Journals Watch - Breast cancer, diets and statins

Not had time to read the latest journals? Let Dr Sally Hope bring you up to date with the research.

Combined HRT was associated with more invasive breast cancer (Photograph: SPL)
Combined HRT was associated with more invasive breast cancer (Photograph: SPL)

HRT and breast cancer incidence
JAMA 2010; 304 (15): 1684-92

This is the 11-year follow-up data from the women's health initiative trial of 16,608 postmenopausal women who either had combined HRT (equine estrogens 0.625mg plus medroxyprogesterone acetate 2.5 mg per day) or placebo.

Women on the combined HRT had more invasive breast cancers than the placebo group (hazard ratio 1.25) and were more likely to be node positive. There were more deaths attributed to breast cancer and more deaths from all causes occurring after breast cancer diagnosis in the HRT group compared with the control group.

These findings for combined HRT are consistent with the British million women's study.

Protein content and glycaemic index in dieting
N Engl J Med 2010; 363: 2102-13

In this trial, obese adults (mean BMI 34kg/m2) who had lost 8 per cent of their body weight by sticking to an 800kcal diet were monitored.

A total of 773 patients were randomised to one of five diets to prevent weight regain over a 26-week period.

The diets were: low protein and low glycaemic index; low protein and high glycaemic index; high protein and low glycaemic index; high protein and high glycaemic index or control. A total of 548 patients completed the intervention.

Fewer participants in the high protein and the low glycaemic index groups than in the low protein and high glycaemic index group dropped out of the study.

Only the low protein and high glycaemic index diet was associated with subsequent significant weight regain (p=0.003).

High-sensitivity CRP and de novo major depression
Br J Psychiatry 2010; 197: 372-7

The authors set out to see if raised serum high-sensitivity CRP (hsCRP) concentration is associated with an increased risk of de novo major depressive disorder.

In a retrospective cohort study, 822 randomly selected women were followed for a decade. At the start, 644 (aged 20-84 years) had no prior history of depression. Over 10 years there were 48 cases of de novo major depressive disorder.

The hazard ratio for depression increased by 44 per cent for each standard deviation increase in log-transformed hsCRP. Adjustments for lifestyle factors, medications and comorbidities failed to explain the observed increased risk for depression.

The conclusion is that serum hsCRP is an independent risk marker for de novo major depressive disorder in women.

Long-term statins for patients with coronary heart disease and abnormal LFTs
Lancet 2010; doi:10.1016/S0140-6736(10)61272-X

In 437 patients with heart disease and abnormal liver function (possibly associated with non-alcoholic fatty liver disease), the 227 patients who were treated with a statin had a substantial improvement in LFTs, whereas 210 not treated with a statin had further increases of liver enzyme concentrations.

Cardiovascular events occurred in 10 per cent of 227 patients with abnormal liver tests who received a statin and 30 per cent of 210 patients with abnormal liver tests who did not receive a statin. The reduction in cardiovascular events was greater (p=0.0074) than for heart disease patients with normal LFTs.

The abnormal LFT group were defined as having alanine amino-transferase or aspartate amino-transferase less than three times the normal range, which is moderately abnormal.

Use of PPIs in early pregnancy
N Engl J Med 2010; 363: 2114-23

Indigestion is very common in pregnancy and women take PPIs for reflux. This Danish study looked at the use of PPIs from four weeks pre-conception through to 12 weeks of gestation and from zero through to 12 weeks of gestation.

Among 840,968 live births, 5,082 involved exposure to PPIs between four weeks before conception and the end of the first trimester of pregnancy.

There were 174 major birth defects in infants whose mothers had been exposed to PPIs during this period (3.4 per cent), compared with 21,811 in the group whose mothers had not been exposed (2.6 per cent - adjusted prevalence odds ratio, 1.23).

In analyses limited to exposure during the first trimester, there were 118 major birth defects among 3,651 infants exposed to PPIs (3.2 per cent), and the adjusted prevalence odds ratio was 1.10 (95 per cent CI, 0.91 to 1.34).

Exposure to PPIs during the first trimester of pregnancy was not associated with a significantly increased risk of major birth defects.

Guidelines on androgens, health and sexuality
Maturitas 2010; 67(3): 275-89

The British Society for Sexual Medicine (BSSM) has initiated and led the development of guidelines for the assessment of testosterone deficiency in women and men.

The guidelines provide a summary of data on testosterone in women including: difficulties with assays, contradictory studies and treatment options and guidance. In three studies with a total of nearly 5,000 women, it was found that there was no consistent correlation between sexual functioning and androgens.

The nurses' health study showed women receiving testosterone had a 17.2 per cent increased risk of breast cancer per year of use. There is no good cardiovascular safety data.

Men with a testosterone level below eight nanomoles per litre usually benefit from testosterone treatment. A non-fasting blood should be taken at 9am to get an accurate total testosterone level.

Treatment levels should aim for 15 millimoles per litre. At three months, if there is no symptomatic improvement, treatment should be stopped.The PSA should be measured at three and 12 months and any increment greater than 1.4 nanogram/ml warrants urological investigation.

Treatment of men with sexual desire, arousal and ejaculatory problems should be individually tailored to the patient, but may include testosterone therapy, psychosexual therapy and erectogenic agents.

  • Dr Hope is a GP in Woodstock, Oxfordshire and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

 CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Agree a practice protocol for testosterone replacement therapy, including 9am testosterone measurements and PSA estimations at three and 12 months.
  • Do an audit on patients with Read codes of non-alcoholic fatty liver and heart disease, and check their statin usage.
  • Present to colleagues on the association between hsCRP and depression and discuss how this could impact on your management of patients with systemic inflammation.

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