Prophylactic drug treatment with aspirin, statins and anti-hypertensive agents has had a major impact on the incidence of cardiovascular disease and is now well established. Progress in therapeutic cancer prevention has been much slower; only recently have effective agents been clearly established. Breast cancer has led the way and endocrine agents used to treat it—notably tamoxifen and the aromatase inhibitors—have now been shown to have a substantial preventive effect as well. However, these agents carry some toxicity and thus identifying high-risk women who are likely to benefit most is a key priority. In contrast, the ability of low-dose aspirin to prevent about one-third of colorectal, gastric, and oesophageal cancers, combined with its much lower toxicity profile, make it attractive for a much larger proportion of the general population. Vaccination against the human papilloma virus is also a preventive intervention with large benefits for the whole population. Here I recall my involvement in these initiatives and offer a personal viewpoint on what has been achieved and what remains to be done. Increased oestrogen levels such as those associated with oral contraceptives ,2 postmenopausal hormone therapy4 and postmenopausal obesity5 had been shown to increase breast cancer risk. However, little real progress was made in showing that reducing the oestrogen stimulus could reduce risk until Jordan6 reported that tamoxifen treatment led to lower breast cancer rates in 7,12-Dimethylbenz(a)anthracene (DMBA)-induced tumours in rats.Breast cancer has led the way in terms of developing preventive therapy for cancer. My interest began in 1979 when I first joined the Imperial Cancer Research Fund. I came to London from Oxford, to work on the Guernsey study of hormonal risk factors for breast cancer with Mick Bulbrook and John Hayward. Oestrogen had been linked, in some not fully understood way, as a major risk factor and the earliest observations go back over 100 years to Beatson,7  study in the UK, Australia and New Zealand; a North American study—NSABP-P1, coordinated by the National Surgical Adjuvant Breast and Bowel Project; and a study in hysterectomised women in Italy  trial, or NSABP-P2, in which almost 20,000 women were randomised between these two agents. Despite the indications that it might be more effective than tamoxifen, based on an indirect comparison from the MORE trial of raloxifene vs placebo with other trials of tamoxifen vs placebo, this direct comparison indicated that it was about 25% less effective, although the side-effect profile was more favourable. Both tamoxifen and raloxifene have now been approved for prevention by the Food and Drug Administration in the United States and recommended for prevention by National Institute for Health and Care Excellence (NICE) in the United Kingdom.Subsequent to the tamoxifen prevention trials, clinical trials of three other selective oestrogen receptor modulators were conducted, primarily to look at the role of these agents in preventing fractures in women with osteoporosis. They all showed clear reductions in breast cancer and this subsequently became a second primary endpoint for the Continuing Outcomes Relevant to Evista (CORE) extension of the Multiple Outcomes of Raloxifene Evaluation (MORE) trial of raloxifene, in a subsequent follow-up period  trial and other subsequent trials showed that aromatase inhibitors were more effective at reducing recurrence from breast cancer in the adjuvant setting than tamoxifen. I had the good fortune to be the statistician for the ATAC trial and I was able to monitor the data on contralateral tumours as they developed. It was with great excitement that I was able to show this data to the steering committee at time of the first planned efficacy analysis of the trial, which indicated that anastrozole was not only more effective than tamoxifen in preventing recurrence of breast cancer but was also more effective at preventing new disease in the contralateral breast. Other trials comparing tamoxifen with aromatase inhibitors subsequently also demonstrated this superiority20 Fig. .Fig. 3Re21 which was larger than the ~ 30% seen with tamoxifen in the four tamoxifen prevention trials. Another trial using the aromatase inhibitor exemestane also showed a strong reduction of 53% for all cancers and a 65% reduction for invasive cancers compared with placebo.22 Overall, the aromatase inhibitors are more active than tamoxifen, both for preventing disease recurrence and reducing the development of new cancers. An ongoing challenge, however, is to determine which individuals are more likely to respond to an aromatase inhibitor or tamoxifen, and today we still have few markers to guide that decision. The only current possibility is reduction in breast density at 6–12 months, which has been clearly established to be a predictor of response to tamoxifen26 and more recently appears to also be useful for aromatase inhibitors.28Thus, in 2003 we began the IBIS-II trial of anastrozole versus placebo in high-risk women. A major concern when planning this trial was whether the comparator should be placebo or tamoxifen and we had several long arguments about this. In the end, it was accepted that although tamoxifen clearly showed a reduction in cancer incidence, it was not widely used because of a lack of evidence for an overall long-term clinical benefit, and a full evaluation of side effects such as endometrial cancer, increased venous thromboses and a range of menopausal symptoms associated with oestrogen suppression was needed before this could be considered a “standard of care”. It was ultimately decided that the best design was to compare anastrozole to placebo. After a 5-year median follow-up, this trial showed a 53% reduction in all breast cancer,29 reflecting my work with Jonathan Tyrer. Mathematically, it has several interesting features: in particular, it uses a segregation model to deal with family history of breast cancer, combined with a proportional hazards model to deal with the other known risk factors such as age, weight, reproductive history, hormone replacement therapy and prior benign breast disease. Subsequent versions of this model have been released and we are now using version 8, which was developed with Adam Brentnall. This includes a measurement of mammographic breast density and a single nucleotide polymorphism (SNP) score to look for low penetrance but common germline genetic differences.30One of the spin-offs from the prevention trials was the need to develop a model, which would predict the risk of breast cancer with sufficient accuracy to identify women at sufficient risk to be offered preventive tamoxifen or anastrozole. The model developed is known either as the IBIS model or the Tyrer–Cuzick model,33 .The model has now been widely validated and used to determine the need for preventive therapy or magnetic resonance imaging screening. More recently, it has emerged as a tool to guide the individual choice of screening intervals in so-called “risk adapted” screening algorithms. This may prove an important concept and would effectively expand screening programs to include a prevention component, with the idea being to conduct a risk assessment in all consenting women at their first screen. This would include a questionnaire to record “classical” factors as listed above, an assessment of density on their initial mammogram and a genetic SNP score based on a saliva sample. Several studies have now shown that these three factors are largely independent and contribute almost equally to the assessment of breast cancer risk34 Uptake of preventive therapy has been very low35 and if it is to be an effective component of a comprehensive breast cancer prevention programme, e.g., as statins have been for the prevention of cardiovascular disease, we need to convince the medical profession and the public of the value of this approach.The biggest challenge now in therapeutic breast cancer prevention is not so much to identify high-risk women or specific effective agents, but to widely communicate this information in a way that is understandable to general practitioners and the general public.36 showed that sulindac had a preventive effect on polyps in individuals with polyposis coli. Over the years, additional studies have shown the same is true for aspirin  bleeding or haemorrhagic stroke.39It is now apparent that aspirin has a large preventive effect on both the incidence and mortality from colorectal cancer, as well as gastric and oesophageal cancers.44 A multisite trial (Add-Aspirin)45 in colorectal, gastric, oesophageal, breast, lung and prostate cancer is also now underway, as well as a smaller trial in early prostate cancer in combination with vitamin D (PROVENT).Aspirin also shows promise for the adjuvant treatment of these cancers and a large trial in colorectal cancer is almost fully recruited (ASCOLT).46 Inflammation is likely to be involved in some way but the doses mostly used are too low for the standard Cox2 anti-inflammatory processes to be responsible; a major challenge is thus to understand more clearly the mechanisms by which aspirin prevents these cancers. We also need to more clearly understand who is at increased risk of GI bleeding, which is the major side-effect of aspirin even when used at low doses.The results on cancer prevention were a serendipitous finding in trials looking at low-dose aspirin to prevent cardiovascular disease, and as yet we have no clear understanding about the mechanism by which this takes place.It is surprising that it took so long for the anti-cancer effects of aspirin to be discovered; a main part of the reason for this is that very little effect occurs in the first 5 years of follow-up after starting aspirin, and only long-term use for more than 5 years shows a beneficial effect on cancer, whereas the bleeding effects occur almost immediately. Thus, long-term follow-up is essential to determine the overall risk-benefit ratio of aspirin’s prophylactic use.38 It is not clear at which age a protein pump inhibitor should be offered, but its use does offer prospects for continuing prophylactic aspirin in older ages, which is certainly likely to be beneficial to cardiovascular disease prevention as well.I believe that the evidence for an overall beneficial effect of aspirin is already strong enough to begin to make recommendations for the general population, after excluding those at high risk of bleeding. Nevertheless, several issues remain to help refine this indication. In particular the duration of use is not clearly established, although use for at least 5 years and probably 10 years is the minimum that should be offered. Continued use depends on the ratio of continued benefits versus increasing GI bleeding side-effects as an individual ages. Some evidence from the cardiovascular trials suggests a long-term benefit of aspirin after completion of the prescribed duration within the trial. However, it is not known how many of the participants continued to take aspirin after the trial was over and direct evidence on optimal duration of use is needed. Evidence on the risks of GI bleeding associated with aspirin in the elderly also needs refinement. A recent study indicated a clear increase in serious and fatal bleeds with aspirin in individuals aged more than 75 years, but it was shown that this could be avoided by the concomitant use of a proton pump inhibitor.48 together with an important proportion of other anogenital cancers as well as oropharyngeal cancer.Another major advance in the area of ‘preventive therapy’ is the development of HPV vaccines. The newest nine-valent vaccine offers prospects of eliminating 90% of cervical cancer,It also needs to be acknowledged that by identifying and treating precursor lesions, screening has had a preventive effect on cervix and colorectal cancers, and early detection has reduced the mortality from breast, prostate and lung cancer.49Our successes to date in therapeutic cancer prevention have been based on repurposing drugs originally developed for other uses, i.e., endocrine agents used for breast cancer treatment, taking advantage of the fact that effects on the contralateral breast provide an opportunity to assess preventive effects. For aspirin, most of the trials were for cardiovascular disease prevention, and long-term follow-up provided clear evidence for an anti-cancer effect as well. Given the expense of running large prevention trials and developing new agents from scratch, it seems likely that future preventive agents will be identified from agents used for other indications and repurposed for cancer prevention. Programmes to actively explore opportunities to do this will be essential for expanding our portfolio of useful agents to prevent cancer. This is probably best achieved by mining general practice databases and large cohorts such as the UK Biobank. Promising agents include metformin, bisphosphonates, vitamin D and some dietary elements such as curcumin and sulforaphane.It is clear that a major obstacle in establishing the role of therapeutic cancer prevention is achieving wider acceptance by the profession and the general population. The cardiologists have been very successful in this respect; one aspect of their success has been to label risk factors such as high cholesterol or high blood pressure as diseases in their own right and thus worthy of treatment. Such factors are in short supply for cancer, and even in breast cancer, where risk assessment is the most developed, the only known marker is breast density (discussed above). We need to find ways to make preventive therapy more widely discussed and offered, and adding a prevention component to the breast cancer screening, and eventually other screening programmes, is one promising avenue. Aspirin has suffered from the fact that many authorities and societies that have made recommendations on preventive use reviewed it at a time before the benefits on cancer were known, and only  when considered for cardiovascular disease prevention alone, where the general population the risks associated with GI bleeding were similar to the benefits. This has changed dramatically with the discovery of a major effect on cancer incidence, which dominates any effect on cardiovascular disease, but sadly the older recommendations are still widely believed. One approach to establishing aspirin as a more widespread preventive agent would be to get NICE to review the evidence and hopefully make a recommendation for aspirin use in the general population.50 His surveys have indicated that GPs are prepared to continue to prescribe preventive medicine such as tamoxifen or aromatase inhibitors to women at high risk of breast cancer, provided therapy is initiated in specialist centres and then referred to the general practitioner for continued use. This work and continuing studies in this area are essential if we are to achieve a change of opinion in the medical profession, which is key to widespread acceptance.50Dr Sam Smith has made a major effort to understand the reluctance of general practitioners to recommend preventive therapy for cancer.


BBD) have a high risk of breast cancer. However, no biomarkers have been clearly established to predict cancer in these women. Our aim was to explore whether estrogen receptor (ER), progesterone receptor (PR), and Ki67 expression stratify risk of breast cancer in screened women with BBD. We conducted a nested case–control study. Women with breast cancer and prior BBDs (86 cases) were matched to women with prior BBDs who were free from breast cancer (172 controls). The matching factors were age at BBD diagnosis, type of BBD, and follow‐up time since BBD diagnosis. ER, PR, and Ki67 expression were obtained from BBDs’ specimens. Conditional logistic regression was used to estimate odds ratios (ORs), and 95% confidence intervals (CIs) of breast cancer risk according to ER, PR, and Ki67 expression. Women with >90% of ER expression had a higher risk of breast cancer  than women with ≤70% of ER expression. Similarly, women with >80% of PR expression had a higher risk of breast cancer  than women with ≤40% of PR expression. Women with proliferative disease and ≥1% of Ki67 expression had a nonsignificantly increased risk of breast cancer  than women with <1% of Ki67 expression. A high expression of ER and PR in BBD is associated with an increased risk of subsequent breast cancer. In proliferative disease, high Ki67 expression may also have an increased risk. This information is helpful to better characterize BBD and is one more step toward personalizing the clinical management of these women.Women with benign breast diseases ( Benign breast diseases (BBD) are associated with an increased risk of subsequent breast cancer The introduction of mammographic screening has led to a rise in the detection of BBD In order to better understand the biological characteristics of BBD, a few authors have focused on estrogen receptor (ER) To date, no biomarkers have been clearly established to predict cancer in women diagnosed with BBD. Moreover, as far as we know, studies that assessed these biomarkers have not been performed in breast cancer screening programs. Ideally, the identification of these biomarkers could improve both our ability to stratify an individual's risk for breast cancer and lead to more accurate follow‐up or screening strategies. Therefore, the aim of our study was to explore whether ER and PR expression stratify risk of breast cancer in screened women with BBD. We also investigated the Ki67 expression in women with proliferative disease.The Spanish breast cancer screening program adheres to the recommendations of the European Guidelines for quality assurance in breast cancer screening and diagnosis N = 4251), were excluded from the analysis because they could not be classified in any of the BBD subtypes. Most of these biopsies with indeterminate classification came from fine‐needle aspiration cytology. Therefore, 6011 women with BBD were followed up until December 31, 2015. Each BBD was classified into one of the following types: (1) nonproliferative disease; (2) proliferative disease without atypia; and (3) proliferative disease with atypia This study was designed as a nested case–control study among the subset of women with pathology‐confirmed BBD within our Spanish screening cohort. The initial cohort subset included 10,262 women with BBD diagnosed in a breast cancer screening program between 1994 and 2011. Characteristics of our cohort have been previously reported Cases and controls were selected from the study cohort subset. Cases were women with BBD who developed breast cancer during follow‐up, whereas controls were women with BBD who remained cancer‐free at least longer than the time to cancer in matched cases. From the 6011 women with BBD, 201 (3.3%) developed breast cancer during follow‐up and were considered cases. We excluded 114 cases because they did not have sufficient tissue to assess biomarker's expression in the BBD sample and one case because it had evidence of mucinous carcinoma in the BBD sample. Thus, 86 cases with sufficient tissue to assess biomarkers’ expression were included in the analysis. We randomly selected two controls per each case. Cases and controls were matched by age at the time of BBD diagnosis, type of BBD , and follow‐up