"Women with a family history of breast cancer should be screened in their thirties," says The Daily Telegraph.

The news relates to an ongoing study that aims to look at the effects of mammography screening in women with a family history of breast cancer when they are between the ages of 35 and 39. 

National guidelines currently recommend that women identified as being at increased risk of breast cancer because of a family history of the disease are offered annual mammography screening from the age of 40. Women at very high risk, such as those with BRCA1 or 2 mutations, are already offered annual MRI screening from the age of 30.

This report covers the first stage of the study, which looked back at the type of screening offered to women in this category at 33 centres across the UK. It found that the majority of the centres surveyed offered mammography, with most offering it on an annual basis.

In the five centres with the most rigorous follow-up, 47 cancers were identified in women, with almost half identified through screening and about a third identified between mammograms.

Comparison of these cancers with results reported in previous studies in unscreened women suggested that in the women offered screening, the cancers identified were smaller and less likely to have spread to the lymph nodes at the time of diagnosis.

The current study gives a snapshot of existing surveillance measures in the UK for women aged 35-39 who have an increased risk of breast cancer because of their family history. But as the centres surveyed were not specifically collecting information in order to analyse the effectiveness of mammography screening, they did not have enough information for a thorough analysis.

Therefore, the second part of this study plans to follow 2,800 high-risk women offered mammography screening on an annual basis up to 2016. These results will give a better idea of the potential benefits, risks and costs of screening in this younger age group.

Where did the story come from?

The study was carried out by researchers from the Genesis Breast Cancer Prevention Centre at the University Hospital of South Manchester NHS Trust and other hospitals and research centres in the UK.

It was funded by Breast Cancer Campaign and was published in the peer-reviewed medical journal, Familial Cancer.

The Daily Telegraph's headline doesn't convey the preliminary nature of these findings, but it does report later on in the story that a larger study is planned and that changes to recommendations are only likely if the larger study confirms the results.

What kind of research was this?

The researchers were reporting on part of a study of breast cancer screening in younger women with a family history of breast cancer (the FH02 study). The first part of the study was a retrospective analysis of the type of breast cancer surveillance that has been offered to these women in the past and what their outcomes were.

In the UK, all women between the ages of 50 and 70 are currently offered mammography. Women whose family history indicates that they are at increased risk are offered annual mammograms from the age of 40 as a form of "surveillance" for the disease. Women at very high risk, including those who are known to carry mutations in one of the BRCA1/BRCA2/TP53 genes, are offered annual MRI screening from the age of 30.

The researchers report that a previous study looked at mammography for women aged 40-49 in the UK with a significant family history of the disease (the FH01 study), but the effects of mammography in women aged 35-39 has not yet been assessed.

The National Institute for Health and Care Excellence (NICE) has produced guidelines on how doctors should classify breast cancer risk in women with a family history of the disease, and how they should be assessed and treated.

The researchers state that in the second part of this study, they will carry out a prospective study to look at the effects of breast cancer surveillance in these younger women. A previous study suggested that the health professionals caring for these women feel that such surveillance is likely to be of benefit. For this reason, it was decided that it would not be ethical to carry out a randomised controlled trial and that the study would compare the participants' results with those from previous studies instead.

What did the research involve?

Retrospective study

The researchers sent a survey to the 33 centres taking part in the study. The survey asked whether they had previously carried out mammographic surveillance in women under the age of 40 with an increased familial risk of breast cancer.

If they answered yes, the survey then asked about exactly how they selected women for surveillance and what this consisted of. They also asked about the outcomes of this surveillance, including the number and type of cancers identified.

The researchers compared these results with the types of cancer reported in studies published previously looking at women:

• aged 40-49 years with a family history of breast cancer who had annual mammography (the FH01 study)
• aged 40-49 years with a family history of breast cancer
• a series of women aged 30-49 having breast cancer surgery
• women aged 35-39 years with a family history of breast cancer who had not been screened

Prospective study

The researchers reported in detail the planned approach for their prospective study. This study aims to identify the likely benefit of annual mammography for women aged 35-39 with a family history of breast cancer.

They will compare the results in this group with results from the preceding study in older women with a family history of the disease (the FH01 study) and the UK Age Trial, a randomised controlled trial that assessed the effects of annual mammography screening in women from the age of 40 (not selected on the basis of family history). This study will also assess the cost of surveillance, so it can estimate its cost effectiveness.

The researchers say they have recruited 2,280 women from 33 centres, and should have reached the target of 2,800 by the end of June 2013. The study is expected to continue until June 2016.

What were the basic results?

In their survey, the researchers found that among the 33 centres:

• mammography screening in women aged 35-39 at increased risk of breast cancer was already carried out in 27 centres
• almost all of this screening was reported to use film mammography, rather than the newer digital mammography
• these 27 centres record a three generation family history and carry out a risk assessment in these women to determine their risk level
• 25 of the centres record the women's lifetime risk of cancer and 22 record whether they have the known genetic mutations which predispose women to breast cancer (BRCA1, BRCA 2 and TP53)
• 26 of the centres offered the women annual mammograms and one centre offered them screening every two years
• 17 centres offered MRI scanning
• 14 centres offered routine physical examinations
• none of the centres routinely offered ultrasound

Five centres had robust systems to reliably identify whether any breast cancers were identified in these women in the period between mammograms (called interval cancers), as well as any detected in the mammogram.

There were 47 breast cancers in the women attending these centres between 1994 and 2010. Ten of these cancers (21%) were already known when the women attended the centres, 22 were new cancers (47%) identified through screening, and 15 (32%) were detected between mammograms.

Compared with two groups of unscreened women with breast cancer – one who had a similar family history and one without a family history – the cancers among the screened women were significantly smaller and less likely to have spread to the lymph nodes.

More of the screened women were alive with no spread of the disease in the screened group than in the two groups of unscreened women with breast cancer. However, the number of deaths from breast cancer was too small to carry out a robust analysis.

How did the researchers interpret the results?

The researchers say that this is the first study to assess the effects of mammography alone in women aged under 40 who are at increased risk of breast cancer.

They say that the results are "encouraging", but that the prospective part of their study is needed to assess the effects of digital mammography in moderate and high-risk women in order to inform cost effectiveness analyses.

Conclusion

The current study gives a snapshot of existing surveillance measures in the UK for women aged 35 to 39 with an increased risk of breast cancer due to their family history.

There are some points to note, which the authors themselves highlight:

• As this first part of the study is retrospective, the centres will not have collected all the relevant information that would allow thorough evaluation of the effects of mammography.
• The number of cancers in women receiving screening described in detail in the current study is small (just 47). The larger prospective part of the study is needed to get better estimates of the rates of cancer in these women.
• Most previous screening in the centres used film mammography, but the newer technique of digital mammography may offer better results. 
• In addition, the comparisons performed in the current part of the study against results in other studies may be affected by differences between the groups of women other than the screening offered. For example, the studies covered different time periods, and breast cancer management may have differed over these periods and could affect the chances of survival.

