Relation of risk of contralateral breast cancer to the interval since the first primary tumour

BACKGROUND

There is no consensus on how to separate contralateral breast cancer (CBC) occurring as distant spread of the primary breast cancer (BC) from an independent CBC.

METHODS

We used standardised incidence ratios (SIRs) to analyse the variations in the risk of CBC over time among 6629 women with BC diagnosed between 1954 and 1983. To explore the most appropriate cutoff to separate the two types of CBC, we analysed the deviance between models including different cutoff points as compared with the basal model with no cutoff date. We also performed a prognostic study through a Cox model.

RESULTS

The SIR was much higher during the first 2 years of follow-up than afterwards. The best cutoff appeared to be 2 years. The risk of early CBC was linked to tumour spread and the risk of late CBC was linked to age and to the size of the tumour. Radiotherapy was not selected by the model either for early or late CBC risk.

CONCLUSION

A clearer pattern of CBC risk might appear if studies used a similar cutoff time after the initial BC.

Randomized trial of adjuvant ovarian suppression in 926 premenopausal patients with early breast cancer treated with adjuvant chemotherapy

PURPOSE

The aim of this multicenter trial was to evaluate the role of ovarian suppression in patients with early breast cancer previously treated with local surgery and adjuvant chemotherapy.

PATIENTS AND METHODS

Nine hundred and twenty-six premenopausal patients with completely resected breast cancer and either axillary node involvement or histological grade 2 or 3 tumors were randomized after surgery to adjuvant chemotherapy alone (control arm) or adjuvant chemotherapy plus ovarian suppression (ovarian suppression arm). Ovarian suppression was obtained by either radiation-induced ovarian ablation or triptorelin for 3 years. The analyses were performed with Cox models stratified by center.

RESULTS

Median follow-up was 9.5 years. Mean age was 43 years. Ninety per cent of patients had histologically proven positive axillary nodes, 63% positive hormonal receptors and 77% had received an anthracycline-based chemotherapy regimen. Ovarian suppression was by radiation-induced ovarian ablation (45% of patients) or with triptorelin (48%). At the time of randomization, all patients had regular menses or their follicle-stimulating hormone and estradiol levels indicated a premenopausal status. The 10-year disease-free survival rates were 49% [95% confidence interval (CI) 44% to 54%] in both arms (P = 0.51). The 10-year overall survival rates were 66% (95% CI 61% to 70%) for the ovarian suppression arm and 68% (95% CI 63% to 73%) for the control arm (P = 0.19). There were no variations in the treatment effect according to age, hormonal receptor status or ovarian suppression modality. However, in patients <40 years of age and with estrogen receptor-positive tumors, ovarian suppression significantly decreased the risk of recurrence (P = 0.01).

CONCLUSIONS

The results of this trial, after at least 10 years of follow-up, do not favor the use of ovarian suppression after adjuvant chemotherapy. The potential beneficial effect in younger women with hormono-dependent tumors should be further assessed.

[Could treatments with beta-blockers be associated with a reduction in cancer risk?]

BACKGROUND

The relationship between the use of anti-hypertensive drugs and cancer risk remains controversial. The main objective of this study was to assess the potential effect of beta-blocker use on cancer risk.

METHODS

In a cohort of 839 patients with cardiovascular disease, followed up prospectively for an average period of 10 years, cancer occurrence was recorded according to the exposure to beta-blockers. The relative risk of cancer associated with beta-blocker use was estimated using a Cox model adjusted on gender and age. Ever- vs never-use of beta-blockers and duration of exposure to the drug were analyzed as time-dependent variables. In addition, the standardized incidence ratios (SIR) were calculated using the corresponding age- and gender-adjusted cancer incidences in the French general population.

RESULTS

A total of 326 beta-blocker users and 513 users of other treatments were included in the cohort. During the follow-up period, representing 8,466 person-years, incident cancer cases were 15 and 59 in beta-blocker ever-users versus never-users, respectively. Using the Cox model, the overall relative risk of cancer was 0.51 (95% confidence interval [95% CI]: 0.29-0.90) in the beta-blocker ever-users versus never-users (p=0.02), with a 6% decrease per year of use (95% CI: 1%-12%; p=0.03). The corresponding SIR ratio between these two groups was 0.44 (95% CI: 0.24-0.76).

CONCLUSION

In this cohort, the beta-blocker treatments appeared to decrease the cancer risk significantly. However, this result should be considered with caution; further work is needed, as some sources of bias associated with this type of epidemiological study cannot be totally excluded.

Late local recurrences in a randomised trial comparing conservative treatment with total mastectomy in early breast cancer patients

BACKGROUND

A randomised trial was conducted comparing wide lumpectomy and breast irradiation with modified radical mastectomy. As the follow-up was long (mean duration 22 years), we analysed the variation in the effect of treatment over time.

PATIENTS AND METHODS

The trial included 179 patients with a breast cancer measuring </=2 cm at macroscopic examination. Eighty-eight patients had breast-conserving surgery and radiotherapy, and 91 underwent mastectomy. All patients had axillary dissection. The analyses were based on Cox models with time-dependent treatment effects.

RESULTS

The effect of treatment on death or metastasis did not vary with time. The risk of local recurrence was lower during the first 5 years for the breast-conserving surgery group as compared with the mastectomy group, but higher after 5 years (P = 10(-4) for a different treatment effect over time). Similar results were found in a database including 1847 patients with small breast tumours at diagnosis. In this analysis, late breast recurrences were also more frequent in the breast-conserving surgery group and this treatment effect was greater among younger patients (</=40 years at the time of diagnosis).

CONCLUSIONS

Late breast recurrences were more frequently observed in younger patients treated with breast-conserving treatment compared with those submitted to mastectomy. These results require confirmation in other randomised studies so that younger patients with early breast cancer can receive adequate counselling and so that a more stringent long-term follow-up policy can be adopted when breast-conserving treatment is planned.

