HEALTHY PEOPLE SEPT 2011. WHAT DO YOU NEED TO KNOW ? The GP should be able to demonstrate an understanding of: The epidemiology of problems presenting.

HEALTHY PEOPLEHEALTHY PEOPLE

SEPT 2011SEPT 2011

WHAT DO YOU NEED TO WHAT DO YOU NEED TO KNOW KNOW

The GP should be able to demonstrate an understanding of

1048698 The epidemiology of problems presenting in primary care

1048698 The risk factors for disease including alcohol and substance abuse accidents child abuse diet exercise

genetics occupation social deprivation and sexual behaviour

1048698 The principles of prevention and preventative strategies

1048698 The principles of immunisation and vaccination and the UKrsquos immunisation programmes

AS WELL AS hellipAS WELL AS hellip 1048698 The benefits and risks of immunisation and

vaccination in order to reassure parents effectively

1048698 The benefits and risks of screening programmes 1048698 The importance of excellent communication and

effective teamwork the role of the public health specialist

and how to access specialist public health advice 1048698 The structure of the healthcare system and the

function of primary care within the wider NHS 1048698 The principles of health surveillance

AND DONrsquoT FORGET AND DONrsquoT FORGET

The GP should also be able to demonstrate the skills required to

1048698 Change patientsrsquo behaviour in health promotion and disease prevention

Aims for todayAims for today Understand the Epidemiology of the two biggest causes of Understand the Epidemiology of the two biggest causes of

death in the UKdeath in the UK

IHD IHD

And cancer And cancer

Have a good idea of the prevention strategies that can be Have a good idea of the prevention strategies that can be employed in Primary Careemployed in Primary Care

Start to look at explaining risk to patients Start to look at explaining risk to patients

Informal Immunisation and health promotion QUIZInformal Immunisation and health promotion QUIZ

EPIDEMIOLOGY OF IHDEPIDEMIOLOGY OF IHD Coronary heart diseaseCoronary heart disease (CHD) is the most common (CHD) is the most common

cause of death (and premature death) in the UKcause of death (and premature death) in the UK

1 in 5 men and 1 in 7 women die from CHD1 in 5 men and 1 in 7 women die from CHD

There are 94000 deaths from CHD in the UK each yearThere are 94000 deaths from CHD in the UK each year

Death rates from CHD have fallen by 45 for people aged Death rates from CHD have fallen by 45 for people aged under 65 years in the last 10 years This fall is fastest in under 65 years in the last 10 years This fall is fastest in those aged 55 years and over It is largely due to a those aged 55 years and over It is largely due to a reduction in major risk factors (mostly smoking) and reduction in major risk factors (mostly smoking) and improvement in treatment and secondary prevention The improvement in treatment and secondary prevention The fall is not as high as that in some other countries such as fall is not as high as that in some other countries such as Australia (48) and Norway (54)Australia (48) and Norway (54)

EPIDEMIOLOGYEPIDEMIOLOGY Death rates from CHD are highest in Death rates from CHD are highest in

Scotland and the North of England and Scotland and the North of England and lowest in the South of England For more lowest in the South of England For more than 25 years these rates have been than 25 years these rates have been consistently highest in Scotlandconsistently highest in Scotland

Death from CHD is more likely during Death from CHD is more likely during winter in 20042005 just under 7000 winter in 20042005 just under 7000 people died from CHD in England and people died from CHD in England and Wales each month in June and July Wales each month in June and July compared with around 9000 in December compared with around 9000 in December and Januaryand January

MORBIDITY OF IHDMORBIDITY OF IHD Morbidity ratesMorbidity rates The average incidence of The average incidence of myocardial infarctionmyocardial infarction is is

600 per 100000 in men aged 30-69 and 200 per 600 per 100000 in men aged 30-69 and 200 per 100000 in women The incidence increases with 100000 in women The incidence increases with ageage

There are about 52000 new cases of There are about 52000 new cases of anginaangina per per year in all men living in the UK and about 43000 year in all men living in the UK and about 43000 new cases in womennew cases in women

