Drugs exist to lower the risk of breast cancer in high-risk women, but they aren’t getting used as often as one might expect. This story does an excellent job of exploring the disparity between research showing the drugs’ effectiveness and the lack of real-world use. We especially like that the story includes the perspective of an independent family physician, who raises some concerns about the drugs and their supporting evidence that cancer specialists might be less likely to emphasize.
The story does have some problems that would have been fairly easy to address. Inflated relative risk figures are presented high up in the story, while more useful absolute figures are buried further down. Costs aren’t fully explored. And since the story emphasizes the need for careful patient decision-making about this treatment, we also thought it would have been valuable to interview some actual patients. With existing groups of women who “meet” on social media to discuss breast cancer, it wouldn’t have been much additional work to include the patient perspective.
This story asks deep questions about perceptions of risk, and why health care providers may not be having nuanced discussions about breast cancer prevention options with their patients. The voices missing from this story are the voices of real patients who have made these decisions. Are they concerned about the sexual side effects that these drugs have the potential to induce? Or are they just not that impressed with the modest absolute risk reduction produced by these drugs? Answering those questions would have made a very strong story even stronger.
The story mentions that these drugs are “covered” by the Affordable Care Act, and that “women with a high risk for breast cancer and a low risk for side effects who try this therapy will not incur out-of-pocket costs.” We’ll call this nod in the direction of costs sufficient for a satisfactory rating, but the story does not discuss these drugs’ prices or the cost of repeated office visits to monitor their side effects. There was an opportunity here for a rich discussion about incurring some upfront cost for a potential for downstream cost savings in terms of lower cancer rates and reduced need for treatment.
The story’s initial discussion of benefits focuses mainly on very attractive relative risk figures. It notes that in one study, women who took tamoxifen “were half as likely to develop breast cancer as similar women who did not take the drug.” And an expert says that high-risk women “could reduce their risks for invasive cancer by approximately 30 to 50 percent.” It’s not until further down in the study that the much less glamorous absolute risk estimate is provided. The story notes that “after looking at multiple trials of tamoxifen and raloxifene, the [U.S. Preventives Services Task Force] noted that these drugs reduced new cases of breast cancer significantly: from 23 cases per 1,000 women in the control groups to 16 cases per 1,000 women in the treatment groups.”
While the story’s framing is problematic, we give the story credit for eventually getting to the key statistics that consumers need. We also applaud the inclusion of nuance from an independent expert. The story quotes Kenneth Lin, a family physician at Georgetown University who worked on developing the task force’s SERM guidelines. He notes that while SERMs may have reduced new cases, they “have not been shown to reduce breast cancer mortality in any study or meta-analysis.” He explains that the drugs may be effective at preventing nonlethal cancers rather than the more serious ones.
We grant a passing grade for the inclusion of statements about increased risk of uterine cancer and other serious side effects. But we have to wish for some discussion of sexual side effects in more common language. Not everyone knows that “hot flashes” and “vaginal dryness” are part of the menopause-like state that chemoprevention creates in some women. We suspect those potential side effects influence women’s decisions.
The exploration of evidence was thorough. The story cites evidence from a number of individual trials, as well as a review of multiple trials conducted by the independent U.S. Preventive Services Task Force. It balances evidence of benefit with restraining expert comments that address limitations in the available studies. It stresses that women at higher risk are likely to benefit more, and acknowledges debate among expert groups about the appropriate cutoffs for treatment.
This story had a couple of issues that raised concern. The intro paragraph notes that 230,000 women annually receive a “devastating” diagnosis of breast cancer. But in reality, there is a wide spectrum of disease and many types of breast cancer are very curable (and, in fact, have spurred debate to no longer call them cancer). We wish the story had made that clearer. And by waiting several paragraphs to mention that preventative drugs are meant only for high risk women, the story may prompt many women at low risk to worry about needing chemoprevention.
On the other hand, the story does include a related sidebar that has a nice discussion of risk factors. It includes the following reassuring statement: “It is important to note that having a risk factor, or even a few of them, does not mean a woman will develop cancer. Most women, in fact, do not.”
The story makes good use of actual interviews with more than one source. The perspective these experts provide is crucial.
Since the story emphasizes patient decision-making surrounding preventative drug treatment, it would have been useful to include the voices of some actual patients who did and did not opt for drug treatment.
The story spends most of its time on drugs for prevention, but wisely does point out lifestyle alternative behaviors known to lower risk.
“Most important, become familiar with your family history, know your risk factors and discuss them with your primary-care physician. Age and family history cannot be controlled, but lifestyle changes — including eating a healthful diet, exercising, not smoking and not over consuming alcohol — are eminently doable and can reduce your risk. These basic tenets of leading a healthy lifestyle have been shown to be important factors in breast cancer prevention.”
It would have been interesting to hear about the comparative effectiveness of instituting lifestyle changes vs. drugs for reducing cancer risk.
The story discusses the availability of these drug therapies.
The story establishes that there is nothing is novel about the therapies under discussion.
There is good reporting from interviews with a variety of researchers and no reliance on a press release.