Radiation dose, chemotherapy, hormonal treatment and risk of second cancer after breast cancer treatment

In total, 281 of the 7711 women who were initially treated for breast cancer between 1954 and 1983 at the Gustave Roussy Institute developed a second malignant neoplasm (SMN) other than second primary breast cancer and nonmelanoma skin cancer at least 1 year after breast cancer treatment. We carried out a nested case-control study to determine the overall relationship between the dose of radiotherapy received at a given anatomical site and the risk of SMN at the same site. In total, 75% of the cases of SMN were previously treated by radiotherapy, as compared to 73% of the controls. In the irradiated patients, the median local dose was higher among cases (3.1 Gy) than among controls (1.3 Gy). More than 40% of the irradiated patients received a local dose of less than 1 Gy. A purely quadratic relationship was observed between the dose of radiation received at an anatomical site and the risk of SMN at this site. According to the quadratic model, the excess risk of SMN was 0.2% (95% CI 0.05-0.5%) when the target organ received 1 Gy. This risk did not differ significantly according to age at the time of radiotherapy (<40 vs >or=40 years). The risk of SMN was 6.7-fold higher for doses of 25 Gy or more than in the absence of radiotherapy. No carcinogenic effect of chemotherapy was observed and a dose-effect relationship between the length of tamoxifen treatment and SMN occurrence was found. This relationship was limited to endometrial cancers and did not modify the relationship with radiation dose. Our results suggest that high radiation doses slightly increase the risk of second malignancies after breast cancer.

[Factors associated with weight gain in women using oral contraceptives: results of a French 2001 opinion poll survey conducted on 1665 women]

OBJECTIVES

To study how often women put on weight when on the pill and to analyse the relationship between that gain in weight and the characteristics of the last 2 types of pill that had been used.

PATIENTS AND METHODS

Three thousand six hundred and nine women representative of the French female population, aged 15 to 45, were recruited thanks to a survey that took place in 2001. Our study mainly concerned the 1665 women who were actually taking the pill at the time of the survey. The data were collected from self-questionnaires.

RESULTS

Thirty per cent of women declared to have gained weight since using their latest pill - only one more kg for 4% of them, 2 kg for 10% but 3 kg or more for the remaining 16%. Gain in weight was more frequent with women less than 25 years of age (35%) than with older ones (29%). This gain in weight did not vary according to either the type of pill, which was then used, or the length of time spent in using it, or the age of first using. It was more frequent when found with other side effects such as breast pain, skin disorders or metrorrhaegias; it was less frequent among women who had already been on the pill in the past than among women using an oral contraceptive for the first time (28% vs 34%; P = 0.008). The shorter the taking the latest pill had been, the greater the frequency of gain in weight was (P = 0.005), women who had presented the most side-effects in the past having changed their pill more rapidly than other women. Finally, a gain in weight was found far more often in women who "did" put on weight with their latest pill than in those who "did not" (53% vs 14%; P = 0.0001). All in all, 8% of women who had been previously been taking the pill had given up this method over a weight problem.

DISCUSSION AND CONCLUSION

Putting on weight when on the pill being in the long term independent of the type of patent medicine used, it would seem necessary to orientate new research centred both on a chemical and a biological as well as a nutritional approach, so as to answer one of the major preoccupations of oral contraceptive users to the fullest.

[Oral contraception in France in 2001: results of an opinion poll survey conducted on 3609 women between 15 and 45]

OBJECTIVES

The aim of this study concerning the taking of the pill in France in 2001 was threefold, i.e. to assess its rate as well as its characteristics of use, and to appraise the most frequent side effects as reported by women.

MATERIAL AND METHOD

Three thousand six hundred and nine women representative of the French female population between 15 and 45 years of age were recruited thanks to a survey, which took place in 2001. The data were collected from self-questionnaires.

RESULTS

Women on the whole have quite a good opinion of oral contraception and most of them are convinced of its efficiency. As far as pill tolerance is concerned, opinions do vary, more than half of the women judging that being on the pill is not without side-effects. Though, the rate of use of oral contraceptives has increased by 12% since 1994. Most women (48%) use first and second generation pills and this in all age brackets. Thirty per cent of women aged 30 to 45 keep loyal to the same patent medicine, which they keep using for more than 10 years. Among the side-effects that can be found, two of them--putting on weight (31%) and hydrosodium retention (26%)--are the most frequently quoted, in all age brackets. This accounts for the relatively low ratio of women who find their pill quite satisfactory (58% of the cases).

DISCUSSION AND CONCLUSION

Despite the diversity of all the different patented pills that are available, efforts are still to be made in order to reduce what side-effects are encountered when using them.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Predictive factors for local recurrence in 2006 patients with surgically resected small breast cancer

BACKGROUND

Analyses of predictive factors for local recurrences are important, as an increasing number of patients with early breast cancer opt for a breast-conserving procedure. This study investigates whether factors predictive of local recurrence differ between patients treated with conservative or radical surgery.

PATIENTS AND METHODS

Two thousands and six patients with invasive breast carcinoma (< or =25 mm) were included. Of these patients, 717 were treated conservatively (lumpectomy and breast irradiation) and 1289 were treated with total mastectomy. All patients had axillary dissection and received lymph node irradiation if axillary nodes were positive. Most patients did not receive adjuvant chemotherapy or additive hormonal treatments. The mean duration of follow-up was 20 years. The main end point was the total local recurrence rate. The risk factors of local recurrence were estimated by multivariate analyses and interaction tests were used for intergroup comparisons.

RESULTS

Statistically significant predictive factors for mastectomized patients were histological grade, extensive axillary node involvement (10 nodes or more), and inner quadrant tumors, which were of borderline significance. Young age, however, was not a prognostic indicator for local recurrence. The main statistically significant factor for patients treated with a conservative approach was young age (< or =40 years). These younger patients had a five-fold increased risk of developing a breast recurrence compared with patients older than 60 years.

CONCLUSIONS

Younger patients with early breast cancer treated with breast-conserving surgery should in particular be followed up at regular intervals so that any sign of local failure can be diagnosed early.

c-erbB-2 (HER-2/neu) gene amplification is a better indicator of poor prognosis than protein over-expression in operable breast-cancer patients

Our aim was to compare the prognostic value of c-erbB-2 gene amplification analyzed by Southern blot with that of protein (p185) over-expression measured by immunohistochemistry in 172 patients with operable breast cancer (BC). Amplification and p185 over-expression were found in 31 (18%) and 51 (30%) BCs, respectively. All but 1 of the tumors showed both amplification and over-expression, while 21 (12%) tumors displayed over-expression without amplification. The risk of death associated with c-erbB-2 gene amplification and p185 over-expression was evaluated by multivariate analysis, taking into account tumor size, histoprognostic grade, hormone receptors and axillary node status. During a mean follow-up of 9.5 (+/-2) years, node involvement (p < 0.001), c-erbB-2 gene amplification (p = 0.02) and negative hormone receptors (p = 0.02) were found to be independent prognostic indicators of the risk of death. Over-expression of p185 with no amplification was not correlated with this risk. When the risk of death associated with c-erbB-2 amplification was studied according to chemo- and hormone therapy, no significant difference was observed between subgroups of subjects. Amplification was also associated (p = 0.02) with the risk of multifocal distant metastases (i.e., metastases detected concomitantly in at least 2 sites) and, thus, with BC aggressiveness. These data show the importance of c-erbB-2 gene amplification in predicting the long-term outcome of patients and in selecting eligible patients for c-erbB-2-targeted therapies.

Adjuvant radiotherapy in breast cancer--the treatment of lymph node areas

Adjuvant radiotherapy decreases the risk of locoregional recurrences threefold, according to the results of many randomized trials and overviews. In patients treated with total mastectomy, the risk of local recurrence is mainly related to the number of involved axillary nodes, i.e. about 25%, 35% and 55% at 10 years when 1-3, 4-9 and 10 or more nodes are involved, respectively. In contrast, at 10 years, less than 15% of patients with negative axillary nodes relapse locally. The effect of adjuvant radiotherapy on distant metastases and overall survival is a controversial issue. On the one hand, recent results are compatible with the existence of a mechanism of secondary dissemination generated from locoregional tumor nests. The beneficial effect of radiotherapy can be observed whether with or without adjuvant systemic treatment. On the other hand, a deleterious late toxic effect, mainly cardiac, has also been shown. The importance of improvements in radiation techniques and quality assurance to obtain a positive balance in terms of overall survival is emphasized.

Increased risk of second cancers following breast cancer: role of the initial treatment

OBJECTIVES AND METHODS

The risk of second primary malignancies (SMN) was studied in a cohort of 4,416 one-year survivors of a breast cancer. The role of the menopausal status and of the initial treatment modalities (surgery, radiotherapy, and chemotherapy) was investigated.

RESULTS

Excluding second primary breast cancer and non-melanoma skin cancer, a total of 193 (4.4%) patients developed a SMN between 1973 and 1992, compared with 136 expected (Standardised Incidence Ratio, SIR = 1.4, 95% CI (1.2-1.6)). No trend towards either an increase or a decrease was noted in the SIR with time after treatment (p = 0.2). The greatest increase in the relative risk concerned soft tissue cancers (SIR = 13.0, 95% CI: 6.8-22.3), followed by leukaemia (SIR = 3.1, 95% CI: 1.7-5.0), melanoma (SIR = 2.7, 95% CI: 1.4-4.8), kidney (SIR = 2.5, 95% CI: 1.2-4.5), ovary (SIR = 2.0, 95% CI: 1.2-3.1) and uterine tumours (SIR = 1.9, 95% CI: 1.4-2.5). The SIR was 3.0 (95% CI 1.8-4.7) in women under 40 at the time of the breast cancer, 1.9 (95% CI: 1.4-2.4) in those aged 40-49 and 1.2 (95% CI 1.0-1.4) in those aged 50 or more. In the 2,514 women who had received radiotherapy as initial treatment without chemotherapy, the SIR for all SMN was 1.6 (95% CI: 1.1-2.3) fold higher than in those who had not received radiotherapy as initial treatment.

CONCLUSION

In conclusion, this study confirms the increased risk of second malignancies in women treated for a breast cancer, and particularly in those who were younger at the time of treatment for breast cancer. Our results also suggest that radiotherapy may play a role in the onset of these second lesions.

Variation in the interaction between familial and reproductive factors on the risk of breast cancer according to age, menopausal status, and degree of familiality

BACKGROUND

Studies have found that reproductive factors might have a variable effect on the occurrence of breast cancer (BC) according to the existence or not of a family history of BC. The effect of a family history of BC on the risk of BC may also vary according to the age at diagnosis and the degree of kinship. This may confound the relation between familial risk and reproductive factors. A combined analysis was performed to study the interaction between familial risk and reproductive factors according to degree of familiality, age at interview and menopausal status.

METHODS

The present analysis included 2948 cases and 4170 controls in seven case-control studies from four countries. The combined relative risks were estimated using a Bayesian random-effects logistic regression model.

RESULTS

The main effects of reproductive life factors on the risk of BC are in agreement with previous studies. Two-way interactions between subject's age or menopausal status and a family history of BC were not significant. Although the three-way interaction between age, familial risk and parity was not significant, familial risk seemed to be increased slightly for women with high parity compared with women with low parity in the older age group, and seemed to be slightly decreased for women with high parity compared with women with low parity in younger women. The subject's age also appeared to have an effect on the interaction between familial risk and the age at first childbirth (P = 0.1).

CONCLUSIONS

A possible influence of reproductive and menstrual factors on familial risk of BC has been suggested previously and was also evident in the present study. Three-way interactions between age, family history and parity or age at first childbirth might exist and they merit further investigation.

c-myc, p53 and bcl-2, apoptosis-related genes in infiltrating breast carcinomas: evidence of a link between bcl-2 protein over-expression and a lower risk of metastasis and death in operable patients

Apoptosis is an important physiological process controlled by multiple genes, including c-myc, p53 and bcl-2, and its inhibition may lead to the development of human cancers. In this study, we analyzed expression of the c-myc gene using Northern blot and of the p53 and bcl-2 proteins by immuno-histochemistry in 175 breast tumor specimens obtained from patients with operable breast cancer. We evaluated the relation between expression of these 3 genes and (i) the main usual prognostic factors (tumor size, histo-prognostic grade, hormone receptors and number of positive nodes); (ii) the risk of death and relapse, taking into account these 4 factors, after a mean period of follow-up of 9.5 years (SD 2 years). Over-expression of c-myc, p53 and bcl-2 was observed in 35%, 23% and 63% of tumors, respectively. Over-expression of c-myc was strongly linked to the number of positive nodes (p = 0.0005). p53 protein expression was associated with both high-grade (p = 0.0001) and hormone receptor-negative (p = 0.0001) tumors. In contrast, bcl-2 protein over-expression was associated with the main favorable prognostic factors and, more particularly, with hormone receptor-positive tumors (p = 0.0001). Multivariate analysis, using the Cox model, showed that only 2 factors were independently linked to the risk of death: number of positive nodes, which increased the risk (p = 0.0001), and bcl-2 protein over-expression, which decreased the risk (p = 0.008). When bcl-2 over-expression was studied in relation to nodal status, hormone receptor status and chemo- and hormone therapy, no significant difference was observed between different subgroups of patients. bcl-2 expression was also associated with a significantly lower risk of distant metastasis (p = 0.04). In conclusion, bcl-2 expression characterizes a particular phenotype of breast cancer with a favorable prognosis, and it may therefore be used as a marker of long-term survival. Int. J. Cancer (Pred. Oncol.) 84:562-567, 1999.

Percutaneous progesterone use and risk of breast cancer: results from a French cohort study of premenopausal women with benign breast disease

Percutaneous progesterone topically applied on the breast has been proposed and widely used in the relief of mastalgia and benign breast disease by numerous gynecologists and general practitioners. However, its chronic use has never been evaluated in relation to breast cancer risk. The association between percutaneous progesterone use and the risk of breast cancer was evaluated in a cohort study of 1150 premenopausal French women with benign breast disease diagnosed in two breast clinics between 1976 and 1979. The follow-up accumulated 12,462 person-years. Percutaneous progesterone had been prescribed to 58% of the women. There was no association between breast cancer risk and the use of percutaneous progesterone (RR = 0.8; 95% confidence interval 0.4-1.6). Although the combined treatment of oral progestogens with percutaneous progesterone significantly decreased the risk of breast cancer (RR = 0.5; 95% confidence interval 0.2-0.9) as compared with nonusers, there was no significant difference in the risk of breast cancer in percutaneous progesterone users versus nonusers among oral progestogen users. Taken together, these results suggest at least an absence of deleterious effects caused by percutaneous progesterone use in women with benign breast disease.

Postmastectomy radiotherapy: randomized trials

Postmastectomy radiotherapy decreases threefold the risk of locoregional recurrences according to the results of many randomized trials and overviews. This risk is mainly related to the number of involved axillary nodes (ie, about 25%, 35%, and 55% at 10 years when 1 to 3, 4 to 9, and 10 or more nodes are involved). In contrast, at 10 years, fewer than 15% of patients with negative axillary nodes relapse locally. The effect of postmastectomy radiotherapy on distant metastases and overall survival is a controversial issue. On the one hand, results are compatible with the existence of a mechanism of secondary dissemination generated from locoregional tumor nests. The beneficial effect of radiotherapy may be observed in the absence or presence of adjuvant systemic treatment. On the other hand, a deleterious late toxic, mainly cardiac, effect of radiation has also been shown. This point emphasizes the importance of radiation technique and quality to obtain a positive balance in terms of overall survival.

[Oral contraception and the risk of breast cancer]

The evaluation of carcinologic risks associated with various types of oral contraceptives remains unclear, because the constant evolution of composition and dosages in oestrogen and progestagen of pill. Since the oral contraceptives introduction 30 years ago, numerous epidemiological studies have analysed the association between OC and breast cancer risk. The recent meta-analysis of the Collaborative Group on Hormonal Factors in Breast Cancer provides large results. Original data from 54 studies representing about 90% of the published epidemiological studies were reanalyzed. The main findings are that is a small increase in the risk of having breast cancer diagnosed in current users of combined oral contraceptives and in women who had stopped use in past 10 years but that there is no evidence of an increase in the risk more than 10 years after stopping use. However, the cancers diagnosed in women who had used oral contraceptives are less advanced clinically than the cancers diagnosed in women who had not used them, suggesting a bias of screening in oral contraceptives users. However, the benefice-risk balance of OC is largely positive. The evaluation of third generation of pill is not yet available. Studies of third generation pill use and breast cancer risk are necessary.

Breast-conserving therapy vs mastectomy in early-stage breast cancer: a meta-analysis of 10-year survival

BACKGROUND

The randomized trials comparing breast-conserving therapy (BCT), i.e., surgery and radiation to the breast, with mastectomy in early-stage breast cancer use a variety of protocols. Meta-analysis may assist in understanding the impact of these differences on survival.

PURPOSE

To evaluate the possible variations of the relative efficacy of BCT and mastectomy in terms of overall survival according to tumor size, nodal status, and use of adjuvant radiation therapy.

METHODS

The most recent published results and, where available, updated patient-level data from randomized controlled trials of BCT and mastectomy for early-stage breast cancer were combined in a meta-analysis using a random effects model. Pooled survival rates and odds ratios were generated according to subgroups of nodal status and tumor size. Five- and 10-year odds ratios were also determined according to adjuvant radiation protocol.

RESULTS

The pooled odds ratio comparing 10-year survival for BCT and mastectomy was 0.91. The odds ratios comparing the two treatment regimens were not significant after grouping according to tumor size and nodal status. When more than 50% of node-positive patients in both the mastectomy and BCT arms received adjuvant radiation, both arms had similar survival rates. When less than 50% of node-positive patients in both arms received adjuvant nodal radiation, the odds ratio was 0.69, and patients receiving BCT had a survival advantage.

