WEEK 3 EBCR – 8A

Sri PuspitaAmalia NPLingga S

Rienna DiansariHarsya DG

Tutor : dr.Dewi Friska

• Mrs. X, 60 years old, complains a lump in her right breast since 4 weeks ago. The lump is not painful and getting bigger over time. It is fixated and has flat surface. There are some changes on her breast skin too. Mrs. X has been menopause since 7 years ago, and with the recommendation of her previous doctor, she has been taking estrogen therapy to prevent heart disease and osteoporosis.

• Her elder sister died 2 months ago from breast cancer and had a history of estrogen-progestin therapy.

• She asked, whether the hormonal therapy could induce breast cancer?

Cases

• In US, 2011 230,480 new cases of invasive breast cancer & 57,650 new cases of non-invasive (in situ) breast cancer.

• In Indonesia The second most common female cancer

• Risk factor exposure to estrogen (hormone replacement therapy), family history, diet, oral contraceptive, breast changes, etc.

• Theory Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them.

Vogel VG. Breast Cancer. 2008. Merck & Co. Available at: http://www.merckmanuals.com/professional/gynecology_and_obstetrics/breast_disorders/breast_cancer.html Tjindarbumi D, Mangunkusumo R. Cancer in Indonesia, Present and Future. Jpn J Clin Oncol 2002; 32.

Background

PICO•Postmenopausal Women

Patient /Problem

• Estrogen TherapyIntervention

• Estrogen-progestine therapyComparison

• Breast cancerOutcome

ACQ

Clinical Question• In postmenopausal women, does estrogen therapy

increase risk of breast cancer compared to estrogen-progestin therapy

Type of Question• Etiology

Search StrategyMETHODS

Selection Criteria

Evidence Based Case ReportArticle 1 Article 2

Title Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis

Menopausal hormone therapy and risk of breast cancer: a meta-analysis of epidemiological studies and randomized controlled trials

Author Nirav R Shah, Jeff Borenstein, and Robert W Dubois

Claudia M Greiser, Eberhard M Greiser, and Martina Dören

Publication/Journal Name

Menopause. 2005; 12 (6): 668-678

Human Reproduction Updates, 2005; 11 (6): 561-573

Number of Studies

15 42

Domain Postmenopause women Postmenopause women/women using hormonal therapy

Determinant Estrogen therapy Estrogen therapy

Comparison

Estrogen-progestin hormonal therapy

Estrogen-progestin hormonal therapy, menopausal hormone therapy (all therapy combined)

Outcome Breast cancer Breast cancer

    article 1* article 2*

validity

What question (PICO) did the systematic review address? Yes, relevant and

clearly stateYes, relevant and

clearly state

Is it unlikely that important, relevant studies were missed? Yes Yes

Were the criteria used to select articles for inclusion appropriate? Yes Yes

Were the included studies sufficiently valid for the type of question asked? Yes Yes

Were the results similar from study to study? Yes Yes

Importancy (result) How are the results presented? Forest plot Forest plot

applicabilityIs our patient so different from those in

study that its result cannot apply?No No

*article 1 : Shah, Borenstein and Dubois.2005*article 2 : Greiser and Doren.2005

VIA

1.Shah et al1

Study or Subgroup Relative Risk95% CI

Estrogen therapy vs breast cancer less than 5 years use more than 5 years use

OR = 1.16 (1.06 – 1.28)OR = 1.16 (1.02 – 1.32)OR = 1.20 (1.06 – 1.37)

Combined hormonal therapy vs breast cancer less than 5 years use more than 5 years use

OR = 1.39 (1.12 – 1.72)

OR = 1.35 (1.16 – 1.57)OR = 1.63 (1.22 – 2.18)

2Shah NR, Borenstein J, Dubois RW. Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis. Menopause. 2005; 12 (6); 668-78

RESULTS

Study or Subgroup Relative Risk95% CI

Menopausal hormone therapy vs breast cancer Case Control Cohort/RCT

OR = 1.34 (1.25 – 1.43)OR = 1.20 (1.06 – 1.37)

Estrogen-progestin hormonal therapy vs breast cancer Case Control Cohort

OR = 1.48 (1.33 – 1.65)OR = 1.95 (1.87 – 2.04)

Estrogen hormonal therapy vs breast cancer Case Control Cohort

OR = 1.18 (1.08 – 1.30)OR = 1.27 (1.19 – 1.35)

2.Greiser et al2

1Greiser CM, Greiser EM, Doren M. Menopausal hormone therapy and risk of breast cancer: a meta-analysis of epidemiological studies and RCT. Human Reproduction Update. 2005; 11 (6); 561-73

ResultsThe result of this two studies has a consistency with almost all previous studies, that using postmenopausal hormonal therapy have a higher risk of breast cancer. Combined EPT is higher than ET. Those study also show that after 1 year discontinuation of PHT, the risk of breast cancer is decrease. But about the risk of breast cancer after discontinuation of PHT, still needs further analysis.

DISCUSSION

Strength and Limitations⁺ searched from some databases such as PubMed,

Cochrane, and Ebsco.⁺ recent studies, last 10 years and the studies are

systematic review and meta-analyses.⁺ validity of that two studies were assessed by

sistematic review worksheet from Central Evidence Based Medicine (CEBM).3

⁺ The studies relevance with our clinical questions₋ systematic reviews are consist only with English

language₋ just use a computer search. We didn’t do a hand

searching or unpublished studies

Those both appraised article are suitable and not so different from our case. Because the patient of the studies and our case are same characteristic, so these studies can be applied to our patient.

CONCLUSION

THANK YOU