Pediatrics. 2010;125:1094-1100.
Clinical Context
IPV is defined as a pattern of coercive behaviors that might include repeated battering and injury, psychological abuse, sexual abuse, progressive social isolation, deprivation, and intimidation perpetuated by someone with a prior or current intimate relationship with the victim, according to the Centers for Disease Control and Prevention 1999 statement.
According to the Bureau of Justice Statistics, 2004 data for the United States showed that 1544 deaths were attributed to IPV, of whom 75% were women. According to the Family Violence Prevention Fund, IPV occurs in heterosexual, lesbian, gay, bisexual, and transgender relationships.
This report from the AAP addresses the effects of IPV exposure on children and recommendations for assessment and response to IPV.
Study Highlights
Child victims of IPV
The most vulnerable groups are girls and women aged 16 to 24 years: 1 in 5 high school students and almost half of college students report dating violence.
IPV occurs in 3% to 19% of pregnant women and is linked with effects on the offspring: preterm labor, low birth weight, intracranial injury, neonatal death, and increased healthcare use and costs.
Co-occurrence of child abuse and IPV has been reported in 30% to 60% of families.
IPV is the leading precursor of child abuse.
Younger children can be collateral victims of IPV if they are being held in a caregiver's arms during battering. Older children who intervene during the incident can also be collateral victims.
Childhood exposure to IPV
Adults with childhood exposure to IPV vs no IPV exposure are 6 times more likely to be emotionally abused, 4.8 times more likely to be physically abused, and 2.6 times more likely to be sexually abused.
IPV exposure and other adverse childhood experiences are linked with smoking, obesity, physical inactivity, depression, and suicide attempts.
Children of abused caregivers have an increased risk for adverse behavioral effects: anxiety, depression, withdrawal, somatic symptoms, attention issues, aggressive behavior, rule-breaking behavior, social functioning problems, difficulty with peer relationships, cruelty to others, poor academic performance, and symptoms of posttraumatic stress disorder.
Adolescents might have the same violence pattern in their relationships with others, and some children might abuse others.
Requirements for reporting IPV to child protective services differ by state based on the child's age, relationship of the child to the perpetrator, and proximity of the child to the violent incident.
Having the caregiver also file a report might be helpful.
Assessment for IPV
Early and repeated questions to identify IPV as part of anticipatory guidance and awareness of risk factors for IPV are recommended.
Universal screening vs a case-finding approach results in greater identification of abuse, but insufficient evidence exists to show difference in morbidity or mortality rates of the victim.
Usually there are no indications of abuse.
Most victims will obtain care for their children instead of for themselves.
Possible indications of abuse include depression, anxiety, not keeping medical appointments, not answering questions about discipline, and frequent visits for complaints not consistent with the medical evaluation.
Self-administered assessments vs verbal assessments are preferred by female victims and might overcome barriers to IPV detection.
Questioning for suspected IPV should be conducted in a sympathetic and sensitive manner in a private setting without the presence of any children, family, friends, and suspected abuser.
Documentation is appropriate with the awareness that the abuser could have access to the records.
A generic statement that IPV assessment occurred and resources offered per protocol is suggested.
Referrals
A community response can be coordinated by pediatricians, obstetricians, prenatal clinic and hospital nurses, social workers, public health administrators, and early childhood education programs.
Resources include the Family Violence Prevention Fund, the American Medical Association, state medical associations, and the AAP.
Knowledge of state laws for reporting partner violence and children exposed to IPV is essential.
Risk for injury or death might increase when the caregiver discloses abuse and tries to leave the abuser.
Firearms should be removed from the home.
Pediatricians should be aware of "stages of change," substance abuse issues, and the role of ethnic and cultural attitudes on disclosure.
Counseling for children should focus on understanding and avoiding violence.
Clinical Implications
IPV of pregnant women or in the household increases the risk for child abuse and short-term and long-term medical, behavioral, and mental health problems in the children.
Recommendations to assess IPV exposure in children include early and repeated questioning as part of anticipatory guidance, self-administered survey with appropriate verbal follow-up, sympathetic and sensitive manner, private setting, and appropriate documentation.
Monday, May 17, 2010
Friday, May 7, 2010
High-Dose Simvastatin Associated With Increased Risk for Myopathy, FDA Warns
From Medscape Medical News > Medscape Alerts
Emma Hitt, PhD
March 19, 2010 — Simvastatin (Zocor, Merck/Schering-Plough Pharmaceuticals), used at the highest approved dose of 80 mg, is associated with an increased risk for myopathy, including rhabdomyolysis, according to the US Food and Drug Administration (FDA).
The alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, was based on a review of data from the large clinical Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) trial. Other sources, including data from clinical trials, observational studies, and adverse event reports, as well as data on prescription use of simvastatin, are under review.
The SEARCH trial evaluated the number of major cardiovascular events (heart attack, revascularization, and cardiovascular death) in 6031 patients with a history of myocardial infarction taking 80 mg of simvastatin and compared that number with that from 6033 patients taking 20 mg of simvastatin. The study included 6.7 years of follow-up.
According to preliminary results, more patients in the simvastatin 80-mg group developed myopathy compared with patients in the simvastatin 20-mg group (52 cases [0.9%] vs 1 case [0.02%]). In addition, 11 patients in the simvastatin 80-mg group (0.02%) developed rhabdomyolysis compared with no patients in the simvastatin 20-mg group.
"Review of simvastatin is part of an ongoing FDA effort to evaluate the risk of statin-associated muscle injury and to provide that information to the public as it becomes available," noted Eric Colman, MD, deputy director of the FDA's Division of Metabolism and Endocrinology Products, in a news release.
According to the FDA, healthcare professionals should consider the following when prescribing simvastatin:
Rhabdomyolysis is a rare class effect associated with statins
The increased risk for muscle injury with the 80-mg dose of simvastatin is compared with the use of lower doses of simvastatin and possibly other statin drugs
Whether simvastatin is clinically appropriate
Discuss with patients the benefits and risks of simvastatin
Potential drug–drug interactions can occur with simvastatin
Last month, simvastatin was one of 27 drugs or drug categories that was included on an FDA watch list, based on potential signs of serious risks or new safety information identified in the agency's Adverse Event Reporting System last year.
Risk for myopathy may be linked to genetic heterogeneity in statin users. A study published in the October 20, 2009, issue of the Journal of American College of Cardiology found that carriers of the reduced-function single nucleotide polymorphism of the SLCO1B1 gene were at increased risk of developing mild statin-induced adverse effects, including myopathy and myalgia. The risk for adverse events was greatest among those treated with simvastatin, but minimal in those receiving pravastatin.
More information about simvastatin and myopathy risk is available on the FDA's Web site.
