This study explores how women diagnosed with breast cancer may be supported by physicians and nurses during physical and existential changes related to oncoplastic breast surgery in Denmark. The following research questions were addressed: (a) how do women experience oncoplastic breast surgery, and (b) how does cancer treatment affect their body image?A descriptive qualitative study design with a six‐step thematic analysis influenced by Braun and Clarke was applied in this study. This paper has been prepared in accordance with the consolidated criteria for reporting qualitative research.Fourteen in‐depth interviews with seven women diagnosed with breast cancer were conducted from August 2018 to March 2019. In this qualitative study, data analysis was performed concurrent with data construction, recognizing that the process of analysis and making sense of data should start during the interviews. We explicitly frame the discussion of the findings in a theory of embodiment influenced by Merleau‐Ponty, consistent with the construct of exploring human experiences to generate meaningful knowledge for applied practice.Two overall themes with related subthemes were identified: (1) 'Treatment is required for life‐threatening cancer', and (2) 'Striving for a new normal body'. Across both themes, women's experiences reflected a 'time pendulum' as they contemplated their past identity, their current rationale and their transition to a future beyond breast cancer with a changed body.Participants reflected on their past, present and future when facing an altered body image caused by their breast cancer diagnosis and oncoplastic breast surgery. The participants in the study expressed broad levels of satisfaction with the results of the oncoplastic breast surgery. The reconstructed breast helped them to live normally again, in particular maintaining interpersonal relationships. Breast reconstruction supported participants' embodiment experiences and redefinition of their 'new normal'.This study showed the dynamic changes in self‐definition from receiving a breast cancer diagnosis and cancer treatment to oncoplastic breast surgery. The main finding of self‐redefinition was from the perspective of breast cancer women who were in a period of transition between post‐diagnosis and consultation for oncoplastic breast surgery. The findings indicate that advanced nurse specialists in the field of oncoplastic breast surgery can enhance psychosocial wellbeing and support women pre‐ and post‐operatively by focusing on patient experiences of self‐image and embodiment. Formerly, the primary focus of breast cancer treatment was lumpectomy or mastectomy, with little to no focus on postsurgical aesthetics or psychosocial aspects related to the process and its result. However, the number of breast cancer survivors continues to grow due to advancements in surgical and medical treatment. Therefore, long‐term outcomes and the experiences of individuals with breast cancer, such as quality of life related to body image and satisfaction, have become increasingly important components of breast cancer treatment and rehabilitation. Moreover, the development of surgical techniques such as microsurgery offers more opportunities and solutions in oncoplastic breast surgery . The care and treatment of women undergoing these surgeries require nurses to consider issues related to body image and other psychosocial aspects. This qualitative study investigated experiences of Danish women diagnosed with breast cancer who received oncoplastic breast surgery to learn how nurses can support women during such bodily and existential changes.1.1The prognosis for breast cancer has significantly improved in recent decades: currently, over 1 million women worldwide are diagnosed with breast cancer annually, and there is a 75% survival rate in most developed countries , who saw human beings as consisting of two parts, body and mind, implying a mechanical perception with no causal connection between the two parts  how do women experience oncoplastic breast surgery over time, and (b) how does cancer treatment affect their body image over time?2.2The design of this study was influenced by the authors' and their nursing colleagues' experiences in a breast surgery outpatient clinic. Nurses reported that physicians advocated for oncoplastic surgery to provide improved aesthetic results after breast cancer and thereby achieve an improved quality of life in the long term, as showed in research . This study was conducted in accordance with the principles of the Declaration of Helsinki  'Treatment is required for life‐threatening cancer', and (2) 'Striving for a new normal body'. Common to the two themes were patients' feelings of being on a pendulum, reflecting on who they were in the past, their current rationale and transitioning to their life beyond breast cancer with a changed body. Figure  'Treatme3.1This theme encapsulates the finding that participants were confronted with life‐threatening cancer that required immediate treatment, and they were highly dependent on physicians for their treatment, and by extension, for their own future. The theme was further divided into two subthemes: 'The priority is to treat the cancer' and 'Being in the hands of the physicians'.3.1.1One tends to associate cancer with death, like cancer equals death' (Participant 1). Another participant described their cancer diagnosis saying, 'I was struck by lightning, but I have been lucky to survive so far' (Participant 7).The subtheme 'The priority is to treat the cancer' was found to be a very strong underlying premise for study participants, as the life‐threatening cancer diagnosis was the overarching fact occupying their minds before thinking of oncoplastic breast surgery. Participants expressed that receiving a cancer diagnosis was like a fatal 'stamp' indicating that they could die without treatment. Living with a cancer diagnosis were described by one participant as: 'The only thing on my mind when I got my diagnosis was for the cancer to disappear and I did not think much about what different kinds of surgery would mean related to femininity or to the choice of surgery in general… I just wanted the breast cancer to go away as soon as possible… (Participant 3).The participants experienced difficulty talking about their wishes related to their future breasts and body image. Treating the cancer in a way that would lead to the best possible outcome was their top priority. One participant said:For the participants in the diagnosis phase, this prioritization of cancer treatment meant, quite rationally, postponing thoughts about having breasts in the future. However, the participants did express concerns related to the potential long‐term effects of an altered body image, and because of this, they proactively requested oncoplastic breast surgery.3.1.2The physicians are in control of my cancer treatment plan… I do not know if I can get the operation while I am in chemotherapy or whether I have to wait until it is finished' (Participant 1).This subtheme captures participants' experiences of dependency during cancer treatment and in relation to the oncoplastic breast surgery, they were offered. The participants who went through chemotherapy stated that the treatment was controlled by their oncologist and that there was a recommended course of treatment to follow to achieve the best possible outcome and recovery. The participants experienced being in the hands of different specialists—breast surgeons, oncologists and plastic surgeons, each of whom had distinct perspectives related to the oncoplastic breast surgery trajectory, which blurred the long‐term plan in participants' minds. This theme was also associated with waiting for chemotherapy to take effect, or waiting to heal from surgery, so that the physician would present the next step in the process of treatment, or 'where to go next.' For example, one participant commented: 'I do tend to get worried… The last time I got filler in my tissue expander, the physician or surgeon told me that I had three to four months to lose weight if I wanted the final operation… At the same time, that is a completely unfair battle for me because I get antihormones which impede and complicate my weight loss. (Participant 6).Approval for oncoplastic surgery was highly dependent on a patient's condition, such as their body mass index and physical status; not all the participants were candidates for all types of breast reconstruction or correction. One participant offered nuanced insights into how she was in the hands of the physician, stating:Participants were dependent on the judgement of physicians, who acted as gatekeepers for treatment and surgical possibilities.3.2By their second interviews, most participants had completed their initial chemotherapy or surgical treatment; some had yet to complete certain steps, such as plastic surgery, expanders, corrections or nipple tattoos. The theme 'Striving for a new normal body' captured participants' reflections on future aspects related to their body and self. This theme also illustrated how the participants were dealing with their body at the time of the interviews, and that the process of identifying with a changed body led to different thoughts on the appearance of their breasts and their acceptance of the cosmetic result. The interpretation flowed into three subthemes: 'At least there is something in my bra,' 'Wishing for a plan for my new breasts' and 'Redefining myself after breast cancer'.3.2.1I could wish for as many as possible to get the [oncoplastic breast] surgery…. It is a big deal that you still have breasts. They may not look very, you know, but I do think they [the surgeons] have done a good job. At least there is something to fill in the bra, so I guess people will never notice that the breast is not mine (Participant 1).The subtheme 'At least there is something in my bra' relates to patient experiences of their breasts post‐surgery: a reconstructed breast had weight and volume even if it was no longer a natural breast. The participants in the study expressed broad levels of satisfaction with the results of the oncoplastic breast surgery. For example, one participant said:I had to accept that it [the breast] looks very different than my own breast, but as I have now got the message that the cancer is gone, I feel now that I can expect a decent result that I can live with the rest of my life. I do feel that I am fairly young. Maybe it would be different if I was 80 years old – then it would not be so important… But the breast and shape does imply a femininity which I have always had… Therefore I think it would be much harder for me if they [the breasts] suddenly were not there… (Participant 7).However, participants had different perspectives on the importance of physical appearance and aesthetic results from oncoplastic breast surgery. A commonality was that participants were pleased that their reconstructed breast had enough volume to fill a bra, therefore obviating a breast prosthesis. As one participant expressed:Participants also compared the surgical outcome with the alternative of having no breast(s) and reasoned that the volume of the reconstructed breast(s) was better than a flat chest due to mastectomy.3.2.2I want to move on with my life now… That is also why I tend to get a bit sceptical [of the reconstruction operation plan]… When can I get the operation, because it stops my work life…?' (Participant 7). When the participants did not have a clear plan, they expressed insecurity, which could indicate uncertainty about reconstruction:I think the plan is on standby for now, they [the physicians] have to see the result. People tell me, like, wow, those [new breasts] are so nice… That might be true, I do not know, and I do not think I can commit to this yet because I do not know if they are finished or if they [the prostheses] are here to stay (Participant 7).During the second interview, the participants had completed the initial phases of treatment and were increasingly preoccupied with the construction of the new breast(s), identified in the 'Wishing for a plan for my new breasts' subtheme. The participants also expressed a wish for a concrete plan for the reconstruction of their breasts as part of returning to daily life, for example: 'I do not quite know how much volume I can get into the expanders. When I ask, I feel that is it not a