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Grand Rounds
CMECNE

Current Hormonal Contraception Methods and Breast Cancer Risk: Prospective Cohort Data

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the need for this study on hormonal contraception and breast cancer risk
2. Counsel women regarding risks benefits of hormonal contraceptive use in light of these results

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

PURPOSE:

  • Previous studies looking at hormonal contraception and breast cancer risk often used formulations with higher estrogen doses with conflicting results   
  • Current contraceptive methods use lower estrogen doses, new progestins and new routes of delivery  
  • Previous studies focused on risks in postmenopausal women 
  • Mørch and colleagues (NEJM, 2017) sought to address the above deficiencies and report their findings using a nationwide epidemiologic analysis of prospectively collected data

METHODS:

  • Prospective Cohort Study  
  • Danish Nationwide Registries  
  • Eligibility: Women in living in Denmark prior to 1995: 15 to 49 years of age on January 1, 1995, and were 15 years of age before December 31, 2012 (a total of 1,837,297 women)  
  • Exclusion: Women with cancer (except nonmelanoma skin cancer); VTE; infertility treatment  
  • Confounders ascertained from national registries 

RESULTS:

Overall Risk of Breast Cancer 

Current or recent users compared to women who never used hormonal contraception .

  • Increased Risk of breast cancer: Relative Risk (RR): 1.20 (95% CI, 1.14 to 1.26) 
  • Risk increased with duration of use: RR 1.09 (95% CI, 0.96 to 1.23) at < 1 year vs 1.38 (95% CI, 1.26 to 1.51) after > 10 years (P=0.002)  
  • Risk remains elevated after ≥5 years but not < 5 years  

Combined oral contraceptives (OCP)  

Little evidence of major differences between various combined oral contraceptives after statistical adjustments for multiple testing 

  • Triphasic RR (1.21; 95% CI, 1.04 to 1.41) vs monophasic RR (1.45; 95% CI, 1.26 to 1.67)  levonorgestrel containing OCPs were similar  
  • In norethisterone or levonorgestrel containing pills, no differences were seen between doses of 50 μg vs 20 – 40 μg of estrogen  
  • When analyses adjusted for the estrogen dose in each product, the RR only remained elevated with gestodene products  
  • For OCPs with 20 – 40 μg of estrogen, the risk of breast cancer depended on duration of use, although the effect was only significance for gestodene containing formulations  

LARC  

Levonorgestrel-releasing intrauterine system (LNG-IUD)  

  • No significant differences compared to OCPs 
  • RR of breast cancer was 1.21 (95% CI, 1.11 to 1.33) 

Contraceptive implants  

  • Few breast-cancer events among users of the progestin-only implant and depot medroxyprogesterone acetate 

Subgroup Analyses 

  • No strong evidence of different patterns in  
    • Women <35 years of age 
    • Nulliparous women  
    • BMI (data only available for parous women)  
    • Smoking  
    • Age at first birth  
  • ‘Suggestion’ that starting hormonal contraceptives < 20 years of age and long duration of use may be associated with increased risk but authors caution that risk estimates were imprecise 

CONCLUSION:

  • Authors state:

The difference in the risk of breast cancer between women who had never used hormonal contraception and current and recent users of any type of hormonal contraception was 13 (95% CI, 10 to 16) per 100,000 person-years; approximately one extra breast cancer was diagnosed for every 7690 women using hormonal contraception for 1 year

This risk should be weighed against important benefits of hormonal contraceptives such as good contraceptive efficacy and reduced risks of ovarian, endometrial, and perhaps colorectal cancer

Learn More – Primary Sources:

Contemporary Hormonal Contraception and the Risk of Breast Cancer

Take a post-test and get CME credits

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Related ObG Topics:

Practical info for your gynecology practice
Hormonal Contraception Benefits – Beyond Pregnancy Prevention
CDC Resources: Contraception in Women with Medical Conditions (US MEC)
Is there a Link Between Oral Contraception Use and Cancer Risk?
ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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