Generic propecia - Finasteride

People with Parkinson’s disease face an increased risk of the most deadly type of skin cancer, new research confirms.

Exams of more than 2,000 people with Parkinson’s disease found that about 1 percent currently had melanoma, Dr. John M. Bertoni of the University of Nebraska Medical Center in Omaha and his colleagues found. Based on the findings, they say, people with the degenerative nerve disease should receive regular skin cancer screening.

A number of studies have found a higher risk for melanoma among people with Parkinson’s disease, which occurs when brain cells that produce dopamine — a signaling chemical with many important functions in the brain — die off. But it hasn’t been clear whether this increased risk is due to the drugs people take to treat Parkinson’s disease or to the disease itself.

To investigate further, Bertoni and colleagues at 31 different centers across North America studied 2,106 patients with Parkinson’s disease. The patients first underwent a neurological exam, and then at a second visit had a dermatologic exam, which included biopsies of any suspicious moles or growths.

The researchers found 20 localized melanomas among the study participants and 4 that had spread beyond the original site, while another 68 patients reported having a history of melanoma.

Among the patients living in the US, the likelihood of having melanoma was more than double that of the general US population, the researchers found. When the findings were compared to statistics from skin cancer screening programs run by the American Academy of Dermatology, the researchers found a more than seven-fold increased risk of melanoma for US Parkinson’s patients.

Since the 1970s, a number of case reports have suggested that levodopa therapy for Parkinson’s disease increases the risk of skin cancer. In the current study, nearly 85 percent of the patients had taken levodopa, but the researchers found no evidence that this drug was associated with melanoma risk.

This study, conclude Bertoni and colleagues, provides more evidence that melanoma occurs more often in patients with Parkinson’s disease than in the population at large and “supports increased melanoma screening” in patients with Parkinson’s disease.

SOURCE: Archives of Neurology.

New research suggests that the type of specialist a prostate cancer patient sees — rather than the patient’s own preference — may determine the treatment he receives.

This is problematic, the study’s authors say, because none of the options now available for treating localized prostate cancer have been shown to be any better than the others.

“The different treatments for prostate cancer…entail different side effects, different recovery profiles, and they require different time commitments,” Dr. Thomas L. Jang of The Cancer Institute of New Jersey in New Brunswick, one of the study’s authors, told Reuters Health. For this reason, he and his colleagues say, it should be the patient’s preferences — rather than the physician’s specialty — that guides treatment decisions.

Current options available for treating prostate cancer that has not spread include watchful waiting, in which a patient receives no treatment but is monitored closely; hormone therapy; radiation therapy; or surgery to remove the prostate. Radiation and surgery both carry the risk of urinary incontinence and impotence; hormone therapy can cause hot flashes, breast tenderness, and loss of sex drive; while watchful waiting may lead to anxiety in men who fear their cancer will spread.

Surveys have suggested that specialists are more likely to recommend the type of treatment they provide; for example, radiation oncologists prefer radiation therapy, while urologists choose surgery.

To investigate whether the type of physician a prostate cancer saw would actually influence the type of treatment he got, Jang and his team looked at Medicare data on more than 85,000 men 65 and older diagnosed between 1994 and 2002 with localized prostate cancer. Within nine months of diagnosis, 21 percent had undergone prostate removal; 42 percent had radiation; 17 percent had hormone therapy; and 20 percent watchful waiting. Jang conducted the study, which is published in the Archives of Internal Medicine, while at Memorial-Sloan Kettering Cancer Center in New York City.

Half of the men had only seen a urologist, while 44 percent had seen a radiation oncologist and a urologist, 3 percent had seen a urologist and a medical oncologist, and 3 percent had seen all three specialists.

One-third of the men who had only seen a urologist underwent prostate surgery, and surgery was the most common treatment for the men who were 65 to 74 years old and only saw a urologist. However, among men of any age who saw a radiation oncologist as well as a urologist, radiation therapy was the most common treatment; 83 percent of these men received radiation therapy.

And men who had been seen by a urologist and a medical oncologist, or a urologist only, were more likely to receive watchful waiting or hormone therapy than men who had seen both urologists and radiation oncologists.

Only about one in five men saw their primary care physician after their diagnosis of prostate cancer and before they received treatment (or within nine months of diagnosis). Nearly 60 percent of these men received watchful waiting, compared to 7 percent of men who hadn’t seen their primary care doctor.

When the researchers looked at individual urologists who had cared for at least 10 of the study participants, they found sharp doctor-to-doctor differences in whether a patient was referred to a radiation oncologists; some urologists frequently made these referrals, while others did so much less often.

Men newly diagnosed with prostate cancer face “a lot of confusion,” Jang noted, because there are so many treatment options available. “The physician who is providing the counseling for these patients should go to great lengths to provide a balanced perspective, an unbiased perspective, on these treatment options.”

And if patients don’t feel they are getting unbiased advice, Jang added, they should get a second opinion. “It’s really our responsibility to provide these men with every single available treatment option.”

SOURCE: Archives of Internal Medicine.

Among people who suffer a stroke, one in 12 are likely to have another stroke soon after the initial attack and one in four will die within a year, according to a new study by researchers from the Medical University of South Carolina.

The state-wide statistics highlight the importance of recognizing that anyone who has had a stroke is at a high risk for having another one and also has an increased likelihood of having other problems, such as a heart attack, experts say

“Our findings suggest that South Carolina and possibly other parts of the United States may have a long way to go in terms of preventing and reducing the risk factors for recurrent strokes,” said Dr. Wuwei Feng, a neurology resident at the university and the study’s lead researcher.

For the study, published in the Feb. 16 issue of Neurology, Feng’s team collected data on almost 10,400 people in South Carolina who’d had a stroke.

They found that 25 percent of those who had a stroke died within a year, and eight percent had another stroke within a year of their first stroke.

After one year, the risk for another stroke or death continued to rise, the researchers found, with about 18 percent having had another stroke within four years. In that time, about six percent had a heart attack and 41 percent had died from any cause, including 27 percent whose deaths were attributed to a stroke or heart attack.

The risks were higher among blacks than among whites, the study noted. The risks also increased with age and the number of other medical problems that people had.

“Stroke is a devastating disease,” Feng said. “Once you have it, you are at a high risk to have another one, as well as heart attack or death.”

Dr. Majaz Moonis, director of stroke services at the University of Massachusetts, said that “this is one more study that essentially points to what many others have already.”

Moonis believes the key to preventing second strokes is aggressive care and follow-up. “It is important to continue to point out the health-care disparities and the need for more aggressive care,” he said.

“In our stroke prevention clinic — where we regularly follow patients with ischemic stroke on a six-month basis with imaging, labs and vascular studies and treat them with very aggressive measures for stroke prevention — the annual rate of recurrent stroke is 1.5 percent, far lower than the community,” Moonis said.

Another stroke expert, Dr. Larry B. Goldstein, director of the Duke University Stroke Center, noted that his own study of stroke patients throughout the United States showed that the highest rate for recurrent stroke was in the Southeast, which has been called the “stroke belt.”

Of course, having a first stroke puts you at a 10-fold increased risk of having another, he said, and “in the country overall, about 20 percent of strokes are recurrent strokes.”

Goldstein also said that, in many cases, not enough effort is directed at preventing a second stroke. Using blood thinners, for example, can reduce the risk for a second stroke by about 48 percent, he said.

“Adequate treatment of high blood pressure reduces the risk by about 40 percent,” Goldstein said. “The use of antiplatelet drugs reduces the risk by about 16 to 20 percent. The use of a statin reduces the risk by about 16 percent.”

In addition, lifestyle changes such as a following a healthier diet, exercising more and quitting smoking will also reduce the risk of a second stroke, he said.

“There are a ton of things we try to do to reduce the risk of recurrent stroke,” Goldstein said.

SOURCES: Wuwei Feng, M.D., resident in neurology, department of neuroscience, Medical University of South Carolina, Charleston, S.C.; Larry B. Goldstein, M.D., professor and director, Duke Stroke Center, Duke University, Durham, N.C.; Majaz Moonis, M.D., director, stroke services, University of Massachusetts Medical School, Worcester, Mass.

Harvard researchers report what they say is a major advance toward the long-sought goal of a genetic test that can distinguish between aggressive prostate cancers that require urgent treatment and slow-growing tumors that can safely be left alone.

Today, many men diagnosed with prostate cancer are treated with radiation or chemotherapy even though most of those cancers will grow so slowly that they are not dangerous. It is the cancers that metastasize — spread outside the prostate gland — that typically are life-threatening.

