BEST in MH clinical question-answering...

Email: [email protected] Phone: 0117 378 4232/4233/4335 @BESTinMH

BEST.awp.nhs.uk

Best Evidence Summaries of Topics in

Mental Healthcare

BEST in MH clinical question-answering service

Question

For people with raised prolactin levels due to taking antipsychotic medication, what is the risk of

developing breast cancer or any other long term physical health complication?

Clarification of question using the PRO structure

Patients: People taking antipsychotic medication

Risk factor: Raised prolactin levels due to antipsychotic medication

Outcome: Breast cancer (primary outcome) or other long term physical health complications

(secondary outcome)

mailto:[email protected]

http://www.twitter.com/bestinmh

http://best.awp.nhs.uk/

Clinical and research implications No definite clinical implications can be made based on the available evidence. Two retrospective cohort studies were identified that addressed this BEST question, one of which suggested that their evidence should reassure physicians and patients that atypical antipsychotics do not increase the risk of breast cancer when compared to typical antipsychotics. The authors of the other trial, however, found a small, but significant increased risk of breast cancer with antipsychotic dopamine antagonist use. These findings led the authors to suggest that current treatment strategies need not be changed, but that the findings need to be confirmed in further rigorously conducted, adequately powered, studies.

What does the evidence say? Number of included studies/reviews (number of participants)

Two retrospective cohort studies met the inclusion criteria for this BEST summary (Azoulay et al.

2011; Wang et al. 2002).

Main findings

The relatively recent study by (Azoulay et al. 2011) used a nested case-control analysis to compare

atypical antipsychotics with typical antipsychotics on increased risk of breast cancer. This study used

primary care data from the UK’s General Practice Research Database. From a cohort of 106,372

people, there were 1,237 cases and 11,625 controls. The mean follow-up period was 5.3 years, for

an overall breast cancer rate of 2.7 per 1000/years. The results of this study demonstrated that

exclusive users of atypical antipsychotics were not at an increased risk of breast cancer when

compared to exclusive users of typical antipsychotics (adjusted rate ratio (RR): 0.81, 95% CI: 0.63,

1.05). The results were similar when patients exclusively prescribed risperidone (known to increase

prolactin levels) were compared with users of typical antipsychotics (adjusted RR: 0.86, 95% CI: 0.60,

1.25). The authors stated that the findings were strengthened by the lack of any dose-response

association (i.e. cumulative duration of use, and cumulative dose).

The earlier study by Wang et al. (2002) compared the use of antipsychotic dopamine antagonists

with the use of random medications other than dopamine antagonists. This study used data from

the New Jersey Medicaid or the New Jersey Pharmaceutical Assistance to the Aged and Disabled

programmes. Mean age of the included participants was not reported; one quarter were reported

to be younger than 40 years, and one quarter were 80 years or older. In contrast to the above study,

the authors reported that antipsychotic dopamine use was associated with a modest but significant

increased risk of developing breast cancer (adjusted hazard ratio (HR): 1.16, 95% CI: 1.07, 1.26), but

not colon cancer (adjusted HR: 1.11, 95% CI: 1.00, 1.22). They also found that the risk of breast

cancer increased with exposure to larger cumulative doses (HR not reported).

Authors conclusions

Azoulay et al. (2011) concluded that compared to typical antipsychotics, atypical antipsychotics do

not increase the risk of breast cancer in patients.

Wang et al. (2002) concluded that “antipsychotic dopamine antagonist use may confer a small but

significant risk of breast cancer. In light of the small hazards and the possibility of residual

confounding, these findings should lead to follow-up investigations but not changes in treatment

strategies.”

Reliability of conclusions/Strength of evidence

The study by Azoulay et al. (2011) was well-conducted, with the exception that, for some outcomes,

relative risks were presented without showing the data from which these results were calculated. It

is likely, however, that the main results are reliable. Similarly, the Wang et al. (2002) appears to be

well-conducted, but as the authors appropriately stated, the results should be viewed as

preliminary.

What do guidelines say?

Neither National Institute for Health and Care Excellence (NICE) nor Scottish Intercollegiate

Guidelines Network (SIGN) guidelines comment on the risk of developing breast cancer or any other

long term physical health complication in people with raised prolactin levels due to taking

antipsychotic medication.