Overall, the current study gives some background information, but the second part of the study will shed more light on the potential effects of mammography surveillance in younger women at increased risk of breast cancer.
 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Family history of breast cancer should mean screening earlier. The Daily Telegraph, June 17 2013

'Screen women aged 30 for breast cancer': Half a million at risk because of family history could be offered mammograms. Daily Mail, June 17 2013

Call for more breast cancer screening. The Times website, June 17 2013

Links To Science

Evans DG et al. Mammographic surveillance in women aged 35–39 at enhanced familial risk of breast cancer (FH02). Familial Cancer. Published online June 4 2013

The findings of a study examining 39 years of breast cancer death rates have hit the headlines, with The Guardian reporting that, 'Breast cancer screening not shown to reduce deaths.' The value of breast cancer screening has been the subject of debate for many years. Every time it seems the question has been settled – as some presumed was the case after the publication of a 2012 review into screening – new evidence emerges that reignites the debate.

The latest study by researchers at Oxford University found that declines in mortality rates over time were highest in women under the age of 40, who are not normally invited for screening. The researchers also found significant downward changes in trend in women aged between 50 and 64 years old, the age group screening is targeted at.

But this change occurred in 1979 in Oxford and in 1990 throughout England, with the researchers concluding that better treatment for breast cancer is behind the trend, not screening programmes. This is because the downward trend began either before screening was introduced or too soon after the introduction of screening for it to have an effect.

Breast cancer screening is an extremely complex topic and it is difficult to assess the value of screening programmes. It may be possible the benefits of screening have been obscured by other risk factors and improvements in treatment. It is hoped the picture will become clearer as more evidence becomes available. 

Where did the story come from?

The study was carried out by researchers from the University of Oxford and was funded by the National Institute for Health Research in the UK.

It was published in the peer-reviewed Journal of the Royal Society of Medicine.

The results of the study were reported well by the media. 

What kind of research was this?

This study was a time-trend analysis of mortality (death) data in England to see whether breast cancer screening using mammography reduced deaths from breast cancer.

As this is an observational study, it is possible the benefits of screening programmes may be obscured by changes in both treatment and risk factors that have occurred over time.

Ideally a randomised controlled trial would be performed to assess the benefits of a screening programme. However, it is unlikely that any new randomised controlled trials of breast cancer screening in the UK will be performed.

To perform a randomised controlled trial, women would have to be prepared to be randomised to screening or to no screening. As there is currently a national screening programme in place, it is unlikely that enough women would be prepared to possibly forgo screening.

What did the research involve?

Researchers analysed the number of women who died from breast cancer in the Oxford region between 1979 and 2009. They focused on data from this region because all causes of death are mentioned on death certificates there, not just the underlying cause of death.

The researchers wanted to try to exclude the possibility that ambiguity about the underlying cause of death or changes in reporting practices distort the true picture. A total of 20,987 death certificates where female breast cancer was noted were included.

The researchers also analysed the rate of death from breast cancer between 1971 and 2009 for the whole of England, where only the underlying cause of death is reported on the death certificate.

Researchers compared trends in the rate of death from breast cancer before and after the English National Breast Cancer Screening Programme was introduced in 1988. Three groups of women were included for the same time period:

• women who had been screened once
• who had been screened several times
• unscreened women

The researchers used a statistical technique called joinpoint analysis to estimate the years in which trends changed. Joinpoint analysis makes use of specialist statistical software to track trends over time. Each joinpoint corresponds to the estimated location of a change in a trend – in this case, mortality.

What were the basic results?

In the Oxford region, of the women with breast cancer mentioned on their death certificate, breast cancer was the underlying cause of death in 96% of women aged under 65 at death, 88% of women aged between 65 and 74, 78% aged between 75 and 84, and 66% of women aged 85 or older.

Trends for breast cancer-related deaths were very similar for whether breast cancer was listed as the underlying cause or whether it was mentioned on the death certificate. This suggests that it is unlikely that changes in death certification practices or changes in the rules for selecting the underlying cause of death affect the change in deaths due to breast cancer over time.

For all ages combined, death rates peaked in 1985 (both when breast cancer was the underlying cause and when breast cancer was mentioned) and then started to decline. This occurred prior to the introduction of the screening programme in 1988.

Between 1979 and 2009, for deaths due to breast cancer as the underlying cause, rates declined uniformly (without a detected change in trend over time):

• for unscreened women aged 40-49 there was a decline of -2.1% per year, and
• for screened women aged 50-64 there was a similar decline of -2.1% per year

There was also a significant change in trend downward in deaths caused by breast cancer in 1987 in women aged 65-74, and in those aged 75 years or older in 1989. These changes occurred before the screening programme was introduced, or before it was likely to have had an effect.

Between 1979 and 2009, rates of breast cancer mentioned on the death certificate also declined uniformly in women aged 40-49 (unscreened) and women aged 50-64 (screened). There was a significant downward change in trend in breast cancer deaths among women aged 65-74 in 1990, and among women aged 75 years or older in 1996.
 
In England, the first estimated changes in trend occurred prior to the introduction of screening, or before screening was likely to have had an effect (between 1982 and 1989). A second downward change in trend occurred in 2001 in women under the age of 40 (who are not routinely screened) and in 1990 in women aged between 50 and 64.

Most significantly, there was no evidence that declines in mortality rates were consistently greater in women in age groups and cohorts that had been screened, or screened several times, compared with other unscreened women in the same time periods.

How did the researchers interpret the results?

The researchers say that, "mortality statistics do not show an effect of mammographic screening on population-based breast cancer mortality in England."

Conclusion

This study of rates of death caused by breast cancer over a 39-year period has found no evidence of the benefits of breast cancer screening. Age-specific mortality rates for women aged between 40 and 49, 50 and 64, and 64 and 74 years peaked prior to the introduction of breast cancer screening in 1988. Declines in mortality were greatest in women under the age of 40 and smallest among women aged 75 years or older.

The researchers found that there were significant changes in downward trend in women aged between 50 and 64 years old – the age group screening is targeted at – but that these occurred in 1979 in Oxford and in 1990 in England. Both of the changes occurred before the introduction of screening, or too soon after the introduction of screening for it to be likely that screening caused the change.

In addition, significant declines in mortality rates per year were seen in women aged under 40, who would not normally be invited for screening.

As an observational study of population level data, several points are worth noting:

• Direct comparisons of individuals who were screened with those who weren't is not possible with this type of study design. Researchers were only able to compare mortality for women in age groups that were likely to have been screened with those who were unlikely to have been screened.
• The results do not rule out a benefit at the level of individual women, but the effect is not large enough to be detected at the population level.
• "Secular" effects – that is, effects that occur over time independently of screening – can obscure the screening effects. For example, the effect of better drug treatments or changes in risk factors such as childbearing patterns over time might have outweighed smaller improvements thanks to screening.