time between BBD diagnosis and end of follow‐up. The sample size for the analysis included 258 women, 86 cases matched to 172 controls.Both invasive and in situ carcinomas detected at regular screening or until the end of follow‐up were analyzed. Age at BBD diagnosis, diagnosis of BBD, follow‐up time between BBD diagnosis and the end of follow‐up, and breast cancer events were retrieved from the breast cancer screening program database and hospital records. All protocol procedures and methods of ascertainment of BBD and breast cancer diagnosis were reviewed and approved by the ethical committees at all participating institutions.Two pathologists independently reviewed the hematoxylin and eosin (H&E) slides from the biopsy blocks for the BBDs. The pathologists were blinded to each biopsy's case or control status. They completed detailed worksheets on the ER, PR, and Ki67 expressions when applied, and the subtype of BBD lesion  Samples were fixed in 4% buffered formalin and embedded in paraffin. Four‐micrometer sections of formalin‐fixed, paraffin‐embedded samples were deparaffinized and rehydrated. Staining H&E control and immunohistochemistry staining were performed for detecting ER, PR, and Ki67 expressions. Suitable positive tissue controls were used as quality control. Immunohistochemistry staining was performed using the Benchmark XT (VENTANA Roche).To study ER and PR, we used the retrieval antigen protocol, endogenous peroxidase inhibition, detection system, DAB, and Hematoxylin from the UltraView system (VENTANA Roche). The primary antibodies used for ER and PR detection were Rabbit anti‐human estrogen receptor alpha (clone SP1) prediluted (VENTANA Roche), and rabbit anti‐human progesterone receptor (clone 1E2) prediluted (VENTANA Roche) and incubated for 20 min at 37°C.To study Ki67, we used the retrieval antigen protocol, endogenous peroxidase inhibition, detection system, DAB, and Hematoxylin from the OptiView system (VENTANA Roche). The primary antibody used for Ki67 expression detection was rabbit anti‐human Ki67 (clon 30‐9) prediluted (VENTANA Roche) and incubated for 12 min at 37°C.The percentage of ER, PR, and Ki67 staining was scored based on the number of positively stained nucleus per 100 studied cells observed with microscopic examination. At first, the entire sample was visualized in order to find the areas corresponding to the BBD lesion. If there were more than one BBD lesion, we evaluated the more severe one . In the case of proliferative disease, we evaluated the biomarker's expression in the areas with the highest proliferative activity. In the case of nonproliferative disease, we evaluated the biomarker's expression in the entire area of the BBD lesion. We did not evaluate the background normal lobules.Pathologic classification of cancer such us invasive carcinoma and carcinoma in situ were ascertained from hospital records.P‐Value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS (v.19).The percentage of ER‐, PR‐, and Ki67‐positive cells in each sample was obtained by the pathologists’ microscopic assessment. We attempted to categorize the distribution of the ER and PR percentages into tertiles and we obtained the following groups: For ER (1) low expression: 0–70%; (2) moderate expression: 71–90%; and (3) high expression: >90%. For PR (1) low expression: 0–40%; (2) moderate expression: 41–80%; and (3) high expression: >80%. Regarding women with proliferative disease, Ki67 was categorized into two groups: (1) low expression: 0% to <1%; and (2) high expression: ≥1%. We calculated the median and range for continuous variables  and t‐tests were used for comparisons. Chi‐square tests were used to compare the distribution of ER, PR, and Ki67 expression across types of BBD and case–control status. Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of breast cancer risk according to ER, PR, and Ki67 expression. We classified women according to the type of BBD and calculated ORs per each group. N = 168) were classified as nonproliferative disease, 30.2% (N = 78) as proliferative disease without atypia, and 4.7% (N = 12) as proliferative disease with atypia. Overall, the mean age at BBD diagnosis was 56.4 years . Median time to cancer diagnosis among cases was 71.4 months , and median length of cancer‐free follow‐up among controls was very similar  (Table N = 67/86), whereas the 22% (N = 19/86) was identified out of the regular screening. Seventy‐seven percent (N = 66/86) of cases were invasive carcinomas, 14% (N = 12/86) were in situ, and the presence of invasion was unknown in 9% (N = 8/86) of cases.Of the 201 subsequent breast cancer cases diagnosed from 1994 to 2015 in the study population, 86 had a previous BBD sample with sufficient tissue to assess ER and PR expression and were included in the analysis. We randomly selected two controls per each case. Thus, the sample size for the analysis included 258 women, 86 cases matched to 172 controls. Of the 258 women with BBD, 65.1% (N = 256/258) showed ≥1% of ER immunostaining expression. The highest ER expression was 98%  of all BBD samples. The ER expression mean scores were 83% and 74% (P < 0.01) in cases and controls, respectively. A higher proportion of BBD samples with >90% positively stained cells were observed in cases than in controls  of all BBD samples. The PR expression mean scores were 68% and 58% (P < 0.01) in cases and controls, respectively. A higher proportion of BBD samples with >80% positively stained cells were observed in cases than in controls (Table Two hundred and fifty‐two of 258 (97.7%) BBD samples showed ≥1% of PR immunostaining expression. The highest PR expression was 98% Fig. N = 2/258 of N = 89/90) proliferative disease samples showed some degree of Ki67 immunostaining expression; 28.9% (N = 26/90) of samples showed <1% of Ki67 expression  than in controls   and progesterone receptors (PR) stratifies the risk of subsequent cancer in women with benign breast diseases (BBD). We found both that women with high expression of ER or PR in BBD had an increased risk of subsequent breast cancer. This increased risk remains present when we analyzed women with nonproliferative disease. To the best of our knowledge, there is scarce evidence about the biomarkers’ expression in these women. Therefore, our results may be useful to improve the clinical management of women with BBD identified in the screening context since they are mostly nonproliferative diseases.We found that women with an ER expression higher than 90% in BBD had double the risk of subsequent breast cancer compared with an ER expression lower than 70%. This finding is in agreement with the hypothesis that estrogens promote normal growth of breast epithelium but it can also have an important role in the pathogenesis of breast cancer. Our results are consistent with two previous studies that reported that ER expression in nonatypical hyperplasia is associated with an increased risk of breast cancer We observed that high PR expression in BBD was associated with increased risk of breast cancer. Increased PR expression has also been observed in hyperplastic enlarged lobular units that are considered as the earliest histologically identifiable lesion with premalignant potential Regarding Ki67, we found a nonsignificant association between high expression and subsequent breast cancer. Conversely, previous studies reported significant associations in women with sclerosis adenosis A better understanding of the characteristics of BBD identified in the context of screening will advance our clinical management of these increased risk lesions. Associations between genetic mutations and ER and PR expression were not addressed in our study. However, we think that further investigation should focus on ER and PR expression as biologically plausible biomarkers of breast cancer risk The main limitation of this study is the relatively small sample size. We were not able to analyze the subset of women with atypical lesions neither differences between in situ and invasive carcinomas because of the small sample size. Further studies with larger number of cases should focus on these women. In addition, the generalizability of our findings is limited to women with BBD who have undergone a biopsy with sufficient tissue to examine ER, PR, and Ki67 expression. On the other hand, this study is strengthened by the fact that two breast pathologists, who were blinded to later cancer outcomes, reviewed all samples. Reproducibility of pathologists’ microscopic examination compared with digitalized measures could be more useful for routine clinical practice in hospitals. Other strengths of this study are the use of a nested case–control design in the context of a screening program and the inclusion of nonproliferative diseases. Previous data came from studies assessing biologic characteristics of BBDs mostly identified in younger women and out of the context of population‐based screening programs. The current findings provide further evidence of the importance of nonproliferative diseases which are the most frequently detected BBDs in our setting In conclusion, a high expression of ER and PR in BBD is associated with increased risk of breast cancer. Although this increased risk was not demonstrated for the subset of nonproliferative or proliferative diseases, we found a tendency in both groups that should be confirmed in larger studies. Particularly in women with proliferative diseases, Ki67 may be associated with an increased risk. We believe that this information is helpful to better‐characterize BBD, and is one more step toward the possibility of personalizing the clinical management of these women in the screening context.None declared.


