Breast Cancer Risk in Female Survivors of Hodgkin's Lymphoma: Lower Risk After Smaller Radiation Volumes

Breast Cancer Risk in Female Survivors of Hodgkin's Lymphoma: Lower Risk After Smaller Radiation Volumes
Marie L. De Bruin, Judith Sparidans, Mars B. van't Veer, Evert M. Noordijk, Marieke W.J. Louwman, Josée M. Zijlstra, Hendrik van den Berg, Nicola S. Russell, Annegien Broeks, Margreet H.A. Baaijens, Berthe M.P. Aleman, and Flora E. van Leeuwen
Journal of Clinical Oncology, Vol 27, No 26 (September 10), 2009: pp. 4239-4246

Link to Journal

Some good signs for the future in this article from the Netherlands on the breast cancer risk reduction following the reduction in radiation volumes for Hodgkin's disease sufferers.

Reduction of radiation volume appears to decrease the risk for Breast Cancer after Hodgkin's Lymphoma. In addition, shorter duration of intact ovarian function after irradiation is associated with a significant reduction of the risk for Breast Cancer

Image display contrast variation negates consistent mammo readings

So it seems that much of the effects found by the DMIST Study were due to image contrast, inherent with digital imaging.................

A report in Radiology from the DMIST investigators in the August edition -
Radiology August 2009 252:348-357

Link to Journal

Readers most frequently attributed differences in DMIST cancer visibility to variations in image contrast—not differences in positioning or compression—between digital and screen-film mammography.

For women with both fatty and dense breasts, the most frequent reason given for the difference in visibility between film-screen and digital mammography was contrast differences between the two modalities. For women with dense breasts, contrast differences accounted for 70 of the 378 reasons given by the readers for better visibility. Positioning, compression, and technique differences accounted for only 37 of the reasons given for improved visibility

The odds of a cancer being more visible on a digital mammogram—rather than being equally visible on digital and screen-film mammograms—were significantly greater for women with dense breasts than for women with non-dense breasts, even with the data adjusted for patient age, lesion type, and mammography system (odds ratio, 2.28; P < .0001).

The odds of a cancer being more visible at digital mammography—rather than being equally visible at digital and screen-film mammography—were significantly greater for lesions imaged with the General Electric digital mammography system than for lesions imaged with the Fischer (P = .0070) and Fuji (P = .0070) devices. No comment was made about Hologic

The significantly better diagnostic accuracy of digital mammography, as compared with screen-film mammography, in women with dense breasts demonstrated in the DMIST was most likely attributable to differences in image contrast, which were most likely due to the inherent system performance improvements that are available with digital mammography. The authors conclude that the DMIST results were attributable primarily to differences in the display and acquisition characteristics of the mammography devices rather than to reader variability.

JNCI response to latest attack on screening by Grotzche et al

JNCI response to latest attack on screening by Grotzche et al

In a very balanced editorial in today's JNCI, Liz Savage writes about the recent letter to The Times of London, and the claim that up to 50% of cancers are diagnosed unnecessarily by the NHS Breast Screening Programme (NHS BSP), but primarily the attack was again on the content of invitation leaflets sent to women at each invitation. These were changed or amended after their last attack in the media a few years ago.

Although some of their criticism remains valid, their wild claims that 50% of cancers detected by screening would never kill women remains unsubstantiated.
While it is clear, that some women have an exceptionally good prognosis, and probably would never have had disease that would have killed them, the majority (or even if it was just the 50%) would definitely have been helped.

Newer genomic typing of tumors may assist at an early stage of diagnosis (perhaps at initial core biopsy) which group of risk she is in, then if low, she may not need any treatment, or just hormone therapy instead of the current more invasive procedures.

Typing, such as that used by mammaprint (nl), may be able to distinguish between three separate groups, with minimal overlap. Laura Vantveer, on sabatical with UCSF from Holland is developing this technique on all our cancers treated at UCSF. The middle group of women with less aggressive subtyping and the ones most likely to be helped by screening, the high risk women showed marked aggressivity at any size, and appear to need everything (including the kitched sink) thrown at them, to get a response (CPR - complete pathological response)

Women with the least aggressive subtype, may be represented by this group who never progress to a 'killer' cancer, and may be overtreated by being offered chemotherapy, radiotherapy or even surgery. If these cancers NEVER kill anyone, maybe a different term - other than carcinoma - may need to be used to indicate that these are a different disease compared with the real cancers.

These are interesting times, and allow us to start thinking more intelligently about screening, and the outcomes from screening. In the meanwhile.... let's get back to ensuring that women are adequately informed about the benefits and risks at their invitation.

