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Vichapat V, Garmo H, Holmqvist M, Liljegren G, Wärnberg F, Lambe M, Fornander T, Adolfsson J, Lüchtenborg M, Holmberg L. Tumor Stage Affects Risk and Prognosis of Contralateral Breast Cancer: Results From a Large Swedish-Population–Based Study. J Clin Oncol 2012; 30:3478-85. [DOI: 10.1200/jco.2011.39.3645] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The number of breast cancer survivors at risk of developing contralateral breast cancer (CBC) is increasing. However, ambiguity remains regarding risk factors and prognosis for women with CBC. Patients and Methods In a cohort of 42,670 women with breast cancer in the Uppsala/Örebro and Stockholm regions in Sweden in 1992 to 2008, we assessed risk factors for and prognosis of metachronous CBC by using survival analysis. Breast cancer–specific survival for women with CBC was evaluated and compared with results for women with unilateral breast cancer (UBC) by using time-dependent Cox-regression modeling. Results An increased risk for CBC was observed among women who had primary breast cancer with ≥ 10 involved lymph nodes compared with node-negative women (adjusted hazard ratio [HR], 1.8; 95% CI, 1.2 to 2.7). The prognosis was poorer in women with CBC than with UBC. The hazard of dying from breast cancer was especially high for women with a short interval time to CBC (adjusted HR, 2.3; 95% CI, 1.8 to 2.8 for CBC diagnosed ≤ 5 years v UBC) and gradually decreased with longer follow-up time but remained higher than the hazard originating from the primary tumor for ≥ 10 years. Conclusion Women with advanced-stage primary breast cancer had an increased risk of developing CBC. CBC is associated with an increased risk of dying from breast cancer throughout a long period of follow-up after the primary tumor. Our findings suggest that the event of CBC marks a new clinical situation in terms of investigations for metastases, treatment considerations, and follow-up strategy.
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Affiliation(s)
- Voralak Vichapat
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Hans Garmo
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Marit Holmqvist
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Liljegren
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Wärnberg
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lambe
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Fornander
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Adolfsson
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Margreet Lüchtenborg
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Holmberg
- Voralak Vichapat, Hans Garmo, Margreet Lüchtenborg, and Lars Holmberg, King's College London, London, United Kingdom; Hans Garmo, Marit Holmqvist, Mats Lambe, and Lars Holmberg, Regional Cancer Centre, Uppsala University Hospital; Fredrik Wärnberg and Lars Holmberg, Uppsala Academic Hospital, Uppsala University, Uppsala; Göran Liljegren, University Hospital, Örebro; and Mats Lambe, Tommy Fornander, and Jan Adolfsson, Karolinska University Hospital, Stockholm, Sweden
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Quinn A, Holloway L, Koh ES, Delaney G, Arumugam S, Goozee G, Metcalfe P. Radiation dose and contralateral breast cancer risk associated with megavoltage cone-beam computed tomographic image verification in breast radiation therapy. Pract Radiat Oncol 2012; 3:93-100. [PMID: 24674311 DOI: 10.1016/j.prro.2012.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/06/2012] [Accepted: 05/08/2012] [Indexed: 11/19/2022]
Abstract
PURPOSE To measure and compare organ doses from a standard tangential breast radiation therapy treatment (50 Gy delivered in 25 fractions) and a megavoltage cone-beam computed tomography (MV-CBCT), taken for weekly image verification, and assess the risk of radiation-induced contralateral breast cancer. METHODS AND MATERIALS Organ doses were measured with thermoluminescent dosimeters placed strategically within a female anthropomorphic phantom. The risk of radiation-induced secondary cancer of the contralateral breast was estimated from these values using excess absolute risk and excess relative risk models. RESULTS The effective dose from a MV-CBCT (8-monitor units) was 35.9 ± 0.2 mSv. Weekly MV-CBCT imaging verification contributes 0.5% and 17% to the total ipsilateral and contralateral breast dose, respectively. For a woman irradiated at age 50 years, the 10-year postirradiation excess relative risk was estimated to be 0.8 and 0.9 for treatment alone and treatment plus weekly MV-CBCT imaging, respectively. The 10-year postirradiation excess absolute risk was estimated to be 4.7 and 5.6 per 10,000 women-years. CONCLUSIONS The increased dose and consequent radiation-induced second cancer risk as calculated by this study introduced by the imaging verification protocols utilizing MV-CBCT in breast radiation therapy must be weighed against the benefits of more accurate treatment. As additional image verification becomes more common, it is important that data be collected in regard to long-term malignancy risk.
