An investigation of the apparent breast cancer epidemic in France: screening and incidence trends in birth cohorts

Incidence of other cancer diagnoses in women with breast cancer: a retrospective cohort study with 42,248 women

PURPOSE

The aim of the present study was to determine whether women diagnosed with breast cancer (BC) have an increased incidence of other cancers, e.g., gastric cancer, lung cancer, skin cancer, and so on, compared to healthy women without a breast cancer diagnosis.

METHODS

This retrospective cohort study was based on data from the Disease Analyzer database (IQVIA) and included adult women with an initial diagnosis of BC documented in one of 1,274 general practices in Germany between January 2000 and December 2018. Women with BC were matched to women without cancer by age, index year, yearly consultation frequency, and co-diagnoses. Univariate Cox regression models were used to study the association between BC and the incidence of other cancer diagnoses.

RESULTS

21,124 women with BC and 21,124 women (mean age: 63 years) without cancer were included. Within 10 years of the index date, 14.3% of women with BC and 10.0% of women without cancer were diagnosed with cancer (p < 0.001). BC was significantly associated with the incidence of other cancer diagnoses (HR: 1.42, p < 0.001). The strongest association was observed for respiratory organ cancer (HR = 1.69, p < 0.001), followed by female genital organ cancer (HR = 1.61, p < 0.001) and cancer of lymphoid and hematopoietic tissue (HR: 1.59, p < 0.001).

CONCLUSION

The results of this study show that women with BC have an increased incidence of another cancer compared to women without cancer. Therefore, it is important to pay particular attention to the development of other malignancies during follow-up in patients with BC. This should be considered especially in patients with a proven genetic mutation.

Effects of fertility on breast cancer incidence trends: comparing France and US

PURPOSE

Breast cancer incidence rates are now higher in France than most other European countries as well as the United States (US). Increasing breast cancer incidence rates globally have often been attributed to declining fertility rates.

METHODS

We compared temporal trends in breast cancer incidence in France and the US, and examined the extent temporal trends in national fertility rates can explain the temporal trends in breast cancer incidence. This study of temporal trends used estimates of annual percent change (APC) from cancer registry data in France and the US (1978-2016) and national fertility data (1958-2011). We estimated the APCs for all ages (overall APC) and for specific age groups (under 50, 50-64 years, and 65 years and over).

RESULTS

The overall APC was over three times higher in France than the US (France APC = 1.63%, 95% CI 1.43-1.84; US APC = 0.51, 95% CI 0.31-0.72). The overall APCs remained positive and statistically significant after adjusting for fertility trends irrespective of assumptions on fertility lags (France APC = 1.61-0.91 for a 5-year to 20-year lag, respectively; US APC = 0.37-0.36 for a 5-year to 20-year lag, respectively). Similarly, among women under 50, the APC was over 3.5 times higher in France than the US (France APC = 1.22, 95% CI 1.07-1.37; US APC = 0.33, 95% CI 0.22-0.44), and APCs remained positive after adjusting for fertility (France APC = 1.21-1.28 for a 5-year to 20-year lag, respectively; US APC = 0.38-0.26 for a 5-year to 20-year lag, respectively).

CONCLUSIONS

Based on these trend analyses, changes in fertility rate trends do not fully explain the increase incidence in breast cancer seen in both France and the US, nor the magnitude of difference between the two countries. This was seen overall and in age-specific groups.

Breast Cancer Incidence Trends in Isfahan Province Compared with those in England over the Period 2001-2013

BACKGROUND

Figures from Iranian cancer registries indicate that Isfahan ranks first in female breast cancer incidence. Although few previous studies have examined whether the breast cancer incidence trend in Isfahan province has increased over a given period of time, this study employed a joint point regression analysis to answer the same question. Moreover, it compared the data of Isfahan province, from a developing country, with those of England, as a representative of developed countries, and tried to explain the causes of the differences observed between the trends.

METHODS

This repeated cross-sectional study was conducted on the data of 6057 women in Isfahan province and of 141,011 women in England with breast cancer over the years 2001-2013. The incidence rates were calculated using direct standardization method and based on the 2013 standard European population. For an analysis of the trends in breast cancer incidence rates, Joint Point Regression program, version 4.3.1.0, released in April 2016, was employed.

RESULTS

The mean age-standardized incidence rate (ASR) was calculated to be 34.7 per100,000 population over the years 2001 to 2013, which indicated an increase from 22 to 68 in Isfahan province. The corresponding mean ASR for England has also risen from 147.5 to 170.1 per 100,000 women during the same time period. The average annual percentage changes (AAPCs) for Isfahan and England were also calculated to be 9.6 and 1.1, respectively. This indicated an increasing trend in breast cancer incidence rates for Isfahan province over the period in question.

CONCLUSIONS

The drastic discrepancy in breast cancer incidence rates between these two regions may be attributed to differences in an improved cancer registry system in Iran and women's developing awareness of the cancer over time.

Behavior of Japanese women after being informed about the benefits and disadvantages of breast cancer screening: a questionnaire survey

BACKGROUND

The US Preventative Services Task Force assessed the efficacy of breast cancer screening according to the sum of its benefits and disadvantages. We estimate that the balance of the benefits and disadvantages varies among women depending on their demographic background.

METHODS

Between March 2016 and March 2017, we conducted a questionnaire survey among Japanese women who underwent population-based or opportunistic breast cancer screening at our multicenter institutions. We investigated the behavior modification among women after being informed about the benefits and disadvantages of breast cancer screening depending on their demographic background.

RESULTS

Out of 3032 questionnaires that were returned, 2936 (96.8%) were evaluated. The percentage of women with prior knowledge about the benefits and disadvantages of breast cancer screening before reading the leaflets that we created was 24%. However, 95% of the women were willing to undergo screening next time, despite knowing the disadvantages. Regarding overdiagnosis, the young women tended to choose usual treatment, and the elderly women tended to choose active surveillance. In response to the question on the significance of screening, the young women wished to avoid death by breast cancer; whereas, the elderly women wished to live a safe life.

CONCLUSION

Our results indicate that the information of disadvantages does not lead to a reduction in screening rates. Additionally, we found that the balance between the benefits and disadvantages of breast cancer screening varies among women depending on their demographic background, especially age.

The Advent of Salivary Breast Cancer Biomarker Detection Using Affinity Sensors

Breast Cancer is one of the world's most notorious diseases affecting two million women in 2018 worldwide. It is a highly heterogeneous disease, making it difficult to treat. However, its linear progression makes it a candidate for early screening programs, and the earlier its detection the higher the chance of recovery. However, one key hurdle for breast cancer screening is the fact that most screening techniques are expensive, time-consuming, and cumbersome, making them impractical for use in several parts of the world. One current trend in breast cancer detection has pointed to a possible solution, the use of salivary breast cancer biomarkers. Saliva is an attractive medium for diagnosis because it is readily available in large quantities, easy to obtain at low cost, and contains all the biomarkers present in blood, albeit in lower quantities. Affinity sensors are devices that detect molecules through their interactions with biological recognition molecules. Their low cost, high sensitivity, and selectivity, as well as rapid detection time make them an attractive alternative to traditional means of detection. In this review article, we discuss the current status of breast cancer diagnosis, its salivary biomarkers, as well as the current trends in the development of affinity sensors for their detection.

Quantifying Overdiagnosis in Cancer Screening: A Systematic Review to Evaluate the Methodology

Background

Overdiagnosis is the main harm of cancer screening programs but is difficult to quantify. This review aims to evaluate existing approaches to estimate the magnitude of overdiagnosis in cancer screening in order to gain insight into the strengths and limitations of these approaches and to provide researchers with guidance to obtain reliable estimates of overdiagnosis in cancer screening.

Methods

A systematic review was done of primary research studies in PubMed that were published before January 1, 2016, and quantified overdiagnosis in breast cancer screening. The studies meeting inclusion criteria were then categorized by their methods to adjust for lead time and to obtain an unscreened reference population. For each approach, we provide an overview of the data required, assumptions made, limitations, and strengths.