FANCM and RECQL have recently been reported as breast cancer susceptibility genes and it has been suggested that they should be included on gene panel tests for breast cancer predisposition. However, the clinical value of testing for mutations in RECQL and FANCM remains to be determined. In this study, we have characterised the spectrum of FANCM and RECQL mutations in women affected with breast or ovarian cancer from South-West Poland and West Ukraine.FANCM and RECQL in germline DNA from unrelated women affected with breast cancer (n = 338) and ovarian cancer (n = 89) from Poland (n = 304) and Ukraine (n = 123). These women were at high-risk of carrying a genetic predisposition to breast and/or ovarian cancer due to a family history and/or early-onset disease.We applied Hi-Plex, an amplicon-based enrichment method for targeted massively parallel sequencing, to screen the coding exons and proximal intron-exon junctions of FANCM:c.1972C > T nonsense mutation (0.23%), and two carriers of the frameshift insertion FANCM:c.1491dup (0.47%). None of the variants we observed in RECQL were predicted to be loss-of-function mutations by standard variant effect prediction tools.Among 427 women screened, we identified one carrier of the FANCM consistent with previous reports. Although initial reports suggesting that mutations in RECQL could be associated with increased breast cancer risk included women from Poland and identified the RECQL:c.1667_1667 + 3delAGTA mutation in 0.23–0.35% of breast cancer cases, we did not observe any carriers in our study cohort. Continued screening, both in research and diagnostic settings, will enable the accumulation of data that is needed to establish the clinical utility of including RECQL and FANCM on gene panel tests.Our study of the Polish and Ukrainian populations has identified a carrier frequency of truncating mutations in The online version of this article (10.1186/s12881-018-0524-x) contains supplementary material, which is available to authorized users. BRCA1 and BRCA2. By increasing the diagnostic yield through the analysis of more breast cancer susceptibility genes, gene panel testing provides more women and their families the opportunity to receive personalised risk assessment and risk management. Given their potential to provide both a clinical service genetic test and accumulate important data related to rare genetic variants in a large number of candidate breast cancer susceptibility genes, panel tests often include more than the bona fide breast cancer predisposition genes ; p = 0.0012 ; p = 0.02 for breast cancer cases diagnosed before the age of 51.FANCM is a member of the Fanconi anemia complemetation group (FANC). The mutations i et al.  and Pete5% CI 1.3–3.32; p RECQL, as compared to 1/1588 unaffected women (p < 0.001) ; p = 0.02, thus suggesting that RECQL:c.1667_1667 + 3delAGTA could be a moderate-risk, rather than a high-risk mutation for breast cancer susceptibility.Following the discovery of these “new breast cancer genes”, it has been suggested that tibility , 9. Howeed women . In theiRECQL and FANCM in unselected women from South-West Poland and West Ukraine affected with breast or ovarian cancer.These results suggest that additional studies are warranted to establish the contribution of mutations in these genes to breast cancer susceptibility. Here we report the application of massively parallel sequencing to characterise the germline mutation spectrum of Participants in this study were unrelated women diagnosed with breast or ovarian cancer recruited after or during the oncological treatment from Wroclaw Medical University, Lower Silesia, Poland, between 2004 and 2008, or Lviv State Oncology Regional Treatment and Diagnostic Center, Lviv, Ukraine between 2004 and 2010  had been diagnosed with invasive cancer . There were 20 cases of cancer in situ . Of the 78 Polish women with ovarian cancer, 11 had hereditary ovarian cancer, 10 had familial ovarian cancer and 57 were sporadic ovarian cancer cases. Of these ovarian cancers, 38 were serous, 15 were endometroid, 10 were mucinous, two were clear cell carcinomas and 13 were adenocarcinomas not otherwise specified. Known carriers of Polish founder mutations in BRCA1  and in BRCA2 (c.5946delT) were excluded from this study.The Polish cohort consisted of 226 women affected with breast cancer and 78 women affected with ovarian cancer. Of the 226 women with breast cancer, 85 had hereditary breast cancer, 17 had familial breast cancer and 124 were sporadic cases, according to the criteria described by Berliner et al. . The majThe Ukrainian cohort consisted of 112 women with breast cancer and 11 women with ovarian cancer. Seventy-four women affected with breast cancer were diagnosed with hereditary cancer and 38 with familial cancer. There were 78, 18 and 2 cases of invasive ductal, lobular and medullary breast cancers, respectively. Of the 11 Ukrainian women with ovarian cancer, two had moderately differentiated carcinoma, one had endometroid adenocarcinoma, one had serous papillary adenocarcinoma, one had low-grade differentiated adenocarcinoma and six had adenocarcinoma not otherwise specified.All participants provided informed consent for participation in this research program, which was approved by the Commission of Bioethics of the Institute of Hereditary Pathology of the National Academy of Medical Sciences of Ukraine, the Ethics Committee of Wroclaw Medical University (Poland), the Ethics Committee of University of Rzeszow (Poland) and the University of Melbourne Human Research Ethics Committee .FANCM (NM_020937.3) and RECQL (NM_002907.3) was performed on lymphocytes-derived germline DNA using the Hi-Plex protocol [Amplicon-based massively parallel sequencing of the coding regions and proximal intron-exon junctions of protocol . Massiveprotocol , 13.FANCM or RECQL were damaging to protein function was assessed with PolyPhen-2 [DNA sequence variant annotation  was performed using CAVA . The prolyPhen-2  and CADDlyPhen-2 . The thrlyPhen-2 .FANCM genetic variants were observed  and two carriers of a frameshift mutation resulting in a predicted premature termination codon: FANCM:c.1491dup; p.(Ser498fs). Of the 24 missense variants identified in the mutation screening, three were predicted probably damaging by an in-silico analysis using Polyphen-2 and CADD. The remaining variants were synonymous variants. No variant affecting consensus splice sites was detected. No ovarian cancer cases were found to carry a loss-of-function mutation in FANCM.A total of 31 distinct ed Table . We idenFANCM:c.1972C > T was diagnosed with invasive ductal carcinoma at the age of 62. Other cancers in the paternal lineage included lung cancer in her father, urinary tract cancer in her uncle and breast cancer in a first-degree cousin. Her maternal aunt had pancreatic cancer.The woman carrying the nonsense mutation FANCM:c.1491dup was observed in two women with breast cancer. Their family pedigrees are reported in Fig. FANCM:c.1491dup was diagnosed with invasive ductal carcinoma at the age of 63. Other cancers in her family included prostate cancer in her father, reproductive organs cancer in her paternal aunt and leukemia in her sister  familial breast cancer cases by Neidhardt et al. in their study of the German population. The carrier frequency of this nonsense mutation in ExAC is 0.01% in the non-Finnish European population. We identified 2/427 (0.47%) carriers of the frameshift insertion FANCM:c.1491dup. This mutation was not observed by Neidhart et al. but is present in the ExAC database at a carrier frequency of 0.008%. There are currently no published reports of missense substitutions in FANCM leading to disruption of FANCM protein function.The present study of breast and ovarian cancer cases from Poland and Ukraine identified 1/427 (0.23%) carrier of the truncating FANCM consistent with previous reports. Although initial reports suggesting that mutations in RECQL could be associated with increased breast cancer risk included women from Poland and identified the RECQL:c.1667_1667 + 3delAGTA mutation in 0.23% [Our study of the Polish and Ukrainian populations has identified carrier frequency of truncating mutations in in 0.23%  to 0.35%in 0.23%  of breasRECQL and FANCM, very large sample sizes and family based studies are required. With the inclusion of these genes in panel tests for breast cancer susceptibility, both in research and clinical settings, additional families with mutations will be identified and contribute to a better understanding of the breast cancer risk associated with mutations in these genes. Although interpretation of the genetic data derived from this testing will be limited in the short term, data will accumulate, ultimately enabling a better understanding of the role of RECQL and FANCM in susceptibility to breast cancer and establishing the clinical utility of including these genes on gene panel tests. This data could also contribute to work assessing the possible association between ovarian cancer risk and RECQL and FANCM mutations for which there is currently no evidence.In order to estimate individual breast cancer risk for carriers of mutations in


Cox regression yielded adjusted relative risks. Statistical significance was assessed using correction for multiple testing. Overall, colorectal cancer risk was significantly associated with height, body mass index (BMI), smoking, alcohol intake, physical activity, parity and menopausal hormone therapy use. For smoking there was substantial heterogeneity across morphological types; relative risks around two or greater were seen in current smokers both for signet ring cell and for neuroendocrine tumours. Obese women were also at higher risk for signet ring cell tumours. For adenocarcinomas, the large majority of colorectal cancers in the cohort, all risk factor associations were weak. There was little or no heterogeneity in risk between tumours of the right colon, left colon and rectum for any of the 14 factors examined. These epidemiological findings complement an emerging picture from molecular studies of possible different developmental pathways for different tumour types.Associations between behavioural and other personal factors and colorectal cancer risk have been reported to vary by tumour characteristics, but evidence is inconsistent. In a large UK‐based prospective study we examined associations of 14 postulated risk factors with colorectal cancer risk overall, and across three anatomical sites and four morphological subtypes. Among 1.3 million women, 18,518 incident colorectal cancers were identified during 13.8 (SD 3.4) years follow‐up  What's new?via distinct pathways, likely depending on the type of precancerous lesion. To explore risk factor associations by anatomical site and tumor morphology, the authors of this study examined data from the Million Women Study cohort, with more than 18,500 incident colorectal cancer cases. While there was little evidence for risk