A C TA Obstetricia et Gynecologica Letter to the Editor
References 1. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of breech presentation. Guideline No. 20a, December 2006. Reviewed 2010; Available online at: http://www.rcog.org. uk/files/rcog-corp/uploaded-files/GT20aExternalCephalic Version.pdf (accessed October 27, 2013). 2. Hannah ME, Hannah W J, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356:1375–83.
3. Walker SP, McCarthy EA, Ugoni A, Lee A, Lim S, Permezel M. Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds. Obstet Gynecol. 2007;109:67–72. 4. Nassar N, Roberts CL, Cameron CA, Peat B. Outcomes of external cephalic version and breech presentation at term, an audit of deliveries at a Sydney tertiary obstetric hospital, 1997–2004. Acta Obstet Gynecol Scand. 2006;85:1231–8. 5. Wise MR, Sadler L, Ansell D. Successful but limited use of external cephalic version in Auckland. Aust N Z J Obstet Gynaecol. 2008;48:467–72.
Induced abortion and breast cancer
Sir This letter to the editor concerns the reply by C.M. Bra€ uner and J. Attermann to comments by J. Brind and P. Carroll published on-line in September 2013 (1), following previous correspondence in an earlier issue (2) regarding the article of Bra€ uner and co-workers (3). The reply by C.M. Bra€ uner and J. Attermann to our letters is interesting and also puzzling! They maintain the reason for not having access to the Danish national register that holds the abortion records was “not a lack of political will”. If it was for the reason of “simply a lack of time and resources” and access to the register is possible for a future study, one hopes this will indeed be a priority when future research on breast cancer is being planned in Denmark. The authors were “reluctant” to include in situ carcinomas because this “might have introduced selection bias” as “reporting of this type of cancer probably is incomplete”. It seems that the in situ carcinomas show up quite well on the X-rays in screening but are not otherwise easily detectable. So there would hardly be much reason to expect selection bias. Reporting of these carcinomas in situ to national cancer registries is certainly desirable and is usual practice in the UK and other European countries with effective national registration of newly diagnosed cancers. For lack of relevant Danish data in my 2007 paper (4), there were no forecasts of in situ carcinomas in Denmark and of course this accords with “In situ carcinomas are not … included in the Danish Cancer Registry. Therefore it would be difficult to obtain these data”. To calculate the in situ carcinomas anticipated for six other countries, I had simply assumed that the ratio of in situ to malignant carcinomas discovered in the screened age groups, as reported by their cancer registries, would remain fixed. But now of course the new digital screening machines are finding more in situ carcinomas and in some countries like the UK the age range for cancer screening has been extended upwards. The ratio of in situ to malignant disease can now exceed 12% in age groups screened. It would be a good idea if the Danish Cancer Registry did count and report the in situ carcinomas that have now become a larger part of the overall breast cancer picture.
It was surprising that this study found no association between induced abortion and breast cancer among parous older women. The new Chinese study by Huang et al. (5), which is a metaanalysis of 36 Chinese small sample (34 case-control and 2 cohort) studies, finds “that induced abortion is significantly associated with an increased risk of breast cancer among Chinese females, and the risk of breast cancer increases as the number of IA increases.” [Correction added on 28 January 2014, after first online publication: Sentence was amended.] This adds to the evidence for recognition of induced abortion as a risk factor in breast cancer, which remains still unacknowledged by most leading epidemiologists. When breast cancer incidence is so high it is a reason for concern that such a major public health issue as breast cancer aetiology continues to be unresolved. When there are as many as 50 000 new cases of breast cancer reported here each year, the British breast cancer epidemiologists explain this only in vague terms. The remarkable social gradient of female breast cancer, whereby women in the higher socio-economic groups have more breast cancer and less of the other cancers, is well known and widely reported in many countries but remains unexplained (4). It is to be hoped that the authorities will allow access to national registers that include induced abortion records in countries like Denmark and Finland where there is the potential to definitively resolve the issue of breast cancer risks post abortion. Meanwhile, this substantial study by C.M. Bra€ uner et al. can point the way to how this might be approached.
Patrick Carroll* Pension and Population Research Institute (PAPRI), London, UK *Corresponding Author: Patrick Carroll E-mail: [email protected]
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 521–523
DOI: 10.1111/aogs.12315
523
Letter to the Editor
References 1. Bra€ uner CM, Attermann J. Reply to comments by Dr. Brind and Mr. Carroll on our study No evidence of an association between induced abortion and breast cancer among parous older women: Our conclusion remains valid. Acta Obstet Gynecol Scand. 2013;92:1429–30. 2. Carroll P. Induced abortion and breast cancer. Acta Obstet Gynecol Scand. 2013;92:1428. 3. Bra€ uner CM, Overvad K, Tjønneland A, Attermann J. Induced abortion and breast cancer among parous women:
a Danish cohort study. Acta Obstet Gynecol Scand. 2013;92:700–5. 4. Carroll PS. The breast cancer epidemic: modeling and forecasts based on abortion and other risk factors. J Am Phys Surg. 2007;12:72–8. 5. Huang Y, Zhang X, Li W, Song F, Dai H, Wang J et al. A meta-analysis of the association between induced abortion and breast cancer risk among Chinese females. Cancer Causes Control. 2013. 24 November. doi:10.1007/ s10552-013-0325-7. [Epub ahead of print].
Sonoelastography of the uterine cervix
Sir I have read with great interest Quantitive sonoelastography of the uterine cervix by interposition of a synthetic reference material written by Hee et al. (1). Quantitive elastography is a new technique which represents a promising new diagnosic tool for the uterine cervix, especially in diagnosing cervical insufficiency, premature deliveries and post-term pregnancies. In our study “Sonoelastography of the uterine cervix as a new diagnostic tool of cervical assesment in pregnant women-preliminary report” published in 2013, we also used quantitive sonoelastography to assess the uterine cervix during pregnancy (2). I am very happy to hear that Hee et al. found independently from our team that stiffness of the anterior cervical lip is more reliable than stiffness of the posterior one. Our study was carried on 59 patients between 28 and 39 weeks of pregnancy, using the strain ratio index to measure stiffness of the cervix and evaluating the correlation between the length of the cervix and the strain ratio index. We also found a correlation between compressibility of the anterior cervical lip and cervical length. We were not able to explain this phenomenon and are therefore are very interested in the explanation published by Hee et al. Furthermore, their work is very important for us because we also had problems reproducing the cervical examination, as we did not know how to reproduce the same pressure on the cervix during following examinations. This problem is very common in contemporary studies of quantitive elastography (3,4). The idea of using reference material seems reasonable and could solve this problem, so we are keeping our fingers crossed that Hee et al. will continue their efforts to put this method into clinical practice. Furthermore, we think that by improving quantitive elastography in this way will result in a more accurate method than that proposed and described by SwiatkowskaFreund et al., where compression was generated by the woman’s breathing or arterial pulsation, making the measurement less predictable and less objective (5).
524
Tomasz Fuchs*, Michal Pomorski and Mariusz Zimmer Department of Obstetrics and Gynecology, Wroclaw Medical University, Wroclaw, Poland *Corresponding Author: Tomasz Fuchs E-mail: [email protected] DOI: 10.1111/aogs.12356
References 1. Hee L, Sandager P, Petersen O, Uldbjerg N. Quantitative sonoelastography of the uterine cervix by interposition of a synthetic reference material. Acta Obstet Gynecol Scand. 2013;92:1244–9. 2. Fuchs T, Woyton R, Pomorski M, Wiatrowski A, Slejman N, Tomialowicz M, et al. Sonoelastography of the uterine cervix as a new diagnostic tool of cervical assessment in pregnant women – preliminary report. Ginekol Pol. 2013;84:12–6. 3. Molina FS, Gomez LF, Florido J, Padilla MC, Nicolaides KH. Quantification of cervical elastography: a reproducibility study. Ultrasound Obstet Gynecol. 2012;39:685–9. 4. Fruscalzo A, Schmitz R. Quantitative cervical elastography in pregnancy. Ultrasound Obstet Gynecol. 2012;40:612. 5. Swiatkowska-Freund M, Preis K. Elastography of the uterine cervix: implications for success of induction of labor. Ultrasound Obstet Gynecol. 2011;38:52–6.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 521–524
References 1. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of breech presentation. Guideline No. 20a, December 2006. Reviewed 2010; Available online at: http://www.rcog.org. uk/files/rcog-corp/uploaded-files/GT20aExternalCephalic Version.pdf (accessed October 27, 2013). 2. Hannah ME, Hannah W J, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356:1375–83.