Previous FDA safety communications on the increased risk for muscle injury with simvastatin in patients who concurrently take other medications is also available on the FDA's Web site.
Simvastatin is sold as a single agent and also in combination with ezetimibe (Vytorin, Merck/Schering-Plough Pharmaceuticals) and in combination with niacin (Simcor, Abbott Laboratories).
Rhabdomyolysis is the most serious form of myopathy and is associated with severe renal toxicity and failure, and occasional fatalities.
Adverse events related to simvastatin should be communicated to MedWatch by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, Maryland 20852-9787.
Emma Hitt, PhD
March 19, 2010 — Simvastatin (Zocor, Merck/Schering-Plough Pharmaceuticals), used at the highest approved dose of 80 mg, is associated with an increased risk for myopathy, including rhabdomyolysis, according to the US Food and Drug Administration (FDA).
The alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, was based on a review of data from the large clinical Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) trial. Other sources, including data from clinical trials, observational studies, and adverse event reports, as well as data on prescription use of simvastatin, are under review.
The SEARCH trial evaluated the number of major cardiovascular events (heart attack, revascularization, and cardiovascular death) in 6031 patients with a history of myocardial infarction taking 80 mg of simvastatin and compared that number with that from 6033 patients taking 20 mg of simvastatin. The study included 6.7 years of follow-up.
According to preliminary results, more patients in the simvastatin 80-mg group developed myopathy compared with patients in the simvastatin 20-mg group (52 cases [0.9%] vs 1 case [0.02%]). In addition, 11 patients in the simvastatin 80-mg group (0.02%) developed rhabdomyolysis compared with no patients in the simvastatin 20-mg group.
"Review of simvastatin is part of an ongoing FDA effort to evaluate the risk of statin-associated muscle injury and to provide that information to the public as it becomes available," noted Eric Colman, MD, deputy director of the FDA's Division of Metabolism and Endocrinology Products, in a news release.
According to the FDA, healthcare professionals should consider the following when prescribing simvastatin:
Rhabdomyolysis is a rare class effect associated with statins
The increased risk for muscle injury with the 80-mg dose of simvastatin is compared with the use of lower doses of simvastatin and possibly other statin drugs
Whether simvastatin is clinically appropriate
Discuss with patients the benefits and risks of simvastatin
Potential drug–drug interactions can occur with simvastatin
Last month, simvastatin was one of 27 drugs or drug categories that was included on an FDA watch list, based on potential signs of serious risks or new safety information identified in the agency's Adverse Event Reporting System last year.
Risk for myopathy may be linked to genetic heterogeneity in statin users. A study published in the October 20, 2009, issue of the Journal of American College of Cardiology found that carriers of the reduced-function single nucleotide polymorphism of the SLCO1B1 gene were at increased risk of developing mild statin-induced adverse effects, including myopathy and myalgia. The risk for adverse events was greatest among those treated with simvastatin, but minimal in those receiving pravastatin.
More information about simvastatin and myopathy risk is available on the FDA's Web site.
Previous FDA safety communications on the increased risk for muscle injury with simvastatin in patients who concurrently take other medications is also available on the FDA's Web site.
Simvastatin is sold as a single agent and also in combination with ezetimibe (Vytorin, Merck/Schering-Plough Pharmaceuticals) and in combination with niacin (Simcor, Abbott Laboratories).
Rhabdomyolysis is the most serious form of myopathy and is associated with severe renal toxicity and failure, and occasional fatalities.
Adverse events related to simvastatin should be communicated to MedWatch by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, Maryland 20852-9787.
Hepatocellular Carcinoma Continues to Increase in US
From Medscape Medical News
Zosia Chustecka
May 7, 2010 — The incidence of hepatocellular carcinoma increased significantly in the United States between 2001 and 2006, according to the latest population-based estimates reported by the Center for Diseases Control and Prevention (CDC).
The increase is reported in the May 7 issue of Morbidity and Mortality Weekly Report (MMWR). The report coincides with Hepatitis Awareness Month in the United States, which is in its fifteenth year.
The MMWR report notes that the average annual incidence rate of hepatocellular carcinoma increased significantly, from 2.7 per 100,000 people in 2001 to 3.2 per 100,000 people in 2006, with an average annual percentage change in incidence rate of 3.5%.
The findings indicate continued increases in hepatocellular carcinoma incidence, write the authors, adding that improvements in viral hepatitis services are needed to reverse this trend.
This call for improved action on hepatitis, a leading cause of hepatocellular cancer, echoes the detailed recommendations for action laid out recently in a report from the Institute of Medicine (IOM), as reported by Medscape Oncology.
That IOM report recommended a national strategy for the prevention and control of hepatitis B and C virus infection, pointing out that it disproportionately affects minorities.
The latest figures from the CDC show persistent racial/ethnic disparities, the authors add. The incidence of hepatocellular carcinoma was highest among Asians/Pacific Islanders (7.8 per 100,000 people), followed by blacks (4.2), American Indians/Alaska Natives (3.2), and whites (2.6). The incidence among Hispanics (5.7 per 100,000 people) was nearly double that for non-Hispanics (2.8).
Most Cases Preventable
Hepatocellular carcinoma is the ninth leading cause of cancer death in the United States (and the third leading cause worldwide), the CDC authors note. But most cases could be prevented, they point out.
Chronic hepatitis B and C virus infections account for 78% of all hepatocellular cancer in the United States, and prevention of virus transmission and progression of chronic viral disease has been shown to decrease the incidence of this cancer, they point out.
Improvements in viral hepatitis services and public health surveillance are needed, the authors suggest. These should include full implementation of vaccine-based strategies to eliminate hepatitis B, and screening and care referrals for individuals chronically infected with hepatitis B or C. Most Americans who already have a chronic viral hepatitis are unaware of their infection, the authors point out.
The subject of hepatitis leading to liver cancer — and how it can be prevented — was discussed in some detail when the IOM report was released in January 2010, when detailed plans for action — many involving the CDC — were outlined.
At that time, Andrew Muir, MD, clinical director of hepatology at Duke University School of Medicine in Durham, North Carolina, said that the IOM report highlights "many important issues we see in our clinics."
"Too many patients are unaware they have viral hepatitis, and this makes it difficult to control the spread of these infections and provide appropriate treatment to those infected. Too many patients present to our clinics in the late stages of cirrhosis or with advanced liver cancer. If we could identify these patients sooner, we [would be able to use the effective treatment strategies we have] to help them avoid these devastating complications," Dr. Muir said.
"We need coordinated surveillance and educational programs to aid us in these efforts," he concluded.
MMWR. 2010;59(17);517-520.
