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20th January 2023
Using contrast-enhanced cone beam breast CT provides a more accurate assessment of residual tumour following neoadjuvant chemotherapy compared to magnetic resonance imaging (MRI) according to the findings of a comparative study by Chinese researchers.
Neoadjuvant chemotherapy is used prior to breast cancer surgery in patients with locally advanced breast cancer to reduce the size of the tumour. An assessment of the size of unresectable residual tumour is required since this is an important factor in the local recurrence of disease following breast conserving therapy. Radiological examination has an important role in the assessment of residual tumour and MRI has been shown to be more accurate that other imaging modalities for an evaluation of the response to treatment. Cone beam breast CT is a relatively novel technique that has shown promise for the early diagnosis of malignant breast cancer and can also differentiate between malignant and benign breast tissue.
However, to date, no studies have examined the accuracy of cone beam breast CT for the assessment of residual tumour following neoadjuvant chemotherapy. In the current study, the Chinese team compared cone beam breast CT and MRI for the assessment of tumour size following neoadjuvant chemotherapy and retrospectively compared the results of the two methods with those obtained with the findings from pathology. In addition, the researchers examined the predictive value of the two approaches for a pathological complete response. The level of agreement between the tumour size based on the two methods was compared to the findings on pathology and assessed using the intraclass correlation coefficient (ICC).
Cone beam breast CT and assessment of residual tumour
Data were available for 91 women with a median age of 45 years, the majority (73.6%) of whom were premenopausal.
When compared with pathology, there was good agreement for the cone beam breast CT (ICC = 0.64, 95% CI 0.35 – 0.78). In contrast, comparison with MRI was only moderate (ICC= 0.59, 95% CI 0.36 – 0.77). In subgroup analysis, the cone beam was also superior to MRI for residual ductal carcinoma in situ (p < 0.001).
For predictive purposes, the area under the receiver operating characteristics curve for predicting a pathological complete response were similar for both imaging modalities (AUC = 0.749 for cone beam and 0.733 for MRI, p > 0.05).
The authors concluded that cone beam breast CT was superior to MRI for an assessment of residual tumour following neoadjuvant chemotherapy and could therefore be seen as an alternative means of assessment.
Citation
Wang Y et al. Accuracy of Preoperative Contrast-enhanced Cone Beam Breast CT in Assessment of Residual Tumor after Neoadjuvant Chemotherapy: A Comparative Study with Breast MRI. Acad Radiol 2023
20th December 2022
Widespread state medical marijuana legalisation in the US is associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer according to an analysis by US researchers.
Pain is an extremely common cancer symptom with a 2022 meta-analysis of 12 studies (10 with breast cancer and 2 lung cancer) patients, finding a pooled pain prevalence rate of 40%. Although paracetamol and non-steroidal anti-inflammatory drugs are universally accepted as part of the treatment of cancer pain at any stage of the WHO analgesic ladder, strong opioids are the mainstay of analgesic therapy in treating moderate to severe cancer-related pain. Nevertheless, with tightened regulations leading to a decrease in opioid prescribing across the United States, evidence points to a decline in opioid use among end-of-life care in those with cancer although there has been a rise in pain-related emergency department visits, suggesting that end of life cancer pain management may be worsening. Although medical marijuana has been studied and found to be efficacious for relief of pain in patients with advanced cancer pain not fully relieved by strong opioids, a 2016 review suggested that while marijuana may have the potential for refractory cancer pain, much of the data are based on animal data, small trials, or are outdated.
With the potential to help patients with cancer pain, in the current study, US researchers set out to assess the associations between medical marijuana legalisation and opioid-related and pain-related outcomes for adult patients receiving cancer treatment. The team used data from national commercial claims between 2012 to 2017. The researchers assessed several measures including the proportion of patients having 1 or more days of opioids and 1 or more pain-related emergency department visits or hospital events, during the 6 months after a new cancer diagnosis.
Medical marijuana and opiate use
A total of 38,189 patients with newly diagnosed breast cancer, 12,816 with colorectal cancer (55.4% male) and 7,190 (51.1% female) with lung cancer were included in the analysis.
