The Royal Marsden Hospital pilot tamoxifen chemoprevention trial

Chemoprevention and Lifestyle Modifications for Risk Reduction in Sporadic and Hereditary Breast Cancer

Female breast cancer is the most commonly diagnosed malignancy worldwide. Risk assessment helps to identify women at increased risk of breast cancer and allows the adoption of a comprehensive approach to reducing breast cancer incidence through personalized interventions, including lifestyle modification, chemoprevention, intensified surveillance with breast imaging, genetic counseling, and testing. Primary prevention means acting on modifiable risk factors to reduce breast cancer occurrence. Chemoprevention with tamoxifen, raloxifene, anastrozole, and exemestane has already shown benefits in decreasing breast cancer incidence in women at an increased risk for breast cancer. For healthy women carrying BRCA 1 or BRCA 2 pathogenic/likely pathogenic (P/LP) germline variants, the efficacy of chemoprevention is still controversial. Adopting chemoprevention strategies and the choice among agents should depend on the safety profile and risk-benefit ratio. Unfortunately, the uptake of these agents has been low. Lifestyle modifications can reduce breast cancer incidence, and the recommendations for BRCA 1 or BRCA 2 P/LP germline variant carriers are comparable to the general population. This review summarizes the most recent evidence regarding the efficacy of chemoprevention and lifestyle interventions in women with sporadic and hereditary breast cancer.

Treat more than heat-New therapeutic implications of Cimicifuga racemosa through AMPK-dependent metabolic effects

BACKGROUND

Cimicifuga racemosa extracts (CRE) have obtained a "well-established use status" in the treatment of postmenopausal (i.e., climacteric) complaints, which predominantly include vasomotor symptoms such as hot flushes and sweating, as well as nervousness, irritability, and metabolic changes. Although characteristic postmenopausal complaints are known for a very long time and the beneficial effects of CRE on climacteric symptoms are well accepted, both the pathophysiology of postmenopausal symptoms and the mechanism of action of CREs are not yet fully understood. In particular, current hypotheses suggest that changes in the α-adrenergic and serotonergic signaling pathways secondary to estrogen depletion are responsible for the development of hot flushes.

PURPOSE

Some of the symptoms associated with menopause cannot be explained by these hypotheses. Therefore, we attempted to extend our classic understanding of menopause by integrating of partly age-related metabolic impairments.

METHODS

A comprehensive literature survey was performed using the PubMed database for articles published through September 2021. The following search terms were used: (cimicifuga OR AMPK) AND (hot flush* OR hot flash* OR menopaus* OR osteoporos* OR cancer OR antioxida* OR cardiovasc*). No limits were set with respect to language, and the references cited in the articles retrieved were used to identify additional publications.

RESULTS

We found that menopause is a manifestation of the general aging process, with specific metabolic changes that aggravate menopausal symptoms, which are accelerated by estrogen depletion and associated neurotransmitter dysregulation. Cimicifuga extracts with their metabolic effects mitigate climacteric symptoms but may also modulate the aging process itself. Central to these effects are effects of CRE on the metabolic key regulator, the AMP-activated protein kinase (AMPK).

CONCLUSIONS

As an extension of this effect dimension, other off-label indications may appear attractive in the sense of repurposing of this herbal treatment.

Participant-Reported Symptoms and Their Effect on Long-Term Adherence in the International Breast Cancer Intervention Study I (IBIS I)

Purpose To assess the role of participant-reported symptoms on long-term adherence to preventive therapy in the United Kingdom sample of the International Breast Cancer Intervention Study (IBIS-I). IBIS-I was a randomized controlled trial that investigated the effectiveness of tamoxifen in reducing the risk of breast cancer among women at increased risk of the disease. Participants and Methods Women were randomly assigned to tamoxifen versus placebo (20 mg/day; n = 4,279). After 456 exclusions, 3,823 women were included in this analysis. Adherence (< 4.5 years or ≥ 4.5 years) was calculated using data from six monthly clinical visits. Analyses were adjusted for age, Tyrer-Cuzick risk, smoking, use of hormone replacement therapy, menopausal status, baseline menopausal symptoms, and treatment. Results Overall, 69.7% of women were adherent for at least 4.5 years (tamoxifen: 65.2% v placebo: 74.0%; P < .001). Differences in adherence between treatment arms were observed from 12 months onward (all P < .01) and were largest at 54 months. Dropout rates were highest in the first 12 to 18 months and decreased thereafter. Women reporting nausea/vomiting were less likely to be adherent in both the tamoxifen (odds ratio [OR], 0.57; 95% CI, 0.37 to 0.86; P = .007) and placebo (OR, 0.58; 95% CI, 0.37 to 0.93; P = .023) arms. Headaches were associated with adherence only in the placebo arm (OR, 0.62; 95% CI, 0.42 to 0.91; P = .016), whereas gynecologic symptoms were significant only in the tamoxifen arm (OR, 0.77; 95% CI, 0.62 to 0.97; P = .024). Effect sizes for each symptom on adherence were not significantly different between the treatment groups ( P > .05). In both treatment arms, we observed significant trends for lower adherence with increasing severity for all symptoms ( P < .01) except headaches ( P = .054). Conclusion In the IBIS-I trial, experiencing predefined symptoms in the first 6 months reduced long-term adherence. Effects were similar between treatment arms, suggesting that women were attributing age-related symptoms to preventive therapy. Interventions were required to support symptom management.

Response of gene expression in zebrafish exposed to pharmaceutical mixtures: Implications for environmental risk

Complex mixtures of pharmaceutical chemicals in surface waters indicate potential for mixture effects in aquatic organisms. The objective of the present study was to evaluate whether effects on target gene expression and enzymatic activity of individual substances at environmentally relevant concentrations were additive when mixed. Expression of zebrafish cytochrome P4501A (cyp1a) and vitellogenin (vtg) genes as well as activity of ethoxyresorufin-O-deethylase (EROD) were analyzed after exposure (96h) to caffeine-Caf, ibuprofen-Ibu, and carbamazepine-Cbz (0.05 and 5µM), tamoxifen-Tmx (0.003 and 0.3µM), and after exposure to pharmaceutical mixtures (low mix: 0.05µM of Caf, Ibu, Cbz and 0.003µM of Tmx, and high mix: 5µM of Caf, Ibu, Cbz and 0.3µM of Tmx). Pharmaceuticals tested individually caused significant down regulation of both cyp1a and vtg, but EROD activity was not affected. Exposure to low mix did not cause a significant change in gene expression; however, the high mix caused significant up-regulation of cyp1a but did not affect vtg expression. Up-regulation of cyp1a was consistent with induction of EROD activity in larvae exposed to high mix. The complex mixture induced different responses than those observed by the individual substances. Additive toxicity was not supported, and results indicate the need to evaluate complex mixtures rather than models based on individual effects, since in environment drugs are not found in isolation and the effects of their mixtures is poorly understood.