Date question received: 06/17/2015

Date searches conducted: 15/07/2015

Date answer completed: 27/07/2015

References

Cohort / Case control studies

1. Azoulay, L., Yin, H., Renoux, C., & Suissa, S. (2011). The use of atypical antipsychotics and the risk of breast cancer. Breast Cancer Research and Treatment, 129(2), 541-548.

2. Wang, P. S., Walker, A. M., Tsuang, M. T., Orav, E. J., Glynn, R. J., Levin, R., & Avorn, J. (2002).

Dopamine antagonists and the development of breast cancer. Archives of General Psychiatry, 59(12), 1147-1154.

Results

Cohort Studies

Author

(year)

Inclusion criteria Number of

participants

Summary of results Risk of bias

Azoulay

et al.

(2011)

Participants:

Women aged 18 or over who were

prescribed antipsychotic medication

(typical or atypical), with at least 12

months of standard medical history

available in the General Practice Research

Database (GPRD) - between 1 Jan 1988

and 31 Dec 2007, with follow-up until 31

Dec 2010. Patients with a history of breast

cancer were excluded.

Case-controls: Data from up to 10 controls

(taken from the same cohort) were

compared with every incident of breast

cancer. Controls were matched by age,

date of entry on to the cohort, use of

antipsychotic medication and duration of

follow-up.

Exposure:

Prescription of antipsychotic medication.

Typical antipsychotics that were

considered included: benperidol,

chlorpromazine, droperidol, flupentixol,

Cohort:

106,362

(1,237 cases

and 11,625

controls)

The mean (SD) age at cohort entry was 63 (21.6) years, and

the mean duration of follow-up was 5.3 (4.8) years.

The authors reported that exclusive users of atypical

antipsychotics were not at an increased risk of breast cancer

when compared to exclusive users of typical antipsychotics

(adjusted* RR: 0.81, 95% CI: 0.63, 1.05).

The results were also similar between new users (adjusted*

RR: 0.87, 95% CI: 0.63, 1.21) and those who had been taking

antipsychotic medication at least in the year prior to data

collection (adjusted* RR: 0.75, 95% CI: 0.48, 1.17). When

atypical antipsychotic users were categorised by drug type,

no increased risk was found among those prescribed

risperidone (adjusted* RR: 0.86, 95% CI: 0.60, 1.25).

Based on secondary analyses, the authors found no

significant difference in breast risk cancer risk between pre-

and post-menopausal patients. Past use of hormone

replacement therapy (HRT) did not modify the risk, and no

difference was observed between patients exclusively

prescribed antipsychotics known to increase prolactin levels,

compared to those who were not prescribed these

Low

fluphenazine, fluspirilene, haloperidol,

levomepromazine, loxapine, oxypertine,

pericyazine, perphenazine, pimozide,

pipotiazine, promazine, sulpiride,

thioridazine, trifluoperazine, trifluperidol,

and zuclopenthixol. Atypical antipsychotics

that were considered included:

amisulpride, aripiprazole, clozapine,

olanzapine, quetiapine, remoxipride,

risperidone, sertindole, and zotepine.

Outcome:

Incidence of breast cancer diagnosis.

pharmaceuticals (adjusted* RR: 1.06, 95% CI: 0.92, 1.22).

* The logistic models were adjusted for potential

confounding factors including: excessive alcohol use, obesity

(BMI ≥ 30), smoking status, aspirin use, selective serotonin

reuptake inhibitors, statins, previous cancer (other than non-

melanoma skin cancer and breast cancer), hypertension,

insulin, metformin, other oral hypoglycaemic agents, prior

oophorectomy, prior use of HRT, prior use of oral

contraceptives, schizophrenia and related disorders, bipolar

disorder, other psychotic disorders, dementia, major

depression with or without psychotic features, and others.

Wang

et al.

(2002)

Participants:

Cohort: Women aged 20 or over who had

been prescribed medication or accessed a

medical service at least once during two

consecutive 6-month periods during the

period between Jan 1, 1989 and June 30,

1995. All participants were enrolled in the

Medicaid or the Pharmaceutical Assistance

to the Aged and Disabled programmes of

New Jersey, USA. Women with a history of

breast cancer or prescription of tamoxifen

citrate were excluded.

Patients: Women within the cohort who

had been prescribed dopamine

antagonists (mainly antipsychotic

medication).

108,008

(52,819

patients

taking

antipsychotic

medication

and 55,289

controls)

The authors reported that antipsychotic dopamine antagonist

use was associated with a modest but significant increased

risk of developing breast cancer (adjusted HR: 1.16, 95% CI:

1.07, 1.26), but not colon cancer (adjusted HR: 1.11, 95% CI:

1.00, 1.22).

