American College of Physicians: Internal Medicine — Doctors for Adults ®

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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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
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
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 Infection Prevention
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 Iowa City, IA, 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.

Everything Health
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.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
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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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
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.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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