Breast cancer has become a concerning health problem worldwide due to its increasing incidence rate. Women from developing countries are dying off due to the lack of knowledge on breast cancer and its different early detection programs.This study explores the level of knowledge about breast cancer risk factors, early warning signs, screening, and therapeutic approaches and their influential determinants among university and medical college students.A cross‐sectional study was conducted, including 567 female university‐level students . This study used a semi‐structured questionnaire about four aspects  of breast cancer, latent class analysis (LCA), and latent class regression (LCR) for investigation.The percent of knowing correct answers of risk factors, early warning signs, screening approaches, and therapeutic methods were 86.3%, 69.8%, 70.2%, and 51.2%, respectively for medical students who had a high level of awareness and those for university students were 73.0%, 66.8%, 35.9%, and 24.7%. On the other hand, only 37.95% of medical students had been practicing Breast self‐examination (BSE), while it was 18.37% for university students. The most effective predictors of the high level of awareness were age, advertisements (ad) promoting awareness about breast cancer, programs/campaign related to breast cancer, and personal breast problem history.Taken together, the awareness level about four aspects of breast cancer is low among university students and is moderately high among medical students. Therefore, relevant health education programs in every educational institute are urgently needed to improve the awareness levels among female students to improve women's health at home and abroad. In 2018, the percentage of breast cancer among newly diagnosed cases in both genders was 12.3%, and in women, it was 25.4% (excluding non‐melanoma skin cancer).The common warning signs of breast cancer are a lump in the breast or under the armpit, pulling in the breast, pain in the breast/nipple, puckering/dimpling breast skin, bleeding or discharge from the nipple, rash in the nipple or breast skin, redness of breast skin, and changes in the size of the breast due to swelling.The knowledge about the risk factors, early warning signs, screening methods and therapeutic methods can be varied respective to a person's educational level, economic status, family history of breast cancer and marital status.Many studies suggested the strong relation of level of awareness with the early detection of breast cancer,This study aims to find out the current awareness level about breast cancer among university‐level female students. Moreover, to identify which factors affect the awareness level of students. As we know, they have more access to various mediums to know the details of this than other sections of the population. Hopefully, this study will help policymakers plan intervention strategies to make women more aware of various aspects of breast cancer.2We conducted a cross‐sectional study on undergraduate and graduate‐level students in Sylhet city in the northeastern part of Bangladesh. There are six universities and five medical colleges, among which two universities and one medical college are public institutions in this city. Due to limited resources and lack of cooperation, the study population was female students of one university and one medical college. We considered students of five academic years  of all departments from the university. Similarly, we included Medical College students of five academic years  and intern doctors.There were two groups in the population, and between them, one group had medical knowledge, and the other group had no such knowledge. The group with medical knowledge included female students of medical college, and the group with no such knowledge included the female students of the university. The calculation of sample sizes of the two groups followed the following procedure.d = 0.05, Z‐score for 95% confidence interval, z = 1.96, and N = Population size.We applied simple random sampling to collect a comparable and representative sample from each group without equal respondents in two groups. To get the required number of samples, we considered the level of significance, p = 0.05, and so, q = 1 – p = .05. When estimating the sample size, the population size for the group having medical knowledge was N = 535 and for the other group receiving no medical knowledge was N = 3160. For calculating the total number of respondents included in the sample from two assemblies, we used the following equationsAs we had no idea about the proportions aware of breast cancer, we selected We developed a semi‐structured questionnaire with various information about breast cancer and took different vital questions from the Breast Module of the Cancer Awareness Measure, developed by Cancer Research UK, King's College London, and University College London in 2009. Moreover, the questions of the last five sections were based on the American Cancer SocietyWe collected data from the halls of female students, which the educational institutions provide. We included students of different academic years randomly from February 2, 2019 to March 15, 2019. Data collectors went room to room and described the objective of the study. A student received a questionnaire if she was interested in participating voluntarily; otherwise was not bothered. We completed the data collection procedure by taking the necessary time allowing flexibility to the respondents.Data processing steps included data entry, data editing, and necessary adjustment for data analysis. For data processing steps, we used Statistical Package for Social Sciences (SPSS) version 22.0. We edited data on some sections‐ where respondents gave unfitting or meaningless answers and some places to get consistent results among respondents.SD) for numerical variables and percentage for categorical variables. We considered the structure of the dataset as a latent structure as we selected variables from the sections of risk factors, early warning signs, screening approaches and therapeutic methods, which are categorical variables with two categories‐ “Yes” and “No”. We wanted to find out distinct classes with similar understanding/knowledge among individuals and the chance of participants being in different classes. Furthermore, we analyzed this by applying latent class analysis (LCA) method to each section of the dataset individually to fulfill the aim. LCA was developed for this setting where multiple categorical variables describe one idea and a hidden categorical variable that influences those multiple variables. Participants were assessed based on having adequate or low knowledge about items of each section, and the correct answer for each question was finalized before applying the LCA. Then to measure the extent of effects of factors on the awareness levels about breast cancer, we used latent class regression (LCR), the extended version of LCA. LCR uses the constructed categories by the LCA as the dependent variable for running logistic regression. For factors, obtained coefficients can be converted into odds ratio (OR) to interpret them simply as the participant's chance of being in another category than the reference category. In this study, we used six factors that somehow connected to the awareness level of breast cancer. These factors are the age of respondents, marital status, personal breast problem history, ads promoting awareness about breast cancer, educational program/campaign, and relative with breast cancer. We used the statistical modeling program Mplus version 7.0 to run this part of the analysis.We did descriptive analyses and stated mean (±33.1SD) age of participants of the medical college was 21.61(1.56) years, and mean (±SD) height and weight were 1.58 (±0.05) meters and 53.04 (±9.10) kg, respectively. Among 224 medical students, the majority of them (97.32%) were single, 76.34% were never attending any programs/campaigns related to breast cancer, and a total of 75% of students saw ads that promoted awareness of breast cancer. In addition, 91.96% of students had no family history of breast cancer, and 62.05% did not practice breast self‐examination . Furthermore, having a family history of breast cancer also positively affected being in the high awareness group, but the impact was not significant . Also, we could see that other factors had no positive or significant effect on being in class‐1. Determinants having a negative impact, but not notable were personal breast problem history (OR = 0.34), being married (OR = 0.35), educational program/campaign related to breast cancer (OR = 0.52), and ads that promote awareness about breast cancer (OR = 0.63). For early warning signs of breast cancer, the age of respondents significantly affected the respondents to be in high awareness class . Having seen ads that promote breast cancer awareness positively affected being in high awareness class, but the impact was not significant . OR portrayed that Respondents having relatives with breast cancer tended to be in the high awareness class, and the association had not been found significant . Moreover, being married (OR = 0.18), personal breast problem history (OR = 0.68), and program/campaign related to breast cancer (OR = 0.94) had a negative effect, although the impacts were not significant  in case of screening approaches of breast cancer. Along with this, factors having positive effect but not significant, in order of importance, were personal breast problem history , program/campaign related to breast cancer  and ads that promote breast cancer awareness . It was also evident that being married had a significantly negative impact on an individual in high awareness class. Having a family member/relative with breast cancer had a negative impact but was not significant. As we can see, like other parts, the age of respondents had a significantly positive effect on individuals being in high awareness class  for therapeutic methods of breast cancer. On the other hand, programs/campaigns related to breast cancer (OR = 1.64) and ads promoting awareness of breast cancer (OR = 1.62) positively but not significantly impacted individuals in high awareness class. Moreover, being married (OR = 0.30), personal breast history problem (OR = 0.79), having a relative with breast cancer (OR = 0.79) had a negative but not significant effect on individuals