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Affiliation(s)
- Alexandra Quinn
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia; Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia.
| | - Lois Holloway
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia; Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia; School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Eng-Siew Koh
- Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Collaboration for Cancer Outcomes Research and Evaluation, Liverpool Hospital, Liverpool, NSW, Australia
| | - Geoff Delaney
- Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Collaboration for Cancer Outcomes Research and Evaluation, Liverpool Hospital, Liverpool, NSW, Australia; School of Medicine, University of Western Sydney, Sydney, NSW, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia
| | - Gary Goozee
- Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia
| | - Peter Metcalfe
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia; Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia
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Taggart F, Donnelly P, Dunn J. Options for early breast cancer follow-up in primary and secondary care - a systematic review. BMC Cancer 2012; 12:238. [PMID: 22695275 PMCID: PMC3502561 DOI: 10.1186/1471-2407-12-238] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 06/13/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Both incidence of breast cancer and survival have increased in recent years and there is a need to review follow up strategies. This study aims to assess the evidence for benefits of follow-up in different settings for women who have had treatment for early breast cancer. METHOD A systematic review to identify key criteria for follow up and then address research questions. Key criteria were: 1) Risk of second breast cancer over time - incidence compared to general population. 2) Incidence and method of detection of local recurrence and second ipsi and contra-lateral breast cancer. 3) Level 1-4 evidence of the benefits of hospital or alternative setting follow-up for survival and well-being. Data sources to identify criteria were MEDLINE, EMBASE, AMED, CINAHL, PSYCHINFO, ZETOC, Health Management Information Consortium, Science Direct. For the systematic review to address research questions searches were performed using MEDLINE (2011). Studies included were population studies using cancer registry data for incidence of new cancers, cohort studies with long term follow up for recurrence and detection of new primaries and RCTs not restricted to special populations for trials of alternative follow up and lifestyle interventions. RESULTS Women who have had breast cancer have an increased risk of a second primary breast cancer for at least 20 years compared to the general population. Mammographically detected local recurrences or those detected by women themselves gave better survival than those detected by clinical examination. Follow up in alternative settings to the specialist clinic is acceptable to women but trials are underpowered for survival. CONCLUSIONS Long term support, surveillance mammography and fast access to medical treatment at point of need may be better than hospital based surveillance limited to five years but further large, randomised controlled trials are needed.
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Affiliation(s)
- Frances Taggart
- Warwick Medical School Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK
| | - Peter Donnelly
- Breast Care Directorate, South Devon Healthcare NHS Foundation Trust, Lawes Bridge, Torquay, TQ2 7AA, UK
| | - Janet Dunn
- Warwick Medical School Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK
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Brooks JD, Teraoka SN, Reiner AS, Satagopan JM, Bernstein L, Thomas DC, Capanu M, Stovall M, Smith SA, Wei S, Shore RE, Boice JD, Lynch CF, Mellemkjaer L, Malone KE, Liang X, Haile RW, Concannon P, Bernstein JL. Variants in activators and downstream targets of ATM, radiation exposure, and contralateral breast cancer risk in the WECARE study. Hum Mutat 2012; 33:158-64. [PMID: 21898661 PMCID: PMC3240722 DOI: 10.1002/humu.21604] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 08/25/2011] [Indexed: 11/07/2022]
Abstract
Ionizing radiation (IR) is a breast carcinogen that induces DNA double-strand breaks (DSBs), and variation in genes involved in the DNA DSB response has been implicated in radiation-induced breast cancer. The Women's Environmental, Cancer, and Radiation Epidemiology (WECARE) study is a population-based study of cases with contralateral breast cancer (CBC) and matched controls with unilateral breast cancer. The location-specific radiation dose received by the contralateral breast was estimated from radiotherapy records and mathematical models. One hundred fifty-two SNPs in six genes (CHEK2, MRE11A, MDC1, NBN, RAD50, TP53BP1) involved in the DNA DSBs response were genotyped. No variants or haplotypes were associated with CBC risk (649 cases and 1,284 controls) and no variants were found to interact with radiation dose. Carriers of a RAD50 haplotype exposed to ≥1 gray (Gy) had an increased risk of CBC compared with unexposed carriers (Rate ratios [RR] = 4.31 [95% confidence intervals [CI] 1.93-9.62]); with an excess relative risk (ERR) per Gy = 2.13 [95% CI 0.61-5.33]). Although the results of this study were largely null, carriers of a haplotype in RAD50 treated with radiation had a greater CBC risk than unexposed carriers. This suggests that carriers of this haplotype may be susceptible to the DNA-damaging effects of radiation therapy associated with radiation-induced breast cancer.