The 4Ps of Breast Cancer Chemoprevention: Putting Proven Principles into Practice

The pioneering Royal Marsden Tamoxifen Prevention Trial recruited 2,471 eligible high-risk women to be randomized to either placebo or tamoxifen (20 mg daily) for 8 years. Breast cancer incidence was evaluated at a median of 18.4 years from the start of the study. There was a 32% reduction in estrogen/progesterone receptor (ER/PR)-positive breast cancers after tamoxifen treatment finished. Translational research, to study "the good, the bad, and the ugly of tamoxifen" in the 1980s, subsequently ensured women's safety from possible increases in osteoperosis, coronary heart disease, and endometrial cancer. Other tamoxifen chemoprevention trials followed. The result of laboratory research was the unanticipated discovery of raloxifene to prevent osteoporosis and breast cancer at the same time. A new group of medicines, now known as selective ER modulators, was established. Indeed, the ability to prevent or delay multiple diseases with a single cheap medicine has the potential to alleviate pressure on health care systems that are overwhelmed. It is a priority to educate physicians appropriately to apply recommended proven medicines as preventives. Cancer Prev Res; 10(4); 219-22. ©2017 AACRSee related article by Detre, et al., Cancer Prev Res 2017;10(3):171-6.

Factors affecting uptake and adherence to breast cancer chemoprevention: a systematic review and meta-analysis

BACKGROUND

Preventive therapy is a risk reduction option for women who have an increased risk of breast cancer. The effectiveness of preventive therapy to reduce breast cancer incidence depends on adequate levels of uptake and adherence to therapy. We aimed to systematically review articles reporting uptake and adherence to therapeutic agents to prevent breast cancer among women at increased risk, and identify the psychological, clinical and demographic factors affecting these outcomes.

DESIGN

Searches were carried out in PubMed, CINAHL, EMBASE and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles, and a further 4 studies were identified from reference lists, giving a total of 57. This review was prospectively registered with PROSPERO (CRD42014014957).

RESULTS

Twenty-four articles reporting 26 studies of uptake in 21 423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% [95% confidence interval (CI) 13.6-19.0], with high heterogeneity (I(2) = 98.9%, P < 0.001). Uptake was unaffected by study location or agent, but was significantly higher in trials [25.2% (95% CI 18.3-32.2)] than in non-trial settings [8.7% (95% CI 6.8-10.9)] (P < 0.001). Factors associated with higher uptake included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial concerns, and older age. Adherence (day-to-day use or persistence) over the first year was adequate. However, only one study reported a persistence of ≥ 80% by 5 years. Factors associated with lower adherence included allocation to tamoxifen (versus placebo or raloxifene), depression, smoking and older age. Risk of breast cancer was discussed in all qualitative studies.

CONCLUSION

Uptake of therapeutic agents for the prevention of breast cancer is low, and long-term persistence is often insufficient for women to experience the full preventive effect. Uptake is higher in trials, suggesting further work should focus on implementing preventive therapy within routine care.

Is the step-wise tiered approach for ERA of pharmaceuticals useful for the assessment of cancer therapeutic drugs present in marine environment?

Methotrexate (MTX) and tamoxifen (TMX) cancer therapeutic drugs have been detected within the aquatic environment. Nevertheless, MTX and TMX research is essentially bio-medically orientated, with few studies addressing the question of its toxicity in fresh water organisms, and none to its' effect in the marine environment. To the authors' knowledge, Environmental Risk Assessments (ERA) for pharmaceuticals has mainly been designed for freshwater and terrestrial environments (European Medicines Agency-EMEA guideline, 2006). Therefore, the purpose of this research was (1) to assess effect of MTX and TMX in marine organism using the EMEA guideline, (2) to develop an ERA methodology for marine environment, and (3) to evaluate the suitability of including a biomarker approach in Phase III. To reach these aims, a risk assessment of MTX and TMX was performed following EMEA guideline, including a 2-tier approach during Phase III, applying lysosomal membrane stability (LMS) as a screening biomarker in tier-1 and a battery of biochemical biomarkers in tier-2. Results from Phase II indicated that MTX was not toxic for bacteria, microalgae and sea urchin at the concentrations tested, thus no further assessment was required, while TMX indicated a possible risk. Therefore, Phase III was performed for only TMX. Ruditapes philippinarum were exposed during 14 days to TMX (0.1, 1, 10, 50 μg L(-1)). At the end of the experiment, clams exposed to environmental concentration indicated significant changes in LMS compared to the control (p<0.01); thus a second tier was applied. A significant induction of biomarkers (activity of Ethoxyresorufin O-deethylase [EROD], glutathione S-transferase [GST], glutathione peroxidase [GPX], and lipid peroxidation [LPO] levels) was observed in digestive gland tissues of clams compared with control (p<0.01). Finally, this study indicated that MTX was not toxic at an environmental concentration, whilst TMX was potentially toxic for marine biota. This study has shown the necessity to create specific guidelines in order to evaluate effects of pharmaceuticals in marine environment which includes sensitive endpoints. The inadequacy of current EMEA guideline to predict chemotherapy agents toxicity in Phase II was displayed whilst the usefulness of other tests were demonstrated. The 2-tier approach, applied in Phase III, appears to be suitable for an ERA of cancer therapeutic drugs in the marine environment.

Yes, caffeine, ibuprofen, carbamazepine, novobiocin and tamoxifen have an effect on Corbicula fluminea (Müller, 1774)

Reports indicating the presence of pharmaceutical in fresh water environment in the ngL(-1) to µgL(-1) range are occurring with increasing frequency. It is also a fact that pharmaceuticals may produce adverse effects on aquatic organisms. Nevertheless, there is still a lack of knowledge regarding how these emergent contaminants may affect aquatic biota. The goal of this research was to evaluate the sublethal responses in Corbicula fluminea such as, general stress (lysosomal membrane stability [LMS]), biomarkers of phase I and II (etoxyresorufin O-deethylase [EROD], dibenzylfluorescein dealkylase [DBF], gluthathione-S-transferase [GST]), oxidative stress (gluthathione reductase [GR], gluthathione peroxidase [GPX], lipid peroxidation [LPO]), and biomarkers of effect (DNA damage) after 21 days of exposure to caffeine, ibuprofen, carbamazepine, novobiocin and tamoxifen at 0.1, 1, 5, 10, 15, 50µgL(-1). Environmental concentrations tested in this study caused general stress and produced changes on biomarkers tested. LMS, responses from phase I and II enzymatic activity, oxidative stress, and biomarker of effect represent important ecotoxicological information, and will provide a useful reference for the assessment of selected drugs and the effects which these compounds may have on aquatic invertebrates, using C. fluminea as a bioindicator species.

Is tamoxifen a genotoxic carcinogen in women?

The anti-oestrogen tamoxifen, which is widely used in the treatment of breast cancer and is also approved for the prevention of this disease, causes an increased incidence of endometrial cancer in women. The ability of tamoxifen to induce endometrial tumours and the underlying carcinogenic mechanisms have been a subject of intense interest over the last approximately 20 years. They are central to the assessment of risks versus benefits for the drug, especially in a chemopreventive context. This review outlines the clinical justification for using tamoxifen as a chemopreventive agent and describes the genotoxic mechanisms considered responsible for tamoxifen-induced tumours in rat liver and how these might relate to women. In rat hepatic tissue, tamoxifen is metabolically activated via alpha-hydroxylation and sulphate conjugation to give a reactive species that binds to DNA predominantly at the N(2)-position of guanine, producing pro-mutagenic lesions. Whether tamoxifen-DNA adducts contribute similarly to the development of cancers in women depends on whether they can be formed in human tissues and the type of specific molecular and cellular responses they induce, if present. This review discusses the current data relating to these issues and highlights areas where further research is needed.

Risks, benefits, and effects on quality of life of selective estrogen-receptor modulator therapy in postmenopausal women at increased risk of breast cancer

The evidence regarding the risks, benefits, and quality of life impact of tamoxifen and raloxifene for prevention of breast cancer in postmenopausal women was reviewed. Five placebo-controlled trials were identified, four with tamoxifen and one with raloxifene. The individual placebo-controlled trials of tamoxifen for breast cancer prevention vary in size and risk status of the women who participated. An overview of the four trials found a 30% to 40% reduction in the risk of breast cancer. Serious adverse events include an increased risk of uterine cancer, venous thromboembolic events, and cataracts. Fracture risk was reduced. Quality of life was not significantly impaired, but women treated with tamoxifen had more vasomotor symptoms and vaginal discharge. In the single trial of raloxifene in postmenopausal women, there was a substantial reduction in the risks of breast cancer and fracture and no increased risk of uterine cancer. However, there was an increased risk of venous thromboembolic events. In the trial directly comparing tamoxifen with raloxifene in postmenopausal high-risk women, there was no significant difference in the risk of invasive breast cancer, but tamoxifen significantly reduced noninvasive breast cancer. The toxicity profiles for the two drugs were similar, with the exception of fewer hysterectomies, pulmonary emboli, and deep vein thrombosis in the raloxifene-treated group. There are now two effective Selective estrogen-receptor modulators available for use in postmenopausal women to reduce the risk of breast cancer. Women at high risk of breast cancer should be offered this therapy, and if one drug is not well tolerated, the other should be considered.

The effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients

OBJECTIVE

To investigate the effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients.

METHODS

A retrospective review was performed on the 207 patients who had taken tamoxifen or anastrozole, as adjuvant hormonal therapy after breast cancer surgery between January 2003 and December 2006. Gynecologic surveillance constituted of ultrasonographic exam of the endometrial thickness and ovarian cyst formation. The patients were classified into three groups and analyzed; premenopausal/postmenopausal women receiving tamoxifen and women receiving anastrozole.

RESULTS

Mean duration of follow up was 20.6+/-6.6 months. There was no difference of mean endometrial thickness before hormonal therapy among the three groups (p=0.327). In women receiving tamoxifen, the endometrium was continuously thickened in proportion to the duration of the therapy irrespective of menopausal status while it remained unchanged in women receiving anastrozole (p<0.05). Endometrial biopsies were performed in 28 patients receiving tamoxifen. The most common histologic finding was proliferative endometrium in premenopausal women (7/21) and atrophic endometrium in postmenopausal women (6/7). There was no case of endometrial cancer in both groups. Ovarian cyst was found in 32 women and the most were developed in premenopausal women receiving tamoxifen (30/32). All of them showed benign nature on transvaginal ultrasonographic findings.

CONCLUSION

Women undergoing adjuvant hormonal therapy after breast cancer surgery exhibited changes in the endometrium and ovary. However most changes were not a serious problem in this study and frequent gynecologic surveillance in these patients needs further investigation.

Management of women who have a genetic predisposition for breast cancer

The management of women who have a genetic predisposition for breast cancer requires careful planning. Women who have BRCA 1 and BRCA 2 mutations are at increased risk for breast cancer and for other cancers as well, particularly ovarian cancer. Screening, prophlyactic surgery, and chemoprevention are commonly utilized strategies in the management of these patients, and women may choose more than one of these strategies. No randomized prospective trials have assessed the impact of these strategies specifically in mutation carriers. All patients should be informed that screening, prophylactic surgery, and chemoprevention have the potential for harm as well as benefit.

The 38th David A. Karnofsky lecture: the paradoxical actions of estrogen in breast cancer--survival or death?

During the first David A. Karnofsky Award lecture entitled "Thoughts on Chemical Therapy" in 1970, Sir Alexander Haddow commented about the dramatic regressions observed with estrogen in some breast cancers in postmenopausal women, but regrettably the mechanism was unknown. He was concerned that a cancer-specific target would remain elusive, without tests to predict response to therapy. At that time, I was conducting research for my PhD on an obscure group of estrogen derivatives called nonsteroidal antiestrogens. Antiestrogens had failed to fulfill their promise as postcoital contraceptives and were unlikely to be developed further by the pharmaceutical industry. In 1972, that perspective started to change and ICI 46,474 was subsequently reinvented as the first targeted therapy for breast cancer. The scientific strategy of targeting the estrogen receptor (ER) in the tumor, treating patients with long-term adjuvant therapy, examining active metabolites, and considering chemoprevention all translated through clinical trials to clinical practice during the next 35 years. Hundreds of thousands of women now have enhanced survivorship after their diagnosis of ER-positive breast cancer. However, it was the recognition of selective ER modulation (SERM) that created a new dimension in therapeutics. Nonsteroidal antiestrogens selectively turn on or turn off estrogen target tissues throughout the body. Patient care was immediately affected by the recognition in the laboratory that tamoxifen would potentially increase the growth of endometrial cancer during long-term adjuvant therapy. At that time, a failed breast cancer drug, keoxifene, was found to maintain bone density of rats (estrogenic action) while simultaneously preventing mammary carcinogenesis (antiestrogenic action). Perhaps a SERM used to prevent osteoporosis could simultaneously prevent breast cancer? Keoxifene was renamed raloxifene and became the first SERM for the treatment and prevention of osteoporosis as well as the prevention of breast cancer, but without an increase in endometrial cancer. There the story might have ended had the study of antihormone resistance not revealed a vulnerability of cancer cells that could be exploited in the clinic. The evolution of antihormone resistance over years of therapy reconfigures the survival mechanism of the breast cancer cell, so estrogen no longer is a survival signal but a death signal. Remarkably, remaining tumor tissue is again responsive to continuing antihormone therapy. This new discovery is currently being evaluated in clinical trials but it also solves the mystery mechanism of chemical therapy with estrogen noted by Haddow in the first Karnofsky lecture.

Tumorigenic effects of tamoxifen on the female genital tract

Tamoxifen is widely used for endocrine treatment and breast cancer prevention. It acts as both an estrogen antagonist in breast tissue and an estrogen agonist in the female lower genital tract. Tamoxifen causes severe gynecologic side effects, such as endometrial cancer. This review focuses on the effects of prolonged tamoxifen treatment on the human female genital tract and considers its tumorigenicity in the gynecologic organs through clinical data analysis. Tamoxifen is associated with an increased incidence of benign endometrial lesions such as polyps and hyperplasia and a two- to four-fold increased risk of endometrial cancer in postmenopausal patients. Moreover, the incidence of functional ovarian cysts is significantly high in premenopausal tamoxifen users. To prevent tamoxifen from having severe side effects in gynecologic organs, frequent gynecological examination should be performed for both premenopausal and postmenopausal patients with breast cancer who are treated with this drug.

Gynecologic and hormonal effects of raloxifene in premenopausal women

OBJECTIVE

To assess the effects of raloxifene on the ovaries, uterus, and serum hormone levels in premenopausal women.

DESIGN

Prospective study comparing pretreatment findings with findings for those on treatment.

SETTING

Government research hospital.

PATIENT(S)

Thirty women 35 to 47 years of age who were at high risk of breast cancer and had regular, ovulatory menstrual cycles.

INTERVENTION(S)

Raloxifene (60 mg) and calcium (1,200 mg) daily for 2 years.

MAIN OUTCOME MEASURE(S)

Sonographic evidence of ovarian stimulation (>or=2 corpora lutea, or follicular cysts of >2 cm, or single follicular cyst of >3 cm). Changes in endometrial thickness, fibroid size, hormone levels, and menstrual-cycle length.

RESULT(S)

Fifteen subjects developed some cycles with asymptomatic ovarian stimulation, and 9 developed benign endometrial polyps, compared with 2 subjects and 1 subject pretreatment, respectively. Uterine fibroid size was unchanged during raloxifene use in 16 subjects with fibroids. On treatment, E(2) levels increased significantly only during the follicular phase, with peak E(2) levels significantly higher in cycles showing ovarian stimulation compared with those without. Sex hormone-binding globulin increased, but levels of LH, FSH, P, DHEAS, and T did not. Endometrial thickness and cycle length were unchanged.

CONCLUSION(S)

Premenopausal subjects receiving raloxifene showed sonographic and hormonal evidence of ovarian stimulation. Endometrial thickness, cycle length, and fibroid size were unchanged. Benign asymptomatic endometrial polyps developed in some.

Chemoprevention Strategies 2006

OPINION STATEMENT

Several large, prospective trials have evaluated tamoxifen compared with placebo for breast cancer risk reduction in women at increased risk for breast cancer. The risk of developing breast cancer is the primary determinant of net benefit, with greater net benefits accruing to women with the highest risk of breast cancer. Both age and the presence of factors that increase the risk of toxicity have the greatest effect on the net benefit associated with tamoxifen. The greatest clinical benefit with least side effects is derived from the use of tamoxifen in younger, premenopausal women who are less likely to have thromboembolic complications and uterine cancer, in women without a uterus, and in women at higher breast cancer risk such as those with atypical hyperplasia or lobular carcinoma in situ. Tamoxifen may offer benefit to women who are carriers of BRCA2 mutations, although no prospective trials have been conducted. Compared to placebo in postmenopausal women at average risk of breast cancer in published trials of osteoporosis, raloxifene reduces the risk of invasive breast cancer. Among younger postmenopausal women who are at increased risk of breast cancer, raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer. Raloxifene appears to be less effective than tamoxifen in reducing the risk of in situ breast cancer. In high-risk, younger, postmenopausal women, raloxifene appears to offer net benefit when comparing reduction of the risk of breast cancer and the prevention of fractures with the risk of stroke, venous thromboembolic events, uterine events, as well as symptomatic side effects.

Ovarian cancer risk in premenopausal and perimenopausal women treated with Tamoxifen: a case-control study

As tamoxifen stimulates ovarian steroidogenesis in premenopausal women, induces ovulation and increases the incidence of benign ovarian cysts, there has been concern that it might also increase ovarian cancer risk in women treated premenopausally. In a national case–control study in Britain, treatment histories were collected for 158 cases of ovarian cancer after breast cancer diagnosed at ages under 55 years and 464 controls who had breast cancer at these ages without subsequent ovarian cancer. Risk of ovarian cancer was not raised for women overall who had taken tamoxifen (odds ratio (OR)=0.9, 95% confidence interval (CI) 0.6–1.3) or for those treated when premenopausal (OR=1.0, 95% CI 0.6–1.6) or perimenopausal (OR=0.7, 95% CI 0.2–2.4). There was also no relation of risk to daily dose, duration or cumulative dose of tamoxifen, or time since last use. There was, however, a significantly raised risk in relation to non-hormonal chemotherapy. The results suggest that tamoxifen treatment of premenopausal or perimenopausal women does not materially affect ovarian cancer risk, but that non-hormonal chemotherapy might increase risk.

Ovarian cyst torsion and extreme ovarian stimulation in a premenopausal patient treated with tamoxifen for ductal carcinoma in situ of the breast

Tamoxifen is increasingly used in adjuvant endocrine therapy for postsurgery breast cancer patients and in chemoprevention for high-risk patients. We present a case of bilateral ovarian cyst development with consecutive unilateral cyst torsion and elevated serum estradiol in a premenopausal patient treated with tamoxifen after breast-conserving surgery.

Tamoxifen treatment after adjuvant chemotherapy has opposite effects on bone mineral density in premenopausal patients depending on menstrual status

PURPOSE

Adjuvant chemotherapy followed by tamoxifen is a standard treatment option for women with intermediate or high-risk hormone receptor-positive breast cancer. Premenopausal women treated with chemotherapy often develop early menopause and thus, enter a period of accelerated bone loss. We conducted a prospective study of the effect of sequential adjuvant therapy with chemotherapy followed by tamoxifen on bone mineral density (BMD) in premenopausal patients.