The largest risks of developing breast cancer were among

women followed for 6 years or longer (adjusted HR: 2.37,

95% CI: 1.25, 4.47). No significant effects were observed for

shorter follow-up periods.

The two lowest quartiles of cumulative doses of dopamine

antagonists were not associated with elevated breast cancer

risks, but the two highest were associated with significantly

elevated risks (results presented in a graph only).

Low

Controls: Women who had been

prescribed medication other than

dopamine antagonists, matched by age

and month of their first prescription within

the cohort study period.

Exposure:

Prescription of dopamine antagonists

including phenothiazines (acetophenazine,

chloropromazine, fluphenazine,

mesoridazine, perphenazine, promazine,

thioridazine, and trifluoperazine),

thioxanthenes (chloroprothixene and

thiothixene), and butyrophenes

(haloperidol).

Outcome:

Incidence of breast cancer and colon

cancer diagnosis.

When analyses were made by classes of dopamine

antagonists, phenothiazines were associated significantly

elevated hazards of developing breast cancer (adjusted HR:

1.19, 95% CI: 1.08, 1.32), but thioxanthenes and

butyrophenones were not. For individual antagoinsts,

significantly elevated risks were observed for trifluoperazine

(adjusted HR: 1.30, 95% CI: 1.06, 1.60), and thioridazine

(adjusted HR: 1.15, 95% CI: 1.00, 1.31), but the authors noted

that many of the other drug-specific estimates were

underpowered.

* Analyses were adjusted for potential confounding factors

including: age, ‘race’, and socio-economic status, use of

oestrogens, benign mammary dysplasia, obesity, and

malignancies other than breast cancer, Charlson score, health

care use, and rates of mammography.

Risk of bias:

Cohort studies Study RISK OF BIAS (ASSESSED USING SIGN GUIDANCE FOR COHORT STUDIES)

Question

(clearly

focussed)

Subject selection

(comparable

groups, loss to

follow-up)

Outcome assessment

(clearly defined,

reliable and blinded to

exposure)

Confounding

(accounted for

in design and

analysis)

Statistical

analysis

(reporting of

confidence

intervals)

Overall

assessment

Azoulay et al. 2011 Wang et al. 2002

Low risk High risk ? Unclear risk

Search details

Source Search Strategy Number

of hits

Relevant evidence

identified

Guidelines

NICE

breast cancer antipsychotic prolactin

breast cancer antipsychotic

0

8

0

0

Systematic Reviews

Medline

1. Medline; (Antipsychotic AND medication).ti,ab; 4968 results.

2. Medline; (antipsychotic AND drugs).ti,ab; 7594 results.

3. Medline; exp ANTIPSYCHOTIC AGENTS/; 104388 results.

4. Medline; exp DRUG THERAPY/; 1130814 results.

5. Medline; 1 OR 2 OR 3 OR 4; 1221981 results.

6. Medline; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab;

10578 results.

7. Medline; exp PROLACTIN/; 37679 results.

8. Medline; 6 OR 7; 40767 results.

9. Medline; exp LACTATION DISORDERS/; 3090 results.

10. Medline; 6 OR 7 OR 9; 42767 results.

11. Medline; (breast adj1 cancer).ti,ab; 184435 results.

12. Medline; (physical AND health AND (problem* OR disorder* OR illness* OR

complication*)).ti,ab; 28443 results.


14. Medline; 5 AND 10 AND 13; 102 results.

15. Medline; (((("systematic* review*") OR meta-analytic* OR metanalysis OR

metaanalysis OR ("meta analysis") OR meta-synthesis OR metasynthesis OR ("meta

synthesis") OR meta-regression OR metaregression OR ("meta regression") OR

(synthes* adj3 literature) OR (synthes* adj3 evidence) OR ("integrative review")

OR ("data synthesis") OR ("research synthesis") OR ("narrative synthesis") OR

2 0

("systematic study") OR ("systematic studies")))).ti,ab; 129160 results.

16. Medline; META-ANALYSIS AS TOPIC/; 14045 results.

17. Medline; meta-analysis.ti,ab,pt; 81643 results.

18. Medline; ((("systematic comparison*") OR ("systematic overview*") OR

("evidence based review") OR ("comprehensive review") OR ("critical review") OR

("quantitative review") OR ("structured review") OR ("realist review") OR ("realist

synthesis"))).ti,ab; 23752 results.


