Decision aid on breast cancer screening reduces attendance rate: results of a large-scale, randomized, controlled study by the DECIDEO group

Controversies regarding the benefits of breast cancer screening programs have led to the promotion of new strategies taking into account individual preferences, such as decision aid. The aim of this study was to assess the impact of a decision aid leaflet on the participation of women invited to participate in a national breast cancer screening program. This Randomized, multicentre, controlled trial. Women aged 50 to 74 years, were randomly assigned to receive either a decision aid or the usual invitation letter. Primary outcome was the participation rate 12 months after the invitation. 16 000 women were randomized and 15 844 included in the modified intention-to-treat analysis. The participation rate in the intervention group was 40.25% (3174/7885 women) compared with 42.13% (3353/7959) in the control group (p = 0.02). Previous attendance for screening (RR = 6.24; [95%IC: 5.75-6.77]; p < 0.0001) and medium household income (RR = 1.05; [95%IC: 1.01-1.09]; p = 0.0074) were independently associated with attendance for screening. This large-scale study demonstrates that the decision aid reduced the participation rate. The decision aid activate the decision making process of women toward non-attendance to screening. These results show the importance of promoting informed patient choices, especially when those choices cannot be anticipated.

[HPV prophylactic vaccine coverage in France: Results of a survey among high school and university students in Marseilles' area]

OBJECTIVE

To assess HPV prophylactic vaccine coverage among French high school and university students as well as their level of education about this vaccine.

PATIENTS AND METHODS

An anonymous survey was conducted among 2500 high school and university students from the area of Marseilles, France, from December 2009 to April 2010.

RESULTS

A total of 2018 questionnaires were collected (80.7% participation rate). Mean age of participants was 20 years (range, 15-45 years). Only 671 (35.4%) participants reported having been vaccinated against HPV, of whom 510 (73.4%) had completed the three injections scheme. Practice of cytological cervical cancer screening was not significantly influenced by vaccination status. Thus, 578 (45.2%) participants who had not been vaccinated already had had a cervical cytology performed, versus 295 (43.3%) vaccinated ones (P=0.445). Among those not being vaccinated, 671 (49.8%) fulfilled criteria for a catch-up vaccination, of whom only 325 (48.4%) agreed for such a catch-up. Main reasons given for refusal for a catch-up vaccination were the lack of information about HPV vaccine and fear of side effects. In total, 1722 (90%) considered themselves as educated about the HPV vaccine. Source of education was attributed to doctors and media by 54.4% and 53.7% of participants, respectively. Educational role attributed to school and university was poor (3.4%).

CONCLUSION

Despite apparent satisfactory level of education, HPV prophylactic vaccine coverage among high school and university students appears to be insufficient.

[Patients' preferences and decision-making: state of the art and applications in cancer]

BACKGROUND

This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients' rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process' in breast cancer, our research area.

METHODS AND RESULTS

We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients' preferences elicitation, which not only increases patients' knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management.

CONCLUSION

Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.

Seeking a second opinion: Do patients need a second opinion when practice guidelines exist?

INTRODUCTION

Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons?

METHODS

We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion.

RESULTS

We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case.

SUMMARY AND CONCLUSION

We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.

Prognosis of early-onset breast cancer based on BRCA1/2 mutation status in a French population-based cohort

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Background: The debate concerning poorer survival for patients with breast cancer (BC) carrying a BRCA1 germline mutation is unresolved, and requires additional data from population-based studies. Methods: We followed 232 women with invasive BC under age 46, ascertained prospectively through a French population-based BC registry, and tested for BRCA1/2 mutations (median follow-up: 82 months). We compared tumour characteristics and survival rates between 21 BRCA1/2 deleterious mutation carriers and 211 non-carriers. Results: As compared to sporadic tumours, BRCA1/2 tumours showed higher grade (p = 0.02), fewer ductal carcinoma in situ (p = 0.02), more frequent medullary histology (p = 0.02), more frequent negative oestrogen and progesterone receptors (p = 0.001 each). At five years, BC-specific survival, metastasis-free survival, ipsilateral recurrence-free survival and contralateral BC-free survival rates for BRCA1/2 mutation carriers were 95.0%, 94.7%, 100% and 90.0% respectively, compared with 89.6%, 78.2%, 88.8% and 94.4% respectively, for non-carriers (not significant). Rates for women carrying only a BRCA1 mutation were 93.3%, 93.3%, 100%, 86.7%, respectively. 76% of BRCA1/2 carriers received chemotherapy. Conclusions: Despite unfavourable tumour features, we found no evidence for poorer short-term survival in BRCA1 mutation carriers compared to non-carriers in this prospective population-based cohort. The high rate of BRCA1 carriers who received chemotherapy for their BC should question the positive impact of this treatment, as suggested by preclinical studies showing increased chemosensitivity of BRCA1-associated tumours.

