The HPV circus is still in town with plenty of sound and fury. Before we climb on the bandwagon and start expensive HPV DNA testing - as we are encouraged to do by commercial interests - let us be quite sure we are acting in our patients' best interests and not using technological improvements for the sake of science.
As our editorial points out, healthy young women will not thank you for a cancer scare, no matter how diligently you explain its significance. The evidence does not exist that HPV DNA screening reduces deaths from cervical cancer.
There is plenty else to amaze or amuse as the festive season approaches - so hang onto your sense of humour.
The following pieces are recommended reading for subspecialists and those in training:
Diagnosis and management of cervical cancer. Petignat & Roy BMJ 2007;335:765-8
Epilepsy in pregnancy. Thomson & Hiilesmaa BMJ 2007;335:769-73
04 December, 2007
06 November, 2007
Cancer and Oral Contraception
Do oral contraceptives increase the risk of cancer? The answer is no, but it has taken 40 years to prove it. In 1968 GPs recruited a large group of women who had, or had not, taken oral contraceptives and followed them to see if the pill had carcinogenic effects.
The UK Royal College of GPs has now published the results of over a million women-years and the outcomes are reassuring (Hannaford et al BMJ 2007;335:651-4).
Most of the 46 000 women are now post-menopausal and moving into the years when cancers are more common but pill use is more distant, so the detection of protection or enhancement of risk is now measurable.
Overall, pill-users had a lower risk of cancers of the colon, rectum, uterus, ovaries and tumours of unknown site. The differences were statistically significant trends with absolute values of 1 to 5 per 10 000 women years. The authors believe that today's lower doses of estrogen will have similar effects, so we can reassure our patients that there are benefits rather than risks as far as cancer and the pill are concerned.
The UK Royal College of GPs has now published the results of over a million women-years and the outcomes are reassuring (Hannaford et al BMJ 2007;335:651-4).
Most of the 46 000 women are now post-menopausal and moving into the years when cancers are more common but pill use is more distant, so the detection of protection or enhancement of risk is now measurable.
Overall, pill-users had a lower risk of cancers of the colon, rectum, uterus, ovaries and tumours of unknown site. The differences were statistically significant trends with absolute values of 1 to 5 per 10 000 women years. The authors believe that today's lower doses of estrogen will have similar effects, so we can reassure our patients that there are benefits rather than risks as far as cancer and the pill are concerned.
24 October, 2007
HPV vaccine policy
HIV vaccines are receiving ongoing high profile. Their potential is huge but the implementation of vaccination programmes the source of rich debate (BMJ 2007;335 Lo 357-8, Raffle 375-7 & Franco 378-9).
The first argument is that existing cervical cancer screening programmes in developed countries reduce deaths by 80% and it is difficult to argue with these success rates. The costs may even come down with HPV triaged follow up, and the expenditure on a vaccine initiative is formidable. There is no doubt the conventional screening policies will be required on an ongoing basis, but with the opportunity for protecting future generations from primary HPV infection and preventing precancerous and cancerous lesions is too inviting to reject.
The second point is those who would benefit most are the at-risk populations, all in developing countries. Again implementation would be the most challenging but the rewards the greatest.
Finally, the attention to the benefits of screening and prophylaxis will probably be the greatest spin-off. The debate, the rhetoric, the policies, the arguments for and against, the money, the political stances, the religious views and the medical science all contribute to the opening of discussions about women's health.
Should we not all engage as vociferously as we dare on promoting interaction on sexual and adolescent health questions and provide the medical science to inform opinion?
This is an entrée not to be missed.
The first argument is that existing cervical cancer screening programmes in developed countries reduce deaths by 80% and it is difficult to argue with these success rates. The costs may even come down with HPV triaged follow up, and the expenditure on a vaccine initiative is formidable. There is no doubt the conventional screening policies will be required on an ongoing basis, but with the opportunity for protecting future generations from primary HPV infection and preventing precancerous and cancerous lesions is too inviting to reject.
The second point is those who would benefit most are the at-risk populations, all in developing countries. Again implementation would be the most challenging but the rewards the greatest.
Finally, the attention to the benefits of screening and prophylaxis will probably be the greatest spin-off. The debate, the rhetoric, the policies, the arguments for and against, the money, the political stances, the religious views and the medical science all contribute to the opening of discussions about women's health.
Should we not all engage as vociferously as we dare on promoting interaction on sexual and adolescent health questions and provide the medical science to inform opinion?
This is an entrée not to be missed.
04 October, 2007
Soy phytoestrogens
Natural estrogens have great appeal to women as an alternate to conventional hormones at and beyond the menopause. Concerns about the negative effects of standard drugs persuade some women to try phytoestrogens as a “softer option”.
It is difficult for clinicians to advise on such preparations as evidence of benefit - and more importantly harm - is lacking, and it has taken massive trials to uncover the small absolute detrimental effects of estrogens. Until equally stringent trials show the safety of phytoestrogens we will have to rely on smaller studies to show the way.
Marini et al (Ann Int Med 2007;146:839-47) have demonstrated in a RCT of 400 women that genistein, which is found in soy products, increases bone mineral density in osteopenic postmenopausal women. 54 mg of genistein daily for 2 years had positive effects on bone density and turnover compared with placebo, opening the way for long-term trials on fracture effects as well as uterine and breast safety.
It is difficult for clinicians to advise on such preparations as evidence of benefit - and more importantly harm - is lacking, and it has taken massive trials to uncover the small absolute detrimental effects of estrogens. Until equally stringent trials show the safety of phytoestrogens we will have to rely on smaller studies to show the way.
Marini et al (Ann Int Med 2007;146:839-47) have demonstrated in a RCT of 400 women that genistein, which is found in soy products, increases bone mineral density in osteopenic postmenopausal women. 54 mg of genistein daily for 2 years had positive effects on bone density and turnover compared with placebo, opening the way for long-term trials on fracture effects as well as uterine and breast safety.
07 September, 2007
Diet and health
The long-term prognosis for breast cancer survivors continues to improve. Better treatment, adjuvant chemo- and hormonal therapies offer women an excellent outlook, especially if the disease is detected early.
In addition, support groups give psychological comfort, exercise seems to be beneficial, and now a large study has looked at diet and survival. Pierce et al (JAMA 2007;298:289-98) allocated women after early stage breast cancer care to either a diet very high in fruit, vegetables and fibre but low in fat or a comparison dietary pattern which recommended “5-A-Day” fruit and vegetables.
The “extra fruit, fibre 'n veg” with low fat did not make a difference to recurrence, metastases or all-cause mortality over a period of seven years. Perhaps if the control group had been given no dietary instructions, and gained weight, there might have been a difference but failing to advise women about diet would be considered unethical. Where patients gain weight by not balancing intake and expenditure, the prognosis is poorer, so energy balance may be more important than extreme diets (Grapstur & Khan pp 335-6).
