Timing of Hormonal Replacement Therapy Affects Breast Cancer Risk LONDON—New data by a group from Oxford University in England show that women who wait ≥5 years after menopause to start hormone replacement therapy (HRT) are less likely to get breast cancer than women who initiate HRT almost as soon as they experience menopause. The authors note that multiple studies have demonstrated an increased risk of breast cancer for women taking HRT after menopause, but they said few have considered whether the interval between onset of menopause and start of HRT influences risk.
In conducting the retrospective analysis, Valerie Beral, FRS, and associates relied on data for 1.13 million postmenopausal women (median age, 56.6 years) recruited in 1996-2001 to participate in the United Kingdom’s Million Women Study. Investigators estimated the adjusted relative risk (RR) of breast cancer for current HRT users (n = 394,697), past users (n = 221,056), and never-users (n = 513,272). Women in the HRT group were further stratified according to time elapsed between menopause and initiation of HRT, type of hormone used, and duration of HRT.
A total of 15,759 cases of breast cancer were reported, with 9632 (61%) incidents in women currently or previously on HRT. RR was significantly greater in women who started HRT before or within 5 years of menopause (RR, 1.43; 95% confidence interval [CI], 1.35-1.51; P <.001) than for women who waited at least 5 years after menopause to begin HRT (RR, 1.05; 95% CI, 0.89- 1.24; P = .6). Women who did not begin HRT until ≥5 years after menopause had nearly the same risk of breast cancer as women who never used HRT. The breast cancer risk was lower for women who waited ≥5 years after menopause to begin HRT regardless of type or duration of HRT and body mass index. Complete findings were published in the Journal of the National Cancer Institute.
What Women Need to Know About Mammography LONDON—False-positive mammography results increase anxiety and decrease quality of life (QOL) for some women, negative effects that persist for 1 year or longer. Lideke van der Steeg, PhD, and colleagues from St. Elisabeth Hospital in Tilburg, the Netherlands, say their findings suggest that clinicians need to do a better job of informing women before breast cancer screening about the pros and cons of the procedure.
Over a 5-year period, women who received abnormal mammography results at 1 of 3 Dutch hospitals were invited to enroll in the study. Investigators administered questionnaires that assessed QOL in various areas. Of the 385 women who completed the surveys, 152 had a breast cancer diagnosis and 233 received a false-positive result following mammography.
Medical records showed that women in the false-positive group often underwent more tests to rule out a breast cancer diagnosis than women confirmed to have breast cancer. Only 14% of women with confirmed breast cancer had ≥4 diagnostic procedures compared with 32% of women eventually found not to have breast cancer. More than half (54.9%) of women in the false-positive group had to go back to the outpatient clinic for additional work-up within the first year of initial screening, with some women returning as many as 8 times.
The researchers believe the multiple screenings and procedures to rule out breast cancer, which included biopsies in some cases, gave rise to the women’s anxiety and negatively affected their QOL. For some women, particularly those prone to anxiety, the reduction in QOL was significant.
“Cancer screening is intuitively appealing, and common sense dictates that early detection is good and without risk,” van der Steeg and her team wrote in the article appearing in the British Journal of Surgery, noting that most breast cancer screening programs have been shown to reduce breast cancer– related deaths. Many women, however, overestimate their odds of breast cancer and the benefits of mammography, and they are unaware of the falsepositive risk. This rate is typically said to hover around 6% in the United States, but varies according to region, clinician experience, and patient characteristics; the risk of a false positive increases with successive mammograms.
The authors add that women are also not aware of potential dangers of receiving a false-positive mammography result, such as the need for additional tests and the associated increase in anxiety and diminished QOL. This information is not touted in campaigns promoting routine mammography screening, and van der Steeg and colleagues urge clinicians to provide women with balanced information about breast cancer screening, addressing the benefits and risks of the procedure.
Prevalence of Depression in Breast Cancer Patients Overestimated LONDON—A British study published in Lancet Oncology undermines the widely held belief that depression is endemic in patients with cancer. Investigators for the meta-analysis found that 30% to 40% of patients seen in oncologic, hematologic, and palliative- care settings suffered from a combination of mood disorders. As a result, “Clinicians should remain vigilant for mood complications, not just depression,” said the authors of the study, led by Alex J. Mitchell, MRCPsych, Department of Cancer Studies and Molecular Med icine, Leicester Royal Infirmary, Leicestershire Partnership Trust, United Kingdom.
The research team looked at data from 94 studies encompassing 14,078 adults in 14 countries who were screened for depression, anxiety, and adjustment disorders in the first 5 years after cancer diagnosis. The prevalence of mood disorders, including depression, was assessed using criteria from the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases.
Overall, 29.0% of patients in palliative- care settings (n = 4007) and 38.2% of patients in oncologic and hematologic settings (38.2%) experienced mood disorders. Rates of depression were similar between patients in palliative-care settings and those in oncologic and hematologic settings (16.5% vs 16.3%, respectively). Compared with patients in the palliativecare setting, patients in the oncologic and hematologic setting were slightly more likely to have an adjustment disorder (15.4% vs 19.4%, respectively) and clinically significant anxiety (9.8% vs 10.3%, respectively).
Mitchell and associates emphasized that although patients with cancer experience depression less often than commonly thought, it “remains an important and overlooked complication of cancer.” According to the authors, studies suggest patients with depression are less likely to remain active in their medical care, have longer hospital stays, and have significantly worse quality of life and survival outcomes.
The authors added that their study highlights the need for clinicians to remain vigilant for signs of a number of mood disorders in patients. They recommended using simple screening tools to evaluate patients for distress, declines in quality of life, unmet needs, and a desire for help.
Although the rates of mood disorders and depression remained fairly consistent when stratifying data by age, sex, and clinical setting, the investigators said the studies did not provide sufficient information for them to assess results by cancer type or duration of illness
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