N-Nitroso compounds are thought to play a significant role in the development of gastric cancer. Epidemiological data, however, are sparse in examining the associations between biomarkers of exposure to N-nitroso compounds and the risk of gastric cancer.N-nitroso compounds and risk of gastric cancer. Information on demographics, usual dietary intake, and use of alcohol and tobacco was collected through in-person interviews at enrollment. Urinary levels of nitrate, nitrite, N-nitroso-2-methylthiazolidine-4-carboxylic acid (NMTCA), N-nitrosoproline (NPRO), N-nitrososarcosine (NSAR), N-nitrosothiazolidine-4-carboxylic acid (NTCA), as well as serum H. pylori antibodies were quantified in 191 gastric cancer cases and 569 individually matched controls. Logistic regression method was used to assess the association between urinary levels of N-nitroso compounds and risk of gastric cancer.A nested case-control study within a prospective cohort of 18,244 middle-aged and older men in Shanghai, China, was conducted to examine the association between urinary level of N-nitroso compounds. Among individuals seronegative for antibodies to H. pylori, elevated levels of urinary nitrate were associated with increased risk of gastric cancer. The multivariate-adjusted odds ratios for the second and third tertiles of nitrate were 3.27  and 4.82 , respectively, compared with the lowest tertile (P for trend = 0.042). There was no statistically significant association between urinary levels of nitrite or N-nitroso compounds and risk of gastric cancer. Urinary NMTCA level was significantly associated with consumption of alcohol and preserved meat and fish food items.Compared with controls, gastric cancer patients had overall comparable levels of urinary nitrate, nitrite, and N-nitroso compounds, may increase the risk of gastric cancer among individuals without a history of H. pylori infection.The present study demonstrates that exposure to nitrate, a precursor of  Despite the decrease in incidence and mortality rates of stomach cancer worldwide over the past three decades, gastric cancer is the fourth most commonly diagnosed cancer and the third most common cause of cancer death . Even ifN-Nitroso compounds (NOCs) have shown carcinogenic effects in experimental studies. Approximately 300 NOCs have been tested for carcinogenicity in laboratory experiments, with 90% of them demonstrating carcinogenic effects across different animal species, including higher primates [2O3 and (H2NO2) +, both of which are nitrite-derived nitrosation agents. Nitrite could derive either directly from food, or indirectly from reduction of nitrate by oral and enteric bacteria [primates , 6. Certprimates . Accordiprimates . Humans primates . Endogenbacteria –14. Endobacteria , 16. In bacteria . Nitrosabacteria . Approxibacteria . IndividN-nitroso-2-methylthiazolidine-4-carboxylic acid (NMTCA), N-nitrosoproline (NPRO), N-nitrososarcosine (NSAR), and N-nitrosothiazolidine-4-carboxylic acid (NTCA) 4 major non-volatile NOCs present in human urine [in vivo administration of nitrate and N-nitrosamine precursors has shown high efficiency in the production of NMTCA, NTCA and NPRO [H. pylori bacteria, alcohol consumption, cigarette smoking, and serum/urinary antioxidant measurement on the NOC-gastric cancer association.[Epidemiological studies examining the association between NOCs or NOC-containing food and gastric cancer risk have produced inconsistent results . These ian urine . The halan urine . The in and NPRO , 23. Thuand NPRO , 22, 24.ociation.The design of the Shanghai Cohort Study has been described in detail elsewhere , 27. BriCurrent diet was assessed through a food frequency questionnaire that included 45 food items representing commonly consumed local foods in Shanghai, China, in early 1980’s. Annual follow-up for incident cancers and deaths has been carried out since 1986. All surviving participants were contacted in-person annually for vital status and cancer diagnosis. We also performed record linkage analysis with databases of the Shanghai Cancer Registry and Shanghai Municipal Vital Statistics. By the end of 2012, only 609 (3.3%) original cohort participants were lost to our annual follow-up interview. In addition, 573 (3.1%) subjects refused our request for annual follow-up interviews, although their cancer and vital status have been ascertained and updated through the annual record linkage analyses. Thus the follow-up for incidence of cancer and death among cohort participants was almost complete. The present study included 197 patients with incident gastric cancer whose initial diagnosis was made between date of enrollment and March 1998. Diagnoses of 179 (91%) cancers were based on histopathologic evidence. The remaining 18 (9%) cases were diagnosed based on radiographic imagines with consistent clinical evidence (n = 14) or death certificate only (n = 4). There were 45 patients with cancer at gastric cardia and 146 at non-cardia.For each case, we chose three control subjects randomly among all eligible participants of the cohort study who met the matching criteria. All three chosen controls were individually matched to index cases by age (±2 years), month and year of biospecimen collection, and neighborhood of residence at recruitment.The aliquots of urine samples of the subjects were pulled from the biospecimen repository and then sorted into the matched case-control sets. All 4 urine samples within a given matched case-control set  were arranged in a random order and tested in the same batch for all laboratory measurements. The case/control status of the test urine samples was blind to laboratory personnel.N-nitrosopipecolic acid (NPIC) as internal standard, 2.0 g sodium chloride (NaCl), and 1.5 mL 20% ammonium sulfamate solution in 1.8 M H2SO4. The combined extracts were dried over anhydrous sodium sulfate and concentrated to dryness by rotary evaporator at 30°C, and derivatized in 2 ml ether with excess diazomethane .The methyl ester of the five N-nitrosamino acids in ethereal solution were concentrated to 0.1 ml and quantified with a 10 μl aliquot by GC-TEA. For gas chromatography, a glass column (2 m x 3 mm i.d.) packed with 5% FFAP on Chromosorb WHP (80–100 mesh) was used at a temperature of 180°C. The temperature of the injection port of the gas chromatography was 200°C, and the flow rate of the nitrogen carrying gas was 50 ml/min. For the thermal energy analysis, the temperature of the pyrolyzer was 500°C, interface was 200°C, and vacuum to 0.9 mm Hg. The recoveries of NSAR, NPRO, NMTCA, and NTCA added at 30 ug/L each were 75%, 79%, 91% and 96%, respectively. The detection limits ranged from 0.1 to 0.5 μg/L, depending on the compound.NSAR, NPRO, NTCA and NMTCA were analyzed by a gas chromatography coupled with thermal energy analyzer (GC-TEA) according to the method described previously . Briefly4 solution was added and incubated at 50–60°C for another 10 min, and additional 1 ml 0.5 N NaOH was added before the contents cooled to room temperature. After adding 17.6 ml of water, the sample was passed through filter paper and the filtrate was collected after discarding the first 10 ml filtrate. For measurement of nitrite, 5 ml 0.5% sulfanilamide and 2 ml 0.5% N-(1-naphthyl) ethylenediamine dihydrochloride was added to the 10 ml aliquot of filtrate described above before the absorbance of the final solution was read at 540 nm. For determination of nitrate, 5 ml NH4OH buffer solution and 18 ml water was added to 2 ml filtrate before it passed through a Cd column at 3–5 ml/min. The column was washed with 15 ml water and the combined effluent collected. After adding 5 ml 0.5% sulfanilamide and 2 ml 0.5% N-(1-naphthyl) ethylenediamine dihydrochloride, the absorbance of the final solution was read at 540 nm after standing for 20 min. The final concentrations of nitrite and nitrate were calculated using the standard curve. For quality control purpose, two batches of urine samples with three duplicates each that were blind to laboratory personnel were dispersed among the test samples. The intra- and inter-assay coefficients of variation for all NOCs and their precursors measured were 4–15% and 12–33%%, respectively.Nitrate and nitrite were analyzed according to the method described previously with some modification . CadmiumH. pylori was determined by detection of serum immunoglobulin G (IgG) antibodies to H. pylori using an enzyme-linked immunosorbent assay (ELISA) described previously [H. pylori strains that were prevalent in the study population [A history of infection with eviously . This ELpulation . The metpulation , 30.Of 197 cases and 591 controls, urine samples of 6 cases (and 18 their matched controls) and additional 4 controls had missing values of one or more urinary measurements. Therefore, the present study included 191 cases and 569 matched control subjects after excluding these subjects with missing values in the primary analyses. In addition, we added urinary nitrite assay late on the study samples and had values of nitrite on 104 cases and 308 matched controls only, on which all statistical analysis involving urinary nitrite was based.2 test was used to compare the distributions of selected demographics, cigarette smoking, alcohol consumption and IgG antibodies to H. pylori between cases and controls. The analysis of covariance method was used to examine differences in the geometric mean of urinary nitrate, nitrite and NOCs across different levels of smoking, alcohol intake, or serologic status of H. pylori infection, intake of fresh dark green vegetables, intake of salted/pickled vegetables, or intake of preserved meats, fish or eggs among control subjects only. The Wilcoxon statistic method was used to assess the difference in the distributions of urinary NOCs or their precursors between cases and controls.The concentrations of urinary nitrate, nitrite and 4 NOCs measured were expressed as μg/g creatinine to take into account varying water content in urine across different individuals. The distributions of the concentrations of these urinary analytes were markedly skewed with few subjects possessing high values, which were normalized, to a large extent, by their logarithmic transformation. Therefore, formal statistical tests on continuous values of NOCs, nitrate and nitrite were performed on logarithmically transformed values. Spearman rank correlation analysis was performed to assess the relationships between individual urinary NOCs, serum antioxidants and urinary EGC. The χP’s for trends. Study subjects were grouped into three levels  based on the tertile or high/low distributions of detectable urinary NOCs among all control subjects. The linear trend test for the exposure-disease risk associations was based on ordinal values (0–2) for the three exposure levels. We also examined the NOC-gastric cancer risk association in subgroups stratified by cigarette smoking (ever or never), alcohol consumption (ever or never), serologic status of H. pylori (negative or positive), levels of serum antioxidants , or level of urinary EGC , as well as by subsite of gastric cancer (cardia and non-cardia). For the subgroup analyses, matched sets were broken and unconditional logistic regression was used to maximize the sample size available for stratified statistical analysis. The matching factors  were included in all unconditional logistic regression models as covariates. The presence of H. pylori antibodies in serum, cigarette smoking, heavy alcohol consumption, serum levels of β-carotene and vitamin C, and urinary level of EGC were identified risk/protective factors for gastric cancer in this study population [Conditional logistic regression method was used to assess the associations between levels of urinary NOCs, nitrate and nitrite and gastric cancer risk . The asspulation –30, 32. P’s reported are two-sided, and those that were less than 0.05 were considered to be statistically significant.Statistical computing was conducted using SAS version 9.2 . All 2) or level of education between cases and controls. Individuals who developed gastric cancer consumed more cigarettes and alcohol, and were more likely to be seropositive for IgG antibodies to H. pylori than their matched controls (The mean age (standard deviation) of case patients at cancer diagnosis was 63.4 (5.6) years. The average time interval between biospecimen collection and cancer diagnosis was 5.1 (3.0) years (ranging from 1 month to 12 years). There was no significant difference in body mass index . Smokers or those positive for antibodies to H. pylori were associated with statistically borderline significant elevation of urinary nitrite. There was no