Secondary outcomes of the trial include the impact of the weight loss intervention on overall survival, body weight, physical activity, dietary intakes, incidence of comorbidities, serum biomarkers and patient reported outcomes. Participants are randomized 1:1 to a 2-year, telephone-based weight loss intervention or to an education control group. The intervention is delivered through 42 telephone calls, delivered by health coaches based at the Dana-Farber Cancer Institute. Calls are supplemented by an intervention workbook, as well as a number of tools to help facilitate weight loss. Intervention goals include loss of 10% of baseline body weight, achieved through caloric restriction and increased physical activity. This large-scale study testing the impact of purposeful weight loss after cancer diagnosis on the risk of breast cancer recurrence and mortality has the potential to make weight loss programs a standard part of breast cancer treatment.Excess body weight is a poor prognostic factor in women with early breast cancer, but the effect of weight loss on the risk of breast cancer recurrence and mortality in women who are overweight or obese at the time of breast cancer diagnosis has not been evaluated. The Alliance for Clinical Trials in Oncology Breast Cancer Weight Loss trial, also known as A011401, is testing the impact of a telephone-based weight loss program on invasive disease-free survival in 3136 women with a body mass index ≥27 kg/m Analyses by menopausal status did not demonstrate significant heterogeneity between premenopausal and postmenopausal women; however, risk estimates appeared greater in premenopausal women [RR-1.75 ) 1.26–2.41] as compared to post-menopausal women [RR -1.34 (95% CI 1.18–1.53)].Growing evidence suggests that obesity is associated with increased risk of recurrence and mortality in women diagnosed with early stage breast cancer.4 Intervention participants experienced on average a 2.7 kg (3.7%) weight loss over 5 years and a 24% reduction in breast cancer recurrence as compared to control participants. In contrast, the Women’s Healthy Eating and Living (WHEL) Study randomized 3088 women to a high fruit and vegetable, low-fat diet or usual care control group.5 Participants assigned to the intervention group did not lose weight, and there was no difference in rates of recurrence between the intervention and control groups. Although there are a number of differences between the two trials, it has been hypothesized that weight loss is one of the potential drivers of the improved outcomes seen in women randomized to the low-fat dietary intervention in the WINS trial.There are few data from observational studies describing the relationship between weight loss after breast cancer diagnosis and disease outcomes. Two randomized trials that tested the impact of dietary modification on disease-free survival in women with early-stage breast cancer shed some light on this issue. The Women’s Interventional Nutrition Study (WINS) randomized 2400 breast cancer patients to a low-fat dietary intervention or usual care control group.8 Goodwin and colleagues demonstrated a two-fold increase in the risk of breast cancer recurrence and a three-fold increase in the risk of death in patients within the highest quartile of fasting insulin levels compared to the lowest.6 Another study demonstrated that women with high levels of c-peptide at the time of breast cancer diagnosis had a lower event-free survival compared to women with lower levels of c-peptide.9 In addition to insulin, other metabolic hormones, such as insulin-like growth factor-1 and the adipokines leptin and adiponectin, have been associated with poor outcomes in patients with early-stage breast cancer.14The biologic mechanisms underlying the relationship between lifestyle factors and breast cancer prognosis are not well understood. Studies have demonstrated that elevated levels of fasting insulin at the time of breast cancer diagnosis, commonly observed in individuals with obesity, are linked to an increased risk of breast cancer recurrence and death.15 Obesity is associated with subclinical inflammation in human breast white adipose tissue.16 Preclinical data demonstrate that higher levels or genetic alterations in inflammatory biomarkers such as TNFα and IL-2 are associated with increased breast cancer risk, and cohort studies have demonstrated that inflammatory biomarkers such as c-reactive protein and IL-6 are associated poor prognosis in early-stage breast cancer.17Chronic inflammation, also associated with obesity, has also been linked to breast cancer risk and prognosis.2.Despite observational data supporting a relationship between weight and breast cancer prognosis, as well as translational work providing a biologic rationale for this relationship, there is little information regarding the impact of weight loss upon the risk of recurrence and mortality in women with early-stage breast cancer. Given that weight is a modifiable factor, further research is needed to determine if weight loss could be an effective strategy to improve prognosis in overweight and obese women with breast cancer. This manuscript describes the design of the Randomized Phase III Trial Evaluating the Role of Weight Loss in Adjuvant Treatment of Overweight and Obese Women with Early Breast Cancer (A011401). The trial, also known as the Breast Cancer Weight Loss (BWEL) study, is designed to test the impact of a telephone-based weight loss intervention on rates of breast cancer recurrence in women with early-stage breast cancer who have a body mass index (BMI) of at least 27 kg/mThe concept for A011401 was developed through a coordinated effort of the NCI Clinical Trials Cooperative Groups (now NCTN/NCORP groups) in a process facilitated by the National Cancer Institute (NCI). A Clinical Trials Planning Meeting that included representatives from all of the U.S. National Clinical Trials Network (NCTN) groups, NIH staff focused on weight loss, patient advocates, and external experts in weight loss, exercise physiology, nutrition science, behavioral medicine and biostatistics, was convened in February 2014 by the NCI. Meeting attendees reviewed the evidence linking obesity to breast cancer outcomes, as well as data demonstrating the feasibility of implementing a large-scale weight loss trial in breast cancer patients, and concluded that there was sufficient evidence to support the development of a randomized trial testing the impact of weight loss on disease-free and overall survival (OS) in overweight and obese women with early-stage breast cancer.Following the planning meeting, a writing group was formed that included representatives of each of the NCTN groups, patient advocates and experts in weight loss, exercise and nutrition. Through a process that took several months, a concept was drafted and feedback was collected from writing group members and the Breast Cancer Committees of the NCTN groups. A number of considerations shaped final study design. For example, competing considerations influenced eligibility criteria and sample size. Given the many known benefits of weight loss in terms of general health, there was a desire to ensure that the study would be powered to detect even a relatively modest benefit of the lifestyle intervention. At the same time, the complexity and cost of administering a lifestyle intervention to a large group of breast cancer survivors led to the need to keep the sample size as small as possible. Thus, in order to provide enough power to evaluate the primary endpoint with a manageable sample size, eligibility was restricted to patients with stage II and III disease. Additionally, in order to enroll a large enough population of women with stage II–III disease who were representative of the broad racial, ethnic, geographic and socioeconomic diversity of breast cancer patients, it was necessary to utilize a lifestyle intervention that could be delivered to patients enrolled through a large number of centers, leading to the development of a telephone-based weight loss program for the trial.The concept developed by the writing groups was approved by the Alliance for Clinical Trials in Oncology (Alliance). The final concept was approved by NCI and finally by the Breast Cancer Steering Committee in April 2015. The study protocol was approved by the Clinical Trials Evaluation Program (CTEP) and subsequently by the NCI Adult Central Institutional Review Board. The study is being conducted in accordance with all relevant protocols.18The primary objective of the BWEL trial is to test the impact of a telephone-based weight loss intervention on invasive disease-free survival (IDFS), an aggregate endpoint that includes locoregional and distant breast cancer recurrence, contralateral invasive breast cancer, new primary non-breast cancer, and death from any cause.The trial also includes a number of secondary and correlative outcomes Table . These iSecondary analyses will also evaluate the impact of the intervention on IDFS and OS in patient subsets defined by menopausal status and tumor hormone-receptor status.BWEL is a randomized trial evaluating the effect of a weight loss intervention plus health education materials vs. health education materials alone on IDFS in women with early breast cancer Fig. .Target enrollment is 3136. The trial sponsor is the Alliance, with intergroup participation from NCTN, U.S. NCI Community Oncology Research Program (NCORP) and Canadian Clinical Trials Group (CCTG) sites. Participants are randomized 1:1 to a 2-year telephone-based weight loss intervention plus a health education program or to a health education program alone control group. Patients are enrolled through local clinic sites, and the weight loss intervention is administered centrally from a call center based at the Dana-Farber Cancer Institute. The trial aims for robust minority enrollment, with accrual strategies including the availability of intervention materials in Spanish, outreach efforts to advocacy groups, and partnerships with clinic sites serving minority populations.2, be able to read and speak English (the study will open to Spanish speaking patients in 2017), and have completed all chemotherapy, radiation and surgery at least 21 days prior to study enrollment. Participants with metastatic cancer or diabetes treated with insulin or sulfonylurea drugs are ineligible for enrollment. Each participant must sign an IRB-approved, protocol-specific informed consent in accordance with federal and institutional guidelines.Key eligibility criteria include histologic diagnosis of stage II–III, HER-2 negative breast cancer within the past 12 months. Patients with triple negative breast cancer may have any stage II–III non-inflammatory breast cancer; those with estrogen and/or progesterone receptor positive breast cancer must have involved lymph nodes or a T3 tumor. Participants must be females ≥18 years of age, have a BMI of at least 27 kg/mAll patients in both the intervention and control groups receive information focused on breast cancer survivorship. The program includes: yearly mailings of educational materials, such as the National Cancer Institute’s Facing Forward booklet; biannual study newsletters; invitations to webinars regarding breast cancer survivorship; and annual holiday and anniversary cards. All English-speaking participants receive a 2-year subscription to the Harvard Women’s Health Watch, a newsletter focused on topics related to women’s health. Spanish-speaking patients will receive NIH Medlineplus Salud.19 Look Ahead,20 and Lifestyle Intervention Adjuvant (LISA) studies,21 with materials updated to reflect recent research in weight loss and breast cancer.Participants randomized to the weight loss intervention arm receive a 2-year, telephone-based, lifestyle intervention that promotes weight loss through caloric restriction and increased physical activity. The intervention is based on Social Cognitive Theory and adapted from the evidence-based Diabetes Prevention Program (DPP),Intervention participants are assigned a trained coach at the BWEL call center at Dana-Farber Cancer Institute and are provided 42 phone calls over the 2-year intervention period. Calls are delivered weekly for the first 12 weeks, bi-weekly for the remainder of the 1st year, and monthly in the 2nd year. Participants receive a lifestyle workbook to accompany the coaching sessions and have access to a study website to support self-monitoring of diet and physical activity throughout the study. Participants receive a number of tools to assist in meeting weight loss goals, including a wireless scale and wearable activity sensor , a food scale (Ozeri Corp), meal replacement shakes , measuring cups, and the American Cancer Society Healthy Living cookbook. A toolbox approach is used to tailor the intervention to optimize behavior change for individual participants. Examples of toolbox items include alternative dietary plans and coupons for exercise classes or equipment.2.Weight loss: 10% of baseline weight (0.5–1.0 kg per week) to a BMI no less than 21 kg/mCaloric intake: calorie deficit of 500 to 1000 kcal/day based on current weight, with levels ranging from 1200–1499 kcal/day for patients weighing less than 250 lbs at baseline and 1500–1800 kcal/day for patients weighing more than 250 lbs.Physical activity: gradual increase in moderate intensity aerobic physical activity, with target goal of 150 min/week during initial phase of intervention and 225 - 300 min/week in maintenance phase of intervention.19 and the LISA21 study. Standardization is applied to training, certification and supervision of coaches; use of semi-scripted telephone calls; recording and centralized review of calls; centralized calculation of weight, activity and calorie goals; and computerized monitoring of weight, diet and activity changes.Delivery of the telephone intervention is standardized using approaches developed as part of the DPPThe BWEL study was designed to allow participating sites to collect data from study participants using methods common to other NCTN/NCORP group trials, while measures specific to the lifestyle intervention are collected centrally by the BWEL call center and intervention team. Participants undergo study visits at their local site at the time of enrollment (baseline), every 6 months for 3 years, and then annually for an additional 7 years. Study measures collected at sites include anthropometric measures, blood draws, questionnaires, and assessments of disease status and adverse events Table . In addiDetailed measures of physical activity, dietary intake, and PRO are being collected in a pre-planned, representative subset of 514 intervention and control participants at baseline and at 6, 24 and 36 months. This health behaviors and quality of life correlative study (A011401-HO1) uses a prospective, longitudinal design to assess differences in changes in health behaviors and patient-reported outcomes (PRO) over time between arms  also provide fasting whole blood samples and a block of tumor and benign breast tissue collected at the time of breast surgery (A011401-ST1). Planned correlative analyses are described in Table This randomized controlled trial of a weight loss intervention in overweight and obese women with early stage breast cancer consists of two arms: a telephone-based intervention group and a health education control group. Patients are randomized 1:1 within stratification factors: menopausal status , hormone receptor status of the tumor (ER and/or PR positive vs. ER and PR negative), and race/ethnicity (African American vs. Hispanic vs. Other).The primary objective of this trial is to compare the effect of the telephone-based intervention vs. a health educational control on IDFS. The total sample size is 3136 patients. Patient follow-up for primary and secondary endpoints will continue to a maximum of 10 years from trial enrollment.22 As a secondary analysis to estimate the effects of the intervention, we will use a multivariate Cox proportional hazard model to evaluate differences between arms after adjusting for stratification factors and the additional covariates of known importance to breast cancer including age, tumor size, number of involved nodes, and tumor grade.22 The 5-year IDFS in the control educational arm is assumed to be 77%, based on results from the control arm of E510323 where patients with stage II and III breast cancer received standard adjuvant chemotherapy.The primary comparison of IDFS among intervention assignments will be performed in the intent-to-treat (ITT) population of all randomized patients using a stratified logrank test with a one-sided type I error rate of 0.025.A target hazard ratio of 0.80 between groups would be clinically meaningful and equates to a 4.1% absolute improvement in IDFS in the intervention arm over the assumed rate in the control arm. Final analysis will occur after 739 events of invasive disease are observed, to provide 85% power to reject the null hypothesis under the target hazard ratio. Accounting for an accrual period of 4 years, 4 years of additional follow-up, interim analysis plans for IDFS, and a constant hazard of loss-to-follow-up in the ITT population of 5% by 4 years due to withdrawn consent or other reasons, requires a total sample size of 3136 patients.Statistical analyses will be conducted by the Alliance Statistics and Data Center. Interim monitoring will be conducted semi-annually by the Alliance Data and Safety Monitoring Board (DSMB). Under standard monitoring procedures, the DSMB will monitor study accrual and adverse events. The DSMB will also consider the evidence regarding safety, i.e., adverse events and the feasibility of completing the trial. In addition, two formal interim analyses are planned: (1) to determine whether the effectiveness of the intervention induces sufficient weight change, as measured by change in BMI after 12 months, and (2) to evaluate clinical benefit in terms of IDFS in a group sequential design.An analysis for futility to achieve weight loss will be conducted when 25% of the study population has reached the 12-month evaluation point. The DSMB will be provided descriptive statistics for BMI-change by arm. A 4% between group difference in mean percent weight change from baseline to 12-months will be used to define the threshold for minimum effectiveness of the intervention.Z-statistics from stratified long-rank tests will be calculated at each interim analysis, and compared to stopping boundaries using the Lan-DeMets error-spending function (1983). Interim monitoring will begin after 50% of the target IDFS events are reached and continue on a semi-annual basis.Early stopping for superiority and futility is defined under a one-sided hypothesis of clinical benefit and will be conducted using standard group sequential designs for phase III studies of time-to-event outcomes. Specifically, the The BWEL study was activated on August 29, 2016. The study is currently open to accrual at more than 1000 sites in the United States. The study was also approved by the CCTG and is anticipated to open in Canadian centers in the Fall of 2017. Accrual as of July 15, 2017 is 517 participants; accrual is anticipated to be completed in 2020, with results available in approximately 2023.The data are not yet available for the BWEL study as the trial is still in progress.ClinicalTrials.gov Identifier: NCT02750826


BRCA1 or BRCA2 is recognized for its strong familial risk .Genome Wide Association Studies (GWAS) serve as a powerful approach for discovering common risk variants underlying disease etiology. Often these variants reside within the non-coding region of the genome making the determination of functional mechanisms driving susceptibility a challenging task . Differecis-associations (cis-eQTL) were interrogated for association with breast cancer risk. Three SNPs, rs11099601, rs656040 and rs738200 were significantly associated  with an increased risk of breast cancer. The most significant association with increased risk for both ER-positive and ER-negative breast cancer was rs110099601  at 4q21, which constitutes a novel breast cancer susceptibility locus [In the study, Hamdi et al. evaluated 313 SNPs in 175 genes related to cancer for association with breast cancer risk in 46,451 breast cancer cancers and 42,599 controls of Caucasian ancestry participating in the Breast Cancer Association Consortium (BCAC) genotyped using the custom Illumina Infinium array iCOGS  with rs11099601 were functionally annotated using ENCODE chromatin features such as overlapping with Histone epigenetic marks associated with promoters and enhancers or DNAse I hypersensitive sites , which may be particularly effective for tumor types with limited sample sets.In summary, Hamdi et al. reported a novel association to breast cancer risk likely to be related to changes in expression of multiple genes. Importantly, although the approach used by Hamdi et al. may exclude the discovery of genes not previously implicated in cancer, it provides an example of an approach likely to identify variants undetectable under stringent GWAS multiple testing threshold (typically


The ‘common variant, common disease’ model predicts that a significant component of hereditary breast cancer unexplained by pathogenic variants in moderate or high-penetrance genes is due to the cumulative effect of common risk variants in DNA (polygenic risk). Assessing a woman’s breast cancer risk by testing for common risk variants can provide useful information for women who would otherwise receive uninformative results by traditional monogenic testing. Despite increasing support for the utility of common risk variants in hereditary breast cancer, research findings have not yet been integrated into clinical practice. Translational research is therefore critical to ensure results are effectively communicated, and that women do not experience undue adverse psychological outcomes.In this prospective study, 400 women with a personal and/or high risk family history of breast cancer will be recruited from six familial cancer centers (FCCs) in Australia. Eligible women will be invited to attend a FCC and receive their personal polygenic risk result for breast cancer. Genetic health professionals participating in the study will receive training on the return of polygenic risk information and a training manual and visual aids will be developed to facilitate patient communication. Participants will complete up to three self-administered questionnaires over a 12-months period to assess the short-and long-term psychological and behavioral outcomes of receiving or not receiving their personal polygenic risk result.This is the world’s first study to assess the psychological and behavioral impact of offering polygenic risk information to women from families at high risk of breast cancer. Findings from this research will provide the basis for the development of a new service model to provide polygenic risk information in familial cancer clinics.https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372743).The study was retrospectively registered on 27th April 2017 with the Australian and New Zealand Clinical Trials Group  contains supplementary material, which is available to authorized users. Breast cancer is the greatest cause of premature death in Australian women, accounting for approximately 12% of all premature deaths –5.BRCA1/2, TP53, PTEN) and moderate-penetrance  pathogenic gene variants, which were discovered through family linkage or candidate gene approaches. However, current testing only identifies a pathogenic gene variant in fewer than 25% of families tested [Since familial cancer clinics (FCCs) were first established in Australia in the early 1990’s, clinical practice has focused on the molecular diagnosis of high-penetrance  –12. IndiBRCA1 or BRCA2 pathogenic variant had been excluded, and divided them divided into high, intermediate and low polygenic risk groups based on the quartiles of the distribution of the PRS, where the second and third quartiles formed the intermediate risk group. When the features of the three groups were compared, significant differences were identified in the frequency of early-onset and second primary breast cancers. Based on a population lifetime risk of breast cancer of 1 in 11 (9%), the difference in relative risk between low PRS and high PRS was a greater than 4.5-fold, which is equivalent to an average absolute life time breast cancer risk of 6% in the low PRS group and 27% in the high PRS group. Additionally, compared to women with a low PRS, women in the high PRS group had an increased frequency of early onset breast cancers before age 35 years, an approximate two-fold increase in the rate of a contralateral breast cancer, less than half the risk of a BRCA1/2 mutation, and no increased risk of ovarian cancer [The combined effect of common variants is most commonly expressed as a Polygenic Risk Score (PRS). Typically this is calculated by multiplying the risk associated with each SNP that an individual carries, expressed as the per-allele odds ratio, or more commonly adding together the log-odds ratio. Sawyer et al.  examined 1 in 11 %, the din cancer , 10–12. Current Australian eviQ and UK NICE guidelines recommend enhanced surveillance and risk management strategies for women with a lifetime risk of developing breast cancer over 17% . Thus, wBRCA1/2 genes. These studies reported that the uptake of BRCA1/2 genetic testing is more consistently related to psychological factors (i.e. cancer anxiety and perceived risk) than to sociodemographic variables [BRCA1/2 genetic testing among women demonstrate that non-carriers derive significant psychological benefits from genetic testing and experience few adverse psychological effects, while for carries, distress increases shortly after receiving results but returns to pre-testing levels over time [The majority of published studies assessing the psychosocial impact of genetic testing for cancer susceptibility have focused on families with a known pathogenic variant in the ariables . Studiesver time –22. However time , indicatRegarding its impact on health behaviors, one review article concluded that genetic testing for breast cancer susceptibility is associated with increased adherence to recommended screening and uptake of risk-reducing surgery in affected carriers . In contBRCA1/2 testing, interest was more consistently related to psychological factors (i.e. perceived risk and greater cancer worry), rather than sociodemographic variables [To date there has been little research on the uptake and effective communication of this complex polygenic information in the hereditary cancer setting. Early research has been primarily based on hypothetical scenarios assessing interest and attitudes towards testing for common risk variants. These studies have reported a strong interest in polygenic risk testing with interest ranging from 74% to 78% –30. Simiariables –30. Onlyariables , 32. TheDespite increasing support for the utility of common risk variants in hereditary breast cancer –12, reseBRCA1/2 and other genes depending on their family history and phenotype. Unlike index cases, only a small proportion of family members have a personal history of cancer and most have not attended a FCC. To date 3700 of the total study cohort have had genomic testing for 96 SNPs already known to be associated with breast cancer risk.The Common Genomic Variants and Familial Cancer Study  provides a unique cohort in which to systematically ascertain the important psychosocial and clinical implications of testing for polygenic risk and answer a large number of research questions at a small cost . The cohThe information arising from polygenic risk factors is fundamentally different in nature to testing for monogenic high-penetrance genes, which has traditionally formed the basis of the information provided in FCCs. For example, the interpretation of polygenic risk requires greater consideration of the context, including the individual’s personal and family history, and whether testing for monogenic high-penetrance genes has occurred. In addition, the nature of polygenic inheritance means that breast cancer risk will be present for some women in the absence of a familial pattern. Translational research is critical to ensure that results are effectively communicated, in a way that allows improved risk management strategies to be implemented without undue adverse psychological outcomes. This translational study aims to develop a best-practice model of providing polygenic risk results in the hereditary breast cancer setting, to meet the likely future demand for, and prepare for widespread implementation of genomic testing in this setting.The study will invite 400 female participants from the ViP study (including a mixture of index cases and family members) to receive their personal PRS results and will examine the following aims and hypotheses:Aim 1. To determine the interest in polygenic risk assessment and investigate the determinants of accepting this invitation to receive results, i.e. uptake of this offer and factors associated with uptake.i.have higher baseline breast cancer anxiety (primary outcome variable), a need to avoid uncertainty, and they will be more likely to have daughters;ii.be more likely to comply with breast cancer screening guidelines 12 months after receiving their results.Hypothesis 1a) Compared to women who decline their results (‘decliners’), women who receive their results (‘receivers’) will:Aim 2. Assess the short-(2 weeks) and long-term (12 months) psychological and behavioral outcomes, including compliance with recommended screening and preventative strategies, of ‘receivers’ and ‘decliners’.i.have increased breast cancer anxiety compared to baseline in the short-term (2 weeks after receiving results), but breast cancer anxiety will return to baseline levels in the long-term (12 months after receiving results); and.ii.be more likely to report having implemented risk-reducing strategies 12 months after receiving their results when compared to receivers with a low PRS.Hypothesis 2a) Receivers with a high PRS result will:Hypothesis 2b) Unaffected women receiving a low PRS will have decreased breast cancer anxiety 2 weeks after receiving results, which will be sustained at 12 months, compared to affected women who receive a low PRS.Hypothesis 2c) Affected women who receive a high PRS result will exhibit larger increases in breast cancer anxiety from baseline in the short-term (2 weeks after receiving results), compared to unaffected women who receive a high PRS.Protection Motivation Theory is the theoretical framework guiding this research. This theory has been used to identify the predictors of a range of health behaviors, including uptake of whole genome screening , 34. TheAssessing a woman’s breast cancer risk by profiling common risk variants represents a novel approach in clinical genetics. The PRS results referred to in the protocol are research results obtained from the ViP study and will only be available to the 400 women invited to participate in this psychosocial study.This is a prospective study which is being conducted across FCCs in two Australian states (Victoria and Tasmania). The study has been approved by the Peter MacCallum Cancer Centre Ethics Committee (HREC/16/PMCC/2) and the Tasmanian Health and Medical Human Research Ethics Committee (H0016395).The primary psychological outcome measurement is breast cancer anxiety as assessed by the Impact Event Scale (IES). The secondary psychological and behavioral outcomes are: i) general anxiety and depression, ii) test-related distress, positive experiences and uncertainty, iii) concordance with screening guidelines, iv) uptake of preventative strategies, and v) level of decisional regret. The method of determining the PRS has been described elsewhere .Data will be collected through self-reported questionnaires. Over the course of the study, participants will complete up to three questionnaires. Women who choose to receive their PRS result will complete three questionnaires: at baseline (prior to attending the FCC), two weeks after receiving their PRS result, and 12 months after receiving their result. Women who choose not to receive their result will complete two questionnaires: at baseline and 12 months after enrolment in the study  or a high PRS (N = 200). Each group will be stratified by disease status, such that about 100 affected and 100 unaffected women are included in each study group  and relatives (<10%). Men will be excluded from the study as the small sample size will preclude a meaningful statistical comparison with the majority female cohort. Women who receive an intermediate PRS will also be ineligible, because intermediate PRS results do not alter a woman’s risk status and hence risk management advice in a clinically meaningful way. Patients with obvious intellectual or mental impairment that may interfere with the patient’s ability to understand the requirements of the study will also be excluded. Women who are not sufficiently proficient in English to be able to provide written informed consent and complete questionnaires in English will not be recruited to the study.Women selected for inclusion will be invited participate in the psychosocial study by letter. The invitation package will also include a participant information and consent sheet, a response form and a two-page educational pamphlet on genomic testing and breast cancer risk. The educational pamphlet has already been developed and has been pilot-tested with ViP participants to facilitate an informed decision about whether to attend an FCC to receive one’s polygenic risk result (unpublished data).Women will complete the three self-administered questionnaires over a 12-month period  to ‘strongly agree’ (5) with statements such as ‘I am confident I can receive my genomic testing result even if’…‘my family did not want me to, I had to communicate the results to my family’ [ family’ .Uncertainty avoidance – will be assessed using the eight-item Attitudes Towards Uncertainty scale [ty scale , which hty scale . The eig8.Stressful life events: will be assessed using the 12-item List of Threatening Experiences, which measures common threatening life experiences, including serious illness and death in the family [e family . Threate9.Perceived breast cancer risk – will be measured with three items used in a previous study [us study .10.Knowledge of familial breast cancer and polygenic risk – 10 true-false items have been developed to assess knowledge of polygenic inheritance and hereditary breast cancer.11.Breast cancer anxiety: will be measured using the Impact of Events Scale (IES), a measure of intrusion and avoidance toward a stressor, in this case being at risk for breast cancer [t cancer . The IESt cancer . The IESt cancer .12.General anxiety and depression: will be assessed using the Hospital Anxiety and Depression Scale (HADS). The 14-item HADS is a widely used measure of emotional disturbance and has two subscales measuring general anxiety and depression [pression . Each qu13.Concordance with screening guidelines – six items have been developed in concordance with national guidelines for mammography and clinical breast examination [mination  screeninmination . Partici14.Intention to take up and actual uptake of preventative strategies – 15 items have been developed to assess intention and uptake of preventative strategies, including risk-reducing surgery , medication , and lifestyle factors .15.Regret over testing decision – will be assessed using the five-item Decision Regret Scale, which correlates with decisional conflict and quality of life [ of life .16.Recall and interpretation of testing results – three items have been developed to assess recall and understanding of testing results.17.Test-related distress, positive experiences and uncertainty – this measure includes 19 items from a validated questionnaire, the Multidimensional Impact of Risk Assessment Scale [nt Scale , assessi18.Reasons for declining results – will be assessed with 15 items used in a previous study [us study . Women wIn line with clinical care practice, participants will receive their PRS result by attending an in-person appointment with a qualified genetic health professional  at one of the participating FCCs. As the return of polygenic information represents a novel practice in genetic counselling, genetic health professionals at each of the participating FCC will receive training on polygenic inheritance. A training manual will also be developed covering: interpretation of PRS results and current research, genetic counseling frameworks for polygenic inheritance , 45, 46,To measure consultation characteristics, a brief consultation report will be completed after each appointment which includes: participant’s PRS result, type of cancer (for affected women), recommended risk management strategies, number of occasions of service, length of consultation, and health professionals involved in the consultation.Based on similar previous studies , 47, a sFor each of the main outcome variables (e.g. breast cancer anxiety), linear or logistic regression will be used as appropriate. Further multivariable analyses will be used to adjust for potential confounding variables . Appropriate regressions will be performed to investigate whether outcomes differ between receivers and decliners (hypothesis 1a) and between subgroups of affected and unaffected women (hypothesis 2c) and those receiving either a low or high PRS (hypothesis 2b and 2c). Repeated measurements will be analyzed using linear mixed models to assess how outcomes change over time among receivers (hypothesis 2ai and 2b). This approach adjusts for the repeated measures per person and also allows for missing values.To our knowledge this is the world’s first study to assess determinants for uptake of polygenic risk information, and the psychological and behavioral impact of receiving this information. Testing for polygenic risk will result in a paradigm shift in the practice of clinical genetics and oncology. Currently, genetic testing for hereditary cancer is offered in relation to personal and family cancer history, cancer type and/or other clinical criteria based on the likelihood of a pathogenic variant in high- penetrance gene being present, and these genes form the sole basis of the test. Because of this, the majority of women attending FCCs for hereditary breast cancer are not offered testing as they do not meet the minimum criteria for genetic testing. However, it is increasingly clear that breast cancer risk is also associated with other types of genetic risk (e.g. polygenic risk), often in the absence of additional family history for those women who are already affected by cancer. The inclusion of polygenic risk in FCCs will dramatically change service provision and allow access to personalized genetic testing to a wider group of women, including testing of women with breast cancer unselected for family history.Findings from this study will also have implications for testing for common risk variants in other settings (e.g. hereditary cardiovascular disease and diabetes) and this study will provide a model for similar research across other important fields in medicine which are impacted by genomics.A substantive strength of this study is the large and diverse cohort available through the parent ViP study. The parent study aims to recruit every family in Victoria and Tasmania that attended a FCC to undergo genetic testing for hereditary breast cancer. The multicenter approach and diverse cohort will increase the external validity and generalization of the study findings. The sample size in the current study will provide sufficient power to detect clinically meaningful effects for the key outcome variable of breast cancer anxiety.The study is a prospective study, which employs, wherever possible, validated measures that have been utilized previously with women at high risk for breast cancer. In applying this study design we hope to build a comprehensive picture of the psychological and behavioral outcomes associated with receiving polygenic breast cancer risk information.Two potential limitations of the study must also be acknowledged. Firstly, it was beyond the capacity of the research to translate the patient questionnaires into other languages. Hence, women from non-English speaking backgrounds cannot be included. Secondly, this study will not involve development and assessment of pre-testing genetic counselling as the PRS results are available as part of the parent ViP study. The focus of this translational research is to explore the uptake of PRS results and psychological and behavioral outcomes associated with receiving or not receiving one’s PRS result. Future research will be able to explore pre-testing genetic counselling and the informed consent process including the provision of information of the benefits and limitations of SNP testing.


A recent paper in Drug and Alcohol Review analysed the information on cancer disseminated by 27 alcohol industry funded organisations. The independent UK alcohol education charity Drinkaware was among the organisations whose information was studied, and based on the analysis claims were made of misrepresentation of evidence about the alcohol‐related risk of cancer and alcohol industry influence. This commentary challenges the validity of these findings in respect to the evidence relating to the Drinkaware information, as the analysis is found to be misrepresenting the information by both disregarding the wider information content provided and the order and prominence with which alcohol‐related cancer risk is presented. Furthermore, it is argued that the public has a right to be provided with relevant evidence‐based information about cancer risk. It is critical that Drinkaware’s important public health function is not compromised by unjustified allegations of inaccuracy and by unwarranted attacks on its independence and integrity. The analysis is reported to have involved extraction of data independently by two authors, who coded and analysed data using documentary analysis methods. They report their method as comprising: ‘reading and understanding meanings of individual texts to identify subthemes; identification of thematic clusters of nodes; triangulation between documents and organisations; checking for reliability/validity and the use of representative examples.’The authors claim that the analysis demonstrated that most of the organisations included in the study were disseminating misrepresentations of the evidence about the association between alcohol and cancer, and that strategies of ‘denial/omission’, ‘distortion’ and ‘distraction’ were employed. The paper concluded that the alcohol industry appears to be engaged in extensive misrepresentation of evidence about the alcohol‐related risk of cancer through its influence on the organisations studied.Drinkaware was included among the 27 organisations considered. We address in this commentary the claims made in the paper specifically concerning Drinkaware, as we are only involved with information content provided by this organisation.Looking at the substance of the analysis, material from Drinkaware is explicitly mentioned in relation to the ‘distraction’ strategy as an example of seeking to minimise the role of alcohol by pointing to a wide range of other risk factors, presenting alcohol as ‘just one risk among many’. The one quote from the Drinkaware website that is presented in the manuscript is the following:‘For example, the fact that you are female is a risk factor in developing breast cancer. We also know breast cancer is age‐related so you're more likely to develop it as you get older and that you're more prone to breast cancer if it is part of your family history. These are all factors beyond our control. We also know that risk is related to the ‘hormone environment’ that women experience during the course of early pregnancy, child birth and breastfeeding which all exert a protective effect.’et al. claim that providing this information is misleading because it emphasises potential moderating factors ‘without acknowledging the clear independent risk of alcohol consumption’. However, all the statements made in this paragraph have long been accepted as mainstream opinion in the breast cancer medical and scientific community and there is overwhelming evidence of their correctness. As medical and scientific advisors we stand by the importance of including this information, and it is our opinion that without this paragraph we would have failed to provide women with a complete picture of the risks of alcohol and breast cancer, making us guilty of precisely the crimes of omission of which Petticrew et al. accuse other bodies.Petticrew et al. paper). This webpage clearly, comprehensively and unequivocally sets out the evidence linking alcohol to the causation of breast cancer and its sources. The first section on the webpage presents the research evidence: ‘It is clear from a number of large scale studies that there is a link between alcohol consumption and cancer. Globally, one in five (21.6%) of all alcohol‐related deaths are due to cancer. Breast cancer is the most common cancer among women’. Below this, three key points are emphasised: ‘[t]here is good evidence to suggest that alcohol increases the risk of developing breast cancer’; ‘[o]f course drinking alcohol does not mean you will automatically get breast cancer, it does mean your risk of developing it will be increased’ and ‘[h]ow much you drink over your lifetime is what increases the risk’. When presenting further details of the research evidence it is highlighted that ‘[a] number of studies have found that a woman’s risk of breast cancer increases by 7–12% for every 10 g of alcohol per day’. Throughout, the relevant primary sources for these evidence claims are clearly referenced. Other webpages on the Drinkaware website address the link between alcohol and several other cancers, with which we note Petticrew et al. do not find fault.Furthermore, in using only this quote the authors fail to make any reference to the comprehensive provision of information in the preceding paragraphs on the same Drinkaware webpage: ‘Alcohol and breast cancer’ (provided in Supplementary Table 2 published together with the Petticrew et al., we stand by its content and refute any misrepresentation of the clear independent risk of alcohol consumption in relation to breast cancer, either intentional or unintentional. Therefore, such criticism is, in our considered opinion, wholly unjustified and unprofessional.Having reviewed very carefully the page singled out for criticism by Petticrew Furthermore, we categorically refute the authors’ inference that information on alcohol and breast cancer provided by Drinkaware was influenced in any way by the alcohol industry. Drinkaware was established in 2007 as an independent alcohol education charity. It is run by an independent Board of Trustees, and all medical and health information provided by Drinkaware is developed with guidance from and approval of an independent Medical Advisory Panel of senior medical and scientific experts. Drinkaware is acknowledged by UK government agencies to be a major provider of evidence‐based public information on alcohol in the UK, with more than 9 million individual website visitors each year et al. to address the inaccuracies in their paper, which we have highlighted in this commentary.It is vital that Drinkaware’s important public health function is not compromised by unjustified allegations of inaccuracy and by entirely unwarranted attacks on its independence and integrity. We therefore expect Petticrew


Body size in early life is inversely associated with adult breast cancer (BC) risk, but it is unclear whether the associations differ by tumor characteristics.In a pooled analysis of two Swedish population-based studies consisting of 6731 invasive BC cases and 28,705 age-matched cancer-free controls, we examined the associations between body size in early life and BC risk. Self-reported body sizes at ages 7 and 18 years were collected by a validated nine-level pictogram . Odds ratios (OR) and corresponding 95% confidence intervals (CI) were estimated from multivariable logistic regression models in case-control analyses, adjusting for study, age at diagnosis, age at menarche, number of children, hormone replacement therapy, and family history of BC. Body size change between ages 7 and 18 were also examined in relation to BC risk. Case-only analyses were performed to test whether the associations differed by tumor characteristics.trend <0.001 and 0.72 (0.64–0.80), Ptrend <0.001, respectively). The majority of the women (~85%) did not change body size categories between age 7 and 18 . Women who remained medium or large between ages 7 and 18 had significantly decreased BC risk compared to those who remained small. A reduction in body size between ages 7 and 18 was also found to be inversely associated with BC risk (0.90 (0.81–1.00)). No significant association was found between body size at age 7 and tumor characteristics. Body size at age 18 was found to be inversely associated with tumor size (Ptrend = 0.006), but not estrogen receptor status and lymph node involvement. For all analyses, the overall inferences did not change appreciably after further adjustment for adult body mass index.Medium or large body size at age 7 and 18 was associated with a statistically significant decreased BC risk compared to small body size (pooled OR (95% CI): comparing large to small, 0.78 (0.70–0.86), POur data provide further support for a strong and independent inverse relationship between early life body size and BC risk. The association between body size at age 18 and tumor size could be mediated by mammographic density.The online version of this article (doi:10.1186/s13058-017-0875-9) contains supplementary material, which is available to authorized users. There is a considerable amount of evidence suggesting that larger adult body size, mostly measured as body mass index (BMI), increases risk of breast cancer among postmenopausal women –3; and cBRCA1 tumor suppressor gene - both of which reduce the likelihood of breast tissue becoming cancerous [However, previous studies have reported that larger body size in early life appears to decrease breast cancer risk in both the premenopausal –14 and pancerous . Other rancerous . Therefoancerous .Breast cancer is not just one disease, but a heterogeneous mixture of different tumor subtypes. Recent meta-analyses , 23 haveIn this study, we used two independent Swedish breast cancer population-based studies including 6731 invasive breast cancer cases and 28,705 age-matched controls in an effort to elucidate the association between body size in early life and adult breast cancer risk, by menopausal status and tumor characteristics.This study was based on two population-based case-control studies, namely, Karolinska mammography project for risk prediction of breast cancer (KARMA) and Linné-bröst 1 (LIBRO1). For KARMA, all women who underwent screening or clinical mammography between January 2011 and March 2013 at four participating hospitals in Sweden were invited to participate in the study. The participants were recruited from the Stockholm South General Hospital (50%), Helsingborg Hospital (27%), Skåne University Hospital, Lund (14%) and Landskrona Hospital (9%). The majority of the participants were recruited during the year 2012 (54%). During the recruitment period, a total of 210,233 women were invited to participate in the KARMA study, of whom 70,877 women (34%) joined the study. The mean ± standard deviation (SD) age at invitation and recruitment was 53.7 ± 9.9 years and 54.6 ± 10.0) years, respectively. As of October 2015, this cohort includes 3448 women with invasive breast cancer (cases), of whom 2749 (79.7%) women had prevalent cancer (i.e. the women were diagnosed before entering the study).P = 0.81). Four controls were randomly selected for each KARMA/LIBRO1 case from the pool of approximately 68,000 cancer-free KARMA participants, frequency matched on age  and geographical location .For LIBRO1, all women diagnosed with invasive breast cancer were identified through Stockholm-Gotland Regional Breast Cancer quality register between January 2001 and December 2008. A total of 5265 women with invasive breast cancer (cases) (response rate 61%) participated in the study. There was no significant difference in the mean ages between those who participated (63.3 years) and those who did not participate (63.9 years) in the study .The covariates included in this study were age at completion of the questionnaire , age at menarche , number of children , ever use of hormone replacement therapy (HRT) , family history of breast cancer in first-degree relatives including children , and BMI at the time of the questionnaire response . Women with breast cancer were considered to be postmenopausal in our analyses if they had no menstruation during the last 12 months prior to their breast cancer diagnosis. Control women were considered to be postmenopausal if they had no menstruation during the last 12 months prior to study entry.Information on ER status, tumor size (T), lymph node involvement (N) and distant metastases (M) were retrieved from the Swedish Cancer Register for a subset of cases. The degree of missingness for information retrieved on tumor characteristics ranged between 37.8 and 43.5% in KARMA and between 21.7 and 26.9% in LIBRO1  and corresponding 95% confidence intervals (CI) for the associations between body size in early life and adult breast cancer risk, overall and stratified by menopausal status. In addition to the covariates described above, we also further adjusted for BMI at the time of questionnaire response in separate models to clarify whether the associations between pre-adult body size and breast cancer risk were independent of adult anthropometry. To assess trends across the small, medium and large body size categories, we assigned the median somatotype to everyone with somatotypes in that category and then included this new variable as a continuous predictor in separate logistic regression models. Heterogeneity of associations between breast cancer and body size by tumor characteristics was assessed using logistic regression analyses restricted to cases  with the tumor characteristic as the outcome variable.P < 0.001) reported being of large body size at age 7 than women with breast cancer  and age at 18 . Conversely, mean BMI at the time of questionnaire response was higher among women with breast cancer than in controls. Self-reported body size at age 7 and at age 18 was positively correlated . Women with breast cancer were more likely to be postmenopausal, a larger proportion was nulliparous and more women reported family history of breast cancer compared to controls in both studies.Table trend <0.001, Table P for interaction >0.05)  Table . SimilarThe majority of the women (~85%) did not change body size categories between age 7 and 18 years  . Berkey BRCA1) in the mammary gland [Estrogen, depending on the timing of exposure, is thought to have a dual impact on breast carcinogenesis . Though ry gland , 36.However, if we consider the ovaries as a major source of estrogen production after puberty, then the estrogen-induced causal pathway will play a less prominent role in the association between body size at age 18 and breast cancer. An alternative explanation for the inverse relationship between adolescent body size and breast cancer risk might be due to increased serum insulin and androgen levels , which cAlthough body size in early life has been consistently associated with reduced breast cancer risk, the findings on how body size in early life influences tumor characteristics are not consistent. While Baer et al.  found stOur study is unique as it was based on two independent population-based case-control studies with a large number of breast cancer cases and matched controls including both premenopausal and postmenopausal women. In addition, we used the same validated pictogram to assess early life body size, had detailed information on covariates in both studies and also examined variation by tumor subtypes. However, some limitations warrant discussion. First, we depended on women’s recall of their body size at earlier ages, which could be subject to measurement bias. However, it is unlikely that women with breast cancer reported body size in early life differently from controls. No women in the validation study reported somatotypes greater than level 7; thus the effect of extreme body fatness could not be assessed . On the In conclusion, our data provided further support for an inverse relationship between early life body size and breast cancer in adulthood. We also showed a significant association between body size at age 18 years and tumor size, which could potentially be mediated by mammographic density. The public health implications of this study should be interpreted cautiously and in consideration of other comorbidities in adulthood.


