Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease.

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, 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 relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Experience with the Copper-7 and Copper-T intrauterine devices at Siriraj Hospital in Bangkok, Thailand.

PIP: A report of 2 studies focusing on the 2 year performance of Copper-7 (Cu-7) and Copper-T (Cu-T) IUDs is presented with particular reference to the characteristics of the users. 198 women had the Cu-7 IUD inserted and 200 women had the Cu-T inserted while menstruating or immediately after menstruation. In both devices, the copper wire had the same surface area. Of the sociodemographic and reproductive characteristics of the study groups, only the age and parity distributions were significantly different. The median age for the Cu-7 users was 26.8 years compared to 31.5 years for the Cu-T group. A median of 2.2 live births for the Cu-7 group is lower than for the Cu-T users (3.2 live births). Performance of the 2 devices did not differ significantly, over the study period. The net cumulative continuation rates were 68.6/100 Cu-7 users and 78.2/100 Cu-T users. At the end of 1 year, the gross cumulative pregnancy rate with the device in place was the same for both groups, .6/100 women. After 2 years, 2 additional Cu-7 users became pregnant, and the gross cumulative pregnancy rate was 2.3/100 women; the Cu-T rate remained the same. The pregnant women in the Cu-7 group were under 30 years of age. The gross cumulative expulsion rates at the end of 1 year were 5.0/100 Cu-7 users and 1.8/100 Cu-T users; after 2 years, the rates were 5.7/100 Cu-7 users and 2.5/100 Cu-T users. The majority in both groups were under 30 years old. For both groups, discontinuation of the IUDs because of pain was more frequent than for bleeding. The gross cumulative discontinuation rates of removals for bleeding/pain were 4.1/100 Cu-7 users and 2.4/100 Cu-T users at 1 year and 7.1/100 Cu-7 users and 5.7/100 Cu-T users after 2 years. 81.3% of these discontinuations occurred in women under 30 years old for the Cu-7 group compared to only 45.5% of the women discontinuing the Cu-Ts. The age-parity effect is difficult to specify due to the infrequency of events. However, younger less parous women, which was a higher proportion of the Cu-7 group, did have a higher incidence of expulsions and Cu-7 removals for pain/bleeding. The Cu-T group had a much higher proportion of women with previous IUD experience. The results suggest that the Cu-7 is as effective as the Cu-T device in minimizing the incidence of pregnancy, expulsion, and bleeding/pain removal.^ieng

Outcome of pregnancy in the presence of intrauterine device.

The outcome of 196 pregnancies with Lippes Loop in situ was studied. In 102 cases with inaccessible thread, the IUD was left in place. Ninety-four women had the IUD removed when the thread was still visible. The incidence of spontaneous abortion and premature delivery was 56.8% in the group of 102, and was significantly higher than in those women whose loop was removed. No serious complications occurred in any of the cases. The results suggested that the IUD should be removed early in pregnancy when the string is still accessible.

PIP: 196 cases of confirmed intrauterine pregnancy with an IUD in place were followed up. The 94 women whose IUD thread was still visible had the device removed. In 102 cases the thread was inaccessible and the IUD was allowed to remain. Visibility of the thread seemed to depend on the gestational period, with 98% of women seen at 8 or less weeks of pregnancy having a visible thread and only 2.1% of the cases seen after 9-12 weeks of pregnancy. Spontaneous abortion or premature delivery occurred in more than 1/2 the women who continued their pregnancies with the IUD remaining in place. This was a significantly higher rate than for the women whose IUDs were removed. No serious complications resulted in any of the 196 cases. Results of the study suggest that, if a pregnancy occurs with an IUD in place, the IUD should be removed as soon as possible if the string remains visible.

Comparison of culdoscopic and laparoscopic tubal sterilization.

The growing number of women requesting interval sterilization (apart from term delivery or abortion procedures) necessitates the re-evaluation of traditional surgical procedures. A total of 800 women--the first 400 women undergoing culdoscopic and laparoscopic tubal sterilization procedures at Siriraj Hospital in Bangkok, Thailand--evaluate the appropriateness of the two sterilization procedures for use in interval sterilization programs. No serious operative complications occurred in either group. However, the rate of postoperative complications was considerably higher for the culdoscopic group than for the laparoscopic group. Hospitalization was required for only a small percentage of the patients and most had resumed their normal activities within two days of the operation. This study indicates that both procedures are effective and may be safely performed on an outpatient basis without general anesthetics and with minimal discomfort for the patients.