Further to Naming and shaming.

Dr John Stevenson, from the National Heart & Lung Institute, recently wrote an article commenting on post menopausal hormone therapy (HT*) and breast cancer (Stevenson JC et al. HRT and breast cancer risk: a realistic perspective. Climacteric. 2011; 14:633-6).  Here are some quotes from the abstract:

“We have concerns over the validity of their [the Women’s Health Initiative researchers] statistical analyses […] We suspect that the apparent increase in mortality is the result of surveillance and detection bias rather than a true cause and effect. Even if such an effect were true, mortality from breast cancer would still be a very rare event. We also question the clinical relevance and applicability of their findings. […] Even if combined estrogen–progestogen HRT did cause an increase in breast cancer risk, and this is not proven, the magnitude of that risk is small, and less than that risk seen with many lifestyle factors. HRT is a benefit, not a risk, for those women requiring it.”

A month or so later he co-wrote an article about the place of HT in the primary prevention of cardiovascular disease.  Maclaran K; Stevenson JC. (2012). Primary prevention of cardiovascular disease with HRT. Womens Health (Lond Engl). 8:63-74.  Again the abstract gives the tone:

[…] Menopause is associated with the development of cardiovascular risk factors and there are many plausible biological mechanisms through which estrogen may confer cardiovascular protection. […] It is now becoming clearer that the beneficial cardiovascular effects of estrogen are greatest in younger women and those closest to menopause. This has led to the development of the timing hypothesis. Use of age-appropriate estrogen doses is crucial to maximize cardiovascular benefits while minimizing risk of adverse effects such as venous thromboembolism and stroke.

These are the latest of dozens of review articles and opinion pieces casting doubt on the results of the WHI trials. Here is a partial list. Stevenson since WHIb

According to Stevenson the WHI results are biologically implausible, their statistical methods wrong, and they studied the wrong hormone, in the wrong dose, on the wrong patients. When he refers to the risks of HT his language, “small risks”, “low risks”, “rare effect” minimises the danger, but he never applies such language to the benefits of HT.  Every comment he makes is in the direction of questioning the harms and playing up the benefits of HT.  Search as I might I cannot find him ever finding a scientific flaw, which underestimates a benefit or overestimates a harm.

Why does he do it?  I don’t know Dr Stevenson personally, but he is a respected expert on mineral metabolism and the effect of sex steroids on cardiovascular risk factors.  It’s perfectly reasonable for such an expert to remind clinicians  that there are plausible mechanisms whereby estrogen might benefit the heart. He did just that in a BMJ editorial (Stevenson and Whitehead 2002) just that after WHI was published. His title “Hormone replacement therapy: findings of women’s health initiative trial need not alarm users”, reveals his opinion, which has clearly not changed.

But why does he go on saying the same thngs in obscure rarely cited journals?  Maturitas has an impact factor of only 2.1 – the average article is cited twice.  Climacteric 2.1, J Fam Plan & Reprod Health Care 1.2, Calc Tiss Intern 2.7, Best Pract Res Clin Obstet Gynaecol 1.8, and Gynecol Endocrinol 1.5.  Five journals he writes in, Womens Health, Menopause Intl, Pract Cardiovasc Risk Man, J Br Med Soc, and Curr Osteoporosis Reports don’t to even have an impact factor. It surely isn’t for the enhancement of his scientific reputation.

Could it be that Schering Plough, Wyeth/Pfizer, Bayer, Meda and Merck/Theramex, who fund Dr Stevenson’s research, and pay him lecture and consultancy fees, don’t care about scientific impact. They just want otherwise reputable researchers to claim that there is controversy over the risks and benefits of HT.

Professor Kim Fox, the head of the National Heart and Lung Institute, should grumble if Stevenson writes this guff during his paid working time. He might even wonder if he is completely confident that he is employing a disinterested scientific seeker after truth.

Jim Thornton

*Hormone replacement therapy (HRT) changed to hormone therapy (HT) Jan 2016