Zosia Chustecka
May 7, 2010 — The incidence of hepatocellular carcinoma increased significantly in the United States between 2001 and 2006, according to the latest population-based estimates reported by the Center for Diseases Control and Prevention (CDC).
The increase is reported in the May 7 issue of Morbidity and Mortality Weekly Report (MMWR). The report coincides with Hepatitis Awareness Month in the United States, which is in its fifteenth year.
The MMWR report notes that the average annual incidence rate of hepatocellular carcinoma increased significantly, from 2.7 per 100,000 people in 2001 to 3.2 per 100,000 people in 2006, with an average annual percentage change in incidence rate of 3.5%.
The findings indicate continued increases in hepatocellular carcinoma incidence, write the authors, adding that improvements in viral hepatitis services are needed to reverse this trend.
This call for improved action on hepatitis, a leading cause of hepatocellular cancer, echoes the detailed recommendations for action laid out recently in a report from the Institute of Medicine (IOM), as reported by Medscape Oncology.
That IOM report recommended a national strategy for the prevention and control of hepatitis B and C virus infection, pointing out that it disproportionately affects minorities.
The latest figures from the CDC show persistent racial/ethnic disparities, the authors add. The incidence of hepatocellular carcinoma was highest among Asians/Pacific Islanders (7.8 per 100,000 people), followed by blacks (4.2), American Indians/Alaska Natives (3.2), and whites (2.6). The incidence among Hispanics (5.7 per 100,000 people) was nearly double that for non-Hispanics (2.8).
Most Cases Preventable
Hepatocellular carcinoma is the ninth leading cause of cancer death in the United States (and the third leading cause worldwide), the CDC authors note. But most cases could be prevented, they point out.
Chronic hepatitis B and C virus infections account for 78% of all hepatocellular cancer in the United States, and prevention of virus transmission and progression of chronic viral disease has been shown to decrease the incidence of this cancer, they point out.
Improvements in viral hepatitis services and public health surveillance are needed, the authors suggest. These should include full implementation of vaccine-based strategies to eliminate hepatitis B, and screening and care referrals for individuals chronically infected with hepatitis B or C. Most Americans who already have a chronic viral hepatitis are unaware of their infection, the authors point out.
The subject of hepatitis leading to liver cancer — and how it can be prevented — was discussed in some detail when the IOM report was released in January 2010, when detailed plans for action — many involving the CDC — were outlined.
At that time, Andrew Muir, MD, clinical director of hepatology at Duke University School of Medicine in Durham, North Carolina, said that the IOM report highlights "many important issues we see in our clinics."
"Too many patients are unaware they have viral hepatitis, and this makes it difficult to control the spread of these infections and provide appropriate treatment to those infected. Too many patients present to our clinics in the late stages of cirrhosis or with advanced liver cancer. If we could identify these patients sooner, we [would be able to use the effective treatment strategies we have] to help them avoid these devastating complications," Dr. Muir said.
"We need coordinated surveillance and educational programs to aid us in these efforts," he concluded.
MMWR. 2010;59(17);517-520.
Thursday, May 6, 2010
Screening Mammograms May Have Low Accuracy in Younger Women
From Medscape Medical News
Laurie Barclay, MD
May 5, 2010 — Screening mammograms in younger women have low accuracy and detect few cancers, according to the results of a study published online May 3 in the Journal of the National Cancer Institute.
"Few data have been published on mammography performance in women who are younger than 40 years," write Bonnie C. Yankaskas, PhD, from the University of North Carolina at Chapel Hill, and colleagues. "We pooled data from six mammography registries across the United States from the Breast Cancer Surveillance Consortium."
The study cohort consisted of 117,738 women who had their first screening or diagnostic mammogram during 1995 to 2005, when they were 18 to 39 years of age. Follow-up for 1 year allowed the investigators to measure the accuracy of mammographic evaluation, recall rate for screening examinations, and sensitivity, specificity, positive predictive value, and cancer detection rate for all mammograms.
No cancers were detected in 637 screening mammograms performed in women 18 to 24 years of age. The largest number of screening mammograms in this study was in women aged 35 to 39 years (n = 73,335). In this group, the recall rate was 12.7% (95% confidence interval [CI], 12.4% - 12.9%), sensitivity was 76.1% (95% CI, 69.2% - 82.6%), specificity was 87.5% (95% CI, 87.2% - 87.7%), positive predictive value was 1.3% (95% CI, 1.1% - 1.5%), and cancer detection rate was 1.6 cancers per 1000 mammograms (95% CI, 1.3 - 1.9 cancers per 1000 mammograms).
Of the 86,871 women screened, 67,468 (77.7%) reported no family history of breast cancer. Across all age groups, the age-adjusted rates for diagnostic mammograms were sensitivity of 85.7% (95% CI, 82.7% - 88.7%), specificity of 88.8% (95% CI, 88.4% - 89.1%), positive predictive value of 14.6% (95% CI, 13.3% - 15.8%), and cancer detection rate of 14.3 cancers per 1000 mammograms (95% CI, 13.0 - 15.7 cancers per 1000 mammograms). Except for specificity, diagnostic measures of mammography performance were better in women who had a breast lump.
"Younger women have very low breast cancer rates but after mammography experience high recall rates, high rates of additional imaging, and low cancer detection rates," the study authors write. "We found no cancers in women younger than 25 years and poor performance for the large group of women aged 35-39 years. In a theoretical population of 10 000 women aged 35-39 years, 1266 women who are screened will receive further workup, with 16 cancers detected and 1250 women receiving a false-positive result."
Limitations of this study include a substantial amount of missing data and the inability to collect a complete family pedigree or BRCA1 or BRCA2 status, which would help identify women at very high risk.
The journal editors note that screening young women is not without potential harms, which may include additional radiation exposure, anxiety because of false-positive findings, and costs of additional imaging.
In an accompanying editorial, Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment, Denver, calls this a "landmark descriptive study." He also points out that even women who had a family history of breast cancer had the same detection and false-positive rates as women without known family history, casting doubt on the recommendation of some health groups for early screening of women with a positive family history.
"[W]e must continue to strive for better tests and better treatments," Dr. Calonge writes. "We need clinical trial data on the screening utility of any modality or strategy for high-risk women in this age group and better data on the use of early or other enhanced screening for women with high-risk genetic mutations. Furthermore, we should not be satisfied with better detection rates alone: We need evidence that early detection of these cancers translates to improvements in important health outcomes. "
The National Cancer Institute–funded Breast Cancer Surveillance Consortium supported this study. Financial relationships for the authors were not reported in the study.
J Natl Cancer Inst. Published online May 3, 2010.
Laurie Barclay, MD
May 5, 2010 — Screening mammograms in younger women have low accuracy and detect few cancers, according to the results of a study published online May 3 in the Journal of the National Cancer Institute.
