Pharmacists play role in fighting breast cancer
Pharmacists play a key role in the fight against breast cancer. Being an integral part of the health care team, providing information necessary to help patients make informed decisions, and assisting in good clinical outcomes are among the goals pharmacists have set for pharmaceutical care.
As regular counselors of patients, pharmacists also are in a prime position to encourage patients to seek and be regular about preventive measures. They also can counsel patients who are on or are considering hormone replacement therapy (HRT) regarding its risks and benefits. Because HRT with estrogen may be associated with an increased risk of breast cancer, patients must weigh that risk against the potential benefits of a reduction of overall mortality based on the use of the drug. A family history of breast cancer also should be factored into counseling and decision making.
Assessing potential risk
Patients may ask their pharmacists about using tamoxifen to help prevent breast cancer. Clinical evidence suggests that tamoxifen reduces the risk of developing breast cancer in women who are at high risk for the disease. As with most clinical decisions, however, one must review the risk/ benefit ratio involved. Tamoxifen can put patients at a higher risk for developing endometrial cancer or for experiencing thrombotic vascular events such as stroke, pulmonary embolism, or deep vein thrombosis.1
Pharmacists can help patients learn their estimated personal risk of developing breast cancer by using the Breast Cancer Risk Assessment Tool, a computer program developed by scientists at the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project. The program assesses patients by asking for information regarding personal history of breast abnormalities, current age, age at first menstrual period, age at first live birth, history of breast cancer among first-degree family members, history of breast biopsy, and race. The program estimates the risk of developing cancer over the next five years and over the patient’s lifetime. A diskette containing the assessment tool software is available free by request at http://cancer trials.nci.nih.gov/forms/CtRiskDisk.html.
Patients who ask for informative scientific information on the Internet regarding breast and other types of cancer can be directed to the National Cancer Institute’s site at http://cancernet.nci.nih.gov/. Additionally, free publications on the prevention, early detection, diagnosis, and treatment of breast cancer may be obtained from the National Cancer Institute’s Cancer Informa-tion Service by calling (800) 4-CANCER.
Not only does mammography (MMG) serve to provide early detection of breast cancer, it also appears to provide good outcomes in those cancers that are detected. In a report in the April 24 issue of Archives of Internal Medicine, Sandra Y. Moody-Ayers, MD, and colleagues from Yale University School of Medicine share the results of their study.2
The team performed a review of medical records of a natural cohort of 233 women who received their first antineoplastic treatment for breast cancer at Yale-New Haven Hospital between Jan. 1 and Dec. 31, 1988, with a median follow-up of 82.4 months. Members of the cohort had a median age of 62 years (range 26 to 87 years); 90% were white; and 93% had private insurance and/or Medicare.
Among the women, 14% had a history of breast cancer among first-degree relatives, and 68% of patients were post-menopausal. Clinically, 78% of patients had TNM (see box, below) stages 0, I, or IIA. Cancer was detected in the cohort by MMG screening in 42%, by other screening in 40%, and by symptomatic manifestation in 18%.
Of 31 patients with carcinoma in situ (CIS; microscopic lesions in the area of the ducts and lobules of the breast), none suffered recurrences or death, despite detection method of the cancer. Of those with stages I and IIA cancer, none of those detected by MMG had cancer deaths; one had a recurrence. In that same group, among those detected by other screening or by symptoms, 11 women suffered cancer death or had a recurrence. Similar results were seen among those in stage IIB and in the combined stages III and IV groups; those with cancers detected by MMG screening had better outcomes. All patients had surgery, and the MMG-screened group was not treated more aggressively than those detected by other means. Therefore, treatment is not the reason for better outcomes for MMG-screened women, according to the study.
The skinny on prevention
Recently, the question has been raised whether obesity is a barrier to preventive care of both cervical and breast cancer. Because obesity often is accompanied by poor self-esteem and body image, it is thought that poor self-perception may prevent obese women from pursuing Pap smears and mammograms. Christina C. Wee and colleagues addressed that question in recent paper in the Annals of Internal Medicine.3 Wee et al. performed a population-based survey using 11,435 responses from women to the "Year 2000 Supplement" of the 1994 National Health Interview Survey.
Results of the study showed that overweight women (body mass index 25 to < 30 kg/m2) and obese women (body mass index 30 kg/m2) "reported significantly lower rates of screening with Pap smears in the previous three years than did normal-weight women." The heavier women also tended to be older, less likely to be white or to have private health insurance, and were lower in socioeconomic status. They reported more illness than their thin counterparts and were more likely to seek care from general internists and family physicians than from gynecologists.
As members of the health care team, pharmacists can remind patients to perform monthly breast self-examinations and report any changes right away to their physicians. Patients also should be reminded to have yearly mammograms upon reaching the age of 40. Because mammography alone does not reveal all cases of breast cancer, the American Cancer Society recommends three methods of detection for asymptomatic women at usual risk for breast cancer:4
• Women ages 40 and older should have a screening mammogram every year.
• Between the ages of 20 and 39, women should have a clinical breast examination by a health professional every three years. After age 40, women should have a breast exam by a health professional every year.
• Women ages 20 and older should perform breast self-examination every month. By making that a habit, women become familiar with how their breasts normally feel and can detect changes more readily.
• Women with risk factors for breast cancer should discuss detection methods with their physicians and may decide to start mammography earlier than age 40.
Results of a recent survey by Caredata.com show that women are more likely to re-enroll in their health plans when either the plan or the physician encourages them to receive preventive tests and services that apply to them, including Pap smears and mammograms.
"Health plans have a real opportunity to keep female members healthier as well as more satisfied and loyal to their plan by encouraging more preventative services," says Tony Morgan, vice president of Research for Caredata.com’s Consumer Research Group.
1. Wickerham DL, Cronin W, et al. The NSABP Breast Cancer Prevention Trial (BCPT): A progress report. Proceedings of the American Society of Clinical Oncology 1993; 12:A-76, 69.
2. Moody-Ayers SY, Wells CK, Feinstein AR. "Benign" tumors and "early detection" in mammography-screened patients of a natural cohort with breast cancer. Arch Intern Med 2000; 160:1,109-1,115.
3. Wee CC, McCarthy EP, Davis RB, Phillips RS. Screening for cervical and breast cancer: Is obesity an unrecognized barrier to preventive care? Ann Intern Med 2000; 132:697-704.
4. www3.cancer.org/cancerinfo/load_cont.asp?st= ds&ct=5&language=english.