P < 5 × 10−8. The associations for 10 of these loci were replicated in an independent sample of 16,787 cases and 16,680 controls of Asian women (P < 0.05). In addition, we replicated the associations for 78 of the 166 known risk variants at P < 0.05 in Asians. These findings improve our understanding of breast cancer genetics and etiology and extend previous findings from studies of European descendants to Asian women.Known risk variants explain only a small proportion of breast cancer heritability, particularly in Asian women. To search for additional genetic susceptibility loci for breast cancer, here we perform a meta-analysis of data from genome-wide association studies (GWAS) conducted in Asians  and European descendants . We identified 31 potential novel loci with the lead variant showing an association with breast cancer risk at  In breast cancer, genome-wide associations studies (GWAS) have highlighted loci associated with disease risk. Here, the authors perform a meta-analysis of GWAS data from Asian populations, discovering 31 potential new risk loci, 10 of which are validated in an independent disease cohort. Genetic linkage studies and family-based studies have identified many high- and moderate-penetrance mutations in breast cancer predisposition genes, including BRCA1, BRCA2, PTEN, ATM, PALB2, and CHEK22. In addition, large-scale genome-wide association studies (GWAS), conducted primarily in Asian and European women, have identified more than 180 susceptibility loci for breast cancer risk8. These identified loci explain a relatively small proportion of familial relative risk of breast cancer8.Breast cancer is the most commonly diagnosed malignancy and the leading cause of cancer-related deaths in women worldwide16. It also has been shown that a large proportion of common susceptibility loci are shared between Asian and European populations, although the lead variants in many loci may differ between these two populations8. To search for novel breast cancer susceptibility loci, we conducted Asian-specific and cross-ancestry meta-analyses combining the data of the ABCC and the Breast Cancer Association Consortium (BCAC) with a total sample size of approximately 310,000 women . We herein report the discovery of 31 potential novel risk loci for breast cancer and the replication of a large number of known breast cancer susceptibility loci in Asian women.The Asia Breast Cancer Consortium (ABCC) is the largest breast cancer GWAS consortium conducted in Asian-ancestry populations. We have shown previously that GWAS conducted in Asians could uncover cancer genetic risk variants that are either unique to the Asian population or more difficult to identify in studies conducted in European womenP < 5 × 10−8) . No evidence of heterogeneity in associations was observed between the two racial populations except for rs2758598 and rs142360995 . The OR estimates for these 28 SNPs by study within the ABCC and BCAC consortia are presented in Supplementary Data r2 > 0.4 in either Asians or Europeans) from the online catalog of published GWAS . Pleiotropy was found for seven of the 28 newly-associated SNPs  with ER-positive breast cancer risk (Table P < 0.05). Heterogeneity between ER+ and ER- breast cancer risk (Pheterogeneity < 0.05) was observed for rs73006998, rs7765429, rs144145984, rs78588049, and rs12481286.All of the 28 SNPs showed a nominally significant association , including rs3790585 (1p34.1), rs73006998 (3q25.1), rs6940159 (6q27), rs855596 (12q23.2), and rs75004998 (14q24.3).Of the 28 SNPs, 22 were investigated in an independent set of 10,829 cases and 10,996 controls included in ABCC and an additional 5958 cases and 5684 controls from studies conducted in Malaysia and Singapore (see Methods). A significant association at P < 1 × 10−4), and all correlated (r2 > 0.1 in 1000 Genome East Asians) except for rs7693779, at 4p12 .Of the 28 SNPs newly identified to be associated with breast cancer risk, 13 SNPs are intronic, one in UTR, and 14 in intergenic regions. Using data from ENCODE and Roadmap, we found that the majority of these 28 overlapped with genomic functional biofeatures that were indicative of promoters or enhancers , snurportin 1 (SNUPN), mannosidase alpha class 2 C member 1 (MAN2C1), T-Box 1 (TBX1), MutY DNA glycosylase (MUTYH), lysyl oxidase like 2 (LOXL2), stanniocalcin 1 (STC1), and semaphorin 4 A (SEMA4A). SNP rs144145984 was the eQTL for both LOXL2 and STC1 genes, but the association for STC1 is much stronger. Similarly, SNP rs8027365 was associated with expression levels of two genes, MAN2C1 and SNUPN.To identify target genes of the 28 newly identified lead SNPs, we conducted TBX1 and LOXL2, we were able to build breast-tissue and/or cross-tissue models for all other eQTL-identified candidate genes with a prediction R2 > 0.01 . We imputed expressions of seven genes other than TBX1 and LOXL2 and showed that these genes were associated with breast cancer risk in either the ABCC or BCAC data at P < 0.05  were removed. Of the 166 SNPs, 78 were found to be associated with breast cancer risk at P < 0.05, while 131 showed associations that were consistent in direction with those originally reported , with two at 6q25.1 (ESR1 and TAB2), and one each at 15q26.1 (PRC1), 16q12.1 (TOX3), and 21q22.12 (LINC00160). Additionally, borderline genome-wide significant associations were found in seven loci including 2q14.1, 2q35, 3p24.1, 5q33.3, 9q33.3, 12p13.1 and 17q22 (P < 1 × 10−6 in Asians).Of the 183 risk variants of breast cancer reported previously, 11 and 172 were originally discovered in studies conducted in Asians and European-ancestry populations, respectively. We were able to investigate 166 variants because 15 variants originally discovered in European populations were (nearly) monomorphic in Asians and two in high LD with rs2747652 (P < 5 × 10−8 in Asians). Five of these eight loci, including 5q11.2, 9p21.3, 12q24.21, 18q12.3, and 21q21.1, have not previously been linked to breast cancer risk in Asian populations. Significant heterogeneity between Asian and European-ancestry populations was observed (Pheterogeneity < 0.05) at 5q11.2, 9p21.3, 12q24.21, 16q12.1, and 21q21.1, and the strength of the association was stronger in Asian than European-ancestry women.We searched extensively for additional independent associations in Asians by conducting conditional analysis for variants located 500 kb of the 166 previously reported SNPs. A total of 820 SNPs from 21 loci were associated with breast cancer risk after conditioning on known risk variants in Asians  obtained from Asian-specific meta-analysis. Women with a high estimated PRS had a 3.6-fold higher risk of breast cancer compared to those who had a low PRS , we replicated in Asian women 78 of the GWAS-identified risk variants for breast cancer. Since the risk variants initially reported in European populations might not be the lead SNPs in Asians, we performed further analyses to show that 21 known susceptibility loci may harbor additional independent signals, of which 16 showed at least one stronger association than the originally reported risk SNP. Our study has generated substantial novel information to improve the understanding of breast cancer genetics and etiology and provides clues for future studies to functionally characterize the risk variants and candidate genes identified in our study.SMC2 gene. SMC2 encodes the structural maintenance of chromosomes protein-2, an essential subunit of the condensin complex I and II. The protein is critically involved in chromosome condensation and segregation during cell cycles17. Emerging evidence shows that SMC2 mutations and dysregulated expression are associated with multiple cancers18.Similar to other GWAS, nearly all of the newly identified risk variants mapped to intergenic regions or introns of genes. One exception was rs10820600, which is located in the 5′-UTR region of the YBEY, SNUPN, MAN2C1, LINC00886, TBX1, SEMA4A, and MUTYH. For example, the locus at 21q22.3 (rs35418111) showed compelling evidence of influencing expression of YBEY, a gene that encodes a highly conserved metalloprotein. Our gene-based analysis indicated a potential oncogenic role of YBEY in breast cancer development. Although the function of YBEY has not been fully elucidated, dysregulation of its expressions caused by copy number variation has been found in familial and early-onset breast cancer19, as well as colorectal cancer20. Further, we showed that MAN2C1 may play a protective role against breast carcinogenesis in the gene-based analysis. However, another study found that MAN2C1 promotes cancer growth via a negative regulation of phosphatase and tensin homolog (PTEN) function in prostate and breast cancer cell lines21. These results suggested that MAN2C1 may have distinct functional impact on cancer initiation compared to that on tumor progression. Few studies have investigated the mechanistic roles of LINC00886, SNUPN and SEMA4A in cancer initiation. Germline mutations in SEMA4A have been linked to the predisposition of familial colorectal cancer type X22. Our study provides the first evidence linking these two genes to breast cancer susceptibility.Of the thirteen lead risk variants located in the introns of genes, six showed strong evidence of cis-regulation for seven genes nearby, including LOXL2 and STC1 were pinpointed as cis targets of rs144145984 at 8p21.2. LOXL2 is a member of the lysyl oxidase family of amine oxidases and STC1 belongs to the glycoprotein hormones family. Research regarding the functions of LOXL2 and STC1 in cancer development is limited. However, pre-clinical studies have implicated LOXL2 and STC1 in the progression of breast cancer24. Inhibiting LOXL2 activity shows a 55–75% decrease in primary tumor volume in female athymic nude mice, which were implanted with MDA-MB-231 human breast cancer cells23. The reduction in tumor burden was suspected to be mediated by the inhibition of angiogenesis. A recent study suggested the role of STC1 played in the breast tumorigenesis could be subtype-dependent24. A cancer promoting function was found in murine mammary tumor cells and human triple negative breast cancer lines (MDA-MB-231), while an opposite function was shown in luminal breast cancer lines .Potential candidate genes were also revealed by the newly associated variants lying in the intergenic regions between coding genes. r2 = 0.94 in EA and 0.43 in East Asians). The G allele of rs703556 is associated with lower mammographic dense area in women25. Mammographic density, an established risk factor for breast cancer26, is a measure based on the radiographic appearance of the breast by mammography. Several loci were related to other cancers or benign tumors. SNPs in 22q11.21, 1q22 and 4q12 were found to be associated with risk of prostate cancer27, testicular germ cell tumor28 and leiomyoma, respectively29. We hypothesize potential underlying mechanisms via hormone metabolism for these loci. Variants at 10p12.2 (PIP4K2A) indicated an association with risk of acute lymphoblastic leukemia30 and 6p22.3 (CASC15) with endometrial cancer31, lung cancer32, and neuroblastoma33. These regions implicated in genetic susceptibility across different types of cancers may serve as prioritized target of interest for future fine-mapping studies. For some of the phenotypes like blood cell counts and sodium levels, we currently lack the proper knowledge to decipher the likely mechanisms that link them to breast cancer development.The pleiotropy of rs855596 at 12q23.2 provided a plausible mechanistic link for the observed genetic association with breast cancer risk. The minor (T) allele of rs855596 is associated with decreased breast cancer risk and is linked to the minor allele G of the nearby rs703556 , although no heterogeneity was observed. Previously, the same locus was reported to be associated with hormonal receptor-positive breast cancer, with a borderline genome-wide significance in a Japanese population 34. We found significant heterogeneity by ER status for this locus and the association was primarily driven by ER-positive cancer. Racial heterogeneity was also observed for many known risk variants initially reported in European populations. It may be attributable to multiple factors including the Winner’s curse35, population-specific LD structure, and false positives in the original GWAS.Notable racial heterogeneity was found for the loci at 1q22 (rs2758598) and 8q24.11 (rs142360995), which may reflect the differential regional LD structures and allele frequency between the two populations at these loci. The effect sizes in Asians are larger than those in European populations for both SNPs, over four times for rs142360995 and two times for rs2758598. The association at 3q25.1 (rs73006998) was dominant by estimates in Asians  and OncoArray projects ; twelve studies contributed samples to either or both projects. The BCAC-European dataset consisted of three sub-sets, GWAS , COGS , and OncoArray projects 8. A total of 80,428 and 26,948 cases had ER-positive and -negative breast cancer, respectively.The overall cross-ancestry meta-analysis was conducted using data from two large consortia, the ABCC and BCAC. Detailed descriptions of participating studies are included in Supplementary Note 1. Briefly, in the ABCC, genome-wide SNP data were generated from 24,206 breast cancer cases and 24,775 unaffected controls recruited from studies conducted in mainland China, South Korea, and Japan . There was no overlap in samples from participating studies.EX chip, have been described elsewhere37  across multi-racial populations. We added to the MEGAEX chip ~80k variants selected from our GWAS of breast and colorectal cancers and exome sequencing data for breast cancer cases in Asian-ancestry populations. In total, 2.1 million variants were included on this array. Quality control (QC) procedure include: samples were excluded if they (i) had genotyping call rate <95%; (ii) were male based on genotype data; (ii) had a close relationship with a Pi-HAT estimate >0.25; (iii) were heterozygosity outliers; (iv) were ancestry outliers. SNPs were excluded if they had (i) a call rate <95%; (ii) no clear genotyping clusters; (iii) a minor allele frequency <0.001; (iv) a Hardy-Weinberg equilibrium test of P < 1 × 10−6; (v) genotyping concordance < 95% among the duplicated QC samples37. All of the datasets were imputed using the 1000 Genomes Project Phase 3 mixed populations as the reference panel, except for the BioBank Japan (BBJ1) study, in which the HapMap Phase II (release 22) was used. Only SNPs with an imputation R2 > 0.3 were included in the further analyses.All of the genotyping and quality control procedures for GWAS, except for the expanded MEGAr2 > 0.8 in Asians (1000 Genome) was selected. Of the 28 newly identified risk variants, 22 were successfully genotyped by Sequenom and evaluated in the association analysis, while six failed in the probe designing stage. Additional 11,642 independent samples from MYBRCA and SGBCC studies (Supplementary Note 1) were also included in the replication stage in evaluation of the 22 newly identified risk variants.Genotyping of the replication set of cases and controls was completed using the iPLEX Sequenom MassArray platform . One negative control (water), two blinded duplicates and two samples from the HapMap project were included as QC samples in each 96-well plate. Samples or SNPs that had a genotyping call rate of <95% were excluded. We also excluded SNPs that had a concordance with the QC samples of <95% or an unclear genotype call. If the assay could not be designed for the lead SNP, a surrogate SNP which is in LD with the lead SNP with 38. Principal components analyses were conducted within each GWAS dataset. Age and the top two PCs were included as covariates for in all regression models. Study (COGS) or country/region (OncoArray) was also included in the analyses of BCAC data8. The number of PCs to be included in the regression was determined by evaluation of Scree plot. Sensitivity analyses were conducted to include top 10 PCs, which showed very similar ORs as those derived from analyses adjusted for two PCs . However, three additional lead SNPs that did not meet this criterion can also be found in Supplementary Table r2 < 0.1). The significant locus is considered novel if it is located 500 kb away from the 183 known risk loci for breast cancer The LD with known risk SNPs was also checked to verify the independence. Among the newly associated loci, we further applied the method implemented in MR-MEGA40 to account for the population heterogeneity for two loci showing significant heterogeneity in the cross-ancestry fixed-effect meta-analysis. The results were shown in the Supplementary Table λ) was estimated by dividing the 50th percentile of the test statistic by 0.455 (the 50th percentile for a χ2 distribution on 1 degree of freedom)41. We standardized the inflation statistic to account for the large size of our study by calculating λ1000 8. For the replication stage, analyses were conducted with an adjustment for age and study.Logistic regression analysis was performed within each study of Asian women to obtain a per-allele odds ratio (OR) for each SNP using PLINK2.042 to perform the conditional analysis for the BBJ1, Seoul Breast Cancer Study (SeBCS), and BCAC European GWAS, for which only summary statistics data were available. MEGA array genotyping data was used as reference panel for LD estimation. The results of individual study were combined by a fixed-effect meta-analysis using METAL. SNPs showing an association with breast cancer risk at Pconditional < 1 × 10−4 were considered independent secondary association signals. The analysis was also performed within known susceptibility loci. All statistical tests were two-sided.For each of the Asian studies with GWAS data (Supplementary Table −8), we had >80% power to detect the association between SNP and breast cancer risk with an OR of >1.06, 1.07, and 1.11 and EAF of 0.10 in the analysis of ER-positive, ER-negative cancer and all cancer combined, respectively  were performed using HaploReg v4.143. The functional annotation of chromatin states from chromHMM, DNase I hypersensitive and histone modifications such as H3K4, H3K9 and H3K27, were based on the epigenetic data in human breast mammary epithelial cells (HMEC), MCF-7 cells, and other cell lines from the Encyclopedia of DNA Elements (ENCODE) Project and Roadmap Epigenetics Project. We further applied GARFIELD44 to assess functional enrichment for all risk loci identified to date for breast cancer risk and those newly reported in the current study. According to GARFIELD, the significance level for the enrichment analysis was set to 9.7 × 10−5. Known risk loci (±500 kb) were removed when evaluating functional enrichment for the newly identified loci.Novel risk loci were defined as those ±500 Kb away from the lead risk variant reported by previous GWAS conducted in populations of Asian or European-ancestry for breast cancer. The lead risk SNPs newly identified in our study were defined as the variant showing an association with breast cancer risk with the lowest N = 85, GTEx, women of European ancestry), breast tumor  and adjacent normal tissues . We focused on cis-eQTL analyses for genes residing ±500 Kb flanking each newly associated leading SNP. The details of data processing were described in Supplementary Note 2.To identify target genes, we performed eQTL analysis utilized four independent sets of gene expression data derived from normal breast , with tenfold cross-validation45. To further increase statistical power, we also utilized 6,124 samples across 39 tissue types from 369 unique European individuals who had genome-wide genotype data available to build cross-tissue models47. The expression of a gene for individual 48.We recently conducted a transcriptome wide association study (TWAS) to investigate associations of genetically predicted gene expression with the risk of breast cancerP < 0.05/166) to generate polygenetic risk score (PRS). PRS were calculated as βs, used to generate the score were obtained from Asian-specific meta-analysis. The association between the score and breast cancer risk was tested in the samples from Shanghai Women’s Health Study , which were also contributed to the Asian MEGA project. The PRS was tested in both continuous (1 SD change) and categorical forms (deciles in controls). The area under the curve was also calculated to show its discriminatory ability. Overfitting is less a concern as SWHS participants only accounted for a very small proportion in the Asian-specific meta-analysis (~8%).We used the 11 risk SNPs originally reported in Asian populations, 28 newly identified SNPs from the current analysis (Table Further information on research design is available in the Supplementary InformationPeer Review FileDescription of Additional Supplementary FilesSupplementary Data 1Supplementary Data 2Supplementary Data 3Supplementary Data 4Supplementary Data 5Supplementary Data 6Reporting Summary


