Abstract
Almost half of all women surveyed in a recent JAMA study experienced pain for 2–3 years following breast cancer treatment.
The study, which looked at 3754 breast cancer patients in Denmark, concludes that persistent pain after breast cancer treatment is a significant clinical problem.
The women questioned were aged 18–70 years and had received surgery and adjuvant therapy for breast cancer in the years of 2005 and 2006. They were surveyed in April 2008, an average of 26 months after surgery.
Of the 3252 women who returned the questionnaire, 47% indicated pain after surgery. Of these women, 13% reported chronic pain, whilst 48% described their pain as ‘light’.
Patients also reported sensory disturbances, such as after-sensations, burning or sensory loss.
The study found that age affects the number of women reporting pain after breast cancer surgery. More than half of women under 40 years of age reported pain (approximately 60%) whilst only 40% of those over 40 years of age indicated persistent pain. Women aged 18– 39 years were most likely to experience chronic pain.
Those who had received adjuvant radio-therapy were also more likely to report pain, but chemotherapy treatment had no effect on the questionnaire results.
The likelihood of reporting pain or sensory disturbances was increased if women had undergone axillary lymph node dissection compared with those who had experienced sentinel lymph node dissection.
The pain experienced following breast cancer surgery can be caused by a number of mechanisms, including nerve damage related to surgical technique.
The underarm was the area where dis-comfort was most frequently reported, followed by the arm, breast area and the side of the body.
“Based on the results of our study together with previously reported findings, chronic pain after breast cancer surgery and adjuvant therapy may predominantly be characterized as a neuropathic pain state and probably related to intraoperative injury of the intercostal-brachial nerve. In accordance with these findings, preliminary observations with nerve-sparing techniques may suggest such approaches to reduce the risk of developing a chronic neuropathic pain state,” the authors, Rune Gärtner of the University of Copenhagen, Denmark and colleagues, claim.
“However, such studies need to be larger and more detailed, taking all the different subgroups as studied in our investigation into consideration.”
In an accompanying editorial Christine Laronga and colleagues describe the paper's findings, stating they “should prove helpful in the search for achieving effective relief of pain after breast cancer surgery.”
The editorial suggests that in the future, “Patients at high risk for the development of postsurgical pain syndrome should be identified, should have therapy initiated early, and the effects of early intervention should be assessed. Management requires a multidisciplinary approach that includes evaluation by surgeons, medical oncologists, radiation oncologists, pain management specialists, psychologists and psychiatrists, social workers, and experts in rehabilitation medicine.”
Source: Gärtner R, Maj-Britt J, Meilsen J, Ewertz M, Kroman, N, Kehlet H: Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 302(18), 1985–1992 (2009).
ACOG releases new cervical screening guidelines
New evidence-based guidelines, released in the American College of Obstetricians and Gynecologists' ACOG Practice Bulletin, advise that cervical cytology screening in women should begin at the age of 21 years, with less frequent subsequent rescreening than previously recommended.
Until now, women have been advised to have their first screen either 3 years after becoming sexually active, or upon reaching 21 years, depending upon which comes first. However, it is known that young women are prone to developing cervical abnormalities that appear to be precancerous, but eventually disappear if left alone.
When these growths are discovered by the use of Pap tests, doctors often remove them, in procedures that can injure the cervix and lead to pregnancy-related problems, including premature birth and an increased risk of Caesarean section.
“Adolescents have most of their child-bearing years ahead of them, so it is important to avoid unnecessary procedures that negatively affect the cervix,” explains Alan Waxman, University of New Mexico, USA, who headed the document developed by ACOG's Committee on Practice Bulletins– Gynecology. “Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.”
The ACOG Committee recommends screening every 2 years for women under the age of 30 years. For women over 30 years of age who have had three consecutive negative screenings, screening may occur at 3-year intervals. Women with certain risk factors may require more frequent screenings, such as those infected with HIV, the immuno-suppressed, those with in utero exposure to diethylstilbestrol (DES) and women with a history of cancer or cervical intraepithelial neoplasia. Screening can be discontinued for most women aged between 65 and 70 years, or who have had a hysterectomy for benign indications and no history of high-grade cervical intraepithelial neoplasia.
“The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” adds Waxman. “A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”
Both the New York Times and the Washington Post report that the release of these guidelines within the same week as the US Preventive Services Task Force issued guidelines recommending a reduction in the frequency of mammography scans was a coincidence. Both recognized that the ACOG guidelines would add fuel to the political firestorm over cost-cutting in healthcare reform. Cheryl Iglesia, Chairwoman of a panel involved in developing the Pap smear guidelines, insists that the group updates its advice regularly based on new medical information, and the latest recommendations had been discussed for several years, “long before the Obama health plan came into existence.” She called the timing “an unfortunate perfect storm,” adding that, “There's no political agenda with regard to these recommendations.”
Source: American College of Obstetricians and Gynecologists': www.acog.org
In brief…
Baynosa J, Westphal L, Madrigrano A, Wapnir I: J. Am. Coll. Surg. 209(5), 603–607 (2009).
A recent study found that oocyte retrieval to preserve fertility of female cancer patients caused no significant time delay in starting cancer treatment. The study investigated 82 women under the age of 40 years. Of these women, 19 underwent oocyte retrieval (of whom 84% had never been pregnant) and 63 did not undergo oocyte retrieval (of whom only 25% had never been pregnant). The authors found that there was no significant difference in the time the women waited for surgery. Those who underwent fertility preservation procedures waited an average of 46 days for surgery, whilst those who did not waited approximately 31 days. There was also no significant difference in the time it took to receive chemotherapy. The study concluded that the time required for oocyte retrieval should not be a concern to patients and clinicians when deciding whether to attempt fertility preservation procedures, since it does not significantly prolong the time from diagnosis to the initiation of treatment.
Nabipour I, Kelentarhormonzi M, Larijani B, Assadi M, Sanjdideh Z: Metabolism DOI:10.1016/j.metabol.2009.09.019 (2009) (Epub ahead of print). An Iranian study has found that osteoprotogerin (OPG) levels are significantly higher in women with Type 2 diabetes than in nondiabetic women. The study was the first to look at the relationship between the bone resorption inhibitor, OPG, and metabolic syndrome in postmenopausal women. A total of 382 women took part in the study; of these, 102 had Type 2 diabetes and 280 did not have Type 2 diabetes. Nabipour et al. measured cardiovascular risk factors and OPG levels. The researchers report that the mean serum OPG level was higher in women with Type 2 diabetes than those without diabetes: 4.33 versus 3.84 pmol/l, respectively. OPG levels did not differ significantly between women with or without metabolic syndrome, hypertension, dyslipidemia, glucose intolerance or abdominal obesity. The authors conclude that circulating OPG levels are associated with diabetes in postmenopausal women, independent of cardiovascular risk factors.
Study finds possible link between pre-eclampsia and decreased thyroid function
In a study published in the November issue of BMJ, scientists have found a possible link between pre-eclampsia and decreased thyroid function.
Susan Shurin (NICHD, MD, USA) states: “The findings suggest that the possible development of hypothyroidism is a consideration in patients with a history of pre-eclampsia.”
Pre-eclampsia is a complication associated with pregnancy; women with the condition develop symptoms including high blood pressure and proteinuria. Pre-eclampsia can be potentially life-threatening and risks increase with severity of the condition. The only cure is delivery of the baby.
The cause of pre-eclampsia is uncertain and previous research has shown that increased levels of antiangiogenic factors may lead to symptoms of pre-eclampsia.
Authors of the study state that soluble fms-like tyrosine kinase 1 function by inhibiting VEGF and placental growth factor signaling. Furthermore, they state that recent research has demonstrated the risk of hypothyroidism was elevated in cancer patients who had had prolonged treatment with VEGF inhibitors.
Researchers based their investigation on two studies: the Calcium for Pre-eclampsia Prevention (CPEP) trial cohort and a Norwegian population-based cohort study.
The first study indicated that women with pre-eclampsia had higher levels of thyroid-stimulating hormone near the end of their pregnancies than women with no history of pre-eclampsia. Increased levels of thyroid-stimulating hormone indicate that the thyroid is not functioning properly.
The second study discovered that women with pre-eclampsia during pregnancy were more likely than other women to have “concentrations of thyroid stimulating hormone above the clinical reference range many years after pregnancy”.
Richard Levine (NICHD, MD, USA) states: “Many of these women (tested more than an average of 20 years after first pregnancy) still had reduced thyroid function. This suggests that a history of pre-eclampsia may predispose women to the later development of a reduced thyroid function.”
Source: Levine RJ, Vatten LJ, Horowitz GL et al.: Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study. BMJ DOI: 10.1136/bmj.b4336 (2009) (Epub ahead of print).
WHO reports HIV as the leading cause of death in women, while study suggests large proportion of pregnant women in Uganda avoid HIV testing
HIV is the leading cause of death among adult women in Africa, and the leading cause for reproductive-age women worldwide, according to a recent WHO report.
The report, Women and health: today's evidence tomorrow's agenda, highlights unsafe sex and lack of contraception as important risk factors for death and disability in young women age in low- and middle-income countries.
Together, the three leading causes of death in resource-limited settings, HIV/AIDS, maternal conditions and tuberculosis, account for half of all deaths.
Meanwhile, a recent survey reveals that only 60% of pregnant women in Uganda who underwent medical checks in 2007 were tested for HIV, despite a national policy of ‘opt-out’ HIV screening.
The study surveys the large proportion of women who are actively avoiding HIV screening, which is one of the most important access points for treatment in Africa and critical in preventing mother-to-child transmission of HIV.
“…only 60% of pregnant women in Uganda who underwent medical checks in 2007 were tested for HIV.”
“There should be more studies like this one that look into why people do not have access to or refuse to accept interventions that could prevent HIV infection among their offspring”, contends Anne Buve from the Institute of Tropical Medicine, Belgium.
A clinical trial in South Africa proved that adding zidovudine and lamivudine to standard nevripine monotherapy is effectve at reducing HIV resistance in mothers and newborns.
Dara Lehman (Fred Hutchinson Cancer Research Center, WA, USA) and colleagues contributed a perspective article to appear with the report, which is published in PLoS Medicine. They argue that if the study has not missed resistance, this new approach may “strike the right balance of a feasible regimen that minimizes resistance” in resource-poor settings where combination antiretroviral therapy may not be available for longer term use in pregnancy.
Source: Larsson EC, Waiswa P, Thorson A et al.: Low uptake of HIV testing during antenatal care: a population-based study from eastern Uganda. AIDS 23(14), 1924–1926 (2009).
Strength-building exercises may help to relieve neck and shoulder pain of female office workers
A Danish study has found that five strength-building exercises can help to alleviate the pain of repetitive strain injury caused by office work.
In a previous study, more than half of female office workers reported frequent neck pain. This pain is mostly caused by trapezius myalgia – a tightness and tenderness in the muscle which runs down the back of the neck.
Lars Andersen and colleagues looked at the trapezium muscle function and how it improves with different types of exercise. Five strength-specific exercises – the one-arm row, shoulder abduction, shoulder elevation, reverse fly and upright row – were found to be the most beneficial at relieving pain.
The 10-week study involved 42 women office workers who regularly used a computer and carried out other repetitive tasks at work. The participants were asked to carry out shoulder abductions, contracting their shoulder muscles as hard and as quickly as possible. The researchers took muscle biopsies and analyzed the muscle strength and activation.
The women were then divided into three different groups. Two of these groups performed contrasting types of physical exercise whilst the third acted as a control group.
One group were asked to carry out specific strength training. They each did three sets of three out of the five types of exercise, three times a week for the study duration. The second group spent 20 min cycling on an exercise bike three-times a week throughout the study. The control group did no physical training at all.
After the training period the participants performed more shoulder abductions and the muscle fibers were studied again. Maximal muscle strength increased 18–29%, whilst rapid muscle strength was found to increase by as much as 61–115%.
Strength training reduced pain levels by more than 50%. It was also found to improve rapid force capacity and increasing muscle power. It is thought the training enhanced the body's ability to rapidly activate the neck musclea due to improved nerve signaling.
Source: Andersen L, Andersen J, Suetta C, Kjaer M, Sogaard K, Sogaard G: Effect of contrasting physical exercise interventions on rapid force capacity of chronically painful muscles. J. Appl. Physiol. 107, 1414–1419 (2009).
Meta-analysis suggests metformin does not increase risk of miscarriage with polycystic ovary syndrome
A recent meta-analysis published in the journal Fertility and Sterility, which is the official journal of the American Society of Reproductive Medicine, has reviewed data from several randomized, controlled studies. The data presented support the conclusion that metformin does not alter the risk of miscarriage when taken pregestationally, thereby affirming it as a valuable treatment for pregnant women suffering with polycystic ovary syndrome (PCOS).
Polycystic ovary syndrome develops when production of androgens becomes elevated. It has been linked to an increased risk of miscarriage and spontaneous abortion. The leading treatment for PCOS is the antidiabetic drug, metformin.
Until now, data on the safety of metformin in pregnant women has been limited. This systematic review and metaanalysis examined data from a selection of clinical trials into metformin use in pregnant women published up until June 2008. The analysis investigated abortion rate, defined as involuntary loss of pregnancy before 20 weeks' gestation.
“Until now, data on the safety of metformin in pregnant women has been limited.”
Out of 98 relevant potential studies, 17 (n = 566) fulfilled the eligibility criteria. No significant correlation was observed between metformin effects and miscarriage rate in the cross-examined patient records (odds ratio: 0.89; 95% CI: 0.65-1.21; p = 0.452). The study went on to investigate whether any relationships existed between subgroups within the pregnant women group, to no avail.
The results of this study suggest that the risk of abortion is no higher with metformin treatment. Two Phase III trials are currently ongoing, and these should provide more data on the risks involved in taking this drug during pregnancy.
Source: Palomba S, Falbo A, Orio F Jr, Zullo F: Effect of preconceptional metformin on abortion risk in polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials. Fertil Steril. 92(5), 1646–1648 (2009).