Sandy Hutchens Cancer Prevention

Researchers from the University of Michigan have reported that women at high-risk of breast cancer understand the risks and benefits of tamoxifen [Nolvadex®] prevention, but only 6% choose to take it. The details of this study were published in an early online publication in Breast Cancer Research on November 12, 2009.

Several large clinical trials have shown that tamoxifen can decrease the risk of breast cancer in high-risk women. There are, however, two issues that have prevented widespread use of tamoxifen for breast cancer prevention:

* Who is at risk? The definition of who is high risk is problematic and differs from trial to trial. Generally, high risk includes women with a family history of breast cancer, early menarche, later or no childbirth, or previous breast biopsy, even if negative.

* What are the side effects? In one study, it was found that less than one in five women at high risk would take tamoxifen due to their fears of side effects and the fact that they assumed they were at relatively low risk for developing breast cancer.

Two reports in the February 21, 2007 issue of the Journal of the National Cancer Institute document that tamoxifen can prevent hormone-positive breast cancer in women at high risk.

Researchers affiliated with the Royal Marsden Randomized, Double-Blinded Tamoxifen Breast Cancer Prevention Trial reported 20-year follow-up data. This trial randomly allocated 2,494 women at high risk of developing breast cancer to receive tamoxifen or placebo for eight years. A total of 82 women in the tamoxifen group and 104 in the placebo group developed invasive breast cancer. Researchers affiliated with the first International Breast Cancer Intervention Study (IBIS-I) reported that the breast cancer preventative effects of tamoxifen persist for at least 10 years after a five-year treatment period. This trial randomly allocated 7,145 women at increased risk for developing breast cancer to receive five years of tamoxifen or placebo. With a 96-month follow-up, there were 142 breast cancers in the tamoxifen group and 195 in the placebo group. They observed a preventive effect during the entire period of observation. The main side effects were an increased risk of deep-vein thrombosis and pulmonary embolism during but not after tamoxifen treatment. The estimated risk for developing estrogen receptor-positive breast cancer was 34% lower in the tamoxifen group.

The authors of the present trial sought to determine why few women with increased risk of breast cancer use tamoxifen for chemoprevention. They evaluated 632 women with an average 2.56% risk of developing breast cancer within five years. These women were presented with a tailored decision aid concerning the effectiveness of chemoprevention with tamoxifen and the known side effects. After reviewing the decision aid, 29% of women said they would seek more information from their own physician, and 6% said they would agree to take tamoxifen. These researchers thought that these women had adequate knowledge to make a decision. The stated: “Participants were concerned about the risks of tamoxifen, and many believed that the benefits of tamoxifen did not outweigh the risks.”

Discovering Key to Tamoxifen’s Effectiveness in Treating Breast Cancer may Mean New Treatments

One simple test could end up saving thousands of women’s lives. Yet, for those without health insurance, the test comes too late. According to the American Cancer Society, this year alone an estimated 40,170 women will lose their lives to breast cancer. Meanwhile, it is estimated that 4,000 breast cancer deaths could be prevented just by increasing to 90 percent the percentage of women who receive breast cancer screenings.

Breast cancer often can be treated with early detection. That’s why health insurance that pays for mammograms is especially important. But mammography rates declined between 2003 and 2005, with a notable decrease for Hispanic women (from 65 percent to 59 percent) and African-American women (from 70 percent to 65 percent). Never mind the controversy over mammograms for women under 50; an estimated one in five women over 50 has not received a mammogram in the past two years.

Everyone needs health insurance to keep healthy, yet women are disproportionately underinsured. An estimated 21 million women and girls went without health insurance in 2007, according to the U.S. Census Bureau. And a recent congressional report found that 18 percent of all women not eligible for Medicare are uninsured.

Why are so many women left uncovered? Perhaps it’s because many medical situations faced by women are treated as pre-existing conditions, including breast cancer. The National Cancer Institute estimated that in 2004 approximately 2.4 million women had a history of breast cancer. Without continuing coverage, cancer survivors face steep risks.

Health Insurance Facts: Fighting Cancer With No Insurance

Why are women falling behind in insurance coverage faster than men? According to the Department of Health and Human Services, various factors restrict women’s access to health care, which include a vast array of “pre-existing conditions” such as breast cancer, pregnancy, caesarian section and domestic violence. In addition, women are less likely to be employed full time, which makes them less likely to be eligible for employer-based health benefits. In fact, fewer than half of women have the option of obtaining employer-based coverage.

Any health care reform proposal should take that into consideration and include access to comprehensive care, including preventative care such as mammograms. Americans, men and women alike, understand this need. A recent poll commissioned by Moving Forward, a values-based research initiative developed by the Women Donors Network and the Communications Consortium, found that a strong majority of voters — 87 percent — think insurance companies should be required to cover women’s preventive care and screenings, such as contraception, Pap tests for cervical cancer and breast cancer screenings.

Public health experts recommend health insurance coverage be universal and available to all regardless of work status, place of residence, health status or other factors unrelated to need. Reform should be aimed at achieving quality outcomes and eliminating disparities as well as at being affordable. Coverage also needs to be continuous from birth until end of life without interruptions or delays, as gaps in existing coverage allow women to fall through the cracks.

Reform will bring health care to more American women and their families than ever before in our nation’s history. Women would do well to learn more about their stake in health care reform. One good resource is www.WomenandHealthCareReform.org. The best thing we can do to end breast cancer is to make sure all health insurance coverage is universal — not limited by exclusions due to pre-existing conditions — and includes preventative care and basic services such as breast and cervical cancer screenings. Let’s create a system that provides health care, not just sick care.

Wendy C. Wolf is a board member of Living Beyond Breast Cancer and Women Donors Network and leads WDN’s effort on reproductive and other health issues.