“For the first time, we showed in a mouse model that when you take a gene out, you get metastasis and when you put it back in you don’t get metastasis,” said study author Karen Cichowski, an assistant professor of medicine in the division of genetics at Harvard’s Brigham and Women’s Hospital. “It looks like the entire pathway is driven by this one gene, the cascade that drives metastasis.”

Studies of human prostate cancers have shown the same effect, she said: “We have looked at the genetic pathway in a large number of human tumors, and have found it to be deregulated in more advanced prostate cancers.”

The finding could lead to better treatment of prostate cancer, because the molecule whose production is governed by the gene can be a target of drug therapy, Cichowski said.

The molecule, designated EZH2, is an enzyme, and “enzymes are always good potential therapeutic targets,” she said. “Many companies are working to develop EZH2 inhibitors.”

The Brigham and Women’s program is one of a number being carried out in competitive fashion at several U.S. medical research centers. They are looking at a cluster of genes whose connection with prostate cancer was first described in 2002 by Jer-Tsong Hsieh, a professor of pathology and urology at the University of Texas Southwestern Medical Center at Dallas.

“We complement each other; our findings are very similar,” Hsieh said of the Harvard work. “I am a cell biologist and look for the protein. She uses a genetic approach.”

Hsieh’s group has published several papers on the research, one as recent as last month. One current effort is to develop a chemical reagent that can detect the enzyme, he said.

Another researcher in prostate cancer genetics is Dr. Arul Chinnaiyan, a professor of pathology and urology at the University of Michigan.

The newly reported study “provides a nice mechanistic link as to why EZH2 leads to metastatic cancer,” Chinnaiyan said. “It is exciting because there is a lot of interest in the biotechnology world in developing inhibitors of EZH2.”

His laboratory is working on such inhibitors, Chinnaiyan added.

“Chinnaiyan showed that this gene for EZH2 is highly expressed in advanced prostate cancer,” Cichowski said. “Hsieh showed that a second gene in this genetic pathway was a target of EZH2 and could be silenced by EZH2. It was one of 250 genes targeted by EZH2. We showed that in a mouse model the gene is the primary target of EZH2 in prostate cancer.”

That gene, DAB2IP, is suppressed in human prostate cancer, and the degree of suppression correlates with the aggressiveness of a cancer, the journal report said.

“This is the first study to definitively show not only the gene but also the pathway that drives metastasis in prostate cancer,” Cichowski said. “Now that we know this pathway, there are many ways to target it.”

SOURCES: Karen Cichowski, Ph.D., assistant professor, medicine, division of genetics, Brigham and Women’s Hospital, Boston; Jer-Tsong Hsieh, Ph.D., professor, urology, University of Texas Southwestern Medical Center, Dallas; Arul Chinnaiyan, M.D., Ph.D., professor, pathology and urology, University of Michigan, Ann Arbor

The use of cholesterol-lowering statin drugs increases the chance of developing diabetes by 9 percent, but the absolute risk is low, especially when compared with how much statins reduce the threat of heart disease and heart attack, new research shows.

The researchers analyzed data from 13 clinical trials of statins conducted between 1994 and 2009. The trials included a total of 91,140 people. Of those, 2,226 participants taking statins and 2,052 people in control groups developed diabetes over an average of four years.

Overall, statin therapy was associated with a 9 percent increased risk of developing diabetes, but the risk was higher in older patients. Neither body mass index nor changes in LDL (bad) cholesterol levels appeared to affect the statin-associated risk of developing diabetes.

There’s no evidence that statin therapy raises diabetes risk through a direct molecular mechanism, but this may be a possibility, said study authors Naveed Satar and David Preiss, of the University of Glasgow’s Cardiovascular Research Center, and colleagues.

The researchers noted that slightly improved survival among patients taking statins doesn’t explain the increased risk of developing diabetes. They added that while it’s highly unlikely, the increased risk of diabetes among people taking statins could be a chance finding.

To put their findings in context, the study authors pointed out that if 255 patients took statins for four years, there would be only one extra case of diabetes. However, for each millimole per liter reduction in LDL cholesterol achieved by taking statins, the same 255 patients would experience five fewer major coronary events, such as coronary heart disease death or non-fatal heart attack.

“In view of the overwhelming benefit of statins for reduction of cardiovascular events, the small absolute risk for development of diabetes is outweighed by cardiovascular benefit in the short and medium term in individuals for whom statin therapy is recommended,” the researchers wrote in a news release.

“We therefore suggest that clinical practice for statin therapy does not need to change for patients with moderate or high cardiovascular risk or existing cardiovascular disease. However, the potentially raised diabetes risk should be taken into account if statin therapy is considered for patients at low cardiovascular risk or patient groups in which cardiovascular benefit has not been proven,” they concluded.

The study authors also recommended monitoring of older people taking statins, since they have a higher risk of developing diabetes.

The findings were published online Feb. 16 and will appear in an upcoming print issue of The Lancet.

The benefit of taking statins to reduce cardiovascular risk greatly outweighs the risk of developing diabetes by a ratio of about 9:1, Dr. Christopher P. Cannon, of the cardiovascular division at Brigham and Women’s Hospital and Harvard Medical School in Boston, wrote in an accompanying comment article.

“Nonetheless, this newly identified risk does warrant monitoring, and as such, in addition to periodic monitoring of liver-function tests and creatine kinase, it seems reasonable to add glucose to the list of tests to monitor in older patients on statins,” Cannon said.

SOURCE: The Lancet

Two seemingly unrelated problems might share a genetic component that may make some people more likely to suffer from both migraine and depression, Dutch researchers report.

The connection between migraine and depression has been examined before, but these researchers show that genetics may be the missing link between these two conditions.

“Migraine and depression co-occur far more frequently within subjects than to be expected by chance,” said lead researcher Dr. Gisela M. Terwindt, an assistant professor of neurology at Leiden University Medical Center. “This relationship is bidirectional; migraine patients have an increased risk to develop depression and, vice versa, depressed subjects have an increased risk of getting migraine attacks,” she said.

The report is published in the Jan. 13 online edition of Neurology.

For the report, Terwindt’s team collected data on 2,652 people who took part in the Erasmus Rucphen Family study and were all descendants of 22 couples who lived in Rucphen in the 1850s to 1900s.

Among these people, 360 suffered from migraine, 151 of them had migraine with aura, and 977 had depression. In the latter type of migraine, the headache is preceded by flashes of light. Twenty-five percent of those with migraines also suffered from depression, compared to 13 percent of those without migraines, the researchers found.

Using this data, Terwindt’s group was able to estimate the genetic contribution to both migraine and depression. They found that genetics explained 56 percent of all migraine. For migraine with aura, genetics accounted for 96 percent.

In addition, when they looked at the genetics of having both migraine and depression, the researchers found a shared genetic component, particularly for migraine with aura, Terwindt said. “Migraine patients have, at least partly, a genetic predisposition for depression,” she noted.

In the future, knowing the genetics of these conditions may lead to better treatment and possibly prevention, she said.

“Identification of common genetic factors may significantly improve the insight into the molecular basis of both migraine and depression,” Terwindt said. “This may help in the future to get more insight in the common pathophysiological process underlying both of these disabling disorders. This will, hopefully, lead to prevention of chronic migraine and development of tailored prophylactic treatments.”

Dr. Gretchen E. Tietjen, chairwoman of neurology and director of the Headache Treatment and Research Program at University of Toledo Medical Center in Ohio, said that while genetics play a part in both migraine and depression, it may well take an environmental trigger to actually produce either condition.

Tietjen recently published a series of studies that found that children who experienced abuse or neglect were more likely to suffer from migraine and depression as adults.

“Physical, emotional or sexual abuse, and physical and emotional neglect were strongly tied to depression and other conditions that are found with migraine,” she said.

Tietjen noted that stress in early life can permanently change the brain.

“Genetics is really important, and environment probably is important for turning some of these things on,” she added.

SOURCES: Gisela M. Terwindt, M.D., Ph.D., assistant professor, neurology, Leiden University Medical Center, the Netherlands; Gretchen E. Tietjen, M.D., professor and chairwoman, neurology, and director, Headache Treatment and Research Program, University of Toledo Medical Center, Ohio

War isn’t just tough on soldiers. Army wives whose husbands were deployed have higher rates of depression, anxiety, sleep disorders and other mental health issues than the wives of soldiers who stayed home, a new study shows.

Researchers looked at the medical records of more than 250,000 wives, accounting for most women married to active-duty U.S. Army personnel.

Between 2003 and 2006, about 34 percent of the women’s husbands deployed for one to 11 months, 35 percent deployed for longer than 11 months, while 31 percent of soldiers were not sent overseas.

Among wives of soldiers deployed for up to 11 months, researchers found almost 3,500 more diagnoses of depression, anxiety, sleep disorders and other mental health issues than among wives who husbands stayed home.

The more months a soldier was deployed, the greater the toll on his wife. Among the wives of soldiers gone for longer than 11 months during the four-year period, they found more than 5,300 additional diagnoses of mental health issues.

“The wives of soldiers who are deployed to Iraq and Afghanistan are experiencing greater mental health problems and have a greater need for mental health services,” said study author Alyssa Mansfield, a research epidemiologist at RTI International in Research Triangle Park, N.C., who was at University of North Carolina, Chapel Hill, when she conducted the research. “We also found the longer the [soldier] was deployed, the more likely the spouse was to have a mental health diagnosis.”

The study findings are published in the Jan. 14 issue of the New England Journal of Medicine.

Kristin Henderson, the wife of a Navy chaplain who is serving in Afghanistan and author of While They’re At War: The True Story of American Families on the Homefront, said the findings are not surprising — anxiety and sleepless nights go with the territory. Recently, a fellow military wife confided that she was taking antidepressants to cope with her husband’s deployment. “She said, ‘Oh, everyone is on Prozac here,’” Henderson said.

For the study, researchers excluded male spouses of female soldiers because their numbers are relatively small. Spouses of Reserve and National Guard, as well as those of active-duty Army personnel who had been in the military less than five years, were also not included because researchers did not have full access to medical information on them during the period before, during and after deployment. The study authors controlled for prior diagnosis of mental health issues.

Still, much remains unanswered about the stresses of war on spouses, including whether depression and other mental health issues are most likely to emerge before, during or after deployment, the authors noted.

Each phase of a deployment can cause stress that could contribute to mental health problems, Mansfield said. Before the deployment, there’s anxiety as women prepare themselves and their children for a long absence.

During deployment, women take on added responsibilities as sole caretaker for their home and children, while worrying their husband will be killed or injured. “We know from prior work that the stress surrounding deployment is not limited to the dates of deployments,” Mansfield said.

Even the homecoming, called the reintegration period, isn’t necessarily easy on the family, Henderson said. Soldiers may come home changed, perhaps because of post-traumatic stress disorder (PTSD) or injuries, but in more subtle ways, too.

Wives can also change during the time apart, becoming more independent or simply accustomed to taking care of the children alone.

“The expectations are that everything is going to be OK when he comes home, that any problems we have will be behind us,” Henderson said. “But of course, everybody is different. And the longer the deployment, the more things change.”

In a second study from the same journal, U.S. Navy and Marine Corps personnel who were given morphine immediately after sustaining combat injuries were less likely to have PTSD later on.

Of 696 patients, 243 were diagnosed with PTSD while 453 were not. About 61 percent of those who went on to develop PTSD had received morphine during resuscitation or trauma care efforts within an hour of the injury-causing event, while 76 percent of those who did not develop PTSD had been giving morphine.

“Our findings suggest that the use of morphine during trauma care may reduce the risk of subsequent development of PTSD after serious injury,” wrote the researchers from the Naval Health Research Center in San Diego.

SOURCES: Alyssa Mansfield, Ph.D., M.P.H., RTI International, Research Triangle Park, N.C.; Kristin Henderson, author, Washington, D.C.;

A new study involving data from more than 20,000 individuals has uncovered several DNA sequences linked to impaired pulmonary function. The research, an analysis that combined the results of several smaller studies, provides insight into the mechanisms involved in reaching full lung capacity. The findings may ultimately lead to better understanding of lung function and diseases like asthma and chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States.

“We have known for a while that genetic factors put some people at risk for lower lung function — a factor in COPD and a risk for early mortality. But, we did not know which specific genetic regions were involved,” said Stephanie London, M.D., Dr.P.H., senior investigator at the National Institute of Environmental Health Sciences (NIEHS), part of National Institutes of Health (NIH), and a senior author on the paper. “These findings point to specific gene regions.”

Impaired lung function is a hallmark of COPD and other lung diseases. But it is also linked to mortality from a wide range of other diseases, including cardiovascular disease and cancer. So knowing some of the genes involved is a first step toward understanding the relationship between lung function and mortality, as well as developing new interventions to manage lung diseases.

