Correspondence

Follow-up of Patients with Early Breast Cancer

N Engl J Med 2007; 357:1052-1053September 6, 2007

Article

To the Editor:

In the review of early breast-cancer management by Hayes (June 14 issue),1 the effects of selective estrogen-receptor modulators on the uterus (shown in Table 5 of the article) might have been clearer if raloxifene, which does not adversely affect endometrial tissues2,3 as tamoxifen does, had been listed separately, as it was in Table 4 of the article.

Hideta Sakemi, M.D.
Rakuwakai Otowa Hospital, Kyoto 607-8062, Japan
rakuwadr073@rakuwadr.com

3 References

1. 1

   Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med 2007;356:2505-2513
   Full Text | Web of Science | Medline

2. 2

   Jolly EE, Bjarnason NH, Neven P, et al. Prevention of osteoporosis and uterine effects in postmenopausal women taking raloxifene for 5 years. Menopause 2003;10:337-344
   CrossRef | Web of Science | Medline

3. 3

   Grady D, Ettinger B, Moscarelli E, et al. Safety and adverse effects associated with raloxifene: multiple outcomes of raloxifene evaluation. Obstet Gynecol 2004;104:837-844
   CrossRef | Web of Science | Medline

To the Editor:

The Clinical Practice article by Hayes highlights the problems that face breast-cancer survivors. These patients remain at increased risk for not only recurrence of breast cancer but also cardiovascular disease, as well as other cancers. However, we believe the author missed the unique opportunity to provide specific advice to patients regarding the benefits of lifestyle changes in addition to the usual “diet and exercise.” Several studies have shown the protective effects of low dietary fat, increased physical activity, and an increased intake of fruits and vegetables on breast-cancer outcomes both before and after diagnosis. In a recent study of breast-cancer survivors by Pierce et al.,1 consumption of at least five servings of fruits and vegetables per day and regular exercise were associated with a 50% reduction in the 10-year mortality rate, particularly among women with hormone-receptor–positive cancer.

We believe this is a perfect time in the follow-up period to reinforce the importance of a diet abundant in fruits and vegetables as well as regular physical activity, regardless of symptoms or body weight.

W. Scott Butsch, M.D.
Andres J. Munoz, M.D.
Douglas C. Heimburger, M.D.
University of Alabama at Birmingham, Birmingham, AL 35294-3360
wbutsch@partners.org

1 References

1. 1

   Pierce JP, Stefanick ML, Flatt SW, et al. Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J Clin Oncol 2007;25:2345-2351
   CrossRef | Web of Science | Medline

Author/Editor Response

Sakemi is correct. Table 5 of my article might more clearly have listed only tamoxifen in the description of the effects of selective estrogen-receptor modulators for the treatment of breast cancer, since raloxifene is not indicated for this use. Tamoxifen is associated with an increased risk of secondary endometrial cancers, whereas raloxifene appears not to be. Direct randomized comparison of the two agents in the preventive setting confirms that raloxifene is less commonly associated with endometrial cancers.1,2

With regard to the recommendations by Butsch and colleagues, the effects of intensive dietary intervention on breast-cancer risk in unaffected women and on recurrence after a diagnosis of breast cancer remain controversial. The results from the only two reported randomized clinical trials that have compared such a strategy with standard “good-practice” diets are contradictory, with a reduction in distant recurrence in one trial but no difference in breast-related events or survival in the other.3-5 Longer follow-up in these studies and results from other ongoing studies may be more informative. In the meantime, it seems prudent to recommend moderate dietary modification and exercise for everyone; intensive dietary intervention, which can be expensive and problematic with respect to adherence, is not supported by the available evidence. A dietary intervention cannot replace proven, standard, pharmacologic adjuvant therapies such as chemotherapy, long-term antiestrogen therapies, or both, which have been shown to dramatically reduce mortality due to breast cancer.1

Daniel F. Hayes, M.D.
University of Michigan Comprehensive Cancer Center, Ann Arbor, MI 48109
hayesdf@umich.edu

Since publication of his article, Dr. Hayes reports receiving research funding from AstraZeneca. No further potential conflict of interest relevant to this letter was reported.

5 References

1. 1

   Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:1687-1717
   CrossRef | Web of Science | Medline

2. 2

   Vogel VG, Costantino JP, Wickerham DL, et al. Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA 2006;295:2727-2741[Erratum, JAMA 2006;296:2926.]
   CrossRef | Web of Science | Medline

3. 3

   Chlebowski RT, Blackburn GL, Thomson CA, et al. Dietary fat reduction and breast cancer outcome: interim efficacy results from the Women's Intervention Nutrition Study. J Natl Cancer Inst 2006;98:1767-1776
   CrossRef | Web of Science | Medline

4. 4

   Pierce JP, Natarajan L, Caan BJ, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women's Healthy Eating and Living (WHEL) randomized trial. JAMA 2007;298:289-298
   CrossRef | Web of Science | Medline

5. 5

   Kushi LH, Kwan ML, Lee MM, Ambrosone CB. Lifestyle factors and survival in women with breast cancer. J Nutr 2007;137:Suppl:236S-242S
   Web of Science | Medline