CONCLUSIONS

Patients allocated to BCT have survival rates at least as high as patients allocated to mastectomy. When all protocols were combined, nodal status and tumor size did not significantly alter the relative survival rates. However, under some conditions, particularly for node-positive patients, BCT may confer a relative survival advantage over mastectomy. In particular, mastectomy without adjuvant radiation appears to be inferior to BCT for node-positive patients.

[Risk of thromboembolism and oral contraceptives]

Four studies recently showed an increased risk of venous thromboembolic events (VTE) in current users of oral contraceptives (OCs). This risk was higher in users of Ocs containing third generation progestagens than in users of Ocs containing levonorgestrel. The excess of VTE attributable to the third generation pills should be about 10 per 100 000 woman-years. Conversely, the risk of death due to cardiovascular disease was not significantly increased in users of third generation pills. In addition, the risk of myocardial infarction associated with these latter types of pill was two-fold lower than the risk associated with the pills containing levonorgestrel, and this decrease was of borderline significance (p = 0.10). The results of these different studies are described and discussed in this paper.

Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group

PURPOSES

A randomized trial was conducted to compare tumorectomy and breast irradiation with modified radical mastectomy. We have analyzed the patterns of failure in each arm of the trial and the prognostic factors that have an independent effect on treatment failures and overall survival.

PATIENTS AND METHODS

The trial included 179 patients with breast cancer of up to 20 mm in diameter at macroscopic examination. Eighty-eight patients had conservative management and 91 a mastectomy. All patients had axillary dissection with frozen-section examination. For patients with positive axillary nodes (N+), a second randomization was performed: lymph node irradiation versus no further regional treatment. Patterns of failure were determined by a competing-risk approach and multivariate analysis. A prognostic-score was determined by multivariate analysis.

RESULTS

Overall survival, distant metastasis, contralateral breast cancer, new primary malignancy, and locoregional recurrence rates were not significantly different between the two surgical groups, or between lymph node irradiation groups. Most recurrences appeared during the first 10 years. Three distinct prognostic groups were determined taking into account age, tumor size, histologic grading, and number of positive axillary nodes.

CONCLUSION

Long-term results support conservative treatment with limited surgery and systematic breast irradiation as a safe procedure for the management of small breast cancers. Four easily obtainable clinical and histologic factors may be combined in a prognostic score that is highly predictive of overall and event-free survival.

[Hormonal replacement therapy in menopause and the risk of breast cancer]

Therapeutic trials comparing hormonal replacement therapy (HRT) with a placebo are rare and bring up non conclusive results. The last meta-analysis reported included 31 non randomized studies. It did not show an increased risk of breast cancer in women treated with HRT, compared with untreated women. However, on and after the 10th year of use, the risk increased significantly, although only slightly. This increase of the risk was restricted to the current users of HRT. The three studies published after the meta-analysis showed controversial results, and did not allow any conclusion. These wide disparities between the studies have highlighted the difficulty in interpreting the results of epidemiological studies.

Familial risk, abortion and their interactive effect on the risk of breast cancer--a combined analysis of six case-control studies

In a previous study in France, we reported that the relative risk of breast cancer associated with a family history of breast cancer was higher in those subjects with a history of abortions. The present study was undertaken to check the existence of this interaction in other studies and to investigate whether the interaction is modified by the time at which abortions occur. Data were obtained from six case-control studies in France, Australia and Russia, with information on family history of breast cancer and abortion for 2693 breast cancer cases and 3493 controls. The interaction effect was estimated in each study separately, then combined using a multivariate weighted average. The relative risk conferred by a family history of breast cancer increased with the number of abortions (1.8 for no abortion, 1.9 for one abortion, 2.8 for two or more). There was a significant interaction between total number of abortions and family history (P = 0.04), but this was no longer significant when adjusted for other risk factors. The familial risk was highest for those who had had an abortion before first childbirth (1.9 for abortion after first childbirth, 2.7 for abortion before first childbirth). The adjusted risk associated with family history was significantly higher in those with an abortion before first childbirth (P = 0.04). Our findings suggest a synergism between familial factors and abortion. The interaction was not substantially modified by the type of abortion (spontaneous or induced) but was modified by the time at which it occurred in relation to first childbirth. This suggests an effect of abortion itself rather than predisposition to abortion. Further studies of breast cancer cases, particularly among BRCA1 gene carriers and their families, could improve our understanding of this effect.

[Women at high risk for breast cancer: can we define a group of women in France who could participate in a prevention trial?]

Each year, more than 10,000 women die of breast cancer in France. Whatever the prevention measures adopted, they must be considered with undivided attention. Three factors are associated with an elevated risk of breast cancer: to be 50 or over, a family history of breast cancer affecting the mother and at least one sister (particularly in the event of early-onset breast cancer), or a personal history of benign proliferative breast disease with cellular atypia. High risk subjects can be defined as those who regroup these three factors, but this definition only applies to a population of 800 women in the entire French population. By broadening the definition of high risk subjects to include those aged 50 or over, who have a benign proliferative breast disease with cellular atypia, and a family history defined as "at least two cases if it concerns their mother or sister; or at least three cases, if it concerns aunts, grandmothers or daughters", the number of women would rise to 40,000 in France. In this high risk population, one in every two women will develop a breast cancer during the next 30 years. We consider therefore it ethically feasible to propose a prevention trial to this group of women in France.

