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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Comment: Uptake of chemoprevention for breast cancer in high risk women
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Shailendra Verma, Ottawa,Canada Medical Oncologist,The Ottawa Hospital Regional Cancer Center
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It has been over 5 years since the National Surgical Adjuvant Breast Project (NSABP) published the results of the landmark Breast Cancer Prevention Trial (BCPT). In addition to this study,three randomised trials (tamoxifen vs. placebo) in high risk women have been reported. The combined data from these trials indicate a reduction in breast cancer incidence of 30-40% with tamoxifen.(Cuzick etal Lancet 2003;361:269-300). This was almost a predictable outcome given the long standing observation that, in addition to reducing recurrence rates and mortality significantly in women diagnosed with early stage breast cancer, tamoxifen has a significant impact on the incidence of new contralateral primaries. (2000 Oxford Overview Lancet 2005;365:1687-1717). Tamoxifen is associated with a variety of vasomotor and gynecilogical side effects,. In addition rates of endometrial cancer are increased(RR 2.4,p<0.001) as are rates of thromboembolic events (RR2.0,p<0.001).These important adverse events have been the predominant driving forces in exploring the role of Raloxifene or the aromatase inhibitors in this setting. Until the results of studies such as STAR (Study of Tamoxifen and Raloxifene) are analyzed, tamoxifen is the only SERM that has a track record in the chemoprevention arena. The results of the BCPT have been endorsed by the American Society of Clinical Oncology (JCO 2002;20(15):3328-3343)as well as by the American College of Obstetrics and Gynecology and the National Comprehensive Cancer Network. Given this background, why then is there such reluctance for women to consider tamoxifen chemorpevention, or for primary care providers to recommend it (in appropriate-risk women)? In this context, the study by Taylor and Taguchi is timely and much needed. The observation of an extremely low uptake in women at medium risk, validates the conclusions of Port et al (Ann Surg Onc 2001;8:580-585)and others. Taylor et al do make some interesting observations though in that the most important reasons for deciding against Tamoxifen were fear of adverse events, perceived low risk of breast cancer and the fact that the family doctor did not "recommend it". Importantly, in the present study only 48 out of 89 'high risk' women actually had a discussion with their family doctors, highlighting the apparent reluctance by medical professionals to even raise the subject!This could well be influenced in part by misinterpretation of risk (how high is high?) and biases against the use of Tamoxifen. Curiously this does not stop the misguided use of Raloxifene in this setting- a practise thus far founded on fairly flimsy evidence.!The authors correctly point out that an assessment of family doctor knowledge and attitudes about tamoxifen is sorely lacking in this study. Deciding to take tamoxifen or not is complex decision for most women and often takes a number of visits and considerable discussion ,weighing the possible risks and benefits. In women at risk it is no longer acceptable to remain passive and paternalistic...frank dialogue on the subject is at least the minimum and participation in trials should be encouraged. Competing interests: None declared |
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