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Oestrogen replacement increases cancer risk,

study shows
Scott Gottlieb

BMJ 2001;322;756-
doi:10.1136/bmj.322.7289.756/a

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News
UK strategy to help increase clean
water supplies worldwide
Rhona MacDonald BMJ
154, 200, 142
One billion of the world’s peo-
ple have only dirty water to
drink, and a third lack sanitation,
a recent report from the Depart-
ment for International Develop-
ment has said, supporting the
provision of clean water as a
fundamental right for all.
Its strategy paper Addressing
the Water Crisis is Britain’s
response to the United Nations’
development targets of halving
by the year 2015 the proportion
of people who have no access
to clean water or hygienic
sanitation.
The paper has spelt out the
health risks from dirty water.
Water related diseases, such as
cholera, typhoid, dysentry, bil-
harzia, and trachoma, are the
single largest cause of human
sickness in the world, and they
disproportionately affect poor
people, it said.
In her foreword, Clare Short,
secretary of state for internation-
al development, called for regu-
lar assessment of how countries
were performing. She said: “The
political debate in Britain was
strongly influenced by 19th and
early 20th century surveys docu-
menting the reality of grinding
poverty in our own society. A
Oestrogen
replacement
increases cancer
risk, study shows
Scott Gottlieb New York
64, 65
Postmenopausal women who use
oestrogen replacement therapy
for more than 10 years may be at
increased risk of dying of ovarian
cancer, a new study has found.
Dr Carmen Rodriguez and
colleagues from the American
Cancer Society in Atlanta, Geor-
gia, looked at 944 deaths from
ovarian cancer recorded over 14
years. Among the group, post-
menopausal women who used
oestrogen for at least 10 years
were about twice as likely to
develop ovarian cancer as their
peers who did not take it. Even
756
Downloaded from bmj.com on 5 January 2007
similar effort of political will is
needed in many developing and
transition countries if they are
to give sufficient emphasis to
the needs of their own poor
people.”
But she added: “Neither
Britain nor any other individual
donor country can achieve the
targets alone. Each developing
country should lead the effort if
the international targets are to
be achieved. The international
community, in turn, must pro-
vide support for these govern-
ments committed to the reforms
which are necessary to achieve
them.”
The department spent £82m
($123m) on water related pro-
jects during 1999-2000 and said
that this figure is scheduled to
increase “substantially” over the
next few years. But rather than
directly funding construction of
an infrastructure, it is moving
towards funding strategic and
policy level work.
The department said that its
goal is to “enable poor people to
lead healthier and more produc-
tive lives through improved
management of water resources
and increased sustainable access
to safe drinking water supply
women who used oestrogen for
10 or more years but stopped tak-
ing it remained at risk 29 years
later (JAMA 2001;285:1460-5).
Dr Rodriguez and colleagues
followed nearly 212 000 women
for 14 years. About 22% had used
oestrogen replacement therapy.
Among women who had used
the therapy for at least 10 years,
the rate of death from ovarian
cancer was 64.4 per 100 000
women. This compared with 38.3
per 100 000 women who discon-
tinued oestrogen therapy after at
least 10 years of use and 26.4 per
100 000 women who never used
the therapy. Using oestrogen for
less than 10 years did not increase
risk of developing ovarian cancer.
Postmenopausal use of oestro-
gen has already been associated
with increased risk of hormone
related cancers. The incidence of
endometrial cancer increases
rapidly with use of unopposed
oestrogen; the incidence of breast
Percentage of populations with access to
safe water supply, by region, 1999
100
Percentage of populations
90
80
70
60
50
40
30
20
10
0
b e ca
a
a
ca
ic
i
ni
As
an
rib eri
ro
ri
er
ea
Af
Eu
d Am
Am
Oc
a n tin
rth
Ca
La
No
Source: WHO/UNICEF joint monitoring programme
and appropriate sanitation.” overnight,” said Dr Brundtland.
To do this, it has drafted a “But simple inexpensive mea-
range of proposals, including sures are available that will pro-
encouraging strong leadership vide clean water for millions and
at all levels; supporting a range millions of people in developing
of activities and programmes; countries—now, not in 10 or 20
encouraging research; and dis- years. It is high time to recognise
seminating what has been that safe water supply and ade-
learnt. quate sanitation to protect
The report coincides with a health are among the basic
recent initiative (Water for human rights.”
Health) of the World Health
Organization, launched by its Addressing the Water Crisis is avail-
director general, Dr Gro Harlem able from the Department for Inter-
Brundtland, on 22 March, World national Development (tel 0845
Water Day. 300 4100). Water for Health is avail-
“Clearly, a problem of this able at www.who.int/ or www.world
magnitude cannot be solved waterday.org
cancer, however, increases only
after long term use of oestrogen.
their doctors about the balance of
risk and benefits, based on their
Although evidence exists that
pituitary and sex hormones can
own health profile.
Exactly how oestrogen
cause ovarian cancer, epidemio- replacement therapy increases
logical studies of the association risk of ovarian cancer is not
between postmenopausal use of known. The principal endocrine
oestrogen and ovarian cancer change of menopause is a
have had inconsistent results. decrease in oestrogen secretion
The authors noted that the resulting from depletion of
current findings may not apply ovarian follicles, with conse-
to hormone replacement thera- quent loss of negative feedback
py that includes oestrogen in inhibition to the pituitary gland
combination with other hor- and transient increased levels of
mones such as progesterone. gonadotrophins.
When the study began in the Postmenopausal oestrogen
early 1980s, most women took therapy raises serum oestradiol
only oestrogen and not a combi- and oestrone levels and decreases
nation of hormones, which is the secretion of gonadotrophins.
what women take today. In a previous study of the associa-
“If the association is real—we tion between serum hormone
have to wait for other studies— levels and the development
these results may be relevant for of ovarian cancer, decreasing
women with intact ovaries taking levels of gonadotrophins were
oestrogen for a long period of associated with significantly
time,” Dr Rodriguez said. She rec- higher risk of ovarian cancer
ommended that women talk to (JAMA 1995;274:1926-30).
BMJ VOLUME 322 31 MARCH 2001 bmj.com