IMPORTANT NOTICE
This site was archived on December 31, 2002 (Why? click HERE)
It is not maintained and cannot be relied upon for up to date medical information.
Despite this, there is much useful information which is not time sensitive

TO WELCOME
TO CONTENTS
Breast issues including screening
Breast self-examination - a good idea or not?
A Pap Smear for the Breast?
mammography reporting regulations and list of centres
mammography risks and benefits
breast cancer mortality in Australia
HRT and breast cancer
Bone mass and  risk of breast cancer among postmenopausal women
For a demonstration of cautions when reading a study abstract about the effect of continuous progestin on breast tissue see http://www.oxford.net/~tishy/breastconthrt.html
 

Jan 4, 2003 Excerpt from http://bmj.com/cgi/content/full/326/7379/1
BMJ 2003;326:1-2 ( 4 January )

Editorials: 
Breast self examination 
Does not prevent deaths due to breast cancer, but breast awareness is still important

A large well conducted randomised controlled trial from Shanghai shows conclusively that teaching women how to examine their breasts does not lead to a reduction in mortality due to breast cancer compared with no screening at all.1 The findings should bring to an end more than decade of controversy and confusion in the United Kingdom concerning the efficacy and effectiveness of self examination of the breast.


Sept 11 2002: An editorial on Medscape (free registration required) offers commentary on the ongoing mammography controversy. I think it well worth reading, as are the two articles linked in the extract below. 

From the Editor 
September 2002: Harvesting Controversies for Women and Society
from Medscape Ob/Gyn & Women's Health (Free registration required)
Posted 09/11/2002 
Ursula Snyder, PhD

 
Prominent breast cancer researchers in the United States are again debating the value of mammography, as pointed out in the recent New York Times article covering the publication of the 2 September Annals reports.[16] I urge Medscape members to read the just-posted Medscape article, "Controversy Rages Over Breast Cancer Screening: A Newsmaker Interview With Michael Baum, MD," together with an article published in The New Republic on April 22, 2002, "Search and Destroy: Shannon Brownlee on Why Mammograms Are Not the Answer."

These pieces are important, and both are critical of American medical policy.  Ms. Brownlee urges doctors, hospitals, scientists, and politicians " to turn their focus -- and their money -- toward the emerging technologies that could help doctors more accurately predict which tumors require aggressive treatment and which can safely be left alone.  The United States needs to enter the postmammography era -- and the sooner the better." During the Medscape interview, Dr. Baum exhorts: "No one in their right mind, outside the US, would offer mammography screening to women under age 50.  America has to ask herself why she is out of step with the rest of the world."


April 9, 2002: An article in The New York Times, uses the announcement of a failed screening test for neuroblastoma to illustrate the uncertainties of screening for cancer in general and in particular.  It can be read at http://www.nytimes.com/2002/04/09/science/09CANC.html?pagewanted=1 (free registration required) 
Test Proves Fruitless, Fueling New Debate on Cancer Screening
By GINA KOLATA

For years, it was a medical truism that the earlier cancer could be detected, the better.  Most cancers would inevitably worsen if left untreated, the theory went.  Spontaneous remissions were so rare as to be almost unheard of.

But last week, those assumptions were shattered, at least in the case of a childhood cancer.  A screening test that looked as if it would save children from terrible deaths from a cancer of the nervous system utterly failed to fulfill its promise.

Now the story of that screening and questions about tests for adult cancers like mammography and a blood test for prostate cancer are ushering in a broader debate about cancer screening in general ..........


Yet another salvo in the mammography controversy appeared in the Mch  15, 02 issue of The Lancet at www.thelancet.com  Free registration is required to access the full text, which includes the claim that 

"The recent criticism against the Swedish randomised controlled trials is misleading and scientifically unfounded."
Benefits of screening mammography
Some research has doubted the benefit of screening mammography.  But new data now show that there may be a modest benefit for women aged 55 years or over........ they found a significant 21% reduction in breast cancer mortality for women given screening mammography.  But the benefit was less apparent in women aged 50-54 years.......
The latest round in the screening mammography controversy was triggered by a letter published in the Lancet. To access it, go to www.thelancet.com (free registration is required)and search on "screening mammography". 

Extract from Lancet Volume 359, Number 9304 02 February 2002
Screening mammography: setting the record straight

Sir--Reviews of randomised screening trials done earlier than that undertaken by Ole Olsen and Peter Gøtzsche (Oct 20, p 1340)1 have supported the practice of screening for breast cancer with mammography, particularly for women older than 50 years;2,3 Olsen and Gøtzsche challenge this view.  Unfortunately, they provided one version of their review to The Cochrane Library4 and another (which is not an approved Cochrane review) to The Lancet.1 These two reviews, although similar, differ in some important features that may lead to confusion.

