Press releases Monday 8 February to Friday 12 February 2010

Please remember to credit the BMJas source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Popular antidepressant blocks the beneficial effects of tamoxifen in breast cancer
(2) Review calls for renewed action to create a fairer society
(3) Defeatism is undermining evidence that chronic fatigue syndrome can be treated

(1) Popular antidepressant blocks the beneficial effects of tamoxifen in breast cancer
(Research: Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c693
(Editorial: Interaction of serotonin reuptake inhibitors with tamoxifen)
http://www.bmj.com/cgi/doi/10.1136/bmj.c783

Women with breast cancer who take the antidepressant paroxetine at the same time as tamoxifen are at an increased risk of death, concludes a study published on bmj.com today.

However, the authors stress that their results should not lead patients to stop taking tamoxifen, and do not imply that paroxetine itself causes or influences the course of breast cancer. "This is simply a situation in which paroxetine impairs the effectiveness of tamoxifen," they explain.

Breast cancer is the most commonly diagnosed cancer in women worldwide and the drug tamoxifen significantly improves survival. In order to work, however, tamoxifen must be converted into an active metabolite (endoxifen) by the liver.

But some drugs can interfere with this process. Antidepressants are of particular importance because they are commonly used in women with breast cancer, often for long periods of time. Although many antidepressants have little or no impact on tamoxifen's metabolism, paroxetine, a member of the selective serotonin reuptake inhibitor (SSRI) class of drugs, is a potent inhibitor of the metabolic step that converts tamoxifen to endoxifen.

So Dr Catherine Kelly and colleagues at the Institute for Clinical Evaluative Sciences (ICES) in Toronto set out to investigate whether SSRIs can reduce tamoxifen's effectiveness in practice.

They examined the healthcare records of 2,430 women aged 66 years or older with breast cancer who received tamoxifen between 1993 and 2005. About 30% of these women also received an antidepressant at some time during their treatment with tamoxifen, and paroxetine was the most commonly used agent.

The results show that use of paroxetine, but not other SSRIs, in combination with tamoxifen, was associated with an increased long-term risk of breast cancer death, in a fashion that correlated with the extent of drug overlap.

This supports the theory that paroxetine can reduce or abolish the benefit of tamoxifen in women with breast cancer.

The researchers estimate that treatment with paroxetine for 41% of the total time on tamoxifen (the median in this study) will result in one additional breast cancer death at five years for every 20 women so treated. The risk with more extensive overlap is greater.

"Our findings indicate that the choice of antidepressant can significantly influence survival in women receiving tamoxifen for breast cancer," says Dr David Juurlink, one of the study's authors and a scientist at ICES. "This observation is consistent with what we know about tamoxifen's metabolism. These results highlight a drug interaction that is extremely common, widely underappreciated and potentially life-threatening, yet uniformly avoidable."

"Tamoxifen is a crucial element of therapy for patients with hormone receptor-positive breast cancer regardless of age or breast cancer stage," he adds. "When co-prescription of tamoxifen with an antidepressant is necessary, preference should be given to antidepressants that exhibit little or no impact on tamoxifen's metabolism."

In an accompanying editorial, Frank Andersohn and Stefan Willich from Charité University Medical Center in Berlin say that clinicians should avoid co-prescribing paroxetine and tamoxifen in women with breast cancer, but warn against abrupt withdrawal of SSRI treatment.

They also call for this potential interaction to be made clear on all products containing tamoxifen and paroxetine, and for its promotion amongst physicians and pharmacists.

Contacts:

Research: David Juurlink, Division Head, Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Email: david.juurlink@ices.on.ca
Editorial: Frank Andersohn, Senior Research Associate, Institute for Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin, Germany
Email: frank.andersohn@charite.de

(2) Review calls for renewed action to create a fairer society
(Editorial: Getting to grips with health inequalities at last?)
http://www.bmj.com/cgi/doi/10.1136/bmj.c684
(Analysis: Bucking the inequality gradient through early child development)
http://www.bmj.com/cgi/content/full/340/feb09_1/c468

Politicians from all parties must renew their commitment to tackling health inequalities if we are to create a fairer society, say researchers on bmj.com today.