3. Walker SP, McCarthy EA, Ugoni A, Lee A, Lim S, Permezel M. Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds. Obstet Gynecol. 2007;109:67–72. 4. Nassar N, Roberts CL, Cameron CA, Peat B. Outcomes of external cephalic version and breech presentation at term, an audit of deliveries at a Sydney tertiary obstetric hospital, 1997–2004. Acta Obstet Gynecol Scand. 2006;85:1231–8. 5. Wise MR, Sadler L, Ansell D. Successful but limited use of external cephalic version in Auckland. Aust N Z J Obstet Gynaecol. 2008;48:467–72.
Induced abortion and breast cancer
Sir This letter to the editor concerns the reply by C.M. Bra€ uner and J. Attermann to comments by J. Brind and P. Carroll published on-line in September 2013 (1), following previous correspondence in an earlier issue (2) regarding the article of Bra€ uner and co-workers (3). The reply by C.M. Bra€ uner and J. Attermann to our letters is interesting and also puzzling! They maintain the reason for not having access to the Danish national register that holds the abortion records was “not a lack of political will”. If it was for the reason of “simply a lack of time and resources” and access to the register is possible for a future study, one hopes this will indeed be a priority when future research on breast cancer is being planned in Denmark. The authors were “reluctant” to include in situ carcinomas because this “might have introduced selection bias” as “reporting of this type of cancer probably is incomplete”. It seems that the in situ carcinomas show up quite well on the X-rays in screening but are not otherwise easily detectable. So there would hardly be much reason to expect selection bias. Reporting of these carcinomas in situ to national cancer registries is certainly desirable and is usual practice in the UK and other European countries with effective national registration of newly diagnosed cancers. For lack of relevant Danish data in my 2007 paper (4), there were no forecasts of in situ carcinomas in Denmark and of course this accords with “In situ carcinomas are not … included in the Danish Cancer Registry. Therefore it would be difficult to obtain these data”. To calculate the in situ carcinomas anticipated for six other countries, I had simply assumed that the ratio of in situ to malignant carcinomas discovered in the screened age groups, as reported by their cancer registries, would remain fixed. But now of course the new digital screening machines are finding more in situ carcinomas and in some countries like the UK the age range for cancer screening has been extended upwards. The ratio of in situ to malignant disease can now exceed 12% in age groups screened. It would be a good idea if the Danish Cancer Registry did count and report the in situ carcinomas that have now become a larger part of the overall breast cancer picture.
It was surprising that this study found no association between induced abortion and breast cancer among parous older women. The new Chinese study by Huang et al. (5), which is a metaanalysis of 36 Chinese small sample (34 case-control and 2 cohort) studies, finds “that induced abortion is significantly associated with an increased risk of breast cancer among Chinese females, and the risk of breast cancer increases as the number of IA increases.” [Correction added on 28 January 2014, after first online publication: Sentence was amended.] This adds to the evidence for recognition of induced abortion as a risk factor in breast cancer, which remains still unacknowledged by most leading epidemiologists. When breast cancer incidence is so high it is a reason for concern that such a major public health issue as breast cancer aetiology continues to be unresolved. When there are as many as 50 000 new cases of breast cancer reported here each year, the British breast cancer epidemiologists explain this only in vague terms. The remarkable social gradient of female breast cancer, whereby women in the higher socio-economic groups have more breast cancer and less of the other cancers, is well known and widely reported in many countries but remains unexplained (4). It is to be hoped that the authorities will allow access to national registers that include induced abortion records in countries like Denmark and Finland where there is the potential to definitively resolve the issue of breast cancer risks post abortion. Meanwhile, this substantial study by C.M. Bra€ uner et al. can point the way to how this might be approached.
