PICO Search Assignment Worksheet Name: Jaspreet Kaur Sra 

Brief description of patient problem/setting (summarize the case very briefly):

25 year old female presents to the clinic postpartum 3 weeks. Patient is currently not breastfeeding and formula feeding her infant. She reports her family has a history of endometrial cancer. She concerned about increased risk of endometrial cancer, if she does not breastfeed. 

Search Question:

Is breastfeeding associated with a decreased risk of endometrial cancer? 

Question Type: What kind of question is this? (boxes now checkable in Word)

Prevalence Screening Diagnosis

Prognosis Treatment Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices. 

The highest level of evidence to answer this question will be given by either meta-analysis or systematic review. Another study I would look for are prospective and retrospective studies. Prospective studies will follow the patients over a prolonged period of time to evaluate if they get diagnosed with endometrial cancer. Retrospective studies will evaluate patients with endometrial cancer compared to those that do not to find a common variable. RCT, double is another type of study that will be very helpful to evaluate the topic. However, these patients must be followed up for a prolonged period of time to assess the risk of endometrial cancer which may make an RCT difficult to conduct. 

PICO search terms:

P	I	C	O
Postpartum women	Breastfeeding		Cancer
Females	Exclusive breastfeeding		Endometrial cancer
Women	Lactation

Search tools and strategy used:

Please indicate what databases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters. 

Explain how you narrow your choices to the few selected articles.

I tried to ensure the articles I chose were of the highest evidence possible. My aim was to find a systematic review or meta-analysis. Since the terms are similar, breast cancer related articles would appear and articles that were not related to breastfeeding. Hence, I weaved our articles that did not include endometrial cancer or breast feeding. I was unable to find an RCT related to the topic but did find cohort studies. Adding the population term was limiting my search hence I did not use those terms as breastfeeding can only be done by women. 

Filters/limits applied:

• Recent publications within the past 5 years
• Recent publications within the past 10 years
• Review
• Full Article
• Journal

Databases used:

• PubMed
  1. endometrial cancer lactation→ 111
     1. Filters: 10 years, full text, RCT, systematic review, meta-analysis → 8
     2. Filters: 20 years, full text, RCT, systematic review, meta-analysis, case reports, observational study → 15
  2. Breastfeeding and Endometrial cancer→ 77 
     1. Filters: 20 years, full text, RCT, systematic review, meta-analysis, case reports, observational study → 23
• ScienceDirect
  1. Breastfeeding and Endometrial cancer→ 1262
     1. Filters: 10 years, review articles, research articles, case reports → 401
  2. Risk endometrial cancer due to breastfeeding vs no breastfeeding → 296
     1. Filters: 10 years, review articles, research articles, case reports → 170
• Wiley Online Library
  1. risk of endometrial cancer with no breastfeeding→ 811
     1. Filters: 10 years, journal → 397
• Google Scholar
  1. breastfeeding and endometrial cancer risk → 18,700
     1. Filters: 10 years, any article  → 11,000 
     2. Filters: 10 years, review article → 1830

Results found:

Number of articles returned once relevant limits are added

Results found:

Identify at least 3 articles (or other appropriate reputable sources) that answer your specific question with the highest available level of evidence (you will probably need to look at more than 3 articles to get the 3 most focused and highest level articles to address your question). Please make sure that they are Medline indexed. In addition to providing the hyperlinks, the full-length articles (PDFs) must also be attached in Blackboard.

Please post the citation and abstract for each article (to include the journal and authors’ names and date) and say why you chose it. Please also note what kind of article it is (e.g. meta-analysis, cohort study, or independent blind comparison with gold standard of diagnosis, etc.).

At the bottom of each abstract, please comment on what your key points are from this article (including any points or concepts included in the article, but not present in the abstract – i.e. make the concepts understandable to the reader). Please note that if the evidence is not in the abstract, you must clearly summarize the evidence in your posting. 

