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Take a look at a selection of our recent media coverage:

Dietary supplements used by 40% of those diagnosed with cancer

4th January 2022

Dietary supplements have been found to be used by 40% of adults diagnosed with breast, prostate and colorectal cancer

Dietary supplements (DS) are used by 40% of adult patients diagnosed with either breast, prostate or colorectal cancer according to research by a team from the Department of Behavioural Science and Health, University College London, UK.

Survival from cancer appears to be increasing, with a 2018 global surveillance study finding that survival trends are generally increasing, even for some of the more lethal cancers. While evidence supporting various strategies aimed at reducing cancer risk in those living with and beyond cancer is rather limited, a 2018 report by the World Cancer Research fund and the American Institute for Cancer research, is clear in its view that ‘high-dose dietary supplements are not recommended for cancer prevention’, encouraging individuals to meet their nutritional needs through diet alone. Nevertheless, some data shows that cancer survivors tend to report a higher usage of DS than those with the disease.

For the current study, the authors sought to gain a better understanding the range of and reasons for, use of DS among survivors of breast, prostate and colorectal cancer. They undertook a cross-sectional survey using data from the Advancing Survival Cancer Outcomes Trial (ASCOT) and asked respondents with each of the three cancers, their thoughts about lifestyle and cancer, use of specific foods, e.g. fruits, vegetables, meat and high calorie foods together with information on the use of DS and any other non-prescribed treatments such as herbal extracts. Respondents were asked to express their views (using a Likert scale) on the perceived importance of supplements as an approach to prevent cancer reoccurrence.

Findings

A total of 1049 participants with mean age of 64.4 years (62.1% female) provided usable data for analysis. Breast cancer was the most common (54.4%) among respondents, followed by prostate (25.2%) and colorectal (20.4%). In addition, the majority were of white ethnicity (94%) and 68% had either no (34.9%) or at least one co-morbidity.

In total, 40% of respondents reported DS use, of whom, 32% believed that these supplements were important for a reduction in cancer recurrence. The most commonly used form of supplements were fish oils (13.1%), followed by calcium and vitamin D (9.1%) and multivitamin and minerals (8.2%).

Using regression analysis, the only factors significantly associated with DS use were meeting the requirements for fruit and vegetable intake (odds ratio, OR = 1.36, 95% CI 1.02 – 1.82, p = 0.039), a belief in the importance of supplements to prevent cancer recurrence (OR = 3.13, 95% CI 2.35 – 4.18, p < 0.001) and the absence of obesity (OR = 0.58, 95% CI 0.38 – 0.87, p = 0.010).

The authors concluded that DS use among cancer survivors was common and influenced by patient’s beliefs about recurrence. They added that further work was required to better understand the reasons for such beliefs and how best to provide appropriate supplement advice to those living with a cancer diagnosis.

Citation

Conway RE et al. Dietary supplement use by individuals living with and beyond breast, prostate, and colorectal cancer: A cross‐sectional survey Cancer 2021

Antipsychotic drugs raising prolactin elevate risk of breast cancer in women

20th December 2021

Antipsychotic drugs especially those elevating prolactin levels appears to be associated with an increased risk of breast cancer in women

A study of antipsychotic drugs used by women has revealed an increased risk of breast cancer, which is worse in those drugs which elevate prolactin levels. This was the conclusion by researchers from the Department of Psychiatry, Washington, US.

Over expression of the prolactin (PRL) receptor is seen in more than 95% of human breast cancers and in fact, hyperprolactinaemia inducing antipsychotics cause precancerous cells to progress to cancer via JAK/STAT5 to suppress the apoptosis anticancer barrier. However, although data shows an increasing body of evidence supporting the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative.

For the present analysis, the US team undertook a large epidemiological study, seeking to examine breast cancer risk by categorising antipsychotic drugs based on their ability to raise prolactin levels. Using lithium and anticonvulsants as a comparator, the researchers turned to a commercial health insurance database and identified women between the ages of 18 and 64 with an outpatient prescription for an antipsychotic, anticonvulsant or lithium between 2007 and 2016. They separated antipsychotics into three categories (1, 2 and 3) based on the propensity to raise prolactin, with drugs in category 1 being the highest. Examples included in the different categories were typical neuroleptics such as haloperidol, risperidone (category 1), olanzepine (category 2) and clozapine, quetiapine (category 3). The team identified invasive breast cancer from coding in the medical records and used multivariable Cox hazard models to evaluate the risk of breast cancer and adjusted for several factors including benign breast diseases, smoking, diabetes etc.