significant relation for other urinary NOCs or their precursors with alcohol intake, cigarette smoking or history of H. pylori infection (P for trend = 0.032). There was no statistically significant association between dietary intakes of fresh/preserved vegetables, or preserved meat/fish/egg and urinary levels of nitrite or other NOCs  whereas high intake of fresh dark green vegetables was associated with a statistically non-significant increase in nitrate level overall (P for trend = 0.248), although there was no correlation between intake frequencies of fresh and preserved vegetables . We examined the modifying effect of salted/pickled vegetables on the association between intake of fresh dark green vegetables and urinary levels of nitrate. Among controls who did not consume salted/pickled vegetables, the geometric means (95% CIs) of urinary nitrate for individuals consuming <1, 1, and 2 or more times/day of fresh dark green vegetables were 206.0 (151.5–280.0), 201.3 (144.4–280.5), and 523.0 (274–995.8) mg/g creatinine, respectively (P for trend = 0.069). Among controls who consumed one or more times of salted or pickled vegetables per week, the corresponding figures were 141.9 (110–181.7), 154.8 (117.9–203.1), and 120.0 (70.9–202.6) mg/g creatinine, respectively (P for trend = 0.84). There was a statistically significant interaction between intakes of fresh dark green vegetables and salted/pickled vegetables on urinary level of nitrate (P for interaction = 0.037).High intake of salted/pickled vegetables was inversely associated with urinary nitrate level in a dose-dependent manner  were more than 20 times those of nitrite (7–8 mg/g creatinine) in both cases and controls. Among four NOCs measured, NTCA was at the highest level, followed by NPRO and NMTCA whereas NSAR was at the lowest; more than 60% of study subjects were undetectable for NSAR in urine. Overall there was no significant difference in urinary concentrations of nitrate, nitrite or any NOCs measured between gastric cancer patients and control subjects . Compareitamin C .H. pylori is an underlying cause of gastric cancer, we also examined the associations between urinary levels of nitrate, nitrite and individual NOCs and risk of gastric cancer separately in individuals positive or negative for H. pylori antibodies  for the second and third tertiles of nitrate were 3.27 (0.76–14.03) and 4.82 (1.05–22.17), respectively, compared with the lowest tertile (P for trend = 0.042). There was no evidence for effect modification of H. pylori serologic status on the association between nitrite or any NOCs and risk of gastric cancer .H. pylori . In addition, elevated levels of urinary nitrite were associated with seropositivity to H. pylori, suggesting that infection with H. pylori may enhance the reduction of nitrate to nitrite in vivo. Furthermore, the present study demonstrated a novel dose-dependent relationship between alcohol consumption and urinary levels of NMTCA, suggesting that alcohol intake could play a role in the formation of NOCs in vivo.To the best of our knowledge, the present study was the first utilizing a biomarker approach to investigate the association between NOCs and their precursors and the risk of developing gastric cancer in a prospective cohort study. We observed a statistically significant positive association between urinary nitrate and gastric cancer risk among individuals negative for IgG antibodies to H. pylori is a strong risk factor for gastric cancer [H. pylori in the stomach causes inflammatory damage to the mucosa of the stomach, which may enhance the endogenous formation of NOCs in the stomach [H. pylori supports this hypothesis that H. pylori may contribute to nitrosation process in the stomach. The interactive role of H. pylori and N-nitroso compounds in the development of gastric cancer requires further investigation.Infection with c cancer . The pre stomach , 34, 35.H. pylori, urinary levels of nitrate, a precursor of N-nitroso compounds, were positively associated with risk of gastric cancer. Chronic infection with H. pylori is an established risk factor for gastric cancer. It is not surprising that the association between nitrate and gastric cancer risk was more apparent among individuals without H. pylori infection, a relatively low risk population. The findings of the present study suggest that the effect of nitrate through the nitrosation pathway could be masked by H. pylori infection, especially in the present study population where H. pylori infection is highly prevalent. Given the small sample size and multiple comparison issues, the interpretation of the present study findings with a positive association between urinary nitrate and gastric cancer risk among individuals with negative H. pylori should be made with caution because of possible chance finding. The future studies with a larger sample size are warranted to confirm these results.Among individuals seronegative for IgG antibodies to P for trend = 0.03). Our findings were consistent with the result from a recent study showing that NMTCA were often detected in processed meat products [in vivo and may explain their association with risk of gastric cancer.This study shows that higher levels of NMTCA in the urine of alcohol drinkers compared to non-drinkers. Studies have shown that co-administration of acetaldehyde (a metabolite of ethanol), L-cysteine and nitrite significantly increased urinary excretion of NMTCA in man . The preproducts , 37. TheP = 0.002). In addition, a statistically significant modifying effect of salted/pickled vegetables on the relationship between dark green vegetables and urinary nitrate level was found. Intake of salted/pickled vegetables resulted in a statistically non-significant 20–30% reduction in urinary nitrate level among individuals with less than two times/day of dark green vegetables whereas it resulted in a statistically significant 77% decrease in urinary nitrate level among those consuming two or more times of fresh dark green vegetables (P for interaction = 0.037). The fermentation or pickling process can significantly reduce the amount of nitrate in salted/pickled vegetables by up to 90% [The present study demonstrated a strong, statistically significant inverse association between intake of salted/pickled vegetables and urinary levels of nitrate . The strong effect of H. pylori on gastric carcinogenesis could mask the role of NOCs or their precursors in the risk of gastric cancer development in this study population.Nitrate and nitrite are classified as probably carcinogenic to humans under conditions likely to cause endogenous nitrosation . A positc cancer . In the H. pylori infection, and laboratory measurements of antioxidants  could reduce their potential confounding effect on the NOCs-gastric cancer risk associations. The almost complete follow-up for incident cancer and death minimized the potential bias on results due to the loss to follow-up.Our study had several strengths. A prospective study design and the availability of prediagnostic urine samples minimized the possible influence of disease symptoms on dietary intake and other lifestyle factors. The prospective design of the study also ruled out the possibility of recall bias on exposure. Considering the limitation of food frequency questionnaire in the estimation of exposure levels to both endogenous and exogenous NOCs , urinaryH. pylori antibodies in subgroup analysis with unconditional logistic regression after the matched case-control sets were broken, which prohibited us from conducting further stratified statistical analyses.The present study has several potential limitations. One cannot presume that NOCs levels in a randomly timed, single void urine sample represented the long-term exposure to both exogenous and endogenous NOCs. It would be ideal, but rarely feasible, to assess NOC exposure at multiple time points prior to disease occurrence, especially using a biomarker approach as this study, due to the high cost and logistical complexity involved in the collection of biospecimens at multiple points of time for each subject from a prospective study of large number of participants such as this one. Therefore, the non-differential misclassification due to the use of a single spot urine sample may be the underlying reason for the null findings of urinary NOCs and gastric cancer risk. Another major limitation of the present study was the relatively small sample size, especially those negative for H. pylori. A statistically significant positive association between prediagnosic urinary levels of nitrate and risk of gastric cancer was observed among individuals negative for antibodies to H. pylori. This positive nitrate-gastric cancer risk association was independent of cigarette smoking, alcohol consumption and antioxidant status. The present study also found a strong, dose dependent relationship for the consumption of alcohol or preserved meats and fishes with urinary levels of NMTCA, which sheds some light on our understanding the mechanism of alcohol and preserved protein-rich food items on gastric carcinogenesis. The role of N-nitroso-compounds in the development of gastric cancer in humans is warranted for further investigation.In summary, the present study did not show an overall statistically significant association between urinary levels of selected NOCs or their precursors and risk of gastric cancer in a high-risk population with high prevalence of


The Ninth European Breast Cancer Conference (EBCC-9), one of the largest breast cancer conferences in the world, was held in Glasgow in March 2014, and brought together the voices of doctors, researchers, nurses, and patients. All the major breast cancer advocacy groups and institutions were united in one forum .The Scientific Programme for EBCC-9 highlighted a holistic picture of breast cancer, including research, prevention, treatment, advocacy, and care. Participants were able to discover the most up-to-date developments and findings within the field for implementation into daily practice. Improvements in treatment, as well as enhanced access to care, underlie the sustained decreases in breast cancer mortality seen in 30 European countries from 1989 to 2010. The GLOBOCAN project estimates that for 2012 there were 1.67 million cases of breast cancer worldwide. In Europe, including non-European Union countries, the latest estimates indicate that in 2012 there were 464,000 new cases of breast cancer, accounting for 28.8% of all cancer cases diagnosed in women and 13.5% of all cancer cases diagnosed overall. Globally, the latest estimates indicate that 7.5% of all cancer deaths in Europe in 2012 were attributable to breast cancer. EUROCARE-5 reported that the average five-year survival of European women diagnosed with breast cancer was 82% [Prof Philippe Autier, from the International Prevention Research Institute, Lyon, France, explained that, although the decrease in deaths from breast cancer in 2010 was greatest in those countries with the highest mortality rates in the late 1980s, there were notable exceptions. In 1987–1989 breast cancer mortality rates were highest in England and Wales at 41.9 per 100,000, and lowest, at 20 per 100,000, in Romania. In 2008–2010 these rates were 25.4 and 22, respectively, indicating that mortality decreased by 40.8% in England, while it increased by 11.4% in Romania.According to Prof Autier, screening has played an important role in decreasing the average size of tumours at detection. However, trends in the incidence of advanced breast cancer have remained stable, suggesting that screening does not succeed in detecting potentially life-threatening cancers at an earlier stage, and the number of breast cancers that have already metastasised in distant organs when first diagnosed has not decreased. Hence, these reductions in size simply represent the increasing incidence of small, early, non-life-threatening cancers that are detected by screening, and which give an overall impression that things are getting better in terms of outcomes. Therefore, decreased numbers of breast cancer deaths are largely due to improved treatments, not to screening.Reductions in mortality from breast cancer were greatest in women of less than 50 years of age, with overall reductions of –71.3% to –21.4%, and smallest in women aged 70 and over (from –29.5 to +81.5), with breast cancer mortality among older women continuing to increase in many countries, particularly those in central and eastern Europe.Yet in countries where major screening programmes were implemented after 2000  considerable reductions in deaths from breast cancer were reported.Nevertheless, the global burden of breast cancer remains immense in 2013, with over 1.6 million new cases being diagnosed annually. This burden has been increasing at a rate of 3.1% per year, and while the majority of new cases are diagnosed among women in developed countries, the 450,000 deaths per year from the disease are now equally divided between the developing and developed world.Prof Peter Boyle, Director of the University of Strathclyde Institute of Global Public Health at the International Prevention Research Institute (iPRI) in Lyon, France, informed the conference that in Scotland the death rate from breast cancer is now at its lowest level in over 100 years, thanks to the contributions from a variety of sources, including the development and availability of effective treatments, increased awareness among women, the national NHS Breast Screening programme, and free access for all women to high-quality diagnostic and treatment facilities.However, women in low income countries, and particularly in Africa, tend to seek medical attention for their disease only once it is at an advanced stage and has spread to other parts of the body, and by this stage the only option is palliation, which is often itself not available or, at best, not optimal. The World Breast Cancer Report 2012 collected data about groups of breast cancer patients from institutes throughout the world to develop a clearer picture of the current situation. In high-income countries, such as the United Kingdom and Australia, there were very few women diagnosed initially with stage III or IV disease, whereas in countries such as Kenya and Uganda almost all women with breast cancer presented at these later stages.An increasing population size, longer life expectancy, a decrease in the stigma attached to a diagnosis of breast cancer, increases in awareness, and the introduction of early detection programmes in lower resource countries will inevitably lead to an increase in the numbers of new cases being diagnosed. Prof Boyle concluded by saying that epidemiology has a vital role to play both in elucidating the current situation and in bringing it to the notice of those who are able to do something about it.Recent studies showed that lifestyle choices are becoming more and more important in the prevention of breast cancer, avoiding a recurrence of breast cancer and helping to improve life as survivors of breast cancer.According to the research presented to the Ninth European Breast Cancer Conference (EBCC-9) on 20 March, practising sport for more than an hour a day can reduce the risk of contracting breast cancer, and this applies to women of any age and any weight, and also from any geographical location. Compared with the least active women, those with the highest level of physical activity reduced their risk of breast cancer by 12%. Prof Mathieu Boniol, Research Director at the International Prevention Research Institute, Lyon, France, reported the results of a metaanalysis of 37 studies published between 1987 and 2013, representing over four million women. Although the results varied according to tumour type, the overall message was encouraging. However, in women taking hormone replacement therapy (HRT), the protective effect of exercise seemed to be cancelled out. Nevertheless, increased awareness of the side effects of HRT means that its use is decreasing in a number of countries, and this means that the beneficial effects of activity will most likely grow in the years to come. Physical activity is known to have a protective role in other cancers, as well as in disorders, such as cardiovascular disease. Although the mechanisms for its effect are unclear, the results are largely independent of body mass index (BMI), so the effect must be due to more than weight control. The researchers found no indication that breast cancer risk would decrease only when physical activity started at a young age. Both obesity and diabetes have adverse effects on outcomes in breast cancer patients who receive chemotherapy as primary treatment before surgery (neoadjuvant chemotherapy). Although a high BMI is known to have a negative impact on cancer development and prognosis, until now there has been uncertainty as to whether having a high BMI had an equal effect on patients with different types of breast tumours.2, which is often the limit when calculating doses. Final analysis of outcomes from the two groups in the joint study showed a significant decrease in distant disease-free survival (DDFS) or in distant relapse-free survival in patients with increased BMI in all tumour types, apart from those with HER2-positive tumours. According to Dr Fontanella the exception in this group can probably be explained by the impressive impact of anti-HER2 treatment. In a second study, Dr Fontanella and colleagues investigated the incidence of Type 2 diabetes in patients with early breast cancer at the time of diagnosis, as well as its effect on the outcome after neoadjuvant chemotherapy. Diabetes has been reported in 15% to 20% of elderly breast cancer patients, although in the group of just over 4000 patients studied it was considerably lower. Researchers found that patients with diabetes were more likely to have their cancer diagnosed at a more advanced stage, and this suggests that diabetes may affect the size of the tumour. Patients with diabetes were also found to have worse DDFS rates. Researchers hypothesise that hyperinsulinemia may encourage the growth of tumour cells by providing them with large amounts of glucose. Therefore, a strict control of blood sugar levels might be is essential to the successful treatment of breast cancer.In this regard, Dr Caterina Fontanella, a trainee in medical oncology from the University of Udine  and a research fellow with the German Breast Group presented an analysis based on nearly 11,000 patients with early breast cancer treated with neoadjuvant chemotherapy. She showed that a high BMI adversely affects the chances of surviving without the breast cancer recurring or spreading to other parts of the body, although this detriment was not seen in those women had been diagnosed with HER2-positive disease. The researchers studied data from 8872 early breast cancer patients from the German Breast Group, and 1855 from a joint EORTC/BIG trial. All had received a modern treatment consisting of an anthracycline/taxane-based neoadjuvant chemotherapy, anti-HER-2 drugs, or hormone therapy according to the tumour type and national guidelines. The vast majority of the patients in this study received chemotherapy doses capped at a body surface area of 2.0 min situ (DCIS) between UK hospitals.Analysis of data from the UK NHS Breast Screening Programme has shown significant variations in the outcomes of treatment for women with ductal carcinoma Dr Jeremy Thomas, a consultant pathologist at the Western General Hospital, Edinburgh, UK, reported that although the majority of women with DCIS received the correct surgery for their disease, large numbers of women were undergoing mastectomy for DCIS either as a result of failed breast conservation surgery or for tumours that turned out to be smaller than 20 mm in diameter, and therefore should normally have had a lumpectomy rather than a mastectomy. Usually, decisions about how women with DCIS should be treated are taken in multidisciplinary teams that include radiologists, pathologists, surgeons, oncologists, and nurses. Nevertheless, Dr Thomas reported that, in some hospitals, the discussions in the multidisciplinary teams are not looking in enough detail at the results from the mammograms and pathology to make the right decision about the best surgical treatment for these women. Dr Thomas and his colleagues in The Sloane Project—a multidisciplinary, UK-wide prospective audit of screen-detected non-invasive breast cancers and atypical hyperplasias—collected data from 8313 patients with DCIS detected during screening from 2003 onwards.They reported that of 6633 women who were treated with breast conservation surgery, 799 (12%) required a subsequent mastectomy. Failed breast conservation surgery accounted for one-third of all the women who ended up having a mastectomy, and was usually because of under-estimation of the extent of the disease from the mammograms. The total number of women who had mastectomies, including those for whom mastectomy was the first course of action as well as those who had failed breast conservation, was 2479; of these, 510 (21%) had mastectomies for tumours smaller than 20 mm in diameter, which would normally have been better treated with a lumpectomy. To analyse the variations between hospitals, Dr Thomas and his colleagues selected 57 hospitals that had submitted data on the highest number of patients. These hospitals had data on between 50 and 387 cases each, making a total of over 6000 patients, which was around 80% of the total number of women being studied. The proportion of failed breast conservation surgery in these hospitals ranged from 3% to 32%, while the proportion of mastectomies for small tumours ranged from 0 to 60%. The researchers then divided the 57 hospitals into three subgroups, with 19 hospitals in each, based on how often the wrong surgery was carried out. In the high frequency group for failed conservation surgery there was an adverse outcome on average in 22.3% of cases, in the medium group in 13.4% of cases, and in the low group in 7% of cases. Dr Thomas concluded by affirming that the UK NHS Screening Programme is working well and that the right surgical decisions are being made in the majority of cases. However, the significant variation between hospitals shows that the approach can be improved.A study of over 50,000 women participating in the UK NHS Breast Screening Programme has found that, while three-yearly screening intervals are appropriate for the majority of women, approximately one-third of women are at higher risk of developing cancer and might benefit from more frequent mammograms. Prof Gareth Evans, from the University of Manchester (UK), reported that identifying the degree of risk of developing breast cancer in individual women would enable healthcare professionals to target screening and preventive measures better. To see if this was feasible, he and his colleagues from Manchester and Queen Mary University of London (UK) collected extra information from women attending routine breast screening in Manchester and who had agreed to participate in the Predicting Risk Of breast Cancer At Screening study. A questionnaire was used to collect information on important breast cancer risk factors, such as family history and lifestyle; where appropriate, genetic information was collected by analysing saliva samples; breast density was measured from the mammogram and given a ‘visual assessment score’ (VAS), which indicated the percentage of dense tissue in the breast. The study started in 2009 and the first 53,467 women were included in the analysis reported at EBCC-9. During this time 634 women developed breast cancer. The NHS Breast Screening Programme is usually open to women between the ages of 47 and 73 years, and the ‘normal’ risk of developing breast cancer within the next ten years varies from 2.4% at the age of 47years to 3.5% at the age of 70 years. The risk factor questionnaire indicated that 676 (1.4%) women had a high risk of developing breast cancer of 8% or more over the next ten years, with a further 4591 (8.6%) women having a moderately increased risk of between 5% and 8%.When Prof Evans and his colleagues combined the results from the risk factor questionnaire and VAS to make the results more accurate at defining the women’s risks, they found that 1280 (2%) of women had a high risk (8% or more) of developing breast cancer with 29 (2.3%) developing breast cancer. There were 14,720 women with an above average risk (over 3.5%) of developing breast cancer in the next ten years and, indeed, 267 (1.8%) had developed breast cancer in the four-year period from 2009. This left 36,748 women with average or below average risk of developing breast cancer, and, of these, only 371 (1%) developed breast cancer. When looking specifically at the 3432 women in this group who had a low (less than 1%) ten-year risk, only 10 (0.3%) developed breast cancer during the four years. The researchers also found that among the 36,748 women at average or below average risk, only 45 cancers that had started to spread to the lymph nodes were found during the four years, which was equivalent to about three per 100,000 women a year, compared with around 11 per 100,000 women a year in those at above average risk. Proportions of cancers that were further