About 4 of men and 05 of women in the UK About 4 of men and 05 of women in the UK have had a heart attack Prevalence increases have had a heart attack Prevalence increases with age and is higher in menwith age and is higher in men

8 of men and 3 of women aged 55 to 64 years 8 of men and 3 of women aged 55 to 64 years and about 14 of men and 8 of women aged 65 and about 14 of men and 8 of women aged 65 to 74 years have or have had anginato 74 years have or have had angina

MORBIDITY hellipMORBIDITY hellip The prevalence of CHD in Britain according to Quality and The prevalence of CHD in Britain according to Quality and

Outcomes Framework (QOF) data was 37 of all GP Outcomes Framework (QOF) data was 37 of all GP registrations The prevalence of CHD was higher in Scotland registrations The prevalence of CHD was higher in Scotland (46) than in Wales (43) or England (35)(46) than in Wales (43) or England (35)

The prevalence is higher in the North of England and Wales The prevalence is higher in the North of England and Wales than in the South of Englandthan in the South of England

The prevalence is higher in lower socioeconomic groupsThe prevalence is higher in lower socioeconomic groups

Of note mortality from CHD is falling but morbidity appears Of note mortality from CHD is falling but morbidity appears to be risingto be rising

RISK FACTORSRISK FACTORS

The aetiology of CHD is multifactorial The aetiology of CHD is multifactorial

It is the result of interaction between genetic lifestyle and It is the result of interaction between genetic lifestyle and environmental factorsenvironmental factors

AgeAge CHD increases with age This is a non-modifiable risk factorCHD increases with age This is a non-modifiable risk factor

GenderGender Traditionally CHD has been considered a disease of men Traditionally CHD has been considered a disease of men

However CHD is the leading cause of death in both men However CHD is the leading cause of death in both men and womenand women

It is responsible for a third of all deaths in women worldwide It is responsible for a third of all deaths in women worldwide and half of all deaths in women over the age of 50 years in and half of all deaths in women over the age of 50 years in developing countriesdeveloping countries

SOCIAL DEPRIVATIONSOCIAL DEPRIVATION In England and Wales there is a positive correlation In England and Wales there is a positive correlation

between deaths from circulatory diseases and levels of between deaths from circulatory diseases and levels of deprivationdeprivation

There is a marked difference in prevalence of coronary There is a marked difference in prevalence of coronary heart disease between and within communitiesheart disease between and within communities

Men and women living in the West of Scotland are nearly Men and women living in the West of Scotland are nearly six times more likely to die prematurely from CHD than six times more likely to die prematurely from CHD than men and women living in the South West of Englandmen and women living in the South West of England

Within London people living in Tower Hamlets have a three Within London people living in Tower Hamlets have a three times increased risk of dying prematurely from CHD than times increased risk of dying prematurely from CHD than those in Kensington and Chelseathose in Kensington and Chelsea

The difference in CHD rates in different socioeconomic The difference in CHD rates in different socioeconomic groups is related to many factors including diet smoking groups is related to many factors including diet smoking exercise and alcoholexercise and alcohol

SMOKINGSMOKING In 2001 27 of adults aged 16 years and over In 2001 27 of adults aged 16 years and over

smoked cigarettes in England 28 of men and smoked cigarettes in England 28 of men and 25 of women25 of women

Mortality from CHD is 60 higher in smokersMortality from CHD is 60 higher in smokers Regular exposure to passive smoking increases Regular exposure to passive smoking increases

CHD risk by 25CHD risk by 25 In 2000 about 1 in 8 deaths from cardiovascular In 2000 about 1 in 8 deaths from cardiovascular

disease (CVD) were attributable to smoking in the disease (CVD) were attributable to smoking in the UKUK

World Health Organization (WHO) research World Health Organization (WHO) research estimates that over 20 of CVD is due to estimates that over 20 of CVD is due to smokingsmoking