Findings

A total of 312,702 women with a median age of 41 years were identified as new users of antipsychotic drugs and 228, 035 women with a median age of 39 years, who were new users of anticonvulsants. From the whole sample, 914 women (0.2%) with a median age of 53 years, developed invasive breast cancer.

Women with use of any antipsychotic medication has a higher overall risk of breast cancer compared to those taking anticonvulsants or lithium (hazard ratio, HR = 1.40, 95% CI 1.19 – 1.64) although after adjustment, the hazard ratio reduced to 1.35 (95% CI 1.14 – 1.61).

In fully adjusted models, for the highest prolactin elevating category (1), the adjusted hazard ratio, aHR was 1.62 (95% CI 1.30 – 2.03), 1.54 (95% CI 1.19 – 1.99) for category 2 and non-significant for category 3. When analysing by age, younger women remained at an increased risk after adjustment (aHR = 1.91, 95% CI 1.21 – 3.01) compared to women aged 51 to 64 years (aHR = 1.43, 95% CI 1.01 – 2.03).

Discussing these findings, the authors noted how women using category 1 and 2 antipsychotic drugs had a significantly elevated risk of breast cancer compared to the comparator drugs. They suggested that younger women prescribed category 1 or 2 drugs should be considered for more frequent mammography screening.

Citation

Rahman T et al. Risk of Breast Cancer With Prolactin Elevating Antipsychotic Drugs. An Observational Study of US Women (Ages 18–64 Years) J Clin Psychopharmacol 2021

HRT use increases risk of disease recurrence in breast cancer survivors

18th November 2021

Meta-analysis shows HRT use among women who have survived breast cancer is associated with a significant increased risk of disease recurrence.

Hormone replacement therapy (HRT) use for the management of menopausal symptoms in women with a history of breast cancer is associated with a significant increase in the risk of disease recurrence according to a meta-analysis by researchers from Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy. Although there have been major advances in the treatment of breast cancer, the blocking of oestrogen is associated with several adverse effects which negatively impact on a patient’s quality of life. HRT use is the most effective treatment for symptoms related to a reduction in the level of oestrogen although its use in breast cancer survivors is generally avoided. Among healthy women, the use of oestrogen only HRT leads to a reduced risk of breast cancer but when oestrogen is combined medroxyprogesterone, the risk is increased. Though it is generally advised that the use of HRT is avoided in patients with a history of breast cancer it has been suggested that there is insufficient evidence to contra-indicate HRT in breast cancer survivors.

With some uncertainty over whether HRT increases the risk in breast cancer survivors who experience oestrogen depletion-related symptoms, the Italian team decided to perform a systematic review and meta-analysis to assess the overall safety of systemic HRT use and its impact on disease recurrence in breast cancer survivors. They searched all of the main databases but restricted their search to articles published in English, randomised, placebo-controlled trials with breast cancer survivors and any studies reporting on the recurrence of breast cancer.

Findings

The literature search identified 12 studies of which, only 4 were included in the final analysis examining the effect of HRT on 4050 breast cancer survivors. All trials had randomised patients to either HRT or placebo with a total of 2022 patients randomised to HRT, either oestrogen/progestogen combinations or tibolone.

There was a low degree of heterogeneity in studies and compared to the placebo group, the use of HRT significantly increased the risk of breast cancer recurrence (hazard ratio, HR = 1.46, 95% CI 1.12 – 1.91, p = 0.006). In subgroup analysis, among patients with hormone receptor-positive tumours, the risk of disease recurrence was also significantly increased in those using hormonal therapy (HR = 1.80, 95% CI 1.15 – 2.82, p = 0.010). In contrast, in patients with hormone receptor-negative disease, there was no significant increase in risk (HR = 1.19, 95% CI 0.80 – 1.77, p = 0.39). In a further analysis, the risk of breast cancer recurrence was no different between combined HRT and tibolone (HR = 1.51 95% CI 0.84 – 2.72).

Based on these findings, the authors concluded that future research should focus on finding alternatives to hormone replacement therapy for women who have survived breast cancer yet experience symptoms related to oestrogen deficiency.

Citation

Poggio F et al. Safety of systemic hormone replacement therapy in breast cancer survivors: a systematic review and meta-analysis. Breast Cancer Res Treat 2021

Cannabis used for symptom relief in nearly half of women with breast cancer

25th October 2021

Cannabis use for the relief of symptoms in women with breast cancer was reported by 42% those in a US survey of an online health group.

