Why Did Doctors Keep Prescribing Cancer?

We’ve known about the role of estrogen in breast cancer going back to the 1800s, when surgical removal of the ovaries seemed to help in some cases. Ovaries were said to send out “mysterious” influences to the rest of the body, which were identified as estrogen in 1923. The medical profession jumped on this discovery and started injecting menopausal women by the thousands, and it was said that “[t]he ‘shot’ gives a ‘respectable’ hook on which to hang the visit to the doctor…” Soon, there were pills and patches, and medical journals like the Journal of the American Medical Association regaled doctors with ads I feature in my video How Did Doctors Not Know About the Risks of Hormone Therapy? on how they can “help the women to happiness by simply prescribing estrogen” and, “[w]hen women outlive their ovaries…,” there is Premarin.

As far back as the 1940s, concerns were raised that this practice might cause breast cancer, noting it would have been nice to figure this out before we started dosing women en masse. But breast cancer risk didn’t seem to matter as much, because heart disease was the number-one killer of women, reviews concluded, and because women taking hormones appeared to have lower heart attack rates, which would outweigh any additional breast cancer. However, women taking estrogen tended to be of a higher socioeconomic class, exercised more, and engaged in other healthy lifestyle changes like consuming more dietary fiber and getting their cholesterol checked. So, maybe that’s why women taking estrogen appeared to be protected from heart disease. Perhaps it had nothing to do with the drugs themselves. Despite the medical profession’s “enthusiasm for estrogen replacement therapy,” only a randomized clinical trial could really resolve this question. We would need to divide women into two groups, with half getting the hormones and half getting a placebo, and follow them out for a few years. There was no such study…until the 1990s, when the Women’s Health Initiative study was designed.

Wait a second. Why did it take the bulk of a century to decide to definitively study the safety of something prescribed to millions of women? Perhaps because there had never been a female director of the National Institutes of Health until then. “Just three weeks after being named NIH Director in 1991, [Bernadine Healy] went before Congress to announce, ‘We need a moon walk for women.’ That ‘moon walk’ took the form of the Women’s Health Initiative, the most definitive, far-reaching clinical trial of women’s health ever undertaken in the United States.”

The bombshell landed in summer 2002. There was so much more invasive breast cancer in the hormone users that they were forced to stop the study prematurely. What about heart disease? Wasn’t that supposed to balance things out? The women didn’t just have more breast cancer—they had more heart attacks, more strokes, and more blood clots to their lungs.

The news that women treated with hormone replacement therapy “experienced higher rates of breast cancer, cardiovascular disease, and overall harm has rocked women and physicians across the country.” Estrogen started out as the most prescribed drug in America before the study, but, after, the number of prescriptions dropped immediately and, within a year, so did the incidence of breast cancer in the United States.

The most important question about this story is why were we all so surprised? There had been “decades of repeated warnings” about the risks of cancer. In fact, the reason breast cancer patients had so much trouble suing the pharmaceutical company was that “the drugs have contained warning labels for decades.” And, with that disclosure, surely any reasonable physician would have included it in their risk and benefit discussions with their patients, right? It’s like the warning labels on packs of cigarettes. If you get lung cancer now, you should have known better. And, so, if you were on hormone replacement therapy and got breast cancer, don’t blame the drug company. They warned you about the risks, right there in the fine print.

Why didn’t more doctors warn their patients? Even after the study came out, millions of prescriptions continued to be dispensed. That’s a lot of cancer in our patients we caused, wrote one doctor. “How long will it take us to discard the financial gains, to admit that we are harming many of our patients, and to start changing our prescription habits?”

“Why did this practice continue in the face of mounting evidence of harm?” Well, it is a multibillion-dollar industry. “Despite an overwhelming amount of evidence to the contrary, many physicians still believe that estrogenic hormones have overall health benefits,” a “non-evidence-based perception [that] may be the result of decades of carefully orchestrated corporate influence on medical literature.” Indeed, “[d]ozens of ghostwritten reviews and commentaries published in medical journals and supplements were used to promote unproven benefits and downplay harms of menopausal hormone therapy…” PR companies were paid to write the articles that were then passed off as having been written by some expert.

What now? “Gynecologists must switch allegiance from eminence-based to evidence-based medicine.” In other words, they must consider what the science says and not just what some so-called expert says. It’s been said that the “current culture of gynecology encourages the dissemination of health advice based on advertising rather than science.”

“Women were placed in the way of harm by their physicians, who acted as unsuspecting patsies for the pharmaceutical companies.” If we really wanted to prevent heart attacks in women, simple lifestyle behaviors can eliminate more than 90 percent of heart attack risk. So, instead of being Big Pharma’s pawns, “recommending a healthful diet, increased exercise, and smoking cessation would truly benefit women’s health.”


