Clinical Review

• Breast self-exam: Helpful or not? • HPV vaccine promises cost-effective benefits Ovarian cancer: • HRT increases risk • Consolidation therapy extends disease-free interval

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Gynecologic oncology is a dynamic subspecialty—one with several important recent developments. For example, closer scrutiny of breast self-examination has changed its status from “required” to optional, and greater understanding of cervical carcinoma and its causes is leading to a vaccine for human papillomavirus (HPV) 16/18 in the near future—an achievement likely to be highly cost-effective.

On the ovarian cancer front, data from the Women’s Health Initiative suggest an increase in cancer rates in women who take hormone replacement therapy (HRT). In fact, ovarian cancer remains our greatest challenge, since 70% of patients are not diagnosed until they reach advanced stages III and IV, when 5-year survival ranges from 5% to 40%. Fortunately, recent findings suggest consolidation therapy may help extend survival and disease-free intervals.

This update focuses on important studies in each of these areas, highlighting significant progress in understanding, preventing, identifying, and treating gynecologic malignancies.

Breast self-examination: Helpful or not?

Hackshaw AK, Paul EA. Breast self-examination and death from breast cancer: a meta-analysis. Br J Cancer. 2003; 88:1047–1053.

With 1 in 6 women likely to develop breast cancer, the drive to identify patients with early disease continues apace, especially since survival frequently depends upon it. While mammography remains the gold standard for breast cancer screening, the role of breast self-examination (BSE) is controversial. In May 2003, the American Cancer Society revised its guidelines, changing BSE from a routine to an optional practice. The meta-analysis by Hackshaw and Paul evaluated the effect of BSE on the death rate from breast cancer, reviewing 20 observational and 3 clinical trials on BSE and death or, alternatively, BSE and advanced breast cancer (a surrogate for poor prognosis and increased death rate). They evaluated BSE in women who:

  • Practice BSE routinely
  • Found tumors during BSE
  • Are trained in BSE
Advantages seen in observational studies likely due to bias and confounding variables. The only trials demonstrating an advantage for BSE were observational studies of breast cancer patients who performed BSE prior to diagnosis. These demonstrated a lower risk of mortality (relative risk [RR], 0.64; 95% confidence interval [CI], 0.56–0.73) and advanced cancer (RR, 0.60; 95% CI, 0.46–0.80).

However, these results are likely caused by bias and confounding. For example, many patients who practiced BSE were younger and of higher socioeconomic status than women who did not. A confounding variable in the observational studies was the presence of slow-growing tumors.

BSE did not lower death rate. No study found a lower death rate in women who detected their breast cancer during BSE (RR, 0.9; 95% CI, 0.72–1.12). Nor did the death rate diminish among women who were trained to perform BSE (RR, 1.01; 95% CI 0.92–1.12), although BSE did appear to prompt many women to seek medical advice. Unfortunately, many studies evaluating the effects of BSE also include mammography, which makes it difficult to isolate effects due solely to BSE.

Clinical implications. Although this meta-analysis supports the American Cancer Society recommendation not to require breast self-examination as a cancer screening tool, I have managed a number of patients who presented with breast masses identified through BSE. Many of these women were low-risk and younger than 30 years. For that reason, I continue to instruct and encourage patients to perform BSE, since it is easily taught and carried out.

I believe BSE helps empower women to take control of their health.

Related Reading

  • American Cancer Society News Today. Role of breast self-examination changes in guidelines. Available at: www.cancer.org/docroot/NWS/NWS_1.asp Accessed June 16, 2004.
  • Vahabi M. Breast cancer screening methods: a review of the evidence. Health Care Women Intern. 2003;24:773–793.

Adding HPV vaccine to cervical cancer screening would be cost-effective

Goldie SJ, Kohli M, Grima D, et al. Projected clinical benefits and cost-effectiveness of a human papillomavirus 16/18 virus. J Natl Cancer Inst. 2004;96:604–615.

Because of the link between cervical cancer or dysplasia and HPV infection, HPV vaccination in childhood or adolescence would virtually eradicate cervical cancer. It also would be cost-effective, compared with the cost of screening, evaluating, and treating dysplasia and cervical cancer.

In 2002, Koutsky et al1 reported a randomized, prospective trial of an HPV-16 vaccine, in which they found vaccination to be 100% effective (95% confidence interval [CI], 90–100; P<.001 with an incidence of persistent hpv-16 infection per woman-years in vaccinated women versus among controls. at the time its publication this trial was largest ever conducted hpv vaccine enrolled placebo group and>

Following the Koutsky trial, Goldie and colleagues reported on a computer-based model to evaluate the efficacy and cost of vaccinating patients with an HPV 16/18 vaccine. Using the Markov model, they simulated HPV infection and carcinogenesis. However, rather than evaluate the cost-effectiveness of the vaccine as a single modality, they added it to current cytologic testing, evaluating screening intervals of 1 to 5 years with conventional and liquid-based smears.

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