CYP1A1 gene polymorphisms and tobacco smoking are among several risk factors for various types of cancers, but their influence on breast cancer remains controversial. We analyzed the possible association of CYP1A1 gene polymorphisms and tobacco smoking-related breast cancer in women from Iraq.CYP1A1 gene  of 199 histologically verified breast cancer patients’ and 160 cancer-free control women’s specimens were performed by using PCR-based restriction fragment length polymorphism.In this case–control study, gene polymorphism of CYP1A1m1T/C appeared in 16.1, 29.6, and 54.3% of women with breast cancer, respectively, compared with 41.2, 40, and 18.8% in the control group, respectively. CYP1A1m1 CC genotype and C allele were significantly associated with increased risks for breast cancer in patients  compared with controls . While the three genotype frequencies  of CYP1A1m2A/G were detected in 20.1, 31.2, and 48.7% in patients compared with 46.3, 40.6, and 13.1% in controls, respectively. The frequency of GG genotypes and G allele was significantly higher in patients  than in the controls . Smoking women having either CC or GG genotypes showed a highly significant association with increased risk of breast cancer . On the other hand, the T and A alleles of predominantly seen in healthy smoking women .Three genotype frequencies  of CYP1A1m1 and m2 were significantly associated with elevated risk of breast cancer in Iraqi women, while the T and A alleles were predominantly seen in healthy controls which may indicate their protective role. The C and G association with breast cancer incidence was more prevalent among tobacco smoking patients. These polymorphisms may be used as biomarkers of breast cancer in women from Iraq.These findings indicated that both C and G alleles of  It is known that a combination of genetic and environmental risk factors such as hypertension, tobacco use, obesity, and exposure to estrogen and polycyclic aromatic hydrocarbons were shown to be involved in breast cancer , 2. TherCYP) is a superfamily of enzymes, including CYP1A1, which catalyze several reactions such as drugs, cholesterol, steroid including estrogen and environmental pollutant breakdown and metabolizes several procarcinogens into active human carcinogens  and CYP1A1m2 (A4889G) as a risk in smoking women for breast cancer has not been examined in the local population. This work analyzed the genotype distribution and allele frequencies of CYP1A1m1 and CYP1A1m2 variants in Iraqi women with breast cancer. The study also investigated whether the active tobacco smoking status and duration alter the relationship between genotype distribution and the risk of breast cancer in Iraq.In Iraq, breast cancer is the most frequently diagnosed malignancy and the first leading cause of cancer death among women where it accounts for one-third of registered cancers . The rolThis study consisted of 199 women with breast cancer and 160 cancer-free female controls. The histologically confirmed cases of breast cancer were recruited for approximately 2 years, 1st January 2015–30th January 2017 from Hospitals in Baghdad. The information on the demographic characteristics including medical and reporoductive histories of tobacco smoking for all participants about duration of their current and previous smoking habits. All procedures were conducted in accordance with the ethical standards of the Human Ethics Committee approval provided by the Ministry of Health (No. 6426). A written informed consent was obtained from all study participants after receiving approval of the experimental protocol by the ethics committee according to the Helsinki Declaration.CYP1A1 T6235C (m1) and CYP1A1 A4889G (m2) polymorphisms and breast cancer risk were combined and included: tobacco smoke, polycyclic aromatic hydrocarbons’ cytochrome P4501A1 , and breast cancer. Research papers, case studies, and review articles of relevant literature were manually searched to identify additional appropriate analyses.Thorough research was performed using NCBI-Resources, UCSC genome browser, and Ensemble databases. Search terms for the CYP1A1m1 and m2 gene polymorphisms were searched in Ensemble, UCSC genome browsers, and GenBank databases. Several tools in the databases were used to retrieve and analyze the sequences, identify the strand (forward and/or reverse), flip the strand, and search for a particular sequence. The precise genomic map locations of the identified sequences were verified and updated to hg38 version of human genome sequence assembly by using the Gene Sorter and Table Browser tools of UCSC Genome Bioinformatics database.The genomic criteria of CYP1A1 genotypes at the m1 and m2 sites were analyzed by PCR-based restriction fragment length polymorphism as described earlier with slight modification  contained 100 ng template DNA, 0.2 µM each primer, 0.2 mM each dNTP, and 1.0 U Taq polymerase . To amplify the fragments containing m1 and m2 regions, the reaction involved an initial denaturation step of 7 min at 95°C, followed by 35 cycles of 30 s at 95°C, 1 min at 61°C for m1 (63°C for m2) 35 s at 72°C and a final elongation step of 7 min at 72°C. The restriction enzyme Msp1  was used to distinguish the m1 polymorphism as gain of an Msp1 restriction site occurs in the polymorphic allele. The wild-type m1 allele shows a single band representing the entire 340 bp fragment and variant allele results in two fragments of 200 and 140 bp. The restriction enzyme BsrD1  was used to distinguish the m2 polymorphism from the same 204 bp product in two different reactions. The cleavage sites were lost in the case of the m2 mutations and resulted in a single band, whereas the wild-type m2 alleles generated 149 and 55 bp bands. The restriction-digested products were analyzed by electrophoresis on a 3% agarose gel containing ethidium bromide and visualized under a UV illuminator.Genomic DNA was extracted from whole blood samples of patients and controls using the QIAamp DNA mini Kit  according to the manufacturer’s instructions. fication , 29, 30.2) statistics for the goodness-of-fit (1 degree of freedom) between cases and controls. A multivariate analysis using the logistic regression was used to obtain the adjusted crude odds ratio (OR) with a 95% confidence interval (CI) and to assess the associations between variables of the CYP1A1 m1 and m2 genotypes between breast cancer cases, control group and smoking status. Covariates include age, smoking duration, and postmenopausal and familial history. For all statistical tests, the level of significance was two-sided at p < 0.05. All of the statistical analyses were performed with Statistical Analysis System software V.8 .The Hardy–Weinberg (HW) equilibrium was tested using chi-squared  has SNP ID: rs1048943 with five synonyms, rs52810784, rs17861092, rs3188998, rs386513458, and VAR_001243. Whereas, m2, also known T6235C has SNP ID: rs4646903 of three synonyms, rs116877783, rs5030838, and rs17861083. The wild allele of m1 codes isoleucine (I) or ancestral phenylalanine (F), while mutant m1 allele leads to missense mutation resulting in an isoleucine (I) change to valine (V). Allele m1 is mapped at chr15:74720644, which has four alleles (T/A/C/G). Genotype m2 is the downstream gene variant which is mapped at chr15:74719300, with three alleles (A/G/T).The human p = 328) noted among patients (48.6 ± 2.0 years) and the healthy control group (47.8 ± 2.0 years) on the age risk factor. Whereas only the mean duration of smoking showed a significant difference  between smoking women with breast cancer (30.1 ± 10.2 years) and the control group (21.4 ± 9.9 years). This may indicate that a longer smoking period may contribute to susceptible of women to breast carcinogenesis. All cancer patients were confirmed to have invasive ductal or lobular carcinoma by histopathology testing. The percentage of postmenopausal breast cancer patients was 46.7% which is very similar to the postmenopausal percentage of controls, 44.4%. This excludes the effect of estrogen exposure in our patient population as a significant factor.This study included 199 women with breast cancer and 160 cancer-free controls. Table CYP1A1m1T/C and CYP1A1m2A/G displayed three genotypes with variable ratios in women with breast cancer and in the control group  . Similarly, a highly significant difference was observed with the GG genotype of CYP1A1m2 being prevalent in 48.7% of breast cancer patients and only 13.1% of the control group . The heterozygous mutant genotypes for both m1 and m2 genes had significant differences between patients and controls , respectively. On the other hand, the homozygous wild genotypes for m1 (TT) and m2 (AA) were significantly higher in the control groups . This may reflect the protective role of the T  and A  alleles in the normal population against susceptibility to breast cancer. The C and G allele frequencies were higher  in breast cancer patients  compared with the control group (10.3%)  (Table CYP1A1m2/m2 mutant GG genotype was significantly higher in smoking women (83.4%) than the control group (7.7%) . On the other hand, results of both m1 and m2 homozygous wild TT and AA genotypes were higher in control group women who smoked, 75.6 and 78.2% compared with women with breast cancer (4.6 and 3.7%) . Similar patterns of C and G allele frequencies were also obtained among smoking patients (86 and 90%)  (Table The influence of tobacco smoking on the distribution of group 10.% (OR = 1group 10.% (OR = 1CYP1A1 m1 and m2 polymorphisms were ascertained between smoking and non-smoking patients (Table CYP1A1m1/m1 CC mutant genotype in smokers resulted in a greater risk for breast cancer (75.9%), than in non-smoking patients (21.9%) . By contrast, the non-smoking patients carrying the homozygous wild TT genotype were more frequent (34%) than the smoking breast cancer patients (4.6%) . Similarly, the CYP1A1m2 genotype distribution showed that mutant GG genotype in smoking patients was at a higher risk for breast cancer (83.3%) in comparison with the same genotype in non-smoking patients (18.7%) . While the homozygous wild-type AA genotype was more prevalent in non-smoking breast cancer patients (38.5%) than those in the smoking breast cancer patients (3.7%) .The risk of breast cancer related ts Table . The resCYP1A1m1 T6345C and CYP1A1m2 A4889G with breast cancer risk in women from Iraq. The results demonstrated that gene polymorphisms of both CYP1A1m1 CC and CYP1A1m2 GG mutant genotypes and C, G allele frequencies were significantly associated with a higher risk for breast cancer when compared with healthy controls. The patient and control groups were in HW equilibrium at both CYP1A1m1 and m2. In addition, the interaction between these two polymorphic mutant genotypes and tobacco smoking was strongly correlated with a higher risk of breast cancer among tobacco smoking women in Iraq. This interaction may highlight the significant influence of the CYP1A1 gene polymorphisms on various risk factors, such as tobacco smoking, associated with breast cancer. In general, the CYP1A1 polymorphisms may vary between populations due to differences in race or ethnicity of other populations  at position 426 in the mutant protein which assessed as non-detrimental variant assessed by online service PolyPhen 2 (http://genetics.bwh.harvard.edu/pph2), whereas the m1 variant is considered as a polymorphism variant with a T>C substitution at 6235 position in the 3′ non-coding region.In this case–control study, we investigated the correlation between tobacco smoking and gene polymorphisms of ulations . The polulations , 12, 15,ulations , 16, Sibulations , Canadiaulations , Kashmirulations , 33, Hisulations , Egyptiaulations . On the CYP1A1 polymorphisms in breast cancer risk in individuals, however, has been conflicting. Some studies have shown that CYP1A1 polymorphisms are significantly associated with breast cancer risk (CYP1A1 gene polymorphisms were associated with a lower risk of breast cancer among Japanese women (CYP1A1 gene polymorphism and breast cancer risk in various parts of the world (CYP1A1 gene polymorphism effect on cancer induction can be attributed to different pathways such as phase 1 bioactivation of xenobiotics and involvement in the metabolisms of estrogen (converting the metabolites into carcinogens) that leads to elevating the risk of breast cancer , by affecting cell signaling pathways, might reflect the role of the AhR in tumor progression (CYP1A1 or CYP2, where both are involved in the metabolism of estrogen which may lead to alteration in steroid levels modulating bioactivation of therapeutic agents and xenobiotics and elevating the risk of breast cancer in smoking women. A larger sample size study including smoking women living in rural areas women is needed to unravel the complex interplay effects between gene polymorphisms and tobacco smoking and to compare between local environmental factors.The increased risk of breast cancer among long duration smoking patients in Iraq was associated with both gression , 42. TheCYP1A1m1 CC and m2 GG genotypes and C and G alleles with the increased risk of women of breast cancer in Iraq. Moreover, this strong association at both genotype and allele levels was exacerbated among tobacco smoking women with breast cancer. On the other hand, the wild TT, AA genotypes, and T and A allele carriers were significantly prevalent among healthy non-cancerous women which persist among smoking women as well. Therefore, T and A alleles may play a protective role against breast cancer in this population. The predominance of C and G alleles among tobacco smoking women with breast cancer may suggest a role in breast cancer susceptibility among Iraqi women which could have prognostic implications in breast cancer.Results of this study showed a statistically significant association between the polymorphisms of Ethical clearance was obtained from the Ministry of Health of Iraq Government. The study participants were informed about the study in Arabic, including the purpose of the study. Only those who agreed and signed the informed consent were included. PI ensured partcipants’ confidentiality and anonumity as well as no risk or harm involved.