Two-thirds of U.S. adult women are overweight or obese. High body mass index (BMI) and adult weight gain are risk factors for a number of chronic diseases, including postmenopausal breast cancer. The higher postmenopausal breast cancer risk in women with elevated BMI is likely to be attributable to related metabolic disturbances including altered circulating sex steroid hormones and adipokines, elevated pro-inflammatory cytokines, and insulin resistance. Metformin is a widely used antidiabetic drug that has demonstrated favorable effects on metabolic disturbances and as such may lead to lower breast cancer risk in obese women. Further, the anti-proliferative effects of metformin suggest it may decrease breast density, an accepted biomarker of breast cancer risk.n = 75) or placebo (n = 75) for 12 months. The primary endpoint is change in breast density, based on magnetic resonance imaging (MRI) acquired fat-water features. Secondary outcomes include changes in serum insulin levels, serum insulin-like growth factor (IGF)-1 to insulin-like growth factor binding protein (IGFBP)-3 ratio, serum IGF-2 levels, serum testosterone levels, serum leptin to adiponectin ratio, body weight, and waist circumference. Exploratory outcomes include changes in metabolomic profiles in plasma and nipple aspirate fluid. Changes in tissue architecture as well as cellular and molecular targets in breast tissue collected in a subgroup of participants will also be explored.This is a Phase II randomized, double-blind, placebo-controlled trial of metformin in overweight/obese premenopausal women who have elements of metabolic syndrome. Eligible participants will be randomized to receive metformin 850 mg BID (The study will evaluate whether metformin can result in favorable changes in breast density, select proteins and hormones, products of body metabolism, and body weight and composition. The study should help determine the potential breast cancer preventive activity of metformin in a growing population at risk for multiple diseases.NCT02028221. Registered on January 2, 2014. Grant #: 1R01CA172444-01A1 awarded on Sept 11, 2013.ClinicalTrials.gov Identifier:  It is predicted that by 2030 there will be 65 million more obese adults in the USA which will contribute to 492,000–669,000 additional cases of cancer . In addiMetformin is a biguanide indicated as an adjunct to diet and exercise to improve glycemic control in adults and children with type 2 diabetes mellitus. It has been used worldwide for over 40 years to treat type 2 diabetes, and was approved in the United States by the Food and Drug Administration as an antidiabetic in 1995  as well Metformin exerts favorable effects on multiple metabolic disturbances that may lead to reduction of breast cancer risk. In diabetics, metformin treatment resulted in favorable changes in circulating levels of leptin and adiponectin , 14. In In addition to indirect effects, metformin may exert a direct effect in mammary tissue through the activation of the AMP-activated protein kinase (AMPK) signaling pathway, leading to an antiproliferative effect and induction of apoptosis –25. HoweSome, but not all case control and cohort studies investigating the relationship between diabetes and cancer have found that treatment with metformin appears to substantially reduce the risk for development of cancer in individuals diagnosed with diabetes , 28, incN = 200) did not show an overall decrease in tumor cell proliferation after 4 weeks of metformin intervention [Recent window-of-opportunity neoadjuvant trials reported clinical activity of metformin in non-diabetic women with operable invasive breast cancer. Two small non-placebo controlled trials showed decreased tumor cell proliferation following a short-term metformin intervention prior to surgery , 37. A crvention . Howeverrvention . In a rervention , suggestAn ongoing, large Phase III randomized trial (NCIC CTG MA.32) in over 3,500 early stage breast cancer patients aims to determine whether adding metformin to standard adjuvant therapy will improve invasive disease free survival. Recently published interim data from this trial shows a statistically significant decrease in weight, insulin, glucose, leptin, and CRP at six months in the metformin arm verses placebo . The outThe overall objective of our study is to evaluate the effect of metformin on biomarkers that have shown strong clinical and scientific relevance to breast cancer risk and have high potential to be modulated by metformin in a cohort of overweight premenopausal women. The primary study aim is to determine the effect of metformin on breast density. Studies suggest that women with dense tissue in more than 60–75 % of the breast are at 4-6-fold greater risk of developing breast cancer than those with no dense tissue –42. We hThis study is one of the first placebo-controlled, randomized trials to determine metformin effects on multiple metabolic disturbances as well as anthropometric measures in non-diabetic women. In addition, we will explore the application of metabolomics analysis to both plasma and nipple aspirate fluid as a systems biology approach to assess the potential chemopreventive mechanisms of metformin and to understand metabolic features affecting systemic and