Snippets

DOI: 10.1111/j.1471-0528.2011.03141.x
www.bjog.org

Whats new in the other journals?

Screening for ovarian cancer
It has been speculated that screening for
ovarian cancer in postmenopausal women
with cancer antigen 125 (CA-125) and
transvaginal ultrasound could be a useful
way of reducing mortality from one of the
five leading causes of cancer death in
women. There was hope that annual testing
with biochemical and biophysical methods
could create a stage shift, which is a
decrease in the absolute number of women
diagnosed with late-stage disease identified
by screening compared with usual care.
Now a report from the authoritative Prostate, Lung, Colorectal and Ovarian Cancer
Screening Randomized Controlled Trial
has been published by Buys et al. (JAMA
2011;305:2295303).
A group of nearly 80 000 women in the
USA between the ages of 55 and 75 years
were allocated to annual CA-125 plus transvaginal ultrasound screening or usual care,
which was in essence only reaction to signs
or symptoms. The entire cohort was followed up for 13 years. They found that
although slightly more (8 versus 6%)
women in the intervention group had surgical procedures, the cause-specific and allcause mortality rates were no different.
There was no stage shift with the screening
mostly (75%) picking up late-stage disease.
There were false positives in the 40 000
participants screened, in total about 3000
women, all of whom required further diagnostic procedures including laparotomy in
a third of women, which carries its own
costs and morbidity. The conclusion was
that annual screening does not reduce disease-specific mortality in women of average
risk for ovarian cancer but does increase
invasive medical procedures and associated
harms.
The results show that, in its present
form, ovarian cancer screening does more
harm than good and should not be carried
out on a routine basis. This has direct
implications for Well Woman surveillance.
Our task as doctors is to know the evidence
and advise women accordingly.

Bilateral salpingo-oophorectomy at
hysterectomy or not?
New evidence is available about the advantages or disadvantages of removing the
ovaries in older women at the time of
hysterectomy for benign disease. Current
wisdom suggests that even after the age of
50 years the ovaries play some protective
role in providing hormones preventing cardiovascular disease, making the case for
their preservation.
Now a large study has found that bilateral
salpingo-oophorectomy (BSO) at hysterectomy may not have an adverse effect on cardiovascular health or indeed hip fracture,
cancer or total mortality compared with
ovarian conservation (Jacoby et al. Arch Int
Med 2011;171:7608). The researchers followed up over 25 000 women between 50
and 80 years old for 8 years, 56% of whom
had BSO and 46% who had their ovaries
preserved, and they found no increased risk
one way or the otherexcept for ovarian
cancer risk. This was 0.02% in the BSO
group and 0.33% in the conservation group
with the number needed to treat 323.
Although rare, this increased risk may be
sufficient to swing the pendulum back
towards BSO in the face of equipoise in cardiovascular risk. A womans life-time risk of
ovarian cancer is 1.2%.

Breast cancer prevention

There are drugs that reduce a postmenopausal womans risk of developing breast
cancer. Selective estrogen-receptor modulators like tamoxifen and raloxifene are such
chemopreventative agents and can decrease
the chances of breast cancer by up to 50%
in high-risk individuals. Despite this efficacy, few women, even in high-risk categories, avail themselves of treatment possibly
because of anti-estrogenic effects or for fear
of serious toxic effects, although these are
rare.
The quest for alternative therapies has led
to the investigation of aromatase inhibitors,
for example letrozole, which has proved

2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

highly effective in preventative contralateral

primary breast cancers. Now the results of a
large trial with another aromatase inhibitor,
exemestane, have been published by Gross
et al. (NEJM 2011;364:238191). They allocated moderately increased-risk women to
exemestane or placebo and followed them
up for 3 years. Those on exemestane had a
65% relative reduction in the annual incidence of invasive breast cancer (0.19 versus
0.55%). There were no significant differences
between the groups in terms of adverse
effects.
This study, dubbed the MAP3 trial, was
large, impressively conducted and, in the
view of many, definitive. It may well
change attitudes to prophylaxis with an editorial in the same issue clearly calling for
its wider uptake with the exhortation We
have run out of excuses. What are we waiting for? (Davidson and Kensler N Engl J
Med 2011;364:24634).

The diethylstibestrol story

The story of diethylstilbestrol (DES) broke
40 years ago. A paper by Herbst et al.
(N Engl J Med 1971;284:87881) noted the
association between maternal ingestion of
DES and a rare malignancy in their
offspring some two decades later. The
cancer was a clear-cell adenocarcinoma of
the vagina caused by DES disrupting the
organisation of uterine muscle into layers,
preventing the stratification of vaginal
epithelium and the resorption of vaginal
glands as well as leading to loss of the uterotubal junction.
The in utero carcinogenic effects lead to
aberrant embryogenesis in the fetus with
resulting vaginal cancer, uterine anomalies
and increased rates of miscarriagethe precise indication for which the DES had been
taken so many years before. In addition,
male fetuses exposed to DES had higher incidences of epididymal cysts, microphallus,
cryptorchidism and testicular hypoplasia
than non-exposed individuals (Goodman
et al. N Engl J Med 2011;3764:20834).