“Leveraging our investment in collecting these samples has led to new findings and will help focus future research efforts,” said James P. Kiley, Ph.D., director of the Division of Lung Diseases at the National Heart, Lung, and Blood Institute (NHLBI).

To conduct the analysis that is published online in the Dec. 13, 2009 issue of Nature Genetics, the researchers used data from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium. CHARGE is an ongoing study — a group of groups — that combines genome-wide association study (GWAS) results from several population-based studies. Pooling data from many studies gives much greater power to find the specific genes involved than looking at any one study alone.

The GWAS approach involves measuring hundreds of thousands of genetic variants, in thousands of individuals, in hopes of finding novel genetic variations associated with specific diseases or conditions.

This meta-analysis provided data from more than 20,000 participants. The individual studies included three US-based population studies supported by the NHLBI — the Artherosclerosis Risk in Communities, the Cardiovascular Health Study, and the Framingham Heart Study — and the Rotterdam Study in the Netherlands.

The researchers focused on finding genetic commonalities in DNA that lead to some people having lower lung function than others of the same age, gender, race, size and smoking history.

One way researchers determine airflow obstruction is by using a machine called a spirometer to measure how much air a person breathes in and out, as well as how fast it is blown out, or expired. Spirometry is an important tool used to diagnose asthma, pulmonary fibrosis, cystic fibrosis, COPD, as well as the impact of environmental exposure on lung health. In disease, the ratio between forced expiratory volume (FEV1) and forced vital capacity (FVC) — an indicator of airflow obstruction — is abnormally low.

“This is a beautiful example of how modern genomic approaches can unearth valuable new insights from previous research,” said NIEHS Director Linda Birnbaum, Ph.D. “It sets us on a course for learning much more about how lung diseases develop and how environmental triggers like smoking and air pollution work in combination with genes.”

For more information about lung diseases, visit http://www.nhlbi.nih.gov/health/public/lung/index.htm.

With a growing array of choices for breast cancer treatment, researchers are now trying to pinpoint the best combination of therapies or the best order in which to give cancer drugs to patients.

In some cases, combination therapies will improve survival and sometimes the order in which therapies are given does not matter, said experts presenting new data at a Friday press briefing at the San Antonio Breast Cancer Symposium.

“The most dramatic finding [presented at the briefing] is that continuing Herceptin therapy after tumor progression improves survival,” said moderator Dr. Edith Perez, director of the Breast Cancer Program at the Mayo Clinic in Jacksonville, Fla. “It is the first time this has been shown.”

In that study, Dr. Kimberly Blackwell, director of the Clinical Trials Program in Breast Cancer at Duke University Medical Center, reported that combining the drug lapatinib (Tykerb) with trastuzumab (Herceptin) was better than single-drug therapy in women who have HER2-positive breast cancer that has spread.

Cancers that are HER2-positive test positive for a protein called human epidermal growth factor receptor 2, which fuels cancer cell growth.

Tykerb inhibits HER2 and the receptor, while Herceptin binds to the HER2 protein — a kind of double-punch, the researcher explained.

Blackwell reported on 296 women with breast cancer that had spread. Half got the drug Tykerb, 1,500 milligrams a day; the other half got 1,000 milligrams of Tykerb a day plus the Herceptin at a dose geared to their body weight.

The women’s tumors had already progressed while on a number of other treatments, so they were running out of options.

The findings? “There was significant improvement in overall survival in favor of the combination of lapatinib and trastuzumab compared to the single agent lapatinib,” Blackwell said. There was a 26 percent reduction in the risk of death if both agents were used.

Put in more human terms, that means that “15 more out of 100 women are alive at a year because of combination therapy.”

In another report, Dr. Daniel Rea, senior lecturer in medical oncology at the University of Birmingham in the UK, compared two approaches for postmenopausal women with early stage hormone-sensitive breast cancer. In the trial, 9,775 postmenopausal women with hormone-positive (the most common type) early breast cancer were assigned to get the drug exemestane (Aromasin) at 25 milligrams a day or tamoxifen at 20 milligrams a day. That was in 2001, and in 2004 the researchers assigned all the women who were getting tamoxifen to switch to Aromasin after 2.5 or three years.

