Familial risks in second primary breast cancer based on a family cancer database

Breast Cancer Family History and Contralateral Breast Cancer Risk in Young Women: An Update From the Women's Environmental Cancer and Radiation Epidemiology Study

Purpose The Women's Environmental Cancer and Radiation Epidemiology (WECARE) study demonstrated the importance of breast cancer family history on contralateral breast cancer (CBC) risk, even for noncarriers of deleterious BRCA1/2 mutations. With the completion of WECARE II, updated risk estimates are reported. Additional analyses that exclude women negative for deleterious mutations in ATM, CHEK2*1100delC, and PALB2 were performed. Patients and Methods The WECARE Study is a population-based case-control study that compared 1,521 CBC cases with 2,212 individually matched unilateral breast cancer (UBC) controls. Participants were younger than age 55 years when diagnosed with a first invasive breast cancer between 1985 and 2008. Women were interviewed about breast cancer risk factors, including family history. A subset of women was screened for deleterious mutations in BRCA1/2, ATM, CHEK2*1100delC, and PALB2. Rate ratios (RRs) were estimated using multivariable conditional logistic regression. Cumulative absolute risks (ARs) were estimated by combining RRs from the WECARE Study and population-based SEER*Stat cancer incidence data. Results Women with any first-degree relative with breast cancer had a 10-year AR of 8.1% for CBC (95% CI, 6.7% to 9.8%). Risks also were increased if the relative was diagnosed at an age younger than 40 years (10-year AR, 13.5%; 95% CI, 8.8% to 20.8%) or with CBC (10-year AR, 14.1%; 95% CI, 9.5% to 20.7%). These risks are comparable with those seen in BRCA1/2 deleterious mutation carriers (10-year AR, 18.4%; 95% CI, 16.0% to 21.3%). In the subset of women who tested negative for deleterious mutations in BRCA1/2, ATM, CHEK2*1100delC, and PALB2, estimates were unchanged. Adjustment for known breast cancer single-nucleotide polymorphisms did not affect estimates. Conclusion Breast cancer family history confers a high CBC risk, even after excluding women with deleterious mutations. Clinicians are urged to use detailed family histories to guide treatment and future screening decisions for young women with breast cancer.

Body mass index, weight change, and risk of second primary breast cancer in the WECARE study: influence of estrogen receptor status of the first breast cancer

Studies examining the relationship between body mass index (BMI) and risk of contralateral breast cancer (CBC) have reported mixed findings. We previously showed that obese postmenopausal women with estrogen receptor (ER)‐negative breast cancer have a fivefold higher risk of CBC compared with normal weight women. In the current analysis, we reexamined this relationship in the expanded Women's Environmental Cancer and Radiation Epidemiology (WECARE) Study, focusing on the impact of menopausal status and ER status of the first breast cancer. The WECARE Study is a population‐based case–control study of young women with CBC (cases, N = 1386) and with unilateral breast cancer (controls, N = 2045). Rate ratios (RR) and 95% confidence intervals (CI) were calculated to assess the relationship between BMI and risk of CBC stratified by menopausal and ER status. Positive associations with obesity and weight gain were limited to women who became postmenopausal following their first primary breast cancer. Among those with an ER‐negative first breast cancer, obesity (vs. normal weight) at first diagnosis was associated with an increased risk of CBC (RR = 1.9, 95% CI: 1.02, 3.4). Also, weight gain of ≥10 kg after first diagnosis was associated with an almost twofold increased risk of CBC (RR = 1.9, 95% CI: 0.99, 3.8). These results suggest that women with an ER‐negative first primary cancer who are obese at first primary diagnosis or who experience a large weight gain afterward may benefit from heightened surveillance. Future studies are needed to address the impact of weight loss interventions on risk of CBC.

Risk of second cancers cancer after a first primary breast cancer: a systematic review and meta-analysis

OBJECTIVE

To examine the scientific evidence and the risk of second primary cancers in women diagnosed with a first primary breast cancer.

