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Breast Cancer Risk Factors IN THIS ISSUE ERT Affects Mammography Previous studies have shown that mammographic breast density increases with estrogen replacement therapy (ERT). The present study indicates that current use of ERT is associated with lower specificity (more false-positive readings) and lower sensitivity (more false-negative readings) of screening mammography. These factors could increase the biopsy rate and cost and decrease the effectiveness of breast cancer screening, the researchers say. Laya et al. (p. 643) studied 8779 postmenopausal women aged 50 years or older who underwent screening mammography and filled out questionnaires about ERT use and personal health histories. One year later, cancers had been diagnosed in 63 women, of whom 56 had true-positive readings and seven had falsenegative readings on their screening mammograms. Results showed that mammographic specificities for never users, former users, and current users of ERT were 86%, 86%, and 82%, respectively; mammographic sensitivities were 94%, 94%, and 69%, respectively. In an editorial, Black and Fletcher (p. 627) say the findings by Laya et al. provide direct evidence that ERT lowers mammographic specificity and sensitivity. Lower specificity, they suggest, could substantially increase false-positive rates and the resulting costs; lower sensitivity may also substantially decrease the ability of screening to reduce breast cancer mortality. Nevertheless, the benefits of ERT in reducing mortality from heart disease and osteoporosis may still outweigh these drawbacks, the editorial writers say. They also suggest that the findings of Laya et al. be replicated because 1) the statistically significant differences in specificity were small and 2) although the differences in sensitivity were larger, the confidence intervals were wide. They conclude that women should be informed of the multiple effects of ERT so they can make decisions based on facts and personal preference. Height, recent adiposity (weight/ height1-5), and recent weight change (between current and preceding decades of life) are predictors of breast cancer risk in Asian-American women, a study suggests. Increased adiposity and weight gain in the decade preceding diagnosis may be especially predictive of increased risk, Ziegler et al. (p. 650) report. While these findings need confirmation in other studies, the researchers suggest that weight maintenance and/or loss might have a substantial and relatively rapid impact—possibly within a decade—on breast cancer risk. Whether specific changes in diet and physical activity must accompany the weight loss needs further investigation, they say. The researchers used interviews to collect information about height, usual adult weight, and usual weight in each decade of life from 597 Asian-American women with breast cancer, aged 20-55 years, and from 966 control subjects. They found that women who were 66 inches or more in height had twice the breast cancer risk (relative risk = 2.01) of women 59 inches or less in height. Except for a reduced risk in the heavy, younger women, risk was positively associated with usual adult adiposity. Trends inriskbecame more striking as adiposity in each succeeding decade of adult life was considered. Psychological Predictors Previous studies have found that psychological factors, like depression or hostility, might predict length of survival. The present study by Tross et al. (p. 661) finds no evidence that psychological distress — as measured by the Symptom Check List90-Revised questionnaire (SCL-90-R) covering depression, hostility, and other psychological symptom areas—predicted disease-free or overall survival in women with stage II breast cancer. The investigators recommend that, rather than focusing on general psychological symptoms, future research should concentrate on specific theory-driven constructs as potential predictors of survival. Using the SCL-90-R, Tross et al. identified low, medium, and high levels of distress in 280 women with stage II breast cancer who were taking part in a larger trial of adjuvant therapy regimens involv- Journal of the National Cancer Institute, Vol. 88, No. 10, May 15, 1996 ing cyclophosphamide-methotrexatefluorouracil-vincristine-prednisone for two 6-week cycles or six 4-week cycles with or without vinblastine-doxorubicinthiotepa-fluoxymesterone. Stepwise Cox statistical regressions that controlled for sociodemographic and medical variables found no significant predictive effect of level of distress on disease-free and overall survival. In an editorial, Spiegel (p. 629) says the study by Tross et al. is an exceptionally fine investigation of the relationship between psychological distress and cancer survival. The study, however, may be limited by sample bias, he says: For example, women may have chosen to participate (self-selected) because they lacked the depression that might predict poorer outcome or the feistiness (uncooperativeness) that might predict better outcome. Spiegel reviews current knowledge about the effects of the mind on cancer, concluding that research on more specific constructs, such as suppression of distress, active coping strategies, and psychosocial intervention, should provide a more definitive test of the mind-body hypothesis. 5-FU and Colorectal Cancer Hansen et al. (p. 668) found no statistically significant difference in overall survival in patients with previously untreated metastatic colorectal cancer who were treated with continuous-infusion fluorouracil (5-FU) compared with bolus 5-FU. Continuous-infusion 5-FU, however, produced better response rates with less toxicity and longer time to disease progression, and the researchers suggest that it be considered as initial therapy for advanced colorectal cancer. Brain Lymphoma and AIDS The incidence of brain lymphoma appears to be several thousand times higher in persons with acquired immunodeficiency syndrome (AIDS) than in the general population, Cote et al. (p. 675) report. The increased brain lymphoma incidence in the AIDS population helped raise the overall incidence ninefold between 1980 and 1989, they say. But the researchers also detected a significant increase in brain lymphoma among persons without AIDS that remains unexplained. IN THIS ISSUE 625 The Surgery Branch of The National Cancer Institute Is Seeking Patients with the Following Malignancies for Combined Modality or Innovative Immunotherapy Programs: • METASTATIC MELANOMA AND KIDNEY CANCER • • STAGE II OR LOCALLY ADVANCED BREAST CANCER • • METASTATIC COLORECTAL CANCER TO THE LIVER • • LOCOREGIONAL GASTRIC OR PANCREATIC CANCER • • MESOTHELIOMA, PULMONARY METASTASES, STAGE III A AND B LUNG CANCER OR ESOPHAGEAL CANCER • • LOCALIZED SOFT TISSUE SARCOMAS • • PERITONEAL CARCINOMATOSIS • Care for all patients is provided at the clinical center at the National Institutes of Health in Bethesda, Maryland. For more information on cancer programs, please call (301) 496-1533 1W1ONAL V^iiv> CAN<CER INSTIT >TITUTE A PUBLIC SERVICE ANNOUNCEMENT COURTESY OF THIS PUBLICATION