In addition, support groups give psychological comfort, exercise seems to be beneficial, and now a large study has looked at diet and survival. Pierce et al (JAMA 2007;298:289-98) allocated women after early stage breast cancer care to either a diet very high in fruit, vegetables and fibre but low in fat or a comparison dietary pattern which recommended “5-A-Day” fruit and vegetables.
The “extra fruit, fibre 'n veg” with low fat did not make a difference to recurrence, metastases or all-cause mortality over a period of seven years. Perhaps if the control group had been given no dietary instructions, and gained weight, there might have been a difference but failing to advise women about diet would be considered unethical. Where patients gain weight by not balancing intake and expenditure, the prognosis is poorer, so energy balance may be more important than extreme diets (Grapstur & Khan pp 335-6).
08 August, 2007
Depression in pregnancy
Women are more likely than men to suffer from depression, especially during their reproductive years. Rates of depression are higher where stressful circumstances exist such as poverty, lack of education, sexual inequality, poor social support and in pregnancy. Single and adolescent pregnant women are especially at risk.
Pregnancy is a socially and physiologically demanding time and a woman who is just coping with the stresses of life may find the additional burden unmanageable. Mood regulation is modified by sex steroids, specifically the cortisol stress system mediated via the hypothalamic-pituitary-adrenal axis which is overactive in depressed people.
In developed countries, the rate of depression in pregnancy is at least 10% and double that in poorer countries. Irrespective of their socio-economic status, women with affective disorders have a high relapse rate in pregnancy which, in turn, is reflected in poorer maternal and fetal outcomes - mostly early delivery and growth restriction. Again, the common pathway of depression and social adversity is likely to be through the cortisol stress hormone system (O'Keane & Marsh BMJ 2007;334:1003-5).
Given these high rates of occurrence, depression should be specifically enquired about antenatally and actively managed if present. Since two-thirds of women stopping antidepressants during pregnancy will relapse, discontinuation is seldom advisable as the resultant depression can lead to unhealthy behaviours such as smoking, drinking alcohol, substance abuse and poor clinic attendance. About a quarter of those remaining on treatment will relapse, so surveillance levels must remain high.
The teratogenicity of antidepressants has been prominent in the journals recently. Selective serotonin reuptake inhibitors (SSRIs) were introduced in the 1980s as safe mood elevators because of their reasonably rapid onset of action, which is ten days according to the latest reports, plus fewer side effects and lower risk when taken in overdose. Nevertheless, there were incidental reports of birth defects such as nervous system or cardiac abnormalities, and cautions were issued. Now two large studies are reported in NEJM (Louik et al 2007;356:2675-83 and Alwan et al 2007;356:2684-92) which are case-controlled evaluations showing a small absolute risk of SSRIs being causative of defects if taken in the first trimester. These are certainly nothing like the risk posed by thalidomide or isotretinoin. In the US the use of these drugs is increasing and the latest data suggest that 10% of all pregnant women are taking an SSRI (Cooper et al AJOG 2007;196:544-5).
In an editorial, Greene (NEJM 2007;356:2732-3) says it would be pleasing to say there is no risk from SSRIs, but that is not possible. To quote from these major studies, “it is important to keep in perspective that the absolute risks of these rare defects are small” and “the absolute risks associated with SSRIs appear small in comparison with the baseline risks of birth defects that exist in every pregnancy”.
Pregnancy is a socially and physiologically demanding time and a woman who is just coping with the stresses of life may find the additional burden unmanageable. Mood regulation is modified by sex steroids, specifically the cortisol stress system mediated via the hypothalamic-pituitary-adrenal axis which is overactive in depressed people.
In developed countries, the rate of depression in pregnancy is at least 10% and double that in poorer countries. Irrespective of their socio-economic status, women with affective disorders have a high relapse rate in pregnancy which, in turn, is reflected in poorer maternal and fetal outcomes - mostly early delivery and growth restriction. Again, the common pathway of depression and social adversity is likely to be through the cortisol stress hormone system (O'Keane & Marsh BMJ 2007;334:1003-5).
Given these high rates of occurrence, depression should be specifically enquired about antenatally and actively managed if present. Since two-thirds of women stopping antidepressants during pregnancy will relapse, discontinuation is seldom advisable as the resultant depression can lead to unhealthy behaviours such as smoking, drinking alcohol, substance abuse and poor clinic attendance. About a quarter of those remaining on treatment will relapse, so surveillance levels must remain high.
The teratogenicity of antidepressants has been prominent in the journals recently. Selective serotonin reuptake inhibitors (SSRIs) were introduced in the 1980s as safe mood elevators because of their reasonably rapid onset of action, which is ten days according to the latest reports, plus fewer side effects and lower risk when taken in overdose. Nevertheless, there were incidental reports of birth defects such as nervous system or cardiac abnormalities, and cautions were issued. Now two large studies are reported in NEJM (Louik et al 2007;356:2675-83 and Alwan et al 2007;356:2684-92) which are case-controlled evaluations showing a small absolute risk of SSRIs being causative of defects if taken in the first trimester. These are certainly nothing like the risk posed by thalidomide or isotretinoin. In the US the use of these drugs is increasing and the latest data suggest that 10% of all pregnant women are taking an SSRI (Cooper et al AJOG 2007;196:544-5).
In an editorial, Greene (NEJM 2007;356:2732-3) says it would be pleasing to say there is no risk from SSRIs, but that is not possible. To quote from these major studies, “it is important to keep in perspective that the absolute risks of these rare defects are small” and “the absolute risks associated with SSRIs appear small in comparison with the baseline risks of birth defects that exist in every pregnancy”.
04 July, 2007
Aspirin and colorectal cancer
Many studies have shown that the regular use of aspirin reduces the risk of colorectal neoplasms. Quite how this works is not clear but it is thought to be related to prostaglandin metabolism or, more specifically, to aspirin's ability to inhibit the enzyme cyclo-oxygenase-2 (COX-2).
If this is the mechanism by which aspirin reduces colorectal cancers then it would be cancers that over-express COX-2 that would occur less frequently in aspirin users. Chan et al (NEJM 2007;356:2131-42) looked at this theory by histochemical assays of cancers removed from men and women in two large surveys and matched these against aspirin intake. They found that cancers that over-express COX-2 were reduced by aspirin but not cancers that had weak COX-2 expression.
The effect was found relative to increasing aspirin dose and duration of use. Flossmann et al (Lancet 2007;369:1603-13) showed that 300mg per day for 5 years is effective in primary prevention but the latency time is 10 years so patients have to be dedicated to their health.