Their views come as an independent review by Professor Sir Michael Marmot is published, outlining the most effective strategies for reducing health inequalities in England from 2010.

The review is critical of the poor record of policy success in tackling health inequalities and advocates two aims: to improve health and wellbeing for all and to reduce health inequalities. To achieve these it wants social justice, health, and sustainability to be at the heart of all policies.

But David Hunter, Professor of Health Policy and Management at Durham University and colleagues question whether "there is sufficient genuine and sustainable political will to tackle health inequalities."

There are few votes in health inequalities, they warn, and "although the report is at pains to point out, as others have, that we are all adversely affected and our lives diminished by the growing health gap, this message could easily get lost."

They outline three reasons for the lack of progress. The first is a focus on individual lifestyle interventions rather than action at a governmental level. "The response to the Marmot report must avoid this at all costs," they say.

The second - a deep seated inability to join up policy and delivery across government is, they argue "evidence of how fossilised our institutional structures have become and how incapable they are of providing effective solutions to the complex problems we face."

The third reason for policy failure, they say, lies in the realm of politics. "With the economic outlook bleak and an election looming, the temptation will be for politicians to say that we can't afford to deal with health inequalities just yet. The imperative is to show that we can’t afford not to."

The policy changes needed for Marmot's recommendations to succeed can occur only if these three obstacles to progress are confronted, they conclude. Underpinning these must be a real political commitment at all levels, because a fairer society will benefit all.

A good start in life is the key to reducing health and social inequalities in society, according to an analysis article also published on bmj.comtoday. Clyde Hertzman and colleagues argue that governments in both rich and poor countries should be investing more in programmes to support early child development.

Contact:

David Hunter, Professor of Health Policy and Management, Wolfson Research Institute, Durham University Queen's Campus, Stockton on Tees, UK
Email d.j.hunter@durham.ac.uk

(3) Defeatism is undermining evidence that chronic fatigue syndrome can be treated
(Editorial: Chronic fatigue syndrome)
http://www.bmj.com/cgi/content/full/340/feb11_1/c738

An air of defeatism exists within the medical profession about chronic fatigue syndrome that is undermining evidence that it can be treated, argue three senior doctors in this week's BMJ.

The recent acquittal of Kay Gilderdale, who had been charged with the attempted murder of her 31 year old daughter Lynn, has led to blanket press coverage. Yet Alastair Santhouse, consultant at The South London and Maudsley NHS Foundation Trust and colleagues from Institute of Psychiatry, King's College London, argue that the media has largely portrayed the condition as a progressive, paralysing, and commonly fatal illness, and little has been said about the uncertainties and controversies that this diagnosis has always attracted.

While not commenting on this specific case, the authors point out that severe presentations of chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) such as that of Lynn Gilderdale are unusual, and that, if a diagnosis of CFS/ME is made, data clearly show that mortality is not increased.

The greatest risk to life is likely to be suicide, they explain. And this is often linked to depression that can be effectively treated.

Treatments such as cognitive behavioural therapy and graded exercise therapy have also been shown to work in CFS/ME and are recommended by the National Institute for Health and Clinical Excellence (NICE). In patients with severe CFS/ME, such programmes may be prolonged, but they can be the trigger for improvements and sometimes dramatic recovery, add the authors.

In contrast, the alternative to treatment is often no treatment, and this can have a disastrous effect on the patient, who may feel that the medical profession has given up on them as a hopeless case, they warn.

Undoubtedly current treatments could be improved, recovery may not be complete in many cases, and access to services for those too disabled to attend hospital clinics needs to be improved, they write. Furthermore, doctors are often uncertain about what they are dealing with, and perhaps inevitably a breakdown of trust between doctors and the patients and their families often occurs.

But they believe that the medical profession must continue to go with the evidence in choosing treatments, in what can be a fraught clinical situation. "We owe it to our patients and to our professionalism to do what we can to help those with this potentially treatable condition because, notwithstanding the difficulties, this is our primary duty," they conclude.

Contact:

Louise Pratt, Acting Public Relations and Communications Manager, Institute of Psychiatry, King's College London, UK
Email louise.a.pratt@kcl.ac.uk

For more information please contact:

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
[[$FOOTER]] http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc