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Bernhardt SM, Dasari P, Walsh D, Raymond W, Hull ML, Townsend AR, Price TJ, Ingman WV. The menstrual cycle is an under-appreciated factor in premenopausal breast cancer diagnosis and treatment. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.coemr.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Bernhardt SM, Dasari P, Walsh D, Townsend AR, Price TJ, Ingman WV. Timing of breast cancer surgery during the menstrual cycle-is there an optimal time of the month? Oncol Lett 2020; 20:2045-2057. [PMID: 32782523 PMCID: PMC7400969 DOI: 10.3892/ol.2020.11771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
An intriguing relationship between menstrual cycle phase at the time of breast cancer surgery and clinical outcomes was first proposed in the late 1980s. Despite a number of clinical studies conducted to address this, as well as meta-analyses and systematic reviews, there remains significant controversy surrounding the effect of menstrual cycle phase at time of surgery on the prognosis of premenopausal breast cancer. While some studies have suggested that surgery performed during the luteal phase results in the most favourable outcome, other studies report the follicular phase is more favourable, and others show no association. Given the conflicting results, there remains insufficient evidence to determine whether there is an optimal time of the month to perform surgery. This issue has dogged breast cancer surgery for decades; knowledge of an optimal time of the month to conduct surgery would be a simple approach to improving patient outcomes. This review explores the potential biological mechanisms through which the hormonal milieu might contribute to differences in prognosis, and why clinical findings are so variable. It is concluded that a significant problem with current clinical research is the lack of insight from mechanistic studies. While there are a number of plausible biological mechanisms that could lead to altered survival, supporting evidence is limited. There are also variable approaches to defining the menstrual cycle phase and hormone receptor status of the tumour and few studies controlled for prognostic factors such as tumour size and stage, or addressed the impact of adjuvant treatments. Elucidation of the specific confounding factors, as well as biological mechanistic pathways that could explain the potential relationship between timing of surgery and survival, will greatly assist in designing robust well-controlled prospective clinical studies to evaluate this paradigm.
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Affiliation(s)
- Sarah M Bernhardt
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Pallave Dasari
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - David Walsh
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia
| | - Amanda R Townsend
- Department of Medical Oncology, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia
| | - Wendy V Ingman
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
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Kang KD, Bae S, Kim HJ, Hwang IG, Kim SM, Han DH. The Relationship between Physical Activity Intensity and Mental Health Status in Patients with Breast Cancer. J Korean Med Sci 2017; 32:1345-1350. [PMID: 28665072 PMCID: PMC5494335 DOI: 10.3346/jkms.2017.32.8.1345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 05/13/2017] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate the correlation between physical activity (PA) level and mental health status in a population-based sample of Korean female patients with breast cancer. Our analysis included 76 patients with breast cancer and 44 healthy controls. The Korean versions of the International Physical Activity Questionnaire (IPAQ), Beck Depressive Inventory (BDI), State-Trait Anxiety Inventory-KY (STAI-KY), and Somatosensory Amplification Scale (SSAS), and Quality of Life (QOL) scale were assessed. The frequency of moderate PA level in breast cancer patients was significantly lower than that of healthy control subjects (t = -2.6; P = 0.011). In turn, the incidence of low PA level in breast cancer patients was significantly higher than that observed in healthy controls (t = 2.85; P = 0.005). A moderate PA level was inversely correlated with BDI score (r = -0.35; P = 0.008) and was positively correlated with QOL score (r = 0.38; P = 0.011). A low level of PA was inversely correlated with SSAS score (r = -0.39; P < 0.001). In healthy controls, a high level of PA was positively correlated with QOL score (r = 0.50; P = 0.043). Moderate PA level was inversely correlated with SSAS score (r = -0.59; P < 0.001). A low level of PA was also positively correlated with BDI score (r = 0.35; P = 0.008). A moderate or low intensity of PA was inversely correlated with depression and somatosensory amplification and was positively correlated with QOL in breast cancer patients. Finally, we suggest that progressively low-to-moderate levels of PA can be well adapted to positively impact several measures of mental health.
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Affiliation(s)
- Kyoung Doo Kang
- Department of Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sujin Bae
- Department of Industry Academic Cooperation Foundation, Chung-Ang University, Seoul, Korea
| | - Hee Jun Kim
- Department of Psychiatry, Chung-Ang University Hospital, Seoul, Korea
| | - In Gyu Hwang
- Department of Psychiatry, Chung-Ang University Hospital, Seoul, Korea
| | - Sun Mi Kim
- Department of Psychiatry, Chung-Ang University Hospital, Seoul, Korea
| | - Doug Hyun Han
- Department of Psychiatry, Chung-Ang University Hospital, Seoul, Korea.