No significant financial relationships to disclose.

Participation secondaire des femmes au dépistage organisé du cancer du sein

BACKGROUND

In France, breast cancer is the most frequently occurring cancer and the leading cause of cancer deaths in women. Breast cancer screening has been shown to reduce breast cancer mortality by 30% provided attendance rate is 70% and re-screening interval is two to three years. Maintaining a high rate of reattendance is also important. The decline with time of completion rates of re-screening will lessen the benefits of a breast cancer screening program.

METHODS

A review of published studies examining factors associated with attendance and reattendance to breast cancer screening.

RESULTS

Positive views about initial screening are determining factors in reattendance: mammography should not be painful and embarrassing, appointments should be punctual and clinic staff courteous and supportive. Psychological factors influencing attendance also influence reattendance as does intention to participate, a major predictor of repeat participation and as do perceived susceptibility of breast cancer, perceived benefits of mammography, absence of emotional barriers. These factors can be modified by experience of previous screening. Other predicting factors of attendance continue to influence reattendance: practice of other preventive health behaviors, outside support from physicians, knowledge of breast cancer and screening.

CONCLUSION

A better understanding of factors influencing attendance is necessary to increase the impact of breast cancer screening. Field studies are necessary to support the elaboration of publicity campaigns aimed at increasing participation.

Dendritic cell infiltration and prognosis of early stage breast cancer

PURPOSE

Although dendritic cells (DC) and T cells can infiltrate primary breast carcinoma, it remains unclear whether the immune response influences the clinical outcome.

EXPERIMENTAL DESIGN

T lymphocytes and DC infiltration within primary tumors was investigated in 152 patients with invasive nonmetastatic breast cancer. CD1a, CD3, CD68, CD123, CD207/Langerin, and CD208/DC-LAMP expression was assessed with semiquantitative immunohistochemical analysis. Expression of chemokines involved in DC migration (MIP-3a/CCL20, MIP-3b/CCL19, and 6Ckine/CCL21) was also examined. The correlation between these markers and the characteristics of the tumors, as well as relapse-free and overall survival was analyzed. Significant prognostic parameters were then tested in a validation series.

RESULTS

Infiltration by immature CD207/Langerin+ DC was found in a third of the cancers and did not correlate with clinicopathological data. Presence of mature CD208/DC-LAMP+ DC (56%) and CD3+ T cells (82%) strongly correlated with lymph node involvement and tumor grade. Among the chemokines analyzed, only the presence of MIP-3b/CCL19 in 57% of the tumors correlated with prolonged overall survival. CD123+ plasmacytoid DC (pDC) infiltrated 13% of the primary tumors. Their presence was strongly associated with shorter overall survival (93% versus 58% at 60 months) and relapse-free survival (90% versus 37% at 60 months) and was found to be an independent prognostic factor for overall survival and relapse-free survival and confirmed in an independent validation series of 103 patients.

CONCLUSIONS

Infiltration by pDC of primary localized breast tumor correlates with an adverse outcome, suggesting their contribution in the progression of breast cancer.

Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients

AIM

The aim was to identify a subset of breast cancer patient with positive sentinel nodes (SNs) for whom secondary axillary clearance would be unnecessary.

METHODS

Between March 1999 and May 2001, 288 patients with T0-T2 breast cancer less than 3cm in diameter had SN detection either by a colorimetric method or using a combined technique. SNs were stained with haematoxylin and eosin (H&E). For all negative SNs, serial sections and immunochemistry (IHC) were performed. All patients with positive SNs underwent a complete axillary lymph node dissection. One hundred and twenty patients were SN positve.

RESULTS

Non-sentinel node positivity (NSNP) was closely associated with the size of the tumour (14.3%, 54.1% and 51.8% for pT1a-b, pT1c and pT2 tumours respectively) and with the size of the SN metastasis: 15.9% IHC detected micrometastasis, 33.3% and 78.8% micro- and macrometastasis detected with H&E staining respectively. NSNP was found in 24.0% and 42.8% of patients with pT1c breast cancer and with micrometastasis detected by IHC and H&E staining. The node positivity rate reached 81.1% for pT1c lesions with macrometastasis in the SN. For the patients with pT2 breast cancer, these rates were 12.5% (IHC), 28.5% (H&E) 91.1% (macrometastasis).

CONCLUSIONS

We are unable to isolate precisely a subset of patients for whom total axillary lymph node dissection would be unnecessary. A subset of 14 small tumours (<1cm diameter) demonstrated micrometastases in the SN without NSNP.

[How to evaluate the quality of information transfer from physician to patient? Choice of psychometric tests for a decision tree in a Regional Cancer Centre]

BACKGROUND

Decision boards are used to transfer information from physicians to patients to help them participate in the clinical decision-making process. We present the tests and results of the psychometric properties of a decision board in a sample of healthy volunteers.

