If confirmed, our study suggests that the blood arsenic level may be a useful predictive marker of cancer risk in women.Arsenic is recognized as a potent carcinogen at high concentrations, but the relationship between environmental arsenic and breast cancer risk has not well been studied. Most research has focused on the effect of arsenic in populations with high endemic exposure, and not in populations with arsenic levels within normal limits. We sought to determine if blood arsenic levels predict the risk of breast and other cancers risk among women in northern Poland. The cohort consisted of 1,702 healthy women, aged 40 and above, identified between 2010 and 2017. Blood arsenic level was determined by inductively coupled plasma mass spectrometry. After an average of 4.5 years of follow‐up (range 0.7–7.3 years), there were 110 incident cases of cancer diagnosed in the cohort, including 68 cases of breast cancer. Women in the highest quartile of arsenic had a highly significant 13‐fold increased risk of developing breast cancer, compared to women in the lowest quartile . Results were similar for arsenic and all incident cancers (HR quartile 4  What's new?Arsenic has long been recognized as a potent carcinogen at high concentrations. But can it affect cancer risk at “normal,” environmental concentrations? In this Polish study, the authors found that women whose blood levels of arsenic were in the highest quartile had a 13‐fold increased risk of developing breast cancer, compared to women in the lowest quartile. If confirmed in further studies, these results suggests that blood arsenic level may be a useful predictive marker of cancer risk in women. BRCA1, PALB2, CHEK2, NBN and other susceptibility genes as well as single nucleotide polymorphism profiles which can be used to generate personalized risk scores.The lifetime risk of breast cancer among women in Poland is approximately 6% and efforts are underway to better individualize risk, that is, to identify factors that allow us to stratify women into various risk categories. At the genetic level, these include mutations in BRCA1 mutation and 5,000 women who do not have a BRCA1 mutation. Study participants are cancer‐free at inception and are followed prospectively to identify new cases of cancer. To date, we have enrolled 1,700 noncarrier women and we have followed these women for an average of 4.5 years.Over the past 50 years, there has been considerable attention paid to various measures of diet and breast cancer risk in prospective studies.bona fide carcinogen for cancers of the skin, bladder and lung, but most studies to date have been based on highly exposed populations and little attention has been paid to the possible carcinogenic effect of low levels of arsenic.et al., and Joo et al., who found arsenic levels to be significantly higher in hair of breast cancer patients as compared to unaffected controls.et al. evaluated the association between long‐term rice consumption  and cancer risk in the Nurses' Health Studies and Health Professional Follow‐up Study.BRCA1 mutation.In the current study, we use the biorepository to address the question of blood arsenic as a possible risk factor for cancer. Arsenic has long been recognized by International Agency for Research on Cancer as a BRCA1. In addition, a separate aliquot of 10 mL of whole blood was taken for research purposes and stored at −80°C. Blood samples were taken between 8 a.m. and 2 p.m. from Monday to Friday. The patients were requested not to eat nor to drink water for 4 hrs prior to the venipuncture.The study subjects were women aged 40 and above who had received genetic counseling and genetic testing at the Pomeranian Medical University between September 2010 and April 2017. No woman had been diagnosed with breast cancer or another type of cancer at the time of study entry. All study subjects provided written informed consent to participate in the study and all agreed to provide a blood specimen for research purposes. The study protocol was approved by the research ethics board of the Pomeranian Medical University. At the first outpatient clinic visit, a blood sample was taken for genetic testing for three founder mutations in Subjects completed a detailed questionnaire which included information about family history of cancer, age, smoking, hormones usage, personal medical history including adnexectomy and breast cancer screening history.BRCA1 mutations . Women with a BRCA1 mutation were excluded from our study and will be the subject of a separate report.All subjects were tested for the three Total arsenic concentration in blood samples was measured by inductively coupled plasma mass spectrometer (ICP‐MS), using the Elan Dynamic Reaction Cell‐e  instrument. Arsenic was measured in dynamic reaction cell mode with oxygen  as a reaction gas. Under these conditions, arsenic forms oxides within the cell (AsO+) which can be detected at m/z 91, known to be free from spectral interferences. To compensate for instrument drift and matrix effects, rhodium was set as internal standard. All the parameters of Elan Dynamic Reaction Cell‐e used during measurement are available upon request.The blank reagent consisted of high purity water (>18 MΩ), tetramethylammonium hydroxide , Triton X‐100 (PerkinElmer), n‐butanol  and disodium EDTA . Calibration curve standards  were prepared by diluting stock solution (50 μg/L) of 10 mg/L Multi‐element Calibration Standard 3 (PerkinElmer Pure Plus) with blank reagent. The matrix matched calibration method was used. The correlation coefficients for arsenic calibration curves were greater than 0.999.The accuracy of the method was validated using three different certified reference materials: National Institute of Standards and Technology 955c  and Plasmonorm Whole Blood Level 1 . First, the level of the National Institute of Standards and Technology 955c reference material has been taken into consideration by analytics. The reference concentration value for arsenic in SRM955c Caprine Blood, Level 1 reported by National Institute of Standards and Technology is 2.07 ± 0.67 μg/L. These results are far away from values reported by our analytical laboratory and other authors.BRCA1 mutation. Information on incident cancers was retrieved from the medical records and review of the pathology records of the treating Pomeranian hospitals. Subjects were classified into quartiles according to the blood arsenic level determined at the single measurement ensuring an equal number of women in each quartile. Women were followed from the date of blood draw or age 40 (whichever came last) to the first of breast cancer, death from another cause, or January 1, 2018. The annual incidence rates were calculated by comparing the number of events to person‐years of observation. Standardized incidence ratios were constructed by comparing the calculated age‐specific breast cancer rates to the Polish national breast cancer rates. The cumulative incidence of breast cancer in the entire cohort and in each of the four quartiles was estimated to 5 years, based on the Kaplan‐Meier method. Crude differences in cumulative incidence by arsenic quartile were tested for statistical significance using the log‐rank test. A multivariate hazard ratio (HR) was generated using the multivariate Cox model for arsenic by quartile (using the lowest quartile as the reference), adjusting for age at blood draw , smoking (ever/never), number of first‐degree relatives with breast cancer , oophorectomy (yes/no) and hormone replacement therapy use (yes/no). In a secondary analysis, we repeated the analysis using all cancers as the outcome. In this secondary analysis, patients were followed from the date of blood draw until the first cancer, death from another cause or January 1, 2018.There were 1,702 subjects enrolled in the follow‐up study; subjects were cancer‐free at baseline and did not carry a founder The cohort consisted of 1,702 women. None of the women had a prior history of cancer, but 34% had a family history of breast cancer and 7% had a family history of ovarian cancer. Of the 1,702 women, 58 had two or more first‐degree relatives with breast cancer, 515 had a single first‐degree relative with breast cancer and 1,129 had no first‐degree relative with breast cancer. Nine women had two or more first‐degree relatives with ovarian cancer, 117 had a single first‐degree relative with ovarian cancer and 1,576 had no first‐degree relative with ovarian cancer. A single arsenic measurement was available for each woman and, on average, 54 months had elapsed between the date of the blood draw and the date of arsenic measurement (range 8–88 months). The mean arsenic levels for different subgroups are presented in Table The women were followed for an average of 4.5 years from the date of the blood draw (range 0.7–7.3). Collectively, the 1,702 women contributed 7,731 person‐years of follow‐up. Over the entire follow‐up period, there were 110 incident cases of cancer diagnosed in the cohort, including 68 cases of breast cancer, 6 cases of ovarian cancer and 36 cases at other sites (Table p‐trend <0.0001). Findings were similar in the analysis adjusted for age, smoking status (ever/never), number of first‐degree relatives with breast cancer , oophorectomy (yes/no) and hormone replacement therapy use (yes/no). In the adjusted analysis, women in the highest quartile of arsenic had a highly significant 13‐fold increased risk of developing breast cancer compared to women in the lowest quartile .The 1,702 women were divided into four categories (quartiles) of equal size, based on their total blood arsenic level. The univariate and multivariate HRs of developing breast cancer with increasing quartile of arsenic levels are presented in Table The annual risk of breast cancer varied widely according to the blood arsenic level. For those in the first (lowest) quartile of blood arsenic levels, the annual risk was 152 per 100,000 per years; for those in the second quartile, the risk was 798 per 100,000 per year, for those in the third quartile the risk was 941 per 100,000 per year and for those in the highest quartile the risk was 1,855 per 100,000 per year. These incidence rates are depicted graphically in Figure p‐log rank test <0.0001).In a secondary analysis, we considered all 110 cancers as the endpoint Table . The resp < 0.0001). Similarly, in the analysis of all cancers combined, the HR comparing women in the highest vs. lowest quartile of blood arsenic was 13.3 (p < 0.0001). These findings suggest that in Poland blood arsenic status (even at low concentrations) is a strong predictor of breast cancer. This is a single study and needs to be repeated in Poland and elsewhere.In this prospective cohort study of Polish women at an elevated risk of breast cancer because of their family history, we found a strong and statistically significant association between baseline blood arsenic levels and the subsequent risk of breast cancer and with all cancers combined. There were only three breast cancers diagnosed among 426 women in the lowest quartile of arsenic (mean arsenic level 0.48 μg/L) compared to 33 cases diagnosed among the 425 women in the highest quartile (mean level 2.33 μg/L). This represents a HR of 13.2 and this association was highly significant  that may impact upon both arsenic levels and breast cancer risk. Importantly, we also observed a similar relationship between arsenic levels and all other cancers combined. With regard to multiple comparisons, we also evaluated the relationship between three other micronutrients  and risk, but found no other significant associations (data not shown).Given the strength of the associations reported here and the importance of the potential implications, it is important that we explore the possible reasons underlying these observations. We have considered the possibility that these are chance findings, but given the large effect sizes and associated Arsenic compounds, which occur both naturally and as a result of human activity, can be divided into three types: organic, inorganic and arsine gas.Most of the epidemiologic evidence surrounding arsenic exposure has reported in terms of an increased risk of cancers of the lung, skin and bladder.via food consumption given that arsenic levels in water have been standardized to 10 μg/L for public drinking, in accordance with the World Health Organization standards.via food consumption or previous consumption of contaminated water.In humans, primary arsenic exposure is primarily from ingestion of contaminated food or water, with less from inhalation and consumption of foods with low quantities .The mechanisms by which low arsenic levels increase the risk of breast cancer are unknown. In females, arsenic may influence development of cancers by disrupting the function of estrogen receptors and suppressing the signaling pathway of estrogen.An association has been reported between polymorphisms in the arsenic methyltransferase gene (AS3MT) and arsenic‐related cancer risk.et al. recently demonstrated significantly elevated rates of cancer mortality due to lung, bladder and kidney cancer up to 40 years after exposure to elevated arsenic levels in water suggestive of a long latency period between arsenic exposure and cancer development.vs. organic) within total blood measurements. This analysis is crucial for further studies given the known carcinogenicity of the inorganic arsenic species. Moreover, it is known that arsenic has a short half‐life and is cleared from the blood within 3 to 6 hrs and thus our measurements represent a recent arsenic exposure.49–51 Importantly, we have not explored the various factors whereby arsenic is absorbed, stored and eliminated and it is possible that one of these metabolic processes has a relationship to breast cancer risk as well. It may be that the findings are not generalizable to other populations because of other factors including family history, ethnicity, geographic variation or different sources of arsenic .There are several limitations associated with our study. We only had one blood sample available for arsenic quantification and were not able to assess reproducibility over time. Although one measure of arsenic may not reflect long‐term exposure, Smith In summary, chronic low‐level exposure to arsenic compounds may lead to more than 10‐fold increased breast and all other cancer risk in Polish females. Unexpectedly, the blood arsenic level may be particularly strong marker of low/high cancer risk in women. For validation of above findings, further investigations on additional groups of females from Poland and other countries are needed.