PATIENTS AND METHODS

One hundred eleven premenopausal women with early breast cancer were treated with adjuvant chemotherapy. Patients with hormone receptor-positive tumors went on to tamoxifen 6 months after the beginning of the chemotherapy (tamoxifen group), while those with hormone receptor-negative tumors received no further therapy (control group). The effect of tamoxifen and menstrual status on BMD was studied.

RESULTS

Tamoxifen treatment and menopausal status correlated significantly with the changes in lumbar spine BMD (P < .0001). A significant bone loss was noted in those tamoxifen-treated patients who continued to menstruate after chemotherapy. At 3 years of follow-up, menstruating patients on tamoxifen had lost -4.6% of their baseline BMD values, while a modest gain of +0.6% was noted in the control group. In contrast, bone loss was reduced among tamoxifen-treated women as compared with controls in patients who developed chemotherapy-induced early menopause. In amenorrheic patients, the lumbar spine BMD values decreased -6.8% in tamoxifen users and -9.5% in the controls, respectively.

CONCLUSION

We conclude that tamoxifen usage was associated with bone loss in patients who continued to menstruate after adjuvant chemotherapy. On the contrary, tamoxifen decreased bone loss in those women who developed chemotherapy-induced amenorrhea.

Ovarian cyst formation in patients using tamoxifen for breast cancer

OBJECTIVE

The purpose of this study was to evaluate patient-related parameters that determine ovarian cyst formation in women using tamoxifen for breast cancer.

METHODS

A retrospective review of tamoxifen-treated women with breast cancer who were followed up in the outpatient clinic at Ankara Oncology Hospital between January 2002 and December 2004 was performed. Tamoxifen doses and duration, post-treatment menstrual function, adjuvant therapy, ultrasonographic and hormonal [follicle-stimulating hormone and serum estradiol (E(2))] data, details of gynecologic surgical procedure and histopathology were recorded.

RESULTS

Twenty-nine of 150 tamoxifen-treated patients (19.3%) had ovarian cysts. Cysts were detected in 28 of 57 pre-menopausal women (49.1%) and 1 of 93 post-menopausal women (1.1%). Patients with ovarian cysts had higher serum E(2) levels compared with patients without cysts (24 versus 345 pg/ml; P < 0.001). Patients with ovarian cysts had <1 year amenorrhoea duration (P < 0.001) compared with the patients without cysts. Adjuvant standard chemotherapy did not have relationship between the development of ovarian cysts. Multivariant analysis showed that cyst development is related to high E(2) levels (P < 0.05).

CONCLUSIONS

Patients still having a menstrual cycle during tamoxifen had high risk (58.33%) of developing ovarian cysts. We have described an association between pre-menopausal patients using tamoxifen with high E(2) level and ovarian cyst enlargement.

Rat tail skin temperature regulation by estrogen, phytoestrogens and tamoxifen

OBJECTIVE

Develop a rat model for the evaluation of estrogenic agents on estrogen deficiency-induced changes in thermoregulation.

METHODS

OVX rats are impaired in thermoregulation which manifests itself as an elevation in basal tail skin temperature (TST) and are less able to respond to temperature changes than intact rats.

RESULTS

Administration of estrogen subcutaneously to estrogen-depleted rats either as depot formulation, biodegradable pellets, or daily injections, suppressed the increased TST. OVX rats maintained on a diet devoid of phytoestrogens had a higher TST by several degrees than OVX rats fed normal chow, offering greater ability to test estrogenic agents on thermoregulation. Depletion of estrogen in intact rats via chronic administration of leuprolide acetate, a GnRH agonist, also increased TST, which was in turn suppressed by estrogen. In intact rats, tamoxifen exhibited estrogen antagonistic activity elevating TST, while in OVX rats, tamoxifen acted as an agonist by suppressing TST.

CONCLUSION

OVX rats kept on a diet devoid of phytoestrogens are a sensitive model for estrogen-dependent thermoregulation.

Bone mineral density among premenopausal women with early breast cancer in a randomized trial of adjuvant endocrine therapy

PURPOSE

To examine the effects on bone mineral density of 2 years of treatment with a luteinizing hormone-releasing hormone (LHRH) agonist alone or in combination with tamoxifen or tamoxifen alone in premenopausal breast cancer.

PATIENTS AND METHODS

We recruited 89 women from two centers in Stockholm participating in a randomized multicenter trial of three different endocrine approaches in the adjuvant setting (Zoladex in Premenopausal Patients Trial). The women were assigned to receive the LHRH agonist goserelin with or without tamoxifen, tamoxifen alone, or no endocrine therapy. The treatment was given for 2 years. We measured total-body bone density before start of treatment and at 12, 24, and 36 months.

RESULTS

After 2 years of treatment, there was a significant loss of bone mineral density (mean change, -5%; P <.001) in the women receiving goserelin alone. The combined goserelin and tamoxifen treatment, as well as tamoxifen alone, resulted in a lesser but statistically significant decline in bone mineral density (mean change, -1.4%; P =.02; and -1.5%; P <.001). One year after cessation of treatment, the goserelin group alone showed a partial recovery from bone loss (mean change, 1.5%; P =.02).

CONCLUSION

Two years of ovarian ablation from goserelin treatment caused a significant reduction in bone mineral density but there was a partial recovery from the bone loss 1 year after cessation of treatment. The addition of tamoxifen seems to partially counteract the demineralizing effects of goserelin.

Tamoxifen treatment reverses the adverse effects of chemotherapy-induced ovarian failure on serum lipids

In all, 146 premenopausal women with early stage breast cancer were treated with adjuvant chemotherapy. In addition, 5-year tamoxifen treatment was started after chemotherapy to those 112 patients with hormone-receptor-positive tumours while those with hormone-receptor-negative tumours received no further therapy. The serum lipid levels were followed in both groups. The levels of serum total and low-density lipoprotein (LDL) cholesterol increased significantly after chemotherapy only in patients who developed ovarian dysfunction. Total cholesterol increased +9.5% and LDL cholesterol +16.6% in patients who developed amenorrhoea (P<0.00001 and 0.00001, respectively). The cholesterol levels did not change in patients who preserved regular menstruation after chemotherapy. After 6 months of tamoxifen therapy, the total cholesterol decreased −9.7% and the LDL cholesterol −16.7% from levels after the chemotherapy, while the cholesterol concentrations remained at increased levels in the control group (P=0.001 and P<0.0001, respectively). The high-density lipoprotein cholesterol levels did not change significantly in either tamoxifen or control group. The effects of tamoxifen treatment on serum lipids after chemotherapy have not been studied before. Our current study suggests that adjuvant tamoxifen therapy reverses the adverse effects of chemotherapy-induced ovarian failure on total and LDL cholesterol and even lowers their serum levels below the baseline.

The management of familial breast cancer

Epidemiological studies over the past several decades have consistently supported the concept that a proportion of breast cancers develop as the result of an inherited familial predisposition. However, until recently our understanding and knowledge of the underlying genetic processes involved have been limited. Current advances in molecular biology have shown that hereditary breast cancer may arise as the result of mutations of several specific gene loci including BRCA1, BRCA2, ATM gene, PTEN and p53. Several other less frequently occurring predisposition genes such as the androgen receptor gene (AR), the HNPCC genes and the oestrogen receptor gene may also be involved, but to a lesser extent. It is estimated that approximately 5-10% of all breast cancers involve one of these inherited predisposition genes, with BRCA1 and BRCA2 accounting for up to 90% of this group. Mutation analysis is complex in nature and is presently in a developmental and evolving phase, for which reason genetic testing should be offered on a selective basis and through genetic counselling clinics. This report reviews the current knowledge and roles of the various predisposition genes and discusses the management implications for both affected and nonaffected members of breast cancer families. Comprehensive and informative counselling is critical for women with an inherited predisposition to breast cancer and this has led to the evolution of familial cancer clinics involving a multi-disciplinary specialist team approach. Familial cancer clinics can provide individuals with information about their risk of developing breast cancer and offer advice regarding the various management options presently available.

Side effects of adjuvant endocrine treatment in premenopausal breast cancer patients: a prospective randomized study

PURPOSE

To compare the effect of adjuvant endocrine therapies with and without chemotherapy on physical symptoms, anxiety, and depressive symptoms in premenopausal women with breast cancer in a randomized clinical trial (the Zoladex in Premenopausal Patients trial).

PATIENTS AND METHODS

The patients were randomly assigned to goserelin, goserelin plus tamoxifen, tamoxifen alone, or no endocrine therapy. The duration of the endocrine treatment was 2 years. The groups were observed for 3 years after primary treatment (ie, during 2 years of active treatment as well as 1 year after cessation of the adjuvant endocrine therapy). All patients with node-positive disease received adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (CMF), which was given concurrently with the endocrine treatment.

RESULTS

Patients treated with CMF typically reported higher levels of physical symptoms than did patients who did not receive CMF. It was only among patients who did not receive chemotherapy that the endocrine treatment had differential effects. Goserelin was most burdensome and resulted in similar symptom levels as those of CMF, whereas the side effects of tamoxifen alone were milder. After cessation of the endocrine treatment, the side effects diminished in patients who had not received CMF, whereas patients treated with CMF reported ongoing problems at the 3-year follow-up. In contrast, anxiety and depressive symptoms were not significantly affected by endocrine treatment or chemotherapy during the 3 years of assessment.

CONCLUSION

Goserelin and tamoxifen resulted in menopausal symptoms, but these symptoms were reversible. However, women treated with CMF experienced physical symptoms throughout the whole study period.

Effect of tamoxifen on venous thrombosis risk factors in women without cancer: the Breast Cancer Prevention Trial

Tamoxifen reduces breast cancer incidence among healthy women, but is associated with an increased risk of venous thrombosis. We studied the 6 month effects of tamoxifen on venous thrombosis risk factors in women without cancer. One hundred and eleven women at one centre who were participants in a multicentre breast cancer prevention trial were randomized, in double-blind fashion, to receive 20 mg/d of tamoxifen or placebo. The activated protein C (APC) ratio and concentrations of antithrombin, protein C antigen, and total protein S were measured at baseline and 6 months of treatment. None of the factors changed over 6 months in placebo-treated women. Among tamoxifen-treated women, antithrombin and protein S, but not protein C or APC ratio were reduced. Sequential antithrombin concentrations with tamoxifen were 114% and 104% (P = 0.001 compared with placebo). Sequential protein S concentrations with tamoxifen were 18.42 and 17.30 micro g/ml (P = 0.02 compared with placebo). Reductions in antithrombin and protein S were greater in postmenopausal women, but did not differ by other risk factors for venous thrombosis, such as body mass index. Reductions of antithrombin and protein S, but not protein C or APC resistance, might relate to the increased risk of venous thrombosis associated with tamoxifen treatment.

Safety issues surrounding the use of aromatase inhibitors in breast cancer

Third generation aromatase inhibitors (AIs) are now established therapy in advanced oestrogen receptor (ER)-positive breast cancer. As the use of AIs expands to include adjuvant treatment of early breast cancer and breast cancer prevention, tolerability and effects on other organs such as bone will become as important as the antitumour properties of the drugs. In direct comparisons with tamoxifen, AIs have a better toxicity profile with fewer patients stopping therapy because of drug-related side effects. There is a lower incidence of thromboembolic events and vaginal bleeding compared with tamoxifen. Although published information about the side effects of AIs is scarce, it is likely that they will have adverse effects on bone and possibly also on lipid metabolism. Subprotocols of ongoing adjuvant trials are investigating these effects. It is likely that the choice of which third generation AI to use will be largely determined by its tolerability and safety profile, since it is likely that the currently available drugs have similar efficacy.

Breast cancer chemoprevention: risk-benefit effects of the antioestrogen tamoxifen

The anti-oestrogen tamoxifen, which is widely used as adjuvant therapy for breast cancer, is undergoing evaluation as a chemopreventive agent in women at increased risk of developing this disease. Recent results from the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 prevention trial show a 49% reduction in breast cancer incidence in healthy, high-risk women. However, tamoxifen treatment has the serious side effect of increasing the incidence of endometrial cancer in women and long-term administration of tamoxifen causes hepatic tumours in rats. These liver tumours are induced via a genotoxic mechanism, but the mechanisms responsible for endometrial cancer in women are not yet known and are a focus of much debate. This review describes the findings from the chemoprevention trials and problems associated with the use of tamoxifen in this setting. The mechanism of carcinogenesis in rat liver is explained in detail and compared to the situation in humans, with a view to assessing the risks associated with tamoxifen therapy and predicting whether other anti-oestrogens might be safer alternatives.