20. Medline; ((medline OR pubmed OR cochrane OR embase OR cinahl OR psyclit

OR psycinfo OR psychlit OR psychinfo OR (literature adj3 search*) OR (database*

adj3 search*) OR (bibliographic adj3 search*) OR (electronic adj3 search*) OR

(electronic adj3 database*) OR (computerized adj3 search*) OR (computerised

adj3 search*) OR (internet adj3 search*) OR ("included studies") OR ("inclusion

studies") OR ("inclusion criteria") OR ("selection criteria") OR ("selection criteria")

OR ("predetermined criteria"))).ti,ab; 183679 results.

21. Medline; ((medline OR pubmed OR cochrane OR embase OR cinahl OR psyclit




adj3 search*) OR (internet adj3 search*) OR ("included studies") OR ("inclusion

studies") OR ("inclusion criteria") OR ("selection criteria") OR ("selection criteria")

OR ("predetermined criteria"))).ab; 180869 results.

22. Medline; (((("predefined criteria") OR (assess* adj3 (quality OR validity)) OR

(select* adj3 (study OR studies)) OR (data adj3 extract*) OR ("extracted data") OR

(data adj2 abstracted) OR (data adj3 abstraction) OR ("published intervention") OR

((study OR studies) adj2 evaluat*) OR (intervention* adj2 evaluat*) OR

("confidence interval") OR heterogeneity OR pooled OR pooling OR ("odds ratio*")

OR Jadad OR coding))).ti,ab; 954604 results.


24. Medline; 19 AND 23; 92261 results.

25. Medline; review.ti; 285627 results.


27. Medline; ((review* adj4 (papers OR trials OR studies OR evidence OR

intervention* OR evaluation*))).ti,ab; 134959 results.


29. Medline; (letter OR editorial OR comment).pt; 1404092 results.

30. Medline; exp ANIMALS/; 17905366 results.

31. Medline; exp HUMANS/; 13884984 results.

32. Medline; 30 NOT 31; 4020382 results.


34. Medline; 28 NOT 33; 260262 results.

35. Medline; 34 [Limit to: Publication Year 2010-2015]; 130720 results.


CINAHL 1. CINAHL; (Antipsychotic AND medication).ti,ab; 899 results.

2. CINAHL; (antipsychotic AND drugs).ti,ab; 767 results.

3. CINAHL; exp ANTIPSYCHOTIC AGENTS/; 9075 results.

4. CINAHL; exp DRUG THERAPY/; 80434 results.

5. CINAHL; 1 OR 2 OR 3 OR 4; 88804 results.

6. CINAHL; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab; 146

results.

7. CINAHL; exp PROLACTIN/; 472 results.

8. CINAHL; 6 OR 7; 550 results.

9. CINAHL; exp LACTATION DISORDERS/; 536 results.

10. CINAHL; 6 OR 7 OR 9; 1055 results.

11. CINAHL; (breast adj1 cancer).ti,ab; 25833 results.

12. CINAHL; (physical AND health AND (problem* OR disorder* OR illness* OR



0 0

14. CINAHL; 5 AND 10 AND 13; 8 results.

15. CINAHL; 14 [Limit to: (Publication Type Systematic Review)]; 0 results.

EMBASE 1. EMBASE; (Antipsychotic AND medication).ti,ab; 8098 results.

2. EMBASE; (antipsychotic AND drugs).ti,ab; 10958 results.

3. EMBASE; exp ANTIPSYCHOTIC AGENTS/; 212020 results.

4. EMBASE; exp DRUG THERAPY/; 1821292 results.

5. EMBASE; 1 OR 2 OR 3 OR 4; 1977913 results.

6. EMBASE; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab;

12229 results.

7. EMBASE; exp PROLACTIN/; 44217 results.

8. EMBASE; 6 OR 7; 47099 results.

9. EMBASE; exp LACTATION DISORDERS/; 1710 results.

10. EMBASE; 6 OR 7 OR 9; 48525 results.

11. EMBASE; (breast adj1 cancer).ti,ab; 253440 results.

12. EMBASE; (physical AND health AND (problem* OR disorder* OR illness* OR



14. EMBASE; 5 AND 10 AND 13; 272 results.

15. EMBASE; 14 [Limit to: (EBM-Evidence Based Medicine Systematic Review) and

Publication Year 2010-2015]; 1 results.

