Hormone replacement therapy and endometrial cancer: are current regimens safe?
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Arteriosclerosis↗
Biomedical subjects
V L Ernster
Publications and source records attributed to V L Ernster.
A comparison of two methods to teach smoking-cessation techniques to medical students.
PURPOSE: To evaluate two smoking-cessation practice exercises, one using standardized patients (SPs), the other using role playing by medical students. METHOD: In the spring of 1994 all 120 first-year University of California, San Francisco, School of Medicine Students were given lectures on the health effects of smoking and how physicians can help patients quit. Afterward some of the students were randomly assigned to two groups in which to practice counseling patients: Group 1 (n = 35) used SPs, Group 2 (n = 37) used role playing. Each of the Group 1 students practiced smoking-cessation techniques with an SP; the SP evaluated the student on cognitive and communication skills, assigned an overall rating, and provide feedback using a standardized form. The Group 2 students (as well as the 48 students not assigned to a group) role-played in pairs and used the same form to provide feedback. All the students evaluated their respective practice practices. Two weeks later 24 Group 1 and 31 Group 2 students participated in a clinic-skills-assessment exercise using SPs. As in the Group 1 practice exercise, each student was evaluated by an SP on cognitive and communication skills and assigned an overall rating. Data were analyzed through a number of statistical methods. The cost of the SP program was determined. RESULTS: The Group 1 students rated their practice exercise much more favorably than did the Group 2 students. However, there was no significant difference between the groups in their ratings by the SPs on the clinical-skills-assessment exercise. The use of SPs cost a great deal more than did the use of role playing. CONCLUSION: Although the students rated the SPs higher than they did the role playing, the two tools produced similar levels of skills attainment. The data suggest that having students practice smoking-cessation techniques through role playing may be as effective as using the more extensive SPs.
Education, Medical, Undergraduate↗
Mammography screening for women aged 40 through 49--a guidelines saga and a clarion call for informed decision making.
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Adult↗
Breast Cancer Surveillance Consortium: a national mammography screening and outcomes database.
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Breast Neoplasms↗
Incidence of and treatment for ductal carcinoma in situ of the breast.
OBJECTIVE: To describe trends in incidence and treatment for ductal carcinoma in situ (DCIS) of the breast in the United States between 1973 and 1992 and to estimate total numbers of in situ cases diagnosed and numbers treated by mastectomy since 1983, when screening mammography for breast cancer began to become widespread. DESIGN: Analysis of population-based breast cancer incidence data collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program since 1973 and treatment data collected by the SEER program since 1983. STUDY POPULATION: All women in the geographic areas af the United States included in the SEER program. MAIN OUTCOME MEASURES: Annual age-adjusted and age-specific incidence rates for DCIS; time trends in distribution of cases by type of treatment; percentage of cases treated by mastectomy by geographic area; and estimated numbers for the entire United States of DCIS cases, mastectomies for DCIS, and cases attributable to mammography. RESULTS: There was a marked increase in DCIS incidence beginning in the early 1980s. Average annual increases in rates between 1973 and 1983 and between 1983 and 1992 changed from 0.3% to 12.0% among women aged 30 to 39 years, from 0.4% to 17.4% among women aged 40 to 49, and from 5.2% to 18.1% among women aged 50 years or older. The total estimated number of DCIS cases in the United States in 1992 (23,368) was 200% higher than expected based on 1983 rates and trends between 1973 and 1983. Between 1983 and 1992, there was a marked decline in the proportion of DCIS cases treated by mastectomy (from 71% to 43.8%) and an increase in those treated by lumpectomy (from 25.6% to 53.3%). In 1992, 23.3% of cases were treated by lumpectomy and radiation, 30.2% by lumpectomy alone, and 2.6% with no surgery. Treatment patterns varied substantially by geographic area, with 57.7% of cases in New Mexico treated by mastectomy in 1992 compared with 28.8% in Connecticut. Despite the decline in the proportion of cases treated by mastectomy, the increased DCIS incidence rates resulted in an increase in the absolute number of cases treated by mastectomy until 1990 (n=10,657); in 1992, there were an estimated 10,242 DCIS cases treated by mastectomy. CONCLUSIONS: Incidence rates of DCIS of the breast have increased dramatically since 1983. This increase correlates with the widespread adoption of modern mammographic screening. While early detection of invasive breast cancer is beneficial, the value of DCIS detection is currently unknown. There is cause for concern about the large number of DCIS cases that are being diagnosed as a consequence of screening mammography, most of which are treated by some form of surgery. In addition, the proportion of cases treated by mastectomy may be inappropriately high, particularly in some areas of the United States.
Adult↗
Female lung cancer.
Female lung cancer death rates increased by more than 550 percent between 1950 and 1991. In 1986 lung cancer surpassed breast cancer to become the leading cause of cancer death in women in the United States. The lung cancer epidemic is primarily attributable to cigarette smoking, which is responsible for at least 80% of the disease in women. There are gender differences in the distribution of lung cancer by histologic type, even controlling for smoking, and some data suggest greater female than male susceptibility to lung cancer at a given level of smoking. Exposure to environmental tobacco smoke increases risk of lung cancer in nonsmoking women. Family history of lung cancer, personal history of lung disease (e.g. asthma, chronic bronchitis, pneumonia, or tuberculosis), and a history of radiotherapy also appear to be associated with increased risk. Data specific to women on the role of household radon exposures or of specific occupational or environmental exposures are relatively sparse and inconsistent. Finally, many studies have reported a decreased risk of lung cancer in individuals who consume high levels of fruits and vegetables; however, clinical trials fail to support a beneficial effect of beta-carotene supplementation. Since cigarette smoking accounts for the vast majority of lung cancer cases in women, efforts to prevent adolescent girls from starting to smoke and to encourage cessation among established smokers have the greatest potential for reducing the female lung cancer burden.
Female↗
Efficacy of screening mammography. A meta-analysis.
OBJECTIVE: To determine the efficacy of screening mammography by age, number of mammographic views per screen, screening interval, and duration of follow-up. DESIGN: Literature review and meta-analysis. DATA IDENTIFICATION AND ANALYSIS: Literature search of English-language studies reported from January 1966 to October 31, 1993, using MEDLINE, manual literature review, and consultation with experts. A total of 13 studies were selected, and their results were combined using meta-analytic techniques based on the assumption of fixed effects. MAIN RESULTS: The overall summary relative risk (RR) estimate for breast cancer mortality for women aged 50 to 74 years undergoing screening mammography compared with those who did not was 0.74 (95% confidence interval [CI], 0.66 to 0.83). The magnitude of the benefit in this age group was similar regardless of number of mammographic views per screen, screening interval, or duration of follow-up. In contrast, none of the summary RR estimates for women aged 40 to 49 years was significantly less than 1.0, irrespective of screening intervention or duration of follow-up. The overall summary RR estimate in women aged 40 to 49 years was 0.93 (95% CI, 0.76 to 1.13); the summary RR estimate for those studies that used two-view mammography was 0.87 (95% CI, 0.68 to 1.12) compared with 1.02 (95% CI, 0.73 to 1.44) for those studies that used one-view mammography, and for those studies with 7 to 9 years of follow-up, the summary RR estimate was 1.02 (95% CI, 0.82 to 1.27) compared with 0.83 (95% CI, 0.65 to 1.06) for those studies with 10 to 12 years of follow-up. CONCLUSION: Screening mammography significantly reduces breast cancer mortality in women aged 50 to 74 years after 7 to 9 years of follow-up, regardless of screening interval or number of mammographic views per screen. There is no reduction in breast cancer mortality in women aged 40 to 49 years after 7 to 9 years of follow-up. Screening mammography may be effective in reducing breast cancer mortality in women aged 40 to 49 years after 10 to 12 years of follow-up, but the same benefit could probably be achieved by beginning screening at menopause or 50 years of age.
Adult↗
Facial wrinkling in men and women, by smoking status.
OBJECTIVES: This study examined the association of smoking status and pack-years of smoking with facial wrinkling in men and women. METHODS: We conducted a cross-sectional study of 299 never smokers, 551 former smokers and 286 current smokers, aged 30 through 69 years, drawn from a health maintenance organization. Smoking status, pack-years of smoking, and potential confounding variables were assessed by questionnaire. Facial wrinkle category, a dichotomous variable, and facial wrinkle score, a computed continuous variable, were assessed by blinded standardized visual assessment. Wrinkling was so uncommon among 30- through 39-year-old subjects that analyses were restricted to subjects aged 40 and over (227 never smokers, 456 former smokers, and 228 current smokers). RESULTS: With age, average sun exposure, and body mass index controlled, the estimated relative risk of moderate/severe wrinkling for current smokers compared to never smokers was 2.3 (95% confidence interval [CI] = 1.2, 4.2) among men and 3.1 (95% CI = 1.6, 5.9) among women. Pack-years was positively associated with facial wrinkle score in women aged 40 through 69 years and in men aged 40 through 59 years. In both groups, the increased risk of wrinkling was equivalent to about 1.4 years of aging. CONCLUSIONS: Our results support earlier findings that risk of facial wrinkling is greater in cigarette smokers than in never smokers.
Adult↗
Smoking cessation curriculum for first-year medical students.
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Curriculum↗
Nested case-control studies.
The nested case-control study design (or the case-control in a cohort study) is described here and compared with other designs, including the classic case-control and cohort studies and the case-cohort study. In the nested case-control study, cases of a disease that occur in a defined cohort are identified and, for each, a specified number of matched controls is selected from among those in the cohort who have not developed the disease by the time of disease occurrence in the case. For many research questions, the nested case-control design potentially offers impressive reductions in costs and efforts of data collection and analysis compared with the full cohort approach, with relatively minor loss in statistical efficiency. The nested case-control design is particularly advantageous for studies of biologic precursors of disease. To advance its prevention research agenda, NIH might be encouraged to maintain a registry of new and existing cohorts, with an inventory of data collected for each; to foster the development of specimen banks; and to serve as a clearinghouse for information about optimal storage conditions for various types of specimens.
Case-Control Studies↗
The epidemiology of lung cancer in women.
Female lung cancer mortality rates have increased dramatically since 1950, and in 1987 lung cancer surpassed breast cancer as the leading cause of cancer death among US women. The epidemic in women, as in men, is attributable to cigarette smoking. Smoking prevalence in women peaked in the 1960s and 1970s and has since been declining, although fully 23.5% of adult women were current smokers in 1991. As a reflection of declines in smoking prevalence, lung cancer incidence and mortality rates are declining slightly in women under 45 years old, and it is predicted that overall age-adjusted rates may begin to turn around early in the next century. Survival for the disease is poor; the relative 5-year survival rate for women diagnosed between 1981 and 1987 was only 16% for whites and 13% for African-Americans. This article describes trends in female lung cancer rates by race and age, provides staging and survival statistics, and briefly reviews the evidence on smoking and other risk factors (environmental tobacco smoke, radon, pollution, family history, previous lung disease, and diet) for lung cancer in women.
Adolescent↗
Hormone therapy to prevent disease and prolong life in postmenopausal women.
PURPOSE: To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong life. DATA SOURCES: Review of the English-language literature since 1970 on the effect of estrogen therapy and estrogen plus progestin therapy on endometrial cancer, breast cancer, coronary heart disease, osteoporosis, and stroke. We used standard meta-analytic statistical methods to pool estimates from studies to determine summary relative risks for these diseases in hormone users and modified lifetable methods to estimate changes in lifetime probability and life expectancy due to use of hormone regimens. RESULTS: There is evidence that estrogen therapy decreases risk for coronary heart disease and for hip fracture, but long-term estrogen therapy increases risk for endometrial cancer and may be associated with a small increase in risk for breast cancer. The increase in endometrial cancer risk can probably be avoided by adding a progestin to the estrogen regimen for women who have a uterus, but the effects of combination hormones on risk for other diseases has not been adequately studied. We present estimates for changes in lifetime probabilities of disease and life expectancy due to hormone therapy in women who have had a hysterectomy; with coronary heart disease; and at increased risk for coronary heart disease, hip fracture, and breast cancer. CONCLUSIONS: Hormone therapy should probably be recommended for women who have had a hysterectomy and for those with coronary heart disease or at high risk for coronary heart disease. For other women, the best course of action is unclear.
Breast Neoplasms↗
Breast cancer incidence in women with abnormal cytology in nipple aspirates of breast fluid.
This is a prospective study of breast cancer risk in relation to nipple aspirate fluid cytology in 2,701 volunteer white women from the San Francisco Bay Area first enrolled between 1973 and 1980. The women were not pregnant or lactating and were free of breast cancer within 6 months of entry into the study. The breast cancer status of this cohort was determined between June 1988 and April 1991. Follow-up was complete for 87% (n = 2,343) of the cohort, representing 29,961 person-years and an average of 12.7 years of follow-up. The overall breast cancer incidence was 4.4% (104 of 2,343) and rose with fluid cytology findings as follows: no fluid obtained, 2.6% (9 of 352); unsatisfactory specimen, 4.8% (15 of 315); normal cytology, 4.3% (56 of 1,291); epithelial hyperplasia, 5.5% (18 of 327); and atypical hyperplasia, 10.3% (6 of 58). Relative risks for breast cancer and their 95% confidence intervals were estimated by Cox regression, adjusting for age and year of entry. Compared with the relative risk for women who yielded no fluid, relative risks were: unsatisfactory specimen, relative risk (RR) = 1.4 (95% confidence interval (CI) 0.6-3.3); normal cytology, RR = 1.8 (95% CI 0.9-3.6); epithelial hyperplasia, RR = 2.5 (95% CI 1.1-5.5); and atypical hyperplasia, RR = 4.9 (95% CI 1.7-13.9). These findings were strongest for and were mainly confined to women aged 25-54 years. Women with atypical hyperplasia and a first-degree family history of breast cancer were six times more likely to develop breast cancer than were women with atypical hyperplasia but without a family history of breast cancer (95% CI 1.0-30.2). These findings provide strong support for our hypothesis that hyperplasia and atypical hyperplasia diagnosed in nipple aspirates of breast fluid are associated with an increased risk of breast cancer.