METHODS

In the Regional Cancer Centre located in Lyon, we developed a decision board for post-menopausal women with breast cancer after lumpectomy without any poor prognostic factors. Two treatment options were proposed, one involving chemotherapy and the other not. We tested for the following psychometric properties: comprehension, construct validity and reliability. Comprehension was evaluated using a questionnaire, in order to test whether the rates of correct answers were due to chance alone. The construct validity was assessed by changing the information provided (relapse and survival rates, characteristics of chemotherapy) and testing whether the proportion of healthy volunteers choosing an option changed in a predictable and significant way. The reliability was evaluated using the test-retest method. Two reliability statistics were computed: the Pearson correlation and the Intraclass Correlation Coefficient.

RESULTS

In the sample of 40 healthy volunteers, 23 chose the option with chemotherapy and 17 the option without chemotherapy. Results show that the decision board was comprehensive, valid (the women changed their choices in a predictable way) and reliable (Pearson correlation and Intraclass Correlation Coefficient close to 1).

CONCLUSION

The choice of the psychometrics properties tested and the statistical tests used are discussed. The psychometric properties of our tool are found to be satisfactory.

Shared decision-making in question

Over recent years, communication within the physician-patient relationship has been profoundly changing. New modes of conveying diagnostic and therapeutic information influence the way in which decisions regarding treatment are made. We propose a critical review of the various theoretical models as presented in the literature, from the paternalistic to the shared decision model, in order to reveal conceptual ambiguities and their related methodological problems. This analysis leads to a project for clarifying these problems through a research protocol based on shared decision-making.

Lymphatic mapping and sentinel node biopsy of operable breast cancer

The aim of this study was to evaluate the reliability and accuracy of sentinel node biopsy for invasive breast cancer and the predictability of axillary node status. Between January 1996 and June 1997 a total of 73 patients underwent patent blue dye lymphatic mapping and sentinel node biopsy followed by standard (level I and II) axillary node dissection (one bilateral procedure). The sentinel node was identified in 82.4% (61/74) of the cases and was predictive of axillary status in 96.7% (59/61). The false-negative rate of the procedure was 8.0% (2/25). The sentinel node was involved in 37.7% (23/61) and was the only one invaded in 30.4% (7/23). The sensitivity of the procedure was 92% (CI95% 74-99%) and its specificity 100%. It is currently considered to be an attractive new procedure undergoing evaluation in prospective controlled trials. This study confirmed the reliability and reproducibility of intraoperative lymphatic mapping and sentinel node biopsy. This is the first step toward a new era of minimally invasive axillary surgery for breast cancer.

[INSERM-FNCLCC collective expertise. Recommendations for medical management of women with genetic risk of developing breast and/or ovarian cancer]

BACKGROUND

Almost 10% of breast and ovarian cancer are inherited, and the majority are linked to BRCA1 and BRCA2 germline mutations. Despite the uncertainty in the management of women gene carriers, consensus guidelines were defined to assist practitioners', and patients' decisions about the health care decisions to be made.

METHODOLOGY

The Ad Hoc Committee consisted of 14 experts designated by the French National Institute for Health and Medical Research. They all attended eleven workshops at which a systematic analytical review of more than 3500 articles was carried out. Five additional experts critically analysed the first version of the report. CRITERIA AND DECISION PROCESS: Two thresholds were defined on a probability scale giving the risk of developing breast or ovarian cancer, to serve as a means of deciding as whether an intervention is worthwhile. The first threshold is that above which an intervention can be envisaged or recommended; the second is that under which an intervention can be ruled out; between the two, the decision has to be made on a each by case basis. STRATEGIES ANALYZED: About breast cancer: 1) hormonal interventions; 2) primary prevention (diet, family planning and chemoprevention); 3) screening (breast self-examination, clinician breast examination, tumor markers, imaging); 4) prophylactic mastectomy. About ovarian cancer: 1) hormonal stimulation; 2) screening (clinical screening, ultrasound and tumor markers); 3) prophylactic oophorectomy.

MAIN CONCLUSIONS

With each strategy the following points were dealt with; the information to be delivered to the Consultant, the procedure and the indications. In addition, the Committee's opinion about BRCA1 and BRCA2 mutation screening is that population-based or even large scale implementation are not justified. Although no scientific evidence is available, the Committee feels that specific management is indispensable and advocates the use of defined and evaluated procedures, and involvement in clinical trials.

[INSERM-FNCLCC collective expert's report. Recommendations for management of women having a genetic risk of developing breast and/or ovarian cancer. National Federation of Centers of the Fight Against Cancer]

BACKGROUND

Almost 10% of breast and ovarian cancer are inherited, and the majority are linked to BRCA1 and BRCA2 germline mutations. Despite the uncertainty, consensus guidelines were defined to assist practitioners', and patients' decisions about the health care decisions to be made.

METHODOLOGY

The Ad Hoc Committee consisted of 14 experts designated by the French National Institute for Health and Medical Research. They all attended eleven workshops at which a systematic analytical review of more than 3500 articles was carried out. Five additional experts critically analyzed the first version of the report.

PROCESS

Two thresholds were defined on a probability scale giving the risk of developing breast or ovarian cancer, to serve as a means of deciding as whether an intervention is worthwhile. The first threshold is that above which an intervention can be envisaged or recommended; the second is that under which an intervention can be ruled out; between the two, the decision has to be made on a each by case basis. SCREENING AND PREVENTIVE STRATEGIES ANALYZED: About breast cancer: 1) hormonal interventions; 2) primary prevention (diet, family planning and chemoprevention); 3) screening (breast self-examination, clinician breast examination, tumor markers, imaging); 4) prophylactic mastectomy. About ovarian cancer: 1) hormonal stimulation; 2) screening (clinical screening, ultrasound and tumor markers); 3) prophylactic oophorectomy.

MAIN CONCLUSIONS

With each strategy the following points were dealt with: the information to be delivered to the consultant, the procedure and the indications. The Committee's opinion about BRCA mutation screening is that population-based or even large scale implementation are not justified. The Committee feels that specific management is indispensable and advocates the use of defined and evaluated procedures, and involvement in clinical trials.

[Inserm ad hoc committee: Recommendations for the management of women with a genetic risk for developing cancer of the breast and/or the ovary]

BACKGROUND

Almost 10% of breast and ovarian cancer are inherited, and the majority are linked to BRCA1 and BRCA2 germline mutations. Despite the uncertainty, consensus guidelines were defined to assist practitioners', and patients' decisions about the health care decisions to be made.

METHODOLOGY

The ad hoc committee consisted of 14 experts designated by the French National Institute for Health and Medical Research. They all attended eleven workshops at which a systematic analytical review of more than 3,500 articles was carried out. Five additional experts critically analyzed the first version of the report.

PROCESS

Two thresholds were defined on a probability scale giving the risk of developing breast or ovarian cancer, to serve as a means of deciding as whether an intervention is worthwhile. The first threshold is that above which an intervention can be envisaged or recommended; the second is that under which an intervention can be ruled out; between the two, the decision has to be made on a each by case basis. SCREENING AND PREVENTIVE STRATEGIES ANALYZED: About breast cancer: 1) hormonal interventions; 2) primary prevention (diet, family planning and chemoprevention); 3) screening (breast self-examination, clinician breast examination, tumor markers, imaging); 4) prophylactic mastectomy. About ovarian cancer: 1) hormonal stimulation; 2) screening (clinical screening, ultrasound and tumor markers); 3) prophylactic oophorectomy.

MAIN CONCLUSIONS

With each strategy the following points were dealt with: the information to be delivered to the consult and, the procedure and the indications. The committee's opinion about BRCA mutation screening is that population-based or even large scale implementation are not justified. The committee feels that specific management is indispensable and advocates the use of defined and evaluated procedures, and involvement in clinical trials.

Stereoscopic visualization of three-dimensional ultrasonic data applied to breast tumours

OBJECTIVE

This paper presents a technique for stereoscopic visualization applied to three-dimensional (3D) ultrasonic breast data.

METHODS

A motorized acquisition system has been designed to translate regularly a linear-phased array transducer, in order to provide a series of parallel echographic slices of the breast. During acquisition, the breast is compressed between a plane support and a plexiglass plate to avoid breast motion. A window in this plate provides access for ultrasonic exploration. From the series of cross-sectional scans, a 3D volume is formed by interpolation between the successive ultrasonic images. A stereoscopic computer-graphic method has been developed to visualize these 3D ultrasonic data. Two conical transparent projections of the volume are computed from two slightly different viewpoints. These two projections make up the stereoscopic pair. This pair is displayed on a stereoscopic monitor for the visualization of the 3D data with the depth dimension.

RESULTS

The acquisition system and the method for computing the stereo-echograms were validated using an agar gel phantom. In vivo breast experiments were also performed.

CONCLUSION

Visualization of stereo-echographic projections improves the perception of depth and shape of breast tumours.

Recommendations for medical management of hereditary breast and ovarian cancer: the French National Ad Hoc Committee

BACKGROUND AND PURPOSE

Almost 10% of breast and ovarian cancers are familial, and the majority are linked to BRCA1 and BRCA2 germline mutations. Despite uncertainty about the management of female gene carriers, consensus guidelines have been established to assist practitioners and consultees in making health care decisions.

