Reduction in breast cancer deaths is due to treatment not screening, finds study

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The fall in breast cancer mortality seen after widespread mammography screening was introduced in the US was mainly due to improved systemic therapy and not earlier detection of tumours, a comparison of national cancer data before and after the introduction of screening programmes has shown.

Combined HRT may raise breast cancer risk, study finds

Women taking combined hormone replacement therapy (HRT) are 2.7 times more likely to develop breast cancer than non-users, and the risk may increase with longer use, a study published in the British Journal of Cancer has found.

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The researchers, from the Institute of Cancer Research in London, said that previous studies may have substantially underestimated the risk of breast cancer from combined HRT, as they did not update information about a woman’s HRT use or analyse accurately to allow for her age at menopause.

The new research was part of the Breast Cancer Now Generations Study, which is following more than 100 000 women for 40 years to investigate the causes of breast cancer.

NICE recommends dropping two drugs from Cancer Drugs Fund

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Two drugs currently provided under the Cancer Drugs Fund (CDF) should cease to be available because they are not cost effective, the National Institute for Health and Care Excellence (NICE) has concluded.

Everolimus for breast cancer (Afinitor, Novartis) and ibrutinib for mantle cell lymphoma (Imbruvica, Janssen) do not meet the grade, says NICE in draft guidance now open for consultation.Nice_logo

Stress is unlikely to increase breast cancer risk, study finds

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A large prospective study, published in Breast Cancer Research, has found no association between breast cancer risk and stress levels or adverse life events.1 Women with breast cancer have often attributed their cancer to psychological stress, although the scientific evidence for this has been inconclusive.

The Generations study, set up by Breast Cancer Now, the United Kingdom’s largest breast cancer research charity, included 106 000 women in the UK.

Women are four times less likely to have curative surgery if breast cancer is diagnosed as emergency rather than urgent GP referral

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Women with breast cancer are four times less likely to have potentially curative surgery if their condition is diagnosed as an emergency rather than through an urgent GP referral, a report from Public Health England and Cancer Research UK has shown.

On a national level the report looked at how treatment varies in different cancers, depending on the patient’s route to diagnosis.

Fresh pair of eyes may speed up cancer diagnosis

Researchers have found that symptoms of bowel cancer tended to be identified slightly more quickly when patients consulted an unknown doctor rather than their usual GP.

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The study, published in the British Journal of General Practice, included data for 2000 to 2009 from the General Practice Research Database. The study included around 18 500 patients with breast, bowel, or lung cancer whose relevant cancer symptoms or signs were identified up to 12 months before the eventual diagnosis.

BMJ Learning looks at Immunisation

How knowledgeable are you about the current immunisation schedule for children? What are the contraindications for vaccines? Can you reassure parents about immunisation myths? If not, then this module is for you. Childhood immunisation

Plus other popular modules in women’s health.

Urinary incontinence in women: in association with NICE

Heavy menstrual bleeding: in association with NICE

Suspected breast cancer: when you should refer – in association with NICE

Sexual health: contraception and unplanned pregnancy in young women

NICE guidance – updates

Keeping you up-to-datenice 1

Guidance by topic: the following guidance topics matching your health area preferences have been published or updated


NICE updates: June 2013

More treatments for women at risk of breast cancer                            

Updated guidance from NICE gives more options to women to reduce their risk of breast cancer. NICE recommends tamoxifen or raloxifene as preventative treatments for certain women at high risk of breast cancer due to a family history.

Nicotine products can help people to cut down before quitting smoking         

Licensed nicotine products, such as patches and gum, should be offered to people who smoke and are struggling to quit to help them cut down on cigarettes, NICE says. NICE recommends that stop smoking advisers and health professionals advise people to stop smoking in one go, but for those who aren’t ready or are unable to stop in one step, they should suggest considering a harm-reduction approach.

Offer range of effective treatments for people with hep B

More people with hepatitis B should be assessed, referred and offered the range of clinical and cost effective treatments available for the disease, according to NICE. In its first clinical guideline on hepatitis B, NICE recommends a range of measures to help raise awareness of the condition and reduce the current variation in treatments offered.

Older patients at high risk of hospital falls

Updated guidelines from NICE recommend that healthcare professionals should consider patients aged 65 or older, and those aged over 50 with underlying conditions such as stroke, at high risk of falling while in hospital care.

Podcasts available on falls and antisocial behaviour and conduct disorders

We’ve produced implementation podcasts on our updated falls guidance and our guideline on antisocial behaviour and conduct disorders to help you get the most out of these products.

Two shared learning examples from London and Portsmouth on hepatitis B are also now available, which highlight innovative uses of NICE guidance.

Let us know what you think of our draft guidance on behaviour change. The behaviours covered are alcohol, diet, physical activity, sexual behaviour and smoking, and the consultation closes on 31 July 2013.

We’d also like to hear your thoughts on our draft update of our guideline on neuropathic pain. Neuropathic pain is pain caused by a lesion or disease of the central somatosensory nervous system. The consultation closes on 18 July 2013.


BMJ Case Reports; Jain Y.K.; Kokan J.S; 2013

An interesting case of screen-detected breast cancer encasing a ventriculoperitoneal shunt was published recently in BMJ Case Reports, 2013, 1757-790X (2013)

Abstract:  A 67-year-old woman was diagnosed with a breast cancer via screening encasing the ventriculoperitoneal shunt. Triple assessment including MRI scan of the breast confirmed the presence of a breast mass and the tubing of the ventriculoperitoneal shunt was running directly through the mass. She underwent wide local excision of the breast cancer as well as rerouting of VP shunt as a joint procedure with the neurosurgery team and recovered uneventfully. This is a very rare and an interesting case and required management involving a different specialty.

Source: Embase

New titles in the Health Technology Assessment Journal

17.11 Evaluation of mammographic surveillance services in women aged 40-49 years with a moderate family history of breast cancer: a single-arm cohort study  (Duffy)

17.10 The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients  (Roberts)

17.09 A systematic review and economic evaluation of new-generation computed tomography scanners for imaging in coronary artery disease and congenital heart disease: Somatom Definition Flash, Aquilion ONE, Brilliance iCT and Discovery CT750 HD  (Westwood)

17.08 Adjunctive colposcopy technologies for examination of the uterine cervix – DySIS, LuViva Advanced Cervical Scan and Niris Imaging System: a systematic review and economic evaluation  (Wade)

17.07 Study of the use of antidepressants for depression in dementia: the HTA -SADD trial – a multicentre, randomised, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine  (Banerjee)


NICE considers preventative treatment for breast cancer

breastc keyboardThe National Health Service is considering giving women with a strong family history of breast cancer treatment to prevent the disease from developing.

The National Institute for Health and Clinical Excellence (NICE) is currently in the process of updating its clinical guideline on familial breast cancer[i]. Today (15 January), NICE has begun a consultation on a draft version of the guideline with new, provisional recommendations relating to genetic testing[ii], screening and the use of preventive treatments. The draft update also, for the first time, makes recommendations for people with a recent diagnosis of breast cancer who also have a family history of the disease.

New unit at hospital

Published by The Buxton Advertiser on Saturday 25 August 2012

A NEW dedicated Breast and Gynaecology Unit is set to open at Macclesfield District General Hospital.

The new purpose-built unit, which opens on September 3, will provide high quality services for the diagnosis, screening and treatment of breast cancer and outpatient facilities for a wide range of gynaecology problems, with the latest equipment and techniques all under one roof.

There will be five consultation rooms, two rooms dedicated to digital mammography and a further two rooms for breast ultrasound in the new unit.

via New unit at hospital – Health – Buxton Advertiser.

In the news from OnMedica

A blood test could help predict breast cancer survival.   More – click here >>

This week read our clinical article on meningitis, a serious condition where prompt diagnosis and treatment improve both morbidity and mortality. To read more on this article click here >>

The European Medicines Agency
has granted marketing authorisation for Signifor, an orphan medicine, used for treating Cushing’s disease when surgery has failed.  To read more on this article click here >>

At least seven models are commonly used to evaluate cardiovascular risk. A systematic review of comparative studies in the BMJ investigates which has the best prognostic performance.  To read more on this article click here >>

Assessment of the relationship between adherence with antiemetic drug therapy and control of nausea and vomiting in breast cancer patients receiving anthracycline-based chemotherapy

Assessment of the relationship between adherence with antiemetic drug therapy and control of nausea and vomiting in breast cancer patients receiving anthracycline-based chemotherapy