Adolescent↗
Histopathology of smokeless tobacco lesions in professional baseball players. Associations with different types of tobacco.
We examined 142 biopsy specimens of smokeless tobacco-associated oral mucosal lesions from 133 professional baseball players. Four types of epithelial change were observed in the specimens: hyperparakeratosis, hyperorthokeratosis, pale surface staining, and basal cell hyperplasia. These types of epithelial change were associated with the type of smokeless tobacco used (snuff or chewing tobacco) but not with the duration (years) or amount (hours per day) of use. The thickness of hyperkeratosis in a specimen correlated directly with the amount of smokeless tobacco use. The use of snuff was more frequently associated with development of oral mucosal lesions than was the use of chewing tobacco, and snuff appeared to cause a greater variety and severity of epithelial change than did chewing tobacco.
Adult↗
Smokeless tobacco use prevents aphthous stomatitis.
Aphthous stomatitis is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smoking has been reported to protect against aphthous ulcers. To determine whether smokeless tobacco use also protects against aphthous ulcers, we examined the oral mucosa in 1456 professional baseball players, about half of whom were smokeless tobacco (ST) users. After controlling for the confounding effects of age, race, cigarette smoking, alcohol consumption, and dental hygiene practices, ST use was found to significantly reduce the risk of aphthous ulcers among these healthy young men (odds ratio = 0.4; p = 0.04). It has been suggested that cigarette smoking prevents aphthous ulcers by causing increased keratinization of the oral mucosa, and ST may protect by the same mechanism. Alternatively, a component of tobacco that is systemically absorbed might be responsible for protecting against aphthous ulcers. If the mechanism that protects ST users against aphthous ulcers is systemic, then nicotine is the likely protective factor.
Adolescent↗
Women's attitudes toward careers in academic medicine at the University of California, San Francisco.
In order to identify the concerns and possible barriers for women considering careers in academic medicine, in 1990 the authors surveyed both men and women medical students, housestaff, postdoctoral students, and junior faculty at The University of California, San Francisco (UCSF). The authors achieved a 58% response rate from students and faculty, a 21% response rate from postdoctoral students, and a 15% response rate from housestaff. Results indicated that women at all levels were less interested in academic careers than were their male colleagues. Concerns about balancing family responsibilities, clinical practice, and teaching in addition to the research required of an academic career were mentioned most frequently. Women, especially those among the housestaff and junior faculty, reported fewer mentor relationships and role models. The authors discuss these findings in relation to other studies and describe what they are doing to foster women's interest and success in academic medicine at UCSF.
Attitude↗
Reduction of Langerhans cells in smokeless tobacco-associated oral mucosal lesions.
Localized absence of epithelial Langerhans cells (LC) has been shown to affect systemic immune responses, allow microbial colonization and play a possible role in carcinogenesis. Because use of smokeless tobacco is associated with abnormal oral mucosal changes and development of carcinoma, we examined lesion and control specimens from 17 current users of smokeless tobacco to determine whether lesions showed changes in LC number or antigen expression. We identified LC by immunohistochemistry with antibodies to the antigens T6, HLA-DR, HLA-DQ, and HLA-DP. Lesion specimens contained fewer LC (means of 6 LC/mm and 10 LC/mm2) than did the corresponding control specimens (means of 14 LC/mm and 30 LC/mm2), and in each pair of lesion and autologous control specimens the reduction in LC was on average 58% (range, 3% to 95%). There were no apparent differences between lesion and control specimens in the number of LC expressing each of the four marker antigens. Reductions in LC occurred in all types of smokeless tobacco-associated lesions, regardless of increased epithelial thickness or changes in keratinization. Our data indicate that smokeless tobacco reduces the number of Langerhans cells at its site of contact with the oral mucosa.
Antigens, Surface↗