1 0

PsychINFO 1. PsycInfo; (Antipsychotic AND medication).ti,ab; 4771 results.

2. PsycInfo; (antipsychotic AND drugs).ti,ab; 5431 results.

3. PsycInfo; exp ANTIPSYCHOTIC AGENTS/; 184 results.

4. PsycInfo; exp DRUG THERAPY/; 115571 results.

5. PsycInfo; 1 OR 2 OR 3 OR 4; 119481 results.

6. PsycInfo; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab; 1419

results.

7. PsycInfo; exp PROLACTIN/; 2365 results.

8. PsycInfo; 6 OR 7; 2991 results.

1 0

9. PsycInfo; exp LACTATION DISORDERS/; 0 results.

10. PsycInfo; 6 OR 7 OR 9; 2991 results.

11. PsycInfo; (breast adj1 cancer).ti,ab; 8827 results.

12. PsycInfo; (physical AND health AND (problem* OR disorder* OR illness* OR



14. PsycInfo; 5 AND 8 AND 13; 8 results.

15. PsycInfo; ((systematic* adj1 review*) OR meta-analytic* OR metanalysis OR

metaanalysis OR (meta adj1 analysis) OR meta-synthesis OR metasynthesis OR

(meta adj1 synthesis) OR meta-regression OR . AND metaregression OR (meta adj1

regression) OR (synthes* adj3 literature) OR (synthes* adj3 evidence) OR

(integrative adj1 review) OR (data adj1 synthesis) OR (research adj1 synthesis) OR

(narrative adj1 synthesis) OR (systematic adj1 study) OR (systematic adj1

studies)).ti,ab; 37460 results.

16. PsycInfo; meta-analysis.ti,ab,pt; 16118 results.

17. PsycInfo; ((systematic adj1 comparison*) OR (systematic adj1 overview*) OR

(evidence AND based AND review) OR (comprehensive adj1 review) OR (critical

adj1 review) OR (quantitative adj1 review) OR (structured adj1 review) OR (realist

adj1 review) OR (realist adj1 synthesis)).ti,ab; 22471 results.


19. PsycInfo; review.pt; 115062 results.

20. PsycInfo; (medline OR pubmed OR cochrane OR embase OR cinahl OR psyclit




adj3 search*) OR (internet adj3 search*) OR (included adj1 studies) OR (inclusion

adj3 studies) OR (inclusion adj1 criteria) OR (selection adj1 criteria) OR (selection

adj1 criteria) OR (predetermined AND criteria)).ab; 3653167 results.

21. PsycInfo; ((predefined adj1 criteria) OR (assess* adj3 (quality OR validity)) OR

(select* adj3 (study OR studies)) OR (data adj3 extract*) OR (extracted adj1 data)

OR (data adj2 abstracted) OR (data adj3 abstraction) OR (published adj1

intervention) OR ((study OR studies) adj2 evaluat*) OR (intervention* adj2

evaluat*) OR (confidence adj1 interval) OR heterogeneity OR pooled OR pooling

OR (odds adj1 ratio*) OR Jadad OR coding).ab; 131412 results.


23. PsycInfo; 18 AND 22; 55958 results.

24. PsycInfo; review.ti; 122999 results.


26. PsycInfo; ((review* adj4 (papers OR trials OR studies OR evidence OR

intervention* OR evaluation*))).ti,ab; 52677 results.


28. PsycInfo; (letter OR editorial OR comment).pt; 156316 results.

29. PsycInfo; exp ANIMALS/; 6773 results.

30. PsycInfo; exp HUMANS/; 1795 results.

31. PsycInfo; 29 NOT 30; 6460 results.


33. PsycInfo; 27 NOT 32; 185104 results.

34. PsycInfo; META ANALYSIS/; 14573 results.


36. PsycInfo; 35 [Limit to: Publication Year 2010-2015]; 62790 results.


Primary Studies

MEDLINE

1. Medline; (Antipsychotic AND medication).ti,ab; 4968 results.

2. Medline; (antipsychotic AND drugs).ti,ab; 7594 results.

3. Medline; exp ANTIPSYCHOTIC AGENTS/; 104388 results.

4. Medline; exp DRUG THERAPY/; 1130814 results.


6. Medline; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab;

102 2

10578 results.

7. Medline; exp PROLACTIN/; 37679 results.


9. Medline; exp LACTATION DISORDERS/; 3090 results.


11. Medline; (breast adj1 cancer).ti,ab; 184435 results.

12. Medline; (physical AND health AND (problem* OR disorder* OR illness* OR



14. Medline; 5 AND 10 AND 13; 102 results.

CINAHL

1. CINAHL; (Antipsychotic AND medication).ti,ab; 899 results.

2. CINAHL; (antipsychotic AND drugs).ti,ab; 767 results.

3. CINAHL; exp ANTIPSYCHOTIC AGENTS/; 9075 results.

4. CINAHL; exp DRUG THERAPY/; 80434 results.

5. CINAHL; 1 OR 2 OR 3 OR 4; 88804 results.

6. CINAHL; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab; 146

results.

7. CINAHL; exp PROLACTIN/; 472 results.


9. CINAHL; exp LACTATION DISORDERS/; 536 results.

10. CINAHL; 6 OR 7 OR 9; 1055 results.

11. CINAHL; (breast adj1 cancer).ti,ab; 25833 results.

12. CINAHL; (physical AND health AND (problem* OR disorder* OR illness* OR



14. CINAHL; 5 AND 10 AND 13; 8 results.

8 0

PsycINFO

1. PsycInfo; (Antipsychotic AND medication).ti,ab; 4771 results.

2. PsycInfo; (antipsychotic AND drugs).ti,ab; 5431 results.

3. PsycInfo; exp ANTIPSYCHOTIC AGENTS/; 184 results.

8 0

4. PsycInfo; exp DRUG THERAPY/; 115571 results.


6. PsycInfo; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab; 1419

results.

7. PsycInfo; exp PROLACTIN/; 2365 results.


9. PsycInfo; exp LACTATION DISORDERS/; 0 results.


11. PsycInfo; (breast adj1 cancer).ti,ab; 8827 results.

12. PsycInfo; (physical AND health AND (problem* OR disorder* OR illness* OR



14. PsycInfo; 5 AND 8 AND 13; 8 results.

CENTRAL

#1 Antipsychotic medication 1727

#2 antipsychotic drugs 1499

#3 MeSH descriptor: [Antipsychotic Agents] explode all trees 3895

#4 MeSH descriptor: [Drug Therapy] explode all trees 118981

#5 #1 or #2 or #3 or #4 122716

#6 (Raise* or increase* or high*) Prolactin level* 1541

#7 MeSH descriptor: [Hyperprolactinemia] explode all trees 130

#8 MeSH descriptor: [Prolactin] explode all trees 1584

#9 #6 or #7 or #8 2466

#10 MeSH descriptor: [Breast Neoplasms] explode all trees 9046

#11 breast adj1 cancer 30

#12 #10 or #11 9072

#13 physical health (problem* or disorder* or illness* or complication*)

9335

#14 #12 or #13 18268

#15 #5 and #9 and #14 71 (Trials 11)

11 0

Embase 1. EMBASE; (Antipsychotic AND medication).ti,ab; 8098 results.

2. EMBASE; (antipsychotic AND drugs).ti,ab; 10958 results.

3. EMBASE; exp ANTIPSYCHOTIC AGENTS/; 212020 results.

4. EMBASE; exp DRUG THERAPY/; 1821292 results.

5. EMBASE; 1 OR 2 OR 3 OR 4; 1977913 results.

6. EMBASE; ((Raise* OR increase* OR high*) AND Prolactin AND levels).ti,ab;

12229 results.

7. EMBASE; exp PROLACTIN/; 44217 results.


9. EMBASE; exp LACTATION DISORDERS/; 1710 results.

10. EMBASE; 6 OR 7 OR 9; 48525 results.

11. EMBASE; (breast adj1 cancer).ti,ab; 253440 results.

12. EMBASE; (physical AND health AND (problem* OR disorder* OR illness* OR



14. EMBASE; 5 AND 10 AND 13; 272 results.

272

Disclaimer

BEST in MH answers to clinical questions are for information purposes only. BEST in MH does not make recommendations.

Individual health care providers are responsible for assessing the applicability of BEST in MH answers to their clinical practice. BEST

in MH is not responsible or liable for, directly or indirectly, any form of damage resulting from the use/misuse of information

contained in or implied by these documents. Links to other sites are provided for information purposes only. BEST in MH cannot

accept responsibility for the content of linked sites.

© Best Evidence Summaries of Topics in Mental Health 2013

BEST in MH clinical question-answering...

Documents

Transcript of BEST in MH clinical question-answering...