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Press releases Saturday 27 October 2007

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(1) Women still face cancer risk 25 years after treatment
(2) Is it safe for women to drink small amounts of alcohol in pregnancy?
(3) Reducing social exclusion key to tackling gun crime, say experts

(1) Women still face cancer risk 25 years after treatment
(Risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study)
(Cervical intraepithelial neoplasia and higher long term risk of cancer)
http://www.bmj.com/onlinefirst_date.dtl

Cancer experts are now calling for cytological smears to be offered at regular intervals for at least 25 years after a woman has had severe dysplasia/CIS (carcinoma in situ).

CIS is not cancer but close to it as some cells look cancerous but are superficially in the mucosa (the soft skin-like layer that lines many body cavities such as the nasal and genital passages) and not in any tissue.

Researchers in Sweden studied data from the National Swedish Cancer Register, which included information recorded between 1958 and 2002 on 132,493 women who had a diagnosis of severe dysplasia/CIS.

They found that 881 women had developed cervical cancer and 111 women had vaginal cancer more than one year after the CIS diagnosis.

Women with such a diagnosis are more than twice as likely to develop cancer as the general female population.

They also found that there was an increasing risk of cervical cancer if the woman was older at the time of diagnosis, with a much higher risk for women aged over 50.

The risk also grew as the decades went by as the researchers found that women were twice as likely to develop invasive cervical cancer after diagnosis of CIS if that diagnosis was made in the period 1991-2000 as in the period 1958-1970. This could be due to changes in the forms of treatment in different decades.

The observed number of cases of women who developed vaginal cancer was almost seven times higher than expected

The authors say: "Although most women with high-grade dysplasia have been protected from invasive cancer it must be considered a failure of the medical service when women participate in screening, their pre-cancerous lesions are found and they subject themselves to treatment of those lesions, presumably participate in follow-up programmes and still develop invasive cancer."

They conclude that follow-up care has, so far, been insufficient and women should be offered cytological smears at regular intervals for at least 25 years after treatment. Long term follow up should not stop for women when they reach the age of 60 if they were older than 35-40 at the time of treatment for CIS.

This view is reiterated in accompanying BMJ editorial, which suggests that women treated for CIN3 should have long term screening, even if beyond the normal age limit of regular screening.

Contact:
Bjorn Strander, Senior Consultant, Department of Obstetrics and Gynecology, Sahlgren's Academy, University of Gothenburg, Sweden
Email: bjorn.strander@oc.gu.se 

(2) Is it safe for women to drink small amounts of alcohol in pregnancy?
(Head to Head: Is it all right for women to drink small amounts of alcohol in pregnancy?)
Yes www.bmj.com/cgi/content/full/355/7625/856
No www.bmj.com/cgi/content/full/355/7625/857

The National Institute for Health and Clinical Excellence (NICE) draft guidance on drinking during pregnancy has added to confusion about safety because it's at odds with other official guidance. In this week's BMJ, two experts debate the issue.

Until May of this year, the Department of Health advised pregnant women in England not to drink "more than one to two units of alcohol once or twice a week," writes Pat O'Brien, a consultant obstetrician at the Institute for Women's Health in London. Since then, both the department and the British Medical Association have changed their stance and pregnant women are now told to avoid alcohol completely.

But there is no new evidence, so why the change, he asks?

Fetal alcohol syndrome is a serious condition and is clearly a consequence of heavy alcohol intake during pregnancy, he writes. Nevertheless, there is still no evidence that low to moderate alcohol intake in pregnancy has any long term adverse effects.

He believes that telling women to avoid alcohol completely is therefore overly paternalistic and that women are entitled to decide for themselves (and their babies).

The reasons given for the changed advice are that there is confusion, the advice is unclear, and people don't understand what is meant by a unit of alcohol. But O'Brien argues "if we in the medical and midwifery professions have failed to communicate clearly to women the meaning of safe limits, then we need to put this right - not take the easy option (for us) and ban alcohol completely."

He points to the US, where the surgeon general has since 1981 advised the complete avoidance of alcohol in pregnancy, and all alcohol containing products carry a health warning, yet the incidence of frequent drinking in pregnancy rose from 0.9% in 1991 to 3.5% in 1999. A complete ban is also is likely to increase under-reporting of alcohol consumption as women feel afraid and embarrassed to admit they are drinking during pregnancy, he adds.

On the basis of the evidence we provide, many women will choose abstinence as the safest option. But that choice is the right of each individual woman, he concludes.

But Vivienne Nathanson, Director of Professional Activities at the BMA, argues that abstinence is the safest message for women who are pregnant or planning a pregnancy.

Alcohol can adversely affect the reproductive process in several ways, including infertility, miscarriage, preterm deliveries, stillbirth, and low birthweight babies, she writes. Studies provide robust and consistent evidence that heavy maternal alcohol use is associated with fetal alcohol syndrome, while research has identified vulnerable periods of neonatal development that can be adversely affected by exposure to heavy doses of alcohol.

Evidence is also continuing to emerge on the possible risks of prenatal alcohol exposure at low to moderate levels, she says. For example, studies examining the effects of chronic consumption indicate that low to moderate levels of exposure (two to five units a week) delay the development of the fetus's nervous system and may have a permanent effect. A recent large prospective study has also found that occasional low to moderate drinking during the first trimester may have a negative and persistent effect on children's mental health.

Current guidelines on sensible drinking in the UK can be misinterpreted as people may not clearly understand what units or "standard drinks" are, she adds. Many women will also not know they are pregnant during the early part of the first trimester, during which time they may continue to drink in their pre-pregnancy fashion with no awareness of the risk to their unborn child.

Given the current uncertainty regarding the level of risk to the developing fetus, the lack of clear guidelines, and the confusion about consumption levels, the only sensible message for women who are pregnant or planning a pregnancy must be complete abstinence from alcohol, she concludes.

Contact:
Pat O'Brien, Consultant Obstetrician, Institute for Women's Health, University College London Hospitals, London, UK
Email: patrick.obrien@uclh.nhs.uk 
Vivienne Nathanson, Director of Professional Activities, British Medical Association, London, UK
Email: ftranza@bma.org.uk

(3) Reducing social exclusion key to tackling gun crime, say experts
(Violence and gun crime)
http://www.bmj.com/cgi/content/full/335/7625/837

Reducing social exclusion and deprivation and increasing the protection of children may be more effective at tackling gun crime than focusing on gun control alone, say experts in this week's BMJ.

The headlines about gun crime and violent crime in the United Kingdom are tragic and alarming, and anxiety about the danger of guns is understandably high, write forensic psychotherapist, Gwen Adshead and colleagues. Yet the statistics behind the headlines help to put the problem into context.

For example, firearms offences in the UK constitute 0.4% of all recorded crime; only 0.2% if airguns are excluded. The overall frequency of gun crime in the UK has been decreasing, and in 2005-6 the number of homicides involving firearms was 50: the lowest for 10 years.

But 50 deaths is still too many, say the authors. Children under 16 are the group most likely to die as a result of homicide. They are usually killed by their parents or someone known to them, but in 21% of cases no suspect is identified.

In 2006, a Home Office review on the use of illegal firearms suggested a picture of socially isolated young men, looking for an identity. Of 80 young men studied, 59 came from disrupted family backgrounds and just over half had been excluded from school.

Such disconnected young men may be highly fearful, or highly fearless - both states of mind that are a defence against negative affects like shame, humiliation, anger, and distress, write the authors. Such affects make violence more likely, especially if the young person lacks the capacity to mentalise (think about and regulate their feelings).

So, how can gun crime rates be changed, they ask?

International evidence shows a close correlation between gun ownership and rates of suicide and homicide. However, in the UK, ownership of handguns has been restricted since 1997, yet fatal gun crimes still occur.

The authors believe that improving the welfare of young people at risk of acting violently might be more fruitful. Many of the risk factors for later violence are linked to being raised in a disrupted and abusive family, yet most of the interventions focus on school and community groups - hardly any target abusive parents or families, they say.

They suggest initiatives to help improve young people's mental health, focusing on a small group of children who are at risk of acting violently, rather than the much bigger group of children who will never pose such a risk.

Early identification of children who are most at risk would also help to reduce the development of a paranoid and dangerous mindset that makes a gun one of the easier answers to a conflict, they conclude.

Contact:
Gwen Adshead, Forensic Psychotherapist, Broadmoor Hospital, Crowthorne, Berkshire, UK
Email: gwen.adshead@wlmht.nhs.uk 

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