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RHO archives : Topics : Older Women

Annotated Bibliography

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Population aging and health

Bonita, R. et al. Older women in an aging world: achieving health across the life course. World Health Statistics Quarterly 49:134-141 (1996).
According to this demographic analysis, the health of aging women should be of increasing concern in developing countries. Once women in developing countries survive to middle age, their life expectancy approaches that of women in developed countries. Thus, the demographic transition is accompanied by a gender transition: as maternal mortality declines, women dominate older age groups. More than half of the world's women over age 60 live in developing regions and that proportion will grow. The authors recommend that developing countries begin planning now for the health of future cohorts of women, anticipating changes in their social roles and health needs.

Bonita, R. Women, Ageing, and Health: Achieving Health Across the Life Span. 2nd edition. Geneva: World Health Organization (1998). Available at: www.who.int/hpr/ageing/womenandageing.pdf.
After analyzing current demographic trends and changes in health status and well-being, this monograph outlines health priorities for aging women. Major preventable causes of morbidity and mortality are heart attack and stroke, cancer, and communicable diseases; chronic disabling conditions include musculoskeletal problems, osteoporosis, and incontinence; leading mental health problems are dementia and depression. Economic, social, political, and cultural factors all contribute to these health issues. The author outlines a series of policy, program, advocacy, and research strategies designed to empower women and prevent health problems.

HelpAge International. State of the Worlds Older People 2002. London: HelpAge International (2002). Available at: www.helpage.org/.
Global and regional statistical data on older people living in developing countries and eastern Europe are presented here as well as national policies on aging. The report concludes that all societies discriminate on grounds of age and that policy makers ignore older people. In developing countries, older women outnumber older men, and the gender gap is growing. These women often enter old age in ill health and with few financial resources. The cost of care, transportation difficulties, and negative attitudes of health staff toward older people discourage them from seeking treatment. The HIV/AIDS epidemic has an indirect impact on the health of older people as they must cope, both physically and psychologically, with AIDS deaths and with caring for orphaned grandchildren. Older people also are vulnerable to abuse by family members as well as by lawless members of society. The report advocates policy changes and new programs.

Hill, K. The demography of menopause. Maturitas 23:113-127 (1996).
This article analyzes the size and distribution of the postmenopausal population around the world. Women over age 50 currently make up almost 9 percent of the world population, and their number will grow rapidly in developing countries over the next three decades. An analysis of the ratio of female to male mortality rates by age revealed a consistent pattern: Women have a mortality advantage over men during their 40s and 50s, after the risk of childbirth is behind them, but they begin losing that advantage after menopause. Evidence suggests that the hormonal changes associated with menopause eliminate women's protection against cardiovascular disease.

Kane, P. Priorities for reproductive health: assessing need in the older population in the Asia-Pacific region.Medscape Womens Health 6(4) (2001). Available at: www.medscape.com/viewarticle/408946. (Medscape requires free online registration.)
Morbidity and mortality data related to the reproductive health systems of older women and men in the Asia-Pacific region are reviewed. The burden of STIs among those aged 60 and older is substantial; it contributes, for example, to deaths from syphilis and cervical cancer as well as to the pain of reproductive tract infections. Pregnancy-related ill health, such as maternal hemorrhage, hypertension, and obstructed labor, also can have long-term consequences for older women, including Sheehans syndrome, chronic hypertension, prolapse, and fistula. Cancers of the reproductive system (breast, uterine, ovarian, and prostate) also contribute to morbidity and mortality at older ages. Reproductive health programs need to recognize the needs of older people and provide appropriate services, for example, screening for cancers and asymptomatic STIs.

Knodel J, Ofstedal MB. Gender and aging in the developing world: Where are the men? Population and Development Review. 2003;29(4):677-698.
In recent years, international forums have frequently asserted or implied that older women are universally more vulnerable to social, economic, and health disadvantages than older men. The authors challenge this assumption in an analysis of data from developing countries on the sex ratio of older people, the likelihood and ramifications of being widowed, sex differentials in mortality and morbidity, and gender differences in social and economic well-being. The authors urge researchers to move beyond broad generalizations and accept that gender differences may favor older men or women or neither, depending both on the setting and the aspect of well-being under consideration. In addition, they argue that focusing on gender, to the exclusion of other factors, may detract from efforts to help the elderly.

PATH. Reproductive health: women in their middle years and beyond.Outlook. 14(4):1-6; 1997. Available at: www.path.org/files/eol14_4.pdf.
This article reviews major health issues associated with menopause and aging that affect women between the ages of 35 and 55. It discusses the physiology of menopause, its symptoms, and its sequelae, including increased risks of cardiovascular disease, osteoporosis, breast and cervical cancer, genital prolapse, and urinary and reproductive tract infections. Hormone therapy and other interventions are also reviewed. The author calls for increased attention to the health problems of older women, including education about preventive health measures; screening for hypertension, cervical cancer, and breast cancer; and careful selection of family planning methods for older women who might have existing conditions.

Pratt, C.C. Ageing: a multigenerational, gendered perspective. Bulletin on Ageing 2/3 (1997). Available at: www.un.org/esa/socdev/ageing/agb97232.htm.
Men and women play different roles, receive different rewards, and experience different realities throughout their lives, including old age. Compared with men, women are more likely to be poor, to receive lower retirement benefits, to be caregivers for dependents, to be the victims of violence, to have less political and social influence, and to be widowed. Where resources are limited, within the household and larger society, they are likely to be diverted away from the elderly and toward the young. Women, as family caregivers, are disproportionately affected by the need to work outside the home, care for children, and care for elders. Support for family caregiving is needed.

Senanayake, P. Women and reproductive health in a graying world. International Journal of Gynecology & Obstetrics 70:59-67 (2000).
Increasing longevity will lead to a dramatic increase in the number of older women in developing countries. Health data on these women are scarce but point to a continuing gender differential in later years. Morbidity in older women is predominantly associated with hormonal changes before and during menopause. Important health problems include heart disease and stroke, malignancies, osteoporosis, genito-urinary conditions, sexually transmitted infections, and mental illness. The health and well-being of older women also is affected by widowhood and by the need to act as caregivers, whether women are caring for older spouses, aging parents, disabled adult children, or orphaned grandchildren. More attention must be paid to the health problems of older women in developing countries, to better understand the aging process and to cope with their needs effectively.

Simon MA, Dong XQ. Primary obstetrics and gynecology in developing countries: shifting the focus to older women’s health. Primary Care Update for Ob/Gyns. 2003;10(6):300-303.
Most health services for women in developing countries focus on pregnancy and birth and fail to address the primary health needs of elderly women, whose numbers are increasing sharply. These women mostly face chronic health problems. The authors advocate a multidisciplinary approach including: increased government and public awareness of the aging population; developing a national strategy focused on the health needs of older women in rural and poor urban areas; expanding social service and support systems; integrating health promotion and disease prevention into community health, social services, and the workplace; promoting traditional family attitudes toward older women; emphasizing responsibility for self-care in preventing chronic diseases and reinforcing positive health behaviors; advocating healthy aging; increased education and training for health workers on the process of normal aging and care of the elderly; and further epidemiological research to understand risk factors and treatment options.

World Health Organization. Active Ageing: A Policy Framework. Geneva: WHO (2002). Available at: www.who.int/hpr/ageing/ActiveAgeingPolicyFrame.pdf.
This paper is designed to stimulate discussion and action among decision-makers. It describes the rapid growth of the population over age 60 worldwide and sets out seven key challenges, including the shift to non-communicable disease in developing countries, rising levels of disability, providing care for older people, the feminization of aging, structural inequities, rising health care costs, and redefining older people as active participants and contributors to society. In response to these challenges, the paper explores the concept of active aging as a policy and program goal. Health and independence are one of the pillars of active aging, along with productivity and protection. The determinants of active aging are many, including social, personal, and behavioral factors, the physical environment, economics, and the availability of health and social services. The paper concludes with a long list of policy proposals to reduce disease risk factors, develop effective health and social service systems, reduce the burden of disabilities, enable the active participation of older people in all aspects of society, provide protection to older people, and stimulate research.

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Chronic gynecological and urinary problems

Al-Qutob, R. Menopause-associated problems: types and magnitude. A study in the Ain Al-Basha area, Jordan. Journal of Advanced Nursing 33(5):613-620 (2001).
Physical examinations and laboratory tests revealed high levels of morbidity in a community-based sample of 137 postmenopausal women in Jordan: 37 percent suffered from urinary incontinence, 11 percent from urinary tract infections, 39 percent from reproductive tract infections, 41 percent from genital prolapse, 53 percent from hypertension, 26 percent from anemia, and 27 percent from diabetes. Women were accustomed to suffer in silence and did not reveal the true magnitude of their health problems even with prompting from physicians. Health care providers in Jordan, who primarily focus on women of reproductive age, must be sensitized and trained to deal with the health problems of elderly women.

Arrowsmith, S. et al. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstetrical and Gynecological Survey 51(9):568-574 (1996).
Because prolonged obstructed labor is so prevalent in Africa, the obstetric fistula rate may approach the maternal mortality rate. A review of records at the Addis Ababa Fistula Hospital for Poor Women, which repairs approximately 1,000 fistulas a year, found that the average patient was in labor for 3.9 days. Because obstructed labor applies pressure to tissues over a broad area, it causes multiple injuries, of which vesicovaginal fistulas are just one. Hospital records found that the urethra was damaged in 29 percent of cases, and that scarring frequently decreased bladder volume; as a result there was a high rate of stress incontinence even after fistula repair. Secondary infertility was widespread due to amenorrhea, scarring of the uterus and vagina, cervical injuries, and a high prevalence of PID. Obstructed labor also injures the pelvic bones and nerves, resulting in gait disorders and foot-drop. The divorce rate is high even when women's fistulas are repaired, because they may no longer be able to do heavy work, have intercourse, or bear children.

Ashford, L. Hidden suffering: disabilities from pregnancy and childbirth in less developed countries. MEASURE Communication Policy Brief. Washington, DC: Population Reference Bureau (2002). Available at: www.prb.org/pdf/HiddenSufferingEng.pdf.
About 15 to 20 million of the nearly 120 million women who give birth each year develop long-term disabilities, such as severe anemia, incontinence, damage to the reproductive organs or nervous system, chronic pain, and infertility. These disabilities have profound consequences for a womans family and community, since they may demand costly medical care and/or reduce a womans ability to carry out her household responsibilities. To prevent maternal disabilities, the author recommends ensuring access to essential obstetric care, providing postpartum and postabortion care, promoting family planning, providing adequate antenatal care, improving girls nutrition, and increasing womens age at first birth.

Bang, R.A. et al. High prevalence of gynaecological diseases in rural Indian women. Lancet 1(8629):85-88 (January 14, 1989).
This cross-sectional study of gynecological and sexual diseases examined 650 women living in two Indian villages. Ninety-two percent of all women had at least one gynecological or sexual disease, with women having 3.6 diseases on average. Half were infections of the genital tract, including vaginitis, cervicitis, and pelvic inflammatory disease (PID); menstrual disorders also were common. Only eight percent of the women had previously had a gynecological examination, although 55 percent were aware of having a gynecological disorder.

Barlow, D. et al. A study of European women's experience of the problems of urogenital ageing and its management. Maturitas 27:239-247 (1997).
Interviews with 3,062 women aged 55-75 in six European countries found that 29 percent of postmenopausal women reported at least one of the following symptoms: dysuria, incontinence, urinary frequency, recurrent urinary tract infection, vaginal itching and burning, and dyspareunia. Their occurrence did not change with age, and differences between countries were limited. Urinary frequency and vaginal itch were the symptoms most commonly reported. Over half (58%) of the women with symptoms consulted a doctor, 31 percent took no action, and 11 percent purchased something from a pharmacy.

Berghmans, L.C. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU International 85(3):254-263 (2000).
A systematic review of 15 randomized clinical trials of physical therapies for treatment of urge urinary incontinence in women concludes that there is weak evidence to suggest that bladder (re)training is more effective than no treatment and that bladder (re)training is better than drug therapy. There were too few studies to evaluate either the effects of pelvic floor muscle exercises (with or without biofeedback) or toilet training.

Bhatia, J.C. et al. Levels and determinants of gynecological morbidity in a district of South India. Studies in Family Planning 28(2):95-103 (1997).
During this prospective study, social workers interviewed 385 mothers of young children monthly for a year before asking them to undergo a medical examination. About two-thirds reported at least one menstrual problem to the gynecologist; far fewer discussed menstrual problems with the social workers. Laboratory tests found that 56 percent of the women had a reproductive tract infection, but many cases were asymptomatic. Infections included mucopurulent cervicitis (found in 37 percent of the women), bacterial vaginosis (18%), STIs (10%) and urinary tract infections (7%). There was clinical evidence of vaginitis in 13 percent of the women, cervicitis in 24 percent, pelvic inflammatory disease in 11 percent, cervical ectopy in 10 percent, prolapse in 3 percent, and fistula in 0.3 percent. Nutritional problems were widespread: 88 percent of women were either anemic or suffered from chronic energy deficiency.

Bonetti TR et al. Listening to “felt needs”: investigating genital prolapse in western Nepal. Reproductive Health Matters. 2004;2(23):166-175.
Two studies in Nepal investigated the causes, prevalence, and experience of genital prolapse. The first included a series of 16 focus group discussions with 120 community members, while the second examined 2,072 women who presented with gynecological complaints to local clinics. One-quarter of the women in the clinic-based study had genital prolapse: the average age of onset was 27, and 58 percent had completed two pregnancies or fewer at time of onset. Lifting heavy loads and lack of post-partum rest were the most commonly perceived causes. Prolapse had an adverse effect on the quality of the women’s lives, making it difficult to work and causing pain during intercourse as well as other symptoms. The authors recommend developing gynecological clinics in rural districts to detect and manage prolapse, with qualified physicians rotating through and training local health workers to detect and manage early stage prolapse with ring pessaries. Because self-reported prolapse correlates highly with clinically diagnosed prolapse, the authors also recommend developing a short checklist for district-level health workers to use to screen for prolapse. Family planning and antenatal clinics also should counsel women on avoiding heavy lifting and respecting six weeks of post-partum rest to prevent prolapse.

Cammu, H. et al. A 10-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence. BJU International 85(6):655-658 (2000).
To determine the long-term impact of pelvic floor muscle (PFM) exercises for stress incontinence, postal questionnaires were sent to 45 women who had undergone training 10 years earlier, and their medical files were reviewed. Immediately after completing the course, physiotherapy was considered successful in 24 of the women, 16 of whom remained satisfied with their urinary continence when reassessed 10 years later and 2 of whom eventually underwent surgery. In the group of 21 women where physiotherapy initially failed, 13 underwent surgery and 5 claimed to be much improved without surgery. Women who had good results from PFM exercises practiced them more regularly than others, and an active voluntary PFM contraction before a sudden intra-abdominal pressure rise (“perineal lock”) appeared to be responsible for most of their success. The authors conclude that when PFM training is initially successful, there is a 66 percent chance that the favorable results will persist for at least 10 years.

Cron J. Lessons from the developing world: obstructed labor and the vesico-vaginal fistula. Medscape General Medicine. 2003;5(3). Available at: www.medscape.com/viewarticle/455965.
This article reviews the gynecologic sequelae of obstructed labor including vesico-vaginal fistulas, the epidemiology and etiology of fistulas in both developed and developing countries, and surgical procedures to close fistulas.

Deeb ME et al. Prevalence of reproductive tract infections, genital prolapse, and obesity in a rural community in Lebanon. Bulletin of the World Health Organization. 2003;81(9):639-645. Available at: www.who.int/bulletin/volumes/81/9/en/Deeb0903.pdf.
In a randomly selected sample of 557 never-married women aged 15 to 60 from a rural community in east Lebanon, only 1.2 percent had sexually transmitted infections, while 9.3 percent had endogenous reproductive tract infections. None had invasive cervical cancer, and only one had cervical dysplasia. In contrast, 49.6 percent had genital prolapse and 30.2 percent were obese. The low prevalence of reproductive tract infections may be due to the conservative nature of the community, the high rate of utilization of health care services, and/or the liberal use of antibiotics without a prescription.

Hilton P. Vesico-vaginal fistulas in developing countries. International Journal of Gynecology and Obstetrics. 2003;82:285-295.
Over 90 percent of fistulas in the developing world are obstetric in origin, in contrast to developed countries where most follow pelvic surgery. Fistula rates rise with maternal mortality rates, and annual incidence worldwide may be as high as 500,000. This article thoroughly reviews the evidence on how to manage fistulas, including catheter drainage, skin care, nutrition, physiotherapy, antimicrobial therapy, counseling, and various surgical repair techniques. Cure rates at first operation range from 60 percent to 98 percent. While early intervention in obstructed labor is essential to reduce the incidence of fistulas, major social changes in women’s status and childbearing norms also are needed.

Kumari, S. et al. Self-reported uterine prolapse in a resettlement colony of North India. Journal of Midwifery & Womens Health 45(4):343-350 (2000).
During house-to-house screening of 2,990 married women in Chandigarh, India, 7.6 percent reported symptoms of uterine prolapse. Prevalence increased with parity, and symptoms started before age 30 for 72 percent of women. Of those with symptoms, 21 percent had consulted a doctor and 12 percent a traditional birth attendant, while 57 percent did not seek any treatment. Only 8 of 38 women advised to have an operation did so. Other treatments undertaken included tablets or capsules, injections, ring pessaries, and indigenous techniques involving heel pressure and manual reduction with alcohol. Reasons for not seeking treatment were shyness, lack of husbands cooperation, lack of time, and lack of money. Three-quarters of women who did not seek treatment considered prolapse to be normal.

Morkved, S. et al. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial. Obstetrics and Gynecology 101:313-319 (2003).
This randomized, controlled clinical trial assessed whether intensive pelvic floor muscle training during pregnancy could prevent urinary incontinence. Of the 301 healthy nulliparous pregnant women in the study, 148 were randomly allocated to a 12-week intensive pelvic floor muscle training program supervised by physiotherapists. Significantly fewer women in the training group reported urinary incontinence at 36 weeks’ pregnancy (32% versus 48%, P = .007) and three months after delivery (20% versus 32%, P = .018). Pelvic floor muscle strength also was significantly higher in the training group at both follow-ups.

Parikh, I. et al. Gynaecological morbidity among women in a Bombay slum. Streeihitakarini Working Paper. Mumbai, India: SNDT Women's University. Available at: www.hsph.harvard.edu/. A survey, clinical examination, and lab tests were used to investigate gynecological morbidity in 756 married women living in a slum area of Bombay. Almost three-quarters of the women reported a gynecological condition, including vaginal discharge, lower back pain, abdominal pain, and menstrual disorders. Clinical exams found that 73 percent suffered from one or more conditions, the most common of which were cervicitis (39%) prolapse (19%), and PID (16%). The lab tests found that 49 percent of the women had infections, 23 percent had an STI, while 31 percent had an endogenous infection. According to a logistic regression, sterilized women and IUD users were more likely to report complaints, while age and parity were related to clinically diagnosed morbidity but not to reproductive tract infections. Women were reluctant to seek care for gynecological problems because of their perception of such problems to be a normal part of womanhood, the high cost of treatment, and their reluctance to discuss such problems with male physicians. They consulted faith healers and pharmacists more often than doctors.

Piya-Anant M et al. Integrated health research program for the Thai elderly: prevalence of genital prolapse and effectiveness of pelvic floor exercise to prevent worsening of genital prolapse in elderly women. Journal of the Medical Association of Thailand. 2003;86:509-515.
The prevalence of genital prolapse in a cross-sectional study of 682 Thai women was 70 percent. These women were then enrolled in a case-control study of pelvic floor exercises. After 24 months, during which women in the experimental group performed pelvic floor exercises 30 times daily, genital prolapse had worsened by 72 percent in the control group compared with 27 percent in the experimental group (p = 0.005). Pelvic floor exercises were more effective in women with severe than mild genital prolapse.

Poma, P.A. Nonsurgical management of genital prolapse: a review and recommendations for clinical practice. Journal of Reproductive Medicine 45:789-797 (2000).
As the number of postmenopausal women worldwide increases, the number of cases of genital prolapse will also increase. This article reviews alternatives to surgery, which has become the only widely available treatment for prolapse. Kegel exercises, supplemented with feedback techniques or mechanical means, can be simple and effective. Pessaries can improve urinary incontinence as well as prolapse but must be fitted properly and periodically removed for cleaning. Women using pessaries on a long-term basis need to be evaluated every 3 to 6 months.

Siu LS et al. Compliance with a pelvic muscle exercise program as a causal predictor of urinary stress incontinence amongst Chinese women. Neurourology and Urodynamics. 2003;22:659-663.
A pelvic muscle exercise program enrolled 214 women presenting with urinary stress incontinence in Hong Kong. The women attended one training session each month for fourth months and charted the frequency of incontinence between sessions. By the end of the training program, overall urinary incontinence episodes decreased 85 percent while pelvic muscle strength increased 73 percent. Women who adhered to the program more closely experienced a greater reduction in episodes of incontinence. Age, mode of delivery, menopausal status, history of pelvic surgery, and duration of incontinence did not significantly contribute to predicting incontinence.

Subak, L.L. et al. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstetrics and Gynecology 100:72-78 (2002).
This clinic trial randomly assigned 152 women over age 55 with urinary incontinence to a behavioral therapy or control group. Behavioral therapy was low-intensity and consisted of six instructional sessions on bladder training and the creation of individual voiding schedules. Women in the treatment group had a 50 percent reduction in the number of incontinent episodes, compared with 15 percent for the control group, and the improvement was maintained over six months. The type of incontinence did not affect the efficacy of the intervention. The author concludes that low-intensity behavioral therapy should be the first-line treatment for urinary incontinence in older women.

Thakar, R. and S. Stanton. Management of genital prolapse. British Medical Journal 324:1258-1262 (2002). Available at: http://bmj.com/.
Genital prolapse may cause urinary, bowel, or sexual symptoms, as well feelings of pain or pressure. Contributing factors include childbirth and menopause, and risk increases with age. This review article concludes that there is a lack of good data on the prevention and treatment of prolapse. More research is needed on the role of pelvic floor exercises, pessaries, and the pros and cons of different surgical routes.

United Nations Population Fund (UNFPA). Addressing Obstetric Fistulas. UNFPA Fact Sheets (April 2002). Available at: www.unfpa.org/issues/factsheets/index.htm.
An estimated 2 million women are living with obstetric fistulas although they are almost entirely preventable and can be corrected surgically. This series of fact sheets explains how obstetric fistulas develop and reviews their physiological and psychological consequences. Strategies are described: (1) to prevent obstetric fistulas by addressing social causes, including early age at marriage, poverty and malnutrition, and lack of access to medical care; and (2) to treat women with fistulas by establishing specialist centers that offer surgery, psychological counseling, and social rehabilitation. The final fact sheet outlines efforts being undertaken by an international Working Group on Fistulas to raise awareness of the problem.

UNFPA, EngenderHealth. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries. New York: UNFPA and EngenderHealth; 2003. Available at: www.unfpa.org/fistula/docs.
This rapid assessment study measured the incidence of fistula and the capacity of hospitals to treat it in nine countries of sub-Saharan Africa: Benin, Chad, Malawi, Mali, Mozambique, Niger, Nigeria, Uganda, and Zambia. To lower the incidence of fistula, researchers recommend: information and awareness campaigns on postponing marriage, delaying childbirth by using family planning, and seeking emergency obstetric care; empowerment of women; training in reconstructive surgery to meet the demand for treatment; provision of basic medical equipment and supplies to hospitals; safe and reliable transportation so that poor women can reach hospitals quickly; subsidized care for women with fistulas; and education and counseling for fistula survivors.

Wall, L.L. Fitsari Dan Duniya: an African (Hausa) praise song about vesicovaginal fistulas. Obstetrics and Gynecology 100:1328-1332 (2002).
This commentary describes the response of Nigerian women to a special medical program that repairs the vesicovaginal fistulas that have made them social outcasts. The fistula ward offers them a protective and nurturing environment, in which women can exchange their stories and find the emotional support that is an important element of the treatment. A traditional Hausa praise song, written by one of these women, communicates the horrible situation in which these women find themselves and their profound gratitude for treatment.