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Affiliation(s)
- Jennifer D Brooks
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Teraoka SN, Bernstein JL, Reiner AS, Haile RW, Bernstein L, Lynch CF, Malone KE, Stovall M, Capanu M, Liang X, Smith SA, Mychaleckyj J, Hou X, Mellemkjaer L, Boice JD, Siniard A, Duggan D, Thomas DC, Concannon P. Single nucleotide polymorphisms associated with risk for contralateral breast cancer in the Women's Environment, Cancer, and Radiation Epidemiology (WECARE) Study. Breast Cancer Res 2011; 13:R114. [PMID: 22087758 PMCID: PMC3326556 DOI: 10.1186/bcr3057] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 11/14/2011] [Accepted: 11/17/2011] [Indexed: 12/19/2022] Open
Abstract
Introduction Genome-wide association studies, focusing primarily on unilateral breast cancer, have identified single nucleotide polymorphisms (SNPs) in a number of genomic regions that have alleles associated with a significantly increased risk of breast cancer. In the current study we evaluate the contributions of these previously identified regions to the risk of developing contralateral breast cancer. The most strongly disease-associated SNPs from prior studies were tested for association with contralateral breast cancer. A subset of these SNPs, selected upon their main effects on contralateral breast cancer risk was further evaluated for interaction with treatment modalities and estrogen receptor (ER) status. Methods We genotyped 21 SNPs in 708 women with contralateral breast cancer and 1394 women with unilateral breast cancer who serve as the cases and controls in the Women's Environment, Cancer and Radiation Epidemiology (WECARE) Study. Records of treatment and ER status were available for most of WECARE Study participants. Associations of SNP genotypes and risk for contralateral breast cancer were calculated with multivariable adjusted conditional logistic regression methods. Results Multiple SNPs in the FGFR2 locus were significantly associated with contralateral breast cancer, including rs1219648 (per allele rate ratio (RR) = 1.25, 95%CI = 1.08-1.45). Statistically significant associations with contralateral breast cancer were also observed at rs7313833, near the PTHLH gene (per allele RR = 1.26, 95%CI = 1.08-1.47), rs13387042 (2q35) (per allele RR = 1.19, 95%CI = 1.02-1.37), rs13281615 (8q24) (per allele RR = 1.21, 95%CI = 1.04-1.40), and rs11235127 near TMEM135 (per allele RR = 1.26, 95%CI = 1.04-1.53). The A allele of rs13387042 (2q35) was significantly associated with contralateral breast cancer in ER negative first tumors while the A allele of rs11235127 (near TMEM135) was significantly associated with contralateral breast cancer in ER positive first tumors. Although some SNP genotypes appeared to modify contralateral breast cancer risk with respect to tamoxifen treatment or particular radiation doses, trend tests for such effects were not significant. Conclusions Our results indicate that some common risk variants associated with primary breast cancer also increase risk for contralateral breast cancer, and that these risks vary with the ER status of the first tumor.
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Affiliation(s)
- Sharon N Teraoka
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA 22908-0717, USA.