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Lohmann AE, Goodwin PJ, Chlebowski RT, Pan K, Stambolic V, Dowling RJO. Association of Obesity-Related Metabolic Disruptions With Cancer Risk and Outcome. J Clin Oncol 2016; 34:4249-4255. [PMID: 27903146 DOI: 10.1200/jco.2016.69.6187] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Over the past 40 years, the prevalence of obesity has increased epidemically worldwide, which raises significant concerns regarding public health and the associated economic burden. Obesity is a major risk factor for several conditions including cardiovascular disease and type 2 diabetes, and recent evidence suggests that obesity negatively affects cancer risk and outcome. The relationship between obesity and cancer is complex and involves multiple factors both at the systemic and cellular level. Indeed, disruptions in insulin metabolism, adipokines, inflammation, and sex hormones all contribute to the adverse effects of obesity in cancer development and progression. The focus of this review will be the impact of these systemic obesity-related factors on cancer biology, incidence, and outcome. Potential therapeutic interventions and current clinical trials targeting obesity and its associated factors will also be discussed.
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Affiliation(s)
- Ana Elisa Lohmann
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
| | - Pamela J Goodwin
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
| | - Rowan T Chlebowski
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
| | - Kathy Pan
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
| | - Vuk Stambolic
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
| | - Ryan J O Dowling
- Ana Elisa Lohmann and Pamela J. Goodwin, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto; Vuk Stambolic, University of Toronto; Vuk Stambolic and Ryan J.O. Dowling, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Rowan T. Chlebowski and Kathy Pan, Los Angeles Biomedical Research Institute at Harbor, University of California, Los Angeles Medical Center, Torrance, CA
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Klonoff-Cohen H, An R, Fries T, Le J, Matt GE. Timing of breast cancer surgery, menstrual phase, and prognosis: Systematic review and meta-analysis. Crit Rev Oncol Hematol 2016; 102:1-14. [PMID: 27066938 DOI: 10.1016/j.critrevonc.2016.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 01/05/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND For over 25 years, there has been a debate revolving around the timing of breast cancer surgery, menstrual cycle, and prognosis. METHODS This systematic review synthesizes and evaluates the body of evidence in an effort to inform evidence-based practice. A keyword and reference search was performed in PubMed and Web of Science to identify human studies that met the inclusion criteria. A total of 58 studies (48 international and 10 U.S.-based) were identified. We provided a narrative summary on study findings and conducted a meta-analysis on a subset of studies where quantitative information was available. RESULTS Findings from both qualitative and quantitative analyses were inconclusive regarding performing breast cancer surgery around a specific phase of the menstrual cycle. CONCLUSION Based on the Institute of Medicine criteria, evidence is insufficient to recommend a change in current primary breast cancer surgery practice based on menstrual phase.
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Affiliation(s)
- Hillary Klonoff-Cohen
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, United States.
| | - Ruopeng An
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, United States
| | | | - Jennifer Le
- Department of Kinesiology and Community Health University of Illinois at Urbana-Champaign, United States
| | - Georg E Matt
- Department of Psychology, San Diego State University, United States
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Woodrum DT, Ford JW, Cho BS, Hannawa KK, Stanley JC, Henke PK, Upchurch GR. Differential effect of 17-beta-estradiol on smooth muscle cell and aortic explant MMP2. J Surg Res 2009; 155:48-53. [PMID: 19041098 PMCID: PMC2913053 DOI: 10.1016/j.jss.2008.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 06/21/2008] [Accepted: 07/02/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The present investigation tested the hypothesis that intrinsic gender-related differences exist in rat aortic smooth muscle cell matrix metalloproteinase 2 (MMP2). METHODS This investigation comprised 3 sets of experiments. Experiment I: Adult male and female rat aortic smooth muscle cells (RASMCs) at passages 4-8 were stimulated in serum-free media for 48 h with interleukin(IL)1beta at doses encountered in human abdominal aortic aneurysms (2 ng/mL). Messenger RNA was extracted from the RASMCs, and gene expression of MMP2 and tissue inhibitor of metalloproteinase 2 (TIMP2), a major MMP2 inhibitor, was measured by real-time polymerase chain reaction. MMP2 protein levels in conditioned media were measured by Western blotting, and MMP2 and TIMP2 activity quantified by standard and reverse gelatin zymography. Experiment II: Male and female RASMCs were incubated for 48 h in Dulbecco's modified Eagler's medium containing IL-1beta and 17-beta-estradiol at doses from 1x10(-10) to 1x10(-6) molar. MMP2 