Wall, L.L. Birth trauma and the pelvic floor: lessons from the developing world. Journal of Women's Health 8(2):149-155 (1999).
Obstructed labor remains a common, preventable cause of maternal death in developing countries. When women linger in obstructed labor for days, the pressure of the fetal head on the soft tissues of the pelvis cuts off the blood supply. The most dramatic consequence is an obstetric fistula, which is an abnormal opening between the vagina and the urinary tract or rectum which leads to a complete loss of urinary or fecal control. Millions of women are affected worldwide. Such women are frequently divorced by their husbands, excluded by their families, and driven to the margins of society. Most fistulas can be surgically closed relatively inexpensively, but many women have no access to the medical care needed. Even if the fistula is closed, other injuries related to obstructed labor remain, including injuries to urethra and bladder that cause urinary frequency, urgency, and chronic urinary tract infections; injuries to the vagina and cervix that lead to PID, amenorrhea, and secondary infertility; and injuries to the bones and nerves that cause pronounced limps. The devastating effects of obstructed labor have implications for understanding the stresses of normal labor and delivery on women's pelvic organs and the origins of pelvic organ prolapse and urinary incontinence. The author speculates that good obstetric practice may mean identifying women at risk for serious long-term sequelae like prolapse and conducting preventive cesarean deliveries.

Walraven, G. et al. Menstrual disorders in rural Gambia. Studies in Family Planning 33(3):261-268 (2002).
As part of a community-based reproductive morbidity survey in rural Gambia, a questionnaire was administered by a field worker and by a gynecologist, who also examined the women. Semistructured interviews were conducted to assess knowledge, attitudes, and beliefs in a subsample. Of 607 menstruating women not using hormonal contraceptives, 16 percent complained to the gynecologist of irregular cycles, 14 percent of dysmenorrhea, 8 percent of spotting, and 4 percent of heavy or prolonged bleeding. Most of these women (60%) had not sought health care, perhaps because menstruation is a taboo subject, they were unaware that treatments were available, or they considered their symptoms to be normal. Since relatively simple and inexpensive therapies are often available for menstrual problems, reproductive health programs in developing countries should address them with a combination of information, education, and clinical management.

Walraven, G. et al. The burden of reproductive-organ disease in rural women in The Gambia, West Africa. Lancet 357(9263):1161-1167 (2001). Available at: http://pdf.thelancet.com/. Interviews and gynecological examinations were used to gather data on reproductive health of 1,348 women aged 15-54 living in rural areas of The Gambia. Half of the women (53%) reported symptoms to the gynecologist, but most had never sought health care for them because they thought nothing could be done, the problem was not serious enough, or care would be costly or embarrassing. Seventy percent of the women had at least one reproductive organ disorder; most common were reproductive tract infections (47%), childbirth-related damage to pelvic structures (46%), menstrual dysfunction (34%), and masses (16%). The authors conclude that educating and empowering women to overcome the culture of silence surrounding reproductive organ disorders should be a priority.

Weatherall, M. Biofeedback or pelvic floor muscle exercises for female genuine stress incontinence: a meta-analysis of trials identified in a systematic review. BJU International 83(9):1015-1016 (1999).
This meta-analysis extracted data from five trials on biofeedback and pelvic floor muscle exercises for the treatment of stress urinary incontinence. A pooled analysis of the data found that biofeedback combined with pelvic floor muscle exercises was twice as successful as pelvic floor muscle exercises alone in curing the problem.

Weiss, B.D. and Newman, D.K. New insight into stress urinary incontinence: advice for the primary care clinician. Medscape Clinical Update (2002). Available at: www.medscape.com/viewprogram/1961. (Medscape requires free online registration.)
Age, childbirth, and menopause are among the key risk factors for stress urinary incontinence (SUI), which may affect one-third of older women in the United States. After reviewing the prevalence and physiology of SUI, this continuing medical education module describes how to diagnose and treat the condition. While diagnosis is relatively straightforward, treatment requires choosing from an array of options, each with its own advantages and disadvantages. These include various forms of pelvic muscle exercises, surgery, medications, electrical and magnetic stimulation, devices inserted into the vagina to support the bladder neck or inserted into the urethra to block leakage, and absorbent pads. A patient education tool explaining how to do pelvic muscle exercises is included.

Willhite, L.A. and OConnell, M.B. Urogenital atrophy: prevention and treatment.Pharmacotherapy 21(4):464-480 (2001). Available at: www.medscape.com/viewarticle/409697. (Medscape requires free online registration.)
After discussing the physiology and etiology of urogenital atrophy, this article presents a thorough review of all possible treatment options, including hormone replacement therapy, vaginal rings and tablets, estrogen creams, vaginal moisturizers and lubricants, and herbal products.

Younis, N., et al. A community study of gynecological and related morbidities in rural Egypt. Studies in Family Planning 24(3):175-186 (1993).
Medical examinations of 509 women from two rural villages in Egypt found high levels of gynecological morbidity. Fifty-six percent of all women had genital prolapse, and the risk increased both with a woman's age and number of deliveries. Age and socioeconomic status were associated with urinary tract infections, hypertension, and obesity.

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Breast cancer

Albert, U.S. and Schulz, K.D. Clinical breast examination: what can be recommended for its use to detect breast cancer in countries with limited resources? Breast Journal 9 (Suppl. 2):S90-S93 (2003).
Clinical breast examination (CBE) is the least studied of the modalities for breast cancer screening: there have been no randomized trials of CBE alone on which to base recommendations. However, there is considerable indirect evidence from studies that CBE can be recommended as a method for detecting breast cancer for public health benefit. CBE is inexpensive and easy to perform; it can be readily taught to health care providers; and it can be offered ubiquitously. CBE should be part of any program for early detection of breast cancer worldwide, provided that follow-up medical and oncology care is available. The authors recommend informing physicians and women about the advantages and disadvantages of CBE and promoting research on CBE in countries with limited resources to evaluate its efficacy and effectiveness in relation to age, ethnicity, and race.

Anderson, B.O. et al. Early detection of breast cancer in countries with limited resources. Breast Journal 9 (Suppl. 2):S51-S59 (2003).
The authors propose the following sequential action plan for countries with limited resources to promote early detection of breast cancer: (1) promote the empowerment of women to obtain health care, (2) develop infrastructure for the diagnosis and treatment of breast cancer, (3) begin early detection efforts through breast cancer education and awareness, and (4) when resources permit, expand early detection efforts to include mammographic screening. Education about breast cancer must be culturally appropriate and targeted and tailored to the specific population. When resources become available for screening, they should be invested in screening mammography, as it is the only modality so far shown to reduce breast cancer mortality. Although clinical breast examination (CBE) and breast self-examination (BSE) are important for general breast health education in all countries, the evidence does not support their use as lifesaving screening methods at this time, recognizing that data from countries with very limited resource are lacking. When widespread screening is not possible, screening can begin in an institution, city, or region, or by targeting screening to women at highest risk. To succeed, early detection efforts also must include the health care providers with whom women have contact, whether they are physicians, nurses, midwives, traditional healers, or others.

Bancej, C. et al. Contribution of clinical breast examination to mammography screening in the early detection of breast cancer. Journal of Medical Screening 10(1):16-21 (2003).
This study evaluated the contribution of clinical breast examination (CBE) to four Canadian breast cancer-screening programs. It analyzed outcomes for 300,303 women aged 50 to 69 who received both CBE and mammography between 1996 and 1998. CBE alone contributed in 29 to 37 percent of all referrals and 5 to 6 percent of all cancers detected, compared with 53 to 60 percent of referrals and 60 to 64 percent of cancers for mammography alone. Most cancers detected by CBE (84-89%) were also detected by mammography; fewer cancers detected by mammography (32-37%) were also detected by CBE. On average, CBE increased the rate of detection of small invasive cancers by 2 to 6 percent over rates if mammography was the sole detection method. Without CBE, programs would miss three cancers in every 10,000 screens and 3 to 10 small invasive cancers in every 100,000 screens. The authors conclude that inclusion of CBE in an organized mammography screening program contributes minimally to early detection.

Bartholomew, L.L. and Grimes, D.A. The alleged association between induced abortion and risk of breast cancer: biology or bias? Obstetrical and Gynecological Survey 53(11):708-714 (1998).
A careful analysis of research on induced abortion and risk cancer found methodological problems in case-control studies suggesting a link between the two. These include selection of an inappropriate control group, underreporting of induced abortion by controls, and confounding by other risk factors. Better evidence comes from two large cohort studies that are less susceptible to bias. These found that induced abortion either had no effect on breast cancer or protected against it.