An anonymous survey of cannabis (CB) use found that 42% of women with breast cancer were using it for the relief of symptoms, according research conducted by the online support group, Breastcancer.org, Pennsylvania, US. The use of medicinal CB among those with cancer is not new and has previously been reported by nearly a quarter of respondents with a range of different cancer and mostly for pain relief. In addition, other work has found that 1 in 5 patients of those with cancer admitted to taking CB during chemotherapy. Although in the US, federal law states that the possession of cannabis is illegal, except within approved research settings, as of May 2021, 36 states and four territories allow for the medical use of cannabis products and in many cases, this can be for cancer.

For the present study, the researchers developed their survey and posted it online and members of Breastcancer.org were invited to participate through messaging boards, social media and email newsletters. The survey collected demographic data as well as breast cancer variables e.g., type, stage and treatment status, together with information on their use of cannabis such as timing of use in relation to therapy, e.g., before, during or after treatment, products used, sources and perceptions of the safety of cannabis.

Findings

A total of 612 completed surveys were available for analysis from women with a mean age of 57 years. A total of 64% of respondents reported being very or extremely interested in the medicinal use of cannabis, with the most common source of information being websites (67%) and family and friends (56%). However, only 39% had discussed the use of CB with their physician.

Overall, 42% (257/612) reported having used cannabis although only 23% (58) mentioned that this was specifically for medical purposes, with the remainder using it both medically and for recreational purposes. Among the 257 respondents using cannabis, 79% had used it alongside conventional treatment and 54% reported using it after the completion of therapy. The most common reasons for taking cannabis were for the relief of pain (78%), insomnia (70%),  anxiety (57%), stress (50%) and nausea/vomiting (46%). Moreover, 75% of those using CB believed that it was extremely or very helpful, at relieving their symptoms. Of more concern, was that 57% of those using cannabis stated that this was because they found no other way of treating their symptoms and how 49% stated that they were using CB in the belief that it could treat their cancer.

Interestingly, 78% of respondents somewhat or strongly agreed, that cannabis should be viewed similarly to other plant-based medicines with 71% stating that the benefits of cannabis outweighed its risks.

Commenting on their findings, the researchers noted how the use of CB during therapy was a concern, given the limited data available on interactions. In addition, they suggested that medical providers should discuss the risks and benefits of using CB in those with cancer.

Citation

Weiss MC et al. A Coala-T-Cannabis Survey Study of Breast Cancer Patients’ Use of Cannabis Before, During, and After Treatment. Cancer 2021

Artificial intelligence appears to be less accurate than radiologists in breast cancer screening

23rd September 2021

Breast cancer screening using artificial intelligence systems has been found, in the majority of cases, to be less accurate than a radiologist.

Globally, in 2020, there were an estimated 2.3 million women diagnosed with breast cancer leading to 685,000 deaths. Fortunately, improvements in survival over recent decades have been attributed to population-based breast cancer screening with mammography. In fact, a recent UK study suggested that screening reduces cancer mortality by 38% among women screened at least once.

The use of artificial intelligence (AI) systems for image recognition in breast cancer screening could lead to improvements in the detection of cases, either as a standalone system or as an aid to radiologists. Indeed, there is some evidence to support the value of AI with one retrospective analysis of an AI screening algorithm concluding that it showed better diagnostic performance than a radiologist. Nevertheless, in a 2019 review, it was concluded that while AI systems have good accuracy for breast cancer detection, methodological concerns and evidence gaps exist that limit translation into clinical breast cancer screening settings.

In light of these concerns, a team from the Division of Health Sciences, University of Warwick, UK, were commissioned by the UK National Screening Committee to undertake a systematic review to determine whether there was sufficient evidence to support the introduction of AI for mammographic image analysis in breast screening. They conducted literature searches up to May 2021 and included studies that reported the test accuracy of AI algorithms either alone or in combination with radiologists, to detect breast cancer in digital mammograms in screening practice or in test sets. The team included cancer confirmed by histological analysis of biopsy samples in cases where women were referred for further tests after screening as the reference standard or from symptomatic presentation during follow-up.

Findings
The review identified a total of 12 studies including 131,822 women undergoing breast cancer screening. In studies with a standalone AI system, the algorithm calculated a cancer risk score, categorising women at either high (recall) or low (no recall) risk. When used to assist the radiologist, the AI system simply provided a level of suspicion. In two large retrospective studies including 76,813 women, that compared the AI system with the clinical decisions of a radiologist, 96% of systems were less accurate than a single radiologist and all were less accurate than a double read.
Overall, the authors reported considerably heterogeneity in study methodology, some of which resulted in high concerns over the risk of bias and applicability. In their study, they commented that “evidence is insufficient on the accuracy or clinical effect of introducing AI to examine mammograms anywhere on the screening pathway”.

In the conclusion, the authors noted how AI systems for breast cancer screening are a long way from having the quality and quantity required for implementation into clinical practice.

Citation
Freeman K et al. Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy. BMJ 2021

Less than half of radiologists successfully complete on-line self-assessment

21st September 2021

Using a mammography on-line self-assessment, less than half of Italian radiologists were able to successfully completed the test.

Detection of breast cancer requires that mammography scans are interpreted correctly and thus guidelines on screening require that robust quality control and quality assurance are in place. Although an assessment of performance against standards can be achieved through audits, such audits offer little insight of the diagnostic skills of individual radiologists. The use of on-line self-assessment, using pre-diagnosed mammograms, offers a means of identifying any knowledge gaps and could serve as an important educational tool.

An on-line self-assessment tool was adopted by the Italian Society of Medical Radiology in 2018 as part of a national on-line self-assessment program for interpretation of mammograms and the results have published. The test set was a collection of 24 pathology-confirmed cancers combined with 108 mammograms which were reported on as negative after double reading. All cases were acquired with full-field digital mammography and came from women aged 50 – 69 years, who represent those at average risk of breast cancer. For the assessment, the society determined a pass threshold for sensitivity of 62% (amounting to at least 15/24 cancers correctly identified) and 86% specificity (93/108 negative mammograms correctly identified). The on-line self-assessment was posted on a dedicated website and upon registration, radiologists provided information on demographics such as age, gender, place of work (public or private sector), years of breast imaging experience and a qualitative self-judgement of mammography interpretative skills as “beginner”, “average” and “expert”. As with usual mammography practice, the radiologists were required to submit a dichotomous diagnosis (i.e., positive/negative) for every case. In addition to reporting on the radiologist’s success in the test, the authors employed regression analysis and odds ratios to identify the most important predictor variables for diagnostic accuracy.

Findings
A total of 685 radiologists registered for the on-line self-assessment and 49.9% (342) with a mean age of 46 years (69% female), completed test. Among those completing, two-thirds (64%) self-judged their interpretative skills as “average” and respondents had a median of 8 years breast imaging experience although 38.3% reporting having more than 10 years’ experience. Participants reported a median number of 1501 mammographic interpretations per year and the majority (68.7%) worked in the public rather than private sector.

When examining the proportion who successfully completed the assessment, only 28.7% of radiologists (98/342) passed on their first attempt. After an initial failure, 138 of the remaining 244 radiologists, re-took the test of whom, only 35.5% (49/138) passed. In fact, the authors reported that overall, only 44.2% (151/342) of radiologists who completed the on-line self-assessment were successful.
Using regression analysis, a significant association for diagnostic accuracy was found only for the assessment of > 3,000 mammograms per year compared to < 1,000 (Odds ratio, OR = 3.88, 95% CI 1.07 – 14.14, p = 0.04) and working the in public rather than private sector (OR = 1.65). Other variables such as age, self-judged interpretative skills and years of breast imaging experience had no significant effect.
The authors concluded that their study suggested that breast imaging experience does not guarantee diagnostic accuracy in screening reading. They also noted that their on-line self-assessment test could be included as a criterion for the accreditation process of breast units.

Citation
Brancato B et al. Mammography self?evaluation online test for screening readers: an Italian Society of Medical Radiology (SIRM) initiative. Eur Radiol 2021

Use of tamoxifen and tumour size best predictors of long-term survival in breast cancer

9th July 2021

An analysis of breast cancer trial data suggests that tumour size and use of tamoxifen are both associated with greater long-term survival.

Breast cancer is the most common cancer in women worldwide and in 2020, there were 2.2 million cases and nearly 685,000 deaths. Breast cancer is a heterogenous disease with various types and different sensitivities to treatment, e.g., oestrogen receptor (ER) positive, progesterone receptor (PR) positive and hormone receptor (HR) negative. Among those with ER positive tumours, treatment with adjunctive therapy such as tamoxifen for five years is recommended. Nevertheless, even after treatment with tamoxifen, breast cancer can return over the intervening years, metastasise and lead to death. The use of clinical breast cancer markers such as tumour size or grade can be used to provide estimates of survival for up to 10 years and both increased tumour size and grade are associated with a reduced short-term survival. However, what is far less clear, is whether any of these markers are associated with longer term survival.