differences by tumor site, substantial differences were found for tumor morphology, particularly for smoking, which showed relative risks of twofold or more for some rare colorectal tumors.Evidence suggests that risk factors are differentially linked to colorectal cancer type and tumor site, suggesting that the disease can arise  It has been suggested that risk factors for colorectal cancer may vary by tumour site, and by morphological type, possibly reflecting different pathways by which tumours develop from conventional adenomas or serrated bowel polyps.We report here on associations observed between certain behavioural and personal characteristics and incident colorectal cancer risk, comparing risks across anatomical site and across morphological subtype, in a prospective study of over 1 million UK women.http://www.millionwomenstudy.org.Between 1996 and 2001, around 1.3 million women aged on average 56 years (SD 5) joined the Million Women Study through National Health Service (NHS) breast screening clinics in England and Scotland, completing a questionnaire about anthropometric, social and demographic factors, and other personal characteristics. The cohort has been resurveyed every 3 to 5 years since then. The study design and methods are described in detail elsewhere,All participants gave consent for follow‐up through their medical records, and have been linked to the NHS Central Register; study investigators are routinely notified of deaths, emigration and cancer registrations through the Health and Social Care Information Centre in England, and the Information Services Division in Scotland. Follow‐up data were available for England to December 31, 2013, and for Scotland to December 31, 2008.To date, only about 1% of the cohort has been lost to follow‐up, mainly by emigration and cessation of registration with the NHS; such women contribute person‐years and events up to the date when follow‐up ceased.The information provided for cancer includes the date of diagnosis together with the cancer site i) adenocarcinoma, ICD‐O code M8140/3 (and 12 related codes: Supporting Information Appendix Table ii) mucinous adenocarcinoma, ICD‐O M8480/3 (and three related codes); (iii) signet ring cell carcinoma, ICD‐O code M8490/3; (iv) neuroendocrine tumours, including carcinoid, ICD‐O codes M8246/3, M8240/3, M8243/3 and six related codes; and (v) other tumours: all remaining tumours, including other specified carcinoma, specified non‐carcinoma tumours, and cancers of unspecified morphology.The outcome of interest was incident primary invasive colorectal cancer ICD‐10 C18‐20). For analyses by tumour site, cancers were assigned to the following groups: colon, ICD‐10 C18.0‐18.9; colon right , C18.0 caecum to C18.4 transverse colon; colon left , C18.5 splenic flexure to C18.7 sigmoid colon; rectum, C19‐C20. For analyses by morphological type, cancers were divided into five groups based on the WHO/IARC classification: C18‐20. 2, calculated from reported height and weight); smoking status ; alcohol intake ; strenuous physical activity ; use of hormone replacement therapy for menopause (HT) ; age at menarche ; parity ; number of full‐term pregnancies ; age at menopause ; hysterectomy , sterilisation   and past use of oral contraceptives (OCs) .All exposure variables were measured at study recruitment. The 14 exposures studied were: socioeconomic status (tertiles of the area‐based Townsend deprivation index);n = 44,829). The remaining women contributed person‐years from the date of recruitment to the study until the date of registration for colorectal cancer, the date of death, or last date of follow‐up, whichever was soonest. Women were censored at diagnosis of any non‐colorectal cancer.Women were excluded from the analyses if they had been registered with any invasive cancer other than non‐melanoma skin cancer (ICD‐10 C44) prior to recruitment  regression models were used to estimate hazard ratios  of developing colorectal cancer in relation to the exposures of interest. Attained age was the underlying time variable. There was no evidence of significant violation of the proportional hazards assumption, as assessed by tests based on Schoenfeld residuals.All analyses were stratified by geographical region (10 regions corresponding to the areas covered by the recruiting cancer registries), and mutually adjusted for other exposure variables as appropriate.For adjustment and stratification variables, missing values (<6% for each variable) were assigned to a separate category. A sensitivity analysis was conducted excluding the 15% of women with any missing data on covariates within the model. A further sensitivity analysis was performed among the 1.2 million women in England, censoring at the date of first invitation to bowel cancer screening,  years, were included in the analyses. Women were followed for incident colorectal cancer over 18.1 million person‐years, with a mean duration of follow‐up of 13.8 (SD 3.4) years per woman. During this period, 18,518 incident primary invasive colorectal cancers were registered, with a mean age at diagnosis of 66.9 years (SD 6.2). By site, 12,761 cancers were in the colon , and 5,757 in the rectum. The remaining 1,214 tumours were of overlapping or unknown site. By morphology, 15,543 cancers (83.9%) were reported as adenocarcinoma, 1,270 (6.8%) as mucinous tumours, 107 (0.6%) as signet ring cell tumours, and 234 (1.3%) as neuroendocrine tumours (predominantly carcinoid); the remaining 1,364 cancers were of other or unspecified histological type.Table Table p < 0.05) in relation to taller height, greater BMI, smoking, higher alcohol intake, and in parous versus nulliparous women; and risk was significantly decreased in relation to higher levels of physical activity, and to ever use of hormone replacement therapy. No significant associations were seen for socioeconomic status or for the remaining reproductive factors examined (including number of children in parous women).Table versus nulliparity are not included in the figures (but are given in the Supporting Information Appendix) as the inconsistency with associations by number of births among parous women suggests that this finding may well be due to chance.Figures versus never smokers ; but for the most common subtype, adenocarcinoma, any association with smoking was weak . In the more detailed analyses, risks for both signet ring cell and neuroendocrine tumours were substantially higher for current smokers of 15+ cigarettes per day (RRs around 3) than for current smokers of <15 cigarettes per day (RRs around 1.6), with p < 0.001 for heterogeneity by tumour morphology (Supporting Information Appendix Table 4). Obesity (BMI 30+ vs. <25 kg/m2) was more strongly associated with signet ring cell , mucinous  and neuroendocrine tumours  than with adenocarcinoma ; these differences were of borderline statistical significance (corrected p = 0.055). There was no significant heterogeneity by tumour morphology for height, alcohol intake, use of HT, physical activity or parity  did not differ substantially from those reported above (Supporting Information Appendix Table 5).In this large cohort of UK women, overall risk of incident invasive colorectal cancer was positively associated with height, body mass index, both past and current smoking, and alcohol intake; and inversely associated with physical activity and with use of hormone therapy for the menopause. The relative risk estimates for colorectal cancer were small, generally in the range 0.9 to 1.2. Colorectal cancer risk was lower in parous than in nulliparous women, but there was no trend in risk by number of births among parous women, and no associations were found with other reproductive factors, or with socioeconomic status. For smoking there was substantial heterogeneity across tumour morphological types; strong associations, with relative risks around 2 or greater were seen in current smokers for both signet ring cell and neuroendocrine tumours. Obese women were at similarly increased relative risk for signet ring cell tumours. For adenocarcinoma, the large majority of colorectal cancers in the cohort, the associations with BMI and with smoking were weak, with relative risks around 1.1. No significant differences in risk by tumour location were seen for any of the 14 factors examined.This large prospective study, with 18,600 incident colorectal cancers, provides an opportunity to study risk factor associations in detail, taking account of potential confounding factors. In particular we were able to compare directly associations both by tumour site and by morphological type. For colorectal cancer overall, our results are consistent with past findings of small increases in risk of incident cancer in relation to taller height, adiposity, both past and current smoking, and moderately high alcohol intake; and of small decreases in risk associated with physical exercise, and with use of hormone therapy for menopause. Reproductive factors were in general not associated with risk of colorectal cancer; the lower risk in parous women is not accompanied by evidence for a trend in risk by number of births, and may be due to chance.Existing evidence on risk factor associations by site of colorectal cancer is inconsistent.All the associations between smoking and cancer risk by site were modest. By contrast, the associations we found between smoking and risk of signet ring cell and neuroendocrine tumours are stronger and the results suggest a trend in risk with amount smoked (Supporting Information Appendix Table Strengths of this large study include prospectively‐collected information on potential risk and confounding factors, and virtually complete follow‐up through linkage to routinely‐collected, reliable, cancer registration data, giving sufficient power to compare risk associations directly both by site and by morphological type. The majority of colorectal cancers in this study were diagnosed in women who had not had access to bowel cancer screening, and results remained similar when women invited for screening were excluded from the analyses; screening acceptance has been shown in this cohort to be related to individual characteristics, such as smoking and BMI,We have shown in this large prospective study in UK women that associations of colorectal cancer risk with major lifestyle risk factors do not vary greatly by tumour site. There are however some substantial differences by morphological type, smoking in particular being associated with two to threefold increased risk of signet ring call carcinoma and of neuroendocrine tumours, but only weakly associated with risk of adenocarcinoma.BMIbody mass indexCIconfidence intervalHThormone therapy for menopauseICD‐10Tenth revision of the International Classification of DiseasesICD‐OInternational Classification of Diseases for OncologyNHSNational Health ServiceOCoral contraceptiveRRrelative riskSDstandard deviationSupporting InformationClick here for additional data file.