being in class‐1 (Table 3.2SD) age of university female student participants was 22.59 (±1.55) years, and the mean (±SD) height and weight of them were 1.56 (±0.06) meters and 51.24 (±8.39) kg. Among 343 female university students, 93.88% were single, and 88.92% of students never attended any breast cancer‐related campaign or programs, but 63.56% had seen ads promoting breast cancer awareness. Around 13% of students had a family history of breast cancer, but only 18.37% practiced breast self‐examination (BSE) . In class‐1, the probability of answering “Yes” for any of the nine questions was very low, while in class‐2, the probabilities were high enough. For instance, the chance of correct answer for “something other than milk in nipple” was 81.8% in class‐2 while 11% in class‐1 Table .Table The LCA identified distinct classes from study participants of the university regarding the prevalence of correct answers to therapeutic methods. From the percentage of the correct answers in two latent classes, we found that class‐1 contained most of the participants (75.3%) who had a low level of knowledge about therapeutic methods, while class‐2 included individuals with a high level of knowledge (24.7%). For Surgery/removal of whole or part of the breast, the correct answers were 100% in class‐2, while 8.6% in class‐1 Table .LCR indicated the impacts of six factors on individuals of the university being in high awareness class. In LCR, latent classes were dependent variables, and class‐1 (low awareness) was the reference class like logistic regression. The obtained coefficients of six factors were easy to interpret as OR of belonging in other classes rather than reference one. The coefficients associated with factors for the aspect “risk factors” of breast cancer showed that being married , personal breast problem history , ads promoting awareness about breast cancer , relative with breast cancer  and age  had positive but not significant impact on individuals being in high awareness group rather than reference one while educational program/campaign  had negative but insignificant effect. All six factors had an insignificant impact on differentiating class‐2 from class‐1. From the results, for the early warning signs, it was clear that ads promoting awareness about breast cancer had a significant positive impact on participants being in high awareness class than reference class . Though educational program/campaign had more positive impact but the impact was not significant . Other factors had not any significant effect on distinguishing the latent classes. The factors with significant positive effect on the level of awareness about screening approaches of breast cancer were personal breast problem history , promotional ads of breast cancer awareness , educational program/campaign  and age . From the results for therapeutic methods, educational program/campaign had positive significant impact on differentiating two classes  while being married , ads promoting awareness  and relatives with Breast Cancer  had positive effects which were not much significant Table .4Breast cancer awareness is paramount to diagnose it early and is the most common cancer among women (excluding skin cancer). Being aware of this cancer can reduce the chance of developing breast cancer. Many organizations worldwide are focusing more on the awareness part of breast cancer. They are organizing various campaigns, online tutorials, booklets to teach people of all ages about the importance of early detection and factors that might influence the development of breast cancer. Early detection of breast cancer helps specialists destroy the cancer cell as early as possible, and the treatment of cancer becomes less costly with a higher possibility of recovery. This investigation explored the level of awareness about the risk factors, early warning signs, screening modalities, and therapeutic approaches taken by medics of breast cancer among university and medical students. It also helped to know different factors which could influence their curiosity to be familiar with other aspects of this cancer.The current study gives information on the awareness levels about different parts of breast cancer among university and medical students. The knowledge about breast cancer risk factors among university and medical students is high. However, a relatively small number of university students identified trauma, diet, and early menarche as risk factors of breast cancer. In contrast, the least number of medical students did the same for early menarche and diet. Furthermore, a cross‐sectional study on Iranian adult women provided low awareness about breast cancer risk factors.Our study aimed to discover the awareness about widely‐known curative methods of breast cancer, and the result displayed that awareness level is very low for university students. Surprisingly, the level is also low for medical students. Those university and medical students who had high knowledge about curative procedures gave a high rate of correct answers for each option. A study in India among women of a rural district found low knowledge about therapeutic methodsThe levels of awareness among participants are varied because of their personal information, and necessary steps can change most of the reasons. For medical students, one common influential factor was the respondent's age, and it is evident that the final year students had better knowledge about the aspects of breast cancer than the first‐year students. Alternatively, for university students, age did not effectively influence the awareness levels, which is usual as they will not get any extra course regarding this topic at any level of their education.We found a significant but negative association between marital status and awareness about screening approaches among medical students. A study on Jordanian nurses showed no significant association between marital status and performing BSE,In university students, we found a positive and significant association between age, attending program/campaign, ads promoting awareness about breast cancer, personal breast problem history, and awareness level about screening approaches. Personal breast problem history is an essential factor for awareness about screening approaches because it is evident that after feeling any pain or seeing any unusual changes in the breast, women tend to see doctors. Furthermore, from there, women got to find out different screening methods. It also indicates that students are concerned about their health symptoms and always consult doctors if they find any unusual changes. Moreover, a significant association existed between attending programs/campaigns and awareness levels about therapeutic methods for university students. University students showed that ads promoting awareness about breast cancer could help them get accurate knowledge about breast cancer early warning signs. However, we could not find any significant factors among university students for the knowledge of breast cancer risk factors. In Bangladesh, there are a few ads promoting awareness about any part of breast cancer, and the number of such ads must be increased covering every aspect of breast cancer. Along with this, in each educational institution, programs/campaigns that give details about breast cancer should be organized every year.As awareness about breast cancer is necessary among women, especially aged 15–49 years, the main strong point of this study is that we want to know the extent of knowledge about this among students in Bangladesh who have more access to materials of the necessary information and this type of study was already done in many other countries but not any significant research in Bangladesh. Besides, the statistical technique used in the current study provides fair and trustworthy results about the levels of awareness and effective factors that vary the awareness level about breast cancer.The limitation of this study is that only two educational institutes of one city of Bangladesh were used for participants to investigate the awareness levels. This study can be extended by considering more undergraduate and graduate students or more women aged 15–49 years from every district in Bangladesh. This study is conducted using simple random sampling, and further study can be run by using other random sampling techniques and more samples. Cluster sampling procedure may also be used to investigate the breast cancer patients in different divisions in Bangladesh. Also, to get an in‐depth understanding of the factors that influence the awareness among women, mixed‐method research approaches are possible to employ.5The current study revealed a moderately low awareness level about the screening approaches and therapeutic methods among university students and relatively high awareness among medical students. However, the awareness level concerning breast cancer risk factors was moderate among medical and university students. The results exposed the fact that female students having personal breast problem history, attending programs related to breast cancer, seeing informative ads on breast cancer tended to have a high awareness of breast cancer. Educational programs about breast cancer in every educational institute, events at the community level to raise awareness among women, and voluntarily learning about breast cancer from online events, web pages, and tutorials using technology could be practical steps to take.The authors declare no conflicts of interest.All authors had full access to the dataset used in this study and took full responsibility for the analysis, the accuracy, and the representation of the data. Mst. Farzana Akter: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, and writing‐original draft. Mohammad Ohid Ullah: conceptualization, methodology, supervision, validation, writing‐review & editing.The study was approved by the ethical/research (Thesis) committee 2018 (Session 2016–2017) [Regi/161(council)/1/2233] of the Department of Statistics department, Shahjalal University of Science and Technology, Sylhet, Bangladesh. The objective of this study was clarified verbally to the students, and they signed a written consent form that was included on the top of the questionnaire. They had been assured that their identity would not be linked with the research materials, and they would not be identified or identifiable in any report.