Given that both ER-positive and ERBB2-negative (i.e., HER2) disease are associated with a continuous risk of recurrent disease after the primary diagnosis, a team from the Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden, sought to determine whether both clinically used markers and treatment with tamoxifen were associated with long-term survival in patients with breast cancer. The team turned to data from the Stockholm tamoxifen (STO-3) trial, which enrolled postmenopausal women with lymph-node negative breast cancer and tumours less than 30mm in diameter, between 1976 and 1990 and who were randomised to tamoxifen 40mg daily or no endocrine therapy. In 1983, women with no recurrence after 2 years on tamoxifen, were given the drug for a further 3 years. The team undertook an analysis of tissue samples that were available from patients in the study. The tumour grade (1 to 3) had been assessed in 2014 by a pathologist and tumour size was categorised as T1a/b if 10mm or less, T1c if 11–20mm and T2 if larger than 20mm. All patients had a unique national registration number and which was linked with a cancer registry, allowing the team to obtain long-term follow-up data after 25 years.

Findings
The sample contained 565 postmenopausal women with a mean age of 62 years. Just over half (52.2%) of tumours were graded as T1c and nearly a third (30%), T1a/b. Patients with T1a/b tumours had the best long-term survival (88%) compared to those with T1c tumours (76%) or T2 tumours (63%). Similarly, the highest level of survival (81%) occurred in those with grade 1 tumours compared with grade 3 tumours (65%). Using this data, the team estimated a 69% reduced risk of disease recurrence for those with T1a/b sized tumours (hazard ratio, HR = 0.31, 95% CI 0.17–55). In terms of treatment, those given tamoxifen with grade 1–2 tumours also experienced a significantly reduced risk of disease recurrence (HR = 0.24, 95% CI 0.07 – 0.82) compared with those who did receive the drug. However, use of tamoxifen also produced a significant survival benefit in those with T2 tumours (HR = 0.34).

The authors concluded that tumour size, followed by grade and use of tamoxifen were independently associated with long-term survival in breast cancer.

Citation
Dar H et al. Assessment of 25-Year Survival of Women with Oestrogen Receptor–Positive/ERBB2-Negative Breast Cancer Treated with and Without Tamoxifen Therapy. A Secondary Analysis of Data from the Stockholm Tamoxifen Randomised Clinical Trial. JAMA Netw Open 2021.

Higher BMI linked to increased risk of second cancer in breast cancer patients

25th May 2021

Breast cancer survivors have a greater risk of developing a subsequent cancer but whether this is affected by obesity is unclear.

Cancer of the breast is the most common form of cancer in women although with an early diagnosis, the 5-year survival prognosis ranges from 86 to 99%. Nevertheless, women who survive breast cancer have a 17% increased risk for a second cancer compared to the general population. One factor known to be associated with cancer is obesity with one US study estimating that 40% of all cancer diagnoses occurred in people who were either overweight or obese. However, while much attention has been paid to the effect of obesity on the development of an initial cancer, far less is known about how obesity impacts on the development of a second cancer. As a result, a team from Kaiser Permanente, Denver, US, sought to examine the association between body mass index (BMI) and a second cancer among women who survived invasive breast cancer. Data were extracted from an electronic database and a surveillance tumour registry which provided information on the incidence and type of secondary cancers that occurred. Height and weight measurements within two years prior through one year after the date of the initial breast cancer diagnosis were used to calculate the BMI. All women included had surgery as part of their initial breast cancer and had no evidence of a second cancer one year later. The study outcomes included all second cancers, cancers for which there was a known association with obesity (e.g., oesophageal adenocarcinoma), and ER-positive second breast cancers.

Findings
A total of 6481 women were included in the analysis with a mean age of 60.2 years, of whom 33.4% were classed as overweight or obese (33.8%) at the time of their initial breast cancer diagnosis. During a median follow-up of 88 months, 822 (12.7%) women developed a second cancer, of which 508 (61.8%) were obesity-related and 333 (40.5%) were breast cancer, the majority of which (69.4%) were ER-positive. The authors calculated that every 5 unit increase in BMI was associated with a 7% increased risk of developing any second cancer (relative risk, RR = 1.07, 95% CL 1.01–1.14), a 13% increased for an obesity-related cancer and by 15% for a second ER-positive breast cancer.

The authors calculated that the risk of a second cancer was increased by 5% for every 5 unit increase in BMI. They concluded that these data had important public health implications given the prevalence of obesity and underscored the need for effective preventative strategies.

Citation
Feigelson HS et al. Body Mass Index and Risk of Second Cancer Among Women with Breast Cancer. J Natl Cancer Inst 2021