[Pattern of mortality from ovarian cancer in France 1968-1991]

In a recent meta-analysis of three American case-control studies, Whittermore et al found an increased risk of ovarian cancer in women treated for infertility. We have studied the mortality due to ovarian cancer in France between 1968 and 1991 in order to verify whether the use of these treatments could have modified mortality rates during the 24 years period studied. First, we have noted that among the 3175 deaths from ovarian cancer registered in France in 1991, only 136 occurred in women under 45 years of age, and 943 occurred in women between 45 and 59 years of age. We then observed an important geographical diversity with a higher frequency of ovarian cancer in the North of France as compared to the South. Finally, we observed a 72% increase in mortality during the study period. This increase can be entirely explained by the increase in the mortality rates among women over 60 years of age. Among women under 45, the ovarian cancer rate decreased by 24% between 1968 and 1991. Among women between 45 and 59 years of age, these rates increased by only 8% (or about 0.3% per year). These results imply that a possible effect--in terms of public health--of treatment for infertility does not necessarily translate into a significant increase in mortality from ovarian cancer among women under 60 years of age. This result in no way nullifies the role that epidemiological studies have in verifying the accuracy of risks associated with treatments for infertility.

Association of c-erbB2-gene amplification with poor prognosis in non-inflammatory breast carcinomas but not in carcinomas of the inflammatory type

It is now accepted that c-erbB2-gene amplification is correlated with poor clinical outcome for patients, mainly when axillary nodes are invaded. We have confirmed this result by multivariate analysis in 178 patients with non-inflammatory breast cancer followed up for a mean period of 6.8 years (SD, 1.6 years). In addition, we have shown that c-erbB2 amplification, found in 30 (17%) specimens, was associated with a high risk of multiple metastases developing simultaneously. In contrast, for the 67 patients with inflammatory breast carcinoma, the most aggressive type of breast carcinoma, the c-erbB2 amplification detected in 24 (36%) specimens was not found to be associated with a higher risk of death, suggesting that the c-erbB2 gene plays a different role in the progression of these 2 types of breast cancer. Furthermore, our data stress the importance of the methodological approach used to determine gene amplification. Although Southern blot hybridization is a tumour- and time-consuming method not easy to adopt in routine clinical practice, this method remains a reference quantitative method.

Progestogen use and decreased risk of breast cancer in a cohort study of premenopausal women with benign breast disease

A cohort study of 1,150 premenopausal French women with benign breast disease diagnosed in two breast clinics between 1976 and 1979 was carried out to analyse the relationship between progestogen use and the risk of breast cancer. The follow-up accumulated 12,462 person-years. The risk of breast cancer was estimated using a Poisson regression analysis on person-time data and the proportional hazards model. In the latter analysis, cumulated progestogen use and age were considered as time-varying covariables and adjustment was performed on the main risk factors for breast cancer. Neither overall progestogen use nor the duration of use was found to be significantly associated with the risk of breast cancer. When progestogens were classified into two categories according to their hormonal potency (19-nortestosterone derivatives vs other progestogens), 19-nortestosterone derivative use was found to be significantly associated with a lower risk of breast cancer. In the adjusted model, the corresponding risk of breast cancer was 0.48 (95% confidence interval 0.25-0.90). In addition, there was a linear trend in the decrease of the relative risk of breast cancer with the duration of use (P = 0.02). These results do not support the hypothesis that progestogens might increase the breast cancer risk. They suggest, instead, that treatment with 19-nortestosterone derivatives might have a beneficial effect on the risk of breast cancer in women with benign breast disease.

Can breast reconstruction with gel-filled silicone implants increase the risk of death and second primary cancer in patients treated by mastectomy for breast cancer?

An increased risk of cancer and autoimmune disease associated with gel-filled silicone implants has been suggested recently, but these possible detrimental effects have not been adequately studied in patients with breast cancer. In order to evaluate these effects, we have studied 146 patients with breast cancer treated by mastectomy at the Gustave Roussy Cancer Institute between 1965 and 1983 and who received a gel-filled silicone implant for immediate or delayed breast reconstruction between 1976 and 1984. These patients were compared with 146 matched controls with breast cancer who were treated in the same center by mastectomy without breast reconstruction and were matched for age at diagnosis (within 10 years), year of diagnosis (within 3 years), stage, histologic type of the tumor, histopathologic grade, and nodal status. The relative risks of death, relapse, and second primary cancer were estimated by means of the Cox proportional hazards model stratified on age at diagnosis. The risks of distant metastasis and death due to breast cancer were significantly lower in the breast reconstruction group than in the control group. The risks of local recurrence, second breast cancer, and second primary cancer in another site than the breast were not significantly different between the two groups of patients. Our results do not support the hypothesis of a detrimental effect of gel-filled silicone implants either in the course of breast cancer or in the risk of death due to other diseases.

Variations in the risk of breast cancer associated with a family history of breast cancer according to age at onset and reproductive factors

In a case-control study of 495 breast cancer patients and 785 controls between 20 and 56 years of age, the risk of breast cancer associated with a family history of breast cancer was studied according to age and reproductive factors. The familial risk of breast cancer was not significantly modified by age at onset, age at menarche, number of children, age at first full-term pregnancy, menstrual cycle length or age at menopause. However, the familial risk significantly increased with the number of abortions (p < 0.05) and seemed to decrease after a natural menopause (p = 0.08). These results suggest that a familial predisposition to breast cancer exerts the same influence during the first six decades of life, except maybe when there are isolated or repeated events such as abortions or artificially imposed menopause, in which case the risk is apparently greater.

Oral contraceptive use and risk of benign breast disease in a French case-control study of young women

We report the results of a French hospital-based case-control study designed to analyse the relation between the use of oral contraceptives (OC) and the risk of benign breast disease (BBD). The cases were 286 women, each less than 46 years old, with BBD histologically verified between 1982 and 1985. Controls were 382 patients, matched to cases on year of birth and month of interview, and who were hospitalized for a non-malignant disease other than BBD. Odds ratios were estimated by multivariate regression, taking into account level of education, place of residence, family history of breast cancer, age at menarche, number of children, age at first full-term pregnancy and Quetelet index. The risk of BBD was found to decrease significantly with a longer use of OC before the first full-term pregnancy (FFTP), but there was no association between the risk of BBD and the duration of OC use after FFTP. OC use before FFTP reduced the risk of non-proliferative disease, but did not significantly affect the risk of proliferative disease. These results did not depend on the amount of oestrogen (0.05 mg or more vs < 0.05 mg) contained in OC.