subject of importance and that the issue is being easily bypassed because they tell me that we must wait and see how much volume the expander and skin can hold and how the breast shapes, so I listen to that, although I cannot get a concrete answer… To me, it is important if the breasts look how I want or if I just have to fit into their opinion (Participant 2).Another participant also expressed frustration due to a lack of answers to specific questions they had related to their breasts:I could have used that when I got the breast cancer diagnosis and I was told that my breast should be removed; someone should have talked to me about the options [related to the breast]—what would have been good for me and what could possibly happen' (Participant 1).Another participant raised the issue that plans for breast reconstruction should have been discussed at the diagnosis stage, even though participants often focused initially on treatment rather than future breast reconstruction: '3.2.3My focus has been to get going after the disease, being me and keeping up the everyday life we used to have. For me it was like ‘get into the game,’ cheer up, take a walk and go to work… (Participant 5).During the interviews, participants elaborated on what they experienced as a unique situation: dealing with a cancer diagnosis while simultaneously being hopeful about their future. This subtheme was identified as 'Redefining a self after breast cancer reconstruction'. One participant commented on their way of coping with the situation:Looking at my breasts is very extraordinary. Feeling them is extraordinary. I think it is comparable to giving birth, then the body is a completely different universe until it is healed. In the situation, you adjust to the condition, and you mentally retrieve the situation… It is the same with breasts (Participant 2).Another participant expressed a rather pragmatic way of redefining the body after cancer and reconstructive surgery:‘I felt that my personality suddenly changed…I lost my hair [due to chemotherapy] and then I had just small breasts and no hair…Now, after the [oncoplastic breast] surgery, the only one that is affected by the truth [of the previous cancer] is me and my naked body’ (Participant 2). This participant's experience in particular illustrates how individual experiences were affected by past diagnoses; how they approached defining a new self; and how they thought about their future, including integrating it with their personal history. They were experiencing a transition.Participants also elaborated on how the trajectory of treatment had not only affected their body but also their personality: 4This study was performed to investigate women's experiences with oncoplastic breast surgery and how the cancer treatment affected their experiences of body image. Two themes were identified: (1) ‘Treatment is required for life‐threatening cancer’, and (2) ‘Striving for a new normal body’. The first theme summarizes how participants focused primarily on treating the cancer; at the same time, they were dependent on physicians for their cancer treatment and surgical plans. The second theme expresses participants' reflections on future aspects related to their body and self, including their postsurgical experiences of breast reconstruction; this theme also reflects the fact that participants actively requested a plan and were striving to redefine themselves.The themes and subthemes extracted from the interviews with participants illustrate the complex situation women confront when diagnosed with breast cancer, a potentially life‐threatening disease. The interviews indicate that 6 months after diagnosis, participants remained in a condition of acute crisis related to their cancer diagnoses, a finding confirmed by previous research .https://publons.com/publon/10.1111/jan.15309.The peer review history for this article is available at


Physical activity (PA) changes throughout an individual’s life, but the association between such changes and cancer risk seems to be overlooked in the literature. Thus, this study aimed to examine the association between the trajectories of PA frequency and cancer incidence among middle-aged Korean adults.A total of 1,476,335 eligible participants  aged ≥40 years from the National Health Insurance Service cohort (2002–2018) were included. Assessment of PA frequency was a self-reported measure, based on the question: “How many times per week do you perform exercise that makes you sweat?”. PA frequency trajectories  from 2002 to 2008 were identified using group-based trajectory modeling. Cox proportional hazards regression was used to assess the associations between the PA trajectories and cancer incidence.Five PA frequency trajectories over 7 years were identified: persistently low , persistently moderate , high-to-low , low-to-high , and persistently high . Compared with persistently low frequency, maintaining a high PA frequency was associated with a lower risk of all cancers (Hazard ratio (HR) = 0.92, 95%CI = 0.87–0.98) and breast cancer  among women. There was a lower risk for thyroid cancer among men in the high-to-low , low-to-high , and high PA trajectories . There was a significant association between moderate trajectory and lung cancer in men , in both smoking and non-smoking men.Long-term persistent high frequency of PA as part of the daily routine should be widely promoted and encouraged to reduce the risk for all cancer development in women.The online version contains supplementary material available at 10.1186/s11556-023-00316-5. The protective effect of physical activity (PA) on cancer risk via multiple potential mechanisms, such as reduction in circulating estrogen levels, insulin resistance, and inflammation, has been well-documented . Strong Recently, group-based trajectory modeling (GBTM) was developed as a novel approach that overcomes the disadvantages of the traditional method. GBTM can fully capture behaviors accounted for within-individual variation throughout the life course, and it has been commonly utilized for determining risky behaviors, such as tobacco use and alcohol consumption. Although GBTM has been increasingly applied to identify PA trajectories in relation to mortality and several disease outcomes –6, its aThe association between the trajectory of PA and cancer risk has not been well-explored. To date, only one case-control study has investigated the impact of PA trajectory on pancreatic cancer risk . The traIn South Korea, a high proportion of adults participate in insufficient PA , and it This study used data from a nationwide population-based cohort study that used the database provided by the National Health Insurance Services (NHIS) in South Korea . In brieThe frequency of PA was measured using a questionnaire as part of the general health examination, the main question used was: “How many times per week do you perform exercise that makes you sweat?”, and the five responses were 1) none, 2) 1–2 times, 3)3–4 times, 4)5–6 times, or 5) almost every day. We decided to determine the trajectories of PA frequency from 2002 to 2008 because the questionnaire has changed since 2009. As the general health examination was recommended biennially, four 2-year period time points  were used to measure the trajectories of PA frequency. As aforementioned, we aimed to determine PA trajectories during the longest observable duration; therefore, we chose the exposure period of 7 years, from starting of the database  to the end of time before revising the health examination questionnaire .PA trajectories were identified using the GBTM method proposed by Nagin with the PROC TRAJ in SAS . The maxThe International Classification of Diseases 10th edition (ICD-10) codes were used to evaluate the incidence of all cancer types (C00–C97) and several specific cancers, including colon and rectal (C18–20), liver (C22), lung , breast (C50), corpus uteri (C54), and thyroid gland cancers (C73). Furthermore, a special code for cancer claims (V193) was additionally used to identify cancer occurrence during the follow-up period. All participants were followed-up until the date of cancer onset, death, or the end of the follow-up period .Covariates were retrieved from baseline (2002–2003). Sex and age were included, and income levels were divided into quartiles, from Q1 (lowest income) to Q4 (highest income).2), normal (18.5–22.9 kg/m2), overweight (23–24.9 kg/m2), and obesity (≥25 kg/m2), according to the World Health Organization (WHO) obesity standard for the Asian population [Behavioral risk factors were measured, including smoking status, body mass index (BMI), and alcohol consumption. Smoking status was categorized into three groups: non-smoker, former smoker, and current smoker. BMI was classified as underweight  in the multivariate model for liver cancer. For sensitivity analysis, we examined the association between PA trajectories and cancer incidence by smoking status and BMI groups. All statistical analyses were stratified by sex and performed using SAS 9.4 .More than two-thirds of the study participants had a low frequency of PA , while approximately 15% and only 3% had a moderate and high frequency of PA during approximately 7 years, respectively.The baseline characteristics according to the trajectories PA frequency in men and women are shown in Table During the 9,368,662 person-years of follow-up, 84,703 men developed cancer. In the age-adjusted model, compared to the low category, men with a moderate trajectory of PA had a lower risk for all cancers , and specific cancer of colorectum  and lung . A significantly lower risk for lung cancer was also observed in men with high-to-low and high frequency trajectory of PA. After adjusting for other potential confounders, only significant effect of the moderate trajectory of PA on a lower risk for lung cancer incidence remained . Additionally, compared to the low trajectory, there was a lower risk for thyroid cancer among men in the high-to-low , low-to-high , and high trajectories   and breast cancer   –23. HencThe link between PA and cancer risk, especially that of specific cancers, has been established in observational studies; however, to our knowledge, no study has assessed the effect of PA trajectories on the risk for all cancers. Limited research has shown an inverse impact of non-trajectory-based PA on the development of all cancers , 25. In World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) determined the relationship of total PA with lung cancer risk to be limited-suggestive evidence . A recenThe association between PA and thyroid cancer is inconclusive. The very first case-control study in the US established the hypothesis that regular recreational exercise reduced the risk for thyroid cancer (Odds ratio (OR) = 0.76, 95%CI = 0.59–0.98) and was also supported by other case-control studies in European countries . AnotherThe favorable impact of PA on breast cancer prevention was observed in postmenopausal women, and limited-suggestive evidence for this has been shown among premenopausal women by the WCRF/AICR . A meta-Convincing evidence demonstrated that the highest level of total PA reduced the risk for colon cancer by 20% versus the lowest level  . In the Findings regarding the impact of PA on endometrial cancer risk in women have been largely equivocal as some studies showed an inverse association , 38, whiAdditionally, while our study observed a null association between PA trajectory and risk for liver cancer, WCRF/AICR showed evidence that the association between liver cancer and PA was “limited-suggestive” , and a mOur study had several limitations. First, since the NHIS cohort did not use the global PA questionnaire developed by the WHO , we coulMore than two-thirds of the middle-aged Korean population had a low frequency of PA for approximately 7 years. Compared to persistent low frequency, maintaining a high frequency of PA was significantly associated with a lower risk for the onset of all cancers and breast cancer in women; and thyroid cancer among men. A reduction in the risk for lung and colorectal cancer was also observed for smoking men who had a moderate level of PA frequency relative to those who had a low level of PA frequency. Thus, our study suggests that increasing physical activity as part of the daily routine should be widely promoted to protect individuals against cancer development for women.Additional file 1.