How do women perceive the breast cancer risk associated with breast density, and how do they plan to mitigate their risk?In this qualitative study of women aged 40 to 76 years, family history was perceived as the greatest risk factor for breast cancer. In interviews, few women perceived breast density as a risk factor, and one-third thought that they could not take any actions to reduce their breast cancer risk.Despite laws that require women to be notified about breast density, women did not describe a strong understanding of the risk associated with breast density relative to other breast cancer risk factors. This qualitative study of women of breast cancer screening age examines how women perceived breast density as a cancer risk compared with other breast cancer risk factors. Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density.To assess women’s perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction.This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020.Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk.Of the 2306 women who completed the survey, 1858  completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk.In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed. This study was reviewed by the Boston University Medical Campus Institutional Review Board, which determined that the study met federal exemption criteria and provided a waiver of documentation of informed consent. Approval was for the qualitative interviews  and at the time of transcription. All interview data was deidentified. The study followed the Standards for Reporting Qualitative Research (SRQR) for reporting qualitative data.19This mixed-methods qualitative study included survey data from a national, random-digit-dialing telephone survey coupled with semistructured interviews with a subset of survey respondents. Survey questions examined women’s perception of breast density in relation to other known breast cancer risks; interviews explored women’s understanding of breast cancer risk factors and actions to mitigate risk. This mixed-methods approach allowed us to examine the scope of awareness and understanding. On the basis of prior literature demonstrating differences in perceptions by sociodemographic characteristics,21 Participants were asked in the survey to self-identify their race or ethnicity. We collected race and ethnicity data to allow for oversampling across some groups to ensure that we could conduct analyses that compared findings across groups.The sampling frame consisted of 2306 participants who completed a national, random-digit-dialing survey of the effect of states’ breast density notification laws on knowledge about breast cancer risks associated with breast density. Eligible participants were aged 40 to 76 years, reported having undergone mammography in the prior 2 years, had no history of breast cancer, and had heard of breast density. Within the population-based sampling, efforts were made to ensure a sufficient sample of women from diverse racial and ethnic backgrounds, from states with and without breast density notification laws, and with lower literacy levels, as detailed in prior publications.After completing the survey, women who reported knowing their breast density were invited to participate in a qualitative interview. Those who responded affirmatively were called to schedule an interview. We purposively sampled equal numbers of women who identified as Black, Hispanic, White, or other race or ethnicity as well as those with HL vs LL. In the survey, participants were asked to self-identify their race from a list that included Asian, Black or African American, Native American, Pacific Islander, White, mixed race, or some other race. For these analyses, anyone who responded that they were Native American, Pacific Islander, mixed race, or some other race were classified as other race. For the qualitative interviews, we included respondents who were Asian in the other race category.22 with modified measures tested by patient advisory group members. Advisory group members also reviewed the interview guide. The survey firm, SSRS, conducted all surveys using a standardized interview approach . A review of data from the first 448 survey participants revealed that wording of the risk perceptions questions was confusing. We revised the questions and excluded those participants from analyses due to identified measurement error and incompatibility of responses with subsequent risk questions. For each risk factor, participants were asked the question, “Which do you think puts someone at greater risk for developing breast cancer? Having dense breasts or…” Risk factors were elicited in a random order to minimize ordering bias.2 analyses assessed whether the proportion of women who said having dense breasts puts someone at greater risk for developing breast cancer was associated with participants’ race and ethnicity  or literacy level (HL or LL). Low literacy was defined as either having less than a high school education or reporting sometimes, often, or always needing assistance to complete medical forms using the validated Single Item Literacy Screener.23 We used SPSS statistics software, version 26 (IBM Inc).24 Statistical significance was defined at α = .05. We followed the American Association for Public Opinion Research (AAPOR) reporting guidelines for survey data.25We characterized the proportion of women who said having dense breasts puts someone at a greater risk for developing breast cancer vs the alternative risk factor or “don’t know”; participants with missing responses were excluded from analyses (<1%). Bivariate χ26 We used a matrix coding approach to guide development of themes and justify inclusion or exclusion of interviewees within themes.27 This approach includes arranging data within a table where individual participants represent rows and themes represent columns. We analyzed whether themes varied across literacy levels or across racial and ethnic groups. Qualitative analyses were overseen by a doctoral-level health services researcher (C.M.G.) with expertise in qualitative methods. Two masters-level trained research coordinators and 1 doctoral student participated in data collection and analysis, including co-coding and consensus determination meetings.Women were asked in an open-ended fashion what they thought contributed to breast cancer risk and how they could reduce their breast cancer risk. To organize and support analyses, we developed an analytic memo that described all observed themes.21 = 12.99, P < .001), alcohol consumption , and never having children . A higher proportion of Black women (290 [58%]) and Hispanic women (153 [58%]) rated dense breast as a higher risk than alcohol consumption compared with women of other races . A total of 289 Black (58%) and 153 Hispanic (58%) women also rated dense breasts as a higher risk than nulliparity than women who identified as Asian (74 [45%]), White (377 [48%]), and other race (64 [52%]) .Of the 2306 women who responded to the survey, 1858  completed the revised risk perception questions and were included in the analysis . In compAmong 61 women interviewed, few women perceived breast density as contributing to their risk of developing breast cancer. Most women correctly noted that breast density could make mammograms harder to read: “It’s difficult to detect subsequent lumps or potential problem areas because of the dense breast tissue.” . When asked about their personal risk factors for breast cancer, few women noted that breast density could be a risk factor. One woman described her concern by saying, “Maybe 10% more worried than I was before because of the dense tissue issues. Just a slight uptick, but it’s not overwhelming” .Women most frequently and confidently emphasized family history of cancer or genetic factors as contributing to their own breast cancer risk , and manWhen asked about actions that could reduce their breast cancer risk, many women described detection methods, such as breast self-examinations and mammograms, as prevention strategies. Among women who discussed mammograms or breast self-examinations, a small subset noted that screening methods would not prevent cancer but were useful for potentially detecting breast cancer earlier: “Well, if I go for my annual mammogram and do self-breast examination, I will catch whatever’s growing in my breast will be nipped in the bud...It will be taken care of before it gets out of control” .Women’s descriptions of risk mitigation focused on mammography, with descriptions conflating early detection and prevention. Other ideas for reducing personal breast cancer risk included improving diet, maintaining a healthy weight, quitting smoking, avoiding secondhand smoke, limiting alcohol, and exercising . Many woMany women (17 [28%]) stated that they were not sure if it was possible to reduce their breast cancer risk or that they did not know what actions they could take to reduce their risk: “Do people even know how to prevent breast cancer? I couldn’t even say” . Neither health literacy level nor race or ethnicity appeared to differentiate how women perceived actions that they could take to reduce their breast cancer risk.This mixed-methods qualitative study demonstrated that women perceived family history as the strongest risk factor for breast cancer, with mixed perceptions about other lifestyle or clinical risk factors in relation to breast cancer risk. Among interview respondents who knew their breast density, few women noted breast density as a breast cancer risk factor. Few women understood options for mitigating their personal breast cancer risk.6 few women perceived breast density to be a strong personal risk factor. This finding is not surprising because prior studies14 have shown variable rates of women indicating that breast density contributed to breast cancer risk (23%-66%). Qualitative studies29 of women receiving breast density notifications found that women did not fully understand the clinical term breast density. It is possible that notification language stressing the normality of dense breast tissue in the population confers a sense of reassurance that may contribute to the downplaying of breast density as a risk factor.29Despite breast density being associated with a 1.2 to 4 times higher risk of breast cancer,31 have similarly found that women with family histories of breast cancer perceived their personal risk of cancer to be higher than the estimated risk associated with their family history. The emphasis on family history may be in part a result of clinical elicitation of family and genetic risk factors, including the increased emphasis on genetic testing for BRCA1/2 genes, both clinically and in popular media.33 A 2021 systematic review34 found that in primary care, family history is often the only risk factor elicited to counsel patients on breast cancer risk. Thus, frequent health messaging around family history and breast cancer risk may play a role in how this sample of women perceived their own breast cancer risk. Interviewed women displayed little confidence in their ability to modify their cancer risk, suggesting a need for more comprehensive education about which risk factors are amenable to intervention.In both interviews and surveys, women perceived family history as highly deterministic of future breast cancer. Women without a family history believed they were safe or had limited risk based on this factor alone. Other studies35(p179)36 Women also suggested actions that they thought were generally healthy lifestyle changes, but they were not confident these actions would alter their breast cancer risk. Women may benefit from general guidance and information about cancer prevention strategies, such as tools that can help patients understand overall cancer risk and prevention options.37 Clinical treatments, such as chemoprevention agents, are available to reduce breast cancer risk for women at elevated risk 39 but were not mentioned by any interviewees. This finding is not unexpected because chemoprevention is significantly underused by the eligible population,42 despite being recommended for women at elevated risk.43Few women identified ways in which they could reduce their breast cancer risk. When mentioned, these actions included participating in regular screening, diet and exercise, and avoiding tobacco . Many woThis study has some limitations. Despite efforts to include a racially and ethnically diverse sample on the telephone survey panel, nonresponse bias could have influenced findings. The survey did not ask about women’s perception of the absolute risk associated with each risk factor, limiting our ability to draw conclusions about the accuracy of women’s risk perceptions. Interviewees reported being informed of their personal breast density, but we were unable to verify the nature or timing of this notification. We defined low literacy using a single-item literacy scale combined with educational level, which is an imprecise way to measure literacy, limiting our ability to draw conclusions about the direct effect of literacy on risk perception.20 suggests that understanding of breast density’s contribution to breast cancer risk remains underappreciated by many women. Most notifications encourage women to speak with their physicians, yet prior studies47 found that many clinicians do not feel comfortable counseling on the implications of breast density and cancer risk. Efforts to communicate breast density in part are intended to align with evidence suggesting that breast cancer screening services should be tailored to personal risk to maximize the benefits and avoid undue harms,50 rendering conversations about risk imperative. Women with dense breasts, and thus some elevated risk, are ideal candidates for risk assessment. Tools that incorporate breast density in risk measures, such as one from the Breast Cancer Surveillance Consortium,52 can inform future screening behaviors, including the opportunity for supplemental screening. Supplemental screening not only can lead to increased rates of cancer detection but also may result in more false-positive results and recall appointments.55 Because supplemental screening is not recommended for women at average risk,55 clinicians should use risk assessment to guide discussions with patients about tradeoffs associated with supplemental screening.Our study, coupled with prior research,57 such assessments are underused in primary care.60 Reported barriers include inadequate time, lack of integrated tools, and uncertainty in interpreting results for decision-making.58 A review61 of interventions involving the use of risk assessment tools in primary care concluded that more comprehensive interventions that combined risk assessment with decision support were more likely to have an effect on behavior. In some cases, it may be beneficial to develop partnerships between primary care and radiology to help counsel women on appropriate supplemental screening and/or preventive measures.62 In summary, future laws or regulations involving breast density notifications should ensure that communications promote a more comprehensive understanding of breast cancer risk to inform choices about screening and prevention.Despite available guidance on breast cancer risk assessment to inform screening decisions,


The diet-center hypothesis has gained much support from the apparent protective effect of the Mediterranean diet on breast cancer. However, the evidence of the association between Mediterranean diet adherence and breast cancer molecular subtypes remains small, especially in non-Mediterranean populations.The subjects from the Chinese Wuxi Exposure and Breast Cancer Study, a population-based case-control study, included 818 patients and 935 healthy controls. A validated food frequency questionnaire used for diet assessment and a modified version of the alternate Mediterranean Diet Score, which is called the alternate Chinese Diet Score, was developed to assess adherence to a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern. Soy foods, rapeseed oil, and coarse cereals replaced legumes, olive oil, and whole grains reflecting the cuisine of the region. We examined the association between the vegetable-fruit-soy diet adherence and breast cancer risk, stratified by menopause status  and receptor status  oncogene expression, followed by five specific combinations .P trend < 0.001] and that the inverse association was somewhat stronger to detect among ER- subtypes  and ER–/PR–subtypes . We did not observe any significant association between the vegetable-fruit-soy diet characteristics and ER+ subtype, as well as between PR+ and ER+/PR+ subtypes.The results suggest that the vegetable-fruit-soy dietary pattern was inversely associated with postmenopausal breast cancer risk [4th vs. 1st quartile, odds ratio (OR) = 0.57, 95%CI = 0.41, 0.80; The favorable influence from the Mediterranean diet may also apply to Chinese women. The vegetable-fruit-soy dietary pattern may reduce the risk of postmenopausal breast cancer, particularly among ER- subtype, and ER–/PR–subtype. Some extensive cohort studies reported the inverse association for the dietary pattern characterized by the traditional diet among populations in Mediterranean countries of breast cancer risk –8, whichOf particular interest were the low breast cancer incidences that have been reported in Asian countries . It has However, it is almost impossible to perform a long-term feeding trial in a large-scale population in achieving high compliance to follow the Mediterranean diet except with intensive intervention . TherefoThis study aims to scrutinize the association between a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern, and breast cancer risk among Chinese women, stratified by the menopausal status and different breast tumor molecular subtypes.The Chinese Wuxi Exposure and Breast Cancer Study (2013–2014) was a case-control study of the role of biology, diet, lifestyle, and environmental factors in the etiology of breast cancer in Asian women. Subjects were all adult women and were restricted to local residents who have lived in Wuxi for at least 5 years. All newly diagnosed (the diagnosis date was within 1 year before enrolment) women with breast cancer (ICD code: C50) among local residents identified by cancer registries were eligible to be included as cases. Secondary and recurrent cancers were excluded. Controls were derived from the local area as cases and were 1:1 individually matched with cases by age (±2 years) and residence. As personal information such as name, address, date of birth, and sex for all residents was available in the local demographic information database; eligible controls were randomly identified from this database. For each control chosen, two additional subjects were selected as a backup at the same time. When the first control could not be interviewed, an alternative was enrolled in the study. The selection procedure repeated until an eligible subject was interviewed. A total of 1,042 eligible breast cancer cases and 1,042 health controls were identified during the study period. Case and controls with major dietary habits changed over the past 10 years, which were excluded from this study. In analysis, 818 cases and 935 controls were included, with a frequency match (cases and controls have the same distributions over age and residence). All subjects gave voluntary written informed consent to participate in this research. The Institutional Review Boards of the Jiangsu Centers for Disease Control approved the study protocol.The usual diet was assessed by a validated, semiquantitative food frequency questionnaire (FFQ), which included 149 items along with the recipes commonly used in China; a detailed description is given in Zhao et al. . NutrienDietary intake assessment included whether the food was consumed, consumption frequency (times of per day/week/month/year), and the average amount of food consumption at each time. The 149 food items in the FFQ were classified into 18 predefined food groups based on similarities in nutrient profile and culinary usage.A modified version on the alternate Mediterranean Diet Score (aMED) which we called the alternate Chinese Diet Score (aCHD) was developed to assess adherence to a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern. Soy foods, rapeseed oil, and coarse cereals replaced legumes, olive oil, and whole grains, reflecting the cuisine of the region. The aMED , 19 is aTo test the role of the vegetable-fruit-soy dietary pattern in the etiology of breast cancer, we design an interaction test between the aCHD and the duration of diet habits. The “duration” indicator was based on interviewing subjects about how long they have maintained their current diet habits, and the medians were calculated based on the distribution of the premenopausal controls and postmenopausal controls, respectively.Demographic, lifestyle characteristics, menstrual and reproductive events, dietary intake, medical history, and physical activity-related data were obtained from a structured questionnaire through in-person interviews conducted by trained interviewers. Anthropometric measures were obtained by trained personnel following standardized protocols; the core elements of anthropometry are height, weight, body mass index (BMI), body circumferences , and skinfold thickness. Physical activity was measured by referencing the Global Physical Activity Questionnaire . Women wThe molecular subtypes of breast tumor based on ER status, progesterone-receptor (PR) status, and human epidermal growth factor 2 (HER2) oncogene expression, followed by five specific combinations .t-test or the Wilcoxon rank-sum test and chi-squares tests were performed for continuous and categorical variables, respectively, to compare the differences between cases and controls.The demographic characteristics and anthropometric measures of the subjects were presented as means± SD for normal distribution or median (Q1 and Q3) for non-normal distribution and frequency percentages. A Student’s To estimate the impact of the separate foods component of the vegetable-fruit-soy dietary pattern on breast cancer, we calculated adjusted odds ratios (ORs) for the intake ≥ median of the specific foods component compared to the intake < median (as reference), medians were calculated based on the distribution of the premenopausal controls and postmenopausal controls, respectively.Associations between the aCHD score  and breast cancer were estimated in terms of