The whole Premarin debacle speaks to the importance of putting purported therapies to the test (see, for example, Do Vitamin D Supplements Help with Diabetes, Weight Loss, and Blood Pressure?), as well as to the power of Big Pharma (Eliminating Conflicts of Interest in Medical Research), medical community collusion (American Medical Association Complicity with Big Tobacco), and my most series on mammograms.

What about Plant-Based Bioidentical Hormones and Soy Phytoestrogens for Menopause Hot Flashes? Check out the videos to find out.

In general, patients (and doctors) tend to wildly overestimate the efficacy of pills and procedures. See Why Prevention Is Worth a Ton of Cure and The Actual Benefit of Diet vs. Drugs.

Medical care, in general, may be the third leading cause of death in the United States. See How Doctors Responded to Being Named a Leading Killer.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Why Doctors are So Drug Happy

Who funds most of the studies that show drugs are safe and effective? The drug companies themselves. This is the topic of my video Eliminating Conflicts of Interest in Medical Research.

“It is self-evidently absurd to look to investor-owned companies for unbiased evaluations of their own products…One result of the bias in this literature is that physicians learn to practice a very drug-intensive style of medicine. Even when lifestyle changes would be more effective, physicians and their patients often believe that for every ailment there is a drug.” It’s gotten so bad that “[p]hysicians can no longer rely on the medical literature for valid and reliable information.” That’s quite an accusation. Says who? Says a long-time editor of the New England Journal of Medicine, one of the most prestigious medical journals in the world.

To help expose some of the conflicts of interest corrupting the medical profession, the Drug Company Gift Disclosure Act was introduced in Congress where it died year after year until it was successfully integrated into the Affordable Care Act. Now, there’s a database detailing which doctors get the billions of dollars that are dished out, “permit[ting] patients to make better informed decisions when choosing health care professionals and making treatment decisions.” (I explain how you can easily look up your own doctor in my video Find Out If Your Doctor Takes Drug Company Money.)

In 2008, medical groups endorsed a version of the Act that didn’t require public disclosure unless doctors got at least $500 in gifts, but the 2009 version got stricter, requiring disclosure if you pocketed even $100, leading groups like the American Academy of Family Physicians to start to get a bit nervous. The final wording in Obamacare, however, requires disclosure of even a $10 meal, leading countries around the world to look to the United States for leadership in healthcare ethics. You don’t see that every day!

Now that we have this massive public record, we can really see how honest doctors have been. The financial disclosures by the authors of all the American College of Cardiology and American Heart Association guidelines were matched to the public disclosures of the hundreds of thousands of dollars they received from Big Pharma. The result? “The overall agreement between author and company disclosure was poor.” Nationally, female physicians each received thousands of dollars less than male doctors on average from drug companies each year, though it’s not clear if this is because the women were more ethical or the industry was sexist.

What about conflicts of interest for online clinical support websites? “Point-of-care evidence-based medicine websites allow physicians to answer clinical queries using recent evidence at the bedside” of a patient. Clinicians caring for patients are increasingly reviewing treatment recommendations on these sites to make clinical decisions in real time. For instance, if you’re with a patient, you can just whip out your phone and check one. It’s important that “[m]embers of groups developing formal clinical guidelines are discouraged from interacting with the health industry in a manner that may create a conflict of interest.” Researchers examined one such website called UpToDate, which seemed to provide the most comprehensive diagnoses. Did they find any conflicts of interest? Yes, in every single UpToDate article they examined.

So what do we do with this information? Let’s say we see an article claiming that candy consumption is not associated with health risks and the authors disclose that their research was supported by the National Confectioners Association, a group that used to run ads that said things like: “Put candy in their school lunch. It’s good for them.” We may want to take the results of that article with a grain of salt.

“The problem with financial COIs [conflicts of interest] is that you simply don’t know what to believe.” Maybe this “preoccupation with disclosure hijacked the debate…” Maybe, as Dr. Kassirer, the former chief editor of the New England Journal of Medicine, critiqued, the focus instead should be on eliminating commercial conflicts, not just disclosing them. It’s like campaign finance reform, where the issue is managed more by public disclosure rather than getting money out of politics. Indeed, he writes that “the vast attention paid to failure to disclose conflicts of interest is misplaced, and that more attention must be focused on the financial conflicts themselves.”