METHODS

The literature was searched in Pubmed and Embase and included studies published up to June 2013, using population-based data and IARC/AICR codification rules for multiple primary cancers. A qualitative synthesis was carried out and the methodological quality of the studies evaluated. Standardised incidence ratios (SIRs) on second cancer risk, weighted by the standard error of each study, were pooled using fixed and random effects models. SIRs were also pooled by age at diagnosis (<50 and ≥ 50 years), and time since diagnosis of the first breast cancer (<10 and ≥ 10 years).

RESULTS

15 out of 710 articles fulfilled the inclusion criteria. All of them were retrospective cohort studies either population-based (13 studies) or hospital-based studies (2 studies). The studies varied with respect to number of cases, selection criteria, definition of multiple primary cancers, and the second cancer sites included. SIRs reported in these studies for all cancers combined varied from 1.0 to 1.4. The pooled SIR estimate for second cancer risk was 1.17 (95% CI: 1.10-1.25). By age groups, SIR estimates were 1.51 (95% CI: 1.35-1.70) for women younger than 50 years and 1.11 (95% CI: 1.02-1.21) for those who were older. Women with breast cancer are at risk of second cancers within the first 10 years after the first breast cancer diagnosis (SIR: 1.19; 95% CI: 1.06-1.33), and thereafter (SIR: 1.26; 95% CI: 1.05-1.52).

CONCLUSION

This higher risk of second cancers in women diagnosed with a first primary breast cancer with respect to the general population emphasises the importance of prevention and control policies aimed at reducing incidence of second cancers.

Variants of uncertain significance in BRCA testing: evaluation of surgical decisions, risk perception, and cancer distress

Studies suggest that patients carrying a BRCA variant of uncertain significance (VUS) may have lingering confusion concerning results interpretation. Counseling for uninformative BRCA-negative (UN) results is thought to be more straightforward, despite the fact that both results lead to similar methods of empiric cancer risk counseling. This study compared surgical choices and perceptions between 71 patients with VUS results and 714 patients with UN results. All patients underwent genetic counseling because of a personal or family history of breast or ovarian cancer between 1997 and 2010, and completed a 2-year follow-up survey. Risk-reducing mastectomy rates in both groups were 7% (p = 1.00) and risk-reducing oophorectomy rates were 5% and 3%, respectively (p = 0.42). The VUS group reported less cancer distress reduction than the UN group (23.0% vs 35.8%, respectively, p = 0.043). Over 90% of both groups found the counseling process helpful. Overall, the study suggests that VUS results disclosed in genetic counseling did not cause excessive surgery or exaggerated cancer distress, though patients with a VUS found counseling somewhat less informative or reassuring. Future research on communication of VUS results, including pre-and post-test counseling, is essential for full realization of the potential for genomic medicine.

Embryonic left-right separation mechanism allows confinement of mutation-induced phenotypes to one lateral body half of bilaterians

A fundamental question in developmental biology is how a chimeric animal such as a bilateral gynandromorphic animal can have different phenotypes confined to different lateral body halves, and how mutation-induced phenotypes, such as genetic diseases, can be confined to one lateral body half in patients. Here, I propose that embryos of many, if not all, bilaterian animals are divided into left and right halves at a very early stage (which may vary among different types of animals), after which the descendants of the left-sided and right-sided cells will almost exclusively remain on their original sides, respectively, throughout the remaining development. This embryonic left-right separation mechanism allows (1) mutations and the mutation-induced phenotypes to be strictly confined to one lateral body half in animals and humans; (2) mothers with bilateral hereditary primary breast cancer to transmit their disease to their offspring at twofold of the rate compared to mothers with unilateral hereditary breast cancer; and (3) a mosaic embryo carrying genetic or epigenetic mutations to develop into either an individual with the mutation-induced phenotype confined unilaterally, or a pair of twins displaying complete, partial, or mirror-image discordance for the phenotype. Further, this left-right separation mechanism predicts that the two lateral halves of a patient carrying a unilateral genetic disease can each serve as a case and an internal control, respectively, for genetic and epigenetic comparative studies to identify the disease causations.

