Richard R. Love, MD, MS

While optimal adjuvant hormonal therapies for premenopausal women with operable breast cancer have yet to be defined, discussions and reviews of the state of the art and “areas of confusion” often fail to consider developments that are germane to keeping evidence-based clinical practice truly up-to-date.

If you are like me—closer to retirement than midcareer—after years of coping with the tragedies of patients with cancer, you are being jolted by the occurrence of malignancies or other serious illnesses in close friends. In response, we might be inclined to reassess the rewards of whatever cancer work we do. There's a case to be made for what could be a radical change in at least some of what we do: We should find other ways to use our skills to "repair the world." A translation of the Hebrew phrase "tikkun olam," repairing the world suggests social action and the pursuit of social justice. In particular, I urge considering some foreign service.

The discussions and debates about the use of estrogen replacement therapy (ERT) in women with breast cancer often seem to ignore or at least leave unnoted the extensive data supporting the general premise that increased, but physiologic levels of estrogens are associated with poorer survival in postmenopausal women with breast cancer. Dr. Colditz summarizes various lines of evidence bolstering this general premise, providing us with some needed lessons about the complexities of interpreting epidemiologic studies and about human cancer biology. Particularly illuminating are his discussion of the biases in ERT-breast cancer causation studies and his exploration of the reasons for the apparently better survival in ERT users who develop breast cancer.

The ultimate goal of breast cancer prevention strategies is to reduce the incidence of this disease in populations. Greater understanding of recently identified associations of lactation, alcohol, exercise, and diet with breast

This well-written article can benefit only from reinforcement of a few of its major points, some supplemental discussion about the important role of biologic models in understanding and managing breast cancer development, and a note about the critical need for research and perspectives from the social sciences concerning this subject. I say "only" because this article beautifully and clearly explores some of the language of epidemiology critical to the subject, language which is becoming increasingly important in routine medical practice. Practitioners and, increasingly, the public (medical "consumers") are concerned with risks and numbers.