METHODOLOGY

The Ad Hoc Committee was composed of 14 experts appointed by the French National Institute for Health and Medical Research, all of whom attended eleven workshops at which more than 3500 articles were systematically analyzed. Five additional experts critically analysed the first version of the report. CRITERIA AND DECISION PROCESS: On a probability scale of the risk of developing breast or ovarian cancers, two thresholds were defined for use in determining whether an intervention would be worthwhile. The first is the threshold above which an intervention can be envisaged or recommended, and the second is the one below which an intervention can be ruled out; between the two, the decision has to be made on a case-by-case basis. SCREENING AND PREVENTIVE STRATEGIES ANALYZED: With respect to breast cancer: 1) hormonal interventions; 2) primary prevention (diet, family planning and chemoprevention); 3) screening (breast self-examination, clinician breast examination, tumor markers, imaging); 4) prophylactic mastectomy. With respect to ovarian cancer: 1) hormonal stimulation; 2) screening (clinical screening, ultrasound and tumor markers); 3) prophylactic oophorectomy.

MAIN CONCLUSIONS

For each strategy the following points were addressed: the information to be given to the consultee, the procedure and the indications. In addition, the committee's opinion about BRCA1 and BRCA2 mutation screening is that population-based, or even large-scale, implementation are not justified. Although no scientific evidence is available, the committee feels that specific management is indispensable and advocates the use of defined and evaluated procedures, and participation in clinical trials.

[Identification of axillary sentinel node by lymphotropic dye in breast cancer. Feasibility study apropos of 128 cases]

AIM OF THE STUDY

The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its predictivity of axillary node status.

PATIENTS AND METHODS

Between January 1996 and June 1997, 128 patients with invasive breast carcinomas, referred to the Cancer Center of Strasbourg and Lyon (France), underwent lymphatic mapping (Patent Blue dye) and sentinel node biopsy followed by axillary clearance (Berg's level I to II).

RESULTS

Sentinel node was identified in 76.5% of cases and was predictive of axillary status in 94.9% of cases. The false negative rate of the procedure was 5.1%. Sentinel lymph node was involved in 43.9% of cases and it was the only one involved in 30.2% of cases. The sensitivity of the procedure was 94% (CI: 95% = [88%-98%]) and its specificity 100%.

CONCLUSION

Actually considered as new attractive procedure under ongoing evaluation in prospective controlled trials, this study confirms the feasibility and reproductibility of lymphatic mapping and sentinel node biopsy, first stage before entering a new era of minimally invasive axillary surgery in breast cancer.

Prognostic value of P53 gene mutations in a large series of node-negative breast cancer patients

The most important subgroup of breast cancer patients for which reliable prognostic factors are needed are women without axillary lymph node involvement. Although overall, these patients have a good prognosis, it is known that 20-30% will experience a recurrence of the disease. To determine the prognostic significance of P53 tumor suppressor gene mutation, specimens from 113 primary breast cancers were evaluated for the presence of P53 alterations, as detected by cDNA sequencing of the entire coding sequence of the gene. The median follow-up for patients was 105 months. P53 gene mutation was an independent prognostic marker of early relapse and death. Our results suggest that P53 gene mutations could be an important factor to identify node-negative patients who have a poor prognosis in the absence of adjuvant therapy. Prospective studies should be designed to determine which therapy should be performed in this subgroup of patients.

Bisphosphonate risedronate prevents bone loss in women with artificial menopause due to chemotherapy of breast cancer: a double-blind, placebo-controlled study

PURPOSE

To determine the effectiveness and safety of the bisphosphonate risedronate in preventing bone loss in young women with breast cancer and early menopause induced by chemotherapy who are at major risk for the development of postmenopausal osteoporosis.

PATIENTS AND METHODS

Fifty-three white women, aged 36 to 55 years, with breast cancer and artificially induced menopause were stratified according to prior tamoxifen use. Thirty-six patients received tamoxifen (20 mg/d). Within each stratum, patients were randomly assigned to receive risedronate (n = 27) or placebo (n = 26). Treatment consisted of eight cycles oral risedronate 30 mg/d or placebo daily for 2 weeks followed by 10 weeks of no drug (12 weeks per cycle). Patients were monitored for a third year without treatment.

RESULTS

Main outcomes of the study were changes in lumbar spine and proximal femur (femoral neck, trochanter, and Ward's triangle) bone mineral density (BMD), and biochemical markers of bone turnover. In contrast to a significant decrease of BMD at the lumbar spine and hip in the placebo group, there was an increase in BMD in the risedronate group. On treatment withdrawal, bone loss ensued, which suggests that treatment needs to be continuous to maintain a protective effect on bone mass. At 2 years, the mean difference (+/- SEM) between groups was 2.5% +/- 1.2%, (95% confidence interval [CI], 0.2 to 4.9) at the lumbar spine (P = .041) and 2.6% +/- 1.1%, (95% CI, 0.3 to 4.8) at the femoral neck (P = .029). Similar results were observed at the hip trochanter. Results by stratum indicate a beneficial, although partial, effect of tamoxifen in reducing bone loss. Risedronate was well tolerated and showed a good safety profile, with no evidence of laboratory abnormalities.