Medical marijuana legalisation was associated with a reduction in the rate of 1 or more opioid days from 90.1% to 84.4% (difference = 5.6, 95% CI 2.2 – 9.0, p = 0.01) among breast cancer patients. For colorectal cancer patients, there was also a reduction, this time from 89.4% to 84.4% (difference = 4.9, 95% CI 0.5 – 9.4, p = 0.03). Finally, opioid use reduced from 31.5% to 22.1% (difference = 9.4, 95% CI 0.8 – 17.9, p = 0.03) among patients with lung cancer with recent opioids.
Medical marijuana legalisation was also associated with a reduction in the rate of 1 or more pain-related hospital events from 19.3% to 13.0% (difference = 6.3, 95% CI 0.70 – 12.0, p = 0.03) among patients with lung cancer with recent opioids. However, the difference for the other two forms of cancer was not significant.
The authors concluded that medical marijuana legalisation was associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer.
Citation
Bao Y et al. Medical Marijuana Legalization and Opioid- and Pain-Related Outcomes Among Patients Newly Diagnosed With Cancer Receiving Anticancer Treatment. JAMA Oncol 2022
28th November 2022
Use of radiotherapy for 30 years in patients following breast conserving surgery in conjunction with chemotherapy or tamoxifen, reduces the risk of ipsilateral breast tumour recurrence but does not affect overall survival, according to the findings of follow-up study presented at the European Breast Cancer Conference in November 2022.
For a lot of women with early-stage breast cancer, breast-conserving surgery removes macroscopic disease although the presence of any remaining microscopic tumour tissue, if left untreated, could lead to loco-regional recurrence or life-threatening distant metastases. As a result, adjuvant radiotherapy, is often used and the evidence from over 10,000 women, suggests that radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. In 1976, researchers began a randomised trial to determine whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer. Results after 6 years showed that the relapse rate in the ipsilateral breast was 24.5% in the non-irradiated group compared to 5.8% following breast irradiation. But the researchers continued to monitor patients and the results showed that after 20 years of follow-up, there were no significant differences in overall survival among women who underwent mastectomy and those who underwent lumpectomy with or without postoperative breast irradiation. However, the study did show that the cumulative incidence of recurrent tumour in the ipsilateral breast was 14.3% in the women who underwent breast irradiation, compared with 39.2% in the women without irradiation. In the present Now, researchers are able to present 30-year survival data.
Radiotherapy and overall survival following breast cancer surgery
A total of 585 patients aged ≤70 years with early breast cancer, underwent local excision with a 1 cm margin, axillary node sampling or axillary node clearance.
Overall, researchers observed that ipsilateral breast tumour recurrence was found to be significantly lower in the radiotherapy group (Hazard ratio, HR = 0.39, 95% CI 0.27 – 0.55). For example, local recurrence (LR) after 10 years was 8.8% vs 31% (radiotherapy vs non-irradiated) but this difference reduced after 30 years and was 27.8% (95% CI 19 – 36.5) in the irradiated group and 42.7% (95% CI 35.8 – 49.6) in the non-irradiated group.
Furthermore, there was no difference in overall survival after 30 years (HR = 1.08, 95% CI 0.89 – 1.30, p = 0.43) and the proportion of survivors was broadly similar over time. For instance, overall survival at 10 years was 72.5% vs 70.8% (irradiated vs non-irradiated) and this difference was broadly similar after 30 years (23.7% vs 27.5%).
In a press release from the conference, lead researcher, Professor Ian Kunkler said, ‘We found that there is no long-term improvement in overall survival for those women having radiotherapy‘. He added that ‘The benefits of having radiotherapy in terms of fewer local recurrences are only accrued over the first ten years after radiotherapy; thereafter, the rate of local recurrence is similar whether or not patients had radiotherapy.’
Citation
Williams L et al. Randomised controlled trial of breast conserving therapy: 30 year analysis of the Scottish breast conservation trial. Abstract No 2. 13th European Breast Cancer Conference.
11th July 2022
Cancer screening for breast, colorectal and cervical cancers was significantly reduced during the period of the pandemic compared to pre-pandemic levels according to the results of a systematic review by a group of Italian and US researchers.