advanced were higher in the above average risk women: 32% compared with only 19% in women at average or below average risk. Therefore, these results suggest that three-yearly screening is very effective for around 70% of the female population, but that those women who have a higher than average risk of developing breast cancer probably require more frequent screening, particularly as more advanced cancers were detected in these women. Screening should be annual for the small proportion of women who have an 8% or greater risk of developing cancer over the next ten years.Dr Gerrit-Jan Liefers, a surgical oncologist and head of the geriatric oncology research group at Leiden University Medical Centre reported on the screening programme in the Netherlands. The Netherlands Breast Cancer Screening Programme was extended in 1998 to include women up to the age of 75 years. Dr Liefers and his colleagues looked at results from The Netherlands Cancer Registry for 25,414 women aged between 70 and 75 years, who were diagnosed with breast cancer between 1995 and 2011. They found that after the extension of the upper age limit, the incidence of early stage breast cancer  increased significantly from 260 cases per 100,000 women in 1995 to up to 382 cases per 100,000 women in 2011. Meanwhile, the number of advanced stage breast cancers (stages III and IV) did not change significantly: in 1995 there were 59 cases detected per 100,000 women compared to 53 per 100,000 in 2011.Genetic analyses of results from 1125 postmenopausal women being treated for oestrogen responsive breast cancer have shown that some of them are more likely than others to have a late recurrence of their cancer and might benefit from ten years of hormone therapy rather than five. Prof Mitch Dowsett reported his research showing that women with HER2-negative and ER-positive breast cancer had more than double the risk of their cancer recurring between five and ten years after surgery and five years of adjuvant hormone therapy. Data suggest that these patients, who are those that appear to benefit most from the current standard five years of endocrine treatment, may also benefit from adjuvant hormone treatment that extends beyond five years. The work is a collaboration between his team and that of Prof Jack Cuzick at the Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK. The findings are the latest to come from the ATAC trial , a double-blinded phase III clinical trial that randomly assigned postmenopausal women with early, oestrogen receptor positive (ER+) breast cancer to receive the hormone therapies anastrozole or tamoxifen, or a combination of the two [The EBCC-9—the largest breast cancer conference outside the United States—was made unique by including patient advocates together with breast cancer professionals. The aim of the conference was to disseminate information directly to patient advocates and enable health-care professionals to implement new findings in daily practice.The conference provided a unique multidisciplinary setting for all participants to discuss, inform, and educate themselves about this evolving disease landscape. Moreover, the conference provided the opportunity to implement new findings into daily practice, making a tangible difference for the individual patient.The next conference (EBCC-10) will be held in Amsterdam, The Netherlands, 9–11 March 2016.


In Norway, the breast cancer incidence increased by 50% in the 1990s, during a period with initiation of mammography screening as well as a fourfold increase in use of menopausal hormone therapy (HT). After 2002, the HT use has dropped substantially; however, the breast cancer incidence has declined only marginally. How much mammography screening contributed to the breast cancer incidence increase in the 1990s compared with HT use and specifically different types of HT use, has thus been discussed. Whether HT affects the incidence of subtypes of breast cancer differently has also been questioned. We have linked individual data from several national registries from 2004 to 2009 on 449,717 women aged 50–65 years. 4597 cases of invasive cancer and 681 cases of ductal carcinoma in situ (DCIS) were included in the analysis. We used Cox regression to estimate hazard ratio (HR) as a measure of the relative risk of breast cancer associated with use of HT. The HRs associated with prescriptions of HT for more than 1 year were 2.06 (1.90–2.24) for estrogen and progesterone combinations, 1.03 (0.85–1.25) for systemic estrogens, and 1.23 (1.01–1.51) for tibolone. Invasive lobular carcinoma was more strongly associated with use of estrogen and progesterone combinations, HR = 3.10 (2.51–3.81), than nonlobular carcinoma, HR = 1.94 (1.78–2.12). The corresponding value for DCIS was 1.61 (1.28–2.02). We estimated the population attributable fraction to 8.2%, corresponding to 90 breast cancer cases in 2006 indicating that HT use still caused a major number of breast cancer cases. The breast cancer incidence increased rapidly during the 1990’s Several studies have shown that HT use affects breast cancer risk differently for different histological subtypes, and in particular increases the risk of the second most common subtype of breast cancer, invasive lobular carcinoma Here, we have linked individual data from several high-quality Norwegian registries and studied how breast cancer incidence is associated with both different type of HT use and duration of use. The study period begins in 2004, since individual data on prescription of HT are not available before 2004 and the NBCSP covered all Norwegian counties from 2004. We also present data stratified on histological subtypes.http://www.whocc.no/atc_ddd_methodology/purpose_of_the_atc_ddd_system/). DDD is an estimate on the average maintenance dose of a drug used per day (365 DDD correspond to 1 year use).As part of the evaluation of the NBCSP, funded by the Research Council of Norway, we received anonymized individual data from the nationwide Norwegian Cancer Registry, Statistics Norway, the Norwegian Prescription Database, and the Medical Birth Registry of Norway. We included all Norwegian women aged 50–65 years in 2006 in our analysis. Data from the Cancer Registry cover the period until December 31, 2009. All data files included a unique number for each individual woman which enabled us to merge the files. From the Cancer Registry, we used two different files. One consisted of information on mammography screening activity, including scheduled dates and whether or not each woman underwent screening. The second file from the Cancer Registry included information on all cases of breast cancer and DCIS, including detection date, histological tumor type, and detection mode . Data from Statistics Norway included information on death date, causes of death, and date of emigration. From the Medical Birth Registry, we received information on number of births. Data from the Prescription Database included information on all women who had prescriptions of estrogen preparation or combined estrogen progesterone preparations from 2004, including date of prescription, the name of the drug, the ATC-group, and the defined daily dose (DDD) prescribed (We used Cox regression to estimate hazard ratio (HR) as a measure of the relative risk of breast cancer associated with use of HT. Based on ATC codes and sales names, we stratified the HT into four different groups: estrogen and progesterone combinations (G03F), tibolone (G03CX), vaginal estrogens  and finally systemic estrogens without progesterone . Based on the number of prescribed DDD in 2004 and 2005, the women who were 50–65 years old in 2006 (born 1941–1956) were stratified into four different groups: women with no prescriptions, prescriptions of 1–180 DDD, 181–365 DDD, or more than 365 DDD. The event was defined as the time from January 1, 2006 to either an invasive breast cancer diagnosis or to a DCIS diagnosis. The follow-up period ended on 31.12.2009. We estimated HRs with 95% confidence intervals and adjusted for available risk factors such as age, number of childbirths, and whether or not the woman attended the Norwegian Breast Screening Program between 2004 and 2009. We excluded 84 cases of invasive breast cancer and four cases of DCIS from the analysis because they were detected before the woman got an invitation to screening. We did separate analysis for DCIS and invasive breast cancer and also stratified on histological tumor type, invasive lobular carcinoma, or nonlobular invasive carcinoma.P(HR − 1)/(1 + P(HR − 1)), where P is the proportion of the population using HT, and HR is the hazard rate for invasive breast cancer.The population attributable fraction (PAF) is a measurement which describes the proportion of avoidable breast cancer cases if the HT use was eliminated. The PAF was calculated as The study population includes a total number of 449,717 women aged 50–65 years at the beginning of the study period in 2006. In the analysis, we included 4597 cases of invasive cancer and 681 cases of DCIS diagnosed in 2006–2009. By the end of the study period, 187 of these women had died of breast cancer. Eighty-three percent of the population attended one or more of the three screening rounds in 2004–2009. HT use is described in TableTableThe HRs of invasive breast cancer associated with different types of HT prescriptions and different duration of HT use in 2004–2005 are presented in TableTableBased on the calculated HR of 2.06 in tableIn this study, we observe a 106% increased risk of breast cancer associated with long-term prescription (>1 year) of estrogen and progesterone combinations. The breast cancer risk is not increased by short term prescription (<½ year). For tibolone, we found a 23% increase in the breast cancer risk for long-term prescription. Our estimates correspond with the estimates in the Million Women Study As already published by several authors We also tried to calculate how breast cancer death was affected by HT use, but since there were only 187 breast cancer deaths in the follow-up period, the data were not able to answer this question.A strength of this study is the prospective study design: First, we have used individual data from national registries. Second, data on HT use are not affected by the possibility of recall bias as when using questionnaires. Third, we have also included data on whether or not the women attend the Norwegian Breast Screening Program. Due to overdiagnosis, screening increases the risk of both invasive breast cancer and DCIS There are several weaknesses in the study: First, a lack of information on other possible risk factors as menopausal status, age at menarche, family history of breast cancer, and educational level. In particular, we do not have data on attendance to private mammography and cannot adjust well for the most important confounder—mammography screening. The 15% difference in risk of a breast cancer diagnosis between those attending the screening program and those not attending indicates a high level of opportunistic screening. It is generally accepted that initiation of mammography screening increases the incidence of breast cancer by 30–50% Second, the data on drug prescription began in 2004. This means that women defined as long-term users in our analysis, could have been nonusers before 2004 or could have been users for several years. We are not able to separate these women. Similarly women defined as nonusers in 2004–2005 could in fact be past or never users. The Million Women study shows that women who had ceased HT use the previous year had a slight increased breast cancer risk of 14%, although the breast cancer risk was not increased for all past users Third, the information on HT use is based on prescriptions. We do not have information on compliance, but we would assume that women who have more than one prescription with many DDD prescribed, do use the drug more regularly than those having only one prescription with a lower DDD prescribed.In conclusion, we observe a 106% increased risk of breast cancer associated with long-term prescription (>1 year) of estrogen and progesterone combinations, but we did not find any association between prescription of estrogen-only HT and breast cancer risk. The second most common subtype of breast cancer, invasive lobular carcinoma was more strongly associated with HT use than other subtypes. The risk of the possible precursor lesion, DCIS, was also increased for HT users. The PAF was estimated to 8.2%, corresponding to 90 breast cancer cases in 2006, indicating that even after substantial drop in HT use, still a major number of breast cancer cases were caused by HT-use.


