Treatment of estrogen deficiency symptoms in women surviving breast cancer. Part 4: Urogenital atrophy, vasomotor instability, sleep disorders, and related symptoms

There are several million breast cancer survivors worldwide. In the United States, 180,000 women were diagnosed with breast cancer in 1997, and approximately 97,000 of these women have an extremely low chance of suffering a recurrence of their cancer. With an average age at diagnosis of 60 years and a 25-year expected duration of survival, the current number of breast cancer survivors in the United States may approach 2.5 million women. Since breast cancer is now being detected at an earlier stage than previously and since adjuvant chemotherapy may cause ovarian failure, an increasing number of women are becoming postmenopausal at a younger age after breast cancer treatment. This conference was convened in September 1997 to consider how menopausal breast cancer survivors should be treated at the present time and what future studies are needed to develop improved therapeutic strategies. A total of 47 breast cancer experts and 13 patient advocates participated. The proceedings of the conference are being published in six installments in successive issues of ONCOLOGY. This fourth part focuses on the treatment of urogenital atrophy, vasomotor instability, sleep disorders, and other related symptoms.     

Treatment of estrogen deficiency symptoms in women surviving breast cancer. Part 2: Hormone replacement therapy and breast cancer

There are several million breast cancer survivors worldwide. In the United States, 180,000 women were diagnosed with breast cancer in 1997, and approximately 97,000 of these women have an extremely low chance of suffering a recurrence of their cancer. With an average age at diagnosis of 60 years and a 25-year expected duration of survival, the current number of breast cancer survivors in the United States may approach 2.5 million women. Since breast cancer is now being detected at an earlier stage than previously and since adjuvant chemotherapy may cause ovarian failure, an increasing number of women are becoming postmenopausal at a younger age after breast cancer treatment. This conference was convened in September 1997 to consider how menopausal breast cancer survivors should be treated at the present time and what future studies are needed to develop improved therapeutic strategies. A total of 59 breast cancer experts and patient advocates participated. The proceedings of the conference will be published in six installments in successive issues of ONCOLOGY. The first part, published last month, defined the problem and explored its magnitude and ramifications for patient management. This second part focuses on the benefits and risks of hormone replacement therapy (HRT) in patients with breast cancer.     

Management of complications from estrogen deprivation in breast cancer patients

In the United States today, more than 2 million women live as breast cancer survivors. As the number of cancer survivors grows, the unique long-term side effects of cancer treatment and aging play an increasingly prominent role in the routine care of these patients. Of special concern are the short- and longterm effects of sex hormone deprivation. This article reviews current issues surrounding the acute and late effects associated with hormone deprivation in breast cancer survivors and summarizes the scientific and therapeutic discoveries to date to identify optimal nonestrogenic treatments for symptom control in individual patients.     

Quality of Life in Breast Cancer Survivors as Identified by Focus Groups

Currently, over 1,700,000 women are living with breast cancer in the United States. These long-term survivors of breast cancer are challenged to redirect their energy from issues of cancer treatment and early side effects toward quality of life issues related to long-term survivorship, such as menopause, infertility, fear of recurrence, family distress, and uncertainty. In an attempt to obtain patient perspectives on quality of life and health care issues faced by breast cancer survivors, focus group methodology was utilized in the first year of a 2 year study. The sample was stratified to represent three age groups: < 40 years, 40–60 years and > 60, and was intended to represent different developmental levels believed to have varying experiences with quality of life and potentially divergent needs following breast cancer diagnosis. Results of these focus groups revealed unique quality of life concerns of breast cancer survivors across four domains of physical, psychological, social, and spiritual well being. Each of these domains yields important implications for future research and clinical practice. © 1997 John Wiley & Sons, Ltd.     

The prevalence of cancer among adults in the United States: 1987.