This study provides additional valuable population data to inform the breast cancer screening debate. There is a great deal of information on both the pros and cons of screening. The 2012 review into breast cancer screening estimated that for every 10,000 women invited for screening from the age of 50 for 20 years:

• 43 deaths from breast cancer will be prevented
• 681 breast cancers will be diagnosed
• 129 of these diagnoses will be "overdiagnosed"

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Breast cancer screening not shown to reduce deaths, say researchers. The Guardian, June 11 2013

Breast cancer screening fails to cut deaths. The Daily Telegraph, June 11 2013

Breast screening 'doesn't cut deaths': Study of 40 years of mammograms show 'no evidence' they reduce chance of dying. Mail Online, June 11 2013

Links To Science

Mukhtar TK, Yeates DRG, Goldacre MJ. Breast cancer mortality trends in England and the assessment of the effectiveness of mammography screening: population-based study. Journal for the Royal Society of Medicine. Published online June 10 2013

“North and South health divide: Chilling study reveals premature death is 'postcode lottery',” the Daily Mirror reports.

The news is based on a new interactive map showing the variation in premature death rates across England.

The Longer Lives map, created by the new organisation Public Health England, ranks 150 local authorities by their premature death rates (deaths occurring before age 75).

The interactive map also enables users to compare these areas by five common causes of premature (and potentially preventable) deaths:

• cancer
• heart disease
• stroke
• lung diseases, such as chronic obstructive pulmonary disease 
• liver diseases such as cirrhosis

The simple, colour-coded map enables users to see the variations between each local authority at a glance, including a measure of socioeconomic deprivation.

Much of the media coverage of the new map was dominated by the striking contrast between large parts of the north, coloured red (poor health), and the affluent south, mostly coloured green (good health). However, there are also pockets of poor health in some southern cities, boroughs of London, and in the Midlands.

What information is this map based on?

The information provided in Longer Lives is from the Public Health Outcomes Framework. This uses records of deaths from the Office of National Statistics.

The death rates are standardised to account for the fact that death rates are higher in older populations and adjusts for differences in the age make-up of different areas.

What factors could explain the variations?

Links To The Headlines

Early deaths: Regional variations 'shocking' – Hunt. BBC News, June 11 2013

Councils should look at banning fizzy drinks in schools, says Health Secretary. The Daily Telegraph, June 11 2013

The health gap: New mortality rates show how the north loses out to the south. The Independent, June 11 2013

Steer clear of Manchester to avoid an early grave: City has highest rate of people who die prematurely. Daily Mail, June 11 2013

North and South health divide: Chilling study reveals premature death is 'postcode lottery'. Daily Mirror, June 11 2013

Early Death Atlas Shows 'Shocking' Variations. Sky News, June 11 2013

Most deaths in under-75s are potentially avoidable, says health body. The Guardian, June 11 2013

Want a long life? Live in the south of England. Metro, June 11 2013

The Daily Mail reports on the warning for pregnant women that household chemicals could pose a threat to their babies. ‘Don’t paint the nursery and avoid non-stick frying pans’ the Mail continues. 

The news is based on advice to pregnant or breastfeeding women in a report from the Royal College of Obstetricians and Gynaecologists (RCOG).

The report, titled ‘Chemical exposure during pregnancy: dealing with potential, but unproven, risks to child health’ warns that pregnant and breastfeeding women could be exposed to harmful chemicals through:

• food packaging
• ordinary household products
• medicines
• personal care items such as moisturisers

It is important to stress that the advice is framed in a safety-first approach. There is no credible evidence that any of the items listed above pose a threat to birth outcomes.

A large amount of uncertainty exists because carrying out studies to assess these risks is difficult. This is because virtually all pregnant women are exposed to certain chemicals as they are found in everyday products.

The report provides a list of recommendations and examples of how women can avoid these potentially harmful chemicals (such as to minimise purchasing household furniture, frying pans or cars – see below for more details).

However, these recommendations are based on little evidence of any risk to the child. It recommends women put ‘safety first’ and assume a risk is present even when it may be small or proven not to be harmful.

Reassuringly, the report does say that one option is for mothers to do nothing and acknowledges that it may be difficult to avoid certain exposures.

The advice has prompted criticism by some, arguing that causing stress during pregnancy could do more damage than a theoretical, and as yet unproven, risk of chemical exposure.

Who are RCOG?

The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional membership organisation based in the UK. According to their website, they encourage the study and advancement of the science and practice of obstetrics and gynaecology (women’s reproductive health). They do this through education and training for their members as well as publication of clinical guidelines and reports for patients and practitioners working in this area.

According to the RCOG press release, the report has been produced by an RCOG Scientific Advisory Committee. It says these papers are up to date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology and that the papers are intended to raise awareness of such issues.

Why has this report been produced?

According to the report, no official advice or guidelines exist that inform women who are pregnant or breastfeeding of the potential risks that some chemical exposures could pose for their babies.

Co-author of the paper, Dr Michelle Bellingham from the University of Glasgow, says, ‘there is much conflicting anecdotal [single observations] evidence about environmental chemicals and their potentially adverse effects on developing babies.’

She adds, ‘The information in this report is aimed at addressing this problem and should be conveyed routinely in infertility and antenatal clinics so women are made aware of key facts that will allow them to make informed choices regarding lifestyle changes.’

What evidence did the report look at?

The report states there is some evidence linking exposure to some chemicals during pregnancy with negative birth outcomes. Encouragingly, it emphasizes that this evidence is only of an association and there is no evidence that one causes the other (causality). It also says that some studies show no association between chemical exposure and disease. This evidence is not provided in detail but links to the primary research are included in the report.

The report mentions that other studies looking at this issue have investigated the effects of chemicals on pregnant animals. However, as the report points out, it is often difficult to interpret animal research and caution should be exercised when trying to generalise these findings to humans. In part, because in some of these studies the animals are exposed to levels of chemicals that would never occur in a real world human setting.

The focus of the report, it says, was to provide examples of where chemical exposures can be avoided.

What recommendations did the report make?

The report recommends the best approach for pregnant women is ‘safety-first’. It says this is ‘to assume there is a risk present even when it may be minimal or eventually unfounded.’

Other recommendations provided in the report include:

• use fresh food rather than processed food wherever possible
• reduce use of food and drink in cans or plastic containers
• minimise the use of personal care products such as moisturisers, cosmetics, shower gels and fragrances
• minimise the purchase of newly produced household furniture such as fabrics, non-stick frying pans, and cars while pregnant or breastfeeding
• avoid paint fumes and all pesticides, such as fly spray
• only take over-the-counter medicines when necessary
• do not assume safety of all ‘natural’ named products

Despite this list of recommendations, the report acknowledges that it may be difficult for mothers to deal with the uncertainty of chemical exposure risks and that one option is do nothing.

How has the report been received?

It is fair to say that the report has not been universally well received. Many commentators have criticised the findings as being needlessly alarmist without providing any credible evidence of a threat posed by everyday chemical exposure. Ultimately the report, in the words of the critics, provides little in the way of useful advice.

Tracey Brown, of the Sense About Science charitable trust was quoted by BBC News as saying “Pregnancy is a time when people spend a lot of time and money trying to work out which advice to follow, and which products to buy or avoid. The simple question parents want answered during pregnancy is: 'Should we be worried?'

"What we need is help in navigating these debates about chemicals and pregnancy. Disappointingly, the RCOG report has ducked this."

Conclusion

Nervous mothers-to-be may want to take on board RCOG’s recommendations, though as previously mentioned, the evidence to back up these recommendations is lacking. It is important not to lose sight of established harms that are known to cause damage to a pregnancy:

• smoking
• drinking alcohol
• using drugs
• certain types of medication, such as medications used to treat epilepsy
• eating certain foods, such as pate or liver

Read more about health and wellbeing in pregnancy in the NHS Choices Pregnancy and baby guide.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Food packaging and furniture: What to avoid when you're pregnant. The Independent, June 5 2013

A mum-to-be? Don't paint the nursery and avoid non-stick frying pans: Pregnant women warned over risk to baby from exposure to chemicals. Daily Mail, June 5 2013

Expectant mothers told not to paint the nursery or use non-stick frying pans in case of chemical exposure. The Daily Telegraph, June 5 2013

Chemicals: a worry for pregnant women? BBC News, June 5 2013

Pregnancy safety advice prompts criticism. BBC News, June 5 2013

Pregnant Women Warned Of Chemical Exposure. Sky News, June 5 2013

Pregnant women warned over household products. ITV News, June 5 2013

The actor Michael Douglas discussed his recent throat cancer treatment in an interview with The Guardian this weekend, and revealed that he blamed oral sex for his condition. 

When asked by the newspaper if his throat cancer was caused by his many years of heavy drinking and smoking he was quoted as saying: "No, because without wanting to get too specific this particular cancer is caused by HPV, which actually comes about from cunnilingus." Could he be right? Here are some facts about HPV, oral sex and cancer risk.

What is HPV?

The human papilloma virus (HPV) is the name for a group of viruses that affect your skin and the moist membranes lining your body, for example, in your cervix, anus, mouth and throat.

There are more than 100 types of HPV – 40 of which can affect the genital area.

The HPV virus is very common and is easily spread by sexual activity. As many as half the population will be infected at some time in their life. In most cases, the virus doesn't do any harm because your immune system gets rid of the infection. But in some cases, the infection persists and can lead to health problems.

Can HPV really cause cancer?

Yes. While many types of HPV are harmless, other high-risk types can cause abnormal tissue growth and trigger the onset of cancer.

Cancers linked to HPV infection include:

• cervical cancer
• vaginal cancer
• vulval cancer 
• anal cancer
• cancer of the penis
• some cancers of the head and neck

Some types of HPV can also cause verrucas, skin warts and genital warts.

How can HPV infection be prevented?

Using a condom during sex, including oral and anal sex, can help to prevent HPV infection. However, as condoms do not cover the entire genital area and are often put on after sexual contact has begun, a condom is not always a guarantee against the spread of HPV.

Is there a HPV vaccine?

There are actually two vaccines against HPV: Cervarix and Gardasil. Cervarix protects against two very high-risk types (HPV-16 and HPV-18).

Gardasil also protects against these types, as well as two types that cause genital warts.

The Gardasil vaccine is now part of the NHS childhood vaccination programme and is routinely offered to secondary school girls aged 12 and 13. Giving the vaccine several years before a person is likely to become sexually active increases its effectiveness.

The HPV vaccination programme is intended mainly to reduce the number of cervical cancer cases in the future.

Can boys have the vaccine?

There is no clinical reasons why boys cannot have the vaccine, but it is not currently recommended as part of the NHS vaccination schedule.

If you want your son to be vaccinated then you will have to pay for the vaccine. The course of vaccination consists of three doses with each dose costing around £150.

So did oral sex cause Michael Douglas's cancer?

Based on the available evidence it is impossible to say.

But given what we know about risk factors for these types of cancer, his years of smoking and drinking could well have played a significant part.

The two biggest risk factors for these types of cancer are drinking alcohol and smoking. The risk is even higher if you are both a heavy drinker and a heavy smoker.

For more information, see Can oral sex cause cancer?

What can I do to reduce my cancer risk?

The four most effective methods you can do to reduce your risks are:

• quit smoking if you smoke
• moderate your consumption of alcohol
• eat a healthy balanced diet
• take regular exercise

And while wearing a condom may only provide limited protection against HPV it does offer more effective protection against other nasty STIs (as well as being a good method of contraception to prevent unplanned pregnancies).

Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Michael Douglas on Liberace, Cannes, cancer and cunnilingus. The Guardian, June 2 2013

It's oral sex, not smoking: Michael Douglas says his throat cancer was caused by stress and the human papillomavirus (HPV) – and also says 'cunnilingus is the best cure'. The Independent, June 3 2013

Doctors question Michael Douglas' 'dubious' claim that he contracted throat cancer from 'oral sex'. Mail Online, June 3 2013

Did oral sex cause Michael Douglas's cancer? Channel 4 News, June 3 2013

Oral sex gave me cancer. The Sun, June 3 2013

“A cocktail of drugs can reduce advanced skin cancer tumours by more than 80 per cent,” reports the Mail Online.

The news is based on a small early stage trial of a combination of two drugs, nivolumab and ipilimumab, in people with advanced melanoma (an often fatal form of skin cancer). Both of these ‘monoclonal antibody’ drugs work by encouraging the immune system to attack cancerous cells.

Nivolumab and ipilimumab work in slightly different ways, so the researchers hoped that combining the two would lead to a more effective treatment.

The study found that just over half (535) of the people treated with the highest dose of the drugs (and who had acceptable side effects) showed a measurable response to the drugs. All of these people showed at least an 80% reduction in the size of their tumour.

Advanced melanoma is difficult to treat so the results are encouraging. Unfortunately shrinkage of the tumours does not necessarily mean that the cancer has been cured. Longer-term studies are needed to assess what effect the combination has on life expectancy and overall survival.

The results of the current trial mean it is likely that this will be tested in further trials.

Read more about clinical trials into melanoma in the UK, many of which are recruiting participants.

Where did the story come from?

The study was carried out by researchers from the Memorial Sloan-Kettering Cancer Center and other research centres in the US, as well as researchers from Bristol-Myers Squibb and Dako North America. It was funded by Bristol-Myers Squibb and Ono Pharmaceutical, the manufacturers of the drugs being tested. The study was published in the peer-reviewed New England Journal of Medicine.