In his Oct 20 commentary,5 Richard Horton claims the Cochrane Breast Cancer Group (CBCG) attempted to unduly influence the text of Olsen and Gøtzsche's review in The Cochrane Library.  Since Olsen and Gøtzsche conclude that screening mammography is not justified, Horton implies that we tried to suppress this information, which is not the case.



This was widely reported and commented upon in the general press, including the following decided anti-mammography press release

Wednesday February 6, 4:08 pm Eastern Time Press Release SOURCE: Cancer Prevention Coalition 
Extract from Mammography Is Dangerous Besides Ineffective, Warns Samuel S. Epstein, M.D. 

CHICAGO, Feb. 6 /PRNewswire/ -- The following was released by Samuel S.. Epstein, M.D., Chairman of the Cancer Prevention Coalition and Professor Emeritus of Environmental and Occupational Medicine, University of Illinois School of Public Health, Chicago:

Recent confirmation by Danish researchers of longstanding evidence on the ineffectiveness of screening mammography has been greeted by extensive nationwide headlines.  Entirely missing from this coverage, however, has been any reference to the [following] well-documented dangers of mammography.

The New York Times went beyond the current report to consider if and how the present dilemma might be resolved
http://www.nytimes.com/2002/02/05/health/womenshealth/05MAMM.html
February 5, 2002

Putting Mammograms to the Test 
By GINA KOLATA

In what is considered the gold standard of scientific evidence gathering, a randomized controlled clinical trial, some people are having the potentially lifesaving screening tests, and some are not.  An independent monitoring committee is standing by to see if the cancer death rate in one group exceeds that in the other.  At that point, the study will end.
But when it comes to mammograms, even Dr. Kramer gives up......

Dr. Kramer said: "I never like to say it's impossible.  But in the U.S. it would be very, very difficult" to do a new randomized mammography trial.


Oct 21, 2001 extract from an editorial which can be found through www.thelancet.com/search and entering the title below as the search term
Screening mammography--an overview revisited

"There is no reliable evidence that screening for breast cancer reduces mortality."  This conclusion, published in The Lancet this week, confirms previous controversial analysis from researchers in Denmark.  Peter Gøtzsche and Ole Olsen from the Nordic Cochrane Center, Copenhagen, did a second analysis of data from a previous study.  Reporting the results in a fast-tracked Research letter, they also confirm, with additional data available on thelancet.com, their earlier finding that screening leads to more aggressive treatment, increasing the number of mastectomies by about 20% and the number of mastectomies and tumorectomies by about 30%
The editorial includes further references and explanation of the Cochrane reviews

Extracts only from other commentaries:

http://www.nature.com/nsu/011025/011025-5.html

<snip> "There is an urgency for the data to be re-analysed correctly," says breast-cancer clinician Serge Rozenberg of the Free University of Brussels in Belgium, and for women to be informed of existing doubts over the efficacy of screening.  "This is about millions of women," he says; not acting on this study is "unacceptable".

But some still dispute Olsen and Gotzsche's techniques and findings.  "We estimate that screening is saving on average 1,250 lives a year," says Julietta Patnick, National Coordinator of the UK's National Health Service breast-screening programme, which aims to examine all women over 50 every 3 years.<snip>


http://www.bmj.com/cgi/content/full/323/7319/956(British Medical Journal)
BMJ 2001;323:956 ( 27 October )
Row over breast cancer screening shows that scientists bring "some subjectivity into their work
Susan Mayor, London

The difficulty of getting scientists to reach a consensus on their interpretations of trial data was illustrated last week when two reviewers for the Cochrane Breast Cancer Group published their own review of mammography screening trials after editors from the group had disagreed with some of their conclusions. <snip>
http://www.abc.net.au/science/news/stories/s394891.htm(Australian public radio)
Debate over evidence for breast screening Monday, 22 October 2001
A dispute over breast cancer screening has brought into the spotlight international power plays over the interpretation of medical evidence.

At issue is whether the widespread practice of mammographic screening actually reduces deaths from breast cancer.  Danish researchers Peter Gøtzsche and Ole Olsen, of the Nordic Cochrane Centre in Copenhagen, say there is no reliable evidence that it does, having just reviewed and republished findings that caused a stir when they were first published last year.

