COMMENTARY

December 2004: The Year in Review -- Ob/Gyn & Women's Health

Ursula Snyder, PhD

Disclosures

January 24, 2005

Breast and Gynecologic Cancer

Breast cancer. Short-term, severe caloric restriction may increase the risk of breast cancer, according to the findings of a study of famine survivors.[189] On the other hand, the results of a retrospective study in anorexic women indicate that caloric restriction at an early age protects against invasive breast cancer.[190]

A 12-month randomized clinical trial led by Medscape Ob/Gyn & Women's Health board member Anne McTiernan, MD, PhD, showed that increased physical activity significantly reduces serum estrogens in postmenopausal women and may reduce the risk of breast cancer.[191]

At 2 meetings in 2004, the American Society of Clinical Oncology (ASCO) and European Society for Medical Oncology (ESMO), results of a study of the selective estrogen receptor modulator and osteoporosis drug raloxifene were presented that suggest it may reduce risk of invasive breast cancer in postmenopausal women, even those who were also taking menopausal HT. The treatment was also associated with a 2-fold increase in venous thrombotic events (See Medscape Medical News stories: ASCO and ESMO.) Raloxifene is not approved for chemoprevention of breast cancer, and that recommendation will not be made until raloxifene is compared in a head-to-head trial with tamoxifen.

Ovarian cancer. A 15-year follow-up of the Iowa Women's Health study found that frequent and vigorous physical activity increased the risk of ovarian cancer.[192] The estrogen component of oral menopausal HT is associated with ovarian cancer risk; the risk increases with cumulative oral estrogen intake as opposed to how long the HT is taken.[193] The implication is that minimizing the daily dose of estrogen in an oral HT product may reduce ovarian cancer risk. Primary infertility and endometriosis have also been found to be independently associated with an increase in the risk for ovarian cancer.[96] Finally, a study published this past summer has linked exposure to diesel exhaust with an increased risk of ovarian cancer.[194]

Breast cancer. Findings from a study published in August indicate that only 6% of women undergo annual screening mammography as recommended by the American Cancer Society.[195] Analysis indicates that this underutilization of screening could result in higher mortality levels. Women from traditionally underserved socioeconomic, racial, and ethnic groups, women without insurance, and women who did not speak English had lower levels of use compared with other women. A companion study looked at the age at which women begin mammographic screening[196]:

Women without private health insurance began screening at a median age of 46.6 years, 6.3 years later than women with private health coverage. Women who did not speak English began screening at a median age of 49.3 years, 9.0 years later than women for whom English was the primary language. Women who both lacked private health insurance and spoke a language other than English began screening at a median age of 55.3 years, 15.2 years later than women without these characteristics.

Most cases of late-stage breast cancer in the United States occur because the patient has not undergone mammography screening rather than being due to an absence of detection or breakdown in follow-up.[197] The authors of the study used data from 7 healthcare plans that included 1.5 million women aged 50 years or older. Among case patients, women were more likely to be in the absence-of-screening group if they were aged 75 years or older, or without a family history of breast cancer, and a higher proportion of women from census blocks with less education or lower median annual income were in the absence-of-screening category. The authors suggest women in these groups should be made a top priority for screening implementation.

This year, the Institute of Medicine and National Research Council of the National Academies released the report "Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnoses," which notes that better access to screening is needed and that training more technicians to do mammograms and improving access will do far more to prevent breast cancer deaths in the near future than new technology, such as MRI (See Improved Breast Cancer Screening Access Needed.)

In an observational study, a 2-year interval did not increase the risk of finding advanced breast cancer in women older than 49 years, even in women with dense breasts.[198] (See Medscape Medical News CME story.) Another study found that mammography efficiency and possible efficacy were influenced by HT use, previous surgery, and BMI.[199] (See Medscape Medical CME News story.) During a plenary lecture at the 2004 San Antonio Breast Cancer Symposium, leading Canadian researcher Ellen Warner, MD, urged annual screening with MRI for high-risk women on the basis of results from 2 studies[200,201] indicating that MRI is more effective than mammography. (See Medscape Medical News.)

For more about MRI, please see the following:

Breast MRI Highly Sensitive, But Not Specific, for Breast Cancer

MRI vs Mammography: Live Expert Interview

MRI Is Best for Detecting Breast Cancer in BRCA1/2 Mutation Carriers

CME -- MRI More Sensitive Than Mammography in Women at High Risk of Breast Cancer

Ovarian cancer. This year, the USPSTF recommended against ovarian cancer screening -- a recommendation that remains unchanged from 1996 on the basis of findings that the potential harms outweigh the potential benefits. (See Medscape Medical News CME story and Screening for Ovarian Cancer: Recommendation Statement.)

Cervical cancer. Most American women report being screened for cervical cancer more frequently than recommended. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, instead of the recommended triennial screening.[202] Moreover, women who have had hysterectomies who are not even at risk for cervical cancer are undergoing screening,[203] and both breast and cervical cancer screening are being performed too often in the very elderly.[202,204] At the other end of the age spectrum, ACOG released a new committee opinion on cervical cancer screening in adolescents in which they recommend that adolescent girls (13 to 15 years of age) make their first visit to an Ob/Gyn before Pap smear screening is initiated[205]:

It should be stressed that adolescents should visit an obstetrician-gynecologist before becoming sexually active. Data indicate that currently this is not the case. Most (79%) young women wait 1 month or more after their first intercourse to see a health care provider, with the median wait being 22 months after first intercourse...The American College of Obstetricians and Gynecologists recommends that the first visit to an obstetrician-gynecologist for health guidance, screening, and provision of preventive services should take place around 13-15 years. This visit is even more important in light of the new cervical cancer screening recommendations and is an ideal time to begin to provide education about preventive care needs, including the need for STD testing in sexually active adolescents. This visit often does not include a pelvic examination, especially with the onset of urine-based STD screening options. Thereafter, annual preventive health care visits to a gynecologist are strongly recommended.

Also this year, a study has concluded that colposcopy is unjustified in screening young women for cervical cancer because most low-grade squamous intraepithelial lesions regress.[206] (See Medscape Medical News CME story.)

In poor countries of the world (mainly Latin America, Sub-Saharan Africa, and the Indian subcontinent), cervical cancer has taken on epidemic proportions mostly as the result of a lack of screening -- it is too expensive. The vast majority, about 80%, of the 500,000 new cases of cervical cancer each year occur in these countries, and the Alliance for Cervical Cancer Prevention has estimated that the number of cases could be as high as 750,000 by the year 2020. In December 2004, the Alliance announced the release of an important new manual, "Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers," which aims to help program managers "move from policy to actually organizing, implementing, and monitoring newly developed programmes or strengthening existing cervical cancer prevention and control programs" and focuses on new approaches to screening and treatment in a variety of geographic and sociocultural settings and for a range of resource levels.

Progress with the HPV vaccines developed by GlaxoSmithKline[207] (see Medscape Medical News story) and Merck (see Medscape Medical News story was also reported this year.

This year, 2 studies highlighted the continued disparity in healthcare in the United States. Black women are more likely than white women to experience delays in the diagnosis and treatment of breast cancer.[208] The study found that access to care and poverty index only partly accounted for the differences in delay time -- racial differences in terms of delayed treatment and diagnosis remained even after adjustment for contributing factors. And with respect to cervical cancer, incidence and mortality rates increased with increasing poverty and decreasing education levels:

Patients in lower socioeconomic census tracts had significantly higher rates of late-stage cancer diagnosis and lower rates of cancer survival. Even after controlling for stage, significant differences in survival remained. The 5-year survival rate among women diagnosed with distant-stage cervical cancer was approximately 30% lower in low than in high socioeconomic census tracts. [209]

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