs, selected cost components). Thirty-five articles assessed costs of one specific aspect of an RCT (i.e., 30 on recruitment; five others). The median costs per recruited patient were USD 409 (range: USD 41-6,990). Overall costs of an RCT, as provided in 16 articles, ranged from USD 43-103,254 per patient, and USD 0.2-611.5 Mio per RCT but the methodology of gathering these overall estimates remained unclear in 12 out of 16 articles (75%). CONCLUSION The usefulness of the available empirical evidence on resource use and costs of RCTs is limited. Transparent and comprehensive resource use and cost data are urgently needed to support budget planning for RCTs and help improve sustainability.
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Affiliation(s)
- Benjamin Speich
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland
| | - Belinda von Niederhäusern
- Clinical Trial Unit, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Nadine Schur
- Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland
| | - Lars G Hemkens
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland
| | - Thomas Fürst
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; School of Public Health, Imperial College London, London, United Kingdom
| | - Neera Bhatnagar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Reem Alturki
- Multi Organ Transplant Center, King Fahad Specialist Hospital Dammam, P.O. Box 15215, Dammam 31444, Saudi Arabia
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Kasenda
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland; Department of Medical Oncology, University of Basel and University Hospital Basel, Switzerland
| | - Christiane Pauli-Magnus
- Clinical Trial Unit, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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Hill JA, Ardehali R, Clarke KT, Del Zoppo GJ, Eckhardt LL, Griendling KK, Libby P, Roden DM, Sadek HA, Seidman CE, Vaughan DE. Fundamental Cardiovascular Research: Returns on Societal Investment: A Scientific Statement From the American Heart Association. Circ Res 2017; 121:e2-e8. [PMID: 28652256 DOI: 10.1161/res.0000000000000155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Recent decades have witnessed robust successes in conquering the acutely lethal manifestations of heart and vascular diseases. Many patients who previously would have died now survive. Lifesaving successes like these provide a tremendous and easily recognized benefit to individuals and society. Although cardiovascular mortality has declined, the devastating impact of chronic heart disease and comorbidities on quality of life and healthcare resources continues unabated. Future strides, extending those made in recent decades, will require continued research into mechanisms underlying disease prevention, pathogenesis, progression, and therapeutic intervention. However, severe financial constraints currently jeopardize these efforts. To chart a path for the future, this report analyzes the challenges and opportunities we face in continuing the battle against cardiovascular disease and highlights the return on societal investment afforded by fundamental cardiovascular research.
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Neyt M, Christiaens T, Demotes J, Walley T, Hulstaert F. Publicly funded practice-oriented clinical trials: of importance for healthcare payers. J Comp Eff Res 2016; 5:551-560. [PMID: 27595308 DOI: 10.2217/cer-2016-0018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Many questions of relevance to patients/society are not answered by industry-sponsored clinical trials. We consider whether there are benefits to governments in funding practice-oriented clinical trials. METHODOLOGY A literature search including publications on institutions' websites was performed and supplemented with information gathered from (inter)national stakeholders. RESULTS Areas were identified where public funding of clinical trials is of importance for society, such as head-to-head comparisons or medical areas where companies have no motivation to invest. The available literature suggests publicly funded research programs could provide a positive return on investment. The main hurdles (e.g., sufficient funding and absence of equipoise) and success factors (e.g., selection of research questions and research infrastructure) for the successful conduct of publicly funded trials were identified. CONCLUSION Governments should see public funding of pragmatic practice-oriented clinical trials as a good opportunity to improve the selection and quality of treatments and stimulate efficient use of limited resources.