adjusted ORs and respective 95%CIs by logistic regression models.In the sensitivity analysis, soy foods were often considered to be an independent potential benefit for breast cancer prevention in Asian populations , 24. Thuor≥3), age at first full-term delivery (by years), breastfeeding (no or yes), height (by cm), BMI (in kg/m2), energy intake . In addition, postmenopausal stratification analysis was further adjusted for the menopausal age (by years). All subjects were included in the present analysis, with the missing covariates data imputed by using the fully conditional specification Multivariate Imputation by the Chained Equations method. Interactions were examined by the likelihood ratio tests (LRTs).In analyses, we controlled potential confounders associated with breast cancer risk, included age at diagnosis for cases or enrollment for controls (by years), education , tobacco smoking (no or yes: including smoking and second-hand smoking ≥ 3days/week), moderate physical activity (minutes/day), oral contraceptives use (no or yes: current use or ever use), hormone replacement therapy (no or yes: current use or ever use), family history of breast cancer (no or yes: in a first-degree relative), history of benign breast disease , age at menarche (by years), number of full term births , P-value near 0.05 taken by itself offers only weak evidence against the null hypothesis.All analyses were performed with R version 4.0.2 .The demographic characteristics and anthropometric measures of the subjects stratified by menopausal status are presented in P-value for trend < 0.001) and women with the highest quartile aCHD score had a significantly lower risk compared with women with the lowest quartile aCHD score , while no significant association was found for premenopausal breast cancer (P interaction = 0.013). Long-term (≥median) vegetable-fruit-soy diet adherence (highest quartile of aCHD) significantly reduced postmenopausal breast cancer risk compared with short-term (<median) adherence and showed lowest quartile of aCHD , The association between the vegetable-fruit-soy diet adherence and breast cancer is shown in t cancer . FurtherP-value for trend < 0.001). When all soy foods were excluded from the aCHD score calculation, a high soy-free aCHD score was also found to be inversely associated with postmenopausal breast cancer .Breast cancer risk in association with the quartile of soy foods intake and the modified soy-free aCHD score is also shown in For the impact of the separate food components of the vegetable-fruit-soy dietary pattern on breast cancer, we found alcohol consumption to be a significant risk factor for postmenopausal breast cancer , and a high intake of soy foods was inversely associated with breast cancer . No significant association was observed between separate food components intake and premenopausal breast cancer risk . The aveP trend = 0.003); results were similar for ER-/PR- subtype  (P trend = 0.371). A test for heterogeneity examines the null hypothesis that the beneficial effect of vegetable-fruit-soy diet adherence on the ER- subtype is the same as that of the ER+ subtype. However, the test of heterogeneity yields a P-value of 0.013, conventionally interpreted as being non-significant. Results for ER+/PR+ and ER–/PR– breast cancers were similar to those for ER+ and ER– breast tumors, respectively; results for ER–/PR– /HER2– were not significant.Since the significant inverse association with the vegetable-fruit-soy diet adherence was only found in postmenopausal breast cancer, further analyses for different breast tumor molecular subtypes were restricted only to the postmenopausal participants. We observed the vegetable-fruit-soy diet adherence was significantly inversely associated with of ER- subtype  . We did We found that the vegetable-fruit-soy diet adherence was inversely associated with postmenopausal breast cancer risk, especially with ER- and ER-/PR-subtypes. This favorable influence of the vegetable-fruit-soy diet adherence on postmenopausal breast cancer risk cannot be explained by the single effect of soy foods since only a very slight attenuation in estimates was noted after excluding the effect of soy foods. Our finding supports the hypothesis that food components and their combinations in the vegetable-fruit-soy dietary pattern play an etiologic role in breast cancer.The abundant vegetables and moderate fruits intake are the common features of the Mediterranean and Chinese traditional diets . Both divia estrogen-independent mechanisms, such as inhibiting the nuclear transcription factor jB DNA binding activity and the Akt signaling pathway  , our resThe strengths of our study were the use of a validated food-frequency questionnaire and a modified questionnaire surrounding the Mediterranean dietary pattern and individual dietary factors to examine their association with breast cancer risk in the Chinese female population. Since the diet is a modifiable risk factor, identifying the characterization of the population most susceptible to harmful and beneficial dietary habits is critical for breast cancer prevention policy design. Our findings support vegetable-fruit-soy diet compliance associated with reduced postmenopausal breast cancer risk, especially with ER- or ER-/PR- subtypes.The favorable influence from the Mediterranean diet pattern may also apply to Chinese women, and the vegetable-fruit-soy dietary pattern reduced the risk of postmenopausal breast cancer, particularly among ER- subtype, and ER–/PR–subtype.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Review Boards of the Jiangsu Centers for Disease Control. The patients/participants provided their written informed consent to participate in this study.MW, SC, and PW designed and conducted the study. QZ, ZZ, and JZ developed diet indices and data collection. SC and LL performed the statistical analyses and drafted the manuscript. PW and MW interpreted the data, critically revised the manuscript, and had full responsibility for the analyses and interpretation of the data. SC has full access to all study data. All authors contributed to the preparation of the manuscript and read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BRCA testing, screening and prevention implications, filmed interactions between surgeons, a genetic counsellor and geneticists with a fictitious family .Mainstreaming of germline testing demands that all healthcare professionals have good communication skills, but few have genetic testing and counselling experience. We developed and evaluated educational workshops—Talking about Risk & UncertaintieS of Testing IN Genetics (TRUSTING). Contents included: presentations and exercises, an interview with a geneticist about Twenty-one surgeons, 5 oncologists, 18 nurses and 9 genetic counsellors participated. Knowledge (18 item MCQ), communication skills (responses to 6 questions from proband and relatives) and self-confidence (discussing 9 genetic testing issues) were assessed pre- and post workshop.P < 0.001), as did communication  and self-confidence (P < 0.001).Knowledge scores improved significantly post workshop  6.37–7.74; Healthcare professionals’ knowledge and self-confidence when discussing the risks and uncertainties in genetics are often poor. TRUSTING workshops significantly enhanced attendees’ navigation of communication difficulties encountered and will be rolled out more widely. There are increasing calls for genetic testing of all patients with breast cancer . Such teBRCA1/2 or Lynch Syndrome; (3) helping patients to contextualise such information correctly; (4) assisting patients’ decision-making about further risk-reducing treatment options; and (5) facilitating the sharing of information with family members. Many of these conversations present different challenges that few HCPs have received sufficient training to deal with adequately.All Health Care Professionals (HCPs) working within cancer settings may be faced with issues such as: (1) discussing genetic testing for a germline cancer susceptibility gene; (2) dealing with the consequences of high-risk genetic diagnoses such as BRCA1/2 carriers to non-carriers [BRCA1/BRCA2 pathogenic variant might be scheduled in the future following more thought and discussion about the patient’s desire for pregnancy and the consequences of early oestrogen deprivation.Disclosing the identification of a high-risk genetic susceptibility to breast cancer at the same time as a patient is dealing with their current cancer treatment requires particularly sensitive communication. The implications of any genetic variations have to be conveyed and understood by the patient in a context relevant to their particular cancer diagnosis and treatment. For example, the POSH study showed that young-onset breast cancer patients with symptomatic breast cancer have similar overall medium-term survival comparing carriers . One impOne beneficial outcome of a positive genetic diagnosis (for a pathogenic variant) is that unaffected relatives who carry the same high-risk gene variant can access effective enhanced surveillance or prevention opportunities. A survey of 11,766 women with breast cancer showed the importance of good communication. Respondents reported that mere acquisition of risk information via genetic counselling contributed to a basic level of understanding but that effective communication about risk and uncertainty with salient others, including trusted oncologists and healthcare providers, were an 'essential component' for women to feel that they had sufficient information to discuss breast cancer risk with their children [There are many considerations that are not merely limited to the best way in which to present risk information including the implications of increased risk awareness for an individual and their family that might result in potential harms as well as benefits. For higher-risk individuals, concerns include the inevitable anxiety, a possibility of overtreatment, the complications of risk-reducing surgery (RRS), and worries about insurance, lifestyle choices, having children, to name but a few. There is also disquiet about providing false reassurance to those shown to be at lower risk.Talking about Risk, UncertaintieS of Testing IN Genetics (TRUSTING) programme). Central to the success of this educational model are the ideas of Knowles, Friere, Engel and Lipkin [BRCA1 and BRCA2 testing and results (PA) and (3) facilitator-led group discussion of 6 filmed scenarios with members of a fictitious family in which the proband had triple-negative breast cancer (TNBC) and a BRCA2 pathogenic variant (CSD). Thus, all elements of the programme were designed to improve (HCPs) communication skills, knowledge and self-confidence when talking to individuals about genetic risk, testing, results and implications. We report here an evaluation of the educational programme.We wished to produce evidence-based materials that could later be made available to appropriate trainers and facilitators thus maximising a cascade of educational opportunities for junior and senior HCPs. Using similar methods to those employed in previous successful educational projects such as (TARGET) , lookingd Lipkin –11 who pNB: The correct terminology for a change in the genetic code of a given cancer susceptibility gene that leads to a moderate or high increase in lifetime cancer is a pathogenic variant. This is not a term that patients or clinicians typically use in discussions about genetic testing or results so during the development of the materials, various more commonly used terms were used to describe a pathogenic variant in BRCA1 or BRCA2. For the purposes of this manuscript, this informal terminology is clarified with the technically accurate “pathogenic variant” in parentheses.There were four phases to the study:During Phase 1, we conducted a systematic review of all relevant communication skills training programmes dealing with the genetic testing of high-risk breast cancer patients. We determined their content, methods of delivery, how outcomes had been measured and how successful programmes had been .BRCA1/2 pathogenic variant carriers in Southampton, Brighton and Manchester who described their own communication experiences including recall and understanding of risk, their attitudes to risk-reducing options and problems telling other family members that they too may need testing. Subsequently, we conducted more in-depth interviews with 11 of these women, all were BRCA1 or BRCA2 pathogenic variant heterozygotes, and 5 of whom had or were currently being treated for breast cancer [In Phase 2, we held three focus groups with 32 t cancer .Having established the views of affected families we then had many informal discussions with surgeons, oncologists, specialist nurses, genetic counsellors and geneticists about their own acknowledged communication difficulties, potential training needs and perceptions of other colleagues’ communication difficulties. We also investigated further the primary characteristics of patients and problematic situations that hampered communication about genetics at an educational communication skills day held for a multidisciplinary group.BRCA2 carrier and had many anxieties about treatment options and implications for her family. Her sister aged 54 was also a BRCA2 carrier with concerns about the preventative, risk-reducing measures available to her including continuing to take HRT. Finally, we introduced a younger anxious cousin in whom no BRCA2 pathogenic variant was found but was insistent on having bilateral risk-reducing surgery. Patient simulators (actors) experienced in improvisation were filmed in six unscripted consultations with two surgeons, two geneticists  and a genetic counsellor (GC). This methodology had proved successful in our previous educational initiatives improving communication about risk when discussing gene expression profiling test results [Using the information gained from Phase 2, we generated a fictitious family see Fig.  created  results .Fig. 1FiWe also filmed an interview with a geneticist (GE) about the underlying science, implications for testing and recommendations for the fictitious family and those in general who had gene alterations, areas with which all HCPs advising patients should be familiar.The TRUSTING workshops were designed to be conducted face-to-face in small groups; they were primarily interactive with some didactic presentations, relevant group exercises and facilitator-led discussion of the filmed scenarios. Topics covered include risk awareness of cancer amongst the general population, health literacy and numeracy (of patients and clinicians), ethical implications surrounding genetic testing, and the latest research-based evidence about ways to present complex information about risk.Materials were reviewed by all authors and different parts piloted amongst 4 genetic counsellors, 12 surgeons, 3 specialist breast care/consultant nurses, 2 oncologists and 4 psychologists and the final programme was refined in Phase 4.We then conducted an evaluation of the efficacy and acceptability of 8-h TRUSTING workshops with multidisciplinary HCPs.https://shore-c.sussex.ac.uk).An advertising flyer with dates and information about TRUSTING residential workshops was circulated to potential participants via Breast Cancer meetings, geneticists, Tweets, word of mouth, the Association of Breast Cancer Surgeons, Association of Genetic Nurses and Counsellors and the SHORE-C website newsfeed  points from the Royal College of Physicians. Brighton & Sussex Medical School Research Governance and Ethics Committee approved the study (ref: ERA/RMLS21/6/1) which was funded by the Breast Cancer Research Foundation.BRCA1/2 positive (for a pathogenic variant), RRS, screening and demands from an anxious individual for RRS. Question selection for each participant was based on their speciality e.g. surgeon/oncologist, specialist nurse, geneticist, or genetic counsellor. The maximum possible communication score was 28.In the week prior to workshop attendance, participants were audio-recorded responding to six different videotaped questions, two from each of the three family members (patient simulators), via Zoom. Questions covered areas including the risks of developing breast or ovarian cancer in TNBC, when and what relatives should be told, implications of HRT and risk if A study-specific ten-item questionnaire similar to that used in previous assessments of our educational interventions  was adapAttendees completed an 18 item Multiple Choice Questionnaire (MCQ)  HCPs knowledge about genetic testing, including the communication skills required for effective consultations would improve; (2) HCPs would feel more confident when discussing For the rating of communication, an independent data manager assigned random numbers to each audio-recorded interview. Researchers (VJ & LF), each blinded to time-point, used a study-specific coding checklist, to rate independently key points of knowledge or appropriate reassurance in response to each answer. The rate-rerate reliability agreement of researchers’ own coding scores of participants’ recordings and inter-rater reliability checks on 10% of each other’s ratings were performed using intraclass correlations.The total scores for communications skills (from the audio recordings), knowledge (MCQ), HCP’s intolerance of uncertainty and self-reported confidence levels, are all described using means, standard deviations (SDs), medians, and interquartile ranges (IQRs) by participants’ speciality and overall.As most participants showed improved scores post workshop across all the measurements, we estimated mean post-course changes , their 95% confidence intervals (CIs) and tested the null hypothesis of zero mean change, assuming a t-distribution for the scores changes to quantify these improvements. Each item analysed reflects a distinctive communication area, the interpretation of which is of interest on its own. We do not aim to make an overall communication recommendation based on the amalgamation of all items; therefore, corrections for multiple testing are not necessary. The results are exploratory, and all inferential statements are to be interpreted individually for each item , 19.We also fitted linear regression analyses to HCP’s self-confidence levels on each area of information post-course with intolerance of uncertainty scale as an explanatory variable. Diagnostic plots, including plots of residuals, and Q–Q plots were used to check the model assumptions. The goodness of fit was assessed through the model’s R-squared statistic. The analyses were carried out using the statistical software R .Between June and October 2021, 7 facilitator-led face-to-face workshops were attended by 53 HCPs . All were experienced senior HCPs apart from three genetic counsellors, one surgeon and one oncologist and one nurse, who were either more junior or trainees. Attendees had all participated in various unspecified previous training in genetics generally, but none apart from the genetic counsellors, reported having had any specific communication skills training in genetics.Table The primary personality type that participants felt less confident dealing with were individuals with an anxious predisposition . Other issues found challenging included: those wanting RRS but who are not eligible on the NHS, discussions with people who have a strong family history but who prove negative (for a pathogenic variant) when tested, and those who do not wish to disclose these positive results to the family, those with indeterminate findings and advising individuals who are pathogenic gene variant carriers about HRT .IUS scores by speciality are shown in Table P < 0.001). There were more correct answers post workshop to all questions except for Q4 ‘what proportion of all triple-negative BC are due to a BRCA1 or BRCA2 fault (pathogenic variant)’ , and rate-rerate consistency was high . The wide 95% CI for the inter-rater agreement is due to the small sample size.P < 0.001).A majority of participants’ answers to questions posed by the proband and her family members were rated significantly higher post workshop compared to that pre-workshop (47/53 (88.7%) were higher, 4 participants  worsened slightly (1–2 points) and score of 2 stayed the same). Table Feedback at the end of the workshop revealed that all attendees regarded it as useful, informative, and enjoyable. All (100%) would ‘definitely’ recommend the programme to their colleagues.The primary objective hypotheses of the TRUSTING educational programme evaluation were that post-workshop HCPs’ knowledge base about genetic testing, and the communication skills required for effective consultations, would measurably improve.BRCA1/2 testing and its implications with patients and relevant family members.The subjective hypothesis was that HCPs would also feel more confident about discussing All hypotheses, both objective and subjective were clearly demonstrated permitting confidence in the educational value of the programme.Mainstream genetic testing pathways may prove to be an important means of enabling the identification of breast cancer patients carrying germline pathogenic variants earlier access to (1) more appropriate targeted treatments; (2) risk-reducing procedures; and 3) counselling and testing of relevant family members. The success of such programmes does depend on good multidisciplinary team working and effective communication regarding the implications of genetic testing. There is disquiet however amongst some clinicians regarding their own ability to discuss genetic testing and the resulting management options for patients and affected family members regarding further risk-reducing and prevention strategies . A recen counsellThe literacy and numeracy of most general populations is low thus HCPs need to be adept at describing complex information in flexible ways without being patronising. In England, 43% of adults do not have adequate skills to understand health information only 61% have adequate numeracy skills to understand risk , 23. TheEducational programmes designed to improve communication may fail to change behaviours effectively if the methods used or the contents of them are inappropriate. Our systematic review conducted prior to the development of TRUSTING revealed that there were few publications evaluating interventions explicitly designed to help HCPs discussing hereditary breast cancer risk and testing and that most failed to operationalise the skills that were included, outcome measures or analysis . More reWe incorporated all these essentials into TRUSTING.BRCA2 pathogenic variant and that further evidence is needed demonstrating that a similar programme with different variants and scenarios would necessarily be equally effective.Due to the COVID pandemic restrictions, we were unable to conduct the communication assessments with patient simulators pre and post workshop face to face so used videotaped recordings of the proband and family members asking questions. Attendees’ responses were audio-taped which some found challenging. Despite the potential lack of realism this involved, significant improvements in communication were nevertheless observed post workshop. Attendees had varied experience and training in genetics, all self-selected to participate and were motivated to engage actively with the workshops. It will be interesting to see if the observed benefits are achieved with a wider roll-out of the educational programme. We also acknowledge that the primary focus of the workshops was centred around one fictitious family with a If mainstreaming of genetic testing is to deliver benefits for patients, families and HCPs, then more attention needs to be paid to training. Evaluation of the TRUSTING programme showed that it significantly improved the knowledge, communication skills and self-confidence of attendees sufficiently for us to consider offering the programme further to more clinical cancer teams. We intend to use the same methodology to develop other scenarios for prostate and colorectal cancer.Supplementary Tables 1-5reproducibility checklist