Risk factors for failure of immediate breast reconstruction with prosthesis after total mastectomy for breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) after mastectomy represents a clear improvement in the quality of life of patients with breast cancer, but prosthesis removal is relatively frequent. Therefore, it is important to identify risk factors related to this removal.

METHODS

A series of 142 patients treated with mastectomy and IBR at the Institut Gustave-Roussy between January 1976 and December 1988 were studied. Forty-seven had an in situ carcinoma, 93 an infiltrating carcinoma, and 2 a fibrosarcoma. IBR failures were defined as removal of the prosthesis, and early failures as removal during the first 7 weeks after IBR.

RESULTS

The early failure rate was significantly higher in patients with invasive carcinomas or fibrosarcomas than patients with in situ carcinomas (12% versus 0%, P = 0.04). The risk of late IBR failure was significantly higher in patients who had received postoperative radiation therapy than patients who did not (P = 0.0002). However, this increased risk applied only to women in whom the chest wall was exposed to radiation because of a high risk of recurrence.

CONCLUSION

It might be preferable to postpone breast reconstruction for patients with infiltrating breast carcinoma because early complications are not infrequent and could delay adjuvant chemotherapy. Late complications associated with chest wall irradiation could be avoided with the use of alternative techniques such as the transverse rectus abdominis myocutaneous (TRAM) flap procedure.

Oral contraceptive use and risk of cutaneous malignant melanoma in a case-control study of French women

We report the results of a case-control study designed to analyze the relationship between oral contraceptive use (OC) and the risk of cutaneous malignant melonama (MM) in 240 White women under the age of 45. Five French centers participated in the study between February 1982 and January 1987 for periods of eight to 54 months, depending on the center. Cases were 91 consecutive newly diagnosed patients with histologically verified MM. Each case was matched with one or two controls on year of birth, date of interview, and treatment center. Controls were 149 patients with either malignant or nonmalignant disease who came to the center for diagnosis and treatment. Odds ratios (OR) were estimated by multivariate analyses taking into account age at menarche, sunlight exposure, and skin characteristics. No significant relation was found between the risk of MM and the total duration of OC use, age at start of use, and elapsed time since the first OC use. However, when the analysis was restricted to women aged 30-40 years, i.e., those who were able to use OC for 10 years or more, or who had started OC use 15 years or more before the diagnosis, the risk of MM increased significantly with the duration of OC use (P = 0.03). A total of more than 4,000 hours of sunlight exposure, and menarche before the age of 14 also were found to increase significantly the risk of MM (OR = 5.4, 95 percent confidence interval [CI] = 1.6-18.3; and OR = 3.6, CI = 1.0-12.5, respectively).

Latency and time-dependent exposure in a case-control study

Detailed historical data are elicited often from subjects in retrospective studies, yielding time-dependent measures of exposures. Investigation of a hypothesized period of latency can be made by examining disease/exposure relationships in multiple time windows, either along the age or time-before diagnosis axes. We suggest splitting the data into many time intervals and separately fitting regression models to the available data in each interval. Covariances between estimated coefficients from different intervals are empirically estimated, and used for assessing variability of specified functions of the time-specific coefficients. Alternative methods of interval formation and their consequences are discussed. We apply these methods to a French case-control study of oral contraceptive use and cervical cancer incidence, and compare the results to those of standard analyses.

Can internal mammary chain treatment decrease the risk of death for patients with medial breast cancers and positive axillary lymph nodes?

The effect of internal mammary chain treatment on each type of malignant death-related event was analyzed in 1195 patients with operable breast cancer and histologically involved axillary lymph nodes. A group of 135 patients who had no internal mammary chain treatment was compared with a control group of 1060 patients who were treated by surgery and/or postoperative radiation therapy. In a multivariate analysis taking into account age, clinical size of the tumor, histoprognostic grading, and the number of positive axillary lymph nodes, quantitative interaction tests were used to determine whether the effects of internal mammary chain treatment on each type of malignant event were significantly different for patients with a lateral tumor compared with those with a medial tumor. The authors found that the effects of this treatment on the risks of distant metastases and of secondary breast cancer were not the same for the patients with a medial tumor as for those with a lateral tumor. For the untreated patients with a medial tumor, the risks of distant metastases and second breast cancer were, respectively, 1.6 (P = 0.02) and 2.9 (P = 0.02), compared with the treated patients. Conversely, for women with lateral tumor, no difference between the two treatment groups was observed. Thus, internal mammary chain treatment may improve long-term survival rate in patients with a medial tumor and positive axillary lymph nodes essentially by decreasing the risk of development of distant metastases (mainly brain, distant lymph nodes, multiple simultaneous metastases) and/or a secondary breast cancer.

Evidence for a link between certain psychological factors and the risk of breast cancer in a case-control study. Psycho-Oncologic Group (P.O.G.)

The relationship between psychosomatic characteristics and the risk of breast cancer was studied in women aged from 35 to 65 years, presenting with a clinically palpable breast tumor. To permit a double-blind design, the psychosomatic evaluation obtained by a long open-ended interview was completed before any diagnostic procedure. On the basis of this evaluation, the psychosomatician concluded that the patient was at high or low risk of serious disease. Several other psychological parameters were also recorded, and the diagnosis was then established by cytology or histology. Nineteen of the 77 patients finally included in the study had histologically verified breast cancer. The relative risk (RR) of breast cancer associated with psychosomatic factors was estimated by multivariate unconditional logistic regression, taking into account age at interview, family history of breast cancer, parity and age at first delivery. A significant relationship (p = 0.02) was found between psychosomatic prognosis and the relative risk of breast cancer. Both the low and high risk groups identified by the psychosomaticians had a similar mean age (46.1 versus 47.6 years). Fundamental mental structure played a predominant role in the risk of breast cancer, since no case was observed among the 18 patients with well organized neurosis, and all the 19 malignant tumors were observed among patients with poorly organized neurosis or psychosis (RR = 7.8, p = 0.009). In addition, excessive self-esteem (RR = 10.0, p = 0.02), hysterical disposition (RR = 7.5, p = 0.02), and unresolved recent grief (RR = 8.2, p = 0.05), were found to be significantly related to the risk of breast cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for breast cancer according to age at diagnosis in a French case-control study

