“Breast Cancer in
Postmenopausal Women:
What is the Real Risk?”

 

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Dr. Winnifred Cutler presents her powerpoint presentation to the Annual Meeting of the American Society of Reproductive Medicine in 2009 held in Atlanta, GA.

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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.