1. WEEK 3 EBCR – 8A Sri Puspita Amalia NP Lingga S Rienna Diansari Harsya DG Tutor : dr.Dewi Friska

2. Mrs. X, 60 years old, complains a lump in her right breast since 4 weeks ago. The lump is not painful and getting bigger over time. It is fixated and has flat surface. There are some changes on her breast skin too. Mrs. X has been menopause since 7 years ago, and with the recommendation of her previous doctor, she has been taking estrogen therapy to prevent heart disease and osteoporosis. Her elder sister died 2 months ago from breast cancer and had a history of estrogen-progestin therapy. She asked, whether the hormonal therapy could induce breast cancer? Cases

3. In US, 2011  230,480 new cases of invasive breast cancer & 57,650 new cases of non- invasive (in situ) breast cancer. In Indonesia  The second most common female cancer Risk factor  exposure to estrogen (hormone replacement therapy), family history, diet, oral contraceptive, breast changes, etc. Theory  Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them. Vogel VG. Breast Cancer. 2008. Merck & Co. Available at: http://www.merckmanuals.com/professional/gynecology_and_obstetrics/breast_disorders/breast_cancer.html http://www.merckmanuals.com/professional/gynecology_and_obstetrics/breast_disorders/breast_cancer.html Tjindarbumi D, Mangunkusumo R. Cancer in Indonesia, Present and Future. Jpn J Clin Oncol 2002; 32. Background

4. PICO Postmenopausal Women Patient /Problem Estrogen Therapy Intervention Estrogen-progestine therapy Comparison Breast cancer Outcome ACQ Clinical Question In postmenopausal women, does estrogen therapy increase risk of breast cancer compared to estrogen-progestin therapy Type of Question Etiology

5. Search Strategy METHODS

6. Selection Criteria

9. Evidence Based Case Report Article 1Article 2 TitlePostmenopausal hormone therapy and breast cancer: a systematic review and meta- analysis Menopausal hormone therapy and risk of breast cancer: a meta- analysis of epidemiological studies and randomized controlled trials AuthorNirav R Shah, Jeff Borenstein, and Robert W Dubois Claudia M Greiser, Eberhard M Greiser, and Martina Dören Publication/Jour nal Name Menopause. 2005; 12 (6): 668- 678 Human Reproduction Updates, 2005; 11 (6): 561-573 Number of Studies 1542 DomainPostmenopause womenPostmenopause women/women using hormonal therapy DeterminantEstrogen therapy Comparison Estrogen-progestin hormonal therapy Estrogen-progestin hormonal therapy, menopausal hormone therapy (all therapy combined) Outcome Breast cancer

10. article 1*article 2* validity What question (PICO) did the systematic review address? Yes, relevant and clearly state Is it unlikely that important, relevant studies were missed? Yes Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Yes Were the results similar from study to study? Yes Importan cy (result) How are the results presented?Forest plot applicabi lity Is our patient so different from those in study that its result cannot apply? No *article 1 : Shah, Borenstein and Dubois.2005 *article 2 : Greiser and Doren.2005 VIA

11. 1.Shah et al 1 Study or SubgroupRelative Risk 95% CI Estrogen therapy vs breast cancer less than 5 years use more than 5 years use OR = 1.16 (1.06 – 1.28) OR = 1.16 (1.02 – 1.32) OR = 1.20 (1.06 – 1.37) Combined hormonal therapy vs breast cancer less than 5 years use more than 5 years use OR = 1.39 (1.12 – 1.72) OR = 1.35 (1.16 – 1.57) OR = 1.63 (1.22 – 2.18) 2 Shah NR, Borenstein J, Dubois RW. Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis. Menopause. 2005; 12 (6); 668-78 RESULTS

12. Study or SubgroupRelative Risk 95% CI Menopausal hormone therapy vs breast cancer Case Control Cohort/RCT OR = 1.34 (1.25 – 1.43) OR = 1.20 (1.06 – 1.37) Estrogen-progestin hormonal therapy vs breast cancer Case Control Cohort OR = 1.48 (1.33 – 1.65) OR = 1.95 (1.87 – 2.04) Estrogen hormonal therapy vs breast cancer Case Control Cohort OR = 1.18 (1.08 – 1.30) OR = 1.27 (1.19 – 1.35) 2.Greiser et al 2 1 Greiser CM, Greiser EM, Doren M. Menopausal hormone therapy and risk of breast cancer: a meta-analysis of epidemiological studies and RCT. Human Reproduction Update. 2005; 11 (6); 561-73

13. Results The result of this two studies has a consistency with almost all previous studies, that using postmenopausal hormonal therapy have a higher risk of breast cancer. Combined EPT is higher than ET. Those study also show that after 1 year discontinuation of PHT, the risk of breast cancer is decrease. But about the risk of breast cancer after discontinuation of PHT, still needs further analysis. DISCUSSION

14. Strength and Limitations ⁺ searched from some databases such as PubMed, Cochrane, and Ebsco. ⁺ recent studies, last 10 years and the studies are systematic review and meta-analyses. ⁺ validity of that two studies were assessed by sistematic review worksheet from Central Evidence Based Medicine (CEBM). 3 ⁺ The studies relevance with our clinical questions ₋ systematic reviews are consist only with English language ₋ just use a computer search. We didn’t do a hand searching or unpublished studies

15. Those both appraised article are suitable and not so different from our case. Because the patient of the studies and our case are same characteristic, so these studies can be applied to our patient. CONCLUSION

16. THANK YOU