After Dr. Kassirer effectively resigned from the New England Journal of Medicine, disillusioned with the direction they were taking, Dr. Marcia Angell took over. She was the first female chief editor in the journal’s hundred-year history and lasted about a year. Medical journals “consistently refer to ‘potential’ conflicts of interest,” she wrote, “as though that were different from the real thing, and about disclosing and ‘managing’ them, not about prohibiting them. In short, there seems to be a desire to eliminate the smell of corruption, while keeping the money. Breaking the dependence of the medical profession on the pharmaceutical industry will take more than appointing committees and other gestures. It will take a sharp break from an extremely lucrative pattern of behavior.”


Why do funding sources matter? See my video Disclosing Conflicts of Interest in Medical Research.

The shameful practices of supposed science-based medicine websites, like UpToDate, are the very reason I started NutritionFacts.org in order to share the best available evidence without corrupting commercial influence. If you value my work, please consider becoming a supporter by making a recurring monthly donation to the 501c3 nonprofit that keeps NutritionFacts.org growing and thriving.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Dishonest Doctors

One of the critical questions to ask whenever reading a medical journal article is, “Who funded the study?” In most journals, researchers are required to identify their sources of funding, so what’s the problem? Well, researchers can obscure the true origin of financial support: They can hide it, disguise it, or even launder the money through a front group. A case in point is a study downplaying the risks of lung cancer that was funded in part by the Foundation for Lung Cancer: Early Detection, Prevention, and Treatment. That doesn’t sound so bad until you realize it was underwritten by millions of dollars from a tobacco company. There’s no obligation to “disclose a funding source’s source of funding,” which allows “companies to evade financial disclosure requirements” and makes it harder to “follow the money trail.”

As I discuss in my video Disclosing Conflicts of Interest in Medical Research, why does the funding source matter? Every single one of eight reviews covering over a thousand studies found that research funded by industry is more likely to make conclusions that are favorable to industry. For example, why do some review articles on the health effects of secondhand smoke reach different conclusions than others? The only factor found was whether an author was affiliated with the tobacco industry. “This is a disturbing finding. It suggests that, far from conflict of interest being unimportant in the objective and pure world of science…it is the main factor determining the result of studies.”

Not that we’d even know, because 77 percent of authors failed to disclose the sources of funding. And that’s another problem: The responsibility to disclose funding sources is left entirely up to the authors. So, how many researchers divulge the truth? Evidently, a law was passed in Denmark requiring physicians to register any time they worked with industry, which allowed researchers to cross-reference the studies physicians published to see how honest they were. Forty-eight percent of the time, the conflicts of interest were not disclosed, “reinforc[ing] the perception that physicians simply don’t take conflict of interest seriously” (or at least Danish physicians don’t).

What about the United States? Historically, there had been “no means of confirmation or verification” when an American doctor said they had no conflict of interest. Then in 2007, hip and knee replacement companies were forced to pay hundreds of millions of dollars in fines for giving orthopedic surgeons illegal kickbacks. “[M]any orthopedic surgeons in [the] country made decisions predicated on how much money they could make—choosing which device to implant by going to the highest bidder….[W]e expect doctors to make decisions based on what is in the best interests of their patients,” said the Department of Justice’s U.S. Attorney of the District of New Jersey, “not the best interests of their bank accounts.” Part of the settlement was that the companies would have to make public all the payments they made to physicians. The release of those records offered a rare opportunity to see if physicians were telling the truth on disclosure forms. And, lo and behold, more than half of payments were not disclosed, totalling millions of dollars.

That was for surgeons and medical device companies. What about doctors and drug companies? The same thing happened: Drug companies were forced to disclose who they were paying off. In looking at the publications of the doctors who got the most money—at least $100,000—the study found that they were worse than the surgeons. In 69 percent of the cases, they failed to disclose their industry ties. The problem is that we just assume researchers are going to be honest and tell the truth, but these “findings suggest that the accuracy and completeness of [conflict-of-interest] disclosures cannot be assumed.” So, even when a paper says no conflict of interest, who knows if it’s really true.

A long-time editor-in-chief of the New England Journal of Medicine wrote a scathing piece on drug companies and doctors who failed to disclose hundreds of thousands of dollars from drug companies like GlaxoSmithKline, which has been fined literally billions of dollars for activities such as bribing and suppressing data. When GSK got results that were “commercially unacceptable,” the company just buried them. Billions of dollars in fines get assessed, but for drug companies, that may just be the cost of doing business. “As reprehensible as many [drug] industry practices are…much of the medical profession is even more culpable.” We can expect drug companies to prioritize the bottom line, but maybe we should expect more from the healing profession.


What else might your doctor not be telling you? See:

Good examples of conflicts of interest include:

Instead of just disclosing conflicts of interest, how about getting rid of them? That’s the subject of my video Eliminating Conflicts of Interest in Medical Research.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations: