The incidence of hypopharyngeal cancer has been rapidly increasing, but hypopharyngeal cancer has a poorer prognosis compared to other head and neck cancers. This is because the diagnosis of hypopharyngeal cancer is late due to few symptoms in the early stages. Thus, early diagnosis and prevention are very important in the management of hypopharyngeal cancer. Metabolic syndrome, including a combination of obesity, impaired lipid and glucose metabolism, and hypertension, has recently attracted attention as a risk factor for various cancers. In this study, we investigated the association between metabolic syndrome and hypopharyngeal cancer. We confirmed that metabolic syndrome lowered the risk of hypopharyngeal cancer regardless of age, sex, smoking, and alcohol consumption. This inverse association was more prominent in women than in men.This study evaluated the relationship between metabolic syndrome (MS) and the risk of hypopharyngeal cancer. This retrospective cohort study used data from the Korean National Health Insurance Research Database. A total of 4,567,890 participants who underwent a health checkup in 2008 were enrolled. The participants were followed until 2019, and the incidence of hypopharyngeal cancer was analyzed. We evaluated the risk of hypopharyngeal cancer according to the presence of MS, including obesity, dyslipidemia, hypertension, and diabetes, using a multivariate Cox proportional hazards model adjusted for age, sex, alcohol consumption, and smoking. During the follow-up period, 821 were newly diagnosed with hypopharyngeal cancer. MS was inversely associated with the risk of hypopharyngeal cancer (hazard ratio (HR), 0.83 ). Large waist circumference and high triglyceride levels among MS elements were both inversely related to the risk of hypopharyngeal cancer . The risk of hypopharyngeal cancer decreased with increasing comorbidity of MS in women , but not in men. This study may improve our etiological understanding of hypopharyngeal cancer. Hypopharyngeal cancer has an annual incidence rate of 0.6–1.1 per 100,000 in the United States . AccordiEffective prevention requires the elucidation of the risk factors associated with the development of hypopharyngeal cancer. Established risk factors for hypopharyngeal cancer include male sex, old age, tobacco smoking, alcohol consumption, human papillomavirus type 16, and laryngopharyngeal reflux ,6. MetabHowever, the association between MS and the development of hypopharyngeal cancer has not yet been clearly determined. In the present study, we aimed to evaluate the association of MS with the risk of hypopharyngeal cancer. We hypothesized that an investigation of the development of hypopharyngeal cancer in a nationwide cohort database, including information about MS, would confirm the association between MS and hypopharyngeal cancer. We also analyzed that MS affects the development of hypopharyngeal cancer according to sex.https://nhiss.nhis.or.kr/bd/ab/bdaba000eng.do). The database includes demographic, disease, treatment, and health checkup information. Health checkup information includes data on body measurements, blood tests, tobacco smoking, and alcohol consumption. According to national policy, cancer diagnoses are quickly registered in the KHNIS database. The diagnosis of hypopharyngeal cancer was recorded using codes from the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) [This study adopted a retrospective cohort design using the Korean National Health Insurance Service (KNHIS) database. The KNHIS is a public medical insurance system operated by the Korean government . The KNHD-10-CM) .The initial participants included 6,093,826 individuals aged >40 years who underwent health checkups provided by the KNHIS in 2008. A total of 1,525,936 individuals were excluded because of missing data, a history of HNC, a diagnosis of hypopharyngeal cancer within 12 months, age < 40 years, or a diagnosis of other head and neck cancers . Finally2). The participants were divided into four weight groups according to their BMI  [Age was recorded at the time of enrollment, and body mass index (BMI) was calculated as weight (kg) divided by the square of height (m5 kg/m2) . Abnorma5 kg/m2) . Informa5 kg/m2) . SmokingThe International Diabetes Federation criteria were used to define MS . Patientt-tests and chi-squared tests were used for continuous and categorical variables, respectively. Three Cox regression models were used to evaluate the relative risk of hypopharyngeal cancer according to the following variables: model 1, non-adjusted model; model 2, adjusted for age and sex; and model 3, adjusted for age, sex, smoking, and alcohol consumption. The hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for all models. Statistical significance was set at p < 0.05.Statistical analyses were performed using SAS software, version 9.2 . Continuous variables were described as means and standard deviations, and categorical variables were described as frequencies and percentages. Independent p < 0.001). The age of the patients was higher in the HPC than in the non-HPC . BMI was lower in the HPC than in the non-HPC . BP and glucose levels were higher in the HPC than in the non-HPC . Among the lipid profiles, TC and low-density lipoprotein (LDL) levels were lower in the HPC than in the non-HPC , whereas triglyceride (TG) and HDL levels did not differ between the two groups .The study cohort consisted of 4,567,890 individuals . Of the The HRs of hypopharyngeal cancer for each component of the MS and MS-related variables are described in In this study, we found that MS was related to a decreased risk of hypopharyngeal cancer, and the preventive effect was more pronounced in women than in men. We found that known risk factors, such as male sex, old age, underweight, smoking, and alcohol consumption, were also associated with hypopharyngeal cancer.Males have a 2–5-fold higher incidence of HNC than females, with the ratio varying by area and race ,18. The Smoking and alcohol consumption are well-known risk factors for HNC and synergistically contribute to carcinogenic effects ,20. AccoIn a large pooled epidemiologic study conducted by the International Head and Neck Cancer Epidemiology (INHANCE) Consortium, leanness was related to increased HNC risk, regardless of smoking and alcohol consumption . AccordiThis study analyzed hypertension and diabetes to identify their association with hypopharyngeal cancer risk factors . HyperteHowever, the relationship between MS and HNC risk remains controversial. In a retrospective case–control study using the Surveillance, Epidemiology, and End Results database, Stott-Miller et al. revealed a moderately inverse association between MS and HNC . MS was In general, there are a few possible mechanisms by which MS contributes to cancer development . These iThis study has several limitations. First, this study did not compare the characteristics of patients with and without MS. Although most cohort studies suggest baseline characteristics according to exposure status, this study did not present baseline characteristics according to MS status because a simpler study design was adopted. Second, as with most other retrospective cohort studies using an administrative database, this study could not completely rule out potential limitations such as selection biases and unmeasured confounding factors. Participants were defined as those who underwent health checkups provided by the KNHIS in 2008. Although the selection of subjects for the health checkups was almost random, selection bias cannot be completely excluded because this study did not enroll the entire Korean population. Also, lifestyles such as smoking and alcohol drinking were measured by self-reporting; the possibility of under-reporting still exists. The unmeasured confounding factor in this study was socioeconomic status. Previous studies have revealed a relationship between the risk of head and neck cancers and socioeconomic status . AccordiNevertheless, to the best of our knowledge, this is the first study to comprehensively analyze the association between MS and hypopharyngeal cancer using a nationwide database. Various Cox-regression models showed that metabolic syndrome lowered the risk of hypopharyngeal cancer regardless of age, sex, smoking, and alcohol consumption. This phenomenon was more prominently observed in women than in men. Further studies of other risk factors, such as HPV infection status and laryngopharyngeal reflux, are needed to understand and prevention of hypopharyngeal cancer.In conclusion, this study revealed an inverse association between MS and the risk of hypopharyngeal cancer. The inverse association was clearer in women than in men. Simultaneously, we also re-confirmed the association of established risk factors, such as sex, age, being underweight, smoking, and alcohol consumption, with an increased incidence of hypopharyngeal cancer. This study offers important insights into the risk factors for hypopharyngeal cancer.