Results

A total of 442 studies were identified in the initial search. Forty studies met the inclusion criteria for the qualitative review. We grouped the approaches to adjust for lead time in two main categories: the lead time approach and the excess incidence approach. The lead time approach was further subdivided into the mean lead time approach, lead time distribution approach, and natural history modeling. The excess incidence approach was subdivided into the cumulative incidence approach and early vs late-stage cancer approach. The approaches used to obtain an unscreened reference population were grouped into the following categories: control group of a randomized controlled trial, nonattenders, control region, extrapolation of a prescreening trend, uninvited groups, adjustment for the effect of screening, and natural history modeling.

Conclusions

Each approach to adjust for lead time and obtain an unscreened reference population has its own strengths and limitations, which should be taken into consideration when estimating overdiagnosis.

Trends in breast cancer incidence among women with type-2 diabetes in British general practice

AIMS

To quantify breast cancer incidence in women with type-2 diabetes and assess age-standardized trends in invasive breast cancer incidence over time and by age groups.

METHODS

A population-based cohort study was conducted using the British general practice database (Clinical Practice Research Datalink) using data from 1989 to 2012. All adult women prescribed anti-hyperglycemic medication were selected and matched (1:1) on age and clinical practice to a reference cohort without diabetes.

RESULTS

During approximately 1.6 million person years (py), 2371 breast cancer cases were diagnosed in the diabetes cohort (n=147,998) and 2252 in the reference cohort (n=147,998). Incidence of breast cancer, overall or by age groups, among women with diabetes remained stable over time. The (overall) age-standardized breast cancer IR per 100,000 py of the diabetes cohort (150, 95%CI:143-157) resembled that observed in the reference cohort (148, 95%CI:141-156); with an incidence rate ratio (IRR) of 1.01 (95%CI:0.94-1.08, p>0.05).

CONCLUSIONS

Currently, around 2880 women with type-2 diabetes are diagnosed with breast cancer per year in the United Kingdom. However, breast cancer incidence remained stable in the last 10 years and seems to be comparable in women with and without diabetes.

Is there a genetic anticipation in breast and/or ovarian cancer families with the germline c.3481_3491del11 mutation?

The aim of the current analysis is to evaluate any differences of breast or ovarian cancer age at diagnosis between mothers and daughters carrying the c.3481_3491del11 mutation in the BRCA1 gene. A study cohort of 38 women carrying the c.3481_3491del11 mutation and affected by first breast or ovarian cancer who reported a first breast or ovarian cancer in their mother carrying the c.3481_3491del11 mutation, was identified in 37 different families including members with breast and/or ovarian cancer at the Oncology Institute of Lorraine. Twelve mothers underwent genetic testing. Twenty-five pairs of the 38 mothers-daughters pairs with c.3481_3491del11 mutation were affected by breast cancer and 13 pairs by ovarian cancer. Clinical and genetic data were collected from medical files and family pedigrees. Analyses were conducted for each cancer type. We investigated an early breast cancer detection effect due to early screening programs and also an increased breast tumor aggression. Since major improvements in breast cancer clinical management and imaging techniques appeared after 1980, we compared the age at breast cancer diagnosis and the age at death in mothers and daughters before and after 1980, first, in the group of women including mothers and daughters taken together and then in mothers and daughters separately. The mean age at breast cancer diagnosis was 45.28 ± 10.27 years in mothers and 39.80 ± 7.79 years in daughters (p = 0.026). The difference of age at ovarian cancer diagnosis in mother-daughter pairs was 8.62 ± 12.76 years (p = 0.032). When considering the group of women including mothers and daughters taken together, no significant difference of age at breast cancer diagnosis was found between women affected before 1980 and those affected after 1980 (p = 0.577). However, the age at death increased in these women after 1980 (p = 0.026). Comparison of age at breast cancer diagnosis in mothers and daughters separately, showed that daughters were affected at an earlier age after 1980 (p = 0.002). Daughters had a poor prognosis and died earlier than mothers after 1980. Our results may have reflected genetic anticipation in c.3481_3491del11 mutation breast and ovarian cancer families. In order to confirm our findings, a larger cohort would provide more precision to the difference of ages at breast or ovarian cancer diagnosis between mothers and daughters and more powerful statistical analyses. Increased aggression in daughters' tumors compared to those of mothers could be also considered as a parameter of genetic anticipation. Complete information on tumor profile and proliferation would allow us to study genetic anticipation by comparing the tumor phenotypes between mothers and daughters in the future.

A qualitative study of women's views on overdiagnosis and screening for thyroid cancer in Korea

Background

The incidence of thyroid cancer in Korea has increased by about 25 % every year for the past 10 years. This increase is largely due to a rising incidence in papillary thyroid cancer, which is associated with an overdiagnosis of small tumors that may never become clinically significant. This study was conducted to explore Korean women’s understanding of overdiagnosis and to investigate changes in screening intention in response to overdiagnosis information.

Methods

Focus group interviews were conducted among women of ages 30–69 years, who are commonly targeted in Korea for cancer screening. Women were divided into four groups according to thyroid cancer screening history and history of thyroid disease. Of 51 women who were contacted, 29 (57 %) participated in the interviews.

Results

Prior awareness of thyroid cancer overdiagnosis was minimal. When informed about the risks of overdiagnosis, the participants were often surprised. Overcoming initial malcontent, many women remained skeptic about overdiagnosis and trusted in the advice of their physicians. Meanwhile, some of the study participants found explanations of overdiagnosis difficult to understand. Further, hearing about the risks of overdiagnosis had limited impact on the participants’ attitudes and intentions to undergo thyroid cancer screening, as many women expressed willingness to undergoing continued screening in the future.

Conclusion

A large majority of Korean women eligible for and had undergone thyroid cancer screening were unaware of the potential for overdiagnosis. Nevertheless, overdiagnosis information generally had little impact on their beliefs about thyroid cancer screening and their intentions to undergo future screening. Further research is needed to determine whether these findings could be generalized to the wider Korean population.

Interval cancer rates in the Irish national breast screening programme

OBJECTIVE

To compare interval cancer rates from the Irish breast screening programme, BreastCheck, for the period 2000-2007 with those from other European countries.

METHODS

Data from BreastCheck was linked to National Cancer Registry breast cancer registrations, to calculate numbers of women screened, screen-detected cancers, and interval cancers, by year of screening, in the first and second years after screening, and by initial or subsequent screen. Estimated underlying cancer incidence from the period 1996-1999 inclusive was used to calculate proportionate incidence. We calculated the interval cancer ratio as an alternative measure of the burden of interval cancers.

RESULTS

There were 372,658 screening records for 178,147 women in the period 2000-2007. The overall interval rate was 9.6 per 10,000 screens. In the first year after screening, the interval cancer rate was 5.8 per 10,000 screens and this increased to 13.4 in the second year after screening. The screen detection rate for the period was 53.6 per 10,000 screened for all screens combined. Initial screens produced a higher detection rate at 66.9 per 10,000 screened compared with subsequent screens with a screen-detected rate of 41.4 per 10,000 screens.

CONCLUSION

Interval breast cancer rates for the first years of the programme are within acceptable limits and are comparable with those in other European programmes. Nationwide roll-out together with the adoption of digital mammography may have an impact on interval cancer rates in future years.

Overdiagnosis: epidemiologic concepts and estimation

Overdiagnosis of thyroid cancer was propounded regarding the rapidly increasing incidence in South Korea. Overdiagnosis is defined as 'the detection of cancers that would never have been found were it not for the screening test', and may be an extreme form of lead bias due to indolent cancers, as is inevitable when conducting a cancer screening programme. Because it is solely an epidemiological concept, it can be estimated indirectly by phenomena such as a lack of compensatory drop in post-screening periods, or discrepancies between incidence and mortality. The erstwhile trials for quantifying the overdiagnosis in screening mammography were reviewed in order to secure the data needed to establish its prevalence in South Korea.

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods

OBJECTIVE

To determine the optimal method for quantifying and monitoring overdiagnosis in cancer screening over time.

DESIGN

Systematic review of primary research studies of any design that quantified overdiagnosis from screening for nine types of cancer. We used explicit criteria to critically appraise individual studies and assess strength of the body of evidence for each study design (double blinded review), and assessed the potential for each study design to accurately quantify and monitor overdiagnosis over time.