Article 1 

Citation: Wang, L., Li, J., & Shi, Z. (2015). Association between Breastfeeding and Endometrial Cancer Risk: Evidence from a Systematic Review and Meta-Analysis. Nutrients, 7(7), 5697–5711. https://doi.org/10.3390/nu7075248

Type of Study: Meta- Analysis and Systematic Review

Abstract: Quantification of the association between breastfeeding and risk of endometrial cancer is still conflicting. We therefore conducted a meta-analysis to assess the association between breastfeeding and endometrial cancer risk. Pertinent studies were identified by a search of PubMed and Web of Knowledge through April 2015. A random effect model was used to combine the data for analysis. Sensitivity analysis and publication bias were conducted. Dose-response relationships were assessed by restricted cubic spline and variance-weighted least squares regression analysis. Fourteen articles involving 5158 endometrial cancer cases and 706,946 participants were included in this meta-analysis. Pooled results suggested that breastfeeding significantly reduced the risk of endometrial cancer (summary relative risk (RR): 0.77, 95% CI: 0.62-0.96, I2: 63.0%), especially in North America (summary RR: 0.87, 95% CI: 0.79-0.95). A linear dose-response relationship was found, with the risk of endometrial cancer decreased by 2% for every one-month increase in the duration of breastfeeding (summary RR: 0.98, 95% CI: 0.97-0.99). Our analysis suggested that breastfeeding, particularly a longer duration of breastfeeding, was inversely associated with the risk of endometrial cancer, especially in North America, but not in Europe and Asia, probably due to the small number of cases included. Due to this limitation, further studies originating in other countries are required to assess the association between breastfeeding and endometrial cancer risk.

Reason for Selection: This meta-analysis and systematic review included 4 prospective and 10 retrospective. Majority of the studies were done in North America but some were included from Europe and Asia. US is multicultural, especially New York hence I wanted to include studies that incorporated different ethnicities but yet were of good quality. The studies were inclusive  breastfeeding vs never breastfeeding and endometrial cancer and the amount of time a female breast fed (long time vs short time)

Key Points:Association between ever breastfeeding vs. never breastfeeding and endometrial cancer risk →   The RR of endometrial cancer for the ever breastfeeding compared with never breastfeeding was 0.85 (95% CI: 0.61–1.20; I2: 66.1%).Association of Endometrial cancer compared with Shortest Total Durations of Breastfeeding → RR of endometrial cancer risk for the longest category compared with the shortest category of breastfeeding was 0.71 (95% CI: 0.53–0.95, I2: 60.3%).Results from this meta-analysis suggested that breastfeeding, particularly a longer duration of breastfeeding, was inversely associated with risk of endometrial cancer.Dose-response analysis indicated that the risk reduced in endometrial cancer estimated is 2% for every one month increase in the duration of breastfeedingThere is a significant reduction of endometrial cancer with breastfeeding in North America but not in Europe and Asia.

Article 2 

Citation: Jordan, S. J., Na, R., Johnatty, S. E., Wise, L. A., Adami, H. O., Brinton, L. A., Chen, C., Cook, L. S., Dal Maso, L., De Vivo, I., Freudenheim, J. L., Friedenreich, C. M., La Vecchia, C., McCann, S. E., Moysich, K. B., Lu, L., Olson, S. H., Palmer, J. R., Petruzella, S., Pike, M. C., … Webb, P. M. (2017). Breastfeeding and Endometrial Cancer Risk: An Analysis From the Epidemiology of Endometrial Cancer Consortium. Obstetrics and gynecology, 129(6), 1059–1067. https://doi.org/10.1097/AOG.0000000000002057

Type of Study: Meta-Analysis

ObjectiveTo investigate the association between breastfeeding and endometrial cancer risk using pooled data from 17 studies participating in the Epidemiology of Endometrial Cancer Consortium.MethodsWe conducted a meta-analysis with individual-level data from three cohort and 14 case-control studies. Study-specific odds ratios (ORs) and 95% confidence intervals (CI) were estimated for the association between breastfeeding and risk of endometrial cancer using multivariable logistic regression, and pooled using random-effects meta-analysis. We investigated between-study heterogeneity with I2 and Q statistics and meta-regression.ResultsAfter excluding nulliparous women, the analyses included 8981 women with endometrial cancer and 17241 control women. Ever breastfeeding was associated with an 11% reduction in risk of endometrial cancer (pooled OR=0.89, 95% CI 0.81–0.98). Longer average duration of breastfeeding per child was associated with lower risk of endometrial cancer, although there appeared to be some leveling of this effect beyond 6–9 months. The association with ever breastfeeding was not explained by greater parity and did not vary notably by body mass index or histological subtype (grouped as endometrioid and mucinous versus serous and clear cell).ConclusionsOur findings suggest that reducing endometrial cancer risk can be added to the list of maternal benefits associated with breastfeeding. Ongoing promotion, support and facilitation of this safe and beneficial behavior might therefore contribute to the prevention of this increasingly common cancer.