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Affiliation(s)
- Mattias Neyt
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Thierry Christiaens
- Ghent University, Belgium.,Belgian Centre for Pharmacotherapeutic Information (BCFI), Belguim
| | - Jacques Demotes
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Tom Walley
- University of Liverpool, UK.,National Institute for Health Research (NIHR), UK
| | - Frank Hulstaert
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
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Abstract
OBJECTIVE Most women with moderate to severe vasomotor symptoms (VMS) are untreated. This retrospective matched-cohort study aims to evaluate the healthcare resource utilization, work loss, and cost burden associated with untreated VMS. METHODS Health insurance claims (1999-2011) were used to match (1:1) women with untreated VMS with control women using propensity score. Healthcare resource utilization, work productivity loss (disability + medically related absenteeism), and associated costs were compared between cohorts. RESULTS During the 12-month follow-up, women with untreated VMS (n = 252,273; mean age, 56 y) had significantly higher healthcare resource utilization than women in the control cohort: 82% higher for all-cause outpatient visits (95% CI, 81-83; P < 0.001) and 121% higher (95% CI, 118-124; P < 0.001) for VMS-related outpatient visits. Mean direct costs per patient per year were significantly higher for VMS women (direct cost difference, US$1,346; 95% CI, 1,249-1,449; P < 0.001). VMS women had 57% (95% CI, 51-63; P < 0.001) more indirect work productivity loss days than controls, corresponding to an incremental indirect cost per patient per year associated with untreated VMS of US$770 (95% CI, 726-816; P < 0.001). CONCLUSIONS This study shows that untreated VMS are associated with significantly higher frequency of outpatient visits and incremental direct and indirect costs.
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Pei PP, Weinstein MC, Li XC, Hughes MD, Paltiel AD, Hou T, Parker RA, Gaynes MR, Sax PE, Freedberg KA, Schackman BR, Walensky RP. Prioritizing HIV comparative effectiveness trials based on value of information: generic versus brand-name ART in the US. HIV CLINICAL TRIALS 2015; 16:207-18. [PMID: 26651525 PMCID: PMC4718767 DOI: 10.1080/15284336.2015.1123942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Value of Information (VOI) analysis examines whether to acquire information before making a decision. We introduced VOI to the HIV audience, using the example of generic antiretroviral therapy (ART) in the US. METHODS AND FINDINGS We used a mathematical model and probabilistic sensitivity analysis (PSA) to generate probability distributions of survival (in quality-adjusted life years, QALYs) and cost for three potential first-line ART regimens: three-pill generic, two-pill generic, and single-pill branded. These served as input for a comparison of two hypothetical two-arm trials: three-pill generic versus single-pill branded; and two-pill generic versus single-pill branded. We modeled pre-trial uncertainty by defining probability distributions around key inputs, including 24-week HIV-RNA suppression and subsequent ART failure. We assumed that, without a trial, patients received the single-pill branded strategy. Post-trial, we assumed that patients received the most cost-effective strategy. For both trials, we quantified the probability of changing to a generic-based regimen upon trial completion and the expected VOI in terms of improved health outcomes and costs. Assuming a willingness to pay (WTP) threshold of $100 000/QALY, the three-pill trial led to more treatment changes (84%) than the two-pill trial (78%). Estimated VOI was $48 000 (three-pill trial) and $35 700 (two-pill trial) per future patient initiating ART. CONCLUSIONS A three-pill trial of generic ART is more likely to lead to post-trial treatment changes and to provide more value than a two-pill trial if policy decisions are based on cost-effectiveness. Value of Information analysis can identify trials likely to confer the greatest impact and value for HIV care.
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Affiliation(s)
- Pamela P. Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Milton C. Weinstein
- Harvard School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - X. Cynthia Li
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Taige Hou
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert A. Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Melanie R. Gaynes
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul E. Sax
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
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Fabsitz RR, Papanicolaou GJ, Sholinsky P, Coady SA, Jaquish CE, Nelson CR, Olson JL, Puggal MA, Purkiser KL, Srinivas PR, Wei GS, Wolz M, Sorlie PD. Impact of National Heart, Lung, and Blood Institute-Supported Cardiovascular Epidemiology Research, 1998 to 2012. Circulation 2015; 132:2028-33. [PMID: 26508730 DOI: 10.1161/circulationaha.114.014147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Richard R Fabsitz
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - George J Papanicolaou
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD.
| | - Phyliss Sholinsky
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Sean A Coady
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Cashell E Jaquish
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Cheryl R Nelson
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Jean L Olson
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Mona A Puggal
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Kevin L Purkiser
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Pothur R Srinivas
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Gina S Wei
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Michael Wolz
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
| | - Paul D Sorlie
- From National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Epidemiology Branch, Bethesda, MD
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Geusens P. New insights into treatment of osteoporosis in postmenopausal women. RMD Open 2015; 1:e000051. [PMID: 26557374 PMCID: PMC4632141 DOI: 10.1136/rmdopen-2015-000051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 01/05/2023] Open
Abstract
For the prevention of fractures, antiresorptive drugs (bisphosphonates and denosumab) that decrease high bone resorption and, secondarily, also bone formation, are the mainstream of therapy. Osteoanabolic drugs, such as teriparatide, increase bone formation more than bone resorption, and are used in severe osteoporosis, including patients treated with antiresorptive drugs who still lose bone and have recurrent fractures. New potential drugs for fracture prevention that uncouple bone resorption from bone formation include odanacatib, a specific inhibitor of cathepsin-K, the enzyme that degrades bone collagen type I, that inhibits bone resorption and only temporarily bone formation, and monoclonal antibodies against sclerostin (romosozumab, blosozumab), that stimulate bone formation and decrease bone resorption.
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Affiliation(s)
- Piet Geusens
- Department of Internal Medicine, Division of Rheumatology , CAPHRI School for Public Health and Primary Care, Maastricht University Medical Center , Maastricht , The Netherlands ; Hasselt University, Biomedical Research Institute, and Transnationale Universiteit Limburg , Hasselt , Belgium
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35
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Kaplan RM, Irvin VL. Likelihood of Null Effects of Large NHLBI Clinical Trials Has Increased over Time. PLoS One 2015; 10:e0132382. [PMID: 26244868 PMCID: PMC4526697 DOI: 10.1371/journal.pone.0132382] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022] Open
Abstract
Background We explore whether the number of null results in large National Heart Lung, and Blood Institute (NHLBI) funded trials has increased over time. Methods We identified all large NHLBI supported RCTs between 1970 and 2012 evaluating drugs or dietary supplements for the treatment or prevention of cardiovascular disease. Trials were included if direct costs >$500,000/year, participants were adult humans, and the primary outcome was cardiovascular risk, disease or death. The 55 trials meeting these criteria were coded for whether they were published prior to or after the year 2000, whether they registered in clinicaltrials.gov prior to publication, used active or placebo comparator, and whether or not the trial had industry co-sponsorship. We tabulated whether the study reported a positive, negative, or null result on the primary outcome variable and for total mortality. Results 17 of 30 studies (57%) published prior to 2000 showed a significant benefit of intervention on the primary outcome in comparison to only 2 among the 25 (8%) trials published after 2000 (χ2=12.2,df= 1, p=0.0005). There has been no change in the proportion of trials that compared treatment to placebo versus active comparator. Industry co-sponsorship was unrelated to the probability of reporting a significant benefit. Pre-registration in clinical trials.gov was strongly associated with the trend toward null findings. Conclusions The number NHLBI trials reporting positive results declined after the year 2000. Prospective declaration of outcomes in RCTs, and the adoption of transparent reporting standards, as required by clinicaltrials.gov, may have contributed to the trend toward null findings.
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Affiliation(s)
- Robert M. Kaplan
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
- * E-mail:
| | - Veronica L. Irvin
- Oregon State University, Corvallis, Oregon, United States of America
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36
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Thirumalai A, Rubinow KB, Page ST. An update on testosterone, HDL and cardiovascular risk in men. ACTA ACUST UNITED AC 2015; 10:251-258. [PMID: 26257830 DOI: 10.2217/clp.15.10] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Testosterone prescriptions have risen steadily and sharply in the USA despite a lack of clear understanding of the relationship between androgens and cardiovascular disease. In men with increasing age, testosterone levels decline and cardiovascular disease risk goes up. Ties between hypogonadism and cardiovascular disease are suggested by observational data, yet therapy with testosterone replacement has not been shown to mitigate that risk. To the contrary, recent literature has raised concern for increased cardiovascular disease in certain groups of men receiving testosterone therapy. In this article, we review current literature in an attempt to better understand what it suggests is the true relationship between testosterone and cardiovascular disease. We also take a closer look at effects of testosterone on lipids and HDL in particular, to see if this explains the cardiovascular effects seen in clinical studies.
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Affiliation(s)
- Arthi Thirumalai
- University of Washington, Division of Metabolism, Endocrinology & Nutrition, 1959 NE Pacific Street, Box 356426, Seattle, WA 98195, USA
| | - Katya B Rubinow
- University of Washington, Division of Metabolism, Endocrinology & Nutrition, South Lake Union Campus, 850 Republican Street, Box 358055, Seattle, WA 98109, USA
| | - Stephanie T Page
- University of Washington, Division of Metabolism, Endocrinology & Nutrition, 1959 NE Pacific Street, Box 357138, Seattle, WA 98195, USA
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Abstract
The impact of the findings from the Women's Health Initiative trial of estrogen plus progestin cannot be attributed to any real or imagined conflicts of interest between government, researchers, and journals. Rather, the findings overturned decades of dogma in part promoted by the pharmaceutical industry, and the reaction to these unexpected findings was in direct proportion to their importance in reversing a misguided practice of prescribing the drug for chronic disease prevention. The findings have been widely accepted, as shown by the sustained subsequent reduction in prescriptions. However, conflicts of interest may influence a minority unwilling to accept the findings. The decrease in the use of a drug with an adverse risk profile for prevention of chronic disease is a public good.
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Cumming GP, Currie H, Morris E, Moncur R, Lee AJ. The need to do better - Are we still letting our patients down and at what cost? Post Reprod Health 2015; 21:56-62. [PMID: 25966991 DOI: 10.1177/2053369115586122] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To survey women's views on HRT and alternative therapies and make comparisons with 2007 data. STUDY DESIGN A questionnaire on a UK patient-tailored independent clinician-led website with anonymous responses analysed using descriptive statistics. MAIN OUTCOME MEASURES Answers to survey questions in 2007 and 2014. RESULTS A total of 1476 responses from 33 countries were obtained. Almost 70% of respondents had used/would consider using HRT. Over the last 5 years, 27.7% felt that their views had changed for the better. Most obtained information from health professionals or the Internet. About 51.1% felt that their family doctor did not recognise the importance of the menopause with one-third feeling resistance to being offered HRT. Compared to 2007, significantly more women were aware of the different risks associated with different types of HRT. More women were able to respond positively to the question asking whether or not they felt able to make an informed choice regarding HRT/alternative therapies. CONCLUSIONS There has been negativity and confusion regarding HRT management since the beginning of the millennium. Our findings suggest that we, as health professionals, continue to let our patients down with poor provision of information, inaccurate or wrong information, or access to the right care. The cost of this is women living with preventable sequelae associated with the menopausal transition with a consequent adverse impact on health and the health economy. The importance of the menopause consultation as part of a life course approach is highlighted as well as the emerging discipline of Health Web Science.
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Affiliation(s)
| | | | | | | | - Amanda J Lee
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Abstract
Conflict of interest in scientific publications has become a topic of critical importance. A primary focus has been the relationship between authors, journals and the pharmaceutical industry. That focus must be expanded to include government funding organizations. There are significant benefits to authors and investigators in participating in government-funded research, and to journals in publishing it. There are substantial risks to patients in not considering the potential for conflict of interest.