The prognosis of synchronous and metachronous bilateral breast cancer in Chinese patients

This study was undertaken to determine the differences in the clinicopathology and survival between synchronous bilateral breast cancer (sBBC) and metachronous bilateral breast cancer (mBBC). Additionally, we analyzed the risk factors for single tumors to develop as sBBC or mBBC. Of the 190 bilateral breast cancer (BBC) cases, 84 cases were sBBC and 106 were mBBC. We defined sBBC as two tumors that developed within 12 months, while mBBC was defined as two tumors that developed over more than 12 months. The peak age of onset of the first mBBC tumors was significantly younger than that of sBBC tumors (p = 0.001). There was a higher concordance rate of ER/ER positivity and PR/PR positivity in the first and second tumors of sBBC than mBBC. The two sBBC breast cancers had relatively similar hormone conditions because of the low rate of ER and PR transformation from positive to negative or vice versa. We determined that patients who presented with extracapsular extension (p = 0.008) and ER positivity (p = 0.001) tend to have synchronous cancers, while patients with 3+ HER2 were more likely to develop metachronous tumors. The prognosis for mBBC was better than that for sBBC when the survival time of mBBC was measured from the initial observation of the first tumors.

Risk of asynchronous contralateral breast cancer in noncarriers of BRCA1 and BRCA2 mutations with a family history of breast cancer: a report from the Women's Environmental Cancer and Radiation Epidemiology Study

PURPOSE

To fully characterize the risk of contralateral breast cancer (CBC) in patients with breast cancer with a family history who test negative for BRCA1 and BRCA2 mutations.

PATIENTS AND METHODS

From our population-based case-control study comparing women with CBC to women with unilateral breast cancer (UBC), we selected women who tested negative for BRCA1 and BRCA2 mutations (594 patients with CBC/1,119 control patients with UBC). Rate ratios (RRs) and 95% CIs were estimated to examine the association between family history of breast cancer and risk of asynchronous CBC. Age- and family history-specific 10-year cumulative absolute risks of CBC were estimated.

RESULTS

Family history of breast cancer was associated with increased CBC risk; risk was highest among young women (< 45 years) with first-degree relatives affected at young ages (< 45 years; RR, 2.5; 95% CI, 1.1 to 5.3) or women with first-degree relatives with bilateral disease (RR, 3.6; 95% CI, 2.0 to 6.4). Women diagnosed with UBC before age 55 years with a first-degree family history of CBC had a 10-year risk of CBC of 15.6%.

CONCLUSION

Young women with breast cancer who have a family history of breast cancer and who test negative for deleterious mutations in BRCA1 and BRCA2 are at significantly greater risk of CBC than other breast cancer survivors. This risk varies with diagnosis age, family history of CBC, and degree of relationship to an affected relative. Women with a first-degree family history of bilateral disease have risks of CBC similar to mutation carriers. This has important implications for the clinical management of patients with breast cancer with family history of the disease.

Risk of second breast cancer according to estrogen receptor status and family history

A recent study reported an increased risk of contralateral estrogen-negative breast cancer after a first primary estrogen-negative breast cancer. Our study aims to confirm this result and to evaluate how the risk of second breast cancer occurrence is affected by family history of breast cancer and anti-estrogen treatment. We included all 4,152 women diagnosed with breast cancer between 1995 and 2007, using data from the population-based Geneva Cancer Registry. We compared the incidence of second breast cancer among patients according to estrogen receptor (ER) status with that expected in the general population by age-period Standardized Incidence Ratios (SIRs). Among the cohort, 63 women developed second breast cancer. Patients with ER-positive first tumors had a decreased risk of second breast cancer occurrence (SIR: 0.67, 95% CI: 0.48-0.90), whereas patients with ER-negative primary tumors had an increased risk (SIR: 1.98, 95% CI: 1.19-3.09) limited to ER-negative second tumors (SIR: 7.94, 95% CI: 3.81-14.60). Patients with positive family history had a tenfold (SIR: 9.74, 95% CI: 3.57-21.12) higher risk of ER-negative second tumor which increased to nearly 50-fold (SIR: 46.18, 95% CI: 12.58-118.22) when the first tumor was ER-negative. Treatment with anti-estrogen decreased the risk of second ER-positive tumors but not ER-negative tumors. The risk of second ER-negative breast cancer is very high after a first ER-negative tumor, in particular among women with strong family history. Surveillance and prevention of second cancer occurrence should consider both ER status of the first tumor and family history.