Women with increased breast density are at increased risk of breast cancer. The aim of this research is to evidence for the first time the mammographic breast findings of Papua New Guinean (PNG) women and the relationship between Breast Imaging‐Reporting and Data System (BI‐RADS) assessment, mammographic parenchymal patterns (MPPs) and age.A retrospective analysis of 1357 mammograms of women imaged at the Pacific International Hospital (PIH) from August 2006 to July 2010 was undertaken. Mammographic findings were categorised using the BI‐RADS Atlas® 5th Edition. MPPs were recorded for each woman using the Tabár Pattern I‐V classification system. Age was recorded in years. Statistical analysis was by descriptive analysis and Kruskal–Wallis with Dunn’s post‐test and Spearman’s rho correlation for inferential analysis.n = 17) of malignancies. Linear correlations between variables were weak and not statistically significant: age and Tabár pattern r = 0.031, P = 0.0261; age and BI‐RADS r = 0.018, P = 0.517; Tabár pattern and BI‐RADS r = 0.020, P = 0.459 (n = 1357).True pathological findings ; BI‐RADS 2–5 were noted in 111 women (8.2%); 1242 (91.5%) were negative. BI‐RADS categories for malignancy were reported in 16 (88.9%) of women aged 30 to 60 years. The lower risk Tabár Type I, II and III MPPs were associated with 94.4%  of malignancies.Women with increased breast density are at increased risk of breast cancer. The results of this study again reflect that the incidence of breast cancer in Papua New Guinea cannot be explained by breast density. There was no correlation demonstrated between BI‐RADS categories 4 and 5 for breast malignancy and high‐risk Tabár Type IV and V mammographic parenchymal patterns. The lower risk Tabár Type I, II and III mammographic parenchymal patterns were associated with 94.4% ( Breast cancer is the leading causes of mortality and morbidity amongst females worldwide.It is important to note that the true size of the PNG female population is not actually known and not all groups within PNG have equal access to health care if at all, and hence may not be accurately represented in the known data.Mammography is the most commonly used imaging tool for identifying breast pathology, including breast cancer.However, the WHO also recognises that mammography screening is not cost effective in a limited resource settings such as PNG which has logistical and geographical challenges along with a weak health system.Currently, there is no BSA equivalent, in place in PNG.Hence, although the mammography provided at PIH is referred to in PNG as screening mammography, it is better aligned to the purpose of harm minimisation as described by the WHO, early diagnosis based on awareness of early signs and symptoms rather than asymptomatic screening.Approaches to the reporting of mammographic images are known to vary between screening and diagnostic services and between countries worldwide. However, fundamental radiological interpretation of mammographic images includes the absence or presence of breast pathology and the amount of breast density present.There are two common classification systems in use for classifying mammographic lesions, and these include the Tabár/Royal Australian and New Zealand College of Radiologists (RANZCR) classification, used by BreastScreen Australia and BreastScreen AotearoaThe aim of BI‐RADS is to standardise breast imaging reporting including mammography, ultrasound and magnetic resonance imaging (MRI), through a recommended reporting structure.A strong independent risk factor for breast cancer is breast density.The literature describes a number of longstanding classification systems that categorise and report breast density and the association between increased breast density and breast cancer risk including the BI‐RADS and Tabár systems.In most Western countries, the target age for mammographic screening commences at 50 years and ends at 74 years.Despite the plethora of published information on mammography, breast density and breast cancer, there is very little written about breast cancer in PNG with the few available papers concerning breast cancer dated between 1963 and 2004A retrospective analysis of 1357 mammograms of women who had undergone imaging at the PIH from August 2006 to July 2010 was undertaken. These images are a subset of those taken during this period and simply represent the available images. Mammographic findings were categorised using the BI‐RADS Atlas® Fifth Edition lexicon,The mammographic images used for this study were previously retrospectively assigned one of five Tabár MPP categories by direct observation, and reported by Pape, Spuur and Umo (2017).BI‐RADS scores were additionally correlated to formal diagnosis. Symptomatic presentations were also recorded.Ethics approval and permission to collect data was granted through the University of Papua New Guinea, School of Medicine and Health Science Research Ethics Committee (Project Number 0118) and by the Medical Director and Chief Operating Officer of PIH. Consent to collaborate in this research project was granted from the Head of Division of Radiology at PIH.Descriptive analysis of the data was undertaken and following normality testing non‐parametric tests  were used for subsequent inferential analysis. BI‐RADS groups 0 and 4 were excluded from inferential analyses due to small sample size. Statistical analysis was completed using SPSS ; p < 0.05 was deemed to be statistically significant. Data distributions displayed in a violin plot were created using BoxPlotR.n = 18) women, and 33.36% (n = 6) of these women were aged under 40 years. BI‐RADS categories for malignancy were reported in 16 (88.9%) of women aged 30 to 60 years. The lower risk Tabár Type I, II and III MPPs were associated with 94.4% (n = 17) of malignancies  and Tabár patterns (P < 0.0001).Violin plots have been used to illustrate the distribution of BI‐RADS categories and Tabár patterns by age Fig. . AnalysiP < 0.029) and BI‐RADS 3 and 5 (P < 0.032). All pair‐wise comparisons for Tabár pattern groups show statistical significant with the exception of Pattern II versus Pattern III; P values for other comparisons were P < 0.0001 except for Pattern I versus III (P = 0.047) and Pattern IV versus V (P = 0.002).For BI‐RADS, differences were seen between BI‐RADS 1 and 5 (P < 0.001).Collapsing Tabár groups I‐III as ‘low risk’ and Tabár ‘IV‐V’ as 'high risk' shows that the high‐risk group were younger  compared with those in the low‐risk group .Linear correlations between variables were weak and not statistically significant; age and Tabár pattern n = 55) and the left breast 27% (n = 30), and bilateral pathology was seen in 23.4% (n = 26) of women ; BI‐RADS 3 (n = 2); and BI‐RADS 4 (n = 4). Pathology associated with calcification was determined to be benign (4.3%), malignant (22.2%) and indeterminate (61.4%). Nineteen women were reported to have mass lesions: BI‐RADS 2 (n = 10); BI‐RADS 3 (n = 7); and BI‐RADS 5 (n = 2). Pathology associated with mass lesions was determined to be benign (34.4%), malignant (22.2%) and indeterminate (55.5%).In this study, there were nine women with calcification, BI‐RADS 2 (n = 4) of women with malignant mammographic features were diagnosed with invasive carcinoma. A lack of formalised pathological reporting in PNG has limited the value of these data. Women in PNG reported as having invasive cancers are advised to undergo breast surgery (mastectomy or lumpectomy) followed by radiotherapy and/or chemotherapy treatment which is currently not available in PNG.In Australia, invasive ductal carcinoma is the most common breast cancer type for women aged 50–74 (78.4%).The incidence of benign breast disease has been reported in an American study to increase with age from a rate of 22.6 per 1000 person‐years (2.3%) for women ages 25 to 29 to 35.6 per 1000 person‐year (3.6%) for women aged 40 to 44.In Western countries, age is reported as the greatest risk factor for breast cancer. In Australia, more than three quarters of breast cancers occur in women over the age of 50.Due to the retrospective nature of this study and the limited record keeping of results in PNG, it was difficult to retrieve both biopsy reports and pathology results. Issues with record keeping were also encountered by Halder et al. and reflect a third world screening program in its infancy.This is the first study to report relationships between BI‐RADS category, age and MPP and report histopathological diagnosis of breast disease in the women of PNG since Halder et al. in 2001. Although limited by poor record keeping, this is an important study in that it fails to demonstrate correlation between BI‐RADS category, age and MPP. Importantly, there was no correlation demonstrated between high‐risk BI‐RADS categories 4 and 5 for breast malignancy with high‐risk Tabár Type IV and V breast density patterns. The small number of cancers in the high‐risk categories may limit the validity of this result.Further research with greater scientific rigour and involving a larger population is required to validate the results of this study and to more accurately inform any policy development concerning a dedicated breast screening service in PNG. As BI‐RADS categories for malignancy were reported in 88.9% of women aged 30 to 60, this also suggests a need for any future screening program in PNG to be targeted at women much younger than that of Western countries.The authors declare no conflict of interest.