Source: Journal of Managed Care Pharmacy
Background: There are few prevalence data in the literature on nonadherence to outpatient antiemetic regimens for prophylaxis of chemotherapy-induced nausea and vomiting (CINV).  It is unclear whether adherence with outpatient antiemetic regimens is associated with better CINV control.  Our previous survey research supports the work of clinical pharmacists in collaborative practice with medical oncologists in improving adherence with antiemetic therapy in women undergoing highly emetic chemotherapy for breast cancer. Continue reading

Editorial: HER2 testing in patients with breast cancer

Editorial: HER2 testing in patients with breast cancer

Source: BMJ

This editorial discusses HER2 testing in relation to the use of HER2 targeted drugs for breast cancer. The author comments,” However, to allow proper use of HER2 targeted drugs, results from HER2 testing need to be available in a timely manner. A recent survey of surgeons in the United Kingdom found, worryingly, that only half of patients with invasive cancer had a HER2 result available when treatment was initially discussed”.

Cohort study: Diabetes, metformin, and breast cancer incidence among postmenopausal women

Cohort study: Diabetes, metformin, and breast cancer incidence among postmenopausal women

Source: JCO

There is emerging evidence suggesting that metformin may reduce breast cancer incidence, but reports are mixed and few provide information on tumour characteristics. This study used data from the Women’s Health Initiative (WHI) clinical trials to examine relationships among diabetes, metformin use, and breast cancer in postmenopausal women.   The WHI clinical trials program involves more than 68,019 postmenopausal women who were observed prospectively; 11,290 had diabetes at study entry or developed it during follow-up, and 3,273 developed invasive breast cancer after study entry.   The researchers found that compared with that in women without diabetes, breast cancer incidence in women with diabetes differed by diabetes medication type (P = 0.04). Women with diabetes receiving medications other than metformin had a slightly higher but not statistically significant incidence of breast cancer (hazard ratio [HR], 1.16; 95% CI, 0.93 to 1.45), and women with …

Evidence updates: Cancer

‘Improving outcomes in head and neck cancers: Evidence Update May 2012’ focuses on a summary of selected new evidence relevant to NICE cancer services guidance ‘Improving outcomes in head and neck cancers’ (2004).

‘Familial breast cancer: Evidence Update May 2012’ ( focuses on a summary of selected new evidence relevant to NICE clinical guideline 41 ‘The classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care’ (2006).

In producing the Evidence Updates almost 4,000 pieces of evidence were identified. An Evidence Update Advisory Group, comprised of subject experts, has reviewed the prioritised evidence and provided a commentary.

By producing Evidence Updates, NHS Evidence seeks to reduce the need for individuals, managers and commissioners to search for new evidence and to inform guidance developers of new evidence in their field.

Interesting links from the TRIP database

Eyes on Evidence: Benefit of adjuvant radiotherapy in breast cancer

Overview: Breast cancer is the most common cancer affecting women in Englandand Wales, with about 40,500 new cases diagnosed and 10,900 deaths recorded in Englandand Waleseach year. In men breast cancer is rare, with about 260 cases diagnosed and 68 deaths in Englandand Waleseach year.

Current treatment: Treatment for breast cancer usually involves surgery to remove part, or all, of the breast. Depending on the type and stage of breast cancer, this may be followed by radiotherapy, endocrine therapy, biological therapy or chemotherapy.

The NICE Pathway: breast cancer, brings together all related NICE guidance and associated products on the condition in a set of interactive topic-based diagrams. For all patients with early breast cancer NICE advises starting adjuvant chemotherapy or radiotherapy as soon as clinically possible and within 31 days of surgery.
New evidence: A meta-analysis by The Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) of individual patient data for 10,801 women in 17 randomised trials examined the effect of radiotherapy after breast-conserving surgery on 10 year recurrence and 15 year breast cancer death (Darby 2011).

The findings show a reduction in cancer recurrence within the first year after radiotherapy which lasts throughout the first decade. By 10 years after breast cancer diagnosis, 35% of the women who did not have radiotherapy had a recurrence, compared with only 19% of the women who had radiotherapy. The effect of radiotherapy on breast cancer mortality was evident 15 years after breast cancer diagnosis, by which time 25% of the women who did not have radiotherapy had died from breast cancer compared with 21% of the women who had radiotherapy. These results suggest that killing microscopic tumour foci in the conserved breast with radiotherapy reduces the potential for both local recurrence and distant metastatis.