PPFIA1 is an important regulator of cell migration and invasion, regulating focal adhesion signalling and disassembly. PPFIA1 is frequently amplified in breast cancer, and recent functional studies indicate that PPFIA1 is an important promoter of migration and invasion in breast cancer. This study aims to evaluate the utility of PPFIA1 expression in the luminal breast cancer as a prognostic marker to predict the response to endocrine therapy.Large, well-characterised cohorts of primary luminal breast cancer patients with long-term follow-up was assessed for the clinical impact of PPFIA1 expression at the transcriptomic and proteomic levels. Prognostic significance of PPFIA1 and its relationship with clinical outcome and benefit of endocrine therapy were analysed. In addition, its association with other related-genes was analysed.PPFIBPI), and the cell cycle regulator (CCND1), whereas a negative association was observed with the tumour suppressor gene (CD82). Patients with high PPFIA1 expression were associated with high risk of recurrence, distant metastasis and death from breast cancer (P < 0.05). Importantly, high PPFIA1 expression predicted relapse in a subset of patients who were subject to endocrine treatment alone, and was an independent prognostic marker of unfavourable outcome in these patients (P < 0.05).There was significant association between PPFIA1 expression and a member of the liprin family that involves in cell invasion (These findings support the proposed role for PPFIA1 as a regulator of cell migration in breast cancer and provides definitive evidence for the clinical utility of PPFIA1 expression in patients with luminal breast cancer. Most importantly, our data suggests that PPFIA1 might be a potential predictive marker for poor benefit from endocrine therapy. Breast cancer exhibits significant heterogeneity with different molecular subtypes, and the main subtype of the disease are luminal, Estrogen Receptor positive (ER+)/HER2-negative, tumours which account approximately 75% of all breast cancers. This subtype remains heterogeneous in terms of prognosis and response to treatment , 2. EndoPTPRF Interacting Protein Alpha 1 (PPFIA1), also known as liprin-α1, belongs to the liprin family that includes liprin-α and liprin-β proteins . PPFIA1 In this study, we hypothesised that PPFIAI will play a role in breast cancer and can provide important prognostic information that may help to risk stratify luminal tumors with respect to endocrine therapy.PPFIA1 expression was assessed at the transcriptomic and proteomic levels utilising large and well-characterised annotated cohorts of luminal breast cancer.PPFIA1 with other related-genes was investigated. The METABRIC cohort characteristics are in Supplementary Table PPFIA1 transcriptomic expression in luminal breast cancer and its role in predicting response to endocrine treatment was assessed in; The Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) , Kaplan n = 521). Patients were presented at Nottingham City Hospital (1989–2006), as previously described [PPFIA1 protein expression was assessed in a well-characterised series of luminal primary invasive breast cancer patients, with long-term follow-up  was validated by Western blotting using BT474 human breast cancer cell lysate , which showed a single band of approximately the predicted size (135 kDa)  on 4-μm tissue microarray (TMA) sections using Novolink polymer detection system , as previously described using the PPFIA1 antibody at 1:100 dilution  . TMA cormRNA/protein expression and clinicopathological parameters. To test correlation between two continuous normalised data, Pearson’s correlation coefficient was used. For the continuous variables, differences in mean between three or more groups were assessed using one-way analysis of variance (ANOVA) with the post-hoc Tukey multiple comparison test. T-test was used to assess the difference between two groups. Kaplan-Meier survival curves were used to investigate the association of PPFIA1 mRNA/protein expression with clinical outcome. The endpoint outcomes were breast cancer, recurrence and distant metastasis free survival. Cox regression analysis was used to evaluate the independent prognostic significance of PPFIA1 mRNA/protein expression. The Benjamini–Hochberg procedure for multiple test correction was used. Dichotomisation of PPFIA1 mRNA/protein expression into groups was determined using X-Tile . A p value of <0.05 was considered significant.SPSS  was used for all statistical analysis. The Chi-square test was used to evaluate the association between PPFIA1 PPFIA1 mRNA was observed in 1129/1398 (81%) of cases in the METABRIC cohort.Protein expression of PPFIA1 was observed in the cytoplasm of luminal tumours, and a representative images of IHC staining are shown in  with patients who received endocrine treatment but did not relapse (responsive). Results showed that PPFIA1 mRNA was highly expressed in unresponsive patients in comparison to those who responded to adjuvant endocrine therapy , Supplementary Table PPFIA1 mRNA trend to be significant marker for relapse (P = 0.05), Supplementary Table P < 0.05), Table To further investigate the independence of PPFIA1 as a potential marker for outcome, multivariate cox regression analysis was performed. Results demonstrated that PPFIA1 mRNA expression with other associated-genes was investigated using the METABRIC cohort, and validated using bc-GenExMiner v4.3 dataset, Supplementary Table PPFIA1 mRNA expression and PPFIBPI, also known as (liprin-β1) which is member of the liprin family that involves in cell invasion. Further, a positive correlation was observed with the well-known cell cycle regulators . On the other hand, a negative correlation was observed between PPFIA1 mRNA expression and integrin family genes (ITGB1 and ITGA5) and the tumour suppressor gene (CD82). Taken together, these findings suggest a key role of PPFIA1 in the invasion of luminal tumours and response to treatment.To further understand the potential roles of PPFIA1 in luminal breast cancer and how it might affect the response to the endocrine therapy, correlation of This study has explored the potential effects of PPFIA1 expression in luminal tumours. Our findings establish an important role for PPFIA1 expression in luminal breast cancer and response to endocrine therapy. This study of a well-characterised cohort of clinically annotated patients with early luminal breast cancer demonstrates that high PPFIA1 expression associates with aggressive clinicopathological parameters. Our study also confirmed that patients with high PPFIA1 expression had unfavourable clinical outcome and poor response to endocrine therapy.mRNA and protein expression. In addition, we found that PPFIA1 expression was associated with aggressive clinicopathological parameters. Previous studies show a contradictory role of PPFIA1 in regards to the invasiveness of tumour cells, where silencing of PPFIA1 affects the regulation of dynamic events associated with tumour cells invasion [PPFIA1 is part of a multi-protein complex that is important in the regulation of tumour cell migration and invasion , 10. Higinvasion , 17 wherinvasion . Howeverinvasion , and PPFAnother important finding of this study is that high PPFIA1 expression is associated with short survival within luminal breast cancer subtype. This is consistent with a previous study where association of PPFIA1 amplification with poor survival was only observed in the subset of ER+ cancers with no prognostic effect on ER negative or HER2+ breast cancer subtypes . Indeed,Despite endocrine treatment has proven its enormous value in the treatment of luminal breast cancer, resistance stills a major issue in a proportion of these patients. Therefore, it remains necessary to predict which patients who will potentially benefit or resist this treatment through identifying valuable clinical biomarkers to guide choices of therapies . ER and PPFIA1 is located at the 11q13 amplification region, which occurs in about 20% of breast tumours [CCND1 is the important driver gene of the 11q13 amplicon, and PPFIA1 amplification was found in all CCND1-amplified breast cancers [PPFIA1 mRNA was positively correlated with CCND1 mRNA levels in cases with luminal tumours. Previous studies found that high CCND1 expression and amplification associates with an impaired response to tamoxifen treatment and high risk of relapse in luminal breast cancer [ cancers . We havet cancer , 29. TakPPFIA1 mRNA expression and integrin family members in luminal breast cancer. Our finding supports previous studies that reported PPFIA1 as an essential regulator of integrin signalling which required for efficient cell motility [CD82), which is suggested to inhibit cell migration and invasion via regulating the integrin-mediated signalling [Previous studies suggested that integrin signalling might have a significant role in cell migration and invasion, and also in modulating resistance to anti-cancer treatments , 31. In motility , 32. Furgnalling . In breagnalling . In linegnalling . AltogetPPFIA1 and PPFIBPI in patients with luminal breast cancer, which may confirm their regulatory roles in the migration of tumour cells.PPFIBPI, also known as liprin-β1, is a member of liprin family, and is one of the many binding partners of PPFIA1. A previous study showed that silencing of PPFIBPI causes a significant decrease of cell migration and it was demonstrated that PPFIA1 and PPFIBPI may co-operate in the regulation of tumour cell migration . In thisThis study provides evidence for the role of PPFIA1 expression in luminal breast cancer. Most importantly, our study has clearly showed that PPFIA1 expression is a potential marker for poor benefit from endocrine therapy and its measurement may guide the clinician for alternative therapy.Additional file 1: Supplementary Figure 1. Kaplan–Meier of PPFIA1 mRNA and patient outcome in luminal breast cancer using KM-Plotter dataset for A) survival C) recurrence and D) distant metastasis, and using bc-GenExMiner v4.3 for B) survival and E) metastasis relapse.Additional file 2: Supplementary Figure 2. Kaplan-Meier of PPFIA1 mRNA expression in patients with luminal breast cancer who received endocrine treatment only using KM-Plotter dataset A) recurrence B) distant metastasis and C) survival.Additional file 3: Supplementary Figure 3Additional file 4: Supplementary Table 1. Clinicopathological characteristics of luminal breast cancer cohorts.Additional file 5: Supplementary Table 2. Association of PPFIA1 protein expression and clinicopathological parameters in Nottingham cohort.Additional file 6: Table 3. Multivariate cox analysis of associations between PPFIA1 mRNA expression and clinicopathological parameters in luminal breast cancer using METABRIC cohort.Additional file 7: Supplementary Table 4. Correlation of PPFIA1 mRNA expression with the expression of other related genes.