BRCA gene mutation carrier and automatically eligible). Eight of 139 (5.8%) never had a mammogram, while 17/131 (13%) did not have BTD reported on their mammogram and required radiologist review. Of 131 patients, 22 (16.8%) were clinically impacted by incorporation of BTD: 9/131 (6.9%) became eligible for HROBSP, while 13/131 (9.9%) became ineligible (p = 0.394). It was feasible for the Genetics clinic to incorporate BTD for better risk stratification of eligible women. This did not significantly impact the number of eligible women while optimizing the use of high-risk supplemental MRI screening.Breast tissue density (BTD) is known to increase the risk of breast cancer but is not routinely used in the risk assessment of the population-based High-Risk Ontario Breast Screening Program (HROBSP). This prospective, IRB-approved study assessed the feasibility and impact of incorporating breast tissue density (BTD) into the risk assessment of women referred to HROBSP who were not genetic mutation carriers. All consecutive women aged 40–69 years who met criteria for HROBSP assessment and referred to Genetics from 1 December 2020 to 31 July 2021 had their lifetime risk calculated with and without BTD using Tyrer-Cuzick model version 8 (IBISv8) to gauge overall impact. McNemar’s test was performed to compare eligibility with and without density. 140 women were referred, and 1 was excluded ( Breast cancer risk assessment should be performed for all women ≥25–30 years of age to optimize early detection of breast cancer.2. Women considered at high risk of breast cancer ≥40 years old must undergo screening mammography prior to referral to improve risk assessment.3. Incorporating BTD into risk assessment was feasible, did not increase the overall number of women eligible for B-MRI and optimized supplemental B-MRI screening in women with dense breasts.Breast tissue density (BTD) decreases mammographic sensitivity by masking underlying cancers. It is also a well-established independent risk factor for breast cancer (BC) ,2,3,4. MIn order to maximally benefit from early detection of breast cancer, international guidelines recommend that risk assessment for all women begin at 25–30 years of age ,9. Risk In the Genetics Clinic, prior to the introduction of the CanRisk model, IBISv8 was the predominant instrument used to assess BC risk for eligible women who had never been diagnosed with BC and who were not known genetic mutation carriers (unaffected). Version 8 incorporates BTD (for woman age 40+) and other personal risk factors along with family history of breast and ovarian cancer and is considered the most reliable model for assessing BC risk . HoweverIn this Research Ethics Board approved study from 1 December 2020 to 31 July 2021, genetic counsellors [GCs] performed risk assessments for all women who met Category B criteria for HROBSP screening eligibility (APPENDIX). All patients received one-on-one meeting with a GC. All appointments were virtual (by video or phone) due to the COVID-19 pandemic. Women were excluded from this study if they were under 40 years of age, as incorporation of BTD in IBISv8 is not validated for this age group. Women known to carry a hereditary BC risk gene were automatically eligible for high-risk screening and were excluded.GCs completed the usual HROBSP assessments using IBISv8 and calculated lifetime risk (to age 80) with and without including BTD. The calculated risk with density included was used for determination of eligibility to the HROBSP program. For the purpose of the study, both numbers were recorded, along with information regarding the length of time it took to access the BTD.® categories A, B, C, or D [p < 0.05 was used to determine significance.At our centre, most referrals for HROBSP were sent directly to the OBSP nurse navigator (NN) for triage. The NN ensured that the referral met criteria for HROBSP assessment and then forwarded it to the Genetics clinic. For the study, the NN included the report of the most recent available mammogram with the referral. BTD was assessed visually on mammograms in the region and reported using BI-RADS C, or D   never had a mammogram in the past 10 years (7) or only had a mammogram from another country (1)  with no prior history of BC underwent HROBSP assessment. One was excluded from this study as she was a known carrier of a ntry (1) .Excluding the genetic mutation carrier, 139 women were assessed, 94.2% (131/139) of whom had a mammogram available and 13% (17/131) of whom required review by a radiologist to determine BTD on the mammogram. The incorporation of BTD impacted 16.8% (22/131). When reported BTD was incorporated into the risk assessment, 6.9% (9/131) became eligible for HROBSP and MRI screening; 9.9% (13/131) became ineligible, for a net 3.1% (4/131) fewer eligible patients .p = 0.3938); even when considering the McNemar’s exact test to account for the relatively small sample size (p = 0.5235). Based on these results, the proportion of eligible individuals was not significantly different between the two assessment methods.When comparing the number of patients who were eligible with reported BTD versus the number of patients who were eligible without including density, no significant difference was identified  while 61.5% (8/13) who became ineligible had non-dense breasts (A or B). Five women who had never had a mammogram were 40–49 years old. Three women who had no mammogram available were 50–69 years and had it done outside of Ontario or remotely.When it became routine practice for the HROBSP NN to include the mammogram report in the referral to Genetics, it took no extra time for the GC to add BTD  with the other risk factors and family history information routinely collected from the patient in the risk calculation. This occurred in 87% (114/131) of assessed patients. For 13% (17/131) patients that required contact with the radiologist to help obtain the BI-RADS density score, both the GC/nurse navigator and radiologist estimated that it took about 5 min each, or 10 min in addition to the assessment, because the images were readily available for viewing. In total, for 17 patients at 10 min each, took 170 min.p = 0.3938). Despite having been referred for a high-risk assessment for BC, 5.8% (8/139) women, and the BRCA carrier, had never undergone mammography.Our results demonstrated that it was feasible to incorporate BTD in high-risk assessment for BC. Including BTD in risk assessment optimized supplemental high-risk screening. No patients with non-dense tissue became eligible and 16% (8/50) ineligible, while 12% (10/81) with dense BTD became eligible, only 6% (5/81) (category C) ineligible. More patients with dense BTD were eligible while fewer with non-dense BTD required B-MRI, with an overall reduction of 3.1% (4/131) HROBSP eligible women. Although including density impacted eligibility for 17% women, the overall number of eligible women with vs. without density was not significantly different , 84–90% for scattered fibroglandular densities (B), 69–81% for heterogeneously dense (C) and 57–71% for extremely dense (D) breasts in women 40–74 years of age . The intp < 0.001) [Initial IBIS models did not incorporate BTD v7,2004) but were updated in 2018 (v8), when BTD was shown to be more accurate in long-term assessment of BC risk . Recentl< 0.001) . In this04 but weRecently, as of October 2021, OBSP has made it mandatory for all mammograms reported through the OBSP to include the BTD according to BI-RADS categories. However, at present there is no mandatory requirement for BTD to be reported in diagnostic mammograms or screening mammogram done outside the OBSP program. BTD reporting should be mandatory for all mammograms done in Canada. In future, given these mandatory reporting requirements, it is expected that input from the radiologist will further decrease over time. In this prospective study, 16.9% (22/130) of women were clinically impacted by the incorporation of BTD with 4 fewer women requiring B-MRI. These results were consistent with the retrospective data (14.4% impacted and 4% fewer eligible women).It is notable that 8 women from our prospective study and 8 from the retrospective data had never had a mammogram. In Ontario, population screening for BC with biennial mammograms begins at age 50. Women eligible for HROBSP assessment have a strong family history of breast and/or ovarian cancer and it is generally recommended that these women start annual mammograms (outside of OBSP) beginning at age 40 or 5–10 years prior to the earliest BC diagnosis in the family . It shouBRCA1, BRCA2, PALB2, ATM, CHEK2), and three ovarian cancer risk genes  compared to BRCA1 and BRCA2 only with IBISv8 ([We recognize several limitations in our study. Inter-observer variation is well known in visual categorizing of BTD, and automated BTD was not used in our study. The 2013 BI-RADS 5th ed. density classification is based on the masking effect of BTD, while the 2003 BI-RADS 4th ed.  was base IBISv8 . Unlike IBISv8 (,20. LastOur results provide support for inclusion of BTD into IBISv8 tool for purposes of HROBSP assessment of unaffected women, aged 40–69 y as it impacted the eligibility for MRI in 17% of women. The overall number of patients eligible for B-MRI was not significantly different when density was included, implying that there would not be a substantial impact to the resource requirements of the HR-OBSP. Family physicians are instrumental in assessing patient’s risk for BC. If aware of a family history of BC in a woman 40 years or older, family physicians should order a mammogram to obtain BTD, as incorporating BTD will help to refine and improve risk assessment.