According to GLOBOCAN in 2020 there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths and that cancer screening has contributed to a decrease in both cancer morbidity and mortality. As a result, any reduction in screening could potentially lead to a surge in cases. In fact, modelling studies have already indicated a possibly large increase in cases due to the pandemic. For example, one Canadian simulation suggested that the interruption of services to COVID-19 could lead to an additional 310 cases diagnosed at advanced stages and 110 cancer deaths. Moreover, in a UK-based modelling study, the authors estimated that as a consequence of the pandemic, there would be a 7·9-9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis and for colorectal cancer a 15·3 – 16·6% increase in additional deaths.
However, because of differences in the start date and duration of lockdown measures across the world, for the present study, the researchers wanted to examine how this variation impacted on screening. They focused on breast, colorectal and cervical cancer screening since the beginning of the pandemic and made a comparison with pre-pandemic levels. The team searched all the major databases for observational studies and articles that reported data from cancer registries and which compared the level of screening tests performed before and during the pandemic and in different areas of the world.
Cancer screening reductions during the pandemic
A total of 39 articles were identified and included in the analysis with 21 related to breast, 22 colorectal and 11 for cervical cancers.
For the period between January and October 2020, there was an overall 46.7% (95% CI -55.5% to -37.8%) decrease in breast cancer screening in comparison the pre-pandemic level.
For colorectal cancer, the overall reduction was 44.9% (95% CI -53.8% to -36.1%) and this included a 52.5% reduction in colonoscopy, a 37.8% decrease in faecal occult blood testing and a 37.8% decrease in immuno-chemical testing.
With cervical cancer, the overall reduction was -51.8% (95% CI -64.7% to -38.9%).
Commenting on their findings, the authors noted that these reductions in screening occurred across the world but that there were some obvious differences. For example, Europe saw the largest reduction in mammography compared to North America. although the decrease for both colorectal and cervical cancer screening was similar in both areas. The authors suggested that the most likely explanation for the reduced screening was the ‘stay at home’ order introduced during the early stages of the pandemic.
They concluded that there was a large reduction in cancer screening as a consequence of the COVID-19 pandemic and which could be associated with an increased number of deaths and called for further work to investigate the relationship between cancer diagnosis and treatment during the pandemic.
Citation
Teglia F et al. Global Association of COVID-19 Pandemic Measures With Cancer Screening: A Systematic Review and Meta-analysis JAMA Oncol 2022
4th July 2022
The combination of an artificial intelligence (AI) system and a radiologist provides better screening accuracy for breast cancer as demonstrated by a higher sensitivity and specificity according to the findings of a retrospective analysis by an international team of radiologists.
The use of screening mammography is designed to identify breast cancer at earlier stages as treatment will be more successful. Moreover, in recent years there has been increased interest in the use of AI systems and a recent study found that the use of an AI system outperformed all of the human readers, with a greater area under the receiver operating characteristic curve margin of 11.5% for screening breast cancer mammograms. Nevertheless, a 2021 systematic review which considered the use of AI for image analysis in breast cancer screening programs concluded that the current evidence for AI does not yet allow judgement of its accuracy in breast cancer screening programmes, and it is unclear where on the clinical pathway AI might be of most benefit. Other work that considered the role of AI for breast cancer screening suggested that an AI system can correctly identify a proportion of a screening population as cancer-free and also reduce false positives and therefore has the potential to improve mammography screening efficiency.
But what if an AI and radiologists worked together, so that the AI could initially triage scans and identify normal cases but those with suspected cancer and where there was diagnostic uncertainty, were referred to the radiologist? This was the question addressed in the retrospective analysis by the research team. The system was designed so that the AI system would flag potential cancerous scans and where it was unsure about the diagnosis, for a second read by a radiologist. The team initially trained the AI system using an internal dataset and then used an external data set and compared the interpretation with that of a radiologist. The performance of both the AI and radiologists was assessed in terms of sensitivity and specificity and the test sets contained a mix of both normal and cancerous scans.
AI and radiologists combined performance
For the external data set the radiologist had a higher sensitivity (87.2% vs 84.6%, radiologist vs AI system) and specificity (93.4% vs 91.3%) and in both cases this difference was statistically significant (p < 0.001 for both).