DATA SOURCES

PubMed and Embase up to 28 February 2014; hand searching of systematic reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English language studies of any design that quantified overdiagnosis for any of nine common cancers (prostate, breast, lung, colorectal, melanoma, bladder, renal, thyroid, and uterine); excluded case series, case reports, and reviews that only reported results of other studies.

RESULTS

52 studies met the inclusion criteria. We grouped studies into four methodological categories: (1) follow-up of a well designed randomized controlled trial (n=3), which has low risk of bias but may not be generalizable and is not suitable for monitoring; (2) pathological or imaging studies (n=8), drawing conclusions about overdiagnosis by examining biological characteristics of cancers, a simple design limited by the uncertain assumption that the measured characteristics are highly correlated with disease progression; (3) modeling studies (n=21), which can be done in a shorter time frame but require complex mathematical equations simulating the natural course of screen detected cancer, the fundamental unknown question; and (4) ecological and cohort studies (n=20), which are suitable for monitoring over time but are limited by a lack of agreed standards, by variable data quality, by inadequate follow-up time, and by the potential for population level confounders. Some ecological and cohort studies, however, have addressed these potential weaknesses in reasonable ways.

CONCLUSIONS

Well conducted ecological and cohort studies in multiple settings are the most appropriate approach for quantifying and monitoring overdiagnosis in cancer screening programs. To support this work, we need internationally agreed standards for ecological and cohort studies and a multinational team of unbiased researchers to perform ongoing analysis.

[Breast cancer screening program in France: for optimization of the information]

BACKGROUND

Based on international and national recommendations, organized breast cancer screening in France raises questions of medical ethics built around the key concepts of individual autonomy and public health policy. Because of the evolving knowledge, professionals and institutions involved in the program must review the ethical values associated with this medical practice.

METHODS

The ethical aspects of organized breast cancer screening were studied. In response to newly acquired knowledge highlighted by a review of texts governing this practice in France, proposals for changes resulting from reflections of a working group coordinated by the National Cancer Institute are presented.

RESULTS

Ethical issues raised by screening must find expression in the general principles of the program's organization: acceptability of screening, efficiency, adverse effects, equity of access, free care…, but also at different stages of the procedure: information delivery, first and second invitations, refusal of further diagnostic investigation…

CONCLUSION

A better match between breast cancer screening and recently developed knowledge requires optimal information delivery to women targeted by the program as well as a stronger role for the referring healthcare professional.

[Role of GnRH agonists in preserving female fertility]

The impact of cancer treatment on ovarian function and fertility has been known since the 70s. Preservation of fertility is now an important focus of care for patients of reproductive age with cancer. The beneficial role of GnRH agonists in fertility preservation is controversial since the early 2000s. Recent randomized studies come to overturn this role. The POEMS multicenter randomized trial with long-term follow-up is ongoing and will provide results that could help clarify the current uncertain indication of these compounds in this context.

Is there excess mortality in women screened with mammography: a meta-analysis of non-breast cancer mortality

Background

The objective of our meta-analysis and systematic review was to analyze non-breast cancer mortality in women screened with mammography versus non-screened women to determine whether there is excess mortality caused by screening.

Methods

We searched PubMed and the Web of Science up to 30 November 2010. We included randomized controlled trials with non-breast cancer mortality as the main endpoint. Two authors independently assessed trial quality and extracted data.

Results

There was no significant difference between groups at 13-year follow-up (odds ratio = 1.00 (95% CI 0.98 to 1.03) with average heterogeneity I² = 61%) regardless of the age and the methodological quality of the included studies. The meta-analysis did not reveal excess non-breast cancer mortality caused by screening. If screening does have an effect on excess mortality, it is possible to provide an estimate of its maximum value through the upper confidence interval in good-quality methodological studies: up to 3% in the screened women group (12 deaths per 100,000 women).

Conclusions

The all-cause death rate was not significantly reduced by screening when compared to the rate observed in unscreened women. However, mammography screening does not seem to induce excess mortality. These findings improve information given to patients. Finding more comprehensive data is now going to be difficult given the complexity of the studies. Individual modeling should be used because the studies fail to include all the aspects of a complex situation. The risk/benefit analysis of screening needs to be regularly and independently reassessed.

Immediate and delayed effects of mammographic screening on breast cancer mortality and incidence in birth cohorts

BACKGROUND

Trend studies investigating the impact of mammographic screening usually display age-specific mortality and incidence rates over time, resulting in an underestimate of the benefit of screening, that is, mortality reduction, and an overestimate of its major harmful effect, that is, overdiagnosis. This study proposes a more appropriate way of analysing trends.

METHODS

Breast cancer mortality (1950-2009) and incidence data (1975-2009) were obtained from Statistics Netherlands, 'Stg. Medische registratie' and the National Cancer Registry in the Netherlands for women aged 25-85 years. Data were visualised in age-birth cohort and age-period figures.

RESULTS

Birth cohorts invited to participate in the mammographic screening programme showed a deflection in the breast cancer mortality rates within the first 5 years after invitation. Thereafter, the mortality rate increased, although less rapidly than in uninvited birth cohorts. Furthermore, invited birth cohorts showed a sharp increase in invasive breast cancer incidence rate during the first 5 years of invitation, followed by a moderate increase during the following screening years and a decline after passing the upper age limit.

CONCLUSION

When applying a trend study to estimate the impact of mammographic screening, we recommend using a birth cohort approach.

Incidence of breast cancer and estimates of overdiagnosis after the initiation of a population-based mammography screening program

BACKGROUND

There has been growing interest in the overdiagnosis of breast cancer as a result of mammography screening. We report incidence rates in British Columbia before and after the initiation of population screening and provide estimates of overdiagnosis.

METHODS

We obtained the numbers of breast cancer diagnoses from the BC Cancer Registry and screening histories from the Screening Mammography Program of BC for women aged 30-89 years between 1970 and 2009. We calculated age-specific rates of invasive breast cancer and ductal carcinoma in situ. We compared these rates by age, calendar period and screening participation. We obtained 2 estimates of overdiagnosis from cumulative cancer rates among women between the ages of 40 and 89 years: the first estimate compared participants with nonparticipants; the second estimate compared observed and predicted population rates.

RESULTS

We calculated participation-based estimates of overdiagnosis to be 5.4% for invasive disease alone and 17.3% when ductal carcinoma in situ was included. The corresponding population-based estimates were -0.7% and 6.7%. Participants had higher rates of invasive cancer and ductal carcinoma in situ than nonparticipants but lower rates after screening stopped. Population incidence rates for invasive cancer increased after 1980; by 2009, they had returned to levels similar to those of the 1970s among women under 60 years of age but remained elevated among women 60-79 years old. Rates of ductal carcinoma in situ increased in all age groups.

INTERPRETATION

The extent of overdiagnosis of invasive cancer in our study population was modest and primarily occurred among women over the age of 60 years. However, overdiagnosis of ductal carcinoma in situ was elevated for all age groups. The estimation of overdiagnosis from observational data is complex and subject to many influences. The use of mammography screening in older women has an increased risk of overdiagnosis, which should be considered in screening decisions.

Women's views on overdiagnosis in breast cancer screening: a qualitative study

OBJECTIVE

To elicit women's responses to information about the nature and extent of overdiagnosis in mammography screening (detecting disease that would not present clinically during the woman's lifetime) and explore how awareness of overdiagnosis might influence attitudes and intentions about screening.

DESIGN

Qualitative study using focus groups that included a presentation explaining overdiagnosis, incorporating different published estimates of its rate (1-10%, 30%, 50%) and information on the mortality benefit of screening, with guided group discussions

SETTING

Sydney, Australia

PARTICIPANTS

Fifty women aged 40-79 years with no personal history of breast cancer and with varying levels of education and participation in screening.

RESULTS

Prior awareness of breast cancer overdiagnosis was minimal. Women generally reacted with surprise, but most came to understand the issue. Responses to overdiagnosis and the different estimates of its magnitude were diverse. The highest estimate (50%) made some women perceive a need for more careful personal decision making about screening. In contrast, the lower and intermediate estimates (1-10% and 30%) had limited impact on attitudes and intentions, with many women remaining committed to screening. For some women, the information raised concerns, not about whether to screen but whether to treat a screen detected cancer or consider alternative approaches (such as watchful waiting). Information preferences varied: many women considered it important to take overdiagnosis into account and make informed choices about whether to have screening, but many wanted to be encouraged to be screened.