CONCLUSION

Risedronate appears to be a safe treatment that prevents both trabecular and cortical bone loss in women with menopause induced by chemotherapy for breast cancer.

Pancreatic Neuroendocrine Carcinoma Metastatic to the Breast as Part of the Multiple Endocrine Neoplasia Type 1 Syndrome

Breast metastases from nonmammary tumors are rare. We report here the first case of pancreatic neuroendocrine carcinoma metastatic to the breast in a patient with possible multiple endocrine neoplasia type 1. The diagnosis was supported by histological examination, immunohistochemistry, and ultrastructural analysis. This observation emphasizes the importance of clinical data for an accurate diagnosis, especially during intraoperative examination. When pathologists are faced with an unusual breast tumor larger than 2 cm, we would recommend freezing and/or saving pieces of tissue for ultrastructural analysis, which might help in the diagnosis.

[Motivations for breast reconstruction after mastectomy. A comparative study]

The aim of this study is to define the psychosocial profile and the motivations of women who seek post-mastectomy reconstruction. A questionnaire was administered to 45 women who had breast reconstruction several months after mastectomy and 51 who did not. Statistical analysis of data shows significant differences between the two groups regarding age, education, leisure activities, sexual intercourse and fear of recurrence. A qualitative analysis shows how women feel about reconstruction. The results suggest that information concerning reconstruction must be adapted to the psychosocial profile of women. Moreover, reconstruction must be considered by the surgeon as an essential stage of breast cancer treatment. In order to help women in their choice, they must give them appropriate information on the technique of breast reconstruction, on the risk of relapse and on the possibility of reimbursement of medical expenses.

[Granulomatous mastitis]

Six cases of granulomatous mastitis are reported. Based on a review of the relevant literature, the clinical features, etiology, and management of this pathologic entity are discussed. The definition of granulomatous mastitis is given and the characteristics that distinguish this condition from other inflammatory breast diseases are pointed out.

[Problem of perception and denial of illness in women who had breast cancer]

It has been noted that some patients demonstrate denial when they have a severe illness such as cancer. We observed this type of denial with respect to perception of illness by patients. We interviewed twenty women who had been treated for breast cancer for more than one year. During these interviews, every patient narrated the story of her illness as she remembered it. One year or more after treatment, four women denied the diagnostic which was given to them when the treatments started. These four women were the only ones who never perceived the first signs of the illness. They never saw or felt any change around their breasts, and they are among the five women for whom breast cancer was detected from a systematic mammography. In contrast the other women, who did not manifest such denial, detected themselves an anomaly or were alerted by their physician. Based upon these observations, we discuss the notion of denial when patients have no perception of the illness or its first signs of onset. We pose a question concerning the interest and usefulness of such research concerning the representational process of illness by patients.

Familial ovarian carcinoma: pedigree studies and preliminary results from linkage analysis

Thirty-seven ovarian cancer-prone families have been identified through a French co-operative network. Three main clinical presentations were observed: site-specific ovarian cancer, breast/ovarian carcinoma syndrome and Lynch syndrome II. An additional kindred with features of Li-Fraumeni syndrome is reported. It is expected that a better understanding of the mechanisms of carcinogenesis will allow the development of new methods of screening and treatment. With this aim, recent studies have mapped the gene for early-onset familial breast cancer and breast/ovarian carcinoma syndrome to the same locus in the chromosome 17q12-q23 region. Results from linkage analysis of two breast/ovarian carcinoma families and three breast cancer families favour the hypothesis of genetic heterogeneity among breast and ovarian tumors.

In vitro study of effects of 1,25 dihydroxyvitamin D3 on the morphology of human breast cancer cell line BT.20

The morphological effect induced by 1,25 dihydroxycholecalciferol - 1,25(OH)2VitD3 - on the malignant human breast cell line BT.20 was studied. This cell line is devoid of oestrogen (ER) and progesterone (PGR) receptors. This effect, which requires treatment for at least 3 days, was evidenced by an increase in the cell projection surface, assessed on scanning electron microscopy (SEM) and by quantimetric analysis, for optimal final concentrations of 1.25(OH)2VitD3 in the medium of the order of 10(-11)M. The cells became more spread out and rounded with many junctional systems; there was occlusion of the intercellular space, but hardly any cells overlapped. The cytoskeleton was considerably developed, with microtubules running parallel to the cell surfaces associated with microfilaments. This positive action on cell differentiation was very similar to that noted regarding the reduction in growth under 1,25(OH)2VitD3 treatment. The two actions were, however, observed at different times and with different concentrations of 1,25(OH)2VitD3 in the medium.

