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Andany N.,University of Toronto | Loutfy M.R.,University of Toronto | Loutfy M.R.,Womens College Research Institute
Drugs | Year: 2013

The impact of antiretroviral therapy (ART) on the natural history of HIV-1 infection has resulted in dramatic reductions in disease-associated morbidity and mortality. Additionally, the epidemiology of HIV-1 infection worldwide is changing, as women now represent a substantial proportion of infected adults. As more highly effective and tolerable antiretroviral regimens become available, and as the prevention of mother-to-child transmission becomes an attainable goal in the management of HIV-infected individuals, more and more HIV-positive women are choosing to become pregnant and have children. Consequently, it is important to consider the efficacy and safety of antiretroviral agents in pregnancy. Protease inhibitors are a common class of medication used in the treatment of HIV-1 infection and are increasingly being used in pregnancy. However, several studies have raised concerns regarding pharmacokinetic alterations in pregnancy, particularly in the third trimester, which results in suboptimal drug concentrations and a theoretically higher risk of virologic failure and perinatal transmission. Drug level reductions have been observed with each individual protease inhibitor and dose adjustments in pregnancy are suggested for certain agents. Furthermore, studies have also raised concerns regarding the safety of protease inhibitors in pregnancy, particularly as they may increase the risk of pre-term birth and metabolic disturbances. Overall, protease inhibitors are safe and effective for the treatment of HIV-infected pregnant women. Specifically, ritonavir-boosted lopinavir- and atazanavir-based regimens are preferred in pregnancy, while ritonavir-boosted darunavir- and saquinavir-based therapies are reasonable alternatives. This paper reviews the use of protease inhibitors in pregnancy, focusing on pharmacokinetic and safety considerations, and outlines the recommendations for use of this class of medication in the HIV-1-infected pregnant woman. © 2013 Springer International Publishing Switzerland. Source

Dennis C.-L.,University of Toronto | Dennis C.-L.,Womens College Research Institute
Health Promotion International | Year: 2013

A randomized controlled trial evaluated the effect of telephone-based peer support (mother-to-mother) on preventing postpartum depression among high-risk mothers. This paper reports volunteers' perceptions, which showed that peer support is an effective preventative intervention. Two-hundred and five (205) volunteers were recruited and trained to provide peer support to 349 mothers randomized to the intervention group. Volunteers' perceptions were measured at 12 weeks using the Peer Volunteer Experience Questionnaire, completed by 69% (121) of the 175 volunteers who provided support to at least one mother. Large majorities felt that the training session had prepared them for their role (94.2%), that volunteering did not interfere with their lives (81.8%) and that providing support helped them grow as individuals (87.8%). Over 90% stated that they would become a peer volunteer again, given the opportunity. Recruitment and retention of effective volunteers is essential to the success of any peer-support intervention. Results from this study can assist clinicians and program planners to provide effective training, sufficient on-going support and evaluation and appropriate matching of volunteers to mothers who desire peer support and are at high risk of postpartum depression. © The Author (2012). Published by Oxford University Press. All rights reserved. Source

Narod S.A.,Womens College Research Institute | Narod S.A.,University of Toronto
Breast Cancer Research and Treatment | Year: 2011

If mammographic screening is to be recommended to women aged <50, it is necessary that mammographic screening leads to the detection of small cancers and that the survival rate of young women with small cancers is superior to that of women with larger cancers. We reviewed the survival experience of 2,173 patients with invasive breast cancer. There were 392 cancer-specific deaths in the cohort after a mean of 8.9 years of follow-up. We estimated the effects of young age (age <50) of tumor size (in cm) and of mammogram detected (vs. palpable) on breast cancer survival in the cohort. Young age, tumor size >2 cm and tumor palpability were strong and independent predictors of breast cancer mortality in the cohort. The 10-year survival rate for young women with small mammogram-detected breast cancers (<1 cm) was 94%, compared to 86% for women with palpable cancers in the same size group (P < 0.01). Women with a small non-palpable breast cancer that is diagnosed through a mammogram experience very good survival, compared to women with a palpable breast cancer of similar size. Our findings suggest that mammography preferentially detects cancers with good prognosis and calls into question the assumption that detecting breast cancers when they are small by mammography will impact upon mortality from breast cancer. © 2011 Springer Science+Business Media, LLC. Source

Narod S.A.,Womens College Research Institute
Nature Reviews Clinical Oncology | Year: 2014

An increasingly large proportion of women with unilateral breast cancer are treated with bilateral mastectomy. The rationale behind bilateral surgery is to prevent a second primary breast cancer and thereby to avoid the resultant therapy and eliminate the risk of death from contralateral breast cancer. Bilateral mastectomy has been proposed to benefit women at high risk of contralateral cancer, such as carriers of BRCA1 and BRCA2 mutations, but for women without such mutations, the decision to remove the contralateral breast is controversial. It is important to evaluate the risk of contralateral breast cancer on an individual basis, and to tailor surgical treatment accordingly. On average, the annual risk of contralateral breast cancer is approximately 0.5%, but increases to 3% in carriers of a BRCA1 or BRCA2 mutation. Risk factors for contralateral breast cancer include a young age at first diagnosis of breast cancer and a family history of breast cancer. Contralateral mastectomy has not been proven to reduce mortality from breast cancer, but the benefit of such surgery is not expected to become apparent until the second decade after treatment. An alternative to contralateral mastectomy is adjuvant hormonal therapy (such as tamoxifen), but the extent of risk reduction is smaller (approximately 50%) compared to 95% or more for contralateral mastectomy. This Review focuses on the risk factors for contralateral breast cancer, and discusses the evidence that bilateral mastectomy might reduce mortality in patients with unilateral breast cancer. © 2014 Macmillan Publishers Limited. All rights reserved. Source

Narod S.A.,Womens College Research Institute
Nature Reviews Clinical Oncology | Year: 2012

About one in 300 women will be diagnosed with breast cancer before the age of 40. Advances in screening have not had an impact on mortality in women who are too young to be candidates for screening. Risk factors for early breast cancer include a lean body habitus and recent use of an oral contraceptive. Breast cancers in very young women are typically aggressive, in part owing to the over-representation of high-grade, triple-negative tumours, but young age is an independent negative predictor of cancer-specific survival. Very early age-of-onset also correlates strongly with the risk of local recurrence and with the odds of contralateral breast cancer. Given the high risks of local and distant recurrence in young women with invasive breast cancer, most (if not all) young patients are candidates for chemotherapy. It is hoped that by increasing breast cancer awareness, the proportion of invasive breast cancers that are diagnosed at 2.0 cm or smaller will increase and that this will lead to a reduction in mortality. © 2012 Macmillan Publishers Limited. All rights reserved. Source

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