Breast cancer is one of the leading causes of death worldwide, it affects both men and women. In Saudi Arabia, breast cancer has been the most prevalent type of cancer in women, for the past few years. Dietary habits and cultural beliefs vary according to region, and further studies are required to demonstrate the relationship between these dietary habits and cultural beliefs and the risk of developing breast cancer. This study is aimed to discover the relationship between preventive dietary factors of the Mediterranean diet and rates of breast cancer among postmenopausal women in the Makkah region of Saudi Arabia.A case-control study was conducted in King Abdulla Medical City Hospital, Makkah, Saudi Arabia and included 432 Saudi female participants: 218 in the control group and 214 breast cancer patients. All participants were postmenopausal, around the same age, and all were ethnically Arab Saudis. Data were obtained using a self-administered validated questionnaire.p < 0.05) reduces the risk of breast cancer.Study results showed that a diet that includes 1–2 servings of legumes weekly, 1–5 servings of fish weekly, 1–5 servings of dairy products daily, 3–5 servings of fruits and vegetables daily, and more than one cup of black tea and coffee per day significantly (This study demonstrates that consuming a Mediterranean diet, which includes legumes, fish, fruits and vegetables, black tea, coffee, and low intake of dairy products, works as a preventive factor against breast cancer in postmenopausal females from the Makkah region. Breast cancer is one of the leading causes of death worldwide, with 2.3 million newly diagnosed women in 2020 . In SaudIn addition to a high intake of olive oil, the Mediterranean diet focuses on a plant-based consuming pattern with high fiber intake from fruits and vegetables, legumes, and cereals and high omega-3 from fish and kinds of seafood. Furthermore, moderate intake of dairy products and low intake of red meat and poultry are also recommended in the Mediterranean diet . A recenSeveral risk factors contribute to increased risk of breast cancer, which include alcohol, obesity, a sedentary lifestyle, exogenous estrogen and progesterone, menarche at an early age (<12 years old), previous surgeries or biopsies, previous mammography screenings, and never giving birth or breastfeeding are all risk factors for breast cancer , 7. HoweRegional differences in diet and lifestyle habits play a role in breast cancer development; women in Saudi Arabia have different dietary habits depending on the region they live in and their cultural beliefs. Further studies are required to investigate the effect of dietary habits on breast cancer in different cultures. Additionally, women after menopause could be at higher risk of breast cancer than premenopausal women . TherefoThis case-control study took place in King Abdullah Medical City Hospital in the Makkah region of Saudi Arabia from June 2014 to November 2016. This hospital is the biggest in the region and the only center that provides screening and treatment of cancer locally.p > 0.05) different. Additionally, no significant differences (p > 0.05) were found in caloric intake  between the case and control groups. Diagnoses of breast cancer patients were confirmed by biopsy by the oncologist in the same hospital. To control the racial factors, only ethnically Arab women were invited to this study. The control group was healthy women without any acute or chronic disease and they were chosen from the hospital workers and patients' families or friends. They were selected from the same region and age range as the cases with a single year of age in the match and without any acute or chronic disease. A total of 432 female participants were recruited (214 cancer cases and 218 controls). Only Saudi postmenopausal women who were newly diagnosed with breast cancer and aged above 45 years old were included. A postmenopausal woman is defined as any woman who no longer has her periods for at least a year. The mean ages of the case and control groups were 57 ± 7.3 years old and 56.9 ± 8.6 years old, respectively, which was not significantly , following the Declaration of Helsinki rules. Eligible women read and signed the consent form before starting the data collection.Camellia sinensis). In the Saudi community, black tea is generally offered in an 80-ml cup, while coffee is offered in a 50-ml standard cup. Other food categories that include fish and seafood, olive oil, green leafy vegetables, and legumes were recorded weekly. Daily bread consumption and preferences for either white or whole wheat bread were also assessed. All participants were taught about the serving size for each food item prior to starting the questionnaire. The registered dietitian measured the height and weight of the participants using the Detecto physician scale, available at the hospital . Body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared.Data for this study were collected using convenience sampling and face-to-face interviews. Participants were asked to fill out a questionnaire, supervised by a registered dietitian. The questionnaire recorded personal information and questions about dietary habits; a validated dietary questionnaire from the 2017 work of Azzeh et al.  was usedp < 0.05 was set for the significant differences. A suitable test was used to decide the value of p for each parameter. The data were arranged using a case-control status to verify the differences between the cases and the controls. To assess the risk factors related to breast cancer, the odds ratio (OR), 95% confidence intervals (95% CI), and β-coefficient were determined. All variables were adjusted according to the confounders described in Alsolami et al.'s article ; a value of  article , which wp < 0.001) than the case group  than that of the case group (21.8%). The literacy percentage in the control group (0.5%) was lower (p < 0.001) than that of the case group (7.4%). The case group had a noticeably larger (p < 0.001) family size as compared to the control group. Menarche at an early age (<10 years old) was remarkably higher (p < 0.001) in the case group as compared to the control group. The consumption of hormonal contraceptives was higher (p < 0.001) in the case group as compared to the control group . No differences (p > 0.05) were shown regarding marital status, family history of breast cancer, age of menopause, and breastfeeding duration in either control group or case group. The complete details for the baseline characteristics of the participants were published previously in Alsolami et al.'s research (Results of this study showed that the employment rate in the control group (41.2%) was higher  between the two groups. However, no differences (p > 0.05) between the two groups were found regarding the number of meals consumed per day, poultry intake, and whole wheat vs. white bread.p < 0.05) between the groups based on consumption of fish and seafood (measured in servings per week), leafy vegetables (servings per week), and olive oil (servings per week). Data measuring the consumption of black tea (cups per day) and coffee (cups per day) also showed a difference (p < 0.05) between the case and control groups. Only 8.3% of the control group ate <1 serving of fish and seafood every week when compared to 29.9% of the case group. Around 3.7% of the case group consumed <1 serving per week of green leafy vegetables, while only 1.4% from the control group ate <1 serving per week. Participants in the control group consumed olive oil (p < 0.001) more than the case group; 9.6% of the control group consumed <1 serving of olive oil per week, while 26.2% of the cancer cases consumed <1 serving of olive oil per week. About 56 and 36.4% of the control group and the case group, respectively, consumed 1–2 servings of olive oil per week. Participants with breast cancer tended to drink less black tea (in cups per day) as compared to healthy participants (p < 0.009): 18.7% of the participants with breast cancer consumed <1 cup of tea per day, while 10.1% of the healthy subjects consumed the same amount of tea daily. Subjects from the control group also consumed more coffee: only 9 control subjects (4.1%) drank <1 cup per day as compared to 48 subjects (22.4%) with breast cancer.p = 0.032), as was the consumption of 3–5 servings of dairy products daily . Results also showed a preventive effect of consuming 1–2 servings of legumes per week , 3–5 servings of fruits and vegetables per day , 1–2 servings of fish and sea food per week , and 3–5 servings of fish and sea food per week . Drinking 1–2 cups of tea  or 3–5 cups of tea daily was shown to reduce the incidence of breast cancer . The daily intake of 1–2 cups of coffee , 3–5 cups of coffee , or even more than 5 cups of coffee per day  had shown to reduce the incidence of breast cancer.Potential dietary habits related to breast cancer incidence are shown in In Saudi Arabia, the rate of breast cancer ranges from three to eight confirmed cases for every 1,000 patients. Breast cancer accounts for 14.8% of all cancers reported among Saudi nationals and about 29% of cancers among women of all ages , or by reducing the formation of blood vessels in the tumor (angiogenesis) , 16. A rDairy products are also a good source of calcium, which plays a role in reducing the risk of breast cancer. Although the exact mechanism is still unclear, a meta-analysis of eleven studies by Hidayat et al.  showed aConjugated linoleic acid (CLA) in dairy products is considered a chemoprotective agent. CLA also has antioxidant and anti-inflammatory effects that can decrease the risk of developing breast cancer . ResearcThe study results also showed that the consumption of one to two servings of legumes per week had a negative association with breast cancer incidence. Various phytochemicals in legumes have an inhibitory effect on cell proliferation. Xu and Chang  compreheFruits and vegetables are rich sources of fibers that are known to protect against breast cancer. Women who have a daily intake of three to five servings of fruits and vegetables are 83.9% less likely to develop breast cancer. An important study by Farvid et al.  concludeWomen in the Makkah region consume seafood and fish regularly, especially on holidays. Our study indicates that consuming up to 5 servings of fish and seafood weekly reduces the risk of breast cancer by 78.9–92.8%. The positive effect of fish consumption appeared to be limited to certain common types of cancer, such as breast cancer . EngesetOur study found that the consumption of coffee and black tea had a negative relationship to the development of breast cancer. In black tea, several antioxidant compounds and chemoprotective components are well known; catechins, particularly gallate epigallocatechin, exerted important antioxidant properties by decreasing the number of reactive oxygen species . Other cA systematic review and meta-analysis published in 2015 indicated that the increased consumption of total saturated fat positively affected breast cancer incidence . MoreoveThis study is limited by the semiquantitative measurement of food intake, which is a common problem with studies that use food frequency questionnaires and recall bias. This study was also limited by the regional sample collection, relatively small sample size, and recruitment of exclusively postmenopausal women for both case and control groups. Furthermore, it is noteworthy to perform further studies about the association between the adherence to the Mediterranean diet and breast cancer incidence and/or mortality rate.Our study in the Makkah region concluded that the consumption of fish and seafood, fruits and vegetables, legumes, coffee, black tea, and dairy products can have preventive effects against breast cancer. Dietary factors of the Mediterranean diet that did not show a significant effect on breast cancer incidence included olive oil, whole wheat, and leafy vegetables. It is recommended to perform additional studies using cohort study design in various regions of Saudi Arabia and with more participants.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board of Umm Al-Qura University. The patients/participants provided their written informed consent to participate in this study.FA conceived and designed the study. DH, AQ, KG, WA, AAA, AFA, HAA, and MG conducted research, provided research materials, and collected and organized data. HMA, MA, MH, AYA, SM, MQ, and WB analyzed and interpreted data. All authors wrote the initial and final drafts of the article and critically reviewed and approved the final draft of the manuscript.Taif University Researchers Supporting Project number (TURSP-2020/350), Taif University, Saudi Arabia.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.


We aimed to explore serial mediatory roles of erythrocyte n– 3 PUFAs in association between dietary n– 3 PUFAs and breast cancer risk.Dietary n– 3 PUFAs were measured by gas chromatography. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained using multiple unconditional logistic regression models to examine association between dietary n– 3 PUFAs and breast cancer risk. Mediation analyses with bootstrapping were conducted to investigate indirect effects.Using a case-control study, 850 cases and 861 controls completed structured questionnaires with dietary information. Erythrocyte n– 3 PUFAs and total n– 3 PUFAs was associated with lower risk of breast cancer. The adjusted ORtertile 3 v.1 (95% CI) was 0.70  for ALA, 0.76  for long-chain n– 3 PUFAs and 0.74  for total n– 3 PUFAs, respectively. Mediation analysis showed that erythrocyte long-chain n– 3 PUFAs served as sequential mediators in the relationship between dietary long-chain or total n– 3 PUFAs and breast cancer risk. In particular, erythrocyte long-chain n– 3 PUFAs completely mediated the association between dietary long-chain n– 3 PUFAs and breast cancer risk [indirect effect (95% CI) = –0.982 ]. The relationship between dietary total n– 3 PUFAs and breast cancer risk was partly mediated by erythrocyte long-chain n– 3 PUFAs [indirect effect (95% CI) = –0.107 ], accounting for 19.31%. However, the serial mediation model in dietary ALA and risk of breast cancer was not statistically significant [indirect effect (95% CI) = –0.042 ].Higher intake of dietary ALA, long-chain n– 3 PUFAs to examine their associations with breast cancer risk without considering the variety of metabolic processes. Interventions aimed at increasing erythrocyte long-chain n– 3 PUFAs may represent a promising strategy for breast cancer prevention.This study highlights the complexity and inaccuracy in using a simple analysis of individual dietary  The metabolic equivalent (MET) hours per week was used to estimate physical activity, and the detailed methods of calculating MET have been described previously . The body mass index (BMI) was calculated as the current self-reported body weight (kg) divided by the height squared   and total n– 3 PUFAs (ALA + EPA + DPA + DHA). The major food sources of dietary EPA, DPA, and DHA are fish, seafood and fish oil. Few foods contain only one type of long-chain n– 3 PUFA. Therefore, long-chain n– 3 PUFAs were not disaggregated.Dietary re (FFQ) . For eacre (FFQ) . Our stuFasting venous blood samples were obtained on the second day of the participants’ admission and before any medication, surgery or examination. Erythrocytes were washed three times with normal saline and separated within 2 h of collection and were stored at –80°C for subsequent analysis. Erythrocyte concentrations of fatty acids were measured by gas chromatography (GC).n– 3 PUFAs.The extraction of fatty acids was conducted using the method described by Folch et al.  with chlU-test for continuous variables and χ2 test for categorical variables to examine differences in characteristics between breast cancer cases and controls. Dietary n– 3 PUFA intake was energy-adjusted using the residual method . Second, regression Equation 2 explains the effect of X on the mediating variable M. When the regression coefficient a is significant, it indicates the existence of an effect of the independent variable on the mediating variable. Third, regressing the X and M on Y simultaneously. It reveals the association between X and Y adjusted for M and the association between M and Y adjusted for X (regression Equation 3).We used Mann-Whitney l method  and thennd Hayes , where tn– 3 PUFAs as X, breast cancer as Y, and erythrocyte n– 3 PUFAs as M at 95% confidence interval. A significant mediation effect was established if zero was not between the lower and upper bound. We calculated the direct, indirect and total effects after adjusting for age, BMI, MET-h/week, education, passive smoking, regular drinking, first-degree relatives with cancer and energy intake.A bootstrapping method was applied to test the significance of mediating effect, which has high statistical power . In the P value < 0.05 indicated statistically significant.Analyses were performed using SPSS version 25.0 . A two-sided n– 3 PUFAs and total n– 3 PUFAs than those of controls. Besides, erythrocyte individual and total n– 3 PUFAs proportions in cases were lower than those in controls.The characteristics of the cases and the control subjects are shown in n– 3 PUFAs and total n– 3 PUFAs was associated with decreased risk of breast cancer. The adjusted ORtertile3vstertile1 (95% CI) was 0.70  for ALA, 0.76  for long-chain n– 3 PUFAs and 0.74  for total n– 3 PUFAs, respectively.As presented in n– 3 PUFA intake (see P > 0.05). Positive correlations were observed between dietary long-chain n– 3 PUFAs and erythrocyte long-chain n– 3 PUFAs . Meanwhile, higher intake of total n– 3 PUFAs was related to higher proportions of erythrocyte EPA and DHA , but not DPA . Erythrocyte n– 3 PUFAs were significantly and positively correlated with each other .In control subjects, erythrocyte ALA was not related to any dietary n– 3 PUFAs [total indirect effect (95% CI) = –0.042 ].The results of the mediation analysis on dietary ALA intake and breast cancer risk are reported in n– 3 PUFAs and breast cancer risk (see n– 3 PUFAs and breast cancer risk . The chain mediation of erythrocyte EPA and DPA or DHA between dietary long-chain n– 3 PUFAs and breast cancer was significant . The serial mediating effect of erythrocyte EPA, DPA, and DHA was significant [indirect effect (95% CI) = –0.018 ]. Combined with Mediating analysis revealed the mediation effect on relationship between consumption of dietary long-chain risk see . The dirn– 3 PUFAs and breast cancer risk. Significant direct effect and total indirect effect were found . The total mediating effect of dietary total n– 3 PUFAs on risk of breast cancer was 19.31%. Erythrocyte EPA and DPA partially mediated the effect of dietary total n– 3 PUFAs and breast cancer risk [indirect effect (95% CI) = –0.025 ]. Erythrocyte EPA and DPA accounted for 4.51% on the correlation between dietary total n– 3 PUFAs and breast cancer risk. Similarly, erythrocyte EPA and DHA partially mediated the effect [indirect effect (95% CI) = –0.021 ], accounting for a mediation ratio of 3.79%. The association between dietary total n– 3 PUFA intake and breast cancer risk was partly mediated by erythrocyte EPA, DPA, and DHA sequentially [indirect effect (95% CI) = –0.003 ], accounting for a mediation ratio of 0.54%.n– 3 PUFAs and breast cancer risk, and further explored the serial mediating role of erythrocyte n– 3 PUFAs within the linkage of dietary n– 3 PUFAs and breast cancer risk. The inverse association of dietary long-chain or total n– 3 PUFAs with breast cancer risk could be accounted for the potential beneficial actions of dietary long-chain or total n– 3 PUFAs on increasing erythrocyte long chain n– 3 PUFAs. However, erythrocyte n– 3 PUFAs were not mediators in the association between dietary ALA and breast cancer risk.The current study examined the association between dietary intake of n– 3 PUFAs was not significant in the association between dietary ALA intake and breast cancer risk. There are some possible explanations. First, we failed to find the indirect effect of erythrocyte ALA on the relationship between dietary ALA and breast cancer. ALA, an essential fatty acid, cannot be produced endogenously and is closely tied to dietary exposure. However, consistent with previous studies  the relationship between dietary long-chain l et al.  revieweday occur , 45. DPA species . AA-deri species . The DPAn et al.  demonstrh plasma .n– 3 PUFAs and breast cancer risk was partly mediated by erythrocyte long-chain n– 3 PUFAs. As mentioned above, the source of dietary ALA was complex and diverse. For example, the inverse association of ALA from fruits and vegetables with the risk of breast cancer might be associated with other compounds in fruits and vegetables, such as folate % and 93.32 (±6.41)%, respectively], it was possible that the relationship between total n– 3 PUFAs and breast cancer risk was influenced by other nutrients. The partial mediation implied that there might be other mediators’ worth exploring in the association between dietary total n– 3 PUFAs and breast cancer risk. For example, it was found that mice fed with diets containing increasing amounts of EPA + DHA had decreasing levels of erythrocyte n- 6 PUFAs and increasing levels of erythrocyte saturated fatty acids (SFAs) (n– 3 PUFAs for 4 months had decreased level of erythrocyte n-6 PUFAs and increased level of erythrocyte monounsaturated fatty acids (MUFAs)  . Prisco  (MUFAs) . This inn– 3 PUFAs consumed and breast cancer risk for the first time. Several limitations should be taken into account. Firstly, as a case-control study, the causal sequence of variables cannot be curtained. Longitudinal studies were needed to verify the causality of all variables in the future. Secondly, subjective self-report and recall bias might exist. To diminish it, we used photographs with usual portion size of foods to obtain intake as accurately as possible and recruited patients who were diagnosed less than 3 months before the interview. Thirdly, we only had a single measure of erythrocyte n– 3 PUFAs, which may not ideally reflect long-term exposure. However, one study showed that no statistically significant increase was observed in the level of n– 3 PUFAs over time in the Cardiovascular Health Study across 13 consecutive years of measures (Strengths of this study include the relatively large sample size and a number of potential confounders. We were further able to apply mediation analysis of four mediators on the association between dietary measures . Finallyn– 3 PUFAs on breast cancer risk was at least partially explained by beneficial effects of total n– 3 PUFA intake on increasing the erythrocyte long-chain n– 3 PUFAs. Importantly, erythrocyte long-chain n– 3 PUFAs may fully explain the protective effect of consumed long-chain n– 3 PUFAs on breast cancer risk. The links between dietary n– 3 PUFAs and breast cancer risk may be mediated by erythrocyte long-chain n– 3 PUFAs, whereas evidence of a mediating role of erythrocyte ALA was not supported. This study highlights the complexity in using a simple analysis of dietary individual n– 3 PUFA to predict breast cancer risk without considering the variety of metabolic processes. We demonstrated the possibility of erythrocyte n– 3 PUFAs to interpret the role of dietary n– 3 PUFAs in breast cancer risk. Interventions aimed at increasing erythrocyte long-chain n– 3 PUFAs may represent a promising strategy for breast cancer prevention. Identifying the ratios between long-chain n– 3 PUFAs that are best for human health, including those between n-6 PUFAs could be investigated in future studies.Our findings suggest that the influence of dietary total The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethical Committee of the School of Public Health, Sun Yat-sen University. The patients/participants provided their written informed consent to participate in this study.ZZ collected the data, performed the experiments, analyzed the data, and wrote the manuscript. YJ, XL, DS, TM, and RZ participated in data collection and experiments. CZ was responsible for designing and writing grants, supervision of the research, and wrote the manuscript. All authors contributed to the article and approved the submitted version.