Cardiotoxicity from anticancer therapy affects heart function and structure. Cardiotoxicity can also lead to accelerated development of chronic diseases, especially in the presence of risk factors.n = 36). Questionnaires were self-administered while attending chemotherapy clinic, in the presence of a research assistant.This study aimed to develop and pilot a combined cardiovascular disease and cardiotoxicity risk assessment questionnaire to quantify the potential extent of risk factors in breast cancer patients prior to treatment. The questionnaire underwent content and face validity evaluation by an expert panel followed by pilot testing in a sample of breast cancer patients (Mean age of participants was 54.8 years (range 36–72 years). Participants reported CVD risk factors including diabetes 2.8%, hypertension 19.8%, hypercholesterolaemia 11% and sleep apnoea 5%. Lifestyle risk factors, included not eating the recommended serves of vegetables (100%) or fruit (78%) per day; smoking (13%) and regularly consuming alcohol (75%). Twenty five percent reported being physically inactive, 61%, overweight or obese, 24%, little or no social support and 30% recorded high to very high psychological distress. Participants were highly (75%) reluctant to undertake lifestyle changes; i.e. changing alcohol consumption; dietary habits; good emotional/mental health strategies; improving physical activity; quitting smoking; learning about heart-health and weight loss.This study is an important step towards prevention and management of treatment-associated cardiotoxicity after breast cancer diagnosis. We recommend that our questionnaire is providing important data that should be included in cancer registries so that researchers can establish the relationship between CVD risk profile and cardiotoxicity outcomes and that this study revealed important teaching opportunities that could be used to examine the impact on health literacy and help patients better understand the consequences of cancer treatment. Advances in screening, early detection and treatment of cancer have led to improved survival of patients with cancer, but have also increased morbidity and mortality due to treatment side effects . CardiotApproximately 14,200 cases of breast cancer are diagnosed annually in Australia, with five and ten-year survival rates of 89% and 83% respectively . Agents Cardiac clinicians routinely assess socio-demographic factors  and manage psychosocial factors (e.g. depression) and lifestyle factors  to reduce patients’ risk of cardiac disease. The authors, supported by recent literature, propose that these could be as important to consider as chemotherapy agent and dose in the assessment and management of cancer , 9.To realise the potential of breast cancer treatments, cancer clinicians need assessment strategies that enable them to accurately identify treatment-related and pre-existing cardiac risks and to modify their combined potential to induce heart disease in breast cancer patients . Given tThe most recent European Society of Cardiology (ESC) position paper on cancer treatments and cardiovascular toxicity suggests that identifying high-risk patients prior to the administration of cancer therapy may allow treatment modifications to decrease the risk of subsequently developing cardiotoxicity . HoweverThe aim of this study was to produce a standardised, comprehensive approach to assessing CVD and cardiotoxicity risk before breast cancer treatment.To develop and pilot test the risk assessment questionnaire; andTo obtain preliminary data on the extent and nature of modifiable and non-modifiable cardiovascular risk factors for cardiotoxicity in breast cancer patients.There were two objectives:This study was undertaken in two parts. Initially content development and face validity testing of a questionnaire by an expert panel to assess cardiotoxicity risk, based on the ESC position paper for cardiotoxicity baseline risk factors Table . Followin = 14) comprised representatives from the fields of medical oncology, cardiology, radiation oncology, dietetics, cancer nursing, psycho-oncology, pharmacy, exercise physiology, and two consumer representatives. All members volunteered to provide feedback on the draft questionnaire electronically in two rounds.A small working group of the expert panel members collated a battery of demographic, clinical and validated cardiovascular risk factor assessment tools Table  to form In Round 1, panel members were asked to provide unstructured feedback on all aspects of the preliminary questionnaire. Their qualitative responses were synthesised, reduced and categorised to further modify the questionnaire. The modified questionnaire underwent two further electronic consensus rounds. These rounds focussed on ensuring that all the important items were incorporated; that there was no overlap or ambiguity of items; that items were scored appropriately; and that the questionnaire was relevant to end-users. In addition, the expert panel members were asked to complete a content validity index (CVI) on each question or section (e.g. pre-existing tool). The CVI was a four-point Likert scale that assessed the clarity of each item used, wherein 1 = very unclear, 2 = unclear, 3 = clear, 4 = very clear.The questionnaire was pilot tested for feasibility and acceptability by thirty-six patients from two Australian public facility oncology clinics, one in South Australia and the other in Queensland, between October 2015 and March 2016. As this was a pilot study using a battery of validated instruments, a power calculation was not applicable. The sample size of thirty-six was based on feasibility, time and funding. It is intended that outcomes from this study will be used to generate sample size calculations for future large cohort testing of the questionnaire.This team of investigators recognises that consumers’ experience of breast cancer, their knowledge of the motivations and capacities of consumers to engage with research, coupled with their awareness of consumers’ needs, were integral to the success of this initiative. We consulted the Breast Cancer Network of Australia (BCNA) and the Australian National Heart Foundation in developing this project. We did so because the consumer representatives of these organisations are supported and trained to engage meaningfully in the research context and to advocate for consumers with different experiences to their own. Consumers and policy advisors from both organisations kindly contributed valuable advice about the content, relevance and feasibility of this study, and the BCNA consumer representatives agreed to be named as co-investigators.Inclusion criteria for participants were: a new diagnosis of breast cancer; referral for chemotherapy and/or radiation therapy, up to third chemotherapy cycle; and able to provide informed consent. Exclusion criteria were: beyond third chemotherapy cycle; and unable or unwilling to give consent, or participate.Eligible patients were selected by the clinical oncologist at each site and introduced to the research assistants (RAs). Once patients had been identified, they were approached during their waiting period on, or before, the third session of chemotherapy/radiotherapy treatment and invited to participate in a research survey about cardiotoxicity. Patients were given the participant information sheet and consent form to read, either at that time, or later in their own time. Once consent was received, the participant was given the questionnaire to complete while they waited for chemotherapy. An RA from the team was present to answer any questions that may have arisen, and to collect the data once the respondent had completed the questionnaire.Data were sourced from the medical records of participants for demographics and clinical information (such as diagnosis and chemotherapy regime), as well as self-reported data from the tools within the questionnaire.As per National Heart Foundation guidelines , items