Patrick Carroll* Pension and Population Research Institute (PAPRI), London, UK *Corresponding Author: Patrick Carroll E-mail: [email protected]
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 521–523
DOI: 10.1111/aogs.12315
523
Letter to the Editor
References 1. Bra€ uner CM, Attermann J. Reply to comments by Dr. Brind and Mr. Carroll on our study No evidence of an association between induced abortion and breast cancer among parous older women: Our conclusion remains valid. Acta Obstet Gynecol Scand. 2013;92:1429–30. 2. Carroll P. Induced abortion and breast cancer. Acta Obstet Gynecol Scand. 2013;92:1428. 3. Bra€ uner CM, Overvad K, Tjønneland A, Attermann J. Induced abortion and breast cancer among parous women:
a Danish cohort study. Acta Obstet Gynecol Scand. 2013;92:700–5. 4. Carroll PS. The breast cancer epidemic: modeling and forecasts based on abortion and other risk factors. J Am Phys Surg. 2007;12:72–8. 5. Huang Y, Zhang X, Li W, Song F, Dai H, Wang J et al. A meta-analysis of the association between induced abortion and breast cancer risk among Chinese females. Cancer Causes Control. 2013. 24 November. doi:10.1007/ s10552-013-0325-7. [Epub ahead of print].
Sonoelastography of the uterine cervix
Sir I have read with great interest Quantitive sonoelastography of the uterine cervix by interposition of a synthetic reference material written by Hee et al. (1). Quantitive elastography is a new technique which represents a promising new diagnosic tool for the uterine cervix, especially in diagnosing cervical insufficiency, premature deliveries and post-term pregnancies. In our study “Sonoelastography of the uterine cervix as a new diagnostic tool of cervical assesment in pregnant women-preliminary report” published in 2013, we also used quantitive sonoelastography to assess the uterine cervix during pregnancy (2). I am very happy to hear that Hee et al. found independently from our team that stiffness of the anterior cervical lip is more reliable than stiffness of the posterior one. Our study was carried on 59 patients between 28 and 39 weeks of pregnancy, using the strain ratio index to measure stiffness of the cervix and evaluating the correlation between the length of the cervix and the strain ratio index. We also found a correlation between compressibility of the anterior cervical lip and cervical length. We were not able to explain this phenomenon and are therefore are very interested in the explanation published by Hee et al. Furthermore, their work is very important for us because we also had problems reproducing the cervical examination, as we did not know how to reproduce the same pressure on the cervix during following examinations. This problem is very common in contemporary studies of quantitive elastography (3,4). The idea of using reference material seems reasonable and could solve this problem, so we are keeping our fingers crossed that Hee et al. will continue their efforts to put this method into clinical practice. Furthermore, we think that by improving quantitive elastography in this way will result in a more accurate method than that proposed and described by SwiatkowskaFreund et al., where compression was generated by the woman’s breathing or arterial pulsation, making the measurement less predictable and less objective (5).
524
Tomasz Fuchs*, Michal Pomorski and Mariusz Zimmer Department of Obstetrics and Gynecology, Wroclaw Medical University, Wroclaw, Poland *Corresponding Author: Tomasz Fuchs E-mail: [email protected] DOI: 10.1111/aogs.12356
References 1. Hee L, Sandager P, Petersen O, Uldbjerg N. Quantitative sonoelastography of the uterine cervix by interposition of a synthetic reference material. Acta Obstet Gynecol Scand. 2013;92:1244–9. 2. Fuchs T, Woyton R, Pomorski M, Wiatrowski A, Slejman N, Tomialowicz M, et al. Sonoelastography of the uterine cervix as a new diagnostic tool of cervical assessment in pregnant women – preliminary report. Ginekol Pol. 2013;84:12–6. 3. Molina FS, Gomez LF, Florido J, Padilla MC, Nicolaides KH. Quantification of cervical elastography: a reproducibility study. Ultrasound Obstet Gynecol. 2012;39:685–9. 4. Fruscalzo A, Schmitz R. Quantitative cervical elastography in pregnancy. Ultrasound Obstet Gynecol. 2012;40:612. 5. Swiatkowska-Freund M, Preis K. Elastography of the uterine cervix: implications for success of induction of labor. Ultrasound Obstet Gynecol. 2011;38:52–6.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 521–524
