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Bernhardt SM, Dasari P, Walsh D, Raymond W, Hull ML, Townsend AR, Price TJ, Ingman WV. The menstrual cycle is an under-appreciated factor in premenopausal breast cancer diagnosis and treatment. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.coemr.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Bernhardt SM, Dasari P, Walsh D, Townsend AR, Price TJ, Ingman WV. Timing of breast cancer surgery during the menstrual cycle-is there an optimal time of the month? Oncol Lett 2020; 20:2045-2057. [PMID: 32782523 PMCID: PMC7400969 DOI: 10.3892/ol.2020.11771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
An intriguing relationship between menstrual cycle phase at the time of breast cancer surgery and clinical outcomes was first proposed in the late 1980s. Despite a number of clinical studies conducted to address this, as well as meta-analyses and systematic reviews, there remains significant controversy surrounding the effect of menstrual cycle phase at time of surgery on the prognosis of premenopausal breast cancer. While some studies have suggested that surgery performed during the luteal phase results in the most favourable outcome, other studies report the follicular phase is more favourable, and others show no association. Given the conflicting results, there remains insufficient evidence to determine whether there is an optimal time of the month to perform surgery. This issue has dogged breast cancer surgery for decades; knowledge of an optimal time of the month to conduct surgery would be a simple approach to improving patient outcomes. This review explores the potential biological mechanisms through which the hormonal milieu might contribute to differences in prognosis, and why clinical findings are so variable. It is concluded that a significant problem with current clinical research is the lack of insight from mechanistic studies. While there are a number of plausible biological mechanisms that could lead to altered survival, supporting evidence is limited. There are also variable approaches to defining the menstrual cycle phase and hormone receptor status of the tumour and few studies controlled for prognostic factors such as tumour size and stage, or addressed the impact of adjuvant treatments. Elucidation of the specific confounding factors, as well as biological mechanistic pathways that could explain the potential relationship between timing of surgery and survival, will greatly assist in designing robust well-controlled prospective clinical studies to evaluate this paradigm.
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Affiliation(s)
- Sarah M Bernhardt
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Pallave Dasari
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - David Walsh
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia
| | - Amanda R Townsend
- Department of Medical Oncology, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia
| | - Wendy V Ingman
- Discipline of Surgery, Adelaide Medical School, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia 5011, Australia.,The Robinson Research Institute, University of Adelaide, Adelaide, South Australia 5005, Australia
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Klonoff-Cohen H, An R, Fries T, Le J, Matt GE. Timing of breast cancer surgery, menstrual phase, and prognosis: Systematic review and meta-analysis. Crit Rev Oncol Hematol 2016; 102:1-14. [PMID: 27066938 DOI: 10.1016/j.critrevonc.2016.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 01/05/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND For over 25 years, there has been a debate revolving around the timing of breast cancer surgery, menstrual cycle, and prognosis. METHODS This systematic review synthesizes and evaluates the body of evidence in an effort to inform evidence-based practice. A keyword and reference search was performed in PubMed and Web of Science to identify human studies that met the inclusion criteria. A total of 58 studies (48 international and 10 U.S.-based) were identified. We provided a narrative summary on study findings and conducted a meta-analysis on a subset of studies where quantitative information was available. RESULTS Findings from both qualitative and quantitative analyses were inconclusive regarding performing breast cancer surgery around a specific phase of the menstrual cycle. CONCLUSION Based on the Institute of Medicine criteria, evidence is insufficient to recommend a change in current primary breast cancer surgery practice based on menstrual phase.
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Affiliation(s)
- Hillary Klonoff-Cohen
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, United States.
| | - Ruopeng An
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, United States
| | | | - Jennifer Le
- Department of Kinesiology and Community Health University of Illinois at Urbana-Champaign, United States
| | - Georg E Matt
- Department of Psychology, San Diego State University, United States
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Samuel M, Wai KL, Brennan VK, Yong WS. Timing of breast surgery in premenopausal breast cancer patients. Cochrane Database Syst Rev 2011; 2011:CD003720. [PMID: 21563138 PMCID: PMC8407059 DOI: 10.1002/14651858.cd003720.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The majority of women diagnosed with breast cancer undergo a multidisciplinary treatment with surgical intervention and radiotherapy or chemotherapy, or both. The importance of timing of tumour removal in relation to the menstrual cycle and its influence on disease-free survival and overall survival has been studied by researchers since 1989 but still remains speculative. OBJECTIVES To determine if surgery performed either during the follicular or luteal phase of the menstrual cycle affects the overall and disease-free survival of premenopausal breast cancer patients. SEARCH STRATEGY We searched the Cochrane Breast Cancer Group Trials Register (January 2009), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to January 2009), EMBASE (1974 to September 2006) and the WHO International Clinical Trials Registry Platform (ICTRP) search portal (July 2010). We checked references of articles and communicated with authors. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing breast surgery during the follicular phase of the menstrual cycle with the luteal phase in premenopausal women. Prospective non-RCTs or observational studies were considered if randomised studies were lacking. DATA COLLECTION AND ANALYSIS Three authors independently extracted data and assessed trial quality. MAIN RESULTS Completed randomised trials were not found. There is one trial that is currently ongoing in Italy; the results have yet to be published.Two prospective observational studies had data on recurrence-free survival. One study reported an odds ratio for recurrence rate at one year (where > 1 favours the luteal phase) of 0.86 (95% confidence interval (CI) 0.69 to 1.08); 0.87 at two years (95% CI 0.69 to 1.09); 0.95 at three years (95% CI 0.75 to 1.21); 1.12 at four years (95% CI 0.87 to 1.43); and 1.12 at five years (95% CI 0.87 to 1.43). Another study reported a hazard ratio for overall survival of 1.02 (95% CI 0.995 to 1.04, P = 0.14) and for disease-free survival of 1.00 (95% CI 0.98 to 1.02, P = 0.92) at three years based on the last and first menstrual period. The results were not significant. There was no difference in the recurrence rate whether the surgery was done during the follicular or luteal phase of the menstrual cycle. AUTHORS' CONCLUSIONS In the absence of RCTs, this review provides evidence from large prospective observational studies that timing of surgery does not show a significant effect on survival.
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Affiliation(s)
- Miny Samuel
- Research Triangle Institute-Health Solutions, Williams House, Lloyd Street North, Manchester Science Park, Manchester, UK, M15 6SE
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Kroman N. Timing of breast cancer surgery in relation to the menstrual cycle--the rise and fall of a hypothesis. Acta Oncol 2009; 47:576-9. [PMID: 18465325 DOI: 10.1080/02841860801958287] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
It has been claimed that the timing of surgery in relation to the menstrual cycle can significantly influence the prognosis among premenopausal women with primary breast cancer. The literature on the subject is reviewed. The results are heterogeneous, and the quality of the studies is in general low. Many studies suffer from statistical problems concerning small sample sizes and sub-group analyses. In all, the scientific basis for the hypothesis seems weak.
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Elkum NB, Myles JD, Kumar P. Analyzing biological rhythms in clinical trials. Contemp Clin Trials 2008; 29:720-6. [PMID: 18571991 DOI: 10.1016/j.cct.2008.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 05/06/2008] [Accepted: 05/13/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND The human body exhibits a variety of biological rhythms. There are patterns that correspond, among others, to the daily wake / sleep cycle, a yearly seasonal cycle and, in women, the menstrual cycle. Sine/cosine functions are often used to model biological patterns for continuous data, but this model is not appropriate for analysis of biological rhythms in failure time data. METHODS We consider a method appropriate for analysis of biological rhythms in clinical trials. We present a method to provide an estimate and confidence interval of the time when the minimum hazard is achieved. A motivating example from a clinical trial of adjuvant of pre-menopausal breast cancer patients provides an important illustration of the methodology in practice. RESULTS Adapting the Cosinor method to the Weibull proportional hazards model is proposed as useful way of modeling the biological rhythm data. It presents a method to estimate the time that achieves the minimum hazard along with its associated confidence interval. The application of this technique to the breast cancer data revealed that the optimal day for pre-resection incisional or excisional biopsy of 28-day cycle (i.e. the day associated with the lowest recurrence rate) is day 8 with 95% CI 5-10. We found that older age, fewer positive nodes, smaller tumor size, and experimental treatment are important prognostic factors of longer relapse-free survival. CONCLUSIONS The analysis of biological/circadian rhythms is usually handled by Cosinor rhythmometry method. However, in FTD this is simply not possible. In this case, we propose to adapt the Cosinor method to the Weibull proportional hazard model. The advantage of the proposed method is its ability to model survival data. This method is not limited to breast cancer data, and may be applied to any biological rhythms linked to right censored data.
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Affiliation(s)
- Naser B Elkum
- King Faisal Specialist Hospital and Research Center, Kingdom of Saudi Arabia
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Elkum NB, Myles JD. Modeling biological rhythms in failure time data. J Circadian Rhythms 2006; 4:14. [PMID: 17090302 PMCID: PMC1654184 DOI: 10.1186/1740-3391-4-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 11/07/2006] [Indexed: 11/18/2022] Open
Abstract
Background The human body exhibits a variety of biological rhythms. There are patterns that correspond, among others, to the daily wake/sleep cycle, a yearly seasonal cycle and, in women, the menstrual cycle. Sine/cosine functions are often used to model biological patterns for continuous data, but this model is not appropriate for analysis of biological rhythms in failure time data. Methods We adapt the cosinor method to the proportional hazards model and present a method to provide an estimate and confidence interval of the time when the minimum hazard is achieved. We then apply this model to data taken from a clinical trial of adjuvant of pre-menopausal breast cancer patients. Results The application of this technique to the breast cancer data revealed that the optimal day for pre-resection incisional or excisional biopsy of 28-day cycle (i. e. the day associated with the lowest recurrence rate) is day 8 with 95% confidence interval of 4–12 days. We found that older age, fewer positive nodes, smaller tumor size, and experimental treatment were predictive of longer relapse-free survival. Conclusion In this paper we have described a method for modeling failure time data with an underlying biological rhythm. The advantage of adapting a cosinor model to proportional hazards model is its ability to model right censored data. We have presented a method to provide an estimate and confidence interval of the day in the menstrual cycle where the minimum hazard is achieved. This method is not limited to breast cancer data, and may be applied to any biological rhythms linked to right censored data.
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Affiliation(s)
- Naser B Elkum
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia
| | - James D Myles
- Clinical Statistics, Pfizer Global Research and Development (PGRD), Ann Arbor Laboratories, Ann Arbor, MI 48105, USA
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Chaudhry A, Puntis ML, Gikas P, Mokbel K. Does the timing of breast cancer surgery in pre-menopausal women affect clinical outcome? An update. INTERNATIONAL SEMINARS IN SURGICAL ONCOLOGY 2006; 3:37. [PMID: 17078874 PMCID: PMC1635554 DOI: 10.1186/1477-7800-3-37] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Accepted: 11/01/2006] [Indexed: 11/17/2022]
Abstract
There is some evidence that breast cancer surgery during the luteal phase in pre-menopausal women is associated with a better clinical outcome, however the evidence for this is still equivocal. In this paper, after summarizing the normal physiology of the menstrual cycle, we examine how such an association may occur and provide a comprehensive review of the literature in the area.
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Affiliation(s)
- Anushka Chaudhry
- Dept. of Breast Surgery, St George's Hospital, University of London, Tooting, UK
| | - Michael L Puntis
- Dept. of Breast Surgery, St George's Hospital, University of London, Tooting, UK
| | - Panos Gikas
- Dept. of Breast Surgery, St George's Hospital, University of London, Tooting, UK
| | - Kefah Mokbel
- Dept. of Breast Surgery, St George's Hospital, University of London, Tooting, UK
- The Princess Grace Hospitals, 42-52 Nottingham Place, London W1M 3FD, UK
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You S, Li W, Kobayashi M, Xiong Y, Hrushesky W, Wood P. CREATION OF A STABLE MAMMARY TUMOR CELL LINE THAT MAINTAINS FERTILITY-CYCLE TUMOR BIOLOGY OF THE PARENT TUMOR. ACTA ACUST UNITED AC 2004; 40:187-95. [PMID: 15161341 DOI: 10.1290/1543-706x(2004)40<187:coasmt>2.0.co;2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A mammary tumor cell line, designated MTCL, was successfully established from a mouse primary mammary tumor (MTP). The MTCL cells retain cytokeratin and both estrogen receptor (ER) and progesterone receptor (PR) in vitro. In vitro exposure of MTCL cells to progesterone causes a decrease in the cellular (3)H-thymidine uptake, indicating an inhibition by progesterone on MTCL cellular deoxyribonucleic acid synthesis, whereas exposure of the cells to a high dose of estrogen (15 pg/ml) for 48 h causes an increase of (3)H-thymidine uptake. We inoculated both MTP or MTCL tumor cells into normal cycling female C(3)HeB/FeJ mice and demonstrated that the post-resection metastatic recurrence of MTCL tumors, like the original MTP tumors, depends on the time of tumor resection within the mouse estrous-cycle stage. Both MTCL and MTP tumors have similar histological appearances with the exception of less extensive tumor necrosis and higher vascularity in MTCL tumors. Equivalent levels of sex hormone receptors (ER alpha, ER beta, and PR), epithelial growth hormone receptors (Her2/neu, EGFR1), tumor suppressors (BRCA1, P53), and cell apoptosis-relevant protein (bcl-xl) were found in these in vivo tumors by immunohistochemistry. Cyclin E protein, however, was significantly higher in MTP tumors compared with MTCL tumors. Our results indicate that MTCL cells retain many of the biologic features of the original MTP primary tumor cells, and to our knowledge, it is the first in vitro cell line that has been shown to maintain the estrous-cycle dependence of in vivo cancer metastasis.
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Affiliation(s)
- Shaojin You
- Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, 6439 Garners Ferry Road, Columbia, South Carolina 29209, USA
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