But there are two different versions of their results - one appearing this week in the medical journal The Lancet, and one in the Cochrane Library
<snip>
Professor Alan Coates, chief executive of the Cancer Council of Australia, told ABC News that the Council rejects the Danish research and urges women to take part in screening programs.



June 25, 01 An article in the Canadian Medical Association Journal made the surprise recommendationthat routinely teaching BSE to women beteen 40 and 70 should be abandoned as part of a periodic health examination.
http://www.cma.ca/cmaj/vol-164/issue-13/1837.asp
Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen  for breast cancer? 
To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case-control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results. 
Recommendations: 
Women aged 40-49 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). 

Women aged 50-69 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). 

The lack of sufficient evidence to evaluate the effectiveness of the manoeuvre in women younger than 40 years and those 70 years and older precludes making recommendations for teaching BSE to women in these age groups. The following issues may be important to consider: 

Women younger than 40 years: There is little evidence for effectiveness specific to this group. Because the incidence of breast cancer is low in this age group, the risk of net harm from BSE and BSE instruction is even more likely.

Women 70 years and older: Although the incidence of breast cancer is high in this group, there is insufficient evidence to make a recommendation concerning BSE for women 70 years and older. 

Important note: Although the evidence indicates no benefit from routine instruction, some women will ask to be taught BSE. The potential benefits and harms should be discussed with the woman, and if BSE is taught, care must be taken to ensure she performs BSE in a proficient manner. 

In the same issue, another article athttp://www.cma.ca/cmaj/vol-164/issue-13/1851.asp
argues that the recommendation is premature. It says in part:
.....In summary, we agree with the task force that there is still not much evidence BSE helps and that there is more evidence it can harm. Is it time, therefore, to tell patients that BSE should not be practised? In making this decision, we must consider the effect of eliminating a widely practised procedure. For over 30 years many women have grown to accept BSE as a screening tool for breast cancer. They have become comfortable with examining their breasts and have gained a sense of control over their health care. How will women react to a sudden reversal in medical advice about BSE? How will it affect their reaction to medical advice about other screening methods for breast cancer? <snip>

Meanwhile, clinicians have much stronger evidence for mammography and well-done clinical breast examination, and we should emphasize  these screening methods with our patients. For BSE, we must honestly  share the uncertainties about its potential benefits and harms and then help patients in their decisions about its use.


Note: The practice of BSE is by no means universal. For instance the official UK site at http://www.cancerscreening.nhs.uk/breastscreen/breastawareness.html#routine says in part:
The Department of Health's policy on breast awareness, which has strong support from the nursing and medical professions, encourages women to check their breasts for what is normal for them but does not recommend routine self examination to a set technique. 

There is no scientific evidence to show that a formally taught, ritual self examination, performed at the same time each month, reduces the death rate from breast cancer or is more effective than a more relaxed breast awareness.


Copied with permission from the Breast Cancer Information Site (BCIS) at http://trfn.clpgh.org/bcis/GeneralInfo/bse.html

Breast Self-Exam (BSE)

Why
When To Do a Breast Self-Exam
How To Do Breast Self-Exam

Why

The American Cancer Society recommends that all women over the age of 20 examine their breasts once a month. By examining your breasts regularly, you will know how your breasts normally feel. If a change should happen in your breasts, you will be able to identify it and let your doctor know. Most lumps are found by women themselves. If you find any lumps, thickenings or changes, tell your doctor right away. Remember, most breast lumps are not cancerous, but you don't know if you don't ask. Breast cancer may be successfully treated if you find it and treat it early. Delaying the diagnosis of breast cancer does not change the diagnosis, it only worsens the outcome. 

When to Do a Breast Self-Exam

You should do a Breast Self-Exam (BSE) every month 2 or 3 days after your period. If you do not have regular periods, just do it the same day every month...like the first... or the tenth...or the day that matches your birthday. (Note: just before your period or during pregnancy, your breasts may be somewhat lumpy or more tender.) If you are taking hormones, talk with your doctor about when to do BSE. 