However, when the AI and radiologists worked together, the radiologist’s sensitivity was 89.7% and the specificity 93.8%. In other words, the combination improved both sensitivity and specificity. The authors calculated that this corresponded to a triaging performance, i.e., the fraction of scans which could be automated) of 60.7%.
Based on these findings, the authors concluded that their system leverages the strength of both the radiologist and the AI system and had the potential to improve upon the screening accuracy of radiologists.
Citation
Leibig C et al. Combining the strengths of radiologists and AI for breast cancer screening: a retrospective analysis Lancet Digit Health 2022
27th June 2022
The Institute of Cancer Research, London, strongly welcomes the news that olaparib has been recommended by the European Medicines Agency (EMA) to treat people with high-risk, early-stage breast cancer who have inherited faults in their BRCA1 or BRCA2 genes.
The next step is for the European Commission to grant marketing authorisation, a process likely to take place in the next few months. Once this licensing step is completed, people in the EU with early breast cancer and BRCA mutations, who have already been treated with chemotherapy, either before or after surgery, will be a step closer to accessing olaparib, on its own or in combination with hormone therapy.
The recommendation follows the latest findings from the Phase III OlympiA trial, which showed that adding the targeted drug olaparib to standard treatment cuts the risk of women dying by 32 per cent – resulting in more women remaining cancer free and becoming breast cancer survivors.
Professor Andrew Tutt at The Institute of Cancer Research (ICR) and King’s College London is Chair of the Steering Committee for the OlympiA trial, which was coordinated by the Breast International Group (BIG). Professor Tutt was also involved in early laboratory research at the Breast Cancer Now Toby Robins Research Centre at the ICR on PARP inhibitors such as olaparib, and their subsequent clinical development.
Olaparib, which is taken orally, was recently approved in the US for the same group of people – those with high-risk, early-stage breast cancer who have inherited faults in their BRCA1 or BRCA2 genes.
Olaparib is also approved for use in the US, EU and UK for the treatment of patients with advanced breast cancer who have inherited faults in their BRCA1 or BRCA2 genes and were previously treated with chemotherapy.
OlympiA Steering Committee Chair Professor Andrew Tutt, Professor of Oncology at The Institute of Cancer Research, London, and King’s College London said:
“Olaparib is the first PARP inhibitor to increase the chances of curing people with early-stage breast cancer after initial treatment.
“Most breast cancers identified at an early stage are likely to be cured, but even with the best standard treatments, there is a high-risk group of women who are still likely to see their cancer return. Olaparib is a targeted treatment option that can keep these women with inherited high-risk breast cancer due to BRCA1/2 gene faults free of disease.
“Today’s recommendation brings olaparib a step closer to approval in Europe for people with high-risk, early-stage breast cancer. The next steps are for the MHRA to make a recommendation in the UK, and for NICE to carry out its appraisal, so that NHS patients in England can access olaparib without delay. We hope these processes can proceed as quickly as possible given the EMA recommendation.”
Professor Kristian Helin, Chief Executive of The Institute of Cancer Research, London, said:
“Science carried out at the ICR underpinned the development of PARP inhibitors like olaparib. Initially shown to benefit those with advanced breast, ovarian and prostate cancers, olaparib could now be used to reduce the risk of disease returning in early-stage breast cancer.
“It is tremendously exciting that the OlympiA trial shows olaparib could be successfully used to treat women with early-stage breast cancer and inherited BRCA mutations to improve their survival outcomes.
“BRCA1 and BRCA2 mutations are the most common cause of hereditary breast cancer – around 5 to 10 percent of breast cancers are the result of mutations in these genes. This means that thousands of people with early breast cancer could benefit from being treated with olaparib, and I look forward to seeing BRCA1 and BRCA2 testing used more widely for those diagnosed with early-stage breast cancer, so that we can identify those likely to benefit from this game-changing targeted treatment.”
22nd June 2022
A solution a green tea extract has been found to reduce both the incidence and severity of radiation-induced dermatitis in women undergoing adjunctive radiotherapy after breast cancer surgery. This was the conclusion of a phase 2 randomised, placebo-controlled trial by a team of Chinese researchers.