A conflict of interest, made clear in the research paper, is that many of the researchers are employees or hold stock in the pharmaceutical company that makes both drugs (Bristol-Myers Squibb).

The Mail Online’s report of the study was of a good quality.

What kind of research was this?

This was a paper reporting an ongoing phase I trial of a new combination of drugs in people with advanced melanoma. The drugs used were nivolumab and ipilimumab: both are antibodies that block different proteins which normally help the cancer to evade the immune system.

Ipilimumab has already been granted a license in the UK for use in adults with advanced melanoma who have been previously treated, but whose treatment has not worked or has stopped working. The National Institute for Health and Care Excellence (NICE) has more information on the use of ipilimumab in the NHS.

Nivolumab is a newer drug, has not yet been granted a license for use in the UK, and is currently only available for people who are taking part in clinical trials.

Ipilimumab alone has previously been shown to improve survival in people with advanced melanoma. Different types of cancer, including melanoma, have also been shown to respond to treatment with nivolumab alone. This study wanted to test what happened if both drugs were used together.

A phase I study is the first stage of testing a new drug or combination of drugs in a small number of people to see if their disease shows a response and what the side effects are. If the results are favourable, the drugs would go on to phase II testing of dosing and safety issues in more people and then finally phase III trials to compare it to other accepted treatments.

What did the research involve?

The researchers recruited 86 adults with advanced melanoma skin cancer that had spread to the lymph nodes or spread further in the body (stage III or IV), which could be measured and could not be surgically removed.

To be eligible, people had to be relatively well, with no symptoms or symptoms that only restricted strenuous activity, and have a life expectancy of at least four months.

People who had been treated with these types of drugs before, whose cancer had spread to their nervous system and had not been treated, or who had autoimmune disease, HIV, or hepatitis B or C were excluded.

The researchers were testing two different approaches:

• a concurrent regimen: giving nivolumab and ipilimumab together every three weeks for a total of four doses, followed by nivolumab alone every three weeks for a total of four doses, and then both nivolumab and ipilimumab together every 12 weeks for up to eight doses
• a sequenced regimen: giving nivolumab every two weeks for up to 48 doses in people who had already had at least three doses of ipilimumab. People who had complete response to ipilimumab, or progression of their cancer with evidence of clinical deterioration, or a history of serious adverse effects with ipilimumab were excluded

The two drugs were injected into a vein, and the researchers tested increasing doses of the drugs in successive groups of patients. The participants had their responses monitored using a modified version of standard World Health Organization criteria. These criteria rate response to treatment as complete or partial. Complete response means disappearance of all measurable tumours for at least four weeks, partial response was a reduction by in the size of the measurable tumours by 50% for at least four weeks and no new lesions.

Participants were followed for up to 2.5 years after the start of their treatment. If they initially had a complete response, a partial response, or stable disease for at least 24 weeks but then progressed, they could have the treatment they originally received, again.

What were the basic results?

The researchers treated 53 people with the drugs at the same time, and 33 with the drugs in sequence.

Overall, 40% of people treated concurrently showed an objective response – responded to the treatment – (either complete or partial). Most people who responded had a partial response (16 people), with a few having a complete response (5 people). Of these people, 31% showed a reduction in tumour size of at least 80%. Among the 17 people who received the highest dose of the concurrent regimen that had an acceptable level of side effects, just over half (nine people, 53%) showed an objective response (three complete and six partial). These people all showed a reduction in tumour size of at least 80%.

Almost all participants given the drugs at the same time (93%) had some side effects, mainly rash (55%), itchy skin (47%), fatigue (38%), and diarrhoea (34%). Just over half (53%) had more serious side effects (called grade 3 and 4 events), and in 21% these events meant the dose had to be adjusted.

Fewer people receiving the drugs in sequence showed an objective response (20%), with 73% having side effects, and 18% having the more serious grade 3 or 4 side effects.

With both treatment methods, the side effects were manageable and could be reversed with appropriate treatment. There were no treatment-related deaths.

How did the researchers interpret the results?

The researchers concluded that nivolumab and ipilimumab given together had a “manageable safety profile” and gave rapid responses which appeared to be larger than that previously seen with either of the drugs alone.

Conclusion

This phase I study has suggested that combining two drugs – nivolumab and ipilimumab – can produce a response in people with advanced melanoma with an acceptable safety profile. This type of study is a first step in human studies of new drugs or combinations of drugs.

The authors themselves note that some caution is required due to the small size of the study and the potential for the participants not to be representative of the wider patient population. The results in this study mean the researchers are likely to carry out larger studies comparing this combination of drugs against the combined drugs alone and possibly against other treatments.

The National Institute for Health and Care Excellence (NICE) has recommended ipilimumab given alone as an option for treating advanced melanoma (that has spread (metastatic) or cannot be surgically removed) in people who have received previous treatment.

Nivolumab is a new drug which has not yet gone through the procedure to be granted a license for general use in Europe. Given the generally positive results of this study, it is likely the manufacturer will seek a licence at some point in the future. This usually requires the results of phase III trials to be available.

If this does happen, it is likely that NICE will review the evidence on the drug either alone or in combination with ipilimumab to make a decision on whether it should be made available on the NHS for people with advanced melanoma.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Taking certain cocktail of skin cancer drugs 'can reduce growth of tumours by 80%'. Mail Online, June 2 2013

Links To Science

Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus Ipilimumab in Advanced Melanoma. The New England Journal of Medicine. Published online June 2 2013

"Cancer cell enzymes shown to act as 'good cops'," is the headline on the BBC News website.

The BBC reports on laboratory research into an enzyme called MMP-8 and its effects on breast cancer. The research reveals that while MMP-8 appears to stimulate the growth of breast cancer cells in the short-term, it may slow tumour growth in the long-term.

Scientists are likely to want to explore new treatments that use MMP-8’s ability to slow tumour growth in this way. However, this study used laboratory-grown cells, which don’t behave in the same way as tumour cells within the body. It could be the case that the effect of MMP-8 is different when studied in people.

Nonetheless, this research provides new understanding about how the MMP-8 enzyme influences the growth and development of laboratory-grown breast cancer cells. And while this research has limited immediate implications for people with breast cancer it does contribute new understanding that may help to treat the disease in the future.

Where did the story come from?

The study was carried out by researchers from the University of East Anglia (UK) and the University of Vermont College of Medicine (USA) and was funded by Breast Cancer Campaign, Cancer Research UK, the European Union Framework Programmes 6 and local Norfolk fundraisers.

The study was published in the Journal of Biological Chemistry, a peer-reviewed science journal. It was published as an open-access article so it is free to download.

The reporting of the research was mixed. While the Mail Online exaggerated the results of the study by describing a “breakthrough” that “turns previous thinking on its head”, the BBC coverage was more restrained, including comment from Cancer Research UK on how the research provides "very early clues" about how the enzyme might recruit cells to fight breast cancer.