VDR gene with breast cancer risk which followed by stratified analysis. Vitamin D inhibits cell proliferation via the vitamin D receptor (VDR), which may affect breast cancer risk. This study aimed to investigate the association of ApaI and TaqI polymorphisms of the VDR ApaI and TaqI genotyping were performed by PCR-RFLP. Some demographic and pathologic features of patients were extracted from their archived files and then were analyzed by genotypes distributions. A case-control study was conducted on 150 breast cancer patients and 150 healthy controls.  ApaI and TaqI variations and these parameters. For ApaI polymorphism, our data showed a significant difference between the patient and healthy groups for mutant allele carriers compared with those with AA genotype. Besides, statistical analysis showed that there was a significant association between the C allele and the increased risk of breast cancer. For TaqI polymorphism, statistical analysis revealed that there was a significant association between CC genotype and increased risk of breast cancer. Also, there was a significant association between the C allele and the increased risk of breast cancer. In a preliminary study, stratified analysis based on the size of tumor and lymph node metastasis revealed no significant association between twoVDRApaI and TaqI variations could be considered as genetic risk factors for breast cancer. However, further studies with a larger sample size are required to obtain more accurate outcomes, especially in stratified analysis.Based on our results, the  BRCA1, BRCA2, ATM, PTEN, TP53, BRIP1, PALB2, NBS1, RAD50, MSH2, MLH, and CHEK2 are occurred in about half of the familial breast cancer . Breast cancer is the major cause of death in women worldwide. It is responsible for 16% of all and 22% of invasive female cancers. This cancer is diagnosed as the most frequent cancer among Iranian women . Variations in some genes which involved in growth, differentiation, and apoptosis, may influence breast cancer susceptibility . Although a specific gene responsible for the familial breast cancer is not discovered yet mutations in some suppressor genes such as VDR gene may decrease the levels of VDR expression and increase the risk of breast tumors . Apoptotic and anti-proliferative impacts of vitamin D against different malignancies such as breast cancer have been previously studied . Many studies investigated the effects of vitamin D on breast cancer and confirmed the protective role of vitamin D in this disease . The effects of vitamin D, 1α, 25-dihydroxyvitamin D3 2D3), are through the vitamin D receptor (VDR) which expressed in most cell types, enclosing breast tissues . The active form of vitamin D regulates growth, differentiation, and apoptosis that is mediated by the vitamin D receptor (VDR) . VDR is a member of the nuclear receptor family of steroid hormones that acts as a transcriptional regulatory factor in most tissues . Also, it is reported that vitamin D receptors can play an important role in the pathogenesis of breast cancer . Genetic variants in the VDR gene is located in chromosome 12 (12q13.11) which comprised 11 exons with some common single nucleotide polymorphisms such as ApaI and TaqI. The ApaI variable site  is located in intron 8 of the VDR gene and the TaqI  variation is also located in the same intron. We focused on the distribution of VDR ApaI and TaqI single nucleotide polymorphisms (SNPs) in Isfahan province breast cancer patients compared to a healthy population. This study aimed to investigate the association of the mentioned polymorphisms with breast cancer risk in combination with demographic and pathologic features.Subjects and blood samples collectionA case-control study was conducted to investigate the association of ApaI and TaqI polymorphisms in the VDR gene with breast cancer risk. The 300 samples consisting of 150 patients with breast cancer as a case group and 150 healthy women as a control group were included in this study. All subjects were selected from women who referred to Hospitals in Isfahan province . Women with breast cancer were assessed based on the clinical examinations as well as pathological and mammographic examinations. Also, the breast cancer patients had not been exposed to chemotherapy and/or radiotherapy. The women included in the control group were healthy individuals referring to the same hospital for routine tests and they had no history of breast cancer. Finally, blood samples were collected into sterile tubes containing anticoagulant EDTA sodium salt. Written informed consent obtained from all subjects. The study approved by the Medical Ethics Committee of Kashan University of Medical Sciences.DNA extraction, PCR-RFLP, and DNA sequencingThe genomic DNA extracted from the collected blood samples by a commercial kit according to the manufacturer’s procedure. Genotypes of VDR-ApaI and -TaqI were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. The sense and antisense primers for amplifying the fragment containing both ApaI and TaqI polymorphisms were designed by Oligo7 software . The PCR combination was consist of the following reagents: 10μl of 2X Taq PCR Premix, 0.2 µM each of forward and reverse primers, and 30 ng of extracted DNA up to a total volume of 20 µl. All PCR reagents were purchased from CinnaGen Company . PCR was done in a Peqlab thermal cycler  with a program that was shown in After the PCR procedure, a fragment with 489-bp length containing two ApaI and TaqI SNPs was amplified. This fragment was treated individually once with ApaI and once with TaqI restriction enzymes. Regarding the ApaI polymorphism, the results showed that the 489-bp fragment in some samples was digested into two 220- and 269-bp fragments, and in some samples, it was digested into three 489-, 269- and 220-bp fragments. In some samples, however, only one band containing the 489-bp fragment was observed because there was no restriction site for ApaI in these fragments. Samples showing only one band on agarose gel have the AA genotype. Samples with two bands had the CC genotype and samples with three bands had the AC genotype . About tStatistical analysisAll of the statistical analyses were done by SPSS version 20 . Quantitative variables were analyzed by an independent t-test. Hardy-Weinberg equilibrium (HWE) was checked by the chi-square test for both case and control groups. Differences in allele and genotype frequencies distribution and between control and case groups were evaluated by utilizing a chi-square test. Odds ratio (OR) and 95% confidence interval (CI) were estimated to evaluate the association of different alleles and genotypes with breast cancer and its subgroups . Association of VDR-ApaI and -TaqI polymorphisms with breast cancer riskThis study included a total of 150 healthy women and 150 age-matched breast cancer subjects, that there were no significant differences in body mass index (BMI), and menopause status between two studied groups. Our data showed that the distribution of VDR genotypes for both SNPs was met Hardy-Weinberg equilibrium (HWE) in both the case and control groups.For ApaI polymorphism, alleles with adenine nucleotide were more abundant than other allele. The frequency distribution of AC genotype in the healthy and diseased groups was 40.00% and 48.67%, respectively, while this ratio for CC mutant genotype was 12.00% and 16.00%, respectively. Statistical analysis showed that there was a significant association between AC genotype and increased risk of breast cancer . StatistFor TaqI polymorphism, alleles with thymine nucleotide were more abundant than other allele. The frequency distribution of TC genotype in healthy and patient groups was 39.33% and 45.33%, respectively, while this ratio for CC mutant genotype was 8.00% and 14.00%, respectively. Statistical analysis revealed that there was a significant association between CC genotype and increased risk of breast cancer . StatistStratified analysisThe genotypes distribution for ApaI and TaqI polymorphisms were evaluated for tumor size and lymph node metastasis . With reThe role of genetic and environmental risk factors on the development of breast cancer susceptibility was investigated widely . In breast cancer, the genetic, environmental, behavioral, and the combined effects of risk factors are involved . Research has shown that vitamin D has a protective effect against breast cancer and its deficiency may be a risk factor for the onset and progression of breast cancer . It has been revealed that vitamin D could affect cell proliferation and differentiation in cancers . VDR gene with breast cancer in a case-control study and a stratified analysis. In the case of ApaI polymorphism, there was a significant association between AC genotype and increased risk of breast cancer. Our results showed a significant difference between the patient and healthy groups for C allele carriers compared to those with AA genotype. The frequency of the C allele was higher in the patient group than the control group and the statistical analysis showed that there was a significant association between C allele and increased risk of breast cancer. In addition, TaqI polymorphism was associated with breast cancer risk in some genetic models. But, the stratified analysis based on tumor size and lymph node metastasis revealed no significant associations for both studied SNPs. In the current study, we investigated the association of ApaI and TaqI polymorphisms in the ApaI polymorphism was not associated with breast cancer in any genetic model. But, subgroup analysis showed that the CC genotype is correlated with a high concentration of 25 (OH) D3 in plasma in the tamoxifen receiving group . However, El-Shorbagy et al., (2017) reported that the ApaI polymorphism in the VDR gene is a genetic risk factor for breast cancer in the Egyptian female population . Concerning the TaqI polymorphism, similarly, Ahmed et al., (2019) reported that this genetic variant was not associated with breast cancer risk  But, El-Shorbagy et al., (2017) reported that this polymorphism was associated with risk of breast cancer. Different results from different studies indicate that the association of VDR gene polymorphisms with breast cancer risk may be affected by some factors including race, diet, lifestyle, and environmental factors.Similar studies have been conducted in recent years that have reported different results. For example, Ahmed et al., (2019) investigated the association of this polymorphism with the risk of breast cancer in the Ethiopian female population, whose results showed that the VDR expressed in the mammary gland, normally. It functions against the estrogen-driven proliferation and maintains differentiation, and it may participate in negative-growth regulation of mammary epithelial cells. VDR gene SNPs could be studied as an important factor, because the variants of VDR gene may affect receptor function . Therefore, it can be concluded that VDR polymorphisms may influence vitamin D metabolism and 25(OH) D levels . There are convincing data of the VDR gene in different studies, but to obtain sufficient information regarding the use of vitamin D supplements to prevent or treat breast cancer, is needed more research. Previous studies have shown that vitamin D plays an important role against several cancers including breast cancer. The vitamin D3 receptor (VDR) as a nuclear receptor complexed with its ligand 1-α, 25-dihydroxycholecalciferol  2 D3) could modulate gene expression. The TaqI and ApaI on the VDR gene function.Assessing the molecular effects of genetic polymorphisms on the structure and function of mRNA and protein in vitro and in vivo is time-consuming and costly . But computational methods using bioinformatics tools can be a useful way for molecular analysis especially to evaluate the effects of genetic polymorphisms . In silico analysis is a useful tool to evaluate the effects of SNPs on protein and mRNA structure . Therefore, this tool would be an appropriate approach to study the effects of VDR gene are associated with breast cancer risk. Therefore, these genetic variants can be risk factors for breast cancer. Besides, these polymorphisms can be considered as potential biomarkers for screening women susceptible to breast cancer. However, there are several limitations to the present study that should be considered. The VDR gene interacts with many other genes, so gene-gene interactions, as well as gene-environment interactions, may affect the effects of studied genetic variations. In our study, the absence of baseline data such as sunlight exposure, skin color, and family history may affect the accuracy of the association of TaqI and ApaI polymorphisms in the VDR gene with breast cancer risk. To obtain more accurate information, further studies on a larger sample size in combination with different environmental and genetic factors are needed.In conclusion, our case-control study shows that TaqI and ApaI polymorphisms of the


