Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort

Estrogen affects post-menopausal women differently than estrogen plus progestin replacement therapy

BACKGROUND

In the Women's Health Initiative Randomized Controlled Trial (WHI RCT), estrogen-only treatment compared with combined estrogen-progestin treatment resulted in less coronary artery disease, no increase in breast cancer and no reduction in colorectal cancer. Since we previously reasonably replicated the combined estrogen-progestin WHI RCT using the UK General Practice Research Database (GPRD), estrogen-only treatment was investigated using a similar methodology.

METHODS

This GPRD study simulated the estrogen-only WHI RCT of women who had undergone a hysterectomy except for randomization. The primary analysis examined 11 572 unexposed and 6890 Exposed women (aged 55-79) treated with conjugated equine estrogen and was compared with the combined estrogen-progestin GPRD study.

RESULTS

At baseline, women with a hysterectomy exhibited more cardiovascular disease than those with an intact uterus. In the estrogen-only GPRD study, adjusted hazard ratios (HRs) were 0.50 (0.38-0.67) for myocardial infarction (MI), 1.13 (0.91-1.41) for breast cancer, and 1.18 (0.72-1.92) for colorectal cancer. Compared to the HRs in the estrogen-progestin GPRD study, the estrogen-only results are significantly lower for MI and breast cancer and higher for colon cancer, a pattern similar to the WHI RCT study comparisons.

CONCLUSIONS

This study confirms that post-menopausal women in the overall population respond differently to estrogen-only treatment compared with estrogen-progestin treatment, due to different hormone regimens and/or increased cardiovascular disease in hysterectomized women.

Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study

Large numbers of hormone replacement therapies (HRTs) are available for the treatment of menopausal symptoms. It is still unclear whether some are more deleterious than others regarding breast cancer risk. The goal of this study was to assess and compare the association between different HRTs and breast cancer risk, using data from the French E3N cohort study. Invasive breast cancer cases were identified through biennial self-administered questionnaires completed from 1990 to 2002. During follow-up (mean duration 8.1 postmenopausal years), 2,354 cases of invasive breast cancer occurred among 80,377 postmenopausal women. Compared with HRT never-use, use of estrogen alone was associated with a significant 1.29-fold increased risk (95% confidence interval 1.02-1.65). The association of estrogen-progestagen combinations with breast cancer risk varied significantly according to the type of progestagen: the relative risk was 1.00 (0.83-1.22) for estrogen-progesterone, 1.16 (0.94-1.43) for estrogen-dydrogesterone, and 1.69 (1.50-1.91) for estrogen combined with other progestagens. This latter category involves progestins with different physiologic activities (androgenic, nonandrogenic, antiandrogenic), but their associations with breast cancer risk did not differ significantly from one another. This study found no evidence of an association with risk according to the route of estrogen administration (oral or transdermal/percutaneous). These findings suggest that the choice of the progestagen component in combined HRT is of importance regarding breast cancer risk; it could be preferable to use progesterone or dydrogesterone.

Oral progestagens before menopause and breast cancer risk

We examined the relationship between use of progestagen-only before menopause (except for mini-pills) after the age of 40 and invasive breast cancer risk in 73 664 women from the French E3N cohort study (mean age at start of follow-up, 51.8 years; mean duration of follow-up, 9.1 years). A total of 2390 cases of invasive breast cancer were diagnosed during follow-up. Risk estimates were calculated using the Cox proportional hazard model. Overall, ever use of progestagen before menopause was not significantly associated with risk (relative risk (RR): 1.01, 95% confidence interval: 0.93-1.11). However, we observed a significant increase in risk associated with the duration of use (P-value for trend: 0.012), current use of progestagens for longer than 4.5 years being significantly associated with risk (RR: 1.44, 95% confidence interval: 1.03-2.00). Prolonged use of progestagens after the age of 40 may be associated with an increased risk of breast cancer and the subject needs to be investigated further.

Current breast cancer risks of hormone replacement therapy in postmenopausal women

The controversies surrounding hormone replacement therapy have left many women confused and afraid. Providers have been faced with long-standing assumptions challenged by an abundance of new data in the past few years, with little guidance on how to interpret these findings. The objective of this paper is to provide a framework for understanding breast cancer risk associated with postmenopausal hormone replacement therapy, with a particular focus on how observational studies and randomised trials provide complementary information. This framework considers the data on risks of various hormonal preparations, the profiles of women at risk, and ends with an expert opinion in this context.

Hormone replacement therapy and breast cancer in former users of oral contraceptives—The Norwegian Women and Cancer study

Combined estrogen-progestin menopausal therapy (HRT) and combined estrogen-progestin contraceptives (OC) both increase breast cancer risk during current use and a few years after. We investigated risk of breast cancer in women who were users of HRT dependant on former history of OC use in a large, national population-based cohort study, the Norwegian Women and Cancer study (NOWAC). Exposure information was collected through postal questionnaires. Based on follow-up of 30,118 postmenopausal women by linkage to national registers of cancer, deaths, and emigration we revealed 540 incident breast cancer cases between 1996 and 2004. Compared to never users of either drugs current use of HRT gave a significant (p = 0.002) higher risk of breast cancer in former OC users, RR = 2.45 (95% CI 1.92-3.12), than among never users of OCs, RR = 1.67 (1.32-2.12). Relative risk of current use of HRT was similar for estrogen only and combinations with progestin added in ever users of OCs. The increased risk of breast cancer in current HRT users with a history of former OC use could have potential great impact on postmenopausal breast cancer risk as the proportion of postmenopausal women with former OC use will continue to increase.

New products and regimens (since 2003)

The downturn in the use of hormone replacement therapy since the original publication of the Women's Health Initiative (2002) and Million Women studies (2003) has now stabilized. New products are now being developed which maintain benefits and minimise risks. However, some useful products have been withdrawn by Pharma companies through profitability decisions; other products will regrettably not be launched despite favorable data. New low- and ultra-low-dose oral preparations (containing 0.3 mg conjugated equine estrogens and 0.5 mg estradiol, respectively) appear to maintain benefits for symptom relief and osteoporosis whilst minimizing side-effects and risks. A 14 microg transdermal system appears to maintain bone protection without the need for endometrial protection. New progestogens can minimize progestogenic side-effects through antiandrogenic and antimineralocorticoid effects, e.g. drospirenone, bioidentical progesterone and selective progesterone receptor modulators. A new female androgen patch has been licensed in Europe for treatment of low libido causing distress (hypoactive sexual desire disorder) in surgically menopaused women on estrogen therapy. A non-hormonal option, desvenlafaxine succinate (a serotonin and noradrenaline reuptake inhibitor), for vasomotor symptoms is currently in phase-III clinical trial stage and should be launched in the next year. Additionally, a selective estrogen receptor modulator/conjugated equine estrogen preparation combination currently in phase-III clinical trials is showing encouraging data for efficacy/risks and should provide a further option for women using hormone therapy in the future.

Breast response to menopausal hormone therapy--aspects on proliferation, apoptosis and mammographic density

Breast cancer is the major malignancy among women in the Western world. The breast is clearly a target organ for sex steroid hormones and hormonal treatments have been associated with an increased risk of breast cancer. The balance between proliferation and apoptosis is important for breast cell homeostasis. Mammographic breast density has been identified as a strong and independent risk factor for breast cancer. It seems clear that there is a difference between various hormonal treatments with regard to their effects on breast density and cell proliferation. Also, not all women respond similarly to the same treatment. Combined estrogen and progestogen therapy generally will enhance density and proliferation more than treatment with estrogen alone. Certain constitutional and hormonal factors appear to be predictive of breast reactivity. Older women with a low body mass index respond more strongly to treatment. Estrogen levels have a positive and androgens a negative association to increase in density and proliferation. A combination of increased proliferation and decreased apoptosis could be one mechanism to explain the excess risk of breast cancer during combined estrogen/progestogen treatment. Tibolone seems to have less impact on breast response than conventional hormone therapy. Efforts should be made to identify those women with an adverse response to treatment as well as therapeutic principles with the least possible influence on the breast.

[Hormone replacement therapy for internal risk patients]

Using hormone replacement therapy (HRT), absolute and relative contradictions have to be considered, which are primarily classified according to a "worst case" scenario on the assumption of group effects, in order to satisfy forensic demands. However, in patients with severe complaints it make sense to apply HRT even at increased risk. To minimize the risk, a differentiated choice of the preparation especially in terms of progestin component and application mode is feasible apart from a general dose reduction. For internal risk patients, transdermal estradiol in a patch or gel and neutral progestins like progesterone and dydrogesterone or combination patches for a completely transdermal HRT are to be preferred. In the Women's Health Initiative, a study investigating a population strongly burdened with cardiovascular risks, the most important risks were venous thromboses and strokes, in old age also myocardial infarctions. In this context, the risk groups with diabetes, hypertension and dyslipoproteinemia as well as smokers in general are of particular importance. Other common internal risk groups comprise women with thyroid and hepatobiliary diseases. Rare but prognostically important diseases such as porphyria and lupus erythematosus are considered as relative contraindications. The available data on these risk groups are described and practical recommendations are given.

Menopause: evidence-based practice

Menopause is a physiologic transition and is assuming an increasing importance as the demographic bulge moves through this phase. The transition takes place over several years. It is characterized by depletion of the ovarian follicles, decreasing inhibin leading to increases in follicle-stimulating hormone and loss of the menstrual cycle, accompanied by decreased estradiol production and typical symptoms. The role of hormone therapy in menopause has shifted from preventive use to a limited role in symptom management, for which it remains the most effective intervention. There is good evidence from observational and randomized trials of an increased risk of breast cancer in women on estrogen plus a progestin, compared with those on estrogen alone. There are insufficient data to be able to determine if there are clinically important differences between various progestins and progesterone with respect to breast cancer risk, nor between different regimens. Even relatively short-term exposure to unopposed estrogen will increase the risk of atypical endometrial hyperplasia or cancer; women who have their uterus should be using a progestational agent. Lifestyle changes at menopause are important and effective for preventive health. Recent evidence suggests that the discordance between epidemiologic studies with respect to cardiovascular outcomes and the Women's Health Initiative randomized controlled trial (WHI RCT) data might be attributable in large part to the older age of women enrolled in the WHI.

Breast Cancer Risk in Postmenopausal Women Using Estrogen-Only Therapy

OBJECTIVE

To evaluate whether the risk of estrogen-only therapy on breast cancer varies by dose, constituent, and route of administration.

METHODS

All Finnish women older than age 50 years using oral or transdermal estradiol (n=84,729), oral estriol (n=7,941), or vaginal estrogens (n=18,314) for at least 6 months during 1994-2001 were identified from the national medical reimbursement register. They were followed for breast cancer with the aid of the Finnish Cancer Registry to the end of 2002.

RESULTS

Altogether, 2,171 women with breast cancer were identified. The standardized incidence ratio of breast cancer with systemic estradiol for less than 5 years was 0.93 (95% confidence interval 0.80-1.04), and for estradiol use for 5 years or more, 1.44 (1.29-1.59). Oral and transdermal estradiol was accompanied by a similar risk of breast cancer. The risk was most prominent with the dose greater than 1.9 mg/d orally; whereas the risk associated with transdermal route was not dose-dependent. The standardized incidence ratio for the lobular type of breast cancer (1.58) was slightly higher than that for the ductal type (1.36). The use of estradiol was associated with both localized breast cancer (1.45; 1.26-1.66) and cancer spread to regional nodes (1.35; 1.09-1.65). The incidence of carcinoma in situ (n=32) was increased (2.43; 1.66-3.42) among estradiol users.

CONCLUSION

Estradiol for 5 years or more, either orally or transdermally, means 2-3 extra cases of breast cancer per 1,000 women who are followed for 10 years. Oral estradiol use for less than 5 years, oral estriol, or vaginal estrogens were not associated with a risk of breast cancer.

LEVEL OF EVIDENCE

II-2.

Bioavailability and urinary excretion of isoflavones in humans: effects of soy-based supplements formulation and equol production

Soy isoflavones (IF) are of particular interest for their possible estrogenic effects on the symptoms of menopause. The bioavailability of IF is clearly a factor influencing their biological activity. The first aim of this study was to elucidate the impact of the matrix process and especially the formulation of soy-based capsules on IF bioavailability. Twelve healthy volunteers were recruited for a randomized, double-blind, two-way crossover trial and received a single dose of the two soy-based formulations, one containing a pure soy standardized extract of IF, and the other containing soy flour in addition to the standardized extract of IF. Using a new and validated ELISA method, we measured the plasma and urinary concentrations of genistein, daidzein and its metabolite equol. Based on European Medicine Evaluation Agency recommendations, the main pharmacokinetic parameters allowed us to demonstrate the bioequivalence of the two formulations, indicating that the presence or absence of soy flour did not alter either the absorption or the elimination of daidzein and genistein. As bioequivalence was demonstrated, we pooled data collected during the two study-periods to address another original issue: Did the ability to produce equol affect the bioavailability of daidzein? We demonstrated that daidzein excretion was significantly lower in equol producers compared with equol non producers over the entire elimination period of the soy IF. This difference disappeared when equol excretion was added to daidzein excretion in equol producers. Our results indicated that the production of equol could partly explain the difference in daidzein bioavailability after IF ingestion.

Place du traitement hormonal substitutif dans la prise en charge de l’ostéoporose postménopausique et la prévention du risque fracturaire

The consequences to the bone of estrogen deficiency are early and irreversible. Effective prevention of postmenopausal osteoporosis at the individual level requires early screening of women at risk of fractures and their early treatment. Hormone treatment prevents bone loss and has been proven effective in preventing fractures, even in situations of low risk. The benefit/risk ratio of hormone treatment can be optimized by the choice of the 'right moment' and the 'right treatment'. HRT, administered early and for a limited period, must be integrated into a strategy of long-term osteoporosis prevention that includes using the (drug and nondrug) means most appropriate to the patient's age and clinical condition and choosing the 'right moment' and 'right treatment.'

Breast cancer risk associated with different HRT formulations: a register-based case-control study

Background

Previous epidemiological studies have inconsistently shown a modestly increased breast cancer risk associated with hormone replacement therapy (HRT). Limited information is available about different formulations – particularly concerning different progestins.

Methods

A case-control study was performed within Germany in collaboration with regional cancer registries and tumor centers. Up to 5 controls were matched breast cancer cases. Conditional logistic regression analysis was applied to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI). Stratified analyses were performed to compare the risk of different estrogens, progestins, and combinations.

Results

A total of 3593 cases of breast cancer were identified and compared with 9098 controls. The adjusted overall risk estimate for breast cancer (BC) associated with current or past use of HRT was 1.2 (1.1–1.3), and almost identical for lag times from 6 months to 6 years prior to diagnosis. No significant trend of increasing BC risk was found with increasing duration of HRT use, or time since first or last use in aggregate. Many established BC risk factors significantly modified the effect of HRT on BC risk, particularly first-degree family history of BC, higher age, lower education, higher body mass index (BMI), and never having used oral contraceptives (OCs) during lifetime.

Whereas the overall risk estimates were stable, the numbers in many of the sub-analyses of HRT formulation groups (estrogens, progestins, and combinations) were too small for strong conclusions. Nevertheless, the BC risk seems not to vary much across HRT formulation subgroups. In particular, no substantial difference in BC risk was observed between HRT containing conjugated equine estrogens (CEE) or medroxyprogesterone acetate (MPA) and other formulations more common in Europe.

Conclusion

The BC risk of HRT use is rather small. Low risk estimates for BC and a high potential for residual confounding and bias in this observational study do not permit causal conclusions. Apparently, there is not much variation of the BC risk across HRT formulations (estrogens, progestins). However, the small numbers and the overlapping nature of some of the subgroups suggest cautious interpretation.

Breast cancer in postmenopausal women with and without hormone replacement therapy: preliminary results of the MISSION study

OBJECTIVES

To determine breast cancer prevalence in postmenopausal women with or without hormone replacement therapy (HRT).

PATIENTS AND METHODS

This was a historical-prospective study with random patient selection. Patients were recruited between January 2004 and February 2005, and allocated to two groups: the 'treated group' comprising postmenopausal women on HRT regimens commonly prescribed in France or who had stopped <5 years previously; or the 'untreated group' of postmenopausal women who had never received HRT or stopped >5 years previously.

RESULTS

In total 6755 patients fulfilled all inclusion criteria: 3383 in the treated group and 3372 in the untreated group. The treated group was younger and less overweight than the untreated group (p < 0.0001). The treated group had fewer late menopauses (p = 0.0002) and fewer first-degree family histories of breast cancer (p < 0.0001). Mean HRT duration was 7.9 years; 30.5% of women were treated for >or=10 years. Breast cancer prevalence was 1.01% for the treated group and 6.21% for the untreated group. The European standardized incidence rate of breast cancer in the untreated group was significantly higher than in the French reference population (comparative incidence figure ratio (CIFR) = 2.24; 95% confidence interval (CI) = 1.50-3.36). In contrast, the European standardized incidence rate in the treated group on the studied HRT regimens (excluding some progestins) was not significantly different from that of the reference population (CIFR = 1.04; 95% CI = 0.35-3.15).

CONCLUSION

The differences between the two groups may be due to French gynecologists' treatment strategy of avoiding prescribing HRT to high-risk women, and also perhaps to a specific 'studied HRT' effect.

Incidences and Trends of Second Cancers in Female Breast Cancer Patients: A Fixed Inception Cohort-based Analysis (United States)

OBJECTIVE

To determine incidences and time trends of second cancers among female breast cancer patients.

METHODS

Using data of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we designed three inception cohorts: 1975-1977 (n=25,920), 1983-1985 (n=32,722) and 1991-1993 (n=40,819), and analyzed their incidences of second cancers during the first 8 years after initial breast cancer diagnosis.

RESULTS

Between the 1970s and the 1990s, the incidence rate of malignant second cancer significantly increased among female breast cancer patients, of which second non-Hodgkin's lymphoma and kidney cancer increased by about 150%, while second cancers of the thyroid, uterine corpus and skin melanoma increased 80%, and cancer of the lung increased 50%. The patterns of trend of second cancers were somewhat similar to those of the general population except for second endometrial cancer at all ages and second leukemia and skin melanoma among young patients aged 20-49. In the 1990s, the risk ratios (RR) of all sites cancer were found to be 5.5 (95% CI=5.0-6.1) for age 20-49, 1.3 (1.3-1.4) for age 50-64, and 1.2 (1.1-1.2) for age 65 and over, comparing breast cancer patients to general population. Additionally, radiotherapy slightly increased the risks of second leukemia (RR=1.8, 1.2-2.8), and second endometrial (RR=1.3, 1.0-1.6) and breast (RR=1.2, 1.1-1.3) cancers.

CONCLUSIONS

The fixed inception cohort method is valid for analyzing cancer registry-based second cancer data. By this method, we found that the incidence of second cancer has substantially increased among female breast cancer patients over the past 25 years. Observed changes in incidence may partially reflect the effect of treatments. Because the absolute number of affected patients is small, however, the breast cancer treatments have remained safe for most patients.

Propensity of gynaecologists towards osteoporosis management and treatment

BACKGROUND

Regulation authorities have recently advised against the use of hormone replacement therapy (HRT) as a first choice treatment for postmenopausal osteoporosis, modifying the past consensus.

AIM

Analyse the sensibility to and prescription attitude for osteoporosis.

SETTING

Survey.

POPULATION

Belgian gynaecologists.

METHODS

Case construction: two cases to assess whether gynaecologists are prone to detect osteoporosis, and six others to evaluate their prescription attitude for osteoporosis.

RESULTS

About 80% of the physicians would prescribe a bone mineral density measurement (BMD) to a 66-year-old, non HRT user. About 60% prescribed calcium and Vitamin D when the BMD was normal, 90% would prescribe it when the BMD showed osteopenia or osteoporosis (p < 0.001). Few prescribed HRT (< 25%). Few advised SERMS for normal BMD, 19%-47% prescribed it in osteopenia or osteoporosis (p < 0.001). Few considered a biphosphonate in normal BMD, or osteopenia in the absence of risk factors, 25% considered it in osteopenia in the presence of risk factors, and 80% in osteoporosis (p < 0.001).

CONCLUSION

Most gynaecologists are aware of the osteoporosis problem. They often screen non HRT users and in the event of osteoporosis, they initiate a specific treatment, not HRT, but generally a combination of calcium, Vitamin D and biphosphonates.

Skin climacteric aging and hormone replacement therapy

A gender perspective is indispensable for a full understanding of aging. Menopause is a turning point in women's lives. In addition to the effects of chronological aging, sunlight exposure, and other environmental and endogenous stimuli, the climacteric appears to exert some dramatic consequences on skin biology and aspect. The epidermis may become xerotic and exhibit altered functions. The dermis thins out and its elasticity decreases in concert with the decline in bone mass. The skin microcirculation is impaired. These aspects are some of the better worked-out changes of the climacteric, which in turn seem to be stabilized or in part reversible with hormone replacement therapy (HRT). The HRT effect on menopause consequences on hair growth and sebum production is less impressive. This review summarizes some important impacts of the climacteric on skin, and highlights the benefits of HRT that may influence cosmetic dermatology.

Use of hormones in the menopausal transition period in the Netherlands between 1993 and 1997

OBJECTIVES

To describe the patterns and to assess the indicators of hormone use during the menopausal transition period in a Dutch population.

METHODS

Between 1993 and 1997, 17,357 women aged 49-70 years participated in the Prospect-EPIC (European Prospective Investigation into Cancer and Nutrition) cohort and filled out an extensive questionnaire, which included information about hormone use during menopausal transition and other medical and lifestyle characteristics. Patterns of hormone use were described and various characteristics were evaluated as indicators of current hormone use by logistic regression.

RESULTS

Overall, 13% of women were current hormone users, which was highest in the 49-54 age group (19%). Hysterectomized women and older non-hysterectomized women mainly used unopposed estrogen therapy (ET), whereas younger non-hysterectomized women mainly used oral contraceptives or combined estrogen+progestogen therapy. Of all ever users, 61% used hormones for more than 1 year and 28% for more than 5 years. The most important indicators of hormone use for women without a surgical menopause were age, alcohol use, smoking, parity, ever use of oral contraceptives and family history of breast cancer. For women with a surgical menopause age, parity, ever use of oral contraceptives, diastolic blood pressure and the number of removed ovaries were the most relevant indicators.

CONCLUSIONS

The frequency of hormone use during menopausal transition in the Netherlands is low compared to other western countries, but the duration of use is quite long. Hormone use seems to be largely determined by factors that are known to affect endogenous estrogen levels.

Quality of life assessment in a chemoprevention trial: fenretinide and oral or transdermal HRT

BACKGROUND

Oral conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) relief menopause symptoms, but may increase breast cancer risk, while the effects of transdermal estradiol (E2) and MPA are less known. In previous studies, fenretinide decreased second breast malignancies in premenopausal but not in postmenopausal women, suggesting a hormone-sensitizing effect. We have evaluated the quality of life through a self-administered questionnaire during a randomized study of oral CEE or transdermal E2 and fenretinide or placebo.

METHODS

A total of 226 postmenopausal women were randomly assigned to either CEE 0.625mg/day and placebo (n=55), or CEE and fenretinide 100mg/bid (n=56), or E2, 50microg/day and placebo (n=59), or E2 and fenretinide (n=56) for 12 months. Sequential MPA 10mg/day was added in all groups. Treatment effects were investigated using a validated questionnaire, the Menopause Quality of Life questionnaire (MENQOL).

RESULTS

Oral CEE and transdermal E2 have a comparable activity in reducing menopausal symptoms (p=ns). Both routes ameliorate significantly the symptoms after 1 year of treatment (p<0.0001). Fenretinide does not modify the effects of hormonal replacement therapy.