"Few data have been published on mammography performance in women who are younger than 40 years," write Bonnie C. Yankaskas, PhD, from the University of North Carolina at Chapel Hill, and colleagues. "We pooled data from six mammography registries across the United States from the Breast Cancer Surveillance Consortium."
The study cohort consisted of 117,738 women who had their first screening or diagnostic mammogram during 1995 to 2005, when they were 18 to 39 years of age. Follow-up for 1 year allowed the investigators to measure the accuracy of mammographic evaluation, recall rate for screening examinations, and sensitivity, specificity, positive predictive value, and cancer detection rate for all mammograms.
No cancers were detected in 637 screening mammograms performed in women 18 to 24 years of age. The largest number of screening mammograms in this study was in women aged 35 to 39 years (n = 73,335). In this group, the recall rate was 12.7% (95% confidence interval [CI], 12.4% - 12.9%), sensitivity was 76.1% (95% CI, 69.2% - 82.6%), specificity was 87.5% (95% CI, 87.2% - 87.7%), positive predictive value was 1.3% (95% CI, 1.1% - 1.5%), and cancer detection rate was 1.6 cancers per 1000 mammograms (95% CI, 1.3 - 1.9 cancers per 1000 mammograms).
Of the 86,871 women screened, 67,468 (77.7%) reported no family history of breast cancer. Across all age groups, the age-adjusted rates for diagnostic mammograms were sensitivity of 85.7% (95% CI, 82.7% - 88.7%), specificity of 88.8% (95% CI, 88.4% - 89.1%), positive predictive value of 14.6% (95% CI, 13.3% - 15.8%), and cancer detection rate of 14.3 cancers per 1000 mammograms (95% CI, 13.0 - 15.7 cancers per 1000 mammograms). Except for specificity, diagnostic measures of mammography performance were better in women who had a breast lump.
"Younger women have very low breast cancer rates but after mammography experience high recall rates, high rates of additional imaging, and low cancer detection rates," the study authors write. "We found no cancers in women younger than 25 years and poor performance for the large group of women aged 35-39 years. In a theoretical population of 10 000 women aged 35-39 years, 1266 women who are screened will receive further workup, with 16 cancers detected and 1250 women receiving a false-positive result."
Limitations of this study include a substantial amount of missing data and the inability to collect a complete family pedigree or BRCA1 or BRCA2 status, which would help identify women at very high risk.
The journal editors note that screening young women is not without potential harms, which may include additional radiation exposure, anxiety because of false-positive findings, and costs of additional imaging.
In an accompanying editorial, Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment, Denver, calls this a "landmark descriptive study." He also points out that even women who had a family history of breast cancer had the same detection and false-positive rates as women without known family history, casting doubt on the recommendation of some health groups for early screening of women with a positive family history.
"[W]e must continue to strive for better tests and better treatments," Dr. Calonge writes. "We need clinical trial data on the screening utility of any modality or strategy for high-risk women in this age group and better data on the use of early or other enhanced screening for women with high-risk genetic mutations. Furthermore, we should not be satisfied with better detection rates alone: We need evidence that early detection of these cancers translates to improvements in important health outcomes. "
The National Cancer Institute–funded Breast Cancer Surveillance Consortium supported this study. Financial relationships for the authors were not reported in the study.
J Natl Cancer Inst. Published online May 3, 2010.
Saturday, April 24, 2010
Most Stroke Patients Do Not Recognize Symptoms, Delay Seeking Treatment
From Medscape Medical News
Pauline Anderson
April 22, 2010 — About 70% of patients who suffer a minor stroke or transient ischemic attack (TIA) do not correctly recognize their symptoms, and 30% delay seeking medical attention for more than 24 hours, a new study concludes.
Delays in seeking treatment were unrelated to age, sex, social class, or educational level, the study also found.
These results suggest that public awareness campaigns should emphasize the importance of seeking urgent medical attention, as well as recognizing symptoms, and that targeting such campaigns at specific groups such as the socially disadvantaged is unlikely to have significant benefit, said lead author Arvind Chandratheva, MRCP, a clinical research fellow in the Stroke Prevention Research Unit at the University of Oxford, United Kingdom.
"What you need is a national media campaign that highlights that any symptoms that are sudden onset, particularly with face or arm weakness and speech disturbance, should necessitate urgent medical attention," Dr. Chandratheva said.
The study results were published online April 15 in the journal Stroke: Journal of the American Heart Association.
Seeking Prompt Treatment
The researchers used the Oxford Vascular Study, a population-based study of all vascular events, including stroke and TIA, in about 91,000 people registered with 63 general practitioners in Oxfordshire in the United Kingdom. The current analysis includes consecutive cases of incident or recurrent TIA and minor stroke from April 2002 to April 2007.
Researchers recorded baseline characteristics of all patients and collected information on demographics, risk factors, social class, and educational level. Standard definitions were used to classify cases as TIA or stroke. The authors decided to study TIA separately from minor stroke, as it appears to behave differently; few previous studies have analyzed TIA separately.
The authors determined the delay from symptom onset to first seeking medical attention in relation to whether patients correctly identified the cause of their symptoms, demographic data, risk factors, symptomatology, and the day on which the TIA occurred. They performed a separate analysis on patients who did not seek medical attention for their initial symptoms and presented only after recurrent stroke.
Of the first 1000 consecutive patients, 459 presented after TIA and 541 after minor stroke. Of these, complete data were available on 945 patients. Their mean age was 73 years, and 335 (35%) were aged 80 years or older.
Of patients with TIA, 208 (47%) sought medical attention within 3 hours, the window of time during which thrombolytic therapy is optimally administered, as did 234 (46%) minor stroke patients; 300 (67%) TIA patients and 400 (74%) of those with minor stroke sought medical attention within 24 hours.
Prior stroke and atrial fibrillation were associated with less delay, but prior TIA, myocardial infarction, hypertension, and history of smoking were not. "I presume that people with atrial fibrillation are told that one of the things they have to worry about is a stroke, and so they're aware of what symptoms to look for," said Dr. Chandratheva.
Assumed Incorrect Causes
Among those who sought medical attention, 457 (99.6%) TIA and 535 (98.9%) minor stroke patients could recall their initial perception of the cause of their symptoms or were with a spouse or caregiver who could. In 32% of TIA and 30% of minor stroke patients, their initial impression was correct. The remaining 68% of TIA and 69% of minor stroke patients did not know the cause of their symptoms or assumed incorrect causes.
TIA patients with a lower predicted early risk for stroke were more likely to delay than those at higher risk, especially if they had no motor and speech symptoms (P < .001), the event lasted less than 60 minutes (P < .001), or they were younger than 60 years (P = .075).
