Friday, April 19, 2013
QD: News Every Day--'Broad benefit' and side effects outlined for drugs that reduce breast cancer
Tamoxifen and raloxifene reduced the incidence of invasive breast cancer and fractures by 7 to 9 cases in 1,000 women over 5 years compared with placebo, but not without side effects, concluded a review by the U.S. Preventive Services Task Force.
There was an increased incidence of thromboembolic events, the review concluded. Also, tamoxifen was more effective than raloxifene, but also increased the incidence of endometrial cancer and cataracts.
Seven good- and fair-quality trials were reviewed, and results appeared in the April 16 edition of Annals of Internal Medicine.
New results from STAR (Study of Tamoxifen and Raloxifene) showed that tamoxifen reduced breast cancer incidence more than raloxifene by 5 cases in 1,000 women. Neither reduced breast cancer-specific or all-cause mortality. Both reduced the incidence of fractures, but tamoxifen increased the incidence of thromboembolic events more than raloxifene by 4 cases in 1,000 women.
Specifically, placebo-controlled trials showed a reduction of invasive breast cancer for tamoxifen (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.59 to 0.82; 4 trials; 7 cases in 1,000 women over 5 years) and raloxifene (RR, 0.44; CI, 0.27 to 0.71; 2 trials; 9 cases in 1,000 women). STAR also showed that more women receiving raloxifene had breast cancer than those receiving tamoxifen (RR for raloxifene, 1.24; CI, 1.05 to 1.47; 5 cases in 1,000 women over 5 years).
Placebo-controlled trials also showed that raloxifene reduced incidence of vertebral fractures (RR, 0.61; CI, 0.54 to 0.69; 2 trials; 7 cases in 1,000 women) and tamoxifen reduced incidence of nonvertebral fractures (RR, 0.66; CI, 0.45 to 0.98; 1 trial; 3 cases in 1,000 women). STAR showed that tamoxifen and raloxifene had similar effects on incidence of vertebral fractures.
Thromboembolic event incidence was increased for tamoxifen (RR, 1.93; CI, 1.41 to 2.64; 4 trials; 4 cases in 1,000 women) and raloxifene (RR, 1.60; CI, 1.15 to 2.23; 2 trials; 7 cases in 1,000 women) compared with placebo. STAR showed that raloxifene caused fewer events than tamoxifen in STAR (RR, 0.75; CI, 0.60 to 0.93; 4 cases in 1,000 women). Coronary heart disease event or stroke incidence was not increased in placebo-controlled trials and did not differ in STAR.
Tamoxifen caused more cases of endometrial cancer (RR, 2.13; CI, 1.36 to 3.32; 3 trials; 4 cases in 1,000 women) and was related to more benign gynecologic conditions; surgical procedures, including hysterectomy; and uterine bleeding than placebo. Raloxifene did not increase risk for endometrial cancer or uterine bleeding. In STAR, raloxifene caused fewer cases of endometrial cancer (RR, 0.55; CI, 0.36 to 0.83; 5 cases in 1,000 women), hyperplasia, and procedures than tamoxifen.
Women receiving tamoxifen had more cataract surgeries than those receiving placebo in one trial. Raloxifene did not increase risk for cataracts or cataract surgery compared with placebo and caused fewer cataracts than tamoxifen in STAR (RR, 0.80; CI, 0.72 to 0.95; 15 cases in 1,000 women).
The most common side effects among studies were vasomotor symptoms and vaginal discharge, itching, or dryness for tamoxifen and vasomotor symptoms and leg cramps for raloxifene. In STAR, raloxifene users reported more musculoskeletal problems, dyspareunia and weight gain, whereas tamoxifen users had more gynecologic problems, vasomotor symptoms, leg cramps and bladder control symptoms.
"Despite previous recommendations to identify women at increased risk for breast cancer and offer risk-reducing medications, use is low in the United States," the authors wrote. "It is not clear how to identify candidates for therapy. Although the trials indicate broad benefit, subgroup analysis and decision models suggest that high-risk women, particularly those who had hysterectomies, may derive the most benefit with the least harms."
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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