Different types of microcalcifications observed in breast pathology. Correlations with histopathological diagnosis and radiological examination of operative specimens

Microcalcifications taken from 50 systematized mammary excisions were submitted to light microscopic and scanning electron microscope analysis. Microprobe and x-ray diffraction analyses were also performed. Two main types were observed: Type I microcalcifications composed of weddellite crystals. They were observed in benign breast lesions only (11 cases out of 21) or, in lobular carcinomas in situ (L.C.I.S.) of the breast (5 cases out of 6). They were not seen in 3 cases of intraductal carcinoma (I.D.C.) nor in infiltrating (I.C.) carcinomas (20 cases). Type II microcalcifications, non-cristalline in nature, composed of calcium, phosphate, hydroxyapatite or of phosphorus and calcium associated with other elements, were observed in benign lesions (10 cases out of 21) and in all cases of infiltrating carcinomas. The microcalcifications observed on mammography were also found on the radiographs of systematised mammary excisions from the lesion or from its immediate vicinity, but only when using the appropriate technique. Microcalcifications are therefore an excellent marker of breast lesions but they cannot be simply divided into "benign" or "malignant" types. Nevertheless, the presence of a visible crystalline structure on the radiograph of the specimen argues in favour of a benign breast lesion or of a lobular carcinoma in situ.

[Sterility of tubal origin: microsurgery and fertilization in vitro]

Thanks to recent advances, in-vitro fertilization should alter the clinical indications in cases of sterility due to tubar obstruction. In this article, the authors compare two groups of patients: one group of 109 women treated by means of in-vitro fertilization and another group of 117, treated by microsurgery. In tubar sterility, IVF achieved a 16% pregnancy rate per attempt. In the case of microsurgery, the actuarial rates were calculated (Kaplan Meier method) from a prognostic score. It was found that in the group of women with a "good score", tubar surgery gave results which could be achieved only after 3 or 4 attempts at IVF. On the other hand, in the "poor prognosis" group, IVF was better than microsurgery after a single attempt. Clinical teams should, therefore, reconsider the indications for tubar surgery in the light of the indications for in-vitro fertilization.

Breast cancer and polyps of the colon. A case-control study

A case-control study was conducted involving 145 patients with breast cancer and 144 controls. A pansigmoidoscopy was performed in each case and control. There was no statistically significant difference in the length of the colon explored (cases, 50.3 cm; controls, 48.9). The odds ratio for adenomatous polyps was 2.65 (confidence limits, 1.56 and 3.74). As adenomas of the colon can be considered as precursors of colon cancer, this study demonstrates new evidence of the close relationship between breast and colon cancer. These results show the usefulness of performing a pansigmoidoscopy in all breast cancer patients and, if positive, the removal of all of the polyps through the colonoscope.

Structure and composition of microcalcifications in benign and malignant lesions of the breast: study by light microscopy, transmission and scanning electron microscopy, microprobe analysis, and X-ray diffraction

Microcalcifications previously located by radiography were extracted from 25 fresh specimens obtained from patients who had undergone tumorectomy or systematized mammary exeresis. Two principal types of microcalcifications were distinguished: Type I microcalcifications were amber in color and generally crystalline on scanning electron microscopy, with only one calcium peak on microprobe analysis; x-ray diffraction revealed that weddellite was involved. Type II microcalcifications were whitish, nonbirefringent under polarized light, and generally ovoid or fusiform, with two peaks, one calcium and the other phosphorus, on microprobe analysis; these microcalcifications were composed of calcium phosphate, the most characteristic form of which is hydroxyapatite, in the form of needles arranged in rosettes on transmission electron microscopy. Type I microcalcifications were observed in four of eight benign breast lesions, in two of three in situ lobular carcinomas, and in no intraductal adenocarcinomas or infiltrating carcinomas. Type II microcalcifications were present in all infiltrating carcinomas and intraductal adenocarcinomas; they were also found in benign lesions (four of eight) and even associated with type I microcalcifications in one in situ lobular carcinoma. There are, therefore, no "benign" or "malignant" microcalcifications; however, the presence of weddellite is a strong indication that a lesion is benign or, at most, an in situ lobular carcinoma.

[Value of differential cytology in the diagnosis of preclinical forms of cervix uteri cancer]

The value of "differential cytology" in the diagnosis of preclinical carcinoma of the cervix uteri was assessed from serial sections of operative specimens in a series of 452 patients. Although not absolute, this value was found to be considerable. Used to supplement colposcopy-guided biopsy, it makes it possible to decide on the therapeutic approach (notably simple destruction by laser) without having recourse to conization. However, the results are only valid for the team which presents them, and before deciding to treat intra-epithelial carcinomas by laser destruction, each team must perform the same "quality control".

