New Screening Catches More Breast Cancers
WEDNESDAY, Sept. 3 (HealthDay News) -- While tremendous progress in screening and treatment for breast cancer has been made in recent years, some 184,000 new cases of breast cancer will be diagnosed in the United States in 2008, and about 41,000 women will die of the disease.
Researchers are now focusing their efforts on reducing these numbers even further.
Four studies being presented this week at the American Society of Clinical Oncology's 2008 Breast Cancer Symposium in Washington, D.C., highlight both areas of progress and areas that need extra emphasis.
A screening technique known as molecular breast imaging (MBI) detected three times as many breast cancers in women who have dense breasts and who are at a higher risk of developing the disease. These findings suggest that MBI could one day be added to conventional mammography.
Using an injected radiotracer (provided, for this study, by Bristol-Myers Squibb), MBI is able to detect differences in the behavior of cancer tissue as compared to normal tissue.
In this study, MBI detected 10 of 13 cancers among 375 patients completing a 15-month follow-up period. Mammography, by contrast, detected three of 13 cancers.
"If we had had a combination of both techniques, we would have detected 11 of 13 cancers," said study author Carrie B. Hruska, a research fellow in the department of radiology at the Mayo Clinic in Rochester, Minn. "MBI detected more cancers than screening mammography but didn't produce more false positive results."
Hruska spoke at a Wednesday teleconference with authors of the three other studies.
Also, the number of biopsies that actually resulted in cancer was much higher with MBI (28 percent) than with mammography (18 percent).
"Based on the results, MBI has shown great promise as a valuable adjunct to screening mammography in women with dense breasts and who are at an increased risk of developing cancer," Hruska said.
But while relatively inexpensive and easy to use, MBI is not yet widely available.
"This is an area that is very important, and where we really need to do further work," said Dr. Eric Winer, moderator of the teleconference and director of the breast oncology center at Dana-Farber Cancer Institute in Boston.
A second study, conducted by researchers at Johns Hopkins University, debunks the long-held notion that women in rural areas are more likely to chose mastectomy over lumpectomy because of difficulty traveling to radiation facilities.
Radiation is considered standard-of-care for women after they have received a breast-conserving lumpectomy, although not for women who undergo a mastectomy.
There were no notable differences between radiation rates following lumpectomy for women in rural areas as compared with women in urban areas, although the study did confirm that more women in rural areas (59.9 percent) opted for mastectomy, versus 44.9 percent of women in urban areas.
"The disparity . . . is not necessarily due to the availability of radiation therapy but to other factors," said study author Dr. Lisa K. Jacobs, an assistant professor of surgery at Johns Hopkins University in Baltimore.
"This would seem to suggest that if a woman in a rural area chooses to have a lumpectomy, she will most likely not fall through the cracks in terms of getting radiation, which is somewhat reassuring," Winer said. "But it would be interesting to look at this further."
In a third study, researchers at M.D. Anderson Cancer Center in Houston found that older black women undergoing lumpectomy for early-stage invasive breast cancer were less likely to receive recommended post-surgery radiation therapy than their white counterparts.
Only 65 percent of black women received radiation, compared with 74 percent of white women. "The difference is concerning, given that radiation after lumpectomy is generally considered standard therapy," said study author Dr. Grace Smith, a postdoctoral fellow in the department of radiation oncology at Anderson.
Disparities also existed in the younger range (women aged 65 to 70) of this older group, who were less likely to have medical conditions precluding radiation therapy. Here, 71 percent of black women received potentially lifesaving radiation versus 81 percent of white women.
The largest disparities were evident in the East South Central region of the United States, the Pacific West and New England.
"What seems to be happening is that the use of conservative surgery and radiation opens the door for disparities to play a greater role in limiting access to care," Winer said. In this two-step process (surgery plus radiation), Winer added, "it is possible for women to fall through the cracks."
The final study addressed women with HER2-positive breast cancer, which traditionally has a worse prognosis than other forms of breast cancer.
Chemotherapy and treatment with Herceptin (trastuzumab) before surgery results in a "pathologic complete response," meaning no evidence of invasive disease in the breast or lymph nodes existed in many patients.
Patients who did not have this complete response were three times more likely to have a recurrence, the researchers from M.D. Anderson reported.
In about one-third of those not achieving a complete response, the cancer had converted from HER2-positive disease to HER2-negative disease, meaning it was no longer responsive and had possibly become resistant to HER2-specific therapies such as Herceptin.
The authors stressed the importance of reassessing tissue for HER2 status after preoperative treatment.
Visit the National Cancer Institute for more on breast cancer.