TP53 in Li–Fraumeni syndrome, PTEN in Cowden syndrome, mismatch repair (MMR) genes in Lynch syndrome, CDH1 in diffuse gastric cancer syndrome, STK11 in Peutz–Jeghers syndrome, and NF1 in neurofibromatosis type 1 syndrome. To these, several other genes can be added that act jointly with BRCA1 and BRCA2 in the double-strand break repair system, such as PALB2, ATM, CHEK2, NBN, BRIP1, RAD51C, and RAD51D. Management of primary and secondary cancer prevention in these hereditary cancer syndromes is crucial. In particular, secondary prevention by screening aims to discover precancerous lesions or cancers at their initial stages because early detection could allow for effective treatment and a full recovery. The present review aims to summarize the available literature and suggest proper screening strategies for hereditary breast and/or ovarian cancer syndromes other than BRCA.BRCA1- and BRCA2-associated hereditary breast and ovarian cancer syndromes are among the best-known and most extensively studied hereditary cancer syndromes. Nevertheless, many patients who proved negative at BRCA genetic testing bring pathogenic mutations in other suppressor genes and oncogenes associated with hereditary breast and/or ovarian cancers. These genes include  BRCA1/2 genes [TP53 [PTEN [CDH1 gene mutation [STK11 [NF1 mutations [PALB2 [ATM [CHEK2 [NBN [BRIP1, RAD51C, and RAD51D are associated with an increased ovarian cancer risk [In hereditary cancer syndromes (HCSs), inherited mutations lead to an increased risk of developing certain tumors, frequently at an earlier age than in the rest of the population . Elevate/2 genes , Li–Fraues [TP53 , Cowden 53 [PTEN , 7, diffmutation , Peutz–Jn [STK11  gene, anutations . AdditioLB2 [ATM , CHEK2 [M [CHEK2 , and NBNEK2 [NBN  are corrcer risk .BRCA-associated breast and ovarian cancer. For all other syndromes, on the other hand, the most appropriate screening protocol is still debated.Management of cancer prevention is crucial in HCSs. Cancer prevention can be divided into primary and secondary strategies –23. The BRCA mutations.This review aims to summarize the available literature and suggest proper screening strategies for hereditary breast and/or ovarian cancer syndromes other than those associated with TP53 gene) [TP53 mutations ranges from 1/10,000 to 1/25,000 in the UK and is estimated at 1/20,000 in the US [Li–Fraumeni syndrome is a rare autosomal dominant cancer predisposition syndrome that involves a germline mutation of the tumor protein 53 (53 gene) . The estn the US . The lifn the US . Individn the US .TP53 variants, there are concerns about the safety of repeated mammograms. There is no consensus in the literature, but in light of the limited additional sensitivity of mammography when MRI and alternating whole-body diffusion-weighted MRI are used, risks seem to outweigh benefits [Surveillance recommendations for individuals with Li–Fraumeni syndrome are primarily based on the “Toronto protocol” . For brebenefits –30. In cbenefits , 28. ConAs regards many of the other cancers associated with Li–Fraumeni syndrome, early symptom-based detection is quite difficult. General recommendations include complete physical examination  once in every 3–4 months until the age of 18 and then once in every six months. Annual whole-body diffusion-weighted MRI could allow for early detection of adrenocortical carcinomas and sarcomas, based on the results of multiple international trials , 31, 32.PTEN mutation in 80% of cases [Cowden syndrome is the most prevalent PTEN hamartoma tumor syndrome associated with multiple hamartomatous and/or cancerous lesions in the skin, mucous membranes, thyroid, breast, endometrium, kidney, and brain . Affecteof cases .The lifetime risk of developing breast cancer is 85%, with an average age at diagnosis between 38 and 46 years [The lifetime risk for thyroid cancer  is approximately 35% . Annual The risk for endometrial cancer may be close to 28% . There aHalf as many individuals with Cowden syndrome have adenomatous or hyperplastic colorectal polyps associated with early-onset (<50 years of age) colorectal cancer in 13% of patients . RoutineRenal carcinoma may be present in up to 30% of patients. Melanoma skin cancer is also increased in patients with Cowden disease and may occur in 5% of patients . Yearly Brain tumors as well as vascular malformations occasionally affect individuals with Cowden syndrome. Cerebellar dysplastic gangliocytoma (Lhermitte-Duclos disease), a rare central nervous system tumor, can also be found in Cowden syndrome. However, the risk of developing these conditions is not well defined . In the MLH1, MSH2, MSH6, or PMS2) [EPCAM gene resulting in MSH2 silencing [Lynch syndrome is caused by a germline mutation in one of four DNA mismatch repair genes (or PMS2)  or deletilencing . The estilencing . Lynch silencing .Guidelines for cancer screening in patients with Lynch syndrome have been proposed by several groups including the American College of Gastroenterology, United States Multi-Society Task Force on Colorectal Cancer , EuropeaColonoscopy is recommended once in every 1–2 years starting from 20 to 25 years of age or 2–5 years before than the youngest diagnosis age in the family. Moreover, chromoendoscopy is a promising technique that could facilitate the detection of lesions and flat adenomas .Regarding gynaecologic cancers, lifetime risk varies according to mutated gene and patient's age . TransvaMLH1, MSH2, or EPCAM [Helicobacter pylori is a cause of gastric cancer, testing and treating for this bacterium is suggested [Regarding gastric, duodenal, and more distant small bowel cancer, there is insufficient evidence to recommend surveillance , except or EPCAM . Consideuggested .MSH2 mutation who may benefit from annual urinalysis beginning at 30–35 years of age [There is no clear evidence to support screening for urinary tract cancer, except for individuals with a family history of urothelial cancer or s of age . The Ints of age . Nonethes of age . By reass of age .MLH1 and MSH2, and less frequently in PMS2 and MSH6, could be associated with increased breast cancer risk [Some studies have shown that mutations in cer risk –55. Nevecer risk . HoweverCDH1) gene. A most serious problem is that genetic diagnosis remains unknown in up to 60% of patients [Hereditary diffuse gastric cancer is a cancer susceptibility syndrome defined by the early onset of diffuse gastric cancer with or without lobular breast cancer. It is mainly caused by germline mutations in the epithelial cadherin  is recommended by NCCN guidelines . HoweverSTK11 are associated with Peutz–Jeghers syndrome. This is an autosomal dominant disorder characterized by hamartomatous gastrointestinal polyps, mucocutaneous pigmentation, and an increased risk of colorectal, gastric, pancreatic, gallbladder, small bowel, gynaecologic , breast, testicular, and lung cancers [Germline pathogenic alterations in  cancers .Regarding the risk of colorectal, gastric, and small bowel cancers, colonoscopy, upper endoscopy, and capsule endoscopy should be recommended once in every 2–3 years, starting from the late teens . MoreoveFor breast cancer, annual mammogram and breast MRI screening with contrast should be recommended from 25 years of age. In women, transvaginal ultrasound, serum CA-125, and pelvic exam with Pap smear should be proposed annually beginning at 18 years of age. No data on the benefit of risk-reducing mastectomy are available, so that this procedure may be considered based on family history .In males, annual testicular exam and, subsequently, ultrasound in case of symptomaticity or abnormality on exam are suggested from birth to the teen years .NF1 cause neurofibromatosis type 1. This is an autosomal dominant HCS associated with increased risk for nervous system tumors , gastrointestinal stromal tumors, and breast cancer [Pathogenic variants of t cancer .NF1 mutation becomes similar to that of the rest of the population. Breast MRI could therefore be discontinued [The American Academy of Paediatrics and the American College of Medical Genetics and Genomics have published guidelines for children and adult surveillance , 64. Annontinued , while mBRCA1/2, mutations in other intermediate or low-penetrant genes can increase the risk of breast and/or ovarian cancer. According to a retrospective analysis, these mutations account for 7.4% of patients who met the NCCN criteria for BRCA1/2 mutation test [PALB2, ATM, and CHEK2 [In addition to the known high-penetrance pathogenic variants of ion test . The mosnd CHEK2 .PALB2  [PALB2 have a 35% lifetime risk to develop breast cancer by 70 years of age. The higher the number of relatives affected, the higher the risk [It is estimated that 0.6%–3% of patients with breast cancer harbour a mutation in f BRCA2) , 15, 68.the risk . Breast PALB2 mutations and ovarian cancer. Recently, PALB2 has also been reported to be a new pancreatic cancer susceptibility gene [Some studies highlight a possible association between ity gene . Howeverity gene .ATM have a 33% cumulative lifetime risk for breast cancer by 80 years of age [ATM heterozygous pathogenic variants have been reported in some cases of familial ovarian [ATM pathogenic variants is not recommended in the absence of familial antecedents, while men should be encouraged to participate in prostate cancer screening [ATM mutations cause ataxia telangiectasia, a syndrome characterized by progressive cerebellar ataxia, oculomotor apraxia, immunodeficiency, and general increased risk of malignancies [Individuals carrying heterozygous pathogenic variants in s of age . Mammogrs of age . No datas of