Reproductive factors are well known risk factors for breast cancer; however, little is known about how genetic variants in hormonal pathways interact with that relationship.One thousand one hundred thirty nine cases of breast cancer in women and 1322 frequency-matched controls were compared. Genetic variants in hormonal pathways (identified in the Kyoto Encyclopedia of Genes and Genomes) were screened according to their relationship with breast cancer using the Cochran-Armitage statistic. Information on reproductive factors was obtained using a face-to-face questionnaire. The interaction among the selected genetic variants and reproductive factors was tested with logistic regression.Concerning C allele in rs2229712, compared to nulliparity in non-carriers the ORs for 1–2 and > 2 deliveries were 0.48 (0.28–0.81) and 0.34 (0.19–0.59), and in C carriers they were 0.92 (0.42–1.98) and 0.71 (0.31–1.61). Similar results were found in women carrying the C allele in rs1269851. Carriers of Allele T in rs35652107 and allele C in rs6018027 had the delivery number effect more pronounced.The number of deliveries had a dose-response protective effect on breast cancer; women carrying C allele in rs2229712 did not benefit from this protective effect.The online version of this article (10.1186/s12885-018-4182-3) contains supplementary material, which is available to authorized users. Breast cancer is the most frequent cancer in women with about 1.7 million new cases per year, and the fifth cause of death from cancer overall with about 0.5 million deaths per year [Estrogen levels seem to play a major role in breast cancer . Severalp values in GWAS make it difficult to study genetic variants – environment interactions [Women having a first-degree relative diagnosed with breast cancer have twice the risk of being affected by this disease . A few rractions .Attention has rarely been paid to breast cancer genetic variants and their interaction with reproductive factors. Several genetic pathways have been identified as related to sexual hormone production or signalling. To the best of our knowledge a systematic evaluation of their interaction with reproductive factors leading to breast cancer has not been conducted yet. The main objective in this paper was to study the effect of the interaction between genetic variants in hormonal related pathways and reproductive factors on breast cancer risk.The Multi Case-Control (MCC-Spain) study is a population-based case-control study of common tumours in Spain and has been described elsewhere . It has Cases were identified through an active search that included periodical visits to the collaborating hospital departments , but only histologically confirmed incident cases of breast cancer  with no prior history of the disease were included in this study. Ten out of 12 provinces recruited breast cancer cases and controls. Controls were selected from the general population according to age and sex distribution of the cases included in the study. In this paper, 1139 cases of breast cancer in women and 1322 frequency-matched controls were included.Response rates were 71% for breast cancer and 53% for controls, with no differences in age and province of residence among those who participated and those who refused to participate. The Ethics Committees of participating hospitals approved the study protocols and participants provided written informed consent at the time of enrolment.Participants were interviewed face-to-face by trained interviewers with a comprehensive epidemiological questionnaire that assessed socio-demographic information, personal and family history of cancer, anthropometric data, smoking habits, occupation, physical activity, water consumption, reproductive and medical history and medication/drugs use, sun exposure, sleep habits, use of hygiene products and cosmetics, signs and symptoms. Participant’s weight was recorded by self-report, as estimated 1 year before diagnosis for cases and for controls. Body mass index (BMI) was estimated from self-reported weight and height 1 year before the diagnosis for cases and 1 year prior to the interview for controls. Similar estimates provided total energy consumption.Regarding reproductive history, detailed information was obtained on age at menarche, parity, age at first delivery, menopausal status, age at menopause, hormonal contraceptive use, and postmenopausal hormone therapy.The Infinium Human Exome BeadChip  was used to genotype > 200,000 coding markers plus 5000 additional custom SNPs selected from previous GWAS studies or in genes of interest.http://www.genome.jp/kegg/) [For this analysis we only considered the SNPs selected as follows. Firstly, we searched for sexual hormone pathways in the Kyoto Encyclopedia of Genes and Genomes  ; the folp value lower than 0.001 were included in the main analysis.For each preselected SNP, the Cochran-Armitage statistics was estimated for the SNP-breast cancer (as a whole or any of its subtypes) relationship, using the metric 0, 1, 2 for the number of mutated alleles (i.e.: we assumed the additive model of inheritance). SNPs with In order to adjust for confounding factors, a propensity score was built using non-reproductive risk factors for breast cancer. In order to do that, we performed a logistic regression analysis with breast cancer as outcome and age at recruitment, province of residence, educational level, family history of breast cancer, smoking, and BMI as regressors; the propensity score was created as the predicted probability of being a breast cancer case according to this logistic regression.The main analysis was carried out by logistic regression, using breast cancer as effect and reproductive factors as regressors. This analysis was performed twice: first, without genetic information; second, stratifying by each selected SNP. All logistic regression models were adjusted for the propensity score and the remaining reproductive factors. Their results are reported as odds ratios (OR) with 95% confidence intervals (CI). All statistical analyses were performed with the statistical package Stata 14/SE .One thousand one hundred thirty nine cases and 1322 controls were included in the analysis. Table Table p value lower than 0.001 and were therefore selected for the main analysis , so from here on we limited our analysis to rs1269851 (the one with higher Cochran-Armitage association); results on rs204890 and rs204894 were similar with those on rs1269851.Out of 1314 SNPs preselected, 7 SNPs reached a Cochran-Armitage based p values for interaction were not significant in these two cases.Table The protective effect of the early age at menopause disappeared in women with the C allele in rs2229712 ; the same effect modification was found in women carrying the C allele in rs1269851 and the T allele in rs35652107. No other pattern of effect modification could be found in other reproductive factors. Tables S2-S6 display the effect of reproductive factors on breast cancer risk stratified by genetic variants . The genetic score was obtained adding one point each if the minor allele was present in rs2229712 and rs1269851  and one point each if the minor allele was absent in rs35652107 and rs6018027 . The distribution of this genetic score among cases and controls is summarized in Additional files  , 11. WheIn keeping with our results, mutations in SNPs rs1269851 (ATF6B gene) and rs35652107 (CREB3L1 gene) modify the number of births – breast cancer relationship. In vitro studies have found that mouse granulosa cells with endoplasmic reticulum stress did not show any change in estradiol levels in response to FSH . On the Genetic variant in rs6018027 (SRC gene).One way for sexual hormones to induce cancer is the ability of estradiol to stimulate BAD phosphorylation and prevent apoptosis, which is mediated via MEK/ERK/RPS6KA1 and PI3K and Akt pathways . MutatioSRC gene encodes the protein steroid receptor coactivator-1 (SRC1), which is able to interact with nuclear receptors in the presence of hormones ; in partThe only gene in our analysis that was involved in steroidogenesis was HSD17B3; we have been unable to find any interaction of this gene with reproductive factors. HSD17B3 encodes 17 beta-hydroxysteroid dehydrogenase isoform 3, whose main function is to catalyze the conversion of androstenedione to testosterone in Leydig cells (testes); testosterone would be peripherally converted to dihydrotestosterone -catalyzed by SRDSA1- and to estradiol -catalyzed by CYP19A1. HSD17B3 gene is also transcribed in both subcutaneous abdominal and omental adipose depots in women  althoughp value, which is less stringent than the Bonferroni-corrected value of 0.05/1314 ≈ 0.00005. It should be noted, however, that this p value is not used here for testing hypothesis but for screening SNPs before testing them as reproductive factors-effect modifiers. Screening SNPs with cut-off p values without multiplicity test adjustment have been used previously for this purpose [Several limitations must be mentioned in our results. Firstly, we have selected 7 out of 1314 SNPs by using a Cochran-Armitage 0.001 cut-off  purpose  in GWAS Secondly, the main assumption in our study was that the reproductive factors effect would be modified by genetic variants via hormonal pathways. The four genes we have identifiedhowever, act in several other pathways


Family history is important for identifying candidates for high risk cancer screening and referral for genetic counseling. We sought to determine the percentage of individuals who would be eligible for high risk cancer screening or genetic referral and testing if family history includes an extended (vs limited) family history.Family histories were obtained from 626 women at UVMMC associated mammography centers from 2001 to 2002. ACS guidelines were used to determine eligibility for high risk breast or colon cancer screening. Eligibility for referral for genetic counseling for hereditary breast and colon cancer was determined using the Referral Screening Tool and Amsterdam II screening criteria, respectively. All family histories were assessed for eligibility by a limited history (first degree relatives only) and extended history (first and second degree relatives).Four hundred ninety-nine histories were eligible for review. 18/282 (3.6 %) and 62/123 (12 %) individuals met criteria for high risk breast and colon cancer screening, respectively. 13/18 (72 %) in the high risk breast cancer screening group and 12/62 (19 %) in the high risk colon cancer screening group met criteria based upon an extended family history. 9/282 (1.8 %) and 31/123 (6.2 %) individuals met criteria for genetic counseling referral and testing for breast and colon cancer, respectively. 2/9 (22 %) of individuals in the genetic breast cancer screening group and 21/31 (68 %) individuals in the genetic colon cancer screening group met criteria based upon extended family history.This is one of the first studies to suggest that first degree family history alone is not adequate for identification of candidates for high risk screening and referral for genetic counseling for hereditary breast and colon cancer syndromes. A larger population is needed to further validate this data.The online version of this article (doi:10.1186/s12875-016-0521-0) contains supplementary material, which is available to authorized users. A family history of colorectal or breast cancer may significantly impact screening and management strategies for patients. Individuals with a positive family history of colon cancer may be candidates for earlier initiation of colonoscopy. Individuals with a positive family history of breast cancer may be candidates for screening breast MRI or be eligible for prevention strategies  . FurtherAlthough obtaining a family history is a staple of primary care management, there are significant barriers to obtaining a complete and accurate family history. These barriers include time restraints, patient knowledge and lack of perceived importance by healthcare provider , 7. A keProviders commonly obtain information from first degree relatives but less commonly obtain a more extended family history or age at cancer diagnosis , 11. TheWomen presenting for breast cancer screening at one of several mammography facilities associated with the University of Vermont Medical Center (UVMMC) were given the opportunity to complete and return a family history questionnaire. All women were invited to participate including those for asymptomatic screening and symptomatic referrals. The average age was 63 years and 100 % were female. A consent form was attached to the front of the questionnaire providing a description of the study and requesting permission to use information for this study. Permission was also obtained to contact patients for clarification of information on the questionnaire if necessary. Questionnaires were distributed between May 2001 and May 2002. The study was approved by the UVMMC IRB.Information on all related family members was obtained via questionnaire  and National Comprehensive Cancer Network (NCCN) consider women as high risk with a greater than 20 % lifetime risk of breast cancer due to family history and recommend adding annual screening breast magnetic resonance imaging (MRI) to their annual mammogram for breast cancer screening , 12. We There are several guidelines regarding referral for genetic counseling and testing for hereditary breast cancer including guidelines from American College of Obstetrics and Gynecology (ACoSOG), the National Comprehensive Cancer Network (NCCN) and the US Preventative Service Task Force (USPSTF) , 14, 15.Colorectal Cancer Screening Guidelines and Models for Risk Assessment: Several guidelines exist for colon cancer screening; however, only the ACS includes extended family history in recommendations for high risk individuals. These recommendations suggest that screening begin at age 40 for individuals with any first degree or two second degree relatives at any age with a history of colorectal cancer .Guidelines for referral for genetic counseling or testing for hereditary colon cancer for individuals with no personal history of colorectal cancer have not been developed at this time. However, Hampel at al. suggest that individuals with a lifetime relative risk (RR) ratio of greater than 2.0 be referred for genetic counseling . This crAll questionnaires were transcribed into a Microsoft Access database. Each study participant was assigned a unique, random identification number to allow depersonalization of data. The data was queried for individuals with at least one relative with a primary cancer excluding non-melanomatous skin cancers. This data was then queried to determine individuals who met specific guideline criteria based on their first degree family history followed by individuals who met criteria solely based on a first degree family history.Six hundred twenty-six family history questionnaires were returned between May 2001 and May 2002. Questionnaires were excluded from this analysis if they were not completed correctly, the participant completing the questionnaire had a history of cancer or there was no cancer in the family  who had a greater than 20 % lifetime risk of breast cancer (based on family history) and would therefore be candidates for high risk screening according to ACS guidelines. 5 of these 18 (28 %) individuals were identified using only first degree family information  who would be candidates for referral for hereditary breast cancer counseling. 50 % as many women who met criteria for high risk breast cancer screening met criteria for high risk breast cancer genetic referral. Using only first degree family information, 7 of these 9 (77 %) individuals would be candidates for genetics referral.Using the ACS guidelines for high risk colon cancer screening, we identified 62 individuals 62/499 = 12 %) who would be candidates for high risk colon cancer screening. Using only first degree information, 50 of these 62 (81 %) individuals would be candidates for high risk screening (Table 2 % who wUsing modified Amsterdam II criteria we identified 31 candidates (31/499 = 6.2 %) for referral for screening for hereditary colon cancer. 50 % of women who met criteria for colon cancer genetics referral met criteria for high risk colon cancer screening. Using just a first degree family history, 10 of 31 (32 %) of these individuals would be candidates for referral.st degree only) using current professional society cancer screening guidelines. Using guidelines from the ACS, 72 % of candidates for high risk breast cancer screening and 19 % of candidates for high risk colon cancer screening would have been excluded if extended (2nd degree) family history was not taken into account  would fail to identify a significant number of individuals who would be candidates for high risk cancer screening or referral for cancer genetic counseling. This supports ASCO’s recent recommendations that a minimum family history for cancer patients include 1st and 2nd degree family history information [We have shown that taking such a limited family history (1ormation .Our study does have limitations that must be considered. All study participants were female and of predominantly Caucasian background. Family histories were obtained from women reporting for mammography centers creating potential selection bias as women with a positive breast cancer family history are at increased likelihood to be up-to-date for mammography screening . Our famWe have shown that a significant proportion of candidates for high risk breast and colorectal cancer screening and genetic referral would be excluded if family history is limited to first degree family history. Our data set is small and these conclusions should be validated in a larger and more diverse data set.


P = 0.047 for the codominant model). For rs16944  and rs1143623  have significant associations were found in genetic models. In conclusion, the present analysis suggests a correlation of polymorphic markers within the IL-1 gene locus with the risk in developing breast cancer. Taken together with our finding that IL1B, IL1R1 gene three SNP are also associated with the risk for the disease, we suggest that inflammation via innate and adaptive immunity contributes to multifactorial hereditary predisposition to pathogenesis of the breast cancer.Cytokines are known as important regulators of the cancer involved in inflammatory and immunological responses. This fact and plethora of gene polymorphism data prompted us to investigate IL1 gene polymorphisms in breast cancer (BC) patients. Totally, 530 patients with BC and 628 healthy control women were studied. The genetic polymorphisms for IL1 were analyzed by Massarray Sequencing method. Three single nucleotide polymorphisms (SNPs) identified in IL1B, IL1R1 gene are thought to influence breast cancer risk. The results of the association between IL-1B, IL1R1 polymorphisms and breast cancer risk have significant. We found that the variant TT genotype of rs10490571 was associated with a significantly increased breast cancer risk (TT vs. CC: OR = 2.82, 95% CI = 1.12–7.08,  Breast cancer (BC) is one of the most common causes of cancer death in women and one of the important factors contributing to the whole world health burden . CurrentThe role of cytokines in cancer immunization and carcinogenesis has been recognized . Many stInterleukin (IL) −1 is an endogenous cytokine family involved in inflammation and immune response, including IL-1 alpha (IL-1A), IL-1 beta (IL-1B) and IL-1 receptor antagonist (IL-1Ra) encoded by IL-1RN . IL-1 isMany studies have reported that high IL-1 concentrations in the tumor microenvironment are associated with more toxic tumor phenotypes. For example, in solid tumors, IL-1 has been shown to be upregulated, including melanoma, colon cancer, lung cancer, head and neck cancer, and patients with high IL-1 producing tumours have generally bad prognoses , 18. IL-This hospital-based case–control study consisted of 530 patients and 628 healthy age-matched controls. Of the total 1158 breast cancer cases, the age of the case subjects was 50.69 ± 11.74, the control was 51.04 ± 9.64. Based on menopause status,−, ER+, respectively. PR−, PR+ is 52.5%, 47.5% respectively. Information on status of HER2 expression, 39.2% cases were negative, and 60.8% were positive , Dominant . There was significant association between the rs1143623 C/G allele and BC patients compared to the healthy controls in codominant model .The allele and genotype frequencies of IL-1 in the healthy and case groups are shown in Table P = 0.029). ER+ women three SNPs  were associated with BC risk. It is evident that statistically significant association exists between rs10490571, rs3917318, rs2856838, rs1143627, rs16944 polymorphism and BC risk in PR+ women. With regard to HER2 status, the difference was significant, the OR among HER2+ women was 1.59 (1.15–2.22) for rs10490571, 0.72 (0.55–0.94) for rs3917318 were associated with BC risk, whereas that for HER2− women there was no significant SNPs.From the stratification analyses, it was found that in Table r2 > 0.80) in Figure Among controls, this SNP was found to be in high LD in IL1A and IL1B  and SNP Consortium database for analysis and each had minor allele frequency (MAF) of >5% in Chinese Han population. DNA was isolated from Whole blood were used the GoldMag-Mini Whole Blood Genomic DNA Purification Kit  extracted. Genotypes for SNPs were determined by Sequenom MassARRAY .We used a NanoDrop 2000 (Gene Company Limited) were measured DNA concentrations. We used Sequenom MassARRAY Assay Design 3.0 Software to design a Multiplexed SNP MassEXTEND assay [In the case-control design, we selected 23 SNPs in the IL-1A, ILB, IL1R1, IL1R2 polymorphisms in BC patients from China. These SNPs from DbSNP database  and 95% confidence intervals (CI). computing the odds ratios (ORs) and their 95% confidence intervals (CIs) from both univariate and multivariate logistic regression analyses. Hardy–Weinberg equilibrium was tested by a goodness-of-fit v2 test to compare the observed genotype frequencies to the expected frequencies among the control subjects. Two sided P value of less than 0.05 was considered to be significant.Distribution, allele frequencies were analysed using the chi-square test or


