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Six Step Approach On HRT Prescription

This dissertation aims to highlight the benefits associated with the prescription of HRT despite the risk of breast cancer. Since there was considerable amount of literature available around this topic, it was important to bring together relevant studies which are specifically related to the research question. The literature needed directly depends on the research question as varied questions will need varied evidence (Aveyard and Sharp, 2009). Hence with a clearly focused and narrowed question the evidence needed brought up would be relevant and specific (Aveyard and Sharp, 2009).

It is down to the researcher’s judgement to decide the information needed to answer the question and the importance one information is given over the other (Aveyard, 2010; Aveyard and Sharp, 2009). In order to explore relevant studies, a systematic search strategy was used to trace the broadest collection of published material and answer the research question (Aveyard, 2010). This approach was to assess the maximum amount of relevant studies within the given time and scope for this dissertation (Aveyard, 2010).


The six step approach proposed by (Aveyard and Sharp, 2009) was used to conduct this systematic search which was;

STEP 1 - Stating the focus and formation of the research question

A well crafted and focused research question (Aveyard and Sharp, 2009) helps identify the aims of the study and guide the researcher through the dissertation (Aveyard, 2010). Hence formation of the research question was done using the format of Population, Intervention, comparisons/context, Outcome, Time (PICOT) (Aveyard and Sharp, 2009). The research question “Why is HRT prescribed for menopausal women despite the risks of Breast Cancer?” can be broken into the PICOT format:

Population – menopausal women

Intervention- HRT

Comparison/context- benefits of HRT with the potential risk of Breast Cancer

Outcome – benefits of HRT in presence of breast cancer

Time – 01-01-1996 to 15-10-2010.

STEP 2 - Identification and Selection of key terms

In the process of identifying a comprehensive literature search it is important to decide the key terms as studies are indexed in databases according to specific key terms (Aveyard, 2010). As the first step the key terms which were appropriate to represent the study were explored and other synonyms or alternative words were constructed around it later (Aveyard, 2010). The three terms which come out prominently from the research question were ‘Breast Cancer’, ‘HRT’ and ‘menopausal women’.

During the preliminary literature search a trial search was conducted using the following key terms :

* Breast Cancer *


* Breast Neoplasm *


*Breast Malignancy *


*Breast Disease *


*Breast Disorder *


*Breast Abnormality * and the key term of * Breast Cancer * separately.

The terms other than Breast cancer brought in studies which were generally related to breast cancer treatment. Although a marginal difference in the results was seen but to keep the term specific and bring in relevant studies related to the dissertation the first key term * Breast Cancer * was decided.

For the second term *HRT* or * Hormone Replacement Therapy* was searched and there was a huge difference in the data. Hence the chances of getting diverted from the topic was quite high by using the term *Hormone Replacement Therapy*. And also the fact that the medically used term for Hormone Replacement therapy is *HRT* made using the term *HRT* as a prioritized option. However only after trying the key term *HRT* in combination with other selected key terms could the final decision of using *HRT* as the second term be made.

Using the third search term

* Menopause*


* Menopausal*


* Postmenopausal*, the preliminary search again brought in huge unmanageable difference in results.

It appeared disoriented with varied study types not related to Breast cancer also came up which perhaps could be a hindrance to the integrity of the review.

After many trials and errors of combining different key terms the specific results were seen and the best combination to bring in relevant studies was

*Breast Cancer* AND *HRT* AND *Menopause*.

The terms *Breast Cancer* and *HRT* and *menopause * are the most widely used medical terms in studies hence this combination was the apt choice. They were searched for within the abstract so as to not miss studies which have not mentioned these terms in the title (Aveyard, 2010).

STEP 3 - Identification and Selection of Inclusion and Exclusion Criteria

Rejection of articles is also important for proper selection hence applying inclusion and exclusion criteria helped identify the relevant article from the ones which were not (Aveyard and Sharp, 2009). Essential information about the scale and relevance of the research question helped to form the criteria (Aveyard, 2010). The inclusion and exclusion criteria were ;

Inclusion Criteria:

A study for each year from the year 1996 to 2010.

Studies related to Breast Cancer and HRT.

Randomized Control Trials, cohort and case control studies.

English language.

Exclusion Criteria:

Studies before the year 1996.

Studies related other than breast cancer and HRT.

Case-reports, systematic reviews, Cross sectional studies and surveys.

Initially it was thought of considering studies from 1991 to 2010 but after the preliminary literature search it was deemed appropriate to include studies from the year 1996 to 2010 as the era of massive epidemiological studies began from the mid 1990’s. However it must be noted that there have been studies which have been conducted before 1996. Also this criterion would help understand the latest trend of the use of HRT and its related link to risk of Breast Cancer.

This latest relevance would help the study to be more generalized and practitioners, patients or any person reading this review could identity and understand the current scenario. Many study trials like experimental, epidemiological and observational studies have been conducted to link the use of HRT to breast cancer. Hence it was considered to include RCT’s, cohort and case-control studies.

Since there was sufficient research available for breast cancer it was decided only to include studies related to HRT and breast cancer. However the era of unrest and this debate about the risk associated with long term use of HRT started with the link of both breast and endometrial cancer (Wilson, 1962). But as decades went by and number of breast cancer patients increased so did the field of breast cancer research establishing the aforesaid link. Hence looking at the prevalence, the figures of breast cancer and the debate around its link to use of HRT; it was decided to include studies related only to Breast cancer and HRT for this review.

Although there might be relevant studies to the research question in non- English languages but given the time and scope constraint it would be difficult to translate any such articles. The other reason was perhaps important, conclusive and widely documented studies must have been translated in English language and included in the databases. Also if an attempt to translate the studies was made it may not be optimal to the scientific standards needed and the fact that much published literature is available the need to include non-English language studies wasn’t considered.

Cross sectional studies and surveys which provide a snapshot of any prevalent link in a well defined population were decided to be excluded primarily for two reasons; first to concise the review and bring in specific articles and secondly but most importantly these studies are often used as a part of data collection for RCT’s, cohort and case-control studies (Aveyard, 2010).

A detailed literature review can also be addressed as systematic review (Aveyard, 2010). They were excluded due to the fact that they are reviews in their own right with brief summaries of the best possible studies available then (Aveyard, 2010). The researcher decided to explore and finally conduct this study using the literature review methodology hence systematic review was not appropriate choice for exclusion. Case-reports were excluded as generally they are conducted with a few patients in a clinical setting hence were more susceptible to researcher bias. Also to give the review a broader horizon it was deemed appropriate to exclude them.

STEP 4 - Conducting a comprehensive search using selected key terms and inclusion and exclusion criteria

These well crafted criterion and key terms were used to assist in searching and reviewing the literature so as to identify relevant studies (Greenhalgh and Peacock 2005). There are four main ways of searching for literature (Aveyard, 2010);

1) Electronic searching using computer based databases.

2) Searching reference lists.

3) Hand searching relevant journals specific to the research topic.

4) Contacting authors directly.

Further, “Snowball-Sampling” is an effective approach by hand searching articles of references derived from other studies proved to be an efficient resource for this review (Aveyard, 2010; Greenhalgh and Peacock 2005). The Oxford Brookes library and the John Radcliffe library had a wide range of databases with huge subject indexes of journal articles and other literature related to the topic. The John Radcliffe library also had access to direct collection of journals. Hence it was an extremely efficient resource for searching reference lists and hand searching relevant journals.

The other equally efficient source of wide information for health and social care was the internet (Aveyard, 2010). However to maintain academic and medical standards it has to be acknowledged that not all the information available on the internet is reliable and up to the valid standards needed. If web is being used as a potential resource then it is to be critically questioned for the authorities supporting it, the existence and last updated date of the site and also the relation of the authors to the authority (Aveyard, 2010). When a relevant study for a particular year wasn’t available through the database search, the internet was used to explore if any such study was conducted in that particular year.

There were many databases available; however there was a need to identify the relevant database for the searching strategy (Aveyard, 2010). Initially PubMed, Medline, Cochrane Library, BNI, HMIC and CINAHL came up as relevant health related databases in the Oxford Brookes University library database search. The Cochrane Library database was eliminated as it holds systematic reviews which are excluded in this review (Aveyard, 2010). The database Medline though being a part of Pubmed was included with its link to the web of knowledge bringing in other studies. CINHAL was included as it is a widely used database for nursing research and it also has links to books, non-research papers along with journal articles (Aveyard, 2010).

In sum, Pubmed, MEDLINE (through web of knowledge) and CINHAL databases were used within the limits of the inclusion criteria for studies from 01-01-1996 to 15-10-2010. Along with these resources it was helpful to carefully study other dissertations to develop a vision of the structure and presentation of the dissertation.

STEP 5 - Recording the search strategy

The method used was by conducting search using single key term at a time and then combining them together to display the total article for every database used.

The findings are documented as under:

Database: PUBMED

Search Term *Breast cancer *- Total number of hits: 137949.

Search Term * HRT *- Total number of hits: 6255.

Search Term *Menopause *- Total number of hits: 28727.

Search Term *Breast cancer * AND *HRT* AND *Menopause* -

Total number of hits: 505.

Database: CINHAL

Search Term *Breast cancer *- Total number of hits: 16994.

Search Term * HRT *- Total number of hits: 1139.

Search Term *Menopause *- Total number of hits : 4343.

Search Term *Breast cancer * AND *HRT* AND *Menopause* -

Total number of hits: 41.

Database: MEDLINE (Using ISI Web of knowledge)

Search Term *Breast cancer *- Total number of hits: 92601.

Search Term * HRT *- Total number of hits: 5772.

Search Term *Menopause *- Total number of hits: 12,403.

Search Term *Breast cancer * AND *HRT* AND *Menopause* -

Total number of hits: 275.

STEP 6 - Storing the literature

After the systematic electronic search was conducted, relevant articles were recorded in the data collection table so as to demonstrate transparency of the method used. This table helped the process of retrieving articles in an organised and systematic method (Aveyard, 2007) and provides transparency to the systematic search strategy to assist any replication (Bryman, 2004, Sim and Wright, 2000).

DATA COLLECTION TABLE (Liberati et al, 2009).

505+275+41= 821 from Database search

5 from direct searching in journals.

296 duplicates removed

530 abstracts reviewed

423 excluded

107 articles assessed for eligibility

13 studies included in synthesis

94 full-text articles excluded with various reasons

Initially, 296 duplicates from the database searches were removed using the “Endnote” programme. The 530 abstracts for each reference were read thoroughly to determine the focus of the study (Aveyard, 2010). The literature found was reviewed preliminarily by skimming, comprehending, analyzing and synthesizing the studies a preparation for critiquing them before they were summarized (Burns and Grove, 2005). After the relevant studies were selected as per the inclusion criteria they were hand searched for the full articles especially through the John Radcliffe Library. For this dissertation one study per year was to be selected from 1996 to 2010, but there were no relevant studies available for the year 2000 and 2010, hence 13 studies were selected and critically appraised.

In order to provide a description of the selected studies a table was used to summarise the contents of the studies before they were individually critiqued – see page ** (Aveyard, 2007). The research papers were then appraised using the CASP tools by SPH (2010). During the course of critical appraisal the researcher reviewed every aspect of study thoroughly to establish the trustworthiness and also the relevance of the study to the aims of the review and research question. Codes were assigned to grade the studies and themes were developed covering 2 issues (Aveyard, 2007):

ISSUE 1- Benefits associated with the treatment of HRT

2) ISSUE 2- Breast cancer risk associated with the use of HRT.

The data extracted is divided into two broad areas of benefits associated with the use of HRT and risk of breast cancer associated with the use of HRT as this seemed a sensible way to present the data given the research question.

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