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Snippets

Studies of DES have given rise to the

term endocrine disrupting chemicals,
which are a class of drugs that change gene
expression involving patterning of the
reproductive tract. Understanding the disruption helps to elucidate the mechanism
of diseases caused by a drug given (for
incorrect indications as it transpires) to
pregnant women in whom detrimental
effects only became clear a generation later.
Very humbling.

Flu vaccinations
The 2009 H1N1 influenza pandemic was a
sharp wake-up call. Although overall it was
more benign than anticipated, it took its toll
on pregnant women and their fetuses. Only
now are data of maternal and perinatal suffering emerging and it is clear that pregnancy is an at-risk time to catch influenza.
Publications from the USA (Creanga
et al. AJOG 2011;204:53845) and the UK
(Pierce et al. BMJ 2911;342:d3214) confirm
the virulence of the disease to mothers with
five deaths in about 500 hospitalised
women in the USA as well as perinatal
mortality and morbidity rates up to five
times those in uninfected women. Far fewer
women who were admitted to hospital had
been vaccinated than pregnant women in
general and those admitted did better on
early antiviral agents than those who had
the medication given late or not at all.
Obstetricians need to encourage all
pregnant women to be vaccinated against
seasonal or pandemic flu and to treat them
energetically if they do become infected.

Lifestyle and facts

We all know the rules of a healthy diet
more fruit, vegetables, grains and nuts with
less red meat and a careful watch on calories. Now a very large American study has

added weight to previous findings by naming the culprits which cause us to become
heavier.
Mozaffarian et al. (N Engl J Med 2011;
364:2392404) observed more than 120 000
healthy US adults over two decades and
showed that they generally increased their
body mass with age. Foods associated with
gains were potato chips, potatoes, sugarsweetened drinks and unprocessed red
meats and processed meat. Those associated
with losses were vegetables, whole grains,
fruits, nuts and yoghurt.
It is not only the type of food ingested
but the way it is prepared that makes a difference. For example, fish is associated with
a decrease in the risk of heart failure but it
depends on the method of cooking. In
postmenopausal women, baked or grilled
fish is protective while frying it increases
the risk of cardiac decompensation (Belin
et al. Circ Heart Failure 2011;doi: 10.1161/
circheartfailure.110.960450).
The lifestyle associated with weight loss
and gain was as expected for exercise, alcohol, smoking and sloth. The example here
is television watching, which is not good
for your health. It is the most prevalent of
pastimes and yet under-researched. Now
Grntved and Hu (JAMA 2011;305:2448
55) show that it is bad for youincreasing
your risk of diabetes and cardiovascular
disease and all-cause mortality. You have
been warned.

Intrauterine contraceptive devices

following termination of pregnancy
The use of intrauterine contraceptive
devices (IUCDs) should be increasing.
IUCDs (especially those with progesteronereleasing systems) are becoming more
widely acceptable but remain underused
despite their clear advantages of costsaving, convenience and efficacy. Women

seeking a termination of pregnancy (TOP)

or having an evacuation after a spontaneous miscarriage may be a group for whom
IUCDs could provide close to ideal contraception so research was carried out offering
them the insertion of a device immediately
post-evacuation or after a delay of 2
6 weeks.
Those accepting IUCD insertion were
randomly allocated to immediate or delayed
insertion and followed up for 6 months
(Bednarek et al. NEJM 2011;364:220817).
There were over 500 participants and all
those allocated to immediate insertion were
fitted with IUCDs whereas only two-thirds
of those in the delayed group received
devices. Expulsion rates were 5% in the
immediate group and 2.5% in the delayed
group, which was consistent with a predefined non-inferiority definition. Adverse
events were rare and non-significantly different between the two groups.
There were no pregnancies in those
using the IUCDs, which is in keeping with
first-year failure rates of 0.10.8% quoted
in the literature but five pregnancies (2%)
occurred in the delayed insertion group
and all of these women had failed to attend
their follow-up appointments. It seems that
very few (<1%) expulsions occur unnoticed
so women who want an IUCD after a first
trimester TOP or evacuation can safely be
offered a cheap, uncomplicated and efficient method of contraception.
Misgivings about expulsion rates, infections and acceptance are without foundation so IUCDs can, and should, be offered
to all women whose pregnancies end in the
first trimester. Given that there are about
190 000 TOPs carried out each year in the
UK (Carlowe BMJ 2011;342:d3320) is there
not an opportunity here going abegging? j

Athol Kent

These snippets are excerpts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics
and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at atholkent@
mweb.co.za or visit the website www.jassonline.com.

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2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG