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1.
Background: Benefits and risks of a combined hormone replacement therapy (HRT) based on randomized clinical trial emerged on various disease endpoints in 2002. The Womens Health Initiative (WHI) provides an important health answer for healthy postmenopausal women, such as do not use combined HRT to prevent chronic disease, because of the elevated risk of coronary artery disease (CHD), stroke and venous thromboembolism. In March 2004, the NIH stopped the drugs in the estrogen-alone trial after finding an increase risk of stroke and no effect, neither an increase or a decrease, on risk of CHD after an average of 7 years in the trial. On the other hand, raloxifene, which does not seem to significantly increase the risk of cardiovascular events and could retain skeletal benefits without stimulating endometrial and breast tissue, requires decision-makers since no current data on these disease clinical endpoints have been published. Objective: To construct a multi-disease model based on patient-specific risk factor profiles, and to validate the multi-disease model with several tools of internal and external validities. Methods: A Markov state model was developed. The risks of these various diseases (including coronary artery disease, stroke, hip fracture and breast cancer) are derived from published hazards proportional models which take into account significant risk factors. Canadian-specific rates and data sources for these transition probabilities are derived from published studies and Canadian Health Statistics. The validation of our model were based on several tools of internal and external validities, such as Canadian life expectancy, population-based incidence rate of diseases, clinical trials and other published life expectancy models. Results: First, presumably, small changes in the lifetime probability of dying support the hypothesis that the disease states operate in a largely independent fashion. For instance, the difference in the probability of dying from a particular disease by the complete elimination of a selected disease, such as CHD, stroke or breast cancer, ranged from 0.2 to 2.2% of difference in the lifetime probability of dying of these diseases. Second, we demonstrated that the model adequately predicted the Canadian population life-table and disease-incidence rates from population-based data among women from 45 to 75 years old. The predictions of the model were cross-checked from non-source data, such as predicted outcomes versus observed outcomes from results of clinical trials. Predicted relative risks of CHD event, breast cancer and hip fracture fell in the reported 95% confidence interval of clinical trials. Finally, predicted treatment benefits are comparable with those of published life expectancy models. Conclusions: The results of the study demonstrated that this multi-disease model, including coronary artery disease, stroke, hip fracture and breast cancer, is a valid model to predict the impact on life expectancy or number of events prevented for preventive pharmacological interventions.  相似文献   

2.
OBJECTIVES: The objective of this four part series is to review for the practicing clinician the extensive and sometimes contradictory literature on the effects of estrogen replacement therapy (ERT) and hormone replacement therapy (HRT) in the postmenopausal woman. This third article reviews HRT and the potential excess morbidity from breast cancer, endometrial cancer, venous thromboembolism (VTE), and coronary heart disease (CHD). DESIGN: Studies reviewed were obtained through Medline searches, examination of citations in the articles reviewed from those searches,interviews with local experts in geriatrics, cardiology, and women's health. CONCLUSIONS: Long-term HRT seems to be associated with a small increased risk for breast cancer. The risk of endometrial cancer in women with a uterus using ERT can be eliminated completely with the use of combination estrogen and progestin. HRT may be associated with a small increased risk for VTE; however, the absolute morbidity and mortality attributable to VTE is small and unlikely to impact the net benefit of HRT significantly. Although there is considerable data favoring a beneficial effect of HRT on CHD, initiation of HRT in women with established CHD may be associated with increased risk of adverse cardiac events in the first year after initiation. In counseling patients about the use of long-term HRT, the balance of these risks and the effect of co-morbid illness in the geriatric population should be addressed. Discussion of HRT and the aging brain (stroke, dementia), the net benefit of long-term HRT, and decision-making for the individual patient is forthcoming in the final article of this four-part series.  相似文献   

3.
Postmenopausal osteoporosis is a very common disease, and approximately half of all women aged >50 years will experience an osteoporotic fracture during the remainder of their lifetime. The predominant cause of postmenopausal osteoporosis is the decline in estrogen levels, which causes an increase in bone turnover, and results in a loss of bone mass throughout the entire skeleton. Fragility fractures, either vertebral or nonvertebral, have a considerable adverse effect on quality of life in women with osteoporosis and place a significant burden on society in terms of healthcare costs.Management of postmenopausal osteoporosis includes alteration of modifiable risk factors (e.g. lifestyle and propensity to fall), ensuring adequate calcium and vitamin D intake, and pharmacological treatment to decrease fracture risk by slowing or preventing bone loss and preserving bone strength. Raloxifene (Evista®), a selective estrogen receptor modulator that partially mimics the effects of estrogen on bone and lipid metabolism and acts as an antiestrogen in the breast and endometrium, is indicated for the prevention and treatment of postmenopausal osteoporosis. Raloxifene increases bone mineral density at vertebral and nonvertebral sites, and decreases the risk of vertebral fracture to a similar extent to the bisphosphonates alendronate and risedronate. However, effects on nonvertebral fracture risk, including the risk of hip fracture, have not been observed.Raloxifene appears to reduce breast cancer risk (in women at average risk) and cardiovascular risk (in women at increased risk) without stimulating the endometrium, and does not cause vaginal bleeding or breast pain. However, the drug causes hot flashes in some women, and increases the risk of venous thromboembolic events by about the same amount as hormone replacement therapy (HRT).In economic models, raloxifene is cost effective compared with no treatment, HRT, calcitonin, or alendronate for the prevention or treatment of postmenopausal osteoporosis.In conclusion, raloxifene is a valuable and cost-effective therapy for preventing the progression of osteoporosis and for reducing vertebral fracture risk in osteoporotic postmenopausal women. The tendency for raloxifene to cause hot flashes, and its apparent lack of effect on hip fracture risk, may preclude its use in women with vasomotor symptoms and in patients at high risk for hip fracture. Results from large ongoing trials are needed to confirm the effects of raloxifene on breast cancer and cardiovascular disease. However, the effects of raloxifene on breast cancer and cardiovascular risk without stimulating the endometrium make the drug an attractive therapy for the prevention and treatment of postmenopausal osteoporosis.  相似文献   