cItems included were: cumulative anthracycline dose ≥550 mg—particularly bolus administration—alone or in conjunction with infusional 5-fluorouracil, capecitabine, or taxanes; high-dose cyclophosphamide; aromatase inhibitor or tamoxifen therapy; mTOR inhibition; HER-2 blocking agents, e.g. trastuzumab; anti-angiogenic agents, e.g. bevacizumab; chest irradiation; and co-morbidity of blood cancer [Psychosocial factors were measured using the Kessler Psychological Distress Scale (K10)  and the Participants were asked four additional questions to ascertain their opinion of the questionnaire items: 1) whether the items were easy to understand; 2) whether the items were relevant; 3) whether the format was acceptable; and 4) whether the time taken to complete the assessment was acceptable.Data were manually entered from the questionnaires into Microsoft Excel and a 10% quality data assessment was completed for accuracy. Missing data were examined for extent, pattern, and randomly or systematically missing. Depending on the potential source of bias entailed in the missing data, an appropriate method (e.g. item deletion or data imputation) was then used. All data were then imported into Statistical Package for the Social Sciences (SPSS) for Windows, Version 20.0 , for anaParticipant characteristics and clinical data are presented as frequency and summary descriptive statistics. Continuous variables have been reported as means and standard deviations for normally distributed data. Proportions summarise categorical variables. Comparability of treatments received as per recruitment pathways have been evaluated for participants’ demographic and medical characteristics using cross-tabulations.The expert panel assessed the questionnaire in terms of item relevance using the Likert scales for each section with a mean CVI per item of at least three needed to be accepted. If not, items were modified through further expert panel consultation or deleted, after which consensus was obtained on the final version of the questionnaire. The final questionnaire contained 19 pages and 355 items or variables . These covered demographics, clinical history, cancer treatment, and validated tools to measure current cardiovascular risk factors, cardiac disease and health literacy.The pilot study aimed to recruit twenty participants from each site for a total of forty participants. Final recruitment was thirty-six on completion of the recruitment period.A summary of the characteristics, cancer diagnoses and treatment, and cardiovascular risk factors are presented in Table 2).The lifestyle CVD risk factor questions revealed that no participants were eating the recommended five serves of vegetables per day and 22% ate the recommended two serves of fruits per day . ThirteeDetails of known risk factors for cardiotoxicity from cancer treatment are detailed in Table Knowledge and beliefs of heart disease are presented in Table One of the final questions in the questionnaire asked if participants would be interested in receiving further information or support about risk factor and/or lifestyle modification  and took an average of twenty-five minutes to complete. It is recommended that further work be carried out to shorten the questionnaire before this data collection tool is used again. There was a large variation in the waiting times within the two pre-chemotherapy clinics and some participants became distressed at needing to complete such a large document while waiting to be called to chemotherapy. Others needed to take the questionnaire home to complete. In this case, they were supplied with a reply paid envelope to return to us by mail. An alternative approach may be to administer questionnaires for cardiotoxicity risk assessment while waiting for routine echocardiography prior to cancer treatment; however, only one third of the patients in our study reported having an echocardiogram prior to chemotherapy. Whilst this may have been under-reported, this would still be unlikely to result in a comprehensive capture. Given that cardiac imaging is performed by different service providers, this further complicates the data collection.Secondly, many participants asked the research team why they were being asked about their heart health in the breast cancer chemotherapy clinic. This was a positive finding for the research as it indicated to our team that we had created a teaching opportunity.In the pilot testing, as expected, we found an older group of women than the mean national age . According to the ESC guidelines, age is a risk factor for cardiotoxicity particularly for those fifty years and over. The diagnoses of the participants indicated that they would be receiving potentially cardiotoxic chemotherapy and each patient’s regimen comprised individualised composites and doses of the cytotoxic agents. There was evidence of pre-existing risk factors for CVD in 30% of participants and 61% were overweight or obese reflecting the current CVD risk factor profile of all Australians , 23. ParThe outcomes of this study are relevant to all cancer patients and cancer survivors who have received potential cardiotoxic cancer treatment and the authors stress the importance of a cardio-oncology co-management of patients with an increased burden of risk factors. Australian health services do not currently undertake standardised, comprehensive cardiac risk assessments in breast cancer patients, nor do they provide structured health promotion programs to support breast cancer consumers to minimise lifestyle-related cardiac risk during and after treatment, despite the public and personal health benefits that these would provide. A range of survivorship programs have been implemented in recent years in recognition of the chronic nature of cancer; however, most targeted specific symptoms and were not grounded in sound chronic disease self-management principles and the benefits, not only for heart health but effects on cancer recurrence . They arThis pilot study provides preliminary data for an effectiveness trial to measure the impact of CVD profiling and cardiotoxicity risk assessment, to provide an appropriate clinical pathway to manage patients safely through their cancer treatment. The project team will utilise a ‘bottom up’ approach to drive the translation of this approach into practice, working directly with our established network of consumers, clinicians and key cancer organisations to ensure their engagement. We will demonstrate the personal, clinical and cost-effectiveness benefits of our approach, with the goal being to increase both consumer and clinician awareness and understanding of cardiotoxicity.This study was a pilot and generalisability is limited. The results of the study have provided important lessons about the size, timing, design, location and mode of delivery of the data collection. This was not a random sample of participants and there may have been bias in sampling as oncologists may have chosen patients who were at a higher literacy level, or who were coping better with chemotherapy, than other potential participants. This may have led to selection bias.Valuable lessons will be implemented in the next phase of our research. The opportunity to expand on the teaching opportunities revealed during this pilot study could be used to examine impact on health literacy and help patients better understand the consequences of cancer treatment.This study is an important first step towards evidence-based and personalised assessment, prevention and management of treatment-associated cardiotoxicity after breast cancer. Important teaching opportunities revealed during this pilot study could be used to examine the impact on health literacy and help patients better understand the consequences of cancer treatment. We recommend that our questionnaire is providing important data that should be included in cancer registries so that researchers can establish the relationship between CVD risk profile and cardiotoxicity outcomes.


The mechanism of rapidly increased non‐small cell lung cancer (NSCLC) among never‐smoking Chinese women has not been elucidated. Ovarian sex steroid hormones have been suggested to counteract lung cancer development, and sex hormone‐binding globulin (SHBG) is essential in sex hormones regulation. This study aims to exploring single nucleotide polymorphisms (SNPs) in genomic regions associated with SHBG concentrations that contributed to never‐smoking female NSCLC.Candidate genes were selected by a genome‐wide association (GWAS) meta‐analysis and gene expression profiles of never‐smoking NSCLC of Chinese women. The candidate SNPs limited to common minor allele frequency (MAF), missense variant, ethnic heterogeneous distribution, and SNPs were genotyped using the TaqMan method. A two‐stage case‐control design was adopted for exploration and validation of associations between candidate SNPs and risk of NSCLC. All participants were never‐smoking Chinese women. Chi‐square test and multivariate logistic regression were applied.2B7, which may be related to circulating SHBG concentrations and cancer risk, were identified. A two‐stage case‐control study was conducted in Shenyang and Tianjin represented as the training stage and validation stage, respectively. Under the dominant model, compared to individuals with the wild G/G genotype, the adjusted OR of those with the T allele was 1.58 (95% CI: 1.15–2.16) in Chinese Shenyang training set, and was 1.49 (95% CI: 1.02–2.18) in Chinese Tianjin validation set, both accompanied with a significant trend relationship consistently. UGT2B7 was upregulated in female NSCLC patients’ tumor tissues and was associated with a poor prognosis in NSCLC.Beginning with 12 genomic regions associated with circulating SHBG concentrations and gene expression profiles from never‐smoking NSCLC in Chinese women, candidate SNP rs12233719 and rs7439366 both located in candidate gene UGTOur findings indicated that a sex hormones regulation‐related SNP rs12233719 was associated with never‐smoking female lung cancer risk, which might partially explain NSCLC‐susceptibility in Chinese women. In this study, by conducting a two‐stage case‐control study, we found that a sex hormones regulation related SNP rs12233719 was associated with never‐smoking female lung cancer risk, which might partially explain NSCLC‐susceptibility in Chinese women. And its concentration is able to regulate the bound‐hormone and free‐hormone states, playing as a transport carrier and regulating biological activities of sex hormones.22.1In this study, we adopted a two‐stage case‐control design2.2In stage 1, Chinese Shenyang training stage, including 417 cases and 368 controls, was recruited from April 2011 to July 2015 in Shenyang, China. Inclusion criteria of cases were never‐smoking female who aged over 18 years, newly diagnosed NSCLC patients with histologically confirmation, without radiotherapy and chemotherapy. Inclusion criteria of controls were recruited from residents who lived in the same or nearby communities, healthy participants without cancer. For stage 2, Chinese Tianjin validation stage, was conducted at Tianjin Medical University Cancer Hospital, including 282 cases and 282 controls, as well as approved by ethical review. The recruitment of research participants was the same as mentioned above from January 2006 to May 2011. All subjects were genetically unrelated to the Han ethnic Chinese. Demographic characteristics were collected by structured questionnaires through an in‐person interview, and a peripheral blood sample (10 ml) was required for each participant collected by an ethylenediaminetetraacetic acid (EDTA) vacutainer tube. This study was approved by the Medical Ethics Committees of Human Studies at Tianjin Medical University Cancer Hospital, and written informed consent was signed by each participant.2.3p < 0.05 and absolution of fold changes >1.5). Sequencing data were processed in general pipelines.Eleven never‐smoking female NSCLC patients with paired tumor and adjacent tissues were used for RNA extraction and transcriptome sequencing. Differentially expressed were identified in the cuffdiff 2.2.1 based on the criterion of being significantly alteration  database which contained 17 and 7 never‐smoking female Japanese adenocarcinoma patients with EGFR mutant, respectively. The combined data from GSE11969 and GSE13213 after batch normalization was used to explore the relationship of 2B7UGT expression and diagnosis of lung cancer.Bioinformatics analysis was performed from publicly available data sets. The combined data from 2.6t‐test or Mann–Whitney U test, as appropriate. Propensity score matching (PSM) analysis was conducted by using exact match method, and standard mean difference was used to examine the balance of covariate distribution between cases and controls. Hardy–Weinberg equilibrium was calculated in each control data sample. Odds ratio (OR) and corresponding 95% confidence intervals (95% CI) were calculated to evaluate the associations between SNPs and NSCLC risk. To explore the independent effect of SNPs on the risk of NSCLC, we adjusted for potential confounding including age, family history of cancer by using multivariable conditional logistic regression model. HR was calculated to evaluate the associations between 2B7UGT expression and diagnosis of never‐smoking female NSCLC. Statistically significant was defined as a two‐sided p‐value < 0.05. SAS version 8.2 ((SAS Institute Inc.), R software (version 4.0.2), and GraphPad Prism 6.0 (GraphPad Software Inc.) were used in the study analysis.Comparisons between cases and controls for continuous variables with a normal distribution (presented as the mean ± SD) were conducted by using the independent sample 33.12B7UGT mRNA was upregulated in tumor tissues (data were not shown), 4098 genes were identified. Finally, 91 candidate genes that may be related to circulating SHBG concentrations and cancer risk were selected. Considering the gene function, only 2B7UGT was included, which was related to SHBG concentrations and sex hormones regulation by reported study  and Tianjin (282 cases and 282 controls) as training and validation stage, respectively. Propensity score matching (PSM) analysis was conducted to balance the distribution of age in Tianjin validation set Table . Under t3.4GSE32863 and GSE37764, compared to adjacent normal tissues, 2B7UGT was high expressed in tumor tissues (p = 0.012)   Figure . This re) Figure .4In this study, by conducting a two‐stage case‐control study, we explored SNPs in genomic regions that were associated with SHBG concentrations contributed to never‐smoking female NSCLC. Our findings indicated that sex hormones regulation‐related SNP rs12233719 was associated with NSCLC risk among never‐smoking Chinese women, which might partially explain NSCLC‐susceptibility in Chinese women.2B7UGT at locus 4q13.2 were identified as the candidate gene and SNPs. The 2B7UGT gene is located on chromosome 4q13.2 with the length of 16 kb, and is widely distributed in the breast, lung, kidney, and intestine, which is considered to be highly polymorphic gene.2B7UGT consists of six exons and five introns and can code for 529 amino acid residues. 