A major observational study that was widely accepted as proof that hormone replacement therapy (HRT) increases the risk of breast cancer has been challenged following a new review of the evidence.
The Million Women Study (MWS), which has driven a major drop in the number of menopausal and post-menopausal women being prescribed HRT, did not prove a causal link between HRT and breast cancer and its conclusions were ‘biologically implausible’, the review found.
The British Medical Journal (BMJ) recently claimed the reduction in prescription of HRT had reduced the incidence of breast cancer in the UK – so the review will give many GPs pause for thought.
The MWS analysed new cases of breast cancer arising in women who reported for breast screening in the UK between 1966 and 2001. It concluded that HRT increased the risk of fatal breast cancer by 22%.
The impact of the MWS on NHS prescribing and public perception has been drastic, with some clinicians demanding the banning of HRT while others have argued strongly for its retention as a treatment option for osteoporosis.
The review, published in the Journal of Family Planning and Reproductive Health Care (a BMJ Group journal) used scientific criteria to review the findings of the MWS and highlighted a number of flaws in the study’s design, including:
• Cancers detected in the first few months of the study would have been present beforehand, but these participants were not excluded.
• The use of study participants already reporting for breast screening would have increased the participation of HRT users (and non-HRT users) already aware of potential breast cancer symptoms.
• In a later MWS report, follow-up data on HRT use was not available for over 50% of the study participants.
In addition, the review argued that a 22% increase in the risk of fatal breast cancer due to HRT within the short time frame of the study was “biologically implausible”.
“The name ‘Million Women Study’ implies an authority beyond criticism or refutation. Yet the validity of any study is dependent on the quality of its design, execution, analysis and interpretation,” said the review authors.
The “problems and uncertainties” of the MWS as an observational study meant that its evidence was “unreliable”, they concluded, and so “the only effect of its massive size would have been to confer spurious statistical authority to doubtful findings.”