4.
BACKGROUND: Although the understanding of the health impact of hormone replacement therapy (HRT) is incomplete, even less is known about the attitudes, perceptions, and motivations of women faced with the decision to use HRT. The purpose of this study was to evaluate the relation between HRT use and women's perceptions of the risk and benefits associated with HRT use. METHODS: A written questionnaire was administered to 387 women, aged 45 years and older, responding to a health plan invitation for free bone mineral density screening. Women were asked to estimate the lifetime probability of developing breast cancer, uterine cancer, osteoporosis, and myocardial infarction when taking HRT and when not taking HRT. Women rated their quality of life in their current state of health, with breast cancer, with uterine cancer, with osteoporosis, and after myocardial infarction. RESULTS: HRT users perceived a greater risk reduction using HRT compared with HRT nonusers for osteoporosis (-34.9% vs -17.8%, P <.001) and myocardial infarction (-20.7% vs -8.4%, P <.001). HRT nonusers perceived a greater risk increase using HRT compared with HRT nonusers for breast cancer (16.5% vs 3.3%, P <.001) and uterine cancer (9.2% vs 0.6%, P =.004). HRT users estimated a greater quality-of-life reduction compared with HRT nonusers for osteoporosis (-31.0 vs -24.5, P =.006). CONCLUSIONS: Regardless of whether they used HRT, women in this study overestimated their risk for all four diseases. HRT users perceived greater benefit and less risk using HRT than nonusers. The results of our study show that continuing efforts are needed to help women understand the risks and benefits of HRT.  相似文献   

5.
Key components of preventive health care for middleaged and older women include evaluating the risk for osteoporosis and coronary artery disease, considering hormone replacement therapy (HRT), and cancer screening. HRT is effective for treating the symptoms of acute menopause, and it may prevent some chronic health problems associated with growing older. However, HRT may increase the risks for other diseases.
OBJECTIVE: The purpose of this study was to estimate the level of health care use and costs incurred by post-menopausal women for conditions that have been associated with HRT.
METHODS: National health care survey and discharge data were used to estimate health care use by women age 45 and older for cardiovascular disease, osteoporosis, breast cancer, uterine cancer, and deep-vein thrombosis/ pulmonary embolism. The databases used were the Healthcare Utilization Project-3, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, National Nursing Home Survey, and National Home and Hospice Care Survey. Clinical Classification for Health Policy Research codes were used to identify patients whose primary diagnosis or procedure corresponded with the above conditions. National weights were used to estimate resource use. Treatment costs were estimated using cost-to-charge ratios or Medicare Fee Schedule to calculate costs of individual procedures.
RESULTS: For each of the five conditions, resource use and costs are reported for hospitalization, outpatient, nursing home, and home health care services. Resource use and costs are also reported by age and race/ethnicity.
CONCLUSION: Results of the study may be used to estimate the burden of disease for conditions commonly affecting postmenopausal women and to provide data for cost-effectiveness models comparing newly developed drugs to existing HRTs.  相似文献   

6.
This community mail-based survey received responses from 665 women to questions in three areas: (1) sources of information about menopause, (2) knowledge of health risks associated with menopause, and (3) knowledge about hormone replacement therapy (HRT). Women received information from many sources, including healthcare providers, friends, and mothers, but the number one source of information about menopause was women's magazines (76%). Over half of women surveyed said they had left healthcare appointments with unanswered questions about menopause and HRT. Although women seemed to have a basic understanding of the symptoms of menopause, their knowledge of the long-term health risks affected by menopause was poor. For example, women were much more likely (60%) to know that osteoporosis risk increased with menopause than to know that heart disease risk increased (30%) despite the much higher prevalence and severity of heart disease as a health problem of menopausal women. Many women thought that menopause itself (independent of aging) increased the risk of breast cancer. This finding may help explain the low percentage of women who take HRT for menopause despite proven health benefits. It is clear that better education about menopause needs to be accomplished regarding the long-term risk associated with menopause and the pros and cons of HRT. Strategies for improving education and interactions with healthcare providers are suggested.  相似文献   

