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Current Trends Report of the Recommendations of the 1985 DES Task Force of the U.S. Department of Health and Human Services
In 1978, the U.S. Department of Health, Education, and Welfare set up a DES (diethylstilbestrol (a synthetic estrogen)) Task Force to review all aspects of the DES question and to develop recommendations regarding health issues of DES and research gaps that exist. In 1985, a second DES Task Force of the U.S. Department of Health and Human Services (DHHS) was convened to review recent studies showing a possible increased risk of breast cancer among women given DES during pregnancy and a possible excess of precancerous abnormalities of the cervix and vagina among women exposed to DES in utero (1). BREAST CANCER
Since 1978, results of four investigations relevant to this issue have been published (2-5). Two of these studies were randomized clinical trials reporting the long-term follow-up results of the use of DES during pregnancy. In one, 80 diabetic women received hormonal treatment, and 76 diabetic women received placebos. After 29 years of follow-up, four cases of breast cancer had occurred among the exposed women, and none, among the unexposed women (2). In another study, 10 cases of breast cancer were found among 319 DES-exposed women, and nine, among 331 unexposed women, suggesting there was no excess risk. Exposure occurred in the early 1950s.
Two observational follow-up studies of women treated with DES during pregnancy have also been reported recently (4,5). In these studies, the overall relative risk of breast cancer among the exposed women ranged from 1.2 to 1.5. One study noted that there was no increased risk in the first 20 years of follow-up but that the relative risk rose to 1.6 during the 20-29 years after exposure and to 2.5 for those followed 30 years or more (5).
The 1985 Task Force concluded that:
SQUAMOUS CELL ABNORMALITIES OF THE UTERINE CERVIX IN DES-EXPOSED DAUGHTERS
In 1974, the National Cancer Institute began a multi-institutional cooperative research study, the National Cooperative Diethylstilbestrol Adenosis Project (DESAD Project). The DESAD Project was a large collaborative study involving four groups of DES-exposed persons and having a complex study design.
The 1978 DES Task Force concluded that, in the uterine cervix, the risks for squamous cell cancer were the same in unexposed and exposed daughters, i.e., there was no reliable scientific evidence to indicate that a risk of squamous cell cancer was associated with DES exposure in utero. This conclusion was based primarily on clinical evaluations and on the results from the initial screening examination of DES-exposed daughters in the DESAD Project.
A recent study that has reopened the issue of cervical abnormalities is a report from the DESAD Project summarizing the cytologic and pathologic abnormalities of the cervix and vagina noted during the first 7 years of follow-up of DES-exposed daughters (8). One subset of 744 women was identified from reviews of obstetrical records as exposed in utero to DES and was matched with another subset of 744 women who had not been exposed to DES. Over 7 years of screening, the incidence rate of mild, moderate, and severe dysplasia and of carcinoma in situ of the uterine cervix was substantially higher in the exposed women than in the unexposed (15.7, compared with 7.9 cases per 1,000 persons per year of follow-up) (8). The 1985 Task Force reviewed this report (8) and concluded that a relationship between DES exposure in utero and the risk of subsequently developing squamous cell cancer is not proven but needs further study.
The following considerations were thought to be important in interpreting the reported new finding of an increase in dysplasia among DES-exposed daughters (8):
The Task Force recommended that physicians continue attempts to notify women for whom they had prescribed DES and that DHHS continue to support and encourage research on the possible adverse effects of DES. The Task Force outlined specific areas for further study.
In addition, the Task Force recommended continued dissemination of information to all physicians and DES-exposed mothers and offspring and continued implementation of recommendations for the surveillance of DES-exposed mothers, daughters, and sons. Recommendations for screening DES mothers for breast cancer are the same as those for other women. Details of screening DES-exposed daughters for cervical and vaginal lesions are given in the DES Task Force Report. Copies of the full report can be obtained by contacting: DES, Office of Cancer Communication, Building 31, National Cancer Institute, Bethesda, Maryland 20892; telephone (800) 4-CANCER. Reported by the 1985 DES Task Force, US Dept of Health and Human Svcs.
Editorial Note: Previously reported risk factors for breast cancer include a family history of breast cancer, nulliparity, late age at first birth of a child, prior atypical proliferative disease of the breast, certain ethnic characteristics, high socioeconomic status, early menarche, late menopause, high-fat diet, pregnancies of less than 4-5 months' duration, irregular menstrual cycles, obesity, and lack of exercise (9-11).
Similarly, there are multiple risk factors for cervical cancers. Among those reported are early sexual activity (especially with multiple partners), infections with genital herpes and human papilloma virus, multiple sex partners of the male mate, multiparity, and high chronic alcohol intake (12).
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