Second primary breast cancer occurrence according to hormone receptor status

BACKGROUND

Contralateral second primary breast cancers occur in 4% of female breast cancer survivors. Little is known about differences in risk for second primary breast cancers related to the estrogen and progesterone receptor (hormone receptor [HR]) status of the first tumor.

METHODS

We calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for contralateral primary breast cancers among 4927 women diagnosed with a first breast cancer between January 1, 1992, and December 31, 2004, using the National Cancer Institute's Surveillance, Epidemiology, and End Results database.

RESULTS

For women whose first breast tumors were HR positive, risk of contralateral primary breast cancer was elevated, compared with the general population, adjusted for age, race, and calendar year (SIR = 2.22, 95% CI = 2.15 to 2.29, absolute risk [AR] = 13 cases per 10 000 person-years [PY]), and was not related to the HR status of the second tumor. For women whose first breast tumors were HR negative, the risk of a contralateral primary tumor was statistically significantly higher than that for women whose first tumors were HR positive (SIR = 3.57, 95% CI = 3.38 to 3.78, AR = 18 per 10 000 PY), and it was associated with a much greater likelihood of an HR-negative second tumor (SIR for HR-positive second tumors = 1.94, 95% CI = 1.77 to 2.13, AR = 20 per 10 000 PY; SIR for HR-negative second tumors = 9.81, 95% CI = 9.00 to 10.7, AR = 24 per 10 000 PY). Women who were initially diagnosed with HR-negative tumors when younger than 30 years had greatly elevated risk of HR-negative contralateral tumors, compared with the general population (SIR = 169, 95% CI = 106 to 256, AR = 77 per 10 000 PY). Incidence rates for any contralateral primary cancer following an HR-negative or HR-positive tumor were higher in non-Hispanic blacks, Hispanics, and Asians or Pacific Islanders than in non-Hispanic whites.

CONCLUSIONS

Risk for contralateral second primary breast cancers varies substantially by HR status of the first tumor, age, and race and/or ethnicity. Women with HR-negative first tumors have nearly a 10-fold elevated risk of developing HR-negative second tumors, compared with the general population. These findings warrant intensive surveillance for second breast cancers in women with HR-negative tumors.

Survival after bilateral breast cancer: results from a population-based study

BACKGROUND

Controversy exists on the impact of bilaterality of breast cancer on survival. We used population-based data to compare survival of women with unilateral versus bilateral breast cancer.

PATIENTS AND METHODS

At the Geneva cancer registry, we identified all 7,912 women diagnosed with invasive breast cancer between 1970 and 2002. Breast cancers were categorized as unilateral, synchronous bilateral (contralateral tumour diagnosed within six months after the first tumour) and metachronous bilateral (contralateral tumour diagnosed over six months after the first tumour). With multivariate modelling we compared characteristics and survival between women with unilateral and bilateral disease.

RESULTS

Patients with synchronous bilateral tumours (n = 155, 2.0%) had more often lobular histology and less frequently stage I disease than women with unilateral disease. Women with metachronous breast cancer (n = 219, 2.8%) received less often chemotherapy or hormone therapy for their first tumours. Ten-year disease-specific survival was similar (66%) after unilateral and metachronous bilateral breast cancer, but worse after synchronous bilateral cancer (51%). After adjustment, breast cancer mortality risks were not significantly increased for women with either synchronous or metachronous bilateral disease (Hazard ratios 1.1 (0.8-1.5) and 0.8 (0.5-1.4), respectively).

CONCLUSION

This large population-based study indicates that bilaterality of breast cancer is not associated with impaired survival.