Breast cancer affects a large number of women and according to the World Health Organisation, in 2020, there were 2.3 million women diagnosed with breast cancer and and which led to 685 000 deaths. For the treatment of women with breast cancer, the results from a 20-year follow-up study have shown that lumpectomy, i.e., where there is removal of enough normal breast tissue to ensure that the margins of the resected specimen were free of tumour, followed by irradiation, continues to be an appropriate therapy for women, provided an acceptable cosmetic result can be obtained. However, one troublesome adverse effect of radiotherapy is radiation-induced dermatitis (RID) and while the use of topical prophylactic corticosteroids (e.g., mometasone) is recommended to reduce discomfort and itching, there is no evidence to support the superiority for any specific intervention.
To date, there is some, limited data to show that a green tea extract containing epigallocatechin-3-gallate (EGCG) can help with restitution of skin integrity, possibly mediated via an anti-inflammatory effect. Furthermore, some evidence also shows that a green tea extract can reduce the acute skin-induced reactions after radiation which include pain, the burning-feeling, itching, pulling and tenderness. However, whether the use of this extract could actually prevent the development of radiation-induced dermatitis is unclear and was the subject of the present study.
The Chinese team recruited women with breast cancer undergoing postoperative radiotherapy and then randomised them (2:1), to either the green tea extract or placebo (which was a normal saline solution). Both solutions were sprayed to the whole of the radiation field from day one of therapy and continued until two weeks after completion of treatment. An assessment of RID was made weekly using a scale ranging from 0 (no change) to 4 (worse impairment), i.e., higher scores indicate more severe dermatitis. In addition, patient-reported symptoms including pain, itch and tenderness were also included. The primary outcome was the incidence of grade 2 or worse RID whereas secondary outcomes included patient symptoms.
Green tea extract and RID outcomes
A total of 165 women with a median age of 46 years were enrolled and randomised to EGCG or placebo.
During radiotherapy as the dose was increased, RID began to occur two to three weeks after the start of treatment and the mean appearance time was delayed in the EGCG group compared to placebo (3.27 weeks vs 2.89 weeks, p = 0.001).
The incidence of grade 2 or above RID was 50.5% in the green tea extract group and 72.2% in the placebo arm (p = 0.008). In addition, symptom scores were also lower among the women receiving EGCG.
The authors concluded that prophylactic use of a green tea extract significantly reduced both the incidence and severity of RID and that the extract has the potential to become a new choice for skin care in women receiving radiotherapy.
Citation
Zhao H et al. Efficacy of Epigallocatechin-3-Gallate in Preventing Dermatitis in Patients With Breast Cancer Receiving Postoperative Radiotherapy: A Double-Blind, Placebo-Controlled, Phase 2 Randomized Clinical Trial JAMA Dermatol 2022
7th June 2022
Adding metformin to standard breast cancer chemotherapy in women with non-metastatic, high-risk operable breast cancer, did not lead to a significant improvement of invasive disease-free survival. This was the conclusion of a randomised trial conducted by researchers in Canada, Switzerland and the UK.
Diabetic patients who develop cancer havea 40% higher mortality risk than non-diabetics. In addition, studies have suggested that type 2 diabetes may be associated with 10-20% excess relative risk of breast cancer. The drug metformin is a biguanide that is used in the treatment of type 2 diabetes and works by decreasing gluconeogenesis and increases peripheral utilisation of glucose. In a 2015 meta-analysis of 11 studies, that compared the outcomes of breast cancer therapy in diabetes with and without metformin, the authors concluded that use of metformin in standard cancer therapy might improve both overall and cancer-specific survivals of diabetic patients. However, this is not a consistent finding in the literature. For instance, another study of over 2,300 women with breast cancer, the authors concluded that their study failed to show an association between improved survival and increased cumulative metformin use in breast cancer patients who had recent-onset diabetes. In contrast, a 2012 retrospective analysis, found that diabetic patients with breast cancer who received metformin and neoadjuvant chemotherapy had a higher pathologic complete response rate than those not receiving the drug.
However, the data in the above studies is derived from observational studies which are subject to several forms of bias. As a result, for the current study, the researchers focused specifically on metformin and undertook a randomised trial to determine whether the use of metformin in breast cancer patients without diabetes, positively impacted on treatment outcomes.
Adult women without diabetes who received standard therapy for a T1 to T3, No to N3, MO breast cancer were recruited and stratified as either oestrogen and/or progesterone receptor positive (ER/PgR +) or negative (ER/PgR -). Enrolled participants were then randomised 1:1, to 850 mg of metformin once daily or matching placebo for 4 weeks. The dose was then increased to twice daily for 5 years. Patients were followed-up at 6 and 12 months and then annually. The primary endpoint of the trial was invasive disease-free survival. Secondary outcomes included overall survival and the incidence rates for death.
Metformin and invasive disease-free survival
A total of 3649 women with a mean age of 52.4 years of whom, 2533 were ER/PgR + were recruited. However, futility was declared for the ER/PgR- group and so the analysis was restricted to the 2533 women who were ER/PgR +.
After a median follow-up of 96.2 months, 18.4% of women had invasive disease-free survival (234 in the metformin group vs 231 in the placebo arm), giving an incidence rate of 2.78 per 100 patient-years in the metformin group and 2.74 in the placebo group (hazard ratio, HR = 1.01, 95% CI 0.84 – 1.21, p = 0.93). Similarly, the risk of death was not significantly different (HR = 1.10, 95% CI 0.86 – 1.41, p = 0.47). Although futility was declared for those with ER/PgR-, among the patients who were followed up for a median of 94.1 months, there was also no difference in the level of invasive disease-free survival (HR = 1.01, 95% CI 0.79 – 1.30, p = .082). There were also no significant differences in any of the secondary outcomes.
The authors concluded that despite the evidence from observational studies, use of adjunctive metformin did not improve invasive disease-free survival in women with breast cancer.
Citation
Goodwin PJ et al. Effect of Metformin vs Placebo on Invasive Disease–Free Survival in Patients With Breast Cancer: The MA.32 Randomized Clinical Trial JAMA 2022
18th February 2022
Using aromatase inhibitors reduces the risk of breast cancer recurrence in premenopausal women with ovarian suppression to a greater extent than tamoxifen. This was the key finding of a meta-analysis of individual patient data from randomised trials undertaken by a team from the Early Breast Cancer Trialists’ Collaborative Group, based in Oxford, UK.
An analysis of 20 trials with over 21,000 women in 2011 concluded that 5 years of adjuvant tamoxifen safely reduces 15-year risks of breast cancer recurrence and death. Moreover, aromatase inhibitors such as anastrozole, exemestane or letrozole, which block the conversion of androgens into oestrogens, have been found to reduce recurrence rates of breast cancer by about 30% compared with tamoxifen in postmenopausal women. However, whether this class of drugs can benefit premenopausal women with early-stage oestrogen receptor positive breast cancer and ovarian suppression is unclear.
For the present study, the team undertook a meta-analysis of individual patient data from randomised trials in which an aromatase inhibitor was compared with tamoxifen for between 3 and 5 years in premenopausal women and who were receiving ovarian suppression with goserelin, triptorelin or ablation. Data were collected on patient’s baseline characteristics including age, use of chemotherapy, body mass index, tumour grade, involvement of lymph nodes etc. They set the primary outcome as recurrence of invasive breast cancer, breast cancer mortality, death but without cancer recurrence and all-cause mortality. In addition, they set pre-specified investigations for any recurrence, distant recurrence and mortality during years, 0 – 1, 2 – 4, 5 – 9 and greater than 10 years.
Aromatase inhibitors and breast cancer recurrence
The analysis included data from 7230 premenopausal women with oestrogen-receptor positive tumours.
