Table J6 - Women <50 years having or being considered for HRT

A Evidence based guidelines - the evidence base for mammographic screening for women under the age of 50 years who are being considered for HRT

Evidence Table J6

Women <50 years having or being considered for HRT

A	Clinical Problem	Women <50 having or being considered for HRT
A1	Ref No. in MBUR4 (if any)	J6
A2	Section in MBUR4	Breast Imaging
B	Search strategy: databases used; period; MeSH headings; other key words.	MEDLINE; Embase. Mammography, hormone replacement therapy, per-menopausal.
C	Search results: no. found; no. used.	200; 6
D	Reference numbers of cited references in attached master list.	J6 - 1,2,3,4,5,6
E	Summarised results from each of the cited references	Achuthan (J6,1) showed a similar cancer detection rate as for NHSBSP. Kavanagh(J6, 2) showed no significant difference in sensitivity of mammography for women 40-49 years. Banks (J6, 3) showed an increased risk of interval cancer and false positive recall in all HRT users compare with non-users. Thurfjell (J6 4) showed no significant change in sensitivity or specificity of mammography between users and non-users. Cohen (J6 5) showed a breast density increase from HRT sufficient in 40% of women to cause difficulty in interpretation Litherland (J6 6) showed an increase in recall rate, 37% higher for HRT users than non-users. PPV lower at 3.7% compared with 12.9% on non-users
F	Statement (= the conclusion drawn from E)	Some evidence of equivalent detection rates as NHSBSP. Breast density increases. Increased recalls and lower PPV
G	Evidence level of F classified I - IV	2
H	Investigation	Mammography
I	Recommendation *	3 Not indicated routinely
J	Grade of Recommendation A - C	C
K	Comment (if any) to go in booklet version of MBUR5	HRT has been shown to increase density and benign changes within the breast. There is a subsequent fall in sensitivity and specificity and an increased recall rate from screening. There is minimal evidence for routine mammography prior to starting HRT.
L	Any other comments on this problem (e.g. caveats; suggestions for research or systematic review; cost or opportunity cost; users' views.	Although shown in a small review that the detection rate in pre-menopausal women is as good as the NHSBSP, there is no funding for routine screening for this group of women. Should be considered under table J2 - Screening women age 40-49 years. Chris Flowers

Comments: New evidence of the longer term effects of HRT may change guidelines in the future

References: -

Ref ID	Author; Year; Country; Grade (I-IV).	Aims	Patient population	Study design*	Results
J6 1	Achuthan : 1999: UK; IIb	Research Letter	5436 women outside NHSBSP over 5 year period	Retrospective review	5436 women on or considering use of HRT, outside of the NHSBSP. 31 cancers detected (5.7/1000 women screened). Similar pick up rate as prevalent round NHSBSP
J6 2	Kavanagh ; 2000; Australia; IIb	Review of differences in women on HRT and non users of HRT	103,770 screened women between 40 and 70 years over a 1 year period	Retrospective review	Australian population screening from 40 years of age. Sensitivity was lower in HRT users (64%) than non-users (79%). 20% women age 40-49 were on HRT in 1993. No difference in sensitivity in the 40-49 age group.
J6 3	Banks; 2001; UK; IIb	Review of epidemiological evidence	Eight studies identified.	Review	Total of 367 interval cancers and 8878 false positive recalls in women 50 years and over. Increased risk of interval cancer and false positive recall in all HRT users compare with non-users. Only one study accounted for confounding factors of age and menopause.
J6 4	Thurfjell; 1997; Sweden; IIb	Retrospective study by interview about use of HRT during second round mammography	20,000 women aged 50 years and over	Retrospective review	Sensitivity of screening mammography 96% in current users and 91% in women who had never used HRT. No difference in specificity.
J6 5	Cohen; 1997; UK; IIa	Review of HRT use and effect on interval cancers	3114 women	Retrospective review	3114 women screened in 3 month period had started HRT since previous visit. Breast density increase sufficiently in 40% to cause difficulty in interpretation
J6 6	Litherland: 1997; UK: IIb	To assess effect of HRT on recall rate	5699 consecutive women attending for breast screening	Prospective review	Recall rate 37% higher for HRT users than non-users. PPV lower at 3.7% compared with 12.9% on non-users