CONCLUSIONS

Oral CEE and transdermal E2 have similar effect on menopausal symptoms relief. The choice of the best estrogen replacement therapy (ERT) route should be decided based on a careful analysis of all the clinical aspects of every subject, considering that transdermal therapy may have a safer effect on the cardiovascular system.

A new ‘publication bias’: the mode of publication

The editor of a medical journal may influence the opinion of his readers by a 'publication bias'. This can be through the choice of an editorial at the front of the journal, tutoring the article, the choice of an author from the Editorial Board and the organization of a press conference accompanying the publication. The publicity from which certain studies benefited in recent years has had a negative effect on doctors' prescriptions and comprehension of the published studies.

Previous oral contraceptive use and breast cancer risk according to hormone replacement therapy use among postmenopausal women

OBJECTIVE

To assess postmenopausal breast cancer risk in relation to particular patterns of oral contraceptive (OC) use according to hormone replacement therapy (HRT) exposure.

METHODS

Time-dependent Cox regression models were used to analyse information on postmenopausal women from a large-scale French cohort. Among a total of 68,670 women born between 1925 and 1950, 1405 primary invasive postmenopausal breast cancer cases were identified from 1992 to 2000.

RESULTS

A non-significant decrease in risk of around 10% was associated with ever OC use as compared to never OC use in postmenopausal women. No significant interaction was found between OC and HRT use on postmenopausal breast cancer risk. Breast cancer risk decreased significantly with increasing time since first OC use (test for trend: p=0.01); this was consistent after adjustment for duration of use or for time since last use.

CONCLUSION

No increase in breast cancer risk was associated with previous OC exposure among postmenopausal women, probably because the induction window had closed. Some women may develop breast cancer soon after exposure to OCs, leading to a deficit of cases of older women. Further investigation is therefore required to identify young women at high risk.

Pregnancy, progesterone and progestins in relation to breast cancer risk

In the last two decades the prevailing opinion, supported by the "estrogen augmented by progesterone" hypothesis, has been that progesterone contributes to the development of breast cancer (BC). Support for this opinion was provided by the finding that some synthetic progestins, when added to estrogen in hormone replacement therapy (HRT) for menopausal complaints, increase the BC risk more than estrogen alone. However, recent findings suggest that both the production of progesterone during pregnancy and the progesterone endogenously produced or exogenously administered outside pregnancy, does not increase BC risk, and could even be protective. The increased BC risk found with the addition of synthetic progestins to estrogen in HRT seems in all likelihood due to the fact that these progestins (medroxyprogesterone acetate and 19-nortestosterone-derivatives) are endowed with some non-progesterone-like effects which can potentiate the proliferative action of estrogens. The use of progestational agents in pregnancy, for example to prevent preterm birth, does not cause concern in relation to BC risk.

New progestagens for contraceptive use

The progestins have different pharmacologic properties depending upon the parent molecule, usually testosterone or progesterone (P), from which they are derived. Very small structural changes in the parent molecule may induce considerable differences in the activity of the derivative. In hormonal contraceptives, progestins represent the major agent designed for suppressing ovulation and are used in combination with estrogen (E) usually ethinyl-estradiol (EE). The development of new generations of progestins with improved selectivity profiles has been a great challenge. Steroidal and nonsteroidal progesterone receptor (PR) agonists have been synthesized as well, although the latter are still in a very early stage of development. Several new progestins, have been synthesized in the last two decades. These include dienogest (DNG), drospirenone (DRSP), Nestorone (NES), nomegestrol acetate (NOMAc) and trimegestone (TMG). These new progestins have been designed to have no androgenic or estrogenic actions and to be closer in activity to the physiological hormone P. DRSP differs from the classic progestins as it is derived from spirolactone. It is essentially an antimineralocorticoid steroid with no androgenic effect but a partial antiandrogenic effect. The antiovulatory potency of the different progestins varies. TMG and NES are the most potent progestins synthesized to date, followed by two of the older progestins, keto-desogestrel (keto-DSG) and levonorgestrel (LNG). The new molecules TMG, DRSP and DNG also have antiandrogenic activity. Striking differences exist regarding the side effects among the progestins and the combination with EE leads to other reactions related to the E itself and whether the associated progestin counterbalances, more or less, the estrogenic action. The 19-norprogesterone molecules and the new molecules DRSP and DNG are not androgenic and, therefore, have no negative effect on the lipid profile. Given their pharmacological properties, it is likely that the new progestins may have neutral effects on metabolic or vascular risks. However, this hypothesis must be confirmed in large clinical trials.

Méthodologie de l’enquête MISSION (Ménopause, rISque de cancer du SeIn, mOrbidité et prévaleNce)

OBJECTIVE

The ambition of this article is to detail and to explain the methodology of the study named MISSION (Menopause: breast cancer risk, morbidity and prevalence). The aims of MISSION are to determine the prevalence of breast cancer and global morbidity in France among menopausal women treated or not with hormone replacement therapy (HRT) and followed by a gynecologist.