If this is the mechanism by which aspirin reduces colorectal cancers then it would be cancers that over-express COX-2 that would occur less frequently in aspirin users. Chan et al (NEJM 2007;356:2131-42) looked at this theory by histochemical assays of cancers removed from men and women in two large surveys and matched these against aspirin intake. They found that cancers that over-express COX-2 were reduced by aspirin but not cancers that had weak COX-2 expression.
The effect was found relative to increasing aspirin dose and duration of use. Flossmann et al (Lancet 2007;369:1603-13) showed that 300mg per day for 5 years is effective in primary prevention but the latency time is 10 years so patients have to be dedicated to their health.
30 June, 2007
Does Viagra work for women?
This is a deliberately provocative title. A more accurate heading would be: Does improving a man's erectile dysfunction improve his partner's sexual satisfaction?
The intuitive response is that it should. If a man's problem is reduced, confidence, frequency and performance could be expected to improve, resulting in the couple's greater enjoyment of sex and the woman being more satisfied with this aspect of their relationship.
But sexual function does not work in straight lines. For example, when a man experiences erectile dysfunction (ED), he may be embarrassed or fear ridicule and withdraw, starting a series of events in his partner's mind about self-blame or being unattractive which can reduce her confidence or may arouse suspicions of unfaithfulness. Because the age at which men seek aid for ED is about 58 years and their partners' age about 54 years, these events are likely to coincide with her menopause with its attendant loss of libido and physical symptoms.
For these reasons, research is complex in the field of women's satisfaction from sildenafil (Viagra ® - Pfizer) treatment of men. However, Heiman et al (BJOG 2007;114:437-47) were able to carry out such a study comparing sildenafil with placebo and measuring the woman's perception of outcomes. Unsurprisingly, provided the woman had no dysfunction herself, her satisfaction with their sexual relationship improved significantly if he received sildenafil compared with those whose partners received the placebo. The scores were better for overall satisfaction as well as more detailed questions probing erectile function, orgasmic function, libido, arousal and intercourse satisfaction.
Side effects in the men were infrequent and mild to moderate. Maybe the manufacturers can add another side-effect - increased partner satisfaction?
The intuitive response is that it should. If a man's problem is reduced, confidence, frequency and performance could be expected to improve, resulting in the couple's greater enjoyment of sex and the woman being more satisfied with this aspect of their relationship.
But sexual function does not work in straight lines. For example, when a man experiences erectile dysfunction (ED), he may be embarrassed or fear ridicule and withdraw, starting a series of events in his partner's mind about self-blame or being unattractive which can reduce her confidence or may arouse suspicions of unfaithfulness. Because the age at which men seek aid for ED is about 58 years and their partners' age about 54 years, these events are likely to coincide with her menopause with its attendant loss of libido and physical symptoms.
For these reasons, research is complex in the field of women's satisfaction from sildenafil (Viagra ® - Pfizer) treatment of men. However, Heiman et al (BJOG 2007;114:437-47) were able to carry out such a study comparing sildenafil with placebo and measuring the woman's perception of outcomes. Unsurprisingly, provided the woman had no dysfunction herself, her satisfaction with their sexual relationship improved significantly if he received sildenafil compared with those whose partners received the placebo. The scores were better for overall satisfaction as well as more detailed questions probing erectile function, orgasmic function, libido, arousal and intercourse satisfaction.
Side effects in the men were infrequent and mild to moderate. Maybe the manufacturers can add another side-effect - increased partner satisfaction?
28 June, 2007
Simple health tips - salt
Adult women and men, who reduce their salt intake, reduce their blood pressure. This effect is independent of age, race, baseline blood pressure or body mass. Such information has been around for years but a study by Cook et al (BMJ 2007;334:885-8) now shows that this leads to a long-term reduction in cardiovascular events.
We should restrict our daily intake to 5g per day, or less. We can reduce what we add to our food and support the profession's efforts to have salt levels on foods labeled. Legislation would help and the new data will add weight to the arguments encouraging less salt in prepared foods and declaring how much there is, so prudent purchasing is possible.
We should restrict our daily intake to 5g per day, or less. We can reduce what we add to our food and support the profession's efforts to have salt levels on foods labeled. Legislation would help and the new data will add weight to the arguments encouraging less salt in prepared foods and declaring how much there is, so prudent purchasing is possible.
04 June, 2007
HRT and breast cancer
Breast cancer risk is not increased in estrogen-only HRT but when estrogens are combined with progestins, there is a raised risk that is cumulative. However, there is no evidence of increased mortality and after quitting HRT risk ratios return to normal.
If these data are correct, and if there is a causal or unmasking effect of hormonal therapy on breast cancer, then the rapid reduction in HRT use in America following the Women Health Initiative trial results would have led to a concomitant reduction in cancers detected.
Ravdin et al (NEJM 2007;356:1670-4) report that such a drop in estrogen-receptor-positive breast cancers did occur in 2002-2003 as the number of prescriptions fell from about 50 million to 25 million. This change occurred in postmenopausal women only, strongly implying an association with hormone therapy. The change was of the order of 7% relative risk and the incidence levelled off thereafter.
These findings support a link between combined hormone therapy and breast cancer, but the interpretation should be cautious. The observations concern a particular set of products, a particular age group and a particular type of breast cancer.
The absolute risk of breast cancer for any woman considering hormonal therapy in America remains around 0.30% per annum and this changes to 0.36% per annum on HRT and the effects are cumulative.
This sort of evidence moves our collective wisdom forward but does not answer other questions, such as will these incidences start to rise as the occult cancers reveal themselves later? Or will other forms of hormonal therapy remain free of breast cancer “encouragement”?
So where is the evidence that taking HRT for 10 years after the menopause is harmful?
Is this another example of medicine discovering a magic bullet that is first hailed, then discredited and then, finally, finds its appropriate niche?
JASS certainly believes that the notion of “feminine forever” was a grossly optimistic concept but, equally, there has been an over-reaction to the harmful effects of HRT because of inappropriate hormones given to women long past their menopause - and who were not in the best of health.
Perhaps the pendulum is reaching sanity and hormonal therapy will be useful in the treatment of menopausal symptoms AND offer protection against chronic conditions if used appropriately in terms of initiation, dose, mode of delivery and duration which may well turn out to be 10 years.
The bottom line in 2007 is that starting therapy at the menopause and continuing for a number of years carries little, if any, risk in healthy women. The experts appear in equipoise so it is up to women and their advisors to decide.
It seems clear that initiating combined HRT in women 10 years or more after their menopause does not turn back the clock and probably, on balance, does harm.
If these data are correct, and if there is a causal or unmasking effect of hormonal therapy on breast cancer, then the rapid reduction in HRT use in America following the Women Health Initiative trial results would have led to a concomitant reduction in cancers detected.
Ravdin et al (NEJM 2007;356:1670-4) report that such a drop in estrogen-receptor-positive breast cancers did occur in 2002-2003 as the number of prescriptions fell from about 50 million to 25 million. This change occurred in postmenopausal women only, strongly implying an association with hormone therapy. The change was of the order of 7% relative risk and the incidence levelled off thereafter.
These findings support a link between combined hormone therapy and breast cancer, but the interpretation should be cautious. The observations concern a particular set of products, a particular age group and a particular type of breast cancer.
The absolute risk of breast cancer for any woman considering hormonal therapy in America remains around 0.30% per annum and this changes to 0.36% per annum on HRT and the effects are cumulative.
This sort of evidence moves our collective wisdom forward but does not answer other questions, such as will these incidences start to rise as the occult cancers reveal themselves later? Or will other forms of hormonal therapy remain free of breast cancer “encouragement”?
So where is the evidence that taking HRT for 10 years after the menopause is harmful?
Is this another example of medicine discovering a magic bullet that is first hailed, then discredited and then, finally, finds its appropriate niche?
JASS certainly believes that the notion of “feminine forever” was a grossly optimistic concept but, equally, there has been an over-reaction to the harmful effects of HRT because of inappropriate hormones given to women long past their menopause - and who were not in the best of health.
Perhaps the pendulum is reaching sanity and hormonal therapy will be useful in the treatment of menopausal symptoms AND offer protection against chronic conditions if used appropriately in terms of initiation, dose, mode of delivery and duration which may well turn out to be 10 years.
The bottom line in 2007 is that starting therapy at the menopause and continuing for a number of years carries little, if any, risk in healthy women. The experts appear in equipoise so it is up to women and their advisors to decide.
It seems clear that initiating combined HRT in women 10 years or more after their menopause does not turn back the clock and probably, on balance, does harm.
17 May, 2007
Donating eggs
Women donate eggs for two reasons. Firstly for other women to conceive and, secondly, for research. Both are dogged by controversy on medical, societal and financial grounds. The US and the UK are currently trying to create guidelines and legislation that will allow workers in assisted reproduction and laboratory research to operate without fear of prosecution.
Infertile women undergoing IVF are usually given some form of gonadotropin-releasing hormone to stimulate multiple oocyte production. This hyperstimulation and harvesting results in more oocytes than can be used in fertilisation and embryo transfer in any given cycle, so there are spare oocytes for later use by the woman, or for donation.
Whether the stimulation should be with GnRH agonists or antagonists is one debate and another is whether one or two embryos should be transferred. What is not in question is that the demand for oocytes far exceeds supply. Women below the age of 35 years have significantly higher IVF success rates than older women, precisely the group who are now more often seeking reproductive assistance. The result is that the donation or sale of oocytes has become a big issue.
Clearly the unauthorised harvesting of oocytes is illegal as an Israeli doctor has found to his cost (BMJ 2007;334:557), but what about consented donations to infertile women? The free donation of “extra ova” from women to their infertile fellow patients seems straight-forward enough, but already the problem of incentives has arisen. In private clinics, can these spare oocytes be bought or can the woman be given a discount for her treatment if she donates? This discount for donation occurs in the UK where 75% of all IVF procedures are funded by the patients themselves despite decrees that all infertile couples are entitled to four IVF cycles within the NHS (Ledger Lancet 2007;369:717-8). Moving further along the continuum, is it acceptable for a woman who has no fertility problems to supply oocytes for payment? In the US it is, where thousands of babies are born annually from oocytes acquired from women who receive an average of $5 000 per harvest (Spar NEJM 2007;356:1289-91).
The UK has the Human Fertilisation and Embryology Authority which is the regulator of IVF treatment. It has now ruled that altruistic oocyte donation, in conjunction with fertility treatment or not, is acceptable. The report by Mayor (BMJ 2007;334:445) made no mention of discounts for donations in the private sector - also known as “egg sharing” - so compensation for co-operation remains a grey area. Other places such as Singapore, Israel and South Korea allow donations but without payment or personal benefit.
The role of oocytes in research is more complex, despite the fact they may not be bought for study purposes. Research falls into two categories - infertility or stem cell research. The former is not as contentious, despite using human reproductive material, but the latter is highly controversial using somatic-cell nuclear transfer (SCNT) to create lines of stem cells from which the US administration has withheld federal funding. The arguments go that without payment women will not donate oocytes for research but, attracted by pay, women could be tempted to “sell their eggs” in a competitive market to their own potential detriment.
Infertile women undergoing IVF are usually given some form of gonadotropin-releasing hormone to stimulate multiple oocyte production. This hyperstimulation and harvesting results in more oocytes than can be used in fertilisation and embryo transfer in any given cycle, so there are spare oocytes for later use by the woman, or for donation.
Whether the stimulation should be with GnRH agonists or antagonists is one debate and another is whether one or two embryos should be transferred. What is not in question is that the demand for oocytes far exceeds supply. Women below the age of 35 years have significantly higher IVF success rates than older women, precisely the group who are now more often seeking reproductive assistance. The result is that the donation or sale of oocytes has become a big issue.
Clearly the unauthorised harvesting of oocytes is illegal as an Israeli doctor has found to his cost (BMJ 2007;334:557), but what about consented donations to infertile women? The free donation of “extra ova” from women to their infertile fellow patients seems straight-forward enough, but already the problem of incentives has arisen. In private clinics, can these spare oocytes be bought or can the woman be given a discount for her treatment if she donates? This discount for donation occurs in the UK where 75% of all IVF procedures are funded by the patients themselves despite decrees that all infertile couples are entitled to four IVF cycles within the NHS (Ledger Lancet 2007;369:717-8). Moving further along the continuum, is it acceptable for a woman who has no fertility problems to supply oocytes for payment? In the US it is, where thousands of babies are born annually from oocytes acquired from women who receive an average of $5 000 per harvest (Spar NEJM 2007;356:1289-91).
The UK has the Human Fertilisation and Embryology Authority which is the regulator of IVF treatment. It has now ruled that altruistic oocyte donation, in conjunction with fertility treatment or not, is acceptable. The report by Mayor (BMJ 2007;334:445) made no mention of discounts for donations in the private sector - also known as “egg sharing” - so compensation for co-operation remains a grey area. Other places such as Singapore, Israel and South Korea allow donations but without payment or personal benefit.
The role of oocytes in research is more complex, despite the fact they may not be bought for study purposes. Research falls into two categories - infertility or stem cell research. The former is not as contentious, despite using human reproductive material, but the latter is highly controversial using somatic-cell nuclear transfer (SCNT) to create lines of stem cells from which the US administration has withheld federal funding. The arguments go that without payment women will not donate oocytes for research but, attracted by pay, women could be tempted to “sell their eggs” in a competitive market to their own potential detriment.