POOR NUTRITIONPOOR NUTRITION There are national regional socioeconomic and ethnic differences in There are national regional socioeconomic and ethnic differences in

nutritionnutrition A WHO report in 2003 stated that a diet high in fat (particularly saturated A WHO report in 2003 stated that a diet high in fat (particularly saturated

fat) sodium and sugar and low in complex carbohydrates fruit and fat) sodium and sugar and low in complex carbohydrates fruit and vegetables increases the risk of CVDvegetables increases the risk of CVD

It has been recommended that the percentage food energy derived from It has been recommended that the percentage food energy derived from fat should be 35 with 11 from saturated fat The National Diet and fat should be 35 with 11 from saturated fat The National Diet and Nutrition Survey in 20002001 found that the total energy intake from fat Nutrition Survey in 20002001 found that the total energy intake from fat was 36 in men and 35 in women with 13 from saturated fat It also was 36 in men and 35 in women with 13 from saturated fat It also found that the average intake of fruit and vegetables was fewer than 3 found that the average intake of fruit and vegetables was fewer than 3 portions per day compared with the recommended 5 portions In the same portions per day compared with the recommended 5 portions In the same survey salt intake was 11 g per day for men and 81 g for women survey salt intake was 11 g per day for men and 81 g for women However the Scientific Advisory Committee on Nutrition suggests that salt However the Scientific Advisory Committee on Nutrition suggests that salt intake should be no more than 6 g per dayintake should be no more than 6 g per day

Trans fatty acids reduce high-density lipoprotein (HDL) and increase low-Trans fatty acids reduce high-density lipoprotein (HDL) and increase low-density lipoprotein (LDL) cholesterol and can increase CHD risk A meta-density lipoprotein (LDL) cholesterol and can increase CHD risk A meta-analysis showed that a 2 increase in the energy intake from trans fatty analysis showed that a 2 increase in the energy intake from trans fatty acids increased CHD incidence by 23acids increased CHD incidence by 23

Eating oily fish rich in omega-3 fatty acids has been shown to reduce CHD Eating oily fish rich in omega-3 fatty acids has been shown to reduce CHD mortalitymortality

increased intake in dietary fibre also appears to reduce riskincreased intake in dietary fibre also appears to reduce risk

POOR NUTRITIONPOOR NUTRITION

Trans fatty acids reduce high-density Trans fatty acids reduce high-density lipoprotein (HDL) and increase low-density lipoprotein (HDL) and increase low-density lipoprotein (LDL) cholesterol and can lipoprotein (LDL) cholesterol and can increase CHD risk A meta-analysis showed increase CHD risk A meta-analysis showed that a 2 increase in the energy intake that a 2 increase in the energy intake from trans fatty acids increased CHD from trans fatty acids increased CHD incidence by 23incidence by 23

Eating oily fish rich in omega-3 fatty acids Eating oily fish rich in omega-3 fatty acids has been shown to reduce CHD mortalityhas been shown to reduce CHD mortality

increased intake in dietary fibre also increased intake in dietary fibre also appears to reduce riskappears to reduce risk

INFREQUENT EXERCISEINFREQUENT EXERCISE

Physical activity reduces the risk of CHDPhysical activity reduces the risk of CHD The 2002 World Health Report estimated The 2002 World Health Report estimated

that over 20 of CHD in developed that over 20 of CHD in developed countries was due to physical inactivitycountries was due to physical inactivity

Recommended physical activity levels are Recommended physical activity levels are 30 minutes of moderate physical activity 30 minutes of moderate physical activity on 5 or more days per weekon 5 or more days per week

Over one third of UK adults are estimated Over one third of UK adults are estimated to be inactive (exercised for less than one to be inactive (exercised for less than one occasion of 30 minutes per week)occasion of 30 minutes per week)

ALCOHOL AND WELLBEINGALCOHOL AND WELLBEING 1 to 2 units of alcohol per day reduce the risk of 1 to 2 units of alcohol per day reduce the risk of

CHD Alcohol increases HDL cholesterol and CHD Alcohol increases HDL cholesterol and reduces thrombotic risk Higher levels of reduces thrombotic risk Higher levels of consumption increase risks from other causesconsumption increase risks from other causes

