Q: I have a female patient with significant ocular/dermatologic rosacea. In light of the recent reports linking long-term antibiotic use to breast cancer, are there any substitutes for this patient? Or, are these reports being blown out of proportion?

A: To begin with, penicillin was identified as a slight risk factor for breast cancer, while tetracyclinea popular choice for the treatment of ocular/dermatologic rosaceawas linked with non-Hodgkins lymphoma, according to the most recent study on the link between antibiotic use and breast cancer. The researchers of this study, however, concluded that antibiotic use represents a confounding factor rather than a cause.¹


A previous study revealed that increased use of antibiotics (all of the antibiotic classes studied) were linked with an increased risk of breast cancer.² But, there was no elevated risk of breast cancer seen in those on the highest levels of tetracycline and macrolide solely for the treatment of acne or rosacea. The researchers here also concluded that they could not determine if antibiotic exposure was a causative factor, as other factors, such as overall weakened immune function, could be causative. In contrast, other studies have found no link between antibiotic use and breast cancer.^3,4

So, should you stop prescribing antibiotics and switch to a substitute? Or, are these studies being blown out of proportion?

Ophthalmologist James Aquavella, of Rochester, N.Y., says that there is insufficient data to know if these reports are being looked at as conclusive. While there is a suggestion that there is a risk, more studies are needed to make this link definitive, he says. Still, these studies should increase our awareness of a possible problem and motivate us to decrease the amount of time we place patients on antibiotics. Therefore, prescribe 125mg of tetracycline, for instance, for 30-90 days as opposed to six months to a year, and see if the patient improves enough to switch to substitutes, such as facial creams, cold compresses, artificial tears and limited use of topical steroids, he says.

Optometrist Ann M. Hoscheit, of Gastonia, N.C., believes that these reports have created a knee-jerk reaction. We should be cautious and stay on top of any related medical literature, but none of these studies has established a causal relationship between antibiotic use and breast cancer, she says. Also, there are a multitude of pertinent factors, such as the indication for an antibiotic prescription, that need to be considered in future studies. So, definitely limit long-term antibiotic use to those patients who will not benefit by any other therapy, but do not abandon antibiotics altogether at this time, she says. If, however, you are now reluctant to prescribe antibiotics, consider topical cyclosporine, as there is increasing evidence that it may be helpful in rosacea-induced dry eye and in improving the condition itself, she says.⁵

Ophthalmologist Stephen E. Pascucci, of Bonita Springs, Fla., says that if an antibiotic is the only choice a patient has, have her continue on it as long as you inform her of the potential risk, and document that you have done so. If you are concerned about prescribing antibiotics, however, consider fatty acid replacement and topical cyclosporine, which is particularly effective in the posterior blepharitic population, he says.⁵
 
1. Didham RC, Reith DM, McConnell DW, Harrison KS. Antibiotic exposure and breast cancer in New Zealand. Breast Cancer Res Treat 2005 Jul;92(2):163-7.
2. Velicer CM, Heckbert SR, Lampe JW, et al. Antibiotic use in relation to the risk of breast cancer. JAMA 2004 Feb 18;291(7):827-35.
3. Garcia Rodriguez LA, Gonzalez-Perez A. Use of antibiotics and risk of breast cancer. Am J Epidemiol 2005 Apr 1;161(7):616-9.
4. Sorensen HT, Skriver MV, Friis S, McLaughlin JK, Blot WJ, Baron JA. Use of antibiotics and risk of breast cancer: a population-based case-control study. Br J Cancer 2005 Feb 14;92(3):594-6.
5. Perry HD, Wittpenn JR, DAversa G, Donnenfeld ED. Topical cyclosporine 0.05% for the treatment of chronic, active ocular rosacea. (Poster presentation at the Association for Research in Vision and Ophthalmology 2005. Abstract # 2660)