tissue markers of breast cancer risk. Metabolomic profiling in fluid expressed from the breast may provide information about the breast microenvironment that may not be reflected in plasma. Further, we will also have the opportunity to explore breast-tissue level effects of metformin in a subset of women. Thus, we will have the unique opportunity to explore the associations between metabolic features in nipple aspirate fluid and plasma with markers of breast cancer risk in both plasma and in breast tissue to further our understanding of the underlying biochemical mechanisms affecting these risk markers. Findings from this study will add insight into whether metformin can be used clinically as a pharmacological approach for breast cancer risk reduction in premenopausal women with high adiposity.The primary objective is to determine the effect of metformin intervention on breast density assessed by MRI acquired fat-water features.The secondary objectives are to determine the effect of metformin intervention on metabolic disturbances and body weight/composition, and to apply metabolomics as a systems biology approach to assess the chemopreventive mechanisms of metformin.An exploratory objective is to determine the effect of metformin intervention on tissue architecture as well as cellular and molecular targets in breast tissue collected in a subgroup of participants. We will also explore whether metformin-induced metabolic changes correlate with changes in markers of breast cancer risk or side effects.This is a Phase II double-blind, randomized, placebo-controlled trial of metformin to determine its potential effects on recognized and putative markers of breast cancer risk in overweight or obese premenopausal women with elements of metabolic syndrome. Figure This is a single institution trial conducted at the University of Arizona Cancer Center (UACC), USA. Women will be recruited through clinic offices, television and radio advertising, printed flyers, social media, and word of mouth.Premenopausal women21–54 years of ageNo change in menstrual patterns for the past 6 months preceding the time of registration2 or greaterHave a body mass index of 25 kg/m○ ≥88 cm (≥35 in.) or○ ≥80 cm (≥31 in.) for Asian Americans, individuals with PCOS, or individuals with non-alcoholic fatty liver diseaseLarge waist circumference:○ Elevated triglycerides (≥150 mg/dL (1.7 mmol/L)) or on drug treatment for elevated triglycerides,○ Reduced high-density lipoprotein cholesterol (<50 mg/dL (1.3 mmol/L)) or on drug treatment for reduced high-density lipoprotein cholesterol,○ Elevated blood pressure (≥130 mmHg systolic blood pressure or ≥85 mmHg diastolic blood pressure) or on antihypertensive drug treatment in a patient with a history of hypertension, or○ Elevated fasting glucose (≥100 mg/dL)Have at least one other component of metabolic syndrome :○ ElevatMammogram negative for breast cancer within the 12 months preceding the time of registration for women ≥ 50 years of ageAbility to understand and willingness to sign a written informed consent document○ Amenorrhea for at least 12 months (preceding the time of registration), or○ History of hysterectomy and bilateral salpingo-oophorectomy, or○ At least 55 years of age with prior hysterectomy with or without oophorectomy, or○ Age 35 to 54 with a prior hysterectomy without oophorectomy OR with a status of ovaries unknown with documented follicle-stimulating hormone level demonstrating elevation in postmenopausal rangePostmenopausal womenWomen who are pregnant, planning pregnancy within the next year, or lactating/breastfeedingOn treatment with any drug for diabetesHave uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or any illness that would limit compliance with study requirementsHave received chemotherapy and/or radiation for any malignancy  in the past 5 years (preceding the time of registration)Have received other investigational agents within the past 3 months (preceding the time of registration)Have a history of lactic acidosis or risk factors for lactic acidosisHave renal disease or dysfunction (creatinine ≥ 1.4 mg/dL)Have hepatic dysfunction (bilirubin > 1.5 × ULN unless with Gilberts syndrome or AST/ALT > 3 × ULN)Have a history of alcoholism or high alcohol consumption (average of > 3 standard drinks/day)Have a history of allergic reactions to metformin or similar drugsHave a history of severe claustrophobiaHave electrically, magnetically, or mechanically activated implants including cardiac pacemaker, cochlear implants, magnetic surgical clips or prosthesesHave breast implantsRandomization is performed using computer-generated random permuted blocks. To retain the blind, metformin and placebo supplies are identified by the randomization number. The study staff will dispense the product to subjects based on the assigned randomization number. None of the staff interacting with subjects will know the link between randomization number and actual product. The code that identifies the product will be kept by the study statistician or the designated data manager.Unblinding is not expected to occur until all subjects complete the intervention and data entry is complete. If deemed medically necessary, study agents may be unblinded by the Principle Investigator in