The present study examined dietary risk factors for breast cancer, their association with quality of life, and changes in eating habits in postmenopausal women after mastectomy. The study included 210 women with histologically confirmed invasive breast cancer and 225 women without a cancer diagnosis. Questionnaire data on frequency of intake of 40 different foods, the Block Food Frequency Questionnaire, and SF-36 for evaluation of quality of life were used. All questionnaire data in the patient group were collected after diagnosis. Questions about eating habits covered two time points—before breast cancer diagnosis and after completion of treatment. Logistic regression was applied to calculate the odds ratios of breast cancer risk and 95% confidence intervals. A significant positive association was found between the risk of breast cancer and more frequent intake of red meat, smoked products, offal, animal fat, white bread, potatoes, and sweets, high intake of total fat, and low consumption of dietary fibre. Foods that were inversely associated with the risk of breast cancer included fish, vegetables, fruit, wholemeal bread, and groats. The relationship between quality of life and dietary habits according to the Block Eating Frequency Questionnaire was analysed using multiple regression. It was shown that high intake of total fat reduces the quality of life in its mental components. We observed a positive change in eating habits after cancer diagnosis, albeit not always to the level in the control group. As an important lifestyle component, the diet is of great significance for primary prevention of breast cancer as well as for improving the quality of life of breast cancer patients.  Data published in 2020 show that breast cancer in women is the most commonly diagnosed cancer worldwide, with an estimated 2.3 million new cases 11.7%) per year. A high breast cancer incidence can be observed in Australia, New Zealand, North America, and Europe [1.7% per n = 61,335; mean follow-up time 11.4 years) have shown that weight loss in postmenopausal women is associated with a lower risk of breast cancer  [Established risk factors for breast cancer include sex, age, ethnicity, family history of breast cancer, gene mutations, history of benign breast disease, reproductive history, elevated levels of endogenous sex hormones, and lifestyle factors—alcohol consumption, smoking, poor eating habits, and obesity in postmenopausal women ,5. Resul= 0.020) ,11. ConfIt has been shown that the diet of most adult Poles is not balanced; healthy eating was found only in 15% of them . The dieEarlier detection and improvements in breast cancer treatment positively affect the cancer survival rate. Studies into quality of life and factors affecting the mental status of breast cancer patients are of great significance . There iThe present study examined dietary risk factors of breast cancer, their association with quality of life, and changes in eating habits in postmenopausal women after mastectomy.Participants were recruited from post-mastectomy women’s clubs in south-western Poland. A description of the parent study project and detailed socio-demographic characteristics of all study participants can be found in a previous publication . Data frThe women were classified as post-menopausal if they stopped menstruating a minimum of one year before the beginning of the study, or if they were aged ≥ 55 years. All participants volunteered to take part in the study and provided their written informed consent in accordance with the Declaration of Helsinki. The study was approved by the Research Bioethics Committee of the University School of Physical Education in Wrocław, Poland (Reference No. 27/2014).2)). The participants completed a survey questionnaire on socio-demographic characteristics ; reproductive factors ; as well as family history of breast cancer and the use of hormone replacement therapy.The basic anthropometric measurements included body height, body weight, and BMI (body mass (kg)/body height  and alcohol consumption (having at least one drink) as the number of times per week. One drink was defined as a small beer (330 mL) or a glass of wine (125 mL) or a glass of vodka, liquor, or other spirits (30 mL). In order to determine the frequency of total fat and dietary fibre intake, they completed the Block Food Frequency Questionnaire  with theQuality of life was assessed using a standardised 36-item Short Form Health Survey questionnaire. Permission was obtained from QualityMetric Incorporated to use the Polish version of the questionnaire . SF-36 is commonly applied for subjective assessment of the health status of both healthy patients and patients with breast cancer . It const-test for continuous variables and the chi-squared test for qualitative variables. The odds ratio (OR) for breast cancer risk and the 95% confidence interval (CI) were calculated using logistic regression analysis. The dichotomous variable was breast cancer incidence. The independent variables were the consumed food products (frequency/week) and the sum of points for fat and dietary fibre consumption. The independent variables were categorised based on frequency/week. For assessing the statistical significance of predictors in the logistic regression model for breast cancer risk, two-sided chi-square Wald tests were used. Tests for trend were performed by inputting the dietary variables as continuous variables. The relationships between dietary components and breast cancer risk were examined after adjusting for age and various potential confounding variables such as, family history of breast cancer, place of residence, education level, occupation, long-term stress, age at menarche, age at first birth, parity, breastfeeding duration, age at menopause, hormone replacement therapy, current BMI, alcohol intake, and physical activity. To compare changes in eating habits (frequency per week) between groups (cases before diagnosis vs. cases after diagnosis and treatment vs. control group) a single-factor ANOVA was used. When the ANOVA result was significant, the significance of differences between the groups was checked with Tukey’s test. The relationship between the quality of life of post-mastectomy women who completed treatment and the frequency of fat and dietary fibre intake was analysed using multiple regression. The following variables were included in the regression analysis: age, place of residence, education, occupation, marital status, long-term stress, parity, current body mass index, alcohol intake, physical activity, and foods. The level of statistical significance was set at p < 0.05.All statistical calculations were performed using the Statistica software package . The differences between two samples of independent variables (cases vs. controls) were checked with Student’s After diagnosis and treatment of neoplastic disease, patients reduced the consumption of food products that increased the risk of breast cancer see , includiThe results of multiple regression analysis between quality of life components, according to the SF-36 questionnaire, and the intake of fat and dietary fibre are presented in The present study examined dietary risk factors for breast cancer, their association with quality of life, and changes in eating habits in postmenopausal women after mastectomy. We found statistically significant differences between cases and controls in terms of the frequency of consumption of fourteen foods associated with breast cancer risk.Excessive consumption of animal fat, red meat, sugar, and white flour products, and insufficient amounts of dietary fibre are characteristic for Polish populations ,15. The A high percentage of women after mastectomy in the present study reported intake of smoked products more than three times a week (18.1% and 5.3% in the control group), which was significantly correlated with the breast cancer risk . Tao et al.  also shoThe main components of Polish cuisine are white wheat flour and potatoes, widely present in the Poles’ daily diet. These products feature a high glycemic index. Their consumption as well as sucrose intake leads to rapid increases in blood glucose and release of insulin-like growth factor (IGF), and promotes body mass gains. Epidemiological studies indicate that a reduction of carbohydrates in the diet can effectively reduce the risk of breast cancer . In a KoThe positive effects of frequent intake of fruit and vegetables on breast cancer incidence are often questioned . A studyAnother dietary component examined in terms of its possible association with the risk of breast cancer in women is consumption of fish, which contain n-3 polyunsaturated fatty acids (n-3 PUFA). A recent prospective cohort study  revealedAccording to Templeton et al. , about oThe dietary pattern is an important lifestyle component. In the context of nutrition, the assessment of quality of life also becomes significant. It has been proven that physical exercise and healthy eating lead to a reduction of body fat and an improvement in the quality of life of women . A lifesThere are some limitations of our study. In our research we did not take into consideration detailed clinical parameters of the cancer diagnosis, which may modify the functioning of the risk factors and affect the prognosis for the patients. The results of some long-term observations indicate that the preventive role of higher consumption of fruit and vegetables may be confined to some selected types of breast cancer. Jung et al.  found noAs an important lifestyle component, diet is of great significance for primary prevention of breast cancer as well as for improving the quality of life of breast cancer patients. Promotion of changes in eating habits should be the foundation of all cancer prevention programs.