3 Questions Can Spot Possible Postpartum Depression
TUESDAY, Sept. 2 (HealthDay News) -- Three simple questions were just as good as conventional screening for identifying potential postpartum depression among new mothers.
"Postpartum depression is under-diagnosed," said Dr. Adam Aponte, a pediatrician and associate director for recruitment and retention at Mount Sinai School of Medicine in New York City. "We found the fewer the questions, the better. It opens the door for dialogue about how the mom is doing. The last thing you want is a depressed mom. It's important to screen."
Aponte was not involved in this study, which is in the September issue of Pediatrics.
According to background information in the study, postpartum depression is the most common problem new mothers confront. The condition is characterized by high levels of anxiety, but screening is not routinely performed due to time and other constraints.
The researchers run the Colorado Adolescent Maternity Program (CAMP) for young mothers and their children in Denver. The center, which has both pre-birth and post-birth services, provided a unique opportunity to follow up with new mothers. The lead author of the study, Dr. Catherine Stevens-Simon, founded CAMP and directed it from 1991 to 2006; she passed away in November 2007.
For the study, 199 14- to 26-year-old mothers filled out the standard Edinburgh Postpartum Depression Scale at well-child visits during the first six months after the birth of their child.
The women then filled out three shorter versions of that scale.
A three-item anxiety sub-scale of the Edinburgh Postpartum Depression Scale turned out to be a better screening tool than the two other abbreviated versions which are almost the same as the commonly used Patient Health Questionnaire.
For this sub-scale, new mothers were asked to answer "Yes, most of the time," "Yes, some of the time," "Not very often" or "No, never" to the following statements:
- I have blamed myself unnecessarily when things went wrong.
- I have felt scared or panicky for not very good reason.
- I have been anxious or worried for not very good reason.
"We chose these three questions, because other studies have suggested that postpartum depression has a large anxiety component, and those three questions are related specifically to anxiety," said study co-author Jeanelle Sheeder, a senior instructor in pediatrics at the University of Colorado in Denver. "That subscale would probably be reasonable in other populations as well, because a lot of postpartum depression in general is related to that feeling of not knowing what to do and being scared or panicky."
The subscale identified 16 percent more mothers as depressed than the original, longer questionnaire.
"The beauty of three questions is it helps us hone in on what the patient is going through, so we can investigate further," Aponte said.
The National Women's Health Information Center has more on postpartum depression.
'Extended Cycle' Contraception Garners More Interest
SUNDAY, Aug. 24 (HealthDay News) -- With new "extended cycle" and "continuous" oral contraceptives on the market, women today can choose to have monthly withdrawal bleeding just four times a year -- or not at all.
To many American women of childbearing age, these options have tremendous appeal. In fact, more than two-thirds of women said they are interested in suppressing monthly bleeding, according to national survey results presented at an Association of Reproductive Health Professionals (ARHP) reproductive health conference.
"In the last 10 years, there really has been almost a revolutionary change in the opinions and the views of women regarding menstruation," observed Dr. Lee P. Shulman, professor and chief of reproductive genetics in the Department of Obstetrics and Gynecology at Northwestern University's Feinberg School of Medicine in Chicago.
"It's not just the more mature reproductive women desiring fewer withdrawal bleeds," said Shulman, immediate past chair of the ARHP. "Now that's becoming a more common desire among even younger women seeking hormonal contraception."
Oral contraceptives were initially designed to mimic the natural experience of menstruation. Women took 21 days of "active" pills, containing hormones, and seven days of placebo pills. During the hormone-free week, women experienced withdrawal bleeding, much like a true period.
Today's generation of oral contraceptives includes Seasonale and Seasonique, extended cycle products that reduce bleeding to four times a year, and Lybrel, a continuous-use product that stops monthly bleeding altogether. With Loestrin 24 Fe and Yaz, women still have a monthly bleed, but those "periods" are shorter.
Extended cycling, though, is not a new phenomenon. For years, doctors have being tailoring birth-control regimens to women's needs by having them skip the placebo week of traditional oral contraceptives and go on to a new pack. A woman going on her honeymoon, for example, or being deployed by the military, might seek to avoid bleeding and the need for sanitary protection. Extended regimens have also been used to treat women with endometriosis.
"The only difference recently is that we have these dedicated products," said Patricia Aikens Murphy, associate professor and the Annette Poulson Cumming Presidential Endowed Chair in Women's and Reproductive Health at the University of Utah College of Nursing in Salt Lake City.
Despite mounting interest, women in the survey also expressed some reluctance about the safety of suppressing monthly bleeding. By contrast, 97 percent of physicians who were surveyed said it's medically safe and acceptable.
Shulman attributes women's concerns about whether it's safe and natural to tamper with menstruation to conventional wisdom passed down by mothers and grandmothers. They'll hear about it and say, " 'You're not pregnant; you're supposed to have a period,' or 'Dammit, I had a period for 35 years; you're going to have a period for 35 years,' " he said.
Some women who try extended cycling really like it, because it reduces symptoms such as headache and bloating that occur during the placebo week, Murphy said. And there's some theoretical speculation that overall birth control effectiveness might be improved when women continue to use hormone-containing pills, she added.
"Many failures with birth control pills occur when that seven-day hormone-free interval gets extended longer and women actually run the risk of ovulating -- if you forget to start your pack right when you're supposed to," she explained.
One note of caution, though. These products are associated with a greater frequency of breakthrough bleeding and spotting, Shulman pointed out.
And there are other considerations. It takes most women a few months or more to stop having bleeding, said Susan Wysocki, president and CEO of the National Association of Nurse Practitioners in Women's Health in Washington, D.C.
"I liken it to buying a new pair of shoes," she said. "New shoes take breaking in. But once they are broken in, they are the shoes you like to wear. It takes time to break in a non-cycling contraceptive pill as well."
The Association of Reproductive Health Professionals can tell you more about menstrual suppression .
HRT After Menopause Reduces Symptoms
THURSDAY, Aug. 21 (HealthDay News) -- Hormone replacement therapy, even when it's started many years after menopause, can reduce some of the quality-of-life problems caused by menopause, such as sleep problems and hot flashes.
Australian researchers report that women who started hormone replacement therapy (HRT) after menopause and took it for an average of one year had significant improvements in sexual functioning, and fewer sleep problems, hot flashes and sweating than did women taking a placebo.
"The greatest benefits and least risk from HRT are seen in the 99 percent of women who commence HRT for symptom relief near menopause. [This] trial studied much older women who started HRT on average 13 to 14 years after menopause when they had fewer symptoms. Even in this group, improved quality of life was seen in many [taking HRT]," said study author Dr. Alastair MacLennan, head of obstetrics and gynecology at the Women's and Children's Hospital at the University of Adelaide in Australia.
Results of the study were published in the Aug. 22 issue of the British Medical Journal.
Hormone replacement therapy has been under major scrutiny since the Women's Health Initiative (WHI) study was stopped in 2002 because of increases in blood clots, heart disease, stroke and breast cancer risk in women initiating HRT long after menopause. MacLennan's study (dubbed the WISDOM study), which began in 1999 and was originally intended to follow women for up to 10 years on HRT, was also stopped after the WHI findings were released due to concerns that the risks of HRT might outweigh the benefits.
Even though the trial was stopped early, MacLennan and his colleagues had one-year follow-up data for 2,130 women between the ages of 50 and 69. The average age in this study was 63.8.
The women had been randomly assigned to receive either a combination hormone replacement therapy or a placebo. At the time of follow-up, 1,043 were on HRT and 1,087 were on placebo.
Women taking HRT had improvements in many quality-of-life symptoms. For example, hot flashes occurred in 30 percent of the women in the HRT group before starting the hormones, but in just 14 percent at the one year follow-up. In comparison, 29 percent of women taking placebo had hot flashes at the start of the study, while 25 percent were still experiencing them at the follow-up. Improvements were also seen in night sweats, insomnia and vaginal dryness.
Women in the HRT group were, however, more likely to report breast tenderness and vaginal discharge.
No significant differences were seen in reports of depression between the two groups.
The study authors wrote that if women are considering taking HRT many years after menopause, they needed to balance the benefits of hormone therapy against the possible risks when started after menopause, which include heart disease, blood clots and an increased risk of breast cancer.
"I think this is an important study, because since WHI, many have lost sight of the significant benefits of hormone therapy," said Dr. Steven R. Goldstein, an obstetrician and gynecologist at New York University Langone Medical Center. "This study reinforces the notion that for women with these symptoms, HRT can improve your quality of life. And, the worse your symptoms, the more they'll improve."
Plus, both MacLennan and Goldstein pointed out that most women would initiate HRT near menopause, when these symptoms tend to be most severe, and at that time, potential risks are much lower, and the benefits are likely greater.
"For relief of symptoms, it's OK to go on HRT, as long as you have none of the absolute contraindications, like a history of deep vein thrombosis," concluded Goldstein.
To read more about hormone replacement therapy, go to the American Academy of Family Physicians .