Measuring factors influencing time to presentation is important in developing and evaluating interventions to promote timely cancer diagnosis, yet there is a lack of validated, culturally relevant measurement tools. This study aimed to develop and validate the African Women Awareness of CANcer (AWACAN) tool to measure awareness of breast and cervical cancer in Sub-Saharan Africa (SSA).Development of the AWACAN tool followed 4 steps: 1) Item generation based on existing measures and relevant literature. 2) Refinement of items via assessment of content and face validity using cancer experts’ ratings and think aloud interviews with community participants in Uganda and South Africa. 3) Administration of the tool to community participants, university staff and cancer experts for assessment of validity using test-retest reliability (using Intra-Class Correlation (ICC) and adjusted Kappa coefficients), construct validity (comparing expert and community participant responses using t-tests) and internal reliability (using the Kuder-Richarson (KR-20) coefficient). 4) Translation of the final AWACAN tool into isiXhosa and Acholi.ICC scores indicated good test-retest reliability (≥ 0.7) for all breast cancer knowledge domains and cervical cancer risk factor and lay belief domains. Experts had higher knowledge of breast cancer risk factors (p < 0.001), and cervical cancer risk factors (p = 0.003) and symptoms (p = 0.001) than community participants, but similar knowledge of breast cancer symptoms (p = 0.066). Internal reliability for breast cancer risk factors, lay beliefs and symptom and cervical cancer symptom subscales was good with KR-20 values > 0.7, and lower (0.6) for the cervical cancer risk subscale.The final AWACAN tool includes items on socio-demographic details; breast and cervical cancer symptom awareness, risk factor awareness, lay beliefs, anticipated help-seeking behaviour; and barriers to seeking care. The tools showed evidence of content, face, construct and internal validity and test-retrest reliability and are available for use in SSA in three languages. Breast and cervical cancer are the leading causes of cancer morbidity and mortality in women in Sub-Saharan Africa (SSA). Breast cancer is the most commonly diagnosed cancer among women in SSA, whilst cervical cancer remains the leading cause of cancer death . Most SSStudies have shown that for symptomatic breast cancer, a shorter time between recognition of symptoms by women and first medical consultation is associated with early stage disease, and better breast cancer survival –6. FurthFor people with potential symptoms of cancer, the pathway to cancer diagnosis is complex and influenced by many factors such as symptom and risk awareness, beliefs and barriers to accessing care ,10,14–18Although a few studies have reported on breast and cervical cancer symptom awareness, risk perception and help-seeking behavior in African settings ,10,20,21The four step processes of 1) generating tool items, 2) refining and 3) validating the English version of the AWACAN tool and, 4) developing local language versions of the tool are described below. The outcomes of Step 3 are presented in the results section. Ethics approval for the study was obtained from University of Cape Town, Faculty of Health Sciences Human Research Ethics Committee (HREC 544/2016), the Lacor Hospital Institutional Research Ethics Committee (LHIREC 027/11/2016) and the Ugandan National Council of Science and Technology (UNCST 194/212/01). Written informed consent was obtained from all participants. Permission to access health facilities was obtained from all relevant local health authorities. Permission to conduct interviews with non-medical university staff was obtained from the institutional human resource department.Items to assess breast and cervical cancer symptom and risk factor awareness and help-seeking behavior were generated by reviewing the UK (BCAM) and Cervical Cancer Awareness Measurement (CCAM) tools, the ABC tool, and studies conducted in Africa that used these or other tools to measure constructs of interest to our study , 25–27. et al. [A group of cancer experts based in SSA (n = 48) were invited to complete an anonymous online survey and score the AWACAN tool items in terms of clarity and relevance [(1(poor) - 4 (excellent)], provide reasons for any item scoring < 3, and identify missing items. The experts included breast or cervical cancer health professionals, epidemiologists and public health researchers and were identified from peer-reviewed literature, websites of relevant academic and research organizations and through contacts of research team members. A content validity index [(CVI) number of raters giving a score of ≥3/total number of raters] was calculated for each tool item . Any iteet al. . In totaCognitive interviews using think-aloud methodology –30 were Findings from both the cancer expert review and the cognitive interviews were reviewed and tool items revised where necessary. This resulted in: items being deleted; questions being reworded/rephrased for clarity; definitions being added for poorly understood terms and; a revision of response options for some questions. Items on age-related risk factors (e.g. Do you think that a woman younger than you is more likely to get breast cancer?) were deleted as they were poorly understood by participants and all had a low CVI. An item on participant’s religion was deleted as it had a low CVI (0.56) with cancer experts noting that it could be viewed as being judgemental. Five questions were identified as being redundant as they were covered elsewhere in the questionnaire and were removed. Explanations were added for the terms “hormone replacement therapy” and “menopause” as these were poorly understood by women. All questions with Likert response options had a low CVI (< 78%) and were poorly understood by women during the cognitive interviews. Options for these questions were revised. For example, the question “How confident are you that you would notice a change in your breast?” with response options a. very confident b. fairly confident c. slightly confident and d. not confident at all was changed to “Are you confident that you would notice a change in your breast?” with response options a. yes b. no c. not sure.The refinement process resulted in a second version of the AWACAN tool with a total of 123 items: 12 socio-demographic questions; 53 breast cancer symptom,risk factor, confidence and help-seeking questions; 39 cervical cancer symptom, risk factor, confidence and help-seeking questions and 19 items on barriers to seeking care.Three groups of participants completed the second version of the AWACAN tool:Community participants: Women aged ≥ 18 years and able to speak and understand English were recruited from primary care clinics at the sites used for the cognitive interviews described above. English proficiency was assessed by a trained interviewer during the process of providing study information and obtaining informed consent. Participants that were unable to understand and speak English were excluded. Women were stratified by age during recruitment to ensure representation by older (≥ 50 years) and younger (< 50 years) participants. Trained field workers administered the tool to participants.Cancer experts: Experts who participated in the content validaty exercise (Step 2A) were invited to complete an on-line version of the tool.A convenience sample of non-medical university staff: aged 18 to 65 years were recruited from the University of Cape Town. A trained interviewer administered the tool on two occasions, two weeks apart. Participants were stratified by age (≥ 50 years and < 50 years).All data was entered into Qualtrics and analysed using STATA (Version 13.0). Scores for risk factor knowledge and symptom awareness were calculated with each correct answer to the evidence-based questions in the closed/prompted sections scoring 1 point. Lay beliefsthat were correctly identified as not being a risk factor scored 1 point.The revised 123-item tool was assessed in terms of indicators of test-retest reliability, construct validity and internal reliability.For categorical variables related to awareness (having heard of or knowing someone with relevant cancer), help-seeking behaviour and confidence test-retest reliability was calculated using the Brennan and Prediger prevalence-adjusted and bias-adjusted Kappa. Adjusted Kappas were calculated as the unadjusted Cohen Kappa is prevalence dependant and misleading when ratings fall into a single category ,32. We pFor knowledge domains, test-retest reliability was assessed by comparing the mean test and retest scores of the non-medical staff, using the intra-class correlation coefficient (ICC) with values below 0.5 indicating poor reliability, between 0.5 and 0.75 moderate reliability, between 0.76 and 0.9 good reliability, and above 0.9 excellent reliability .Construct validity was assessed by comparing knowledge scores between the cancer experts and community participant group using t-tests. We hypothesized that if the tool had construct validity then cancer experts would have significantly (p<0.05) higher awareness compared to community respondents.Internal reliability for the risk factor and symptom knowledge constructs were assessed using the Kuder-Richarson (KR-20) coefficient of reliability and the item-to-total correlation coefficients. A KR-20 of > 0.7 was considered to indicate good internal reliability ,36. For Typically, studies measuring internal reliability are based on the assumption that the number of respondents should exceed the number of items by 2 to 20 subjects per item, with a minimum of 100 subjects to ensure stability of the variance-covariance matrix . Our samnd commonest of 11 official languages in SA and Acholi (spoken in Northern Uganda and parts of Kenya and Tanzania) by Acholi and isiXhosa native speakers, and back translated into English to ensure comparability [The English version of the final AWACAN tool was translated into isiXhosa , 23 non-medical staff and 20 cancer expert participants who completed the validation studies (Step 3). There was no loss-to follow up between the first and second round of interviews. The percentage of agreement for responses to the socio-demographic questions was high . Kappa scores for the socio-demographic questions ranged between 0.83 and 1.00.Test-retest reliability was moderate for knowledge of known risk factors, good for symptoms and excellent for lay beliefs of breast cancer . For cerA high proportion of community participants had heard of breast and cervical cancer (90% and 84% respectively) and there were no statistically significant differences between experts and community members for these items .For breast cancer, community participant and expert scores were significantly different for knowledge of evidence-based risk factors and risk lay beliefs but similar for breast cancer symptoms . There wThe internal reliability for the breast cancer knowledge questions was good with KR-20 values > 0.7 for the known risk factors, lay belief and symptom subscales . For cerFollowing assessment of reliability and validity, further adjustments to phrasing of some items were made to improve clarity. The number of questions related to barriers to seeking care was reduced (7 questions removed) as interviewers noted that participants found that this section was too long. In addition the wording of questions was changed to better indicate that these were barriers personally experienced by the respondent. Responses to open questions on risk factors and symptoms were reviewed to identify additional lay beliefs.The final version of the AWACAN tool has a total of 115 items:12 socio-demographic questions;2 introductory questions1 open question on risk factors13 closed prompted evidence-based risk factor questions6 closed prompted questions on lay beliefs related to risk (can serve as distractor items)1 open question on symptom awareness15 closed prompted questions on symptom awareness items. Images of symptoms as they would appear on dark-skinned women were added for 3 items: change in the position of the nipple, pilling in of the nipple, and dimpling of the breast skin1 closed prompted question on symptom lay belief (can serve as distractor item)7 items related to help-seeking behaviour4 items on confidence in relation to breast changes50 breast cancer symptom, risk factor awareness, confidence and help-seeking measures2 introductory questions1 open question on risk factors11 closed prompted evidence-based risk factor questions4 closed prompted questions on lay beliefs related to risk (can serve as distractor items)1 open question on symptom awareness11 closed prompted questions on symptom awareness items1 closed prompted question on symptom lay belief (can serve as distractor item)7 items related to help-seeking behaviour3 items on confidence in relation to detecting cervical cancer signs/symptom41 cervical cancer symptom, risk factor awareness, confidence and help-seeking measures12 items on barriers to seeking care for breast and cervical cancerwww.awacan.onlineSee To our knowledge this is the first validated tool measuring breast and cervical cancer symptom and risk factor awareness, lay beliefs, confidence in appraising potential symptoms, help seeking behaviour and barriers to care in SSA populations. The AWACAN tool follows a similar format to the BCAM and CCAM ,26. KnowOur AWACAN tool performed well in terms of test-retest reliability indicating that the questions are stable over time. Most socio-demographic, help-seeking behaviour and confidence items achieving substantial or higher adjusted kappa coefficients and all knowledge sub-scales showing moderate or higher reliability as measured by the ICC.The AWACAN tool discriminated well between the expert and community level knowledge of breast cancer risk factors and risk lay beliefs. However, breast symptom knowledge was similar between these two groups. This could be a result of greater public awareness of breast symptoms, which is a focus of many breast awareness campaigns. Knowledge of cervical cancer items risk factors and symptoms was significantly higher in cancer experts compared to community participants, establishing construct validity for these subscales. At the stage of psychometric testing we only had one cervical cancer risk lay belief and although experts were better able to identify this lay belief the difference was not statistically different. Using responses from the open-ended questions we were able to identify additional lay belief items.Internal reliability was good for our breast cancer questions, with all knowledge domains achieving a KR-20 above the recommend cut-off value of 0.7. Internal reliability was also high (KR-20 = 0.8) for the cervical cancer symptom domain, but lower (KR-20 = 0.6) for the subsection on risk factors. The three risk factor items contributing to this low internal reliability  were retained in the final tool on grounds of content validity.After establishing good validity for the English version of the tool, it was translated into two 2 local languages (isiXhosa and Acholi), taking into account conceptual and cultural equivalence. In addition to these translations, there are some other important differences between our validated AWACAN tool and the BCAM and CCAM tools. Our tool includes additional prompted items on symptom and risk lay beliefs that were identified from the literature , and in et al [Based on the recommendation of Wachira et al , we deveThe BCAM and CCAM tools make use of Likert scales, which call for a graded response to a series of statements about risk and confidence. Likert scales are widely used in surveys, however studies have reported challenges such as difficulty in understanding graded response options, skipping questions or bias toward either the midpoint or extreme options ,43. DuriUnderstanding women’s help-seeking behaviour and potential barriers to care are critical to informing efforts to improve timely diagnosis of these cancers. The ABC and CAM tools includes measures of barriers to care and help-seeking behaviour relevant in high-income setting ,25,26. WOver the past few decades, there has been an increasing recognition that a holistic and comprehensive approach to women’s health is central to sustainable development ,46. We dA limitation of our study was the difference in mode of delivery to the cancer experts (online) versus other participants (face-to-face) during the validation process. We designed the online tool so that experts were unable to return to previous pages to change responses. However, we recognize that experts could have searched the internet or consulted elsewhere before completing the tool online. We used Classical Test Theory to assess reliability and validity of the AWACAN tool. An alternative would be to use Item Response Theory ,48. HoweWe have demonstrated that the breast and cervical AWACAN tool has evidence of reliability and validity and is ready to be used as a measure of risk factor and symptom awareness, lay beliefs, help seeking behavior and barriers to care for the two leading causes of cancer morbidity among women in SSA.S1 Appendix(PDF)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.


There are various factors that play a major role in influencing the overall health conditions of women diagnosed with breast cancer. The population of women in Makkah region are diverse, therefore it is significant to highlight the possible determinants of breast cancer in this population. This is a case-control study that assessed determinants of breast cancer including socioeconomic factors, health-related characteristics, menstrual histories and breastfeeding among postmenopausal women in Makkah region in Saudi Arabia.A total of 432 female participants (214 cases and 218 controls) were recruited for this study. A validated questionnaire was completed by trained dietitians at King Abdullah Medical City Hospital in the Makkah region of Saudi Arabia.P < 0.05) with unemployment, large family size, lack of knowledge and awareness about breast cancer, obesity, sedentary lifestyle, smoking, starting menarche at an early age, as well as hormonal and non-hormonal contraceptive use. There was no effect of diabetes, hypertension, hyperlipidemia, and duration of breastfeeding on the incidence of breast cancer.Results displayed that determinants of breast cancer were associated significantly (In summary, the results of this study accentuate the possible effect of socioeconomic factors, health-related characteristics and menstrual history on the incidence of breast cancer in postmenopausal women in the Makkah region. Education programs should be applied to increase breast cancer awareness and possibly decrease its incidence. There has been an increasing prevalence of breast cancer among females around the world . In SaudPrevious studies have reported that there are several common factors present in women diagnosed with breast cancer, such as their ages, ages at menarche and menopause, family histories, lifestyles and oral contraceptive usage , 4. HoweThe population of women in the region of Makkah is diverse, with different lifestyle patterns, economic statuses and breastfeeding practices. These factors play significant roles in influencing the overall health conditions and make it an area of interest for investigating the determinants of breast cancer in this specific population. Furthermore, postmenopausal women were more likely to have breast cancer than premenopausal women . TherefoThis case-control study was conducted from June 2014 through November 2016 at King Abdullah Medical City Hospital (KAMC) in the Makkah region of Saudi Arabia. This hospital is the only centre that provides cancer screening and treatment for residents in Makkah region.n = 7 cases and 12 controls), African-Asians ethnicity (n = 3 cases and 4 controls), premenopausal women and/or aged < 45 years (n = 2 cases), metastatic breast cancer diagnosis (n = 1 case), recurrent breast cancer (n = 1 case), and diagnosis of multiple cancer types (n = 1 case).A total of 432 female participants (214 cases and 218 controls) were recruited for this study. We included postmenopausal Saudi women of Arabic ethnicity aged > 45 years from the Makkah region who were newly diagnosed with breast cancer that was biopsy confirmed by a cancer pathologist in KAMC. Studies have showed that factors associated to breast cancer differs in racial groups , 7. Ther2) was calculated after measuring the weight and height in the hospital and at the time of the data collection. Any participant with a BMI < 18.5 kg/m2 was classified as underweight, normal weight was 18.5–24.9 kg/m2, overweight was 25–29.9 kg/m2 and obese was > 30 kg/m2.Convenience sampling was used to collect the data for this study. As a routine work in the hospital, all newly diagnosed cancer patients should meet a registered dietitian to evaluate his/her nutritional status. During this evaluation, a self-administered questionnaire was completed by each of the participants via a face-to-face interview. The socioeconomic factors, health-related characteristics, menstrual histories as well as breastfeeding duration tested in this study were part of a previously validated questionnaire developed by Wilson et al. (2013)  that focP-value < 0.05 was set for the significant differences. The Kolmogorov-Smirnov normality test was used to determine the normality of distribution. The P-value for each parameter was determined using a suitable test, which is mentioned as a footnote in each table. In order to ascertain the differences between the cases and the controls, the data from the participants was stratified using a case-control status. A chi squared test and t-test were conducted for the parametric and nonparametric variables to determine the differences in the socioeconomic factors, health-related characteristics, menstrual histories and breastfeeding durations.All of the statistical tests were completed using IBM SPSS Statistics for Windows version 20.0 , and a To determine the possible risk factors related to breast cancer, the odds ratio (OR), 95% confidence interval (95% CI) and β-coefficient were determined by using a logistic regression test. All of the variables were adjusted for potential confounders; age (continuous), BMI (continuous), employment, family income, education, family size, marital status, physical activity, smoking, family history of breast cancer, other health problems, contraceptive use, age at menarche, age at menopause, and breastfeeding duration.P < 0.001), such as employment, income, education and family size.An overview of the socioeconomic characteristics of the participants is presented in Table The highest employment status percentage in both groups was 81.7% employed participants in the control group, with 73.8% unemployed in the case group. Nearly one-half of the participants in the case group (43.9%) fell in the low-income category of < 5000 Saudi Riyal (SR) of monthly income (~ 1333.17 American Dollar) when compared to the control group (9.6%). Both groups had low percentages in the highest income category of > 20,000 SR (~ 5332.70 USD): 14.7% for the control group and 3.8% for the case group.P > 0.05); the percentages of married participants were fairly high in both groups (87.6% for the controls and 94.1% for the cases).The illiteracy rate was higher among the cases (15%) when compared to the control group (0.9%). All of the participants in both groups reported varied results in obtaining an education, with a higher result for postsecondary education of 87.1% for the control group, compared to 22.3% for the case group for the same level of education. Having a large family size (6 or more family members) was more common in the case