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Brooks JD, John EM, Mellemkjær L, Reiner AS, Malone KE, Lynch CF, Figueiredo JC, Haile RW, Shore RE, Bernstein JL, Bernstein L. Body mass index and risk of second primary breast cancer: the WECARE Study. Breast Cancer Res Treat 2011; 131:571-80. [PMID: 21892703 DOI: 10.1007/s10549-011-1743-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/13/2011] [Indexed: 11/25/2022]
Abstract
The identification of potentially modifiable risk factors, such as body size, could allow for interventions that could help reduce the burden of contralateral breast cancer (CBC) among breast cancer survivors. Studies examining the relationship between body mass index (BMI) and CBC have yielded mixed results. From the population-based, case-control, Women's Environmental, Cancer and Radiation Epidemiology (WECARE) Study, we included 511 women with CBC (cases) and 999 women with unilateral breast cancer (controls) who had never used postmenopausal hormone therapy. Rate ratios (RR) and 95% confidence intervals (CI) were used to assess the relationship between BMI and CBC risk. No associations between BMI at first diagnosis or weight-change between first diagnosis and date of CBC diagnosis (or corresponding date in matched controls) and CBC risk were seen. However, obese (BMI ≥ 30 kg/m(2)) postmenopausal women with estrogen receptor (ER)-negative first primary tumors (n = 12 cases and 9 controls) were at an increased risk of CBC compared with normal weight women (BMI < 25 kg/m(2)) (n = 43 cases and 98 controls) (RR = 5.64 (95% CI 1.76, 18.1)). No association between BMI and CBC risk was seen in premenopausal or postmenopausal women with ER-positive first primaries. Overall, BMI is not associated with CBC risk in this population of young breast cancer survivors. Our finding of an over five-fold higher risk of CBC in a small subgroup of obese postmenopausal women with an ER-negative first primary breast cancer is based on limited numbers and requires confirmation in a larger study.
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Affiliation(s)
- Jennifer D Brooks
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 307 E 63rd Street, 3rd Floor, New York, NY, USA.
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Bilateral breast cancer: analysis of incidence, outcome, survival and disease characteristics. Breast Cancer Res Treat 2010; 126:131-40. [DOI: 10.1007/s10549-010-1057-y] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 07/08/2010] [Indexed: 11/26/2022]
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Yao K, Stewart AK, Winchester DJ, Winchester DP. Trends in Contralateral Prophylactic Mastectomy for Unilateral Cancer: A Report From the National Cancer Data Base, 1998–2007. Ann Surg Oncol 2010; 17:2554-62. [DOI: 10.1245/s10434-010-1091-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Indexed: 11/18/2022]
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Bernstein JL, Haile RW, Stovall M, Boice JD, Shore RE, Langholz B, Thomas DC, Bernstein L, Lynch CF, Olsen JH, Malone KE, Mellemkjaer L, Borresen-Dale AL, Rosenstein BS, Teraoka SN, Diep AT, Smith SA, Capanu M, Reiner AS, Liang X, Gatti RA, Concannon P. Radiation exposure, the ATM Gene, and contralateral breast cancer in the women's environmental cancer and radiation epidemiology study. J Natl Cancer Inst 2010; 102:475-83. [PMID: 20305132 DOI: 10.1093/jnci/djq055] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Ionizing radiation is a known mutagen and an established breast carcinogen. The ATM gene is a key regulator of cellular responses to the DNA damage induced by ionizing radiation. We investigated whether genetic variants in ATM play a clinically significant role in radiation-induced contralateral breast cancer in women. METHODS The Women's Environmental, Cancer, and Radiation Epidemiology Study is an international population-based case-control study nested within a cohort of 52,536 survivors of unilateral breast cancer diagnosed between 1985 and 2000. The 708 case subjects were women with contralateral breast cancer, and the 1397 control subjects were women with unilateral breast cancer matched to the case subjects on age, follow-up time, registry reporting region, and race and/or ethnicity. All women were interviewed and underwent full mutation screening of the entire ATM gene. Complete medical treatment history information was collected, and for all women who received radiotherapy, the radiation dose to the contralateral breast was reconstructed using radiotherapy records and radiation measurements. Rate ratios (RRs) and corresponding 95% confidence intervals (CIs) were estimated by using multivariable conditional logistic regression. All P values are two-sided. RESULTS Among women who carried a rare ATM missense variant (ie, one carried by <1% of the study participants) that was predicted to be deleterious, those who were exposed to radiation (mean radiation exposure = 1.2 Gy, SD = 0.7) had a statistically significantly higher risk of contralateral breast cancer compared with unexposed women who carried the wild-type genotype (0.01-0.99 Gy: RR = 2.8, 95% CI = 1.2 to 6.5; > or =1.0 Gy: RR = 3.3, 95% CI = 1.4 to 8.0) or compared with unexposed women who carried the same predicted deleterious missense variant (0.01-0.99 Gy: RR = 5.3, 95% CI = 1.6 to 17.3; > or =1.0 Gy: RR = 5.8, 95% CI = 1.8 to 19.0; P(trend) = .044). CONCLUSIONS Women who carry rare deleterious ATM missense variants and who are treated with radiation may have an elevated risk of developing contralateral breast cancer. However, the rarity of these deleterious missense variants in human populations implies that ATM mutations could account for only a small portion of second primary breast cancers.