2B7UGT was a well‐known pharmacogene belonging to the uridine diphosphate glucuronyltransferase (UGT) gene family,2B7UGT had unique specificity for estrogens and catechol estrogens, including estradiol, estriol, 4‐OH‐estrone, and 4‐OH‐estradiol, serving a significant role in the elimination of exogenous and endogenous estrogens.2B7UGT was recently reported to increase SHBG levels in premenopausal women with oral contraceptive use.2B7UGT and cancer risk, including breast and prostate cancer. Thus, factors affecting the expression and enzyme activity of 2B7UGT may play an important role in tumorigenesis, of which the 2B7UGT mutation may be one of the essential factors involved in the occurrence and development of cancer.In this study, rs12233719 and rs7439366 both located in 2B7UGT, rs12233719 was another missense mutation at position 211 (G211T). A G>T transversion at position G211T was associated with an amino acid change from Ala71 to Ser71, which resulted in a change from a lipophilic residue to a hydrophilic residue.2B7UGT rs12233719 SNP in all genetic models and breast cancer risk,2B7UGT. While the mechanism of rs12233719 impact on NSCLC was unknown, more functional experiments and further studies are urgent to elucidate the underlying linkage. Besides, according to the source of biological samples and the population of SNPs selection, the findings of our study were limited to Chinese female population, which should be interpreted cautiously.Our study first identified SNP rs12233719 G>T polymorphism being a risk factor of never‐smoking female NSCLC, which could partially explain the NSCLC‐susceptibility to never‐smokers in Chinese women. In the coding region of the 2B7UGT, which may rise the enzymes with either histidine (H) or tyrosine (Y) at amino acid 268.2B7UGT rs7439366 SNP on cancer risk. To explore the role of 2B7UGT SNPs in cancer susceptibility, a meta‐analysis study pooled all eligible studies and found no significant association was observed in all genetic models. Further subgroup analysis found that rs7439366 was associated with colorectal cancer risk.We found rs7439366 was not associated with never‐smoking female NSCLC risk in our study. Polymorphism of rs7439366 is a common missense located in exon 2 of Consideration should also be given to potential limitations in this study. First, we failed to perform vivo or vitro experiment to confirm the relationship between rs12233719 and SHBG concentrations. Second, we only adjusted a few potential confounders in the multivariable logistics regression model, which may lead to bias in an unpredictable direction. Potential residual confounders within the individual participants may affect the estimate, such as menopause status. Menopausal status is closely correlated with women's lung cancer risk, but we were not able to assess this because of the limited data source. Thus, larger studies, especially prospective studies, are warranted in the future. Third, we failed prospectively estimated the sample size for two‐stage case‐control study, as well as the transcriptome sequencing experiment. Due to the retrospective characteristics of case‐control study design, we conducted the exploration and validation in a two‐stage case‐control study for screening SNPs without prospective sample size estimation. Meanwhile, the transcriptome sequencing in 11 paired NSCLC patients and controls samples for screening differential genes in nonsmoking female NSCLC was limited several years ago due to limited clinical samples. Besides, it was a preliminary exploration, as well as lack of proper reference data for sample size estimation. Therefore, the results should be interpreted with caution. In the next step, we will try to expand the sample size based on this study.5In summary, we found that rs12233179, involved in sex hormones regulation, was associated with NSCLC risk among never‐smoking Chinese women. Our finding suggests that the SNP rs12233179 in sex hormones regulation may be significant in Chinese female NSCLC, and provides new insight into the possible role of ovarian sex steroid hormones in lung cancer.6This study was approved by the Medical Ethics Committees of Human Studies at China Medical University, and written information consent was signed by each participant. All participants provided written informed consent.Conceptualization, YQ, LX, and BQ; Data curation, YQ, LX, and BQ; Formal analysis, YQ, LX, LL, and BQ; Methodology, YQ, LX, LL, TZ, TF, and BQ; Project administration, TZ and BQ; Supervision, HY and BQ; Writing—original draft, YQ, LX, HY, and BQ. The final manuscript was revised by all authors, and this version was approved to be published.Table S1‐S3Click here for additional data file.


Since body mass index (BMI) is a convincing risk factor for breast cancer, it is speculated to be associated with lymph node metastasis. However, epidemiological studies are inconclusive. Therefore, this study was conducted to investigate the effect of BMI on the lymph node metastasis risk of breast cancer.I2. Subgroup analysis was done to find possible sources of heterogeneity.Cohort studies that evaluating BMI and lymph node metastasis in breast cancer were selected through various databases including PubMed, PubMed Central (PMC), Web of science, the China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals (VIP) and Wanfang Data Knowledge Service Platform (WanFang) until November 30, 2019. The two-stage, random effect meta-analysis was performed to assess the dose-response relationship between BMI and lymph node metastasis risk. Between-study heterogeneity was assessed using RR)  suggested a significant effect of BMI on the lymph node metastasis risk of breast cancer. The dose-response meta-analysis  indicated a positive linear association between BMI and lymph node metastasis risk. For every 1 kg/m2 increment of BMI, the risk of lymph node metastasis increased by 0.89%. In subgroup analyses, positive linear dose-response relationships between BMI and lymph node metastasis risk were observed among Asian, European, American, premenopausal, postmenopausal, study period less than 5 years, and more than 5 years groups. For every 1 kg/m2 increment of BMI, the risk of lymph node metastasis increased by 0.99, 0.85, 0.61, 1.44, 1.45, 2.22, and 0.61%, respectively.We included a total of 20 studies enrolling 52,904 participants. The summary relative risk (BMI significantly increases the lymph node metastasis risk of breast cancer as linear dose-response reaction. Further studies are needed to identify this association. Breast cancer is one of the most common malignant tumors among females worldwide. According to the International Agency for Research on Cancer’s GLOBOCAN 2018 –5, which2) prevalence was estimated, and obesity rates will be exceed 50% by 2030 [OR = 3.21, 95% CI: 1.15–8.47). In a pooled analysis [2 increment of BMI in postmenopausal women. Furthermore, women who are obese with breast cancer diagnosis were reported to have greater disease mortality, higher recurrence rate and adverse overall and disease-free survival [Although the rise in obesity and overweight showed some signs of leveling off, data from several countries indicated that obesity has become a worldwide epidemic . Based o by 2030 . It was  by 2030 , hyperte by 2030 , type 2  by 2030 , hyperli by 2030 , stroke  by 2030  and some by 2030 , 14. Amo by 2030  conducteanalysis  of eightanalysis  dose-ressurvival , 19. So P = 0.026). In another study [P = 0.003). On the contrary, Yadong Cui’s [OR = 1.28, 95% CI: 0.90–1.81). Therefore, the present dose-response meta-analysis was conducted to investigate the association between obesity, as measured by BMI, and lymph node metastasis in breast cancer, and sub-analyses by different areas, menopausal status, study period were done to explore potential factors that influence the associations deeply.Despite accumulated evidence that obesity may increase breast cancer risk, question remain, whether obesity is associated with lymph node metastasis, the most common form of metastasis in breast cancer? However, there was limited study focused on the relationship between obesity and lymph node metastasis in breast cancer, and the conclusions were inconsistent. For example, in a retrospective review of 1352 breast cancer patients , obese per study  supporting Cui’s  case serIn this study, we searched PubMed, PubMed Central (PMC), Web of science and Chinese academic databases including the China National Knowledge Infrastructure (CNKI), VIP database of Chinese Scientific Journals (VIP) and Wanfang Data Knowledge Service Platform (WanFang) for publications on the association between