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Columbia University School of Public Health, New York, New York 10032 [J. L. K.], and Mount Sinai School of Medicine, New York, New York 10029 [G. S. B.]
This brief review of results of recent epidemiological investigations suggests some additional approaches for future studies. First, the studies of the DES-exposed women and of oral contraceptive users suggest that the timing of exposure may be critical, since the possible effect of both these hormonal agents may be limited to specific time periods of rapid breast development. Studies of other possible etiological agents should also try to focus more on exposures during critical time periods. On the other hand, if such a critical period does not exist in postmenopausal women, then there may be little effect of hormones used at this time. Instead, exposure to higher than average levels of estrogen from estrogen replacement therapy or through greater conversion to estrogen in adipose tissue in obese women may result in only a modest elevation in risk and only after prolonged exposure, because of the relative inactivity of the breast at the time of exposure. Also, the effect of radiation and the possible effects of estrogen replacement therapy and oral contraceptives remind us of the long latency period that may be necessary before an effect is seen for at least some agents. Thus, studies with long-term follow-up and that include long-term users are important in studies of effects of hormones and other exposures.
Among the newly hypothesized etiological agents, it would seem that the possible protective effect of physical activity merits further study. An effect of physical activity has not been well studied in the past, and possible biological mechanisms have been postulated. With regard to alcohol, assessment of the influence of age when consumption began and duration of exposure as well as the identification of plausible mechanisms of action would aid in clarifying the role of alcohol consumption in breast cancer etiology.
Ongoing studies of benign breast diseases are aimed at addressing the question of subgroups at particularly high risk, and ongoing studies of radiation are addressing such questions as the risks from low-dose exposures and the latency period following exposure. The results of these studies will be awaited with interest.
Since it is virtually certain that endogenous sex hormones play a role in breast cancer etiology, continued study of their role with new and improved measurement techniques is obviously of high priority. Likewise, in those cases of breast cancer in which marked familial aggregation is seen, newly developed probes for marker genes will be useful.
Finally, it is also likely that exposures not studied to date are involved in breast cancer etiology, since known risk factors by no means account for the entire risk of breast cancer. Thus, new ideas are needed, particularly regarding exposures at critical time periods.
1 To whom requests for reprints should be addressed, at Division of Epidemiology, Columbia University School of Public Health, 600 W. 168th St., New York, NY 10032.
Received 2/18/88. Revised 7/ 5/88. Accepted 7/11/88.
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