CONCLUSIONS

Women from a range of socioeconomic backgrounds could comprehend the issue of overdiagnosis in mammography screening, and they generally valued information about it. Effects on screening intentions may depend heavily on the rate of overdiagnosis. Overdiagnosis will be new and counterintuitive for many people and may influence screening and treatment decisions in unintended ways, underscoring the need for careful communication.

Breast Cancer Incidence After Risk-Reducing Salpingo-Oophorectomy in BRCA1 and BRCA2 Mutation Carriers

Premenopausal risk-reducing salpingo-oophorectomy (RRSO) in BRCA1/2 mutation carriers effectively reduces ovarian cancer risk, but also reduces breast cancer risk. Breast cancer risk reductions up to 50% have been reported for both BRCA1 and BRCA2 mutation carriers, but recent prospective studies were not able to reproduce this finding for BRCA1 mutation carriers. Breast cancer incidence after RRSO was assessed in a consecutive series of 104 BRCA1 and 58 BRCA2 mutation carriers. On the basis of data from our own centre, and assuming a 50% risk reduction through RRSO at premenopausal age, we expected to find 8 breast cancers (range 6-10) in this population for the reported screening period (532 women-years). In 162 carriers with a median age of 41 years at RRSO, 13 incident breast cancers were diagnosed. In BRCA1 mutation carriers, 12 incident breast cancers were found compared with 5 (range 3-6) expected and in BRCA2 mutation carriers 1 breast cancer was found compared with 3 (range 2-5) expected. Breast cancer incidence after premenopausal RRSO is still high, especially in BRCA1 mutation carriers. Previously reported breast cancer risk reductions up to 50% were not confirmed. As a consequence, continued intensive screening for breast cancer is warranted in BRCA1 and BRCA2 mutation carriers after RRSO.

Effectiveness of water physical therapy on pain, pressure pain sensitivity, and myofascial trigger points in breast cancer survivors: a randomized, controlled clinical trial

OBJECTIVE

To evaluate the effects of an 8-week water physical therapy program on cervical and shoulder pain, pressure sensitivity, and the presence of trigger points (TrPs) in breast cancer survivors.

DESIGN

Randomized, controlled trial.

SETTING

To date, no study has investigated effects of water therapy in breast cancer.

PATIENTS

Sixty-six breast cancer survivors were randomly assigned into two groups: WATER group, who received a water exercise program or CONTROL group who received the usual care treatment for breast cancer.

INTERVENTIONS

The WATER therapy program consisted of 24 sessions (3 times/week over 8 weeks) of low-intensity exercises in a warm pool (32°C). Each session included 10-minute warm-up period; 35 minutes of aerobic, low-intensity endurance, and core stability training; and a 15-minute cool-down period (stretching and relaxation).

OUTCOMES

 Neck and shoulder pain (visual analog scale, 0-100 mm), pressure pain thresholds (PPTs) over C5-C6 zygapophyseal joints, deltoid muscles, second metacarpal, and tibialis anterior muscles, and the presence of TrPs in cervical-shoulder muscles were assessed at baseline and after the 8-week program by an assessor blinded to treatment allocation.

RESULTS

The WATER group demonstrated a between-group improvement for neck pain of -31 mm (95% confidence interval [CI]-49 to -22, P < 0.001; effect size 1.1, 0.81-1.75) and for shoulder-axillary of -19 mm (-40 to -04, P = 0.046; effect size 0.70, 0.14-1.40). Improvements were also noted for PPT levels over C5-C6 joints (between-group differences, affected side: 27.7 kPa, 95% CI 3.9-50.4; unaffected: 18.1 kPa, 95% CI 6.1-52.2). No between-group differences for PPT over the remaining points were observed (P > 0.05). Finally, patients in the WATER program showed a greater reduction of active TrPs as compared with the CONTROL group (P < 0.05).

CONCLUSIONS

 An 8-week water therapy program was effective for improving neck and shoulder/axillary pain, and reducing the presence of TrPs in breast cancer survivors as compared with usual care; however, no significant changes in widespread pressure pain hyperalgesia were found.