How to Do Breast Self-Exam

  1. Lie down. Flatten your right breast by placing a pillow under your right shoulder. Place your right arm behind your head.
  2. Use the sensitive finger pads (where your fingerprints are, not the tips) of the middle three fingers on your left hand. Feel for lumps using a circular, rubbing motion in small, dime-sized circles without lifting the fingers. Powder, oil or lotion can be applied to the breast to make it easier for the fingers to glide over the surface and feel changes.
  3. Press firmly enough to feel different breast tissues, using three different pressures. First, light pressure to just move the skin without jostling the tissue beneath, then medium pressure pressing midway into the tissue, and finally deep pressure to probe more deeply down to the ribs or to the point just short of discomfort..
  4. Completely feel all of the breast and chest area up under your armpit, and up to the collarbone and all the way over to your shoulder to cover breast tissue that extends toward the shoulder.
  5. Use the same pattern to feel every part of the breast tissue. Choose the method easiest for you:
    • Lines: start in the underarm area and move your fingers downward little by little until they are below the breast. Then move your fingers slightly toward the middle, and slowly move back up. Go up and down until you cover the whole area.
    • Circles: Beginning at the outer edge of your breast, move your fingers slowly around the breast in a circle. Move around the breast in smaller and smaller circles, gradually working toward the nipple. Don't forget to check the underarm and upper chest areas, too. 
    • Wedges: Starting at the outer edge of the breast, move your fingers toward the nipple and back to the edge. Check your whole breast, covering one small wedge-shaped section at a time. Be sure to check the underarm area and the upper chest.
  6. After you have completely examined your right breast, then examine your left breast using the same method and your right hand, with a pillow under your left shoulder.
  7. You may want to examine your breasts or do an extra exam while showering. It's easy to slide soapy hands over your skin, and to feel anything unusual.

  8. You should also check your breasts in a mirror looking for any change in size or contour, dimpling of the skin or spontaneous nipple discharge.
For a good description of benign conditions which cause breast lumps see http://www.sjbnet.com/breastproblems.htm 
This site also covers reasons for 'abnormal mammograms, complete with ilustrative images.
A Pap Smear for the Breast? As the result of many years of research by Dr. Susan Love MD and colleagues, there is finally a new approach -ductal lavage - to the breast. 
http://www.susanlovemd.com/lavage_frames.html  has a good illustrated description of the procedure. There is also a list of doctors who are [Mch 2001] performing the procedure.(Extract below) 
Ductal lavage is a washing procedure that can identify cancerous and precancerous cells in the milk ducts of the breast. The procedure has been dubbed "Pap smear for the breast" because, like the test for cervical cancer, it is a nonsurgical approach to identifying abnormal cells, potentially making it possible to find them when they are just thinking about becoming cancer.
Extracts from http://www.fda.gov/bbs/topics/NEWS/NEW00679.html
MAMMOGRAM LAW TAKES EFFECT APRIL 28, 1999

The Food and Drug Administration is further strengthening the nation's standards for mammography centers by requiring that all women who have mammograms must be directly notified in writing about their results.

Although many mammography facilities already provide this service, the FDA rule ensures that written notification occurs promptly, in easy-to-understand language, and that it is provided by every mammography facility in the United States.

Facilities performing mammograms will continue to report results directly to the patient's physician. But they will now provide patients with a separate, easy-to-understand summary report within 30 days. Self-referred patients with no designated healthcare provider will receive both the simplified report and the one doctors normally receive.

If the results are suspicious or suggest cancer, they must be communicated to the patient as soon as possible, ordinarily within five working days. If the results are unclear or incomplete, the FDA recommends that facilities communicate this to patients as soon as possible to avoid delays in follow up care. The exact language of the report and the system for reporting are left up to the facility.

The final regulations also require mammography facilities to transfer original, as opposed to copies of, mammograms to a patient's
physician or to the patient on request. This aids diagnosis by allowing doctors to compare old mammograms with new ones.

Under MQSA, all mammography facilities in the United States must now meet certain stringent standards for equipment, personnel and image quality, be accredited by an FDA-approved accreditation body, be MQSA-certified, and be inspected annually.

Today virtually all 10,000 facilities have fully met standards and are certified to perform mammography. The names and locations of certified mammography facilities are available by calling the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237), or on FDA's Website at www.fda.gov/cdrh/faclist.html.

From the Canadian Family Physician "critical appraisal" series
http://www.cfpc.ca/CFP/1999/cfpjan99critical.htm#False-positive results
False-positive results in breast cancer screening
Michael F. Evans, MD, CCFP

Elmore JG, Barton MB, Moceri VM, Polk S, Arena PJ, Fletcher SW. Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med 1998;338(16):1089-96.

Research question
What is the cumulative risk of a false-positive result in breast cancer screening? How many and what type of diagnostic workups result from false-positive results?
<major snip>
Bottom line
This retrospective review of data from a large American HMO allows us to calculate the risk of false-positive test results in breast cancer screening (both mammography and CBE) but not their effect on the overall health of women, especially their anxiety levels.

