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

Coronary heart disease and HRT in France: MISSION study prospective phase results

OBJECTIVE

To determine the morbidity incidence associated with Hormone Replacement Therapy (HRTs) in postmenopausal women. This paper presents the results concerning the incidence of coronary heart disease (CHD).

DESIGN

MISSION study started on 5 January 2004, the cutoff for data collection was June 2006 (follow-up no. 1). 'Exposed group': postmenopausal women currently on HRT, commonly prescribed in France or stopped < or =5 years previously. 'Unexposed group': never received HRT or stopped >5 years previously.

RESULTS

Data were available for 4949 patients (without CHD at the beginning of the follow-up): 2693 Exposed group and 2256 Unexposed group. The incidence during follow-up no. 1 of postmenopausal CHD was not significantly different in the Exposed group (0.11%) compared with the Unexposed group (0.13%). In the Exposed group the time between start of HRT and menopause was 2.93 +/- 4.46 years in those who experienced CHD and 1.53 +/- 3.20 years in those who had no incidence of CHD (p = 0.3).

CONCLUSION

In the MISSION cohort, no increased risk of CHD was found in the Exposed group compared with the Unexposed group.

Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review

Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.

Breast cancer incidence and hormone replacement therapy: results from the MISSION study, prospective phase

BACKGROUND

The MISSION Study (Menopause: Risk of Breast Cancer, Morbidity and Prevalence) is a historical-prospective study with random patient selection to determine breast cancer incidence in postmenopausal women with or without hormone replacement therapy (HRT). The first prospective follow-up phase started on 5 January 2004 and the cut-off date for data collection was 30 June 2006.

PARTICIPANTS

Patients were divided into two groups: an 'exposed group' of women on HRT regimens commonly prescribed in France or who had stopped < or =5 years previously; and an 'unexposed group' of women who had never received HRT or stopped >5 years previously. In total 6755 patients were included; and prospective data were available for 4949 patients: 2693 in the exposed group and 2256 in the unexposed group. Women in the exposed group were younger, less overweight, and had fewer first-degree family histories of breast cancer than women of the unexposed group. Mean duration of HRT exposure was 8.3 years, with 31% being exposed for > or =10 years.

RESULTS

The incidence of new breast cancer cases was 0.64% in the exposed group and 0.70% in the unexposed group (relative risk RR(exposed/unexposed) = 0.914, 95% confidence interval = 0.449-1.858; not modified when adjusted for age). Mean age at breast cancer diagnosis was similar in both groups. Breast cancer incidence in the exposed group was not significantly affected by the route of estradiol administration (cutaneous 0.69%; oral 0.52%) or HRT type (estradiol alone 0.28%; estradiol + progesterone 0.40%; estradiol + synthetic progestin 0.94%).

CONCLUSION

No evidence was found for an increased risk of breast cancer in women exposed to HRT compared with non-exposed women.

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.