Barton, M.B. et al. Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? Journal of the American Medical Association 282(13):1270-1280 (1999).
This article presents a pooled analysis of controlled trials and case-control studies that included clinical breast examination (CBE) as part of the breast cancer screening modality. The sensitivity of CBE was estimated at 54 percent and the specificity at 94 percent. CBE was able to detect between 3 percent and 45 percent of breast cancers that screening mammography missed. CBE was more accurate when providers used certain specific techniques, including proper positioning of the patient, examining all breast tissue, a vertical-strip search pattern, proper position and movement of the fingers, and spending at least three minutes per breast. Training on silicone breast models improved examiners sensitivity.

Baxter, N. and the Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? Canadian Medical Association Journal 164(13):1837-1846 (2001).
The Canadian Task Force on Preventive Health Care reviewed all reports on the effectiveness of breast self-examination (BSE) in reducing breast cancer mortality. Two large randomized controlled trials, a quasi-randomized trial, a large cohort study, and several case-control studies have failed to show a benefit for regular performance of BSE or BSE education. They do, however, show harm from BSE instruction in the form of increased physician visits and biopsies of benign breast lesions. In addition, teaching and reinforcing BSE may divert resources from other preventive strategies. Therefore, the Task Force recommends against routine teaching of BSE.

Bishop, A. et al. Lives renewed: the emergence of a breast cancer survivor movement in Ukraine. Reproductive Health Matters 9(18):126-134 (2001).
This article describes the emergence of a breast cancer survivor movement in Ukraine that is challenging social stigma against the disease. Breast cancer survivor groups have been formed in 15 cities. They are working to provide information and emotional support to newly diagnosed women in hospitals and to raise public awareness of the disease through public events, outreach activities, and the media. They have also enlisted the support of medical professionals specializing in cancer care.

Bjurstam, N. et al. The Gothenburg breast screening trial. Cancer 97:2387-2396 (2003).
This randomized, controlled trial of mammography screening in Sweden included 51,611 women aged 39-59, of whom 21,650 were invited to screening at 18-month intervals and the remainder were a control group. Screening took place from 1982 to 1991, with follow-up until 1996. Two different evaluation approaches found a nonsignificant 21 percent reduction and a borderline significant 23 percent reduction in the rate of mortality from breast carcinoma with invitation to screening. Analysis by age groups found greater reductions in mortality among women aged 39-44, 45-49, and 55-59; there was no reduction among women aged 50-54. Screening had a similar impact on the incidence of lymph node-positive disease. The incidence of breast cancer in the study group was almost identical to the incidence in the control group after the screening trial ended in the control group.

Braun, C.M. and Itano, J.K. Cancer care in Nepal: variables that affect diagnosis, treatment, and prognosis, a case study. Cancer Nursing 24(2):137-142 (2001).
A case study of a Nepalese woman with breast cancer is presented to illustrate problems with cancer care. After her initial diagnosis, the patient delayed treatment for five months for cultural reasons: she felt her responsibility to look after her husband and family came first. The patients low socioeconomic status and limited education also played a role: treatment was costly and the patient did not understand that delaying would worsen her prognosis. Because of status, gender, and educational differences between the oncologist and the patient, the patient did not ask questions and did not understand her situation. Lack of communication between the oncologist and the nurses prevented the nurses from explaining the situation to the patient. Because the nurses knew little about cancer treatment, they failed to teach the patient about safety precautions for chemotherapy, proper pain management, and exercises to prevent lymphedema. Lack of screening and detection programs in Nepal leads to delayed diagnosis of breast cancer.

Chlebowski, R.T. et al. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative Randomized Trial. JAMA 289(24):3243-3253 (2003).
The Women’s Health Initiative (WHI) is the first randomized, double-blind primary prevention trial of postmenopausal hormones. This article reports on the part of the study comparing combined estrogen/progestin therapy with a placebo, which included 16,608 healthy postmenopausal women aged 50-79 who were followed for approximately five years. The hormone therapy and placebo groups had comparable breast cancer risk characteristics and mammogram readings at baseline. Hormone therapy significantly increased the risks of all breast cancers (hazard ratio = 1.24) and invasive breast cancers (1.24). The invasive breast cancers diagnosed in the hormone therapy group were significantly larger and at a more advanced stage than those in the placebo group. Beginning one year after the initiation of the study, the percentage of women with abnormal mammograms was substantially greater in the hormone therapy than the placebo group. The results suggest that combined hormone therapy may stimulate the growth of breast cancers while hindering their diagnosis, perhaps by increasing the density of breast tissues and thus making mamographic detection more difficult.

Colditz, G.A. and Rosner, B. Cumulative risk of breast cancer to age 70 years according to risk factor status: data from the Nurses' Health Study. American Journal of Epidemiology 152(10):950-964 (2000).
This study evaluated multiple risk factors for breast cancer, including reproductive risk factors, benign breast disease, postmenopausal hormones, weight, and alcohol intake, in the 58,520 women enrolled in the Nurses Health Study between 1980 and 1994. After adjusting for other risk factors, use of unopposed postmenopausal estrogen from age 50 to 60 increased the risk of breast cancer to age 70 by 23 percent compared with a woman who never used hormones. Ten years of use of estrogen plus progestin increased risk to age 70 by 67 percent. A history of benign breast disease and drinking alcohol also increased breast cancer risks.

Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83,000 women with breast cancer from 16 countries. Lancet. 2004;363(9414):1007-1016.
Data on individual women from 53 studies of breast cancer, undertaken in 16 countries with liberal abortion laws, were checked and reanalyzed. The overall relative risks of breast cancer were 0.98 (95% CI 0.92-1.04, p=0.5) for a history of spontaneous abortion and 0.93 (0.89-0.96, p=0.0002) for a history of induced abortion. However, results for induced abortion differed substantially depending on when women were asked whether they had had an abortion: before or after they were diagnosed with breast cancer. Studies that ask women about previous abortions after they are diagnosed with breast cancer seem to yield misleading results, presumably because women with breast cancer are more likely than others to disclose induced abortions. They conclude that neither spontaneous nor induced abortions increase a woman’s risk of developing breast cancer.

Collaborative Group on Hormone Factors in Breast Cancer. Alcohol, tobacco and breast cancer—collaborative reanalysis of individual data form 53 epidemiological studies, including 58 515 women with breast cancer and 95 067 women without the disease. British Journal of Cancer 87:1234-1245 (2002).
This meta-analysis collected, checked, and reanalyzed over 80 percent of the relevant information worldwide on alcohol, tobacco consumption, and breast cancer. Age, parity, women's age when their first child was born, and consumption of alcohol and tobacco were included in the analysis. Alcohol consumption was greater in ever-smokers than never-smokers. Compared with nondrinkers, women who reported drinking alcohol faced an increased risk of breast cancer—whether or not they also smoked—which rose with the amount of alcohol consumed: the relative risk of breast cancer was 1.32 (1.19-1.45, P < 0.00001) for an intake of 35-44 g per day alcohol and 1.46 (1.33-1.61, P < 0.00001) for >/= 45 g per day alcohol. The effect of alcohol substantially confounded the relationship between smoking and breast cancer; when the analyses were restricted to nondrinkers, smoking was not associated with breast cancer. These results suggest that about 4 percent of the breast cancers in developed countries are attributable to alcohol. Because of lower levels of drinking in developing countries, alcohol would have a negligible effect on the incidence of breast cancer there.

Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet 360(9328):187-195 (2002). Available at: www.thelancet.com/.
The Collaborative Group on Hormonal Factors in Breast Cancer has brought together worldwide data from 47 case-control and cohort studies of women with breast cancer in 30 countries. Compared to controls, women with breast cancer had fewer births, were less likely to have ever breastfed, and had breastfed for a shorter time. The relative risk of breast cancer decreased by 4.3 percent for every 12 months of breastfeeding in addition to a decrease of 7 percent for each birth. The associations were significant and were seen consistently for women from developed and developing countries, of different ages and ethnic origins, and with various menstrual and childbearing patterns. The authors conclude that differences in family size and duration of breastfeeding explain much of the difference in breast cancer incidence rates between developed and developing countries. Declines in family size and breastfeeding are contributing to rising rates of breast cancer in developing countries.