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Affiliation(s)
- Jonine L Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 307 E 63rd St Fl 3, New York, NY 10065, USA
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Reding KW, Bernstein JL, Langholz BM, Bernstein L, Haile RW, Begg CB, Lynch CF, Concannon P, Borg A, Teraoka SN, Törngren T, Diep A, Xue S, Bertelsen L, Liang X, Reiner AS, Capanu M, Malone KE. Adjuvant systemic therapy for breast cancer in BRCA1/BRCA2 mutation carriers in a population-based study of risk of contralateral breast cancer. Breast Cancer Res Treat 2010; 123:491-8. [PMID: 20135344 DOI: 10.1007/s10549-010-0769-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 01/22/2010] [Indexed: 01/26/2023]
Abstract
Given the greatly elevated risks of contralateral breast cancer (CBC) observed in breast cancer patients who carry mutations in BRCA1 and BRCA2, it is critical to determine the effectiveness of standard adjuvant therapies in preventing CBC in mutation carriers. The WECARE study is a matched, case-control study of 708 women with CBC as cases and 1,399 women with unilateral breast cancer (UBC) as controls, including 181 BRCA1/BRCA2 mutation carriers. Interviews and medical record reviews provided detailed information on risk factors and breast cancer therapy. All study participants were screened for BRCA1 and BRCA2 mutations using denaturing high-performance liquid chromatography (DHPLC) to detect genetic variants in the coding and flanking regions of the genes. Conditional logistic regression was used to compare the risk of CBC associated with chemotherapy and tamoxifen in BRCA1/BRCA2 mutation carriers and non-carriers. Chemotherapy was associated with lower CBC risk both in non-carriers (RR = 0.6 [95% CI: 0.5-0.7]) and carriers (RR = 0.5 [95% CI: 0.2-1.0]; P value = 0.04). Tamoxifen was associated with a reduced CBC risk in non-carriers (RR = 0.7 [95% CI: 0.6-1.0]; P value = 0.03). We observed a similar but non-significant reduction associated with tamoxifen in mutation carriers (RR = 0.7 [95% CI: 0.3-1.8]). The tests of heterogeneity comparing carriers to non-carriers did not provide evidence for a difference in the associations with chemotherapy (P value = 0.51) nor with tamoxifen (P value = 0.15). Overall, we did not observe a difference in the relative risk reduction associated with adjuvant treatment between BRCA1/BRCA2 mutation carriers and non-carriers. However, given the higher absolute CBC risk in mutation carriers, the potentially greater impact of adjuvant therapy in reducing CBC risk among mutation carriers should be considered when developing treatment plans for these patients.
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Affiliation(s)
- Kerryn W Reding
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Mail Stop M4-B874, Seattle, WA 98109-1024, USA.
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Rubino C, Arriagada R, Delaloge S, Lê MG. Relation of risk of contralateral breast cancer to the interval since the first primary tumour. Br J Cancer 2010; 102:213-9. [PMID: 19920826 PMCID: PMC2813760 DOI: 10.1038/sj.bjc.6605434] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 10/06/2009] [Accepted: 10/17/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is no consensus on how to separate contralateral breast cancer (CBC) occurring as distant spread of the primary breast cancer (BC) from an independent CBC. METHODS We used standardised incidence ratios (SIRs) to analyse the variations in the risk of CBC over time among 6629 women with BC diagnosed between 1954 and 1983. To explore the most appropriate cutoff to separate the two types of CBC, we analysed the deviance between models including different cutoff points as compared with the basal model with no cutoff date. We also performed a prognostic study through a Cox model. RESULTS The SIR was much higher during the first 2 years of follow-up than afterwards. The best cutoff appeared to be 2 years. The risk of early CBC was linked to tumour spread and the risk of late CBC was linked to age and to the size of the tumour. Radiotherapy was not selected by the model either for early or late CBC risk. CONCLUSION A clearer pattern of CBC risk might appear if studies used a similar cutoff time after the initial BC.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnosis
- Breast Neoplasms/epidemiology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/secondary
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Combined Modality Therapy
- Diagnosis, Differential
- Female
- Follow-Up Studies
- Humans
- Incidence
- Lymphatic Irradiation
- Mastectomy
- Middle Aged
- Neoplasms, Multiple Primary/diagnosis
- Neoplasms, Multiple Primary/epidemiology
- Neoplasms, Radiation-Induced/epidemiology
- Neoplasms, Second Primary/diagnosis
- Neoplasms, Second Primary/epidemiology
- Prognosis
- Proportional Hazards Models
- Radiotherapy/adverse effects
- Radiotherapy Dosage
- Risk
- Time Factors
- Young Adult
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Affiliation(s)
- C Rubino
- Institut National de la Santé et de la Recherche Médicale (INSERM), Unit 605, Villejuif Cedex 94805, France.
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63
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Aleskandarany MA, Green AR, Rakha EA, Mohammed RA, Elsheikh SE, Powe DG, Paish EC, Macmillan RD, Chan S, Ahmed SI, Ellis IO. Growth fraction as a predictor of response to chemotherapy in node-negative breast cancer. Int J Cancer 2010; 126:1761-9. [DOI: 10.1002/ijc.24860] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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64
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Alkner S, Bendahl PO, Fernö M, Nordenskjöld B, Rydén L. Tamoxifen reduces the risk of contralateral breast cancer in premenopausal women: Results from a controlled randomised trial. Eur J Cancer 2009; 45:2496-502. [PMID: 19535242 DOI: 10.1016/j.ejca.2009.05.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 04/27/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adjuvant treatment with tamoxifen reduces the risk of contralateral breast cancer in hormone-responsive postmenopausal patients, whereas the effect in premenopausal women has not been fully elucidated. We have therefore studied the effect of tamoxifen on contralateral breast cancer in premenopausal women in a controlled randomised trial. PATIENTS AND METHODS Premenopausal women (564) with stage II breast cancers were randomised to 2 years of tamoxifen versus control irrespective of oestrogen receptor (ER) and progesterone receptor (PgR) status. The median follow-up for patients not developing a contralateral cancer was 14 years. RESULTS In the control group 35 women, and in the tamoxifen group 17 women, developed a contralateral breast cancer as a primary event. Tamoxifen significantly reduced the risk of contralateral breast cancer in all women regardless of age (hazard ratio (HR) 0.5, p=0.02). In subgroup analysis the risk reduction was most pronounced in patients <40 years of age (HR 0.09, p=0.02). A risk reduction was also seen in women 40-49 years of age or 50 years of age, although in these subgroups this did not reach statistical significance. The reduced risk of contralateral breast cancer was persistent during the whole follow-up time. CONCLUSION In this randomised trial, adjuvant treatment using tamoxifen for 2 years reduced the incidence of contralateral breast cancer by 50% in all premenopausal women, and by 90% in women <40 years of age. The effect of tamoxifen was not significantly dependent on time.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Clinical Sciences, Lund, Sweden
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65
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Contralateral mastectomy in patients treated for unilateral breast cancer. CURRENT BREAST CANCER REPORTS 2009. [DOI: 10.1007/s12609-009-0015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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66
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Age-specific incidence of breast cancer in breast cancer survivors and their first-degree relatives. Epidemiology 2009; 20:175-80. [PMID: 19057388 DOI: 10.1097/ede.0b013e318190eee6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The incidence rate of breast cancer in first-degree relatives of women with breast cancer has been hypothesized to become constant at a predetermined age in accordance with observations of a high, roughly constant incidence rate of contralateral breast cancer by age. We attempted to test this hypothesis in the Danish population with cancer registry data. METHODS We determined the age-specific incidence rates of contralateral breast cancer in Danish women who had a first breast cancer before they were 50 years of age and the rates of breast cancer among their first-degree female relatives during 1943 to 1999. The observed rates were tested for trends chi test or evaluated in Cox proportional hazard models. RESULTS A high incidence rate of contralateral breast cancer was observed in women aged 25-44 years, followed by a decreasing rate, which reached a level corresponding to the rate per breast in the general female population at age 65. At ages older than the index patients age at diagnosis, their first-degree female relatives showed significantly increasing incidence rates of breast cancer by age, with a relatively constant absolute difference of 187 breast cancers per 100,000 person-years between the observed rates and the expected rates. CONCLUSION The rate of contralateral breast cancer is particular high at young ages but the excess ebbs as the cohort ages, perhaps due to elimination of predisposed individuals at early ages from the cohort of survivors. First-degree relatives seem to share breast cancer susceptibility genes with the family proband resulting in a constant excess rate of breast cancer throughout life.
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67
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Knight JA, Bernstein L, Largent J, Capanu M, Begg CB, Mellemkjaer L, Lynch CF, Malone KE, Reiner AS, Liang X, Haile RW, Boice JD, Bernstein JL. Alcohol intake and cigarette smoking and risk of a contralateral breast cancer: The Women's Environmental Cancer and Radiation Epidemiology Study. Am J Epidemiol 2009; 169:962-8. [PMID: 19211621 DOI: 10.1093/aje/kwn422] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Women with primary breast cancer are at increased risk of developing second primary breast cancer. Few studies have evaluated risk factors for the development of asynchronous contralateral breast cancer in women with breast cancer. In the Women's Environmental Cancer and Radiation Epidemiology Study (1985-2001), the roles of alcohol and smoking were examined in 708 women with asynchronous contralateral breast cancer (cases) compared with 1,399 women with unilateral breast cancer (controls). Cases and controls aged less than 55 years at first breast cancer diagnosis were identified from 5 population-based cancer registries in the United States and Denmark. Controls were matched to cases on birth year, diagnosis year, registry region, and race and countermatched on radiation treatment. Risk factor information was collected by telephone interview. Rate ratios and 95% confidence intervals were estimated by using conditional logistic regression. Ever regular drinking was associated with an increased risk of asynchronous contralateral breast cancer (rate ratio = 1.3, 95% confidence interval: 1.0, 1.6), and the risk increased with increasing duration (P = 0.03). Smoking was not related to asynchronous contralateral breast cancer. In this, the largest study of asynchronous contralateral breast cancer to date, alcohol is a risk factor for the disease, as it is for a first primary breast cancer.
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Affiliation(s)
- Julia A Knight
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada.
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68
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What is the current status of ovarian suppression/ablation in women with premenopausal early-stage breast cancer? Curr Oncol Rep 2009; 11:45-50. [PMID: 19080741 DOI: 10.1007/s11912-009-0008-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The role of ovarian suppression/ablation (OS/OA) in premenopausal women with hormone receptor-positive breast cancer has been evolving for more than a century. It is clear that OS/OA is an effective adjuvant therapy for these women, but despite numerous studies enrolling thousands of women, many unanswered questions remain. In particular, a major question is whether additional benefit is gained with combination treatment comprising luteinizing hormone-releasing hormone (LH-RH) agonists and tamoxifen over tamoxifen alone. Ongoing trials also are assessing the coupling of aromatase inhibitors (traditionally contraindicated in these patients because of paradoxic stimulation of estrogen production) and LH-RH agonists. Any potential disease-free or overall survival advantage of combination treatment must be balanced against a possible increase in adverse effects and impairment of quality of life. This review focuses on new data on how to incorporate OS/OA into the rational treatment of this challenging patient population.
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69
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What is the current status of ovarian suppression/ablation in women with premenopausal early-stage breast cancer? CURRENT BREAST CANCER REPORTS 2009. [DOI: 10.1007/s12609-009-0006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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70
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Yerushalmi R, Kennecke H, Woods R, Olivotto IA, Speers C, Gelmon KA. Does multicentric/multifocal breast cancer differ from unifocal breast cancer? An analysis of survival and contralateral breast cancer incidence. Breast Cancer Res Treat 2008; 117:365-70. [PMID: 19082705 DOI: 10.1007/s10549-008-0265-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 11/25/2008] [Indexed: 01/13/2023]
Abstract
Purpose we evaluated whether patients with multifocal/multicentric (M/M) breast cancer have different outcomes compared to unifocal (U) disease in terms of survival and the development of contralateral breast cancer (CBC) disease. Methods women diagnosed with stage I-III breast cancer were classified as having U or M/M disease. Prognostic factors were prospectively collected and obtained from the breast cancer outcome unit database. Univariate and multivariable analyses for the incidence of CBC were performed as well as Kaplan-Meier plots. Results 25,320 women met inclusion criteria. The 5-year cumulative incidence of CBC in the U versus M/M group was 2.3% (95% CI 2.1, 2.5) versus 2.4% (95% CI 1.6, 3.4) (P = 0.349). Breast cancer specific survival (BCSS) rate revealed a slightly worse outcome with M/M disease, RR = 1.174 (95% CI 1,004, 1.372). Conclusions M/M breast cancer did not increase the risk of metachronous CBC, but was associated with inferior BCSS.
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Affiliation(s)
- Rinat Yerushalmi
- Division of Medical Oncology, British Columbia Cancer Agency, 600 w 10th Avenue, Vancouver, BC, Canada V5Z 4E6.
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Hooning MJ, Aleman BMP, Hauptmann M, Baaijens MHA, Klijn JGM, Noyon R, Stovall M, van Leeuwen FE. Roles of radiotherapy and chemotherapy in the development of contralateral breast cancer. J Clin Oncol 2008; 26:5561-8. [PMID: 18854572 DOI: 10.1200/jco.2007.16.0192] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Few studies have examined whether modern radiotherapy and chemotherapy affect the risk of contralateral breast cancer (CBC), and results are inconclusive. PATIENTS AND METHODS We assessed long-term risk of CBC in a predominantly young breast cancer (BC) population (n = 7,221), focusing on the effects of radiation dose, chemotherapy, and family history of BC. Risk of CBC was evaluated using Cox proportional hazards regression models. RESULTS Radiotherapy-associated risk of CBC increased with decreasing age at first treatment (age < 35 years, hazard ratio [HR] = 1.78; 95% CI, 0.85 to 3.72; age > 45 years, HR = 1.09; 95% CI, 0.82 to 1.45). Postmastectomy radiotherapy using direct electron fields led to a significantly lower radiation exposure to the contralateral breast than postlumpectomy radiotherapy using tangential fields. Women treated before age 45 years with postlumpectomy radiotherapy experienced 1.5-fold increased risk of CBC compared with those who had postmastectomy radiotherapy. The joint effects of postlumpectomy radiotherapy and strong family history for BC on risk of CBC were greater than expected when individual risks were summed (HR = 3.52; 95% CI, 2.07 to 6.02; P(departure from additivity) = .043). Treatment with adjuvant chemotherapy (cyclophosphamide, methotrexate, and fluorouracil) was associated with a nonsignificantly decreased risk of CBC in the first 5 years of follow-up but did not reduce CBC risk in subsequent years. CONCLUSION Young patients with BC irradiated with breast tangentials experience increased risk of CBC, especially in those with a positive family history of BC. This finding should be taken into account when advising breast radiation with tangential fields to young patients with BC. Adjuvant chemotherapy seemed to reduce the risk of CBC during the first 5 years after treatment only.
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Affiliation(s)
- Maartje J Hooning
- Department of Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
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