Hormone replacement therapy and false positive recall in the Million Women Study: patterns of use, hormonal constituents and consistency of effect

The Comparative Study of the Administration of the Combination Preparation of Isoflavones and Hyaluronic Acid in Menopausal Women for the Treatment of the Symptoms of Menopause, Urogenital Atrophy and Oteoporosis in Relation to Existing Hormone Replacement Therapies

Background

Menopause is characterized by a series of symptoms and effects from the various systems and organs, for which, the decline in estrogen production from the ovaries is considered responsible.

Objective

The aim of this study was to make comparative study of the administration of the combination preparation of isoflavones and hyaluronic acid in menopausal women for the treatment of the symptoms of menopause, urogenital atrophy and osteoporosis in relation to existing hormone replacement therapies.

Methods

In this five-year, double-blind, placebo-controlled clinical study, a total of 274 postmenopausal women were enrolled and classified into three groups. Participants in group A, were 96 women who did not receive Hormone Replacement Therapy (HRT), in the second group, 92 received daily treatment with tibolone (2.5 mg) as monotherapy, and in the third group, 86 received treatment with a pharmaceutical formulation of hyaluronic acid 120 mg and isoflavones. MF11RCE 80 mg.

Results

In the postmenopausal women of our study, a significant reduction of postmenopausal symptoms was found in both groups B and C of participants who received hormone replacement preparations compared to group A who did not receive HRT. Furthermore, no difference in efficacy was observed between the administered preparations of isoflavones and tibolone.

Conclusion

The combination of isoflavones and hyaluronic acid has the same efficacy as tibolone in menopausal symptoms.

Computational Radiology in Breast Cancer Screening and Diagnosis Using Artificial Intelligence

Breast cancer screening has been shown to significantly reduce mortality in women. The increased utilization of screening examinations has led to growing demands for rapid and accurate diagnostic reporting. In modern breast imaging centers, full-field digital mammography (FFDM) has replaced traditional analog mammography, and this has opened new opportunities for developing computational frameworks to automate detection and diagnosis. Artificial intelligence (AI), and its subdomain of deep learning, is showing promising results and improvements on diagnostic accuracy, compared to previous computer-based methods, known as computer-aided detection and diagnosis.

In this commentary, we review the current status of computational radiology, with a focus on deep neural networks used in breast cancer screening and diagnosis. Recent studies are developing a new generation of computer-aided detection and diagnosis systems, as well as leveraging AI-driven tools to efficiently interpret digital mammograms, and breast tomosynthesis imaging. The use of AI in computational radiology necessitates transparency and rigorous testing. However, the overall impact of AI to radiology workflows will potentially yield more efficient and standardized processes as well as improve the level of care to patients with high diagnostic accuracy.

Breast effects of oral, combined 17β-estradiol, and progesterone capsules in menopausal women: a randomized controlled trial

Objective:

To evaluate the effect of a single-capsule, bioidentical 17β-estradiol (E2) and progesterone (P4) hormone therapy on mammograms and breasts in postmenopausal women after 1 year of use.

Methods:

In the 12-month, phase 3, randomized, double-blind, placebo-controlled, multicenter REPLENISH trial, postmenopausal women (40-65 y) with moderate to severe vasomotor symptoms and a uterus were randomized to four active daily dose groups of E2/P4 (TX-001HR) or a placebo group. Mammograms were performed and read locally at screening (or ≤6 months before first dose) and at study end using BI-RADS classification. Incidence of abnormal mammograms and breast adverse events was evaluated.

Results:

All but 8 (0.4%) mammograms at screening were normal (BI-RADS 1 or 2). At 1 year, 39 (2.9%) of the 1,340 study-end mammograms were abnormal (BI-RADS 3 or 4); incidence was 1.7% to3.7% with active doses and 3.1% with placebo. Breast cancer incidence was 0.36% with active doses and 0% with placebo. Breast tenderness was reported at frequencies of 2.4% to 10.8% with active doses versus 0.7% with placebo, and led to eight study discontinuations (1.6% of discontinuations in active groups).

