To evaluate the actual perceptions of hormonal contraceptives (HC) in women of reproductive age in comparison with similar concerns of postmenopausal women in relation to hormone therapy (HT).A questionnaire-based study was conducted in a population of 370 women, 198 (53.5%) premenopausal and 172 (46.5%) postmenopausal. Perceptions were evaluated using specific questions and Likert scales (-5 to +5).Multivariate regression analyses were adjusted for categories of HC/HT use .p < .0001). According to responses, hormonal treatments can increase the risk of developing venous thrombosis  and depression  more in pre-menopause, while they can increase the risk of weight gain more in post-menopause .The greatest oncological concern throughout life was about breast cancer (0.9 ± 0.1). There was the perception that hormonal treatments can increase the risk of developing ovarian cancer more in post-menopause , while they can increase the risk of uterine cervix cancer more in pre-menopause .The most reported adverse effect associated with hormonal treatments was venous thrombosis (1.4 ± 0.1), especially for HC use in premenopausal women (Young patients are primarily concerned about the effects of hormonal treatments on venous thrombosis, mood, breast cancer and cervical cancer risk.Older patients are primarily concerned about the effects of hormonal treatments on weight gain, breast and ovarian cancer risk.The greatest oncological concern throughout life was about breast cancer.Our data suggest that our patients are primarily concerned about the effects of hormonal treatments on venous thrombosis, mood, breast cancer and cervical cancer risk, and, later in life, about their impact on weight gain, breast and ovarian cancer risk. Nowadays, hormonal treatments are commonly used by millions of women worldwide. Most women use at least one hormone therapy at some point of their life in the developed world, including hormonal contraceptives (HC) and hormone therapy (HT) after menopause. Despite being widely-prescribed, users are still doubtful about synthetic hormones, both in pre- and post-menopause.More than 9 million premenopausal women using contraception relied on the contraceptive pill in 2014 in the US , with raIndications for hormone therapy are not limited to women of reproductive age: hormones are also widely used in post-menopausal women, with different therapeutic schemes. For example, HT is used to relieve menopausal symptoms . It is tThe indications for hormone therapies, both pre- and post-menopausal, are many, as are the concerns about them. Deepening the conception that women of all ages have about hormone therapies can help in the counselling that should guide the personalized choice of drugs. For these reasons, in this study we want to investigate the current knowledge of the benefits and risks of hormonal treatments by comparing responses to an identical set of questions from women of reproductive age and postmenopausal women.This is a cross-sectional, observational study performed from December 2019 to May 2020 at the Department of Obstetrics and Gynaecology at Azienda Ospedaliero-Universitaria of Modena  in premenopausal or postmenopausal subjects evaluated at a routine visit.Included subjects were a group of women with no previous oncological diseases evaluated for a routine visit at the general gynecological service of the hospital . This service is where general practitioners send patients for routine gynecological examinations. Therefore, they are in general healthy women who did not present particular gynecological disorders or complaints. Menopausal status was classified as amenorrhoea for over 12 months.After detailed counselling about the study, the women who chose to participate signed an informed consent form. Once included in the study, women were given an identical questionnaire depending on the group they belonged to (pre- or post-menopause) (i.e. use of HC or HT) . The queFor both groups of women, questionnaires collected data on the type of HC/HT eventually used, the brand name of the product, use  and the duration of use (months/years). Women were asked to evaluate how much in their opinion HC/HT could affect the risk of developing some forms of cancer  or diseases , or other classical possible side-effects  using a Likert scale from −5 to +5. For cancers and diseases, −5 = reduces the risk of onset, 0 = neutral effect, +5 = increases the risk of onset, while for symptoms, −5 = worsens with HT, 0 = neutral effect, +5 = improves with HT . For theAn English translation of the specific questionnaires used in this study are reported in The study was designed and conducted in full accordance with the World Medical Association Declaration of Helsinki, as revised in 2002. The ethics committee of Modena approved the use of the questionnaires in our Department (reference 36/17) and a specific informed consent was obtained from each woman for the use of her sensitive data in research analysis.t test. Multivariate logistic and multiple regression analysis were used to investigate risk factors associated with different perceptions in pre or postmenopause, adjusting for confounding such as categories of HC/HT use : candidate variables were included if significant on univariate analysis or clinically relevant. Multiple regression models were used to study the impact of women age. Statistical analysis was performed using the statistical package StatView . Correlations were considered significant at a p-value <.05. Continuous results are expressed as mean ± standard deviation (SD).The questionnaire responses of pre- and post-menopausal women were analyzed and compared. The frequency of answers in the different groups was calculated. When necessary, the prevalence was compared using contingency tables. Comparisons of continuous variables between groups were performed using Student's Assuming a pooled SD of 1 unit, the study was determined to require a sample size of 128 women for each group  to achieve a power of 80% and a level of significance of 5% (two sided), for detecting a true difference in means of 0.35 units in Likert Scale values between different groups.n = 84 never users, n = 202 past users and n = 84 current users.A population of 370 women  was included in the study and completed the specific questionnaires. Of these women, 198 (53.5%) were premenopausal, while 172 (46.5%) were postmenopausal. The features of the two groups and their current/past use of HC and/or HT are reported in The answers to the questions “How much can HC/HT increase or reduce the risk of developing these diseases?” and “How much can HC/HT improve or worsen these symptoms?” are reported in p<.0001). Similarly, a negative effect on cardiovascular diseases is reported more frequently in premenopausal women (p=.0003) (p<.0001) , especially for HC use in premenopausal women (p=.0003) . On the p<.0001) .p = .02)  and mood swings (0.4 ± 0.1). The impact of HT on weight increase was significantly overestimated by postmenopausal women (p = .02) .p>.05), both in pre and in postmenopause.Categories of HC/HT use  were not linked to knowledge of effects of hormonal treatment on disease development and side effects  and depression”  (i.e. greater belief that there is an increase in risk in younger women).Calculations based on the age of included women confirmed the results of menopausal status. In a multiple regression model including all of the evaluated diseases, age was significantly inversely associated with the response to the question “HC/HT can increase the risk of developing venous thrombosis  (i.e. greater belief that there is an increase in risk in older women).In a multiple regression model including all possible symptoms associated with treatment, age was significantly associated with the response to the question “HC/HT can increase the risk of weight increase” . Also, the perceived protective role of HC or HT on colorectal cancer was more evident for HC in premenopausal women (p=.03).The answers to the question “How much can HT increase or reduce the risk of developing these cancers?” are reported in p>.05), with the only exception of the effect on ovarian cancer: current users were significantly more reporting a protective effect (p=.001).Categories of HC/HT use  were not linked to knowledge of effects of hormonal treatments on cancer development  (i.e. greater belief that there is an increase in risk in older women), and inversely associated with the response to the question regarding “developing uterine cervix cancer”  (i.e. greater belief that there is an increase in risk in younger women).In a multiple regression model including all evaluated cancers, age was significantly associated with the response to the question “HC/HT can increase the risk of developing ovarian cancer” . In particular, we have shown a direct increase in fear surrounding the use of hormones with age, for ovarian cancer (more perceived risk in older women), and an inverse relationship for uterine cervix cancer (more perceived risk in younger women).Adequate counselling surrounding hormonal treatments during life may help women recognize the health benefits and risks of these drugs . In dailMost vague complaints attributed to hormonal treatments can be explained by women's negative expectations (the nocebo phenomenon) or by the high background prevalence of such complaints . MoreoveConventional wisdom has been to counsel women thoroughly about hormonal treatments. This practice assumes that anticipatory counselling about side effects will improve acceptability and compliance. However, nocebo phenomenon studies in other areas of medicine suggest that such counselling may have a paradoxical effect: by raising these issues, clinicians may create or aggravate side effects that would not otherwise have occurred .Data on women’s knowledge of the effects of hormonal treatments (both HC and HT) on health and wellbeing are generally very scarce in the literature. Our results concerning venous thrombosis risk are surprising: the perceived risk is more evident in pre- than in post-menopause. Although venous thrombosis incidence naturally increases during the reproductive period of a woman’s life, the difference associated with HC use during this period is relatively low when looking at the whole lifespan; however, the risk during menopause is considerably higher, especially during HT treatment ,17.It is well known that hormones and their fluctuations in the natural menstrual cycle are frequently associated with mood alterations: in the context of negative reports regarding HC and mood, the findings of high-quality prospective studies show that the effect is negligible and the effect of hormones on mood is individual . HoweverCommunicating cancer risk information is relevant to a number of HCPs. Moreover, information about risk can also be important in motivating individuals to engage in cancer screening. Reliable epidemiological assessment of any association of hormone therapy use with cancer requires large numbers and careful control of all potential sources of appreciable bias.HC use has demonstrated a clear and significant protective effect on the risk of ovarian cancer. The risk of endometrial cancer is reduced by about 50% in ever users of HCs, a benefit which is greater with increasing duration of use. An association has been found between increased risk of uterine cervical cancer and long-term HC use. How breast cancer risk changes during HC use remains unclear: if an increased risk exists, it is mainly confined to current and very young users of HC . ConversBreast cancer is the most common cancer diagnosed among women in 140 of 184 countries. According to the 2012 report of the GLOBOCAN Project, breast cancer accounts for 25% (1.67 million) of all new cancer cases : our resConversely, cervical cancer is most frequently diagnosed in women between the ages of 35 and 44, and for this reason it is not surprising that the correlation is more reported by premenopausal women in our study . CervicaNumerous studies of interventions providing tailored information about cancer risk or possible screening, delivered by print or computer, have been conducted in the last decade. However, there is no evidence that the tailoring of these messages affects secondary prevention measures, such as the uptake of breast or uterine cervix cancer screening . In concThere were several limitations of this survey, including its cross-sectional study design and the simplified form of the questionnaire used in both pre- and post-menopausal women. In addition, our sample size calculation was able to recognize a true difference in means of 0.35 unit in some Likert Scale values between different groups, pre vs. postmenopausal women. However, it would be not large enough to enable the possible detection of negligible differences <0.35 point between different groups. Our results have not been corrected for family history of the presented diseases, for educational levels of women and for residual ovarian activity  which could strongly affect their attitudes. The strengths of this study include the in-depth questions and the availability of a large volume of data from participants. Moreover, it is the first published study that evaluates similar questions and perceptions throughout a woman's whole life.The results of the present study should be used to guide our counselling activity when prescribing hormonal treatments in women. Addressing false myths and trying to overcome unjustified worries is one of the most important tasks in therapeutic prescription today. The benefit/risk calculus of HC and HT tips decidedly towards benefits for most women. Our data suggest that our patients are primarily interested in the effect of hormonal treatments on venous thrombosis, mood, breast and cervical cancer risk, and, later in life, impact on weight gain, breast cancer and ovarian cancer risk.Click here for additional data file.


