One of the challenges for Latin American countries is to include in their healthcare systems technologies that can be applied to hereditary cancer detection and management. The aim of the study is to create and validate a questionnaire to identify individuals with possible risk for hereditary cancer predisposition syndromes (HCPS), using different strategies in a Cancer Prevention Service in Brazil. The primary screening questionnaire (PSQ) was developed to identify families at‐risk for HCPS. The PSQ was validated using discrimination measures, and the reproducibility was estimated through kappa coefficient. Patients with at least one affirmative answer had the pedigree drawn using three alternative interview approaches: in‐person, by telephone, or letter. Validation of these approaches was done. Kappa and intraclass correlation coefficients were used to analyze data's reproducibility considering the presence of clinical criteria for HCPS. The PSQ was applied to a convenience sample of 20,000 women of which 3121 (15.6%) answered at least one affirmative question and 1938 had their pedigrees drawn. The PSQ showed sensitivity and specificity scores of 94.4% and 75%, respectively, and a kappa of 0.64. The strategies for pedigree drawing had reproducibility coefficients of 0.976 and 0.850 for the telephone and letter approaches, respectively. Pedigree analysis allowed us to identify 465 individuals (24.0%) fulfilling at least one clinical criterion for HCPS. The PSQ fulfills its function, allowing the identification of HCPS at‐risk families. The use of alternative screening methods may reduce the number of excluded at‐risk individuals/families who live in locations where oncogenetic services are not established. Approximately, 5–10% of cancer cases have a hereditary pattern, which is caused by germline mutations in oncogenes and tumor suppressor genes One of the challenges for Latin American countries is to introduce hereditary cancer healthcare approaches, with new unexpensive technologies, including screening, genetic counseling, and genetic testing for early detection and diagnosis Developed countries also face difficulties related to the identification of HCPS families, due to the increasing demand of patients and families at‐risk for hereditary cancer identified and consequent lack of infrastructure and personnel to meet this growing necessity Accordingly, the aim of this study was to create and validate a simple instrument for the identification of families at‐risk for hereditary breast, ovarian, and/or colorectal cancer, as well as to validate different strategies for pedigree drawing of those at‐risk individuals identified.The primary screening questionnaire (PSQ) intents to be an easy and quick way to identify individuals and/or families probably at‐risk for HCPS, mainly focusing on breast, ovarian, and/or colorectal cancer predisposition syndromes.The PSQ contains information regarding the age of cancer diagnosis and number of tumors in the family, which are the basis of most clinical criteria, such as ASCO The questionnaire was structured to have a YES/NO answer for the following questions: Q1—Personal history of cancer before the age of 50 years; Q2A—First‐ or second‐degree relatives with breast cancer (BC) before the age of 50; Q2B—First‐ or second‐degree relatives with ovarian cancer (OC); Q2C—First‐ or second‐degree relatives with colorectal cancer (CRC) before the age of 50; and Q3—Three or more first‐ or second‐degree relatives with cancer.The PSQ was applied in a convenience sample of 20,000 women from Barretos Cancer Hospital (BCH) during a period of 12 months. Women submitted to a routine mammogram or cervical cancer screening were invited to participate in the study regardless of her personal or family cancer history.The Cancer Prevention Unit at BCH  performs population‐based preventive cancer screening and attends more than 100,000 individuals per year. The Institution also has 12 Mobile Units, which perform prevention screening regarding breast, cervix, prostate, and skin cancer all over the Brazilian territory, reaching remote areas All women who answered affirmatively to at least one of the PSQ questions were invited to participate in a second phase of the study. This secondary screening involved a further analysis of the family cancer history with pedigree drawing (including at least three generations), encompassing maternal and paternal family history. A properly trained healthcare professional (nurse with experience in Cancer Genetics) conducted the second phase, using three different approaches, as described below.After informed consent fulfilling, the appointment consisted of an initial conversation to provide a general explanation about the importance of cancer prevention and early detection. At this moment, educational materials regarding cancer prevention and genetic risk factors associated with cancer development were provided to the participant In this approach, the pedigree was created from information obtained by telephone and by the same interviewer who conducted the in‐person interviews. Telephone conversations lasted 30–40 min. Once again, the language was simple and easily comprehensible for participants with different education levels. After hearing the informed consent (by telephone), the participant could decline to participate in the study and end the telephone call if desired.This approach was performed for those women reporting unavailability to visit the health service, due either to work or domestic activities.In this approach, an envelope with the following items was mailed to the participants: (1) a letter that explained the research project and what procedures were involved in the second phase of the study; (2) two copies of the informed consent; (3) a questionnaire with several questions regarding the family history of cancer in the first‐, second‐, and third‐degree relatives, including the type of cancer, age at diagnosis, current age or age at death, the presence of multiple or bilateral tumors, and the relationship of the cancer patient to the person who was filling out the questionnaire ; and (4) a stamped envelope, so the participant could return the questionnaire and the informed consent, free of charge, by mail.The letter approach was used for those women who could not be reached by telephone (had no telephone number or did not answer the telephone).The sensitivity, specificity, positive, and negative predictive values of the PSQ were evaluated using the kappa coefficient.To calculate the sample size needed for this validation, the presence of a positive family history of cancer was considered. In the case of a positive PSQ, where the expected ratio is 0.80, with a significance of 0.05, absolute error of 0.09 in the confidence interval, and the population size of 1938 (number of women who answered positively in our study and had the pedigree drawn), the validation would require about 69 cases. In the same way, it was possible to identify the proportion of no family history of cancer for those who answered “NO” in the PSQ. Thus, for the negative group of the PSQ , taking into account the expected ratio of 0.80, a significance of 0.05, absolute error 0.075, and population size in the confidence interval, 107 cases would be necessary.Based on these estimates, a sample of 69 women with at least one affirmative answer to the PSQ and 107 women with negative responses to all PSQ questions were randomized. Pedigrees were drawn for all 176 cases. In addition, the PSQ was reapplied 6 months after the first application. At each stage, the questionnaires were applied independently, meaning that the interviewers did not know the answers of previous applications.gold standard strategy. To validate the telephone approach, 60 cases in which the pedigree was created from information obtained “in‐person” were randomly selected. Then, telephone calls were made to these subjects. These confirmation calls were not performed by the same person who performed the in‐person interview, and the callers had no access at the time of the interview or earlier to the previously created pedigrees.The sample size for validation of the approaches  was estimated based on the reproducibility of clinical criteria using the table published by Sim & Wright The validation was also performed for the letter approach. A total of 60 cases whose pedigree was initially created from information obtained by letter were analyzed and systematically compared with the telephone approach once this approach was validated.To verify the reproducibility of the approaches, kappa  and intraclass correlation coefficients  were calculated, by comparing the following variables: fulfillment of HCPS clinical criteria , number of generations, number of generations affected by cancer, total number of tumors, number of first‐ and second‐degree relatives with cancer, and those with cancer before the age of 50.Regarding fulfilling HCPS criteria, the clinical criteria for the main hereditary breast and/or colorectal cancer predisposition syndromes, such as hereditary breast ovarian cancer (HBOC) All families that fulfilled at least one clinical criterion for any HCPS are being referred to the Oncogenetics Department of BCH, and, after genetic counseling and family history confirmation, they are referred to the Center of Molecular Diagnosis of the same Institution for genetic testing, if warranted All the participants completed the informed consent. The study was approved by the Research Ethics Committee of the BCH, Sao Paulo state, Brazil, under protocol number 413/2010.From the total sample of 20,000 women enrolled, 17,092 were from the Mobile Units and 2909 from the Hospital Unit. They were from 381 cities distributed along 20 different Brazilian states. The average age was 51 years (SD = 9.45), ranging from 18 to 79 years of age. As it would be expected, since the participants were women performing regular mammogram and/or cervical cancer screening, the great majority of the participants (91.0%) were older than 40 years.n = 1438, 46.0% of the respondents). Detailed information, question by question, can be found in Table From all of them, 3121 (15.6%) answered affirmatively to at least one PSQ question. The most frequent positive answer was regarding the presence of first‐ or second‐degree relatives with BC before the age of 50  had at least one positive answer and were invited to the second phase of the study. During the second part of the screening, there was an attempted to approach each of the 3121 women in order to draw their pedigree. Of all the participants (3121), 17 were unable to participate in the study , 79 directly verbalized that they did not want to participate, and a total of 1087 were unsuccessfully attempted to be contacted by telephone or letter. In order to eliminate the possibility of bias due to the number of participants that were unable to be contacted, chi‐square test was realized to compare the profile of answers in PSQ in the group that was possible to reach and had the pedigree analysis with the group that was unable to be contacted. The result of this analysis shows that the profile of affirmative responses is similar, reducing the possibility that we have recruited only those of higher risk or those of lower risk.In total, 1938 women  were reached, and the pedigree for each of them was drawn. Using the “in‐person” approach, we were able to reach and draw 220 (11.3%) pedigrees, while 310 (16.0%) and 1408 (72.6%) women were reached by letter and telephone, respectively. Figure We conducted a detailed analysis of all 1938 obtained pedigrees. The number of cancer‐affected probands was 200 (10.3%) excluding skin nonmelanoma cases, and the most frequent type of cancer was breast , cervix/uterus , and thyroid cancer . The families evaluated showed a large number of relatives, ranging from 2 to 30 relatives of first degree and 4–27 of second degree. The mean number of tumors was two per family . Considering the tumor spectrum present in those families, some interesting findings are depicted in Table Regarding clinical criterion for HCPS, the following guidelines were considered: ASCO Among the 1938 families carefully analyzed, 465 (24.0%) had at least one clinical criterion; 402 (20.7%) cases had only one criterion present in the family; 57 (2.9%) fulfilled two different criteria in the family; and 6 (0.3%) had three criteria identified. The results obtained are consistent with the literature, where the less stringent criteria were the more frequently observed: 273 families fulfilling the NCCN criteria for HBOC syndrome The PSQ validity was measured by the sensitivity, specificity, positive and negative predictive values, as well as through the calculation of kappa coefficient for the comparison with pedigree data Fig. A. The seP < 0.001), presenting good concordance between both time points, pointing to the accuracy of self‐reported personal and family history.The reproducibility of the PSQ considering an interval of 6 months between application and reapplication was also evaluated. The kappa value obtained was 0.646  and specificity (75%), showing that it is an effective tool for identifying individuals and/or families at‐risk for hereditary cancer in a population‐based sample. In fact, taking into account that the PSQ was not strict and that HCPS are relatively rare, the NPV (98.1%) revealed that few families at‐risk for hereditary cancer were missed. The PSQ reproducibility was good (kappa coefficient of 0.646), which is a characteristic of a precise and consistent screening tool. It is possible that the kappa coefficient was not higher because family history is dynamic and can change along time.Ashton‐Prolla and colleagues previously developed and applied a questionnaire with seven questions related to breast, ovarian, and colorectal cancer family history in the South of Brazil Regarding secondary screening data , the “presence of clinical criteria for HCPS” was chosen as the “comparison variable” for the analysis of information reproducibility, because most of the evaluated variables  belong to the clinical criteria for the majority of HCPS. Thus, considering the presence of clinical criteria (in the family) as reference, high reproducibility for the telephone (0.976) and letter approaches (0.850) was obtained, which demonstrated that the most important aspects of the family history of cancer could be obtained through both strategies. Therefore, the reliability of the obtained information Several studies report the use of alternative methods for patient access In addition to screening strategies, new alternatives have been used for the genetic counseling process. In a study by Platten et al., genetic counseling was performed by telephone to identify individuals at‐risk and facilitate their assistance An important issue to address is the importance of the educational strategies, once this is a general population that may have never listen about “Oncogenetics” or “Hereditary Cancer” We could, with the present study, identify that, among those who answered positively in the PSQ, 24% (465 women) had at least one clinical criterion for HCPS. Even though the prevalence of HCPS cannot be inferred from this study, the prevalence in a selected sample can still add important information for cancer programs planning. All at‐risk identified cases are being referred to the Oncogenetics department for cancer genetic counseling and, for those families with criteria for genetic testing, the same is performed without any charge to the patient. It is important to emphasize that there is a very low probability that this group of women would have had the opportunity to have a consultation with a geneticist outside the context of the present study, revealing the necessity of screening strategies in countries of lower socioeconomic level.Regarding difficulties faced during the study, we can point out the problem to access the entire population. We had a loss of 38% in the sample group that answered at least one affirmative question in PSQ (3121). This can be justified by the fact that most of the participants were from remote areas (inner region of the country). In addition, the great majority is economically active, which makes harder the possibility of reaching health services.This study has some limitations as the fact that, with few exceptions, the tumor diagnosis was not confirmed by death certificates or pathology reports. Besides, sometimes, the age at cancer diagnoses was not properly considered at the time of PSQ application. When comparing the PSQ answers with the pedigrees, we could see that if the participant had a previous diagnosis of cancer, she got a “YES” in the first PSQ question, regardless of age at diagnosis. The same is true for answers is questions Q2A to Q2C. Another limitation that should be addressed is the fact that some cases of OC may have been lost if they were diagnosed over the age of 50 in the study participants.In conclusion, it is worth noting the importance of using alternative forms of patient access and identification of families at‐risk for hereditary cancer. Considering the extensive Brazilian geographic area, the scarcity of oncogenetics services, and the concentration of these services in a few cities, Brazil , there is a need for different strategies to reduce disparities in healthcare access The process of screening individuals and families who may be at‐risk could be more economical and faster, particularly where the healthcare delivery system remains underdeveloped and where problems occur in the organization and delivery of preventive practices.The achievement of this simple questionnaire (PSQ) during screening tests can be highly effective since the patient is already present in the preventive care environment, not restricting only to populations that have already been diagnosed with cancer or those already considered of high risk.We hereby declare that we have no conflict of interest.Table S1. Response to PSQ questions and fulfillment of clinical criteria for HCPS*.Click here for additional data file.


Pregnancy and parity are associated with subsequent breast cancer risk. Experimental and epidemiologic data suggest a role for pregnancy sex steroid hormones.n = 92). Sex steroids were quantified by high-performance liquid chromatography tandem mass spectrometry. Odds ratios (ORs) and 95% confidence intervals were estimated using conditional logistic regression.We conducted a nested case–control study in the Northern Sweden Maternity Cohort (1975–2007). Eligible women had provided a blood sample in the first 20 weeks of gestation during a primiparous pregnancy leading to a term delivery. The current study includes 223 cases and 417 matched controls (matching factors: age at and date of blood collection). Estrogen receptor (ER) and progesterone receptor (PR) status was available for all cases; androgen receptor (AR) data were available for 41% of cases (log2: 0.64 (0.41–1.00)). Higher testosterone was positively associated with ER+/PR+ disease risk (ORlog2: 1.57 (1.13–2.18)). Early pregnancy estrogens were not associated with risk, except for relatively high estradiol in the context of low progesterone ). None of the investigated hormones were associated with ER–/PR– disease, or with AR+ or AR+/ER+/PR+ disease.Higher concentrations of circulating progesterone in early pregnancy were inversely associated with ER+/PR+ breast cancer risk  contains supplementary material, which is available to authorized users. Pregnancy is associated with a transient increase in risk of breast cancer for up to a decade post delivery, and subsequently confers a protective effect for women younger than 30 at first birth and for estrogen receptor (ER) and progesterone receptor (PR) positive tumors . Animal Endogenous sex steroid hormones and breast cancer risk outside of pregnancy have been extensively investigated in both premenopausal , 4 and pThis prior study within the FMC represents the only published data on pregnancy hormone concentrations and breast cancer risk by hormone receptor status. Therefore, we investigated early pregnancy endogenous hormones and breast cancer risk in primiparous women by hormone receptor subtype  using the Northern Sweden Maternity Cohort (NSMC). In addition, we conducted an exploratory analysis of early pregnancy hormones and breast cancer risk by tumor androgen receptor (AR) status; to our knowledge, this is the first investigation of early pregnancy hormones and breast cancer risk by AR status.The NSMC was established in 1975 and is based at the Northern Sweden University Hospital, Umeå, Sweden. Details of the study and case–control selection have been published previously , 12. Brin = 223) were identified via linkage with the Swedish Cancer Registry; registration of newly diagnosed cancers is based on mandatory reporting; case ascertainment for breast cancer is estimated to be almost 100% [n = 417) were selected among women alive and cancer-free (except nonmelanoma skin cancer) at the time of diagnosis of the corresponding case, with a blood sample available from a singleton primiparous pregnancy resulting in a term birth, and age < 40 years at sample collection. Controls were matched to cases on age at blood sampling (±6 months) and date of blood sampling (±3 months). Data on pregnancy and delivery characteristics were obtained from participants’ medical records.To be eligible for this study, participants had to have provided a blood sample prior to 120 gestational days of pregnancy, during a singleton primiparous pregnancy resulting in a term birth  at delivery >37 to <43 weeks). Women aged 40 years or older at sample collection or with a prior cancer diagnosis (except nonmelanoma skin cancer) were excluded. Further, due to changes in sample handling which may affect hormone measurements, samples drawn after January 1, 1988 were excluded . Invasivost 100% . DetailsTo ascertain hormone receptor status, all tumors were reevaluated by one pathologist (ET) to ensure tumor invasiveness in the analyzed tissue block; immunohistochemical