     • Estimated cumulative risk of having at least one false-positive result during the 10-year period was 49.1%. For those older than 50 the rate was 47.3%.

     • This translates to telling our female patients older than 50 that their risk of requiring unnecessary interventions (eg, biopsies) is almost one in two if they have
     mammography every year for 10 years. If they have it every second year, their risk would be one in four.

     • Cumulative risk of false-positive results was similar for both mammography and CBE. After five screening mammograms the risk was 30.3%; after 10, 56.2%. These rates  dropped to 23.8% and 47.3%, respectively, for those older than 50. After five CBEs the risk was 20.8%; after 10, 34.1%. This dropped to 11.1% and 18.7%, respectively, for omen older than 50.

     • From a natural history point of view, it was interesting to note that cancer was diagnosed in 88 of the 2400 women over the 10 years of the study and that the cancers were picked up by screening mammogram in 58, by CBE in seven, and by patient concern in 23.

     • These data need to be assessed in light of your local breast screening strategy and diagnostic practices.



http://mammography.ucsf.edu/inform/index.cfm
This is an easily read site which provides information in point form about the important basics of mammography and its relationship to breast cancer. It is unusual in that it is not wholly positive. 

Potential Benefits & Risks of Mammograms
About this Web Site: Breast cancer is a commonly diagnosed cancer in women. Mammograms are one way to detect breast cancer. This Website provides up to date information about the potential benefits and risks of screening mammograms according to a woman’s age. 

 Research Study: This Website is also part of a scientific study being conducted at the University of California, San Francisco. Researchers at the university have developed the information on this  site and would like your help evaluating whether the information provided about mammograms helps women make the personal decision whether to have or not have a mammogram. 

   Here’s how to participate: First read the 17 questions and answers in the section "Potential Benefits and Risks of Mammograms." Then complete and submit the questionnaire that follows. The questionnaire includes 20 questions about your impressions of the information you have just read. Personal comments are appreciated and can be included after reading the section "Potential Benefits and Risks of Mammograms" or after completion of the questionnaire. 



Effect of Estrogen and Estrogen-Progestin Replacement Regimens on Mammographic Breast Parenchymal Density By Ingemar Persson, Erik Thurfjell, and Lars Holmberg 

Purpose:Hormone replacement therapy (HRT) may increase the mammographic density with a possible reduction in the sensitivity or specificity. If so, the benefit of mammographic screening in women using HRT could be compromised. We evaluated the hypothesis that HRT regimens have differential effects on the mammographic density depending on treatment regimens or on age. 
Conclusion:HRT with estradiol-progestin regimens, especially continuously combined, may increase the mammographic density in a substantial proportion of women 

J Clin Oncol 15:3201-3207 October 97
http://www.jcojournal.org/abs15_10/v15n10p3201.html



Risk-Based Recommendations for Mammographic Screening for Women inTheir Forties    By M. Gail and B. Rimer 

We assumed that regular mammographic screening is justified for a 50-year-old woman, even one with no risk factors, and that a younger woman with an expected 1-year breast cancer incidence rate as great or greater than that of a 50-year-old woman with no risk factors would benefit sufficiently to justify regular screening. 

Results: Two methods, the exact-age procedure (EAP)and the grouped-age procedure (GAP), were developed. The less precise GAP only requires following a flow diagram. The proportion of white women recommended for screening by the EAP ranges from 10% for 40-year-old women to 95% for 49-year-old women, and the corresponding percentages for black women are 16% and 95%. The assumptions that underlie the guidelines are discussed critically. 

J Clin Oncol 16:3105-3114.
http://www.jcojournal.org/abs16_9/v16n9p3105.html
 

http://www.mja.com.au/public/issues/jan5/smith/smith.html

Extract from: Breast cancer mortality trends in Australia: 1921 to 1994
Catherine L Smith, Anne Kricker, Bruce K Armstrong MJA 1998; 168: 11-14 ©MJA1997 
Abstract - Introduction - Methods - Results - Discussion - Conclusions