Conclusions:

In this phase 3 trial of a combined E2/P4, results of secondary outcomes suggest that E2/P4 may not be associated with increased risk of abnormal mammograms versus placebo, and the incidence of breast tenderness was low relative to most of the rates reported in other studies using hormone therapy.

Factors associated with false-positive mammography at first screen in an Asian population

Introduction

False-positive recall is an issue in national screening programmes. The aim of this study is to investigate the recall rate at first screen and to identify potential predictors of false-positive recall in a multi-ethnic Asian population-based breast cancer screening programme.

Methods

Women aged 50–64 years attending screening mammography for the first time (n = 25,318) were included in this study. The associations between potential predictors (sociodemographic, lifestyle and reproductive) and false-positive recall were evaluated using multivariable logistic regression models.

Results

The recall rate was 7.6% (n = 1,923), of which with 93.8% were false-positive. Factors independently associated with higher false-positive recall included Indian ethnicity (odds ratio [95% confidence interval]: 1.52 [1.25 to 1.84]), premenopause (1.23 [1.04 to 1.44]), nulliparity (1.85 [1.57 to 2.17]), recent breast symptoms (1.72 [1.31 to 2.23]) and history of breast lump excision (1.87 [1.53 to 2.26]). Factors associated with lower risk of false-positive recall included older age at screen (0.84 [0.73 to 0.97]) and use of oral contraceptives (0.87 [0.78 to 0.97]). After further adjustment of percent mammographic density, associations with older age at screening (0.97 [0.84 to 1.11]) and menopausal status (1.12 [0.95 to 1.32]) were attenuated and no longer significant.

Conclusion

For every breast cancer identified, 15 women without cancer were subjected to further testing. Efforts to educate Asian women on what it means to be recalled will be useful in reducing unnecessary stress and anxiety.

Errors in Mammography Cannot be Solved Through Technology Alone

Mammography has been the frontline screening tool for breast cancer for decades. However, high error rates in the form of false negatives (FNs) and false positives (FPs) have persisted despite technological improvements. Radiologists still miss between 10% and 30% of cancers while 80% of woman recalled for additional views have normal outcomes, with 40% of biopsied lesions being benign. Research show that the majority of cancers missed is actually visible and looked at, but either go unnoticed or are deemed to be benign. Causal agents for these errors include human related characteristics resulting in contributory search, perception and decision-making behaviours. Technical, patient and lesion factors are also important relating to positioning, compression, patient size, breast density and presence of breast implants as well as the nature and subtype of the cancer itself, where features such as architectural distortion and triple-negative cancers remain challenging to detect on screening. A better understanding of these causal agents as well as the adoption of technological and educational interventions, which audits reader performance and provide immediate perceptual feedback, should help. This paper reviews the current status of our knowledge around error rates in mammography and explores the factors impacting it. It also presents potential solutions for maximizing diagnostic efficacy thus benefiting the millions of women who undergo this procedure each year.

Consequences of a false-positive mammography result: drug consumption before and after screening

Background Previous research showed women experiencing false-positive mammograms to have greater anxiety about breast cancer than women with normal mammograms. To elucidate psychological effects of false-positive mammograms, we studied impact on drug intake. Methods We calculated the ratio of drug use for women with false-positive versus women with normal mammograms, before and after the event, using population-based registers, 1997-2006. The ratio of the ratios (RRR) assessed the impact. Results Before the test, 40.3% of women from the false-positive group versus 36.2% from the normal group used anxiolytic and antidepressant drugs. There was no difference in use of beta blockers. Hormone therapy was used more frequently by the false-positive, 36.6% versus 28.7%. The proportion of women using anxiolytic and antidepressant drugs increased with 19% from the before to the after period in the false-positive group, and with 16% in the normal group, resulting in an RRR of 1.02 (95% CI 0.92-1.14). RRR was 1.03 for beta blockers, 0.97 for hormone therapy. Conclusion(s) Drugs used to mitigate mood disorders were used more frequently by women with false-positive than by women with normal mammograms already before the screening event, while the changes from before to after screening were similar for both groups. The results point to the importance of control for potential selection in studies of screening effects.

Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy

IMPORTANCE

Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

OBJECTIVE

To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

DESIGN

Prospective cohort.

