© 2004 by Oxford University Press
© 2004 Oxford University Press
IN THIS ISSUE |
In This Issue
Work Situation After Breast CancerIt is unclear whether a breast cancer diagnosis adversely affects work experience. Maunsell et al. (p. 1813) looked for evidence of discrimination at work, defined as negative or involuntary changes in employment situation, associated with breast cancer in a population-based retrospective cohort study conducted in Quebec, Canada. Three years after being diagnosed, slightly more breast cancer survivors (21%) than women in the comparison group (15%) were unemployed, although most women who were not working (84% of survivors and 76% of women in the comparison group) said that the decision to stop working was their own. Among women still employed, no deterioration in working conditions was observed in either group. The authors suggest that, at least for women in health and social systems where health insurance is independent of employment such as in Canada, women diagnosed with breast cancer seldom experience discrimination in the work place.
In an editorial, Schover (p. 1800) discusses how the myths surrounding the psychosocial effects of being diagnosed with breast cancer have been systematically dispelled by Maunsell and colleagues.
Mammography Interval and Late-Stage Breast Cancer
Mammography screening may reduce breast cancer mortality by detecting cancers at an earlier stage. However, the ideal interval between mammograms is unclear. White et al. (p. 1832) investigated whether women diagnosed with breast cancer after having screening mammograms separated by a 2-year interval were more likely to be diagnosed with late-stage disease than women diagnosed with breast cancer after having screening mammograms separated by a 1-year interval. They found that among women age 40-49 years at the index mammogram (i.e., the most recent screen at or before breast cancer diagnosis), those with a 2-year screening interval were more likely to have late-stage disease at diagnosis than those with a 1-year screening interval. There was no increase in late-stage disease for women 50 years or older with a 2-year versus a 1-year screening interval. Women with dense breasts did not appear to benefit more from a 1-year versus 2-year screening interval than women with fatty breasts.
Long-Term Results From Three Breast Cancer Trials
Three randomized trials conducted sequentially by the National Surgical Adjuvant Breast and Bowel Project have shown the importance of postoperative chemotherapy in women with estrogen receptor (ER)-negative breast cancer and negative lymph nodes. In B-13, methotrexate plus 5-fluorouracil (MF) was more effective than surgery alone; in B-19, cyclophosphamide plus MF (CMF) was more effective than MF; and in B-23, CMF was as effective as doxorubicin plus cyclophosphamide (AC). Fisher et al. (p. 1823) present updated findings from those trials, noting that the similarity in their eligibility requirements and conduct allows their results to be interrelated. The update confirms the benefit of chemotherapy in women with ER-negative, lymph node-negative tumors. An analysis by age showed a decreased advantage from chemotherapy with increasing age, which resulted from a better outcome associated with advancing age after surgery alone and not to a poorer outcome from chemotherapy.
In an editorial (p. 1801), Albain notes that the long-term follow-up of the three trials provides solid evidence that adjuvant chemotherapy increases survival of women with ER-negative, node-negative breast cancer. She points out that the issue of degree of chemotherapy benefit by age remains open and suggests that chemotherapy should be considered for all women, regardless of age.
Accuracy of Screening Mammography Interpretation
Radiologists differ in their ability to interpret mammograms accurately. Barlow et al. (p. 1840) investigated whether there was an association between radiologist characteristics and their actual performance. The authors used surveys from 124 radiologists and cancer outcome data from 469,512 mammograms screened by the radiologists from 1996 to 2001. The authors found that radiologist sensitivity increased with volume and that specificity decreased with volume and number of years interpreting mammograms. However, after adjusting for patient factors that affected the threshold for calling a mammogram positive (age, breast density, and previous mammogram), no association between accuracy and years of interpreting mammograms or volume was observed. The authors conclude that increasing volume requirements is unlikely to improve radiologists' overall mammography performance.
Cigarettes, Alcohol, Hepatitis B, and Liver Cancer in Korea
Liver cancer is one of the most common cancers worldwide, particularly in Asia and Africa, where hepatitis infection and aflatoxin exposure are common. Jee et al. (p. 1851) conducted a prospective cohort study of liver cancer in Korea to asses the effects of smoking, alcohol consumption, and hepatitis B on risk of mortality from liver cancer. From 1993 to 2002, 3807 out of the 1,283,112 men and women free of cancer at the beginning of the study died from liver cancer. Smoking, hepatitis B antigen, and heavy drinking were associated with increased mortality from liver cancer in men. In women, only hepatitis B antigen was associated with mortality, and the associated risk was higher than that of men. The authors conclude that the higher mortality associated with hepatitis B observed in women than in men merits further research.
Endogenous Steroid Hormones and Tumor Receptor Status
Although levels of endogenous steroid hormones have been associated with the risk of breast cancer among postmenopausal women, less is known about the association between elevated levels of endogenous progesterone and the risk of breast cancer or about the relationship between levels of endogenous steroid hormone concentrations and the risk of breast cancer by tumor receptor status. Missmer et al. (p. 1856) prospectively investigated these relations in a case-control study within the Nurses' Health Study. They found direct associations between breast cancer risk and the levels of estrogens and androgens but not between breast cancer risk and the level of progesterone or sex hormone binding globulin. Among tumors with both estrogen and progesterone receptors, they found an increased risk of breast cancer associated with estradiol, testosterone, androstenedione, and dehydro-epiandrosterone sulfate. They conclude that circulating levels of sex steroid hormones may be most strongly associated with risk of breast tumors with both estrogen and progesterone receptors.
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