15 May, 2007
OCs and ovarian cancer
Oral contraceptives (OCs) are known to decrease a woman's risk of developing epithelial ovarian cancer. However, the dose of estrogens and progestins in OCs have come down in recent years so it is unclear if the protection previously offered still holds.
Lurie et al (Obstets Gynecol 2007;109:597-607) conducted a case-controlled study on over 700 women with epithelial ovarian cancer that took into account the woman's OC history and matched them with controls who may or may not have used OCs. Their results were conclusive. OCs were effective in decreasing the risk of cancer and the lowest formulations offered the strongest protection. The authors postulate that the antiovulatory mechanisms of OCs are the key factor in reducing malignancy rates and that women taking the lower dose pills are more likely to be compliant compared to high-dose users.
Consistency of use, rather than the hormonal dose probably explains the effect and a reduction in ovarian cancers may well continue due to OC use.
Lurie et al (Obstets Gynecol 2007;109:597-607) conducted a case-controlled study on over 700 women with epithelial ovarian cancer that took into account the woman's OC history and matched them with controls who may or may not have used OCs. Their results were conclusive. OCs were effective in decreasing the risk of cancer and the lowest formulations offered the strongest protection. The authors postulate that the antiovulatory mechanisms of OCs are the key factor in reducing malignancy rates and that women taking the lower dose pills are more likely to be compliant compared to high-dose users.
Consistency of use, rather than the hormonal dose probably explains the effect and a reduction in ovarian cancers may well continue due to OC use.
07 May, 2007
Contralateral breast cancer
Some women diagnosed with early breast cancer in one breast are later found to have cancer in the other breast. Even careful clinical examination and mammography can fail to identify early lesions, so the question arises as to whether more extensive investigations - such as magnetic resonance imaging (MRI) - should not be carried out routinely at the time of the initial diagnosis.
Lehman et al (NEJM 2007;356:1295-303) report on nearly 1 000 women across the US who had early cancer in one breast with negative mammography and clinical examination in the other who then had MRI of the “cancer-free” breast. Within one year of the initial diagnosis they found 3% of the women had or developed cancer in the contralateral breast.
The sensitivity and specificity were not as high as ideally required in a screening test but, with a negative predictive value of 99%, women may well find it acceptable. The cancers found in the contralateral breast were all early and had not spread so MRI evaluation should be considered if malignancy is found in one breast, even if routine investigations are apparently negative.
Lehman et al (NEJM 2007;356:1295-303) report on nearly 1 000 women across the US who had early cancer in one breast with negative mammography and clinical examination in the other who then had MRI of the “cancer-free” breast. Within one year of the initial diagnosis they found 3% of the women had or developed cancer in the contralateral breast.
The sensitivity and specificity were not as high as ideally required in a screening test but, with a negative predictive value of 99%, women may well find it acceptable. The cancers found in the contralateral breast were all early and had not spread so MRI evaluation should be considered if malignancy is found in one breast, even if routine investigations are apparently negative.
06 May, 2007
Exercise after breast cancer
There is evidence that regular exercise is associated with a decreased risk of breast cancer. What is less clear is whether supervised exercise for women recovering from early breast cancer treatment is beneficial. A controlled trial from Scotland now answers some quality-of-life questions.
Mutrie et al (BMJ 2007;334:517-20) followed 100 women allocated to group exercise and 100 controls for three months after their initial treatment and found the exercise group derived functional and psychological benefit, which was immediate and sustained at six months.
It is suggested that the diagnosis of cancer affords a “teachable moment” when people are receptive to changes in lifestyle behaviours and the rigorous research indicates recovery from breast cancer therapy can be enhanced by seizing that moment.
Mutrie et al (BMJ 2007;334:517-20) followed 100 women allocated to group exercise and 100 controls for three months after their initial treatment and found the exercise group derived functional and psychological benefit, which was immediate and sustained at six months.
It is suggested that the diagnosis of cancer affords a “teachable moment” when people are receptive to changes in lifestyle behaviours and the rigorous research indicates recovery from breast cancer therapy can be enhanced by seizing that moment.
03 May, 2007
Women's diets
Obesity is at an all-time high. Humans throughout the world are consuming more calories than they expend, and BMIs continue to rise. Medically this is not good news as there are virtually no benefits from being overweight - and considerable risks.
Obesity is linked to risks of cardiovascular disease, metabolic disorders, cancer incidence, increased mortality and, in women, reproductive dysfunction. Science has produced evidence of the risks and no-one in the developed world can claim ignorance of the dangers of obesity.
Socially, some developing cultures perceive obesity as a marker of success or status but the ample figure is not admired or respected in Western culture. Over the last half century, affluence seems to have changed our views and being overweight has become a feature of society. Whether it has become socially acceptable or not is a sociological question, but medically it simply increases the burden of disease.
The aesthetics are in the eye of the beholder.
Premenopausal women are traditionally figure-conscious, and diets feature in conversations, magazines and respected medical journals. Arguments about diets will continue as “easier” ways to lose weight are touted by the popular press. But is there science to back one diet against another?
Gardner et al from California (JAMA 2007;297:969-77) explored the relative merits of diets that varied in their carbohydrate components. They diligently followed four groups of women in their forties over one year who were randomly allocated to the following diets - Atkins (very low carbo), Zone (low carbo), LEARN (moderate carbo) and Ornish (very high carbo). They looked at metabolic effects and gave the women every incentive - including a modest financial stipend - to stick to their regimens.
The Atkins diet gave the best results biochemically and cardiovascularly and in terms of sustained weight loss compared to the three others which were equally inferior. However, the overall results were only modest, with the Atkins diet women losing about 4.5kg and the others about 2kg over the year.
Since their mean weight at the start was 85kg, the reward for these women's efforts was small and the drop-out rates not insignificant. Obesity is a problem of lifestyle and the individual effects are there for everyone to ponder. Medicine can highlight what each person can eat for optimal health and emphasise through large studies how our society is slumping into soft-option acceptance of unhealthy food consumption.
Obesity is linked to risks of cardiovascular disease, metabolic disorders, cancer incidence, increased mortality and, in women, reproductive dysfunction. Science has produced evidence of the risks and no-one in the developed world can claim ignorance of the dangers of obesity.
Socially, some developing cultures perceive obesity as a marker of success or status but the ample figure is not admired or respected in Western culture. Over the last half century, affluence seems to have changed our views and being overweight has become a feature of society. Whether it has become socially acceptable or not is a sociological question, but medically it simply increases the burden of disease.
The aesthetics are in the eye of the beholder.
Premenopausal women are traditionally figure-conscious, and diets feature in conversations, magazines and respected medical journals. Arguments about diets will continue as “easier” ways to lose weight are touted by the popular press. But is there science to back one diet against another?
Gardner et al from California (JAMA 2007;297:969-77) explored the relative merits of diets that varied in their carbohydrate components. They diligently followed four groups of women in their forties over one year who were randomly allocated to the following diets - Atkins (very low carbo), Zone (low carbo), LEARN (moderate carbo) and Ornish (very high carbo). They looked at metabolic effects and gave the women every incentive - including a modest financial stipend - to stick to their regimens.
The Atkins diet gave the best results biochemically and cardiovascularly and in terms of sustained weight loss compared to the three others which were equally inferior. However, the overall results were only modest, with the Atkins diet women losing about 4.5kg and the others about 2kg over the year.
Since their mean weight at the start was 85kg, the reward for these women's efforts was small and the drop-out rates not insignificant. Obesity is a problem of lifestyle and the individual effects are there for everyone to ponder. Medicine can highlight what each person can eat for optimal health and emphasise through large studies how our society is slumping into soft-option acceptance of unhealthy food consumption.
April JASS
Colleague,
Life-style continues to be a theme that the journals publish for women's health.
There are healthy, weight-reducing diets and exercise on the one hand, and the disadvantages of obesity on the other. Scientific evidence backs sensible eating and physical activity.
These are refreshing data because one might have anticipated research in the 21st century to be moving towards molecular and genetic studies. The fact that epidemiology which describes the maintenance of health is reported, allows us to advise patients about what they can do to help themselves to better health.
The issue of supplementation to prevent congenital abnormalities seems a “no brainer” but most European countries have yet to implement the practice. Is it democracy gone mad that makes them kowtow to mavericks and often whacky science that opposes such enhancement to prevent neural tube and facial cleft defects?
Evidence-based medicine has resulted in major changes in obstetric management yet it seems politicians are reluctant to heed its logic. It should be a cause that O&G societies in each country should be lobbying for - as well as fluoride addition to drinking water.
Life-style continues to be a theme that the journals publish for women's health.
There are healthy, weight-reducing diets and exercise on the one hand, and the disadvantages of obesity on the other. Scientific evidence backs sensible eating and physical activity.
These are refreshing data because one might have anticipated research in the 21st century to be moving towards molecular and genetic studies. The fact that epidemiology which describes the maintenance of health is reported, allows us to advise patients about what they can do to help themselves to better health.
The issue of supplementation to prevent congenital abnormalities seems a “no brainer” but most European countries have yet to implement the practice. Is it democracy gone mad that makes them kowtow to mavericks and often whacky science that opposes such enhancement to prevent neural tube and facial cleft defects?
Evidence-based medicine has resulted in major changes in obstetric management yet it seems politicians are reluctant to heed its logic. It should be a cause that O&G societies in each country should be lobbying for - as well as fluoride addition to drinking water.
16 April, 2007
Obesity and pregnancy
The three major specialist journals carry articles on obesity and pregnancy this month. The definitions are; a BMI over 25 is overweight, over 30 obese, over 35 grossly obese, and over 40 morbidly obese.
The BJOG (Heslehurst 2007;114:187-94) traces maternal obesity over the last 15 years which shows the incidence has increased from 10% to 16% and, if the trend continues, by 2010 the rate will be 22%. This carries implications for hospital staff, facilities and special clinics all requiring more resources.
Some of those requirements will be far more caesarean sections. Bergholt et al (AJOG 2007;196:163-5) tracked a group of uncomplicated primipara and worked out their chances of an emergency CS in labour. Taking women with a BMI of less than 25 as controls, CS rates rose with BMI with those who were grossly obese having four times the risk of a CS. Failure to progress and suspected fetal distress were the main indications while one-quarter of the remaining women had an instrumental delivery.
The authors advise telling women with raised BMIs about their increased risk of CS delivery. Clinicians and patients should be aware of these statistics and share them with labour ward staff.
In the US, more than half of women of reproductive age are overweight and 30% are obese. The lower the socio-economic status, the greater the incidence of obesity. There is a spread of related problems which Catalano (Obstets Gynecol 2007;109:419-33) iterates sequentially: greater risk of miscarriage and congenital abnormalities, later manifestations of the metabolic syndrome including diabetes, cardiac dysfunction, proteinuria, sleep apnoea and fatty-liver disease, greater risk of caesarean section with anaesthetic difficulties, operative challenges, wound disruption or infection and clotting risks. Fetal risks in the short-term are macrosomia and obesity with related poorer outcomes plus long-term consequences in adolescence and adulthood of the metabolic syndrome.
The BJOG (Heslehurst 2007;114:187-94) traces maternal obesity over the last 15 years which shows the incidence has increased from 10% to 16% and, if the trend continues, by 2010 the rate will be 22%. This carries implications for hospital staff, facilities and special clinics all requiring more resources.
Some of those requirements will be far more caesarean sections. Bergholt et al (AJOG 2007;196:163-5) tracked a group of uncomplicated primipara and worked out their chances of an emergency CS in labour. Taking women with a BMI of less than 25 as controls, CS rates rose with BMI with those who were grossly obese having four times the risk of a CS. Failure to progress and suspected fetal distress were the main indications while one-quarter of the remaining women had an instrumental delivery.
The authors advise telling women with raised BMIs about their increased risk of CS delivery. Clinicians and patients should be aware of these statistics and share them with labour ward staff.
In the US, more than half of women of reproductive age are overweight and 30% are obese. The lower the socio-economic status, the greater the incidence of obesity. There is a spread of related problems which Catalano (Obstets Gynecol 2007;109:419-33) iterates sequentially: greater risk of miscarriage and congenital abnormalities, later manifestations of the metabolic syndrome including diabetes, cardiac dysfunction, proteinuria, sleep apnoea and fatty-liver disease, greater risk of caesarean section with anaesthetic difficulties, operative challenges, wound disruption or infection and clotting risks. Fetal risks in the short-term are macrosomia and obesity with related poorer outcomes plus long-term consequences in adolescence and adulthood of the metabolic syndrome.
03 April, 2007
Is fish safe in pregnancy?
Some long-chain omega-3 fatty acids are essential for optimal neuro-development in the fetus. Fish is a rich source of these nutrients but there have been suggestions that fish could contain toxins like mercury that could be detrimental to brain function. Indeed, the current US governmental recommendations advise not more than three servings of seafood per week for pregnant women, but there may be a danger that such restrictions could be counter-productive and can result in fetal brain malnutrition.