This study targeted at developing a robust, prognostic signature based on super-enhancer-related genes (SERGs) to reveal survival prognosis and immune microenvironment of breast cancer.RNA-sequencing data of breast cancer were retrieved from The Cancer Genome Atlas (TCGA), 1069 patients of which were randomly assigned into training or testing set in 1:1 ratio. SERGs were downloaded from Super-Enhancer Database (SEdb). After which, a SERGs signature was established based on the training set, with its prognostic value further validated in the testing set. Subsequently, we identified the potential function enrichment and tumor immune infiltration of the model. Moreover, in vitro experiments were completed to further explore the biological functions of ZIC2 gene (one of the risk genes in the prognostic model) in breast cancer.A risk score system of prognostic value was constructed with 6 SERGs  to find patients in high-risk group with significantly worse prognosis in both training and testing sets. In addition, a multivariate regression was established via integrating the 6 genes with age and N stage, indicating well performance by calibration, time-dependent receiver operating characteristic (ROC) analysis and decision curve analysis (DCA). Further analysis demonstrated that tumor-associated pathological processes and pathways were significantly enriched in the high-risk group. In general, the novel SERGs signature could be applied to screen breast cancer with immunosuppressive microenvironment for the risk score was negatively correlated with ESTIMATE score, tumor-infiltration lymphocytes (such as CD4 + and CD8 + T cell), immune checkpoints and chemotactic factors. Furthermore, down-regulation of ZIC2 gene expression inhibited the cell viability, cellular migration and cell cycle of breast cancer cells.The novel SERGs signature could predict the prognosis of breast cancer; and SERGs might serve as potential therapeutic targets for breast cancer.The online version contains supplementary material available at 10.1186/s12885-023-11241-2. Breast cancer has been the most common global malignancy as well as the leading cause of cancer deaths . During In 2013, Richard A. Young and his colleagues firstly proposed the concept of super-enhancers (SEs), which were a class of cis-regulatory elements with super transcriptional activation characteristics , 12, witIn this study, we obtained RNA-sequence and clinicopathological data of breast cancer patients from The Cancer Genome Atlas (TCGA) database. Then, through a comprehensive bioinformatics analysis, we established a risk score system with 6 prognosis SERGs and validated it by testing set. Meanwhile, enrichment analyses were conducted between the low-risk and high-risk groups to reveal the potential mechanisms and pathways. In addition, analyses based on tumor infiltration immune level, immune checkpoints and chemotactic factors were applied to investigate the associations between SERGs signature and tumor immune microenvironment (TIME). Furthermore, reverse transcription quantitative polymerase chain reaction (RT-qPCR), Western Blot, immunohistochemistry (IHC) and functional experiments (such as Cell Counting Kit-8 (CCK-8) assay, cellular migration assay and cell cycle assay) were all adopted to validate the expression level and significant clinical value of ZIC2 (one of the risk genes in the prognostic model) in cell lines and tissues of breast cancer.https://portal.gdc.cancer.gov/) . Then, the associations between risk score and clinical features were identified, and the predictive value of SERGs signature in subgroups were also presented based on various clinical characteristics.Univariate and multivariate Cox regression analyses were conducted with clinicopathological indicators . Then, integrating the risk score with age and N stage, a multi-variate regression was established by a nomogram to predict the OS rates of 1-, 3- and 5-year. In addition, calibration, time-dependent ROC analysis, concordance index (C-index) and decision curve analysis (DCA) for model were completed to assess the discriminatory ability of the nomogram.P value < 0.05 were considered statistically significant. Then, GSEA (http://software.broadinstitute.org/gsea/index.jsp) (version 3.14.3) . The model was verified by testing set   were analyzed by univariate and multivariate Cox regression in training set Table A, B. TheBased on the DEGs between low-risk and high-risk groups Fig. A, Go andThe results displayed that the risk score was negatively correlated with immune infiltration score  Fig. A, B; furMoreover, we evaluated the relationship between risk score and immune checkpoints Fig. E. The exBesides, we also analyzed the relationship between risk score and chemotactic factors Fig. G. The exP < 0.001)  Fig. L.SEs are a subclass of enhancers that frequently contain multiple enhancer-like elements, characterized by dense binding of master transcription factors (TFs) and Mediator complexes and high signals of active histone marks , 18. MorRecently, the role of SEs in the pathogenesis and prediction of breast cancer has been the research hot spots , 38. HowIn this study, we identified a total of 5,073 DEGs from TCGA-BRCA and 153 SERGs from SEdb 2.0. Then, based on overlapping genes between the two algorithms mentioned above, a total of 55 SERGs were screened and established a 6-SERGs signature with prognostic value on the basis of univariate Cox regression analysis and LASSO regression algorithm. Meanwhile, we also validated the prediction efficiency of risk score system in several subgroups. According to the risk score system, breast cancer patients were divided into low-risk and high-risk groups. The effective and stable of the risk score system were validated in training set  and testing set by KM curve. Then, the age, N stage and risk score were integrated into a nomogram model and calibration plots revealed the robust predictive ability of the prognostic nomogram for OS in the training set. Besides, time-dependent ROC analysis and DCA for model in training and testing sets revealed the well discriminatory ability of the nomogram. Therefore, our prognostic model based on SERGs can competently predict the clinical outcomes of breast cancer patients.The 6-SERGs prognostic model was comprised of POU3F2, NFE2, FOXJ1, KLF15, SPIB, and ZIC2. Previous studies have indicated that the 6 SERGs are involved in invasion, angiogenesis, and malignant phenotypes of breast cancer –44. LiteIn our study, the expression level of ZIC2 in the TCGA databases were negative correlated with OS of breast cancer patients. The mRNA and protein expression levels of breast cancer cell lines were determined, showing that ZIC2 may act as an independent prognostic factor in breast cancer. The in vitro experiments revealed that the down-regulation of ZIC2 gene expression inhibited the cell viability, cellular migration, and cell cycle of breast cancer cells, and ZIC2 might serve as a therapeutic target for breast cancer. In addition, further experimental studies should be conducted to unravel the mechanism by which ZIC2 mediates the malignant function of breast cancer cells, resulting in a poor prognosis for patients.Then, we performed GO and KEGG analyses based on DEGs between low-risk and high-risk groups to evaluate risk score system. The results displayed that DEGs were significantly enriched in terms of T cell activation, lymphocyte differentiation, receptor ligand activity, and cytokine-cytokine receptor interaction, which were closely related to the tumorigenesis and immune microenvironment –58. SubsPatients in the two risk groups had different TIME. The results revealed that the risk score was negatively correlated with ESTIMATE score, which was composed of stromal score and immune score. In tumor infiltrating immune cells, the risk score was negatively correlated with tumor-infiltration lymphocytes (TILs) , which played an important role in immunotherapy –64. AddiThis study was innovative to some extent: it took the SEs as the entry point, with the purpose of discovering potential new biomarker for predicting the prognosis of breast cancer, and a prognostic model on the basis of SERGs was constructed; in addition to validating the model through testing set, the biological function of ZIC2 was also preliminarily explored in vitro experiments. Meanwhile, this study also had three limitations: firstly, it will be better if the performance of the model itself can be further improved; secondly, only one representative risk gene (ZIC2) in the prognostic model was validated in true bench work; thirdly, some patients from TCGA-BRCA lacked of HER-2 status, which might be a cause to the bias.In summary, the 6-SERGs signature is capable of attributing to screen the population with various TIME and is promising to act as prognostic biomarker for breast cancer patients. Therefore, how to accurately identify patients in high-risk and achieve superior immuno-infiltration of “cold” tumors may be the topic of future research –69.The novel SERGs signature could predict the prognosis of breast cancer; moreover, SERGs might have a potential role in serving as therapeutic targets for breast cancer.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4Supplementary Material 5Supplementary Material 6Supplementary Material 7Supplementary Material 8Supplementary Material 9


About 5–10% of breast cancer cases are attributed to a gene mutation. To perform preventive interventions for women with a gene mutation, genetic screening BRCA tests have recently been implemented in Iran. The present study aimed to determine Iranian women’s subjective valuation for screening BRCA tests for early detection of breast cancer to help policymakers to make decisions about genetic screening tests for breast cancer and to know the applicants.An online survey was completed by women older than 30 years old in Tehran, the capital of Iran in 2021. A hypothetical scenario about genetic screening tests for breast cancer was defined. The subjective valuation for the tests was assessed by a willingness to pay (WTP) using the contingent valuation method (CVM) by payment card. Demographics, history of breast cancers, knowledge, and physiological variables were considered as independent variables, and a logistic regression model assessed the relationship between WTP and the variables.660 women were included. 88% of participants intended to participate in BRCA genetic screening for breast cancer if it were free. The mean WTP for the tests was about $ 20. Based on the logistic regression, income, family history of breast or ovarian cancer, and positive attitude were associated with WTP.Iranian women were willing to intend for genetic screening BRCA tests and pay for them as well. The result of the present study is of great importance for policy makers when it comes to funding and determining co-payments for BRCA genetic screening tests. To achieve a high participation rate of women in breast cancer screening plans, a positive attitude should be promoted as a psychological factor. Educational and informative programs can help.The online version contains supplementary material available at 10.1186/s12889-023-15568-0. Breast cancer is the most common cancer among women in the world  and alsoThe mean age for breast cancer in Iranian women is 45 years . ValipouBreast cancer imposed a great economic burden on the health care system. Several studies have been conducted on the costs of breast cancer worldwide. For example, based on a systematic review by Sun et al., the average treatment cost for breast cancer at stages I to III/IV in 2015 were $29,724, $39,322, $57,827, and $ 62,108, respectively [Screening can detect the disease early, saving many years of women’s lives and reducing treatment costs for the health system .About 90–95% of breast cancers are sporadic and depend on demographic, breast-related, hormonal, reproductive, and lifestyle . The resWomen can have a mammogram as a screening method from the age of 40. This method has reduced breast cancer rates by 20% . It is rIn Iran, screening methods such as mammograms and genetic screening tests are performed as a new technology . More thTo our knowledge, this is the first study in Iran that aims to determine the subjective valuation for screening BRCA tests, as it is a new technology for early detection of breast cancer.This was an online cross-sectional population-based