assessments were performed by two pathologists . Paraffin blocks containing tumor tissue were gathered and new sections 4 μm thick were made. Immunohistochemical stains were performed on all cases using the following primary antibodies: estrogen receptor clone SP1, Ventana ready to use 790-4325; progesterone receptor clone IE2, Ventana ready to use 790-4296; and androgen receptor clone F39.4.1, Biogenex 1:50 MU256-UCE. All stains were performed on a Ventana XT platform using locally validated protocols. Immunohistochemical stains were evaluated as follows: brown nuclei were considered positive regardless of staining intensity. The percentage of positive tumor cells was registered. A cutoff value of 10% was used to define receptor positivity.n = 440; phase 2, n = 200) by high-performance liquid chromatography tandem mass spectrometry on an Applied Biosystems API4000 triple-stage quadrupole mass spectrometer. Sex hormone binding globulin (SHBG) was quantified with a solid-phase competitive chemiluminescence assay on an Immulite 2000 Siemens analyzer. Free estradiol and free testosterone were calculated using the formula of Södergård et al. [All serum hormone assays were conducted in the Department of Clinical Chemistry at Umeå University. Samples from cases and matched controls were analyzed in the same analytical batch alongside blinded quality control samples . Sex steroids were quantified in two study phases  from the mean were classified as outliers. No outliers were identified. The study population was categorized into tertiles, based on the study phase-specific distribution in study controls. Risk associated with a doubling of hormone concentration was assessed by modeling the log2; continuous), current smoking (yes/no), placental weight (g), and the neonate’s birth weight (g). None of these factors changed the OR by more than 10%; therefore, these variables were not included in the final models. We further assessed the impact of adjusting for estradiol, in the models evaluating testosterone as the exposure, given that this has been shown to attenuate testosterone–breast cancer associations in previous studies  and 95% confidence intervals (CIs). All models controlled for GA at blood collection; this was decided a priori given established associations between GA and hormone concentrations. Further, we observed changes in the OR of >10% comparing crude to GA-adjusted ORs for a subset of associations. The following factors were considered as potential covariates: number of previous pregnancies at blood collection , maternal body mass index (BMI) at enrollment .phet) between ER+/PR+ and ER–/PR– breast cancer subtypes was assessed using a likelihood ratio test comparing models assuming the same association between the exposures and breast cancer overall to one assuming different associations by subtype. Interaction was tested by including a multiplicative interaction term in the models and evaluating the Wald p value.We conducted analyses by hormone receptor status of the tumor , as well as analyses stratified by age at blood collection (<25 vs ≥25 years), age at diagnosis (<45 vs ≥45 years), lag-time between blood collection and diagnosis (<15 vs ≥15 years and <20 vs ≥ 20 years), number of pregnancies at blood collection (1 vs >1), and parity at diagnosis or index date (1 vs >1). Heterogeneity .All statistical tests are two-sided and considered statistically significant at Median age at blood donation in cases and controls was 26.5 : 1.46 (95% CI: 0.96–2.21), ptrend = 0.04; SHBG: 1.68 (1.05–2.70), ptrend = 0.13) (Table phet = 0.05), free testosterone (phet < 0.01), and progesterone (phet = 0.01) and breast cancer differed by tumor hormone receptor status (Table log2: 1.57 (1.13–2.18); ER–/PR– ORlog2: 0.82 (0.47–1.43)). Progesterone was inversely associated with ER+/PR+ disease (ORlog2: 0.64 (0.41–1.00)) but not significantly associated with ER–/PR– disease (ORlog2: 1.61 (0.77–3.36), phet = 0.01). The association between progesterone and ER+/PR+ breast cancer was strengthened after adjustment for circulating estradiol concentrations (OR log2: 0.56 (0.35–0.91)).Higher early pregnancy testosterone and SHBG were associated with higher breast cancer risk . In these models, the combination of high estradiol and low progesterone, relative to low concentrations of both, was associated with significantly higher risk of overall breast cancer ) Table . Resultsn = 153, ORlog2: 1.57 (1.13–2.18); ER+/PR+ cases with AR data: n = 63, ORlog2: 1.32 (0.78–2.25)).We conducted exploratory analyses by tumor AR status (AR+ and AR+/ER+/PR+); data were available for 41% of cases. Overall, the baseline and case characteristics of cases with and without AR status available were similar ), but not associated with risk in women diagnosed at age < 45 years ); the difference was not statistically significant (phet = 0.28). The association between testosterone and breast cancer risk was strengthened after adjustment for estradiol concentrations (ER–/PR- ORlog2: 0.64 (95% CI: 0.33–1.25); ER+/PR+ ORlog2: 1.64 (1.15–2.33)).In analyses stratified by age at diagnosis, testosterone was positively associated with risk in women with age at diagnosis ≥ 45 years ; however, the individual effect estimates were not statistically significant (<15 years: 0.62 (0.35–1.10); ≥15 years: 1.20 (0.95–1.50)).Results stratified by age at blood collection (<25 vs ≥25 years), age at diagnosis (<45 vs ≥45 years), time from blood collection to diagnosis (<20 vs ≥20 years), gravidity at blood collection (1 vs >1), and parity at diagnosis or selection as a control (1 vs >1) were similar (data not shown). We observed significant heterogeneity for free testosterone when comparing associations among participants with <15 and ≥15 years between blood collection and diagnosis ; ptrend = 0.08). A positive association was observed between estrone and disease risk ; ptrend = 0.12). Pregnancy estradiol and estriol were not associated with risk [n = 1199 cases) [phet < 0.01). Associations among women younger than age 40 years at diagnosis were only observed for ER–/PR– tumors. In the FMC, progesterone was associated with increased risk of ER–/PR– disease among women diagnosed before age 40 years, but not associated with risk among women aged 40 years or older.Sex steroid hormones in pregnancy and breast cancer risk in the mother have been investigated previously in three studies nested within two populations –10. Peckr = 0.63; first and third trimesters, r = 0.39; second and third trimesters, r = 0.64) [In line with findings from the CHDS, we observed an inverse association between progesterone and breast cancer risk in the current study, although this was restricted to ER+/PR+ tumors. Blood collection in the current study was at median 10 weeks GA, in contrast to mean of 34.5 weeks in the CHDS. Progesterone concentrations are modestly correlated across trimesters of a single pregnancy  , suggestWe observed no association between estradiol and breast cancer overall risk in the current study, with the exception of an increased risk of disease in women with relatively high estradiol (above median) and low progesterone (below median), as compared to women with low concentrations of both hormones; this increase in risk was evident for both hormone receptor-positive and receptor-negative disease. Experimental data from animal models suggest that both estradiol and progesterone may be necessary to induce the long-term protective effect of pregnancy, although results differed based on the experimental model , 20. TheGiven the divergent association between estradiol and breast cancer risk in analyses stratified by age at diagnosis in the FMC, we evaluated risk stratified by age at diagnosis in this study (<45 vs ≥45 years). Results were similar in both age groups for estrogens and progesterone, while testosterone was more strongly associated with breast cancer diagnosed at age 45 years or older. Given the age distribution in our cohort, we were unable to evaluate risk using the same age thresholds as the FMC . The FMC population was somewhat older at first birth than the NSMC study population and due to technical considerations , women in the NSMC were diagnosed at an older age  and after longer lag-time between pregnancy and cancer diagnosis . Therefore, our findings from the NSMC may pertain to the long-term impact of early pregnancy hormones and breast cancer risk, whereas the FMC results may better describe risk associated with more proximate exposure to pregnancy hormones.In contrast to estrogens and progesterone, androgens increase gradually across pregnancy, approximately doubling from preconception to the third trimester , 16. AndWe observed higher risk of ER+/PR+ breast cancer risk with higher circulating testosterone concentrations in the current study. In the only prior study on androgens in pregnancy and breast cancer risk, in the FMC , testostlog2: 1.32; ER+/PR+/AR+ ORlog2: 1.36), suggesting the AR may not play an important role in this context.To our knowledge, our study is the first investigation of early pregnancy hormones and maternal breast cancer risk by androgen receptor status. Experimental data suggest that crosstalk between the ER and AR results in impeded receptor signaling of both receptors, thus inhibiting hormone-related growth and proliferation . Furtherr = 0.19, p < 0.01; SHBG: r = −0.20, p < 0.01), as were free estradiol  and free testosterone . Cases and controls were carefully matched for date of blood collection, therefore the weak correlations observed between hormone concentrations and storage time should not impact our results. Hormones change systematically in early pregnancy with GA. We accounted for these changes by adjusting for GA in regression models. An alternative approach would be to use regression residuals. In our study, results adjusting for GA were similar to those using regression residuals. Finally, sample size was limited for analyses of ER–/PR– tumors, and AR data were only available for a subset of cases.Our study has important strengths and limitations. Blood samples were collected and stored using standardized procedures. However, samples are stored at a relatively warm temperature (−20 °C). Estradiol and SHBG concentrations were weakly correlated with storage time (estradiol: We observed an inverse association between early pregnancy progesterone and subsequent risk of ER+/PR+ breast cancer as well as a positive association between early pregnancy testosterone and free testosterone and breast cancer, predominantly in ER+/PR+ tumors. This investigation adds to the limited literature on early pregnancy hormones and breast cancer risk in the mother. As with prior studies, our study investigated whether relatively high vs lower concentrations of hormones were associated with subsequent risk of breast cancer among parous women. Further studies investigating novel markers are necessary to better characterize the relationship between early pregnancy hormones and maternal breast cancer among this population.