What kind of research was this?

This was a laboratory study exploring the role of an enzyme called matrix metalloproteinase-8 (MMP-8) in the growth of breast cancer tumour cells.

MMP-8 performs many essential jobs in a normal cell. The researchers say it is known to activate certain immune system signals (called interleukin-6 and interleukin-8), which are types of molecules that regulate and orchestrate the actions of the immune system.

The researchers comment that, traditionally, scientists thought MMP-8 helped cancer cells grow and spread, but more recent research has suggested it may also prevent cancer cell growth.

This research sought to find out if, and how, MMP-8 inhibited tumour cell growth in laboratory-grown breast cancer cells.

Understanding the biology and chemistry of processes involved in diseases such as cancer through laboratory studies is essential if we want to discover new ways to prevent and treat them.

What did the research involve?

The researchers grew human breast cancer tumour cells in a laboratory. Some cancer cells were deliberately engineered to lack a properly functioning MMP-8 enzyme (called “mutant MMP-8”), whereas others had a fully functional version (known as the “wild-type” version). The intention was to see what effect this had on the ability of the cancer cells to grow and develop.

The researchers paid particular attention to the effect of this manipulation on the immune system signalling molecules interleukin-6 (IL-6) and IL-8, which are known to be involved in the growth and development of cancer cells. Genetic changes within the cells were also measured. 

All the research was carried out in artificially grown laboratory cells and no tests were done in people with cancer.

What were the basic results?

The research found tumour cells containing the wild-type MMP-8 had elevated levels of IL-6 and IL-8 and that, in the short-term, this was associated with higher levels of tumour cell growth. Cells lacking a working MMP-8 enzyme had lower levels of IL-6 and IL-8 and did not grow as well.

However, in the longer term, activity of the MMP-8 enzyme was found to inhibit the growth of the tumour cells and it was found that the IL-6 and IL-8 levels were no longer elevated.

Interestingly, the small number of cells with a working MMP-8 enzyme that did keep on growing in the long-term had somehow maintained their elevated levels of IL-6 and IL-8 but these were no longer dependent on MMP-8 activity. The relationship had changed from the short- to the long-term.

This showed that in the early stages of tumour growth MMP-8 activity stimulated IL-6 and IL-8, which helped the tumour grow, but, later on, MMP-8 activity limited tumour growth and the IL-6 and IL-8 levels returned to normal.

Only cancer cells where MMP-8 activity had become disconnected from IL-6 and IL-8 levels were able to keep growing in the longer term. 

How did the researchers interpret the results?

The researchers concluded that their research showed a “causal connection” between “MMP-8 activity and the IL-6/IL-8 network”, which showed MMP-8 influences the signalling of pro-inflammatory factors (IL-6 and IL-8) that “conventionally promote tumour cells’ growth and development”.

Conclusion

This laboratory study provides new understanding about how the MMP-8 enzyme interacts with inflammatory signals (IL-6 and IL-8). MMP-8 might be something of a double-edged sword. While it stimulates the growth of cancerous cells in the short-term, it may also suppress growth in the long-term.

As with all laboratory studies, new or different discoveries need to be replicated by other research groups to ensure they are accurate and the results weren’t due to chance.

Assuming the research results are valid they could provide an opportunity for cancer researchers to investigate and possibly devise new methods of using MMP-8 activity to supress breast tumour cell growth. However, the research found that some tumour cells kept growing despite the presence of MMP-8. This highlights that cancer cells differ, and that, often, what works in one place and setting may not work in others.

It is important to remember that the researchers investigated breast cancer cells only, so this study alone does not tell us anything about the role of MMP-8 in other cancer types. Similarly, the research used artificially grown breast cancer cells, which may not behave in exactly the same way as tumour cells within a human body.

This research into a new target for drug development provides new and interesting understanding that other researchers can build on. An improved understanding of the biology underpinning breast cancer may lead to the development of new treatments.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Cancer cell enzymes shown to act as 'good cops'. BBC News, May 24 2013

Breast cancer cells can suppress tumour growth 'by releasing protective proteins'. Mail Online, May 24 2013

Links To Science

Thirkettle S, Decock J, Arnold H, et al. Matrix metalloproteinase-8 (collagenase-2) induces the expression of interleukins-6 and -8 in breast cancer cells. The Journal of Biological Chemistry. Published online May 30 2013

Writing in the New York Times, actress Angelina Jolie has announced that she has recently undergone a double mastectomy (where both breasts are surgically removed) followed by breast reconstruction surgery.

She writes that this is because genetic testing revealed she had a 87% chance of developing breast cancer in later life, as well as a 50% risk of ovarian cancer. This means she took a decision to have ‘preventative surgery’.

Jolie explained: "I decided to be proactive and to minimise the risk as much as I could. I made a decision to have a preventative double mastectomy.

"Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action."

What genes contribute to breast cancer risk?

A number of genes, associated with breast cancer, have been identified. People often talk about 'having' these genes, which include BRCA1, BRCA2, TP53 or PTEN. In fact, every women has these genes, but if a fault (mutation) develops in one of the genes then it can increase the risk of a women developing breast cancer.

It is estimated that around 1 in 500 women have a high-risk mutation in one of the genes associated with breast cancer. However, having this high risk mutation does not mean that a woman will definitely develop breast cancer.

What is the risk if you have a faulty breast cancer gene?

If you have a faulty gene, it doesn't mean you'll definitely develop breast cancer, but you are at a higher risk.

Having a fault in one of the breast cancer genes raises the risk of developing breast cancer to between 50% and 85%. In other words, out of every 100 women with a faulty gene, between 50 and 85 of them will develop breast cancer in their lifetime.

Are all women routinely tested for faulty genes?

No. Testing, provided by the NHS, is usually only offered to women thought to be at high risk of having a faulty gene. These include:

• women with a strong family history of breast cancer where a living family member with breast or ovarian cancer is available for testing
• women with a family history of several relatives developing early-onset breast cancer (cancer that develops before the age of 50), as this is often associated with having a faulty gene

Gene testing is also available from private clinics. The tests can be expensive, with available prices quoted on the internet ranging from around £2,000 to £3,000. The Pink Lotus Breast Center, where Angelina Jolie had her treatment, states that it screens for BRCA gene mutations in women without cancer who:

• have two or more family members with breast cancer, one under the age of 50
• have a previously identified BRCA mutation in the family at any age
• are of Ashkenazi Jewish descent with a family history of breast or ovarian cancer

Will I need a mastectomy if I am found to have a faulty gene?

No. There is a range of treatment options available to you.

First, there is the option of what is known as active monitoring. This is where you receive annual screening in the form of mammograms or MRI scans (or sometimes both) to monitor the state of your breast tissue.

Changes in your lifestyle can also reduce your individual breast cancer risk. These include taking plenty of exercise and maintaining a healthy diet.

There is also the option of waiting to see if breast cancer develops, and if it does it can be treated using conventional methods as with other breast cancers. Breast cancer cure rates are good and continue to improve. The chance of making a full recovery, especially if the cancer is detected early, are relatively high compared with other forms of cancer.

Ultimately, there is no right or wrong answer about what you should do. Your care team can provide advice that will allow you to make an informed decision about your treatment. But the decision is one only you can make.

What happens if I decide to have a preventative mastectomy?

As much breast tissue as possible is removed through a single cut horizontally or diagonally across the chest under general anaesthetic. It’s a physically and emotionally draining operation. Expect some pain and fatigue afterwards and to spend one or two nights in hospital. It generally takes three to six weeks to recover fully.

What is breast reconstruction?

Basically, new breasts are formed from skin and muscle from your back, stomach or buttocks, or by using implants. It’s often possible to have reconstruction straight away – in the same operation as the mastectomy – though you can have it done later. Angelina Jolie had her breasts reconstructed with implants nine weeks after her double mastectomy. If your nipples have to be removed during the mastectomy, then they can be reconstructed with skin from another part of your body, and the areola created by tattooing.

Will the new breasts look and feel the same as before?

Reconstructed breasts won’t feel the same to you as your real ones did – the nerves have been cut, so they’ll always be numb, and there will be noticeable scars, but women generally report being happy with the cosmetic outcome. 

Edited by NHS Choices. Follow Behind the Headlines on twitter.

Links To The Headlines

My Medical Choice. New York Times, May 14 2013

'Redheads are at increased risk of skin cancer even if they don't spend time in the sun,' is the headline on the Mail Online website.

The story refers to a discussion piece in a journal that outlines theories about the results of some animal experiments. This research involved mice genetically engineered to have red fur and predisposed to develop melanoma.

Although exposure to ultraviolet (UV) light is known to be a major risk factor for melanomas, the researchers found that genetically engineered mice with red fur still had a high risk of developing melanomas even without UV exposure.

The article discusses potential explanations for why this could be the case, and these theories now need to be tested to see if they are correct.

It is not yet clear how well these animal studies represent what happens in people with red hair. It would be very difficult to test this directly, as keeping people completely away from sunlight would be impractical and potentially unethical.

UV light exposure is known to increase the risk of melanoma in redheads and non-redheads alike. It is important that people with red hair should continue to use sensible precautions to avoid excessive UV exposure and sunburn, despite this news.

Where did the story come from?

The article was written by researchers from the Cutaneous Biology Research Center at Massachusetts General Hospital in the US.

No sources of funding for the article were reported. It was published as an "Ideas and Speculations" article in the journal BioEssays. These pieces are described as "creative thinking and predictions on open questions and recent developments in biology".

The article has been peer-reviewed.

The news is based on an article by researchers that presents possible explanations for their previous finding that genetically engineered mice with red fur and a predisposition to melanoma develop this cancer even without UV exposure.

Some of the Mail Online reporting suggests that the findings of this research are more conclusive than is possible to say at this stage: "Scientists have discovered that the production of red hair pigment causes an increased risk of melanoma".

However, the BioEssays article was only presenting possible explanations for observations from animal experiments. It was not claiming to have definitive proof that these findings apply to humans.

What kind of article was this?

This was an article discussing the potential link between the red pigment in red hair and skin cancer.

People with red hair and fair skin are known to be at greater risk of getting melanoma, the least common but most serious form of skin cancer, which is responsible for around two thousand deaths a year in the UK.

In general, it is thought that redheads' pale skin makes them more susceptible to UV damage from the sun's rays.

However, the authors of the article say that a recent study from their lab suggests that the pigment that causes hair to turn red (pheomelanin) could itself be linked to the increased risk of cancer, even without UV exposure.

In their article, the authors discuss two possible ways in which the red pigment in red hair might increase the risk of cancer. These preliminary ideas – or hypotheses – are based on previous research and a general understanding of human and cancer biology.

A hypothesis is a possible explanation of why something that researchers have observed might happen. Researchers design experiments to test whether their hypothesis is correct. This process is fundamental to the scientific method.

What did the article say?

The researchers first describe how the red colour in red hair is made, and discuss the results of their recent study before going on to present their hypotheses.

Specific cells in the skin called melanocytes make two kinds of pigment – a brown pigment called eumelanin and a red-orange pigment called pheomelanin. A biochemical process within cells determines how much of each pigment is made.

This process involves a protein called MC1R, which influences the switch between the production of these pigments based on the strength of the signal it sends to the cell and whether the cell has enough of the amino acid cysteine.

In redheads, variations in the gene for the MC1R protein means that it sends weak signals. This means that the cells' stores of cysteine are usually enough for it to favour producing the red/orange pigment pheomelanin.

The researchers recently carried out a study where they introduced a genetic mutation commonly found in melanoma cells into the melanocytes of mice. When they also introduced a genetic mutation into these mice that inactivated the MC1R protein, the mice had red fur and developed melanoma, even without UV exposure. If they introduced another genetic mutation that stopped pigment being made altogether, the mice were albino but they did not develop melanoma.

This led the researchers to suspect that the red pigment pheomelanin could be itself increasing the risk of melanoma. Their research also found that the mice with red fur had more damage to their skin cell DNA caused by very reactive chemicals called free radicals. Free radicals can cause damage to cells at a molecular level.

The researchers do not yet know how the red pigment might be linked with the free radical DNA damage that can increase the risk of melanoma. However, they have presented two hypotheses:

The first hypothesis

The researchers' first hypothesis was that the red pigment itself might generate more free radicals, and that these cause DNA damage that could lead to melanoma. They say that the red pigment is already known to make free radicals when it is exposed to UVA light, but it may be able to do this without UVA light. These free radicals could potentially:

• damage DNA directly
• damage its building blocks, or
• use up the cell's stores of antioxidants, making it more vulnerable to damage by other free radicals

The researchers also discuss in detail the biochemical ways in which the red pigment might generate free radicals.

The second hypothesis

The second hypothesis was that the process of making the red pigment might use up the cell's stores of antioxidants, rather than the red pigment itself. This might make the cells more vulnerable to damage by other free radicals.

They say that the amino acid cysteine used in making the red pigment is also found in the most important antioxidant in the cell, glutathione. If cysteine is used to make the red pigment, this might reduce the cell's ability to make this antioxidant.

The researchers report that red-haired wild boars have been found to have less glutathione in their muscles. However, they acknowledge that it is not possible to say from this whether there is less glutathione due to free radicals from the red pigment itself or the making of the red pigment.

What were the researchers' conclusions?

The researchers presented two hypotheses that could explain how the red skin and hair pigment pheomelanin could increase the risk of the skin cancer melanoma.

They say that their two proposed methods could both be occurring, and that more research could help identify how redheads can reduce their risk of melanoma.