group (81.3%), while the control group showed no noticeable difference in the percentages of having small or large family sizes . There were no significant differences in the marital statuses in either group (P < 0.001), regular exercise (P = 0.009), cancer awareness (P < 0.001), smoking (P < 0.001), diabetes (P < 0.001), hypertension (P < 0.001) and the use of contraceptives (P < 0.001) were significant when testing the differences between the groups. Based on these results, it was clear that there was a higher BMI (obese category) percentage of 63.6% among the cases when compared to the control group (24.3%). It was also evident that regular exercise was practiced among few of the participants in both the control and case groups . Overall, high percentages of the participants were aware of cancer (98.2% for the control group and 81.3% for the case group). Although the results of having a family history of breast cancer were not significant (P > 0.05), the family history results of the patients with breast cancer were higher in the cases (17.8%) than in the participants in the control group (6%). The smoking status showed that 17.8% of the participants in the case group were smokers, compared to 1.4% being smokers in the control group.With regard to the health-related characteristics for the participants in this study Table , the BMIAdditionally, the percentage of breast cancer patients diagnosed with diabetes was higher (33.6%) than the diabetic participants in the control group (7.8%). Similarly, hypertension was higher in the cases when compared to the control group . The screening for positive hyperlipidaemia results showed no significant difference between the two groups, but the percentage was low in the participants in the control group (12.8%) when compared to the cases (18.7%). The use of hormonal contraceptive types was higher in the cases (43.9%), whereas the highest percentage in the control group (60.6%) included those participants not using any contraceptive methods.The results of the menstruation histories and breastfeeding durations are shown in Table P < 0.001). This was similar to the results of being in the low-income category of < 5000 SR (~ 1333.17 USD) . Additionally, the results showed a positive association between having a large family size (6 members and more) and breast cancer . Moreover, having a primary level of education had a positive association with breast cancer .The correlations between the potential dependent variables for breast cancer are shown in Table P < 0.001), which was significant in the obese BMI category . Additionally, having an awareness about breast cancer and the smoking status were significant factors correlated with breast cancer. Having no awareness was positively associated with breast cancer , while being a smoker showed an increased risk of breast factor in this study . Moreover, the use of both types of contraceptive methods, hormonal and nonhormonal, increased the risk of breast cancer. In fact, the higher risk was involved in using a hormonal type of contraception .The health-related characteristics, such as the BMI, exhibited positive correlations to breast cancer . The not significantly identified variables by regression test; overweight, diabetes, hypertension and age of stated menstruation > 15 years old, were not included in this study as determinants of breast cancer.Beginning one’s menstruation cycle at an early age (10 years old or less) increased the risk of breast cancer, according to the results of this study  is highly associated with an increased risk of breast cancer . One metObviously, the effects of the hormonal changes on a woman’s body during reproductive age can increase the risk of breast cancer, and the effects of synthetic hormones are no exception. Several studies have found a reverse effect of contraceptives on breast tissue –35. The This study was limited by the convenience sampling technique, the regional sample collection, and postmenopausal women recruitment. Other determinants of breast cancer are recommended to study in Makkah region, such as dietary habits and breast density. However, it does highlight the importance of determining the risk factors for breast cancer using cohort studies consisting of a nationwide and large sample size, such studies are limited. Therefore, due to the paucity of research concerning of breast cancer in Makkah region, this study adds to the body of knowledge for future research to expand on this area.This study showed that most of the socioeconomic, health related status and menstruation history variables were determinant risk factors for breast cancer in postmenopausal women in the Makkah region. To illustrate, education, economic status, obesity, lack of exercise, cancer awareness, smoking, hormonal and non-hormonal contraceptive use and an early menstruation age were identified as significant in this study, and they should be considered in culturally sensible prevention programs for women in the Makkah region of Saudi Arabia.


BRCA1 andBRCA2; mutations in several other genes may also conferbreast cancer risk. Genetic testing and counseling can help patientsunderstand their risk and assist clinicians in choosing therapies. We aimedto uncover what patients know, experience, and think with regard to breastcancer genetics in Kenya.Breast cancer ranks among the most common adult cancers in Kenya. Individualswith a family history of the disease are at increased risk. Mutations mostcommonly associated with breast cancer affect Participants included breast cancer survivors age > 18 years. Participantscompleted a demographic questionnaire before participating in focus groupdiscussions to uncover knowledge of, experiences with, and attitudes towardthe genetics of breast cancer. Data were analyzed by inductive thematicanalysis.Four focus groups were conducted. Participants had rudimentary knowledgeabout genetics and cancer development, and although they understood breastcancer could be familial, many suspected environmental factors causingspontaneous disease. They reported limited experience with counseling aboutgenetic risk, perceiving that their physicians were too busy to providecomprehensive information. Many indicated they promoted cancer screeningamong family to promote early diagnosis. Participants expressed a need formore comprehensive counseling and access to genetic testing, recognizing theadded clarity it would bring to their families’ risk of cancer.Improved communication from health care teams could clarify the risk ofcancer for affected families. The introduction of affordable genetic testingand counseling for breast cancer in Kenya is welcomed by survivors. Hereditary breast cancer isassociated with mutations in BRCA18 orBRCA29;mutations in other genes may also confer breast cancer risk.10 Clinical genetic testingidentifies causative familial mutations. Genetic counseling helps patientsunderstand their risk. However, in low- and middle-income countries, cancer geneticservices are often unavailable or inaccessible because of financial and otherbarriers. Genetic counseling is also limited, because genetic counselors are rareand physicians lack training in this respect.Family history of breast cancer increases the risk of developing cancer12 There is a need for concomitantenhancement of genetic counseling. It is equally important to understand what cancersurvivors know about the genetics of their disease and uncover their experience withand perspectives on cancer genetics, because use of genetic services is dependent onsocial factors.13 In this respect,we conducted focus groups with Kenyan breast cancer survivors to gain insight intotheir knowledge, attitudes, and experiences regarding genetics and heritablecancer.New technologies have made genetic testing a reality in resource-limitedsettings.This qualitative, cross-sectional study aimed to uncover Kenyan breast cancersurvivors’ knowledge, experiences, and attitudes regarding breast cancergenetics. The study was approved by the University of Nairobi Ethics andResearch Committee.Participants were recruited from monthly breast cancer support groups hosted byFaraja Cancer Support Trust, a cancer support organization. Interestedparticipants were asked to connect with the study team to enroll in thestudy.Kenyan female breast cancer survivors age > 18 years who could communicate ineither English or Swahili were eligible. A breast cancer survivor was defined asan individual who had received a breast cancer diagnosis and undergone treatmentin Kenya. All participants provided written informed consent.Participants completed a brief questionnaire, which asked for basic demographicinformation and details about their diagnosis  and 2. FAudio recordings were transcribed verbatim in English. Participants weredeidentified using alphanumeric codes . Data were managed using NVivo 11software . Two researcherscoded the transcripts independently, using a codebook generated together.Discrepancies were settled by a third researcher. Data were analyzed usinginductive thematic analysis.Four focus groups with 21 female breast cancer survivors were conducted. Mostparticipants were between the ages of 41 and 55 years (43%), identified Swahili(86%) or English (67%) as a primary language, lived in a city (52%), and hadKikuyu ethnicity (71%). Additional demographic information is listed in Most participants reported being the only person in their family diagnosed withbreast cancer (62%). Most were diagnosed in the last 1 to 5 years (71%). Oneparticipant reported having undergone genetic testing. When asked if breastcancer was heritable in their family, participants responded either no (48%) orunknown 48%; . A summaParticipants generally described breast cancer as the proliferation ofabnormal cells:“I would define the word cancer as I have gone through. Normalcells in the body that turn so they become abnormal and they startmultiplying. They multiply uncontrollably. Something likethat.” —J3One participant initially thought cancer was a communicable diseasebecause people in her family had different types of cancer:“I was very sure much worried because my husband died in 1991because he had a stomach cancer and my sister died in 1996, she hada cervical cancer. Then I thought one of them gave me thecancer.” —M7Most participants understood terms genetics or inheritance as relating tofamilial traits passed on from generation to generation:“I think the genetic is something to do with genes, themakeup, what makes up the genes that make a person. And when youhave now the gene that is having the cancerous, makeup, is the onethat makes you a potential for cancer. Now you get it because of… you inherited it from the parents. One of your parentscould be carrying the gene and then pass it on to you. And then youcan either have it because you get it from both the parents, you canget it from one of them. Or you can maybe lucky and you don’tget it but you still carry it to one of your child or something likethat.” —J6However, some expressed more familiarity with the term inheritance thanwith gene or genetic:“I don’t know genetic but inheritance. You inherit fromyour family. It runs in the family. That’s the meaning of theword inheritance. But I don’t know, I’m not very clearabout genetic.” —J5When family history was present, participants concluded that the cancercould have been inherited; however, they were not certain:“I think as for me my mom had breast cancer. And she died whenshe was just 33 years from breast cancer. When they took the testfor my disease, they said it was triple negative, it was not causedby hormones. The doctor say that it could be inherited but I havenot done any test to conclude that. Yeah, so I thought that maybe Icould have got the gene from my mother.” —M2Participants often pinpointed specific lifestyle factors that could causecancer:“Then of course the regular things that we are told all thetime. Smoking, eating the wrong food, not exercising, those things,combination of factors, including stress.” —J4Family planning methods were identified as possible cancer causes. Theabsence of family history sometimes made it easier to believe birthcontrol may have been the cause:“Her mom doesn’t have it and she has never heard ofbreast cancer before. So that’s why she thought familyplanning might be the cause.” —J22Birth control as a cause of breast cancer development was perceived to besupported by physicians:“In her case, she thought it was family planning. Shehad—I think a patch?