Davidson, T. Abortion and breast cancer: a hard decision made harder. Lancet Oncology 2:756-758 (2001).
A review of the published evidence for and against a causal relationship between induced abortion and breast cancer reveals methodological flaws in case-control studies that may cause spurious associations. Large cohort studies that are less susceptible to bias have found either no effect or a protective effect by induced abortions on breast cancer risk. The author concludes that the data do not justify warning women about breast cancer risks when counseling them about abortion.

de Koning HJ. Why improvement in survival of screen-detected cases is not necessarily equivalent to benefit? The Breast. 2003;12(5):299-301.
This editorial argues that four kinds of bias make it difficult to analyze the impact of screening tests, such as mammography, which detect asymptomatic disease. Survival curves are biased by: lead-time (the amount of time a diagnosis is advanced by a screening test), length bias (the detection of people with more slowly progressing disease), selection bias (different characteristics of people who agree to be screened), and overdiagnosis bias (screen-detected lesions labeled as cancer that would not have progressed to a clinical diagnosis). The author concludes that apparent improvements in survival curves do not always reflect real health benefits.

Duffy, S.W. et al. The impact of organized mammography service screening on breast carcinoma in seven Swedish counties. Cancer 95:458-469 (2002).
Using data from a national death register and mammography screening centers in seven counties in Sweden, the authors found a 44 percent reduction in breast cancer mortality among women who were actually exposed to mammography screening compared with the prescreening period. When all women, screened or not, are included, there was a 32 percent reduction in breast cancer mortality in counties with more than ten years of organized screening and an 18 percent reduction in counties with ten years or less of organized screening.

Forbes, J.F. The incidence of breast cancer: the global burden, public health considerations. Seminars in Oncology 24(1, Suppl. 1):S1-20-S1-35 (1997).
Worldwide, breast cancer is the second most common cancer among women, and its incidence is rising. As yet the burden of breast cancer is less in developing countries, both because the age-specific incidence is lower and the countries have a relatively younger population. Financial and psychosocial costs of breast cancer are great in every region of the world. Effective control of breast cancer requires prevention, early diagnosis, and access to effective treatments. Mammography screening and improved treatments have reduced mortality rates in the United States and United Kingdom. In developing countries, the number of cases of breast cancer will rise sharply in the future as life expectancy increases and the underlying risk of breast cancer rises.

Gao, Y.T. et al. Association of menstrual and reproductive factors with breast cancer risk: results from the Shanghai study. International Journal of Cancer 87:295-300 (2000).
A regression analysis of a case-control study involving 3,000 women explored factors that might explain the rising incidence of breast cancer in Shanghai over the past 20 years. Menarche at age 13 or younger was an important explanatory factor for cases diagnosed among younger women (age 40 or under), while older age at first live birth and menopause was more important for older women. Results suggest that changes in menstrual patterns among women in Shanghai, probably due to changes in lifestyle and behavior related to socioeconomic development, may be responsible for the increase in the incidence of breast cancer.

Hackshaw, A.K. and Paul, E.A. Breast self-examination and death from breast cancer: a meta-analysis. British Journal of Cancer 88:1047-1053 (2003).
This meta-analysis of the effect of regular breast self-examination (BSE) on breast cancer mortality includes 20 observational studies and 3 clinical trials. Pooled results show a lower risk of mortality (pooled relative risk = 0.64, 95% CI 0.56-0.73) and of advanced breast cancer (pooled relative risk = 0.60, 95% CI 0.46-0.80) in women who reported practicing BSE before their diagnosis of breast cancer, but these results are probably due to bias and confounding. Death rates were not lower for women who detected their cancers during self-examination (pooled relative risk 0.90, 95% CI 0.72-1.12). Nor do trials of BSE training, in which most women reported practicing it regularly, show lower mortality in the BSE group (pooled relative risk = 1.01, 95% CI 0.92-1.12). However, BSE is associated with more women seeking medical advice and having biopsies. The authors conclude that regular BSE is not an effective method of reducing breast cancer mortality.

Hirose K et al. Dietary factors protective against breast cancer in Japanese premenopausal and postmenopausal women. International Journal of Cancer. 2003;107:276-282.
This case-referent study examined the possibility that the Japanese diet contributes to the low incidence of breast cancer in Japan. A total of 2,385 breast cancer cases were compared with 19,013 women who did not have cancer. High intakes of milk and green-yellow vegetables protected both pre- and postmenopausal women against developing breast cancer. High intakes of fish and fruit reduced the risk of postmenopausal breast cancer by 25 percent and 39 percent respectively. The authors conclude that the traditional Japanese diet may protect against breast cancer, especially in postmenopausal women.

Hoffman, M. et al. Breast cancer incidence and determinants of cancer stage in the Western Cape. South African Medical Journal 90(12):1212-1216 (2000).
This study interviewed 249 women diagnosed with invasive breast cancer over a two-year period at hospitals in Cape Town, South Africa. The incidence rate for colored women was nearly double that for black women: 25.6 versus 14.7 per 100,000. The incidence rate in urban areas was nearly double that in rural areas: 26.6 versus 16.3 per 100,000. Over half the cases (57.8%) were stages 1 and 2. Earlier stage at diagnosis was significantly associated with higher educational level, membership of a medical aid society, residence in an urban area, and a positive family history. This suggests that awareness and access to better health care is associated with earlier detection. The authors recommend education and improved access to diagnostic measures, especially in rural and disadvantaged populations.

Holcombe, C. et al. The differential diagnosis and management of breast lumps in the Tropics. Tropical Doctor 29:42-46 (1999).
While breast cancer is less common in Africa than in the West, it presents a challenge to the doctor since women usually do not seek care until their disease is advanced. This article discusses the challenges of diagnosing and treating breast cancer in settings where resources—and therapeutic options—are limited. Most benign conditions may be treated by breast-conserving procedures. Most carcinomas, if operable, require mastectomy with axillary node clearance and adjuvant therapy.

Humphrey, L.L. et al. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine 137(5, Part 1):347-360 (2002).
This meta-analysis critically examined eight randomized, controlled trials of mammography and two trial evaluating breast self-examination. In studies of fair quality or better, screening with mammography reduced death rates from breast cancer by 16 percent, and 1,224 women needed to be screened to prevent one death after 14 years of observation. Among women under 50 years, mammography reduced breast cancer death rates by 15 percent, and 1,792 women needed to be screened to prevent one death after 14 years of observation. For clinical breast examination and breast self-examination, evidence from randomized trials in inconclusive.

Klemi PJ et al. Significant improvement in breast cancer survival through population-based mammography screening. The Breast. 2003;12:308-313.
This study evaluated the effect of population-based mammography screening on breast cancer survival among 36,000 women in Finland aged 40-74 during the years 1987-1997. Survival was greater in the screened group (P<0.0001), probably because cancers detected by screening or in the intervals between screening (n=685) were smaller (P<0.0001), more localized (P<0.0001) and histologically better differentiated (P<0.0001) than clinically diagnosed cancers (n=184).

Lee, S.Y. et al. Effect of lifetime lactation on breast cancer risk: a Korean women’s cohort study. International Journal of Cancer 105:390-393 (2003).
Data for this study come from a prospective cohort study of 110,604 premenopausal parous women in Korea who were followed for six years. After controlling for age, age at menarche, number of children, age at first pregnancy, oral contraceptive use, smoking, exercise, and obesity, there was a clear trend of decreasing breast cancer risk with increased duration of breastfeeding. Compared with women who had never breastfed, the relative risk of breast cancer was 0.7 for women who reported breastfeeding for 13-24 months and 0.6 for those who had breastfed longer than 24 months.

Leung, G.M. et al. Will screening mammography in the East do more good than harm? American Journal of Public Health 92:1841-1846 (2002).
This article systematically applies the evidence for population-based mammography to a Chinese population, in which the relatively low prevalence of breast cancer reduces the positive predictive value of mammography. The small volume and denser tissue in the average Chinese breast also may limit the sensitivity and specificity of mammography, creating a high rate of false positives among positive screens (from 86 to 98%). The authors calculate that in Hong Kong 1,302 healthy women would need to be screened annually for 10 years to prevent 1 death, and the number of women suffering complications due to biopsies necessitated by false positive results would be greater than the number of lives saved. The authors conclude that there is insufficient evidence to justify population-based breast cancer screening by mammography for women in Hong Kong and other Asian populations with low breast cancer prevalence.

Lipworth, L. et al. History of breast-feeding in relation to breast cancer risk: a review of the epidemiologic literature. Journal of the National Cancer Institute 92(4):302-312 (2000).
This article reviews the epidemiological data from case-control studies on the impact of breastfeeding on breast cancer risk. Results are inconclusive, suggesting that breastfeeding has either no impact or a weak protective effect against breast cancer. Some studies show a protective effect associated with long-term breastfeeding, possibly confined to premenopausal women. The lack of prolonged breastfeeding in Western study populations may explain why other studies did not find any impact. The article discusses the biological mechanisms that might explain a protective effect of breastfeeding.

Matthews, C.E. et al. Lifetime physical activity and breast cancer risk in the Shanghai Breast Cancer Study. British Journal of Cancer 84(7):994-1001 (2001).
This case-control study analyzed physical activity during adolescence and adulthood in 1,459 women newly diagnosed with breast cancer and 1,556 age-matched controls living in Shanghai. The women were interviewed regarding their participation in exercise and sports, household activities, walking and cycling, and occupational activity. Exercise during adolescence reduced the risk of breast cancer by 16 percent, during adulthood by 32 percent, and during both adolescence and adulthood by 53 percent. Risk reductions were greater when women reported exercising for a greater number of years. Lifetime occupational activity also reduced risk.

McPherson, K. et al. ABC of breast diseases: breast cancer—epidemiology, risk factors, and genetics. British Medical Journal 321:624-628 (2000). Available at: http://bmj.com/cgi/reprint/321/7261/624.pdf.
This article reviews the magnitude of established risk factors for breast cancer, including age, country, age at menarche and menopause, age at first pregnancy, family history, previous benign breast disease, radiation, diet, weight, alcohol intake, smoking, oral contraceptive use, and hormone replacement therapy. Three possible avenues for preventing breast cancer are described: tamoxifen, dietary interventions, and retinoids.

McTiernan A et al. Recreational physical activity and the risk of breast cancer in postmenopausal women: The Women’s Health Initiative cohort study. JAMA. 2003;290(10):1331-1336.
This article examines data on past and present physical activity among the 74,171 US women aged 50-79 who were enrolled in the Women’s Health Initiative prospective cohort study. There were 1,780 newly diagnosed cases of breast cancer over a mean follow-up of 4.7 years. Strenuous physical activity in the past (at ages 18, 35, and 50) reduced the risk of breast cancer. Less strenuous physical activity in the present also reduced breast cancer risks: risks fell by 18% for women who did the equivalent of 1.25 to 2.5 hours per week of brisk walking and were even lower for those who engaged in more hours of exercise.

Miller, A.B. Screening opportunities in developing countries: problems and opportunities. Cancer Treatment and Research 86:183-189 (1996).
Cancer is becoming an important cause of morbidity and mortality in developing countries. This article discusses whether screening programs that diagnose cancers early, when they are more easily treated, are an appropriate intervention in these settings. Cancer screening is appropriate when: (1) the cancer is common and carries high morbidity and/or mortality, (2) effective treatments known to reduce morbidity and mortality from the disease are available, and (3) the screening procedure is acceptable to people, relatively inexpensive, and safe. The author concludes that screening for cervical cancer, using cervical smears, and for breast cancer, using breast self-examination, is reasonable in developing countries.

Miller, A.B. et al. The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomized screening trial of mammography in women age 40 to 49 years. Annals of Internal Medicine 137(5, Part 1):305-312 (2002).
This article extends the follow-up of 50,430 Canadian women aged 40 to 49, equal numbers of whom were randomly assigned to annual mammography and breast physical examinations for four to five years OR to a single breast physical examination and usual community care. After 11 to 16 years of follow-up, more cases of breast cancer were diagnosed in the mammography group (592 cases of invasive breast cancer and 71 cases of in situ breast cancer) than in the usual care group (552 and 29, respectively). Breast cancer mortality, however, did not differ significantly between the groups: there were 105 breast cancer deaths in the mammography group and 108 deaths in the usual care group.

Miller, A.B. et al. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. Journal of the National Cancer Institute 92(18):490-499 (2000).
This trial randomly assigned nearly 40,000 women aged 50-59 to annual mammography along with clinical breast examination, or to clinical breast examination only. Mammography found more cancers than clinical breast examination, but the additional cancers were lymph node negative and small in size. At the 13-year follow-up, the breast cancer mortality in the two groups was the same. Thus, the addition of annual mammography screening to clinical breast examination had no impact on breast cancer mortality. The authors suggest that annual clinical breast examination might be a good alternative for screening where mammography services are unavailable.

Mittra, I. et al. Is clinical breast examination an acceptable alternative to mammographic screening? British Medical Journal 321:1071-1073 (2000). Available at: http://bmj.bmjjournals.com/.
This essay questions whether mammography is the only acceptable modality for screening for breast cancer. While mammography detects some cancers early, many will never progress and their detection causes needless biopsies and anxiety. In contrast, clinical breast examination tends to detect cancers that are potentially lethal and does not require complicated and expensive technology. The authors argue, based on the second Canadian national breast screening study, that clinical breast examination may have as big an impact on breast cancer mortality as mammography screening, with fewer adverse effects on women. Clinical breast examination may be especially suitable for the developing world.

Nystrom, L. et al. Long-term effects of mammography screening: updated overview of the Swedish randomized trials. Lancet 359:909-919 (2002).
This study follows up the Malmo portion of the Swedish two-county randomized controlled trial of mammography screening. Results show a significant 21 percent reduction in breast cancer mortality in the group receiving screening compared with the control group; total mortality was reduced by 2 percent. The reduction in mortality was greatest (33%) in the 60-69 age group, but significant effects were seen in every five-year age group from 55 to 69. Benefits first emerged at four years after randomization and continued to increase to about ten years, after which they were maintained throughout the follow-up period (a median of 15.8 years). After discussing the methodology of the trial in detail, the authors reject outside criticism as scientifically unfounded.

Olsen, O. and Gotzsche, P.C. Cochrane review on screening for breast cancer with mammography. Lancet 358:1340-1342 (2001). Available at: http://pdf.thelancet.com/.
After reassessing the seven randomized trials of screening mammography during a Cochrane review, the authors conclude that there is no reliable evidence that mass screening reduces mortality. Methodological flaws undermine the results of the studies, and the worst two are omitted from this reanalysis. Of the remaining trials, the two with the best methodology found no effect on breast cancer mortality. Assessment of cause of death was unreliable and biased in favor of screening so that the only reliable mortality estimates are those for overall mortality. Total mortality rates were unaffected by mass screening. Screening also led to more aggressive treatment, increasing the number of mastectomies and tumorectomies by about 30 percent. The full report is available online (http://image.thelancet.com/lancet/extra/fullreport.pdf).

Otto, S.J. et al. Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet 361:1411-1417 (2003).
To assess the impact of a mammography screening program for women aged 50-69 years in the Netherlands on mortality, this study examined data for 27,948 women who died of breast cancer between 1980 and 1999. Compared with breast cancer mortality rates in 1986-88, mortality rates in women aged 55-74 years fell significantly in 1997 and subsequent years as predicted, reaching -19.9 percent in 2001. Mortality rates had been increasing by an annual 0.3 percent until screening was introduced; thereafter rates declined by 1.7 percent per year (95% CI 2.39-0.96) in women aged 55-74 years and by 1.2 percent per year in those aged 45-54 years (2.40 to 0.07). Adjuvant systemic therapy is unlikely to be the cause of this turning point, since the mortality rates continued to rise up to one year after implementation in municipalities where screening began after 1995.

Paoletti X et al. Induced and spontaneous abortion and breast cancer risk: results from the E3N cohort study. International Journal of Cancer. 2003;106:270-276.
Analysis of a large-scale cohort study of environmental and reproductive factors shows no association between breast cancer and a history of induced abortion over ten years of follow-up, after adjusting for potential confounders. This was true for the entire study sample of 100,000 women (who were aged 40-65 when the study began in 1990) and for all subgroups. Overall the association between spontaneous abortion and breast cancer was not significant (RR = 1.05), but the data suggest that the risk of postmenopausal breast cancer may increase with repeated miscarriages.

PATH. Breast cancer: increasing incidence, limited options. Outlook 19(4) (June 2002). Available at: www.path.org/files/eol19_4.pdf.
Over the past several decades, the risk of breast cancer in developed countries has increased by one to two percent annually. Available data for developing countries indicates that age-standardized incidence rates are rising even more rapidly in low-incidence regions such as Africa and Asia. This article discusses these trends and other issues—including risk factors, screening approaches, and quality-of-life issues—with a focus on developing-country settings, and shows that policy makers must carefully weigh the costs and benefits of fighting breast cancer against competing health needs.

Pathak, D.R. and Whittemore, A.S. Combined effects of body size, parity, and menstrual events on breast cancer incidence in seven countries. American Journal of Epidemiology 135(2):153-167 (1992).
This study examined case-control data from countries where the incidence of breast cancer is high (United States and Wales), medium (Brazil, Greece, and Yugoslavia), and low (Japan and Taiwan). The same patterns were seen in all seven countries. Incidence rates jumped after first childbirth and then increased more slowly with age afterwards. Rates increased with age more slowly after menopause than before. Rates decreased with body mass among premenopausal women in high-risk countries, but increased with body mass in all other groups of women. The authors conclude that reproductive events and body fat exert similar effects on all women, regardless of breast cancer rates in their country of residence.

Reichenbach, L. The politics of priority setting for reproductive health: breast and cervical cancer in Ghana. Reproductive Health Matters 10(20):47-58 (2002).
This paper discusses how reproductive health priorities are set in developing countries, using a case study from Ghana to illustrate. According to incidence and mortality rates, health impacts, and screening and treatment costs, cervical cancer clearly should take priority over breast cancer in Ghana but this information was not readily available to policy makers in the 1990s. Instead, they assigned priority to breast cancer due to lobbying by Ghanaian womens organizations, the inability of the Ministry of Health to communicate the risks of cervical cancer, and the association of breast cancer with positive images of motherhood as opposed to cervical cancers association with illicit sex and poor genital hygiene. Policymakers should expand their approach to priority setting to include all stakeholders and should rely on more comprehensive forms of evidence.

Sankaranarayanan, S. et al. An overview of cancer survival in developing countries. In Cancer Survival in Developing Countries. IARC Scientific Publications No. 145, pp. 135-157. Lyon, France: International Agency for Research on Cancer (1999).
This chapter presents population-based cancer survival data for 10 populations in five developing countries (China, Cuba, India, Philippines, and Thailand) and compares them to data from the United States and Europe. For female breast cancer, survival rates are poorer in developing than developed countries due to later detection of disease and inadequate treatment. Comparatively high survival rates in Shanghai may be due to greater awareness of breast cancer and thus diagnosis at an earlier stage of disease. The authors conclude that linking early detection with adequate treatment can increase survival rates for several cancer sites, including the breast. They call for population-based cancer registries of sample populations in many developing countries; high-resolution studies of diagnosis, treatment, and outcome for samples of patients from these registries; community-based intervention trials to identify low-technology, low-cost screening tests and prevention measures; and balanced investment in diagnostic and treatment facilities. Also needed are supportive and palliative care and consensus treatment protocols.

Schwartsmann, G. Breast cancer in South America: challenges to improve early detection and medical management of a public health problem. Journal of Clinical Oncology 19(18s):118s-124s (2001).
Breast cancer is a major public health issue in South America, especially in temperate areas, including Argentina, Chile, Uruguay, and southern Brazil. Potential risk factors include higher socioeconomic status, obesity, low parity, diet, and organochloride exposure. Mortality rates are high because a significant proportion of patients are not diagnosed until their cancers have reached stages II or III. The Latin American Group for the Study of Breast Diseases and the South American Office for Anticancer Drug Development are working to improve breast cancer treatment.

Shapiro, S.L. Quality of life and breast cancer: relationship to psychosocial variables. Journal of Clinical Psychology 57(4):501-519 (2001).
A diagnosis of breast cancer elicits great distress. Many patients become depressed and anxious about the possibility of sickness, pain, and premature death. They are also concerned about their body image and sexuality. Women may experience feelings of helplessness, loss of control, and stress, and they may rely on unproductive coping strategies based on repression and denial. Emotional expression, social support, and spirituality can help women handle the experience. A considerable body of research shows that psychosocial interventions can help women cope with the stress of breast cancer. Preliminary results from a current study find that breast cancer patients quality of life is correlated with psychosocial variables, especially positive modes of control.

Tabar, L. et al. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet 361:1405-1410 (2003).
This study examines the long-term effect of mammography screening on breast cancer mortality, taking into account potential biases from self-selection, changes in breast cancer incidence, and classification of cause of death. The analysis compared breast cancer deaths in two Swedish counties during the 20 years before screening was introduced (1958-1977) and the 20 years after its introduction (1978-1997). The analysis divided the women into age groups invited for screening (40-69 years) and not invited (20-39 years) and by whether or not the women had actually received screening. After adjusting for age, self-selection bias, and changes in breast cancer incidence, the data shows that breast cancer mortality among 40-69 year-olds dropped more among women who were screened (relative risk 0.56, P < 0.0001) than those who were not screened (0.84, P = 0.03). In the 40-49-year age-group, deaths from breast cancer fell significantly only among women who were screened (0.52, P < 0.0001).

Thomas, D.B. et al. Randomized trial of breast self-examination in Shanghai: Final results. Journal of the National Cancer Institute 94(19):1455-1457 (2002).
This trial randomized over 267,000 female factory workers in Shanghai, China, to either a breast-self examination instruction group or a control group. Women in the instruction group received intensive training in breast self-examination, attended two reinforcement sessions, and received multiple reminders to practice the technique. There was a high level of participation in the instruction group. After 10 to 11 years, more than twice as many benign breast lesions were detected in the instruction than the control group, suggesting a higher level of suspicion for women who were trained. However, there was no significant difference in the numbers of breast cancers detected in the two groups, in their stage or size, or in cumulative breast cancer mortality rates.

Vogel, V.G. Breast cancer prevention: a review of current evidence. CA Cancer Journal Clinic 50:156-170 (2000). Available at: http://caonline.amcancersoc.org/cgi/reprint/50/3/156.pdf.
Currently two approaches have been proven to decrease breast cancer incidence: prophylactic mastectomy and preventive therapy with tamoxifen. Because surgery has severe physical and psychological consequences, it is considered only in very high-risk cases. Tamoxifen carries both benefits (for heart disease and osteoporosis as well as breast cancer) and risks (side effects and increased risk of endometrial cancer). There are many lifestyle modifications (diet, weight loss, smoking, alcohol consumption, and exercise) that may affect breast cancer risk and are recommended for all women as part of a healthy lifestyle; however, their ability to prevent breast cancer has not yet been proven.

Vorobiof, D.A. et al. Breast cancer incidence in South Africa. Journal of Clinical Oncology 19(18s):125s-127s (2001).
Breast cancer has overtaken cervical cancer as the leading cancer among women in South Africa, but incidence rates remain far lower than in the United States or United Kingdom. Within South Africa, the incidence of breast cancer is lower among black women than other racial groups. However, black women present at later stages of disease than other women, due in part to lack of access to oncology facilities and in part to cultural beliefs that link cancer to witchcraft. To improve long-term prognosis and survival among breast cancer patients in South Africa, the author calls for educational awareness campaigns, socioeconomic improvement, access to diagnostic resources, higher standards of health care, and sensitivity to patients beliefs.

Ye, Z. et al. Breast cancer in relation to induced abortions in a cohort of Chinese women. British Journal of Cancer 87:977-981 (2002).
This study used a baseline questionnaire to assess whether subsequent breast cancer risk was associated with induced abortion in a cohort of 267,000 women enrolled in a randomized trial of breast self-examination in Shanghai. After adjusting for potential confounding factors, there was no increase in breast cancer risk for women who had had an induced abortion, nor was there a trend in risk with number of abortions. Detailed interviews with 652 cases and 694 controls drawn from the cohort confirmed these results.

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