age . ATM het ovarian , pancrea ovarian , and pro ovarian  cancer. creening . Homozyggnancies .CHEK2 germline mutation is higher in Northern European countries than in Mediterranean ones. Certain mutations in the CHEK2 gene (c.1100delC and I157T) are associated with increased breast cancer risk, with a cumulative lifetime risk ranging from 28% to 37% depending on family history [CHEK2 variants, there is also an increased risk of other malignancies including colon, prostate, kidney, bladder, and thyroid cancers [CHEK2 mutations [The rate of  history , 75. Mam history . No data history . Within  cancers , with thutations . CurrentNBN mutation 675del5 have an increased risk of developing numerous types of cancer, including breast (up to 30% at 80 years of age) and ovarian cancer. Moreover, an unestimated increased risk of prostate cancer at 80 years of age is also apparent in men [NBN mutations leads to the Nijmegen breakage syndrome, a rare autosomal recessive syndrome of chromosomal instability mainly characterized by microcephaly at birth, combined immunodeficiency, and predisposition to malignancies. Approximately 40% of the affected patients develop a malignancy before the age of 21 [Individuals with slavic founder heterozygous t in men . The prege of 21 . In slavBARD1 germline variants are significantly associated with early-onset breast cancer, according to recent studies [BARD1 gene variants. However, the starting age and the frequency of mammogram and/or breast MRI have not been established yet.Deleterious  studies , 79. On BRIP1, RAD51C, or RAD51D are associated with an increased risk of developing ovarian cancer. The prevalence rate of BRIP1, RAD51C, or RAD51D pathogenic variants is about 1% in women with ovarian cancer [BRIP1, RAD51C, or RAD51D are not associated with an increased risk for breast cancer [Mutations in n cancer . Neverthn cancer . NCCN gun cancer . At prest cancer .BRCA1/2 were not found. However, the lifetime risk in case of low-penetrant genes has not been defined yet and additional prospective studies are needed to establish a more customised screening program for carriers. Summary of the recommendations for each predisposition gene discussed in the present review is reported in In the last years, a large number of large case-control studies have shown the correlation between mutations in some genes and an increased risk of developing breast and/or ovarian cancer, explaining tumor recurrence in those families where mutations in


Pinteraction = 0.015). Comparable results were obtained for the original aMED including alcohol. In conclusion, higher MD adherence was not associated with a reduced risk of colorectal cancer or anatomical subsites in the context of a Dutch population.Mediterranean diet (MD) adherence has been associated with a large variety of health benefits. However, prospective studies investigating the relation between MD adherence and colorectal cancer risk had inconsistent results. In this analysis of the Netherlands Cohort Study (NLCS), we evaluated sex- and subsite-specific associations of MD adherence with colorectal cancer risk. In 1986, 120,852 subjects filled out the NLCS baseline questionnaire, which incorporated a 150-item food frequency questionnaire. MD adherence was estimated through alternate Mediterranean diet scores including and excluding alcohol . Using 20.3 year follow-up data, 1993 male and 1574 female colorectal cancer cases could be included in multivariable case-cohort analyses. aMEDr was not significantly associated with colorectal cancer risk, regardless of sex. Hazard ratios  per two-point increment were 1.04 (0.95–1.13) for men and 0.97 (0.88–1.07) for women. Additionally, there was no evidence of an inverse association with any of the colorectal cancer subsites . In women, the association between aMEDr and colorectal cancer risk was significantly modified by smoking status (The online version of this article (10.1007/s10654-019-00549-8) contains supplementary material, which is available to authorized users. Globally, colorectal cancer was an important contributor to the total cancer burden in 2018, ranking third and second in terms of incidence and mortality, respectively , which oThe traditional Mediterranean diet (MD), typical for the olive-cultivating areas bordering the Mediterranean basin in the early 1960s, has been associated with a large variety of health benefits, including decreases in all-cause mortality as well as cardiovascular disease risk and mortality –8. This The relation between a priori defined MD adherence and colorectal cancer risk has been evaluated in a number of prospective studies so far, with mixed results. Though some studies reported MD adherence to be associated with a significantly reduced colorectal cancer risk –12, inveThe colorectum can anatomically be divided in the proximal colon, distal colon, and rectum. Depending on the anatomical subsite, colorectal tumors may develop through distinct molecular pathways and show varying patterns of (epi)genetic changes , 22. FurIn the present analysis, we aimed to investigate associations of MD adherence with risks of colorectal cancer and anatomical subsites  in the prospective Netherlands Cohort Study (NLCS). The level of MD adherence was assessed using a priori defined MD scores with and without alcohol component. Moreover, associations were estimated separately for men and women.The NLCS was conducted among 58,279 men and 62,573 women, who were aged 55–69 years –26. At bAfter 20.3 years of follow-up, 4084 subcohort members and 3966 cases with incident and microscopically confirmed colorectal cancer (ICD-O-3 codes: C18–C20) were eligible for inclusion in the present analyses  , 28. PreMD adherence was assessed using the alternate Mediterranean diet score (aMED), which is a variant of the traditional Mediterranean diet score (tMED) developed by Trichopoulou et al., that was adapted for usage in the United States –33. aMEDModerate and heavy alcohol consumption have been associated with an increased colorectal cancer risk , 35. TheCox proportional hazards analyses were conducted to estimate hazards ratios (HRs) and 95% confidence intervals (95% CIs) for sex-specific associations of MD adherence with incidences of total colorectal cancer and anatomical subsites . Duration of follow-up was used as time variable and person-years at risk of subcohort members were calculated from baseline until colorectal cancer diagnosis, death, emigration, loss to follow-up, or end of follow-up, whichever came first. To account for the increased variance inherent to the case-cohort design, we estimated standard errors using the robust Huber–White sandwich estimator . Scaled MD scores were included as categorical and continuous terms in age- and multivariable-adjusted Cox models. Based on the literature, we included the following predefined confounders in the multivariable-adjusted models: age at baseline, cigarette smoking behaviour , body mass index (BMI), alcohol consumption , total daily energy intake, highest level of education, non-occupational physical activity, and family history of colorectal cancer. Other covariates considered were height, history of diabetes, history of chronic bowel irritation, use of hormone replacement therapy (women only), and long-term use of non-steroidal anti-inflammatory drugs. These factors did not change the HR estimates of aMEDr ≥ 10% and were therefore not included in the final model.P values for trends over the MD adherence categories were obtained by appointing sex-specific median MD score values among subcohort members to each category and fitting these as continuous terms in Cox regression models. Performances of models including MD score variants with and without alcohol  were compared using Akaike’s Information Criterion (AIC)   and 0.518 (colon vs. rectum)]. Similar to men, no significant association was observed between aMEDr and colorectal cancer risk in women [HRper two-point increment (95% CI) 0.97 (0.88–1.07)]  and 0.194 (colon vs. rectum)], results suggested a weak inverse association between aMEDr and rectal cancer risk in women [HRper two-point increment (95% CI) 0.91 (0.76–1.08)]. Comparable results were obtained for the original aMED including alcohol in both men and women  0.78 (0.63–0.98)]. In contrast, a positive association was suggested in female current smokers, with a significant positive trend over the aMEDr categories . Finally, there was no evidence of an association in women who had never smoked. No significant interactions were observed between aMEDr and other potential colorectal cancer risk factors  in men and women, or smoking status in men  were not significantly associated with risks of colorectal, colon, and rectal cancer in men and women Table . PerformPinteraction = 0.015). A significant inverse association was observed in female ex-smokers, whereas a positive association was suggested in female current smokers. For colorectal cancer risk, the best model performance was obtained when alcohol intake was not included in the MD score.In this prospective cohort study, a priori defined MD adherence, assessed by aMEDr, was not significantly associated with colorectal cancer risk. Associations were absent for all investigated anatomical subsites and in both men and women. The association between aMEDr and colorectal cancer risk in women was significantly modified by smoking status  , 17, 20.None of the aMEDr components was individually associated with colorectal cancer risk in the present study. Possibly, the individual effects of the aMEDr components were too weak to be detected. Combining these components into a dietary pattern score increases the likelihood that the potentially weak individual effects are being detected. Furthermore, by investigating the effect of a dietary pattern, one allows for synergistic or antagonistic interactions between the dietary components, and solves confounding and collinearity problems associated with the analysis of single food groups. Finally, the contrast within the study population in terms of overall healthiness of the diet is possibly increased when considering the MD as a whole, which increases the chance of detecting true effects, if present , 47, 48.The potentially distinct etiological backgrounds of tumors arising in the proximal colon, distal colon, and rectum and varying exposures to (carcinogens in) fecal matter across subsites may cause heterogeneous susceptibilities to (lifestyle) risk factors , 49. SubIn women in our cohort, associations between MD adherence and colorectal cancer risk significantly differed across strata of smoking status, with oppositely directed associations being observed in former smokers (inverse) and current smokers (positive). Smoking status did not significantly interact with MD adherence in female participants of the NHS . HoweverColorectal cancers usually develop slowly over the course of 10–15 years , making In conclusion, results of this large prospective cohort study do not support the hypothesis that higher MD adherence is associated with a reduced risk of colorectal cancer. MD adherence was not significantly associated with the risk of any of the colorectal cancer subsites in both men and women.Supplementary material 1 (PDF 528 kb)Below is the link to the electronic supplementary material.


Background: Lymphedema is a condition in which excessive fluid accumulates in soft tissues. It is a common complication of breast cancer treatments. It can lead to serious consequences and interfere with the activity of daily living. This study aimed to determine the level of awareness of breast-cancer-related lymphedema (BCRL) among women with breast cancer in the Kingdom of Saudi Arabia. This was a descriptive quantitative cross-sectional design that included a convenience sample of women diagnosed with breast cancer in the Kingdom of Saudi Arabia. Data were collected by distributing a self-administrated online questionnaire consisting of four parts, including demographic data (five items), the status of education about BCRL (three items), basic medical history of breast cancer (six items), and BCRL level of awareness of risk factors and management (nine items). Results: In total, 95 out of 135 of participants did not know about lymphedema, 119 of the participants (88.1%) did not receive any explanation about the possibility of lymphedema from their medical team before surgery, and 121 of them (89.6%) did not receive it after surgery. The most significant factor affecting participants’ level of awareness regarding BCRL was the lack of information about the possibility of BCRL occurrence, which was not provided to them by the medical team. Recommendation: Early and continuous education for future management is essential to prevent problems related to BCRL and improve quality of life. Breast cancer is a type of cancer in which breast cells grow out of control. It is considered to be one of the most common cancers affecting women worldwide, with an incidence of 23%  and 28.7Lymphedema has different causes, and it commonly occurs as a result of breast cancer treatment such as radiotherapy, chemotherapy, and lymph node dissection . LymphedIt can be managed by multiple treatments, including compression therapy, therapeutic exercises, and pharmacotherapy , but theBCRL can lead to serious consequences and have a negative impact on the quality of life of women with breast cancer in many aspects, such as psychological problems that can disturb body image, anxiety, depression, social isolation, and sexual problems ,19,20,21This study aimed to determine the level of awareness of breast-cancer-related lymphedema (BCRL) among women with BC in the Kingdom of Saudi Arabia, as well as provide the basic data needed to initiate proper education.The research question was, “What is the level of lymphedema awareness among women with breast cancer in the Kingdom of Saudi Arabia?” Therefore, our study was done to determine the level of awareness of BCRL among women with breast cancer in the Kingdom of Saudi Arabia and to determine the gap of knowledge so as to provide basic data needed to initiate an early and proper educational program about BCRL for women with breast cancer.There are 10 studies that discuss the awareness of lymphedema among women with breast cancer. For example, one study aimed to explore the evidence for cancer-related lymphedema. The results show that physical activity and sentinel lymph node biopsy can minimize the risk of lymphedema (LE), while chemotherapy and obesity are considered as risk factors for increasing LE. Lymphoscintigraphy may increase awareness regarding LE, which can reduce the development of LE .A literature review was done in the United States in 2016 to review the knowledge of public health care providers on BCRL. It was found that the long-lasting risk factors for BCRL include the following: axillary node involvement, the type of breast surgery, and radiotherapy . AnotherIn addition, a study was conducted to explore the prevalence of lymphedema occurrence in women undergoing breast cancer treatment. It showed that the prevalence of lymphedema among 250 women undergoing breast cancer treatment was 44.8%, and this is considered to be relevant because it is a disease that affects many aspects of a patient’s overall health  . A totalFurthermore, another study was published in Business at Kaiser Permanente Northern California (2012). The results show that lymphedema awareness varied depending on the age of the breast cancer patients .Likewise, a qualitative systematic review was published in Clonmel. The participants expressed their inability to engage in daily activities, thus leading to a decrease in their quality of life. The results show that the participants lacked information regarding BCRL . A similFurther, a cross-sectional study was done in New York, United Sates, which aimed to investigate cognitive and symptomatic outcomes when providing information about BCRL. The results were as follows: 57% of participants said that they had received information on BCRL, 18% of the participants did not have symptoms of BCRL, and the participants who received information about BCRL had fewer symptoms than the participants who did not receive information regarding BCRL .The researchers had to use old studies as a reference in the literature review to reach the necessary numbers of studies, and there was no adequate recent research about BCRL in general and BCRL level of awareness in particular.A descriptive quantitative cross-sectional design was used among females with breast cancer in Saudi Arabia.This study was conducted in Saudi Arabia.A convenience sample of 135 voluntary participants involved in the study included adult women with breast cancer or women who were breast cancer survivors. Their ages were 18 years and above, and they lived in the Kingdom of Saudi Arabia. We excluded males who have breast cancer, women with breast cancer under 18 years old, and persons outside the Kingdom of Saudi Arabia. A convenience sample of women with breast cancer was conducted through an electronic questionnaire. The researchers introduced the study aim, objectives, and the significance of the study to the participants, and the consent form was obtained from the participants at the beginning of the questionnaire as follows: Your answer to the questionnaire questions means that you agree to participate in this study. The questionnaire took approximately 5–7 min.The data were collected using a descriptive cross-sectional electronic online questionnaire, which can reach a large number of participants. The participants can answer with complete privacy and anonymity, and it can cover every aspect of a topic. It is considered to be more reliable and offers a quick, practical, and cost-effective way to obtain the desired results and save data collectors’ time. On the other hand, electronic online questionnaires do not include open-ended questions. Therefore, participants cannot convey their feelings or emotions, some participant may not answer all the questions with credibility, and there is no chance for explanation or clarification of questions from the researchers when participants fill out the questionnaire. In this study, we used an adopted questionnaire from a previous study done in Korea to determine the level of awareness regarding BCRL .The electronic online questionnaire consisted of a total of 23 questions in two languages; the participants could choose either Arabic or English. It consisted of four parts. The first part included demographic data (five items) such as age, body weight, height, region, and dominant hand. The second part concerned status of education about BCRL (three items), including the following: did they know about lymphedema, did they receive any explanation about lymphedema from health care providers before surgery, and did they receive any explanation about lymphedema from health care providers after surgery. The third part was the basic medical history of breast cancer (six items), including disease duration, lymphedema treatment, lymph node dissection, lymphedema diagnosis, if they received chemotherapy after surgery, and if they received radiotherapy after surgery. The fourth part covered BCRL level of awareness of risk factors and management (nine items), including upper limb hygiene, mild trauma to the upper limb, tight clothing or wearing bracelets, excessive use of upper extremities, weight gain, is lymphedema a disease that should be treated, is lymphedema completely curable, which activities help lymphedema occurrence, and which department can manage lymphedema. The participants’ responses were measured by answering multiple choice and yes or no questions.We obtained ethical approval from the Faculty of Nursing at King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia. Ethical approval included the purpose of conducting this study, the questionnaire, and sampling method. We obtained the data from participants who were selected according to the following inclusion and exclusion criteria: adult women with breast cancer or women who are breast cancer survivors, their ages were 18 years and above, and they live in the Kingdom of Saudi Arabia. The exclusion criteria were males who have breast cancer, women with breast cancer under the age of 18 years old, and persons outside the Kingdom of Saudi Arabia.An electronic online questionnaire was used that included informed consent, which was distributed through social media applications such as WhatsApp, Twitter, and Instagram.Descriptive analysis was performed after data collection using Statistical Package for Social Sciences (SPSS software)  version 26 in the form of means, percentages, frequencies, and standard deviations.Of the study sample, 52.6% were between the ages of 18 and 35 years, 18.5% were between 36 and 45 years, 26.7% were between 46 and 65 years, and 2.2% were 65 years or above. Regarding weight, 47.4% of the participants weighed less than 60 kg, 47.4% weighed between 60 and 100 kg, and 3% weighed more than 100 kg. Regarding height, 71.1% of participants were less than 160 cm, 25.2% were between 160 and 170 cm, and 3.7% were more than 170 cm. Regarding region, 9.6% of participants lived in the Central Region, 71.9% of them lived in the Western Region, 6.7% of them lived in the Eastern Region, and 5.2% of them lived in the Southern Region. Of the study sample, 92.6% were right-hand dominant and 7.4% were left-hand dominant. .The study was done to investigate the level of lymphedema awareness among women with breast cancer in the Kingdom of Saudi Arabia, as it is considered to be a common complication among women with breast cancer. It was found that the majority of the participants in this study did not know about lymphedema (70.4%) . A similFurthermore, a study on a total of 103 women with breast cancer stated that knowledge of lymphedema was remarkably related to adherence of women with breast cancer to the recommended strategies of the treatment plan, and women who recognized lymphedema risk management showed greater adherence to the recommended strategies . LikewisAnalysis of the questionnaire used in this study shows that the most significant factor affecting participants’ level of awareness regarding BCRL is the lack of information about the possibility of BCRL occurrence, which was not provided by the medical team . A previous study suggested that an early educational program regarding BCRL awareness for women with breast cancer could be a major factor in preventing the development of lymphedema, and detecting the signs and symptoms of BCRL, early diagnosis, and proper treatment will lead to improving patients’ quality of life . In addiThis study revealed the emerging need for medical teams to provide women with breast cancer the necessary information regarding BCRL. Moreover, the findings of our study highlight the need for providing early education programs for women with breast cancer carried out by the nursing staff, who are considered to be important members of the health care team involved in the care plan and who are most in contact with the patients. The nursing staff must also have adequate knowledge regarding BCRL signs and symptoms, risk factors, and how to prevent it when caring for women with breast cancer in order to help and educate women with breast cancer to be more knowledgeable and to decrease the likelihood of developing BCRL.This was the first study to investigate the level of awareness of BCRL among women with breast cancer in the Kingdom of Saudi Arabia. The study showed an extremely low level of awareness regarding BCRL among the women with breast cancer who participated in this study from different regions of the Kingdom of Saudi Arabia in comparison with another study in another country . The mosThe limitations of this study include the small number of participants. Moreover, this study was conducted during the Coronavirus Disease 2019 (COVID-19) pandemic, which forced us to change the number of the target population and the method for data collection from face-to-face interviews  to an electronic online questionnaire distributed through social media applications such as WhatsApp, Twitter, and Instagram. Therefore, the time required to conduct this study was limited, which was considered to be the most significant factor for us in our study. In addition to these limitations, there were limited numbers of recent studies about the level of awareness of BCRL globally. So, we were forced to use old studies as a reference in this research. Further, no studies had been conducted regarding the level of awareness of BCRL among women with breast cancer in the Kingdom of Saudi Arabia.The study results indicate that there is an intense need for developing an early educational program regarding the possibility of BCRL occurrence for women with breast cancer, especially women who have undergone breast cancer surgery and have received chemotherapy or radiotherapy, as these are considered to be major risk factors for developing BCRL. This educational program should be provided during the early course of treatment by the medical team, as such information plays a significant role in preventing problems related to BCRL for women with breast cancer and will increase their awareness about signs, symptoms, and risk factors. Therefore, early detection and proper treatment should be provided to improve patients’ quality of life and to ensure a better outcome for women with breast cancer. We advise that medical teams should have a continuous educational program emphasizing especially the importance of the awareness of BCRL to educate and increase the knowledge of women with breast cancer and their caregivers.In addition, as there is serious relationship between the level of awareness of BCRL and improving the quality of life of women with breast cancer, this study revealed that there is an emerging need for more studies to be conducted regarding the level of awareness of women with breast cancer about BCRL in the Kingdom of Saudi Arabia.We recommend that future studies investigate the relationship between the level of lymphedema awareness and improving the quality of life of women with breast cancer and engage a greater number of participants.


Wide implementation of mammography screening has resulted in increased numbers of women diagnosed with breast carcinoma in situ. We aimed to determine the risk of invasive breast cancer in relatives of patients with breast carcinoma in situ in comparison to the risk in relatives of patients with invasive breast cancer.We analyzed the occurrence of cancer in a nationwide cohort including all 5,099,172 Swedish women born after 1931 with at least one known first-degree relative. This was a record linkage study of Swedish family cancer datasets, including cancer registry data collected from January 1, 1958, to December 31, 2015. We calculated standardized incidence ratios (SIRs) and 10-year cumulative risk of breast cancer diagnosis for women with a family history of in situ and invasive breast cancer.–1.7) when compared to those who had no family history of invasive breast cancer or breast carcinoma in situ in either first- or second-degree relatives. Similarly, having one first-degree relative with invasive breast cancer was associated with 70%  increased risk. The 10-year cumulative risk for women at age 50 with a relative with breast carcinoma in situ was 3.5% (2.9–3.9%) and was not significantly different from 3.7% (3.6–3.8%) risk for 50-year-old women with a relative with invasive breast cancer .Having one first-degree relative with breast carcinoma in situ was associated with 50% increased risk of invasive breast cancer (SIR = 1.5, 95% CI 1.4The risk of invasive breast cancer for women with a family history of breast carcinoma in situ was comparable to that for women with a family history of invasive breast cancer. Therefore, family history of breast carcinoma in situ should not be overlooked in recommendations for breast cancer prevention for women with a family history of breast cancer. Breast cancer is a major cause of cancer morbidity and mortality worldwide, accounting for a quarter of all new cancer cases . Many hiBreast carcinoma in situ, also known as stage 0 breast carcinoma or intraductal carcinoma, is defined by the presence and proliferation of malignant cells that remain confined within the breast duct above the basement membrane without spreading through the walls of the ducts into the nearby breast tissue . The majHaving a family history of invasive breast cancer is known to be associated with an increased risk of the disease , 10. IndThis study used an ambidirectional design including both retrospective (family history) and prospective  components of the study, in which a cohort of Swedish women born after 1931 was followed up from 1958 onwards for invasive breast cancer diagnosis through record linkage. The datasets and thus the exposure and outcome of interest are updated biannually. For this study, we used the latest version available with follow-up by the end of 2015.This study was based on record linkage of several nationwide Swedish datasets: The Multi-Generation Register, which is a genealogy dataset, in which families comprising of offspring (born after 1931) are linked to their parents. The Multi-Generation Register was linked with the Swedish Cancer Registry (started in 1958) using unique personal identification numbers. The personal identifiers have been pseudonymized and replaced with technical serial numbers to prevent the identification of individuals in the datasets. The linkage and structure of the linked datasets have been previously described elsewhere , 13. TheThe latest version of family cancer datasets (with information by the end of 2015), which was updated in 2017, was used in this study and includes records of more than 12.8 million individuals with genealogical data, about 1.7 million records of primary invasive cancers, and around 0.5 million records of carcinomas in situ. The behavior of breast cancer tumors (in situ or invasive) had been defined by the cancer registry based on the 3rd digit of the Pathological Anatomic Diagnosis (PAD) code  from 1958 to 1992 and 5th digit of morphology code in the second/third version of International Classification of Diseases coding system for Oncology  from 1993 onward. Both ductal and lobular breast carcinoma in situ were included. Further information on the grade of carcinoma in situ was not available. We also used longitudinal demographic and socio-economic data from national censuses. Data from January 1, 1958, to December 31, 2015, were collected. Data were analyzed from October 1, 2018, to January 31, 2020.All women resident in Sweden and born after 1931 (the offspring generation) were eligible for the study. We restricted the current analysis to the offspring generation to minimize possible birth cohort effects because we found lower incidence rates of breast cancer in the parental generation. Through the linked datasets, it was possible to establish the numbers of both first-degree and second-degree relatives affected with invasive breast cancer or breast carcinoma in situ diagnosis, including their ages at diagnosis. Out of 6,332,770 women with genealogical data, 5,099,172 women who were born after 1931 were included in our analysis. Participants were followed up from birth, year of immigration, or the starting year of cancer registry (1958), whichever came latest, and follow-up ended at year of invasive breast cancer diagnosis, year of death, year of emigration, or end of the study (2015), whichever came earliest.The standardized incidence ratio (SIR) was used to compare cancer risk according to family history status of invasive and breast carcinoma in situ. The SIRs were calculated as ratios of the observed (O) to the expected (E) number of cases. It has been reported that using the disease incidence in the entire population as an approximate measure of the disease incidence in the unexposed population, which is a common practice in SIR calculation, results in a bias towards the null, the magnitude of which depends on the prevalence of the exposure and the magnitude of the true relative risk . The oppe−(10-year cumulative rate)). Similarly, the lifetime cumulative rate was calculated as the sum of age-specific incidence rates from birth to age 79 years. The lifetime risk was derived from the lifetime cumulative rate using the formula: lifetime cumulative risk = 100 × (1 − e−(lifetime cumulative rate)). All analyses were conducted in SAS software version 9.4 .The 10-year cumulative risk of invasive breast cancer in women with family history of breast carcinoma in situ or invasive breast cancer was calculated as follows: the age-specific incidence rate at a certain age A was calculated as the number of cases at age A divided by available person-years of follow-up at that age. The sum of 10 consecutive 1-year age-specific incidence rates from age A provided the 10-year cumulative incidence rate at that age. The 10-year cumulative rate was then converted into a 10-year cumulative risk using the following formula: 10-year cumulative risk = 100 ×  did not have a family history of in situ or invasive breast cancer in first- and second-degree relatives by the end of the study. Among 40,352 women with family history of only breast carcinoma in situ in first-degree and second-degree relatives, 584 developed invasive breast cancer during the follow-up.During the study period, 5,099,172 women were followed up. The majority of the women  compared to having no family history of in situ or invasive breast cancer in first-degree and second-degree relatives  was similar to the risk associated with having an affected mother with breast carcinoma in situ  and was comparable to when either relative had invasive breast cancer Table . HoweverWe did a stratified analysis by period, 1958–1994 and 1995–2015, corresponding to the period before or during scale up of mammography screening and the period after attaining nationwide coverage in Sweden. In the 1958–1994 period, the relative risk of breast cancer in relatives of patients with breast carcinoma in situ was 2-fold  and that of relatives of patients with invasive breast cancer was 80% increased  compared to women without family history Table . During At age 50 years, the 10-year cumulative risk (risk of developing breast cancer in the next 10 years) for women in the general population was 2.2%  were also comparable between women with family history of in situ and those with invasive breast cancer, except at young ages (less than 35 years).Our study benefited from several register-based nationwide Swedish family cancer datasets linked together, the world’s largest of their kind, with structures that allow for accurate assessment of family history constellation of breast cancer and breast carcinoma in situ. Specifically, the use of medically verified cancer registry data enabled accurate differentiation between family history of in situ and invasive breast cancer, which is likely to be misreported in studies using patient-reported data . The larAlthough risk estimates derived from Swedish cancer datasets are generally precise, there is a possibility of bias, which may arise if the diagnosis of cancer in a woman’s relatives occurred before the start of the population-based registers resulting in misclassification of family history. However, a previous study showed that for breast cancer, risk estimates from the Swedish multi-generational cohort do not generally seem to be biased by left truncation . Bias maMany studies have provided familial risks of breast cancer, mainly either as invasive or mixed with in situ family history mainly in first-degree relatives , 24, 25.Similar genetic variants have been shown to predispose to increased risk of both in situ and invasive breast cancer . A studyImplementation of mammography screening has resulted in increased incidence of breast cancer, particularly of in situ tumors. Because this increase in incidence has been without a commensurate decrease in incidence of late-stage tumors, it has been deduced that most increase in incidence of in situ tumors was due to detection of indolent tumors and considered as overdiagnosed . HoweverThis study, which is based on high-quality data, provides population-level evidence that the risk of breast cancer in women whose relatives are affected with breast carcinoma in situ is rather similar to that in women whose relatives have invasive breast cancer. Thus, family history of breast carcinoma in situ should not be overlooked. Cancer prevention guidelines and recommendations for women with a family history of invasive breast cancer could also be applicable to women with family history of breast carcinoma in situ.Additional file 1 : Table S1. Relative risk of breast carcinoma in situ in women with family history of invasive breast cancer or breast carcinoma in situ.