—that she used to put on her hand,and she got a lump. And she had been using the family planning forthree years. So when she went to see the doctor, the first thing hesaid was to remove the patch.” —J21Some participants were given some form of risk counseling for familymembers:“[The doctor] told me if I have a daughter, since it isrunning in the family, and my mother died at 64, I got mine, I wasdiagnosed at 43. So he told me that my daughter should start goingfor breast cancer examinations at 23. Yeah, half the age.”—J6Some participants reported not having a discussion on genetics but beinginterviewed about their family history:“No, there wasn’t any discussion on that [genetics].But there is a form that they were filling whereby they were askingyou if your dad had cancer or your mom had breast cancer.”—J21Participants believed that health care professionals were too busy tocommunicate to their families about familial risks of breast cancer:“They [the doctors] actually don’t have time. Becausewe would like them to at least spend some time to call our family,maybe our spouse or our children and then maybe they are in a betterposition to explain to them and then us, ourselves.”—M2An underlying current of distrust of medical professionals was evident inmost focus groups. The business of physicians was often explained asresulting from a perceived financial incentive:“They don’t want to take their time to explain to youbecause they are expecting the next patient. Because as many patientgets in that is how they are counting their pocket.”—J5Participants did not explicitly speak about increased risk of cancer tofamily members. However, they promoted screening to their family:“So like in my family, I’ve sensitized the peoplearound me, my sisters and my brothers. I’ve encouraged mysisters to be going for mammograms and my mom.”—J1One participant encouraged her daughter to get a mammogram but recognizedthe financial barrier to accessing the service:“I won’t like her to pass through what I passedthrough…. Because mammogram, she had when she had money. Sheshould go for checkup. So the moment she gets money, I’mencouraging her to go for checkup.” —J14Participants also spoke about how female family members held the worrythat they would also be affected:“But I remember the first month, my daughter who is 20 now.She was very devastated. She used to Google and find out aboutbreast cancer. She would always touch her breasts to find out if shehad a lump.” —J14Most participants reported having no experience with genetic testing. Oneindividual had accessed genetic testing and counseling in India. Theexperience was described as having provided clarity:“For my case, I’m the first one to have cancer in myfamily, my extended family, from whichever side. I have done a genetictest and it was negative. So I’m happy at least it does not godown to my children.” —J13Many expressed a need to better understand breast cancer to develop furthercompetency in informing family members:“At that point, you don’t even know what breast cancer is.So you just tell them it is breast cancer but they don’t knowwhat it is and you yourself don’t know what it is.”—J13One participant spoke of the value of genetic testing but stressed that it isinaccessible in Kenya because of high costs:“When [my sister] learned that I have breast cancer, she lives inthe US, she went for that test, the genetic test. She did. Which cameout negative. She said it was expensive but it was necessary for her toalleviate the fear and know that. So for me, I think it’ssomething that people should learn, maybe to embrace. Because like yousay, knowledge is power. Because when you know, at least it can bereached by each and everybody, because here in Kenya we want thesethings to happen but like what she said, sometimes you have nothing. Youdon’t have any coins.” —J6Some saw value in providing affordable genetic testing in the future:“No one ever told me to go for a gene test or…. So I have adaughter. I would not like her to go through what I’ve gonethrough that by the time they came to diagnose [the cancer] in me, thecancer was at third stage. They could have seen it early, at an earlystage so I think if they gave us some affordable gene test, we will takeour children, our girl child, and from there they will tell us the wayforward.” —M212 Thiswill require strengthening of genetic counseling services; therefore, we sought touncover how breast cancer survivors in Kenya understand, experience, andconceptualize the underlying genetics of their disease. We found that survivorsgenerally understood that breast cancer could be heritable but did not often fullycomprehend how this risk translated to themselves or their family members. Thedemographic survey revealed that although seven participants knew of family memberswho also had breast cancer, they reported that breast cancer was not heritable, orthey did not know if it was heritable in their case. Again, later in discussions,participants cited positive family history but used terms such as 'maybe' and 'couldbe' when talking about whether they had inherited the trait; one participantinitially thought her cancer was communicable. It is important for health carepractitioners to be aware of this misunderstanding so that they can dispelconfusion. Participants who indicated they had triple-negative breast cancer mentioned it during the discussion ofinheritance. Triple-negative breast cancer does not express receptors for estrogen,progesterone, or human epidermal growth factor receptor 2/neu, and can be suggestiveof heritable breast cancer, especially in women diagnosed at age < 60years.14 Internationalguidelines recommend that individuals with triple-negative breast cancer be referredfor genetic testing or counseling. Triple-negative breast cancer may have a higherincidence in Africa15; it ispossible that physicians are aware of this risk and discuss the possibility ofhereditary disease more comprehensively with these patients.The recent focus on and efforts to build capacity in African genomic science promisesto revolutionize care for genomic disorders like cancer.16 More importantly, another studyshowed robust evidence that contraceptive use confers no increased risk of breastcancer to the general population.17 Only for BRCA1 mutation carriers do oralcontraceptives incur this increased risk18; however, in Kenya, where genetic testing is not performedroutinely, none of the participants in our study would have known if they wereBRCA1 carriers. It is possible that because physicians do notknow the mutation status of the patient they are counseling, they may speculate thattheir patient is a mutation carrier and counsel conservatively. Taken together, theabundance of misinformation about breast cancer illustrates a need for genetictesting and counseling to comprehensively and accurately outline risks to facilitateinformed decision making on the part of patients.Participants offered much discussion on environmental or lifestyle factors that areknown to increase risk of breast cancer. Survivors often indicated they perceiveduse of birth control as a risk factor in breast cancer development. Despite thiswidespread perception, only one study has shown a small increased risk of breastcancer while using contraceptives, which diminishes over time.19 In China,commercialization of medicine, along with high patient expectations and inadequatetraining of physicians in patient communication, is a contributor topatient-physician mistrust, often with violent consequences.21 In Kenya, further research may be necessary to delineatehow medical mistrust may affect uptake and use of genetic services.Study participants reported limited experience with genetic counseling. Many recalledbeing asked for detailed family history by their physicians but often perceived thathealth care professionals were too busy to provide them with quality communicationand were mainly interested in generating revenue. The underlying mistrust ofphysicians prevalent in our discussions is consistent with prior research suggestingthat commercialization of medicine significantly weakens patient-physiciantrust.24 and even medical oncologists scorelow on knowledge tests of cancer genomics.25 Genetic counselors are primed to take this role26; however, in Kenya, where geneticcounselors do not exist, alternative models of counseling may need to be developedand tested.27 Disease-basedgenetic education programs for physicians may be one way to build capacity in thisarea.28Incorporating genetic counseling into standard of care could help improve patientunderstanding and strengthen the patient-physician relationship. However, there maybe an unrealistic patient expectation that physicians have a comprehensiveunderstanding of genetic testing and its implications. In reality, studies fromaround the world consistently have shown that physicians perceive themselves to beill versed in clinical genetics or would prefer assistance in sharing results withpatients,30 Some might arguethat a positive genetic test might cause undue stress; however, evidence indicatesthat genetic testing and appropriate counseling does not increase distress overtime.33 A systematic review on uptake of genetic servicesfinds that 59% of women with breast cancer choose to undergo genetictesting.34 Ourparticipants expressed a desire for access to genetic services, rationalizing thatit could help relatives identify their risk of breast cancer. Hereditary breastcancer is also associated with increased risk of other cancers ,10 for whichgenetic testing would help deduce the risk; however, no participant discussed thisadditional benefit.Genetic testing could also improve knowledge of and clarify communication from thehealth care team. There is a growing body of evidence suggesting that all womenshould be tested for breast cancer–predisposing mutations, regardless ofpresence or absence of family history.36 and inour study, this was identified as a recognized challenge to overcome. In future,genetic testing could be covered by the national health insurance fund, as one wayto provide affordable service to patients. Physician recommendation is anotherpredictor of uptake,37 so it is important to educatephysicians on this opportunity as it develops in Kenya. It is possible to developbreast cancer genetic services in sub-Saharan Africa.40 However,given the distrust of the medical community uncovered by our study, the value ofgenetic testing must be clearly articulated to patients to avoid further damagingpatient-physician relations.The one participant who had received genetic testing and counseling had traveled toIndia for treatment, presumably having the financial means to do so. Financialbarriers are known to prevent uptake of genetic services,The main limitation of this study is that it represents perspectives from survivorsfrom a relatively uniform population that primarily identified as urban, Kikuyu, andhaving completed secondary school or higher. Additional studies in differentgeographic areas and demographic groups may yield more diverse perspectives.In conclusion, there is a need for improved education among Kenyan breast cancersurvivors about genetics. With better understanding of genetics through tailorededucation in support groups, patient-oriented genetic testing and counseling couldbe introduced in Kenya in the near future.


The association between dietary acrylamide intake and estrogen receptor-positive (ER+) breast cancer risk in epidemiological studies is inconsistent. By analyzing gene-acrylamide interactions for ER+ breast cancer risk, we aimed to clarify the role of acrylamide intake in ER+ breast cancer etiology.n = 1449) and ER+ breast cancer cases (n = 844) was assessed with a food frequency questionnaire. We genotyped single nucleotide polymorphisms (SNPs) in genes in acrylamide metabolism, sex steroid systems, oxidative stress and DNA repair. Multiplicative interaction between acrylamide intake and SNPs was assessed with Cox proportional hazards analysis, based on 20.3 years of follow-up.The prospective Netherlands Cohort Study on diet and cancer includes 62,573 women, aged 55–69 years. At baseline, a random subcohort of 2589 women was sampled from the total cohort for a case–cohort analysis approach. Dietary acrylamide intake of subcohort members  contains supplementary material, which is available to authorized users. Acrylamide, a probable human carcinogen (IARC class 2A), was discovered in 2002 in various heat-treated carbohydrate-rich foods, such as cookies, potato crisps, French fries and coffee. Acrylamide is a small hydrophilic compound that is distributed throughout the body with the blood. In theory, it can thus cause cancer everywhere in the body. Acrylamide is a multisite carcinogen in rodents, in which it causes, among other, mammary gland tumors in females . The meccytochrome P450, family 2, subfamily E, polypeptide 1 (CYP2E1) and the deletions of the genes glutathione s-transferase M1 and T1 (GSTM1 and GSTT1) -3: C50). Information on estrogen receptor status was obtained from the National Cancer Registry and the Dutch Pathology Registry and was assessed by either immunohistochemistry or biochemical assay. Cases and subcohort members were excluded from analysis if their dietary data were incomplete or inconsistent, if they had not sent in toenail clippings, and if they had no or inferior  data on SNPs. Figure A valid and reproducible food frequency questionnaire with questions on 150 food items was used for estimating dietary habits , 12. DieThe selection of genes focused on genes involved in (1) acrylamide metabolism and (2) the most often hypothesized mechanisms of acrylamide-induced carcinogenesis : (2a) seGSTM1 and GSTT1 deletions (3 SNPs each) and 60 SNPs in other genes, see Supplemental Table 1.In the end, we genotyped 6 SNPs to determine DNA was isolated from 15 mg of toenail clippings, following the protocol developed by Cline et al. , in an op value. 3 out of the 60 SNPs that were genotyped had a call rate < 80% and were not included in the analyses. 6 SNPs out of the remaining 57 SNPs did not adhere to Hardy–Weinberg equilibrium (HWE) (p < 0.05). With regard to the SNPs selected to represent the GSTM1 deletion, rs10857795 was not called in 36%, rs200184852 in 42% and rs74837985 in only 2% of the subcohort. The latter value appears to be due to genotyping error. Therefore, we decided to base the assessment of the absence/presence of the GSTM1 gene only on rs10857795 and rs200184852. 31% of the subcohort had a missing value for both rs10857795 and rs200184852. With regard to GSTT1, rs2844008 was not called in 58%, rs4630 in 16%, and rs140309 in 11% of the subcohort. 8% of the subcohort had a missing value for all 3 GSTT1 SNPs.Supplemental Table 2 shows the 60 SNPs with their location, call frequencies, and HWE n = 190) were duplicate samples in order to check the reproducibility of genotyping, which was > 99%. We excluded samples with a call rate < 95% .5% of the samples (Hazard rate ratios (HRs) and 95% confidence intervals were obtained through Cox proportional hazards regression with STATA software (package 13), using the robust Huber–White sandwich estimator to account for additional variance introduced by sampling from the cohort. We checked the proportional hazards assumption using scaled Schoenfeld residuals.Covariables selected for inclusion in the Cox proportional hazards analysis models were selected based on the literature: age, body mass index, height, age at menarche, age at menopause, age at first childbirth, parity, ever use of oral contraceptives, ever use of postmenopausal hormones, history of benign breast disease, family history of breast cancer and energy intake. Smoking status, the duration of smoking and the number of cigarettes per day were included in the model, because cigarette smoke contains acrylamide. Smokers have on average four times higher levels of acrylamide-hemoglobin adducts than non-smokers , 20. To Multiplicative interaction between acrylamide intake and SNPs was tested using product terms of the continuous acrylamide intake variable and genotype. For statistical power reasons, we used a dominant genetic model for all SNPs. Tests for acrylamide dose–response trends in strata of the genotypes were performed by fitting the mean acrylamide intake in the tertiles as a continuous variable.We applied the false discovery rate method developed by Benjamini–Hochberg to adjust for multiple testing  with thep values are reported throughout this paper.Two-sided Table There was a statistically non-significant inverse association between acrylamide and ER+ breast cancer risk after 20.3 years of follow-up in all women (HR of highest versus the lowest quintile of intake: 0.85 (95% CI 0.66–1.09) and 0.94 (0.88–1.00) per 10 µg/day increment of intake) but with no clear dose–response relationship. There was no association in never-smoking women (HR of highest versus the lowest quintile of intake: 1.18 (95% CI 0.85–1.64) and 1.02 (0.93–1.11) per 10 µg/day increment of intake) (Table UDP glucuronosyltransferase family 1 member A complex (UGT1A) (p trend = 0.08), rs4919682 and rs4919687 in cytochrome P450, family 17, subfamily A, polypeptide 1 (CYP17A1) , rs915906 in CYP2E1 (p trend = 0.09), and rs3219489 in human MutY homolog (hMYH) (p trend = 0.07).Table Table GSTT1, when represented by rs140309, showed a statistically significant interaction with acrylamide intake (p interaction = 0.01) and this interaction remained statistically significant after adjustment for multiple testing . The same interaction was observed for never smokers. Women with a homozygous deletion of the GSTT1 gene were at a statistically significantly decreased acrylamide-associated risk of ER+ breast cancer [HR 0.35 (95% CI 0.15–0.83) among all women and HR 0.16 (95% CI 0.04–0.68) among never-smoking women in the highest tertile of acrylamide intake versus the lowest], while there was no association with acrylamide intake among women with at least 1 copy of the gene.The homozygous deletion of cytochrome P450, family 1, subfamily B, polypeptide 1 (CYP1B1) , rs2959008 and rs7173655  in cytochrome P450, family 11, subfamily A, polypeptide 1 (CYP11A1) , and rs1052133 in human 8-oxo-7,8-dihydroguanine DNA glycosylase 1 (hOGG1) . Women homozygous for the wild-type allele of CYP1B1 were at a statistically significantly decreased acrylamide-associated risk of ER+ breast cancer, while women with at least 1 variant allele were not. Among never smokers, this pattern was not seen, although the interaction was nominally statistically significant (p interaction = 0.03). In this subgroup, there was a statistically non-significant increase in risk in women with at least one variant allele, while there was no association between acrylamide and risk in women with two wild-type alleles. The two SNPs in CYP11A1 both showed that women homozygous for the wild-type allele were at a decreased acrylamide-associated risk while there was no association for women with at least one variant allele. This was seen both among all women and among never smokers. Only women with one or two variant alleles of rs1052133 in hOGG1 were at a decreased acrylamide-associated risk of ER+ breast cancer. Women who were homozygous wild types did not show an association between acrylamide and ER+ breast cancer. The effect modification was less clear among never smokers.There were four more interactions that remained statistically significant after adjustment for multiple testing, with the following SNPs: rs1056827 in CYP2E1 did not show an interaction with acrylamide intake among all women, nor among never-smoking women. There was also no interaction between the deletion of GSTM1 and acrylamide, or SNPs in other acrylamide-metabolizing genes.In Table NQO1 and rs6838248 in SLC7A11 specifically among never smokers.Supplemental Table 3 shows the nominally statistically significant interactions that did not withstand adjustment for multiple testing, namely: rs1800566 in UGT1A, rs11252859 in AKR1C1, rs11252887 in AKR1C2, rs1280350 in MGC12965, rs1042157 and rs6839 in SULT1A1, rs737865 in COMT, rs10432782 in SOD1, rs4880 and rs5746136 in SOD2, rs1047303 in the HSD3B1/B2 gene cluster, rs6259 in SHBG, rs6759180 in RRM2, and rs2228001 in XPC .Finally, there were some clear differences in the association with acrylamide between genotypes without a statistically significant interaction, namely for: rs2070959 in CYP1B1, rs2959008 and rs7173655 in CYP11A1, the GSTT1 gene deletion, and rs1052133 in hOGG1. These interactions remained statistically significant after adjustment for multiple testing.As far as we know, this is the first study to analyze acrylamide-gene interactions for breast cancer risk. We observed interactions between acrylamide intake and rs1056827 in Contrary to what we found in a previous analysis for ER+ breast cancer albeit not statistically significant , acrylamCYP2E1 on the association between acrylamide and cancer risk may thus contribute important information on the causality of the association. We observed no interaction between 3 SNPS in CYP2E1 and acrylamide intake for ER+ breast cancer risk and there were no clear differences in the risk between the genotypes, contrary to what was observed for endometrial [CYP2E1 SNPs are in the intronic region of the gene and there is no clear information about their functionality but the wild-type allele of rs6413432 has been shown to be associated with an increased risk of prostate cancer [Glycidamide (the epoxide metabolite of acrylamide formed through metabolism by CYP2E1) is often thought to be responsible for acrylamide-induced carcinogenesis due to genotoxicity (mutagenicity and/or clastogenicity ). Studyiometrial  and ovarometrial . We havee cancer  and othee cancer .GSTT1 (deletion represented by rs140309) were at a decreased acrylamide-associated risk of ER+ breast cancer but the number of cases with a homozygous GSTT1 deletion was rather small (n = 87). In contrast, we previously observed women with at least one copy of the GSTT1 gene to be at an increased acrylamide-associated risk of endometrial and ovarian cancer [GSTM1.We observed that women with a homozygous deletion of all n = 8. In contCYP1B1. Women who were homozygous wild types for this allele were at a decreased risk of acrylamide-associated ER+ breast cancer. In never smokers, the interaction was less clear. CYP1B1 is a phase I biotransformation enzyme involved in the metabolism of various exogenous and endogenous compounds and is mainly expressed in endocrine tissues like the endometrium, ovarium and breast. CYP1B1 converts estrogens to hydroxy metabolites (catechol estrogens) which are potent estrogens and furthermore CYP1B1 oxidizes catechol estrogens to chemically reactive semiquinone and quinone intermediates that can bind to DNA and cause mutations. Exposure of mouse spermatocytes to acrylamide and glycidamide led to increased CYP1B1 expression [CYP1B1 expression in human epithelial cells [We observed a statistically significant interaction between acrylamide intake and rs1056827 in al cells . Possiblal cells . Due to CYP11A1: rs2959008 and rs7173655; acrylamide intake was associated with a decreased ER+ breast cancer risk in women who were homozygous for the wild type of these alleles. CYP11A1 is involved in the formation of pregnenolone from cholesterol, the first and rate-limiting step in steroid hormone synthesis. Both CYP11A1 SNPs are in the intronic region of the gene and there is no information available about their functionality. The variant allele of rs2959008 was associated with a decreased breast cancer risk in Han Chinese [CYP11A1 in reproductive tissues [CYP11A1 expression in testis tissue of male Sprague–Dawley rats [CYP11A1 SNPs.Acrylamide interacted statistically significantly with 2 SNPs in  Chinese . There i Chinese . Acrylam tissues  but to dley rats . This diCYP2E1 SNPs which leaves the possibility that there may not be a true association between acrylamide intake and breast cancer risk. If true, the interactions between acrylamide and HSD3B SNPs for ovarian cancer [CYP1B1 and CYP11A1 SNPs for breast cancer in the current study give some indications that acrylamide may interfere with progesterone metabolism. However, there was no association between acrylamide intake and progesterone in a cross-sectional study in premenopausal women [Progesterone opposes the proliferative effect of estrogens in the endometrium and ovaries while it is thought to have proliferative effects in mammary tissue . A mechan cancer  and betwal women . In animal women –38. NevehOGG1 showed an inverse association between acrylamide intake and ER+ breast cancer risk. The hOGG1 gene is part of the base excision DNA repair pathway, responsible for the excision of 8-oxoguanine (8-oxoG), a mutagenic DNA base byproduct of reactive oxygen species. Although the variant allele is hypothesized to have decreased enzyme activity [Only women with variant alleles of rs1052133 in activity , 40, a ractivity , while aactivity . BecauseNQO1 and rs6838248 in SLC7A11. Additionally, there were some clear differences in the association with acrylamide between genotypes without a statistically significant interaction, for: rs2070959 in UGT1A, rs11252859 in AKR1C1, rs11252887 in AKR1C2, rs1280350 in MGC12965, rs1042157 and rs6839 in SULT1A1, rs737865 in COMT, rs10432782 in SOD1, rs4880 and rs5746136 in SOD2, rs1047303 in the HSD3B1/B2 gene cluster, rs6259 in SHBG, rs6759180 in RRM2, and rs2228001 in XPC. For all these SNPs it is even more important that the interaction between acrylamide intake and these SNPs is corroborated in other studies to be able to judge whether our findings represent true interactions or not.There were two other nominally statistically significant interactions between acrylamide intake and other SNPs: rs1800566 in r = 0.82, p < 0.001) [This study has some limitations. Acrylamide levels vary considerably within foods due to processing and varieties used. Despite the large variation in acrylamide levels within foods, acrylamide intake as assessed by food frequency questionnaires and acrylamide to hemoglobin adducts (biomarker for exposure) have been shown to correlate moderately in several studies, e.g. , 44. Thu< 0.001) . To concGSTT1, AKR1C1, NQO1, the HSD3B1/B2 gene cluster, XPC, and MGC12965. These genes therefore deserve attention in future studies.Some of the nominally statistically significant interactions that we observed are, without a doubt, chance findings. However, it is of interest that some of the genes that we observed to interact with acrylamide for ER+ breast cancer risk or that showed clear differences in risk between the genotypes also did so for endometrial  and ovarThe strengths of this study are the complete follow-up and its prospective nature.CYP2E1 SNPs for ER+ breast cancer risk. After adjustment for multiple testing, this study showed statistically significant interactions between rs1056827 in CYP1B1, rs2959008 and rs7173655 in CYP11A1, the deletion of GSTT1, and rs1052133 in hOGG1 and acrylamide intake for ER+ breast cancer risk. Based on this study and analyses for endometrial and ovarian cancer, we recommend follow-up of interactions between acrylamide intake and genetic polymorphisms in CYP1B1, CYP11A1, the HSD3B1/B2 gene cluster, CYP2E1, GSTs, hOGG1, AKR1C1, NQO1, GPX1, XPC and MGC12965, and additional research on the possible effect of acrylamide on progesterone metabolism in humans.In conclusion, we did not observe a positive association between dietary acrylamide intake and ER+ breast cancer risk. Unexpectedly, our results gave some indications for an inverse association. Unlike for endometrial and ovarian cancer, there was no interaction between acrylamide intake and Below is the link to the electronic supplementary material.Supplementary material 1 (DOC 1306 KB)


Breast cancer survivors have a high incidence of osteoporosis-related fractures; the associated factors are understudied. We investigated incidence of bone fracture and its associations with soy food consumption, exercise, and body mass index among breast cancer survivors.This prospective study included 4139 stage 0–III breast cancer patients and 1987 pre-/perimenopausal and 2152 postmenopausal patients. Fractures were assessed at 18 months and at 3, 5, and 10 years after cancer diagnosis. Osteoporotic fractures were defined as fractures caused by falls from standing height and at sites associated with osteoporosis. Exercise and soy isoflavone intake were assessed at 6 and 18 months postdiagnosis. Weight and height were measured at baseline. Lifetable and Cox regression analyses were employed. All statistical tests were two sided.Ptrend < .001) but not among postmenopausal patients (Pinteraction < .01). Overweight  was a risk factor for pre-/perimenopausal patients  but not for postmenopausal patients . Exercise was inversely associated with osteoporotic fractures in postmenopausal patients  following a dose-response pattern (Ptrend = .035), an association not modified by menopausal status.The 10-year incidence for osteoporotic fractures was 2.9% and 4.4% for pre-/perimenopausal and postmenopausal patients, respectively. High soy isoflavone intake was associated with reduced risk among pre-/perimenopausal patients (hazard ratio [HR] = 0.22, 95% confidence interval [CI] = 0.09 to 0.53, for soy isoflavone mg/d ≥56.06 vs <31.31; Our findings, especially the novel association of soy food intake with osteoporotic fractures in breast cancer survivors, if confirmed, can help guide future strategies for fracture risk reduction in this vulnerable population. Breast cancer patients have a higher incidence of osteoporosis-related fractures compared with age-matched healthy women ,2. This Estrogen exerts its effect on target cells through binding estrogen receptors (ERs) . ModulatSeveral other modifiable lifestyle-related factors may influence the risk of bone fracture via estrogen-related and other biological mechanisms . Body maIn the present study, we investigated the incidence of clinical osteoporotic fracture among breast cancer survivors and evaluated its associations with soy food consumption, BMI, and exercise in a large prospective observational cohort of Chinese breast cancer survivors.This study used data from the Shanghai Breast Cancer Survival Study (SBCSS), a large population-based longitudinal cohort of 5042 breast cancer survivors. Details of the study design and methodology have been previously described . BrieflyThe SBCSS was approved by the institutional review boards of Vanderbilt University and the Shanghai Municipal Center for Disease Control and Prevention. Written informed consent was obtained from all study participants.The primary outcomes of interest were any fracture and osteoporotic fracture that occurred during the 10 years following diagnosis. Osteoporotic fractures were defined as low-trauma fractures , occurring in anatomic sites commonly associated with osteoporosis following the approach of Warriner et al  15)..15).Menopausal status and age at menopause were assessed at baseline. Women were considered pre-/perimenopausal if they had regular menses or had ceased menstruation for less than 12 months, and menopausal if they had ceased menstruation for 12 months or longer, excluding temporary cessation of menstruation due to pregnancy or breastfeeding.Information regarding dietary soy intake  was collected at baseline and 18-month surveys using a validated food frequency questionnaire . Total sWeight and height were measured following a standard protocol at baseline. BMI was estimated by dividing weight in kilograms by the square of height in meters. BMI was then categorized into underweight (≤18.5), normal weight (18.5–24.9), overweight (25.0–29.9), and obese (≥30.0).Information regarding exercise was assessed using a validated questionnaire . IntensiWe included tamoxifen in the analysis because it is a SERM with a known influence on bone density and is commonly used in breast cancer treatment. Tamoxifen use (defined as use for greater than 1 month after breast cancer diagnosis) was assessed at baseline and each follow-up encounter. We also calculated cumulative duration of use since cancer diagnosis, which was categorized as 1–16 months and 17 or more months in our analysis.Of the 5042 SBCSS participants, we excluded participants with missing fracture data across all three surveys (n = 894) from this study and those with stage IV breast cancer (n = 9) to avoid confounding from bone metastases that could lead to fracture. The remaining 4139 women were included in the fracture incidence analysis: 1987 pre-/perimenopausal and 2152 postmenopausal patients. For the association analyses, we further excluded underweight patients  and patients who had a fracture (n = 19) or had breast cancer metastases (n = 14) within the first 6 months of breast cancer diagnosis because the influence of malnutrition and active cancer treatments is difficult to control for. This yielded 3986 women.2 tests for categorical variables and Student t tests for the continuous variables were performed to compare characteristics of patients who developed fracture and those who remained event free. Ten-year fracture incidence rate was estimated by lifetable method.Pearson χMultivariable Cox regression models were applied to evaluate the associations of variables under study  with incidence of any fracture and osteoporotic fracture, reported as hazard ratios (HRs) and 95% confidence intervals (CIs). In the Cox regression, entry time was at the date of enrollment (baseline survey), and exit time was date of first fracture occurrence after cancer diagnosis. Study participants were censored from the analysis at the time of death, self-reported metastases, or last follow-up date, depending on which came first. In the analysis for osteoporotic fracture, patients were censored if they had nonosteoporotic fractures to avoid bias from potential changes in lifestyle and other preventive measures that may be adopted following any type of fracture. Covariates adjusted for in the model included known/suspected risk factors for bone fracture based on the literature and factors that were associated with bone fracture risk in univariate analysis of our own data. These included age at cancer diagnosis, history of bone fracture before cancer diagnosis, use of calcium supplements, parity, education level, aromatase inhibitor use, and breast cancer stage.Stratified analyses by baseline menopausal status and tamoxifen use evaluated whether these two factors modify the effect of lifestyle factors on bone fracture. Multiplicative interaction was evaluated using the log likelihood ratio test, which compared the model including only the main effects with the model including both main effects and interactive terms. All statistical tests were based on two-tailed probability and a significance level set at alpha (α) less than 0.05.The mean age of all patients at baseline was 54.4 years (SD = 10.0). Forty-eight percent of the women were pre-/perimenopausal and 52% were postmenopausal. The 10-year bone fracture incidence was 13.3% for any fracture and 3.6% for osteoporosis fracture; 11.1% and 2.9% for pre-/perimenopausal women and 15.4% and 4.4% for postmenopausal women, respectively. The incidence for osteoporotic fractures by age strata at cancer diagnosis was 2.73% (<50 years), 4.01% (50–59 years), 5.22% (60–69 years), and 3.84% (≥70 years) .P = .01) and less likely to exercise (P = .03) or to use tamoxifen (P = .009). No differences by cancer stage, ER, or progesterone receptor (PR)-positive status and other treatment types were noted across patient groups (The mean age of patients with any fractures (55.9 [9.8] years) and osteoporotic fractures (56.2 [9.8 ]years) was older than patients with no fractures (53.6 [10.0] years) at cancer diagnosis. Patients with osteoporotic fractures were more likely to be postmenopausal (t groups .Ptrend = .006). Tamoxifen use was associated with a reduced risk of both any fracture  and osteoporotic fractures  (Ptrend = .002 for both).In the overall study population, soy isoflavone intake was not associated with fracture risk, nor was category of BMI. Exercise of at least 12.55 MET hours per week was associated with reduced risk of osteoporotic fracture, but not for any bone fracture  compared with exercise less than 4.50 MET. A dose-response association was also observed for osteoporotic fractures (to 0.81) . A dose-Pinteraction = .001). Compared with the lowest tertile of soy isoflavone intake (<31.38 mg/d), the highest tertile of soy isoflavone intake (≥56.06 mg/d) was associated with 77% reduced risk of osteoporotic fractures  in pre-/perimenopausal women. Overweight was associated with an increased risk of osteoporotic fractures  in pre-/perimenopausal but a marginally reduced risk  in postmenopausal women (Pinteraction = .01). Exercise was associated with reduced risk of osteoporotic fractures only in postmenopausal women  following a dose-response pattern (Ptrend = .035). Tamoxifen use was associated with reduced risk of osteoporotic fracture in pre-/perimenopausal and postmenopausal women, particularly for cases with a long duration of use, although the point estimates did not reach a statistically significant difference, likely because of reduced sample size.Results from stratified analyses by menopausal status are shown in Analyses stratified by both menopausal status and tamoxifen use did not reveal any effect modification (data not shown).In this large-scale longitudinal study, we found that 13.3% of breast cancer survivors developed a bone fracture and 3.6% had an osteoporotic fracture during the 10-year period following cancer diagnosis. These rates are higher than age-matched healthy women , who participated in a population-based cohort study of 75 000 women that we conducted in the same geographic area . ObservWe found the first evidence that high soy isoflavone intake was associated with a low risk for osteoporotic fractures in pre-/perimenopausal but not in postmenopausal breast cancer survivors. Soy isoflavones, a natural SERM, have been shown to be inversely associated with risk of recurrence and death in breast cancer patients ,22. The We observed that overweight/obesity was associated with increased relative risk of osteoporotic fractures among premenopausal breast cancer patients but a statistically nonsignificantly reduced risk among postmenopausal women. The latter may be attributable, in part, to the low number of obese patients included in the present study. Previous studies, including two recent meta-studies ,12, haveConsistent with previous studies showing that physical activity is associated with reduced risk of osteoporotic fractures in older women ,13, we fAs expected and consistent with several previous studies, including a large population-based study reporting 32% reduced risk of osteoporotic fracture for tamoxifen use , we founTo our knowledge, this is the first study to evaluate the association of soy food consumption with osteoporotic bone fracture among breast cancer survivors and the largest investigation on other modifiable risk factors. The strengths of this study include the longitudinal study design, repeated exposure measurements, and high response rate. Some limitations, however, exist. First, fracture incidences and exposures were self-reported. Therefore, misclassification, particularly for osteoporotic fractures, is possible. However, a previous study has shown self-reported fracture incidences were, in general, accurate . Our finIn summary, we found novel evidence that among pre-/perimenopausal breast cancer survivors, soy isoflavone intake is inversely associated with osteoporotic fracture risk, and overweight/obesity with increased osteoporotic fracture risk. Exercise and tamoxifen use were inversely associated with the risk for osteoporotic fracture. Our findings, if confirmed, can help guide development of comprehensive fracture risk reduction strategies  in this vulnerable population.The SBCSS was supported by grants from the Department of Defense Breast Cancer Research Program (DAMD 17-02-1-0607) and the National Cancer Institute (R01 CA118229). The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation and approval of the manuscript. The content of the information does not necessarily reflect the position or the policy of the government, and no official endorsement should be inferred.Affiliations of authors: Yale College, Yale University, New Haven, CT (NZ); Section of Rheumatology, Yale School of Medicine, Yale University, New Haven, CT (EH); Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN ; Shanghai Municipal Center for Disease Prevention and Control, Shanghai, China ; Shanghai Cancer Hospital, Fudan University, Shanghai, China (YZ).The authors declare no conflicts of interest regarding the publication of this article.The authors are in debt to the study participants and research team of the SBCSS. Dr Hsieh is supported by NIH/Fogarty International Center K01TW009995 and the Yale Center for Clinical Investigation/Doris Duke Foundation Fund to Retain Clinical Scientists.Supplementary_Data_pkz017Click here for additional data file.


To investigate the risks of ovarian, breast, and corpus uteri cancer in women who have had assisted reproduction.Large, population based, data linkage cohort study.All women who had assisted reproduction in Great Britain, 1991-2010, as recorded by the Human Fertilisation and Embryology Authority (HFEA).HFEA fertility records for cohort members were linked to national cancer registrations.Observed first diagnosis of ovarian, breast, and corpus uteri cancer in cohort members were compared with age, sex, and period specific expectation. Standardised incidence ratios (SIRs) were calculated by use of age, sex, and period specific national incidence rates.v 146.9 cancers expected; SIR 1.12, 95% confidence interval 0.95 to 1.30) was found during an average of 8.8 years’ follow-up. This study found no significantly increased risks of breast cancer overall  or invasive breast cancer . An increased risk of in situ breast cancer  1.7 cases per 100 000 person years, 95% confidence interval 0.2 to 3.2) was detected, associated with an increasing number of treatment cycles (P=0.03). There was an increased risk of ovarian cancer , both invasive  and borderline . Increased risks of ovarian tumours were limited to women with endometriosis, low parity, or both. This study found no increased risk of any ovarian tumour in women treated because of only male factor or unexplained infertility.255 786 women contributed 2 257 789 person years’ follow-up. No significant increased risk of corpus uteri cancer (164 cancers observed No increased risk of corpus uteri or invasive breast cancer was detected in women who had had assisted reproduction, but increased risks of in situ breast cancer and invasive and borderline ovarian tumours were found in this study. Our results suggest that ovarian tumour risks could be due to patient characteristics, rather than assisted reproduction itself, although both surveillance bias and the effect of treatment are also possibilities. Ongoing monitoring of this population is essential. Assisted reproduction cycles usually involve exposure to supraphysiological levels of oestradiol, exogenous gonadotropins, and multiple ovarian punctures, all potentially carcinogenic.Studies investigating breast cancer risks in women who underwent assisted reproduction are inconsistent.Given previous inconsistent results, small study size, and lack of information on potential confounders, we undertook a population based linkage study in Britain to provide risk estimates for ovarian, breast, and corpus uteri cancer, in a cohort of over 266 000 women undergoing assisted reproduction, with information on potential confounders such as parity and infertility diagnosis.We defined assisted reproduction as “treatments or procedures that include in vitro handling of both human oocytes and sperm or embryos, for the purpose of reproduction.”UK law mandates reporting of all assisted reproduction cycles to the HFEA. For cycles performed before October 2009, research use of these data was permitted, but consent could be withdrawn retrospectively. Fewer than 300 women had done so before this study began (based on the level of reporting detail provided by the HFEA). The study cohort, January 1991 to September 2009, therefore represents about 99.7% of the at-risk population. For cycles performed October 2009 onwards, prospective consent was required. Overall consent was not provided for an estimated 7% of women undergoing assisted reproduction in 1991-2010 , who were therefore not included in this study, representing a loss of less than 1% of person years’ follow-up .HFEA records were linked to the National Health Service Central Registers of England, Wales, and Scotland  in a one-off linkage. Completeness and accuracy of these registers have been described.Follow-up was calculated from date of first treatment (estimated as the mid-point of the first treatment year) until the date of any cancer diagnosis, death, emigration, or study end (March 2011), whichever came first. For analyses involving number of cycles, infertility duration, and live and multiple births, person years at risk were calculated from date of last treatment (estimated as mid-point of the last treatment year), because the HFEA did not record intermediate dates required for time dependent analysis. To calculate expected cancers, we multiplied the person years at risk by corresponding national incidence rates  for the general female population of England and Wales. Standardised incidence ratios were calculated by the comparison of observed values with expected values. We calculated 95% confidence intervals, two sided P values, and trends assuming a Poisson distribution.Representatives from patient support groups were consulted on the original research question, design, and planning of this study. Approval of the study and waiver of the requirement for individual consent were obtained from the UK Health Research Authority Confidentiality Advisory Group and London Research Ethics Committee (references 5.04(b)/10 and 10/H0720/18, respectively). Given the anonymous nature of the final dataset, it is not possible to disseminate results to individual study participants; instead results will be shared with fertility practitioners and clinics through the Human Fertility and Embryology Authority networks.In total, 255 786 women contributed 2 257 789 person years’ follow-up. Average follow-up was 8.8 years (range 1-19 years), with 105 436 (41%) followed for at least 10 years. Average age at first treatment was 34.5 years. Infertility cause involved at least one female factor in 111 658 women , and tubal disease). Infertility was unexplained in 47 757 (19%) women, and was due only to male factors in 84 871 (33%). Average infertility duration was 4.9 years. Women had 1.8 stimulated cycles on average, with only 20% (n=50 485) having more than two stimulated cycles. About half the study population had at least one live birth after treatment completion .v 2641.2 expected cancers; standardised incidence ratio 0.98 ; absolute excess risk −2.8 cases per 100 000 person years ; There was no overall increased risk of breast cancer ; absolute excess risk 1.7 cases per 100 000 person years (0.2 to 3.2); We found significant risk reductions with increasing duration since treatment completion P=0.01; , and in Risk of corpus uteri cancer was not significantly raised ; absolute excess risk 0.8 cases per 100 000 person years ; An overall increased risk of ovarian cancer was observed in our study population ; absolute excess risk 5.0 cases per 100 000 person years ; v 188.1expected cancers, standardised incidence ratio 1.40 , absolute excess risk 3.4 cases per 100 000 person years  and 141 v 103.7, 1.36 (1.15 to 1.60), 1.7 cases per 100 000 person years (0.7 to 2.8), respectively; When tumours were classified as invasive or borderline, significant excesses of both were noted  and any diagnosis of female factor infertility ), particularly endometriosis (2.03 (1.18 to 3.25)) or tubal disease (1.62 (1.21 to 2.12); Parous women who did not have a diagnosis of endometriosis did not have an increased risk of ovarian cancer overall ), invasive tumours (1.03 (0.82 to 1.27)), or borderline tumours (1.02 (0.75 to 1.35); Assisted reproduction is practiced worldwide, and more than five million children have been born as a result.Menopausal status did not seem to account for the significant reduction in risk with increasing follow-up. Despite no increased risk of invasive breast tumours, there was a significant increase in in situ tumours which was significantly associated with increasing number of stimulated cycles. Interpretation of these findings is challenging: the significant association with increasing number of cycles suggests a causal association, yet there was no overall increased risk of breast cancer. Other potential explanations include surveillance bias, chance, and potential confounding by factors such as socioeconomic status, given that most cycles within our cohort were privately funded. To our knowledge, this study is the first to analyse risks of in situ and invasive breast cancers after assisted reproduction separately, so there are no previous data with which to compare.Risk of corpus uteri cancer overall was not raised in our study. Women with the known risk factor of nulliparityWe found an excess of ovarian cancer compared with age standardised expectation. Significant increases were observed for both invasive and borderline tumours, but were not seen in women without the known risk factors of endometriosisAlthough the increased risk in borderline ovarian cancer in women with assisted reproduction could be genuine, it could also be due to surveillance bias. The frequency of borderline tumour diagnosis is increased in ovarian cancer screening studies using ultrasound,Most studies investigating risks of cancer in women after assisted reproduction have been small,Women treated with assisted reproduction are likely to differ from the general population in their parity, age at first birth, age at menopause, and the incidence of predisposing conditions such as endometriosis. More information on these and other factors  would be useful. Comparison to women with untreated infertility problems might have been beneficial, although interpretational problems would remain because of potential selection factors for treatment. Although our study was not able to compare with such a group as some smaller studies have done,Infertility diagnoses were reported by treating fertility clinics to the HFEA. No data were available about how such diagnoses were made. Further details of specific treatments could have enabled detailed analysis of risk by treatment type. However, over our 19 year study period, ovarian stimulation regimens as part of assisted reproductive cycles have been relatively constant, with the majority of advances leading to better success rates having occurred in assisted reproduction laboratories. Gonadotrophin injections have been used for ovarian stimulation and human chorionic gonadotropin for triggering ovulation throughout the study period, and while new highly purified and recombinant versions have been used in more recent years, they are essentially equivalent. Clomifene citrate was used as additional ovarian stimulation in the pioneering years of assisted reproduction treatment, but this was uncommon by 1991. Downregulated cycles using GnRH (gonadotrophin releasing hormone) agonists were standard by 1991 and not replaced by GnRH antagonists as standard until after the study period. Progesterone support was used throughout the study period. The number of ovarian punctures per cycle and information about fertility treatment before assisted reproduction were not available.In this large, national population based study of British women after assisted reproductive technology treatment, no increased risk of corpus uteri or invasive breast cancer was detected. There was an increased risk of in situ breast cancer associated with increasing number of treatment cycles. We also observed an excess of all types of ovarian cancer. However, our results suggest that this finding is more likely due to underlying patient characteristics, rather than assisted reproduction itself. We were not able to distinguish between a genuine increase in risk of borderline ovarian tumours and other explanations including surveillance bias. Further investigation of this and longer follow-up is warranted to continue monitoring these important outcomes in this ever growing population.Risks of reproductive cancers in women who have undergone assisted reproduction procedures are uncertainSome previous studies have suggested a possible increased risk of breast cancer in women treated at younger ages and with multiple cycles; previous studies investigating endometrial cancer risk are underpoweredEarly studies suggested increased risks of ovarian cancer in these women, while more recent studies are more reassuring, although inconsistent, regarding any increase in borderline ovarian tumoursIn this large population based study, endometrial cancer was not increased in women who had assisted reproduction in Great Britain in 1991-2010 when compared with the general populationThe risk of breast cancer overall and of invasive breast cancer was not increased, but there was a small increased risk of in situ breast cancerIncreased risks of ovarian cancer, both invasive and borderline, were observed but limited to women with other known risk factors; these findings require further investigation