consultation with the Medical Director in the event of a serious adverse event (SAE).Subjects will be on agent intervention for 12 months (52 ± 4 weeks). For the first four weeks, 1 metformin (850 mg) or placebo tablet will be taken once daily with food. For the remaining treatment period, metformin or placebo tablets will be taken twice daily with food.Participants may not use non-study metformin or other biguanides while on study. Medications with potential interaction with metformin (e.g. cationic drugs) will be carefully reviewed and monitored closely while subjects are on study. All medications (prescription and over-the-counter), vitamin and mineral supplements, and/or herbs taken by the participant will be documented on the concomitant medication case report form and include: start and stop date, dose and route of administration, and indication.A schedule of study procedures is presented in Table Review of medical history and medication usage historyCollection of demographic information Collection of anthropometric measurements Collection of breast cancer risk information Collection of information on menstrual patterns/cyclesMeasures of vital signs .A fasting blood sample for complete blood count with differential (CBC/w diff), comprehensive metabolic panel (CMP), lipids, and follicle-stimulating hormone and/or estradiol for women with uncertain menopausal statusUrine pregnancy testPotential subjects will present to clinic for a detailed discussion of the protocol with the study coordinator. Signed informed consent will be obtained prior to any study-related activities or procedures being conducted. Subjects are registered onto the protocol on the day of consent. Participants will then undergo the following procedures for screening.Anthropometric measurementsA fasting blood for research biomarkersCollection of urine for urine pregnancy test and research testsVital signsUpdate information on menstrual patterns/cyclesUpdate medication usageCompletion of the Arizona Food Frequency Questionnaire (AFFQ) to measure usual dietary intake and the Arizona Activity Frequency Questionnaire (AAFQ) to assess usual physical activityCollection of nipple aspirate fluid (NAF)MRI assessment of breast density – MRI is performed on a Seimens 3T MRI system using a 16 channel breast MRI coil system. Fat-water maps will be obtained using a multi-point Gradient Echo DIXON imaging method developed by Siemens –50. WomeOptional core needle biopsy - for participants who consent to this optional procedure, the medical specialist will use a 14-gauge needle under ultrasound guidance to obtain up to 8 tissue cores from areas of high density in one of the breastsParticipants who meet all selection criteria will undergo the following baseline procedures. When feasible, these procedures will be scheduled in the midluteal phase of the menstrual cycle.Following completion of baseline evaluation, participants will be randomized to receive metformin or placebo for 12 months. Participants will be asked to keep an adverse event (AE) diary and menstrual calendar throughout the study. In addition, participants will be provided with an intake calendar for recording medication usage. Study personnel will contact study participants within a week after study agent has been initiated and within a week following the scheduled dose increase to assess compliance and any potential problems.Collection of urine for urine pregnancy test and research testsVital signsUpdate information on menstrual patterns/cyclesUpdate medication usageSide effect evaluationReturn unused pillsReceive a new supply of study medicationAnthropometric measurementsCollection of a fasting blood and NAF sample for research biomarkersMRI assessment of the breastOptional breast core biopsyParticipants will return at month 6 (26 ± 4 weeks) to undergo the following procedures:When feasible, the month 6 procedures will be scheduled in the mid-luteal phase of the menstrual cycle.Collection of urine for urine pregnancy test and research testsVital signsUpdate information on menstrual patterns/cyclesUpdate medication usageReturn unused pillsSide effects evaluationAnthropometric measurementsA fasting blood for CBC/CMP/lipids and research biomarkersNAF collectionMRI assessment of breast densityCompletion of AFFQ and AAFQParticipants will be instructed to take the study agent until the day of the last study procedure. At the end of the 12-month agent intervention (52 ± 4 weeks), participants will return to the clinic to undergo the following procedures:When feasible, the month 12 procedures will be scheduled in the midluteal phase of the menstrual cycle.After completing the study intervention, participants will be followed for 2 weeks for any adverse reactions.Throughout the study, study personnel will contact study participants as needed between clinic visits to assess compliance and any potential problems. In addition to clinic visits with study endpoint collections, participants will return to the clinic at month 3 (13 ± 2 weeks) and month 9 (39 ± 2 weeks) after initiation of agent intervention in order to conduct a urine pregnancy test, obtain vital signs, update menstrual cycle information, update medication usage, and to evaluate side effects to ensure safety as well as