The increase in breast cancer incidence has enhanced attention towards breast cancer risk. The aim of this study was to determine the risk of breast cancer and risk perception of women, factors that affect risk perception, and to determine differences between absolute risk and the perception of risk.st degree relative with breast cancer in Bahçeşehir town in Istanbul, Turkey between Jul 2012 and Dec 2012. Data were collected through face-to-face interviews. The level of risk for breast cancer has been calculated using GRM and the Breast Cancer Risk Assessment Form (BCRAF). Breast cancer risk perception (BCRP), has been evaluated by visual analogue 100-cm-long scale.This cross-sectional study was carried out among 346 women whose score in the Gail Risk Model (GRM) was ≥ 1.67% and/or had a 1P<0.001), and the BCRAF and BCRP scores (P<0.001). Factors related to high-risk perception were age (40–59 yr), post-menopausal phase, high-very high economic income level, existence of breast cancer in the family, having regular breast self-examination and clinical breast examination (P<0.05).Even though 39.6% of the women considered themselves as high-risk carriers, according to the GRM and the BCRAF, only 11.6% and 9.8% of women were in the “high risk” category, respectively. There was a positive significant correlation between the GRM and the BCRAF scores (In women with high risk of breast, cancer there is a significant difference between the women’s risk perception and their absolute risk level. Breast cancer is one of the most frequent cancers around the world, also one of the most common causes of cancer-related death among women –5. It isth after lung, prostate, and skin cancer , late labor (˃30 yr); induced abortion; late menopause (˃55 yr); hormonal replacement treatment (HRT); alcohol over-consumption; smoking; lack of physical activity; diet rich in fat; body mass index (BMI); and high socio-economic level  yr, late–17, 26.The level of breast cancer risk can be calculated with risk models based on risk factors such as the Gail Risk Model (GRM), the Claus Model, the Tyrer-Cuzick Model, and the Breast Cancer Risk Assessment Form (BCRAF). Those risk models are essential to demonstrate the absolute risk, and thus to compare risk perception with actual risk , 26, 27.Determination of individual breast cancer risk perception (BCRP) is as important as the determination of the level of absolute risk , 27–31. The aim of this study was to determine the risk of breast cancer and risk perception of women, factors that affect risk perception and to determine differences between absolute risk and the perception of risk. In addition, we aimed to show a relation between BCRAF and GRM.This study was designed as a cross-sectional study based on society.st degree relative with breast cancer. The participants had not been diagnosed as having breast cancer. Three hundred eighty of these 425 high-risk women were accepted to participate in the study. Twenty-four women who did not respond to all of the questions and 10 who wished to leave the study were excluded from the final analysis. The research was completed with 346 women, 81.4% of the study sample.This study was conducted in Bahçeşehir town in Istanbul, which is the most populous and most important city from economic and socio-cultural aspects in Turkey’s northwest. Bahçeşehir town was Turkey’s first satellite city, an important commercial and business center. In 2008, the Turkey Breast Health Association launched the Bahçeşehir Community-Based Breast Cancer Screening Program in this town, which has a quality population and residence register system. The program that provided free of charge for all services, is the first organized population-based breast cancer screening program in Turkey. Overall, 5680 women aged 40–69 yr and only live in the Bahçeşehir town were attended in the program, planned to last 10 yr (2008–2018). Screening activities were initiated at the end of 2008. The population for this study consisted of 5530 women aged between 40–69 yr who live in the Bahçeşehir town and attended the Bahçeşehir Community-Based Breast Cancer Screening Program between Jan 2009, and Jun 2012. Among these women, 425 women were selected as samples to the study program because their GRM score was ≥1.67% and/or they had a 1Tables published by WHO were used to determine the sample size of the study. A 17.6% rate of breast cancer risk of Turkish women . The stuThe data collection tools included a questionnaire form, Gail Risk Assessment tool, BCRAF and a visual analog scale for breast cancer risk perception.Data related to descriptive features and breast cancer risk factors of women were collected with the questionnaire form. This form was conceived through a review of published study , 29, 30,in situ , is also accepted and recommended by the Turkish Ministry of Health to be used to determine the level of breast cancer risk. This form consists of 6 sections and 20 items. The objectives in the form, used to determine the level of breast cancer risk, include age, family history, personal history, birth giving age, menstrual history, and women’s body structure. Each answer for the related risk factor is graded by assigning points and a total score is calculated to determine the risk level. Breast cancer risk according to the total risk score is classified as low risk (200 points and below), moderate risk (201 to 300 points), high risk (301–400 points), and the highest risk (more than 400 points) , 16, 26.BCRP was evaluated using a 100-cm-long visual analogue scale. Level of risk perception was determined using the results taken from the scale and defined as: 0% no risk, 1%–49% low risk, 50% moderate risk, 51%–100% high risk , 27.Participants were visited in their houses. The data of this study was collected between Jul 2012 and Dec 2012 through face-to-face interviews with the participants. The interviews lasted approximately 20 min.Ethical approval was obtained before the study began from the Local Ethics Committee of University of Istanbul, Istanbul Faculty of Medicine (No: 04). The participants were informed that their participation was based on voluntariness.P<0.001 level, 99.9% confidence intervals (CI)). Whether there was a difference among the BCRP and descriptive features and protection behaviors of breast cancer was evaluated using Pearson’s Chi-square test . In addition, logistic regression analysis was used to identify factors that affected the BCRP level .Full data were collected from 346 women who were all included in the final analysis. Data were analyzed using frequency, percentage, mean, standard deviation, Pearson’s Chi-square test, Spearman’s correlation, and logistics regression analysis. The relationship between risk assessment models and BCRAF score was evaluated with Spearman’s correlation ; most were married (76.6%) and in their post-menopausal phase (73.1%); according to their BMI, 40.5% were overweight and 31.8% were obese. About 63% of the women had menarche after the age of 12 yr; 93.6% had had live births; 72.8% had had their first birth before the age of 30 yr, and 91.4% had breastfed their babies; 24.3% had a history of breast-related disease; 23.1% had undergone biopsy; and among those who had a history of breast cancer in their family (58.7%), 87.7% had a history of breast cancer in their 1elatives .P<0.001), and the BCRAF and BCRP scores   .P>0.05)  . BCRP le P˂0.05, .P˂0.05, Higher BCRP levels were found in women aged between 40–59 yr, women in the post-menopausal phase, women whose economic situation was in the high to very high level, women with a history of breast cancer in their families, and women who had regular BSE and CBE P˂0.05, . In the Breast cancer is an important public health problem, which has worldwide increasing prevalence –4, 6, 13st degree relative with breast cancer, were tended to undergo significantly more mammography scans  have been completely observed by the authors.


For this reason, they established a BMI genetic score that included 84 BMI-associated genetic variants. The data for the study were received from two major databases – Breast Cancer Association Consortium and Discovery, Biology, and Risk of Inherited Variants in Breast Cancer – with a total of approximately 62,000 entries on breast cancer patients and 83,000 entries on healthy women. For both databases, a genetically predicted BMI had a highly significant inverse correlation to breast cancer risk, which was evident for both pre- and post-menopausal groups, in direct contradiction to ‘common’ conceptions. Thus, based on the data, the breast cancer risk (OR) for BMI >26.6 versus <25.0 was equal for pre- and post-menopausal females at 0.78 and 0.88, respectively, while for progressive BMI increase . Of note, the correlation in this case was even more significant than the one for BMI itself . Whetheret al. [Finally, the question of whether one should review  existinet al.  remains et al. [In conclusion, we should acknowledge that the unexpected results of the study by Guo et al.  imply a


Increasing age is a risk factor for developing cancer. Yet, older people commonly underestimate this risk, are less likely to be aware of the early symptoms, and are more likely to be diagnosed with advanced stage cancer. Mass media are a key influence on the public’s understanding health issues, including cancer risk. This study investigates how news media have represented age and other risk factors in the most common cancers over time.Eight hundred articles about the four most common cancers  published within eight UK national newspapers in 2003, 2004, 2013 and 2014 were identified using the Nexis database. Relevant manifest content of articles was coded quantitatively and subjected to descriptive statistical analysis in SPSS to identify patterns across the data.Risk was presented in half of the articles but this was rarely discussed in any depth and around a quarter of all articles introduced more than one risk factor, irrespective of cancer site. Age was mentioned as a risk factor in approximately 12% of all articles and this varied by cancer site. Age was most frequently reported in relation to prostate cancer and least often in articles about lung cancer. Articles featuring personal narratives more frequently focused on younger people and this was more pronounced in non-celebrity stories; only 15% of non-celebrity narratives were about people over 60. Other common risks discussed were family history and genetics, smoking, diet, alcohol, and environmental factors. Family history and genetics together featured as the most common risk factors. Risk factor reporting varied by site and family history was most commonly associated with breast cancer, diet with bowel cancer and smoking with lung cancer.Age and older adults were largely obscured in media representation of cancer and cancer experience. Indeed common risk factors in general were rarely discussed in any depth. Our findings will usefully inform the development of future cancer awareness campaigns and media guidelines. It is important that older adults appreciate their heightened risk, particularly in the context of help-seeking decisions. The global burden of cancer is significant and incidence is increasing . Much ofDespite age emerging as an increasingly important risk factor for cancer, older adults commonly underestimate their risk, are less likely to be aware of early symptoms and are more likely to be diagnosed with cancer when it is in an advanced stage –8. Robb Cancer awareness has been linked with helpseeking and presentation, and older adults are amongst those with lower awareness , 14. In Early diagnosis of cancer relies not only on prompt presentation of symptoms suggestive of cancer but also on national screening programmes. In the UK there are currently three national screening programmes for cancer – breast, bowel and cervical cancer – and all impose an upper age limit. While eligibility for automatic screening invitations stop at 70 and 74 for breast and bowel cancer respectively, those who wish to continue screening are encouraged to opt in to programmes . Taken tCancer risk factors include modifiable risks, such as smoking, alcohol, obesity and sun exposure as well as other risks such as increasing age and family history. Studies that seek to assess public awareness of such risk typically find high levels of awareness of the risks associated with smoking but lower awareness of other risk factors. Only 4% of those surveyed mentioned older age as a risk factor unprompted and this rose to 36% when prompted. International comparisons have shown that awareness of the links between cancer and increased age was lower in the UK, Canada and Australia as compared with Scandinavian countries . PortrayHow people understand and act on information is often mediated and amplified through the mass media, therefore the media are a key influence on the public’s understandings and awareness of health issues, including cancer risk. Indeed the media are likely to be a key information source for those that do not seek ‘formal’ health information from other sources. The agenda-setting function of media is long-recognised and the media plays a role in shaping public understandings and health behaviours by choosing what news to report and how to report it . As far Celebrity coverage notwithstanding, the media framing literature demonstrates that portrayals of cancer are often negative, promoting frames of dread and fear , 44, andJust as the media frames the representation of cancer the way in which older adults are portrayed in the media is not without critique. Many studies of a range of media - print media, television and advertising – typically conclude that older people are underrepresented , 49. Whe“cancer AND breast OR prostate OR lung OR colorectal OR bowel” within article headlines. All articles were read  to remove duplicate articles and exclude those that did not meet two inclusion criteria: the article must focus on breast, prostate, lung or colorectal cancer risk, and the article must be in news, feature or editorial format . We excluded articles, coded as ‘breakthrough’ stories that reported new or novel treatments but did not discuss risk. The search identified a total of 928 articles: 368 from 2003/4 and 560 from 2013/14. Following review, 128 were excluded due to either being duplicates of previously-accepted articles or failing to meet one or both of the inclusion criteria. This left 800 articles eligible for coding and analysis.We chose eight UK daily national newspapers and their Sunday counterparts, representing three genres of newspapers: ‘serious’ – Daily Telegraph & Sunday Telegraph; ‘mid-market’ – Daily Mail & Mail on Sunday and the Daily Express & Sunday Express; and ‘tabloids’ – Daily Mirror & Sunday Mirror. These newspapers were selected as their readers tend to be older . To provTo develop a coding frame, researchers  read all the articles and identified categories and developed coding around our key a priori research questions: 1-How frequently is age represented as a risk factor for breast, prostate, lung, and colorectal cancers over time? 2-How does the frequency of age as a risk factor compare to other risk factors represented in breast, prostate, lung, and colorectal cancers?The research team worked in close collaboration, checking and validating coding. Once all the data were coded, the data were entered into an SPSS file for descriptive statistical analysis to identify patterns across the data. To examine these patterns and provide more contextual explanations for differences across the data, free text was added into frameworks for textual analysis. Data were analysed by YC and CP. A binomial test was used to measure the significance of the difference in article count between the two time periods, and chi-square tests were used to test whether citations of specific risk factors differed significantly by time period.Though we initially coded family history and genes separately we found that they rarely appeared individually and are likely to be conflated by readerships. Moreover, many of the articles presented risk factors, but few gave in-depth information on risks or associations. We therefore thought it necessary to distinguish between articles that ‘mentioned’ risk and those that ‘discussed’ risk or risk factors in more detail. Table n = 226, 71.3%) and 2013–14 . A total of 317 articles about cancer were published in 2003–4, and 483 in 2013–14 – a statistically significant (p < 0.001) difference of 52.4%. Risks were represented in just under half (49.5%) of all articles, and 25% of articles introduced more than one risk factor.As Table n = 514), age was mentioned in 59 (11.5%), and discussed in detail in 12 (2.3%) of them. Age was mentioned in 23 (14.2%) and discussed in 6 (3.7%) in the articles about prostate cancer. In the 61 articles about colorectal cancer, age was mentioned in 14 (23.0%) and discussed in one (1.59%). Finally, age was mentioned once (1.6%) and discussed once (1.6%) in the 63 articles about lung cancer. Comparing the two time periods, age was either mentioned or discussed as a risk factor in 59 (18.6%) articles in 2003–4 and 58 (12.0%) articles in 2013–14, a significant  difference. However, this difference was not present in each cancer site; the proportions within articles about prostate, colorectal and lung cancer did not vary significantly  between time periods, while the proportion of articles about breast cancer citing age (in either a brief mention or a more detailed discussion) varied significantly  between 2003 and 4  and 2013–14 .Across all cancer sites age was briefly mentioned as a risk factor for 97 articles (12.1%), and discussed in 20 (2.5%) articles. In the articles about breast cancer  were aged 61 years or older, 43 (35.5%) between 41 and 60 years and 35 (28.9%) 41 years or younger. In the 114 articles describing non-celebrities (which were largely about how these ‘ordinary’ people coped with cancer), 18 (15.8%) were aged 61 years or older, compared to 52 (43.9%) aged 41–60 and 46 (40.4%) aged 40 or younger.n = 122, 15.3%); family history and / or genes ; smoking ; alcohol , and environmental factors . Age was discussed as a risk factor in 20 (2.5%) articles. Diet  and family history and/or genes  were discussed more frequently, while alcohol , and smoking  were discussed less frequently. Table n = 29, 14.2%).In addition to the 117 (14.6%) citations of age as a risk factor, articles reported on: diet (p = 0.012) and environment  were mentioned more frequently in the first time period than the second within articles about breast cancer, genes and/or family history were mentioned more frequently in the second . In addition to risk factors, mentions of risk reducers were coded; breast feeding was mentioned as a risk reducer for breast cancer 17 (3.3%) times and discussed in detail three (0.6%) times. Ninety-one articles (17.7%) mentioned breast cancer screening, and 25 (4.9%) of those mentioned some criticism of screening.Table p = 0.038), which were mentioned just twice in 2003–4 and not at all in 2013–14. Forty-seven articles (29.0%) mentioned prostate cancer screening, of those 25 mentioned a criticism of screening.Age  was the risk factor most commonly linked with prostate cancer, while diet , genes and/or family history  also featured. The only risk factor that varied significantly between time periods within articles about prostate cancer was environmental factors , environment was mentioned eight times (12.7%) and discussed five times (7.9%), and genes and/or family history were mentioned four times (6.3%) and discussed twice (3.2%). Age was mentioned in one article (1.6%) and discussed in another (1.6%). No risk factors varied significantly by time period within articles about lung cancer. Only five articles (7.9%) mentioned screening for lung cancer, and one of those mentioned a criticism of screening.p = 0.029) varied by time period: no articles about colorectal cancer mentioned alcohol in 2003–4, while nine mentioned alcohol in 2013–4. Nineteen articles (31.1%) mentioned screening for colorectal cancer, and three of those articles mentioned a criticism of screening.Diet was the most frequently mentioned risk factor , followed by age , family history and/or genes  and alcohol . Alcohol was the only risk factor that significantly . We found that more articles about cancer were published during the later period, though we did not find an equivalent increase in the number of articles linking cancer with increasing age. Fewer than 15% of articles documented an association between cancer and increased age, and only 2.5% of all articles discussed the importance of age in any depth. Between the two time periods the proportion of articles that mentioned age as a risk factor for prostate, lung and colorectal cancer remained relatively stable; but decreased significantly by 14% in articles about breast cancer. As well as age we also considered the range of other risk factors that appeared in the included articles. The most commonly cited risk factors varied by cancer site: breast cancer and genes and/or family history; prostate cancer and age; lung cancer and smoking; and colorectal cancer and diet. Among stories that featured personal narratives the main actors were typically under 60, and ‘non-celebrities’ were more likely to be younger still. We found that not only is age largely invisible but that risk more generally receives little attention. Yet, we found a discrepancy between the emphasis placed on some risk factors and the proportion of cancers attributed to such risks, for example the most common risk factor presented for breast cancer was family history and/or genes, which accounts for fewer than 5% of all breast cancers . As a prA major strength of our work is that while previous analyses of media representations of cancer have been conducted, few focus on how risk and specific risk factors are characterised. If we accept the role of the media as an information-giving vehicle it is useful to gain an insight into how the risk narrative is framed and we have demonstrated that certain cancer sites and risks are overrepresented at the expense of other relevant risk factors. It is also helpful to consider differences in two time periods ten years apart. However, we acknowledge that these two separate snap-shots cannot give evidence of continuous trends over time. Additionally, though we restricted our analysis to print media, which remain a popular and widespread source of information , other media such as magazines, television broadcasts, radio, online news and social media are increasingly important. Moreover, we did not look at images or the size and prominence of headlines, but purely analysed the content of the article text. As is inherent to content analysis, we cannot determine how the public digest and act on the content analysed.While analyses of the media representation of cancer are not new –58 previOur findings contribute to this body of evidence. We found breast cancer dominated media coverage and although such coverage is consistent with incidence, media attention was not commensurate with mortality. Lung cancer, which is responsible for the largest proportion of cancer deaths, was covered less frequently .Previous studies have shown that media coverage has a demonstrable impact on behaviour. High-profile celebrity cases, such as Jade Goody’s diagnosis of cervical cancer and Kylie Minogue’s diagnosis of breast cancer were associated with increased screening uptake –42. We pAge was largely invisible in stories containing personal narratives about individuals and as a risk factor in itself. Jones  concludeWe did however find that risk factors associated with lung, colorectal and prostate cancer  matched current awareness messages. However, the most common risk factor presented for breast cancer was family history and/or genes, which accounts for fewer than 5% of all breast cancers . MoreoveAs well as inaccurate or missing risk information, it is worth emphasising that risk generally receives limited attention. We found few in-depth discussions of risk factors and instead they were merely ‘mentioned’, appearing in list-like form. Although the risk factors are accurate a surface approach fails to capture the complexity in the risk message. Our findings contribute to a growing body of work , 65 thatAlthough the risk of cancer increases as we get older, this doesn’t mean that you will definitely get cancer at some point. But it does mean that being aware of changes in your body, and going to the doctor if you notice anything unusual or that doesn’t go away, is even more important as we age. [ we age. As the above extract from Cancer Research UK’s website suggests older adults should be vigilant about cancer yet this is not reflected in the news media coverage of cancer risk. Taken together invisibility, inaccuracy and information overload build a skewed picture that cancer is a disease which affects younger people. Moreover, we demonstrate that family history of, or a genetic predisposition to cancer dominates aetiological explanations. Older adults with no family history may understandably underestimate their heightened risk. While focusing on age as a risk factor in the conventional sense, insofar as age is not modifiable, may be seen as problematic there are valid reasons for exploring the representation of the associations between ageing and cancer. Older adults experience poorer cancer outcomes, have lower awareness of risk and symptoms and are more likely to experience late stage diagnosis. Symptom appraisal studies have shown that older adults often attribute symptoms to natural consequences of ageing and therefore tend to seek help less promptly , 72. MedCommon cancer stories, although skewed towards younger age groups, tend to emphasise the random and unpredictable nature of the disease by reinforcing the ‘atypical case’. Accurate risk messages are therefore diluted and prevention strategies may feel unattainable. This may be particularly relevant for older adults who believe that there is little value in adopting or maintaining healthier behaviours. While it may be naïve and unreasonable to expect the media to shift away from its primary human interest function to become a mouthpiece for health educators, our findings have implications for those committed to awareness raising and information giving across the population. There is a pressing need to present a balanced and accurate representation of the sub-groups of the population most at risk of cancer. Older adults rarely see themselves represented among those that are affected by cancer, and therefore education and awareness raising messages need to counteract and re-balance messages. Stakeholders (including cancer research organisations and charities and representative groups for older people) should consider collaborating with media organisations and journalists to understand each other’s values. Indeed the co-production of reporting guidelines that balance the need for the media to focus on human interest stories while simultaneously representing a more convincing cancer picture is strongly indicted by our findings. This could only increase the quality of the journalism, and potentially enhance awareness of risk factors among readers.


NBS1, was shown to be associated with increased susceptibility to lung and colorectal cancer. However, the relation between rs2735383 and susceptibility to breast cancer is not yet clear. Therefore, we genotyped rs2735383 in 1,170 familial non-BRCA1/2 breast cancer cases and 1,077 controls using PCR-based restriction fragment length polymorphism (RFLP-PCR) analysis, but found no association between rs2735383CC and breast cancer risk . Because we could not exclude a small effect size due to a limited sample size, we further analyzed imputed rs2735383 genotypes (r2 > 0.999) of 47,640 breast cancer cases and 46,656 controls from the Breast Cancer Association Consortium (BCAC). However, rs2735383CC was not associated with overall breast cancer risk in European  nor in Asian women . Subgroup analyses by age, age at menarche, age at menopause, menopausal status, number of pregnancies, breast feeding, family history and receptor status also did not reveal a significant association. This study therefore does not support the involvement of the genotype at NBS1 rs2735383 in breast cancer susceptibility.NBS1, also known as NBN, plays an important role in maintaining genomic stability. Interestingly, rs2735383 G > C, located in a microRNA binding site in the 3′-untranslated region (UTR) of  When left unrepaired, DSBs may cause genomic instability, cell death and cancer13The DNA damage response (DDR) pathway maintains the stability of the human genome via a complex network of pathways integrating signal transduction, regulation of the cell cycle and repair of DNA. Double-strand breaks (DSBs), a particularly severe form of DNA damage, arise as a consequence of cell replication, programmed DNA rearrangements  are involved in DNA repair7MCPH1as a novel breast cancer susceptibility gene illustrates that this hypothesis still holdsThe DDR plays an important role in susceptibility to breast cancer. In fact, all of the currently identified high- and moderate-risk breast cancer genes  and has its origin in the Slavic populationNBS1 mutations implicated in Nijmegen breakage syndrome are p.I171V and p.R215W. Although both mutations associate with an overall cancer risk of 4-fold and 2-fold, respectively, there does not seem to be an increased risk to develop breast cancer specificallyIn this respect, the NBS1  have also been reported to be associated with risks for several cancer types. Recent meta-analyses for rs1805794 have, however, shown that this variant does not associate with breast cancer risk131415131617NBS1, has been shown to modulate the binding ability of microRNA-629 in lung cancer cells and microRNA-509-5p in colorectal cancer cells, affect NBS1 transcriptional activity and decrease NBS1 mRNA and NBS1 protein levels1913NBS1 rs2735383 is associated with breast cancer risk in the Rotterdam Breast Cancer Study (RBCS) by RFLP-PCR and in 45 studies of BCAC through imputation of the iCOGS arrayBesides the rare Nijmegen breakage syndrome-associated mutations, two common variants in NBS1 rs2735383 and breast cancer risk, we analyzed NBS1 rs2735383 by RFLP-PCR in 1,269 non-BRCA1/2 familial breast cancer patients and 1,159 controls from RBCS. Since genetic risk factors are usually enriched in familial/early-onset breast cancer cases, specifically selecting these breast cancer patients improves statistical power. Among the cases, 516 had the GG genotype, 507 had the GC genotype and 147 had the CC genotype at rs2735383  = 0.342). Among the controls, 462 had the GG genotype, 501 had the GC genotype and 114 had the CC genotype (MAF = 0.338). For both cases and controls, the genotypes of rs2735383 were in Hardy-Weinberg equilibrium (HWE). Because rs2735383 CC was associated with an increased risk of lung cancer and colorectal cancer under a recessive genetic model13P = 0.144; P < 0.001), whereas the colorectal cancer risk had been associated with an OR of 1.55 13(i.e. OR < 1.28). Therefore, we cannot exclude rs2735383 CC is associated with breast cancer, but confers a smaller risk.To evaluate the association between NBS1 rs2735383 in BCAC studies through imputation. Since we had data available for RBCS on rs2735383 from both the PCR-based RFLP and from imputation, we first evaluated the concordance between the two methods. In total, from 1,313 samples (i.e. 646 cases and 667 controls) we had genotypes for rs2738353 available from both RFLP-PCR and imputation. Importantly, the agreement between the two methods was 97.1%  and was similar among cases and controls (i.e. 98.1% versus 96.1%). Moreover, case-control ORs for imputed data were comparable to ORs obtained by RFLP-PCR . Therefore, we used the imputed data on rs2735383 to evaluate further its association with breast cancer risk.For this reason we analyzed P = 0.556; P = 0.684; P = 0.984; 13P = 0.961; P = 0.900; P = 0.911; NBS1 rs2735383 is not associated with an increased risk to develop invasive breast cancer.For the overall analysis in Europeans we had 41,915 cases and 40,042 controls available from 36 case-control studies. However, rs2735383 was not associated with breast cancer risk in Europeans, neither under a recessive genetic model 13NBS1 rs2735383 with breast cancer risk. We found that the CC genotype of rs2735383 did not confer an increased breast cancer risk, neither in the overall analyses nor in the subgroup analyses.The CC genotype of the common variant rs2735383 in the 3′UTR of et al. consisting of 239 premenopausal breast cancer patients and 477 matched controls from the Nurses’ Health Study II showed that rs2735383 did not associate with breast cancer risk under an additive genetic model et al. consisting of 450 breast cancer patients and 450 cancer-free controls from the Henan Province in China also found no association with overall breast cancer riski.e. 450 cases and 450 controls in the study of Wu et al.), could have easily given rise to false positive findings. Therefore, one should be careful when reporting positive findings from multiple small subgroup comparisons and always use appropriate levels of statistical significanceet al. there is no mention of multiple testing correction.In agreement with these results, a small study by Han NBS1 gene through either binding of microRNA-629 to the 3′-UTR of NBS1 gene in lung cancer cells or the binding of microRNA-509-5p to the 3′-UTR of NBS1 gene in colorectal cancer cells19NBS1 may reduce the efficiency of DSB repair, this way the rs2735383CC genotype likely confers an increased lung and colorectal cancer risk. According to our study, however, the rs2735383CC genotype does not confer an increased breast cancer risk. Considering that in lung and colorectal cancer cells different microRNAs appear to be downregulating NBS1 expression, tissue specific expression of these microRNAs may likely play a role. Besides microRNA-509 and microRNA-629, the C allele at rs2735383 has also been predicted to enhance the binding of microRNA-499 and microRNA-508 to the 3′UTR of NBS1NBS1 cannot be downregulated by any of these microRNAs. At least in breast cancer cells, none of these microRNAs, except microRNA-629, are expressed at substantial levels . Since microRNAs are often deregulated between normal tissue and cancer tissue, this does not necessarily represent the situation in normal breast cells. Thus, further evaluation of the miRNA expression levels in normal (breast) tissue, but also their correlation with the genotype at rs2735383 should provide more insight for the tissue specificity of rs2735383 and cancer risk.It was found that the rs2735383CC genotype significantly decreased the expression of the i.e. OR > 1.04 for Europeans and OR > 1.11 for Asians) between the genotype at rs2735383 in the 3′UTR of NBS1 and breast cancer susceptibility.Importantly, in contrast to lung and colorectal cancer susceptibility, the results of this study do not support the presence of an association . RBCS controls  came from the same database and geographic location as the RBCS cases and included women from cystic fibrosis families who were either spouses of individuals at risk of being carrier of a CFTR mutation or individuals who were tested negative for a CFTR mutation. The median age of the RBCS controls was 41 years (range 10–97 years).RBCS cases  came from the database of the Clinical Genetics Department at Erasmus University Medical Centre in Rotterdam, representing the Southwestern part of the Netherlands. First, we selected families that presented with at least two cases of female breast cancer or at least one case of female breast cancer and one case of ovarian cancer in first- or second-degree relatives. In addition, at least one of these two cases needed to be diagnosed before the age of 60. For each selected family, the youngest breast cancer patient who had been tested for i.e. two studies) were not included because power in the analyses would be low due to a relatively low MAF (i.e. 0.123) and small amount of cases . Each study was approved by its relevant governing research ethics committee and all study participants provided written informed consent. The experimental protocol was approved by the Medical Ethical Committee of the Erasmus Medical Center Rotterdam and the study was carried out in accordance with the Code of Conduct of the Federation of Medical Scientific Societies in the Netherlands (http://www.fmwv.nl). Following genotyping on the iCOGS arrayBCAC consists of case-control studies of unrelated womenNBS1 including rs2735383 was amplified in a duplex PCR reaction together with a 713 bp fragment of the LRRC4 gene. Primers for NBS1 and LRRC4 were present in the PCR reaction at a final concentration of 0.25 and 1 μM, respectively, and sequences are available in LRRC4 fragment served as an internal digestion control and generated two fragments of 549 and 164 bp upon complete digestion with ScfI . The 324 bp amplified NBS1 fragment was only digested when the major G allele was present at rs2735383, thereby generating two fragments of 233 and 91 bp. Thus upon successful digestion with ScfI, samples with rs2735383 GG generated four fragments, samples with rs2735383 GC generated five fragments and samples with rs2735383 CC generated three fragments (A 324 bp fragment of the 3′UTR of ragments .i.e. when MAF >0.05) or <99% (i.e. when MAF <0.05), deviation from HWE (i.e. P < 10–7), or >2% duplicate discordance.Genotyping of BCAC studies was performed previously using the custom iCOGS Illumina Infinium iSelect BeadChipNBS1 rs2735383 was imputed with an imputation r2 > 0.999 in both Europeans and Asians.Imputation of genotypes was performed using 1000 Genomes Project data (v3 April 2012 release) as the reference panelNBS1 rs2735383 and invasive breast cancer risk was evaluated by logistic regression analysis providing ORs and 95% CIs. In the analyses of BCAC studies, ORs were adjusted for study, age, and PCs. In the analyses of RBCS, ethnicity was not a confounding factor thus reported ORs were unadjusted for PCs. For the European and Asian BCAC studies, we additionally performed study-specific logistic regression analysis adjusting for age and PCs, and pooled the log ORs in a fixed-effects meta-analysis. Subgroup analyses within the European BCAC studies were based on age (i.e. ≤50 years and >50 years), age at menarche (i.e. ≤13 years and >13 years), age at menopause (i.e. ≤50 years and >50 years), menopausal status , number of full-term pregnancies (i.e. ≤2 and >2), breast feeding (i.e. no and yes), first-degree family history of breast cancer and receptor status . Clinical and demographic characteristics of the BCAC cases are presented in NBS1 rs2735383 and the clinical and demographic characteristics were evaluated using a χ2 test. All P-values were two-sided and P < 0.05 was considered to be statistically significant after correction for multiple testing by the Bonferroni procedure. Logistic regression analyses were performed using SPSS statistics version 23  and fixed-effects meta-analyses using Stata version 13 .The association between How to cite this article: Liu, J. et al. rs2735383, located at a microRNA binding site in the 3′UTR of NBS1, is not associated with breast cancer risk. Sci. Rep.6, 36874; doi: 10.1038/srep36874 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with an estimated prevalence of 4–21% in reproductive aged women. The altered metabolic and hormonal environment among women with PCOS may increase their risk of some types of cancer.We performed a comprehensive review of the literature using numerous search terms for all studies examining the associations between polycystic ovary syndrome and related characteristics and cancer published in English through October 2016. This review summarizes the epidemiological findings on the associations between PCOS and endometrial, ovarian, and breast cancers and discusses the methodological issues, complexities, and underlying mechanisms of these associations.We identified 11 individual studies and 3 meta-analyses on the associations between PCOS and endometrial cancer, 8 studies and 1 meta-analysis for ovarian cancer, and 10 studies and 1 meta-analysis for breast cancer. Multiple studies reported that women with PCOS were at a higher risk for endometrial cancer; however, many did not take into account body mass index (BMI), a strong and well-established risk factor for endometrial cancer. The association with ovarian cancer was less clear, but a potentially increased risk of the borderline serous subtype was reported by two studies. No consistent association between PCOS risk and breast cancer was observed.The associations between PCOS and endometrial, ovarian, and breast cancer are complex, with the need to consider many methodological issues in future analyses. Larger well-designed studies, or pooled analyses, may help clarify these complex associations. Polycystic ovary syndrome (PCOS) is a complex endocrine disorder characterized by oligomenorrhea, hyperandrogenism, and polycystic ovaries. It has an estimated prevalence of 4–21% in reproductive aged women depending on the diagnostic criteria and population examined . In the First described by Stein and Leventhal in 1935 as women with polycystic ovaries, amenorrhea, and hirsutism , PCOS isThe clinical presentation of PCOS varies but commonly includes ovulatory dysfunction , hirsutism, acne, and polycystic ovaries (PCO). Women with PCOS commonly have insulin resistance and metabolic syndrome –19. In aAn association between PCOS and endometrial cancer was first suggested over fifty years ago by a series of small case reports, but these studies were limited by lack of control groups and small numbers . Three mFive studies have examined the association between PCOS and endometrial cancer without accounting for BMI Table . Two of Endometrial tumors display a variety of histologic features but the majority of cases are adenocarcinomas (>95%) and can be classified into two main subtypes, endometrioid (Type I) and non-endometrioid (Type II) , 50. As PCOS has been hypothesized to increase ovarian cancer risk through increased androgen exposure . EvidencEpithelial ovarian cancer consists of molecularly and etiologically distinct subgroups that can be separated into four main histologic subtypes –67. ThusCharacteristics and consequences of PCOS have been previously associated with both increased and decreased risk of breast cancer. For example, infertility due to an ovulatory disorder has been shown to decrease breast cancer risk  while obThough women were not specifically classified by PCOS status, we reported in the Nurses’ Health Study II, a cohort including more than 100,000 women and followed prospectively, that women who reported infertility due to ovulatory disorders had no increase in breast cancer risk. In fact, women with ovulatory disorders that were treated for infertility had a significantly lower risk compared to women with no reported infertility . AnovulaThe literature examining the association between PCOS and cancers other than endometrial, breast, and ovarian, is scarce. Although not previously described, more kidney, colon, and brain cancers were observed among women with PCOS compared to expected rates in the general Danish population . In addiSince high BMI is a common characteristic of PCOS, –31 one cBeyond BMI, the adjustment for cancer risk factors varied widely between studies and may also explain differences between studies as some characteristics of PCOS, such as infertility, are risk factors for these cancers. Reproductive risk factors such as parity and age at first birth may have different distributions in those with and without PCOS due to the increased risk of infertility in women with PCOS. In addition, women with PCOS are at increased risk of type II diabetes , 21, insPCOS is characterized by prolonged anovulation with consequent exposure to estrogen unopposed by progesterone , 84, whiAlternatively, elevated androgens may play a role. Hyperandrogenism is one major component of all three clinical diagnostic criteria for PCOS. In 1998, Risch proposed that ovarian cancer might be associated with factors related to androgen stimulation of ovarian cells, and animFor women who are not attempting to become pregnant, combined oral contraceptives are often one of the first-line treatments for menstrual irregularities in women with PCOS . CombineAmong women with PCOS, metformin is prescribed to treat or reduce the risk of type II diabetes, improve insulin resistance, and in some cases to help regulate the menstrual cycle/induce ovulation. Evidence has suggested that metformin use may be protective against various forms of cancer. This is supported by laboratory studies that demonstrate metformin’s anti-cancer activities . Howevern = 7), an established risk factor for postmenopausal breast cancer, the SRR was 0.8 (95% CI = 0.7–1.0), and when limited to prospective studies (n = 7), the SRR was 0.9 (95% CI = 0.9–1.0). However, a more recent analyses among women in general practice databases from Germany and the United Kingdom reported no association between metformin users and breast cancer incidence when compared users of sulfonylurea and insulin  [Breast cancer has been the most studied of the three cancers with respect to the influence of metformin. A 2014 meta-analysis including 13 studies reported a summary risk estimate (SRR) of 0.9 (95% CI = 0.8–1.0) for the association between metformin use and breast cancer incidence . When lictively) .The epidemiologic data examining the relation between metformin and endometrial cancer have generally suggested no association or a protective association between metformin and endometrial cancer. Among women in the UK-based General Practice Research Database (GPRD) no significant association was observed between metformin and endometrial cancer with an OR of 0.9 (95% CI = 0.6–1.2)  SimilarlThe association between metformin use and ovarian cancer has been less studied than breast or endometrial cancer. However, metformin use has been demonstrated to influence ovarian cancer cell growth in vitro and in vivo , 104 andPrevious studies on the associations between fertility drugs and risk of hormone related cancers have produced mixed results. The inconsistencies are likely due to the combining of different drug types, self-reported drugs use, limited power and information about dosages, short follow-up, and reproductive confounders that are highly correlated with drug use . ClomiphClomiphene’s action as an ovulation inducer provides strong biological plausibility for its influence on ovarian cancer risk as ovulatory damage likely plays a prominent role in ovarian cancer risk . Most reEndometrial cancer has been the least studied of the hormone related cancers in relation to clomiphene use. An association has been hypothesized since clomiphene has chemical properties similar to tamoxifen, a drug that has been associated with endometrial cancer risk . HoweverFewer studies have examined the associations between clomiphene and cancers other then endometrial, ovarian, or breast cancer. A recent analysis in a cohort of over 12,000 infertile women reported that clomiphene was statistically significant increased risk of melanoma , a non-significant increased risk of thyroid cancer , and no increased risks for colorectal or lung cancer .Letrozole, an aromatase inhibitor, has more recently been considered as an additional treatment option for anovulatory infertility. While longitudinal data does not yet exist to adequately examine the association between letrozole use for ovulatory infertility and hormone related cancer risk, letrozole is currently used as an adjuvant treatment for hormone receptor positive postmenopausal breast cancer  thus it The associations between PCOS and endometrial, ovarian, and breast cancer are complex, requiring consideration of PCOS diagnostic criteria, etiologic heterogeneity of cancer subtypes, confounding and mediating factors, menopausal status, co-morbid conditions, as well as treatment options that may also influence cancer risk. In addition, the rarity of ovarian and endometrial cancers make these cancers even more difficult to study. Larger well-designed studies, or pooled analyses, may help clarify these complex associations.


ORs) and corresponding 95% confidence intervals (CIs) were estimated using logistic regression models. The ORs were 0.88 (95% CI: 0.78–0.98) for an age at menarche ≥14 years and 1.39 (95% CI: 1.07–1.81) for an age of 30 years or older at first pregnancy. Body mass index (BMI) was positively associated with breast cancer risk in women older than 50 years , while the association tended to be inverse in younger women. A high mammographic density increased breast cancer risk . The ORs were 1.67 (95% CI: 1.47–1.89) and 2.04 (95% CI: 1.38–3.00) for one first‐degree relative and two or more relatives affected by breast cancer, respectively. Our study confirms the role of major recognized risk factors for breast cancer in our population and provides the basis for a stratification of the participants in the mammographic screening according to different levels of risk.Breast cancer is the most common cancer diagnosis and the leading cause of cancer death among women in the world, and differences across populations indicate a role of hormonal, reproductive and lifestyle factors. This study is based on a cohort of 78,050 women invited to undergo a mammogram by Local Health Authority of Milan, between 2003 and 2007. We carried out a nested case–control study including all the 3303 incident breast cancer cases diagnosed up to 2015, and 9909 controls matched by age and year of enrollment. Odds ratios ( Breast cancer is the most common cancer diagnosis and the leading cause of cancer death among women in the world, with 1.7 million cases and 521,900 deaths estimated in 2012 An early age at menarche—which implies the onset of a mature hormonal pattern, including onset of ovulation, cyclic hormonal changes, and menstruation—has been consistently related to an increased risk of breast cancer, with an estimated 5% of increase in risk for every year of menarche anticipation Another well‐established risk factor for breast cancer is a family history of the disease in first‐degree relatives, the risk being further increased in the presence of more than one affected relative Among lifestyle risk factors, alcohol drinking has been consistently related to breast cancer, with an increase in risk of about 20% for moderate drinkers and of 60% for heavy drinkers In this study, we evaluated the role of hormonal factors, lifestyle habits, and family history of breast cancer, using data from a large cohort of women invited to participate to a mammographic screening program in Italy. To our knowledge, this is the first study that quantified these associations in an Italian population participating to an organized a mammographic screening program.Fattori di Rischio per il Carcinoma della Mammella), supported by a specific grant of the Italian League of Cancer Prevention.This study is based on data from a cohort of 78,050 women, aged between 41 and 76 years, resident in the municipality of Milan, who were invited to participate in the mammographic screening program of the Local Health Authority of Milan from 2003 to 2007 in the framework of a study with the acronym of FRiCaM .In order to obtain information from a sample of nonscreened women, 20,000 questionnaires were sent by mail to nonattenders to a mammographic screening: 6652 women, who did not adhere to the mammographic screening, accepted to provide the questionnaire through postal delivery (33%).The questionnaire requested detailed information on socio‐demographic characteristics, anthropometric measures, menstrual and reproductive history, health status, family history of cancer (including breast), and lifestyle factors, including dietary habits. Mammographic density was available only for the sample of screened women and was read by experienced screening radiologists and classified in three categories: (1) almost entirely fat (less than 25 percent glandular), (2) scattered fibroglandular densities or heterogeneously dense (approximately 25–75% glandular), and (3) extremely dense (more than 75% glandular).As all study participants provided a written informed consent together with the questionnaire, the date of the signing of the consensus was considered as the date of enrollment in the study. Breast cancer cases were identified through record linkage between the cohort and the Cancer Registry of Milan, which is active since 1999. This allowed to identify 3532 breast cancer cases diagnosed up to 2015. Among these, we excluded 229 women who had a date of diagnosis preceding the date of enrollment in the study. Thus, the final number of breast cancer cases included in this study is 3303. The study was approved by the Ethics Committee of the Local Health Authority of Milan. Record linkage with the Cancer Registry of Milan and with Civil Registry allowed to assess vital status and absence of cancer among the controls at the end of the follow‐up period.Within the screening cohort, we carried out a nested case–control study. All the 3303 incident breast cancer cases were included. For each case, three control subjects were chosen at random among cohort members alive and free of breast cancer, individually matched to cases by age (in quinquennia) and year of enrollment in the study. Thus, the present work is based on 3303 incident cases of breast cancer and 9909 matched controls.2), alcohol drinking , age at menarche , age at first birth , menopausal status , family history of breast cancer , when appropriate . Women with a missing value for an exposure variable were excluded from the analysis of that variable, while women with missing values on a confounding variable were included in the analyses, using a separate category for missing values. None of the confounding variables had missing values for more than 5% of both cases and controls. Regression analyses with ordered categories were used to test the presence of a linear trend.We estimated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) of breast cancer for the selected risk factors, through logistic regression models conditioned on age in quinquennia and year of enrollment, and adjusted for education , marital status , body mass index .Table P = 0.0265). A higher age at first live birth was associated with an increased risk of breast cancer , with a significant trend in risk (P = 0.0006). Previous breast biopsies were associated with an increase in breast cancer risk . Mammographic density was associated with breast cancer risk, the ORs being 1.59 (95% CI: 1.31–1.93) for a density <25%, 2.25 (95% CI: 1.86–2.73) for 25–75%, and 2.61 (95% CI: 2.02–3.38) for >75%, as compared to almost entirely adipose tissue (P < 0.0001). Among women older than 50 years, cases were more frequently overweight  or obese  as compared to women with a body mass index (BMI) <20 (P for trend <0.0001), while among women younger than 50 years BMI tended to be inversely related to breast cancer, though in the absence of statistical significance. Women who experienced a previous breast surgery had an increased risk of breast cancer . Family history of breast cancer in first‐degree relatives was associated with an increased risk of breast cancer, the ORs being 1.67 (95% CI: 1.47–1.89) for women with one relative affected by breast cancer and 2.04 (95% CI: 1.38–3.00) for women with two or more relatives affected by breast cancer (P for trend <0.0001). No significant association was evident for the other considered factors, including menopausal status, oral contraceptives use, hormone replacement therapy use, previous diagnosis of other cancers, previous ovarian surgery, previous Smear test, and previous mammography.Table P for trend <0.0001). An inverse association was evident for fruit consumption . No significant association emerged for the remaining considered lifestyle factors, including tobacco smoking, consumption of vegetables, cheese, red and white meat, and fish.Table In the present study, we carried out a comprehensive assessment of the role of several hormonal and lifestyle factors for breast cancer, using data from a large cohort of women participating in a mammographic screening program in Italy. We observed a 12% reduced risk of developing breast cancer for women who had the menarche at 14 years old or after, and a 39% increased risk for women who had their first pregnancy at 30 years old or after. These results are in line with those from previous studies As for the role of body weight on breast cancer risk, it was dependent on age—as a proxy of menopausal status—in our, as well as in previous studies Mammographic density—that is, the overall percentage of dense tissue observed in the mammogram—has been consistently related to breast cancer risk and is modulated by hormonal, reproductive, and lifestyle risk factors associated with the disease. Our observation of an increased risk of breast cancer associated with a higher mammographic density is in agreement with previous studies Our study also confirmed that breast cancer risk is higher among women with a family history of breast cancer, the increase in risk being 67% among women with a first‐degree relative affected, and twofold in women with more than one relative affected by breast cancer. Several studies have reported this association, which may be due both to the fact that the relatives tend to be exposed to the same environmental and lifestyle factors, as well as to the fact that they share inheritable genetic susceptibility.Considering lifestyle factors, we observed an increased risk of breast cancer among regular alcohol drinkers, which has been reported previously We did not observe any significant role of dietary habits, with the only exception of fruit consumption, which was inversely related to breast cancer risk. Although several studies have been carried out on the role of dietary habits on breast cancer etiology, this is still an open issue, and the evidence on specific foods or nutrients is controversial, with weak and inconsistent associations reported, if any Among the strengths of the present study, there are the population‐based design, the large sample size, and the use of prospectively collected data on several risk factors for breast cancer. Potential limitations arise from the use of a self‐administered questionnaire, which is more prone to response bias, and the possibility of unmeasured and residual confounding, which cannot be completely ruled out. In particular, we did not have information on physical activity, which is known to decrease breast cancer risk. Moreover, participants in a screening program may be not completely representative of the general population, having healthier lifestyle habits and being more health conscious than women who did not undergo the screening. However, the associations observed in the present study are generally consistent with the literature, thus reassuring against any major differential misclassification.Thus, our study confirms the role of major recognized risk factors for breast cancer—including age at menarche, age at first pregnancy, alcohol drinking, and BMI —which are used in predictive models to estimate the individual absolute risk to develop breast cancer The datasets are not available as they belong to the Agency for Health Protection of the Province of Milan.None declared.