Migraines is likely to play a protective role in the risk of breast cancer. Some studies have shown that there is an inverse relationship between migraine and breast cancer, and some studies have not found an association; therefore, results from previous studies have been inconclusive and we conducted a meta-analysis to evaluate association between migraine and breast cancer.PubMed, EMBASE, Scopus and Web of Science were searched to identify studies on the association between migraine and breast cancer from January 1, 2000 through March 12, 2021. The pooled relative risk (RR) and the 95% confidence intervals (CI) was used to measure this relationship by assuming a random effects meta-analytic model.A total of 10 studies were included. Our study revealed that there was statistically significant inverse relationship between migraine and breast cancer in case-control studies 0.68 , but no significant relationship was found in cohort studies 0.98 . Also, migraine reduced the risk of ductal carcinoma 0.84 , and lobular carcinoma 0.83 . With respect to ER_PR status no association between migraine and breast cancer was found. We found no evidence of publication bias.Our analysis demonstrated a statistically significantly inverse relationship between migraine and total risk of breast cancer only in case-control studies. In summary, cohort studies do not support an inverse association between migraine and incident breast cancer. While in case-control studies, migraine has an inverse association with ductal carcinoma and lobular carcinoma of breast. The most prevalent malignancy in women is breast cancer . In 2020Migraine is a common primary headache disorder that is more prevalent in women than in men , 11 and Estrogen is likely to play a role in the pathogenesis of migraines and breast cancer and studies have shown an association between them. The first case–control study that was conducted in 2008, indicated that patients with a history of migraine had a lower risk of invasive ductal and invasive lobular breast cancer compared to those without migraine  and otheTo identify observational studies on the association between migraine and breast cancer, a comprehensive search was performed of several electronic databases including PubMed, EMBASE, Scopus and Web of Science from January 1, 2000 through March 12, 2021. The search term comprised the following keywords: “breast cancer”, “breast neoplasms”, “breast cancer lymphedema”, “unilateral breast neoplasms”, “inflammatory breast neoplasms”, “mammary neoplasms”, “breast invasive ductal carcinoma”, “metastatic breast cancer”, “migraine”, “migraine disorders”, “basilar type migraine”, “transformed migraine”, “migraine with aura”, “migraine without aura”, “complicated migraine”, “episodic migraine”, “hemiplegic migraine”, “menstrual migraine”, “ophthalmoplegic migraine”, “retinal migraine”, “sporadic hemiplegic migraine”, and “vestibular migraine”. Also, we investigated references of all articles to identify studies were not included during the initial search. The following inclusion criteria were selected for meta-analysis: the study subjects were adult (≥ 18 years old), the study comprised a case-control or cohort study design, the primary outcome was risk of breast cancer, the relative risk (RR) or odds ratio (OR) and the corresponding 95% confidence interval (CI) of the breast cancer associated with migraine were presented and finally, studies published in English. Furthermore, the exclusion criteria were articles include letter to the editor, case report, review and meta-analysis.Initially, we screened the titles and abstracts of all studies to identify those that met the inclusion criteria. Full-texts were assessed for studies that were difficult to screen with titles and abstracts only. Two authors (EH and FKH) screened final full texts and decision was made for each study after reading the full texts of all potentially eligible articles. In cases of disagreement, a third review author was consulted or were resolved by discussion. Totally, 705 articles were retrieved, of which a total of 10 articles remained after the review process shown in A structured data extraction form was used to extract data from the papers. The extracted data included: last name of the first author, publication year, country, study design, study purpose, sample characteristics, sample size, mean age, confounders. Extraction of data was done by same two review authors (EH and FKH) who conducted the study selection independently.The quality of studies was assessed using Newcastle—Ottawa quality assessment scale (NOS) adapted for observational studies . The NOS2 statistic. Subgroup analysis carried out according to the study design (case-control or cohort), hormone receptor status (ER+_PR+ or ER+_PR- or ER-_PR-), and histologic subtype . Leave-one-out sensitivity analysis was performed to identify influential studies in meta-analysis. Publication bias was determined by funnel plot and Begg’s and Egger’s tests. The p value of <0.05 considered as statistically significant. The analyses were performed using Stata software version 14.The pooled RR and the 95% confidence intervals were used to measure the association between migraine and the risk of breast cancer by assuming a random effects meta-analytic model. We used adjusted estimates and assumed that the odds ratios (ORs) from case-control studies approximated hazard ratios. Statistical heterogeneity was evaluated using Cochran’s Q-test and ISearch strategy and the algorithm of study selection are shown in In Ghorbani et al. study, the diagnosis of different types of headaches was made based on The International Headache Society (IHS) guidelines. Min Shi et al. examine the possible associations between breast cancer and migraine overall and between cancer subcategories and the two migraine subtypes; menstrually-related from non-menstrually-related migraine. C winter et al. and Lowry et al. considered migraine characteristics . Migraine with aura was defined as at least two headaches accompanied by any visual disturbances such as flickering lights, spots, and lines or loss of vision before or during a headache, not attributed to other disorders . In othe2 = 72.9%; P = 0.005) and case-control studies  and among all studies . 2 = 80.4%; P = 0.000), but heterogeneity decreased among lobular breast cancer studies . The results of the relationship between migraine and breast cancer stratified by hormone receptor status are shown in 2 = 38.2%; P = 0.152) and ER-_PR-  groups.In addition, Leave-one-out sensitivity analysis was performed to identify influential studies on pooled RR in meta-analysis. Our results showed that no single study significantly changed the pooled RR. Overall, we determined the possibility of publication bias using the funnel plot  as well The relationship between migraine and breast cancer was first studied in 2008 in a study by Mathes et al. the study reported that a history of migraine is associated with a decreased risk of breast cancer, particularly among ER+ /PR+ ductal and lobular carcinomas . A studyThe relationship between migraine and breast cancer is still unclear because both migraine and breast cancer are associated with estrogen and the mechanism of action of estrogen is very complex . Also onIn the present study, 10 articles were identified and included from PubMed, ISI, Embase and Scopus for a meta-analysis that concerns the association between migraine and the risk of breast cancer. Our analysis demonstrated a statistically significantly inverse relationship between migraine and the total risk of breast cancer. The evidence indicative of strong heterogeneity was positively detected among studies which could be due to differences in ages, study design, adjustment for confounding factors, and other unknown factors.Although a statistically significantly inverse relationship has been observed between breast cancer and migraine, its biological mechanisms is unclear . MigrainAnother explanation for a lower risk of breast cancer in women with a history of migraines could be that such women are more likely to avoid migraine triggers , some of which are also risk factors for breast cancer , 21, 32.Subgroups analysis by study design (cohort and case control), Histological subtype  and hormone receptor  was performed. Notably, such an inverse relationship was identified in the case–control studies , 20, 22,The results of our study were similar to previous meta-analysis studies that found a statistically significantly inverse association between migraine and the total risk of breast cancer . Also, i2 statistic to detect of heterogeneity. The evidence indicated that strong heterogeneity was detected among studies, but in lobular breast cancer significant decrease in heterogeneity was observed and no evidence of heterogeneity in the ER+_PR- and ER-_PR- groups was found. There can be various reasons for heterogeneity between studies. The first reason could be the attributed to the number of studies (including ten studies) in the meta-analysis. The second reason could be the difference in sample size of different studies. The third reason for heterogeneity could be publication year. The eligible studies were published from 2000 to 2021. The fourth reason could be related to the geographical area of the published studies. Most of the studies were in the United States. Also, differences in instrumental, methodology  and study population may be other sources of heterogeneity. Finally, the studies that we examined are prone to measurement bias and selection bias.We used the Q-test and IOur study had some limitations. First, we included studies written in English language. Second, due to the limited number of studies, we have combined cohort and case control studies. Third limitation of this study could be that in case–control studies, information may not have been accurate because it was obtained through self-reporting and there is a possibility of recall bias. Fourth, the studies that reviewed were from 2000 to 2021 and we did not include studies before 2000. Finally, some variables, such as age, that may affect heterogeneity due to limited information have not been studied.Our analysis demonstrated a statistically significantly inverse relationship between migraine and the total risk of breast cancer. In summary, results from this meta-analysis demonstrated that cohort studies do not support an inverse association between migraine and incident breast cancer. While case-control studies suggest an inverse association between migraine and breast cancer risk. The results of meta-analysis studies are valuable. Therefore, researchers can use this study for future research.S1 Checklist(DOCX)Click here for additional data file.


