The American Society of Clinical Oncology (ASCO) recently published clinical practice guidelines on the role of bisphosphonates and bone health. The criteria for high-risk patients are: all women over 65; all women aged 60 to 64 with a family history of osteoporosis, body weight of less than 70kg (~150 lbs.), history of fracture; postmenopausal women of any age taking an aromatase inhibitor (e.g., Arimidex, Femara, etc.); and younger women who have had an induced menopause. Screening is not recommended for low-risk women. High-risk women screened using dual x-ray absorptiometry (DEXA) who have a T score of -1 to -2.5, are recommended to increase their exercise levels and take calcium and vitamin D. For those with a T score of -2.5 or higher, exercise, vitamin D, and a bisphosphonate are recommended. Today, most breast cancer patients become long-term survivors and are thus candidates for osteoporosis and associated fragility fractures. Because chemotherapy can cause early menopause and lower estrogen levels post-menopausally, oncologists are urged to view all patients as potentially vulnerable and send them for early and regular screening of bone density levels. (Ravdin, P.M. Bisphosphonates and bone health in women with breast cancer: Clinical practice guidelines. also Managing the risk of osteoporosis and fracture in women with a history of breast cancer. Medscape Hematology-Oncology, 6 (2), 2003)

Eagerly-awaited results from the first head-to-head trial between the anti-cancer drugs docetaxel (Taxotere) and paclitaxel (Taxol) have shown that there was a better overall response rate and longer survival among patients given Taxotere, although it was also associated with more severe side effects. The results were presented on September 24th at the European Cancer Conference in Copenhagen.

Radiologists on this continent are more prone to label screening mammograms as abnormal than their counterparts in other countries, according to a recent report. The proportion of false positive mammogram readings that resulted in further diagnostic evaluation (not to mention patient anxiety and increased costs) ranged from 5.5% to 15.0% in eight reports from North America as compared to false positives ranging from 1.2% to 12.6% in 24 reports from Hong Kong, Australia and Europe. (Elmore JG. Journal of the National Cancer Institute 95:1384-93; 2003)

A Canadian field study was conducted to determine what health food store employees recommended to individuals seeking treatment for breast cancer. A wide variety of products were sold, none of which is supported by evidence of benefit, at a mean cost per month of close to $60. In the 34 stores visited by the team, only 15 employees recommended a vist to a health care professional. The authors stress the importance of physicians' enquiring about use of natural health products when counselling breast cancer patients. (Mills E, Ernst E, Singh R , Ross C, Wilson K. Health food store recommendations: Implications for breast cancer patients. Breast Cancer Research 5(55):R170-R174, 2003)

The Million Women Study conducted in the U.K. provides strong additional evidence that the use of combination (estrogen/progestin) hormone replacement therapy is associated with a substantially greater risk of breast cancer. The results indicate that combined HRT causes four times as many extra breast cancers (as would normally be expected) as compared to estrogen-only HRT. (Million Women Study Collaborators, V. Beral et al. Breast cancer and hormone replacement therapy in the Million Women Study. Lancet, 362 (9382):419-427)

New studies from the Women's Health Initiative indicate that HRT does not reduce the risk of Alzheimer's Disease. Of the 4,894 participants aged 65 or over in the WHI, 61 were diagnosed with probable dementia. Forty of the 61 (or 66%) were in the HRT group while only 21 (34%) were not taking HRT. The principal investigator of this substudy has speculated that HRT may increase the risk of blood clots and clog tiny blood vessels in the brain, which might injure brain cells and contribute to Alzheimer's and/or other dementia. (Shumaker SA, Legault C, Rapp SR et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. Journal of the American Medical Association, 289(20):2651-62; 2003)

Novartis has developed a new bisphosphonate for use in reduction of risk of fracture associated with advanced breast and other cancers. Although the new product, Zometa (zoledronic acid) has proved more effective than another bisphosphonate, Aredia (pamidronate disodium), 9-15% of patients on Zometa had evidence of renal (kidney) deterioration. Other side effects of both products were bone pain, nausea and fatigue. Zometa is usually administered intravenously once a month. (Rosen LS, Gordon D, Kaminski M et al. Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer, Oct. 15/03; 98(8):1735-1744)

Médecins Sans Frontières has announced the creation of the world's first not-for-profit drug research organization. The planners hope that the initiative will work to develop drugs to combat diseases in third-world countries that are virtually ignored by the profit-driven pharmaceutical companies. Most of the research will be done in the developing world by public-sector scientists and there will be no marketing costs, meaning that new drugs should be brought in at significantly reduced costs. Some brand-name companies such as Merck Frosst and GlaxoSmithKline have agreed to help. Canada has yet to commit funds to the project (Alan Cassels, JAMC, Sept. 16/03;169(6): 590).