Another 2,500 patients were enrolled and assigned to get either Aromasin or tamoxifen followed by Aromasin.

“The outcome is identical,” Rea said. At five years, there was 85 percent disease-free survival in both groups.

“Both of these strategies appear to be reasonable approaches for those with early cancer,” he said.

Perez said the additional option to choose between the drugs may be of special interest to patients because of the cost savings. Aromasin typically costs more than tamoxifen, she said. Tamoxifen is now available as a generic drug.

Blackwell received honorariums from GlaxoSmithKline (which makes Tykerb) and Genentech (which makes Herceptin) to conduct the study; Rea reports research funding from Novartis and Pfizer.

Adding chemotherapy to standard cancer-suppressing tamoxifen can boost survival in postmenopausal women with the most common type of breast cancer, known as estrogen receptor-positive, and it’s best given before the tamoxifen regimen starts, according to a new study.

“Chemotherapy with Adriamycin adds to your survival benefit over and above what tamoxifen would do if you are postmenopausal and have positive lymph nodes and estrogen receptor-positive cancer [the most common type],” explained Dr. Kathy Albain, the lead researcher and professor of medicine at Loyola University Chicago Stritch School of Medicine.

And in another study, Albain found that screening breast tumors with an available multi-gene test spots patients who may not need this form of chemotherapy, despite fitting the standard profile.

Both studies are published online Dec. 10, the first in the journal The Lancet and the second in The Lancet Oncology. Albain is also due to present her findings Thursday at the annual San Antonio Breast Cancer Symposium in San Antonio, Texas.

In estrogen receptor-positive cancer, tumor cells carry many receptors on their surfaces to which estrogen can attach, fueling tumor growth. Tamoxifen works by blocking the receptors.

Experts have long debated whether women with estrogen receptor-positive cancers — whose growth is fueled by circulating estrogen — would get more benefit from having a chemotherapy regimen on top of tamoxifen.

Albain led a research team from multiple centers that followed nearly 1,500 breast cancer patients for up to 13 years, with a median (half longer, half less) of nearly nine years. All were past menopause and had hormone receptor-positive cancer that had spread to at least one lymph node in the armpit area.

Albain’s team assigned 381 women to tamoxifen alone, 587 to chemotherapy alone and 590 to both, with some receiving tamoxifen and chemo together and some in a sequential manner.

Tamoxifen was taken daily for five years. The chemo regimen used is called CAF, for “cyclophosphamide, Adriamycin and 5-fluorouracil.”

In all, after accounting for study dropouts, 1,460 women received treatment.

The combined treatments of chemo plus tamoxifen increased the women’s disease-free survival by 24 percent, Albain found. When her team looked at which delivery protocol worked best — simultaneous tamoxifen and chemotherapy or chemo followed by tamoxifen — the sequential approach was found to be better, giving slightly better disease-free survival.

Ten-year disease-free survival estimates were 57 percent for the combination group and 48 percent for the tamoxifen-only group, the researchers found.

However, women receiving chemo were more likely to have drops in white blood cells, important for fighting infections, the team noted. And they were also more prone to blood clots, congestive heart failure and other complications.

In a second study, Albain’s team analyzed whether a gene test, called Oncotype DX, could predict which women would benefit from chemotherapy. Genomic Health, which makes the test, helped fund the study, along with the U.S. National Cancer Institute.

The test, which Albain said is already widely used, is done on the tumor itself. “This puts 21 genes together and comes up with a score,” she said. The score — low, intermediate, high — predicts the risk of recurrence over 10 years if a woman used tamoxifen alone.

When the researchers performed the test on 367 specimens, they found a low score identified those women who may not need the chemo, despite the fact that they have cancer that spread to lymph nodes.

“This is a positive study, there’s no question,” said Dr. Joanne Mortimer, vice chair of medical oncology for the City of Hope Cancer Center in Duarte, Calif., of the first study. “This study tells us [that] if you have positive lymph nodes [and are postmenopausal with estrogen receptor-positive cancer], you should have both chemo and tamoxifen, because the survival was better.”

But, she added, “when you give everyone [who has the estrogen receptor-positive, node-positive breast cancer] chemotherapy, probably there are some who don’t need it.”

According to Mortimer, that’s why the gene test looks promising — it may spare some women from having to have chemo while ensuring that those who will benefit from the treatment get it.