MATERIAL AND METHOD

6600 menopausal women [3300 with HRT -- ie for estrogen: only estradiol via oral or transdermal administration; for progestogen: natural progesterone or assimiled or one pregnane derived (excluding medroxyprogesterone acetate) or non-pregnane derived -- and 3300 without HRT] will be enrolled in France between January 5 2004 and February 28 2005 by 825 gynecologists, members or not of the National Federation of Medical Gynecologists (FNCGM). This study design is a historico-prospective with case randomization. MISSION is conducted by a Theramex-Merck Laboratories initiative in collaboration with a WHO (World Health Organization) Collaborating Center for Public Health Aspects of Rheumatic Diseases and a multidisciplinary expert group.

CONCLUSION

First results of this study will contribute to better knowledge of women health.

Menopausal hormone therapy and risk of breast cancer: a meta-analysis of epidemiological studies and randomized controlled trials

We conducted meta-analyses to assess the impact of menopausal hormone therapy (MHT) on the risk of incident invasive breast cancer (BC) in cohort studies (CS), case-control studies (CCS) and randomized controlled trials (RCTs) published 1989-2004. We used published data providing information upon unopposed estrogen therapy (ET), estrogen-progestin therapy (EPT) or all MHT combined. Major outcomes were MHT-associated overall risk of BC and change of risk per year used. There is a linear increase of overall risk by midterm year of case ascertainment based upon data of all study types for MHT and to a larger extent for EPT, not for ET. Effects are larger in CS than in CCS. Meta-analyses stratified by <1992 versus > or =1992 as midterm year of case ascertainment indicate larger summary risks for the latter period for all MHT analysed, in particular for EPT. Annual increases in BC risk for EPT across study types are 0-9%, for ET 0-3%. In conclusion, there is evidence that relative risks for BC risks by MHT, in particular EPT, have been increasing in recent years. Given the widespread use of MHT, and often long duration, more detailed knowledge about differential BC risks of both estrogens and progestins are necessary to minimize BC risk in symptomatic women who consider MHT.

New evidence regarding hormone replacement therapies is urgently required

Controversies about the safety of different postmenopausal hormone therapies (HTs) started 30 years ago and reached a peak in 2003 after the publication of the results from the Women Health Initiative (WHI) trial and the Million Women Study (MWS) [Writing group for the women's health initiative investigations. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288:321-33; Million women study collaborators. Breast cancer and hormone-replacement therapy in the million women study. Lancet 2003;362:419-27]. The single HT formulation used in the WHI trial for non hysterectomized women-an association of oral conjugated equine estrogens (CEE-0.625 mg/day) and a synthetic progestin, medroxyprogesterone acetate (MPA-2.5 mg/day)-increases the risks of venous thromboembolism, cardiovascular disease, stroke and breast cancer. The MWS, an observational study, showed an increased breast cancer risk in users of estrogens combined with either medroxyprogesterone acetate (MPA), norethisterone, or norgestrel. It is unclear and questionable to what extent these results might be extrapolated to other HRT regimens, that differ in their doses, compositions and administration routes, and that were not assessed in the WHI trial and the MWS. Significant results were achieved with the publication of the WHI estrogen-only arm study [Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA 2004;291:1701-1712] in which hormone therapy was reserved to women who had carried out hysterectomy. What emerged from this study will allow us to have some important argument to develop.

Comparison of the in vitro estrogenic activities of compounds from hops (Humulus lupulus) and red clover (Trifolium pratense)

Because the prevailing form of hormone replacement therapy is associated with the development of cancer in breast and endometrial tissues, alternatives are needed for the management of menopausal symptoms. Formulations of Trifolium pratense L. (red clover) are being used to alleviate menopause-associated hot flashes but have shown mixed results in clinical trials. The strobiles of Humulus lupulusL. (hops) have been reported to contain the prenylflavanone, 8-prenylnaringenin (8-PN), as the most estrogenic constituent, and this was confirmed using an estrogen receptor ligand screening assay utilizing ultrafiltration mass spectrometry. Extracts of hops and red clover and their individual constituents including 8-PN, 6-prenylnaringenin (6-PN), isoxanthohumol (IX), and xanthohumol (XN) from hops and daidzein, formononetin, biochanin A, and genistein from red clover were compared using a variety of in vitro estrogenic assays. The IC50 values for the estrogen receptor alpha and beta binding assays were 15 and 27 microg/mL, respectively, for hops and 18.0 and 2.0 microg/mL, respectively, for the red clover extract. Both of the extracts, genistein, and 8-PN activated the estrogen response element (ERE) in Ishikawa cells while the extracts, biochanin A, genistein, and 8-PN, significantly induced ERE-luciferase expression in MCF-7 cells. Hop and red clover extracts as well as 8-PN up-regulated progesterone receptor (PR) mRNA in the Ishikawa cell line. In the MCF-7 cell line, PR mRNA was significantly up-regulated by the extracts, biochanin A, genistein, 8-PN, and IX. The two extracts had EC50 values of 1.1 and 1.9 microg/mL, respectively, in the alkaline phosphatase induction assay. On the basis of these data, hops and red clover could be attractive for the development as herbal dietary supplements to alleviate menopause-associated symptoms.