Tamoxifen effects on subjective and psychosexual well-being, in a randomised breast cancer study comparing high-dose and standard-dose chemotherapy

To evaluate the impact of tamoxifen on subjective and psychosexual well-being in breast cancer patients in relation to type of prior chemotherapy and menopausal status. Longitudinal interview study in breast cancer patients during and after adjuvant tamoxifen use. Menopausal status was defined by last menstrual period and serum oestradiol and FSH levels. Gynaecology outpatient clinic, Tertiary Referral Hospital, January 1995 to September 1999. Breast cancer patients <56 years of age, participating in a randomised trial comparing adjuvant high-dose (n=45) and standard-dose (n=53) chemotherapy, followed by radiotherapy and tamoxifen. Relative incidence and correlation of subjective and psychosexual symptoms during and after tamoxifen. During tamoxifen the most frequent complaints were hot flushes (85%), disturbed sleep (55%), vaginal dryness and/or dyspareunia (47%), decreased sexual desire (44%) and musculo-skeletal symptoms (43%). Disturbed sleep correlated with hot flushes (P<0.0005) and concentration problems (P<0.05). Decreased sexual interest correlated with vaginal dryness (P<0.0005) and/or dyspareunia (P<0.0005). In the high-dose group more patients became postmenopausal (95% vs 33%) and more patients reported symptoms than in the standard-dose group (P<0.05). After discontinuation of tamoxifen, symptoms decreased significantly. However, hot flushes, disturbed sleep and vaginal dryness persisted more often in patients who remained postmenopausal after high-dose chemotherapy (P<0.05). Overall, during tamoxifen patients reported many symptoms. More patients become postmenopausal after high-dose chemotherapy, and they remain often symptomatic after tamoxifen.

Selective estrogen receptor modulators (SERMs) and retinoids in breast cancer chemoprevention

Tamoxifen has been shown to decrease the risk of invasive breast cancer by 49% and noninvasive breast cancer by 50%. Tamoxifen is also associated with a threefold increased risk of endometrial cancer. Raloxifene, a second-generation selective estrogen receptor modulator (SERM), has not been associated with endometrial cancer risk, and is currently under study in a large, multi-institutional, randomized Study of Tamoxifen and Raloxifene (STAR) for breast cancer prevention in postmenopausal women. A pilot trial of raloxifene in premenopausal women to assess the safety, tolerability, effects on bone mineral density, mammographic density, and other biological endpoints is ongoing. The retinoids have been shown to decrease mammary tumors in rodent carcinogenesis models. The Italian trial of fenretinide (4-HPR) in women with stage I breast cancer randomized women to fenretinide or no intervention. This study did not show an overall effect of decreasing the risk of contralateral breast cancer. However, a protective effect was suggested in premenopausal women. It has been suggested that this effect may be related to insulin-like growth factor 1 (IGF-1), which has been shown to be modulated by fenretinide in premenopausal but not postmenopausal women. Pilot studies of SERMs alone and in combination with retinoids or other agents provide a model for testing the safety and tolerability, pharmacokinetics and pharmacodynamics, and biomarker modulation in high-risk women. These studies can provide information as to both the pathophysiology of carcinogenesis and the mechanism of action of chemopreventive agents, and help select agents and doses for testing in large randomized studies.

Tamoxifen and the female reproductive tract

The use of tamoxifen among women with breast cancer or at high risk of the disease has greatly expanded over the past several decades. Tamoxifen has a complex effect on the female reproductive tract and several tamoxifen-associated changes have been described among tamoxifen users. These include endometrial thickening, cervical and endometrial polyps, endometrial hyperplasia, endometrial adenocarcinoma, uterine sarcoma, increase in the size of uterine leiomyomata, exacerbation of endometriosis and ovarian cysts. The most common uterine change associated with tamoxifen is endometrial polyps. The annual incidence of endometrial cancer among women on tamoxifen is 2 per 1000 and seems to be related to the cumulative tamoxifen dose. It is not clear whether endometrial cancer occurring among women on tamoxifen is of worse prognosis than endometrial cancer occurring among women not receiving tamoxifen. Tamoxifen is associated with several sonographic changes which make the use of ultrasound in surveillance of these patients difficult. There is no indication to implement routine screening for endometrial cancer among all women on tamoxifen. However, endometrial biopsy, preferably via hysteroscopy, should be considered in women with uterine bleeding.

The relationship of tamoxifen with dementia, depression, and dependence in activities of daily living in elderly nursing home residents

OBJECTIVES

To evaluate the association between tamoxifen treatment and the prevalence of Alzheimer's disease, other dementias, depression, and the levels of dependence in activities of daily living (ADL) in elderly, nursing home residents.

PARTICIPANTS

93,031 women, at least 65 years old, whose data were part of the 1993 New York State MDS, and for whom there was documentation of treatment with at least one medication.

SETTING

New York State long-term care facilities.

DESIGN

Cross-sectional study via secondary analysis of 1,385 matched sets of residents. Each set included one resident who received tamoxifen treatment and up to four residents who did not.

MEASUREMENTS

Included age, ethnicity, tamoxifen treatment, hormone replacement therapy, depression, levels of dependence in ADL and in cognitive skills for daily decision-making, and documentation of Alzheimer's disease and other dementias.

RESULTS

Women receiving tamoxifen were less likely to have a diagnosis of Alzheimer's disease documented on the MDS (odds ratio: 0.674; 95% confidence interval: 0.551-0.823), were significantly more independent in bed mobility, eating, toileting (in each case P < 0.0001), personal hygiene (P = 0.0155), dressing (P = 0.0015), transferring (P = 0.0006), locomotion (P = 0.0016), and they had better cognitive skills for daily decision-making (P < 0.0001). They were, however, 42% more likely to have a MDS diagnosis of depression (P < 0.0001). All tests of statistical significance are two-sided.

CONCLUSION

In this population, tamoxifen was associated with a higher level of independence in ADL and decision-making. While the MDS also suggested a relationship of tamoxifen with a lower prevalence of Alzheimer's disease, there seemed to be an increased prevalence of depression among treated women. The findings of this cross-sectional study could be evaluated in the randomized clinical trial that has just begun, and that will compare tamoxifen and raloxifene treatments.

Progress in the prevention of breast cancer: concept to reality

In 1936, Professor Antoine Lacassagne suggested that breast cancer could be prevented by developing drugs to block estrogen action in the breast. Jensen discovered the physiologic target, the estrogen receptor, that regulates estrogen action in its target tissues and Lerner discovered the first nonsteroidal antiestrogen MER25. However, the success of tamoxifen as a treatment of breast cancer opened the door for the testing of the worth of tamoxifen to reduce breast cancer incidence in high-risk women. In 1998, Fisher showed that tamoxifen could reduce breast cancer incidence by 50%. Nevertheless, only half the women who develop breast cancer have risk factors other than age, so what can be done for women without risk factors? The recognition that nonsteroidal antiestrogens have the ability to modulate estrogen action selectively has advanced the design and development of new drug for multiple diseases. Tamoxifen and raloxifene maintain bone density and raloxifene is now used to prevent osteoporosis and is being tested as a preventive for coronary heart disease and breast cancer. The drug group is now known as selective estrogen receptor modulators (SERMs) and the challenge is to design new agents for multiple applications. If the 20th century was the era of chemotherapy, the 21st century will be the era of chemoprevention.