Conclusion

The researchers' article discusses potential ways in which the red pigment found in the cells of people with red hair might increase the risk of melanoma, the most serious form of skin cancer. It is not a standard report of a research study, but the authors put forward potential explanations for their previous research findings. These now need to be tested to see if they are correct.

The researchers' previous research found that mice genetically engineered to be predisposed to melanoma and red fur developed melanomas even without UV exposure. It is not clear to what extent these genetically engineered mice represent what happens in humans.

It would be very challenging to test this – keeping people completely away from UV light would not be feasible or ethical, as we need some sun exposure to make vitamin D, which is needed to make and maintain strong bones. For this reason, research in mice can be very helpful.

It is important that redheads do not take this news as a reason not to protect themselves from the effects of the sun. We already know that UV light exposure increases the risk of melanoma in people regardless of hair colour. People with red hair should continue to use sensible precautions to avoid excessive UV exposure and sunburn.

Read more about reducing your melanoma risk. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Redheads are at increased risk of skin cancer even if they don't spend time in the sun. Mail Online, May 10 2013

Links To Science

Morgan AM, Lo J, Fisher DE. How does pheomelanin synthesis contribute to melanomagenesis? BioEssays. Published online May 7 2013

Much of the UK media are covering the release of data that indicates breast cancer rates in the under-50s are now at a record high. Changes in childbirth patterns and alcohol consumption could be to blame, according to a leading charity.

The news follows new data released by Cancer Research UK. Its data shows that breast cancer diagnoses among women aged under 50 have now reached an all-time high, breaking the 10,000 mark for the first time in 2010. One in five diagnosed breast cancer cases are now in women under the age of 50.

Possible explanations for the increases are speculated to be due to known hormonal risk factors for cancer – such as having children later in life. Increased alcohol intake, another risk factor for breast cancer, could also be involved.

The rise in the number of new cases is not restricted to the under-50s: there has been a steady increase in the number of cases diagnosed for women of all ages since the 1970s.

But the rise isn’t necessarily as bad as it sounds. For example it could reflect better breast awareness and improved diagnosis and screening, which in turn might lead to early treatment and improved chances of survival.

The good news is that – despite the increase in breast cancer diagnoses – breast cancer deaths are actually falling. An increasing number of women are now survivors of breast cancer.

What does the data show?

Breast cancer is the most common cancer among women, accounting for almost a third of all new cancer cases in women. Cancer Research UK reports how their latest statistics revealed that in 2010, there were 10,000 new cases diagnosed among women aged under 50. This is an 11% increase from 15 years previously in 1995 when there were 7,700 cases of breast cancer diagnosed among women in this age group.

One in five breast cancers (20%) are now diagnosed in women aged under 50. Nearly half of breast cancers (48%) are diagnosed in women aged between 50 and 69 – the age group currently invited for breast cancer screening.

However, the rise in the number of breast cancer cases is not restricted to the under-50s. Since the 1970s there has been a gradual and steady increase in the number of breast cancer cases. Overall there was an 18% increase in rates between 1995 and 2010.

What are the possible reasons behind the increased rates among younger women?

Cancer Research UK says that, though it is not clear why cases of breast cancer are increasing among younger women, alcohol intake and hormonal factors may play a role.

Alcohol

Alcohol is an established risk factor for breast cancer. Cancer Research UK reports that the combined results of two large systematic reviews of the published evidence, in addition to findings from the UK Million Women Study, suggest that each additional unit of alcohol per day can increase a woman’s risk of the disease by between 7% and 12%. The research suggests that by the age of 80, roughly the following number of women will have developed breast cancer:

• 9 out of 100 if they don't drink at all
• 10 out of 100 if they have two drinks a day
• 13 out of 100 if they have six drinks a day

However, as Cancer Research UK does say, the possible risk increase from alcohol is less compared to the greater influence of other factors – particularly hormonal factors.

Hormonal factors

Very generally, increased exposure to the hormone oestrogen is associated with increased risk of breast cancer because it can stimulate breast cancer cells to grow. Higher lifetime oestrogen exposure is associated with:

• starting periods at a younger age
• going through the menopause at a later age
• use of the combined oral contraceptive pill (which contains oestrogen)
• fewer (or no) pregnancies
• shorter duration of (or no) breastfeeding
• use of HRT (which contains oestrogen)

Both having children and breastfeeding are known to be protective against breast cancer. In theory the younger a woman is when she has her first pregnancy, and the more pregnancies she has in her lifetime, further decreases her risk. Similarly, the more a woman breastfeeds will decrease her risk. Therefore, modern western lifestyles (that include women generally starting families later and having smaller families) may give some possible explanation to the increase in breast cancer rates among younger women.

Are there any positive signs?

Despite the increased rates among women overall and specifically among women aged under 50, Cancer Research UK does report some good news: that fewer women than ever before are now dying from breast cancer. This due to better treatment, the charity says.

The rate of women aged under 50 who are dying from breast cancer has fallen by 40% since the early 1990s. Twenty years ago, the death rate from breast cancer in the under-50s was 9 per 100,000 women in the UK.  By late 2000, this had fallen to 5 per 100,000 women. More than 8 in 10 women diagnosed with breast cancer before the age of 50 are now reported to survive the disease for at least five years.

Although not discussed by the Cancer Research UK report, the rise in cases could be a reflection of increased awareness of breast cancer and increased rates of diagnosis and improvement in screening techniques.

As a concluding message, Sara Hiom, Cancer Research UK’s director of health information, says: “Breast cancer is more common in older women, but these figures show that younger women are also at risk of developing the disease. Women of all ages who notice anything different about their breasts, including changes in size, shape or feel; a lump or thickening; nipple discharge or rash; dimpling, puckering or redness of the skin, should see their GP straight away, even if they have attended breast cancer screening.

“It’s more likely not to be cancer, but if it is, detecting it early gives the best chance of successful treatment,” she added.

What can I do to reduce my risk of breast cancer?

Unlike some other cancers, the body of evidence about proven methods of reducing risk is relatively small. Though most experts would recommend that:

• you stick to the recommended alcohol consumption rates for women
• you take plenty of exercise
• you maintain a healthy weight
• avoid smoking

It is also important that you attend breast cancer screening appointments when invited. Women aged 50 to 70, who are registered with a GP, are automatically invited for screening every three years.

Read more about the NHS Breast Screening Programme.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Breast cancer cases in UK under-50s top 10,000 a year. BBC News. May 3 2013

Breast cancer rates increase among younger women. The Guardian, May 3 2013

Breast cancer cases soar to 27 a day among the under-50s... and experts fear modern lifestyles are to blame. Daily Mail, May 3 2013

Under-50s with breast cancer at record high. The Daily Telegraph, May 3 2013

Breast cancer on the rise in under 50s who now account for 1 in 5 cases. Daily Mirror, May 3 2013

Links To Science

Cancer Research UK. Breast cancer in women under 50 tops 10,000 cases for first time. May 3 2013