The researchers note that there was no substantial adverse effect of radiotherapy on the 15-year risk of death from the aggregate of all causes other than breast cancer so that, among the women who did have radiotherapy, the 15-year risk of death from any cause was reduced by almost as much as the reduction in breast cancer mortality. They add that screening, surgery, pathology, radiotherapy, and systemic therapy have all changed substantially since most of these women were randomly assigned, so the absolute recurrence reduction with radiotherapy in future patients might differ greatly from that recorded in these trials.

However, because radiotherapy roughly halved the recurrence rate after breast-conserving surgery in a wide range of patients with very different absolute risks suggests that it might also roughly halve the recurrence rate in future patients given breast-conserving surgery.

Commentary: “This report updates an earlier 2005 systematic overview of radiotherapy effects in women undergoing adjuvant radiotherapy for early breast cancer. It represents the most authoritative statement available on treatment outcomes, based as it is on level I evidence. The updated evidence confirms that the beneficial effects persist for at least 15 years, and that there is no evidence of adverse effects on survival even after this long interval. The subgroup analyses suggest that identifiable populations of women have more to gain than others, particularly younger age groups and those of any age with higher grade tumours. Older age groups with small, oestrogen receptor rich, low grade tumours appear to have low risks of local relapse after complete microscopic resection and adjuvant endocrine therapy, even without radiotherapy, raising the opportunity for prospective cohort studies evaluating selective avoidance of radiotherapy in future”. –

John Yarnold, Professor of Clinical Oncology,InstituteofCancerResearch andRoyal MarsdenHospital, Sutton.

Crotch-Harvey MA: Breast Cancer Research, November 2011: Conference abstract

Title: Occult breast carcinoma presenting with axillary lymphadenopathy
Citation: Breast Cancer Research, November 2011, vol./is. 13/(S11-S12), 1465-5411 (04 Nov 2011)  Author(s): Crotch-Harvey M.A.
Abstract: Introduction Occult breast carcinoma presenting with axillary lymphadenopathy is an uncommon but difficult clinical problem. The most appropriate diagnostic pathway, the prognosis and the best form of treatment may be uncertain. To answer these questions, we have examined the outcomes of women presenting in this way over a number of years. Methods Thirteen women were identified prospectively over a 12- year period, presenting with suspicious lymphadenopathy but no identifiable breast tumour on initial mammography or ultrasound. Biopsy of the abnormal nodes was consistent with a breast primary in all cases. All women had further imaging with breast MRI (11 cases), breast scintigraphy (one case) and CT scanning of the chest and abdomen. Second-look ultrasound was targeted to suspicious areas identified on second-line imaging. The type of treatment, presence of distant metastases and survival were recorded. Results Further imaging revealed a primary breast lesion in seven cases, six remained truly occult. Follow-up ranged from 3 to 144 months (mean 38 months). Three patients died, one is alive with distant metastases and nine remain disease free. Those with no identifiable primary were treated with chemotherapy usually in combination with radiotherapy. Conclusion The use of MRI and targeted ultrasound-guided biopsy revealed primary tumours in approximately half our cases presenting with lymphadenopathy and negative conventional imaging. Chemotherapy with radiotherapy appears to be an effective treatment for occult breast cancer. The initial staging tests are crucial and if clear the prognosis appears similar to patients with breast cancer and positive axillary nodes.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available in selected fulltext at BioMedCentral
Available in fulltext at National Library of Medicine

Articles from the TRIP database

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. (Lancet) Abstract available – Full text articles may be ordered from other libraries in the region.

MRI for breast cancer screening, diagnosis, and treatment. (Lancet)  (Abstract only)

Colorectal cancer: the diagnosis and management of colorectal cancer (National Institute for Health and Clinical Excellence – Clinical Guidelines (UK))

King’s Fund reports on Breast Cancer Care

Improving outcomes and experiences for older women with breast cancer
This briefing focuses on the key issues for older women affected by breast cancer and presents recommendations for service improvements in three main areas: early diagnosis; treatment and assessment; and information and support.