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Hormone-replacement therapy and the risk of breast-cancer
Mcrturilus. I3 ( I99 I ) 373-35 I
337
Elsevier Scientific Publishers Ireland Ltd.
MAT 00640
Abstract Section 9 IO46929 How American oncologists treat breast cancer: An assessment of tbe influence of clinical trials Belanger D.; Moore M.; Tannock 1. Ontario Cancrr Insrirutr, 500 Sherbournr SI, Toronto. Ont. M4X IKO J. CLIN. ONCOL.
1991 911 (7-16)
The present study was designed to assessthe preferred methods of treatment of breast cancer by American oncologists, and the impact ofclinical trials on their practice. We mailed 465 questionnaires to surgical. radiation, or medical oncologists. The questionnaire described five hypothetic patients with breast cancur, and respondents were asked to select their preferred treatment for each patient. For primary breast cancer. most physicians would oBer the choice of local excision followed by radiation therapy or modified radical mastectomy. About 80%)of physicians would prescribe adjuvant chemotherapy for a premenopausal woman with estrogen receptor-negative, axillary node negative breast cancer, and for a post-menopausal woman with estrogen receptor-negative, node-positive disease. This policy was favored by male and female physicians of each specialty. Almost all respondents would treat a young woman with inflammatory breast cancer with initial chemotherapy followed by radiation and/or surgery. and about 60% would recommend chemotherapy to a postmenopausal patient with estrogen receptor-negative disease and minimally symptomatic bone metastases. Clinical trials have compared treatment strategies that could be applied to patients described in our questionnaire. Preferred treatments for primary breast cancer. and for inflammatory breast cancer are supported by the results of clinical trials. Recommendation of adjuvant chemotherapy for node-negative breast cancer is not based on a con&tent demonstration of improvement in rurvival. although randomized trials with short follow-up have shown delay to recurrence. Recommendation ol adjuvant chemotherapy for a postmenopausal woman with node-positive breast cancer is contrary to the results of large randomized controlled trials (and to a metaanalysis). which have shown that this policy does not lead to improved survival. Our report suggests that even large randomized clinical trials may have a minimal impact on practice if their results run counter to belief in the value of the treatment. 91053010
Hormone-replacement therapy and the risk of breast-cancer Hulka B.S. Department of Epdemiology, University r?fNorth Cumlinrr in CIRI~PI Hill, Chupel Hill. NC CA CANCER J. CLIN. 1990 40/S (289-296) At least 30 epidemiologic studies designed to identify an association between hormone-replacement therapy and breast cancer risk have been published since 1974. In general, the design. quality. and analytic strategies used in these studies have improved over the years, and the number of subjc’*s in each study has increased. The results from studies published prior to 1985 can be summarized as showing a small increase in the risk of breast cancer after many years of estrogen use. Even this tentative conctlrsion is debatable. however, since many rigorous studies showed no association between estrogen use and breast cancer. This review will summarize the earlier lindings and emphasize several large, recent studier, that add at least two new dimensions to this body of research; they provide data from Europe and on the addition of progestins to the therapeutic regimen. This review indicates the following: I. Analyses of ever versus never use ofestrogen-replacement therapy show no association with breast cancer risk. 2. Duration of estrogenreplacement therapy affects risk. Based on studies in the United States. a relative risk of about I .5 may
338 be reachedafter IS or more yearsof use. 3. The increasein risk after long-duration hormone use is przrznt for women with either a natural or a surgical menopause. 4. European studies exhibit higher risks atier shorter durations of hormone use than do US studies. 5. The type of estrogen used and the addition of progestins to hormone-replacement therapy may alter the risk of breast cancer. Data that substantiate these points are reviewed and placed in context with hormonal theories of carcinogenesis.
91057447 Risk lactors for breast caacec Unger C.; Rageth J.C.; Wyss P.: Spillmann M.; Hochuli E. Universitatsfrauenklinilr, Frauenklinikstrasse IO, CH-8091 Zurich SCHWEIZ. MED, WOCHENSCHR. 1991 12111-2 (30.36) A group of 992 breastcancer patients(risk group, R) was compared with a group of482 patients hospitalized for non oncologic reasons and matched for age and year of hospitalization (comparison group, C). The Endings confhrn the following factors as risk factors for breast cancer: nulliparity (R 28.8%. C 17.5%. p < 0.001). late first birth (over 34 years of age) (R I I .4X. C 5. I%, p c 0.001). diabetes mellitus (R 7.0% C 3.8%. p = 0.017). hypertension (R 25.7%. C 18.I’%, p - 0.0016), alcohol (R 9.4% C 5.9% p = 0.03). positive family history (R 14.8%. V 5.3%. p < 0.001) and breast surgery for benign disease (R 13%. C 7.5% p = 0.002). Frequently mentioned risk factors such as early menarche and late menopause did not emerge as risk factors in our study. Cigarette smoking did not show a protective effect but even tended to be more frequent in the risk group. Multiparity (more than 2 births) was protective (R 22, I%, C 32.4%. p < 0.001). The findings on hormonal replacement therapy (R 7. I’%, V 17.0% p < 0.01) might have been influenced by a selection bias (hospitalization of patients in the comparison group because of complications of hormonal replacement therapy such as bleeding) and are thus not fully conclusive. It can at least be said that hormonal replacement therapy is not more frequent in the risk group.