This is quite an issue so the study by Hibbeln et al (Lancet 2007;369:578-85) is a welcome source of information. They investigated 12 000 children whose mothers had recorded how much seafood they ingested during the index pregnancy and measured it against the child's intellectual, social, communication and fine-motor development up to 8 years of age. They found that the lower the seafood intake, the greater the risk of dysfunction. Fish was protective of normal development and function - exactly the opposite of the US advice. On balance, women are not putting their unborn child at risk by eating three or more portions of fish per week.
As Myers & Davidson say in an editorial (Lancet 2007;369:537-8), the dangers of fish-eating in pregnancy have been misrepresented and are misleading and are not based on any evidence of harm.
This is quite an issue so the study by Hibbeln et al (Lancet 2007;369:578-85) is a welcome source of information. They investigated 12 000 children whose mothers had recorded how much seafood they ingested during the index pregnancy and measured it against the child's intellectual, social, communication and fine-motor development up to 8 years of age. They found that the lower the seafood intake, the greater the risk of dysfunction. Fish was protective of normal development and function - exactly the opposite of the US advice. On balance, women are not putting their unborn child at risk by eating three or more portions of fish per week.
As Myers & Davidson say in an editorial (Lancet 2007;369:537-8), the dangers of fish-eating in pregnancy have been misrepresented and are misleading and are not based on any evidence of harm.
March JASS is out
“We are what we eat” is an old chestnut.
The journals are full of articles on how diets affect risk of disease and, with the prevalence of obesity at an all-time high, there is no lack of publications on diets that affect weight. The dangers of being overweight in pregnancy are well documented and the review by Catalano (see summary) highlights these.
Those wishing to supplement their diets with healthy additives should do so with caution. More is not necessarily better and the antioxidant story is sobering.
Pregnant women's intake is also revealing and the article on the dangers of eating fish is a real “myth-buster”.
Also in the life-style paradigm, sex is enjoying a greater press with the tensions between medicalising sexual function and suppressing information receiving attention. What is normal function and what is dysfunction?
You decide how much is enough of what!
The journals are full of articles on how diets affect risk of disease and, with the prevalence of obesity at an all-time high, there is no lack of publications on diets that affect weight. The dangers of being overweight in pregnancy are well documented and the review by Catalano (see summary) highlights these.
Those wishing to supplement their diets with healthy additives should do so with caution. More is not necessarily better and the antioxidant story is sobering.
Pregnant women's intake is also revealing and the article on the dangers of eating fish is a real “myth-buster”.
Also in the life-style paradigm, sex is enjoying a greater press with the tensions between medicalising sexual function and suppressing information receiving attention. What is normal function and what is dysfunction?
You decide how much is enough of what!
05 March, 2007
Density or detection in breast cancer
Radiologically, the breast varies according to its tissue composition. Fat is radiographically translucent and appears dark on the film. Epithelium and stroma are radiographically opaque or dense and appear light on the film. The amount of radio-opaque tissue is referred to as the breast's density and generally the higher a woman's breast density, the greater her risk of developing breast cancer.
As well as the increased risk, high breast density makes the interpretation of mammography films more difficult, so early lesions may go undetected, leading to poorer outcomes. It is difficult to say whether it is the breast density per se which increases the risk or the delay in diagnosis because of the density which is the problem.
In an attempt to resolve the issue, Boyd et al from Canada (NEJM 2007;356:227-36) noted the woman's breast density at her first mammography and then carefully tracked her risk of subsequent cancer using modern techniques. Thus they hoped to eliminate the detection problem and quantify the risk of high density breast tissue. Their results were conclusive in that women with densities over 75% were five times more likely to develop breast cancer than those with densities below 10%.
Kerlikowske in an editorial (pp 297-9) draws these data together with other risk factors, such as age, family history, BRCA status, and makes a plea for defining each woman's risk status and advise her about mammography accordingly. The density factor is a major risk and seems especially important in women aged 50 to 55 years. Better detection methods, possibly with digital as opposed to film screening may help but the bottom line remains - the greater the breast density, the greater the risk.
As well as the increased risk, high breast density makes the interpretation of mammography films more difficult, so early lesions may go undetected, leading to poorer outcomes. It is difficult to say whether it is the breast density per se which increases the risk or the delay in diagnosis because of the density which is the problem.
In an attempt to resolve the issue, Boyd et al from Canada (NEJM 2007;356:227-36) noted the woman's breast density at her first mammography and then carefully tracked her risk of subsequent cancer using modern techniques. Thus they hoped to eliminate the detection problem and quantify the risk of high density breast tissue. Their results were conclusive in that women with densities over 75% were five times more likely to develop breast cancer than those with densities below 10%.
Kerlikowske in an editorial (pp 297-9) draws these data together with other risk factors, such as age, family history, BRCA status, and makes a plea for defining each woman's risk status and advise her about mammography accordingly. The density factor is a major risk and seems especially important in women aged 50 to 55 years. Better detection methods, possibly with digital as opposed to film screening may help but the bottom line remains - the greater the breast density, the greater the risk.
The latest JASS is out
The medical journals are changing. The BMJ looks more like Time magazine than a medical journal with attention-grabbing coloured text and photos. The American Journal of O&G has reduced itself to summaries-only for the paper version, leaving subscribers to go to the electronic version for the full text.
The content is changing too with summaries from other journals, Cochrane abstracts in Obstets Gynecol, as well as articles on politics, prostitutes and sexual behaviour. These changes may be responses to the challenge of information technology with the delivery of data via the internet or podcasts. It seems even television is threatened by the popularity of mobile phones, iPods, SMS and personal communication networks. If you don't believe this - ask your children!
There really does seem to be an honest move away from the stereotyped medical journalism of the last century and certainly the journals' willingness to prod the establishment on moral matters seems healthy to JASS.
All of this competition for attention means more work for JASS to distill the wisdom from the razzamatazz.
With pleasure.
Remember, what you see on this blog is just a sample of the full JASS you can receive by going to the website and subscribing.
The content is changing too with summaries from other journals, Cochrane abstracts in Obstets Gynecol, as well as articles on politics, prostitutes and sexual behaviour. These changes may be responses to the challenge of information technology with the delivery of data via the internet or podcasts. It seems even television is threatened by the popularity of mobile phones, iPods, SMS and personal communication networks. If you don't believe this - ask your children!
There really does seem to be an honest move away from the stereotyped medical journalism of the last century and certainly the journals' willingness to prod the establishment on moral matters seems healthy to JASS.
All of this competition for attention means more work for JASS to distill the wisdom from the razzamatazz.
With pleasure.
Remember, what you see on this blog is just a sample of the full JASS you can receive by going to the website and subscribing.
