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Ten-years of tamoxifen could become next standard regimen to treat estrogen-receptor positive breast cancers

MD-FM Thursday December 6th, 2012

Sarah :
MD FM — Medical News from around the the world with Peter Goodwin

PETER: Hello, and to begin with taking tamoxifen during 10 years rather than during 5 years appeared better to treat estrogen-receptor positive breast cancers –a small yet significant gain…

SARAH : These are the findings of the ATLAS study published in The Lancet and presented at the 2012 San Antonio Breast Cancer Symposium, which showed that a 10-year regimen had a small but real advantage in terms of both long-term survival and recurrence rates compared to the standard approach.

PETER : Yes, 5 years of tamoxifen is currently the gold standard for treating ER positive breast cancers. And did they find anything in terms of additional side effects?

SARAH: The main side effects were a very small yet significant increase in the likelihood of getting a bloodclot inside the lungs, and a very small yet significant increase risk developing endometrial cancer among post-menopausal women.

PETER: So is that it --are all women with ER-positive breast cancer going to be prolonged to 10 years tamoxifen starting today?

SARAH: Well not just yet! Pr. Trevor Powles, who wrote an editorial on the study, said two more studies in the pipeline are hopefully going to confirm these results.

Bob-Powles: “Now if this trial is confirmed, then I think we’ve got to say that the optimal treatment for tamoxifen would be 10 years of treatment. That would mean that women who’ve had 5 years of tamoxifen could be considered for another 5 years. Now the thing we don’t know, obviously, is how long a gap you could have if you’ve stopped it five years ago, after 5 years of treatment... could you restart it for another 5 years? We don’t know the answer to that. But we do know that women who are on tamoxifen at the present time should continue for a further 5 years, if this trial is confirmed”

SARAH: That was Trevor Powles, from the Institute of Cancer Research in London.

PETER: News straight from the 2012 San Antonio Breast Cancer Symposium: hypofractioned radiotherapy was safe and effective at treating early breast cancer at ten year follow up. So that means: A total lower radiation dose given in fewer, slightly larger fractions, and delivered over a shorter period of time was as safe and effective than the standard five-week schedule of radiotherapy.


PETER: Chromosomal microarray can replace conventional karyotyping when fetal structural anomalies have been identified on ultrasonography.

SARAH: These are the conclusions of a NEJM study led in over 4400 women undergoing prenatal diagnosis, which found that microarray analysis revealed clinically relevant deletions or duplications in 6% of samples with a structural anomaly. However, In women with conditions such as advanced maternal age or for Down syndrome screening, the advantages of microarray were less clearcut,  revealing clinically relevant deletions or duplications in only 1.7% of cases.

Bob-Dugoff: “I’m not saying that you shouldn’t offer it to patients with advanced maternal age or who have positive Down syndrome disease, I just think right now it’s really important that these patients are councilled before they get the microarray, so that they understand the implications of the test, so they’re aware that there’s a 1.7% chance that this is going to pick up an abnormality that the standard conventional kariotyping wouldn’t pick up, but there’s also a chance that it’s going to pick up a result that we’re not going to be able to tell you if its pathologic or not. And so some patients might decide that they’d find that too stressful, and they’re not going to want it. Other patients are going to say “I can live with that --I want the test” -So that’s all I’m saying: it’s not as clear, the benefits are not as clear. But as we are able to interprete the significance, as the number of uncertain results goes down --which it will in the future --then I think there will be a clear benefit to just using the microarray in everyone.  ”

PETER: That was Pr. Duggoff, from Philadelphia, who wrote an editorial on this and 2 other NEJM articles concerning recent applications of genomic technologies in prenatal diagnosis.

PETER: Risks of atrial fibrillation increased with decreasing levels of thyroid-stimulating hormone (TSH) in linear fashion..

SARAH: Yes –these are the conclusions of a study in the BMJ, which found that not only overt hyperthyroidism was associated with atrial fibrillation, but also milder forms of elevated thyroid function. In contrast, hypothyroidism was associated with a lower risk of atrial fibrillation:

Bob Selmer –1: “We found a dose-response relationship between the different levels of thyroid dysfunction and the risk of atrial fibrillation. If you look at it it’s like driving a car: hyperthyroidism is like pushing the gas pedal and hypothyroidism or myxedema is pushing the break, basically.”

SARAH: That was lead author of the study Dr. Christian Selmer, from of Gentofte University Hospital in Hellerup in Denmark. His team examined the risk of atrial fibrillation in relation to the whole spectrum of thyroid diseases (which had not been previously investigated), from a large database of over 580,000 individuals who had had a thyroid function blood test performed.

Bob Selmer-2: “The main conclusion here is that it looks as if even slightly elevated thyroid function is a risk factor for atrial fibrillation. So if you have a patient and they have even mildly elevated thyroid function, then you should of course check their ECG”

SARAH: Again that was Dr. Selmer, who stressed that although atrial fibrillation was closely associated with thyroid activity in this study, this study did not prove a causal relationship between the two.


PETER: Ciclosporin was no more effective than infliximab to treat severe ulcerative colitis refractory to intravenous steroids …

SARAH: Yes, this is according to a randomized study published in The Lancet. The main outcomes showed that at one-week-post-treatment-initiation: 86% of patients on ciclosporin achieved a clinical response, 84% of those on infliximab. At day 98: 60% of patients on ciclosporin had failed treatment vs. 54% of those on infliximab – percentages the authors considered roughly equivalent. Safety data was also equivalent.

PETER: So far the use of infliximab to treat for refractory ulcerative colitis has been controversial, and in some countries like the UK it remains difficult to get a hold of the agent rapidly

SARAH: Yes, and while this study did not favor one drug over the other, lead author David Laharie, from Bordeaux in France, told us there are clinical instances in which one agent is preferable than the other:

Bob Laharie: “I think patients with less severe attacks or short disease durations may receive ciclo first, because if they don’t respond well to ciclosporin we can propose, in referential centers, a third line medical therapy with infliximab to avoid emergent colectomy. On the opposite way, patients with a long disease duration, a confusion between ulcerative colitis and Crohn’s disease or previous thiopurin exposure should receive infliximab first because they are not good candidates for ciclosporin”

PETER: That was Pr. Laharie, from France.

BREVE 1 Sur fond musical
PETER: Finally, in brief a survey conducted the US found that a low percentage of medical residents actually plan to become general practitioners. The authors of the JAMA study say this is a concern since primary care physicians are expected to play an increasingly critical role in health care provision as the population ages, the burden of chronic disease grows and health care reform targets coverage of tens of millions of currently uninsured patients.

And …..
HIV transmission can be reduced by using antiretroviral therapy in serodiscordant couples –according to a population-based study published in The Lancet. However, this protective effect of ART seemed to only last during one year, and was not effective when the HIV-positive partners injected drugs or had very high CD4 cell counts.

That's all from MDFM for now. We'll be back next week


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Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
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