A dose-dependent relationship between alcohol consumption and increased breast cancer risk is well established, even at low levels of consumption. Australian women in midlife (45–64 years) are at highest lifetime risk for developing breast cancer but demonstrate low awareness of this link. We explore women’s exposure to messages about alcohol and breast cancer in Australian print media in the period 2002–2018. Methods: Paired thematic and framing analyses were undertaken of Australian print media from three time-defined subsamples: 2002–2004, 2009–2011, and 2016–2018. Results: Five key themes arose from the thematic framing analysis: Ascribing Blame, Individual Responsibility, Cultural Entrenchment, False Equilibrium, and Recognition of Population Impact. The framing analysis showed that the alcohol–breast cancer link was predominantly framed as a behavioural concern, neglecting medical and societal frames. Discussion: We explore the representations of the alcohol and breast cancer risk relationship. We found their portrayal to be conflicting and unbalanced at times and tended to emphasise individual choice and responsibility in modifying health behaviours. We argue that key stakeholders including government, public health, and media should accept shared responsibility for increasing awareness of the alcohol–breast cancer link and invite media advocates to assist with brokering correct public health information. Despite clear epidemiological evidence that alcohol consumption is a risk factor for breast cancer , women’sAgainst this backdrop, we know that targeting a modifiable risk factor such as alcohol is a good approach to reducing the disease burden of breast cancer ,6. BaadeAlcohol has been described as an ‘integral part’  of the ADespite the NHMRC guidelines, alcohol consumption in Australia is high, relative to other high-income countries . The mosConcomitantly, the alcohol industry promotes the notion of alcohol as a ‘normal, everyday product’ and women specifically are targeted by alcohol marketing, obvious through the feminisation and ‘pinking’ of alcohol products . In AustThe purpose of this research was to explore whether/where/how the relationship between alcohol and breast cancer has appeared in Australian newspapers to identify recommendations of how the alcohol–breast cancer link can be more effectively portrayed in the media, with the intent of raising awareness for women of this link, rather than contributing to further confusion.A media analysis was undertaken using an innovative analytical approach developed by Foley et al.  designedPrint newspapers were selected as the source for analysis. While newspaper readership has declined over previous years, the proportion of Australians who continue to regularly read newspapers has remained stable . More thWhen identifying relevant time periods, we utilised contextual information to signpost where points of interest about alcohol–breast cancer messaging might be observed in the data. The initial time period identified was 2009–2011—a ‘peak’ period due to the release of three significant public health documents which brought attention to alcohol harms. These included updated NHMRC drinking guidelines (2009) which reflected new understandings of the health impacts resulting from even low levels of alcohol consumption ; an updaTwo time points either side of this ‘peak’ were then identified as comparative time periods. A ‘pre’ period, 2002–2004, four to seven years prior to the release of the documents was chosen. In the period 2002–2004, the IARC classified alcoholic beverages as a Group 1 carcinogen  but had alcohol’, ‘beer’, ‘wine’, ‘spirits’ or ‘drinking’ in conjunction with ‘cancer’ or ‘tumour’, as well as ‘breast’. A total of 1047 newspaper articles were identified within the three time periods. Details of all newspaper articles were entered into a spreadsheet and assessed for eligibility, searching for articles directly discussing the consumption of alcohol in relation to breast cancer. Over 800 articles mentioned the key search terms separately and did not discuss alcohol in relation to breast cancer . These articles, in addition to duplicates Factiva had missed, were excluded. The remaining 203 articles commented on alcohol and cancer, of which 153 directly referred to breast cancer in relation to alcohol consumption specifically. Thus, 153 newspaper articles were included for analysis .The newspapers with the highest readership, representing the two major corporations, were included, along with their Sunday paper counterparts . The FacThematic and framing analyses were combined following Foley et al.’s methodology ,30. FirsSecondly, framing analysis facilitated exploration of how stories were presented and shaped in the newspapers, through the identification of included or excluded information, to subsequently influence audience understanding and interpretation . DrawingAcross the time periods of analysis, several changes were noted in the portrayal of the alcohol–breast cancer link. This was demonstrated through the number of articles published in each time period, the emphasis on varying themes that emerged from the thematic analysis, as well as how news articles were positioned within medical, behavioural or societal frames across these time periods.n = 66), compared to the pre-period 2002–2004 (n = 50) and post-period 2016–2018 (n = 37)  . Surpris(n = 37) . The artThe thematic analysis revealed five key themes present to varying degrees across the three time periods. The most prominent themes—Individual Responsibility and False Equilibrium—were strongly positioned in each time frame. Meanwhile, the themes Ascribing Blame, Cultural Entrenchment, and Recognition of Population Impact were more subtly portrayed during the pre-period (2002–2004) but became more apparent during the peak (2009–2011) and post- (2016–2018) periods. An important finding was that in in the period 2002–2004, the benefits of alcohol to health were quite prominently featured, whereas in in the period 2016–2018, any such benefits were portrayed as ‘not worth the potential risk of developing breast cancer’.Over the years, newspapers portrayed the relationship between alcohol consumption and breast cancer as inherently an individual ‘female’ problem. Breast cancer, resulting from alcohol consumption was identified as an outcome associated with being of the female sex. The choices females made and the interactions of these decisions  with their unique biological design were ‘blamed’ for increased breast cancer incidences.She said drinking had contributed to rising numbers of breast cancer cases, although other factors such as the trend for women to remain childless or have smaller numbers of children and not breastfeed had probably had a bigger effect.The impact of hormone replacement therapy (HRT) in the alcohol–breast cancer risk mix was often reported during this time:But women whose mothers or sisters had breast cancer, or those taking post-menopausal oestrogen replacement, are at greater risk from alcohol.By 2016–2018, the focus shifted from the agency of older women and those of child-bearing age to young females prior to their first pregnancy: Young women who drink alcohol before their first pregnancy face a 35 per cent higher risk of developing breast cancer, new research suggests.Consistent across time periods was the focus on biology and the interaction of alcohol with female hormones (oestrogen) as well as a focus on post-menopausal females who were considered at higher risk of breast cancer from alcohol consumption: Other risks for post-menopausal women were: obesity after menopause, as estrogen after menopause is produced in fat cells, alcohol consumption, some risk for those that were non-identical twins and some risk for those with a family history of breast cancer.Experts aren’t clear on why alcohol increases the risk of breast cancer. One theory is that alcohol increases the levels of oestrogen in the blood, which is a risk factor for developing breast cancer.By presenting females as actively making choices related to childbearing, breastfeeding and hormone treatment, these articles tended to isolate inherent female factors and ascribe a level of blame to females for the increase in alcohol-related breast cancer incidence.Newspaper content from 2009 onwards changed focus from female biological mechanisms to addressing the risk of alcohol consumption behaviours with responsibility for adhering to cancer prevention recommendations positioned within individuals’ control. Although this theme was present across all three time periods, it was most prominent in the articles from 2009 onwards. Alcohol was portrayed as a ‘dangerous’ substance and women were warned to be wary of consuming it. However, the risk alcohol posed in relation to breast cancer was consistently described as modifiable, with individual choice and responsibility highlighted. Women were urged to make necessary changes to reduce their risk:Women should still remain more wary than men when it comes to drinking, however, and not just because of their smaller body size.“You might not be able to help your genes but you can make lifestyle choices.”.Newspaper content that contained recommendations for breast cancer prevention similarly focused on modifying individual behaviours. However, the suggestions provided were often non-specific , and conflicted with previous articles and/or the drinking guidelines at the time , or were vague, including non-standard units of alcohol measurement . Therefore, the implications of different patterns and levels of alcohol consumption in relation to breast cancer risk were unclear:Heavy alcohol consumption is particularly dangerous, with women drinking more than a bottle of wine a day at 40 to 50 per cent higher risk of the disease.Even women who had three to six drinks a week had a 15 per cent increased risk of breast cancer compared with non-drinkers.This amount of alcohol was equivalent to three teaspoons of wine per day, she added.It was not until 2016–2018 that a slight shift toward population-level recommendations was observed in how the newspapers portrayed the alcohol–breast cancer link (described in the Recognition of Population Impact theme below). In the period 2016–2018, articles acknowledged that the public may be less familiar, if not ‘ignorant’ of the relationship between alcohol consumption and breast cancer:The findings are likely to come as a surprise to many Australians, who are well versed on the dangers of tobacco, but remain ignorant of alcohol’s link to mouth, throat, stomach, bowel, breast and liver cancer.Within newspaper content from each period, the individual was positioned as an informed decision maker about this relationship:“It’s about informing them so they can make informed choices.”.“You should certainly be aware of the information available to make an informed decision and, if you do drink, do so in moderation.”.Newspaper discussion in all periods placed a level of accountability for the increase in alcohol-related breast cancers on cultural values which encouraged and normalised alcohol use. Modern and more affluent ‘lifestyles’ were specifically criticised in newspaper reports and blamed for the harm alcohol consumption contributes to increased breast cancer prevalence:Australia’s middle-class lifestyle could also be contributing to the incidence of some cancers such as breast cancer.Modern lifestyles which feature regular drinking, lack of exercise and increased obesity are fueling the disease’s rise, the European Breast Cancer Conference heard.From 2009–2011 onwards, abstinence was portrayed as an unreasonable expectation due to how deeply entrenched alcohol is in women’s everyday lives:Alcohol is often part of everyday life, and it can be hard to avoid it completely.It’s unrealistic to recommend to patients that they completely abstain from alcohol.Consequently, alcohol-related breast cancers were initially portrayed as attributable to a lifestyle which promotes consumption (2002–2004 and 2009–2011) but from 2009–2011 onwards, lifestyles featuring alcohol were presented as unavoidable considering cultural drivers to consume.Alcohol was portrayed as both a ‘tonic’ and ‘poison’ in all time periods, possessing the dichotomous ability to both protect and harm health. Throughout the period 2002–2004, newspapers portrayed alcohol-related harms/benefits as a counterbalance. Whereby, ‘too much alcohol’ put the drinker at risk of breast cancer, while moderate consumption, particularly of good wine, was portrayed as a way to prevent breast cancer, and protect health:The evidence supports theories that a moderate daily intake of wine helps prevent stroke and heart disease, as well as perhaps diabetes and prostate and breast cancer.All women can weigh the benefits of drinking alcohol against the slight increased risk of breast cancer.In the period 2002–2004, and to a lesser extent in the period 2009–2011, messages that alcohol consumption might pose risk for breast cancer was presented alongside content which incorrectly claimed the risk could be mitigated through diet modifications, or that any purported health benefits of alcohol outweighed the risk of breast cancer:The increased danger to individual women, however, is usually outweighed by the significant benefits to cardiovascular health.Eating plenty of folate, a B vitamin found in spinach and broccoli, for example, may reduce the risk of breast cancer associated with alcohol.Interestingly, the risk of breast cancer from alcohol consumption was presented in the periods 2002–2004 and 2009–2011 as greater than some medical treatments and served to justify the use of HRT and supplements:“If you have no symptoms I wouldn’t take it, but the risk of HRT causing breast cancer is really minimal—and people often forget other risk factors such as drinking, or a high fat diet.”.Although combined forms of HRT may slightly increase the chances of breast cancer, the effect is dwarfed by other risk factors, such as obesity, diet and alcohol.In the period 2009–2011, articles about the alcohol–breast cancer link included research findings which claimed the beneficial properties of wine extended beyond prevention to include breast cancer treatment:Red wine could help women with breast cancer boost the chances of their treatment being successful.An ingredient in red wine can stop breast cancer cells growing and may combat resistant forms of the disease.While in the periods 2002–2004 and 2009–2011 the benefits of alcohol were portrayed to outweigh the risks of breast cancer if consumed responsibility, reports of alcohol as protective and beneficial to health faded over time. By 2016–2018, the release of key public health publications seemed to have impacted this balance, and alcohol consumption was no longer considered ‘worth the risk’ of breast cancer. In the period 2016–2018, there was only a single mention, and the article concluded that the risks associated with ‘moderate’ alcohol consumption outweighed any purported health benefits:Is a glass of red wine a day ok? No: This is one “wish list” rule everyone hopes is true. However, health professionals claim benefits in red wine are outnumbered by the negatives in alcohol as a whole. The “red wine is good for you” bandwagon began due to the fact it contains the natural compound resveratrol, which acts like an antioxidant and helps prevent damage to the blood vessels in your heart and reduce your LDL, or bad cholesterol. While this may be true, Australian Medical Association vice-president Dr Tony Bartone says research shows a link to cancer.From 2009–2011 onwards, there was moderate recognition of the increasing population-level impact of alcohol consumption. Articles drew attention to the association of a ‘common cancer’—breast cancer—to alcohol consumption and noted the substantial influence that alcohol could therefore have on reducing the population-wide alcohol-related breast cancer disease burden:In Australia, 5000 or 5 per cent of cancers, including one in five breast cancers, are attributable to long-term, chronic drinking.Alcohol is estimated to cause more than 1500 cancer deaths in Australia every year, with breast and bowel cancers of particular concern… About 1330 bowel cancers and 830 breast cancers are attributed to alcohol each year in Australia, and it has been estimated about 3 per cent of cancers can be blamed on alcohol consumption each year.In addressing the population impact of alcohol on breast cancer incidence, a small number of newspaper articles presented population-level interventions as appropriate solutions:The research will help shape future campaigns warning of the risks of drinking. Graphic labelling similar to those displayed on cigarette packs could also be introduced to minimise harmful drinking.It may be beneficial for public health authorities to consider guidelines specific for cancer survivors, rather than relying on prevention messaging.From the thematic analysis, five themes emerged which presented alcohol as simultaneously harmful and beneficial to breast cancer, as well as deeply embedded in Australian culture, and contributing to a considerable morbidity and mortality burden. Meanwhile, alcohol-related breast cancers were positioned as stemming from inherent female concerns and choices controlled by the individual which were perceived to be the responsibility of the individual to address. Additionally, various conflicting and misleading messages of the potential health harms/risks associated with alcohol consumption were portrayed by newspapers.Using framing analysis of newspaper articles identified news fragments in terms of the extent to which they defined problems, diagnosed causes, made moral judgements, or suggested remedies under a medical, behavioural or societal frame (within each three time periods) . The proNews fragments focusing on biological interactions of alcohol within the body and resulting pathophysiological effects  were groNews fragments categorised to the behavioural frame addressed individual choices and behaviours ,35. HereNews fragments categorised to the societal frame referenced community concerns of alcohol-related health harms and broad structural factors contributing to these harms ,37. In tOur discussion focusses on how portrayals of the alcohol–breast cancer link change in newspapers over time and the potential implications that this has for women’s awareness and public health more generally. Accurately representing the relationship between alcohol consumption and increased breast cancer risk via the media can be considered a shared responsibility between the media, the government, the alcohol industry, and individuals ,39, becaOur findings are consistent with previous research examining media coverage of breast cancer and alcohol, whereby journalists were found to ‘cherry pick’ when reporting findings of scientific studies by paying particular attention to controversial findings of single studies, thereby contributing to conflicting messages in the print media . AdditioThe way the media ‘frames’ the link between alcohol and breast cancer is critical as it can shape future behaviours of the ‘responsible parties’ and define whose responsibilities they are. Our analyses showed that the behavioural frame took prominence, with women consistently portrayed as responsible for health decision making. The medical and societal framing of the alcohol–breast cancer link was generally neglected by the media, with structural factors infrequently ascribed as contributing to increased risk of breast cancer resulting from alcohol. The medical frame featured mildly in the period 2002–2004 but waned shortly thereafter, and the societal frame only began to emerge in the period 2016–2018. The privileging of the behavioural factors results in an unbalanced portrayal of the alcohol–breast cancer link and obscures some of the structural forces of disease risk as well as those medical issues beyond individual control. This can contribute to increased blame (and self-blame) for individuals that develop breast cancer, while also neglecting opportunities to raise and leverage public awareness and action on the commercial determinants of health. While it does appear that the societal angle was drawn on more by media in more recent times, integrating information that links health outcomes with population changes  would be of vital assistance to contextualising alcohol consumption as a modifiable risk factor for breast cancer.We focus this section particularly on the implications of our study for governments, the alcohol industry, and media organisations.The media has a shared responsibility to inform the Australian population of alcohol-related breast cancer risks and prevention strategies. Due to the media’s reliance on academic research and the simultaneous reliance of researchers on the media to promote their findings, there is an opportunity for these parties to restructure the current media landscape and focus on health outcomes . DedicatStrategies employed by the alcohol industry were evident in media stories analysed. Just as the newspaper articles reflected alcohol to be culturally entrenched and the responsibility of the individual to curb consumption and reduce health risks, so too does the alcohol industry promote alcohol as a part of everyday Australian society and target individual behaviours when disseminating ‘drink responsibly’ messages ,18,54. DSince we completed this analysis, the NHMRC drinking guidelines have been revised, now acknowledging ‘the less you drink, the lower your risk of harm from alcohol’ . Whilst This study only examined how messages were portrayed to the reader rather than how it is received—we cannot make assertions that suggest the content is interpreted by all women in the same way ,60. BuilMedia can influence the beliefs and behaviours of their audience as well as direct public discussion and political objectives. How the media represents the relationship between alcohol consumption and breast cancer is therefore important for informing women of alcohol-related breast cancer risk. This study demonstrates that the Australian print media has not consistently or accurately portrayed the alcohol–breast cancer link, instead exposing readers to conflicting and controversial news stories focused predominately on individual behaviours. This study identified the most prominent themes and frames portrayed in Australian newspapers over three time periods, representative of the message disseminated by the media about the alcohol–breast cancer link. Over three time periods, five themes were revealed: Ascribing Blame, Individual Responsibility, Cultural Entrenchment, False Equilibrium, and Recognition of Population Impact. Further, one frame was most prominent across all time periods: Behavioural. The commonality between the findings of the thematic and framing analyses was the focus on the individual choices and behaviours which contributed to the alcohol-related breast cancer burden, and subsequently their responsibility to enact changes to reduce this burden. Furthermore, the representation of the alcohol–breast cancer link was found to be incomplete and contradictory—new articles commonly reported results or outdated claims which conflicted with evidence-based information about the causal relationship between alcohol and breast cancer. Through media advocacy and public health promotion, media platforms can be better utilised to disseminate more balanced representations of the relationship between alcohol and breast cancer as well as the wider range of avenues to address the structural drivers of this disease.


For milk, a significant decrease in BC risk was observed for an increase in consumption of one glass/week, OR trend = 0.95, 5% decrease, in both strata of menopause. In contrast, for hard cheese, a significant increase in the risk of 10% was observed only in premenopausal women, OR trend = 1.10. Cottage cheese consumption significantly reduced BC risk by 20%, OR trend = 0.80, for an increase in one serving/week for postmenopausal women only. Our results show that individual dairy products have a statistically significant but bi-directional relationship with BC risk, which differs for premenopausal and postmenopausal women.Lack of consistency in the relationship between dairy products consumption and breast cancer (BC) risk motivated us to evaluate this association in a case-control study of BC among Polish women. The study includes 1699 women 26–79 years of age, 823 BC cases identified in Cancer Registries and 876 randomly selected controls from the national population registry. Using a validated, semiquantitative food frequency questionnaire (FFQ), the consumption of dairy products was collected for a time period of 10–15 years prior to BC diagnosis. We used logistic regression, adjusting for potential confounders, to assess the relationship between total dairy consumption as well as individual dairy groups of milk, cottage cheese and hard cheese and BC risk for premenopausal and postmenopausal women. For total consumption, a significant decrease in BC risk was observed with increased consumption of one serving/week, OR  The relationship between the consumption of selected food groups, individual foods or their nutrients and risk of various cancers has been extensively studied globally, with inconsistent results. Wiseman 2018) [8 [1], baThe assessment of the relationship between breast cancer risk and the group of dairy products has been inconsistent, as observed in several meta-analysis publications. Moorman and Terry, in their 2004 review of over 40 studies, pointed out the variations in the ways that dairy products consumption are analyzed and reported. Some studies provide information for total dairy products consumption, while others break it down into components such as milk products, cheeses, or fermented milk, while still others group them into categories of low-fat products vs. high-fat products. The timing of consumption is also considered in some studies, such as childhood vs. adulthood. Among the studies reviewed, the effect of total dairy consumption on breast cancer risk was evaluated in three cohorts and nine case-control studies. The three cohorts observed a significant inverse relationship between breast cancer risk and total dairy products consumption, with one study observing it only for premenopausal women. The results for the nine case-control studies were highly inconsistent: two observed inverse association, five no association and two observed increased breast cancer risk. By summarizing the results of over 40 studies reviewed, which evaluated the effect of total dairy intake as well as the various subgroups of dairy products on breast cancer risk, they concluded that consumption of dairy products did not show a consistent relationship with the risk of breast cancer . The mosThis lack of consistency regarding the role of dairy foods as a group (and milk) in the etiology of breast cancer was already noted in previous collective Breast Cancer Reports . In the This means that the problem of assessing the relationship between dairy products and breast cancer risk remains open. Milk and dairy products are too important a food group in the diet of many societies to leave the conclusion about their role in breast cancer risk undefined. Additional studies evaluating the association between dairy product consumption and breast cancer risk are needed.The ambiguous results of the meta-analysis carried out so far, and the lack of strong evidence regarding the relationship of dairy foods with breast cancer risk in the updated Reports ,2,7,11 pThe aim of this study is to evaluate the relationship between the usual milk and dairy products consumption from 10 to 15 years before breast cancer diagnosis, based on data collected in an epidemiological case-control study of breast cancer in Polish women in three different regions of Poland.This case-control study is the Polish component of the two-arm population-based case-control study  entitled: “Breast Cancer in Women of Polish Ancestry” funded by the National Cancer Institute, National Institutes of Health, USA. The study is known in the field as “The Polish Women’s Health Study (PWHS)” and was initiated in the years 2001–2003. A review of the literature on breast cancer incidence in Poland showed that in the 1980s, the incidence of breast cancer in Poland was much lower compared to other European countries or US. The goal of the Polish arm of the PWHS was to evaluate the effect of the traditional Polish diet on breast cancer risk. Therefore, the time period of 1985–1989 was chosen for the assessment of dietary and other exposures because the year 1989 brought, in Poland, changes from centrally planned to a free-market economy that influenced social and economic changes, including changes in dietary habits.Breast cancer cases were identified in several Regional Cancer Registries from three regions of the country: western Poland in Poznań, the Wielkopolskie Cancer Center and the Center for Prevention and Epidemiology of Cancer; southern Poland in Gliwice at the Oncology Center and in Katowice at the Department of Internal Diseases and Oncological Chemotherapy of the Silesian Medical Academy; and eastern Poland in Białystok, the Białystok Oncology Center. The recruitment of incident breast cancer cases aged 20–79 years old from each registry started simultaneously with cases diagnosed on 1 January 2000 and continued until 200 consecutively diagnosed cases were identified. Cases were not eligible to participate if they had a previous diagnosis of in situ or invasive breast cancer or any other cancer except common skin cancer. Population-based controls were frequently matched to the age and residence distribution of breast cancer cases in 1999 at each of the five involved Oncological Centers. Women for the control sample were drawn from the national population registry (PESEL) kept by the relevant government institutions for every center separately. The selection process of controls ensured that a random sample of potential controls was chosen to reflect the frequency distribution based on 5-year age groups and place of residence of the breast cancer cases. Potential controls who, at initial screening, disclosed that they were diagnosed with breast cancer or any other cancer, except common skin cancer, before 1 January 2000, were excluded from the control group. The total number of participants in the study was 1734. After quality verification of each questionnaire, 35 questionnaires were rejected due to overestimated energy consumption, a previous diagnosis of breast or other cancers among controls not disclosed at initial screening, previous diagnosis of breast or other cancers prior to 1 January 2000, among cases, and exclusion of participants who were 80 years or older at the time of the interview. Therefore, the final sample included 1699 women aged 26–79 years of age, of which 823 are breast cancer cases and 876 population-based controls, frequency matched on age in 5-year age interval and place of residence to the cases. The response rates for the cases were 72.4% and for controls 50.7%. The study was approved by the Bioethics Committees in Poland and the USA.Usual dietary intake during the 1985–1989 time period used a validated, semiquantitative food frequency questionnaire (FFQ) modeled on the Nurses’ Health Study (NHS) 1986 long questionnaire and supplemented with traditional Polish products and dishes. The questionnaire consisted of 130 questions about food items. The frequency of consumption was assessed in times per day, week, month, or year. For bread, eggs, bacon and alcoholic beverages, the typical serving size was ascertained. Otherwise, the average serving size was assumed.FFQ section entitled “Dairy Foods” included questions about usual consumption of (1) cow’s milk: low fat, skimmed and whole milk , fermented milk and yogurt (yogurt was grouped with milk because over 80% of women never consumed yogurt during 1985–1989 since it was just being introduced to the market); (2) cottage cheese: including farmer’s cheese and homogenized cheese; (3) hard cheese: including yellow cheeses, Camembert and Brie style cheeses and other processed cheeses. Average serving sizes for these three dairy groups were assumed to be: 220 mL milk, 60 g cottage cheese and 30 g hard cheese.In order to help participants with the recall of their usual diet during that time period, thus reducing recall bias, two graphic aids were developed and used. First, a life event calendar was introduced at the start of the interview, which allowed women to enter important life events such as marriages, births, change in residence or other important events that occurred during 1985–1989. The date of the Chernobyl accident, 26 April 1986 (4/26/1986), was also written into the calendar. This helped participants to place themselves from the start of the interview into the time period for which dietary and other lifestyle exposures were collected in the questionnaire. Second, for dietary assessment, a set of graphic cards with names of the foods and dishes corresponding to those in each question within a section was shown to the participants to help them recall the frequency of consumption for these products. Thus, when the question about the consumption of specific food was read by an interviewer, participants not only heard the name of the food but also were able to see it written as well as see a picture for some products/foods. Interviewers were instructed and had prompts in the questionnaire to frequently remind participants about the time period for which the participant was to report her food consumption. The FFQ interview was performed in the same way in the case and control sample, under as similar a condition as possible. FFQ concerned the years 1985–1989, i.e., period of 10–15 years before clinical diagnosis (in 2000) for cases and year of interview for healthy controls. The interviewers were trained nutritionists, doctors or nurses.2) during 1985–1989 was calculated based on body weight and height reported for that time period during the interview. Physical activity included questions about all types of activities, including sleep; light, moderate and heavy household activities; recreational activities; occupational activities; and stair climbing. Total METs  were calculated for each participant based on the intensity and duration of each activity during a 24-h day [For several exposures/covariates listed below, their occurrence was collected up to the time of the interview for controls and time of diagnosis for cases. First-degree family history was considered positive if a mother, sister or daughter had been diagnosed with BC. Age at menarche was assessed by the onset of the first menstrual period. Full-term pregnancy (FTP) was defined as a pregnancy lasting 24 or more weeks, irrespective of the outcome. Age at any first FTP was calculated from the date when the first pregnancy ended relative to the participant’s birthdate. For assessment of the use of oral contraceptive or hormone replacement therapy, participants were provided a list of hormonal preparations available during that time period for oral contraception (pills or injections) or hormone replacement therapy . For the following exposures/covariates, information was collected for the time period 1985–1989, thus the same time period as for dietary exposures. Body mass index . In order to test for group differences between cases and controls, for demographic and other characteristics, we used logistic regression models adjusted for age and site: age at diagnosis (cases) or interview (controls)  and site . To test for case/control differences between the distribution of total and individual dairy products consumption as continuous variables, due to skewness of these distributions, a nonparametric equivalent of a two-sample To evaluate the association between total and individual dairy products consumption and risk of breast cancer, stratified by menopausal status in 1987, we used multivariable logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CI). To evaluate these associations, we categorized consumption in servings/week as follows: total  and milk consumption in glasses/week . For cottage cheese, we used terciles of servings/week , and for hard cheese, we used quartiles of servings/week  among controls, respectively. Because servings/week cluster at certain values, the distribution of controls for terciles was the closest serving size to 33% and 25% for quartiles. Two participants were missing information for the consumption of cottage cheese, and one for hard cheese. They were assigned median value specific for the site, age group and case/control status.Model 1 assessed the association, measured by OR and 95% CI, between breast cancer risk and increasing consumption as defined by the specific categories for total and each dairy product, relative to the respective low category of consumption. In Model 1, we adjusted only for the two variables on which the cases and controls were frequency matched by design, site and age categories. In Model 2, we additionally adjusted for all potential confounders, and in Model 3, we also included all three dairy products to obtain mutually adjusted (for the consumption of the other two dairy products) ORs and 95% CI. The ORs from Model 3 represents the independent effect of a given dairy product after adjustment for consumption of the other two dairy products, accounting for co-exposure and collinearity between consumption of these products.The potential confounders included in Model 1 are: age and site: age at diagnosis (cases) or interview (controls)  and site . In Model 2, we additionally adjusted for: first degree family history of breast cancer (yes/no); age at menarche ; age at first full-term pregnancy ; use of OC (yes/no); use of hormone replacement therapy (yes/no); BMI in 1895–1989 ; physical activity in 1985–1989 in quartiles of METs/day for controls ; total energy intake  in quartiles for controls ; alcohol intake (drinks/week) in 1985–1989 . For Model 3, we added all individual dairy products to Model 2.p-value <0.05 was considered statistically significant, “ns” represents a non-significant p-value.To test for linear trend, which assessed for dose–response relationship for total and each of the dairy products (serving/week), we used median values for each of the categories of consumption and entered it as a continuous variable in the model. This provides us with OR and 95% CI for the trend of one serving/week for total consumption and consumption of a given dairy product. Models for the linear trend are adjusted for the same potential confounders as assessment of ORs for the individual categories of consumption in Model 1, Model 2 and Model 3. A The distribution of selected characteristics by case/control status is presented in p-values from the Mann–Whitney test, which compared the distributions of consumption between cases and controls. For total dairy products consumption, continuous distribution of servings/week did not differ significantly between cases and controls for either menopausal status. For milk, the controls had significantly higher consumption than cases in both groups of menopausal status. For cottage cheese, a higher consumption by controls was observed only for postmenopausal women and for hard cheese, a reverse was observed, a higher consumption by cases and only in premenopausal women.p < 0.001. The correlation between milk consumption and hard cheeses was not significant for premenopausal controls and postmenopausal cases, positive for premenopausal cases  and negative for postmenopausal controls We also evaluated the pattern of co-consumption by participants of the three dairy groups , using Spearman correlation analysis . This anWe evaluated the association between dairy product consumption and risk of breast cancer, separately within the strata of participants’ menopausal status in 1987 . Odds ratrend = 0.99, p = 0.24 was observed, while after adjustment for the potential confounders (Model 2), it reached statistical significance, OR trend = 0.98, p = 0.01. For Model 2, premenopausal women (for milk), we observed a significant decrease in risk of breast cancer with increasing milk consumption. For the highest category of consumption , relative to ≤3.5 glasses/week, or half a glass per day, we observed a 56% reduction in breast cancer risk, which reached statistical significance . The model for linear trend, using medians for each category, showed a significant decrease in risk , i.e., 5% decrease in risk of breast cancer for an increase in milk consumption of one glass/week. The consumption of cottage cheese was not associated with the risk of developing breast cancer for premenopausal women. The consumption of hard cheese showed a significant increase in risk for consumption of >3–<4.5 servings/week with OR = 1.60, 95% CI = 1.16–2.22. The consumption of ≥4.5 servings/week also increased risk, however, it did not reach our defined statistical significance of p < 0.05 . The model for linear trend across the medians for each consumption category of hard cheese, evaluated as a continuous variable, showed a significant increase in risk with an increase in consumption of one serving/week  or 10% increase in the risk of developing breast cancer, with an increase in consumption of one serving/week of hard cheese.The multivariate adjustment for potential confounders (Model 2) did not change our OR estimates substantially from those observed in Model 1, with the exception of total dairy consumption for premenopausal women. In Model 1, a statistically non-significant OR trend = 0.98, 95% CI = 0.94–1.01, p = 0.20). For milk, we observed a significant decrease in risk for breast cancer of 59%  for women who were consumers of (10.5–≤14) glasses of milk/week, relative to low consumers. For women who were in the next higher category of milk consumption (>14 glasses/week), relative to low consumers, a decrease in risk was also observed (OR = 0.55), which did not reach statistical significance (95% CI = 0.27–1.13). The linear trend for a decrease in risk with increasing consumption of milk in postmenopausal women was of the same magnitude as for premenopausal women and was statistically significant , i.e., 5% decrease in risk for an increase in consumption of one glass/week. Increasing consumption of cottage cheese, in contrast to premenopausal women, showed a significant protective effect. The ORs for the two categories , relative to reference category (≤1.5 servings/week), are OR = 0.57, 95% CI = 0.33–0.99 and OR = 0.48, 95% CI = 0.29–0.80, respectively. The linear trend for decreased risk is statistically significant with OR trend =0.80, p = 0.009, or a 20% reduction in risk with an increase in consumption of cottage cheese by one serving/week. Consumption of hard cheese did not show statistically significant increases across the categories; however, for the highest category of consumption, ≥4.5 servings/week, a non-significant increase in risk was observed . A linear trend was of the same order of magnitude as for premenopausal women; however, it did not reach statistical significance potentially due to the smaller sample size , i.e., 11% increase in risk for an increase in consumption of one serving/week of hard cheese.For postmenopausal women (Model 2), total dairy products consumption showed a significant decrease for one category (>17.5–≤21) servings/week . The linear trend, although of similar magnitude as for premenopausal women, did not reach statistical significance, potentially due to the smaller sample size , no association with consumption of cottage cheese and an increase in risk for hard cheese . For postmenopausal women, the pattern for cottage cheese remained the same as in Model 2, i.e., a significant decrease in risk for an increase in consumption of cottage cheese of one serving/week . However, due to the high correlation between milk and cottage cheese consumption, the independent effect of milk consumption measured by adjusted OR for the decrease in risk with increased milk consumption did not reach statistical significance . The pattern observed for hard cheese in the mutually adjusted Model 3 was similar to that observed in Model 2 and also did not reach statistical significance, although the point estimate was of similar magnitude as in premenopausal women . However, a significant increase in risk was observed for the highest category (≥4.5 servings/week) of hard cheese consumption (after adjustment for consumption of the other two dairy products). The observed OR for the highest category relative to the reference category was: .Additionally, we ran Model 3, which included all potential confounders from Model 2, as well as all three dairy products as co-exposures. For premenopausal women, the observed pattern remained similar to that observed for individual products in Model 2. A significant reduction in risk was observed with increasing intake of milk  separately.trend = 0.98, p = 0.01), this decrease was of a smaller magnitude than the decrease observed for milk alone . Moreover, for postmenopausal women, no decrease in risk was observed for total dairy consumption. However, high consumption of milk decreased breast cancer risk for both premenopausal and postmenopausal women. For both groups, the magnitude of reduction per one glass/week of milk consumption, evaluated by a linear trend, was the same , and both estimates reached statistical significance. A reverse relationship was observed for hard cheeses. For premenopausal women, a statistically significant increase in risk (10% increase OR trend = 1.10) was observed for each increase in consumption of one serving/week. For postmenopausal women, the pattern of increase in risk was not consistent, although the linear trend for an increase in risk was similar in magnitude (OR linear trend = 1.11); however, it did not reach statistical significance. Potential reasons could be the smaller sample size for postmenopausal women and inconsistency in the observed pattern. Cottage cheeses, which are closer in their content of calcium and other nutrients to milk than hard cheeses, also had a different relationship with risk by menopausal status. There was no significant association with risk for premenopausal women and strong protective effect for postmenopausal women. The linear trend for postmenopausal women was OR trend = 0.80 and was highly statistically significant with a value of p = 0.009. Our findings illustrate the need for a separate analysis of each dairy product group because of their bidirectional effect on breast cancer risk, as well as stratified by menopausal status.Our findings confirmed that total dairy product consumption does not capture the bidirectional relationship of individual dairy groups with the risk of breast cancer. We found in the adjusted model for potential confounders (Model 2) that for premenopausal women, although a significant decrease in risk was observed for an increase in one serving/week of total dairy products , butyric acid and vaccenic acid, as well as whey proteins and the composition of microorganisms in the fermented products.The presence of calcium and its homeostasis regulate the balance in blood serum and tissues. Calcium promotes cell differentiation, reduces proliferation and enhances apoptosis. The functioning of calcium is modulated by vitamin D, which also induces apoptosis, reduces cell proliferation and promotes the ability to differentiate cells ,23,24,25Linoleic acid with CLA coupled bonds may affect the development of cancer both by directly interfering with the carcinogenesis process and indirectly by reducing the amount of adipose tissue in the body. Of particular importance is the action of CLA isomers in the neoplastic process within the mammary glands at various stages: initiation, promotion and progression ,27. StudStudies that come to the conclusion that increased milk consumption increases breast cancer risk include pooled analysis , cohort The contents of the many ingredients in milk and dairy products that can potentially reduce or increase breast cancer risk are not equivalent when measured in 100 g of the product or in terms of usual serving size consumed as shown in Food Composition Tables. A recent publication  for the The different dietary habits with respect to consumption of dairy products in different countries, thus affecting the distribution of the proportion of consumed individual products, the lack of equivalency for the content of the nutrients and other substances, hypothesized to increase or decrease breast cancer risk, and our findings for the different effect of individual dairy group products, point out that dairy products composition is heterogenous and each product groups should be analyzed individually.Finally, it is worth considering that the collection of information on dietary habits, the Food Frequency Questionnaire (FFQ), which is the method of choice for studying the effect of nutritional habits and cancer risk , could aThe strengths of our study include: the standardized in-person interview of cases and controls by highly trained personnel, nutritionists, physicians and nurses, who were aware of the potential for recall and information bias if administration of the questionnaire and probing for answers was not consistent between cases and controls; use of FFQ, the method of choice for collecting information on usual diet from any time period, both in case-control as well as cohort studies evaluating the association of dietary products with cancer risk; the well-defined time period of reference, memorable as it immediately preceded major economic and political changes in Poland; use of life events calendar to help participants bring back the memories of that time period and use of graphic show cards to allow for better understanding of a question about given product/food by allowing participants to read the question and not just hear it; collection of relevant potential confounders, such a physical activity and weight, for the same time period as the assessment of the diet and our ability to classify participants on their menopausal status during that time period; and finally as mentioned above, analysis of dairy products consumption 10–15 years prior to diagnosis, which allows us to evaluate their role in the process of carcinogenesis that occurs over a long time period, when habitual intake of dairy products and their interaction with women’s hormonal status can act either as anti-promoters or promoters in the process of carcinogenesis.There are also several limitations. First, our sample size was limited, especially for postmenopausal women. Therefore, some of the estimates for linear trends in postmenopausal women, similar in magnitude to those of premenopausal women, did not reach statistical significance at α = 0.05. Similarly, due to limited sample size, our power was limited to assess statistically for the heterogeneity of associations (by including interaction terms in our models) for menopausal status as well as other potential modifiers such as family history or BMI. Second, as in any case-control study, diet recall was retrospective, and thus the potential for recall bias cannot be excluded. Although our referent time period was 10–15 years before the interview, women could identify with important events such as the Solidarity movement in Poland or the 1986 Chernobyl atomic reactor accident, thus more easily recalling their usual diet at that time. Given that the literature is inconsistent about the effect of dairy products on breast cancer risk, we do not believe that recall/information bias would be differential by case/control status; of course, we are not able to test this assumption. Finally, even though we adjusted for many reproductive and other lifestyle factors for breast cancer, residual confounding cannot be excluded.In summary, we conclude that the results of our study, which includes analysis of both the total dairy products consumption as well as analysis by individual dairy products, strongly supports the view that analysis of total consumption does not reflect the bi-directional relationship of specific dairy products with the risk of developing breast cancer. In our study, milk consumption is associated with a reduced risk of breast cancer in both premenopausal and postmenopausal women, while the protective effect of cottage cheese achieved statistical significance only in postmenopausal women. In contrast, a significant increase in breast cancer risk was observed with increases in the consumption of hard cheeses in premenopausal women. Total consumption of dairy products showed a significant reduction in risk only for premenopausal women. The magnitude of risk reduction was smaller than that observed for milk, the largest component of total dairy consumption in our sample. Given the bi-directional effect of the individual dairy products on breast cancer risk, the magnitude and direction of the association between total dairy product consumption and breast cancer risk will be influenced by the culturally determined distribution of the individual dairy products consumption in any given population. Thus, further research into the effect of dairy products consumption in relation to the preclinical stages of breast cancer development is desirable because of their role in the usual diet of populations and their potential role in breast cancer prevention.


Proponents argue that polygenic risk score (PRS) testing, based on panels of risk SNPs, will revolutionize the prevention and early detection of cancer through individualised risk management strategies and streamlining of the current ‘one-size-fits all’ population screening programs4. Such a model is highly seductive for the rationalisation of healthcare provision. UK government enthusiasm for PRSs is well demonstrated within the recent Genome UK report and 2020 update to the Life Sciences Strategy5. Indeed, reflecting governmental endorsement of predictive genomics, the UK government’s Secretary of State for Health and Social Care, Matthew Hancock, rather questionably enthused that his recent PRS-derived lifetime prostate cancer risk estimate of 15% (compared to a prior of 13%) “may have saved his life”7. To establish the requisite governance and data infrastructure for population-level genomic profiling, national projects such as the 100,000 Genomes Project  and the Accelerating Detection of Disease programme (up to 5 million volunteers) were initiated9. Following initial discontinuation by the U.S. Food and Drug Administration of the 23andMe PRS service11, there has been a resurgence within the direct-to-consumer genomics market of PRS predictions for many diseases. While the value of additional biomarkers to improve the targeting of measures for cancer prevention and early detection is indisputable, for PRS to be clinically useful, two assertions must be proven correct. The first assertion is that PRSs provides sufficient risk discrimination. The second is that this risk discrimination is meaningful in the context of absolute risk of that cancer and applicable in the context of respective tools available for prevention and early detection.Genome-wide association studies (GWAS) have identified associations between common genetic variants, single nucleotide polymorphisms (SNPs) and the risk of developing different cancers13. Two commonly presented measures of discrimination derived from these distributions are: (i) comparison of the RR for those at the top and bottom tails of the PRS distribution (ii) comparison for specified PRS cut-offs of the proportion of affected individuals with ‘positive’ PRS (‘detection rate’) versus the proportion of unaffected individuals falling within the same PRS score range )  to the mean. Up- or down-modification by these PRSs against baseline cancer risk results in minimal absolute difference in risk. Acknowledgement that the PRS for a chosen disease provides useful information for only a few percent of people is often countered by the argument that PRSs can be generated for dozens of cancer types, such that each individual is likely to be in an ‘extreme’ tail of PRS for at least one cancer type. However, in practice, clinical decision-making is driven by absolute risk, rather than relative risk per se. Hence, for all but the most common cancers, PRS reveals absolute increase in cancer risk against baseline that is miniscule even at the extreme upper tail of PRS. For example, for those in the respective top 5% of PRS, lifetime risk for breast cancer is elevated from 11.8 to 19.0% (1.6-fold), lifetime risk of prostate cancer is elevated from 12.7 to 22.2% (1.75-fold) and lifetime risk of colorectal cancer is elevated from 4.6 to 6.9% (1.5-fold). For less common cancers, the absolute risk increase is much lower: for women in the respective top 5% of ovarian cancer PRS lifetime risk is elevated 1.3-fold (from 1.6 to 2.1%)16. As an example, digital mammography for breast cancer screening has an AUC of 0.7817. PRSs constructed from cancer SNP sets derived from GWAS yield only AUCs ranging from 0.53  to 0.67 (prostate cancer)  curve, with the probability that a randomly selected case having a higher PRS than a randomly selected control being quantified by the area under the ROC curve (AUC). An AUC of 0.5 reflects a testing tool with no discrimination. While the threshold for clinical discrimination clearly depends on the benefit-risk profile of the proposed intervention, broadly speaking AUC values of 0.7–0.8 are considered as acceptable and >0.8 as affording good discriminationer) Fig. .Fig. 2Re−8 for declaring a SNP association guards against type 1 error but inevitably has limited the number of SNPs included in PRS testing panels. Methodologies such as LDpred apply a Bayesian genome-wide genetic risk prediction to incorporate SNP-correlations “tagged” by current arrays irrespective of association P-value18. However, to the extent that such methods have been explored, the discriminatory power for these ‘expanded’ PRSs is at best only very modestly improved20. The (likely) final generation of GWASs for common cancers such as breast and colorectal cancers is currently underway. Despite aggregating the’world-wide’ resource of available samples, power remains prohibitive and these experiments are unlikely to harvest more than 80% of the heritable risk for these cancers3. Even disregarding this and calculating PRS based on the full disease heritability, i.e. the hypothetical situation of identifying the full complement of risk SNPs, the AUCs for the common cancers remain disappointingly modest (0.64–0.73)3.The GWAS so far performed have only identified SNPs contributing 10–30% of common variant heritability for their respective cancers. It is widely asserted that discriminatory value of PRS will improve dramatically ‘in the future’, once additional rafts of new disease-associated SNPs are delivered. Imposing a threshold of 5 × 1023; some authors erroneously inflate their AUC by combining the two as if orthogonal25. For most cancer types, the AUC for non-genetic factors is modest27. When modelled, the well-established modifiable risk factors have additive effects with SNP associations and therefore only modestly improve the AUC28. Breast cancer has the best characterised set of non-genetic risk factors: the AUC for these risk factors is 0.637 while the AUC of the current PRS is 0.631; and in combination the AUC is 0.68329. Again, while aetiological epidemiological research continues to be a dynamic field, it would seem naïve to predict imminent discovery of robustly associated new non-genetic risk factors of sizeable effect.Another argument pertains to the boost in predictive value of PRS when applied in combination with non-genetic risk factors. Family history can be an important risk factor for cancer but is correlated with PRS31. From modelled adaptation of the UK breast cancer screening programme such that screening of women age 35–79 would be offered on the basis of PRS rather than age alone, it has been predicted that screening could be reduced by 24% at the cost of reduction in screen-detectable cases of 14%32. Although this indicates potential for more efficient targeting of screening, there is concern that: (i) genomic profiling will do little to improve and could even reduce uptake of existing cancer screening programmes, which for breast cancer in the UK is currently only 69%33, and (ii) the incidence of breast cancers in those from whom breast screening has been ‘withheld’ (or in fact ‘withdrawn’) would be perceived by the public as too high. Another proposal is that PRSs could be combined as a Bayesian Prior to a population screening test, such that the more expensive and/or invasive confirmatory test is only triggered when a positive screening test  arises in individuals with high PRS. In practice, where the screening test itself has good performance characteristics, for example Faecal Immunochemical Test (FIT) for detection of colorectal cancer, the negative predictive value of PRSs will be insufficient to exclude disease in those with a positive screening test. Conversely, where the performance of the screening test is poorer (e.g. prostate specific antigen (PSA) for prostate cancer), the limited positive predictive value of the PRS adds little, resulting in a large group of PRS-false-positives receiving an invasive, confirmatory investigation. Hence, where screening is effective, inexpensive and safe, the limited additional boost in detection added by PRS stratification is arguably likely to be outweighed by the cost, complexity of delivery of population risk-profiling with the potential for reduced participation. Well-designed trials are therefore essential to avoid inadvertent disruption of existing screening programmes with documented evidence of benefit34. Where screening is not effective, inexpensive, or safe, the addition of a PRS is unlikely to make it so.There are many who acknowledge PRS to be a weak predictor of individual cancer risk but who suggest that it could still be useful to individualise population screening programmes, for example by excluding ‘low risk’ individuals from screening35. While an attractive proposition, few agents are currently licenced for this purpose and clinical studies of new agents for chemoprevention are challenging. The risk-benefit profile of an agent dictates the level of disease risk at which administration is justified; thus the value of PRS stratification in determining administration would be very much contingent on the performance of PRS in discriminating those at sufficiently elevated risk. Administration of chemopreventative agents based on PRS-stratified groups has not yet been trialled for any agents and would require careful consideration37. While communicating DNA-based disease risk assessments may have a role in promoting risk-reducing behaviour38, evidence for this is currently lacking and there is a potential to introduce harm, particularly in the absence of counselling and clinical utility39. Furthermore, if PRS is to be used, it has to be universally applicable to all in the population regardless of ancestry to ensure equity in provision of healthcare resource. Presently the majority of PRSs are based on studies of European ancestry40 and their performance is poor in non-European populations41. This consideration is frequently offered as a minor technical ‘footnote’ to the value proposition of PRSs: given the limited predictive capabilities of existing PRS generated from decades of massive studies of available samples, it is unclear how this deficit will actually be addressed in the foreseeable future.PRS testing has been suggested as a method of identifying individuals who may benefit from cancer chemopreventative agentsBRCA1 and MLH1 is not under dispute: such mutations provide effective risk discrimination and there are established clinical pathways for those in whom mutations are identified. However, the notion that PRSs will offer equivalent utility population-wide by providing informative risk stratification across multiple diseases is misleading. Raising unrealistic expectations and implementing programmes without careful evaluation risks compromising the application of PRSs for specific niches, and indeed, of genomic medicine as a whole.The clinical utility of identification of high-impact mutations in genes such as Supplementary Information


Epidemiological studies suggest that high intake of soy isoflavones may protect against breast cancer, but causal relationships can only be established by experimental trials. Thus, we aimed to provide a systematic review of randomized controlled trials (RCTs) on the effect of an isoflavone intake on risk factors of breast cancer in healthy subjects. After a systematic literature search in PubMed, 18 different RCTs with pre- and/or postmenopausal women were included and investigated for details according to the PRISMA guideline. In these studies, isoflavones were provided by soy food or supplements in amounts between 36.5–235 mg/d for a period of 1–36 months. Breast density, estrogens including precursors, metabolites, estrogen response such as length of menstrual cycle, and markers of proliferation and inflammation were considered. However, in most studies, differences were not detectable between isoflavone and control/placebo treatment despite a good adherence to isoflavone treatment, irrespective of the kind of intervention, the dose of isoflavones used, and the duration of isoflavone treatment. However, the lack of significant changes in most studies does not prove the lack of effects as a sample size calculation was often missing. Taking into account the risk of bias and methodological limitations, there is little evidence that isoflavone treatment modulates risk factors of breast cancer in pre- and postmenopausal women. Future studies should calculate the sample size to detect possible effects and consider methodological details to improve the study quality. Breast cancer is the most frequent type of cancer in women globally. Each year, about 2.3 million women worldwide develop breast cancer, and about 685,000 people were estimated to die from breast cancer in 2020 . Women fBreast cancer is favored by race, ethnicity, family history of cancer, genetic variants and mutations of genes modulating DNA repair. Age at menarche, parity, as well as age at first pregnancy affect the risk by modulating the long-term sex hormone levels. Physical inactivity is a modifiable risk factor as well as diet. Whereas certain foods and food ingredients increase the risk of breast cancer , others like soy or isoflavones seems to be protective .More than 25 years ago, a population-based case-control study revealed a higher breast cancer rate in women of Chinese, Japanese, and Filipino ethnicities migrating to USA and Hawaii than in the countries of origin, which approximated in Asian-Americans born in the West to the U.S. white rate. However, the risk increased among Asian immigrants in the U.S. over several generations, suggesting that the Western lifestyle substantially increased the breast cancer risk .In contrast to the Western diet, the Asian diet is traditionally rich in foods produced from soybeans as main ingredients. As soy products are the major dietary source of isoflavones, the intake of isoflavones in Asia  is much higher than in Europe (0.37–4.5 mg/d) and in USA (0.73–3.3 mg/d) despite considerable variation between individual studies  to [4-(OH)-E1 + 4-(OH)-E2 + 4-(MeO)-E1] may be beneficial as 2-OH-metabolites weaken the estrogen effect [50-values for daidzein and cytochrome P450 1A1 are not available yet [In postmenopausal women, urinary excretion of E1 , E1S [501 [1S [2 ,53, prog1 [1S [2 ,53, LH [1 [1S [2 ,53, and n effect , while 4n effect . On the n effect ,51,52,53n effect  were notable yet .2 [2 [In women with different menopausal states, changes in estrogen homeostasis by isoflavone treatment are also unlikely as the serum/plasma concentration of E2 ,57, prog2 ,57,58, L2 , SHBG [52 [2 ,58, grow2 [2 , cytolog2 [2 ,57. It i2 [2 . With reTaken together, most RCTs with pre- and/or postmenopausal women did not show a response to isoflavone treatment, although the dose of isoflavones ingested and the duration of treatment varied between the studies . Breast density was determined after 10 , 12 37,,37,49,55clinicaltrials.gov. The risk of detection bias was always, and the risk of other bias often low. As the overall RoB of RCTs funded by industry was high [The overall RoB in trials with premenopausal women was often higher  than in trials with postmenopausal women  and in mixed groups . The risk of attrition bias was quite different between the studies. For most studies, the risk of selection bias, reporting bias and the risk of allocation concealment remains unclear as relevant details were not reported, and the study protocol not registered in was high ,53 or unwas high ,55, simiwas high ,48,57,58was high ,52,54,56The sample size was calculated in four trials ,55,57,58Moreover, pooling data as in meta-analyses increases the sample size and the probability to detect an effect by isoflavone treatment. A meta-analysis of eight RCTs published in 2010 investigated the impact of isoflavone-rich foods or supplements on breast density and related parameters. A small increase in breast density was detectable for premenopausal women, but not for postmenopausal women and all women.This systematic review of RCTs investigates the response of isoflavone treatment to parameters which are considered as risk factor for breast cancer. These RCTs were described in detail and assessed for RoB to provide a clear picture on the effect induced by isoflavone intake in women with different menopausal states. Moreover, each study was checked for sample size calculation to evaluate imprecision.Literature was only searched in PubMed as this has shown to be an optimal tool in the field of biomedical research, even with free access ,28. WithRisk factors of breast cancer  did not change in most trials despite a good adherence to isoflavone treatment, independent of the kind of intervention, the dose of isoflavones used and the duration of isoflavone treatment. However, the lack of significant changes does not prove the lack of effects as a sample size calculation was missing in most studies. Taking into account the RoB and methodological limitations, there is little evidence that isoflavone treatment modulates risk factors of breast cancer in pre- and postmenopausal women.Future studies should calculate the samples size based on existing results to allow clear conclusions and should report further methodological details to reduce RoB. A meta-analysis of RCTs is warranted to judge if an isoflavone intake might contribute to the prevention of breast cancer.


VEGF polymorphisms with breast cancer risk in North-West Indians.Angiogenesis is a complex and coordinated process regulated by different growth factors and is one of the hallmark features of cancer. VEGF is one of the most important endothelial cell mitogen and has a critical role in normal physiological and tumor angiogenesis. The objective of this study was to investigate the potential association of haplotypes of six VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms. Haplotypes were generated to determine the better contribution of VEGF polymorphisms to breast cancer risk.Samples of 250 breast cancer patients and 250 age and sex matched controls were genotyped for p = 0.003) and CDTGCC  of VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms were significantly associated with decreased risk of breast cancer. CDTCCC haplotype was also significantly associated with reduced risk of breast cancer in pre and post menopausal as well as both obese and non obese patients. Haplotype CDTGCC was marginally associated (p = 0.07) with reduced risk of breast cancer in non-obese patients as compared with non-obese controls where as haplotype AICGTC was marginally associated (p = 0.09) with reduced risk of breast cancer in obese patients when compared with non-obese patients. The CDTGCC haplotype was significantly associated with increased risk of breast cancer in premenopausal obese patients .Haplotypes CDTCCC (OR = 0.56, 95%CI, 0.38–0.81; VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms were significantly associated with breast cancer risk in North-West Indians. Further studies on multiethnic groups with larger sample size are required to confirm our results.Our data indicated that CDTCCC and CDTGCC haplotypes of The online version contains supplementary material available at 10.1186/s12920-021-01060-4. Angiogenesis is one of the hallmark features of cancer . It is aVEGFA also known as VEGF is located at 6p21.3 and it comprises eight exons and seven introns , −2549I/D (−1511I/D), −460T/C (−1498T/C), +405C/G (−634C/G), −7C/T (+1032C/T) and +936C/T polymorphisms with breast cancer risk in North-West Indians. So far there is no combined report on these six VEGF polymorphisms in breast cancer. To the best of our knowledge, this is the first study evaluating the potential association of haplotypes of VEGF −2578C/A (rs699947), −2549I/D (rs35569394), −460T/C (rs833061), +405C/G (rs2010963) −7C/T (rs25648) and +936C/T (rs3025039) polymorphism with breast cancer risk.Haplotype analysis could be a better predictive approach rather than investigating individual polymorphism. It estimates more specific risk and reduces the dimension of association tests and increase statistical power . Due to The study was performed according to Declaration of Helsinki and was approved by the Ethics Committee of Guru Nanak Dev University, Amritsar, Punjab, India. All the subjects gave a written informed consent with a signature or thumb impression. A total of 500 subjects  were analyzed in this study. The patients were investigated at Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar, Punjab (India). The selection criteria of patients and controls have been described in our previous study . All theVEGF −2578C/A, −2549I/D, −460T/C), two 5′-UTR , and one 3´-UTR (+936C/T) polymorphisms were analyzed in this study .The DNA was extracted from EDTA-anti-coagulated blood samples using organic method  with fewudy Fig. . The VEG studies , 35. To 3´-UTR +9C/T polymThe demographic characteristics of study participants were presented in Table VEGF polymorphism were summarized  and CDTGCC  haplotypes were significantly associated with decreased risk of breast cancer  with reduced risk of breast cancer in non-obese patients as compared with non-obese controls (Table p = 0.09) with reduced risk of breast cancer in obese patients when compared with non-obese patients (Table p = 0.02) with increased risk of breast cancer in premenopausal obese patients  transcription factor.The TFSEARCH software was used to predict the functional significance of VEGF haplotypes based on six polymorphisms with breast cancer risk. In previous reported studies, by using the single/double or triple polymorphism approach, VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms have been analyzed to evaluate their potential association with breast cancer risk in different ethnic groups and results are conflicting  and CDTGCC  haplotypes of VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms were significantly associated with reduced risk of breast cancer. In none of the previous studies, these six polymorphisms have been reported together. In Caucasian subjects, − 460T/+405C/ − 7C/, +936C haplotype was associated with reduced risk of breast cancer [. Significant association of VEGF −2578A/−1154A/+405G haplotype with decreased risk of invasive breast cancer has been reported in American population [VEGF −1154A/−2578A/−634G/−460C was associated with decreased risk of breast cancer in Moroccan population [VEGF −2578C/A, −2549I/D, −460T/C, +405C/G, and +936C/T polymorphisms was associated with breast cancer risk in Iranian population [In the present study, we observed that CDTCCC  allele has also been reported in peripheral blood mononuclear cells [In the present study we predicted that ic cells , 81. Coric cells . G allelopoiesis . Disruptar cells . It has ar cells .VEGFA have been reported to be associated with efficacy and toxicity of anti—VEGF agents [VEGF −2578A/−1154G/+405G haplotype was associated with marginally improved prognosis whereas haplotype −2578C/−1154G/+405G was significantly associated with adverse prognosis in HER2 positive breast cancer patients [VEGF haplotypes with therapy response has also been documented in other cancer types. The CACC haplotype of VEGF −460T/C, −116G/A, +405C/G, and +936C/T polymorphism was significantly associated with worse survival in Korean gastric cancer patients [VEGF −460T/C, +405C/G and +936C/T polymorphism was associated with poorer outcome as compared to other haplotypes [VEGF −2578 C/A, −1154 G/A, −460T/C, +405 G/C and +936C/T polymorphisms was found to be associated with improved progression-free survival in epithelial ovarian cancer patients [VEGF polymorphisms may have implications for aggressiveness and selection of patients suitable for anti-VEGF therapy in context of previously reported literature. The VEGF haplotypes in independent cohorts are insightful for identification of cancer risk.Polymorphisms of F agents , 85, 86.F agents . VEGF −2patients . Apart fpatients . In esopplotypes . The AGCpatients . Haplotypatients . Thus, aVEGF −2578C/A, −2549I/D, −460T/C, +405C/G, −7C/T and +936C/T polymorphisms were significantly associated with breast cancer risk in North-West Indians. Further studies on multiethnic groups with larger sample size are required to confirm our results.We report for the first time that CDTCCC and CDTGCC haplotypes of Additional file 1. In silico pathway analysis based on chromosomal instability in breast cancer patients.