Cancer has remained one of the leading causes of death worldwide. In Lesotho, breast and cervical cancers contribute about 43% of all the cancer cases annually.This study is aimed at comparing knowledge, attitudes, and practices between breast and cervical cancers among females in Maseru.This study consists of women residing in five study sites which have clinics that offer cervical and breast cancer-screening services.A cross-sectional study was conducted in June 2021 in Maseru, the Capital city of Lesotho. The participants were interviewed using a pre-tested questionnaire, through which their knowledge, practices about, and attitudes towards breast and cervical cancers were assessed.A total of 228 women aged 15–75 years participated in the study and the majority were aged 30 years and above. Of the women interviewed for cervical cancer, 89.5% had heard of it, 11.8% had heard of its screening, and 7.4% had at least one examination. Similarly, for breast cancer, 77.6% of women who had heard of it, 72.9% had heard of screening, and 40.1% of women did at least one examination.The majority of women were more knowledgeable about cervical cancer than breast cancer. However, more women had heard about breast cancer screening than cervical cancer screening. Therefore, there is a need for awareness campaigns related to cervical cancers’ screening.There is an urgent need to intensify awareness about cervical and breast cancer screening and availability of services at the nearby clinics. Among women, breast cancers have evidence-based methods of prevention and early detection which can be employed even in low-resource countries.2 It has been established that the risk factors for breast cancers are mainly modifiable and include alcohol use, physical inactivity, and obesity.8 However, in relation to breast cancer, the three most important risk factors for women include: gender, age, and family history of breast or ovarian cancers.10 Other risks associated with breast cancer include genetic mutations of genes, such as BRCA1 and BRCA2.11 Exposure to drugs such as diethylstilbesterol and radiation therapy are also implicated in the promotion of breast cancer.12 Women with dense breasts have also been proven to have higher chances of developing breast cancer than average.13 As a way of ensuring and promoting breast health,6 individualised breast cancer risk assessment has been considered paramount.14In 2020, it was further noted that the most commonly diagnosed cancer worldwide is female breast cancer followed by lung cancer.14 This incidence has reportedly been attributed largely to a protective reproductive history of SSA women. The majority of women in SSA reach menarche late and menopause early. There is further high parity with prolonged breastfeeding. They experience irregular menses and fewer ovulatory cycles and these all contribute to the low incidence of breast cancer amongst these women.13 Despite such a low incidence among the SSA women, the majority of breast cancer cases were diagnosed at an advanced stage, resulting in higher mortality rates.15 Delay in patients’ seeking healthcare has been because of people’s ignorance of the early stages of and the stigma associated with the disease.15 Studies have further shown that women’s knowledge about and attitude towards the disease significantly influence their health-seeking behaviour.17Research has shown a relatively low incidence of breast cancer among women in sub-Saharan Africa (SSA) compared to African–American women.11 However, more intensive screening such as performing a mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging has been shown to be more effective especially for the detection of less aggressive cancers and cancers in women with dense breasts.17 Studies have shown that breast cancers mainly detected by the clinical breast examination are those presenting with aggressive features.17 Early diagnosis of breast cancers in symptomatic individuals is relatively simple to implement, with significantly less investment being required.17 Therefore, adequate knowledge is important to influence positive attitudes, beliefs, and practice regarding breast cancers.18Practices such as breast self-examination and clinical breast examination have been shown to reduce breast cancer stage during diagnosis.19 Chronic infections with human papillomavirus (HPV) have reportedly been the main risk factor for cervical cancer.21 This is made worse by sexual intercourse at early ages and, with multiple sexual partners, which increases the risk of contracting cervical HPV infection.23 In addition, higher parity, oral contraceptive use, HIV infection, and smoking are also associated with other high-risk HPV subtypes.22 It was observed that cervical cancer is mostly prevalent in regions with high HIV infection, such as SSA.24 Cervical cancer was the most common cancer diagnosed in 2020 in Lesotho.4 Key to the prevention of cervical cancer is the identification of the premalignant disease through cervical screen as well as vaccination against HPV.25 There is evidence of high acceptability of the HPV vaccine in SSA.23 With the availability of screening and the HPV vaccine as well as generally slow progression of the disease,22 cervical cancer is considered nearly completely preventable.It was further noted that in developing countries, the cervical cancer-related deaths are almost 90%, and this is attributed to the fact that SSA, Central and South America, and South-Eastern Asia have the highest cervical cancer incidence and mortality rates.26 While the majority of the participants have demonstrated knowledge about and positive attitudes towards these cancers, there have been noticeable poor health-seeking practices with a high incidence of advanced cervical and breast cancer on diagnosis.27 Knowledge about the risk factors of the diseases, the attitude towards these cancers as well as the availability and utilisation of the cervical, and breast cancer-screening services in Lesotho are crucial in the fight against these cancers. The Senkatana Oncology Clinic is a clinic established with the joint effort of the National University of Lesotho and the Senkatana Center of Excellence. The clinic is envisioned to provide cancer treatment as well as engaging in cancer awareness and screening campaigns among the citizens of Lesotho. The study was, therefore, aimed at assessing the baseline knowledge, attitudes, and practices of the residents around the clinic, with the purpose to encourage early diagnosis and treatment of these cancers.However, several studies have shown a gap in the knowledge, practices, and attitudes towards cervical cancer and breast cancer.The quantitative cross-sectional study design was adopted, and a structured questionnaire was used. The study was conducted in June 2021 in Maseru, the Capital city of Lesotho.28 The literacy rate is 87.4% (95% women and 85% men), and Lesotho offers free primary education. About 38% of women and 59% of men are employed.28 The selected study sites have primary healthcare facilities that offer cervical and breast cancer screening. Village health workers offer cancer education to the inhabitants of the selected villages. Patients diagnosed with either cervical or breast cancer are referred to Senkatana Oncology Clinic for care and treatment.The population in Maseru consist of mainly Basotho whose official languages are Sesotho and English. The majority of people live under poor conditions with food insecurity. Most of the people are job seekers who migrated from rural areas. They mostly live under rented housing with electricity, sanitation, and clean water.29 The study population was thought to be approximately 40 000. The anticipated proportion of respondents with adequate knowledge of the selected cancers was be about 50% (p = 0.5). The minimum sample size required was 384 with a margin of error of 5% around the 95% confidence intervals. In order to gain sufficient statistical power, a sample of 500 participants was targeted.The sample size was calculated for a larger study to determine the level of knowledge of selected cancers in both men and women (15–75 years) among household members in Maseru. We used the sample size formula for estimating a population proportion.Villages were selected from the areas served by four satellite clinics in the catchment area of the Senkatana Oncology Clinic in Maseru. One village was selected close to each clinic and a fifth village close to the oncology clinic itself. Convenience sampling was used to obtain approximately 100 participants from households in each village. Where there was more than one eligible person in the household, they were all interviewed. Household members that were not at home during data collection were excluded from the study. This study reports on the data obtained from the women in this sample.32 The questionnaire used a 5-point Likert scale (strongly disagree/disagree/not sure/agree/strongly agree) to measure attitudes related to cervical (19 questions) and breast cancer (16 questions).The validated questionnaire to investigate knowledge and attitudes related to cervical and breast cancer in Lesotho was not available. The data collection tool consisted of 16 closed-ended (yes/no/not sure) questions that determined knowledge of risk factors of cervical cancer and breast cancer, respectively. Other validated questionnaires from Champion’s Health Belief Model Scale and Powe’s Fatalism Inventory (modified version) were adopted in order to formulate questions that determined attitudes.In June 2021, the questionnaire was validated with seven colleagues from the Faculty of Health Sciences and Senkatana clinic. They checked the content of the questionnaire, construction of questions, and the time taken to complete. The data collection tool was translated into Sesotho. Trained interviewers administered the questionnaire to eligible participants in households within the five villages.Questionnaire data were captured in Epi Info 7 and exported to Stata (version 13.1) for statistical analysis. The code of ‘0’ was used for an incorrect or ‘not sure’ response and ‘1’ for a correct response when determining knowledge scores of cervical and breast cancer-related risk factors. A composite score was derived for each of the risk-factor questions. A respondent who was considered as knowledgeable was the one who attained a composite score greater than or equal to 50% (average and above or ≥ 50%).p-value of less than 0.05 and a 95% confidence interval that does not span unity was thus considered as a threshold of statistical significance.Frequency tables were made out of categorical variables, while continuous variables were presented as descriptive measures, including mean and standard deviation or median and range. The association between the binary variables was tested using Odds ratios. Multiple logistic regression analysis was used for all analyses and the aim was to determine the association of possible predictors. A The National Health Research Committee of the Lesotho Ministry of Health of Lesotho, gave approval for the Knowledge, Attitudes and Practice (KAP) study and this number was allocated to the study ID 02-2021. Data collection commenced after approval of the study. Confidentiality was maintained throughout the study; anonymity was maintained from data collection to the end of the study. Informed consent forms were filled by participant prior to taking part in the study. Security of patients’ information was ensured by keeping data in a locked cabinet in the principal investigator (PI) office throughout the duration of the project and all study material will be kept for a period of five years after completion of the project.A total of 228 women participated in this survey with the response rate of 100%. The median age of the participants was 31 (ranging from 15 to 75 years), with approximately half of them (55.7%) aged 30 years and older . The majp = 0.007). However, educational level and occupational level were not significantly associated with awareness of cervical cancer.More than three-quarter of the women (89.5%) had heard of cervical cancer. Multiple logistic regression analysis was used to investigate the association between the outcome variable, ‘ever heard of cervical cancer (yes/no)?’ and selected demographic variables age, education, and occupation. Thirty-year old or older participants were more likely to have ever heard of cervical cancer , 11.8% had heard of cervical cancer screening and 7.4% had undergone a cervical cancer-screening examination. None of the women had ever heard of HPV. Approximately three-quarter of the participants gave the appropriate responses to four of the nine questions related to risk factors for cervical cancer as follows: cervical cancer is preventable (74%); having many different sexual partners is a risk factor (75%); an early onset of sexual activity is a risk factor (73.5%), and sexually transmitted infections (STIs) are a risk factor for cervical cancer (79.4%). Over half of the participants (52.9%) knew HIV as a risk factor for cervical cancer, while 58.8% knew smoking as a risk factor for cervical cancer see .As described in the methodology earlier, when the composite score for knowledge was used, it was indicated that the median knowledge score for the risk factors of cervical cancer was 5 (range 0–9) out of a maximum possible score of 9.p = 0.003). However, educational level and occupational level was not significantly associated with awareness of cervical cancer.More than three-quarter (77.6%) of the women interviewed had ever heard of breast cancer. The multiple logistic regression analysis found a significant association between the outcome variable, ‘ever heard of breast cancer (yes/no)?’ and age. Thirty-year old or older participants were more likely to have ever heard of breast cancer , 72.9% had heard of breast cancer screening. Approximately two-third of the participants gave appropriate responses to only two of the seven questions on risk factors for breast cancer. However, the majority of women (65%) did not consider bigger breasts as a risk factor for breast cancer; on the other hand, 64.4% gave the correct response, and that physical exercises make it less likely of getting breast cancer. Less than half of the participants gave the appropriate response to five of the seven questions on risk factors for breast cancer .As described in the methodology, using the composite score for knowledge, the results showed that the median knowledge score for the risk factors of breast cancer was 3 (range 0–7) out of a maximum possible score of 7. Fewer than half (41.8%) of the women who were aware of breast cancer had above-average knowledge of risk factors for breast cancer.Attitudes towards cervical cancer were assessed separately using 19 questions . Three-qAttitudes towards breast cancer were assessed separately using 16 questions . ApproxiLess than half of the women (40.1%), who have heard of breast cancer, have had a breast cancer examination. Almost half of the women (49.2%) reported knowing how to do a breast-self-examination.27 Thirty-year-old or older participants were more likely to have ever heard of these cancers and education level was not significantly associated with the awareness of these cancers. In the current study, awareness of cervical cancer was not significantly correlated to the level of education. Furthermore, the participants with secondary or higher educated were almost two times more likely to have heard of breast cancer than the rest of the participants. However, contradicting reports on level of education and knowledge on cancers have been noted. For example, some studies have reported a positive association between these two variables, while others observed a negative association. Interestingly, other studies have ruled out any association between the educational level and knowledge on cancers.21The data presented in this KAP study reveal an average age of the sampled population to be 30 years and above, who are Christian by religion, and are mostly single. The results of this study show that many women were aware of cervical and breast cancers. More than three-quarters of women (89.5% and 77.6%) reported to have heard of cervical cancer and breast cancer, respectively. Similar results were seen in the study conducted in Zimbabwe where 85% of the respondents had heard of these cancers.27 This is the most potent barrier to early diagnosis of these cancers. In addition, the studies undertaken in Nepal indicated that increasing awareness of risk factors results in improved cancer-screening behaviour and preventive cancer practice.33The median knowledge score for the risk factors of cervical cancer compared to that of breast cancer was relatively higher – being five (5) out of the maximum score of nine (9) compared to three (3) out of the maximum score of seven (7). Comparing knowledge on the breast cancer risk factors and awareness about breast cancer, it was found out that more than half of the women had knowledge about risk factors and less than half were aware of breast cancer. These results are supported by the studies carried out in other African countries, where it was found that among women, there is relatively low overall knowledge about breast and cervical cancer risk factors.22In the present study, of all the women who were aware of cervical cancer, none knew about HPV, the feature which is the risk factor for cervical cancer. This finding warrants a need for further embarking on campaigns and developing materials geared towards informing about these cancers. HPV is key to the development of cervical cancer. Therefore, individuals who knew about cervical cancer should have been informed about it.34 The majority of the respondents further reported that these cancers may threaten their relationships with their spouse or sexual partner. The respondents’ attitude was generally similar for both cancers.Also noted in this study is the positive attitude of the respondents towards the diagnosis procedures of these cancers, the majority of whom reported a cervical/breast examination as taking short time. While the majority reportedly associated the examinations with no pains, others were reportedly uncertain. They (the latter) further disagreed with the statement ‘I have other more important problems than having a breast/cervical examination’. There is a relatively similar attitude of the respondents towards cervical cancer screening and breast cancer examination as, for both cancers more than 80% of the women disagreed with the statement, ‘I have other problems more important than having breast/cervical examination’. Similarly, according to the study conducted in Ethiopia, half of the respondents who had knowledge had the positive attitude towards cervical cancer screening.n = 177), 72.9% reported to have ever heard of breast cancer screening and 40.1% have done breast cancer screening, while 49.2% reported to know how to do a breast self-examination. On the other hand, among those who were familiar with cervical cancer (n = 204), 11.8% reported to have ever heard of cervical cancer screening and 7.4% had undergone a cervical cancer-screening examination. These results prove that indeed, with greater awareness, there is associated practice. However, more than half of the respondent reported having never had a breast cancer examination. Respondents reported low practice for breast and cervical cancer. This corresponds to Lesotho demography and health survey 2016 that stated that in the past 12 months, screening of breast cancer was 10%, and Pap smear was 4% among women aged 15–49.28 Even lower practice was reported in the study conducted in Zimbabwe, where 96.2% of respondents had never undergone cervical cancer screening.27 Furthermore, the current study findings probably corroborate the studies which have reported a gap in the practice with the knowledge about and attitude towards the breast and cervical cancers.27 However, the current study proves that when the community is informed of the availability of screening services, they do use such services. Therefore, there is need for improvement of strategies to inform the community about breast and cervical cancer-screening services.Among the women familiar with breast cancer (The limitation of the study was that data collection was carried out at the household level during the week when most workers were at work, in which case only the views of the unemployed counterparts and those who were off-duty were gathered for the study. It is worth noting that these participants would also be available for community education, but may not represent the entire study population.The implication of the study is the fact that knowledge, attitudes, and practice regarding cervical and breast cancers were assessed showing clearly that knowledge about the cancers can be improved. This has positive results on screening which will lead to early diagnosis and treatment. In terms of health service, the findings imply that awareness about these diseases should be intensified, because cervical and breast screening are offered in all primary health facilities. As for policy, Lesotho needs to strengthen the newly formed national cancer registry to register all patients who are diagnosed with cervical or breast cancer to ensure early treatment and limit lost to follow up between screening, diagnosis, and treatment. Regarding future research, follow-up qualitative research should be carried out to reveal the real barriers that hinder cervical and breast cancer screening and determine strategies to overcome them.The study has found the majority of participants, particularly 30 years and older being relatively more knowledgeable about cervical cancer than breast cancer. The finding, therefore, necessitates more sensitisation campaigns so as to educate these communities on the two cancers. Despite being that knowledgeable about cervical cancer, the majority of the interviewed women reportedly lack knowledge of HPV as a risk factor for cervical cancer, thus further showing a need for awareness campaigns against the scourge. As such, noting currently high incidences of cervical cancer in Lesotho, the strategies of improving cervical cancer screening and HPV vaccination statistics among women are recommended by this study.


CDC7 gene, cg10816169 near ZNF318 gene, cg03345232 near RIN3 gene, and cg26312998 near RP11-867G23.13 gene, where genetically predicted epigenetic modifications were associated with an increased breast cancer incidence risk. Our findings re-affirmed that alcohol consumption is of high risk for breast cancer incidence even at a very low dose, and the pathogenic effect of alcohol on breast cancer could be due to pathological drinking behaviour and epigenetic modification at several CpG sites, which could be potential intervention targets for breast cancer prevention.Alcohol intake is thought to be a risk factor for breast cancer, but the causal relationship and carcinogenic mechanisms are not clear. We performed an up-to-date meta-analysis of prospective studies to assess observational association, and then conducted MR analysis to make causal inference based on the genetic predisposition to alcohol consumption (“drinks per week”) and pathological drinking behaviours , as well as genetically predicted DNA methylation at by alcohol-related CpG sites in blood. We found an observational dose–response association between alcohol intake and breast cancer incidence with an additional risk of 4% for per 10 g/day increase in alcohol consumption. Genetic predisposition to alcohol consumption (“drinks per week”) was not causally associated with breast cancer incidence at the OR of 1.01 , but problematic alcohol use (PAU) was linked to a higher breast cancer risk at the OR of 1.76  when conditioning on alcohol consumption. Epigenetic MR analysis identified four CpG sites, cg03260624 near The online version contains supplementary material available at 10.1007/s10654-022-00886-1. According to the latest global cancer statistics, the incidence rate of breast cancer has surpassed lung cancer ranking as first, with around 2.3 million new cases in 2020 . MeanwhiHER2) enriched breast cancer relative to ER positive breast cancer , cg26312998 [ZNF318], cg03345232 [RIN3], and cg10816169 [RP11-867G23.13], the OR for breast cancer incidence risk was 1.12 , 1.04 , 1.06 , and 1.07 , respectively. To investigate whether the mQTLs of these four CpG sites would influence the expression of their mapped gene in breast mammary tissue, we queried the GTEx Portal and found that the mQTL rs13447450 of cg03260624 is an eQTL of the CDC7 gene (P = 2.80 × 10–5) and the mQTL rs70953670 of cg26312998 is an eQTL of the ZNF318 gene (P = 0.001) , the incidence risk of HER2-Enriched-like breast cancer increased by 22%  and the incidence risk of triple-negative breast cancer increased by 9%  in the meta-analysis of BCAC and CIMBA per SD change in blood DNA methylation. (Supplementary Table 12).We identified 363 CpG sites related to alcohol consumption of European ancestry . After rWe performed an updated meta-analysis assessing the observational association between alcohol intake and the risk of breast cancer incidence. We then made causal inferences based on the genetic predisposition to alcohol consumption and pathological drinking behaviours proxied by SNPs from two GWASs , 8. FurtR- squared) in these dose–response analyses were not high, which might be because most of the included studies reported risk estimates of alcohol consumption at the light and moderate drinking levels and only few studies reported risk estimates at heavy drinking levels, or there might be other uncontrolled confounders and biases.Meta-analysis of 26 prospective studies confirmed a positive association between alcohol intake and breast cancer incidence, which was dose-dependent. In the stratification analyses, there were significant associations between alcohol drinking and the incidence risk of breast cancer subtypes regardless of the hormone receptor status. In contrast to Sun et al. , we did To make causal inference, we conducted two-sample MR analyses using genetic variants derived from published GWAS of alcohol consumption and pathological drinking behaviours , 8. The CDC7 gene, cg10816169 near ZNF318 gene, cg03345232 near RIN3 gene, and cg26312998 near RP11-867G23.13 gene, where genetically predicted methylation was causally associated with increased breast cancer risk. Furthermore, the mQTL rs13447450 of CpG site cg03260624 and rs70953670 of CpG site cg26312998 are strong eQTLs of the CDC7 gene and the ZNF318 gene in breast mammary tissue, respectively, indicating that the effect of changed methylation at cg03260624 and cg26312998 on breast cancer might be mediated by gene expression.Recent EWAS showed that alcohol consumption can affect DNA methylation in both blood and tissues, indicating that DNA methylation at certain sites could act as a marker for the exposure to alcohol . Based oCDC7 is a protein coding gene, which is essential for the initiation of DNA replication during cell division. It has been reported that overexpression of CDC7 is associated with tumorigenesis [CDC7 has been linked to HER2-Enriched and triple-negative subtypes, accelerated cell cycle progression, arrested tumour differentiation and genomic instability during the tumorigenesis of mammary tissue and led to poorer disease-free survival [CDC7, p53-mutant HER2-overexpressing and triple-negative breast cancer cells undergo an abortive S phase and apoptotic cell death, suggesting the potential therapeutic effect of CDC7 in p53-mutant breast cancers [CDC7, and poorer outcome was observed among patients with higher expression of CDC7 [CDC7 would inhibit genotoxin-induced apoptosis and protect cancer cells upon DNA damage response, so that it would enhance chemotherapy resistance [CDC7 was also highly expressed among colorectal cancer patients and interacted with the expression of p53 [igenesis . The incsurvival . By targ cancers . Moreove of CDC7 . It has sistance . Meanwhin of p53 .CDC7 on multiple cancers, the other two genes and the lncRNA are novel in relation to genetic predisposition to cancer, with the potential to be new targets in the treatment and prevention of breast cancer. ZNF318 is a member of the zinc finger protein family, encoding the Cys2His2-type [ZBP89, also known as ZNF148, has been reported to have oncogenic functions in breast cancer, melanoma and gastric cancer, but repressing cell proliferation and inducing apoptosis in colorectal cancer. Generally, the zinc finger family participated in all the principal pathways of cancer progression and could act as oncogenes or tumour suppressor genes in different contexts [ZNF318 in breast cancer development. RIN3 is a protein coding gene of the RAS and RAB interactor family, which was discovered functioning as a guanine nucleotide exchange for RAB5B and RAB31, involved in the vesicle transportation [RIN3 is a novel risk locus for Alzheimer’s Disease due to the dysfunction of endocytic trafficking and had effects on the development of Paget’s Disease of Bone [RIN3 and breast cancer has not been previously reported. Though mapped to lncRNA RP11-867G23.13, CpG site cg10816169 was also close to the gene CD248, which encoded transmembrane glycoprotein functioning as a receptor in tumour angiogenesis. By cross-talking with both pro- and anti-angiogenic signals and extracellular matrix components, and participating in dynamic vascular remodelling, CD248 could facilitate tumour growth [CD248 and is investigated in clinical trials for colorectal cancer, melanoma and sarcoma [Though previous studies had reported the impact of is2-type . Acting contexts . No prevortation . A genom of Bone , 36. Butr growth . Besides sarcoma –40.Our study has several strengths and limitations. We examined the causal relationship between alcohol and breast cancer incidence comprehensively by aggregating both quantitative and qualitative traits of alcohol consumption, with drinks per week reflecting the general effects of drinking, AUD and PAU representing pathological drinking behaviours. We also appraised the causal effects of genetically predicted methylation at alcohol associated CpG sites on the incidence risk of breast cancer under the framework of MR, which can strengthen causal inference by minimizing unobserved confounding and diminishing reverse causality . HoweverIn conclusion, with an updated meta-analysis of prospective studies, our study re-affirmed the dose–response association between alcohol intake and breast cancer incidence. Evaluating the causal effect using the two-sample MR approach, the pathogenic effect of alcohol on breast cancer could be due to pathological drinking behaviour and epigenetic modification at several CpG sites, which could be potential intervention targets for breast cancer prevention.Supplementary file 1 (DOCX 2197 KB)Supplementary file 2 (XLSX 117 KB)Below is the link to the electronic supplementary material.