BRCA1, 4.0 [1.9–9.1] for BRCA2, 3.4 [1.4–8.4] for ATM and 4.3 [1.0–17.0] for PALB2. Our findings provide a population-based perspective to gene-panel testing for breast cancer predisposition and opportunities to improve predictors for identifying women who carry pathogenic variants in breast cancer predisposition genes.Population-based estimates of breast cancer risk for carriers of pathogenic variants identified by gene-panel testing are urgently required. Most prior research has been based on women selected for high-risk features and more data is needed to make inference about breast cancer risk for women unselected for family history, an important consideration of population screening. We tested 1464 women diagnosed with breast cancer and 862 age-matched controls participating in the Australian Breast Cancer Family Study (ABCFS), and 6549 healthy, older Australian women enroled in the ASPirin in Reducing Events in the Elderly (ASPREE) study for rare germline variants using a 24-gene-panel. Odds ratios (ORs) were estimated using unconditional logistic regression adjusted for age and other potential confounders. We identified pathogenic variants in 11.1% of the ABCFS cases, 3.7% of the ABCFS controls and 2.2% of the ASPREE (control) participants. The estimated breast cancer OR [95% confidence interval] was 5.3 [2.1–16.2] for  BRCA1 and BRCA2. This increase in actionable findings is in the order of 5–10% depending on the setting, inclusion criteria for actionable variants and study design5.Data from breast cancer predisposition gene panel testing are accumulating rapidly as it becomes more affordable and more accessible in different settings, including clinical care. Large studies based in clinical and commercial testing laboratories have demonstrated that gene panel testing has increased the number of clinically actionable variants identified in women undergoing testing, compared with previous testing that included only 8. Far fewer data are available to make inference about breast cancer risk for women unselected for family history, which is important to consider for population screening of affected and unaffected women. The value of population-based case-control studies and gene panel testing have recently been illustrated by Hu et al.9 who reported the outcome of a US-based study (CARRIERS consortium), involving over 32,000 affected and 32,000 unaffected women and Dorling et al.10 who reported the outcome of an international study (BRIDGES) involving 60,000 women affected and over 53,000 women unaffected by breast cancer. These studies provided improved estimates of the prevalence and the magnitude of breast cancer risk associated with pathogenic variants in known breast cancer predisposition genes to guide genetic counselling.Most of this work has been based on women selected for high-risk features, such as personal or family history of breast cancer, who underwent gene panel testing for cancer susceptibility at commercial laboratories4. Kurian et al.11 linked cancer registries from Georgia and California (USA) to the gene panel testing outcomes from four key clinical testing laboratories. Their study linked 24.1% of the 77,085 women with breast cancer to genetic testing results and reported that panel testing increased the frequency of actionable genetic findings by 1.5%. Several large studies have reported estimates of breast cancer risk associated with carrying a rare germline variant in a gene included in these gene panel tests16.Several studies have only included women affected by breast cancer (case only) and have reported variant prevalenceHere, we report the prevalence and breast cancer risk estimates associated with pathogenic rare variants identified in breast cancer predisposition gene panel tests, conducted in an Australian population-based case-control study of breast cancer (with an emphasis on early age at disease onset), involving both (i) age-matched population-based controls and (ii) a healthy older group of Australian women as controls.Table BRCA1 or BRCA2 in the ABCFS cases, ABCFS controls and ASPREE controls were 73 (5%), 22 (3%) and 128 (2%) respectively.There were 162 (11%) ABCFS cases with a pathogenic variant, compared with 32 (4%) of the ABCFS controls and 145 (2%) of the ASPREE controls , though there was evidence of an association from unadjusted analyses , with average ages at diagnosis of 38.2 [95% CI: 36.7–39.8] years and 42.4 [95% CI: 40.3–44.6] years, respectively. Carriers with pathogenic variants in BRCA1 or BRCA2 were also more likely to have a family history of breast cancer than carriers of pathogenic variants in the other genes (p < 0.0001).Breast cancer case subjects with pathogenic variants in BRCA1 were strongly associated with an increased risk of ER-negative breast cancer  and all other CHEK2 pathogenic variants (p = 0.75). CHEK2 pathogenic variant carriers are an important group of women to identify as they are at an increased risk of contralateral breast cancer and have a lower survival compared with non-CHEK2 pathogenic variant carriers (these data are predominantly informed by information about CHEK2 c.1100delC22) and could benefit from specific screening modalities such as magnetic resonance imaging23.Consistent with many other studies we found that, after pathogenic variants in ATM, only one of which was ATM c.7271T > G, a pathogenic variant that is well described in the Australian population and has an established association with a substantially increased risk of breast cancer26. Breast cancer risk estimates for women carrying other pathogenic variants in ATM have been consistently reported to be in the order of 2–3-fold16.We identified 17 carriers of pathogenic variants in BRCA1 and BRCA2 of ~4% when affected women attending high-risk clinics are the study subjects and gene panel tests are applied2. The prevalence of pathogenic variants in genes other than BRCA1 or BRCA2 are also similar in reports from clinical series of affected women (unselected for family history)4. Our findings are consistent with previous work in this setting and illustrate that, in contrast to pathogenic variants in BRCA1 and BRCA2 which are less prevalent in women diagnosed at older ages, the prevalence of pathogenic variants in other breast cancer genes is independent of age at diagnosis9.The literature has consistently reported a prevalence of germline pathogenic variants in genes other than BRCA1 or BRCA2 was 5%, as high as that reported from groups of women from high-risk clinical settings. This frequency may be surprising given the population-based ABCFS recruited participants unselected for family history. However, other attributes of the ABCFS participants and the nature of the breast cancer risks associated with pathogenic variants in genes other than BRCA1 and BRCA2 may partially provide an explanation. Predictive factors used to identify families appropriate to refer to high-risk genetics clinics, which include family history, have not been found to be as predictive for carrying pathogenic variants in genes other than BRCA1 and BRCA24. In addition, the average penetrance of pathogenic variants in these genes, although not precisely estimated beyond PALB228, is anticipated to be lower than for pathogenic variants in BRCA1 and BRCA2. The relative risks estimated here and elsewhere support this expectation. Therefore, by not selecting for affected women with a family history, yet having a focus on early onset disease, the ABCFS has a prevalence of pathogenic variants in other breast cancer susceptibility genes similar to that of highly selected women attending genetics services. Improved predictors for identifying women and families who carry pathogenic variants in breast cancer predisposition genes other than BRCA1 and BRCA2 are urgently needed.In our Australian population-based case subjects, the frequency of pathogenic variants in genes other than 30. Large publicly available databases have recently become available, including ExAC and gnomAD. Although they constitute invaluable resources as variant frequency databases and can be used to filter out “common” variants that are unlikely to be associated with increased risk of disease, these databases have important limitations when used as controls in case-control studies12. These limitations include (i) potential technical artefacts resulting from the aggregation of data generated by different sequencing platforms, (ii) differences in the call sets due to the cases and controls not being jointly processed or annotated, (iii) the absence or limited lifestyle and ancestry information for the control subjects and (iv) the absence of genetic information available at the individual subject level as only variant-based data is available. In the context of gene-burden analysis for rare conditions, these public databases can serve as reasonable control datasets with additional computational precautions to mitigate the above-mentioned issues, as described by Guo et al.31. For common diseases including cancer, they are still likely to contain affected individuals, even when excluding the TCGA sample set of gnomAD and ExAC. By using 862 population-based age-match controls from the ABCFS and 6549 older healthy Australian women participating in ASPREE, our study overcame some of these limitations.A significant challenge for studies in this setting, and the assessment of very rare variants, is the availability of suitable datasets to use as reference controls. Few have had resources that provide population-specific reference control datasets of suitable size to incorporate into risk estimation methodologyThe inclusion of older controls from ASPREE in this study means that our unadjusted OR estimates are biased, so we adjusted all ORs in our main analyses for age and other potential confounders . A sensitivity analysis based just on the age-matched cases and controls from the ABCFS gave broadly similar ORs as the main analyses, validating our adjustment methods and our adjusted OR estimates.8 or Myriad11 who regularly deposit their classification calls into ClinVar. For genes such as BRCA1, BRCA2, TP53 or the mismatch repair genes, we were also able to keep our pathogenicity assessment contemporary with regular updates from the genes respective expert panels.In our study, although different sequencing platforms have been used to generate the raw sequencing data, we aimed to reduce potential artefactual variant calls by utilising the processing pipeline that was the most appropriate for the sequencing technology used to produce the raw sequencing data for the case and the control subjects, then harmonising the variant calls by (i) restricting calls to regions that are equally able to be called across the three targeted regions and (ii) applying the same filtering and annotation pipelines. Our study used ClinVar to select pathogenic variants to include, as a group, in our association analysis. Although the level of confidence in ClinVar calls can be variable, as demonstrated by the star rating system or the “Conflicting evidence of pathogenicity” label, this approach allowed us to harmonise our pathogenicity calls with other studies, e.g., from AmbryBRCA1 and BRCA2, although some recent and promising progress has been made for PALB232. A large number of unclassified variants (n = 924) were identified in the case subjects of the ABCFS in this study. It is likely that an extremely small number of these variants will be classified as pathogenic in the future. Recent data from Dorling et al.10, provided further evidence for breast cancer risk for missense variants in a number of breast cancer susceptibility genes, most notably CHEK233. Considerable effort has been invested by the ENIGMA consortium to understand the effect of deleterious variants in these genes and keep the variant classification up-to-date and publicly available.A limitation of our approach is the potential to underestimate the contribution of missense variants, as they are very challenging to classify. Functional assays can provide important additional information