"What was slightly reassuring was that people with high-risk characteristics such as motor symptoms or speech disturbance or longer duration of events do tend to present more quickly, so I suppose that even if they don't know what their symptoms are, at least those high-risk patients are presenting earlier," said Dr. Chandratheva.
Longer Delays on Weekends
In patients with TIA, occurrence on the weekend was associated with the longest delays, with a median delay of 41.96 hours on Saturday and 24.00 hours on Sunday compared with 3.5 hours on Monday. "I think the reason for the delay on the weekend was that patients were waiting to see their primary care physician," said Dr. Chandratheva. "We have to emphasize that sudden onset of symptoms such as motor symptoms and speech symptoms should necessitate urgent medical attention, and that patients shouldn't just wait to see their primary care physician."
Indeed, the study found that first healthcare provider contacted by patients after the event was the family practitioner in 355 (77%) patients with TIAs and 390 (72%) patients with minor stroke.
The study results did not change across several demographic factors. "Social class didn't make a difference, economic status didn't make a difference, and educational level didn't make a difference," said Dr. Chandratheva, adding that this makes it difficult to target a national campaign to a specific group.
Although some people who did recognize their symptoms still delayed getting treatment, correct recognition of symptoms was associated with significantly shorter delays to presenting to medical attention for patients with TIA (2.3 vs 7.3 hours; P = .005).
Of the 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. "These are people who just came into hospital with their recurrent stroke and never even sought medical attention for their initial event," commented Dr. Chandratheva.
Few Can Identify TIA Symptoms
The authors noted that a telephone survey of randomly sampled US adults found that only 8.6% could identify a typical symptom of a TIA, and a Swiss survey found that only 2.8% identified TIA as a disease requiring urgent attention.
According to the authors, the lack of awareness about the need to seek medical attention was likely underestimated in the study, as all study participants did eventually report their symptoms. "There is an unknown proportion of patients who have 1 TIA and never present to medical attention so we may never know about them," added Dr. Chandratheva.
Another possible limitation of the study is that it relied on data from Oxfordshire, a county with a slightly higher educational level and socioeconomic status than other areas. "You'd expect people who are more educated and have more economic wealth to have more health awareness, but we didn't find this to be the case, so if anything, the figures were slightly underestimated," said Dr. Chandratheva.
He also pointed out that the vast majority of patients in the study were white.
Urgent Attention
Reached for a comment, Ralph L. Sacco, MD, chairman of neurology at the Miller School of Medicine, University of Miami, and chief of neurology at Jackson Memorial Hospital, Miami, Florida, and a spokesperson for the American Academy of Neurology, said the study emphasizes the fact that too many people do not realize that calling 911 is the most important action to take if they have warning symptoms of a stroke.
"We need to not only educate the public about the warning symptoms, but also about the need to get urgent attention," he said in an email to Medscape Neurology. "We urge people to call 911 and get to the closest stroke center, rather than calling their primary care doctor."
However, educating the public about recognizing stroke symptoms and getting immediate attention for them can be "tricky," said Gary Abrams, MD, professor of neurology at the University of California–San Francisco, and a spokesperson for the American Academy of Neurology.
"Unlike crushing chest pain, which heralds a heart attack and gets people to emergency attention quickly, symptoms of stroke can sometimes be subtle; they can be transient and reversible," he said.
Although he supports public awareness campaigns and thinks they should continue, Dr. Abrams said he is not sure he has "great hopes" for significantly changing patient behavior. "And I wonder if you could almost get an overreaction, with emergency rooms being flooded every time patients felt dizzy or had trouble finding the right word. It's a tough educational project; worthy but tough."
The study was supported by the UK Medical Research Council, the National Institute of Health Research, the Stroke Association, the Dunhill Medical Trust, and the National Institute of Health Researcher Biomedical Research Centre, Oxford. The authors have disclosed no relevant financial relationships.
Stroke. Published online April 15, 2010.
Pauline Anderson
April 22, 2010 — About 70% of patients who suffer a minor stroke or transient ischemic attack (TIA) do not correctly recognize their symptoms, and 30% delay seeking medical attention for more than 24 hours, a new study concludes.
Delays in seeking treatment were unrelated to age, sex, social class, or educational level, the study also found.
These results suggest that public awareness campaigns should emphasize the importance of seeking urgent medical attention, as well as recognizing symptoms, and that targeting such campaigns at specific groups such as the socially disadvantaged is unlikely to have significant benefit, said lead author Arvind Chandratheva, MRCP, a clinical research fellow in the Stroke Prevention Research Unit at the University of Oxford, United Kingdom.
"What you need is a national media campaign that highlights that any symptoms that are sudden onset, particularly with face or arm weakness and speech disturbance, should necessitate urgent medical attention," Dr. Chandratheva said.
The study results were published online April 15 in the journal Stroke: Journal of the American Heart Association.
Seeking Prompt Treatment
The researchers used the Oxford Vascular Study, a population-based study of all vascular events, including stroke and TIA, in about 91,000 people registered with 63 general practitioners in Oxfordshire in the United Kingdom. The current analysis includes consecutive cases of incident or recurrent TIA and minor stroke from April 2002 to April 2007.
Researchers recorded baseline characteristics of all patients and collected information on demographics, risk factors, social class, and educational level. Standard definitions were used to classify cases as TIA or stroke. The authors decided to study TIA separately from minor stroke, as it appears to behave differently; few previous studies have analyzed TIA separately.
The authors determined the delay from symptom onset to first seeking medical attention in relation to whether patients correctly identified the cause of their symptoms, demographic data, risk factors, symptomatology, and the day on which the TIA occurred. They performed a separate analysis on patients who did not seek medical attention for their initial symptoms and presented only after recurrent stroke.
Of the first 1000 consecutive patients, 459 presented after TIA and 541 after minor stroke. Of these, complete data were available on 945 patients. Their mean age was 73 years, and 335 (35%) were aged 80 years or older.
Of patients with TIA, 208 (47%) sought medical attention within 3 hours, the window of time during which thrombolytic therapy is optimally administered, as did 234 (46%) minor stroke patients; 300 (67%) TIA patients and 400 (74%) of those with minor stroke sought medical attention within 24 hours.
Prior stroke and atrial fibrillation were associated with less delay, but prior TIA, myocardial infarction, hypertension, and history of smoking were not. "I presume that people with atrial fibrillation are told that one of the things they have to worry about is a stroke, and so they're aware of what symptoms to look for," said Dr. Chandratheva.
Assumed Incorrect Causes
Among those who sought medical attention, 457 (99.6%) TIA and 535 (98.9%) minor stroke patients could recall their initial perception of the cause of their symptoms or were with a spouse or caregiver who could. In 32% of TIA and 30% of minor stroke patients, their initial impression was correct. The remaining 68% of TIA and 69% of minor stroke patients did not know the cause of their symptoms or assumed incorrect causes.