In a French case-control study of 1010 women with breast cancer and 1950 controls with nonmalignant disease, the variations of the effects of 8 risk factors for breast cancer as a function of age at diagnosis, were analysed by tests of homogeneity and trend. The risks associated with a late age at first full-term pregnancy and with nulliparity were different between age-groups (test of homogeneity: p = 0.03), and the highest risks for these two factors were observed in women 45-54 years old. The risks associated with Quetelet index were also found to vary with age at diagnosis (test for trend: p = 0.008). A high Quetelet index decreased the risk of breast cancer in the younger age-groups; this decrease of risk became progressively less important with advancing age, and no such effect was found in the oldest age-group. Inverse results were observed for a tall stature (test for trend: p = 0.04): a tall stature increased the risk of breast cancer in the younger age-groups, and the figures suggested a reverse effect in the oldest group. No large variation with age was found for the effects of age at menarche, history of breast cancer death in mother or sisters, prior biopsy for benign breast disease, and weight. In conclusion, the relative importance of certain risk factors for breast cancer is closely related to age at diagnosis. Nulliparity and a late age at first birth appear to be major risk factors only for middle-aged women, whereas a low Quetelet index and a tall stature appear to increase the risk of breast cancer only for younger women.

Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer

A randomized trial was conducted at the Institut Gustave-Roussy (IGR) between 1972 and 1980 comparing tumorectomy and breast irradiation with modified radical mastectomy. One hundred and seventy-nine patients with an infiltrating breast carcinoma up to 20 mm in diameter at macroscopic examination were included: 88 had conservative management, and 91 a mastectomy. All patients had a low-axillary dissection with immediate histological examination. For the patients with positive axillary nodes, a complete axillary dissection was undertaken. Overall survival, distant metastasis, contralateral breast cancer and locoregional recurrence rates were not significantly different between the two treatment groups.

Characteristics of reproductive life and risk of breast cancer in a case-control study of young nulliparous women

Between 1982 and 1985, a case-control study of nulliparous women, aged 25-45, was conducted to analyse the relationships between the risk of breast cancer and causes of nulliparity, including contraceptive methods. Fifty-one cases of breast cancer diagnosed less than 3 months before interview were matched with 95 controls on age at diagnosis, year of interview, and medical center. The causes of nulliparity related to female sterility or subfertility (mechanical or hormonal disorders) were not found to be associated with a significantly higher risk of breast cancer. The causes related to fertilization failure, i.e. no sexual partner, rare sexual intercourse (less than once per month), or partner with abnormal semen, were found to lead to an increased risk. Detailed analysis of contraceptive methods showed that the risk of breast cancer increased (p = 0.02) with a longer duration of use of barrier methods (withdrawal or condom). Conversely, the risk significantly decreased (p = 0.004) with a longer duration of use of non-barrier methods (oral contraceptives, IUD, cap, local spermicides, vaginal douche, safe period, or no method), i.e. methods allowing a direct exposure to human semen.

Long-term effect of internal mammary chain treatment. Results of a multivariate analysis of 1195 patients with operable breast cancer and positive axillary nodes

A multivariate analysis on 1195 patients with operable breast cancer and histologically positive axillary nodes treated by mastectomy and complete axillary dissection at the Institut Gustave-Roussy between 1958 and 1978 suggests a beneficial effect of treatment of the internal mammary chain (IMC) on the risks of death and distant metastasis for the patients with medial tumors. For these patients, surgical IMC dissection and post-operative irradiation have similar effects on both the risk of death and of distant metastasis. For the patients with lateral tumors, no beneficial effect of the treatment of the IMC on these two risks was observed. Postoperative irradiation to the IMC, axilla, chest wall and supraclavicular nodes significantly decreases the risk of locoregional recurrences independent of the tumor site and surgical management of the lymph nodes.

Is it useful to remove internal mammary nodes in operable breast cancer?

From September 1963 to January 1968, 243 patients with operable breast cancer were included in a randomized trial designed to compare classical radical mastectomy (RM) alone to extended mastectomy (EM), i.e. RM plus internal mammary dissection. One hundred and seventeen patients underwent RM, and 126 EM. After a mean follow-up time of 20 years, no significant differences were observed between the two treatment groups for overall survival, for the relapse-free survival rates, nor for distant metastasis, or locoregional recurrence rates. From a regression model, significant interactions were found between risk of death, EM, and both nodal status and site of the tumour. When compared to RM, EM significantly decreased the risk of death for patients with internal or medial tumour and positive axillary nodes (P = 0.05). No beneficial effect of EM was observed for any of the other patients; on the contrary, EM seemed to increase the risk of death for the patients with external tumour and negative axillary nodes (P = 0.07).

C-myc proto-oncogene expression and prognosis in early carcinoma of the uterine cervix

Expression of the c-myc gene was studied by northern blot and slot blot hybridisation in 72 specimens of stage I or II squamous cell carcinoma of the uterine cervix. In 25 of the 72 tumours c-myc proto-oncogene was overexpressed (ie, at levels 4-20 times higher than in normal tissues). Patients whose tumours showed c-myc overexpression had an eight-fold greater incidence of early relapse than the other patients (p = 0.001). The 18-month relapse-free survival rates were, respectively, 49% and 90% for these two groups of patients.

Consumption of dairy produce and alcohol in a case-control study of breast cancer

In a French case-control study of 1,010 breast cancer cases and 1,950 controls with nonmalignant diseases, the risk of breast cancer was found to be positively associated with frequency of cheese consumption and the level of fat in the milk consumed. A negative association was found between frequency of yogurt consumption and the risk of breast cancer. No association was found between the consumption of butter and the risk of breast cancer. The positive association between a daily consumption of alcohol and the risk of breast cancer previously reported was not altered when dairy produce consumption was taken into account.