Vitamin D deficiency, which has been linked to an increased risk of colorectal cancer, is particularly common among African Americans. Previous studies of vitamin D status and breast cancer risk, mostly conducted in white women, have had conflicting results. We examined the relationship between predicted vitamin D status and incidence of breast cancer in a cohort of 59,000 African American women.Participants in the Black Women’s Health Study have been followed by biennial mail questionnaires since 1995, with self-reported diagnoses of cancer confirmed by hospital and cancer registry records. Repeated five-fold cross-validation with linear regression was used to derive the best 25-hydroxyvitamin D (25(OH)D) prediction model based on measured 25(OH)D in plasma specimens obtained from 2856 participants in 2013–2015 and questionnaire-based variables from the same time frame. In the full cohort, including 1454 cases of incident invasive breast cancer, Cox proportional hazards models were used to compute the incidence rate ratio (IRR) for each quartile of predicted vitamin D score relative to the highest quartile. Predicted vitamin D score for each two-year exposure period was a cumulative average of predicted scores from all exposure periods up to that time.p for trend 0.015; the IRR for the lowest versus highest quartile was 1.23 .Twenty-two percent of women with measured 25(OH)D were categorized as “deficient” (<20 ng/mL) and another 25 % as “insufficient” (20–29 ng/mL). The prediction model explained 25 % of variation in measured 25(OH)D and the correlation coefficient for predicted versus observed 25(OH)D averaged across all cross-validation runs was 0.49 (SD 0.026). Breast cancer risk increased with decreasing quartile of predicted 25(OH)D, In prospective data, African American women in the lowest quartile of cumulative predicted 25(OH)D were estimated to have a 23 % increased risk of breast cancer relative to those with relatively high levels. Preventing vitamin D deficiency may be an effective means of reducing breast cancer incidence in African American women. Mechanisms underlying the possible anticancer effects of 1,25(OH)2D include induction of apoptosis, stimulation of differentiation, anti-inflammatory effects, anti-proliferative effects, and inhibition of angiogenesis, invasion, and metastasis . Howeverthe skin , 13.Each of the study designs used for assessment of the relationship between vitamin D status and risk of breast cancer has drawbacks. Case-control studies of plasma or serum 25(OH)D levels are prone to reverse causality because blood specimens are usually drawn around the time of breast cancer surgery, at which point 25(OH)D levels may have been affected by the disease process or patients may have changed their habits regarding time spent outdoors, diet, and supplementation.Prospective cohort studies with pre-diagnostic blood specimens overcome the problem of reverse causality. However, they typically have only a single blood draw for each participant, representing exposure status at only one point in time, whereas evidence suggests that 25(OH)D levels vary over time depending upon season, age, weight, and other characteristics , 15. StuWhile predicted 25(OH)D will be imprecise for any given individual, it can be effective for ranking study participants into disparate categories of exposure, such as lowest quartile vs. highest quartile of predicted value. The validity of this method will depend on the specimens used for establishing the prediction model, collection of data on the important determinants of 25(OH)D levels in the study population, and availability of repeated measures of those determinants over time.We used prospectively collected data and blood specimens from 2856 study participants in the Black Women’s Health Study to develop a prediction model for 25(OH)D. We then assessed the relationship between predicted vitamin D status and risk of breast cancer in the entire cohort.The Black Women’s Health Study (BWHS) began in 1995 when 59,000 African American women aged 21–69 years from across the USA completed mailed health questionnaires. Participants have completed follow-up questionnaires every two years. Follow-up was complete through 2013 for over 85 % of person-time since 1995. The Institutional Review Board of Boston University approved the protocol and reviewed the study annually.At baseline, participants were asked about use of vitamin D supplements, use of multivitamins, weight, height, number of births, timing of each full-term birth, lactation, age at menarche, use of oral contraceptives, breast cancer in first-degree relatives, vigorous physical activity, alcohol consumption, cigarette smoking, menopausal status, age at menopause, use of supplemental female hormones, years of education, and many other factors. The biennial follow-up questionnaires ascertained occurrences of incident breast cancer and updated information on use of vitamin D supplements and multivitamins, and most other variables. A modified version of the NCI-Block food frequency questionnaire was used to ascertain usual diet in 1995 and 2001 .Each BWHS questionnaire asks about new diagnoses of breast cancer and the year of diagnosis. Participants are contacted for permission to obtain pathology reports and other medical records and data are also obtained from state cancer registries in the 24 states in which 95 % of participants live. We were able to obtain medical records, cancer registry records, or both for approximately 95 % of women who reported incident breast cancer, of which 99 % were confirmed. Only cases of confirmed incident breast cancer were included in the present analysis. In the early years of the study, 1995–2000, testing for estrogen receptor (ER) and progesterone receptor (PR) was not universal, and thus we have missing data on ER and PR status for some participants. Among cases with known status, the proportions with ER+/PR+, ER+/PR-, ER-/PR+, and ER-/PR- tumors are 50 %, 14 %, 2 %, and 34 %, respectively, similar to the distributions observed for African American women in the SEER registry and other population-based data –20. In pCollection of blood specimens from BWHS participants began in 2012 and will continue through 2017, by which time all living study participants will have had an opportunity to provide a sample. Of participants approached to date, about 25 % have provided samples. Participants are mailed an informed consent, explanatory materials, a pre-printed laboratory requisition form, and instructions for locating a nearby blood collection site. Blood specimens are collected and tested by Quest Diagnostics  an accredited national clinical laboratory , 23. Liq2) , vigorous exercise, walking for exercise, current cigarette smoking, current alcohol consumption, use of female hormones, use of oral contraceptives, and menopausal status. Dietary intake of vitamin D derived from responses to a modified version of the NCI-Block food frequency questionnaire completed in 2001 was also considered as a predictor. A solar UV-B flux variable  was created as a proxy for ambient sun exposure based on state of residence in 2013 and the reported average annual UV-B radiation in each state [Development of the prediction model was based on 25(OH)D values obtained from assays of plasma samples provided between 2013 and early 2015, the period immediately following completion of the 2013 BWHS questionnaire. During that period, 3539 participants provided blood samples with signed informed consent. We excluded 276 women with prevalent cancer at the time of the blood draw and 407 who had missing data on any of the candidate predictors of 25(OH)D, for an analytic sample of 2856. Variables that were known or suspected to be related to endogenous levels of 25(OH)D and for which data were available from the 2013 questionnaire were considered as possible predictors: use of vitamin D supplements , multivitamin use , body mass index D prediction model . The 285Baseline data from the 1995 BWHS questionnaire were then used in combination with beta-coefficients for each of the predictors to compute a predicted 25(OH)D level at baseline in 1995 for the entire BWHS cohort. Participants were excluded from the analyses if they had missing data on any of the predictors at baseline. Predicted 25(OH)D level was then updated every two years using the same beta coefficients and new values of the predictors. If data were missing for a given variable at some point during follow-up, the value from the previous cycle was carried forward. We then computed a cumulative average of predicted 25(OH)D. The cumulative average method , 30 has 2). Covariates that changed over time were treated as time-dependent. In addition to the overall analyses, we conducted analyses separately for ER+ and ER- breast cancer and within strata of age (<45 years and ≥45 years) and current use of vitamin D supplements .Analyses of the association between predicted vitamin D status and breast cancer risk included all BWHS participants who had not been diagnosed with cancer prior to enrollment in the cohort and had complete information from the baseline questionnaire on each of the variables included in the 25(OH)D prediction model. Each participant contributed person-time from baseline in 1995 until diagnosis of breast cancer, death, loss to follow-up, or end of follow-up in 2013, whichever came first. Predicted 25(OH)D status was analyzed in quartiles, with highest quartile as the reference category. We used Cox proportional hazards regression, stratified by age (year) and questionnaire cycle (two years) to estimate the incidence rate ratio (IRR) and 95 % confidence interval (CI) for quartile of predicted 25(OH)D in relation to breast cancer incidence, with adjustment for number of births , age at first birth , age at menarche , age at menopause , first-degree family history of breast cancer , recent oral contraceptive use (within the previous 5 years), long-term oral contraceptive use (≥10 years), duration of use of estrogen with progesterone postmenopausal hormones (≥5 years), and BMI D had an increased risk of breast cancer: the IRR for the lowest vs. highest quartile (reference) was 1.06  in analyses adjusted for age and period and 1.23  in multivariable analyses (Table P trend = 0.015). The association between predicted 25(OH)D and ER+ breast cancer