Among these women, 888 (12.6%) experienced a breast cancer recurrence and 418 (5.9%) deaths occurred of which 54 were unrelated to breast cancer. When compared to women receiving tamoxifen, use of aromatase inhibitors led to a significant reduction in the rate of breast cancer recurrence (ratio ratio, RR = 0.79, 95% CI 0.69 – 0.90, p = 0.0005). Interestingly, the main benefit from aromatase inhibitors on the risk of recurrence was only seen in year 0 – 4 of follow-up (RR = 0.68, 95% CI 0.55 – 0.85, p < 0.0001). Between years 5 – 9, there was no further benefit (RR = 0.98, 95% CI 0.73 – 1.33, p = 0.89). The authors calculated the 5-year absolute risk of breast cancer recurrence to be 3.2% which was lower for aromatase inhibitors compared to tamoxifen (6.9% vs 10.1%). There was also a significant reduction in the risk of distant recurrence with aromatase inhibitors (RR = 0.83, p = 0.018) compared to tamoxifen but again this benefit was lost over time.
There was no difference in the risk of breast cancer mortality compared to tamoxifen (RR = 1.01, 95% CI 0.82 – 1.24, p = 0.94), death without recurrence (RR = 1.30, 95% CI 0.75 – 2.25, p = 0.34) and all-cause mortality (RR = 1.04, 95% CI 0.86 – 1.27, p = 0.68). Interestingly, women experienced a higher incidence of fractures with aromatase inhibitors (6.4% vs 5.1%).
The authors concluded that compared to tamoxifen, use of an aromatase inhibitor, reduced the absolute risk of breast cancer recurrence by 3% at 5 and 10 years. They also called for future studies to examine the effect of endocrine therapy and ovarian suppression on women’s quality of life alongside the reduced risk of breast cancer recurrence.
Citation
Early Breast Cancer Trialists’ Collaborative Group. Aromatase inhibitors versus tamoxifen in premenopausal women with oestrogen receptor-positive early-stage breast cancer treated with ovarian suppression: a patient-level meta-analysis of 7030 women from four randomised trials Lancet Oncol 2022
10th February 2022
Breast cancer scans for women with no recognisable risk factors for the disease has identified that around 40% of these women have a tumour, emphasising the need to continue scanning eligible women. This was the conclusion of a study by researchers from the Sydney School of Public Health, University of Sydney, Australia.
A 2015 systematic review of the benefits and harms of breast cancer screening concluded that for women of all ages and at average risk, screening was associated with a reduction in breast cancer mortality of approximately 20%. However, risk-stratification of breast cancer screening might improve the cost-effectiveness of the whole scanning process and at the same time, potentially reduce any associated risks. In fact, a 2018 study found that not offering breast cancer screening to women at lower risk could improve the cost-effectiveness of the screening programme, through reducing over diagnosis and at the same time, maintaining the benefits of screening. Nevertheless, little is known about the screening outcomes for women without any known breast cancer risk factors and who are therefore assumed to be at a lower risk.
For the present study, the Australian team examined the breast cancer scan outcomes for women deemed to be at the lower end of the risk spectrum. They undertook a retrospective analysis of clinical data routinely collected in the BreastScreen Western Australia (BSWA) program and included women aged 40 years and older. Although the program does stratify women in terms of their risk, i.e., those with > 2 affected first-degree relatives etc), women age 40 and over can volunteer to participate, despite not being in the target group. The researchers collected variables such as age, need for repeat scans together with information such as a previous history of breast or ovarian cancer, use of hormone replacement therapy etc. The scans were then categorised as having none of these factors verses at least one factor and age bands of 40 -49, 50 -59, 60 – 69 and > 70 years were created. The outcomes of interest were cancer detection rates at screening (CDR) per 10,000 screens and the interval cancer rates (ICR) per 10,000 women-years.
Breast cancer scans and detection of tumours
A total of 1,026,137 screens were performed including 323,082 in women aged > 40 years, who had a mean age of 58.5 years. Among the total scans, 44.7% of women had at least one risk factor although for 55.3% of screens, the women had none of the recorded risk factors.
In the screens without any risk factors, the CDR was 50 (95% CI 48 – 52) per 10,000 screens and the ICR was 7.9 (95% CI 7.4 – 8.4). Overall, in all of the scans in which cancer was detected, for 40.9% of cases, there were no recognised risk factors present.
The authors concluded that given how many of the scans identified cancers in women without risk factors, their finding did not justify less frequent screening of women without recognised risks.
Citation
Noguchi N et al. Evidence from a BreastScreen cohort does not support a longer inter-screen interval in women who have no conventional risk factors for breast cancer Breast 2022
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