Breastfeeding practices among employed Thai women in Chiang Mai

In many developing countries, labor force participation by women in the childbearing years has increased rapidly. Social and economic changes present new challenges for women attempting to combine their roles as workers and mothers. Little is known about how these challenges affect infant feeding choices. This multidisciplinary study investigated work and infant feeding decisions among 313 employed women in Chiang Mai, Thailand. Resumption of employment generally had negative affects on breastfeeding rates and duration. At 6 months postpartum, women who worked inside the home breastfed more than those working in the formal sector at jobs with inflexible hours (home, 80%; public sector, 37%; private sector, 39%). Women who were working outside the home for a long period or had shift jobs encountered many obstacles to maintaining breastfeeding, and most gave it up within 1 month after resuming employment. There is a need for multisectoral policies that address obstacles to breastfeeding among women in the paid labor force in Thailand.

Urinary tract infection as nidus for systemic spread and septic arthritis

A 12-year-old bearded collie was diagnosed with septic arthritis. The same beta-hemolytic streptococcus was cultured from the joint, blood, and urine. With arthritis, it is important to search for an inciting cause (this case, urinary tract infection) and to differentiate infectious from immune-mediated disorders, as treatment may be very different.

Lobular carcinoma in situ: current concepts and controversies

Clinical and clinicopathologic studies performed over the last 50 years have elucidated many of the important features of lobular carcinoma in situ. However, certain aspects of the natural history, treatment, and diagnosis of these lesions remain controversial. The purpose of this article is to review the current understanding of lobular carcinoma in situ and to highlight some of the controversies surrounding this entity.

Postmastectomy radiation therapy: A surgical perspective

Controversy exists about whether postmastectomy radiotherapy prolongs survival or is merely of benefit to maintain local control. Surgical series of patients treated by radical or modified radical mastectomy alone show locoregional failure rates ranging from 4% to 26%. The likelihood of involvement of supraclavicular and internal mammary nodal metastases increases as the extent of axillary nodal involvement increases. Adjuvant systemic therapy appears to have limited impact on the incidence of locoregional failure. Untreated nodal disease is a potential source of tumor dissemination and provides a biological rationale for a survival benefit for irradiation.

The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation

CONTEXT

Raloxifene hydrochloride is a selective estrogen receptor modulator that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism, and blood clotting.

OBJECTIVE

To determine whether women taking raloxifene have a lower risk of invasive breast cancer.

DESIGN AND SETTING

The Multiple Outcomes of Raloxifene Evaluation (MORE), a multicenter, randomized, double-blind trial, in which women taking raloxifene or placebo were followed up for a median of 40 months (SD, 3 years), from 1994 through 1998, at 180 clinical centers composed of community settings and medical practices in 25 countries, mainly in the United States and Europe.

PARTICIPANTS

A total of 7705 postmenopausal women, younger than 81 (mean age, 66.5) years, with osteoporosis, defined by the presence of vertebral fractures or a femoral neck or spine T-score of at least 2.5 SDs below the mean for young healthy women. Almost all participants (96%) were white. Women who had a history of breast cancer or who were taking estrogen were excluded.

INTERVENTION

Raloxifene, 60 mg, 2 tablets daily; or raloxifene, 60 mg, 1 tablet daily and 1 placebo tablet; or 2 placebo tablets.

MAIN OUTCOME MEASURES

New cases of breast cancer, confirmed by histopathology. Transvaginal ultrasonography was used to assess the endometrial effects of raloxifene in 1781 women. Deep vein thrombosis or pulmonary embolism were determined by chart review.

RESULTS

Thirteen cases of breast cancer were confirmed among the 5129 women assigned to raloxifene vs 27 among the 2576 women assigned to placebo (relative risk [RR], 0.24; 95% confidence interval [CI], 0.13-0.44; P<.001). To prevent 1 case of breast cancer, 126 women would need to be treated. Raloxifene decreased the risk of estrogen receptor-positive breast cancer by 90% (RR, 0.10; 95% CI, 0.04-0.24), but not estrogen receptor-negative invasive breast cancer (RR, 0.88; 95% CI, 0.26-3.0). Raloxifene increased the risk of venous thromboembolic disease (RR, 3.1; 95% CI, 1.5-6.2), but did not increase the risk of endometrial cancer (RR, 0.8; 95% CI, 0.2-2.7).

