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Breast cancer survival

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

More and more women are being diagnosed with early stage breast cancer. Surgery is generally less radical than it was two decades ago, being lumpectomy or breast-conserving combined with sentinel lymph node dissection. Sentinel axillary node dissection is based on injecting dye into the primary lesion and examining the nodes to which the dye drains for metastases. The presence or absence of sentinel node metastases is used in decision-making about follow-up chemotherapy and long-term hormone treatment. Modern trends have a lowered threshold for chemotherapy and the use of selective estrogen receptor modulators or aromatase inhibitors, which combine to give excellent prognoses for T1 and T2 lesions (the TNM staging system is used by researchers and stands for Tumour/Node/Metastasis; T1–T4 represent the size of the tumour and the extent to which it has grown into neighbouring breast tissue).

Sentinel node pathology examination is conventionally carried out using traditional tissue-staining techniques but immunochemical methods are available that can identify metastases not seen with routine histology methods. It is not known whether occult spread picked up by histochemical techniques is important in forecasting overall survival or recurrence. A study of over 5000 women in the USA now answers this question (Giuliano et al. JAMA 2011;306:385–93). They followed up the women for a minimum of 6 years and demonstrated that occult metastases found by the more sophisticated histopathology techniques in sentinel nodes did not indicate poorer survival.

This is reassuring and allowed the authors to conclude that advanced immunohistochemical testing is not warranted if sentinel nodes are clear by conventional detection methods. The overall 5-year survival rate was 95% for the entire cohort.

Breast cancer treatment and infertility

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

The median age of women diagnosed with breast cancer is 61 years. Roughly 10% are diagnosed before turning 45 and 5% before 40 and younger age carries a poorer prognosis so these women usually have chemotherapy as well. This can be neoadjuvant (before surgery) or classical adjunct chemotherapy postoperatively.

The toxicity of this treatment on the ovaries is profound, causing oocyte death in primordial follicles, damaging ovarian reserve and interrupting follicle recruitment and maturation. The resultant premature menopause with amenorrhoea, sexual dysfunction and infertility is devastating for young women so many methods of avoiding the situation or enhancing recovery are being actively pursued. (Rugo and Rosen JAMA 2011;306:312–14). The younger the woman the more likely she is to regain ovarian function, but options include the use of less toxic agents and ‘protecting hormones’ such as gonadotrophin-releasing hormone agonists, which when given with the chemotherapy show promise. The latest research indicates that the agonist triptorelin given with the cytotoxics allows the resumption of menstrual function within a year of stopping therapy in 90% of recipients compared with 75% not receiving it (Del Mastro et al. JAMA 2011;306:269–76). This does not imply fertility but pretreatment oocyte harvesting and other anticipatory measures do give hope. The field is being dubbed oncofertility (Snyder and Pearse JAMA 2011;306:202–3).

Older women’s health

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

The Nurses’ Health Study in the USA is an amazing source of research material. A quarter of a century ago over 120 000 middle-aged female nurses agreed to be followed up in terms of their lifestyle and medical records every 3 years. As the cohort has aged they have provided a unique insight into the natural history of Ms America—of what keeps her healthy and what does not.

The latest data show what protects from, or is associated with, sudden cardiac death (Chiuve et al. JAMA 2011;306:62–9). Cardiovascular disease is the commonest cause of death in old women and half of all cardiac deaths occur suddenly in women with no history of coronary heart disease. Gathering the records of two-thirds of the original group, the researchers identified four factors that were independently and synergistically associated with the risk of sudden cardiac death.

Not smoking, a normal body mass index (BMI), regular exercise and a healthy diet, on their own or collectively, lowered the women’s risk of cardiac death. It seems that women can ‘choose their risk’ by adjusting their lifestyle. Smoking takes 10 years off a woman’s life expectancy, obesity incrementally increases risk from a BMI of 25 upwards, moderate to vigorous exercise for 30 minutes per day is protective, as is a Mediterranean-style diet defined as food high in vegetables, fruit, nuts, whole grain, legumes, fish, n-3 fatty acids, moderate alcohol intake and little red or processed meat.

Another study, this time over 30 years, followed a group of Scottish women and recorded what they died from (Hart et al. BMJ 2011;342:d3785). The data refer exclusively to non-smoking women.

The researchers found strong correlations between social class and all-cause mortality. The higher the woman’s social class, the lower her mortality rate, which is not surprising but what was unexpected was that the women in the lower classes were on average shorter, had poorer lung function and higher blood pressure. The other association was between lower social class and being overweight or obese, which in turn correlated with dying from coronary heart disease, stroke and respiratory disease.

In summary they could show longitudinally that the difference in social class mortality was largely the result of higher incidences of obesity, raised systolic blood pressure and poor lung function in women from lower social classes. These differences were most marked at the extremes of social class. Over the entire group, about half died from cardiovascular disease and a quarter from cancer, and it is presumed that improving living standards and decreasing risk factors will prevent premature deaths.

There is observational evidence that regular exercise in old women helps maintain cognitive function, even if it is of low intensity. Standing, and preferably moving about, rather than being sedentary, were associated with lower incidences of cognitive impairment in those at high risk of cardiovascular events (Vercambre et al. Arch Intern Med 2011;171:1244–50 and Larson Arch Intern Med 2011;171:1258–9).

The evidence is clear from this and numerous recent publications, and all doctors have a duty to explain to women the best lifestyle choices for primary prevention.

US family planning

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

About half of the pregnancies that occur in the USA each year are unplanned. Another statistic is that by the time American women reach the end of their reproductive lives, half will have had an unintended pregnancy.

Some of these unplanned conceptions are not wanted and are terminated—up to half—but those continuing need to be supported. Recent estimates suggest that a ‘Medicaid-covered birth’ (including antenatal care, delivery, postpartum and first-year care) costs at least $12 000. Prevention of an unplanned pregnancy would not only eliminate the cost of the pregnancy or its termination, but would also save lives for the obvious but oft forgotten fact that a woman cannot die from a pregnancy she does not have.

About $2 billion is spent annually on publically funded family planning, which saves $7 billion in unplanned pregnancies, or put another way, for every $1 of tax-payers money, $3.7 is saved in pregnancy costs. Although contraceptive services are state-funded, there may be extra expenses for some methods, which deter their use in the very group most in need of reliable long-term protection. A calculation shows that 52% of all the unintended pregnancies come from 10% of women who use no contraception at all.

Costs per year are $130 for a copper-containing intrauterine contraceptive device (IUCD) $320 for an implant, $400 for a levonorgestrel-releasing IUCD and $680 for oral contraceptives. It is hoped that the new laws on health care in the USA will provide full cover to all for the most fundamental and cost-effective preventive care—family planning (Cleland et al. NEJM 2011;364:e37.

Extremely low birthweight children grow up

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

Improved neonatal care has resulted in the survival of many more extremely low birthweight (ELBW) children. Babies born weighing less than 1 kg are known to have higher physical, cognitive and social rates of disability than children born with a normal birthweight. As these ELBW babies grow up they have a much higher prevalence of chronic conditions than controls, these being around 75% (compared with 40%) at the age of 8 years and researchers are now looking at how they cope in adolescence (Hack et al. JAMA 2011;306:394–401).

They found that through puberty the differences between ELBW children and their normal weight counterparts did not change, indicating that disadvantages remained but did not worsen. The one area where ELBW children did not maintain parity was obesity, with more of them having abnormally high BMI than when they were tested 5 years previously.

Long-term disadvantages in respect of cardiovascular and metabolic disorders are forecast for this group and follow up into adulthood is awaited.

Texting, smoking and attending

  1. Top of page
  2. Breast cancer survival
  3. Breast cancer treatment and infertility
  4. Older women’s health
  5. US family planning
  6. Extremely low birthweight children grow up
  7. Texting, smoking and attending

Most people who smoke want to give up the habit but cannot. Techniques to assist giving up rely on ongoing encouragement to those who do quit as relapse rates are as high as 95%. One promising way of supporting ex-smokers is by text messaging to their mobile phones. A trial from London showed that sustained abstinence at 6 months was 10% in those receiving ‘txt2stop’ messages compared with 5% in those being sent non-smoking-related text (Free et al. Lancet 2011;378:49–55).

Has such innovative support been given to pregnant women?

Are we missing several tricks by not texting health messages or appointment reminders to our patients in Obstetrics and Gynaecology in the public and private sectors?