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WOMEN AT HIGH RISK TO BREAST CANCER Developments in Oncology Volume 57 The titles published in this series are listed at the end of this volume. WOMEN AT HIGH RISK TO BREAST CANCER edited by BASIL A. STOLL Honorary Consultant Physician to Oncology Department, St. Thomas' Hospital and to Joint Breast Clinic, Royal Free Hospital, London, UK KLUWER ACADEMIC PUBLISHERS DORDRECHT / BOSTON / LONDON Library of Congress Cataloging-in-Publication Data Women at high risk to breast cancer. (Developments in oncology) Includes index. 1. Breast-Cancer-Etiology. 2. Breast-Cancer- Prevention. 3. Breast - Cancer - Epidemiology. I. Stoll, Basil A. (Basil Arnold) II. Series. [DNLM: 1. Breast Neoplasms-familial & genetic. 2. Breast Neoplasms~prevention & control. 3. Risk. WI DE998N / WP 870 W872] RC280.B8W66 1988 616.99'449071 88-26610 ISBN -13: 978-94-010-7091-1 e-ISBN -13 :978-94-009-1327-1 DOl: 10.1007/978-94-009-1327-1 Published by Kluwer"Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. Kluwer Academic Publishers incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press. Sold and distributed in the U.S.A. and Canada by Kluwer Academic Publishers, 101 Philip Drive, Norwell, MA 02061, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. Printed on acid-free paper All Rights Reserved © 1989 Kluwer Academic Publishers Softcover reprint of the hardcover 1st edition 1989 Reprinted 1991 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. Contents Preface VII List of Contributors IX Part One Who is at High Risk? Chapter 1 In Search of Guidelines 3 Basil A Stoll Chapter 2 Effect of Race, Geography and Social Class 15 Curtis Mettlin and Elinor R. Schoenfeld Chapter 3 Familial and Genetic Factors - New Evidence 27 Henry T. Lynch, Joseph N. Marcus, Patrice Watson and Jane F. Lynch Chapter 4 Hormonal and Reproductive Factors -. New Evidence 41 M. Jawed Iqbal and W. Taylor Chapter 5 Relationship to Previous Breast Disease 47 William D. Dupont and David L. Page Chapter 6 Relationship to Diet and Body Size 57 Stephanie J. London and Walter C. Willett Part Two An Individualised Approach to Control Chapter 7 Calculating a Woman's Degree of Risk 75 AB. Miller and M.T. Schechter Chapter 8 Can Oral Contraceptives Reduce Breast Cancer Risk? 85 Basil A Stoll Chapter 9 Clinical Cost-Benefit of Screening Programmes 95 Ruth Ellman Chapter 10 Prospects for Breast Cancer Prevention 107 Basil A Stoll Chapter 11 Counselling Women at High Risk 121 J oem Beckmann Index 129 Preface A reprint of the 1989 edition of this book has been made necessary by continuing demand after rapid exhaustion of the first printing. In the two years since its appearance, there has been relatively little expansion of knowledge on this topic, and its massive accumulation of references still remains an authoritative guide in the difficult task of developing a national breast cancer prevention model. At the same time, its thesis has been sharpened by the publication of a companion volume Approaches to Breast Cancer Prevention (Kluwer, 1991) similarly edited byrne. Breast cancer is on the increase throughout the Western world where it is a major source of anxiety among women. The disease is also becoming more frequent in Asian and South American countries where once it was relatively uncommon. Multiple factors are suspected of promoting the disease and the increasing risk is attributed to recent changes in life-style and diet. This book is intended to provide an authoritative and balanced survey of the latest research into the genetic, familial, hormonal, reproductive, nutritional, social and geographic factors known to be associated with an increased predisposition to the disease. Because of the overwhelming evidence that breast qmcer has already disseminated by the time the tumour is large enough to be felt, there is increasing pressure for earlier diagnosis. There are reports that well organised mass screening programmes can lead to improved survival rates and there are pressures for population screening. If such programmes are to be pursued they must be highly efficient, and associated with intensive health education if they are to avoid creating undue anxiety among women who are invited to participate. Although all women are potentially at risk for breast cancer, we need to develop a risk index to recognise women with a high degree of risk who need intensive monitoring. Such women will require skilful counselling. Although recent research sug- gests that hormonal manipulation or dietary change may delay progression of the disease to the malignant phase, careful planning is required if women are to be di- rected into suitable clinical trials of preventive methods. This book should be useful not only for clinicians and epidemiologists but also for health educators, counsellors, nurses and psychosocial professionals. Being inter- disciplinary, it has been written with a fully practical approach and quotes only the most recent and seminal references'. I must express my thanks to the contributors who rose to this challenge. In order to make each chapter complete in itself, it was found necessary to permit a small degree of overlap with others. BASIL A. STOLL London 1991 List of Contributors J oem Beckman, PhD Assistant Professor, Department of Psychology, Universities of Odense and Aarhus; Chief Psychologist, Odense University Hospital, Denmark William D. Dupont, PhD Associate Professor of Biostatistics, Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA Ruth Ellman, MRCP, MFCM Deputy Director, DHSS Screening Evaluation Unit; Senior Lecturer in Epidemiology, Institute of Cancer Research, London, UK M. Jawed Iqbal, PhD Senior Lecturer, Tumour Biology Unit, Rayne Institute, King's College School of Medicine, London, UK Stephanie J. London, MD Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA Henry T. Lynch, MD Professor and Chairman, Department of Preventive Medicine and Public Health, Creighton University School of Medicine and The Hereditary Cancer Consultation Center, Omaha, Nebraska, USA Jane F. Lynch, BSN Department of Preventive Medicine and Public Health, Creighton University School of Medicine and The Hereditary Cancer Consultation Center, Omaha, Nebraska, USA Joseph N. Marcus, MD Department of Pathology, Creighton University School of Medicine and The Hereditary Cancer Consultation Center, Omaha, Nebraska, USA Curtis Mettlin, PhD Director, Cancer Control and Epidemiology, Roswell Park Memorial Institute, Buffalo, New York, USA AB. Miller, MB, FRCP(C), FRCP Professor, Department of Preventive Medicine and Biostatistics; Director, National Breast Screening Study, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada David L. Page, MD Professor of Pathology and Associate Professor of Epidemiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA M.T. Schechter, MD, MSc, PhD Assistant Professor and National Health Scholar, Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada Elinor R. Schoenfeld, PhD Department of Cancer Control and Epidemiology, Roswell Park Memorial Institute, Buffalo, New York, USA Basil A Stoll, FRCR, FFR Consulting Physician, Department of Oncology, St. Thomas' Hospital, and to Joint Breast Clinic, Royal Free Hospital, London, UK W. Taylor, PhD, MIBiol Reader in Steroid Biochemistry, Department of Physiological Sciences, The Medical School, University of Newcastle upori Tyne, UK Patrice Watson, PhD Department of Preventive Medicine and Public Health, Creighton University School of Medicine and The Hereditary Cancer Consultation Center, Omaha, Nebraska, USA Walter C. Willett, MD, Dr.PH Professor of Nutritional Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA PART ONE WHO IS AT HIGH RISK? 3 Chapter 1 In Search of Guidelines BASILA. STOLL The expectations of the 1950s have not been fulfilled and the number of women dying from breast cancer has increased over the past 30 years both in the UK and the USA [1, 2]. It appears that earlier diagnosis and claims of more effective treatments have not been reflected by improvement in the 5 year survival rates of treated cases over the past 15 years [3]. How then are we going to reduce deaths from breast cancer in the Western world? While we may develop more effective agents for eradicating the tumour once it has disseminated, an alternative is to develop more effective methods of detecting the primary tumour before it has disseminated or, better still, of ar- resting it at an even earlier stage. This book is concerned with the latter goals. It examines the current guidelines on: (a) how to recognise those individuals who are most at risk to the development of breast cancer; (b) how to screen and monitor these women in order to detect the earl- iest evidence of cancer; and (c) how the progression of the primary lesion may be ar- rested in an attempt to prevent the cancer from manifesting clinically. The following chapters set out the current guidelines for each procedure against the background of the latest scientific evidence. But to select a monitoring or protection programme for a women who is thought to be at high risk to breast cancer involves more than a consideration of guidelines. Because of the uncertainties, choices must involve value judgements both by the women and by the physician. For each individual women, the possible benefit must be weighed against the trouble, expense and anxiety attached to the procedure, and if the facilities are provided by the state, they must be proved worthwhile [4]. This chapter provides an introductory perspective and also examines the cost -benefit ratio of monitoring and protection programmes, not only from the point of view of the individual but also that of society in general.