Journals Watch - Breast cancer, fractures and alcohol

Not had time to read the journals? Let Dr Raj Thakkar bring you up to date on the latest research.

Trastuzumab was found to improve survival rates after breast cancer (Photograph: SPL)
Trastuzumab was found to improve survival rates after breast cancer (Photograph: SPL)

Trastuzumab for patients with HER2-positive early breast cancer
Lancet Oncology 2011; doi: 10.1016/S1470-2045(11) 70033-X
While recent studies have shown that the prevalence of breast cancer has increased, others have demonstrated improved survival.

Some of the improved one-year survival data in early breast cancer is attributable to treatment with non-chemotherapeutic systemic therapies, such as trastuzumab, which is a monoclonal antibody against the human epidermal growth factor receptor 2 (HER2). Around 25 per cent of patients with breast cancer are HER2 positive.

This trial was a randomised, open-label trial which compared neoadjuvant, adjuvant or combination trastuzumab treatment versus observation looking at four-year disease-free survival. Around 3,500 patients with early HER2 positive breast cancer were included in the study.

The four-year disease-free survival was 78.6 per cent in the one-year treatment group compared with 72.2 per cent in the observation group.

Adverse events in the treatment group were cardiac failure, hypertension, back pain, arthralgia, headaches, diarrhoea, flushing and central line infections. Each of these effects occurred in less than 1 per cent of patients.

Efficacy of a Vero-cell-culture-derived trivalent influenza vaccine
Lancet 2011; 377: 751-9

Patients continue to question the safety and efficacy of vaccinations, particularly influenza. This double-blind study aimed to answer some of these questions.

This US trial involved 7,250 patients who were assigned to receive either placebo or Vero-cell-culture-derived influenza vaccine during the 2008/9 season. The vaccination efficacy was found to be 78.5 per cent (95 per cent CI 60.8-88.2). No serious vaccine-related adverse events were reported, although participants did experience minor and self-limiting side-effects.

The authors concluded that as well as egg-derived vaccines, this vaccine may also be used to help protect patients against seasonal influenza.

Bisphosphonates and the risk of fractures in older women
JAMA 2011; 305: 783-9

While oral bisphosphonates have revolutionised the treatment of osteoporosis, adverse effects, such as jaw osteonecrosis, have been seen.

This case control study looked at whether the adverse bone remodelling effects of bisphosphonates increase the risk of subtrochanteric or femoral shaft fractures.

Each of the cases in this Canadian-based trial had five controls. Osteoporotic fractures were also assessed. A total of 716 women (68 years or older) who had suffered a subtrochanteric or femoral shaft fracture after being commenced on bisphosphonates and 9,723 women with typical osteoporotic fractures were identified.

The authors concluded there was a 2.74 (95 per cent CI 1.25-6.02) times increased risk of subtrochanteric or femoral shaft fracture and 0.76 (95 per cent CI 0.63-0.93) reduced risk of typical osteoporotic fracture after five years of bisphosphonate use.

While these data seem concerning, the authors do state the absolute increased risk of fractures is low.

Gender differences in venous thromboembolism
BMJ 2011; 342: d813

Venous thromboembolism (VTE) continues to pose a significant morbidity and mortality risk. A number of risk factors are mentioned in the literature and in risk scores. This fascinating study looked at the influence of gender on VTE.

The study included 2,554 patients with first VTE. The recurrence rate of unprovoked VTE was 5.3 per cent in women and 9.5 per cent in men at one year and 9.1 per cent and 19.7 per cent in women and men respectively at three years.

Men had a higher risk of recurrent disease (hazard ratio 2.2, 95 per cent CI 1.7-2.8). After discounting the influence of hormones on recurrent disease, the risk remained 1.8 times higher in men.

In contrast to unprovoked VTE, there was no gender difference in recurrent provoked disease, such as secondary to surgery. This study may influence decision-making in prescribing anticoagulants to men with VTE.

Alcohol and cardiovascular disease
BMJ 2011; 342: d671

A number of new risk factors for cardiovascular disease have been identified in recent years, including waist-to-hip ratio and high-sensitivity CRP. Historical data has implied a J-shaped curve with respect to cardiovascular mortality and alcohol consumption.

This meta-analysis of 84 studies looked at the influence of alcohol on cardiovascular disease. The end points included coronary and cerebrovascular incidences and mortality.

Alcohol consumption, relative to non-alcohol drinkers, was shown to significantly reduce the risk of coronary artery disease mortality (relative risk 0.75) and coronary artery disease (relative risk 0.71). The influence of alcohol on stroke and stroke mortality was not significant.

Mortality from coronary artery disease was lowest in people who consumed one to two alcoholic drinks per day. All-cause mortality was also lower in people who drank alcohol compared with non-drinkers.

This data confirms the historical J-shaped mortality curves but, also, may modify the lifestyle advice offered to patients. 

Socioeconomic status and primary cutaneous melanoma
Mayo Clin Proc 2011; 86: 113-9
Malignant melanoma poses a major health concern, particularly given its increasing incidence.

This study of 1,443 patients looked at the influence of social status on Breslow thickness and survival of stage 1 and 2 cutaneous melanoma.

A number of socioeconomic factors influenced Breslow thickness, including social class and living arrangements. The data revealed that in comparison with high socioeconomic status, melanoma-related death was seven times higher in people in lower socioeconomic groups who are living alone and two times higher in those with a low socioeconomic status living with relatives.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, 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


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

  • Search for all of your patients with breast cancer who are being treated with trastuzumab and make sure they are aware of the possible side-effects.
  • Identify patients with low socioeconomic status and develop a wellbeing clinic to ensure their healthcare is maximised.
  • Review the lifestyle advice given to all of your patients with cardiovascular disease.

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