Challenges in the gynecologic care of premenopausal women with breast cancer

How can additional ultrasonography screening improve the detection of occult breast cancer in women with dense breasts?

Purpose

Although mammography is a gold standard for breast cancer screening, the number of cancers that cannot be detected with mammography is substantial, especially in dense-breast (DB) women. Breast sonography can be a useful and powerful screening tool in these cases. The aim of this study is to assess the application of whole-breast sonography in the evaluation of breast lesions in women with DB tissue and estimate its accuracy in comparison with mammography.

Material and methods

A total of 207 asymptomatic DB women participated in this study. The breast tissue density was assessed using ACR BI-RADS. Patients underwent high-resolution ultrasonography of the breast in addition to physical examination and mammography. Different risk factors were also assessed.

Results

152 of 207 (73.4%) cases who had mammography performed had DB, and 55 (26.6%) cases had very dense breasts (very DBs). None of the cases had a positive history of malignancy, while 19% of them had a positive history of breast cancer in first- or second-degree relatives.

Conclusions

All findings were higher in cases with DB compared to very DBs except for fibroadenoma, which was detected more in cases with very DBs. Our study showed that the prevalence of different breast lesions had a significant relationship with the density of the breast. In our study, 48.3% of the cases were diagnosed with a lesion in their sonography result, although 81.0% of them were benign lesions, and the other 19.0% needed follow-up or biopsy evaluation. A substantial number of mammographically occult breast lesions, either benign or malignant, could be detected by ultrasound in DB tissue.

Unique aspects of caring for young breast cancer patients

Breast cancer is the most commonly diagnosed malignancy in young women in the USA. Although breast cancer mortality has decreased overall, survival rates in young women remain lower than those in older women. Young women with breast cancer comprise a special population due to the aggressive biology of their tumors as well as their unique psychosocial concerns. Although general treatment principles are similar regardless of age, recent developments from research focused on younger women have provided new insights to guide treatment of this special population. This article will focus on these new developments in areas including endocrine therapy and fertility preservation as well as the unique treatment-related sequelae and psychosocial concerns among young women with breast cancer face.

Incidence of chemotherapy-induced ovarian failure in premenopausal women undergoing chemotherapy for breast cancer

INTRODUCTION

Breast cancer is increasingly reported in young premenopausal women in Asia. Adjuvant chemotherapy improves survival; however, it has a unique consequence of ovarian failure in premenopausal patients.

OBJECTIVE

This study's aim was to find the incidence of chemotherapy-induced ovarian failure (CIOF) and reversible amenorrhea in premenopausal non-metastatic breast cancer patients.

METHOD

This mixed retrospective and prospective study follows premenopausal breast cancer patients receiving chemotherapy between 2008 and 2012. Patients in the prospective arm were followed up with menstrual history and serum ovarian hormones (follicle-stimulating hormone [FSH] and estradiol) until 1 year post-chemotherapy, and patients in the retrospective arm were contacted for their menstrual history.

RESULTS

The mean age of the 102 subjects was 43.3 years. Of the patients, 93.1 and 77.9 % were amenorrheic at completion of chemotherapy and at 12 months post-chemotherapy, respectively. Of those who developed amenorrhea, 24.6 % regained menstruation, on average after 7.86 (range 1-15) months post-chemotherapy. Age was the only statistically significant risk factor. CIOF and reversible amenorrhea was 57 and 50 % at <35 years, 95 and 31.6 % at 35-45 years, and 97.9 and 14.9 % at >50 years, respectively. The 33 prospective patients' estradiol and FSH levels seem to correlate well with onset of amenorrhea, with a falling estradiol and rising FSH trend. Tamoxifen use was associated with elevated estradiol levels 1 year post-chemotherapy.

CONCLUSION

This study found a high incidence of CIOF, with a relatively low rate of reversible amenorrhea. Premenopausal patients should be counselled prior to treatment and education and support provided.

Baseline hysteroscopic assessment of endometrium in asymptomatic postmenopausal women with estrogen receptor-positive breast cancer

OBJECTIVE

The goal of this study was to evaluate the true prevalence of endometrial pathology in asymptomatic postmenopausal estrogen receptor-positive (ER-positive) breast cancer patients and to know whether some patients are particularly at risk.

METHODS

A preliminary cross-sectional study was carried out with 130 postmenopausal ER-positive breast cancer patients. Before any treatment, diagnostic hysteroscopy and endometrial biopsy were performed in all women. Histopathological findings were considered the gold standard in estimating the prevalence of endometrial disease, which was analyzed according to different risk factors.