was similar to that for breast cancer overall, with a multivariable-adjusted IRR for lowest vs. highest quartile of 1.26 . For ER- breast cancer, the IRR was 1.12  for the same comparison.There was evidence of a linear trend toward increasing risk with decreasing quartile of predicted 25(OH)D (P interaction = 0.18).In age-specific analyses Table , IRRs foWhen the analyses were repeated using a simple update of predicted 25(OH)D instead of a cumulative average, the results were essentially the same: the IRR for lowest quartile to highest quartile for all breast cancer was 1.23 .To our knowledge, this is the first study to use a 25(OH)D prediction model to assess the relationship between vitamin D status and incidence of breast cancer. Women in the lowest quartile of predicted 25(OH)D over the course of follow-up were estimated to have a 23 % increased risk of breast cancer compared with those in the highest quartile. Based on the distribution of measured plasma 25(OH)D levels in the 2856 specimens that formed the basis of the prediction model, almost all women in the lowest quartile would have had a level considered deficient, and all women in the highest quartile would have had levels considered sufficient. In analyses stratified by BMI, a significant positive association was observed only among obese women.Most previous studies of vitamin D status in relation to breast cancer risk used serum or plasma levels of 25(OH)D from a single point in time as the measure of vitamin D exposure. Higher levels were associated with lower risk in a number of case-control studies , 36. TheIn the Nurses’ Health Study II, there was a significant interaction with BMI, with a strong positive interaction observed among women in the highest category of BMI ≥25) but no association among women with BMI <25  but no a–40. The Although findings from basic research suggest that vitamin D may have a greater impact on ER+ breast cancer than ER- breast cancer through attenuation of estrogen signaling and synthesis, –43, prevCirculating levels of 25(OH)D change over time, with a single measurement reflecting vitamin D from dietary and solar sources within a three-week half-life . Since mOther studies have assessed intake of foods containing vitamin D or intake of vitamin D supplements in relation to breast cancer risk. Several studies found reduced risk of breast cancer among women who took supplements or were in the highest categories of dietary intake –50, wherA notable strength of the present study is the k-fold cross-validation method used to develop and test the prediction model. Most previous vitamin D status prediction models have been based on model development in a single training set with testing in a single test set , 33, 58.Prediction models for vitamin D status may perform better in populations with African ancestry than in populations with European ancestry because sun exposure, which is difficult to quantify, contributes less to 25(OH)D levels among African Americans, because on average persons of African ancestry have darker skin pigmentation. Thus, variables such as use of vitamin D supplements, BMI, and cigarette smoking, will tend to be more important predictors in an African American population. In a study of circulating 25(OH)D levels in African American and white participants from a nationwide study of radiologic technologists, UV radiation factors  were associated with 25(OH)D levels in white Americans, but not in African Americans . In the Several other surveys have reported higher proportions of vitamin D deficiency among African American women than were observed in our study sample , 62. TheA limitation of the present study is the lack of granular data on vitamin D supplements. We did not collect data on the dose of the supplement. The prediction model might have been stronger if separate variables for low dose  and high dose  were included in the model. Nevertheless, supplement use accounted for 10 % of the variability in predicted vitamin D status in our study. Another potential limitation is lack of data on degree of skin pigmentation. However, two recent studies of skin pigmentation and 25(OH)D levels among several racial/ethnic groups found that measured constitutive skin color did not improve prediction of 25(OH)D concentrations when included in a model that had terms for race/ethnicity , 64.Genetic variation may explain some of the interpersonal variation in 25(OH)D concentrations. We did not include genetic variants in the prediction model because there is a lack of consensus on which variants are associated with 25(OH)D in African Americans , 60, 65,In conclusion, data from this large prospective study suggest that African American women who have low predicted 25(OH)D have a greater risk of breast cancer relative to those who have sufficiently high levels. Vitamin D deficiency is common among African Americans. Indeed, of the 2856 BWHS participants who provided a blood sample in 2013–2015, 47 % had levels below 30 ng/mL (insufficient or deficient) and 22 % had levels below 20 ng/mL (deficient). If the present findings are confirmed in other prospective studies, preventing vitamin D deficiency may be an effective means of reducing breast cancer incidence in African American women.1,25(OH)2D, 1,25-dihydroxyvitamin D; 25(OH)D, 25-hydroxyvitamin D; BMI, body mass index; BWHS, Black Women’s Health Study; CI, confidence interval; ER, estrogen receptor; IRR, incidence rate ratio; LC-MS/MS, liquid chromatography-tandem mass spectrometry; SD, standard deviation


VDR gene, rs1544410 (BsmI) and rs2228570 (FokI), are inconsistently associated with breast cancer risk in Caucasian populations, while data for Asians are scarce. Here, we investigated the possible contribution of these SNPs to breast cancer risk in Pakistani breast cancer patients and in controls participating in a hospital-based breast cancer case-control study (PAK-BCCC).Vitamin D is postulated to decrease the risk of breast cancer by inhibiting cell proliferation via the vitamin D receptor (VDR). Two common single nucleotide polymorphisms (SNPs) in the BsmI and FokI SNPs was performed by PCR-based restriction fragment length polymorphism (RFLP) analysis of 463 genetically enriched female breast cancer cases with known BRCA1/2 status and in 1,012 controls from Pakistan. The association between SNP genotypes and breast cancer risk was investigated by logistic regression adjusted for potential breast cancer risk factors and stratified by BRCA1/2 status and family history. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.Genotyping of the BsmI was associated with an increased breast cancer risk . Subgroup analysis revealed that this effect was restricted to BRCA1/2 non-carriers  and was stronger in those who reported a positive family history of breast and/or ovarian cancer . No association with breast cancer risk was detected for the FokI SNP.The b allele of the BsmI polymorphism in the VDR gene may be associated with an increased breast cancer risk in Pakistani women negative for BRCA1/2 germline mutations.The  Variants in the high and moderate penetrance breast cancer susceptibility genes BRCA1, BRCA2, TP53, CHEK2 and RAD51C account for approximately 20% of hereditary breast cancer in Pakistan . The overall frequency of consanguineous marriages, mainly first cousin marriages, ranges from 56% to 66.4% [BsmI SNP in controls has also been previously observed in other association studies conducted in Caucasian and African-American populations [In the control group in the present study, we observed a deviation from the expected HWE for the igration . BsmI gesettlers . No evidto 66.4% –45. Notaulations ,31,46.BRCA1/2 mutation status allowed risk estimates in homogenous patient groups of BRCA1/2 carriers and non-carriers.The present study has a number of strengths. We used genetically enriched cases, which are more likely to carry at-risk alleles than are unselected breast cancer patients. We also used at least two controls per case, which improves the power of the study . MoreoveBsmI SNP and breast cancer risk. We also did not measure vitamin D serum levels to examine interactions between vitamin D levels and VDR SNPs in relation to breast cancer risk. A high prevalence of vitamin D deficiency has been reported in Pakistani women [VDR SNPs. Another limitation of the study is that we did not investigate candidate gene variants in other genes of the vitamin D pathway, such as those encoding vitamin D binding protein (DBP) or enzymes involved in vitamin D activation and degradation  [The study has certain limitations. It is a hospital-based case-control study, which may have introduced some selection bias. The potential for some survival bias also existed, since only 73% of cases were recruited within the first year of diagnosis. Furthermore, we did not investigate the potential modifying effects of environmental factors, such as dietary factors, on the observed association of the ni women , newly dni women , and Pakni women  and the ni women . Vitaminni women –53. In tCYP24A1) ,55, whicBsmI in the VDR gene may be associated with an increased breast cancer risk in Pakistani women who are negative for BRCA1/2 germline mutations. Future large studies in Asia are warranted to validate our findings.In conclusion, our study provides evidence that the b allele of the S1 FigA) PCR-RFLP products were separated on a 2% agarose gel containing ethidium bromide and scored by UV visualization. Lane 1: DNA marker (100 bp); lanes 2, 4, 7, 9, 11: AA genotype; lanes 3, 5, 8, 10: AG genotype; lanes 6, 12, 13: GG genotype (B-D) Sequencing profiles of control DNA samples showing the sequence of the reverse strand of part of intron 8 near the 3’end of the VDR gene with the C to T nucleotide change. (B) CC genotype; (C) CT genotype; (D) TT genotype.((TIF)Click here for additional data file.S2 FigA) PCR-RFLP products were separated on a 2% agarose gel containing ethidium bromide and scored by UV visualization. Lane 1: DNA marker (50 bp); lanes 2, 7, 9, 10, 12, 13: CC genotype; lanes 3, 5, 6, 8, 11: CT genotype; lane 4: TT genotype (B-D) Sequencing profiles of control DNA samples showing the sequence of the reverse strand of part of exon 2 of the VDR gene with the A to G nucleotide change. (B) AA genotype; (C) AG genotype; (D) GG genotype.((TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.