SETTING

Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

PARTICIPANTS

Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

MAIN OUTCOMES AND MEASURES

We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

RESULTS

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

CONCLUSIONS AND RELEVANCE

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Circulating tumor cells measurements in hepatocellular carcinoma

Liver cancer is the fifth most common cancer in men and the seventh in women. During the past 20 years, the incidence of HCC has tripled while the 5-year survival rate has remained below 12%. The presence of circulating tumor cells (CTC) reflects the aggressiveness nature of a tumor. Many attempts have been made to develop assays that reliably detect and enumerate the CTC during the development of the HCC. In this case, the challenges are (1) there are few markers specific to the HCC (tumor cells versus nontumor cells) and (2) they can be used to quantify the number of CTC in the bloodstream. Another technical challenge consists of finding few CTC mixed with million leukocytes and billion erythrocytes. CTC detection and identification can be used to estimate prognosis and may serve as an early marker to assess antitumor activity of treatment. CTC can also be used to predict progression-free survival and overall survival. CTC are an interesting source of biological information in order to understand dissemination, drug resistance, and treatment-induced cell death. Our aim is to review and analyze the different new methods existing to detect, enumerate, and characterize the CTC in the peripheral circulation of patients with HCC.

Hormone replacement therapy dependent changes in breast cancer-related gene expression in breast tissue of healthy postmenopausal women

Risk assessment of future breast cancer risk through exposure to sex steroids currently relies on clinical scorings such as mammographic density. Knowledge about the gene expression patterns in existing breast cancer tumors may be used to identify risk factors in the breast tissue of women still free of cancer. The differential effects of estradiol, estradiol together with gestagens, or tibolone on breast cancer-related gene expression in normal breast tissue samples taken from postmenopausal women may be used to identify gene expression profiles associated with a higher breast cancer risk. Breast tissue samples were taken from 33 healthy postmenopausal women both before and after a six month treatment with either 2mg micronized estradiol [E2], 2mg micronized estradiol and 1mg norethisterone acetate [E2+NETA], 2.5mg tibolone [T] or [no HRT]. Except for [E2], which was only given to women after hysterectomy, the allocation to each of the three groups was randomized. The expression of 102 mRNAs and 46 microRNAs putatively involved in breast cancer was prospectively determined in the biopsies of 6 women receiving [no HRT], 5 women receiving [E2], 5 women receiving [E2+NETA], and 6 receiving [T]. Using epithelial and endothelial markers genes, non-representative biopsies from 11 women were eliminated. Treatment of postmenopausal women with [E2+NETA] resulted in the highest number of differentially (p<0.05) regulated genes (16.2%) compared to baseline, followed by [E2] (10.1%) and [T] (4.7%). Among genes that were significantly down-regulated by [E2+NETA] ranked estrogen-receptor-1 (ESR1, p=0.019) and androgen receptor (AR, p=0.019), whereas CYP1B1, a gene encoding an estrogen-metabolizing enzyme, was significantly up-regulated (p=0.016). Mammary cells triggered by [E2+NETA] and [E2] adjust for steroidogenic up-regulation through down-regulation of the estrogen-receptor pathway. In this prospective study, prolonged administration of [E2+NETA] and to a lesser extent of [E2] but not [T] were associated in otherwise healthy breast tissue with a change in the expression of genes putatively involved in breast cancer. Our data suggest that normal mammary cells triggered by [E2+NETA] adjust for steroidogenic up-regulation through down-regulation of the estrogen-receptor pathway. This feasibility study provides the basis for whole genome analyses to identify novel markers involved in increased breast cancer risk.

Postmenopausal hormone therapy and breast cancer risk: current status and unanswered questions

Many women take hormone therapy (HT) for menopausal symptom relief. Studies have tried to clarify whether various factors can modify the risk of HT, such as the age at initiation, dose, duration, or type of HT, or characteristics of the individual, such as family history or body mass index. The relative risks of breast cancer associated with HT across various subgroups of women should be considered similar, but absolute risks can vary significantly among women and this may inform individual decision making. For breast cancer survivors, systemic HT should be discouraged.