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Significant differences were also found in the genotype distributions of RASA2 rs16851483 T/T homozygote and CADM1 rs12286929 G/A heterozygote between cases and controls, with an OR of 1.68 (95% CI: 1.10–2.56) and 0.80 (95% CI: 0.64–0.99), respectively. Furthermore, significant interactions were observed between polymorphisms of three genes and body fatness for the risk of breast cancer based on both additive and multiplicative scales. These results of our study suggest that body fatness possibly plays an important role in the development of breast cancer and this risk might be modified by specific genotypes of some potential genes, especially for obese women in China.Genome-wide association studies (GWAS) have indicated that gene polymorphisms in alleles of RAS p21 protein activator 2 (RASA2), cell adhesion molecule 1 (CADM1) and hypoxia inducible factor 1 alpha subunit inhibitor (HIF1AN) are associated with the risk of obesity. In this study, we explored the interactions between candidate SNPs of RASA2 (rs16851483), CADM1 (rs12286929) and HIF1AN (rs17094222) and body fatness for breast cancer risk. Unconditional logistic regression models were applied to measure the associations of related factors with breast cancer by odds ratios (ORs) and 95% confidence intervals (CIs). It was observed that cases had a statistically higher body mass index (BMI ≥ 28 kg/m Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related death among women globally. It was estimated that 1.7 million cases and 521,900 deaths occurred in 2012, which accounted for 25% of all cancer cases and 15% of all cancer-related deaths among females worldwide .The development and progression of breast cancer is a multi-step complicated process which involves both environmental and genetic factors . Of the The individual susceptibility of breast cancer is also influenced by genetic factors, including obesity-related genes, such as PPARG, LPL, PON1 and PON2 . SeveralP < 0.001). There were no statistically significant differences in the distribution of other characteristics between cases and controls.The demographic characteristics of participants are presented in Table P < 0.001). In detail, compared with the individuals with normal body fatness, the increased risk was observed for overweight , obesity , WC ≥ 90  and WHR ≥ 0.90 . After stratified by menopausal status, this effect was similar in postmenopausal women. For those with BMI ≥ 28 and WC ≥ 90, ORs were 2.19 (95%CI: 1.49–3.23) and 3.56 (95% CI: 2.45–5.18) among postmenopausal women, much higher than those of premenopausal women. WHR was observed to have strong relationship with breast cancer regardless of menopausal status. The adjusted ORs for WHR ≥ 0.90 in premenopausal group and postmenopausal group were 3.27 (95% CI: 1.85–5.79) and 2.42 (95% CI:1.43–4.12), respectively, as compared to individuals with a normal WHR.As shown in Table The distribution of genotype frequencies for RASA2 rs16851483), CADM1 (rs12286929) and HIF1AN (rs17094222) polymorphisms between cases and controls, as well as their associations with breast cancer risk are presented in Table , CADM1 , rs12286929 (CADM1) and rs17094222 (HIF1AN) polymorphisms and their interactions with high body fatness on the development of breast cancer among Chinese women. Results showed that the T/T genotype of RASA2 (rs16851483) was associated with increased breast cancer risk, and the G/A genotype of CADM1 (rs12286929) might play a role in reducing the risk of breast cancer. Moreover, we found that high body fatness such as BMI ≥ 28kg/m2) were observed to have an increased risk of developing breast cancer, especially in postmenopausal women. Furthermore, postmenopausal women with greater WC or WHR had a higher risk of breast cancer as compared to normal individuals. Our findings were consistent with those from several previous studies [Etiologic evidence indicates that breast cancer is a complicated disease which is affected by environmental, genetic, and economic conditions as well as lifestyles . Body fa studies , 23. As  studies , it coulObesity could be affected by multiple genes . The mecThe SNP rs16851483 is located in intron 7 of RASA2 gene. The protein encoded by RASA2 gene is a member of the GAP1 family of GTPase-activating proteins and stimulates GTPase activity of normal RAS p21 (wild-type RAS), but not its oncogenic counterpart. Acting as a suppressor of RAS function, RASA2 protein enhances weak intrinsic GTPase activity of RAS proteins to result in the inactive GDP-bound form of RAS, thus allowing control of cellular proliferation, survival, differentiation, motility and transcription , 30. RASThe SNP rs12286929 is located in the 5’-noncoding region of CADM1 gene. CADM1, also known as TSLC1 (Tumor Suppressor in Lung Cancer 1), was first found in human chromosome 11q23.2 as a new suppressor gene when exploring correlation between human non-small cell lung cancer and CADM1 through functional experiments . The immThe SNP rs17094222 is located in 3’ untranslated region of HIF1AN gene. HIF1AN, also called FIH-1 (factor-inhibiting hypoxia inducible factor 1), is an asparaginyl β-hydroxylase enzyme to hydroxylate the HIF-α, thus preventing its transcriptional activity in response to hypoxia . HIF-1 iThis study provided a novel insight into the roles of obesity and gene polymorphisms of RASA2, CADM1 and HIF1AN in the development of breast cancer. However, there were several limitations in the present study. First, body fatness indices including BMI, WC and WHR were calculated based on measurement after disease occurrence. It is possible that lifestyle changes post cancer diagnosis might influence body fatness. Actually we tried to collect such information before disease onset, however, almost 50% of data were missing because cases were not able to remember their accurate information before disease onset. Second, the selected obesity-related gene polymorphisms were initially identified in western countries and have not been sufficiently studied among Chinese population. More evidence is required to support the findings from the present study. Third, we did not obtain the information on estrogen receptor (ER) status of breast cancer. So the association was not analyzed according to ER positive and ER negative tumors.In conclusion, our study confirms that body fatness plays an important role in the development of breast cancer in Chinese population, especially among postmenopausal women. Such risk might be modified by specific polymorphisms of obesity-related genes such as RASA2 rs16851483, CADM1 rs12286929 and HIF1AN rs17094222, yielding some novel insights into breast carcinogenesis. Genetic predispositions together with body fatness and other lifestyle factors may ultimately determine individual risk of breast cancer in Chinese women. These meaningful findings can be potentially used to evaluate individual inherited susceptibility to breast cancer, especially for those women with overweight and obesity, thus screening high risk persons in public health, as well as provide effective biological markers for early diagnosis of breast cancer in the clinic. It must be also noted that much more work still requires to be done based on larger cohort studies with different ethnical backgrounds in the future to further validate our current results.This study was performed according to the Declaration of Helsinki and approved by the Ethics Committee of Jiangsu Provincial Center for Disease Control and Prevention . The written informed consent was obtained from all participants.A population-based case-control study on breast cancer has been conducted in Wuxi City of Jiangsu Province from 2013–2014. Wuxi is a developed city located in the south of Jiangsu, with a total population of 4,802,673 in 2015. Women accounted for nearly 50% of the population.All study participants were restricted to local female residents who have lived in the study area for at least 5 years. Cases consisted of newly diagnosed primary breast cancer patients, and information from the local population-based cancer registry was used to exclude recurrent patients. All cases were identified according to the International Classification of Diseases, tenth revision . Eligible controls were randomly selected from the general population and were derived from the same area as cases, frequency-matched within 5 years of age. Individuals with any history of cancer were excluded. During the study period, a total of 1,410 new breast cancer cases were identified in local inhabitants and 1,072 controls were selected. Finally, 864 cases and 940 controls were recruited. The corresponding response rates of cases and controls were 61.3% and 87.7%, respectively. After excluding participants who had incomplete information, 818 cases and 935 controls were included in data analysis.All eligible participants were invited to Wuxi Maternal and Child Health Hospital, which is the largest women's and children's healthcare hospital in Wuxi City. With written informed consent, a pre-tested structured questionnaire was used to obtain epidemiological data by trained investigators through face-to-face interviews. The questionnaire included detailed information on known or potential risk or protective factors for breast cancer, such as demographic information, socio-economic status, moderate physical activity, disease history, etc. Anthropometric measurements including height, weight, waist circumference, and hip circumference were obtained at the time of interview. Because most cases couldn't remember accurate body fatness before disease occurrence, values of on-site measurements were used in subsequent analysis. Blood samples were collected by 5ml EDTA anticoagulation tube for further lab analyses.The newly identified 20 genomic loci most tightly associated with obesity from previous genetic study  were iniP > 0.05).DNA was extracted from 200 μl of peripheral blood using QIAamp DNA Blood Mini Kit  following the manufacturer's instructions. All extracted DNA was stored at −80°C. RASA2 rs16851483, CADM1 rs12286929 and HIF1AN rs17094222 genotyping among cases and controls were performed using the Sequenom MassARRAY platform provided by CapitalBio . Around 5% of randomly selected samples were repeated for quality control. Call rates were above 95% and concordance was observed at 100%. Hardy-Weinberg equilibrium (HWE) was assessed for defined different genotypes. All frequencies of these three SNPs conformed to Hardy-Weinberg equilibrium among controls , waist circumference (WC) and waist-to-hip ratio (WHR). BMI is a measure of overall adiposity, while WC and WHR are commonly used to measure abdominal or central adiposity. BMI was calculated as weight in kilograms (kg) divided by height in squared meters. WHR was calculated by using WC in centimeters (cm) divided by hip circumference in cm. The cutoff points of BMI were defined according to China Adults Overweight and Obesity Prevention and Control Guidelines: BMI < 18.5 kg/mnization –51.t-test (continuous variables) were used to compare the differences in demographic characteristics between cases and controls. Unconditional logistic regression models were applied for evaluating the main associations of different genotypes and body fatness, as well as potential gene-environment interactions with odds ratios (ORs) and 95% confidence intervals (CIs). Confounders were selected based on the results of our preliminary data analysis and previous studies on breast cancer [Pearson's Chi-square test  and Student's t cancer , includi2, WC < 80 cm and WHR < 0.85 with lowest risk genotype were defined as the reference group. The multiplicative interaction was assessed by including the main effect variables and their product terms in the logistic regression model. For the additive interaction, three measures: relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP), and synergy index (SI) were calculated [Statistical interactions between BMI, WC, WHR and genotypes on breast cancer risk were assessed based on both additive and multiplicative scales. BMI < 24 kg/mlculated . The 95%lculated , 55. In Data were analyzed using SAS Office Analytics Server 9.4 .