activity in the conditioned media was then determined. Experiment III: Male rats underwent sustained 17-beta-estradiol exposure for 21 d using extended-release, subcutaneously implanted pellets prior to sacrifice and aortic explantation. Aortas from males, females, and estradiol-treated males were stimulated with IL-1beta for 48-h, and MMP2 activity in the conditioned media was determined. RESULTS Experiment I: MMP2 gene expression was 3-fold higher in male compared with female IL-1beta stimulated RASMCs (P<0.0001). MMP2:TIMP2 gene expression ratio was 7.5-fold greater in male versus female RASMCs. MMP2 protein levels were 3-fold higher (2.68 versus 0.96 o.d./mg total protein, P=0.003) in male versus female RASMCs. Gelatinolytic activity was more than 6-fold higher (15,010 versus 2,472 o.d./mg total protein, P=0.002) in male versus female RASMCs. Experiment II: MMP2 activity in male and female RASMCs was not altered by a wide range of 17-beta-estradiol concentrations. Experiment III: When pretreated with 17-beta-estradiol, MMP2 activity in the media of male rat whole-aortic explants decreased 2-fold (P=0.002). This post-17-beta-estradiol treatment male level was not different than baseline female aortic explant MMP2 levels. CONCLUSIONS MMP2 is higher in male RASMCs compared to female RASMCs. Exogenous 17-beta-estradiol did not alter MMP2 activity in vitro, but in vivo 17-beta-estradiol exposure greatly decreased male aortic MMP2 production to levels seen in the female aorta. Gender differences in MMP2 are speculated to be associated with phenotypic differences in human abdominal aortic aneurysm formation.
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Affiliation(s)
- Derek T Woodrum
- Department of Surgery, Section of Vascular Surgery, Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan 48109-0329, USA
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Holick CN, Newcomb PA, Trentham-Dietz A, Titus-Ernstoff L, Bersch AJ, Stampfer MJ, Baron JA, Egan KM, Willett WC. Physical activity and survival after diagnosis of invasive breast cancer. Cancer Epidemiol Biomarkers Prev 2008; 17:379-86. [PMID: 18250341 DOI: 10.1158/1055-9965.epi-07-0771] [Citation(s) in RCA: 368] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Previous studies suggest that increased physical activity may lower the risk of breast cancer incidence, but less is known about whether levels of physical activity after breast cancer diagnosis can influence survival. We prospectively examined the relation between postdiagnosis recreational physical activity and risk of breast cancer death in women who had a previous invasive breast cancer diagnosed between 1988 and 2001 (at ages 20-79 years). All women completed a questionnaire on recent postdiagnosis physical activity and other lifestyle factors. Among 4,482 women without history of recurrence at the time of completing the questionnaire, 109 died from breast cancer within 6 years of enrollment. Physical activity was expressed as metabolic equivalent task-hours per week (MET-h/wk); hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated using Cox proportional hazards regression. After adjusting for age at diagnosis, stage of disease, state of residence, interval between diagnosis and physical activity assessment, body mass index, menopausal status, hormone therapy use, energy intake, education, family history of breast cancer, and treatment modality compared with women expending <2.8 MET-h/wk in physical activity, women who engaged in greater levels of activity had a significantly lower risk of dying from breast cancer (HR, 0.65; 95% CI, 0.39-1.08 for 2.8-7.9 MET-h/wk; HR, 0.59; 95% CI, 0.35-1.01 for 8.0-20.9 MET-h/wk; and HR, 0.51; 95% CI, 0.29-0.89 for > or =21.0 MET-h/wk; P for trend = 0.05). Results were similar for overall survival (HR, 0.44; 95% CI, 0.32-0.60 for > or =21.0 versus <2.8 MET-h/wk; P for trend <0.001) and were similar regardless of a woman's age, stage of disease, and body mass index. This study provides support for reduced overall mortality and mortality from breast cancer among women who engage in physical activity after breast cancer diagnosis.
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Affiliation(s)
- Crystal N Holick
- Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
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Ingram C, Visovsky C. Exercise intervention to modify physiologic risk factors in cancer survivors. Semin Oncol Nurs 2008; 23:275-84. [PMID: 18022055 DOI: 10.1016/j.soncn.2007.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review the best current evidence regarding the effects of exercise on modifiable risk factors for adverse physiologic outcomes of cancer and its treatment. DATA SOURCES Clinical practice guidelines, systematic reviews, meta-analyses, and single studies. CONCLUSION There is mounting evidence that exercise improves fatigue, physical functioning, and cardio-respiratory fitness. Preliminary evidence suggests that exercise also contributes to improvements in body weight and composition, metabolic risk factors, and immune function. It may also influence disease-free and overall survival in selected populations. IMPLICATIONS FOR NURSING PRACTICE Exercise appears to be a safe and well-tolerated intervention that may minimize or prevent adverse physiologic outcomes of cancer and cancer treatment.