Type of hormone therapy and risk of misclassification at mammography screening

OBJECTIVE

Current users of hormone therapy (HT) are known to have a lower accuracy of mammography screening than do never users. We studied whether the risk of misclassification depends on type of hormone, administration, regimen, and dose of the therapy.

METHODS

We linked data from mammography screening registers with drug prescription registers from Fyn, Denmark to identify current and never HT users among screening participants. We compared false-positive risks and interval cancer proportions between current users of different HT preparations, taking women's age, breast density, screen number, and age of comparison mammogram into account.

RESULTS

Estrogen therapy users had a significantly higher false-positive risk when the administration was by injection instead of oral (relative risk [RR], 2.37; 95% CI, 1.37-4.09). Women using sequential estrogen plus progestogen therapy had a significantly higher false-positive risk (RR, 1.94; 95% CI, 1.16-3.26) and a nonsignificantly higher interval cancer proportion (RR, 4.29; 95% CI, 0.69-26.53) when the administration of both hormones was transdermal instead of oral. Using tibolone instead of comparable hormones gave a nonsignificantly lower false-positive risk and a nonsignificantly higher interval cancer proportion.

CONCLUSIONS

Our data showed increased risks of misclassification at mammography screening among women using estrogen injections or transdermal, sequential estrogen plus progestogen. Tibolone seems to offer no advantage regarding accuracy of screening mammography.

An epidemiological overview of the relationship between hormone replacement therapy and breast cancer

Large-scale randomized clinical trials and observational studies have consistently found that use of hormone replacement therapy (HRT) increases the risk of breast cancer. More recently, ecological studies have shown correlations between dramatic reductions in use of HRT in many countries, and declines in the rates of breast cancer in older women. Meta-analyses of data from the trials and observational studies show that the increase in breast cancer risk is greater for combined estrogen-progestin therapies compared with estrogen alone; that for both types of preparation, breast cancer risk increases with duration of use; and that the risks decrease relatively quickly after cessation of use. For both estrogen-only and combined therapies, the risk of breast cancer is higher if therapy is initiated close to the time of the menopause, relative to the risks in women starting HRT later. Most drug regulatory authorities currently recommend that HRT be prescribed only to fully informed women who have moderate-to-severe menopausal symptoms, for the shortest duration possible; and it is recommended that the need for therapy be reviewed at least every 6-12 months.

Estrogen alone in postmenopausal women and breast cancer detection by means of mammography and breast biopsy

PURPOSE

As the influence of estrogen alone on breast cancer detection is not established, we examined this issue in the Women's Health Initiative trial, which randomly assigned 10,739 postmenopausal women with prior hysterectomy to conjugated equine estrogen (CEE; 0.625 mg/d) or placebo.

METHODS

Screening mammography and breast exams were performed at baseline and annually. Breast biopsies were based on clinical findings. Effects of CEE alone on breast cancer detection were determined by using receiver operating characteristic (ROC) analyses of mammogram performance.

RESULTS

After a 7.1-year mean follow-up, fewer invasive breast cancers were diagnosed in the CEE than in the placebo group, but the difference was not statistically significant. Use of CEE alone increased mammograms with short-interval follow-up recommendations (cumulative, 39.2% v 29.6.3%; P < .001) but not abnormal mammograms (ie, those suggestive of or highly suggestive of malignancy; cumulative, 7.3% v 7.0%; P = .41). Breast biopsies were more frequent in the CEE group (cumulative, 12.5% v 10.7%; P = .004) and less commonly diagnosed as cancer (8.9% v 15.8%, respectively, with positive biopsies; P = .04). Mammographic breast cancer detection in the CEE group was significantly compromised only in the early years of use.

CONCLUSION

CEE alone use for 5 years results in approximately one in 11 and one in 50 women having otherwise avoidable mammograms with short-interval follow-up recommendations or breast biopsies, respectively. Although the breast biopsies on CEE were less commonly diagnosed as cancer, breast cancer detection was not substantially compromised. These findings differ from estrogen-plus-progestin use, for which significantly increased abnormal mammograms and a compromise in breast cancer detection are seen.