survey. The study was conducted from July, 4 to August 30, 2021. The study population was Iranian women older than 30 years in Tehran who had internet access. We focused on Tehran where occur the most cases of breast cancer . A conveThere was no sampling frame and the responses to the questionnaire were completely random.The questionnaire link was sent to anyone who could only respond anonymously and/or forward it to someone else, so the questionnaire link was sent out randomly. The sample size was defined based on Mitchel and Carson .Women’s subjective valuation for the BRCA genetic screening tests for breast cancer was determined using the WTP. Based on the subject theory of value, value defines an individual’s desire or need for a service or object .The questionnaire was designed based on the studies by Manchanda, R., et al. , ThompsoThe designed questionnaire included approximately 50 questions and consisted of six sections: demographic information, personal and family history of breast or ovarian cancer, knowledge of genetic screening tests, perceived risk and worry about developing breast cancer, perceived the risk of genes mutations, and attitude towards performing genetic screening tests.The independent variables were included as follows:Demographic information: Age, marital status, education level, occupational status, monthly income, insurance coverage, and the presence of children were considered as demographic parts of the questionnaire, which were asked through closed-ended responses.Personal and family history of breast or ovarian cancer: This was a “yes” and “no” question where respondents indicated their history of breast or ovarian cancer. The family history question asked about breast or ovarian cancer in the family of blood relatives.Knowledge of genetic risk for breast cancer: The number of 10 questions about the genetics of breast cancer was considered based on Breast Cancer Genetic Counselling Knowledge Questionnaire (BGKQ) [e (BGKQ) , and Kine (BGKQ) . RespondPhysiological variables: Perceived risk of developing breast cancer, perceived risk of gene mutation, worry about developing breast cancer in the future, and attitudes towards genetic screening tests were included in this category. They were computed as follows:Perceived risk of developing breast cancer: The probability of developing breast cancer was asked of respondents who had no history of breast cancer. It was a question by Likert scale question: “I will not get infected at all”, “I will not get infected”, “I am 50% more likely to get it”, “I am more than 50% more likely to get it”, and “I will definitely get breast cancer”.Perceived risk of a gene mutation: The risk of a gene mutation was asked of respondents who had not tested in the past. It was a Likert scale question with the answers “No gene mutation at all”, “Less than 50% chance of having a gene mutation”, “A 50% chance of having a gene mutation”, and “More than 50% chance of having a gene mutation”.Worry about getting breast cancer in the future: This question was asked of respondents who had no personal history of breast cancer. It was a Likert scale question: “Not at all worried”, “Not worried”, “Slightly worried”, “Worried”, and “Very worried”.Attitudes towards genetic screening tests: Based on Manchanda, R., et al. [, et al. , and Kin, et al. . The numWilingness To Pay (WTP)Subjective valuation of genetic screening tests were determined by a WTP using the CVM. Using a survey design, a hypothetical scenario consisting of general and specific information about genetic testing for women over 30 years of age was presented, and participants were asked their maximum WTP for genetic screening tests as an out-of-pocket Fig. .Participants indicated their WTP on a payment card scale that ranged from $4 to more than $434 Table . In addiThe question was, “If the test is not free, what is the maximum amount you are willing to pay as out of pocket for a genetic test for breast cancer present year?“We have converted the indicated WTP in the local currency to USD. Due to wide exchange rate fluctuations, we used a simple moving average of the last 200 days to convert values to U.S. dollars. Accordingly, US $1 is equivalent to IRRDue to the Covid-19 pandemic, an online questionnaire was designed. Social media such as WhatsApp, Telegram, Instagram, and email invitations were used to distribute the questionnaire. At the beginning of the questionnaire, the research objective of the study was explained and respondents were optional to answer the questionnaire. Technical knowledge about genetics of breast cancer was not required and participants were assured that identifying information would remain confidential.Descriptive analysis was undertaken for the variables to present the characteristics of the sample size. Minimum, maximum, and mean for WTP were calculated. The proportion of participants who had WTP was estimated for different subgroups: low-risk women (i.e. women who had no family history of breast or ovarian cancer) and high-risk women (i.e. women who had a family history of breast or ovarian cancer), different income levels, and attitudes towards genetic screening tests.WTP was classified into 0 and 1 for participants who did not have WTP and for participants who did have WTP, respectively. The relationship between WTP and the independent variables was assessed using a logistic regression model. All variables were included in the original logistic regression model. Variables whose p < 0.05 were included in the final logistic model. An alpha level of 0.05 was considered significant in the final model. Odds Ratio, standard error, confidence interval, log likelihood, and chi2 test were reported. Data analysis was conducted using STATA 16 software.3844 persons viewed the online questionnaire. The response rate for the questionnaire was 48%. The average response time of the questionnaire was 11:54 min. Then the number of 1100 persons completed the questioner. Men as well as women younger than 30 years were excluded the study. After data cleaning, finally 660 women older than 30 years old were included the study.The characteristics of respondents are presented in Table Less than 2% of respondents had a history of breast and ovarian cancer. Less than 1% of respondents had a history of other cancers. About 29% and 9% of the respondents had a history of breast and ovarian cancer in their first and second-degree relatives, respectively. For other kinds of cancers, it was about 48%.About 19% of the respondents were not worried about developing breast cancer. About 21.7% of the respondents did not consider themselves at risk of breast cancer, although about 51% of them had indicated a probability of having a gene mutation for breast cancer.Genetic screening BRCA tests are unknown among the participants and they had low knowledge of genetic risk for breast cancer. Although about 25% of the respondents had high knowledge, more than 80% of them had a positive attitude towards performing the tests.More than 88% of the respondents had an intention of the genetic screening tests. Fear of a positive test result was the reason for withdrawing genetic screening tests for breast cancer in about half of the women who were not willing to pay for the test, and optimism was the second most common reason. The reasons for withdrawing the tests are shown in Fig. The mean WTP for the tests was $ 20 . The minimum and maximum were $ 0.43  and $ 434 , respectively. The amount of WTP for the tests was less than $ 4  and between $ 4- $ 22  for 40.65% of the respondents.The WTP was calculated in different subgroups Fig. . The WTPWTP for testing was higher among high-income women and women with positive attitudes towards genetic screening tests for breast cancer than among housewives and women with negative attitudes, respectively.Appendix1.The result of the logistic regression is shown in Table In the present study, the subjective valuation of Iranian women was estimated for genetic screening BRCA tests for prevention or early detection of breast cancer by WTP approach. The results of this study showed that, more than 80% of the participants had the intention to take up the tests. The mean WTP was $ 20 and it was $ 26 for high-risk women. The logistic regression results show that income, family history of breast or ovarian cancer, and attitudes towards genetic screening tests were the factors associated with WTP for the tests.There have been some studies on WTP for curative as well as screening interventions for breast cancer. Based on the study by Deepa Lalla et al., the mean WTP for patients with metastatic breast cancer to avoid treatment side effects was estimated to be $3894 using a conjoint analysis . CompareAccording to Blouin-Bougie, J et al., in 2018, about 90% of women over 35 years in Quebec would like to take genetic screening testing for breast cancer, although the WTP was reported by 57% of them to be less than $100. The contingent valuation method was used for the study . The IraBased on the results of the study by Wong XY et al., income and education were associated with WTP for genetic screening tests for breast cancer in women aged 40–69 years with no history of breast cancer in a discrete choice experiment in 2018 . In our Based on logistic regression, the study by Armstrong et al. in 2000 found that the presence of a family history of breast and ovarian cancer, Jewish ancestry, perceived risk of breast and ovarian cancer, and fear of detection of preventive and curative intervention by the insurance system was associated with the decision to test for BRCA1/2. Interestingly, after counseling, approximately half of the participants opted for genetic screening testing . High-riBased on Miron-Shatz et al., a family history of breast and ovarian cancer, Jewish ancestry, and perceived risk of a gene mutation were associated with willingness to genetic screening tests for US women  whereas It was found out in the current study that attitude is related to WTP for genetic screening tests. Psychological factors such as fear of a positive test result, inclination to have children, fear of losing physical beauty, lack of confidence, and optimism were cited by participants as reasons for unwillingness to take up the tests. This indicates that when these reasons are explained to women by genetic counselors and professionals, their negative attitudes toward genetic testing are reduced and their intention and WTP for testing are also increased. Godard B et al. assessed the factors associated with women’s decision to withdraw genetic screening tests for breast and ovarian cancer in 2007. According to their results, fear of testing positive, travel problems, lack of time, age, personal and health problems, lack of benefits of genetic testing, and lack of insurance coverage were factors associated with withdrawing from the tests . PsycholThe advantage of our study was in assessing the association between knowledge and attitudes toward genetic screening tests and WTP for these tests. Although this was the first study on genetic screening tests for breast cancer in Iran, and the important factors such as physiological variables were identified by the same studies and expert panels, there was some limitations. Less than 2% of the participants had a personal history of breast cancer, so the results might be different if we could focus on women with a personal history of breast cancer. Due to optimism, some women did not perceive the risk of gene mutation, which may affect the results. The majority of Iranian are Muslim, so we could not evaluate the role of religion and race on WTP. As the current study was conducted in Tehran, the results cannot be generalized. Consideration of all Iranian women in future studies may lead to generalization.Although less than 10% of breast cancer cases were attributed to a gene mutation, Iranian women were willing to intend and also pay for BRCA genetic testing at an average cost of $ 20. The finding of the present study has major implications for policymakers when it comes to funding and setting copayments for BRCA genetic screening tests. To achieve high participation rates of women in breast cancer screening plans, positive attitudes should be promoted as a psychological factor. Education and information programs can help.Costing and economic evaluation studies are needed to make a logical decision about which strategy to implement for screening breast cancer attributable to a gene mutation.Below is the link to the electronic supplementary material.Supplementary Material 1


IntroductionCancer is a condition where abnormal cells proliferate uncontrollably, leading to metastasis, which can be related to death. Breast cancer is the most prevalent type among women worldwide. Early detection with screening mammography has contributed to the decline in breast cancer incidence and mortality. Breast cancer patients are more likely to develop cardiovascular disease, with elderly patients dying from complications. Understanding the patients’ cardiovascular status prior to treatment is essential. The study's objective was to evaluate the cardiovascular characteristics of women with breast cancer at diagnosis within the designated time frame of one year.MethodologyThis was a retrospective study that focused on patients in Taif City, Saudi Arabia, who were initially diagnosed with primary breast cancer over a span of one year. The inclusion criteria encompassed eligible patients, while those not meeting the criteria were excluded. Data extraction from patients’ records was conducted, and the analysis was executed using IBM SPSS Statistics for Windows, Version 26.0 .ResultsThis study analyzed the cardiovascular attributes of breast cancer patients, focusing on 136 female cases. The study found significant patterns concerning cardiovascular risk factors in breast cancer patients, categorized by menopausal status. Premenopausal female cases had a mean age of 43.09 ± 8.31 years, while postmenopausal patients had an average age of 58.07 ± 11.70 years. Postmenopausal patients had a higher prevalence of overweight/obesity, irregular menstrual cycles, type II diabetes, hypertension, and hyperlipidemia compared to their premenopausal counterparts. No significant differences were found between the two groups regarding low-density lipoprotein (LDL) cholesterol levels, axillary lymph node metastasis, or distant metastasis. This study emphasized the importance of regular check-ups for menopausal women to detect potential health complications early.ConclusionIn summary, breast cancer is a global health concern, and understanding its impact on the cardiovascular system is crucial for comprehensive patient care. A study in Saudi Arabia found associations between cardiovascular risk factors and menopausal status in breast cancer patients. Postmenopausal patients had more prevalent risk factors, emphasizing the need for proactive assessment and management. Age-appropriate screenings and interventions are essential. Integrated healthcare approaches should consider the interplay between breast cancer and cardiovascular health, with medical professionals vigilant in evaluating and addressing risk factors to mitigate complications and optimize long-term outcomes. Cancer is a condition in which a group of abnormal cells proliferate without control by breaking the rules of normal cell division. Signals constantly influence whether normal cells divide, differentiate into another type of cell, or die. Cancer cells acquire some degree of independence from these signals; hence, they replicate in an unregulated manner. It could be fatal if this proliferation is allowed to continue and spread. In fact, metastasis, the spread of a tumor to a distant site, accounts for nearly 90% of cancer-related deaths . Women aWorldwide, breast cancer is the most prevalent malignancy among women. Over two million new cases of breast cancer, or 11.6% of all cancers, were diagnosed worldwide in 2018. Additionally, breast cancer is the leading cause of cancer-related deaths in women . The appBreast self-examination (BSE), clinical breast examination (CBE), and mammography can all be used to detect breast cancer early. Because breast cancer is frequently diagnosed in its later stages, Arabic women currently face a significant risk of a high mortality rate. The prevalence of breast cancer is rising and affecting a younger population in the Middle East and Gulf region compared to the West. There are very few breast cancer education programs in the Arab world . The incIt has been reported that breast cancer patients are significantly more likely to develop cardiovascular disease . The morA few studies have been conducted internationally regarding the cardiovascular characteristics of breast cancer patients at diagnosis, and these studies indicate there is a correlation between CVRFs and axillary lymph node metastasis (ALNM) .Study designThis study was a retrospective study conducted between April 2023 and July 2023 in Taif City, Kingdom of Saudi Arabia.Study population and sampling methodologyThis study had a sample size of 136 patients, and the data were gathered from patient files at Alhada Armed Forces Hospital in Taif City, Saudi Arabia. The inclusion criteria were all consecutive patients diagnosed with initial primary breast cancer from January 2017 to January 2022. In addition, patients with missing clinical data within their medical files or those diagnosed outside the period under consideration were excluded. Data were collected through a previously validated study by Dong Z in 2021 .Data analysisThe analysis was performed using the latest version of IBM SPSS Statistics for Windows, Version 26.0 . Descriptive statistics such as mean, standard deviation, frequency, and percentage were used to summarize independent variables. Qualitative data was transformed into percentage mean scores. Quantitative data was analyzed using the chi-square test and analysis of variance (ANOVA), while qualitative data was analyzed using the chi-square test and student t-test. A p-value < 0.05 indicated statistical significance.Ethical considerationsEthical approval was provided by the Institutional Review Board (IRB) of Alhada Armed Forces Hospital, Taif (REC.2023-722). The study was performed in accordance with the Declaration of Helsinki, and written informed consent was waived due to its retrospective nature.In this retrospective cross-sectional study, a mass screening involving 136 individuals was conducted in Taif city, Saudi Arabia, over a period of a year. The primary aim was to evaluate the cardiovascular attributes of individuals who were already diagnosed with breast cancer. A thorough analysis of descriptive data was done to assess the prevalence rates of cardiovascular risk factors in individuals previously diagnosed with breast cancer. Subsequently, the study investigated significant correlations among various variables utilizing both t-test and Chi-square test methodologies, employing a significance threshold of 0.05. Finally, a binary multivariate logistic regression analysis was executed to find out potential risk factors associated with axillary lymph node metastasis among patients initially diagnosed with breast cancer.Characteristics of the study populationAs depicted in Figure Combination of cardiovascular risk factors (CVRFs) in premenopausal and postmenopausal patients with breast cancer The data presented in Table Similarly, as depicted in Table Correlation analysis of cardiovascular risk factors (CVRFs) and axillary lymph node metastasis (ALNM) in breast cancer patientsThe relationship between cardiovascular risk factors (CVRFs) and the occurrence of axillary lymph node metastasis (ALNM) in patients with breast cancer was investigated through correlation analysis, as outlined in Table To sum up, in contrast to their premenopausal counterparts, postmenopausal patients diagnosed with breast cancer tend to display an increased prevalence of cardiovascular risk factors and a higher susceptibility to arteriosclerotic vascular diseases. Moreover, no significant relationships have been established between cardiovascular risk factors and the occurrence of axillary lymph node metastasis in breast cancer patients. These findings underscore the importance of regular check-ups for menopausal women, enabling the timely detection of potential health complications.Our study delves into the cardiovascular characteristics of patients initially diagnosed with breast cancer in Saudi Arabia, shedding light on important associations between menopausal status, cardiovascular risk factors, and axillary lymph node metastasis.The demographic characteristics of the study population reveal a notable prevalence of overweight and obesity, irregular menstrual cycles, type 2 diabetes mellitus, and hypertension among breast cancer patients. These findings underscore the importance of assessing cardiovascular risk factors in breast cancer patients, as these factors could potentially influence disease outcomes and treatment strategies. The prevalence of these risk factors in this study aligns with those of previous studies that have reported similar patterns of cardiovascular risk factors in breast cancer patients, indicating the consistency of these associations across different populations .The study’s exploration of the combination of cardiovascular risk factors in premenopausal and postmenopausal breast cancer patients provides a nuanced perspective. Premenopausal patients displayed a notably younger mean age compared to their postmenopausal counterparts, underscoring the expected correlation between menopause and advancing age. This aligns with the findings of prior studies, which reported similar age discrepancies between menopausal stages in breast cancer patients . The staStudies from the cities outside the Taif region provide insights into potential regional variations. Notably, breast cancer patients in the Taif region were diagnosed at a relatively younger age compared to patients from other cities. This discrepancy echoes the findings of a study that highlighted age-related disparities in breast cancer diagnosis across different regions . The obsFurthermore, the significantly higher prevalence of overweight and/or obese patients outside the Taif region points to potential disparities in lifestyle and healthcare access. This result is consistent with that of studies that emphasized the role of geographic factors in shaping health behaviors and outcomes . InteresThe investigation into the correlation between cardiovascular risk factors and axillary lymph node metastasis adds depth to the understanding of disease progression. The lack of statistically significant relationships between these risk factors and axillary lymph node metastasis suggests that while cardiovascular risk factors may influence overall health, they may not directly impact the metastatic spread of breast cancer . This inStudy limitationsDespite the valuable insights provided by this research, it is important to acknowledge certain limitations that may impact the interpretation and generalizability of the findings. Firstly, the study’s sample size of 136 individuals from a single city, Taif, might not fully represent the diverse population of breast cancer patients across Saudi Arabia; the relatively small sample could limit the generalizability of the results to a broader context.In summary, understanding the effects that breast cancer has on the cardiovascular system is essential for providing tailored patient treatment. Breast cancer is a problem that affects the health of people all over the world. Researchers in Taif, Saudi Arabia, looked at breast cancer patients and observed connections between breast cancer patients' menopausal status and cardiovascular risk variables. Patients who had gone through postmenopause had a higher prevalence of cardiovascular risk factors, which highlighted the importance of early examination and therapy. It is vital to conduct tests and therapies that are suitable for the patient's age. Integrated healthcare approaches should take into account the interaction between breast cancer and cardiovascular health, and medical professionals should be alert when evaluating and resolving risk factors in order to reduce the likelihood of complications and maximize the likelihood of positive long-term results. This research makes a significant contribution to the expanding body of knowledge concerning breast cancer's broader influence on patient health. As a result, medical professionals now have the ability to modify strategies for the early detection, prevention, and management of breast cancer and associated cardiovascular risks. It is crucial to take a holistic approach to patient care, placing a priority on the patient's overall health and well-being when treating breast cancer.


Globally and in India, breast cancer is a prevalent malignancy. India saw 178,361 new cases and 90,000 deaths in 2020. Timely detection is vital, highlighting the importance of Breast Self-Examination (BSE), especially in low-income settings. Strengthening BSE in awareness and screening efforts is urgent. Despite awareness, practical application lags due to women’s reluctance. Effective execution demands partnerships, a multi-sectoral strategy, and training grassroots workers.To address these challenges, the present study aims to strengthen the breast cancer screening program using BSE strategy and adopting a referral mechanism for the diagnosis and treatment of suspect cases.A community-based study occurred in specific districts of Rajasthan (2017–2022), enhancing breast cancer screening for women aged 30–65. It involved healthcare providers and local women, utilizing tools like the MT-DM-GP6620 Breast Inspection Model, educational booklets, and semi-structured schedules. The strategy encompassed knowledge assessment, capacity building for healthcare providers, BSE training, increasing women’s breast cancer awareness, suspect case referrals, and phone-based follow-up.Our study encompassed 157,225 women aged 30–65 in Jodhpur, Jalore, and Pali districts. Initial breast self-examination (BSE) awareness was below 1%. BSE training reached 218,978 women using booklets and demonstrations, with 72% aged 30–65 and the rest 15–30. Follow-ups reinforced BSE, leading to 745 identified suspect breast cancer cases, mostly due to painless lumps (332 cases). Capacity-building workshops involving 824 medical and paramedical staff strengthened early breast cancer detection in Jodhpur and Jalore, in collaboration with the district health department.The study model’s success suggests its applicability in other Rajasthan districts, Indian states, and global breast cancer prevention programs. While positive outcomes were evident, challenges related to culture, cost, and benefits warrant consideration. The approach prioritized early detection through community engagement, reducing patient and government burdens. Community involvement and healthcare engagement were pivotal, with breast self-examination proving effective for enhancing awareness and early detection. Promoting BSE education can significantly enhance breast cancer awareness and early detection. Breast cancer (BC) is the most common malignancy among women globally. Breast cancer accounts for 14% of cancers in Indian women, being the most prevalent kind , 3.The 2020 Globocan study delved into 35 different types of cancer in India, spanning all age groups and genders. The findings revealed an approximate of 1.32 million new cancer cases and 851,000 cancer-related deaths. Within this data, there were 178,361 newly diagnosed breast cancer cases, tragically resulting in 90,000 reported fatalities .The National Cancer Registry Programme Report (NCRP) for 2020 presented data on cancer incidence obtained from 28 Population-Based Cancer Registries (PBCRs) spanning the years 2012–2016. These figures served as the foundation for calculating cancer estimates in India. In the case of females, the total number of all-site cancers is expected to rise to 806,218 in 2025, compared to 627,202 in 2015. Specifically, it is projected that breast cancer cases will top the list, with an estimated 232,832 cases among females in the year 2025.Early identification and prompt treatment are the most effective interventions for BC management, according to the World Cancer Report 2020 . BecauseDespite the fact that people are aware of breast cancer, its early diagnosis, and screening technologies, and they have a favorable attitude toward them, there is still a big gap that has to be addressed in terms of its application . DespiteThe NPCDCS program in India, launched in 2010, aimed to screen for common non-communicable diseases like breast, oral, and cervical cancer in 100 districts. ASHA workers led the screening, with support from ANMs and LHVs.The Government of Rajasthan focused on preventing and controlling cancer, diabetes, cardiovascular diseases, and stroke. The modus operandi was to organize camps once a month at a fixed location, usually a Community Health Center (CHC), on a specific day. People with suspected diseases, identified by ANMs, were mobilized by them to attend these camps. They were screened for possible NCDs, treated, and referred to the District Hospital (DH) as needed. The training of Medical Officers, LHVs, ANMs, AWWs, ASHA/ASHA Sahyogini, and home visits by AWWs/ASHA had not yet been realized.With this background, the present study was undertaken with the aim of strengthening breast cancer screening program using BSE strategy and adopting a referral mechanism for the diagnosis and treatment of suspect cases.A community-based study was conducted in the selected blocks of Jodhpur, Jalore, and Pali districts of Rajasthan state. There were 10 blocks in Jodhpur, 8 blocks in Jalore, and 11 blocks in Pali, from which 40% of the blocks were randomly selected from each district. Thus, 4 blocks from Jodhpur, 3 blocks from Jalore, and 4 blocks from Pali were included. Specifically, the selected blocks were Bawari, Luni, Mandore, and Bilara in Jodhpur district; Ahore, Jalore, and Sayla in Jalore district; and Jaitaram, Pali, Sojat, and Rohat in Pali district.All the women aged 30–65 years residing in the selected blocks were considered eligible for the study. Women with a terminal illness or those who were non-cooperative were not included in the study. Also, health care providers such as Medical Officers (MOs), Auxiliary Nurse Midwives (ANMs), Lady Health Visitors (LHVs), Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs) of the selected blocks were included in the study. Those women not available at home during the time of visit and health care staff not present during the capacity building workshop were excluded from the study. Written informed consent was obtained from the study participants before initiation of the study.Timelines: The study was conducted from 2017 to 2022. During this period, the following steps were followed:The first phone call follow-up was conducted after at least one month of BSE training for women. The second phone call follow-up was carried out two months after the first phone call follow-up. Suspect and confirmed cases were also monitored through phone call follow-ups.Steps 1 to 3 were taken parallel throughout the study period.The following tools were used for the study: (1) A semi-structured pretested schedule to collect information on socio-demographic details, knowledge on risk factors, signs and symptoms of BC, family history of breast cancer etc., (2) Suspect case record form and (3) Phone call follow up form for BSE compliance.The following tools were used for the interventions: (1) MT-DM-GP6620 Breast Inspection Model, manufactured By the Micro technologies, (2) Education booklet about BC, (3) video.The model had realistic appearance and precise anatomical structure for inspection and palpation. This natural life size model having implanted innocent tumor and malignant tumor, allowed to practice diagnosis according to the position, size, texture, and movement. Education booklet of breast cancer had pictorial presentation of the symptoms of BC and steps to perform BSE.During the capacity-building workshop for healthcare professionals, we utilized a 12-min video  to raise awareness about various aspects of breast cancer, followed by presentations from experts.We used a breast inspection dummy model and a booklet to generate awareness about breast cancer symptoms, risk factors and breast self-examination (BSE) during house-to-house visits for the community women. Following this, the female research team demonstrated the steps for BSE.The Breast Inspection Model was very useful for raising awareness about the signs and symptoms of breast cancer and for teaching breast self-examination, especially among illiterate women, but also for healthcare professionals and women in general. We had also used phone call follow up to increase adaptation of BSE practices.The study employed Breast Self-Examination (BSE) as its primary strategy, consisting of four components aimed at strengthening breast cancer screening programs in the selected blocks. To achieve this, we reached out to various stakeholders, including community representatives, community volunteers, medical officers, paramedical staff from concerned Primary Health Centers (PHCs) and Community Health Centers (CHCs) in three districts, as well as all block chief medical officers within these selected blocks. We also sought the support of district chief medical health officers and medical colleges. To reach more study participants, we sought the assistance of ASHA, Anganwadi helpers and other volunteers in the community to spread the information the day before the assessment and BSE training. The women in the community voluntarily provided space in their homes for training on BSE.Using a semi- structured schedule, knowledge of health care providers {, Auxiliary Nurse Midwives (ANMs), Lady Health Visitors (LHVs), Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs)} was assessed. A three-tier training program was adopted: a) training of the trainers, which includes training of MOs of all the PHCs and CHCs; b) training of all ANMs and LHVs by the trainers (MOs); c) training of all ASHAs/ASHA Sahyogini and AWWs by ANMs and LHVs. First, subject experts imparted training to the medical officers for clinical breast examination to identify suspect cases with low false positivity and false negativity. Then, LHVs and ANMs were trained by the trained MOs regarding clinical breast examination and education of women about the signs and symptoms of breast cancer. LHVs/ANMs in turn trained ASHA/ASHA Sahyogini, AWWs, and proactive local volunteers.Using a semi-structured schedule, relevant information regarding demographic details, knowledge about risk factors, signs and symptoms of breast cancer, and family history of breast cancer were collected from the study participants by the project staff. After knowledge assessment house-to-house or group meetings (if feasible) were done by the project staff to educate women about symptoms of BC and BSE. BSE training of women was done using the MT-DM- GP6620 breast inspection model and breast cancer awareness through an educational booklet. Women were asked to report breast