Reason for Selection: A meta-analysis is considered as one of the best studies. The experimental group included 8981 women and control group 17241. Majority of the studies were from the USA, but some were from Australia, Italy, Poland and Canada. USA is multicultural hence, it is important to have diversity in the research as well.  It accounted for variables such as age, BMI, race, education, parity and OCP use.

Key Points:Cohort and Case control studies were selected to be part of the meta-analysis. A forest plot was done in order to show the association between endometrial cancer and breastfeeding Overall, there was a 11% reduction of endometrial cancer in patients that breastfed compared to those that never breast fed. However, this association was not linear. Individuals that breastfed for longer than three months were associated with statistically significant reductions in risk. If  breastfeeding was done beyond >6 to 9 months category the risk did not decrease much further.There was a modest reduction in risk of endometrial cancer associated with breastfeeding that was not explained by greater parity and did not vary by BMI or endometrial cancer type (Type I versus Type II).

Article 3: https://link.springer.com/content/pdf/10.1023/A:1008978624266.pdf

Citation: Newcomb, P. A., & Trentham-Dietz, A. (2000). Breast feeding practices in relation to endometrial cancer risk, USA. Cancer causes & control : CCC, 11(7), 663–667. https://doi.org/10.1023/a:1008978624266

Type of Study: Case Control Study

Objective: Breast feeding is associated with reduced estrogen, a pro®le that should be associated with decreased endometrial cancer incidence. We analyzed data from a population-based case±control study of Wisconsin women to evaluate the relation between lactation and endometrial cancer risk.Methods: Cases (n = 586) were identi®ed from a statewide tumor registry; controls (n = 1653) were selected randomly from driver’s license lists and Medicare benefciary. Breast feeding practices and other factors were ascertained by telephone interview.Results: Compared with parous women who did not breast feed, the multivariate relative risk for women who breast fed for at least 2 weeks was 0.90 [95% con®dence interval (CI) 0.72±1.13]; increasing duration was not strongly associated with risk of disease (p for trend 0.4). More recent breast feeding was associated with signi®cantly reduced risks. The relative risk for lactation within the recent three decades was 0.58 (95% CI 0.36±0.96) and for breast feeding at age 30 or greater was 0.50 (95% CI 0.28±0.90). There was a suggestion that risk was increased in women who used lactation suppressant hormones ± usually estrogens ± more recently (p = 0.1) or at a later age (p = 0.1).Conclusions: This study suggests that, like breast cancer, endometrial cancer is modestly inversely associated with lactation.

Reason for Selection: This study is based in the United States and included a large sample size. It accounted for variables such as the total duration of lactation, age at first lactation, age, smoking, education, BMI, parity  and age at first lactation. The information was provided verbally by the subjects and the study was based off of that information which could lead to some inaccurate information. However, the sample size was very large which can cover up the inaccurate information.

Key Points:Wisconsin residents aged 40-79 years were the subjects and were diagnosed with invasive endometrial cancer. The subject size was 586. Controls were selected from the same community as well which yielded a similar distribution to the ages of the experimental group. The control group consisted of 1653 subjects. A 45 minute interview was conducted where questions were asked about breastfeeding, duration of lactation, smoking, BMI and use of postmenuapsul hormones. Results showed that endometrial cancer is associated inversely with lactation. There was an increased risk in women that used lactation suppressant hormones