14 February, 2007
SIDS
The sudden infant death syndrome (SIDS) is the leading cause of infant mortality in developed countries. The risk is greatest in the first six months of life while the autonomic nervous system matures to control the homeostatic functions of respiratory drive, blood pressure regulation, temperature, airway reflexes and arousal. It appears that the functioning of these mechanisms requires serotonin (5 hydroxytryptamine 5HT) to be normally produced, released and cleared in the region of the medulla and brain stem. Where this is not achieved, the risk of SIDS rises, as found in post-mortem demonstrations of excess 5HT by a Californian group led by Paterson (JAMA 2006;296:2134-32).
They showed that 5HT dysregulation was a neuro-chemical abnormality far more frequently found in SIDS victims than controls which may explain an underlying vulnerability and partially explain the male predisposition. Wease-Mayer in an editorial (pp 2143-4) alludes to the preventable factors in SIDS, namely putting all children to sleep on their backs on firm surfaces, avoiding soft bedding and overheating, as well as reducing exposure to antenatal or postnatal smoking. It was found in a recent US survey that two-thirds of children succumbing to SIDS were sleeping prone when they died, so it is time to re-launch the “Back-to-Sleep” campaign.
They showed that 5HT dysregulation was a neuro-chemical abnormality far more frequently found in SIDS victims than controls which may explain an underlying vulnerability and partially explain the male predisposition. Wease-Mayer in an editorial (pp 2143-4) alludes to the preventable factors in SIDS, namely putting all children to sleep on their backs on firm surfaces, avoiding soft bedding and overheating, as well as reducing exposure to antenatal or postnatal smoking. It was found in a recent US survey that two-thirds of children succumbing to SIDS were sleeping prone when they died, so it is time to re-launch the “Back-to-Sleep” campaign.
26 January, 2007
25 January, 2007
Breast feeding and intelligence
There are many advantages to breast feeding - to mother and baby. These include the effect of colostrum on immunity, fewer diarrhoeal diseases, the benefits of omega 3 fatty acids on visual developments in small infants, as well as improved bonding and less breast diseases later. It remains unclear whether the child's intelligence is affected by breast feeding, although it remains an unequaled way of providing ideal nutrition.
To look at the effect of breast feeing on IQ, Der et al defined the known variables in over 5 000 children and teased out factors such as education, race, wealth, smoking, birth order, birth weight and home environment (BMJ 2006;333:945-8). In general, breast-fed babies scored four points higher in testing than formula-fed infants, but almost all this effect was attributable to the mother's IQ. In other words, inheriting the mother's cognitive abilities was more important than being fed her breast milk as measured by intelligence tests.
These findings can be used to reassure mothers who cannot breast feed, but in no way detract from the many other plus factors which should persuade as many women to breast feed as possible for at least six months.
To look at the effect of breast feeing on IQ, Der et al defined the known variables in over 5 000 children and teased out factors such as education, race, wealth, smoking, birth order, birth weight and home environment (BMJ 2006;333:945-8). In general, breast-fed babies scored four points higher in testing than formula-fed infants, but almost all this effect was attributable to the mother's IQ. In other words, inheriting the mother's cognitive abilities was more important than being fed her breast milk as measured by intelligence tests.
These findings can be used to reassure mothers who cannot breast feed, but in no way detract from the many other plus factors which should persuade as many women to breast feed as possible for at least six months.
15 January, 2007
Chemotherapy for breast cancer
Thirty years ago, Bonadonna and his colleagues proved that adjuvant chemotherapy made a difference to survival following initial surgery in women with early breast cancer (Levine & Whelan NEJM 2006;355:1920-2). The original agents, cyclophosphamide, methotrexate and flurouracil (CMF) have been the gold standard against which newer drugs are assessed.
There have been numerous trials of chemotherapy mainly studying anthracyclines and taxanes in various combinations which are of interest to oncologists, but gynaecologists and GPs need to know that:
* adjunct postoperative chemotherapy has a modest benefit on survival
* it has considerable toxicity and is expensive
* its use is determined by the risk of recurrence which in turn depends on tumour size, axillary node status and pathology grade
* receptor status for human epidermal growth factor (HER2) and treatment with trastuzumab is a promising development
* oestrogen receptor status and hormonal treatment with tamoxifen greatly reduces recurrence.
Trials like that of Poole et al (pp 1851-62) will continue to refine the best combination of agents but the next major step forward will be the use of microarray techniques to identify each tumour's gene profile and then tailor the therapy individually.
There have been numerous trials of chemotherapy mainly studying anthracyclines and taxanes in various combinations which are of interest to oncologists, but gynaecologists and GPs need to know that:
* adjunct postoperative chemotherapy has a modest benefit on survival
* it has considerable toxicity and is expensive
* its use is determined by the risk of recurrence which in turn depends on tumour size, axillary node status and pathology grade
* receptor status for human epidermal growth factor (HER2) and treatment with trastuzumab is a promising development
* oestrogen receptor status and hormonal treatment with tamoxifen greatly reduces recurrence.
Trials like that of Poole et al (pp 1851-62) will continue to refine the best combination of agents but the next major step forward will be the use of microarray techniques to identify each tumour's gene profile and then tailor the therapy individually.
05 January, 2007
December JASS out
JASS started in early 1997 so this is our tenth birthday.
It has gone from strength to strength and is now subscribed to in 44 countries.
We thank you for your support and will be offering even better opportunities in 2007. May we remind you that if you belong to an academic institution you may wish to enquire about our corporate subscription rates which allow for onward distribution to staff at attractive rates.
The year ends with global concerns about the lack of progress in women's health in developing nations and generally the ever-widening gap between the haves and the have-nots. The have-nots get the worst deals from the pharmaceutical industry, bear the largest burden of disease with the fewest resources, lose their health care workers to richer countries and seen to have less wise leadership.
Perhaps the new WHO leadership under Dr Chan from China will make a difference.
For those wishing JASS to supply CPD certificates, please complete the 2006 Annual Answer Sheet for the year and send it to us for review and points allocation.
We wish you good health personally from Team JASS and a peaceful New Year.
It has gone from strength to strength and is now subscribed to in 44 countries.
We thank you for your support and will be offering even better opportunities in 2007. May we remind you that if you belong to an academic institution you may wish to enquire about our corporate subscription rates which allow for onward distribution to staff at attractive rates.
The year ends with global concerns about the lack of progress in women's health in developing nations and generally the ever-widening gap between the haves and the have-nots. The have-nots get the worst deals from the pharmaceutical industry, bear the largest burden of disease with the fewest resources, lose their health care workers to richer countries and seen to have less wise leadership.
Perhaps the new WHO leadership under Dr Chan from China will make a difference.
For those wishing JASS to supply CPD certificates, please complete the 2006 Annual Answer Sheet for the year and send it to us for review and points allocation.
We wish you good health personally from Team JASS and a peaceful New Year.
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