TIA patients with a lower predicted early risk for stroke were more likely to delay than those at higher risk, especially if they had no motor and speech symptoms (P < .001), the event lasted less than 60 minutes (P < .001), or they were younger than 60 years (P = .075).
"What was slightly reassuring was that people with high-risk characteristics such as motor symptoms or speech disturbance or longer duration of events do tend to present more quickly, so I suppose that even if they don't know what their symptoms are, at least those high-risk patients are presenting earlier," said Dr. Chandratheva.
Longer Delays on Weekends
In patients with TIA, occurrence on the weekend was associated with the longest delays, with a median delay of 41.96 hours on Saturday and 24.00 hours on Sunday compared with 3.5 hours on Monday. "I think the reason for the delay on the weekend was that patients were waiting to see their primary care physician," said Dr. Chandratheva. "We have to emphasize that sudden onset of symptoms such as motor symptoms and speech symptoms should necessitate urgent medical attention, and that patients shouldn't just wait to see their primary care physician."
Indeed, the study found that first healthcare provider contacted by patients after the event was the family practitioner in 355 (77%) patients with TIAs and 390 (72%) patients with minor stroke.
The study results did not change across several demographic factors. "Social class didn't make a difference, economic status didn't make a difference, and educational level didn't make a difference," said Dr. Chandratheva, adding that this makes it difficult to target a national campaign to a specific group.
Although some people who did recognize their symptoms still delayed getting treatment, correct recognition of symptoms was associated with significantly shorter delays to presenting to medical attention for patients with TIA (2.3 vs 7.3 hours; P = .005).
Of the 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. "These are people who just came into hospital with their recurrent stroke and never even sought medical attention for their initial event," commented Dr. Chandratheva.
Few Can Identify TIA Symptoms
The authors noted that a telephone survey of randomly sampled US adults found that only 8.6% could identify a typical symptom of a TIA, and a Swiss survey found that only 2.8% identified TIA as a disease requiring urgent attention.
According to the authors, the lack of awareness about the need to seek medical attention was likely underestimated in the study, as all study participants did eventually report their symptoms. "There is an unknown proportion of patients who have 1 TIA and never present to medical attention so we may never know about them," added Dr. Chandratheva.
Another possible limitation of the study is that it relied on data from Oxfordshire, a county with a slightly higher educational level and socioeconomic status than other areas. "You'd expect people who are more educated and have more economic wealth to have more health awareness, but we didn't find this to be the case, so if anything, the figures were slightly underestimated," said Dr. Chandratheva.
He also pointed out that the vast majority of patients in the study were white.
Urgent Attention
Reached for a comment, Ralph L. Sacco, MD, chairman of neurology at the Miller School of Medicine, University of Miami, and chief of neurology at Jackson Memorial Hospital, Miami, Florida, and a spokesperson for the American Academy of Neurology, said the study emphasizes the fact that too many people do not realize that calling 911 is the most important action to take if they have warning symptoms of a stroke.
"We need to not only educate the public about the warning symptoms, but also about the need to get urgent attention," he said in an email to Medscape Neurology. "We urge people to call 911 and get to the closest stroke center, rather than calling their primary care doctor."
However, educating the public about recognizing stroke symptoms and getting immediate attention for them can be "tricky," said Gary Abrams, MD, professor of neurology at the University of California–San Francisco, and a spokesperson for the American Academy of Neurology.
"Unlike crushing chest pain, which heralds a heart attack and gets people to emergency attention quickly, symptoms of stroke can sometimes be subtle; they can be transient and reversible," he said.
Although he supports public awareness campaigns and thinks they should continue, Dr. Abrams said he is not sure he has "great hopes" for significantly changing patient behavior. "And I wonder if you could almost get an overreaction, with emergency rooms being flooded every time patients felt dizzy or had trouble finding the right word. It's a tough educational project; worthy but tough."
The study was supported by the UK Medical Research Council, the National Institute of Health Research, the Stroke Association, the Dunhill Medical Trust, and the National Institute of Health Researcher Biomedical Research Centre, Oxford. The authors have disclosed no relevant financial relationships.
Stroke. Published online April 15, 2010.
Added Sugars in Diet Linked to Higher Triglycerides, Lower HDL-C in NHANES Data
From Heartwire
Steve Stiles
April 21, 2010 (Atlanta, Georgia) — It's been clear enough that a high-fat diet can worsen serum lipids, but less so that a diet with a lot of added sugar may do it as well. The case for it is stronger with a cross-sectional look at >6000 US adults that found significant, independent associations between increased intake of sugar-sweetened foods, which typically have added sucrose or high-fructose corn syrup, and elevated triglycerides (TG) and reduced HDL-cholesterol levels [1].
The analysis, based on 1999–2006 data from a National Health and Nutrition Examination Survey (NHANES) population, also suggested a big jump in consumption of added sugar compared with NHANES data from almost 30 years earlier, from 10.6% to 15.8% of daily calories, report its authors, led by Jean A Welsh (Emory University, Atlanta, GA), in the April 21, 2010 issue of the Journal of the American Medical Association.
The dyslipidemia findings echo those from the Framingham Heart Study three years ago that associated elevated TG and low HDL-C, among other markers of the metabolic syndrome, with consumption of at least one sweetened soft drink daily [2]. However, in that study, as reported by heartwire at the time, high intake of soft drinks worsened lipids regardless of whether they contained sugar or artificial sweeteners.
But the NHANES analysis is also consistent with a body of literature linking high-carbohydrate diets with elevated risk of stroke and heart-disease events, prospective short-term studies suggesting that increased sugar consumption promotes dyslipidemia, and the well-recognized worsening effects of greater carbohydrate intake on TG and HDL-C levels, senior author Dr Miriam B Vos (Emory University) told heartwire .
The current study, she said, is noteworthy for extending those prospective observations "to a nationally representative free-living population, people consuming their normal diets." It may also be the first of its kind to associate cardiovascular risk factors with dietary added sugars, which may be a more easily modifiable source of calories than simply "sugar" or "carbohydrates," which take many forms naturally in whole foods, according to Vos.
She proposes that a public-health message to cut back on added sugars, which could be easily identified on food labels, may also be easier to understand and accomplish than a recommendation to reduce sugar in general.
The NHANES sample consisted of 3088 nonpregnant women and 3025 men who didn't have "extremely high" triglyceride levels. Diabetics had also been excluded from the cohort, Vos said, "because we felt they would have been given advice that would have substantially changed their diet." Data on sugar intake was collected by interviewer-assisted 24-hour dietary recall.