RESULTS

Hysteroscopic evaluation was possible in 118 patients (90.7%). Of these patients, 68.6% were older than 60 years, and 51.4% were obese. Endometrial polyps were found in 35 patients (29.6%; 1 polyp with simple hyperplasia), and simple endometrial hyperplasia was found in 1 patient (0.8%), with an overall morbidity of the endometrium of 31.3%. Among all the well-established individual risk factors for endometrial pathology, only patient age, body mass index, and time since menopause were significant predictors of endometrial pathology and/or polyps. There was no statistical difference in the thicknesses of the endometrial lining, but many patients with an endometrial lining of less than 4 mm had polyps of less than 5 mm.

CONCLUSIONS

Asymptomatic postmenopausal women with ER-positive breast cancer have a very high prevalence of baseline subclinical endometrial abnormalities. Therefore, endometrial screening before tamoxifen treatment may be useful in all of these patients, and we believe that it should be performed by hysteroscopy in patients at high risk (obese and older women).

Black Cohosh and Breast Cancer

Background. Many women use black cohosh as a natural treatment for menopausal symptoms. However, controversy exists around safety in breast cancer, because of its purported estrogenic activity. We conducted a systematic review of black cohosh use in women with or at risk of breast cancer. Methods. We searched MEDLINE, Embase, the Cochrane Library, and AMED from inception to July 2012 and October 2012 for human interventional or observational data pertaining to the safety and efficacy of black cohosh in patients with or at risk of breast cancer, including an assessment of the effect of black cohosh on estrogen responsive tissues. Results. Of 450 records, we included 26 articles: 14 randomized controlled trials, 7 uncontrolled trials, and 5 observational studies.The evidence on efficacy for ho t flashes is divided, with some benefits seen when compared with baseline, but not when compared with placebo. Two observational studies found no association between black cohosh and risk of breast cancer, whereas 2 studies reported significant reductions in risk of primary breast cancer among postmenopausal women (adjusted odds ratio = 0.47, 95% confidence interval = 0.27-0.82), and risk of recurrence (adjusted hazard ratio = 0.75, 95% confidence interval = 0.63-0.89). Seventeen trials showed no significant impact on circulating hormone levels or proliferation in estrogen responsive tissues. Conclusions. Current evidence does not support an association between black cohosh and increased risk of breast cancer. There is a lack of evidence supporting the efficacy of black cohosh for reduction of hot flashes in breast cancer patients. Given conflicting but promising results, and apparent safety, further research is warranted.

Altered resting state functional brain network topology in chemotherapy-treated breast cancer survivors

Many women with breast cancer, especially those treated with chemotherapy, experience cognitive decline due in part to neurotoxic brain injury. Recent neuroimaging studies suggest widespread brain structural abnormalities pointing to disruption of large-scale brain networks. We applied resting state functional magnetic resonance imaging and graph theoretical analysis to examine the connectome in breast cancer survivors treated with chemotherapy relative to healthy comparison women. Compared to healthy females, the breast cancer group displayed altered global brain network organization characterized by significantly decreased global clustering as well as disrupted regional network characteristics in frontal, striatal and temporal areas. Breast cancer survivors also showed significantly increased self-report of executive function and memory difficulties compared to healthy females. These results suggest that topological organization of both global and regional brain network properties may be disrupted following breast cancer and chemotherapy. This pattern of altered network organization is believed to result in reduced efficiency of parallel information transfer. This is the first report of alterations in large-scale functional brain networks in this population and contributes novel information regarding the neurobiologic mechanisms underlying breast cancer-related cognitive impairment.

Altered small-world properties of gray matter networks in breast cancer

Background

Breast cancer survivors, particularly those treated with chemotherapy, are at significantly increased risk for long-term cognitive and neurobiologic impairments. These deficits tend to involve skills that are subserved by distributed brain networks. Additionally, neuroimaging studies have shown a diffuse pattern of brain structure changes in chemotherapy-treated breast cancer survivors that might impact large-scale brain networks.

Methods

We therefore applied graph theoretical analysis to compare the gray matter structural networks of female breast cancer survivors with a history of chemotherapy treatment and healthy age and education matched female controls.

Results

Results revealed reduced clustering coefficient and small-world index in the brain network of the breast cancer patients across a range of network densities. In addition, the network of the breast cancer group had less highly interactive nodes and reduced degree/centrality in the frontotemporal regions compared to controls, which may help explain the common impairments of memory and executive functioning among these patients.

Conclusions

These results suggest that breast cancer and chemotherapy may decrease regional connectivity as well as global network organization and integration, reducing efficiency of the network. To our knowledge, this is the first report of altered large-scale brain networks associated with breast cancer and chemotherapy.