Tertiary prevention: implications for improving the quality of life of long-term survivors of cancer

OBJECTIVE

To provide an overview of the incidence, epidemiology, and appropriate screening for second primary malignancies, as well as the nursing implications of tertiary cancer prevention.

DATA SOURCES

Published review articles, book chapters, research reports, and the clinical experience of the author.

CONCLUSION

Many persons successfully treated for malignancy are at risk for a second malignancy. This risk is related to shared risk factors, genetic predisposition, and the toxic effects of therapy. Persons particularly at risk are those who have been successfully treated for breast, gynecologic, colorectal, skin, and lymphoma malignancies.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be knowledgeable regarding the principles of tertiary prevention, be able to identify persons at risk, and provide appropriate patient education and psychosocial support on how to manage the risk and detect second malignancies early.

The Descriptive Epidemiology of Second Primary Breast Cancer

BACKGROUND

It is well established that the incidence rates of first primary breast cancer have been increasing over time. In contrast, the incidence rates of second primary breast cancer are largely undocumented. This study describes the epidemiology of second primary breast cancer among a population-based cohort of 305,533 U.S. women diagnosed with breast cancer between 1973 and 1998.

METHODS

We compared age-specific incidence rates for overall and second primary breast cancer according to year of diagnosis and demographic and tumor characteristics.

RESULTS

Overall, age-specific rates of breast cancer increased with increasing age and year of diagnosis, whereas incidence of second primary breast cancer peaked among young women and declined after 1988. Consistent with what is known about genetic susceptibility to breast cancer, at every age the rate of second primaries was greater than the overall rate; among women age 20 to 29 years the rate of second primary was more than 100 times greater. Although overall age-specific rates of breast cancer for African-American women were lower than for whites, rates of second primaries were higher. Women with a first primary that was either lobular or medullary had a greater likelihood of developing a second primary, although, there were relatively few with these histologic types.

CONCLUSIONS

The pattern of incidence rates for first and second primary breast cancer differ markedly over time and by age.

Parental cancer as a risk factor for bone cancer: a nation-wide study from Sweden

We used the nation-wide Swedish Family-Cancer Database to analyze the risk for bone cancer in offspring by parental cancers and in siblings of bone cancer probands. Additionally, the risk of second cancer following childhood bone cancer was investigated. In offspring, 1,190 bone cancers were diagnosed between years 1958 and 1996. Groups of offspring were compared by calculating standardized incidence ratios (SIRs) for bone cancer. Most bone cancer cases occurred sporadically. Parental breast (SIR 1.7) and prostate (SIR 1.7) cancers were associated with early-onset (<25 years) osteosarcoma in offspring, probably due to Li-Fraumeni syndrome. Giant cell sarcoma was increased by parental breast cancer (SIR 2.9), and early-onset chondrosarcoma by parental kidney cancers (SIR 6.8). Bone cancers conveyed a high risk of second bone and connective tissue cancer.

Second primary neoplasms after 19281 endocrine gland tumours: aetiological links?

The nationwide Swedish Family-Cancer Database of 9.6 million individuals was used to analyse the development of second neoplasia after 6909 thyroid and 12697 other endocrine tumours. Tumour cases were retrieved from the Swedish Cancer Registry from 1958 to 1996. The risk of a second endocrine tumour was markedly increased compared with first endocrine tumour; e.g. the standardised incidence ratios (SIRs) were well over 10 for adrenal tumours after thyroid cancer, and vice versa. Familial risks were higher for the development of second compared with first neoplasms, and the SIRs for men were usually higher than those for women. Many increases between different endocrine glands can probably be ascribed to known cancer syndromes. Even cancers at some other sites were increased after the development of primary endocrine tumours. Notably, small intestinal carcinoids were increased after thyroid and other endocrine tumours, and brain menigiomas were increased after parathyroid and pituitary adenomas. These novel associations suggest shared risk factors for these sites. However, many endocrine tumours are benign and the diagnosis of the first tumour may increase the likelihood of a second diagnosis.