The World Health Report in 2002 estimated that The World Health Report in 2002 estimated that 2 of CHD in men in developed countries is due 2 of CHD in men in developed countries is due to excessive to excessive alcohol consumptionalcohol consumption

Men should drinK no more than 3 to 4 units on Men should drinK no more than 3 to 4 units on any one day and women no more than 2 to 3 any one day and women no more than 2 to 3 unitsunits

Psychosocial wellbeingPsychosocial wellbeing Work stress lack of social support Work stress lack of social support depressiondepression

anxietyanxiety and personality (particularly hostility) can and personality (particularly hostility) can all increase CHD riskall increase CHD risk

Blood pressureBlood pressure

For adults aged 40 to 69 years each 20 For adults aged 40 to 69 years each 20 mm Hg rise in usual systolic blood mm Hg rise in usual systolic blood pressure or 10 mm Hg rise in diastolic pressure or 10 mm Hg rise in diastolic blood pressure doubles the risk of death blood pressure doubles the risk of death from CHDfrom CHD

The INTERHEART study showed that 22 The INTERHEART study showed that 22 of heart attacks in Western Europe were of heart attacks in Western Europe were due to a history of high blood pressure and due to a history of high blood pressure and those with those with hypertensionhypertension had almost twice had almost twice the risk of a heart attackthe risk of a heart attack

CHOLESTEROLCHOLESTEROL CholesterolCholesterol CHD risk is related to cholesterol levelsCHD risk is related to cholesterol levels The INTERHEART study suggested that 45 of The INTERHEART study suggested that 45 of

heart attacks in Western Europe are due to heart attacks in Western Europe are due to abnormal blood lipidsabnormal blood lipids

People with low levels of HDL cholesterol have an People with low levels of HDL cholesterol have an increased risk of CHD and a worse prognosis after increased risk of CHD and a worse prognosis after a myocardial infarctiona myocardial infarction

In the UK it is suggested that the target In the UK it is suggested that the target cholesterol is lt 4 mmolL for people with diabetes cholesterol is lt 4 mmolL for people with diabetes or established CVD or for people at high risk of or established CVD or for people at high risk of developing CVD People with HDL cholesterol lt1 developing CVD People with HDL cholesterol lt1 mmolL should also be considered for treatmentmmolL should also be considered for treatment

OBESITY AND DIABETESOBESITY AND DIABETES Obesity is an independent risk factor for CHD It is Obesity is an independent risk factor for CHD It is

also a risk factor for hypertensionalso a risk factor for hypertensionhyperlipidaemiahyperlipidaemia diabetes and diabetes and impaired glucose toleranceimpaired glucose tolerance

Central or abdominal obesity is most significant Central or abdominal obesity is most significant Those with central obesity have over twice the Those with central obesity have over twice the risk of heart attackrisk of heart attack

DiabetesDiabetes Men with Men with type 2 diabetestype 2 diabetes have a 2 to 4 times have a 2 to 4 times

greater annual risk of CHD women have a 3 to 5 greater annual risk of CHD women have a 3 to 5 times greater risktimes greater risk

Over 4 of men and 3 of women in England Over 4 of men and 3 of women in England have diagnosed diabetes The prevalence is have diagnosed diabetes The prevalence is increasingincreasing

ETHNICITYETHNICITY EthnicityEthnicity South Asians living in the UK (people from India Pakistan South Asians living in the UK (people from India Pakistan

Bangladesh and Sri Lanka) have a higher premature death Bangladesh and Sri Lanka) have a higher premature death rate from CHD (46 higher for men 51 higher for rate from CHD (46 higher for men 51 higher for women)women)

Hypotheses for this include migration disadvantaged Hypotheses for this include migration disadvantaged socioeconomic status proatherogenic diet lack of socioeconomic status proatherogenic diet lack of exercise high levels of homocysteine and lipoprotein(a) exercise high levels of homocysteine and lipoprotein(a) (Lp(a)) endothelial dysfunction and enhanced plaque and (Lp(a)) endothelial dysfunction and enhanced plaque and systemic inflammationsystemic inflammation