cancer symptoms immediately as and when detected by themselves.A woman reporting any of the following symptoms such as painless Lump in the breast, change in size and shape, swelling in the armpit or collarbone, painful lump in armpit, redness or rash in the breast or nipple, breast skin puckering or dimpling, nipple Retraction, unusual nipple discharge, painful lump in breast, and painless lump in armpit for more than one month was considered as a suspect in the study.After identification of suspect cases, we record the details of each case, and the project staff was directed to inform the concerned ASHA/ANM/MO regarding the case and motivate the suspect cases to visit nearby PHC/CHC for a clinical breast examination. Those who were suspected to have breast cancer through the clinical breast examination were referred to nearby tertiary health care settings along with ASHA for further investigation and treatment.A telephone cell was created in the institute and phone calls were made to talk with women participants to know about the compliance of breast self- examination as well as follow-up of the suspect and confirmed cases of breast cancer. Suspect cases were followed up through phone calls/home visits by the project staff/ASHA/ANM and motivated to consult the doctor if any symptoms persisted.IBM SPSS Software 21.0  was used to clean, edit, and analyse the collected data. Descriptive analysis was employed to describe the data.Ethical clearance was obtained from the Institute Ethics Committee of ICMR-NIIRNCD. The entire procedure of this study was conducted in accordance with the ethical standards. Participants were given the assurance that taking part in the study was completely voluntary and that they had the freedom to leave at any moment. Prior to performing the survey, each participant had to sign a participant consent form. Data were stored in a confidential, anonymous manner.In this study, interventional BSE strategy was adopted to strengthen breast cancer screening program in three districts  of Rajasthan. Similarly, knowledge among ASHAs about breast cancer symptoms and risk factors increased from 46 to 64% and 22 to 47%, respectively.As revealed in All the suspect cases of breast cancer were referred to a nearby hospital/health center . Among tAfter the identification of suspect cases, many of them (201/745) did not visit PHC for further check-up, even though we tried to persuade them through phone calls and, home visits, and offered them assistance and transport facilities for check-ups. The reasons given for non-compliance were not understanding the significance of clinical examination, not taking it seriously, treatment-related anxiety, time constraints, financial hardships, family obligations, lack of belief in the health care delivery system, etc.In this study, an attempt was made to test the feasibility of using BSE as a method of improving early detection of BC thereby strengthening breast cancer screening program in three districts  of Rajasthan and develop a referral mechanism for diagnosis and treatment of suspect cases at tertiary health care settings.Formative phase data shows that around 0.2 percent of women were performing breast self-examinations (BSE). However, phone call follow-ups showed that community women were performing BSE and raising awareness about BSE among other women. This approach proved feasible because it required no additional personnel or resources. Any woman can perform a BSE during bathing or before sleeping.To achieve this, first, we assessed the knowledge of all the women (aged 30–65 years) of these districts regarding breast cancer, educated them about breast cancer, and trained them about the practice of breast self-examination using a printed booklet and demonstrating on dummy breast model. We also assessed the knowledge of the medical officers, ANMs/LHVs, and ASHAs of selected blocks in these districts about different aspects of breast cancer and trained them for identifying suspect cases. After the identification of suspect cases, a mechanism was developed to refer these cases to nearby hospitals/health centers for further follow-up. We observed that strengthening breast cancer screening program using strategic education and awareness program is feasible and can be sustained if the project is converted from project mode to program mode and executed by the state government and central government.We faced certain challenges in carrying out this project and appropriate actions were taken accordingly. First, women were reluctant for the survey in the absence of paramedical staff/AWW/AWH. Thus, we took the assistance of ANM/ASHA/AWW/AWH and community volunteers before carrying out various activities. Second, health care providers asked for official order to assist in project activities. In response to that, request letters were sent to Chief Medical Health Officer (CMHO) and Director, ICDS to issue official orders for health care providers to cooperate in the project activities. Third, all the study participants could not be covered which might be due to one-time visit to a household as per protocol and participants’ unavailability during the visit. Thus, to cover more study participants; the message was conveyed through ASHA/AWW/AWH of respective areas the day before assessment and BSE training. Fourth, suspect cases of breast cancer requested transport support to visit PHC/CHC/tertiary care center. MO/ANM/ASHA and research staff of concerned areas took the responsibility to help the suspect cases visit nearby PHC/CHC/tertiary care centre. Also, capacity building of all medical and paramedical staff could not be done due to their engagement in other health care activities. Moreover, due to the COVID-19 pandemic, the study implementation plan could not be timely executed.However, in spite of these challenges, we were able to assess the knowledge of 157,225 women in three districts  representing a large percentage (40%) of the population of these districts. We made 218,978 women aware by using printed booklets and dummy breast models of the disease and trained them on how to practice breast self-examination. The importance of BSE among women for early detection of breast cancer is evident as more than half of the suspect cases were identified after BSE training and demonstration. We trained 824 medical officers/ANMs/AWWs/ASHAs for correctly identifying suspect cases and referring them to appropriate healthcare facilities. The capacity-building workshops proved effective in increasing the knowledge of medical and paramedical personnel for early detection of breast cancer.The, intervention implemented was effective, as evidenced by the phone call follow-up for BSE compliance and the suspect case reporting process, which proved its effectiveness. We could not obtain documents from all confirmed cases, even though most were detected in the first stage of breast cancer.Based on the study results, it can be said that the entire study process was beneficial for both healthcare professionals and the community women. Now, women have learned about the signs, symptoms, and BSE, and they are educating and sharing their experiences with other women. This will be helpful for the early detection of breast cancer and timely treatment, which can save lives and reduce the disease burden. This program also helps dispel myths and reduce women’s reluctance about the disease.This study was limited to three districts of Rajasthan state and there were certain operational difficulties as mentioned in the study. Additionally, recall bias might affect responses relating to BC knowledge of signs, symptoms, and risk factors since they depend on the participants’ understanding abilities.The project was designed jointly with the Government of Rajasthan. In the project, it has been demonstrated in three districts  that the objectives are achievable and can be sustained if the project is converted from project mode to programme mode and executed by the state government. Therefore, it is recommended that:Breast self-examination (BSE) is a crucial tool for increasing breast cancer awareness since it helps women get familiar with their breasts, notice and feel any deviations from the usual, and quickly report any changes they notice.BSE may decrease the barriers preventing women from undergoing clinical breast examination and mammography.Effective educational interventions are needed to encourage women to maintain frequent breast cancer awareness and breast self-examination.In order to detect breast cancer early, all medical and paramedical personnel of the state should be trained.At the grass root level ANMs may be instructed to train women (aged 30–65 years) regarding breast self-examination and may follow-up for breast self-examination compliance annually by the ASHAs.There is need to enhance ultrasound (for breasts) facilities at community health centre and district hospital.There is need to upgrade facilities like FNAC, Mammogram and Biopsy at district hospital.It was observed that patients and their families experience significant hardships as a result of late-stage BC.Therefore, considering the above recommendations, we recommend approaching the government of Rajasthan to adopt the project and transition it into a program. Nevertheless, we hope that the lessons learned through our efforts in this project will assist in its replication, either in part or in full, in other parts of India or in other developing countries.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving humans were approved by National Institute for Implementation Research on Non-Communicable Diseases, Jodhpur. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin. The manuscript presents research on animals that do not require ethical approval for their study.RS: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Visualization, Writing – review & editing, Data curation, Resources, Validation.RH: Data curation, Formal analysis, Project administration, Software, Validation, Writing – review & editing, Conceptualization, Methodology, Supervision. AP: Writing – original draft, Writing – review & editing. GT: Funding acquisition, Methodology, Project administration, Supervision, Writing – review & editing. AS: Writing – review & editing, Data curation, Formal analysis. MT: Data curation, Investigation, Writing – review & editing. PK: Data curation, Formal analysis, Investigation, Project administration, Writing – review & editing.


Summary data from genome-wide association studies (GWAS) can be used in a Mendelian randomisation (MR) phenome-wide association study (PheWAS) to identify causal relationships. We performed a MR-PheWAS of breast, prostate, colorectal, lung, endometrial, oesophageal, renal, and ovarian cancers, comprising 378,142 cases and 485,715 controls. To derive a more comprehensive insight into disease aetiology we systematically mined the literature space for supporting evidence. We evaluated causal relationships for over 3,000 potential risk factors. In addition to identifying well-established risk factors , we provide evidence for specific factors, including dietary intake, sex steroid hormones, plasma lipids and telomere length as determinants of cancer risk. We also implicate molecular factors including plasma levels of IL-18, LAG-3, IGF-1, CT-1, and PRDX1 as risk factors. Our analyses highlight the importance of risk factors that are common to many cancer types but also reveal aetiological differences. A number of the molecular factors we identify have the potential to be biomarkers. Our findings should aid public health prevention strategies to reduce cancer burden. We provide a R/Shiny app ( By 2030 it is predicted there are likely to be 26 million new cancer cases and 17 million cancer-related deaths annually2. Such projections have renewed efforts to identify risk factors to inform cancer prevention programmes.Cancer is currently the third major cause of death with an estimated 18.1 million new cases and nearly 10 million cancer deaths in 20203. The random assortment of these genetic variants at conception mitigates against reverse causation bias. Moreover, in the absence of pleiotropy , MR can provide unconfounded disease risk estimates . Elucidating disease causality using MR is gaining popularity especially given the availability of data from large genome-wide association studies (GWAS) and well-developed analytical frameworks3.For many cancers, despite significant epidemiological research, there are few established risk factors. Although randomised-controlled trials (RCTs) are the gold standard for establishing causal relationships, they are often impractical or unfeasible because of cost, time, and ethical issues. Conversely, case-control studies can be complicated by biases such as reverse causation and confounding. Mendelian randomisation (MR) is an analytical strategy that uses germline genetic variants as instrumental variables (IVs) to infer causal relationships 3. The ra4. A recently proposed agnostic strategy, termed MR-PheWAS, integrates the phenome-wide association study (PheWAS) with MR methodology to identify causal relationships using hitherto unconsidered traits5.Most MR studies of cancer have been predicated on assumptions about disease aetiology or have sought to evaluate purported associations from conventional observational epidemiology6.To identify causal relationships for eight common cancers , and reveal intermediates of risk, we conducted a MR-PheWAS study. We integrated findings with a systematic mining of the literature space to provide supporting evidence and derive a more comprehensive description of disease aetiology 6.The analysis was undertaken using published GWAS data, hence ethical approval was not required.Our study had four elements. Firstly, the identification of genetic variants serving as instruments for exposure traits under investigation; secondly, the acquisition of GWAS data for the eight cancers; thirdly, MR analysis; fourthly, triangulation through literature mining to provide supporting evidence for causal relationships .Supplementary Table 1). For each SNP, the corresponding effect estimate on a trait expressed in per standard deviation (SD) units  and standard error (SE) was obtained. Only SNPs with a minor allele frequency <0.01 and a trait association of P-values <5 × 10−8 in a European population GWAS were considered as instruments. We excluded correlated SNPs at a linkage disequilibrium threshold of r2 >0.01, retaining SNPs with the strongest effect. For binary traits we restricted our analyses to traits with a medical diagnosis, excluding cancer. We removed duplicate exposure traits based on manual curation.Single nucleotide polymorphisms (SNPs), considered genetic instruments, were identified from published studies or MR-Base (https://bcac.ccge.medschl.cam.ac.uk/. accessed July 2022) and prostate cancer 8; (2) GWAS catalogue (https://www.ebi.ac.uk/gwas/), for ovarian, endometrial and lung cancers (accessed September 2022)11; (3) Investigators of published work, for colorectal cancer (CRC), renal cell carcinoma (RCC) and oesophageal cancer14. Cancer subtype summary statistics were available for lung, breast and ovarian cancers. As the UK Biobank was used to obtain genetic instruments for many traits investigated, the CRC and oesophageal GWAS association statistics were recalculated from primary data excluding UK Biobank samples to avoid sample overlap bias (Supplementary Table 2)15.To examine the association of each genetic instrument with cancer risk, we used summary GWAS effect estimates from: (1) Online consortia resources, for breast  model as the primary measurement as it is robust in the presence of pleiotropic effects, provided any heterogeneity is balanced at mean zero (Supplementary Table 3-6)17. Weighted median estimate (WME) and mode-based estimates (MBE) were obtained to assess the robustness of findings (Supplementary Table 7)19. Directional pleiotropy was assessed using MR-Egger regression (Supplementary Table 8)20. The MR Steiger test was used to infer the direction of causal effect for continuous exposure traits (Supplementary Table 9)21. For this we estimated the proportion of variance explained (PVE) using Cancer Research UK lifetime risk estimates for each tumour type (Supplementary Table 10)22. A leave-one-out strategy under the IVW-RE model was employed to assess the potential impact of outlying and pleiotropic SNPs (Supplementary Table 11)23. Because two-sample MR of a binary risk factor and a binary outcome can be biased, we primarily considered whether there exists a significant non-zero effect, and only report ORs for consistency24. Statistical analyses were performed using the TwoSampleMR package v0.5.6 (https://github.com/MRCIEU/TwoSampleMR) in R (v3.4.0)15.For each SNP, causal effects were estimated for cancer as an odds ratio (OR) per SD unit increase in the putative risk factor (ORSD), with 95% confidence intervals (CIs), using the Wald ratio25. We excluded instruments with a F-statistic <10 since these are considered indicative of evidence for weak instrument bias26. We estimated study power, stipulating a P-value of 0.05 for each target a priori across a range of effect sizes as per Brion et al. (Supplementary Table 1)27. Since power estimates for binary exposure traits and binary outcomes in a two-sample setting are unreliable, we did not estimate study power for binary traits24.The power of MR to demonstrate a causal relationship depends on the PVE by the instrumenta priori: robust , PWME or PMBE <0.05, true causal direction and >1 IVs), probable , suggestive (PIVW-RE <0.05 or PWALD <0.05), and non-significant (PIVW-RE ≥0.05 or PWALD ≥0.05) (Supplementary Table 12). While non-significant associations can be due to low statistical power, they also indicate that a moderate causal effect is unlikely. For binary traits we classified associations as being supported (P <0.05) or not supported .The support for a causal relationship with non-binary traits was categorised into four hierarchical levels of statistical significance 28. Within SemMedDB pairs of terms connected by a predicate which are collectively known as ‘literature triples’ (i.e. ‘subject term 1’ – predicates – ‘object term 2’). These literature triples represent semantic relationships between biological entities derived from published literature. To interrogate SemMedDB we queried MELODI Presto and EpiGraphDB to facilitate data mining of epidemiological relationships for molecular and lifestyle traits30. For each putative risk factor-cancer pair the set of triples were overlapped and common terms identified to reveal causal pathways and inform aetiology. Based on the information profile of all literature mined triples, we considered literature spaces with >50 literature triples as being viable, corresponding to 90% of the information content31. We complemented this systematic text mining by referencing reports from the World Cancer Research Fund/American Institute for Cancer Research, and the International Agency for Cancer Research Global Cancer Observatory, as well as querying specific putative relationships in PubMed33.To strengthen evidence for causal relationships identified from the MR analysis we exploited the semantic predications in Semantic MEDLINE Database (SemMedDB), which is based on all PubMed citationsSupplementary Table 17). The number of SNPs used as genetic instruments for each trait ranged from one to 1,335. a priori for each cancer type reflects in part inevitably the size of respective GWAS datasets (Supplementary Table 1).After filtering we analysed 3,661 traits, proxied by 336,191 genetic variants in conjunction with summary genetic data from published GWAS of breast, prostate, colorectal, lung, endometrial, oesophageal, renal, and ovarian cancers  and those for which current evidence is inconclusive into the following categories: cardiometabolic; dietary intake; anthropometrics; immune and inflammatory factors; fatty acid (FA) and lipoprotein metabolism; lifestyle, reproduction, education and behaviour; metabolomics and proteomics; miscellaneous.To aid interpretation we grouped traits related to established cancer risk factors (Supplementary Table 3).Out of the 27,066 graded associations, MR analyses provided robust evidence for a causal relationship with 123 phenotypes , 174 with probable evidence , 1,652 with suggestive evidence . Across the eight cancer types, the largest number of robust associations were observed for endometrial cancer with 37 robust associations, followed by renal cancer (n = 32), CRC (n = 21), lung (n=20), breast (n=10), oesophageal (n=3) and prostate cancer (n=1). No robust MR associations were observed for ovarian cancer (Supplementary Table 3).Across all of the cancer types anthropometric traits showed the highest number of robust MR defined causal relationships , followed by lifestyle, reproduction, education and behaviour . No robust associations were observed for dietary intake or cardiometabolic categories (https://mrcancer.shinyapps.io/mrcan/). To visualise the strength and direction of effect of the causal relationship between each of the traits examined and risk of each cancer type and, where appropriate, their respective subtypes we provide a R/Shiny app (33. Notably: (i) the relationship between metrics of increased body mass index (BMI) with an increased risk of colorectal, lung, renal, endometrial and ovarian cancers34; (ii) cigarette smoking with an increased risk of lung cancer35; (iii) higher alcohol consumption and increased risk of oesophageal, colorectal, lung, renal, endometrial and ovarian cancers36; (iv) reduced physical activity and sedentary behaviour with an increased risk of multiple cancers, including breast, lung, colorectal and endometrial37. As anticipated, exposure traits pertaining to cigarette smoking were not