No national data exist on the prevalence of cancer in the United States population. The authors report the first estimates of prevalence rates of cancer from a population-based sample of the adult population of the United States. Estimates are based on responses collected from the Cancer Control Supplements of the National Health Interview Survey, a population-based sample survey of all people older than 17 years of age in the United States in 1987. Of 44,123 adults questioned, 1593 said they had a nonskin cancer. In 1987, after adjustments, the overall prevalence rate of all types of cancer, excluding nonmelanoma skin cancer, was 3230 per 100,000 adults; the rates for men and women were 1930 and 4412, respectively. The authors estimate that, in 1987, 5.7 million adults in the United States were survivors of nonskin cancer, 3.3% of the adult population. Approximately 89,000 adults had cancer during childhood, or 1.6% of the total. Approximately 3.6 million people were at least 5-year survivors and 900,000 adults had their disease diagnosed during the year before interview. Despite the potential for underreporting and misclassification, these national estimates are in general accord with figures estimated from other sources. Increasing survival after cancer, especially childhood and adolescent cancer, indicates the importance of continued monitoring to provide information needed to plan for adequate health services.     

Breast cancer follow-up: just a burden,or much more?

In the western world, breast cancer is the most common neoplasticdisease in adult women. According to the World Health Organization,>1.2 million people will be diagnosed with breast cancereach year worldwide. With early detection and appropriate treatment,the percentage of women surviving at least 5 years after diagnosisand treatment has shifted from 70% in the early 1970s to 90%in the late 1990s. As of now, in the United States there are2.5 million women who are breast cancer survivors (http://progressreport.cancer.gov/).These women, following cancer treatment, will be kept undera surveillance strategy, called ‘follow-up’. From     

Cancer treatment and survivorship statistics, 2012

Although there has been considerable progress in reducing cancer incidence in the United States, the number of cancer survivors continues to increase due to the aging and growth of the population and improvements in survival rates. As a result, it is increasingly important to understand the unique medical and psychosocial needs of survivors and be aware of resources that can assist patients, caregivers, and health care providers in navigating the various phases of cancer survivorship. To highlight the challenges and opportunities to serve these survivors, the American Cancer Society and the National Cancer Institute estimated the prevalence of cancer survivors on January 1, 2012 and January 1, 2022, by cancer site. Data from Surveillance, Epidemiology, and End Results (SEER) registries were used to describe median age and stage at diagnosis and survival; data from the National Cancer Data Base and the SEER-Medicare Database were used to describe patterns of cancer treatment. An estimated 13.7 million Americans with a history of cancer were alive on January 1, 2012, and by January 1, 2022, that number will increase to nearly 18 million. The 3 most prevalent cancers among males are prostate (43%), colorectal (9%), and melanoma of the skin (7%), and those among females are breast (41%), uterine corpus (8%), and colorectal (8%). This article summarizes common cancer treatments, survival rates, and posttreatment concerns and introduces the new National Cancer Survivorship Resource Center, which has engaged more than 100 volunteer survivorship experts nationwide to develop tools for cancer survivors, caregivers, health care professionals, advocates, and policy makers.     

Migration history, acculturation, and breast cancer risk in Hispanic women.

BACKGROUND: Migrant studies have shown that breast cancer risk increases in women who move from countries with low incidence rates to countries with high rates. We examined the influence of migration history and acculturation on breast cancer risk in Hispanic women ages 35 to 79 years. METHODS: In a population-based case-control study conducted in the San Francisco Bay Area, information on migration history, language usage, and other risk factors for breast cancer was collected through an in-person interview for 991 cases and 1,285 controls. RESULTS: Breast cancer risk was 50% lower in foreign-born Hispanics than U.S.-born Hispanics. Risk increased with increasing duration of residence in the United States, decreasing age at migration, and increasing acculturation. Among long-term foreign-born residents, risk was lower among Hispanics who moved to the United States at age > or =20 years and those who spoke mostly Spanish. The difference in risk between third-generation or higher-generation Hispanics and recent migrants from rural areas was approximately 6-fold in postmenopausal women and 4-fold in premenopausal women. Adjustment for differences in the distribution of breast cancer risk factors greatly attenuated the associations with migration patterns in premenopausal women; reduced risks remained only in those who resided in the United States for <10 years or migrated at age > or =30 years. In postmenopausal women, a 25% to 30% lower risk remained among long-term residents and those who migrated to the United States before age 20 years. CONCLUSIONS: These findings suggest the importance of yet unidentified protective factors among both recent premenopausal migrants and postmenopausal migrants.     