Second primary cancers after anogenital, skin, oral, esophageal and rectal cancers: etiological links?

The Swedish Family-Cancer Database was used to analyze second cancers after oral, esophageal, rectal, cervical, genital and skin (squamous cell carcinoma) cancers. A strong and consistent association of second cancers was observed at all these sites, in men and women. As a novel finding, an association of rectal cancer with the human papillomavirus (HVP)-related cancers was shown. New evidence on an excess of skin cancer with the HPV-related cancers was also provided. As an epidemiological study, the associations were strong and often supported by a number of comparisons. These could not be explained by bias or long-term treatment related effects. However, whether the findings on rectal and skin cancer are due to HPV or other infections, transient or inherited depressed immune function or other constitutional factors remains to be established.

Second primary neoplasms in 633,964 cancer patients in Sweden, 1958-1996

The Swedish Family-Cancer Database was used to analyze concordant (same site) and discordant (different site) second primary neoplasms in 633,964 cancer patients diagnosed from 1958 to 1996. Cases of second malignant neoplasms were extracted from the Database if the diagnosis date of the first and second cancer differed by at least 1 month. The expected numbers of cancers were obtained by applying site-, sex-, age-, period-, residence- and socioeconomic level-specific rates in the corresponding population in the Database to the appropriate person-years at risk. The standardized incidence ratio (SIRs) of a second cancer was taken to be the ratio of observed to expected numbers of second cancers. Of all cancers, 8.5% were subsequent neoplasms (8.4% for males and 8.7% for females). SIRs for both concordant and discordant subsequent cancer were elevated in patients with cancer of the upper aerodigestive tract, colon, nose, breast, other female genitals, testis, kidney, urinary, bladder, skin, nervous system, endocrine, bone, connective tissue, melanoma, lymphoma and leukemia. The risks at some concordant sites, such as nose, squamous cell skin, bone and connective tissue in both sexes, breast in males and upper aerodigestive tract and leukemia in females, were very high (>10). At discordant sites, SIRs were less than 2 but significantly increased after all but gastric and prostatic cancer. Compared with the general population, cancer patients were at a modestly increased risk for new primary cancer after cancers at many sites, calling for attention in treatment, management and prevention.

A population-based study of familial soft tissue tumors

We used the nationwide Swedish Family-Cancer Database to analyze the risk for soft tissue tumors in offspring by parental cancers and in siblings of soft tissue tumor probands. Additionally, risk for second cancer following soft tissue tumor was investigated. In offspring, 1488 soft tissue tumors were diagnosed between years 1958 and 1996. Groups of offspring were compared by calculating standardized incidence ratios (SIRs) for soft tissue tumors. Parental breast, prostate and connective tissue cancers were associated with offspring soft tissue tumors in sex- and age-specific groups. The SIRs were of borderline significance, suggesting a small etiological contribution by Li-Fraumeni syndrome. Soft tissue tumors conveyed a high risk of second soft tissue tumor, probably partially due to recurrences. However, the observed risk for second nervous system cancer was consistent with Li-Fraumeni syndrome. Other associations were unlikely to be due to Li-Fraumeni or other known syndromes, but they could be spurious findings arising from multiple comparisons. Among these, parental stomach cancer (SIR 3.19, 95% CI 1.69-5.17) and endocrine gland tumors (SIR 3.66, 95% CI 1.32-7.17), particularly parathyroid tumors (SIR 4.46, 95% CI 1.41-9.23), were associated with offspring fibrosarcoma, and parental breast cancers with offspring leiomyosarcoma (SIR 2.04, 95% CI 1.08-3.30).

