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Sir In their recent paper on their follow-up (cohort) study of 60,065 newly diagnosed breast cancer patients, Adami et al. (1987) reported that 260 endometrial cancers had been diagnosed after the breast cancer diagnosis compared to an expected number, based on national rates, of 151.1 (relative risk= 260/151.1 = 1.72). This relative risk for the subsequent incidence of endometrial cancer in breast cancer patients increased from 0.95 in patients diagnosed with breast cancer before age 40 to 2.47 in patients diagnosed at 80 years of age or older. The authors go on from this to state that 'there is no obvious common risk factor related to reproductive life which could give a reasonable explanation for [this observed] age-dependent association between cancer of the breast and cancer of the endometrium', and imply that this age dependence is evidence against the 'traditional... paradigm' of seeking the causes of (and link between) these two cancers in terms of 'hormonal expressions of characteristics of reproductive life or... dietary habits'. Their results are, however, in good agreement with what we would predict from our current understanding of the (hormonal) epidemiology of these two cancers. There are a number of well-established risk factors for endometrial cancer. Low parity, late menopause and oestrogen replacement therapy (ERT) all increase the risk of endometrial cancer, while use of combination-type oral contraceptives (COCs) decreases the risk of the disease [see Kelsey et al. (1982) and Henderson et al. (1982) for references]. Obesity is a major risk factor both in premenopausal and post-menopausal women [see La Vecchia et al. (1982) and Henderson et al. (1983) for references]. These risk factors are all explicable in terms of the 'unopposed oestrogen hypothesis' for endometrial cancer (Siiteri, 1978; Nisker et al., 1980; Henderson et al., 1982). Late age at first birth, late age at menopause and use of ERT all increase the risk of breast cancer (Thomas, 1984; Pike & Ross, 1984). We noted above that two of these three breast cancer risk factors, viz. late menopause and ERT, are also risk factors for endometrial cancer; late first birth is too, since late first birth is correlated with low parity. COC use does not, however, protect against breast cancer, and may in some circumstances increase the risk of breast cancer (McPherson & Drife, 1986). The sharp distinction between the protective effect of COC use against endometrial cancer and the lack of any such effect on breast cancer risk clearly shows that the endocrinology of endometrial cancer and breast cancer are not the same. Most important for an understanding of the results of Adami et al. (1987) is the finding that obesity is only associated with an increased risk of breast cancer in older post-menopausal women (Kelsey et al., 1981; Lubin et al., 1985). In pre-menopausal women obesity has been found, in fact, to be associated with a decreased risk of breast cancer (Willett et al., 1985). In the pre-menopausal period obesity acts contrariwise as a risk factor in endometrial cancer and breast cancer. Premenopausal breast cancer patients will tend to be of low parity but non-obese, so that their risk of endometrial cancer will probably be little different from expected as their low parity will slightly increase their risk while their non-obesity

On the age-dependent association between cancer of the breast and endometrium