Persons consuming the most added sugar showed significantly increased adjusted risks of having low HDL-C (<40 mg/dL for men; <50 mg/dL for women) and high TG (>150 mg/dL) according to National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) definitions, compared with those consuming the least. And the likelihoods of having low HDL-C and high TG went up with increasing intake levels (p<0.05 for both trends).
Odds Ratioa for Dyslipidemia Indicatorb by % Total Energy From Added Sugar in NHANES Analysis Indicator 5% to <10%, (n=893) 10% to <17.5% (n=1751) 17.5% to <25% (n=1210) >25% (n=1135)
Low HDL-C 1.0 (0.8–1.4) 1.5 (1.2–1.9) 1.9 (1.5–2.6) 3.1 (2.3–4.3)c
High triglycerides 0.8 (0.7–1.1) 1.1 (0.9–1.4) 1.3 (1.0–1.6) 1.2 (0.9–1.6)c
High LDL-C 0.9 (0.7–1.2) 1.1 (0.9–1.3) 1.1 (0.9–1.5) 1.2 (0.9–1.7)
a. OR (95% CI) vs reference group (<5% energy from added sugar, n=593); adjusted for age; sex; race/ethnicity; poverty; body-mass index; waist circumference; weight change; physical activity; total energy intake; intake of monounsaturated fatty acids, polyunsaturated fatty acids, saturated fatty acids, cholesterol, fiber, and other carbohydrates; hypertension; cigarette smoking; and alcohol use
b. low and high levels as defined by NCEP-ATP III guidelines
c. p<0.05 for trend
Neither finding was true for high LDL-C levels, which appeared unaffected by consumption of added sugar in the population overall. The investigators considered a trend of rising LDL-C with greater sugar intake among women to be of uncertain reliability, as it was only weakly significant (p=0.047) and based on a subgroup analysis, according to Vos.
"Our results support the importance of dietary guidelines that encourage consumers to limit their intake of added sugars," the group concludes, pointing out that the US guidelines caution against excess added sugars without specifying limits on intake and that the government's "Food Guide Pyramid" portrays calories from added sugars as "discretionary" in that they don't satisfy nutritional needs.
"Most discretionary calorie allowances are small, between 100 and 300 calories, especially for individuals who are not physically active," they write. That level is "substantially lower than that currently consumed by adults in the United States."
As heartwire reported last year, the American Heart Association released recommendations for maximum intake of "added sugars," putting "prudent upper limits" on daily intake at 140 kcal for most US men and 100 kcal for most US women, depending on age and activity level [3].
Vos disclosed that she is "author of and receives royalties from a book about childhood obesity" and is partly supported by a career award from the National Institute of Diabetes and Digestive and Kidney Diseases and the Children’s Digestive Health and Nutrition Foundation. The other coauthors had no disclosures.
References
Steve Stiles
April 21, 2010 (Atlanta, Georgia) — It's been clear enough that a high-fat diet can worsen serum lipids, but less so that a diet with a lot of added sugar may do it as well. The case for it is stronger with a cross-sectional look at >6000 US adults that found significant, independent associations between increased intake of sugar-sweetened foods, which typically have added sucrose or high-fructose corn syrup, and elevated triglycerides (TG) and reduced HDL-cholesterol levels [1].
The analysis, based on 1999–2006 data from a National Health and Nutrition Examination Survey (NHANES) population, also suggested a big jump in consumption of added sugar compared with NHANES data from almost 30 years earlier, from 10.6% to 15.8% of daily calories, report its authors, led by Jean A Welsh (Emory University, Atlanta, GA), in the April 21, 2010 issue of the Journal of the American Medical Association.
The dyslipidemia findings echo those from the Framingham Heart Study three years ago that associated elevated TG and low HDL-C, among other markers of the metabolic syndrome, with consumption of at least one sweetened soft drink daily [2]. However, in that study, as reported by heartwire at the time, high intake of soft drinks worsened lipids regardless of whether they contained sugar or artificial sweeteners.
But the NHANES analysis is also consistent with a body of literature linking high-carbohydrate diets with elevated risk of stroke and heart-disease events, prospective short-term studies suggesting that increased sugar consumption promotes dyslipidemia, and the well-recognized worsening effects of greater carbohydrate intake on TG and HDL-C levels, senior author Dr Miriam B Vos (Emory University) told heartwire .
The current study, she said, is noteworthy for extending those prospective observations "to a nationally representative free-living population, people consuming their normal diets." It may also be the first of its kind to associate cardiovascular risk factors with dietary added sugars, which may be a more easily modifiable source of calories than simply "sugar" or "carbohydrates," which take many forms naturally in whole foods, according to Vos.
She proposes that a public-health message to cut back on added sugars, which could be easily identified on food labels, may also be easier to understand and accomplish than a recommendation to reduce sugar in general.
The NHANES sample consisted of 3088 nonpregnant women and 3025 men who didn't have "extremely high" triglyceride levels. Diabetics had also been excluded from the cohort, Vos said, "because we felt they would have been given advice that would have substantially changed their diet." Data on sugar intake was collected by interviewer-assisted 24-hour dietary recall.
Persons consuming the most added sugar showed significantly increased adjusted risks of having low HDL-C (<40 mg/dL for men; <50 mg/dL for women) and high TG (>150 mg/dL) according to National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) definitions, compared with those consuming the least. And the likelihoods of having low HDL-C and high TG went up with increasing intake levels (p<0.05 for both trends).
Odds Ratioa for Dyslipidemia Indicatorb by % Total Energy From Added Sugar in NHANES Analysis Indicator 5% to <10%, (n=893) 10% to <17.5% (n=1751) 17.5% to <25% (n=1210) >25% (n=1135)
Low HDL-C 1.0 (0.8–1.4) 1.5 (1.2–1.9) 1.9 (1.5–2.6) 3.1 (2.3–4.3)c
High triglycerides 0.8 (0.7–1.1) 1.1 (0.9–1.4) 1.3 (1.0–1.6) 1.2 (0.9–1.6)c
High LDL-C 0.9 (0.7–1.2) 1.1 (0.9–1.3) 1.1 (0.9–1.5) 1.2 (0.9–1.7)
a. OR (95% CI) vs reference group (<5% energy from added sugar, n=593); adjusted for age; sex; race/ethnicity; poverty; body-mass index; waist circumference; weight change; physical activity; total energy intake; intake of monounsaturated fatty acids, polyunsaturated fatty acids, saturated fatty acids, cholesterol, fiber, and other carbohydrates; hypertension; cigarette smoking; and alcohol use
b. low and high levels as defined by NCEP-ATP III guidelines
c. p<0.05 for trend
Neither finding was true for high LDL-C levels, which appeared unaffected by consumption of added sugar in the population overall. The investigators considered a trend of rising LDL-C with greater sugar intake among women to be of uncertain reliability, as it was only weakly significant (p=0.047) and based on a subgroup analysis, according to Vos.