for variant classification but are currently less well developed for breast cancer predisposition genes other than Our data provide a population perspective to gene panel testing for breast cancer predisposition and contribute to international efforts to refine the breast cancer risk estimates for genetic variants identified in panel testing in women enriched for early age at breast cancer diagnosis and unselected for family history.The present study includes cases and controls from the Australian Breast Cancer Family Study (ABCFS) and participants from the ASPirin in Reducing Events in the Elderly (ASPREE) study.35.Aspects of the ABCFS relevant to this study are the population-based probands and corresponding data collected at baseline. Briefly, the ABCFS probands were either breast cancer cases (identified through population-complete cancer registries) or age-matched controls. All probands completed interviewer-administered risk factor questionnaires and verification of cancers was sought through pathologist reviews of cancer tissue, pathology reports, cancer registries, medical records, and death certificates37. Our statistical analysis only used ASPREE data that were collected at baseline. ASPREE female participants who reported at baseline a personal history of breast cancer were excluded from the statistical analysis.The ASPREE study is a randomized, placebo-controlled trial for daily low-dose aspirin. We selected Australian participants aged 70 years or older at enrolment, without a previous diagnosis or current symptoms of atherothrombotic cardiovascular disease, physical disability, or dementia. Study design, recruitment, baseline characteristics and outcomes have been previously describedWritten informed consent was obtained from all individual participants included in the study. This study was approved by the Human Research Ethics Committee of the University of Melbourne and Monash University.We analysed rare genetic variants identified in the blood-derived germline DNA of 1,451 women diagnosed with breast cancer and 857 age-matched controls participating in the ABCFS, and 13,197 individuals (6549 women) enroled in the ASPREE trial.ATM: NM_000051, BARD1: NM_000465.2, BRCA1: NM_007294.3, BRCA2: NM_000059.3, BRIP1: NM_032043.2, CDH1: NM_004360.3, CHEK2: NM_007194.3, FANCM: NM_020937.2, MLH1: NM_000249.3, MRE11A: NM_005591.3, MSH2: NM_000251.2, MSH6: NM_000179.2, MUTYH: NM_001128425.1, NBN: NM_002485.4, NF1: NM_000267.3, PALB2: NM_024675.3, PMS2: NM_000535.5, PTEN: NM_000314.4, RAD50: NM_005732.3, RAD51C: NM_058216.2, RAD51D: NM_002878.3, RECQL: NM_002907.3, STK11: NM_000455.4, TP53: NM_000546.5.Our analysis was restricted to the coding region and proximal intron-exon junctions of 24 genes; 38. Gene-panel testing and raw DNA sequencing reads alignment to the reference genome GRCh37 were performed as described in Nguyen-Dumont et al. and Lacaze et al. for the ABCFS and ASPREE subjects, respectively39. Briefly, the ABCFS subjects were sequenced in-house, using either a Hi-Plex panel on the NextSeq55040 or a HaloPlexHS panel on the HiSeq3000 . The ASPREE subjects were sequenced using an AmpliSeq panel on the Ion Torrent S5TM XL  and aligned sequencing files (BAMs) were provided for variant calling in this study.Only selected regions of PMS2 were targeted as described previously41 and restricted to the overlap of the regions targeted by the three panels. For ASPREE controls sequenced on the Ion Torrent platform, variant calling had also been performed using the Torrent Variant Calling Suite v1.5 as previously described42 and the intersection with the variant calls from VarDict was used in downstream analyses. Subsequent genetic analyses were restricted to variants: (i) with the following read depth and variant allele frequency: 50X and 0.2 for Hi-Plex and AmpliSeq samples, and 30X and 0.15 for HaloPlexHS samples. In addition, for the ASPREE samples, we determined a conservative but high-confidence call set by filtering out (i) variants present in more than 0.05% of all ASPREE participants (n = 65), under the assumption that common variants were either sequencing artefacts or too common to be associated with disease risk, and (ii) variants that had passed our quality filters described above in <95% of the genotype calls at a given genomic location, to ensure that variants that progressed to the next analysis stage were adequately covered.Variant calling was performed using VarDict 1.7MUTYH variant carriers are reported in Supplementary Table CHEK2 c.1100delC) were included in this analysis. Also included were PTVs that were absent (unreported) in ClinVar, except if they were located in the last coding exon. Further details can be found in Supplementary Table Variant annotation was performed using VarSeq VSClinical v2.2  and included ClinVar annotations from July 2020. This study focused on rare predicted protein-truncating variants (PTVs) and pathogenic (including likely pathogenic) variants. Rare variants were defined as those identified in ExAC v.0.3 with a minor allele frequency ≤0.01 in the non-Finnish European population (NFE non-TCGA). Genetic variants were considered pathogenic if they were annotated as “Pathogenic” or “Likely Pathogenic” in ClinVar. Mono-allelic pathogenic For each of the genes considered, pathogenic variants were combined and an odds ratio (OR) for their association with breast cancer was estimated using unconditional multivariate logistic regression. These analyses were adjusted for the following potential confounders : age at enrolment, height, body mass index, number of children, number of years of education and number of alcoholic drinks per week. These potential confounders are the known breast cancer risk factors that are available in both the ABCFS and ASPREE datasets, and data harmonisation was performed to make the relevant variables from these two studies comparable.MUTYH, see above) were excluded from the main analyses.Excluded from all statistical analyses were males, ASPREE females with a previous diagnosis of breast cancer, and females with no gene-panel testing data. Women with missing data were excluded from analyses involving the relevant variables, though <1% had missing values for each variable . Women with pathogenic variants in two or more genes (other than p-values for comparing nested models. All p-values were two-sided and a p-value threshold of 0.05 was used to define statistical significance. All analyses were performed using R version 3.4.2.The effect of exclusions and other analytical choices was investigated with sensitivity analyses. Wald confidence intervals were calculated for each OR, and the likelihood ratio test was used to generate Further information on research design is available in the Supplementary InformationReporting Summary


Background: Some literature has studied the relationship between lignans intake and its metabolite, enterolactone, and breast cancer survival, but the results are far from consistent and conclusive. Therefore, we conducted a systematic review and meta-analysis in this situation.Methods: From its inception to August 2020, we conducted a comprehensive search of PubMed, Embase, Web of Science, and Cochrane Library databases. This study reported the correlation between lignans intake and serum enterolactone concentrations and prognosis of breast carcinoma. The total hazard ratios (HRs) and 95% confidence interval (95% CI) were estimated, comparing the highest versus the lowest category of lignans intake and serum enterolactone concentrations, using a fixed or random-effects effect model.Results: A total of 6 articles were included in reporting the all-cause mortality (ACM), breast cancer-specific mortality (BCSM), and recurrence of 2668, 1516, and 474 breast cancer patients in 18053 breast cancer patients. In postmenopausal women with breast cancer, lignans intake or enterolactone concentrations were associated with a reduced risk of all-cause mortality (maximum and minimum) , as was the association with breast cancer-specific mortality (maximum and minimum) . Stratified analysis showed that exposure type and diagnosis time might be the sources of heterogeneity. In premenopausal women, the relationship seemed to be the opposite, showing an increased risk of all-cause mortality (maximum and minimum) in breast cancer patients . No significant association was found between lignans intake or enterolactone concentrations and breast cancer recurrence .Conclusion: This study provides limited evidence that lignans intake and higher serum enterolactone concentrations in postmenopausal women are beneficial to breast cancer patients' prognosis. In premenopausal women, however, the relationship may be reversed. In 2020, the American Cancer Society estimated that the number of new breast cancer cases and deaths that will occur in the United States is equivalent to the data estimated in 2019 Diet and nutrition are recognized modifiable risks of breast cancer  PROSPERO under ID number CRD42020208054 (https://www.crd.york.ac.uk/prospero/).We searched for articles published before August 2020 in PubMed, Embase, Web of Science, and Cochrane library databases. We identified studies by using Medical Subject Headings (MeSH), the keywords used for the systematic search were: (“breast carcinoma” OR “breast cancer”) AND  AND (enterolactone OR lignan), and the specific search formula was given in Supplementary. We would also search by combining the above terms with keywords and reference manuals. This investigation was registered onWe used the following criteria to include eligible articles in this review: (1) research conducted in women diagnosed with breast cancer, (2) report the intake of lignan or the serum level of enterolactone (either before or after diagnosis) as exposure, in at least two categories, (3) report all causes or mortality specific to breast cancer as a result of interest, (4) provide an estimate of the effect as a relative risk (RR) or hazard ratio and the 95% confidence interval (CI) of the corresponding mortality rate for each category, and(5) studies on lignan intake need to have a relatively strict dietary assessment, such as FFQ(food frequency questionnaire), or use a country or center-specific nutritional questionnaire. Besides, articles were excluded if (1) they were abstracts, letters, reviews, or Nonclinical studies, (2) papers with insufficient data for estimating hazard ratio (HR) and 95% confidence interval (Cl), (3) research had duplicate data or repeat analysis.All qualified documents were evaluated and extracted by two independent researchers (LZ and FYJ). If there were conflicting opinions, the two researchers would discuss, seek a third person's views (CXH), and reach a consensus. The included studies included the following characteristics: study name, first author's name, publication date, country, number of subjects/cases, exposure name and level classification, average follow-up time, menopausal status, hazard ratios(HR) of all-cause mortality (ACM), breast cancer-specific mortality (BCSM) and recurrence and 95% confidence intervals (CI), as well as the variables, used to maximize the adjustment of the multivariate analysis. Finally, we chose ASM, BCSM, and recurrence as our endpoints for meta-analysis Table . The facThe Newcastle-Ottawa Scale (NOS) was used to assess the included studies' quality by two independent authors (LZ and FYJ). The NOS score consists of three parts, namely selection (0-4 points), compatibility (0-2 points), and outcome assessment (0-3 points) (Supplementary). Research with NOS score ≥ 6 points was considered a high-quality study and included in the analysis, and finally, six articles were included in the study Figure .2 statistic, which describes the percentage of the total variation in studies due to heterogeneity rather than chance (A P heterogeneity <0.10 or I2 >50% suggested significant heterogeneity). When the heterogeneity is significant, the random-effects model is used; otherwise, the fixed effects model can combine the effect sizes. To test each main study's impact on the combined effect's size, we performed a sensitivity analysis by continuously excluding each study from the primary analysis. Also, we did a subgroup analysis to explore the source of heterogeneity. Although the number of initial studies was small (<10), we still perfected the egger test to investigate potential publication bias. All analyses were conducted with Stata software, version 12 . A P value <0.05 was considered statistically significant.As an index to measure the value of prognosis, HR>1 means that there is a poor prognosis for the maximum group of lignans intake or serum enterolactone levels. Between included trials' heterogeneity was assessed using Cochrane's Q test and quantified by IWe identified 507 publications in 4 databases . After reviewing the titles and abstracts of the retrieved publications and removing duplicates, 45 publications were retained for full-text screening. After excluding studies that did not meet the inclusion criteria, a total of 6 articles Table heterogeneity= 0.845, I2 = 0.00%); These 4 studies also reported the relationship between premenopausal lignans intake or enterolactone in vivo and breast cancer-specific mortality. Because there was no large heterogeneity, the fixed-effects model was used to combine study-specific results.As shown in Figure heterogeneity= 0.063, I2 = 52.2%). Because of the large heterogeneity, we adopted a random-effects model to combine study-specific results. We used subgroup analysis to trace potential sources of heterogeneity between studies and assess the consistency of conclusions between different patient subgroups. Table 2 of cohort:60.0%, Ph=0.082; I2 of case-control: 51.2%, Ph=0.127), the heterogeneity of exposure types is reduced , and the heterogeneity of different diagnosis times is significantly reduced . It can be inferred from the above that the source of heterogeneity has little to do with the type of research, and the type of exposure and the time of diagnosis may be the source of heterogeneity. We also evaluated the stability of the results through sensitivity analysis .In Figure d: P values represent differences between subgroups; Ph: P values for between-study heterogeneity.Pheterogeneity = 0.272, I2 = 17.2%). Seibold's study was conducted in patients after diagnosis, while Cecilie's research was conducted in pre-diagnosed populations. They concluded that the level of enterolactone in the body has nothing to do with breast cancer recurrence.Two papers Begg and Egger's tests indicated no publication bias in the meta-analyses for the association between lignans intake or serum enterolactone and all-cause mortality and breast cancer-specific mortality. Although there was little literature included in the review (n=6<10), we still performed these two tests to detect publication bias. Among them, publication bias was not detected for the association between premenopausal lignans intake or serum enterolactone and all-cause mortality (Pr >|z|=1 for Begg's tests and P >|t|=0.975 for Egger's tests); so was breast cancer-specific mortality (Pr >|z|=0.734 for Begg's tests and P >|t|=0.611 for Egger's tests). Publication bias was also not detected for the association between postmenopausal lignans intake or serum enterolactone and all-cause mortality (Pr >|z|=0.133 for Begg's tests and P >|t|=0.087 for Egger's tests), and breast cancer-specific mortality (Pr >|z|=0.452 for Begg's tests and P >|t|=0.093 for Egger's tests). Figure Many studies have investigated the relationship between lignans intake or the concentration of enterolactone in its blood metabolites and the prognosis of breast cancer. Still, the conclusions were not entirely consistent and accurate. Therefore, we reviewed the published literature and conducted a meta-analysis to make a more precise estimate of this relationship. Our meta-analysis combined the outcomes of 18053 breast cancer patients from 6 individual studies, indicating that in postmenopausal breast cancer patients, the intake of lignans or the concentration of enterolactone in the body has a reduced risk relationship with the patient's all-cause mortality (maximum vs. minimum) , as was the relationship with breast cancer-specific mortality (maximum vs. minimum) . Subgroup analysis also showed that the type of exposure and time to diagnosis might be the source of heterogeneity, rather than the kind of study design. In premenopausal women, this relationship seemed to be the opposite, showing a trend of increased risk with all-cause mortality in breast cancer patients (maximum vs. minimum) .In our research, the aggregated estimates were stable when limited to the included articles and seemed to explain some problems. In postmenopausal women, breast cancer patients tended to have a good prognosis when the intake of lignans or enterolactone concentration in the blood is higher. McCann's study has similar conclusions In this study, we also explored the relationship between the upper and lower quartile lignans intake or the concentration of enterolactone levels and breast cancer prognosis. We provided a meta-analysis of studies Polyphenolic phytochemicals (such as lignans) can block and inhibit carcinogenesis and interfere with cell and molecular processors at different carcinogenesis stages. They may also inhibit the activation of pre-carcinogens into electrophilic species and their subsequent interaction with DNA to prevent the occurrence of cancer This research's strengths included a comprehensive and systematic literature review of relevant literature on lignans and its metabolites and breast cancer prognosis. In the postmenopausal women group, we used subgroup analysis to find the source of heterogeneity and used sensitivity analysis to ensure the results' stability, and there is no publication bias. It is also worth talking about the limitations of our literature. First, there was a lack of uniform standards for assessing lignans intake included in the literature; second, dietary supplements also had a particular impact on phytoestrogens. We did not consider the effect in this regard. Finally, we had no fixed limit on the follow-up time; most of them focused on 4-5 years. Future research may need to pay attention to the length of follow-up time. For Guglielmi's analysis In postmenopausal women, lignans' intake and higher serum enterolactone concentration were beneficial to breast cancer patients' prognosis. However, in premenopausal women, such exposure may not benefit the prognosis of the patient. Since there are not many conforming documents included, the conclusions need the support of multi-center, well-designed studies to understand better the potential benefits or harms of lignans and its metabolites to breast cancer patients.Supplementary figures and tables.Click here for additional data file.


Menopausal hormone therapy (HT) prescribing practices have evolved over the last few decades guided by the changing understanding of the treatment’s risks and benefits. Since the Women’s Health Initiative (WHI) trial results in 2002, including post-intervention analysis and cumulative 18-year follow up, it has become clear that the risks of HT are low for healthy women less than age 60 or within ten years from menopause. For those who are experiencing bothersome vasomotor symptoms, the benefits are likely to outweigh the risks in view of HT’s efficacy for symptom management. HT also has a role in preventing osteoporosis in appropriate candidates for treatment. A comprehensive overview of the types, routes, and formulations of currently available HT, as well as HT’s benefits and risks by outcomes of interest are provided to facilitate clinical decision making. Menopausal hormone therapy (HT) prescribing practices have evolved over the last few decades guided by the changing understanding of the treatment’s risks and benefits. Prior to the Women’s Health Initiative (WHI) trial results in 2002, HT was generally accepted as appropriate and safe for treatment of menopausal symptoms, as well as for chronic disease prevention including cardiovascular disease (CVD) prevention –4. The uSymptoms are common during menopause with up to 70 - 80% of women experiencing vasomotor symptoms (hot flashes and/or night sweats).12 HT is the most effective treatment for the relief of vasomotor symptoms (VMS), and also reduces bone loss, fracture risk and can treat the genitourinary syndrome of menopause (GSM) when used locally . DiffereOverall, the recommendation is to use an individualized approach when treating symptomatic menopausal women with periodic reevaluation that includes the appropriate type, dose, formulation and route of administration to meet treatment goals for the duration needed. The following review aims to provide a practical tool for healthcare professionals caring for menopausal women by discussing in detail various types and formulations of HT available as well as the risks and benefits of HT for common outcomes of interest in clinical practice.Various formulations and routes are available to allow for an individualized approach to menopause care including estrogens, progestogens, and tissue selective estrogen complex (TSEC). Estrogen therapy alone is used for post-menopausal women who have undergone a hysterectomy . EstrogeEstrogens are well absorbed through the gastrointestinal (GI) tract, skin and mucus membranes. Formulations are available as oral preparations, transdermal patches, sprays, gels, topical emulsion preparations, vaginal preparations, in combination with progesterone, and in a TSEC , 18. TaIn the US, oral estrogen therapy in the most widely used formulation. Estradiol is converted to estrone during first pass metabolism such that estrone is the major hormone found in the circulation . Risks oTransdermal and topical estrogens bypass first pass metabolism so can be dosed lower than oral estrogen. Because of the avoidance of the first pass metabolism, they have less impact on triglycerides, coagulation factors and gallbladder disease , 18. AbsTransdermal estrogen patches have a higher likelihood of causing skin irritation compared to other topical or oral formulations. Topical formulations including gels, sprays and emulsions may lead to a small amount of estradiol transferred if skin-to-skin contact is made within two hours of administration .Low-dose vaginal estrogen therapy use is FDA approved to treat moderate-to-severe vaginal dryness and dyspareunia caused by GSM . It comeProgestogen therapy is primarily used to avoid an increased risk of endometrial cancer for a woman on systemic estrogen, as unopposed estrogen thickens the uterine lining and increases risk of endometrial cancer. Progestogens protect against this endometrial thickening by decreasing estrogen receptors in target tissues and by inhibiting the luteinizing hormone surge that results in increased estrogen production from ovaries , 21. ProProgestogen options include micronized progesterone and synthetic progestins, such as MPA or norenthindrone. Micronized progesterone is bioidentical to the hormone made endogenously and has efficient oral absorption. It can also be given vaginally, as was done in ELITE . CompareProgestogens come in oral and transdermal forms. The most commonly used and widely studied formulation of progestogens in the United States (US) is the oral progestin MPA. Oral progesterone has mild sedating effects, micronized progesterone significantly decreases VMS and helps with sleep . TransdeFDA-approved combined estrogen-progestogen formulations provide adequate dosing of progestogen for endometrial protection, and include continuous-cyclic estrogen- progestogen, continuous combined estrogen-progestogen therapy, and intermittent combined estrogen-progestogen therapy . ContinuWhile various options of combined estrogen progestogen therapy (EPT) are available, no evidence supports one regimen over the other. The Postmenopausal Estrogen/Progestin Interventions (PEPI) trial showed that, among women with a uterus on estrogen therapy alone, a 34% increased risk of endometrial hyperplasia, was observed, while those on combined therapy had a risk of 1% . ContinuUterine bleeding with use of EPT oftentimes results from withdrawal bleeding after progestogen cessation or breakthrough bleeding. Forty percent of women on continuous- combined EPT will have break through bleeding in the first 3-6 months . BreakthTSECs pairs a selective estrogen-receptor modulator with estrogen. The FDA approved medication marketed as DuaVee combines 20 mg bazedoxifene, a selective estrogen-receptor modulator, with 0.45 mg oCEE for use in postmenopausal women with a uterus. It is used for moderate to severe VMS and for prevention of osteoporosis. Compared to placebo, TSEC had a similar profile in that it did not increase breast tenderness, breast density, or endometrial thickness; avoiding these conditions may be indications to use this therapy over other formulations. Amenorrhea occurs in more than 83% of users –32. It hEstrogen is the most effective treatment for VMS. Women with an intact uterus require combined progestogen therapy with estrogen for endometrial protection. For those without a uterus, estrogen alone can be used. Since the risk-benefit profile of HT treatment in symptomatic menopausal women is impacted by age, time since menopause and existing comorbidities, shared decision making is critical in determining what HT formulation and route to use and when discontinuation is appropriate . Table The relationship between HT and cardiovascular disease is complex. Prior to the WHI, observational studies had suggested that HT was associated with lower CVD incidence and all-cause mortality, comparing users and nonusers , 41. In The WHI aimed to evaluate through an RCT the cardiovascular effects of HT in women, specifically assessing rates of CHD as the primary outcome. Unexpectedly, the WHI trial  showed an elevated risk of cardiovascular events in the oCEE + MPA treatment arm in all women  . Since 2Based on data from the intervention phase of the WHI, women aged 50 to 79 years in the overall cohort on oCEE + MPA had increased risk of CHD, defined as non-fatal myocardial infarction and coronary death, compared to placebo, whereas women on oCEE alone had neutral CHD outcomes. Sub-analysis from the WHI showed that age made a difference in CHD outcomes, supporting the timing hypothesis. In the oCEE arm, women aged 50 to 59 trended toward decreased risk of CHD compared to women aged 70 to 79  , 45. FolImportantly, cumulative follow up at 18 years showed no difference in cardiovascular mortality between the oCEE + MPA or oCEE group versus placebo for women age 50 to 79 years . Furthermore, there was no significant difference in CVD mortality when groups were stratified by age . PotentiA Cochrane review in 2015 of RCTs of HT showed an overall reduction in risk of CHD and all-cause mortality in women who started HT within 10 years of menopause . CompareDOPS, a large open-label study with no placebo arm, was started at the same time as the WHI and enrolled women between the ages of 45 and 58 who were randomized to HT with triphasic estradiol and norethisterone acetate, 2 mg estradiol per day or no treatment. Shierbeck, et al. used data from this trial to study a primary composite end point of death or admission to the hospital for heart failure and myocardial infarction. After 10 years of intervention, they found that those receiving HT had significantly reduced risk of the primary CVD composite endpoint compared to no treatment  .Summary: HT has favorable or neutral effects on CHD risk when started in women younger than 60 years old or within 10 years of menopause, in the absence of contraindications.The type, formulation and route of HT carry different side effects and risks. The WHI trial showed that unopposed oCEE has less adverse cardiovascular outcomes than an estrogen plus progestin formulation , 38, 50.The risk of ischemic stroke was higher in both the oCEE and oCEE + MPA groups during the WHI initial intervention study for women ages 50 to 79 years (HR: 1.35 [95%CI: 1.07 -1.76] and 1.37 [95%CI: 1.07-1.70]). No significant differences were noted when stratified by 10-year age groups , 36.Summary: The findings for HT and stroke have been inconsistent, but systematic reviews suggest that stroke risk depends on age and time from menopause; women who initiate HT younger than 60 years of age or who are within 10 years of menopause onset do not appear to have an increased risk of stroke.It has been well established that estrogen, especially oral estrogens, increase VTE risk , 52, 53.A meta-analysis of 19 RCTs all using oral estrogens with or without a progestogen found that women who started HT fewer than 10 years after menopause and younger than 60 showed that it increased the risk of VTE compared to placebo, without differences by age group  , 36. ForSummary: Risk of VTE differs based on HT formulation. Oral HT increases the risk of VTE, whereas transdermal HT does not appear to increase the risk of VTE.Estrogen deficiency is thought to increase risk of heart failure with preserved ejection fraction due to an increase in cardiac mass and association with diastolic dysfunction . Small oSummary: Overall, HT does not seem to alter the risk of heart failure with or without reduced ejection fraction, or the risk of heart-failure-related mortality.Oral and transdermal estrogen use have both been shown to lower blood glucose and improve insulin sensitivity; while oral estrogen has a stronger effect . EstrogeWomen on oCEE + MPA in the WHI had a statistically significant reduced risk of type 2 diabetes mellitus (T2DM) compared to placebo . Women in the oCEE-alone arm also showed this benefit  . The HeaSummary: HT reduces the risk of T2DM, lowers fasting blood glucose and HbA1c and improves insulin sensitivity.Weight gain and central weight re-distribution is common for women post-menopause –66. DisrAfter menopause it’s not uncommon to see increases in total cholesterol, increases in low-density lipoprotein (LDL), and increases in lipoprotein (a) (Lp(a)) . A meta-Summary: HT tends to be weight neutral in post-menopausal women, although it may favorably affect body composition, including decreasing visceral fat, increasing lean body mass, and improving the lipid profile. Specific effects, however, vary by HT formulation, regimen, and route of delivery.Women suffer from Alzheimer’s disease (AD), the most common form of dementia, at a higher incidence than men. While this may be due to the increased life-span of women, it is also possible that sex-specific factors such as reductions in estrogen and organizational effects of sex steroid hormones in the female brain early in development confer increased risk and influence incidence differences , 70. TheIn the WHI, women older than 65 years were enrolled in the WHI Memory Study (WHIMS). Women in the oCEE + MPA arm had double the risk of dementia compared to women assigned placebo (oCEE+MPA HR 2.01 (95% CI: 1.19-3.42); oCEE alone HR 1.47  . The WomShao et al. examined whether or not the timing or type of HT played a role in risk of AD in 1,768 women in the population-based Cache County Study. Results showed that women who started HT within 5 years of menopause had a 30% reduced risk of AD (95% CI: 0.49-0.99). Those who started HT 5 or more years after menopause had increased rates with a similar HR as the WHI memory study  . KEEPS hSummary: HT appears to increase the risk of AD when initiated in older women or those more distant from menopause onset. When initiated in early menopause, however, HT appears to have a neutral effect on cognitive function.Both observational studies prior to the WHI and the WHI suggested increased breast cancer risk in HT users , 79. TheDuring 13-year cumulative follow-up, women randomized to oCEE + MPA continued to show statistically significant risk of invasive breast cancer compared to women assigned to placebo . The absolute risk of breast cancer is considered rare with <1 additional case/1,000 person years of use, which is less than the risk associated with drinking two glasses of wine per day and similar to the risk seen with obesity or a sedentary lifestyle , 81.Those on oCEE alone did not show an increased risk, and in fact showed a nonsignificant reduction in breast cancer risk after an average of 7.2 years of randomization. At 11.8 years, those on oCEE vs placebo had a statistically significant reduction in overall breast cancer  and in deaths from breast cancer  . At 13 yBreast cancer risk in the setting of HT is likely variable based on formulation of HT. Transdermal estradiol alone may have less of a protective effect on breast cancer risk than oral oCEE alone due to different effects on the breast tissue; however, prospective randomized controlled trials have not been done to compare them directly and sub-analysis of the Million Women Study found no statistical differences between the different formulations , 83. AddSummary: Breast cancer risk varies based on HT formulation and duration of use. oCEE +MPA increases risk of breast cancer but not breast cancer mortality. In contrast, oCEE alone reduces the risk of breast cancer and breast cancer mortality.Post-menopausal women have been shown to have a 1.5 times higher risk of colon cancer than pre-menopausal women of the same age . Prior tObservational studies since the WHI have shown protective effects of recent and current HT use on colorectal cancer with reduction in incidence and mortality from colorectal cancer . An obseSummary: While more research is needed, initial data suggests oCEE + MPA lowers the risk of colon cancer while oCEE alone does not.th most common cancer in women in the US and hormone dependent in 90% of cases  . Total cSummary: At long term follow up, the incidence of total cancer mortality did not differ between the HT and placebo groups.Osteoporosis affects 10 million Americans and is projected to increase by 50% by 2025 . Post-meBoth oCEE + MPA and oCEE alone reduced risk of hip fractures by 33% compared to placebo during the intervention phase of the WHI  .Summary: Both oCEE + MPA and oCEE alone significantly reduce the risk of hip fracture, although these benefits may dissipate over time after stopping HT.The risk of vertebral fractures was significantly lower during the intervention phase for both oCEE plus MPA and oCEE compared to placebo  . The redSummary: HT reduces the risk of vertebral fractures.Intervention data showed a significant risk reduction of all fractures in both HT groups compared to placebo  . For comSummary: HT reduces risk of all fractures. A difference in preventing fractures has not been found between bisphosphonates and estrogen.All-cause mortality was not different between either HT group vs placebo during the intervention phase of WHI or during 13 year cumulative follow up . The cumSummary: The effect of HT on all-cause mortality varies by age, with a trend toward reduction in mortality among younger women but not among older women distant from menopause onset.Early menopause is associated with numerous long-term health consequences including increased risks of osteoporosis, cognition and mood changes, heart disease, stroke, Parkinson disease, ophthalmic disorders and early mortality , 102. ThWomen undergoing hysterectomy with bilateral oophorectomy have a reduced risk of ovarian and breast cancer but do face adverse effects if menopause is induced prematurely . BilaterA recent sub analysis of the WHI estrogen- alone arm evaluated women with prior hysterectomy with or without BSO to assess effects of HT on women depending on BSO status. Both during the intervention phase and at cumulative 18 year follow up, there was no difference in HT’s effects on CHD, breast cancer, all-cause mortality or a global index score  between women with or without BSO. Global index HRs during the intervention phase generally increased (were more adverse) as age increased: 0.85 (95%CI: 0.54-1.34), 0.94 (95%CI: 0.74-1.19) and 1.42 (95% CI: 1.09-1.86) for respective 10-year age groups. During an 18 year cumulative follow up, younger women in the oCEE group had significantly reduced all-cause mortality compared to older women . Those without BSO did not show a difference when stratified by age during the intervention phase and at cumulative follow up . Thus, iSystemic HT is not recommended in women with active breast cancer or a history of breast cancer due to an increased risk of recurrence , 104–106Many women continue to report vasomotor symptoms beyond age 60, with over 40% of women aged 60 - 65 reporting moderate to severe VMS , 109. FoHT is the most effective treatment for the vasomotor symptoms of menopause, which are common and can adversely impact a woman’s life. It is clear now that the safety of HT depends on a woman’s age and duration of time since menopause, such that the benefits tend to outweigh the risks in healthy women less than age 60 or within ten years from menopause. There are various types, formulations and routes of HT available to women so that their healthcare practitioner can tailor and individualize their treatment to manage their symptoms. Guidelines from NAMS, ACOG and the Endocrine Society as well MenoPro app, a free mobile app and decision-support tool from NAMS, provide assistance to practitioners treating menopausal women.JM, JK, and JEM all contributed to the literature review, drafting and editing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Breast cancer remains the leading cause of death for women globally, including in Indonesia. Breast cancer screening plays a vital role in reducing deaths caused by breast cancer. However, breast cancer screening rate is still low and studies on determinants for breast cancer screening is limited in Indonesia. This study aimed to identify the determinants of breast cancer screening among women in Indonesia. This population-based study was conducted among 827 women who lived in either rural and urban areas, using a stratified sampling design where were based on province and locality combinations. Data were analysed using a binary logistic regression model to assess the associations between independent and dependent variables. As many as 827 women with an average age of 29.91 (± 11.14) years old participated in this study. The overall breast cancer screening among women was 18.74%. Knowledge of breast cancer risk factors, signs, and symptoms , age of 35 to 39 years old , and household income of ≥6,000,000 IDR (≥457 USD)  were associated with breast cancer screening attendance. In contrast, Christian women had a significantly lower breast cancer screening rate that women from other religions . The overall breast cancer screening attendance was poor among Indonesian women population. Age, household income, religion, and knowledge of breast cancer risk factors were identified as the determinant factors for breast cancer screening. Breast cancer is widely known as a global women’s health problem and the leading cause of death  among women in all countries in the world, including Indonesia . According to the World Health Organization (WHO) (2016), 73% of all deaths in Indonesia is related to non-communicable diseases (NCDs), in which 12% are assigned to cancer. Most cancer patient deaths are linked to a delayed diagnosis that patients have presented an advanced stage during their first contact with health providers. This is especially true for developing countries like Indonesia. Breast cancer screening is suggested to play a vital role in reducing the mortality rate of breast cancer . Breast cancer in Indonesia ranks first as the cause of death among women in Indonesia. Based on the data from the Indonesian Basic Health Research (2013), the prevalence of cancer among the population of all ages in Indonesia is 1.4%, with the highest in Yogyakarta Province with 4.1%. There are several options available for breast cancer screening, namely, mammography, ultrasonography, clinical breast examination (CBE), and breast self-examination (BSE) . A previous study revealed that mammography is now well recognized and recommended for early detection of breast cancer . Early presentation of breast cancer and access to optimal treatment are the keys to improved survival rates of breast cancer patients . However, access to mammography is often unaffordable in many developing countries such as Indonesia due to financial barriers and limited health care resources . By contrast, in developed countries, when organized mammography screening-based national population programs conducted in their health care setting, most breast cancer patients improved their prognosis . In addition, various socio-economic factors  and psychological factors  also become barriers for accessing breast cancer screening . Adequate knowledge of breast cancer signs and symptoms also become one of the factors that correlate with CBE and mammogram utilization in the form of regular breast check-up. In Indonesia, a significant number of women are diagnosed for breast cancer in the advanced stage of the disease due to lack of knowledge and awareness, insufficient social support, numerous psychosocial factors, and, often times, the socio-characteristics of breast cancer patients . A large-scale study in Ghana found that the educational background of a breast cancer patient is significantly associated with breast cancer screening . Also, many previous studies in both developed and developing countries have demonstrated the followings as factors influencing the breast cancer screening practice, namely: individual and sociodemographic factors; limited access of health insurance; and ethnicity. These factors contribute to the delay in early detection of breast cancer signs and symptoms  . To date, there has not been any study that focuses on the determinant factors of breast cancer screening in Indonesian population that they remain largely unexplored despite the fact that the Indonesian Ministry of Health has launched a prevention and early detection program that encourage women to have regular breast check-up using by accessing CBE at the primary health care centers. For that reason, this study aimed to comprehensively identify the determinant factors associated with routine breast cancer screening attendance among Indonesian women. Study design and sample populationThis cross-sectional study was conducted in three provinces in Indonesia  that represented the spectrums of heterogeneity in Indonesian culture, religion, and socioeconomic status women. These three provinces were selected purposively as the location of the study because they were included in Indonesia’s effort to prevent breast cancer and able to represent the diverse socioeconomic and culture of Indonesia . All parData collection process The questionnaire used in this study was the BCAS-I that has been validated in Solikhah et al., (2017). The dependent variable of this study was breast cancer screening consisted of Yes-No questions that “did you ever have clinical breast examination (CBE) or mammogram or ultrasonography ever at any point per year in their life”. Confirming that they have done mammography/CBE/ultrasonography, the data from the interview results are then confirmed in the registration data at the primary health care centre, and if the participant is diagnosed with breast cancer, then it is categorized as “Yes” and vice versa. Independent variables were age, religion, education level, marital status, occupation, monthly income, health insurance, and knowledge of breast cancer risk factors, knowledge of signs, and symptoms. Knowledge was measured using a categorical response scale  on possible symptoms of breast cancer and understanding the risk factors of breast cancer. Items with correct answers were given 1 point, while the incorrect answers received 0 point. Results were then classified as categorical data (poor knowledge versus good knowledge).Data analysis Data on participant characteristics were analyzed descriptively with means and standard deviation for continuous data and percentages for categorized data. The chi-square test was then performed to explore the relationship between sociodemographic, knowledge of breast cancer risk factors, signs, and symptoms, and breast cancer screening attendance. If the chi-square test assumptions were violated , the Fisher’s Exact test was employed. The binary logistic regression model was performed to estimate the odds ratio (OR) and 95% confidence intervals for the associations between sociodemographic characteristics, knowledge of breast cancer risk factors, signs, and symptoms, and breast cancer screening. Step-ward regression modelling was used to identify factors associated with breast cancer screening. Multicollinearity between independent variables was checked using STATA version 14 software package.The average age of the participants in this study was 29.91 (± 11.14) years old with most of them were students (34.46%). The education level of the participants was distributed across the elementary school, junior high school, senior high school, undergraduate, and postgraduate with 8.71%, 7.13%, 38.57%, 43.05, and 2.54%, respectively. More than half of the participants had a monthly income of less than 2,000,000 IDR (<152 USD) (77.15%). Good knowledge of breast cancer risk factors, signs, and symptoms was seen in 69.77% (n=577) of the subjects . UnsurprResults of the binary logistic regression model on the association between all independent variables and breast cancer screening are presented in This study sought to elucidate the determinants and its association with breast cancer screening attendance among women in Indonesia. At present, the specific cause of breast cancer has yet to be identified. Many women, especially in developing countries like Indonesia, are diagnosed with advanced breast cancer, which negatively impacts their survival rate . Lack of knowledge of the early signs and symptoms of breast cancer and the poor awareness on the importance of early detection is the major cause of the late diagnosis among women, which is more apparent in countries with limited resources such as Indonesia , particularly in countries with limited resources like in Indonesia. Breast cancer patients who are diagnosed in advanced stages have a poor prognosis and a low survival rate.The present study revealed that knowledge of breast cancer is indeed associated with breast cancer screening attendance in Indonesian women. This finding confirms the association between knowledge of breast cancer risk, signs, and symptoms and breast cancer screening attendance observed in another population . These may relate to the likelihood that women with relevant knowledge tend to make better decision to participate in breast cancer screening because they are able to weigh between the advantages and disadvantages of participating in the screening, thus able to make appropriate choices . Furthermore, the result of this study demonstrated a low level of awareness towards breast cancer screening among Indonesian women. This poor awareness might be the consequences of inadequate education level and knowledge on the importance to do mammography or ultrasonography when there is a change in shape or bleeding in the breast. Inadequate household income also affects the decision of women to have early breast cancer screening earlier. The result of this study is in line with that of a previous study on Korean women that demonstrated poverty as affecting women’s ability to pay for cancer screening . Although systematic reviews have revealed that breast cancer screening might give negative effects for breast cancer patients such as false positive, false negative, over-diagnoses, pain during mammography-use, and psychological impact , mammography, as the screening tool for early detection of breast cancer, has been shown to significantly save lives. About 5 in 10,000 women aged 40 - 49 years, 10 in 10,000 women aged 50 – 59 years and 42 out of 10,000 women aged 60 – 69 years received the benefits from having mammography . Breast cancer screening at ages 40 – 49 years is a proven strategy to reduce breast cancer deaths that it is suggested to start breast cancer screening at the age of 40 years old . However, the results of a cost effectiveness analysis showed that screening is more effective in the 50-59 years age group compared to those under 50 years and over 60 years . A guideline for breast cancer screening in Columbia proposed that screening should be carried out routinely every 2 years under several strategies: annual screening for all women aged 50 to 74 years and annual screening for the risk group, which includes women with a family history of breast cancer diagnosis .In addition to the education level, adult age (35-39 years old), Christian, and monthly income (the rich) affect the breast screening attendance positively. Age has been demonstrated as a factor that plays a role in a person’s behaviour in conducting breast health checks in another study . A previous study has shown that adults have a higher awareness towards the health of their breasts , which is supported by the finding in this study that adulthood is one of the influencing factors of the breast cancer screening . Nonetheless, this is contrary to the finding in Saudi Arabia that presented the older age group to be more aware of having a breast check that the younger ones . Age is a key predictor in a person’s life experience that will positively associated with decision-making behaviour . This study also showed that Christian women were significantly associated with lower breast cancer screening attendance. A small number of Christian breast cancer patients were identified in Indonesia (6.05%), which may reflect the fact that Christian is a minority religion in Indonesia, which is known as one of the countries with the biggest Muslim population. Most patients experience fear, anxiety, and discomfort when they are diagnosed for breast cancer and during the treatment, making it necessary for them to get support from family members, friend, and relatives. One of the form of coping distress among these patients is the stronger belief in God. Most Asian are influenced by culture, including kinship, and beliefs that family, significant others, and religion play a strong role in dealing with the critical phase of the disease . Monthly income is also proven to have a strong influence on breast cancer screening in this study. This is in line with a previous study which explained that family finance relates to access to health . A study conducted in Singapore showed that the high cost of screening is perceived as a barrier to breast cancer screening . In addition, rich women had more flexibility to have health checks compared to those with low income. In contrast, poor women who have experience breast-health problems find it difficult to access health-services . A study that addressed barriers for breast cancer screening among women identified the financial problem, geographic and public transportation obstacles, long waiting times, physical obstacles (women with disabilities), inadequate healthcare provider skills and knowledge, and psychological distress of patients as the barriers for accessing the health service . Indicators for effective breast cancer screening, especially for developing countries like Indonesia, are affordable cost, painless methods, increased knowledge and awareness of breast cancer risk, good privacy, and shorter waiting time . The fact that women with a higher monthly  are significantly associated with breast cancer screening is our study support the findings in a previous study stating that limited financial and geographic concerns are perceived as barriers of breast cancer screening .To the best our knowledge, this is the first large population-based study with a high response rate on breast cancer screening attendance. Despite the representativeness of the participants in terms of diverse cultures and geography of Indonesia, the education level of the participants, which is undergraduate education, does not represent the education level of the majority of Indonesian women. Nevertheless, the level of education is not shown to have a statistical association with breast cancer screening attitude that it can be deemed negligible. The limitation of this study originates from the fact that it is a single time-point study, resulting in a lack of information on the causal relationship between the risk factors for breast cancer screening. The self-reporting nature of this study can also introduce recall bias.In conclusion, the overall breast cancer screening attendance is poor among women in Indonesia. Age, household income, religion, and knowledge of breast cancer risk factor were identified as factors that influence breast cancer screening attendance. Therefore, appropriate education on breast cancer should be provided. All authors confirm contribution to the manuscript as follows: SS study conception, design, analysis data, LL and SS, analysed and interpreted data, RM and DSSR performed initial manuscript. All authors approved the final version of the manuscript.


Epidemiological evidence suggests that synchronous or metachronous presentation of breast and thyroid cancers exceeds that predicted by chance alone. The following potential explanations have been hypothesized: common environmental or hormonal factors, oncogenic effect of the treatment for the first cancer, closer follow-up of cancer survivors, shared underlying genetic risk factors. While some cases were found to be related to monogenic disorders with autosomal inheritance, the genetic background of most cases of co-occurring breast and thyroid cancer is thought to be polygenic.n = 15) to patients with co-occurring breast and thyroid cancer (n = 19) using next generation sequencing of 112 hereditary cancer risk genes. Identified variants were categorized based on their known association with breast cancer and oncogenesis in general.In this retrospective case-control study we compared the genetic profile of patients with a history of breast cancer . The difference was also significant when we compared the number of SNPs with potential or known association with any malignancy .No difference between patients with breast and double cancers was observed in clinical and pathological characteristics or the number of neutral SNPs. The unweighted and weighted number of SNPs with an established or potential association with breast cancer was significantly lower in the group with breast cancer only (mean difference − 0.58, BCa 95% CI , Our findings are compatible with the hypothesis of genetic predisposition in the co-occurrence of breast and thyroid cancer. Further exploration of the underlying genetic mechanisms may help in the identification of patients with an elevated risk for a second cancer at the diagnosis of the first cancer. An increased co-occurrence of breast cancer (BC) and differentiated thyroid cancer (TC) compared to chance alone has been found repeatedly in recent decades , 2. NumeA number of hypotheses have been suggested to explain these findings , 4. The 131 treatment for thyroid tumors have both been implicated in carcinogenesis , t(27.26) = − 2.17, p = 0.039, g = 0.70 for weighted scores).We found a significantly lower number of SNPs with potential or known association with breast cancer in the BC only group  = − 2.30, p = 0.206, g = 0.39), while the number of potentially associated SNP or those with a known association was nominally lower in the BC only group  = − 1.72, p = 0.096, g = 0.59 and mean difference − 0.27, BCa 95% CI , t(31.37) = − 1.55, p = 0.131, g = 0.51, respectively).The individual number of SNPs with no known genetic association with cancer was nominally higher in the BC only group  = 1.30, p = 0.032, g = 0.76) and weighted  = − 2.51, p = 0.017, g = 0.83) scores.When we lumped together SNPs with potential or known association with carcinogenesis to increase statistical power, we found significantly higher values in the synchronous/metachronous cancer group compared to the BC only group using both unweighted  = − 2.24, In our study, we found a significantly higher burden of established and potential germline cancer risk variants among subjects with a history of metachronous thyroid and breast cancer compared to patients with a history of breast cancer only. The trend was similar and effect sizes were still considerable when we assessed the number of SNPs with known and potential cancer risk separately. However, in these cases, probably due to lack of power, statistical significance was not reached. Our results are compatible with the hypothesis that the sporadic co-occurrence of thyroid and breast cancer is of multigenetic origin and probably related to the burden of the carcinogenic SNPs rather than an individual gene alteration.Comparison of clinical features of breast cancer, such as onset, stage, histology and treatment also yielded no significant differences. There was a non-significant tendency for later age of breast cancer onset in the study group which is contrary to previous findings .The metachronous and synchronous occurrence of breast and thyroid cancer has been first described nearly four decades ago . The relOne potential hypothesis explaining this bidirectional relationship implicates common hormonal factors and is rooted in the overwhelming predominance of both cancer types in reproductive-aged women . EstrogeEndocrine disrupting chemicals (EDC) have been linked to numerous types of hormone dependent malignancies including both thyroid and breast cancer , 37. In Other theories suggest the role of prior cancer treatment in the development of the second primary malignancy. Despite several improvements minimizing radiation scatter to surrounding tissues, there is a definitely increased risk for certain malignancies following external beam radiation for breast cancer . While sThe increased co-occurrence of these tumor types could also be related to surveillance bias. The higher compliance with, and higher rate of screening efforts among cancer survivors could also affect the time of diagnosis and could lead the substantial overdiagnosis of clinically irrelevant second primary malignancy . This seCowden syndrome (CS) and Cowden-like syndromes (CLS) are characterised by hamartomas and an extremely increased risk for several types of malignancies including breast cancer, thyroid cancer, endometrial cancer, colorectal cancer, and melanoma with standardized incidence ratios for breast and thyroid cancer in the range of 6 to 9 . CS and The main strengths of this study were the state-of-the-art genetic analysis using NGS technology, and the fact that both cases and controls came from the same source population. The main limitation of our research was the relatively low number of patients limiting statistical power even in analyses of genetic scores. Furthermore, our study was unable to identify or investigate any single genetic risk locus behind synchronous/metachronous cancer development. Two types of bias could also have affected our findings. First, participants were recruited years after diagnosis potentially leading to survivor bias. Second, the exclusion of controls with less than 12 years of follow-up lead to an age difference between our study groups that is contrary to previous findings , and proIn conclusion, we reported an increased burden of carcinogenic SNPs in people with both thyroid and breast cancer compared to individuals with breast cancer only, based on whole exome sequencing of 112 known hereditary cancer risk genes. We found no differences in clinicopathologic parameters between the groups suggesting that both groups have similar presentation at the time of diagnosis of breast cancer. While our study was not powered to identify specific risk loci for metachronous cancer development, our findings further support the multigenetic etiology of co-occurring breast and thyroid cancer. Our findings do not directly contradict any of the other, previously detailed theories explaining the association between these tumor types. Nevertheless, our results do underline the need for further genetic research in this field, which are lacking at the moment.