The premature death rate from CHD in West Africans and The premature death rate from CHD in West Africans and people from the Caribbean is much lower (half the rate people from the Caribbean is much lower (half the rate compared with the general population for men and two-compared with the general population for men and two-thirds of the rate for women)thirds of the rate for women)

FAMILY HISTORYFAMILY HISTORY Family historyFamily history First-degree relatives of patients with premature First-degree relatives of patients with premature

myocardial infarction have double the risk themselvesmyocardial infarction have double the risk themselves Premature CHD is that before age 55 years in men and 60 Premature CHD is that before age 55 years in men and 60

years in womenyears in women More than one third of admissions for premature More than one third of admissions for premature

myocardial infarction could be prevented by screening and myocardial infarction could be prevented by screening and treating first-degree relativestreating first-degree relatives

Genetic predisposition and shared lifestyle are likely to Genetic predisposition and shared lifestyle are likely to contributecontribute

Several regions of the human genome have been shown to Several regions of the human genome have been shown to be associated with either CHD or hypertensionbe associated with either CHD or hypertension

ECONOMIC COSTECONOMIC COST

In 2006 CVD cost the healthcare system in the In 2006 CVD cost the healthcare system in the UK around pound144 billion This represents a cost UK around pound144 billion This represents a cost per capita of just under pound250 The cost of hospital per capita of just under pound250 The cost of hospital care for people who have CVD accounts for about care for people who have CVD accounts for about 72 of these costs whereas 20 of the cost is 72 of these costs whereas 20 of the cost is due to drugsdue to drugs

In 2006 production losses due to mortality and In 2006 production losses due to mortality and morbidity associated with CVD cost the UK over morbidity associated with CVD cost the UK over pound82 billion with around 55 of this cost due to pound82 billion with around 55 of this cost due to death and 45 due to illness in those of working death and 45 due to illness in those of working ageage

PUBLIC HEALTH TARGETSPUBLIC HEALTH TARGETS Public health targetsPublic health targetsThree-year average mortality rates for Three-year average mortality rates for

circulatory diseases (ages under 75 years) for England have fallen circulatory diseases (ages under 75 years) for England have fallen by 440 since the baseline The minimum target requirement for by 440 since the baseline The minimum target requirement for a 40 reduction by 2009-2011 has been met ahead of schedulea 40 reduction by 2009-2011 has been met ahead of schedule

The absolute gap in mortality rates for circulatory diseases (ages The absolute gap in mortality rates for circulatory diseases (ages under 75 years) between the Spearhead Group and England as a under 75 years) between the Spearhead Group and England as a whole has reduced by 359 since the baseline compared with whole has reduced by 359 since the baseline compared with the required target reduction of 40 by 2009-2011 The the required target reduction of 40 by 2009-2011 The Spearhead Group consists of the 70 local authority areas that are Spearhead Group consists of the 70 local authority areas that are in the bottom fifth nationally for 3 or more of the following 5 in the bottom fifth nationally for 3 or more of the following 5 factors male life expectancy at birth female life expectancy at factors male life expectancy at birth female life expectancy at birth cancer mortality rate in the under-75s CVD mortality rate in birth cancer mortality rate in the under-75s CVD mortality rate in the under-75s and the Index of Multiple Deprivation (2004)the under-75s and the Index of Multiple Deprivation (2004)

WHAT CAN BE DONE AT A WHAT CAN BE DONE AT A PRACTICE LEVEL PRACTICE LEVEL

GET INTO SMALL GROUPS AND GET INTO SMALL GROUPS AND CONSIDER ALL THE INTERVENTIONS CONSIDER ALL THE INTERVENTIONS YOU CAN THINK OF TO PROMOTE YOU CAN THINK OF TO PROMOTE INCREASED AWARENESS OF IHD AND INCREASED AWARENESS OF IHD AND ENCOURAGE PREVENTION OF IHD ENCOURAGE PREVENTION OF IHD WITHIN THE PRACTICE COMMUNITYWITHIN THE PRACTICE COMMUNITY