"Our results support the importance of dietary guidelines that encourage consumers to limit their intake of added sugars," the group concludes, pointing out that the US guidelines caution against excess added sugars without specifying limits on intake and that the government's "Food Guide Pyramid" portrays calories from added sugars as "discretionary" in that they don't satisfy nutritional needs.
"Most discretionary calorie allowances are small, between 100 and 300 calories, especially for individuals who are not physically active," they write. That level is "substantially lower than that currently consumed by adults in the United States."
As heartwire reported last year, the American Heart Association released recommendations for maximum intake of "added sugars," putting "prudent upper limits" on daily intake at 140 kcal for most US men and 100 kcal for most US women, depending on age and activity level [3].
Vos disclosed that she is "author of and receives royalties from a book about childhood obesity" and is partly supported by a career award from the National Institute of Diabetes and Digestive and Kidney Diseases and the Children’s Digestive Health and Nutrition Foundation. The other coauthors had no disclosures.
References
Progress in Blood Test for Breast Cancer
From WebMD Health News
Charlene Laino
April 21, 2010 (Washington, D.C.) — Researchers report they’re a step closer to developing a blood test for the early detection of breast cancer.
Using data from the large Women’s Health Initiative (WHI), they found that levels of epidermal growth factor receptor (EGFR) may be elevated in the blood of women as long as 17 months prior to their breast cancer diagnosis. EGFR is critical for the growth and spread of breast cancer cells.
By itself, EGFR did not prove useful as a marker for breast cancer detection, says Christopher Li, MD, PhD, associate member of the epidemiology program at the Fred Hutchinson Cancer Research Center in Seattle.
The goal is to develop a panel of biomarkers that would be more accurate, he tells WebMD.
EGFR Levels Elevated Before Breast Cancer Diagnosis
The study involved 688 women with estrogen receptor-positive breast cancer whose blood was drawn within 17 months prior to their cancer diagnosis. Their blood test results were compared to those of 688 women of similar ages without any sign of cancer.
The findings were presented at the American Association for Cancer Research 101st Annual Meeting.
Overall, the researchers identified 79 proteins whose levels appeared to be elevated in the blood of women with cancer, compared with the other women.
One of the proteins that could be validated using a commercially available assay was EGFR.
So the researchers divided about 400 of the women into four groups depending on their EGFR levels. Those in the highest quarter had a nearly threefold increased risk of developing breast cancer compared with those in the lowest quarter.
Then the researchers looked only at EGFR levels among the nearly 150 current users of estrogen plus progestin hormone therapy. "We know hormone therapy has a major impact in levels on circulating proteins in the blood," Li explains.
Among these women, those in the highest quarter had nine times the risk of developing breast cancer compared with those in the lowest quarter. Li says the researchers aren't exactly sure why hormone therapy had such a big impact.
As a single marker among current estrogen plus progestin users, EGFR levels could correctly identify 90% of women who would not develop breast cancer.
But they correctly identified only 31% of women who would develop breast cancer.
Panel of Biomarkers Could Be Used for Breast Cancer Screening
Nevertheless, Li is optimistic. "We identified 71 other proteins that may also serve as markers, which we hope to test in the future," he says.
"We also want to see if combining a biomarker panel with mammography will further increase the accuracy of the overall screening approach," Li says.
"This gives us a clue that there may be biomarkers that we can use to better predict breast cancer," says Jennifer Eng-Wong, MD, a breast cancer specialist at Fox Chase Cancer Center in Philadelphia.
Many other studies looking for biomarkers for breast cancer haven’t panned out, the researchers note.
One of the strengths of this study is that the researchers had access to blood drawn prior to women being diagnosed with breast cancer, Eng-Wong tells WebMD.
"If you use blood later, once they’re diagnosed and have clinical symptoms, it's too late," Li says.
Charlene Laino
April 21, 2010 (Washington, D.C.) — Researchers report they’re a step closer to developing a blood test for the early detection of breast cancer.
Using data from the large Women’s Health Initiative (WHI), they found that levels of epidermal growth factor receptor (EGFR) may be elevated in the blood of women as long as 17 months prior to their breast cancer diagnosis. EGFR is critical for the growth and spread of breast cancer cells.
By itself, EGFR did not prove useful as a marker for breast cancer detection, says Christopher Li, MD, PhD, associate member of the epidemiology program at the Fred Hutchinson Cancer Research Center in Seattle.
The goal is to develop a panel of biomarkers that would be more accurate, he tells WebMD.
EGFR Levels Elevated Before Breast Cancer Diagnosis
The study involved 688 women with estrogen receptor-positive breast cancer whose blood was drawn within 17 months prior to their cancer diagnosis. Their blood test results were compared to those of 688 women of similar ages without any sign of cancer.
The findings were presented at the American Association for Cancer Research 101st Annual Meeting.
Overall, the researchers identified 79 proteins whose levels appeared to be elevated in the blood of women with cancer, compared with the other women.
One of the proteins that could be validated using a commercially available assay was EGFR.
So the researchers divided about 400 of the women into four groups depending on their EGFR levels. Those in the highest quarter had a nearly threefold increased risk of developing breast cancer compared with those in the lowest quarter.
Then the researchers looked only at EGFR levels among the nearly 150 current users of estrogen plus progestin hormone therapy. "We know hormone therapy has a major impact in levels on circulating proteins in the blood," Li explains.
Among these women, those in the highest quarter had nine times the risk of developing breast cancer compared with those in the lowest quarter. Li says the researchers aren't exactly sure why hormone therapy had such a big impact.
As a single marker among current estrogen plus progestin users, EGFR levels could correctly identify 90% of women who would not develop breast cancer.
But they correctly identified only 31% of women who would develop breast cancer.
Panel of Biomarkers Could Be Used for Breast Cancer Screening
Nevertheless, Li is optimistic. "We identified 71 other proteins that may also serve as markers, which we hope to test in the future," he says.
"We also want to see if combining a biomarker panel with mammography will further increase the accuracy of the overall screening approach," Li says.
"This gives us a clue that there may be biomarkers that we can use to better predict breast cancer," says Jennifer Eng-Wong, MD, a breast cancer specialist at Fox Chase Cancer Center in Philadelphia.
Many other studies looking for biomarkers for breast cancer haven’t panned out, the researchers note.
One of the strengths of this study is that the researchers had access to blood drawn prior to women being diagnosed with breast cancer, Eng-Wong tells WebMD.
"If you use blood later, once they’re diagnosed and have clinical symptoms, it's too late," Li says.
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