Progestins and progesterone in hormone replacement therapy and the risk of breast cancer

Controlled studies and most observational studies published over the last 5 years suggest that the addition of synthetic progestins to estrogen in hormone replacement therapy (HRT), particularly in continuous-combined regimen, increases the breast cancer (BC) risk compared to estrogen alone. By contrast, a recent study suggests that the addition of natural progesterone in cyclic regimens does not affect BC risk. This finding is consistent with in vivo data suggesting that progesterone does not have a detrimental effect on breast tissue. The increased BC risk found with the addition of synthetic progestins to estrogen could be due to the regimen and/or the kind of progestin used. Continuous-combined regimen inhibits the sloughing of mammary epithelium that occurs after progesterone withdrawal in a cyclic regimen. More importantly, the progestins used (medroxyprogesterone acetate and 19-Nortestosterone-derivatives) are endowed with some non-progesterone-like effects, which can potentiate the proliferative action of estrogens. Particularly relevant seem to be the metabolic and hepatocellular effects (decreased insulin sensitivity, increased levels and activity of insulin-like growth factor-I, and decreased levels of SHBG), which contrast the opposite effects induced by oral estrogen.

Estimated numbers of postmenopausal women treated by hormone therapy in France

OBJECTIVES

To estimate the number of women aged 50-69 years treated by hormone therapy (HT) in France before Women's Health Initiative's (WHI) results and to evaluate the potential decrease of HT prescriptions since the publication of WHI clinical trial.

METHODS

We used data from eight computerized databases of French cohort studies providing information on HT and constituted by women aged over 50 years living in metropolitan France. From these, we used direct standardization on the French population to estimate the prevalence of HT users across 5 years age groups. Data from the National Health Insurance Agency on two time-periods November 2002-January 2003 and November 2003-January 2004 were used to evaluate the evolution of HT prescriptions since WHI's publication among women aged 50-69 years living in the Rhône-Alpes region.

RESULTS

The crude prevalence of HT users among women aged 50-69 years was 52.3% (51.8-52.8) and corresponds to a standardized prevalence of 35.7% (35.1-36.4), that is about 2.56 (2.51-2.59) million women. Standardized prevalence was the highest in 50-54 years age group then it decreased significantly across the older age groups (p<10(-6)). HT reimbursements decreased significantly between the two studied time-periods in the Rhône-Alpes region (p<10(-6)) from -14 to -45%, depending on the considered age groups (65-69 or 50-54 years).

CONCLUSIONS

Although WHI results have been criticized by French professional societies based on the fact that treatments used were different in France--mainly transdermal estrogens--and that French postmenopausal women were at lower vascular risk than those of the WHI, the release of this study had effect on the prescription before the French regulatory agency (AFSSAPS) edited limiting recommendations for HT prescription. Further efforts have to be made to collect systematically information on preventive treatments used at menopause followed by evaluation studies.

Report from the Rockefellar Foundation Sponsored International Workshop on reducing mortality and improving quality of life in long-term survivors of Hodgkin's disease: July 9-16, 2003, Bellagio, Italy

A workshop, sponsored by the Rockefellar Foundation, was held between 9 to 16 July, 2003 to devise strategies to reduce mortality and improve quality of life of long-term survivors of Hodgkin's disease. Participants were selected for their clinical and research background on late effects after Hodgkin's disease therapy. Experts from both developed and developing nations were represented in the workshop, and efforts were made to ensure that the proposed strategies would be globally applicable whenever possible. The types of late complications, magnitude of the problem, contributing risk factors, methodology to assess the risk, and challenges faced by developing countries were presented. The main areas of late effects of Hodgkin's disease discussed were as follows: second malignancy, cardiac disease, infection, pulmonary dysfunction, endocrine abnormalities, and quality of life. This report summarizes the findings of the workshop, recommendations, and proposed research priorities in each of the above areas.

Postmenopausal hormone therapy and breast cancer: What is the problem?

Observational studies provide evidence that breast cancer risk is increased with long-term oral use of postmenopausal estrogen replacement therapy (ET). Various large cohort studies have shown that the addition of a progestogen in combined hormone replacement therapy (EPT) increases this risk further. Prospective, randomized controlled trials have confirmed this for the continuous combined regimen. So, why not tell our patients, "Stop using ET and EPT, it is dangerous to your health!"? The answer is: there are too many problems to allow such an oversimplified, definite statement. What is the problem? There is more than one! The problems are as follows: In conclusion, we have a problem as we cannot formulate any general advice that holds for the majority of European postmenopausal women due to lack of consistency, lack of biological plausibility, and lack of relevance of randomized clinical trial data to our daily practical work. So, we have a problem and not a firm basis for undisputable statements.