IHD PREVENTIONIHD PREVENTION HEALTH AWARENESS DAYSHEALTH AWARENESS DAYS OPPOTUNISTIVE BP CHECKSOPPOTUNISTIVE BP CHECKS SMOKING CESSATION CLINICSSMOKING CESSATION CLINICS WEIGHT MANAGEMENT CLINICS WEIGHT WEIGHT MANAGEMENT CLINICS WEIGHT

LOSS VOUCHERSLOSS VOUCHERS REFERRAL FOR EXERCISE ON REFERRAL FOR EXERCISE ON

PRESCRIPTION AND LOCAL GYM PRESCRIPTION AND LOCAL GYM MEMBERSHIP REDUCTION SCHEMESMEMBERSHIP REDUCTION SCHEMES

DIABETES SCREENINGDIABETES SCREENING ALCOHOL SCREENING AND REFERRAL ALCOHOL SCREENING AND REFERRAL

INFORMATIONINFORMATION

IHD PREVENTIONIHD PREVENTION COMMUNITY LINKS COMMUNITY LINKS IN SCHOOLS WITH AID FROM SCHOOL NURSES TO IN SCHOOLS WITH AID FROM SCHOOL NURSES TO

PROMOTE HEALTHY EATING AND EXERISE AS PROMOTE HEALTHY EATING AND EXERISE AS WELL AS ADVICE ABOUT SMOKING AND ALCOHOLWELL AS ADVICE ABOUT SMOKING AND ALCOHOL

LOCAL PUBS ndash ENCOUAGE INFO RE HEALTHY LOCAL PUBS ndash ENCOUAGE INFO RE HEALTHY OPTIONS OPTIONS

LOCAL SUPERMARKETS ndash SPOT TESTING FOR DM LOCAL SUPERMARKETS ndash SPOT TESTING FOR DM AND BPAND BP

LOCAL RADIO AND NEWSPAPER ADVERTISINGLOCAL RADIO AND NEWSPAPER ADVERTISING HEALTH AWARENESS CAFES AND THEATRE HEALTH AWARENESS CAFES AND THEATRE

GROUPSGROUPS

EPIDEMIOLOGY OF CANCEREPIDEMIOLOGY OF CANCER

RISK FACTORSRISK FACTORS

The most significant risk factor is The most significant risk factor is age According to cancer researcher age According to cancer researcher Robert A WeinbergRobert A Weinberg If we lived long If we lived long enough sooner or later we all would enough sooner or later we all would get cancer get cancer

Cancer ndash risk factorsCancer ndash risk factors Over a third of cancer deaths worldwide are due to Over a third of cancer deaths worldwide are due to

potentially modifiable risk factors The leading modifiable potentially modifiable risk factors The leading modifiable risk factors worldwide arerisk factors worldwide are

tobacco smokingtobacco smoking which is strongly associated with lung which is strongly associated with lung cancer mouth and throat cancercancer mouth and throat cancer

drinking alcoholdrinking alcohol which is associated with a small increase which is associated with a small increase in oral esophageal breast and other cancersin oral esophageal breast and other cancers

a diet low in a diet low in fruitfruit and and vegetablesvegetables physical inactivity which is associated with increased risk physical inactivity which is associated with increased risk

of colon breast and possibly other cancersof colon breast and possibly other cancers obesityobesity which is associated with colon breast endometrial which is associated with colon breast endometrial

and possibly other cancersand possibly other cancers sexual transmission of sexual transmission of human human papillomaviruspapillomavirus which which

causes causes cervical cancercervical cancer and some forms of and some forms of anal canceranal cancer Men with cancer are twice as likely as women to have a Men with cancer are twice as likely as women to have a

modifiable risk factor for their diseasemodifiable risk factor for their disease

OTHER RISK FACTORS FOR OTHER RISK FACTORS FOR CANCERCANCER

Other lifestyle and environmental factors known to affect cancer Other lifestyle and environmental factors known to affect cancer risk (either beneficially or detrimentally) include the use of risk (either beneficially or detrimentally) include the use of exogenous hormones (eg exogenous hormones (eg hormone replacement hormone replacement therapytherapycauses breast cancer) exposure to ionizing causes breast cancer) exposure to ionizing radiation and ultraviolet radiation and certain occupational and radiation and ultraviolet radiation and certain occupational and chemical exposureschemical exposures