91059443 An assessmentof smlivaryfunction in healthy premeaopausalaad postmenopausalfemales Ship J.A.; Patton L.L.: Tylenda CA. Notionollnsrirureof Dental Research,National Institutesof Health, Woo Rockville Pike, Bethe.& MD 20892 J. GERONTOL. 1991 46/l (MII-MIS) The elderly represent the most rapidly growing segment of the U.S. population, and the majority of this group are females, The average woman can anticipate living about a third of her life beyond menopause, and many U.S. women undergo hormonal replacement in an attempt to relieve menopausal symptoms. Little is understood about the relationship between menopause, hormonal replacement therapy, and the oral structures,although oral discomfort, xerostomia, and salivary hypofunction have been associatedwith postmenopausalwomen. The effects of menopausal status and estrogen therapy on subjective reports of oral dryness and discomfort and objective measurements of major salivary gland output were assessed in 43 healthy premenopausaiand postmenopausalfemales. No complaints of xerostomia or burning mouth and no alterations in the quantity of saliva occurred in this population. This study suggeststhat among healthy women salivary gland function is not significantly influenced by menopause or hormonal replacement therapy. 91059926 Endometrial tbickaess as measuredby omlovagiwl ultrasonographyfor identifying e&met&l Granberg S.: Wikland M.: Karlsson B.; Norstrom A.: Friberg L.-G. Department of Obstetrics and Gynecology, Suhlgrenska Hospital, 413 45 Goteborg AM. J. OBSTET. GYNECOL.
abnormality
1991 164/I I (47-52)
Diagnostic curettage has for many years been the meihod of choice to diagnose endometrial cancer in women with postmenopausal bleeding. The costs for curettage performed today are huge. and approximately only It% in this group of women will be diagnosed with endometrial cancer. Thus lessexpansive techniques to obtain endometrial samples have been evaluated, but all of them are invasive. The value
337
Elsevier Scientific Publishers Ireland Ltd.
MAT 00640
Abstract Section 9 IO46929 How American oncologists treat breast cancer: An assessment of tbe influence of clinical trials Belanger D.; Moore M.; Tannock 1. Ontario Cancrr Insrirutr, 500 Sherbournr SI, Toronto. Ont. M4X IKO J. CLIN. ONCOL.
1991 911 (7-16)
The present study was designed to assessthe preferred methods of treatment of breast cancer by American oncologists, and the impact ofclinical trials on their practice. We mailed 465 questionnaires to surgical. radiation, or medical oncologists. The questionnaire described five hypothetic patients with breast cancur, and respondents were asked to select their preferred treatment for each patient. For primary breast cancer. most physicians would oBer the choice of local excision followed by radiation therapy or modified radical mastectomy. About 80%)of physicians would prescribe adjuvant chemotherapy for a premenopausal woman with estrogen receptor-negative, axillary node negative breast cancer, and for a post-menopausal woman with estrogen receptor-negative, node-positive disease. This policy was favored by male and female physicians of each specialty. Almost all respondents would treat a young woman with inflammatory breast cancer with initial chemotherapy followed by radiation and/or surgery. and about 60% would recommend chemotherapy to a postmenopausal patient with estrogen receptor-negative disease and minimally symptomatic bone metastases. Clinical trials have compared treatment strategies that could be applied to patients described in our questionnaire. Preferred treatments for primary breast cancer. and for inflammatory breast cancer are supported by the results of clinical trials. Recommendation of adjuvant chemotherapy for node-negative breast cancer is not based on a con&tent demonstration of improvement in rurvival. although randomized trials with short follow-up have shown delay to recurrence. Recommendation ol adjuvant chemotherapy for a postmenopausal woman with node-positive breast cancer is contrary to the results of large randomized controlled trials (and to a metaanalysis). which have shown that this policy does not lead to improved survival. Our report suggests that even large randomized clinical trials may have a minimal impact on practice if their results run counter to belief in the value of the treatment. 91053010
Hormone-replacement therapy and the risk of breast-cancer Hulka B.S. Department of Epdemiology, University r?fNorth Cumlinrr in CIRI~PI Hill, Chupel Hill. NC CA CANCER J. CLIN. 1990 40/S (289-296) At least 30 epidemiologic studies designed to identify an association between hormone-replacement therapy and breast cancer risk have been published since 1974. In general, the design. quality. and analytic strategies used in these studies have improved over the years, and the number of subjc’*s in each study has increased. The results from studies published prior to 1985 can be summarized as showing a small increase in the risk of breast cancer after many years of estrogen use. Even this tentative conctlrsion is debatable. however, since many rigorous studies showed no association between estrogen use and breast cancer. This review will summarize the earlier lindings and emphasize several large, recent studier, that add at least two new dimensions to this body of research; they provide data from Europe and on the addition of progestins to the therapeutic regimen. This review indicates the following: I. Analyses of ever versus never use ofestrogen-replacement therapy show no association with breast cancer risk. 2. Duration of estrogenreplacement therapy affects risk. Based on studies in the United States. a relative risk of about I .5 may
338 be reachedafter IS or more yearsof use. 3. The increasein risk after long-duration hormone use is przrznt for women with either a natural or a surgical menopause. 4. European studies exhibit higher risks atier shorter durations of hormone use than do US studies. 5. The type of estrogen used and the addition of progestins to hormone-replacement therapy may alter the risk of breast cancer. Data that substantiate these points are reviewed and placed in context with hormonal theories of carcinogenesis.