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Affiliation(s)
- Carolyn Ingram
- School of Nursing, Faculty of Health Sciences, McMaster University, 1200 Main St West, HSC - 2J32, Hamilton, Ontario L8N 3Z5, Canada.
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Woodrum DT, Ford JW, Ailawadi G, Pearce CG, Sinha I, Eagleton MJ, Henke PK, Stanley JC, Upchurch GR. Gender differences in rat aortic smooth muscle cell matrix metalloproteinase-9. J Am Coll Surg 2005; 201:398-404. [PMID: 16125073 DOI: 10.1016/j.jamcollsurg.2005.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Revised: 03/30/2005] [Accepted: 04/04/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND A predilection exists for men to develop abdominal aortic aneurysms (AAAs), but the reasons for this gender predisposition are not known. Matrix metalloproteinase-9 (MMP-9) has been implicated in both human and experimental AAAs. This investigation tested the hypothesis that male and female gender differences exist in the production of MMP-9 by rat aortic smooth muscle cells (RASMCs). STUDY DESIGN In the first set of experiments, cultured male and female RASMCs were stimulated with interleukin-1 beta (IL-1beta) at 2 ng/mL. Messenger RNA was extracted from the RASMCs and gene expression of MMP-9 and tissue inhibitor of metalloproteinase-1 (TIMP-1), an MMP-9 inhibitor, was measured by quantitative real-time polymerase chain reaction. Cell culture media were collected for measurement of MMP-9 protein levels and MMP-9 activity by Western blotting and gelatin zymography, respectively. In the second set of experiments, male RASMCs were treated with 17-beta-estradiol (10(-10) to 10(-6) mol/L) and MMP-9 activity was measured. In the third set of experiments, male rats were pretreated with estradiol, and MMP-9 activity was measured in the media from explanted aortas. RESULTS MMP-9 gene expression was 10-fold higher in male versus female RASMCs (p=0.003). MMP-9 protein levels (p=0.005) and gelatinolytic activities (p=0.01) were also greater in male than female RASMCs. TIMP-1 expression was fourfold higher in male versus female RASMCs (p<0.001). Estradiol-treated male RASMCs did not exhibit a decrease in MMP-9 activity. But aortic explants from male rats pretreated with 17-beta-estradiol had 60% less MMP-9 activity than explants from male controls (p=0.03). CONCLUSIONS MMP-9 and TIMP-1 are greater in male than in female RASMCs. These findings support the tenet that gender-related differences in MMP-9 may contribute to AAA formation.
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Affiliation(s)
- Derek T Woodrum
- Jobst Vascular Research Laboratories, Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Holmes MD, Kroenke CH. Beyond treatment: lifestyle choices after breast cancer to enhance quality of life and survival. Womens Health Issues 2004; 14:11-3. [PMID: 15001183 DOI: 10.1016/j.whi.2003.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Indexed: 11/17/2022]
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Abstract
Concern exists that the reduction in breast cancer risk associated with the onset of the menopause will be negated with exposure to hormone replacement therapy (HRT). Evidence from large-scale randomised HRT trials support observational data that have shown a modest increase in breast cancer risk with long-term use (i.e. >15 years) of combined therapy, although this falls following HRT cessation suggesting a growth-promoting effect. Randomised evidence demonstrates that the efficacy of anti-estrogens, aromatase inhibitors and raloxifene in the treatment and chemoprevention of breast cancer are restricted to women with oestrogen receptor positive (ER +ve) disease; however, HRT has not been associated conclusively with a predominance of hormone sensitive breast cancer. Despite stimulating the breast cancer cell growth, HRT has not been shown to increase breast cancer recurrence or mortality when prescribed to breast cancer survivors experiencing oestrogen deficiency symptoms and randomised trials have been recommended and commenced. In conjunction with controlled breast cancer trials demonstrating a therapeutic benefit of high dose estrogens and interest in the use of additive oestrogen therapy in patients developing resistance to oestrogen deprivation, the dogma that HRT is an absolute contra-indication following diagnosis is challenged.
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Affiliation(s)
- Jo Marsden
- Academic Department of Surgery, The Royal Marsden Hospital Trust, Fulham Road, London SW3 6JJ, UK.
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