Genetic epidemiology of multistage carcinogenesis

It is commonly believed that cancer is a multistage, polygenic disease. Even though conceptually appealing, the evidence supporting the multistage theory remains limited. Most known tumor suppresser genes are associated with monogenic dominant cancers following a two-hit pathway. We review results from a recent twin study on 90000 individuals that give support to the multistage theory. Statistically significant heritability estimates were shown for cancers of the colorectum (35%), breast (27%), and prostate (42%). These estimates are much higher than those obtained from family studies in which parents and offspring, or sibs are compared. The difference can be accounted for by the involvement of many genes. A polygenic cancer would show small effects in family studies but large effects in twin studies. We present calculations on the decrease in familial risks when the number of genes involved increases or when the penetrance decreases. We test the apparent number of stages involved in the main cancers from the Swedish Family-Cancer Database. The logarithms of the slopes suggest large differences in the apparent numbers of mutations involved in different cancers. The number of mutations required appears to be less in familial breast cancer compared to sporadic breast cancer. Study designs for gene identification should be revised to accommodate polygenic cancers.

Risk factors and age-incidence relationships for contralateral breast cancer

The nation-wide Swedish Family-Cancer Database was used to analyze the risk of contralateral breast cancer among 72,092 women with unilateral breast cancer. Contralateral breast cancer, defined as being diagnosed 6 months or more after the first breast cancer, affected 2,529 women (3.5%). In a young age group the incidence of contralateral breast cancer was 50 times higher than the incidence of first breast cancer; for all contralateral breast cancer the difference was 5-fold. Because only 1 breast was at risk for contralateral breast cancer, the true differences to unilateral cancer were 2 times higher. The age-incidence relationship was unusual, exhibiting a high incidence (800/10(5) person-years) component at an early age (25 to 49 years) and a lower incidence (460/10(5) person-years) component at a later age (50-80 years). The discrete components suggest population heterogeneity. Age at diagnosis of the first breast cancer and family history of breast cancer associated with the risk of contralateral breast cancer. Other, weaker risk factors were birth cohort, age at first childbirth, parity and interval between first and second breast cancer. The incidence of familial contralateral breast cancer was 1. 5 times higher than that of sporadic disease, and its age-incidence curve also exhibited 2 separate components. The age-incidence relationships of contralateral breast cancer suggest that the disease affects a small and heterogeneous susceptible population.

Epidemiology, prevention, and early detection of breast cancer

Decreases in the incidence of breast cancer have not been achieved, but there is a downward trend in age-adjusted breast cancer mortality rates in the United States. Recent epidemiologic investigations continue to refine our understanding of the role of established breast cancer risk factors, such as reproductive characteristics and body mass index, and in the process advance understanding of the etiology of breast cancer. Important strides are being made in the chemoprevention of breast cancer, but clarifying the potential contributions of factors such as diet, physical activity, and cigarette smoke to the breast cancer burden is a high priority because these lifestyle behaviors also have important implications for primary prevention. The role of both environmental and endogenous exposures in breast carcinogenesis will be more clearly elucidated by studies that account for genetic polymorphisms, some of which may lead to differential susceptibility to harmful agents.

Screening for second cancers and osteoporosis in long-term survivors

PURPOSE

The purpose of this preliminary study was to describe the extent to which healthcare providers recommend the screening strategies for early detection described by the American Cancer Society (ACS), for breast, gynecologic, and colorectal cancer, and by the National Osteoporosis Foundation (NOF), for osteoporosis, to women who are long-term survivors of breast, ovarian, or endometrial cancer.

DESCRIPTION OF THE STUDY

A four-part survey was developed for this study, with the first three parts based on the ACS guidelines for breast, gynecologic, and colorectal cancer screening and the NOF guidelines for osteoporosis screening. The fourth part related to personal characteristics, setting, knowledge, and perceptions of the nurses surveyed. A random sample of outpatient nurses was obtained from the Oncology Nursing Society. Of 668 nurses, 321 (48%) responded (Oncology Certified Nurse (OCN) 68.1%; Advanced Oncology Certified Nurse (AOCN) 16.6%).

RESULTS

The most consistently performed screenings that were reported were mammogram (range 74.2-87.7%), professional breast examination (range 73.9-83.7%), and Pap test and pelvic examination (range 61.8-85.2%). The least frequently performed screenings are flexible sigmoidoscopy/colonoscopy (range 20.2-27.7%), bone mineral density testing (range 16.9-19.0%), and height measurement (range 22.5-28.3%). Less than one third of survivors are offered counseling on strategies to promote bone health.