 Abstract
Objective: To analyse breast cancer mortality trends in Australia and to see if mammographic screening has yet led to a reduction in mortality. 
Design: Retrospective analysis of trends in mortality rates from breast cancer in Australian women between 1921 and 1994, and in potentially explanatory variables such as fertility, body size, age at menarche, and screening. 
Results: Changes in breast cancer mortality in Australian women could not be explained by chance variation alone. Mortality rose steadily (average annual increase, 1.0%) to 1940-1944, fell to the 1960s and early 1970s, and rose (average annual increase, 0.3%) to the late 1980s. Between 1985-1989 and 1990-1994, breast cancer mortality fell by 3.2% in women 50-69 years of age (the target age group for mammographic screening) and by 4.2% in women 25-49 years of age. There was almost no change ( - 0.2%) in breast cancer mortality in older women in this period. The proportion of women screened in all age groups increased substantially between 1988 and 1994; nearly 65% of women in the target age group had had at least one mammogram by 1994. Decreases in fertility were followed by increases in mortality, and vice versa. 
Conclusions: Trends in breast cancer mortality have probably been influenced by changing fertility, nutrition and body-size increases among Australian women. Improvements in stage at diagnosis and treatment have probably moderated the upwards pressure on mortality caused by an increasing incidence. Recent falls in mortality could be expected to continue as more women participate in the mammographic screening program. This trend should be more clearly evident in the second half of the 1990s.

June 19, 01 A further study (in the Journal of the National Cancer Institute) confirms that high bone density has a down side 
http://jnci.oupjournals.org/cgi/content/abstract/93/12/930
Bone Mass and Breast Cancer Risk in Older Women: Differences by Stage at Diagnosis
Conclusions: Elderly women with high BMD have an increased risk of breast cancer, especially advanced cancer, compared with women with low BMD
Take a look at http://www.webcom.com/mjljweb/jrnlclb/vol2/a45.html for 
Bone mass and the risk of breast cancer among postmenopausal women
Authors: Zhang Y, Kiel D, Kreger B, Cupples L, Ellison R, Dorgan J, Schatzkin A, et al. 
Source: New England Journal of Medicine. 336:611-7. February 27, 1997. 
Institutions: Boston University; Harvard University; the Framingham Study. 
Financial support: National Institutes of Health; Boston University School of Medicine. 

Summary

Background

The role of estrogen in the promotion of breast cancer is difficult to quantitate. Isolated measurement of serum estrogens may not reflect long-term exposure. Studies linking estrogen replacement therapy to breast cancer are subject to bias, since most of them have been case-control studies. 

Bone density in women is related, in part, to estrogen exposure. Thus, if long-term estrogen exposure increases bone density and also increases the risk of breast cancer, there should be a positive correlation between bone density and the incidence of breast cancer. This study was designed to look at this issue, using data from the Framingham study. 

 "Comparing age-specific quartiles of bone density 1 through 4 (increasing bone density), there were 12 women with breast  cancer in quartile 1, 17 in quartile 2, 18 in quartile 3 and 44 in quartile 4." 



An abstract of a related study is at 
http://www4.ncbi.nlm.nih.gov/htbin-post/Entrez/query?form=6&db=m&uid=97047874&Dopt=r
JAMA 1996 Nov 6;276(17):1404-1408
Bone mineral density and risk of breast cancer in older women: the study of osteoporotic fractures. Study of Osteoporotic Fractures Research Group. 
Cauley JA, Lucas FL, Kuller LH, Vogt MT, Browner WS, Cummings SR 
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA 15261, USA. 

"Women with BMD above the 25th percentile were at 2.0 to 2.5 times increased risk of breast cancer compared with women below the 25th percentile. Results were consistent across all BMD sites."


 http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_277/no_19/letter1.htm#le6821 The title of the page is JAMA Letters - May 21, 1997 
Estrogen Replacement Therapy: New Options, Continuing Concerns 

skipping partway down the page to this: 

To the Editor.--In their Editorial, Dr Insogna and coauthors[1] misquote the report of the Study of Osteoporotic Fractures.[2] In doing so, they appear to miss their main point. In their report, Cauley et al state: "Our findings suggest that the risk of breast cancer associated with hormone replacement therapy may have been underestimated by previous investigators [emphasis added] because osteoporosis is a primary indication for its use." Cauley et al do not purport to show direct evidence that HRT is associated with breast cancer but do show that bone mineral density is correlated with breast cancer risk. A direct corollary of this is that patients with low bone mineral density (ie, with osteoporosis) have a lower risk of breast cancer than patients with normal bone mineral density. Thus, if users of HRT are more likely to have osteoporosis than nonusers, yet users are found to have the same breast cancer risk as nonusers, it follows that HRT must have increased the low breast cancer risk of osteoporotic users to achieve the same level of risk as the nonosteoporotic nonusers.

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