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting(# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Lianlian Wang , Jingxi Li and Zhan Shi	Meta- Analysis and Systematic Review	706,946 participants Six studies were conducted in North America, four in Asia, three in Europe and one was a mix-population study.  Four prospective studies and 10 retrospective studies were selected. (1) have a prospective or retrospective design;(2) the exposure of interest were the association between ever breastfeeding (the women with a history of breastfeeding) vs. never breastfeeding or the total duration of breastfeeding; (3) the outcome of interest was endometrial cancer; (4) relative risk (RR) or odds ratio (OR) with a 95% confidence interval (CI) was provided (5)  dose-response analysis.	The outcome studied was to assess the associationbetween breastfeeding and endometrial cancer risk.	Breastfeeding, particularly a longer duration of breastfeeding, was inverselyassociated with the risk of endometrial cancer, especially in North America, but not inEurope and Asia probably due to the small number of cases included.Dose-response analysis indicated that the risk reduced in endometrial cancer estimated is 2% for every one month increase in the duration of breastfeeding. In this study, there was a significant association between breastfeeding and endometrial cancer.	1 This meta-analysis of observational studies,was prone to recall or selection bias inherent in the original studies, especially in case-control studies.The information on exposures for prospective study is collected before the diagnosis of the disease, sothat it is less susceptible to bias than retrospective studies. In our meta-analysis, the significant association was only found inretrospective studies, but not in the prospective studies, while only four studies included were prospectiveDesign. 2 Some of the individual studies did not adjust for potential confounders. This may have introduced bias in anunpredictable direction. Breastfeeding is associated with a lower levels of BMI and lower prevalence of smoking. These factors were not adjusted in all the studies. 3 There is only one study involving seven casesreporting breastfeeding duration of more than six years. However, a subgroup analysis  was done for the  studies that were only of duration at twoyears. The pooled RR was 0.79 (95% CI: 0.59–0.98). The result of subgroup analysis is consistent withour overall results. 4. There were no significant associations found for ever breastfeeding compared withnever breastfeeding.
Susan J. Jordan, Renhua Na, Sharon E. Johnatty, Lauren A.Wise, Hans Olov Adami, Louise A. Brinton, Chu Chen, Linda S. Cook, Luigino Dal Maso, Immaculata De Vivo, Jo L.Freudenheim, Christine M. Friedenreich,Carlo La Vecchia, Susan E. McCann, Kirsten B. Moysich, Lingeng Lu, Sara H. Olson, Julie R. Palmer, Stacey Petruzella, Malcolm C. Pike, Timothy R. Rebbeck, Fulvio Ricceri, Harvey A.Risch, Carlotta Sacerdote Veronica Wendy Setiawan, Todd R.Sponholtz Xiao Ou Shu, MD, Amanda B. Spurdle, ElisabeteWeiderpass, Nicolas Wentzensen, Hannah P. Yang, Herbert Yu, and Penelope M. Webb.	Meta-Analysis	8981 women withendometrial cancer and 17241 control women.  17 studies that participating in the Epidemiology of Endometrial Cancer Consortium were selected.  14 case-control and  3 cohort studies were included.  Cohort studies were analyzed as nested case-control studies with four controls matched on birth year randomly selected for each case from cohort members who had not had a hysterectomy or an endometrial cancer diagnosis.	The outcome that was studied was to investigate the association between breastfeeding and endometrial cancer risk using pooled data from 17 studies participating in the Epidemiology of Endometrial Cancer Consortium.	The risk reduction associated with increasing total duration of breastfeeding was not linear. The analyses of individual episodes of breastfeeding (average breastfeeding/child, average breastfeeding/child breastfed) also showed that individual breastfeeding durations beyond three months were associated with statistically significant reductions in risk. However, beyond the >6 to 9 months category the odds ratios did not appear to decrease much further. It is important to note that the number of women who breastfed individual children for longer than this were small and therefore these estimates are less precise.An  inverse association with breastfeeding was weaker in women born pre-1950.Longer averageduration of breastfeeding per child was associated with lower risk of endometrial cancer, althoughthere appeared to be some levelling of this effect beyond 6–9 months.	There was limited  information on factors that predispose women tobreastfeed or data on when menstruation recommenced. Hence these were not considered in ouranalyses. Most of the studies were of case-control design with potential self-selection ofmore health-conscious controls, perhaps more likely to have breastfed. All studies relied on retrospective self-report of breastfeeding, which for many women occurred years prior to study participation. It was possible there was a bias of subject to recall error. Despite the inclusion of >26000 women, relatively few womenbreastfed for long durations making estimates for these categories less precise.
Polly A. NewcombAmy Trentham-Dietz	Case Control Study	Subject:  586 Controls: 1653 All participants were female Wisconsin residents aged40±79 years. Incident invasive endometrial cancer cases. Community controls were selected randomly fromlists of licensed drivers (if less than 65 years old) andMedicare beneficiary  compiled by the Health CareFinancing Administration (if 65±79 years old).	The outcome investigated was to evaluate the relation between lactation and endometrial cancer risk.	Compared with parous women who did not breast feed, the multivariate relative risk for women whobreast fed for at least 2 weeks was 0.90 [95% confidence interval (CI) 0.72±1.13]; increasing duration was notstrongly associated with risk of disease (p for trend 0.4). More recent breastfeeding was associated with significantlyreduced risks.Also, women withage at age lactation >30 years had a 50% lower risk(95% CI 0.28±0.90). Age did not appear to modify theassociation between lactation and risk of endometrialcancer, nor did parity, body mass, use of postmenopausal hormones,or smoking status.	The subjects were only women from Wisconsin which does not accurately represent the population of USA. The small samplesize constrained the  evaluation of longer-term lactation.  Only 11% (34) of cases reported breastfeedingdurations of greater than 24 months