CONCLUSION

Among postmenopausal women with osteoporosis, the risk of invasive breast cancer was decreased by 76% during 3 years of treatment with raloxifene.

Hormone replacement therapy and risk of breast cancer with a favorable histology: results of the Iowa Women's Health Study

CONTEXT

Long-term, postmenopausal use of hormone replacement therapy (HRT) appears to increase breast cancer risk. Whether the effect of HRT use on risk of breast cancer varies among histological types of invasive carcinoma is unknown.

OBJECTIVE

To determine associations between HRT use and risk of ductal carcinoma in situ (DCIS), invasive carcinoma with favorable histology, and invasive ductal or lobular carcinoma.

DESIGN

Prospective cohort study whose participants were followed up continuously for 11 years from January 1986 to December 1996.

SETTING AND PARTICIPANTS

Iowa Women's Health Study, a population-based random sample of postmenopausal women aged 55 to 69 years in 1986. A total of 1520 incident breast cancer cases occurred in the at-risk cohort of 37 105 women.

MAIN OUTCOME MEASURES

Multivariate-adjusted relative risk (RR) of tumor-specific breast cancers associated with duration of ever, current, or past HRT use.

RESULTS

Duration of ever HRT use was associated with risk of invasive carcinoma with a favorable histology, with an RR of 1.81 (95% confidence interval [CI], 1.07-3.07) for those who used HRT 5 or fewer years vs an RR of 2.65 (95% CI, 1.34-5.23) for those who used HRT for more than 5 years (P for trend = .005) after adjustment for age and other breast cancer risk factors. There was no association between ever HRT use and the incidence of DCIS or invasive ductal or lobular carcinoma. Among current hormone users, after adjusting for age and other breast cancer risk factors, the RRs (95% CIs) of invasive carcinoma with a favorable histology were 4.42 (2.00-9.76) and 2.63 (1.18-5.89) for 5 or fewer years of use and for more than 5 years of use, respectively. Risk of invasive ductal or lobular carcinoma was associated with current use (< or =5 years) of HRT with an RR of 1.38 (95% CI, 1.03-1.85).

CONCLUSIONS

Exposure to HRT was associated most strongly with an increased risk of invasive breast cancer with a favorable prognosis. These data add important clinical information for assessing the risks and benefits of HRT use.

Belt worn control system and battery for the percutaneous model of the Jarvik 2000 heart

A belt worn controller and lithium-ion battery pack have been developed for use with the initial clinical trials of the Jarvik 2000 heart. Patient interface considerations, safety, and simplicity were major design inputs for the system. The controller was developed using all analog technology to avoid difficulties with electromagnetic interference (EMI), to minimize susceptibility to electrostatic discharge, and to avoid the need for software validation. Manual control of pump speed is accomplished by a patient operated knob, according to physician instructions for rest and exercise for each individual patient. The system includes alarms and indicators which show the following: the amount of remaining battery charge, if the battery is low and needs replacement, the power in watts being consumed, if the power consumed is above 15 W, if the pump is running below the selected speed setting, and if the pump stops. The control box, curved to be worn on the belt, is only 2.5 inches high for comfort when sitting. The battery pack, also form fitted for patient comfort, weighs just over 1 1/2 pounds and supplies 65 W-h of energy storage, sufficient to run the device for over 8 h at nominal load.

Identification of the woman at risk for breast cancer: problem solved?

The clinical availability of antiestrogens to reduce breast cancer incidence has focused increased attention on the ability to identify women at increased risk for breast cancer development. Multiple risk factors, which can be grouped under the headings of genetic and familial factors, hormonal factors, benign breast disease, and environmental factors have been described. However, of these risk factors, only genetic mutations and atypical hyperplasia, lobular carcinoma in situ, and ductal carcinoma in situ have a relative risk of four or more. Many of the other risk factors, although associated with statistically significant increases in risk in large populations, are of little practical significance for the individual woman. Lack of knowledge of the interactions among various positive and negative risk factors also complicates the evaluation of risk. In addition, the impact of some risk factors may not be constant over time, and the majority of data on risk come from studies of white women, and little is known about the impact of ethnic diversity on these factors. Finally, there is no consensus about what level of increase in risk is necessary for a women to be labeled "high risk." It is important to recognize that only 50% of breast cancers occur in women with identifiable risk factors other than age. Thus, an improved ability to define risk status is needed if prevention studies directed at high-risk women are to have a major impact on breast cancer incidence and mortality.

Impact of same-day screening mammography availability: results of a controlled clinical trial

BACKGROUND

We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations.

PATIENTS AND METHODS

Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group).

MAIN OUTCOME MEASURES

Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography.

RESULT

Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P<.001), increasing to 61% and 49% at 6 months (P<.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P<.001), women who were not employed (54% vs 36%; P<.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P<.001) within the last 5 years.

CONCLUSIONS

Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.

Accuracy of AJCC staging for breast cancer patients undergoing re-excision for positive margins. American Joint Committee on Cancer

BACKGROUND

The current AJCC protocol for breast cancer staging does not include additional tumor found at the time of re-excision in the calculation of tumor size. We hypothesize that the AJCC protocol may result in understaging and undertreatment of breast cancer patients who have additional tumor found at re-excision.

METHODS

In a retrospective chart review of breast cancer patients, patients with tumor present at re-excision for positive margins were placed in group 1 (n=72); patients with no tumor present at re-excision, or who underwent a single, negative margin procedure were placed in group 2 (n=147).

RESULTS

Patients in group 1 had a higher risk of nodal metastases when compared to patients in group 2. Mean tumor size did not differ significantly between the subgroups. Positive re-excision was strongly associated with lymph node metastases on multivariate analysis after correction for age, grade, stage, and lymphatic invasion (odds ratio=3.13, 95% CI=1.58 6.18, P=.0011).

CONCLUSIONS

Current AJCC guidelines may result in undertreatment of breast cancer patients with positive re-excisions. The presence of additional tumor at the time of re-excision should be considered when determining the need for systemic therapy, and may be relevant in determining T stage.

The evaluation of breast masses in women younger than forty years of age

BACKGROUND

Breast masses in young women are common, but carcinoma is rare. This study was undertaken to determine how often a complaint of mass was found to represent a dominant mass and to define the role of breast imaging and fine-needle aspiration cytology (FNA) in the evaluation of clinically nonworrisome masses.

METHODS

A retrospective review was made of 605 patients younger than 40 years of age with a breast mass between February 1994 and February 1996.

RESULTS

Dominant masses were confirmed by surgeon examination in 36% of 484 self-detected masses compared with 29% of physician-detected masses (difference not significant). With pathologic confirmation, 29% of self-detected masses had a dominant mass compared with 19% of physician-detected masses (P = .02). Carcinoma was present in 5% of both groups and not predicted by family history. Imaging studies were not useful in patients with normal examinations but were more likely to identify dominant masses in patients with an examination described as benign (P < .001). FNA did not identify any cancers in normal or benign examinations.

CONCLUSIONS

Self-examination is as reliable as a general physician examination in detecting breast masses. When an examination by an experienced surgeon is normal, imaging studies and FNA are low yield. When the examination is equivocal, directed ultrasonography is a useful adjunct.

Ductography for nipple discharge: no replacement for ductal excision

BACKGROUND

Current management of nipple discharge depends on clinical history to distinguish pathologic from physiologic discharge. We investigated whether ductography supplied additional information in the decision for surgery and/or the localization of pathologic lesion.

METHODS

A retrospective review of patients with a presenting complaint of nipple discharge seen at the Lynn Sage Breast Center was conducted from January 1995 to June 1996. Medical records, pathology, and ductograms were reviewed.

RESULTS

Of 91 patients with nipple discharge, 49 met the criteria for physiologic discharge and 42 had pathologic discharge. Eleven with physiologic discharge had ductograms; none were abnormal. Four of 20 preoperative ductograms were normal but showed intraductal papillomas at the time of surgery; 6 of 20 (30%) had multiple lesions. Four lesions on ductograms did not demonstrate corresponding lesions in the surgical specimen. It is uncertain whether this is due to a missed lesion or a false-positive ductogram.

CONCLUSIONS

Modern ductography does not reliably exclude intraductal pathology and is not a substitute for surgery in patients with pathologic discharge. Its utility is in identifying multiple lesions or those with lesions in the periphery of the breast.

The National Cancer Data Base 10-year survey of breast carcinoma treatment at hospitals in the United States

BACKGROUND

The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcome data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995) data are described herein.

METHODS

Since 1989, seven calls for data have been issued, yielding reports on a total of 240,031 breast carcinoma patients for the years included in this analysis. A total of 1849 hospital cancer registries responded to at least 1 of the calls for data.

RESULTS

A continuous improvement in care was reported. By 1995, 45.8% (nearly one-half) of breast carcinoma patients were diagnosed early as Stage 0 or I, and early stage patients (Stage 0 or I) were most often treated with partial mastectomy (in 58% of cases). Favorable 10-year relative survival rates for Stage 0 (95%) and Stage I (88%) breast carcinoma patients were reported. Patients who were presumed to be Stage I and were not selected for axillary dissection had poorer survival. Survival differences were reported for different treatment groups within individual stage strata. Over the 10-year observation period, fewer patients from lower-income neighborhoods were diagnosed with early stage breast carcinoma. In general, the annual relative survival rate remained constant over the 10-year observation period (with no plateau after 5 years) within each stage and for all stages combined.

CONCLUSIONS

Improvements in diagnosis and treatment during the period 1985-1995 were demonstrated by these data. The NCDB breast carcinoma data are appropriate norms for formal quality assurance purposes, such as those specified by the Standards of the Commission on Cancer published by the American College of Surgeons Commission on Cancer. Cancer committees and other clinicians working within the hospital setting should assess and compare stage distribution, stage specific treatment patterns, and the correlations between the outcomes of patients and both disease stage and treatment.

Breast-conserving surgery in the neoadjuvant setting

The use of neoadjuvant chemotherapy for the treatment of patients with operable breast cancer remains controversial. Neoadjuvant chemotherapy is highly effective in achieving significant tumor regression. However, the primary goal of improved survival has yet to be clearly demonstrated. The largest prospective trial with adequate follow-up to report 5-year disease-free survival data demonstrated no significant difference between patients treated with neoadjuvant chemotherapy followed by locoregional treatment and locoregional treatment followed by adjuvant chemotherapy. Survival data from the National Surgical Adjuvant Breast and Bowel Project B-18 trial are not yet available. The potential impact on the breast conservation rate for patients with early operable breast cancer is small, and careful follow-up of the long-term risk of local recurrence for patients with neoadjuvant therapy induced downstaging followed by BCT is not yet available. At this time, neoadjuvant chemotherapy for the treatment of patients with operable breast cancer should be considered investigational.

Breast conservation for mammographically occult carcinoma

OBJECTIVE

Preoperative mammography is an essential part of the evaluation of patient eligibility for breast conserving therapy.

SUMMARY BACKGROUND DATA

It is uncertain whether factors that contribute to the nonvisualization of carcinoma on mammograms are indications for mastectomy. The purpose of this study was to determine if the failure to identify clinically evident carcinoma on a mammogram is a contraindication to breast conserving therapy.

METHODS

An analysis of 268 women with 269 clinically evident carcinomas who were treated from June 1988 to September 1993 was performed. Contraindications to breast preservation included multicentric tumors, diffuse indeterminate microcalcifications, pregnancy, prior irradiation to the breast region, the inability to achieve negative margins after two surgical procedures, and a large tumor to breast ratio.

RESULTS

Mammographically occult tumors (MO) were present in 52 patients (19%). The mean age of patients with MO tumors was 52 versus 57 for mammographically evident (ME) tumors (p = 0.009), but the incidence by decade did not vary. Special histologic tumor types were more frequent among MO than ME tumors (13.5% vs. 1.8%, p < 0.001). Tumor size, the incidence of axillary node metastases, and stage did not vary. An equal proportion of patients with MO and ME tumors were candidates for breast preservation (67% vs. 70%), and a large tumor to breast ratio was the most common contraindication in both groups.

CONCLUSIONS

Even with modem mammographic technology, MO tumors remain a significant problem. This study did not demonstrate an association between MO tumors and factors such as size, unfavorable histology, or multicentricity which would preclude the use of breast conserving therapy. These results support the treatment of MO tumors with breast conserving surgery after a detailed clinical evaluation.