causally related to lung cancer in never smokers. Paradoxically, but as reported in previous MR analyses, increased BMI was associated with reduced risk of prostate and breast cancer, and an inverse relationship between smoking and prostate cancer risk was observed38. Our analysis also supports the reported relationship between higher levels of sex hormone-binding globulin with reduced endometrial cancer risk and a relationship between testosterone with risk of endometrial cancer and breast cancers40. Notably, exposure traits related to testosterone levels were only causally associated with luminal-A and luminal-B breast cancer subtypes.Many of the identified causal relationships, especially those that were statistically robust or probable, have been reported in previous MR studies and are related to established risk factor categoriesWith respect to dietary intake our analysis demonstrated probable associations between genetically predicted higher levels of coffee, oily fish, and cheese intake with reduced CRC risk and suggestive associations between genetically predicted beef and poultry intake and elevated CRC risk. We found suggestive associations between genetically predicted high serum vitamin B12 with colorectal and prostate cancer, serum calcium and 25-hydroxyvitamin-D with RCC, low blood selenium with colorectal and oesophageal cancers and methionine and zinc with reduced CRC risk. We observed no association between genetically predicted blood levels of circulating carotenoids or vitamins B6 and E for any of the cancers.In terms of glucose homeostasis, no relationship between genetically predicted blood glucose or glycated haemoglobin was shown for any of the eight cancers. However, higher levels of genetically predicted levels of fasting insulin and insulin growth factor 1 (IGF-1) and lower proinsulin showed associations with CRC. Additionally, a suggestive association between proinsulin and renal cancer, fasting insulin and lung and endometrial cancers, and IGF-1 levels and breast cancer was observed. Amongst genetically predicted higher levels of lipoproteins, the only associations were a probable association between high density lipoprotein cholesterol (HDL-C) and breast cancer and suggestive associations between low density lipoprotein cholesterol (LDL-C) with CRC, and total cholesterol and ovarian cancer.Genetically predicted levels of plasma FAs showed an association with reduced cancer risk. Specifically, for the omega-6 polyunsaturated FAs, lower levels of arachidonic acid (20:4n6) and gamma-linoleic acid (18:3n6) and higher levels of linoleic acid (18:2n6) and adrenic acid (22:4n6)) with reduced risk of CRC; for the omega-3 polyunsaturated FAs  and breast cancer risk, and arachidonic acid and endometrial cancer.A relationship between longer lymphocyte telomere length (LTL) and an increased risk of six of the eight cancer types was identified - robust with respect to renal and lung cancers, probable for breast and prostate cancers and suggestive for colorectal and ovarian cancers.In addition to a robust association between higher HLA-DR dendritic plasmacytoid levels and risk of prostate cancer, 26 probable associations between genetically predicted levels of other circulating immune and inflammatory factors were shown across the cancers studied. These included higher levels of IL-18 with reduced risk of lung cancer, with specificity for lung cancer in never smokers.41, benign breast disease and breast cancer42, oesophageal reflux with risk of oesophageal cancer (Supplementary Table 13)43. Other associations included possible relationships between pulmonary fibrosis and lung cancer44, as well as the relationship between a diagnosis of schizophrenia and lung cancer, which has been observed in conventional epidemiological studies45. It was noteworthy, however, that we did not find evidence to support the purported relationship between hypertension and risk of developing RCC. Similarly, our analysis did not provide evidence to support a causal relationship between either type 1 or type 2 diabetes and an increased cancer risk.Our MR analysis provides support for the known relationship between colonic polyps and CRCSupplementary Table 18). Overlapping risk factor-cancer pairings from our MR analysis yielded on average 49 potential causal relationships. Supplementary Table 19 stratifies the literature space size by trait category while recognising that causal relationships with a small literature space could be reflective of deficiencies in semantic mapping relationships with large literature spaces support triangulation. Supplementary Table 20 provides the complete list of potential mediators for each trait. Illustrating the use of triangulation using a large literature space (defined herein as >50 triples) to support causal relationships, To provide support for the associations and to gain molecular insights into the underlying biological basis of relationships we performed triangulation through systematic literature mining. We identified 55,105 literature triples across the eight different cancer types and 680,375 literature triples across the MR defined putative risk factors (47. Whilst LAG-3 inhibition is an attractive therapeutic target in restoring T-cell function, we demonstrate genetically elevated LAG-3 levels as being associated with reduced CRC, endometrial and lung cancer. In all three of these cancers, the association appears to be at least partly mediated through IL-10 and the seemingly paradoxical relationship between LAG-3 levels and tumourgenesis suggests potentiation of T-cell function by serum LAG-3 rather than cell membrane expressed LAG-348. We identify genetically predicted IL-18 levels as being associated with an increased risk of lung cancer. Our literature mining also supports a role for the decoy inhibitory protein, IL-18BP as being a mediator of lung cancer risk as well as IL-10, IL-12, IL-4 and TNF49. Finally, PRDX1, a member of the peroxiredoxin family of antioxidant enzymes, interacts with the androgen receptor to enhance its transactivation resulting in increased EGFR-mediated signalling and an increased prostate cancer risk46.IGF-1, which is reported to play a role in multiple cancers, appears to mediate its effect in part through beta-catenin and BRAF signalling, modulating CRC and breast cancer riskBy performing a MR-PheWAS we have been able to agnostically examine the relationship between multiple traits and the risk of eight different cancer types, restricted only by the availability of suitable genetic instruments. Importantly, many of the traits we examined have not previously been the subject of conventional epidemiological studies or been assessed by MR. Even for risk factors that were examined in many previous analyses, the number of cases and controls in our study has afforded greater power to identify potential causal associations. This has allowed us to exclude large causal effects on cancer risk for the majority of exposure traits examined in our study.50; the autophagy associated cytokine cardiotrophin-1 with lung, endometrial, prostate and breast cancer and the tumour progression associated antigen CD63 with endometrial cancer52. Levels of these and other plasma proteins potentially represent biomarkers worthy of future prospective studies. Clustering of MR causal effect sizes for each trait cancer relationship highlights the importance of risk factors common to many cancers but also reveal differences in their impact in part likely to be reflective of underlying biology (In addition to identifying causal relationships for the well-established lifestyle traits, which validates our approach, we implicate other lifestyle factors that have been putatively associated by observational epidemiology contributing to cancer risk. For example, the protective effects of physical activity, coffee, oily fish, fresh/dried fruit intake for CRC risk. A number of the causal relationships we identify have been the subject of studies of individual traits and include the association between longer LTL with increased risk of RCC and lung cancers; sex steroid hormones and risk of breast and endometrial cancer; and circulating lipids with CRC and breast cancer. Using genetic instruments for plasma proteome constituents has allowed us to identify hitherto unexplored potential risk factors for a number of the cancers, including: the cytokine like molecule, FAM3D, which plays a role in host defence against inflammation associated carcinogenesis with lung cancer biology .54. Secondly, correcting for multiple testing guards against false positives especially when based on a single exposure outcome. However, the potential for false negatives is not unsubstantial. Since we have not adjusted for between trait correlations, our associations are inevitably conservative. Thirdly, for a number of traits, we had limited power to demonstrate causal associations of small effect. Fourthly, not unique to our MR analysis, is the inability of our study to deconvolute time-varying effects of genetic variants as evidenced by the relationship between obesity and breast cancer risk55. Finally, as with all MR studies, excluding pleiotropic IVs is challenging. To address this, we incorporated information from weighted median and mode-based estimate methods, to classify the strength of causal associations. However, there are inevitably limitations to such modelling as exemplified by the strong relationship between plasma FA and risk of CRC which has been shown to be driven by the pleiotropic FADS locus which has a profound effect on the metabolism of multiple FA through its gene expression56.A principal assumption in MR is that variants used as IVs are associated with the exposure trait under investigation. We therefore used SNPs associated with exposure traits at genome-wide significance. Furthermore, only IVs from European populations were used to limit bias from population stratification. Our MR analysis does, however, have limitations. Firstly, we were limited to studying phenotypes with genetic instruments available, moreover traits such as food intake or television watching can be highly correlated with other exposures making deconvolution of the causal risk factor problematicA major concern articulated regarding any MR-PheWAS is the need to provide supporting evidence from alternative sources. Herein we have sought to address this by conducting a systematic interrogation of the literature space and potentially identify intermediates to explain relationships. Although literature mined data is inevitably noisy and driven by publication bias, we have been able to provide a narrative of the causal relationships for a number of risk factors, which are attractive candidates for molecular validation.Complementary studies are required to delineate the exact biological mechanisms underpinning associations. Our analysis does however highlight important targets for primary prevention of cancer in the population. The limited power to robustly characterise relationships between exposure traits and cancer in this study, provides an impetus for larger MR studies. Finally, we recognise that MR is not infallible and replication and triangulation of findings using different data sources, and if possible, benchmarking against RCTs is highly desirable. Such efforts could identify additional factors as targets to reduce the overall burden of cancer.1