Conclusion(s):

– Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Article one: 

Results from this meta-analysis suggested that breastfeeding, particularly a longer

duration of breastfeeding, was inversely associated with risk of endometrial cancer. Dose-response analysis indicated that the risk reduced in endometrial cancer estimated is 2% for every one month increase in the duration of breastfeeding. In our study, we found a significant association between breastfeeding and endometrial cancer in North America, but not in Europe and Asia, probably due to the small number of cases included. The overarching conclusion is that breastfeeding is associated with a decreased chance of endometrial cancer. 

Article two: 

Results from this article prove that there is a  modest reduction in risk of endometrial cancer associated with breastfeeding. This reduction was not explained by greater parity, did not vary by BMI or endometrial cancer type. The reduction was associated with an increasing duration of breastfeeding upto 6 to 9 months. These results suggest that reduction in endometrial cancer risk

could be added to the list of maternal benefits associated with breastfeeding for more than

six months. The large sample size,  ability to define exposure levels consistently across studies, to adjust consistently for potential confounders and the inclusion of studies from different US populations and different countries were strengths of the study. Breastfeeding can suppress gonadotrophin-releasing hormone inhibiting ovarian follicular growth and reducing estradiol levels to within the postmenopausal range. At these levels, endometrial cell mitoses are virtually absent. Estrogen levels in breastfeeding women appear to depend on suckling stimuli, with the lowest levels found in women  breastfeeding exclusively. The overarching conclusion suggests that promoting breastfeeding for 6 months may have the benefit of preventing endometrial cancer. 

Article 3: 

This study suggests that, like breast cancer, endometrial cancer is modestly inversely associated with lactation. Lactation was associated with a very modest reduction in risk of endometrial cancer in parous women. This inverse association was strongest in women with more recent breast feeding experiences. Women who used lactation suppressants appeared to be at slightly increased risk of endometrial cancer, with the greatest risk among those who used these agents more recently. Estrogen  levels decreased during lactation and it is hypothesized that lower levels of estrogen should reduce the risk of endometrial cancer.  The finding that long duration of lactation is more strongly associated with risk supports this mechanism. The waning beneficial effect of lactation over time is also consistent with the reversible effects of exogenous hormones. Since the risk of endometrial cancer increases with age the benefits of estrogen suppression may be greater at older ages at lactation. The results appear to parallel the inverse association between lactation and breast cancer risk  and suggest estrogen suppression is the likely mechanism in conferring protection for both these cancers. The overarching conclusion is that there is an inverse relationship with breastfeeding and endometrial cancer. 

PICO Question: 

Is breastfeeding associated with a decreased risk of endometrial cancer?

What is the clinical “bottom line” derived from these articles in answer to your question?

The risk of endometrial cancer is related to estrogen levels. Increasing exogenous or endogenous estrogen hormones may cause endometrial cancer. During breastfeeding, estrogen levels are lower. From a pathophysiology perspective, breastfeeding will reduce risk of endometrial cancer. 

The clinical bottom line is that current research and evidence is inclining towards a decreased risk of endometrial cancer after breast feeding. The systematic reviews and meta-analysis that included  retrospective and prospective studies showed a significant reduction in endometrial cancer for patients that breast fed. The second article was a meta-analysis on case control and cohort studies. This article assessed different variables that can interfere with the diagnosis of endometrial cancer such as BMI and parity. Although the last article was not as diverse and the sample size was smaller compared to the meta-analyses and systematic review it assessed other confounding variables such as smoking, BMI, breastfeeding duration. Even after adjusting for different variables, breastfeeding was associated with a decreased risk of endometrial cancer.  Doing an RCT will be difficult for this topic, but should be considered in the future for more valid evidence. 