Multiple cancer prevalence: a growing challenge in long-term survivorship.

OBJECTIVE: The present study was designed to estimate the number of and describe the pattern of disease among cancer survivors living with a history of multiple malignant tumors in the United States. METHODS: Incidence and follow-up data from the Surveillance, Epidemiology, and End Results program (1975-2001) were used to calculate the number of survivors with more than one malignant primary at January 1, 2002. U.S. prevalence counts were calculated by multiplying the age, sex, and race-specific prevalence proportions from the Surveillance, Epidemiology, and End Results program by the corresponding U.S. populations. RESULTS: We estimate that 756,467 people in the United States have been affected by cancer more than once between 1975 and 2001, representing almost 8% of the current cancer survivor population. Women whose first primary in that period was breast cancer represent 25% of survivors with multiple cancers, followed by men and women (15%) whose first primary was colorectal cancer and men (13%) whose first primary was prostate cancer. DISCUSSION: The findings in this report have important implications for public health practice. With individuals diagnosed with cancer living longer and the aging of the U.S. population, the number who will develop multiple malignancies is expected to increase. As a consequence, there is a growing need to promote effective cancer screening along with healthy life-styles among these at-risk populations if we are to ensure optimal physical and psychosocial well-being of these long-term cancer survivors and their families. Efforts to design and evaluate effective, efficient, and equitable approaches to surveillance for second malignancies will be critical in reducing the national burden of cancer.     

Diagnosis and treatment of breast cancer in the elderly

As the population of the United States ages, women over the age of 65 have become a prominent cohort in the breast cancer population, with approximately 50% of all new breast cancers occurring in women aged 65 years and older. Early studies in breast cancer often excluded women based on age or comorbidity, leaving physicians and patients with a growing number of diagnostic and treatment options, each of which often carry short-term morbidity risks for potential long-term gain. We review the current data available for diagnosis and treatment of elderly women with breast cancer in both the adjuvant and metastatic disease setting. In addition, the role of screening and new concepts in prevention are discussed with emphasis on the older patient.     

The epidemiology of second primary cancers.

BACKGROUND: Due to improvements in early detection, supportive care, and treatment, the number of cancer survivors in the United States has tripled since 1971 and is growing by 2% each year. In 2001, there were approximately 10 million cancer survivors, representing 3.5% of the population. As survival after a diagnosis of cancer improves, quantification of the late effects of cancer and its therapy become critical. One of the most serious events experienced by cancer survivors is the diagnosis of a new cancer. Second- or higher-order cancers now account for approximately 16% of incident cancers reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Subsequent neoplasms may not necessarily be attributable to prior cancer treatment but may also reflect the effect of shared etiologic factors, environmental exposures, host characteristics, and combinations of influences, including gene-environment and gene-gene interactions. METHODS/RESULTS: This review will focus on selected highlights and recent findings in treatment-associated malignancies, with an emphasis on survivors of adult cancer. Current study methods will also be summarized. CONCLUSIONS: Important opportunities for future research include the prospective identification of patient subgroups that might be at heightened susceptibility of developing therapy-associated second cancers to modify planned treatments or select alternative management strategies. For the burgeoning population of cancer survivors treated successfully with past regimens, including those therapies that have been subsequently refined, continued quantification of late effects, including second cancers, remains highly relevant in terms of raising clinician and patient awareness, for informed counseling, and for the development of risk-adapted long-term management strategies.     

Coordination of care in breast cancer survivors: an overview

The number of breast cancer survivors in the United States is increasing. With longer survival, there has been an increase in the complexity and duration of posttreatment care. Multidisciplinary care teams are needed to participate across the broad spectrum of issues that breast cancer survivors face. In this setting, the need for well-established patterns of communication between care providers is increasingly apparent. We have created a multidisciplinary approach to the management of breast cancer survivors to improve communication and education between providers and patients. This approach could be extended to the care and management of survivors of other types of cancer.     

A case-control interview study of breast cancer among Japanese A-bomb survivors. II. Interactions with radiation dose

Three breast cancer risk factors were evaluated in terms of their interactions with radiation dose in a case-control interview study of Japanese A-bomb survivors. Cases and controls were matched on age at the time of the hombings and radiation dose, and dose-related risk was estimated from cohort rather than case-control data. Each factor—age at first full-term pregnancy, number of deliveries, and cumulative lactation period summed over births—conformed reasonably well to a multiplicative interaction model with radiation dose (the additive interactive model, in which the absolute excess risk associated with a factor is assumed to be independent of radiation dose, was rejected). An important implication of the finding is that early age at first full-term pregnancy, multiple births, and lengthy cumulative lactation are all protective against radiation-related, as well as baseline, breast cancer. Analyses by age at exposure to radiation suggest that, among women exposed to radiation in childhood or adolescence, a first full-term pregnancy at an early agefollowing exposure may be protective against radiation-related risk.The Radiation Effects Research Foundation (formerly the Atomic Bomb Casualty Commission) was established in April 1975 as a private nonprofit Japanese Foundation, supported equally by the Government of Japan through the Ministry of Health and Welfare, and the Government of the United States through the National Academy of Sciences under contract with the Department of Energy. The present work was performed as part of a collaboration between RERF and the US National Cancer Institute.     

Menopausal-type symptoms in young breast cancer survivors.

BACKGROUND: There has been little previous information available about menopausal-type symptoms in very young breast cancer survivors. METHODS: In collaboration with the Young Survival Coalition, we conducted an Internet-based survey of women with a history of breast cancer diagnosed at age 40 years or younger using items derived from the Breast Cancer Prevention Trial symptom checklist. RESULTS: A total of 371 respondents were eligible for analysis. Mean age at diagnosis was 32.8 years and mean age at follow-up 36.2 years; 89% of women received chemotherapy, 49% tamoxifen, 15% ovarian suppression, 4% aromatase inhibitors. At the time of survey, 37% were taking tamoxifen and 9% ovarian suppression. Excluding women on ovarian suppression, 77% of women were premenopausal at follow-up. Many women reported bothersome menopausal-type symptoms. In particular, 46% of women reported hot flashes and 39% reported dyspareunia. In a linear regression model of symptom scores, current ovarian suppression, postmenopausal status, baseline anxiety before the diagnosis, pregnancy after the diagnosis, prior chemotherapy, and lower perceived financial status were associated with more bothersome symptoms. CONCLUSION: A substantial number of young breast cancer survivors experience bothersome menopausal symptoms. While the women who responded to our survey may represent a select group of survivors, these findings may have important implications for treatment decision making and long-term quality of life of young women with breast cancer.     

The economic burden of prostate cancer,California, 1998

BACKGROUND: Prostate cancer is the most common malignancy diagnosed among men in the United States. This article reviews previous studies of the annual cost of all cancers and of prostate cancer in the United States and California and estimates the direct and indirect costs of prostate cancer in California in 1998. METHODS: Hospitalization costs, including costs of primary and secondary diagnoses of prostate cancer, were derived from the California Hospital Discharge data set (CHDS). Charges were converted to costs using hospital specific cost-to-charge ratios and an imputed cost for Health Maintenance Organization hospitalizations. Other direct medical costs were derived from the 1997 Medical Expenditure Panel Survey. Indirect mortality costs are the product of the number of deaths and the expected value of a male's future earnings taking into account age at death, earning patterns at successive ages, labor force participation, imputed value of housekeeping services, and a 3% discount rate. RESULTS: Prostate cancer direct health care costs in California were estimated at 180 million dollars, and lost productivity from premature death was estimated at 180 million dollars, for a total cost of 360 million dollars in 1998. The disease is largely one of older men; hospitalization costs account for three-fifths of total direct costs, and Medicare and private health insurance share almost equally in paying for hospital care. CONCLUSIONS: It is critical to identify cost-effective screening efforts that permit early detection of prostate cancer to reduce illness, premature deaths, and the high costs of prostate cancer.     

