Janet Osuch

Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting

Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier‐stage cancers are generally more numerous, include less toxic alternatives, and are usually more effective than treatments for later‐stage cancers. For average‐risk women aged 40 and younger, earlier detection of palpable tumors identified by CBE can lead to earlier therapy. After age 40, when mammography is recommended, CBE is regarded as an adjunct to mammography. Recent debate, however, has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women and particularly to improved survival and reduced mortality rates. Clinicians remain widely divided about the level of evidence supporting CBE and their confidence in the examination. Yet, CBE is practiced extensively in the United States and continues to be recommended by many leading health organizations. It is in this context that this report provides a brief review of evidence for CBEs role in the earlier detection of breast cancer, highlights current practice issues, and presents recommendations that, when implemented, could contribute to greater standardization of the practice and reporting of CBE. These recommendations may also lead to improved evidence of the nature and extent of CBEs contribution to the earlier detection of breast cancer.

Lifetime Reproductive and Anthropometric Risk Factors for Breast Cancer in Postmenopausal Women

Hormonally-linked adult reproductive and anthropometric risk factors have been well established in the etiology of postmenopausal breast cancer, though early life exposures have been evaluated only more recently. Here, we examine the evidence for associations between lifetime reproductive and anthropometric risk factors for postmenopausal breast cancer. The review finds some evidence for the hypothesis that breast cancer risk is determined by the number of susceptible stem cells, modified by the hormonal environment. The in utero experience of an infant may be associated with postmenopausal breast cancer; preeclampsia may decrease and greater birthweight increase risk, but more evidence is needed. Earlier and more rapid childhood growth appears to increase postmenopausal breast cancer risk and childhood obesity to decrease risk, but very few studies have yet examined these associations. Increased final height and earlier age at menarche are consistently associated with increased risk for postmenopausal breast cancer. Later age at first birth, decreased parity, later menopausal age, use of hormone replacement therapy (especially progestin containing), and increased postmenopausal adiposity are well-established risk factors for postmenopausal breast cancer. The effect of a womans own pregnancy conditions and lactation are not established. Further investigation is needed to identify whether events occurring early in life modify later events or accumulate over the life course. Many aspects of this research can be conducted by examining the influence of early life events on intermediary events without the need for longitudinal data.

Maternal levels of dichlorodiphenyl-dichloroethylene (DDE) may increase weight and body mass index in adult female offspring

Objectives: To investigate the effect of prenatal exposure to polychlorinated biphenyls (PCBs) and dichlorodiphenyl-dichloroethylene (DDE) on weight, height and body mass index (BMI) in adult female offspring of the Michigan fisheater cohort examined between 1973 and 1991. Methods: 259 mothers from the Michigan fisheater cohort were studied. Prenatal exposure to PCBs and DDE was estimated by extrapolating maternal measurements to the time that the women gave birth. 213 daughters aged 20–50 years in 2000 were identified and 83% of them participated in at least one of two repeated investigations in 2001/02 (n = 151) and 2006/07 (n = 129). To assess the effect of prenatal PCB and DDE exposure on anthropometric measurements, generalised estimating equations nested for repeated measurements (2001/02 and 2006/07) and for sharing the same mother were used. We controlled for maternal height and BMI and for daughters’ age, birth weight, having been breastfed and number of pregnancies. Results: Maternal height and BMI were significant predictors of the daughters’ height, weight and BMI. Low birth weight (<2500 g) was significantly associated with reduced adult offspring weight and BMI. The weight and BMI of adult offspring were statistically significantly associated with the extrapolated prenatal DDE levels of their mothers. Controlling for confounders and compared to maternal DDE levels of <1.503 μg/l, offspring BMI was increased by 1.65 when prenatal DDE levels were 1.503–2.9 μg/l and by 2.88 if levels were >2.9 μg/l. Prenatal PCB levels showed no effect. Conclusion: Prenatal exposure to the oestrogenic endocrine-disrupting chemical DDE may contribute to the obesity epidemic in women.

Observation interval for evaluating the costs of surgical interventions for older women with a new diagnosis of breast cancer.

Objective.To estimate the episodic costs of surgical treatments for breast cancer. Methods.The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model. Results.It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P <0.05) less costly than a mastectomy alone (

The Breast Cancer and the Environment Research Centers: Transdisciplinary Research on the Role of the Environment in Breast Cancer Etiology

4,955 vs.

Postmenopausal hormone replacement therapy: effects on normal mammary gland in humans and in a mouse postmenopausal model.

9,049). Conclusions.By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.

Progestins and breast cancer.

Objectives We introduce and describe the Breast Cancer and the Environment Research Centers (BCERC), a research network with a transdisciplinary approach to elucidating the role of environmental factors in pubertal development as a window on breast cancer etiology. We describe the organization of four national centers integrated into the BCERC network. Data sources Investigators use a common conceptual framework based on multiple levels of biologic, behavioral, and social organization across the life span. The approach connects basic biologic studies with rodent models and tissue culture systems, a coordinated multicenter epidemiologic cohort study of prepubertal girls, and the integration of community members of breast cancer advocates as key members of the research team to comprise the network. Data extraction Relevant literature is reviewed that describes current knowledge across levels of organization. Individual research questions and hypotheses in BCERC are driven by gaps in our knowledge that are presented at genetic, metabolic, cellular, individual, and environmental (physical and social) levels. Data synthesis As data collection on the cohort, animal experiments, and analyses proceed, results will be synthesized through a transdisciplinary approach. Conclusion Center investigators are addressing a large number of specific research questions related to early pubertal onset, which is an established risk factor for breast cancer. BCERC research findings aimed at the primary prevention of breast cancer will be disseminated to the scientific community and to the public by breast cancer advocates, who have been integral members of the research process from its inception.

The Emotional Journey of Women Experiencing a Breast Abnormality

Endogenous estrogen exposure has long been implicated in the causation of breast cancer through a mechanism of epithelial cell proliferation. Whether estrogen, progesterone, or both exhibit mitogenic activity and promote carcinogenesis in the human breast has been the subject of considerable debate. The purpose of this review article is to examine the evidence for the effects of hormone replacement therapy in its various forms on the biology of the postmenopausal breast both in humans and in an animal model, and to identify the gaps in knowledge that research will need to address to further understand this complex issue.

A Historical Perspective on Breast Cancer Activism in the United States: From Education and Support to Partnership in Scientific Research

Progesterone (P) regulates proliferation and differentiation in the normal mammary gland in mouse, rat and human. Progesterone has also been implicated in the etiology and pathogenesis of human breast cancer. The focus of this review is on recent advances in understanding the role of the progesterone receptor (PR) and functional significance of PR isoforms, PRA and PRB, in the normal mammary gland and in mammary cancer in mouse, rat and human.

BREASTAID: Clinical results from early development of a clinical decision rule for palpable solid breast masses

Using grounded theory, a multidisciplinary study team compared the narratives of 30 women who had recently experienced a breast cancer scare. Even though 10 women received a benign diagnosis, all women reported a difficult time prediagnosis, characterized by an array of emotions and contemplation of the meaning of life. Diagnosis separated the two groups with emotional relief dominant for the benign group and intensification of emotions for the cancer group. For those diagnosed with cancer, three factors contributed to arriving at a point of acceptance about the diagnosis and treatment: (a) sustained coping mechanisms; (b) a belief system that shifted the meaning of the cancer experience; and (c) the ability to manage non-cancer-related stressful events. Implications include the need for tailored biopsychosocial treatments that focus on reducing stress, enhancing support systems, reframing beliefs about the illness, and providing the opportunity for the women to talk about their experiences.