The association of malnutrition in early life with breast cancer risk has been studied in Europe by investigating survivors of the Dutch Hunger Winter Famine, but not in China. We evaluated the effect of exposure to the 1959–1961 Great Leap Forward famine on subsequent breast cancer risk in Chinese women.A total of 59,060 women born in 1955~1966 were recruited from Minhang district, Shanghai, China, during the period 2008 to 2012. A baseline survey was conducted to collect demographic characteristics and known risk factors for breast cancer. Incident breast cancers were identified by conducting record linkage with the Shanghai Cancer Registry up to June 30, 2015, and confirmed through medical records. Cumulative probabilities of cancer incidence were evaluated after adjusting for age, educational level and other confounders. Cox regression models were applied to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of breast cancer.The overall crude incidence of in situ and invasive breast cancer were 19.2 and 115.0 per 100,000, respectively, in women conceived or born during the famine (1959–1962), slightly higher than those in women born before (1955–1958)  and after (1963–1966) . Particularly, at age group of 50–52 years when all participants contributed person-year of observations, the age-specific incidence of invasive breast cancer was higher in pre-natal exposed women  than in post-natal exposed  and unexposed women . However, the incidence of cancer in situ was slightly lower in pre-natal exposed women at the age group. Adjusted cumulative probabilities of breast cancer incidence, both in-situ and invasive, were also observed to be higher in women exposed to the famine, however, the difference was not statistically significant.Our results suggest a possible adverse, but limited, impact of exposure to the Great famine on the risk of breast cancer in Chinese women.The online version of this article (10.1186/s12885-017-3794-3) contains supplementary material, which is available to authorized users. Breast cancer, the most common malignancy in women worldwide, is responsible for nearly one-fifth of deaths in women aged 40 to 50 years . The incAccording to Barker’s “fetal origin” hypothesis, adverse intrauterine conditions may have a profound effect on health in later life . TrichopThe Dutch famine was a severe but short-term period of malnutrition that occurred in a previously and subsequently well-nourished population . The GreIn this study, we compared the incidence of the breast cancer among Chinese women born during and after the Great Famine with those born before the event, and thus evaluated the potential effect of malnutrition in early life on breast cancer risk.This retrospective study used data from a former breast cancer screening program provided to female permanent residents of Shanghai who were living in communities of Minhang district, Shanghai, China, at the time of interview. As described in our previous report , 149,577In-person interviews were conducted for all participants using a structured questionnaire to collect information on demographic characteristics, reproductive factors, family history of breast cancer and prior diagnosis of any breast diseases  of the Center of Disease Prevention and Control of Minhang district, Shanghai, China. Verbal consent was obtained from each participant.All subjects of the study were followed-up by a record linkage with the Shanghai Cancer Registry and the Shanghai Vital Statistics. The start time of following-up was from the date of recruitment which was from May 23, 2008 to Sep 30, 2012 in calendar time or from 42 to 57 years old with respect to age of the subjects. In April 2016, the record linkage was conducted for all subjects using the unique ID number, a number given to each Chinese citizen by birth and remaining unchanged in whole life, to identify the incident breast cancer and obtain vital status up to June 30, 2015. Information about the Shanghai Cancer Registry system has been described in detail elsewhere –26. BrieThe incident breast cancer cases were identified according to ICD-10 codes of C50. Basic demographic characteristic, tumor site, pathological type and stage of the cancer were available in the system. All incident breast cancer cases identified through linkage were subsequently confirmed by medical record examination.n = 17,772), while those born before 1959 were regarded post-natal exposure  and those born after 1962 were treated as unexposed group . The post-natal exposure group was used as the reference group. Time at risk started at the date of baseline survey and ended at the date of diagnosis of breast cancer, date of death, or ending date of following-up , whichever occurred first.Since the Great Chinese Famine occurred in 1959 and continued until 1961, exposure to the Famine was defined based on birth year of our subjects. As did previous studies , women bChi-square tests were used to compare demographic characteristics of study participants across the three birth-year subgroups. The direct adjusted cumulative probabilities of breast cancer incidence were calculated and curved based on a stratified Cox regression model proposed by Zhang et al. . Cox prop values less than 0.05 were considered statistically significant. All statistics were analyzed using SAS statistical package (version 9.3).All tests were two sided, and p > 0.05). The post-natal exposure group, however, were more likely to have a lower level of education, later age at menopause, an irregular menstrual cycle and a family history of breast cancer (p < 0.0001), but less likely in marriage and breast fed compared to other two groups.Presented in Table During a total of 302, 019 person years of following-up, 373 incident breast cancer patients were identified, including 43 with cancer in situ and 330 with cancer invasive. As shown in Table After adjusting for potential confounders, we found that the prenatal exposure group had a slightly elevated hazard ratio (HR) of cancer invasive  and cancer in situ  compared to the post-natal exposure group, while those unexposed to the Famine had a moderate lower risk of cancer in situ , but a slightly higher risk of invasive breast cancer . However, the associations did not reach statistical significance . As shown in Table We curved the adjusted cumulative probabilities of breast cancer incidence along with follow-up time by birth years in Fig. Sensitivity analyses observed similar results. As presented in Table The Great Famine in China, which has been viewed as a “natural experiment” in Chinese population, provides us a unique opportunity to evaluate how energy and nutrient deprivation in early life affects the subsequent risk of breast cancer in Chinese women. In this study including 59,060 Chinese women born in 1955–1966, we found that the women exposed to famine during gestation had a slightly higher incidence of breast cancer compared to those born before and after the famine period. The elevated breast cancer incidence in exposed women was observed at age group of 50–52 years, when all participants contributed person-years of observations. However, the associations did not reach statistical significance, suggesting that the effect of extreme malnutrition in early life on subsequent risk of breast cancer may not be profound in this population.Several biological mechanisms have been proposed to explain the effect of malnutrition in early life on subsequent risk of breast cancer. According to Barker’s “fetal origin” hypothesis, adverse intrauterine conditions may affect human health in later life , possiblOur results, although much weaker than those observed in women exposed to the 1944 to 1945 Dutch Famine in early life , 17, somThe changed reproductive factors may also contribute to the higher risk of breast cancer in exposed women. It has been suggested that famine exposure in early life may influence women’s reproductive performance in later life , 41. In The strengths of this study include the relatively large sample size, long-term following-up, and relative homogeneity in reproductive patterns due to the “one child” family plan policy that persisted for more than 30 years from 1978 to 2016 in China.However, the study has several limitations. First, we used the birth year rather than individual exposure data to define exposed or unexposed groups, which may have led to misclassification bias. Second, the study was not based on a birth cohort, but just included women born between 1955 and 1966. It was estimated that about 15–30 million people starved to death during the Great Famine . FetusesIn summary, our finding of a non-statistically significant higher incidence of breast cancer in Chinese women exposed to the Great Famine suggests a potential moderate effect of malnutrition in early life on subsequent risk of breast cancer. Longer following-up of this cohort of women is warranted to confirm our results.