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Chemoprevention of Breast Cancer

Recommendations and Rationale


This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations for the chemoprevention of breast cancer and the supporting scientific evidence. The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article "Chemoprevention of Breast Cancer: A Summary of the Evidence"1 and in the summary of the evidence and Systematic Evidence Review2.


Summary of Recommendation

  • The U.S. Preventive Services Task Force (USPSTF) recommends against routine use of tamoxifen or raloxifene for the primary prevention of breast cancer in women at low or average risk for breast cancer. (See Clinical Considerations for a discussion of risk.)

    Rating: D recommendation.

    Rationale: The USPSTF found fair evidence that tamoxifen and raloxifene may prevent some breast cancers in women at low or average risk for breast cancer, based on extrapolation from studies of women at higher risk. The USPSTF concluded, however, that the potential harms of chemoprevention may outweigh the potential benefits in women who are not at high risk for breast cancer.

  • The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. (Go to Clinical Considerations for a discussion of risk.) Clinicians should inform patients of the potential benefits and harms of chemoprevention.

    Rating: B recommendation.

    Rationale: The USPSTF found fair evidence that treatment with tamoxifen can significantly reduce the risk for invasive estrogen-receptor-positive breast cancer in women at high risk for breast cancer and that the likelihood of benefit increases as the risk for breast cancer increases. The USPSTF found consistent but less abundant evidence for the benefit of raloxifene. The USPSTF found good evidence that tamoxifen and raloxifene increase the risk for thromboembolic events (for example, stroke, pulmonary embolism, and deep venous thrombosis) and symptomatic side effects (for example, hot flashes) and that tamoxifen, but not raloxifene, increases the risk for endometrial cancer. The USPSTF concluded that the balance of benefits and harms may be favorable for some high-risk women but will depend on breast cancer risk, risk for potential harms, and individual patient preferences.


Contents

Clinical Considerations
Scientific Evidence
Recommendations of Others
References
Members of the Task Force
Contact the Task Force
Available Products

Task Force Ratings
Strength of Recommendations and Quality of Evidence

Clinical Considerations

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Scientific Evidence

Epidemiology and Clinical Consequences

Breast cancer is the most common non-skin cancer in women. An estimated 203,500 new cases of invasive breast cancer will be diagnosed in 2002, and 39,600 women will die from the disease.3 Although the USPSTF concluded that early detection of breast cancer through mammography has reduced deaths from breast cancer, the effectiveness of mammography is limited. Another approach to reducing breast cancer deaths is chemoprevention for primary prevention of cancer.

Potential Benefits of Chemoprevention

The use of agents to prevent the development of breast cancer was suggested by trials of breast cancer treatment with tamoxifen, a compound with both estrogen-like and anti-estrogen properties (a selective estrogen receptor modulator).4 A meta-analysis of 55 studies evaluating tamoxifen for the treatment of women with breast cancer found that the drug was associated with an approximately 50 percent reduction in the risk for developing new cancers in the opposite breast among women who took the drug for 5 years.5

The USPSTF found and evaluated 4 randomized controlled trials (RCTs) of breast cancer chemoprevention in women who had never had breast cancer.4 Three of these trials used tamoxifen as the chemopreventive agent6-8; one trial used raloxifene, another selective estrogen receptor modulator.9

Of the 3 RCTs of tamoxifen, the largest (the Breast Cancer Prevention Trial—BCPT), with 13,388 women enrolled, found a risk reduction of invasive cancer of 49 percent among women at high risk for breast cancer (estimated 5-year risk of 1.66 percent or greater).7 Over the course of the BCPT, a total of 264 women were diagnosed with invasive breast cancer: 175 in the placebo group and 89 in the tamoxifen group (RR, 0.51; 95 percent CI, 0.39-0.66). The absolute risk reduction was 21.4 cases per 1,000 women over 5 years.

The two other tamoxifen RCTs did not show a similar benefit. The relative risk reduction for breast cancer was 0.94 (95 percent CI, 0.59-1.43) for the Royal Marsden Hospital study6 and 0.87 (95 percent CI, 0.62-2.14) for the Italian Tamoxifen Prevention Study.8 Although the reasons for these discrepant results are not definitively established, possible explanations include differences in the duration of therapy and differences between women enrolled in each study.1 The average duration of therapy was shorter in the European trials and, compared with the women enrolled in BCPT, the women in these trials were younger, had more estrogen-receptor-negative cancers, and were more likely to be taking hormone replacement therapy or to have had an oopherectomy.1

The study evaluating raloxifene in postmenopausal women with osteoporosis found a 76 percent risk reduction (RR, 0.24; 95 percent CI, 0.13-0.44) in the development of invasive breast cancer.9 After a median followup of 40 months, the absolute risk reduction among women taking raloxifene was 7.9 cases per 1,000 women (number needed to treat, 126).9 When effective, both raloxifene and tamoxifen were effective only against estrogen receptor-positive tumors.1

Potential Harms of Chemoprevention

Both tamoxifen and raloxifene increase the risk for thromboembolic events and hot flashes; tamoxifen increases the risk for endometrial cancer.1 The number of total thromboembolic events in all four trials was small, and differences in specific complication rates between the treatment and placebo arms were statistically significant only for pulmonary embolism.1 Among women aged 50 and older, for whom the potential harms of tamoxifen and raloxifene are more common than they are for younger women, the BCPT reported that after a median of 55 months of use, tamoxifen:

Fewer thromboembolic events occurred among women younger than 50, and the trial found no significant difference in incidence between the tamoxifen and placebo groups in this age group.7 The relative risk increase in venous thromboembolism from tamoxifen or raloxifene appears similar to the risk for venous thromboembolism from oral contraceptives or hormone replacement therapy.1

Among women aged 50 and older in the BCPT, participants who received tamoxifen, compared with those who took placebo, had a 4.0 times greater risk (95 percent CI, 1.70-10.90) of developing Stage 1 endometrial cancer (0.8 cancers/1,000 women taking placebo vs 3.1 cancers/1,000 women taking tamoxifen for a median of 55 months).7 Among women younger than 50, the BCPT found no significant difference in endometrial cancer rates between the two groups. No deaths attributed to endometrial cancer occurred in the trial.7 Raloxifene has not been associated with an increase in endometrial cancer.9

The BCPT reported that women in the tamoxifen group were at increased risk for developing cataracts and having cataract surgery compared with placebo (RR, 1.14 [95 percent CI, 1.01-1.29] and 1.57 [95 percent CI, 1.16-2.14], respectively).7

Quality-of-life issues have also been of concern and were addressed in the BCPT. Women in the BCPT reported increased rates of bothersome hot flashes (45.7 percent in the tamoxifen group vs 28.7 percent in the placebo group) and bothersome vaginal discharge (12.4 percent in the tamoxifen group vs 4.5 percent in the placebo group).7 Women given raloxifene also noted higher rates of hot flashes than women given placebo (10.7 percent in the ralixifene group vs 6.4 percent in the placebo group).9

Although long-term adherence for highly motivated women was about 80 percent in the BCPT trial and about 90 percent in the raloxifene trial, adherence rates in the general population are unknown.2

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Recommendations of Others

The American College of Obstetricians and Gynecologists emphasizes the importance of clinician judgment and recommends that any decision to use tamoxifen be made on an individual basis after consideration of the patient's medical history, risk assessment, and preferences, and with attention to the ability to manage complications of therapy.10 The American Society of Clinical Oncology suggests that women with a 5-year projected risk for breast cancer greater than or equal to 1.66 percent may be offered tamoxifen to reduce their risk. They also recommend that raloxifene use should be reserved for treatment of osteoporosis in postmenopausal women.11 The Canadian Task Force on Preventive Health Care recommends that clinicians counsel women at high risk for breast cancer (Gail index ≥1.66 percent for 5 years) about the potential benefits and harms of breast cancer prevention with tamoxifen.12

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References

1. Kinsinger LA, Harris, R, Lewis C, Woddell M. Chemoprevention of breast cancer: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137(1):59-69.

2. Kinsinger LA, Harris, R, Lewis C, Woddell M. Chemoprevention of Breast Cancer Systematic Evidence Review No. 8. (Prepared by the RTI-UNC Evidence-based Practice Center under Contract No. 290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality, July 2002. Available at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.chapter.2527.

3. Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23-47.

4. Early Breast Cancer Trialists' Collaborative Group. Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women. Lancet 1992;339:1-15.

5. Early Breast Cancer Trialists' Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998;351:1451-67.

6. Powles T, Eeles R, Ashley S, et al. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet 1998;352:98-101.

7. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998;90:1371-88.

8. Veronesi U, Maisonneuve P, Costa A, Sacchini V, Maltoni C, Robertson C, Rotmensz N, Boyle P. Prevention of breast cancer with tamoxifen: preliminary findings from the Italian randomised trial among hysterectomised women. Italian Tamoxifen Prevention Study. Lancet 1998;352:93-7.

9. Cummings SR, Eckert S, Krueger KA, et al. The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation. JAMA 1999;281:2189-97.

10. American College of Obstetricians and Gynecologists. Tamoxifen and the prevention of breast cancer in high-risk women. ACOG Committee Opinion 224. Washington, DC: ACOG, 1999.

11. Chlebowski RT, Collyar DE, Somerfield MR, Pfister DG. American Society of Clinical Oncology Technology Assessment on Breast Cancer Risk Reduction Strategies: Tamoxifen and Raloxifene. J Clin Oncol 1999;17:1939-54.

12. Levine M, Moutquin JM, Walton R, Feightner J. Chemoprevention of breast cancer. A joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. CMAJ 2001 Jun 12;164:1681-90.

13. Gail MH, Costantino JH, Bryant J, et al. Weighing the risks and benefits of tamoxifen treatment for preventing breast cancer. J Natl Cancer Inst 1999;91:1829-46.

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Members of the Task Force

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., F.A.A.N., Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Clinical Professor and Director, Department of Medicine, University of Texas Health Science Center, and Director, National Program Office for Robert Wood Johnson Generalist Physician Faculty Scholars Program, San Antonio, TX); Tracy C. Orleans, Ph.D. (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N., F.A.A.N. (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, MD., MSPH (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor, Department of Obstetrics and Gynecology, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine, Virginia Commonwealth University, Fairfax, VA).

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Contact the Task Force

Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850..

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Available Products

This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.uspreventiveservicestaskforce.org.

Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.

Source: This recommendation first appeared in Ann Intern Med 2002;137(1):56-8.

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Current as of July 2002


Internet Citation:

U.S. Preventive Services Task Force. Chemoprevention of Breast Cancer: Recommendations and Rationale. July 2002. http://www.uspreventiveservicestaskforce.org/3rduspstf/breastchemo/breastchemorr.htm


 


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