Breast Cancer in Postmenopausal Women:
What is the Real Risk?
Dr. Winnifred Cutler presents her powerpoint presentation to the Annual Meeting of the American Society of Reproductive Medicine in 2009 held in Atlanta, GA.
Below is a summary of the slideshow content:
Breast Cancer in Postmenopausal Women: What Is The Real Risk?
(A Tough Search for Unbiased Data)
- Winnifred B. Cutler, PhD
Regula E. Burki, MD, FACOG
Elizabeth Genovese, MD, MBA, FACOEM
Millicent G. Zacher, M.Ed, DO FACOG
What prompted us to search?
Causes of Death in Women-- Misrepresentation in “scientific” media
-- Misperceptions in peer reviewed papers“32% lifetime risk”1
“2nd highest cause of death in women”2→ Women are terrified
1 Zimmerman 08 Ann Beh Med
2 Carroll 08 Menopause
Deaths per 100,000 Women 1. Heart Disease 2. Cerebro-Vascular Disease 3. Pulmonary Malignancies 4. Chronic Lung Diseases 5. Breast Cancer 6. Diabetes Mellitus 7. Accidents CDC 1999
How did we calculate breast cancer incidence?
18 breast cancer studies
-- RCT, observational trials, screening studies
-- all studies in women ≥ 40
-- 87.6% of breast cancer occur age ≥ 44*
Slide 5 - Trials Table
- number of women with breast cancer
- number of women examined
duration ranged from 2.6 to 25 yrs
*NCI 2009
Trial #Women Age Years Incidence Ref UK Million ~1,000,000 50-64 2.6 <1 % 1 Danish NH 10,874 >44 6 2.2 % 2 Melbourne 13,444 40-69 12 2.5% 3 Finnish Registry 110,371 >50 7 1.97% 4 French Cohort 3175 >49 9 3.3% 5 WHI I 16,610 50-79 5.2 Prempro 1.95 %
Placebo 1.53 %6a WHI II 10,739 50-79 7.1 Premarin 1.96%
Placebo 2.45%6b US NH 69,586 >44 16 2.7% 7 US Rec Rev 814 59-62 3 1.96% 8 Australia Rec Rev 508 40-79 5.8 1.4% 9 Missouri Cohort 3375 61-62 3 to 12 2.1% 10 US NH Subgroup 11,169 43-69 10 2.88% 11 Osteo Fx 9704 >64 3.2 1.2% 12 Italy ORDET 4040 40-69 3.5 0.6% 13 N Y U 7063 <65 5.5 1.8% 14 US BCDDP 283,222 40-93 7 1.5% 15 UK Mammo Screen 39,197 45-64 7 first screen 0.53 %
subseq. screen 0.33 %16 Sweden-Malmo 42,283 45-68 25 5.96% 17 Norwegian Cohorts 229,256 50-64 6 1.8% 18
Breast Cancer Incidence Among Healthy Postmenopausal Women
Trial # Women Age Years Incidence Ref Melbourne 13,444 40-69 12 2.5 % 3 US NH 69,586 >44 16 2.7 % 7 US NH Subgroup 11,169 43-69 10 2.88 % 11 Sweden-Malmo 42,283 45-68 25 5.96 % 17
Mammogram Screening Trials
Trial # Women Age Yrs Incidence UK Mammo Screen 39,197 45-64 7 first screen 0.53 %
subseq screen 0.33 %Sweden-Malmo 42,283 45-68 25 5.96 %
16-32% rate of overdiagnosis1Norwegian
Cohorts229,256 50-64 6 1.8 %
20% regression of early stage tumors21 Zachrisson 2006 BMJ
2 Zahl 2008 Arch Int Med
Why is the true incidence so much lower than the reported risk estimates?
--The risk estimates are based on SEER*
--We believe that the SEER methodology arrives at spuriously high breast cancer risk estimates* Surveillance, Epidemiology, and End Results
Critique of SEER Methodology (1)
(first, a fourth grade math lesson)6 (Numerator) =6%
100 (Denominator)6 (Numerator) = 9.0%
67 (Denominator↓)8 (Numerator↑) =8%
100 (Denominator)8 (Numerator↑) = 11.9%
67 (Denominator↓)
Critique of SEER Methodology (2)
-- SEER denominator and SEER numerator may not correspond to the same population
- Denominator based on census data
- Numerator derived from cancer registries
1 Ward 2009
2 Feuer 1993
Critique of SEER Methodology (3)
--Both SEER denominator and SEER numerator are “massaged”
--Denominator spuriously low
- 10 year census lags behind actual numbers
undocumented population not included1--Numerator spuriously high
- numerator “adjusted” upwards by investigators2
1 Ward 2009
2 Feuer 1993Conclusion (1)
-- Spuriously low denominator and high numerator in SEER artificially increase incidence from which future risk estimates are generated.
--True risk for postmenopausal women may be less than half currently “estimated” by SEER predictions.
Conclusion (2)
This risk can be further lowered by prescribing TLCs with proven benefit
- non smoking
- moderate alcohol consumption
- adequate exposure to sunshine or vitamin D
- low fat dairy foods
- increased whole grains, fruits and vegetables
- regular physical and social exercise
- maintaining a normal BMI
(END OF SLIDES)To View the Abstract please click here
To View the Press Release please click here
About the Author: Winnifred Cutler, PhD, Founded Athena Institute for Women’s Wellness in 1986, is a reproductive biologist and longtime champion of improving the quality of healthcare for women, has authored two medical texts and 6 other books; most recently Hormones and Your Health: The Smart Woman’s Guide to Hormonal and Alternative Therapies for Menopause.