I would explain to the patient that research is currently inclining towards breast feeding being associated with decreased risk of endometrial cancer. It is also important to explain the pathophysiology behind it for the patient to have a better understanding. Adding to this I would discuss with the patient why she made the decision to not breast feed and if she fully understands the benefit of breastfeeding for her and her baby. Simultaneously, I would not want to pressurize her into breastfeeding as this is a difficult task. However, I would want to make sure she makes an informed decision and assesses risk vs benefits before making a decision. 

Weight of the Evidence 

• Article One: : Wang, L., Li, J., & Shi, Z. (2015). Association between Breastfeeding and Endometrial Cancer Risk: Evidence from a Systematic Review and Meta-Analysis. Nutrients, 7(7), 5697–5711. https://doi.org/10.3390/nu7075248

This article is both a systematic review and meta-analysis with a very large sample size. It included studies done in the USA and a few from Europe which shows how diverse the subjects were. It included studies that assessed, never versus ever breastfeeding, longest versus shortest breastfeeding time period and dose-response analysis. In order to choose the studies the quality of study was first determined. The Preferred Reporting Items for Systematic reviews and Meta-Analyses for randomized trials (PRISMA) and Newcastle–Ottawa Scale were used. High quality studies were chosen. Meta-analyses and systematic review provides the highest level of evidence. Furthermore, the highest quality studies were chosen, the studies contained a diverse population and there was also a very  large sample size. Due to these reasons the first article is ranked as number one. 

•  Jordan, S. J., Na, R., Johnatty, S. E., Wise, L. A., Adami, H. O., Brinton, L. A., Chen, C., Cook, L. S., Dal Maso, L., De Vivo, I., Freudenheim, J. L., Friedenreich, C. M., La Vecchia, C., McCann, S. E., Moysich, K. B., Lu, L., Olson, S. H., Palmer, J. R., Petruzella, S., Pike, M. C., … Webb, P. M. (2017). Breastfeeding and Endometrial Cancer Risk: An Analysis From the Epidemiology of Endometrial Cancer Consortium. Obstetrics and gynecology, 129(6), 1059–1067. https://doi.org/10.1097/AOG.0000000000002057

This study was a meta-analysis which is considered one of best types of studies. 17 studies were included. The sample size was 8981 women with endometrial cancer and 17241 control. The studies selected were case-control studies. The main difference was this article included case-control studies and had a lower sample size. The lower sample size redirected me towards choosing article 2 as the second ranked article. However, the evidence of this article is also great due to the high quality studies being chosen, the ability to be able to define the exposure level (length of breastfeeding), adjusting for potential confounders and including studies from different US populations. The overarching conclusion was that the longer average duration  until 6 to 9 months of breastfeeding per child was associated with lower risk of endometrial cancer. 

• Newcomb, P. A., & Trentham-Dietz, A. (2000). Breast feeding practices in relation to endometrial cancer risk, USA. Cancer causes & control : CCC, 11(7), 663–667. https://doi.org/10.1023/a:1008978624266

This study was based out of Wisconsin with a low sample size in comparison to the other two studies. The study is about 20 years old as well. Due to these reasons this study would be ranked three. The overarching conclusion of this study was that there is an inverse relationship with breastfeeding and endometrial cancer. 

Clinical Significance: 

Based on the findings of the articles, I would conclude that breastfeeding and endometrial cancer are inversely related. It is beneficial for the women to breastfeed and one of the positive factors is reduction of endometrial cancer. Although it is easy to recommend women to breastfeed, it is not easy to do. Breastfeeding is difficult and some common issues that women come across are producing an appropriate supply of milk, pumping, mastitis, cracked nipples and breast engorgement. Along with this, the social factor of breastfeeding in public and society despising it can cause breastfeeding to be a difficult task. It is important to consider these factors and risk vs benefits  before a woman decides to breastfeed.

Other considerations important in weighing this evidence to guide practice

Although the studies done contain evidence supporting the hypothesis that breastfeeding reduces the risk of breast cancer, there are not enough studies on it. More research needs to be done on the topic to compare never breastfeeding to individuals that do breast feed. Randomized trials should be conducted to determine if breastfeeding and endometrial cancer have an inverse relationship. More trials need to be conducted that take into consideration factors such as the length of time spent breastfeeding, age of the subject and number of pregnancies that subjects have. Although this may be difficult, factors that increase the chances of an individual having endometrial cancer such as family history, smoking, obesity should also be taken into consideration. This would allow for a stronger conclusion if breastfeeding reduced endometrial cancer.