A sudden increased interest in genetic information related to breast cancer was also noted by Wikipedia which announced that the page describing the gene, BRCA 1, was viewed nearly 30,000 times the day of Angelina’s announcement. Moreover, many physicians report that cancer genetic clinics have seen an uptake in women seeking BRCA 1/2 genetic testing following Ms. Jolie’s disclosure.Prophylactic mastectomy to reduce the risk of developing breast cancer in the presence of a BRCA mutation has been available for many years. Yet, immediately after Angelina Jolie’s announcement of her decision to undergo a bilateral prophylactic mastectomy, the level of women’s interest in genetic testing and/or preventive surgical intervention soared incredibly as witnessed by the increased number of information requests followed the announcement. FORCE  according to their specific health status. Moreover, the development of metacognition abilities that raise the awareness of patients (and physicians!) about heuristics and the effects they can have in altering rational decisions is necessary in order to reduce biased decisions and cognitive distortions. Such knowledge is supposed to prevent erroneous expectations or excessive requests of screening and treatment options that are useless or unrelated to the individual’s personal health status.The authors did not receive any financial support and have no competing interests.


Alcohol drinking is linked to the development of breast cancer. However, there is little knowledge about the impact of alcohol consumption on breast cancer risk among African women.We conducted a case-control study among 2,138 women with invasive breast cancer and 2,589 controls in Nigeria, Cameroon, and Uganda from 1998 to 2013. A structured questionnaire was used to collect information on alcohol consumption, defined as consuming alcoholic beverages at least once a week for six months or more. Logistic regression was used to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI).P-trend <0.001), with 10-year increase of drinking associated with a 54% increased risk (95% CI: 1.29–1.84).Among healthy controls, the overall alcohol consumption prevalence was 10.4%, and the prevalence in Nigeria, Cameroon, and Uganda were 5.0%, 34.6%, and 50.0%, respectively. Cases were more likely to have consumed alcohol . Both past  and current drinking  were associated with breast cancer risk. A dose-response relationship was observed for duration of alcohol drinking (We found a positive relationship between alcohol consumption and breast cancer risk, suggesting that this modifiable risk factor should be addressed in breast cancer prevention programs in Africa. Breast cancer is a leading cause of cancer morbidity and mortality for women world-wide Most studies of alcohol and breast cancer have assessed alcohol use in terms of ever-drinking versus nondrinking or the average daily dose The African Breast Cancer Study was originally started in Nigeria in 1998 and was expanded to Uganda and Cameroon in 2011 using the same questionnaire and protocol. The study protocol was reviewed by the institutional review boards of the three sites and the University of Chicago , University of Ibadan/University College Hospital Ethics Committee (UI/IRC/02/0003), Cameroon National Ethics Committee (N141/CNE/SE/2010), and Makerere University College of Health Sciences Ethics Committee (2011-023)). The study setting and design at the Nigeria site are described in detail elsewhere Trained interviewers at the three sites performed structured questionnaire interviews, measured height and weight, and obtained blood samples. The questionnaire included questions about demographics, family history of breast cancer and history of benign breast disease, lifestyle factors, menstrual and reproductive history, and alcohol consumption patterns.Before 2006, alcohol consumption was asked in Nigeria in terms of average volume of alcohol consumed per week . After 2006, the measurement was changed to average number of drinks per week. In Uganda and Cameroon, the alcohol consumption was asked in terms of average number of drinks per week. To convert the amount of alcohol into a common unit, the following conversion criteria were used: 350 mL bottle of beer  ≈150 mL glass of wine  ≈50 mL shot of spirits  ≈18 mL pure ethanol, which is equivalent to one standard drink. We then summed the amount of pure ethanol the participant consumed irrespective of the type of drink. We subsequently converted the volume of pure ethanol to gram: 1 mL  = 0.8 gram. Each standard drink is hence equivalent to about 14.4 grams of pure ethanol. We also constructed a new variable called the life-time alcohol consumption, which was defined as gram-years: the average daily amount of alcohol in grams was multiplied by the subject's duration of alcohol consumption in years.We defined alcohol drinking as having ever consumed alcoholic beverages at least once a week for continuous six months or more. In addition, we measured other alcohol drinking patterns: status of drinking , age at first drink, duration of alcohol drinking, and average amount of alcohol consumed daily. Duration of alcohol drinking was grouped into four categories: never drank, 1–9, 10–19, and ≥20 years. Average amount of alcohol consumed daily was also grouped into four categories: never drank, 0.1–4.9, 5.0–9.9, and ≥10.0 grams. Age at first drink had five categories: never drank, ≤18, 19–24, 25–29, and ≥30 years. Life-time alcohol consumption was also categorized into five groups: never drank, 0.1–29.9, 30.0–79.9, 80.0–159.9, and ≥160.0 gram-years.t-test or Wilcoxon rank-sum test for continuous variables and χ2 test or Fisher's exact test for categorical variables. All P-values reported are two-sided. We calculated the percentages of control women who were currently consuming alcohol by the age groups of 18–34, 35–44, 45–54, and ≥55 years.Demographic factors and potential confounding factors for breast cancer were compared between cases and controls using student 2), menopausal status , age at first live birth , and parity . Adjusted odds ratio (aOR) and 95% confidence interval (CI) were computed from the logistic regression models. Ever drank, status of drinking, and type of alcohol consumed  were included in the models solely as categorical variables. Age at first drink, duration of alcohol drinking, average amount of alcohol consumed daily, and life-time alcohol consumption were analyzed as both categorical variables and continuous variables. Stratified analyses were also performed to compare the breast cancer risk between ever-drinkers vs. never-drinkers across different strata of demographic and reproductive variables, such as premenopausal vs. post-menopausal women. Potential confounding variables were adjusted for in these analyses.Multiple logistic regression models were used to examine the association between breast cancer and various patterns of alcohol consumption while adjusting for study site and other potential confounders listed below. These confounders were adjusted for in every multivariable logistic regression model and were defined as follows: age at diagnosis or interview , ethnicity , education , age at menarche , family history of breast cancer , history of benign breast disease , hormonal contraceptive use , fertility drugs , height, body mass index , were conducted with STATA 13.0 .There were missing data for age at first drink, duration of alcohol drinking, average volume of drinking, and other important covariates. To use all available information and avoid bias due to list-wise deletion in the multivariable analysis, we conducted multiple imputations via chained equations approach for imputation A total of 2,138 breast cancer cases and 2,589 controls (women without breast cancer) were enrolled in the study between March 1998 and July 2013, including 1,756 cases and 2,217 controls in Nigeria, 192 cases and 182 controls in Cameroon, and 190 cases and 190 controls in Uganda. Overall, there were 1,311 (1.7%) missing values across 16 variables in Among healthy controls, 10.4% were alcohol drinkers, and the percentage of ever drinkers in Cameroon, Nigeria, and Uganda were 34.6%, 5.0%, and 50.0%, respectively. P-trend: <0.001). We also found that alcohol consumption was associated with breast cancer risk, regardless of alcohol amount; breast cancer risk increase was shown even in the category of women who consume 0.1–4.9 g/day . In the variable life-time alcohol consumption, increased breast cancer risk was observed for subjects who consume at least 30 gram-years or more of alcohol . We also found a statistically significant trend, with each 100 gram-years contributing a 29% increase in breast cancer risk . The complete case analysis, in which subjects with missing values in any of the variables in the models were dropped, showed similar study findings (findings .P = 0.03 for both tests). In parous women, the association between drinking alcohol and breast cancer was weaker  than that in nulliparous women . There was no statistically significant association between alcohol consumption and breast cancer among women with BMI ≤25 kg/m2 , while among women with BMI >25 kg/m2, ever-drinkers had nearly twice the odds for breast cancer than never-drinkers . For other stratification variables, drinkers had similarly elevated risks for breast cancer compared to non-drinkers across the strata of these variables.Our case-control study of 4,727 African women from Nigeria, Cameroon, and Uganda showed a positive relationship between breast cancer and alcohol drinking. Overall, the odds of having breast cancer were 62% higher among women who ever consumed alcohol than among no-drinkers. This finding was in general agreement with literature. The current evidence on the relationship between alcohol consumption and female breast cancer risk is largely based on studies conducted in Caucasian populations Our study also found that women who were past drinkers (54% increase) had almost the same elevated risk as women who were current drinkers (71% increase). Our study showed a dose-response relationship between duration of alcohol drinking and breast cancer risk; women who drank for 20 years or longer had almost twice the odds of being cancer cases compared with non-drinkers. This relationship was confirmed in some studies The effect of alcohol drinking among nulliparous women was significantly elevated compared to that among parous women. This result is consistent with prior studies which suggests that the carcinogenic effect of alcohol consumption is strongest between menarche and the first full term pregnancy and could be implicated in both increased risk of breast cancer and benign breast disease 2, clinically defined as overweight or obese, had a greater risk of developing breast cancer. This suggests that obesity and alcohol drinking may have joint effects on risk of breast cancer among women. Being overweight or obese has been shown to be a risk factor for postmenopausal breast cancer In addition, alcohol drinking among women with BMI >25 kg/mHeterogeneity in the level of alcohol consumption was observed among women in three African countries. Using a definition of alcohol drinking as having at least one drink every week for a continuous 6 months or more, the percentage of ever drinkers in Nigeria, Cameroon, and Uganda were 5.0%, 34.6%, and 50.0%, respectively. This is in line with previous surveys of alcohol consumption in the three countries, although it is not straightforward to directly compare with previous studies due to different definition of alcohol drinking. According to the WHO country surveys conducted from 2003 to 2005, the percent of women who are lifetime abstainers in Nigeria, Cameroon, and Uganda were 50.9%, 39.8%, 36.7%, respectively Although some studies have suggested that recall bias only had minor effects on alcohol reporting and on the estimation of risk for breast cancer In conclusion, our study found a positive relationship between alcohol consumption and breast cancer risk among sub-Saharan African women. The adoption of a Western lifestyle and erosion of many traditional customs that prohibited alcohol drinking has led to drastic changes in alcohol consumption patterns, including greater drinking among young people and women Table S1Multivariable logistic regression analyses of alcohol consumption and breast cancer risk among women in Nigeria, Cameroon and Uganda, 1998–2013: Complete case analysis (N = 4157).(DOC)Click here for additional data file.