[Tubal epithelium. Scanning electron microscopy in the menstrual cycle, in pregnancy and in the menopause (author's transl)]

The Fallopian tubes of 18 women who were either in reproductive age or were menopausal were studied by scanning electron microscopy. There were different cells seen in the epithelium. These were ciliated and non-ciliated cells, and cells, with a single cilium which was central and cells with short cilia. These elements undergo cyclical changes: secretory phenomena are at their maximum during the ovulatory phase. There is no sudden desquamation in tubal epithelium, nor is there massive deciliation. All the same, there are images that look like marguerites (described in the text) which are evidence of cellular regeneration. The appearance suggests a state of rest in precocious menopausal women and in pregnancy. The phenomena seen during the secretory phases disappear and the distribution of the cells is modified. Deciliation is found 20 to 30 years after the menopause. The physiological significance of these phenomena is still uncertain and their role in pathology has still to be defined.

[The heterogeneity of micropolycystic ovary syndrome. 77 cases (author's transl)]

Seventy seven cases of micropolycystic ovaries were reviewed. All of the patients underwent either coelioscopy or wedge resection of the ovaries. It was thus possible to classify the patients into two groups on the basis of the size of the ovaries (MPCO-A, large ovaries, more than twice the normal size; MPCO-B, ovaries only slightly increased in size or normal). There were differences from a clinical, laboratory and therapeutic standpoint. In MPCO-A, spaniomenorrhea predominated, clinical hyperandrogenism was often absent and 17 ketosteroids lower. Response to hypothalamic gonadotrophic hormone liberation factor was explosive in luteotrophic hormone, but at 120 minutes levels were lower in MPCO-A than in MPCO-B. Wedge resection failed completely in 23% of cases of MPCO-A and in 66% of cases of MPCO-B. This study confirmed current concepts of the heterogeneity of MPCO syndrome.

[An electroencephalographic study of the foetus during labour. Technique and interpretation (author's transl)]

The authors report their experiences in recording foetal E.E.Gs at the time of labour, based on 140 studies. They studied normal E.E.Gs and emphasise the existence of a sleep-waking pattern during dilatation. They consider the E.E.G. changes during the different stages of labour and assess the results against other techniques used to assess foetal well-being. They record the effects on the E.E.G. of various anaesthetics and analgesics given to the mother. The difficulty of the technique is stressed and they conclude that despite the obvious interest of the technique it is not currently suitable for routine obstetric practice.

[Difficulties in the detection and the diagnosis of carcinoma in situ of the uterine cervix in the presence of associated dysplasia]

Ninety nine cases of carcinoma in situ of the cervix are reported. In all cases, the definitive diagnosis was established after study of an operative specimen (cone biopsy or hysterectomy) examined by serial section. Pre-operative cytology was falsely negative (or suggestive of simple dysplasia) in 35,4 per cent of cases and pre-operative biopsy falsely negative in 40 per cent. These errors were approximately twice as common in cases in which dysplasia was present in association with the caricinoma (40 cases) than in those cases in which the malignancy alone was present (59 cases). The practical conclusions which may be drawn from these findings in relation to detection and diagnosis are discussed.

[Acid-base equilibrium during acute fetal hypoxia. Experimental study]

The authors studied the effects of acute hypoxia of short duration in eight pregnant ewes that had been anaesthetised. They showed that during the experiment the E.E.G. as well as the pH and pCO and the maternal lactate levels were not changed and that therefore changes that can be found in the fetus are due solely to its own hypoxia and not due to transmission from the mother. In the fetus the trace flattens in about 30 minutes on an average. After this interval a moderate drop in pH occurs at the same time as an increase in lactacidemia and the relationship between lactate and pyruvate. The heart rate is changed in a variable manner: it accelerates if the basal rate is less than 180 beats a minute and slows if it is above 180. Blood pressure rises. Changes in the cardio-vascular system always precede those in the electroencephalograms.

Serum gastrin level in early childhood

Serum gastrin concentration was measured in newborns and infants with no gastrointestinal disorders, in the fasting state and after food stimulation. Mean fasting concentration in 14 newborns aged 1 to 12 days (130 . 4 pg/ml +/- 11 . 4 SE) was significantly higher than the mean value in 23 infants aged 1.5 to 22 months (101.4 +/- 6.6 pg/ml). Ingestion of the usual milk meal resulted in a definite rise of the serum gastrin level in the 5 subjects tested (3 newborns and 2 infants). The mean fasting serum gastrin level in 6 babies with hiatus hernia and gastro-oesophageal reflux was found to be no different from the corresponding value in 8 age-matched controls. However, a conspicuously raised fasting gastrin concentration was observed in one infant with lower oesophageal dyskinesia. The results indicate that the release of gastrin and the reactivity of the hormone-producing sites to food stimulation in early life are similar to those in adult humans. No defect of gastrin release was shown in patients with gastro-oesophageal reflux.