7.
BACKGROUND AND METHODOLOGY: Late 'age at menopause' is a recognised risk factor for postmenopausal breast cancer and is also associated with decreased use of hormone replacement therapy (HRT). When investigating the association between HRT use and breast cancer risk it is therefore necessary to adjust for the potential confounder, 'age at menopause'. 'Age at menopause', however, cannot be determined for women with a hysterectomy and ovarian conservation. Using data on 13 357 postmenopausal women in whom 396 cases of invasive breast cancer were diagnosed during 9 years of follow-up from the Melbourne Collaborative Cohort Study, we compared the estimates of relative risk of HRT use for breast cancer for three different methods of dealing with missing data: complete-case analysis, single imputation and multiple imputation. RESULTS: 'Age at menopause' was missing for 17% of the data. Both HRT use and 'age at menopause' were significant risk factors for breast cancer, although 'age at menopause' only marginally confounded the estimates of risk for HRT. Women with 'age at menopause' missing did not represent a random sample of the population. Complete-case analyses resulted in higher estimates of the risk associated with HRT use compared with the different methods of imputation. DISCUSSION AND CONCLUSIONS: We recommend that analyses investigating the association between HRT and breast cancer should present the results in two ways: excluding women with 'age at menopause' missing and including the women using multiple imputation. For both methods, estimates of risk, with and without the adjustment of 'age at menopause', should be given.  相似文献   

8.
Since coronary heart disease (CHD) is the leading cause of death in American women it is therefore likely the leading cause of death among lesbians. Prevention of CHD is a major health issue for lesbians. Efforts must continue to empower all lesbians to take personal preventative action to prevent CHD. Women in general do not believe they are at risk for CHD. A common misperception is that CHD is a man's disease and the most likely threat to a woman's life is breast cancer. This misperception probably exists among lesbians as well. Over a lifetime, a woman is 10 times more likely to develop CHD than she is breast cancer. Breast cancer remains an important health concern for woman, but CHD risk must be addressed with potent educational and advocacy programs for the health of our communities. Prevention of the clinical manifestations of CHD hinges upon the prevention of plaque formation. It is an obligation of primary care providers to give advice regarding the prevention of plaque formation and therefore the prevention of subsequent CHD events and to collaborate with patients to address these issues in an individually tailored manner. This review addresses risk factors for CHD in lesbians to assist providers in achievement of that goal.  相似文献   

9.
Gail MH 《Statistics in medicine》2012,31(23):2687-2696
An ideal preventive intervention would have negligible side effects and could be applied to the entire population, thus achieving maximal preventive impact. Unfortunately, many interventions have adverse effects and beneficial effects. For example, tamoxifen reduces the risk of breast cancer by about 50% and the risk of hip fracture by 45%, but increases the risk of stroke by about 60%; other serious adverse effects include endometrial cancer and pulmonary embolus. Hence, tamoxifen should only be given to the subset of the population with high enough risks of breast cancer and hip fracture such that the preventive benefits outweigh the risks. Recommendations for preventive use of tamoxifen have been based primarily on breast cancer risk. Age-specific and race-specific rates were considered for other health outcomes, but not risk models. In this paper, we investigate the extent to which modeling not only the risk of breast cancer, but also the risk of stroke, can improve the decision to take tamoxifen. These calculations also give insight into the relative benefits of improving the discriminatory accuracy of such risk models versus improving the preventive effectiveness or reducing the adverse risks of the intervention. Depending on the discriminatory accuracies of the risk models, there may be considerable advantage to modeling the risks of more than one health outcome. Published 2012. This article is a US Government work and is in the public domain in the USA.  相似文献   

10.
Research on hormone replacement therapy (HRT) in the 21st century has been dominated by the findings of the Women’s Health Initiative (WHI) and Million Women Study (MWS). Clinical practice has changed accordingly. Both studies confirm an increase in the risk of breast cancer among women using combined HRT (oestrogen and progestogen) when compared with women who have never used HRT. The risk among women using oestrogen-only preparations of HRT, according to the MWS, is increased, but to a lesser extent than for women using combined HRT. In contrast the WHI Study suggests that oestrogen alone is not associated with an increased risk of breast cancer. Despite these different findings most evidence-based guidelines from professional organizations still advise use of HRT only for the relief of menopausal symptoms and only short term. Routine use of unopposed oestrogen for women with a uterus is being discussed but is still not recommended. New data have also led to the recommendation that HRT is contraindicated for women who have had breast cancer. More research is needed on the contribution of progestogens to the increased risk of breast cancer and on the safety of different routes of administration of both oestrogen and progestogen.  相似文献   

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