Many studies have started to search for the perfect aesthetic breast in order to create a pars-pro-toto for reconstruction, but especially for aesthetic surgery. To date, no representative study with anatomically accurate models was performed.In an online based United-States-census-representative survey with 1049 participants, questions regarding the preferred breast were asked utilizing lifelike morphed 3D-generated female models for the first time. Attributes such as breast pole ratio, areola size, breast direction and projection were asked.The results show that, contrary to what has been claimed in previous studies, an upper-pole-to-lower-pole ratio of 55:45 is preferred by both female and male participants. When it comes to breast size, on the other hand, there are clear gender-specific differences. While women opted for a cup size around B, the men preferred larger cup sizes. Moreover, the smallest depicted areola size of 30 mm was favored among all groups in the survey.Most publications used rather detrimental models for their surveys. We therefore opted for computer-generated 3D models and varied their naturalness. This enabled us to ensure a more aesthetic and accurate illustration and thus obtained more comparable and reliable results paired with the representation of the US-population. Taken together this study unveiled unexpected insights into the population favored breast attributes that might change operative planning in breast surgery.http://www.springer.com/00266.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  Over time, the optical ideal of the female breast has changed and there are also different preferences in different cultures. Today's preference is mainly shaped by the increased use of media and social media recently. The breast stands as a symbol for femininity, not only in its designation as a secondary gender characteristic, but also in society. Many women identify themselves as women through them, and the aesthetics of the breast contribute significantly to their well-being. With over 287,000 breast augmentations in 2019 it is one of the most performed surgical procedures in the USA . SeveralSo far, not conclusive anatomical model has been reportedThe aim of this study is to create a model for the ideal breast with an optimized model in combination with a population-based survey that can be utilized to optimize reconstructive and aesthetic breast surgery.A web-based questionnaire with several sub-categories was created depicting the most discussed elements in aesthetic breast surgery. The first part contained general questions about demography, level of education, relationship status as well as the feeling about the own breast, the own body preference as well as the attitude towards aesthetic interventions. The second part contained sets of different series of images, each with a morphed property. The questionnaire was entered into the SurveyMonkey  system. The target audience was reached through SurveyMonkey® Audience with a guarantee of a cross national sample. To represent the US-population, a sample size was chosen that has a margin of error of 4% with a confidence level of 99%.The following parameter were separately morphed into the image panels: Proportions of upper and lower pole  in two different body types, the size of the mamilla , the upper and lower pole fullness  in the three-quarters profile view as well as side view, the distance from the median line to the mamilla  in the three-quarters profile view as well as front view, a nine images panel with different characters of fullness and natural profiles, different cup sizes of the breast  in the three-quarters profile view as well as front view.3D models were generated and morphed in DAZ Studio 3D . Morphed pictures were randomly shuffled for each respondent to avoid a bias.F-Test), p values for pairwise comparisons were analyzed via two-tailed unpaired t test with (heteroscedasticity) or without (homoscedasticity) Welch’s correction. For correlation between two bivariate nominal values Phi and Cramer-V test were performed for two bivariate ordinal Kendall-Tau-B. All analyses were performed using GraphPad PRISM . Statistical significances were set at a p value < 0.05.After testing for homo- or heteroscedasticity , followed by Asian/Pacific Islander (10%), Hispanics (10%), Black/African Americans (9%), multiple ethnicities and others (2%) and American Indian or Alaskan Natives (2%). 922 (88%) respondents were born in the USA. Further details are depicted in Table p = 0.05)—see Fig. 1012 participants responded to the question “Please select the most aesthetic breast from the following pictures?” with different ratios of the breast poles. There is an overall tendency toward a small lower pole. Around 50% of all participants preferred 50:50 and 55:45 ratios. Distinguishing female and male respondents showed no difference in breast pole ratio preferences. In the second question the favored upper pole projection was determined by 1005 participants. In DAZ Studio 3D the upper pole projection was changed according to the program settings (-100% to +100% upper pole projection). Overall, the participants preferred an increased upper pole projection. However, female participants exceptionally selected enhanced upper pole projection in the ¾-view and side view. This trend was statistically significant comparing women and men (p = 0.03)—see Fig. The areola diameter was accurately transferred onto the 3D models with Measure Metrics for DAZ Studio . Overall, 1009 participants preferred smaller areolaes. There was no significant difference comparing female and male responses. In another question the preference of the nipple-to-nipple distance was determined among 1003 participants. Taken together, a preference for narrow breasts with the shortest in the survey covered distance of 210 mm was mostly selected. This trend was attenuated in the front view, connoting a different perception of the diameter in the different view. In both views, male participants tended to a longer nipple-to-nipple distance with a significant correlation in the frontal view as compared to women (n = 998) favored B and C cup sizes. Breaking down the sex of the participants, male tended to choose larger breasts while women prefer B-cup in the 3/4-view. This disparity was statistically significant (p < 0.001) comparing women and men. In the frontal view there was an overall trend to larger breast sizes. However, the tendency of men to favor larger breasts was conserved and statistically significant (p = 0.004)—see Fig. Another question series addressed the preferred breast cup size. Breast size was adjusted to the model by applying the EN 13402 defined cup sizes under the guidance of Measure Metrics for DAZ Studio . In the 3/4-view the overall population (n = 554) were asked whether they had a previous breast augmentation or never had any cosmetic surgery done on their body. Participants were excluded who already had any other cosmetic procedure done. Excluding those a total of 425 female participants responded to this question. Both groups were compared regarding their responses about the favored breast cup size. Once a woman received a breast augmentation, she favored larger breasts. This was significant in the 3/4-view (p = 0.05) as well as in the frontal view (p = 0.026) comparing women with previous breast augmentation and women without any cosmetic procedure in the history. The mean actual cup size of women in both groups was a C-cup.In the survey, female participants (p < 0.001) and front view (p = 0.03) as well. The mean actual cup size of women in both cohorts was a C-cup.Furthermore, the preference for breast size was compared between women who consider breast augmentation and women who would not have their breasts enlarged. Participants who consider breast surgery due to aesthetic reasons tend to prefer larger breast sizes in the 3/4-view (p = 0.003) compared to participants who never had not received prior cosmetic breast procedure. This correlation was not observed between participants who would change their breast size and who would not—see Fig. Asking the same groups for their preferences in breast pole ratios there was no significant correlation. Women who had a prior breasts augmentation performed, prefer smaller areola diameters  or the target audience is biased, e.g., by a panel of experts or selected target groups, e.g., patients who have undergone aesthetic surgery. As a result, the present study is the only one of its kind to represent the population adequately.Female participants who underwent or consider to breast augmentation tend to prefer larger cup sizes. However, neither of the groups differ significantly in their actual cup sizes. One confounder of this finding might be the age groups. There were significantly more participants with breast augmentation prorated in the group of the 35 to 44 years old women compared to women without any aesthetic intervention in the same age group. Older female participants had prorated fewer breast augmentations in the group of 65 years old women and above. On the other hand, there was no significant correlation between the age group and a preference for the cup-size overall. Interestingly female participants who underwent a breast augmentation prefer smaller areola sizes but not the group of participants who would do an augmentation. Again, there is no significant correlation between age groups of female participants and the preference for a specific areola size. While women around the age of 25 to 44 tend to be more open to aesthetic surgery and underwent more aesthetic procedures there is no specific age dependent preference for the breast cup size or areolar diameter. The reason for this finding might be a sociocultural and medial bias on participants who had or tend to do aesthetic breast surgery. They are influenced by  media, more informed and might have higher expectations on their breast as these participants follow-up with the look of their breast.The main limitation of our study are the different views of the models. When evaluating our results, a difference was found between front view and 3/4-view. This is particularly evident in the breast size and the nipple distance. This incongruence is probably due to possible light shadows that arise from the change of perspective in the images. The finding of divergent perceptions due to differing views is a current obstacle in psychological research . HoweverAnother point worth discussing is the representation of different ethnic groups in the models. Nevertheless, the model was limited to one ethnic group, as including more ethnicities would have made the survey unmanageably complex and therefore lead to many survey cancellations. In addition, there is the question of depicting the breast shapes of different ethnic groups, for which there is too little data or simply changing the skin color, which would not have added any added value. Therefore, limitation to one ethnic group as most of the previous studies was the most suitable option.The summarized findings of this study are taken together in Fig. Based on the methodological composition of the study through the census-based survey with over 1000 participants and the naturally morphed 3D models, we conclude a realistic representation of the preference for the female breast. The purpose of the study is not to set up one-sided guide values for proportionality or nipple size, but rather to do away with dogmatic, sometimes invalid, statements. The study provides tendencies, but a key statement of the study remains the individuality of each breast, which is not subject to a given value. Further aspects of this study that should be incorporated into clinical practice are breast augmentation that has already taken place, changes the patient's expectations, but also the fact that social media has an increasingly important influence on self-image.In summary, it can be stated that especially the newly discovered upper-pole-to-lower-pole-proportion of 55:45 and the areola size of 30 mm are remarkable and could influence future breast surgery.