BRCA1/BRCA2 significantly increase the risk of breast and ovarian cancer in women. This case report describes a BRCA1 germline mutation identified in a woman with stage IV epithelial ovarian cancer and the provision of genetic counseling about BRCA1-associated breast cancer risk in the three years following diagnosis. The report centers on the patient’s enquiry about risk-reducing breast surgery. We focus on the challenges for health professionals and patients in understanding and balancing the risks and benefits of major prophylactic surgery in the context of a potentially life-limiting cancer diagnosis. Breast cancer risk management in BRCA1/BRCA2 carriers with advanced ovarian cancer is an under-explored area of genetic counseling research. This article includes a case report, a review of the relevant literature and considers some implications for practice.Germline mutations in  BRCA1/BRCA2-associated cancer risk management includes increased cancer surveillance and risk reduction strategies. For breast cancer risk, additional screening using mammography and MRI is recommended with the aim of detecting cancer at an early stage  polymerase (PARP) inhibitors  with no residual disease after total abdominal hysterectomy and no evidence of disease after six months of adjuvant chemotherapy. The patient was interested in accessing risk reducing breast surgery and after an initial discussion 17 months post ovarian cancer diagnosis, she requested follow up in the genetics clinic 2 years and 10 months post diagnosis for a further discussion to weigh up the risks and potential benefits. The patient articulated her motivations for asking about risk reducing breast surgery as wanting to stay free from cancer for as many years as possible. She was already familiar with information about ovarian cancer prognosis in general and her own excellent response to treatment from appointments with her oncology team.This case describes a 54 year old diagnosed with stage IV high grade serous ovarian cancer. The patient provided adequate family history information, reporting relatively few cancers in a large family, except for suspected ovarian cancer in her paternal grandmother (unconfirmed). Genetic testing was carried out via the Genetic Testing in Epithelial Ovarian Cancer study  ovarian cancer but no personal history of breast cancer were followed over 10 years. The women were calculated as having a lower 5-year risk of primary breast cancer of 6%, compared to 16% for the unaffected mutation carrier controls. The 10-year breast cancer risk in women with BRCA1/BRCA2-associated ovarian cancer was 11%, compared to 28% in the control group .A small number of studies have indicated that breast cancer risk is lower in BRCA1/BRCA2 mutation carriers with epithelial ovarian cancer to assess metachronous breast cancer risk. Among the 164 participants, 18 breast cancers were diagnosed, but no breast cancer related deaths occurred  after ovarian cancer diagnosis. During the follow up period, 203 women died of ovarian cancer, but only 20 women developed breast cancer. Of the four cancer deaths amongst these 20 women, two died from breast cancer and two from recurrent ovarian cancer. The aim of the study by McGee et al. was to estimate breast cancer risk and all-cause mortality after ovarian cancer in BRCA1/BRCA2 carriers in order to simulate the impact of providing MRI or risk-reducing mastectomy subsequent to ovarian cancer diagnosis. Their simulation reported a less than 1% reduction in the chance of dying  before age 80 due to breast MRI screening and a less than 2% reduction due to risk-reducing mastectomy. In the absence of a consensus on the minimum expected benefit to validate MRI or mastectomy, the authors suggest based on their data that these options should be offered to all BRCA1/BRCA2 carriers with Stage I/II ovarian cancer, but only offered to those with Stage III/IV ovarian cancer diagnosed before age 50 or at least 10 years post ovarian cancer diagnosis without recurrence.Similarly, Domchek et al.  studied e et al.  also fouBRCA1/BRCA2 carriers after ovarian cancer compared to controls was provided by a database review conducted by Gangi et al. , checking understanding and providing a designated time and space to focus on current concerns. The patient did not appear anxious or distressed by the information provided, but did express gratitude for the opportunity to ask questions in a review appointment. Towards the end of the session, she asked at what stage it would be advisable to review the question about breast cancer risk management and the suggestion of a review on request five years after diagnosis was mutually agreed.BRCA1/BRCA2 carriers with a previous diagnosis of ovarian cancer is appropriate is not easily answered by current research evidence. This is reflected by guidelines on breast cancer risk management in BRCA1/BRCA2 carriers, which do not give clear recommendations for women with a previous diagnosis of ovarian cancer, but support discussion of the option of risk-reducing breast surgery with women on a case-by-case basis (NCCN, If and when risk-reducing breast surgery in is NCCN, . Contraiis NCCN, . UncertaBRCA1/BRCA2 carriers, due to the available data from relevant research studies. Five-year risks were also chosen for genetic counseling in this case in order to answer the patient’s questions addressing risk management in the short- to medium-term. In our case report, a fuller discussion on the potential risks and benefits of risk-reducing breast surgery took place almost three years after ovarian cancer diagnosis without signs of recurrence. In this situation, it may be more appropriate to consider the impact on the risk/benefit ratio at the ten-year mark. Ten years after ovarian cancer diagnosis there is less uncertainty about the chance of relapse, which is significantly reduced (Narod The chance of surviving ovarian cancer increases with the number of recurrence-free years post diagnosis Narod . The figed Narod . HoweverBRCA1/BRCA2 mutation, genetic counselors have breast cancer risk management on their agenda. Who raises this issue and when it is raised during the consultation depends on many factors, which may include the patient’s pre-test understanding of BRCA1/BRCA2 mutation risks, family history and response to ovarian cancer treatment. In the case described here, information on breast cancer risk management options, including risk-reducing strategies, were presented in general terms. In this way, risk-reducing surgery was raised as having been proven to reduce breast cancer risk in BRCA1/BRCA2 carriers, but also as something not usually considered when the focus is on ovarian cancer treatment. For women who have an excellent response to treatment and are well two to three years later, there is potential for a mismatch between what a genetic counselor perceives as a remaining focus on ovarian cancer and how a patient views this, whilst being told there are no signs of relapse at regular oncology reviews. For many women, who are not interested in risk-reducing mastectomy, further genetic counseling to address this time-sensitive issue may not be required. For those interested in risk-reducing mastectomy, review is needed to provide updated information on the potential risks and benefits, as well to provide psychosocial support in decision making.When providing genetic counseling to women with ovarian cancer and a recently identified BRCA1/BRCA2 mutation (Heiniger et al. Part of the genetic counseling acknowledged the importance of hope and optimism as strategies for coping with uncertainty. There is evidence to show that fear of ovarian cancer recurrence is linked to reduced levels of hope (Ozga et al. BRCA1/BRCA2 mutation shortly after ovarian cancer diagnosis, the initial focus is often placed on treatment implications for the woman and risks to her relatives. This report highlights the genetic counseling needs of the index case and shows how these needs can change over time. Genetic counseling for women with ongoing questions about breast cancer risk management is time sensitive and is influenced by the number of years since ovarian cancer diagnosis. Who initiates genetic counseling review will depend on various factors, including if the clinical genetics center has a regular recall system for BRCA1/BRCA2 carriers. In the absence of systematic follow up, genetic counselors should seek to empower patients at every opportunity, so that they willingly seek further genetic counseling input as required.Following the identification of a BRCA1/BRCA2 mutation will be identified. Open and supportive dialogue between clinical genetics and oncology health professionals is likely to have patient benefits. For women with ovarian cancer and a BRCA1/BRCA2 germline mutation who are interested in risk-reducing breast surgery, realistic information should be presented in an individualized way, in order to facilitate women making decisions about their own life and body. Individual factors in this situation will include tumor stage, time since diagnosis, current health, age, patient breast cancer risk perception and risk management preferences. This involves a careful balance of providing complex risk information whilst taking into account the information and emotional needs of the individual. Clinical genetics professionals are well placed to provide this service. Qualitative research to evaluate how women adapt to and view BRCA1/BRCA2-related breast cancer risk after ovarian cancer could further inform genetic counseling practice. Longer term quantitative studies are also needed to provide information about breast cancer risk to women with a BRCA1/BRCA2 mutation who are disease-free more than five years after treatment for ovarian cancer.The provision of genetic counseling described was aided by a supportive relationship with oncology colleagues. As genetic testing becomes integrated into the routine management of individuals with ovarian cancer, more women with a germline