Age of Diagnosis of Breast Cancer in China: Almost 10 Years Earlier than in the United States and the European Union

Background: The study aimed to describe the age distribution of breast cancer diagnosis among Chinesefemales for comparison with the United States and the European Union, and provide evidence for the screeningtarget population in China. Materials and Methods: Median age was estimated from hospital databases from 7tertiary hospitals in China. Population-based data in China, United States and European Union was extracted fromthe National Central Cancer Registry, SEER program and GLOBOCAN 2008, respectively. Age-standardizeddistribution of breast cancer at diagnosis in the 3 areas was estimated based on the World Standard Population2000. Results: The median age of breast cancer at diagnosis was around 50 in China, nearly 10 years earlier thanUnited States and European Union. The diagnosis age in China did not vary between subgroups of calendaryear, region and pathological characteristics. With adjustment for population structure, median age of breastcancer at diagnosis was 50~54 in China, but 55~59 in United States and European Union. Conclusions: Themedian diagnosis age of female breast cancer is much earlier in China than in the United States and the EuropeanUnion pointing to racial differences in genetics and lifestyle. Screening programs should start at an earlier agefor Chinese women and age disparities between Chinese and Western women warrant further studies.     

Exposure,susceptibility, and breast cancer risk: A hypothesis regarding exogenous carcinogens,breast tissue development,and social gradients,including black/white differences,in breast cancer incidence

Summary At present, known risk factors account for only one-third of breast cancer cases diagnosed in the United States. They explain an even smaller fraction of the ten-fold variation in international breast cancer incidence rates. The low population-attributable risk of these identified risk factors, plus the existence of phenomena that cannot be easily explained by current etiologic hypotheses (such as the higher rate of breast cancer among black as compared to white women under age 40 within the United States), suggests that unidentified risk factors contribute substantially to breast cancer causation. This paper summarizes evidence to propose that two socially-conditioned factors determine a society's breast cancer incidence and its social gradients in risk: 1) the extent of exposure to exogenous carcinogens, and 2) breast tissue susceptibility to these exposures. It is further hypothesized that breast tissue susceptibility is inversely related to breast tissue differentiation, and that socially-mediated reproductive patterns (involving both early-terminated and full-term pregnancies) affect susceptibility both by altering (via hormonally-mediated mechanisms) the number and ratio of undifferentiated and differentiated cells, and by stimulating the growth of initiated and transformed cells. This view is presented in contrast to hypotheses that propose exposure to endogenous hormones as the major determinant of breast cancer risk.     

Trends in outpatient breast cancer surgery among Medicare fee-for-service patients in the United States from 1993 to 2002

The practice of outpatient breast cancer surgery has been controversial in the United States. This study aimed to update time trends and geographic variation in outpatient breast cancer surgery among elderly Medicare fee-for-service women in the United States. Using the 1993-2002 linked Surveillance, Epidemiology and End Results (SEER)-Medicare claims data and the Area Resource Files, we identified 2 study samples, including the women whose breast cancers were the first-ever-diagnosed cancer at age 65 years...     

Cancer statistics for the US Hispanic/Latino population, 2021

The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.     

Physician and patient characteristics associated with outpatient breast cancer screening recommendations in the United States: analysis of the National Ambulatory Medical Care Survey Data 1996–2004

Background The primary goal of breast cancer screening tests is to find cancer at an early stage before a person has any symptoms. Evidence suggests that screening examinations such as mammography and clinical breast examinations (CBE) are effective in early detection of breast cancer. Physician recommendation is an important reason many women undergo screening. This study examined the physician and patients related factors associated with physician recommendations for breast cancer screening in the United States (US) outpatient settings. Methods This cross-sectional study used data from the National Ambulatory Medical Care Survey (NAMCS) from 1996–2004. Women aged ≥40 years were included in the study sample. Multivariate logistic regression analyses were used to study the objectives. Results Weighted analysis indicated that physicians performed 198 million CBEs and made 110 million mammography recommendations over the study period (1996–2004). Patients’ age, duration of visits, history of previous breast cancer diagnosis, and source of insurance were significant predictors of screening recommendations in this population. Obstetricians and gynecologists were more likely to perform a CBE and recommend mammography than other specialty physicians. Conclusions These findings indicated that there were certain disparities regarding the physician recommendations of breast cancer screening for women in the US outpatient settings.