Recording of hormone therapy and breast density in breast screening programs: summary and recommendations of the International Cancer Screening Network

Breast density and the use of hormone therapy (HT) for menopausal symptoms alter the risk of breast cancer and both factors influence screening mammography performance. The International Cancer Screening Network (ICSN) surveyed its 29 member countries and found that few programs record breast density or the use of HT among screening participants. This may affect the ability of programs to assess their effectiveness in reducing breast cancer mortality. Seven countries recorded the use of HT at screening, and some were able to link screening records to individual prescribing records of HT. Eight countries reported recording breast density at screening mammography for some or all women screened. The recommendations of the ICSN for recording information about breast density and HT are presented.

Decreased accuracy in interpretation of community-based screening mammography for women with multiple clinical risk factors

OBJECTIVE

To assess the impact of women's breast cancer risk factors (use of hormone therapy, family history of breast cancer, previous breast biopsy) on radiologists' mammographic interpretive performance and whether the influence of risk factors varies according to radiologist characteristics.

STUDY DESIGN AND SETTING

Screening mammograms (n=638,947) performed from 1996 to 2005 by 134 radiologists from three Breast Cancer Surveillance Consortium registries was linked to cancer outcomes, radiologist surveys, and patient questionnaires. Interpretive performance measures were modeled using marginal and conditional logistic regression.

RESULTS

Having one or more clinical risk factors was associated with higher recall rates (1 vs. 0 risk factors: odds ratio [OR]=1.17, 95% confidence interval [CI]=1.15-1.19; > or = 2 vs. 0: OR=1.43, 95% CI=1.40-1.47) and lower specificity (1 vs. 0: OR=0.86 [95% CI=0.84-0.88]; > or = 2 vs. 0: OR=0.70 [95% CI=0.68-0.72]) without a corresponding improvement in sensitivity and only a small increase in positive predictive value (1 vs. 0: OR=1.08 [95% CI=0.99-1.19]; > or = 2 vs. 0: OR=1.12 [95% CI=0.99-1.26]). There was no indication that influence of risk factors varied by radiologist characteristics.

CONCLUSION

Women with clinical risk factors who undergo screening mammography are more likely recalled for false-positive evaluation without an associated increase in cancer detection. Radiologists and patients with risk factors should be aware of this increased risk of adverse screening events.

[Hormones and mammographic breast density]

Breast constitutional density may be altered and increased (acquired density) by hormonal interventions such as hormone replacement therapy (HRT). The effects of endogenous (steroids, prolactin, insulin-like factors...) and exogenous (HRT, levonorgestrel IUD, tibolone, tamoxifen, SERMs) hormones will be reviewed. Continuous combined estrogen-progestin preparations are most likely to cause an increase in density. Estrogen alone and tibolone are less likely to cause an increase in density. The sensitivity and specificity of mammography are decreased, with increased risk of interval carcinoma and rate of short interval follow-up from false positive results. The issue with regards to interruption of the hormonal therapy prior to mammography, and the duration of the interruption, are discussed.

The European Menopause Survey 2005: women's perceptions on the menopause and postmenopausal hormone therapy

OBJECTIVES

To identify and describe current women's thoughts about the menopause, hormone treatment (HT) and perceptions about breast cancer.

METHODS

Between December 2004 and January 2005, 4201 postmenopausal women in seven European countries were interviewed via a standardized computer-aided telephone interview protocol.

RESULTS

Almost all women reported to have experienced climacteric symptoms, and 63% of the women rated them as being severe. Only 52% of women were aware of the benefits of HT for relief of climacteric symptoms. Although 84% felt that severe symptoms should be treated, only 40% had used HT at some point in time. Thirty-four percent of the women preferring treatment with natural products did so because of the risk of breast cancer associated with HT. HT was recognized by 59% of the women as one of the most important contributors to an increased breast cancer risk. Most women received their information about HT and breast cancer risk from the media.

CONCLUSIONS

This European survey reveals that the majority of women experience climacteric symptoms but that their decision whether or not to use HT is highly dependent on their concern about breast cancer risk. An increase in knowledge of the benefits and risks of HT is required for women to make appropriate decisions about hormone use.