Mammographic density is a strong breast cancer risk factor and a major determinant of screening sensitivity. However, there is currently no validated estimation method for full-field digital mammography (FFDM).The performance of three area-based approaches  and three fully-automated volumetric methods ) were assessed in 3168 FFDM images from 414 cases and 685 controls. Linear regression models were used to assess associations between breast cancer risk factors and density among controls, and logistic regression models to assess density-breast cancer risk associations, adjusting for age, body mass index (BMI) and reproductive variables.P for trend <0.0001 for all). The ImageJ-based method had a slightly higher ability to discriminate between cases and controls (area under the curve (AUC) for PD = 0.68, P = 0.05), and Quantra slightly lower , than Cumulus (AUC = 0.65).Quantra and the ImageJ-based approach failed to produce readings for 4% and 11% of the participants. All six density assessment methods showed that percent density (PD) was inversely associated with age, BMI, being parous and postmenopausal at mammography. PD was positively associated with breast cancer for all methods, but with the increase in risk per standard deviation increment in PD being highest for Volpara  and Cumulus  and lower for the ImageJ-based method , Quantra  and SXA . Women in the top PD quintile (or BI-RADS 4) had 8.26 (4.28 to 15.96), 3.94 (2.26 to 6.86), 3.38 (2.00 to 5.72), 2.99 (1.76 to 5.09), 2.55 (1.46 to 4.43) and 2.96 (0.50 to 17.5) times the risk of those in the bottom one (or BI-RADS 1), respectively, for Volpara, Quantra, Cumulus, SXA, ImageJ-based method, and BI-RADS  contains supplementary material, which is available to authorized users. Mammographic density is one of the strongest breast cancer risk factors ,2], whi, whi2], There are several area-based -10] and and10] aWe conducted the first comparison of the ability of six methods of mammographic density measurement to predict breast cancer risk, including well-established analogue methods adapted for, and novel methods developed for FFDM.Cases were women with newly diagnosed breast cancer in the Royal Marsden Hospital (RMH), London, between April 2010 and July 2012. Controls were women who attended routine screening at the Central and East London Breast Screening Service (CELBSS) during the same period and were found to be breast cancer free. CELBSS is part of the England and Wales national mammographic screening programme offered once every three years to women aged 50 (47 from 2012) to 70 years (older women can self-refer) . Women wData on breast cancer risk factors Table  were col2) and PD, separately for each image. From raw images the volumetric methods, which were all fully-automated, estimated breast, absolute dense and absolute non-dense volumes , and PD. They comprised: (i) Volpara v1.0  [Density readings were performed on anonymised images from both breasts in controls and from the unaffected breast for cases Figure . The areZealand) , which yZealand) , which cZealand) , which rκ statistic . Inter-method correlation and rank agreement was assessed by estimating the Spearman's rank correlation coefficient (r) and the proportion of control women classified in the same, or the same ±1 adjacent, quintile.Appropriate transformations  were applied to normalise the distributions generated by the five quantitative methods. Scatter and Bland-Altman plots were used to compare the transformed distributions separately for each view and breast combination. Intra-method reliability  of a single density value (left or right image of a CC or MLO view), and of the left-right average for that view, was estimated as the percentage of the total variance due to between-subject variance among control women. Intra-observer BI-RADS agreement was assessed using weighted Associations of breast cancer risk factors with PD, and absolute density and non-density, were assessed among controls, by linear regression models adjusting for age, body mass index (BMI) and reproductive variables. Regression coefficients represent the difference in each density measure  associated with a unit change in the explanatory variable.P-values are two-sided.Logistic regression models were fitted to examine associations between density and breast cancer risk, adjusting for age, BMI, and reproductive variables (further adjustment for ethnicity did not affect the results). For the quantitative methods, the density measurements from the unaffected breast for cases and a randomly selected breast for controls were included in the models as continuous variables (in SD scores) or as quintiles (defined among controls). Sensitivity analyses included estimates by view; restriction to participants with density readings available for all quantitative methods; restriction to those aged <80 years; and use of multiple imputation methods to impute values for women with missing confounder data. The area under the curve (AUC) of the receiver operating characteristic curve was used to compare the ability of the various quantitative methods to discriminate between cases and controls. Analyses were performed in Stata 13.1 . All P-vP <0.0001).In all, 463 cases and 727 controls were recruited , but only 414 cases and 685 controls were eligible  Figure . Relativr >0.77 for all; see Additional file r >0.93 for all; Additional file r ≤0.41 except, as expected, for strong ImageJ-based versus Cumulus correlation (r = 0.90)); Additional file r from 0.76 (SXA-Volpara) to 0.92 (ImageJ-Cumulus))  and intra-reader reliability for Cumulus  were high. The reliability of PD measurements based on a single film  and on the left-right mean (ICC >0.91) were high for all quantitative methods regardless of view, driven by very high reliability for breast size  but somewhat lower for absolute density  of the PD associations with breast cancer risk factors were remarkably similar across the five quantitative methods, and in the direction expected, given the effects of these variables on risk Figure . All fivP for linear trend (Pt) = 0.06), increasing BMI (Pt <0.0001) and being parous versus nulliparous (odds ratio (OR): 0.38; 95% CI 0.20, 0.74).Mutually adjusted analyses showed that the odds of having a BI-RADS score ≥3 relative to a score <3 decreased with increasing age , 2.55 1.46, 4.43), 8.26 , 3.94  and 2.99  times the risk of those in the bottom one, respectively, for Cumulus, ImageJ-based method, Volpara, Quantra and SXA  than the ImageJ-based method 1.45; 1.21, 1.74), and for Volpara  than the other volumetric methods, Quantra  and SXA  , and Quantra slightly poorer , than Cumulus (AUC = 0.64)   produced for each participant, at the time of mammography, a digital image with the density measurements super-imposed on it, which is convenient in screening/clinical settings, but not efficient in large-scale studies as the density measurements for analysis will have to be extracted manually from these images  contributed equally. The three senior authors  contributed equally.Additional file 1: Description of the six mammographic density assessment methods.(DOCX 47 KB)Figure S2. Distributions of breast area/volume estimates taken from the left CC* view for control women, by method . Figure S3. PD readings* from BI-RADS, ImageJ-based method, Volpara, Quantra and single energy x-ray absorptiometry (SXA) versus those from Cumulus in control women. *Mean of four breast/view readings per woman (except for Quantra and SXA - see Methods). Values are plotted on the appropriate transformed scale (see Methods). Figure S4. Absolute density readings* from BI-RADS, ImageJ-based method, Volpara, Quantra and SXA versus those from Cumulus in control women. *Mean of four breast/view readings per woman (except for Quantra and SXA - see Methods). Values are plotted on the appropriate transformed scale (see Methods). Figure S5. Breast area/volume readings* from BI-RADS, ImageJ-based method, Volpara, Quantra and SXA versus those from Cumulus. *Mean of four breast/view readings per woman (except for Quantra and SXA - see Methods). Values are plotted on the appropriate transformed scale (see Methods). Figure S6. Mutually adjusted association of breast cancer risk factors with absolute density readings* in control women, by method. HT, hormonal therapy; OC, oral contraceptives; Pt, P for linear trend. *Mean of four breast/view readings per woman (except for Quantra and SXA - see Methods). Figure S7. Mutually adjusted association of breast cancer risk factors with absolute non-density readings* in control women, by method. HT, hormonal therapy; OC, oral contraceptives; Pt, P for linear trend. *Mean of four breast/view readings per woman (except for Quantra and SXA - see Methods). (PPTX 399 KB)Additional file 2: Figure S1.: Distributions of absolute density estimates taken from the left cranio-cauldal (CC)* view for control women, by method . r) between the various quantitative methods of quantifying percent density in control women. Table S2. Quintile agreement between the five quantitative methods of quantifying percent density in control women. Table S3. Distribution of density readings and level of agreement by method, breast and view in control women. Table S4. Area under the receiving operating curve (AUC) for percent and absolute density for each quantitative method. (DOCX 47 KB)Additional file 3: Table S1.: Spearman's rank correlation coefficients (Authors’ original file for figure 1Authors’ original file for figure 2Authors’ original file for figure 3Authors’ original file for figure 4Authors’ original file for figure 5Authors’ original file for figure 6Below are the links to the authors’ original submitted files for images.