[Counselling, genetic testing and prevention in women with hereditary breast- and ovarian cancer. Interdisciplinary recommendations of the consortium "Hereditary Breast- and Ovarian Cancer" of the German Cancer AiD]

Women with familial predisposition for breast and ovarian cancer represent a small group of patients with very high risk for developing breast and/ or ovarian cancer before the age of 50 years. The individual breast cancer risk can be assessed by genetic counselling and can be specified by genetic diagnostics. As part of the gynaecological consultation, adequate preventive measures are offered. Psycho-oncological counselling may help in decision making. For hereditary carcinomas, counselling is still not considered as a routine medical care, even though basic and routine preventive measures are insufficient for this group of high risk patients. Within the last years, 12 specialized centres in Germany have developed a patient care concept for women with a familial risk for breast and ovarian cancer. Establishment of these centres for familial breast and ovarian cancer and use of evidence-based medical care was initiated in a nationwide interdisciplinary joint research project and supported by the German Cancer AiD. These measures were integrated in a quality assurance concept for structure, process and result optimization. Thus, all requirements for introducing these services into routine patient management have been fulfilled.

[Palliative therapy of breast cancer]

Metastatic breast cancer is considered an incurable disease. The choice of drug or drug combination in palliative therapy is determined by the subjective symptoms of the patient and by the more objective parameters age and general health status, localization of metastases and aggressiveness of the disease, which is described by the necessity to achieve remission. The relation between the effectiveness aimed for and the subjective quality of life is described by the term 'therapeutic index'. With receptor-positive tumours and under low remission pressure, endocrine therapy is the method of choice when considering sustaining the quality of life--here aromatase inhibitors have replaced the former gold standard anti-estrogen tamoxifen. With receptor-negative tumors or under high remission pressure the therapy decision is far more difficult. The cytostatic therapy can be performed as mono- or polychemotherapy. In both cases taxanes show a higher effectiveness when compared to standard therapies, with Docetaxel giving the highest response rate and (as shown in a recent Cochrane analysis) increasing overall survival with a HR of 0.88. We describe taxane-containing therapy regimes in the context of modern therapy options. Current data presented by 4 chosen studies are described, as well as AGO recommendations on palliative therapy.

[Chemoprevention of breast cancer: a literature review and report on the current status in Germany]

The prevention of breast cancer is increasingly of focus in health-politics policies and has gained a valid position in the area of medical intervention. Data from a current meta-analysis of all four randomised Tamoxifen prevention studies illustrate a reduction of 38 % (Odds ratio 0.62; 95 % CI 0.42-0.89) in the incidence of breast cancer. This observation lead to registration of this drug in the USA for the prevention of breast cancer in women with a calculated 5-year risk of > 1.66 %. In addition to Tamoxifen, further substances are currently being tested with the aim of improving the therapeutic index whilst reducing incidence and mortality rates. These are primarily substances which have proven efficacy in the treatment of breast cancer (other antioestrogens, aromatase inhibitors and GnRH-analogues) or those whose mechanism of action predict a preventative effect (retinoids, phytooestrogens, substitution preparations e. g. Tibolone). In Germany, chemoprevention is currently only to be recommended within study protocols, as to date no substance is approved in the indication 'prevention of breast cancer'. A essential contribution to the accrual of valid data is the conduct of breast cancer prevention trials. The participation of women with high risk of breast cancer in Germany is, in contrast to comparable international studies, problematic. Data on the current knowledge and attitude of the female population towards such trials (gathered via a questionnaire of the DACH in 7 000 women) show that only 19.5 % of the women questioned during a consultation with a gynaecologist were aware of the possibility of active chemoprevention. However, 55.3 % stated that they would be prepared to take such a substance, were chemoprevention possible. Studies for both pre- and post-menopausal women with increased risk of breast cancer are currently active in Germany (GISS and IBIS-II of the study group GABG - German Adjuvant Breast cancer Group). An intensive information campaign to raise public awareness of breast cancer risk amongst women and their physicians is planned in conjunction with the IBIS-II study (www.brustkrebsvorbeugen.de). Latest literature recommendations for prevention of breast cancer (Chlebowski et al.) have been assessed.

[Mutations in the dihydropyrimidine dehydrogenase gene and their role in 5-fluororuracil intolerance]

Cancer patients developing severe side effects upon chemotherapy with 5-fluorouracil (5-FU) are assumed to display reduced activity of the enzyme dihydropyrimidine dehydrogenase (DPD). Meanwhile over 20 different mutations are known in the dihydropyrimidine dehydrogenase gene (DPYD) which could be associated with a loss of enzyme function. For most of these genetic alterations, however, clear genotype-phenotype relations are still lacking. We are conducting a population study using a German cohort to determine the frequency of DPD defects in the German population and to detect new toxicity-associated mutations. Our aim is to develop a sensitive and efficient screening of tumor patients to identify patients with mutations in the DPYD gene which might be related to 5-FU-toxicity. For this purpose we analysed the whole coding region of DPYD by the technique of denaturing HPLC (DHPLC). The DHPLC analysis turned out to be a reliable method for the investigation of large samples in an acceptable cost and time range. To further elucidate the molecular basis of the DPD deficiency syndrome we will continue to analyse a patient panel receiving 5-FU.

[Three case reports of breast abscess after nipple piercing: underestimated health problems of a fashion phenomenon]

OBJECTIVE

Piercing is a growing fashion trend among young people. Nipple piercing has shown an increase over the last years. We report about three coincidental cases of breast abscess after nipple piercing within the last months in our clinics and discuss the related problems for health and society.

MATERIAL AND METHODS

Retrospective analysis of three case reports regarding course of illness and reasons as well as review of literature and internet.

RESULTS

Three patients average age 31.9 (28-35) years were hospitalized with breast abscess after nipple piercing (2 x left, 1 x right). The distance piercing to infection was on average 7.7 (5-12) months. In all patients the abscess was incised and the abscess cavity removed, two had an irrigation tubing for a three days, all received i. v. antibiotics postoperatively. Evidence for bacteria was found in case 1: PCR-confirmation of atypical mycobacteria and coagulase negative staphylococcus, case 2: coagulase negative staphylococcus and group B-streptococcus and case 3: green and microaerophilic staphylococcus. The length of hospital stay was on average 8.0 (6-9) days/case, the hospital costs were 3 624,54 e (3 000,26-4 310,58 e) euro;/case. In a follow-up period of 10,0 (5-15) months one relapse occurred which had to be re-operated.

CONCLUSION

Nipple piercing has grown in popularity within the last years and is in general not a stigma of a subculture or lower social classes any more. However, the risk for breast infection is on the one hand underestimated by the women and on the other hand played down by piercing studios. Breast infection after nipple piercing is rarely documented in scientific literature and data bases. Only seven case reports are scientifically published so far. Healing of the wound channel varies and can take up to 6-12 months. The risk for infection is approximately 10-20 %, often in a interval of months after the procedure. Insufficient understanding as well as inconsequent performance of hygienic preparation of the wound beneath other risk factors like nicotine abuse, wrongs size of jewelry, post breast enlargement with prosthesis etc. increase the risk of breast infection after nipple piercing. Due to obvious under documentation this is the largest series of breast infection after nipple piercing in the world.

[Primary and secondary breast cancer prevention. Knowledge, assessment and participation among the female population of Schleswig-Holstein]

OBJECTIVE

The intention was to find out to what extend women in Schleswig-Holstein were informed about primary and secondary preventive measures concerning breast cancer, how they assess their efficiency and in how far they are willing to take part in them. From June 1999 to April 2000 1 520 women in Schleswig-Holsteins were asked to complete a questionnaire about breast cancer prevention. There was a representative opinion poll of the market research company "Institut für Gesundheitsforschung München (Infratest)".

RESULTS

Most of the women (90.6 %) believed in the efficiency of early recognition of breast cancer at the gynaecologist, only 79.3 % of them stated that they took the chance of taking part in the annual examination. According to the doctors Union "Kassenärztliche Vereinigung", only 50.4 % of the female members of health insurance schemes took part in examinations concerning the early recognition of breast cancer in 1999. The degree of knowledge about and participation in preventive measures depend on the age of the women. The gynaecologist was named as the most important source of information and counselling.

CONCLUSION

In future the population needs more information and instruction concerning breast cancer preventive measures.

[Prevention in familial breast cancer susceptibility]

First retrospective data show that hereditary Breast cancer risk can be positively influenced by prophylactic surgical procedures and hereby a thorough consultation seem to be an option for mutant gene carriers. A first evaluation of the women of 1050 high-risk families by the German Consortium "Hereditary Breast and Ovarian Cancer promoted by the German Cancer Aid (Deutsche Krebshilfe)" has shown that approximately 80% of the women concerned decide to participate in an intensive early detection--programme and only 5% of the women have decided to submit themselves to prophylactic surgical measures. This again shows how absolutely necessary the elaboration and evaluation of early detection measures within the different investigation projects are.

Comparative genomic hybridization detects genetic imbalances in primary ovarian carcinomas as correlated with grade of differentiation

BACKGROUND

In the current study the authors attempted to evaluate genetic alterations in a large set of primary ovarian carcinomas and to compare the genetic findings with clinical parameters such as grade of tumor differentiation. This strategy was applied to identify chromosomal regions containing genes associated with tumor progression.

METHODS

Genetic imbalances were assessed in 106 primary ovarian carcinomas using comparative genomic hybridization (CGH). CGH was applied because it is a powerful tool with which to screen the entire genome of a tumor for genetic changes by highlighting regions of altered DNA sequence copy numbers (deletions and amplifications). Multivariate statistical standard procedures were used to determine an association between tumor grading and genetic alterations.

RESULTS

One hundred three carcinomas showed aberrant CGH profiles. The most frequent alterations were amplifications of 8q, 1q, 20q, 3q, and 19p, which occurred in 69-53% of tumors, and underrepresentations of 13q, 4q, and 18q, which occurred in 54-50% of tumors. Undifferentiated ovarian carcinomas (World Health Organization Grade 3) were found to be correlated significantly with underrepresentation of 11p and 13q as well as with overrepresentation of 8q and 7p (P = 0.001, 0.001, 0.01, and 0.027, respectively). However, 12p underrepresentation and 18p overrepresentation were significantly more frequent in well and moderately differentiated tumors (P = 0.01 and 0.004, respectively). To facilitate the interpretation and clinical application of the results of the current study, the significant aberrations were translated into a score system. This score system can be used easily for the prediction of an undifferentiated phenotype with a specificity and sensitivity of 79% and 86%, respectively.

CONCLUSIONS

The current study data show that primary ovarian carcinomas are based on consistent genetic alterations that most likely are important for the development of this tumor entity. The correlation between certain aberrations and undifferentiated carcinomas may help to discriminate between primary and secondary genetic events and may indicate the location of those genes involved in cellular functions associated with tumor progression and the development of anaplastic and aggressive phenotypes.

Mutation analysis of p53 in ovarian tumors by DHPLC

Up to now, ovarian carcinomas represent a major health problem among female cancers because they are the leading cause of death from gynecological malignancy. A high proportion of these tumors selects for mutations in the p53 gene. There is evidence that inactivation of the p53 protein could indicate poor prognosis and chemoresistance of patients. To set up a fast and sensitive test for p53 defects in tumor tissues, we analyzed ovarian cancer cells by denaturing high-performance liquid chromatography (DHPLC). A primer set spanning the whole coding region of p53 with seven fragments was designed and appropriate heteroduplex detection in DHPLC analysis was elaborated. The analysis of 45 ovarian tumor specimens yielded 17 genetic alterations (38%) occurring exclusively in the malignant tissue of the patients. In addition, frequent polymorphisms present in normal compared to tumor tissue could serve as a tool for the rapid identification of loss of heterozygosity (LOH) in the tumor. We observed that LOH in intron 2 or 3 correlated well with a lack of one allele in mutated fragments. In conclusion, DHPLC screening appears to be a sensitive and effective test for genetic alterations in tumors with p53 involvement. Since p53 mutations point to a poor prognosis state in several cancers, a fast screening of tumor material for genetic variations may have implications for further individual treatment of patients.