BMI and lymph node metastasis in breast cancer in humans up to November 30, 2019. The following combination of keywords was used to identify studies from electronic databases: (obesity OR “body mass index” OR BMI) AND (“breast cancer”) AND (“metastasis”). To avoid missing any relevant studies, all reference lists of eligible articles and related reviews were searched for additional publications. We did not include unpublished documents and grey literature, such as conference abstracts, theses (including dissertations) and patents.Studies were included according to the following criteria: (1) full-text articles were available as Chinese or English language; (2) study design was a cohort study; (3) the height and weight of patients were measured at the time of diagnosis; (4) studies had BMI categories of no fewer than three, and provided the number of cases for each BMI category; (5) studies reported the metastasis type of patients, such as lymph node metastasis, positive lymph nodes and so on. If more than one publication of a given study exists, only the publication with higher number participants was included.All potential relevant publications were inserted in EndNote X8 software. Then, qualified studies were obtained for full-text screening. After the final evaluation, the authors extracted and recorded the required data: name of the first author; year of publication; country of origin; age (range) of study population; study period; intervals of each BMI category; cases number of each category and so on.Using the Newcastle-Ottawa’s Scale (NOS), the quality of the included studies were assessed. This scale ranges from 0 to 9 stars and awards four stars for selection of study participants, two stars for comparability of studies, and three stars for the adequate ascertainment of outcomes, and each item is assigned with a star if a study meets the criteria. We considered a study to be of high quality if its NOS score was more than six stars.Study selection, data extraction, and quality assessment were done by two independent reviewers, and any controversies across selecting eligible articles were resolved by mutual discussion.RR) and its 95%CI were considered as the effect size of all studies. For the highest versus lowest category meta-analysis, the risk estimates for the highest compared with the lowest categories of BMI was combined using the DerSimonian and Laird random-effects model [The relative risk  statistic. An I2 above 50% indicated high heterogeneity, and a random effect model was implemented. Predefined subgroup analyses based on area, menopausal status, study period and study population were conducted to detect potential sources of heterogeneity. To explore the influence of each study on the pooled effect size, a sensitivity analysis was used by omitting one study at a time. Publication bias was identified with the Begg’s rank correlation test and Egger’s regression test [Heterogeneity among studies was assessed by I-square , and the random effect model was used for meta-analysis. The results showed that there was a link between BMI and the lymph node metastasis risk of breast cancer, with a summary RR of 1.10 (95%CI: 1.06–1.15) , European  and American  women. Interestingly, there were positive associations both in the premenopausal women  and postmenopausal women . Besides, we conducted a subgroup analysis stratified by study period, the RR  of less than and equal to 5 years was prominent higher than that of more than 5 years . For study population, positive significant associations between BMI and lymph node metastasis were observed in non-TNBC , while poor association in TNBC patients . The subgroup analyses are shown in Table When subgroup analyses were done for different areas, the results showed significant associations between BMI and lymph node metastasis of breast cancer in Asian (P = 0.465), which showed no nonlinear dose-response relationship between BMI and lymph node metastasis. Secondly, linear dose-response regression model was used to test the relationship. The goodness of fit test  showed there was heterogeneity among the studies, and the random-effect model was used for the meta-analysis. Regression model test  revealed a positive linear dose-response association between BMI and lymph node metastasis. The results  showed that for every 1 kg/m2 increment of BMI, the risk of lymph node metastasis increased by 0.89%.Figure RR = 1.01, 95%CI: 1.00–1.02), European , American , premenopausal , postmenopausal , study period ≤5 years , study period > 5 years  patients were statistically significant, and the risk increased by 0.99, 0.85, 0.61, 1.44, 1.45, 2.22, and 0.61%, respectively. And the results of other two subgroups (TNBC and non-TNBC) were missing because of too small sample size in TNBC.The detailed information of the dose-response meta-analysis and subgroup analyses are shown in Table RRs indicated little variation ranging from 1.09  to 1.13 , and the result was not influenced by any single study, indicating that the meta-analysis result was stable.For the sensitivity analysis, we omitted one study at a time in turn to assess the potential studies which may influence the main results. The pooled P = 0.003) and studies on non-TNBC patients using Egger’s test (P = 0.003).No publication bias was found for subgroup analyses, except for the overall studies using Egger’s test , and lower probability was observed in Japanese women . Whether this race/ethnicity disparity existed when BMI were assessed remained unknown, although confounding factors, such as socioeconomic status and treatment imbalance, contributed in part. Also, in Chinese Han women, a possible interaction between Interleukin-18-137G/C, −607G/T polymorphisms and BMI in breast cancer patients was identified [2) patients with G/T genotype had a 5.45-fold  increased risk of lymph node metastasis relative to those with T/T homozygotes. Subgroup analyses grouped by race/ethnicity or genotype would be more accurate to explore the linkage between obesity and lymph node metastasis in breast cancer, unfortunately, which was not available in the selected studies.Dose-response meta-analysis results showed that there was a linear dose-response relationship between BMI and lymph node metastasis in breast cancer. For every 1 kg/m’s study  and some’s study , which a’s study . Black wentified . Overwei2) was similar to that in postmenopausal women (1.45%/1 kg/m2). In postmenopausal patients, obese women would have a high concentration of circulating estrogen, since most estrogen is produced in the adipose tissue [Besides, the lymph node metastasis risk of breast cancer with BMI in premenopausal women  of lymph node metastasis with BMI occurred in less than 5 years compared with more than 5 years (0.61%/1 kg/m2). A possible explanation is the apparent older participants  for the relationship of BMI and lymph node metastasis in breast cancer. Secondly, some included articles didn’t group BMI according to WHO standards, so the accuracy of the results would be affected in the highest versus lowest BMI meta-analysis. Thirdly, we didn’t have access to other key individual-level information except area, menopausal status, and study period, such as race, breast cancer sub-types, ER status, progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status, and obesity associated risk factors , to examine the roles of these factors in lymph node metastasis. Finally, the retrospective nature of this meta-analysis could not be ignored, so the results should be interpreted with cautions.In conclusion, BMI significantly increases the lymph node metastasis risk of breast cancer. Overweight and obese breast cancer patients might benefit from adhering to a healthy lifestyle aiming at losing or controlling weight, as part of the comprehensive oncologic therapy. Further original studies are warranted to identify the link of BMI and lymph node metastasis in breast cancer.