An estimated 100,000 to 200,000 women in Canada have breast implants, of which 20% are probably for cosmetic reconstruction after mastectomy. Despite the switch from silicone gel to saline-filled implants, the post-surgery complication rate remains high. Following implantation, over half of respondents in a recent study reported at least one additional breast-implant-related surgery. Because there is no public record of the number of such surgeries performed or their health outcomes in Canada, epidemiologists are now asking that a Breast Implant Registry be formed to track the results of such surgeries and help women to make rational decisions. More details are available at . Early results from European clinical trials suggest that high-quality, coordinated mammographic screening programs in which all women in a target population are invited to be screened every two years can reduce the incidence of advanced breast cancers. Although there is as yet no information about long-term survival rates, the fact that the detection of breast cancers at Stage II or higher has decreased from 65% to around 40% is heartening. This study may help to cool the debate about the risks, benefits and costs of mammography. (Osterweil N. Well-conducted mammography program reduces mortality. http:// medscape.com/viewarticle/462104)

Another view: Northwestern University chemist, Thomas J. Meade, means no disrespect to his medical colleagues, but when he looks at the state of the art in diagnostics, he suggests that, for some procedures, physicians might as well use "stone knives." Take, for example, mammography. "You know going in that there's a one in five chance of a false positive or a false negative. You have an x-ray that's not even smart enough to differentiate a shadow cast by a calcium spot from a tumour. After reading the film and seeing a shadow, they do the prudent thing and stick a 16-gauge needle in you for a biopsy. Then you have to spend the next five days freaking out that you've got breast cancer until you get the results," he says. Read more at : http://www.technologyreview.com/ articles/hamilton0903.asp?p=1

Researchers at Duke University Medical Center have developed a new breast scanner designed to detect subtle changes in breast cells before a lump can be felt, or seen by mammography. The camera uses nuclear medicine to pick up chemical changes in breast cells that signal the cells are becoming malignant. It should be particularly useful for large or dense breasts, difficult to image using traditional mammography. The new device works without breast compression and can be used without removing a bra. In clinical practice, the procedure would take 10-20 minutes to orbit each breast. So far, studies have been restricted to artifical breasts. Testing on women will start as soon as patent approval is received. (For more information, contact Becky Levine at levin005@mc.duke.edu)

Women diagnosed with breast cancer may be smart to seek a second opinion about their mammograms. After a consultation with specialists at a major cancer center, 7% of patients were told that they had more cancer in the same breast or a previously undiscovered tumour in the other breast. When new imaging (mammography or ultrasound) was ordered, nearly 30% of patients in this study received new recommendations (additional or different biopsies, treatment changes, etc.). The results suggest that patients might be wise to check with specialists at a breast cancer centre before making treatment decisions. (For more information, contact Kara Gavin at: kegavin@umich.edu) The U.S. National Cancer Institute has released new figures making it clear that, despite the war on breast cancer, this disease has actually been gaining ground over the past 15 years. The latest numbers (released Oct. 16th) show that the NCI has underestimated the incidence and that new diagnoses have been growing at a rate of 0.6% per year nationwide. Rates vary wildly from area to area, supporting the idea of an environmental link to the disease. Total U.S. federal cancer research spending has increased from US$90 million in 1990 to US$800 million in 2001, yet less than 3% of these dollars have been spent on researching environmental links to breast cancer. Today, numerous health advocates are demanding more research into the possible role of pollutants, radiation, and other environmental factors in driving the disease. (Better Nutrition, Feb. 2003, 65 (2):22)

A group from Sunnybrook Regional Cancer Centre, Toronto, has looked into the needs of long-term breast cancer survivors (i.e., women at least four years disease-free). Well-informed patients were perceived to be better prepared for medical procedures, to participate more actively in treatment decisions, to feel more satisfied with treatment choices and interactions with health professionals, to cope better with the stress of diagnosis, to have decreased levels of anxiety, and to be better able to communicate salient information to their families. The authors of the study emphasize that women continue to be affected by their breast cancer experience many years after treatment ends, that adequate, coherent follow-up care is crucial, and that provision of detailed information about what to expect post-treatment should be routine. (Gray RE, Fitch M, Greenberg M et al. The information needs of well, longer-term survivors of breast cancer. Patient Education and Counseling, 1998;33:245-255