To the Editor: The Special Communication by Dr Esserman and colleagues1 summarized several observations after 20 years of extensive screening for breast and prostate cancer (1986-2006). The authors referred to data from the Surveillance, Epidemiology and End Results (SEER) program to report that the incidence of total invasive breast cancer (excluding in situ lesions) has increased substantially and remains higher than prescreening rates, while the localized (node negative, no skin or chest wall involvement) and regional (node positive, skin or chest wall involvement) breast cancer incidence has declined only slightly. The authors concluded that the increase in the relative fraction of early stage cancers without decrease in the incidence of regional cancers is the result of preferential detection of the slower growing and potentially indolent tumors (length bias).
Although we share the authors' concern, it is important to note that data collected by the SEER program between 1992 and 1998 suggested a difference in the incidence of breast cancer according to hormonal receptor status. The incidence of estrogen receptor– (ER) and/or progesterone receptor– (PR) negative breast cancer was declining while that of ER/PR-positive disease was increasing.2 At least some of this increase might be attributable to the use of hormone therapy in the 1980s and 1990s, since hormone therapy may preferentially increase the risk of ER/PR-positive tumors. Furthermore, hormone-positive tumors are more likely to be diagnosed in less advanced stages than the tumors without expression of hormonal receptors.3
Therefore, it is possible that the localized tumors detected by screening mammography represent, at least in part, cancers attributed to hormonal therapy. It is hoped that the increasing use of screening mammography resulted in early diagnosis, before locally advanced disease or metastatic spread developed. Alternatively, some cancers would have been diagnosed at advanced stages, resulting in a similar increase in the incidence of late stage breast cancer compared with early stage disease. The decrease in the incidence of 3.5% per year from 2001 to 2004 with little additional decrease in 20044 (coincident with the decreased use of hormone therapy because of the data from the Women's Health Initiative linking hormone therapy and breast cancer) supports this hypotheses.5 The differences were unrelated to changes in the frequency of screening mammography.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.