..Information to Pharmacists
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    Your Monthly E-Magazine
    August, 2002

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    HEATHER PYM

    From a Division of General Practice Perspective
    The Challenge Of Timely Response

    The release in JAMA of the US Women's Health Initiative study and implications for long term use of combined Hormone Replacement Therapy (HRT) aroused a fierce media barrage and a consequent public reaction that put my GP colleagues in the Division in the front line.
    A consultant pharmacist working the Division of General Practice - me - was delighted to get to work ascertaining the facts     and disseminating to GPs the information they needed to placate their patients and discuss rationally what the study findings now mean for the many women taking HRT.
    This is a pharmacist task and all the skills of interpreting data, and then discussing this with prescribers, has kept me busy since the study was made known. I envisage a time when this role is the rule rather than the exception in our daily work with drugs used widely in the community. Results of drug and therapeutic studies being conducted around the world are regularly disseminated in the medical literature and the task for individual GPs to keep up is onerous.

    For about five months last year I was visiting GPs with the current state of knowledge in the HRT arena with well researched National Prescribing Service (NPS) materials. There were many unknowns and gaps in the knowledge at that time. Observational studies had identified risks of long term treatment for breast cancer and thromboembolic disease and other risks were unclear. Benefits were well understood particularly for the allaying of menopausal symptoms and increasing bone mineral density.
    Very little could be extrapolated from this knowledge as to the benefit for fracture decrease.

    Now there are some figures that quantify the risks and benefits and some surprises and other facts that support the observation data from previous studies.
    The risk of breast cancer is increased in women taking HRT for greater than 5 years - 8 more cases were detected in 10,000 women taking HRT than in a similar control cohort.
    Coronary heart disease was increased by 7 in the same number.
    There were eight more strokes and 18 more cases of thromboembolic disease.
    On the benefit side were six less cases of colorectal cancer and 44 less cases of osteoporotic fracture.
    The cardiovascular increased risk was a bit of a surprise for many as over the past years it was understood by many practitioners and patients that HRT conferred cardio protection.
    Perhaps for some it was prescribed for such!

    The news last year of HRT causing increased risk for cardiac events in those already having had an event was hailed as a change in knowledge and determined new policy in prescribing.
    Now it appears that for all patients there is an increased cardio- event risk.

    The study has naturally provoked much interest and much alarm depending on how the figures are presented. A 26 percent increase in risk for breast cancer is alarming, until one realizes that this is relative risk and not absolute risk. In assessing an individual woman's risk/benefit the GP needs all the information and an understanding of its application and how this can affect the individual circumstance.
    It is very much an educative and consultative process.
    The paper is available on the web http://jama.ama-assn.org/issues/v288n3/ffull/joc21036.html
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