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40
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Affiliation(s)
- Francis S. Collins
- Corresponding Author: Francis S. Collins, MD, PhD, National Institutes of Health, Office of the Director, 1 Center Dr, Bethesda, MD 20892 ()
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41
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Howell A, Anderson AS, Clarke RB, Duffy SW, Evans DG, Garcia-Closas M, Gescher AJ, Key TJ, Saxton JM, Harvie MN. Risk determination and prevention of breast cancer. Breast Cancer Res 2014; 16:446. [PMID: 25467785 PMCID: PMC4303126 DOI: 10.1186/s13058-014-0446-2] [Citation(s) in RCA: 204] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Breast cancer is an increasing public health problem. Substantial advances have been made in the treatment of breast cancer, but the introduction of methods to predict women at elevated risk and prevent the disease has been less successful. Here, we summarize recent data on newer approaches to risk prediction, available approaches to prevention, how new approaches may be made, and the difficult problem of using what we already know to prevent breast cancer in populations. During 2012, the Breast Cancer Campaign facilitated a series of workshops, each covering a specialty area of breast cancer to identify gaps in our knowledge. The risk-and-prevention panel involved in this exercise was asked to expand and update its report and review recent relevant peer-reviewed literature. The enlarged position paper presented here highlights the key gaps in risk-and-prevention research that were identified, together with recommendations for action. The panel estimated from the relevant literature that potentially 50% of breast cancer could be prevented in the subgroup of women at high and moderate risk of breast cancer by using current chemoprevention (tamoxifen, raloxifene, exemestane, and anastrozole) and that, in all women, lifestyle measures, including weight control, exercise, and moderating alcohol intake, could reduce breast cancer risk by about 30%. Risk may be estimated by standard models potentially with the addition of, for example, mammographic density and appropriate single-nucleotide polymorphisms. This review expands on four areas: (a) the prediction of breast cancer risk, (b) the evidence for the effectiveness of preventive therapy and lifestyle approaches to prevention, (c) how understanding the biology of the breast may lead to new targets for prevention, and (d) a summary of published guidelines for preventive approaches and measures required for their implementation. We hope that efforts to fill these and other gaps will lead to considerable advances in our efforts to predict risk and prevent breast cancer over the next 10 years.
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Affiliation(s)
- Anthony Howell
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, M29 9LT Manchester, UK
- The Christie, NHS Foundation Trust, Wilmslow Road, Manchester, M20 2QJ UK
- Breakthrough Breast Cancer Research Unit, Institute of Cancer Sciences, University of Manchester, Wilmslow Road, Manchester, M20 2QJ UK
| | - Annie S Anderson
- Centre for Public Health Nutrition Research, Division of Cancer Research, Level 7, University of Dundee, Ninewells Hospital & Medical School, Mailbox 7, George Pirie Way, Dundee, DD1 9SY UK
| | - Robert B Clarke
- Breakthrough Breast Cancer Research Unit, Institute of Cancer Sciences, University of Manchester, Wilmslow Road, Manchester, M20 2QJ UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - D Gareth Evans
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, M29 9LT Manchester, UK
- The Christie, NHS Foundation Trust, Wilmslow Road, Manchester, M20 2QJ UK
- Manchester Centre for Genomic Medicine, The University of Manchester, Manchester Academic Health Science Centre, Central Manchester Foundation Trust, St. Mary’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Montserat Garcia-Closas
- Division of Genetics and Epidemiology, Institute of Cancer Research, Cotswold Road, Sutton, SM2 5NG London, UK
| | - Andy J Gescher
- Department of Cancer Studies and Molecular Medicine, University of Leicester, University Road, Leicester, LE2 7LX UK
| | - Timothy J Key
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive, Oxford, OX3 7LF UK
| | - John M Saxton
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, University Drive, Norwich, NR4 7TJ UK
| | - Michelle N Harvie
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, M29 9LT Manchester, UK
- The Christie, NHS Foundation Trust, Wilmslow Road, Manchester, M20 2QJ UK
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Page ST. Testosterone and cardiovascular disease--author's reply. Lancet Diabetes Endocrinol 2014; 2:613. [PMID: 25182459 DOI: 10.1016/s2213-8587(14)70140-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Stephanie T Page
- Endocrinology and Diabetes, Harborview Medical Center, Division of Metabolism and Endocrinology, University of Washington, Seattle, WA 98195, USA.
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