Formestane is feasible and effective in elderly breast cancer patients with comorbidity and disability

Age is a major risk factor for solid tumors, including breast cancer. The majority of elderly breast cancer patients have oestrogen-dependent tumors, thus, tamoxifen is widely administered. However, it has been noted that tamoxifen-related thrombotic events are not exceptional. Due to the increasing prevalence of comorbidity, including vascular diseases, with age, such events are more frequently observed in the aged patients. Formestane, a selective steroidal aromatase inhibitor, may represent a therapeutic option after failure with tamoxifen, or in the presence of vascular diseases contraindicating its administration. The present report provides a new clinical experience on a consecutive series of 45 elderly breast cancer women affected by moderate to severe degree of comorbidity and disability measured by a Comprehensive Geriatric Assessment (CGA) scale validated on oncological patients. Formestane was given intramuscularly at the dose of 250 mg every 2 weeks. The study included 31 patients who had metastatic disease, and 14 who received formestane as an adjuvant treatment. Median age was 74 years (range 65-93), with nine patients > 80 years. Median ECOG Performance Status (PS) was one. The more frequent comorbidities observed in our series were arthrosis-arthritis (64.4% of patients), hypertension (44.4%), vascular diseases (35.5%), CNS diseases (28.8%). Twenty percent of patients presented at least one dependency in Activities of Daily Living (ADL) and 51.2% in Instrumental Activities of Daily Living (IADL). The treatment was well tolerated - only two patients interrupted formestane because of minor adverse reaction at the injection site and generalised itching. In particular Formestane was not responsible for any worsening of pre-treatment comorbidities, especially hypertension and vascular diseases. Objective responses (OR) were observed in 11.1% of advanced patients, while the disease was stabilised in 51.8% subjects. Median duration of OR was 12 months; median overall survival was 11 months. Among patients receiving formestane as adjuvant treatment, three relapsed, with a time to failure (TTF) of 12 months. Formestane is effective and minimally toxic in an elderly breast cancer population with comorbidities and disabilities measured by CGA.

Tamoxifen-induced severe hypertriglyceridemia and pancreatitis

Tamoxifen exhibits favorable effects on the lipid and lipoprotein profile since it decreases the total and LDL cholesterol levels as well as the Lp(a) levels. Additionally, a small increase in serum triglycerides is commonly found after tamoxifen administration. However, severe hypertriglyceridemia which can sometimes be associated with life-threatening complications is occasionally noticed. Herein, we describe a patient who developed tamoxifen-induced severe hypertriglyceridemia and pancreatitis. An analysis of the underlying pathogenetic mechanisms as well as a review of the relevant literature is also provided.

Selective estrogen receptor modulators in reproductive medicine and biology

Estrogen replacement therapy has significant potential benefits for postmenopausal women, such as improvement of menopausal symptoms and protection from osteoporosis, but it may also increase a woman's risk of breast cancer. Also, some women do not take hormone replacement therapy because of such undesirable side effects as breast tenderness and uterine bleeding. Therefore, there is much interest in the development of compounds that provide the benefits of estrogen replacement therapy without the risks and side effects. The selective estrogen receptor modulators make up one class of compounds with both estrogen agonist and antagonist activity. This review discusses the clinical indications, risks, benefits, and mechanisms of action of selective estrogen receptor modulators and related compounds.

Hormone replacement therapy and breast cancer

There is considerable evidence that the risk of breast cancer is related to ovarian function. However, the effect of postmenopausal hormone replacement therapy (HRT) on breast cancer risk continues to be debated in the absence of data from randomised controlled trials. Observational studies suggest that HRT probably promotes the growth of pre-existing breast cancers rather than initiating malignant transformation of breast epithelial cells but without exerting an obviously detrimental effect on disease-specific mortality. The controversy surrounding HRT and breast cancer has become additionally more complex as a result of the dilemma faced by clinicians advising women rendered oestrogen-deficient by breast cancer therapy. Whilst HRT is currently contra-indicated due to theoretical concerns that it will promote disease recurrence, its increasing, ad hoc prescription to symptomatic breast cancer patients has not been associated with an increase in disease recurrence. Large-scale randomised trials of HRT in healthy women and breast cancer survivors are now ongoing but it will be some years before useful clinical information becomes available. Until then, the limitations and biases implicit as a result of the design of observational studies must be borne in mind when interpreting such studies.

Ductal carcinoma in situ (DCIS) of the breast: evolving perspectives

Ductal carcinoma in situ (DCIS) of the breast is an early, localized stage of carcinoma in the process of multistep breast carcinogenesis. The incidence of DCIS is increasing, mainly due to screening mammography, which results in diagnosing the disease in an increasing proportion of asymptomatic patients. Consequently, clinicians are being confronted with growing numbers of women who present with DCIS of the breast; thus, the concepts of managing such patients are assuming greater importance. The most common presentation is calcifications on mammography. DCIS is a biologically and morphologically heterogeneous disease. If left untreated, a significant proportion of these tumours will evolve into invasive cancer. However, when appropriately treated, the prognosis of DCIS is excellent. Optimal management of DCIS remains controversial. The goal in the treatment of patients with DCIS is to control local disease and prevent subsequent development of invasive cancer. For several decades, total mastectomy was the treatment of choice for DCIS and it should still be considered the standard of care, to which more conservative forms of treatment must be compared. Mastectomy is associated with a risk for chest wall recurrence of approximately 1%. Axillary lymph node dissection is not routinely recommended in the management of DCIS. However, mastectomy probably represents overtreatment in a substantial number of patients, especially those with small, mammographically detected lesions. Local excision alone has been suggested in carefully selected patients, whilst the rest of the patients undergoing breast-conservation surgery should be treated with breast irradiation. There is evidence that breast-conservation therapy is an effective option in the management of selected patients with DCIS. The use of radiotherapy after lumpectomy significantly decreases the rate of recurrence. Nuclear grade, presence of comedo necrosis, and margin involvement are the most commonly used predictors of the likelihood of recurrence. There is no role for adjuvant chemotherapy in the management of this disease. The role of tamoxifen in the treatment of DCIS is not clearly defined; tamoxifen should be given only in patients enrolled in clinical trials. Following breast-conservation therapy, about 50% of the tumours recur as invasive cancer. Most patients with recurrent disease can be treated effectively, usually by salvage mastectomy, but also in selected cases by breast-conservation therapy.