Every year at least 200000 people die worldwide from cancer Every year at least 200000 people die worldwide from cancer related to their workplace Millions of workers run the risk of related to their workplace Millions of workers run the risk of developing cancers such as lung cancer and mesotheliomafrom developing cancers such as lung cancer and mesotheliomafrom inhaling asbestos fibers and tobacco smoke or leukemia from inhaling asbestos fibers and tobacco smoke or leukemia from exposure to benzene at their workplaces exposure to benzene at their workplaces

Currently most cancer deaths caused by occupational risk factors Currently most cancer deaths caused by occupational risk factors occur in the developed world It is estimated that approximately occur in the developed world It is estimated that approximately 20000 cancer deaths and 40000 new cases of cancer each year 20000 cancer deaths and 40000 new cases of cancer each year in the US are attributable to occupationin the US are attributable to occupation

CANCER PREVENTIONCANCER PREVENTION

SMALL GROUPS AGAINhellipSMALL GROUPS AGAINhellip

A 55 year old comes to see you and A 55 year old comes to see you and is reluctant to stop her HRT which is reluctant to stop her HRT which she has been taking for 6 years How she has been taking for 6 years How do you explain her risks do you explain her risks

HRT RISKSHRT RISKS

Risks associated with HRT include increased risks Risks associated with HRT include increased risks of breast cancer (with long duration HRT) blood of breast cancer (with long duration HRT) blood clot and possibly cardiovascular disease For clot and possibly cardiovascular disease For many women the benefits outweigh the risks but many women the benefits outweigh the risks but for some alternative treatments for either for some alternative treatments for either symptom control or osteoporosis symptom control or osteoporosis preventiontreatment may be recommendedpreventiontreatment may be recommended

Breast CancerBreast Cancerbull Current opinion is that HRT taken for less than 5 years Current opinion is that HRT taken for less than 5 years

does not significantly increase the risk of breast cancer does not significantly increase the risk of breast cancer but studies have shown that after 5 years of use there but studies have shown that after 5 years of use there is an association with a small increased riskis an association with a small increased risk

HRT and Cancer RiskHRT and Cancer Riskbull Using combined HRT for five years in women aged 50-59 there are six Using combined HRT for five years in women aged 50-59 there are six

additional cases of breast cancer per 1000 women on a baseline additional cases of breast cancer per 1000 women on a baseline incidence of about 10 per 1000 women For oestrogen-only HRT there incidence of about 10 per 1000 women For oestrogen-only HRT there are about two extra cases per 1000 womenare about two extra cases per 1000 women

bull Using combined HRT for five years in women aged 60-69 there are Using combined HRT for five years in women aged 60-69 there are nine extra cases per 1000 women on a baseline incidence of 15 per nine extra cases per 1000 women on a baseline incidence of 15 per 1000 women For oestrogen-only HRT there are three extra cases1000 women For oestrogen-only HRT there are three extra cases

bull If duration of use increases to 10 years in women aged 50-59 taking If duration of use increases to 10 years in women aged 50-59 taking combined HRT there are 24 additional cases of breast cancer per combined HRT there are 24 additional cases of breast cancer per 1000 women on a baseline incidence of 20 per 1000 women For 1000 women on a baseline incidence of 20 per 1000 women For oestrogen-only HRT there are six extra casesoestrogen-only HRT there are six extra cases

bull For women aged 60-69 with 10 years use combined HRT increases For women aged 60-69 with 10 years use combined HRT increases cases of breast cancer by 36 per 1000 on a baseline of 30 per 1000 cases of breast cancer by 36 per 1000 on a baseline of 30 per 1000 women and oestrogen-only by nine caseswomen and oestrogen-only by nine cases

The excess breast cancer risk subsides within five years of The excess breast cancer risk subsides within five years of stoppingstopping