CLINICAL IMPLICATIONS

Knowledge of factors associated with osteoporosis and the use of screening strategies for second malignancies in survivors of breast, ovarian, and endometrial cancers can be used to implement activities such as patient education and clinical practice protocols that will increase the use of current screening recommendations.

Familial cancer risks to offspring from mothers with 2 primary breast cancers: leads to cancer syndromes

The nationwide Swedish Family-Cancer Database was used to analyse the risk of cancer among the offspring of bilateral breast cancer patients. We studied 4,734 such mothers who had 9,391 offspring, of whom 328 presented with a primary cancer in the years 1958-1996. Standardised incidence ratios (SIRs) were increased for breast [SIR 3.05, 95% confidence interval (CI) 2.57-3.59], ovarian (SIR 1.84, 95% CI 1.03-3.05) and anogenital (SIR 1.75, 95% CI 1.11-2.63) cancers and childhood sarcomas (SIR 9.39, 95% CI 1.93-29.13). Additionally, squamous-cell skin cancer was increased among sons and all childhood cancers among daughters. When analysed by histological type, adenocarcinomas of the breast and ovary, all squamous-cell carcinomas and tumours at glandular epithelium (seminomas and intestinal carcinoids) were increased. Mothers with bilateral breast cancer had an excess of 2 or more children with cancer. The increased risk of ovarian cancer is consistent with germline mutations in the BRCA1 and BRCA2 genes, while the risk of soft tissue and bone sarcomas may reflect the association of these tumours with Li-Fraumeni syndrome. The increases in squamous-cell carcinomas at many sites may reflect a new susceptibility syndrome.

Second primary cancer after in situ and invasive cervical cancer

The Swedish Family-Cancer Database was used to analyze 9,426 second primary cancers in 117,830 subjects diagnosed with in situ and 17,556 subjects with invasive cervical cancer from the years 1958-1996. We calculated standardized incidence ratios (SIRs) from age- and period-specific rates for all women. SIRs were elevated after both in situ and invasive cervical cancer for cancers of the upper aerodigestive tract, anus, pancreas, lung, other female genitals, and urinary bladder. Anus and other female genitals, known targets of human papilloma virus, showed SIRs exceeding 3.0 and 10 or more within the year of diagnosis of cervical cancer, probably implying the effects of diagnostic intensity or transient faltering of host immunosurveillance. Among the remaining sites, smoking appeared to be the major cause, but for urinary bladder cancer it only explained one-half of the excess; human papilloma virus infection, possibly through immunosuppression, could account for the remaining excess. Although urinary bladder cancer showed a relatively small SIR compared with anal cancer, because it is more common, the number of attributable cases was about equal for the two sites. Invasive cervical cancer showed an SIR of 2.3 after in situ cancer. On follow-up, we also observed increased SIRs at many radiosensitive sites 10 or more years after diagnosis of invasive cervical cancer.

Epidemiology, prevention, and early detection of breast cancer

Globally, breast cancer is the third most common form of cancer and the most common among women. The age-adjusted incidence rates of breast cancer are 176% higher in developed than in developing nations. Male breast cancer is rare, but important studies provided risk factor information for comparison with studies of female breast cancer. There has been considerable interest in a possible role of organochlorines and polychlorinated biphenyls in the etiology of breast cancer, but the results of several null studies indicate the likelihood of such associations is extremely remote, providing reassuring news for the public. Prophylactic mastectomy was observed to significantly reduce a woman's chances of developing breast cancer, but it does not lower the risk to zero. Tamoxifen was found to be an effective chemopreventive agent in the Breast Cancer Prevention Trial, but this result was not replicated in two randomized trials in Europe. Striking reductions in the risk for breast cancer were observed for raloxifene in a randomized, placebo-controlled trial that had been designed for the prevention of osteoporosis. A large-scale, randomized trial of tamoxifen-verus-raloxifene among women at increased risk for developing breast cancer is now underway.