Triple negative breast cancers are increased in black women regardless of age or body mass index

More on Triple Negative Breast Cancer amongst Black Women - OF ANY AGE
Triple negative breast cancers are increased in black women regardless of age or body mass index
Lesley Stead, Timothy L Lash, Jerome Sobieraj, Dorcas Chi, Jennifer Westrup, Marjory Charlot, Rita Blanchard, John-cho Lee, Thomas King, Carol L Rosenberg

Breast Cancer Research 2009, 11:R18doi:10.1186/bcr2242

Reported online, on the breast cancer research website. black women are three times more likely than other women to develop an aggressive form of breast cancer characterised by "triple negative tumours. The findings held true even when other risk factors such as lifestyle, age and weight were taken into account. In the United States, where the study was conducted, the overall incidence of breast cancer is lower in black women than in white women. But when black women do get breast cancer, it tends to be more advanced when diagnosed, has a higher risk of recurring, and a less favourable outcome.

Black women of diverse background have 3-fold more Tneg tumours than non-black women, regardless of age and BMI.

Researchers led by Carol Rosenberg of Boston University analysed 415 breast cancer cases and noted the number of "triple negative" tumours, so called because three critical proteins -- estrogen and progesterone receptors, and the HER2 gene -- malfunction.

"The odds of having a triple-negative tumour were three times higher for black women than for non-black women," said Rosenberg

It had been known that pre-menopausal black women were disproportionately affected by this deadly form of cancer, but the new study showed that these tumours were just as common in black women diagnosed before or after age 50, obese or not.

The higher prevalence of triple negative breast tumours in black women in all age and weight categories likely contributes to black women's unfavourable breast cancer prognosis

Early detection of second breast cancers improves prognosis in breast cancer survivors

Early detection of second breast cancers improves prognosis in breast cancer survivors
N. Houssami, S. Ciatto, F. Martinelli, R. Bonardi, and S. W. Duffy
Advanced access to the publication of this paper, published online March 19, 2009
The impact of early detection of second breast cancers in women who have survived a primary breast cancer is unknown.
The researchers looked at information on 1,044 women who were seen at a medical center in Florence, Italy, between 1980 and 2005 and who had developed a second breast cancer -- 455 with cancer in the same breast (ipsilateral) and 589 with cancer in the opposite breast (contralateral). Of the second breast cancers, 67 percent were asymptomatic, and 33 percent were symptomatic.

The study found that chances of survival improved between 27 percent and 47 percent if the second breast cancer was detected in the early, asymptomatic stage rather than at a later stage when women started to experience symptoms.

The researchers also found that mammography
was more sensitive than clinical examination for detecting second breast cancers -- 86 percent vs. 57 percent. However, 14 percent of the cancers were detected only by clinical examination.

Asymptomatic cancers were smaller than symptomatic cancers, and early-stage cancers were more common in asymptomatic women (58 percent) than in symptomatic women (23 percent). Fewer women with asymptomatic than symptomatic contralateral cancer had node metastases, an indication the cancer may have spread.

Take home message:
Early detection of second breast cancers can reduce the risk of death by as much as half

First Report of a Necrotising Fasciitis of the Breast Following a Core Needle Biopsy

The first report of the aggressive infection, necrotising fasciitis following core biopsy of the breast has been reported by researchers in France.

In a paper published in The Breast Journal this month, the department of OB/GYN in Montpelier, France, describe the case of a 50 year old woman one week after a 14g stereotactic core biopsy for a BIRADS 4 - suspicious lesion.

This is an aggressive infection with a beta-hemolytic streptococcus, which requires aggressive surgery to clear (debride) the infected tissue. Previously only described following mastectomy or breast reduction, this has now occurred following a simple routine core biopsy.

When consenting a patient for a core biopsy, we routinely describe the complication of infection, along with bruising and non-removal of the target lesion. Based on this case, our management should not change, but it remains a salutary lesson, that the most aggressive type of infection can occur in patients attending for a routine biopsy.

Continued attention to hand hygiene, and an aseptic field during biopsy remain important. Interestingly, the staff performing the biopsy did not have their skin tested for whether they were carriers of the B-Hemolytic strep, so we wil never know whether this was a factor

Moderate Alcohol Intake and Cancer Incidence in Women

Published this week in the Journal of the National Cancer Institute, and available to members on the RCRBG website, is the revelation from the Million Women Study, that any alcohol is 'bad' alcohol, as regards breast cancer risk.

Valerie Beral's team at Oxford demonstrated that increasing but moderate alcohol consumption in women was determined to be associated with an increased risk of cancers of the oral cavity and pharynx, esophagus, larynx, rectum, breast, and liver, and with a decreased risk for thyroid cancer, non–Hodgkin lymphoma, and renal cell carcinoma. No differences in cancer risks were observed between drinkers of wine only and other consumers of alcohol

As ever, this could be seen as a scare story, but has to be taken in context with some of the other proven beneficial effects - eg a glass of red wine and its protective effects against heart disease.
If you are a woman who is at increased risk already from family history or a prior biopsy of atypia, maybe you are the one who needs to be aware of this finding and consider modifying your lifestyle.

In the greater scheme of things, everything has risks and benefits - look at HRT use itself, which was the original target of this research