610-827-2200

“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?

    -- 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

  • Causes of Death in Women
      Deaths per
    100,000 Women
    1. Heart Disease
    268.0
    2. Cerebro-Vascular Disease
    73.8
    3. Pulmonary Malignancies
    45.0
    4. Chronic Lung Diseases
    44.3
    5. Breast Cancer
    29.5
    6. Diabetes Mellitus
    26.7
    7. Accidents
    24.6

    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*

    • number of women with breast cancer
    • number of women examined
    • duration ranged from 2.6 to 25 yrs

      *NCI 2009

  • Slide 5 - Trials Table

    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 overdiagnosis1
Norwegian
Cohorts
229,256 50-64 6 1.8 %
20% regression of early stage tumors2

    1 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 1993

  • Conclusion (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.