91057447 Risk lactors for breast caacec Unger C.; Rageth J.C.; Wyss P.: Spillmann M.; Hochuli E. Universitatsfrauenklinilr, Frauenklinikstrasse IO, CH-8091 Zurich SCHWEIZ. MED, WOCHENSCHR. 1991 12111-2 (30.36) A group of 992 breastcancer patients(risk group, R) was compared with a group of482 patients hospitalized for non oncologic reasons and matched for age and year of hospitalization (comparison group, C). The Endings confhrn the following factors as risk factors for breast cancer: nulliparity (R 28.8%. C 17.5%. p < 0.001). late first birth (over 34 years of age) (R I I .4X. C 5. I%, p c 0.001). diabetes mellitus (R 7.0% C 3.8%. p = 0.017). hypertension (R 25.7%. C 18.I’%, p - 0.0016), alcohol (R 9.4% C 5.9% p = 0.03). positive family history (R 14.8%. V 5.3%. p < 0.001) and breast surgery for benign disease (R 13%. C 7.5% p = 0.002). Frequently mentioned risk factors such as early menarche and late menopause did not emerge as risk factors in our study. Cigarette smoking did not show a protective effect but even tended to be more frequent in the risk group. Multiparity (more than 2 births) was protective (R 22, I%, C 32.4%. p < 0.001). The findings on hormonal replacement therapy (R 7. I’%, V 17.0% p < 0.01) might have been influenced by a selection bias (hospitalization of patients in the comparison group because of complications of hormonal replacement therapy such as bleeding) and are thus not fully conclusive. It can at least be said that hormonal replacement therapy is not more frequent in the risk group.
91059443 An assessmentof smlivaryfunction in healthy premeaopausalaad postmenopausalfemales Ship J.A.; Patton L.L.: Tylenda CA. Notionollnsrirureof Dental Research,National Institutesof Health, Woo Rockville Pike, Bethe.& MD 20892 J. GERONTOL. 1991 46/l (MII-MIS) The elderly represent the most rapidly growing segment of the U.S. population, and the majority of this group are females, The average woman can anticipate living about a third of her life beyond menopause, and many U.S. women undergo hormonal replacement in an attempt to relieve menopausal symptoms. Little is understood about the relationship between menopause, hormonal replacement therapy, and the oral structures,although oral discomfort, xerostomia, and salivary hypofunction have been associatedwith postmenopausalwomen. The effects of menopausal status and estrogen therapy on subjective reports of oral dryness and discomfort and objective measurements of major salivary gland output were assessed in 43 healthy premenopausaiand postmenopausalfemales. No complaints of xerostomia or burning mouth and no alterations in the quantity of saliva occurred in this population. This study suggeststhat among healthy women salivary gland function is not significantly influenced by menopause or hormonal replacement therapy. 91059926 Endometrial tbickaess as measuredby omlovagiwl ultrasonographyfor identifying e&met&l Granberg S.: Wikland M.: Karlsson B.; Norstrom A.: Friberg L.-G. Department of Obstetrics and Gynecology, Suhlgrenska Hospital, 413 45 Goteborg AM. J. OBSTET. GYNECOL.
abnormality
1991 164/I I (47-52)
Diagnostic curettage has for many years been the meihod of choice to diagnose endometrial cancer in women with postmenopausal bleeding. The costs for curettage performed today are huge. and approximately only It% in this group of women will be diagnosed with endometrial cancer. Thus lessexpansive techniques to obtain endometrial samples have been evaluated, but all of them are invasive. The value