participant compliance.All AEs will be assessed according Common Terminology Criteria for Adverse Events Version 4, followed according to good medical practices, and documented.The University of Arizona Cancer Center (UACC) Data and Safety Monitoring Board (DSMB) will provide ongoing oversight for this trial. Routine monitoring will be provided by the UACC Quality Assurance/Quality Control (QA/QC) Program to ensure that the investigation is conducted according to protocol design and regulatory requirements. The Principal Investigator will ensure the accuracy, completeness, legibility and timeliness of the data reported in the Case Report Form (CRF). Source documentation supporting the CRF data will indicate the participant’s participation in the trial and should document the dates and details of study procedures, AEs, and participant status.Our sample size ensures adequate power to test all primary and secondary outcomes. We assume an initial sample size of 75 women per group and allow the possibility of up to 20 % dropout for the 12-month follow-up measurement, resulting in at least 60 evaluable women per group. To determine the detectable effect size, we use a simplified comparison of change between 12 months versus baseline, assuming a two-sided α of 0.05 and 80 % statistical power. For the fat-water MRI-derived change in breast density, we will be able to detect a decrease of 0.516 standard deviation (SD) units in the metformin treated women, equivalent to a 10 % decrease in breast density as determined by standard mammography. For the secondary outcomes , we will also be able to detect a difference of 0.516 SD units. For metabolomic analysis that compares thousands of metabolites, we approximated the effect size by setting a more stringent alpha level of 0.005. For plasma metabolomic analysis we will be able to detect an effect size of 0.667 SD units, while for NAF metabolomic analysis we will be able to detect an effect size of 0.848 SD units (assuming at least 65 % of the women will provide sufficient NAF).The primary study endpoint is to compare the change in breast density as measured by fat-water MRI  between metformin and placebo groups. Additional endpoints such as systemic hormone and cytokines, body weight, waist circumference, and waist-hip ratio will be measured at baseline, 6 and 12 months. Analysis for all study endpoints will be based on a linear mixed-effects model for the observed values across time, to adjust for the correlation among measurements within the same woman. The main effects in the model will be time , treatment group (metformin versus placebo), and the interaction between time and treatment group. The time parameter tests if there is a change among placebo treated women, while the group-by-time interaction tests if the change in metformin treated women differs from that in the placebo group. We expect that a simpler covariance structure, such as compound symmetry, will be adequate for repeated measurements within the same woman . Alternatively, we will compare correlation structures for the longitudinal measurements using Akaike’s information criterion. All endpoints will be assessed for normality, and transformations (such as a logarithmic transformation) will be used as necessary to reduce skewness prior to statistical analysis.q-value) will be calculated [q-value (q ≤ 0.10) is an indication of high confidence in a result. While a higher q-value indicates diminished confidence, it does not necessarily rule out the significance of a result. Other lines of evidence may be taken into consideration when determining whether a result merits further scrutiny. Such evidence may include a) significance in another dimension of the study, b) inclusion in a common pathway with a highly significant compound, or c) residing in a similar functional biochemical family with other significant compounds.For the metabolomic aim, pre- to post-intervention changes in all detectable compounds will be determined and compared between treatment groups using two-sample t-tests. An estimate of the false discovery rate (lculated  to adjusNo interim statistical analyses are planned for this Phase II trial. Accrual, data collection, and any AEs will be monitored on a regular basis. The final dataset will be available to all study investigators.The trial was activated in March of 2014. As of May, 2016, we have consented 152 women. Fifty were ineligible, 5 dropped out prior to agent intervention, 97 initiated agent intervention. It is expected that we will complete accrual by the summer of 2017 and participant treatment by the summer of 2018. Over 80 % of the accrued participants have agreed to undergo the optional breast biopsy. Findings from this study will be published in a peer-reviewed scientific journal and will have wide public health impact because of the growing overweight and obese populations at risk for multiple diseases. With its demonstrated effect in reducing the incidence of diabetes in high-risk adults [AAFQ, Arizona Activity Frequency Questionnaire; AE, adverse event; AFFQ, Arizona Food Frequency Questionnaire; AMPK, AMP-activated protein kinase; CBC/w diff, complete blood count with differential; CMP, comprehensive metabolic panel; DSMB, Data and Safety Monitoring Board; ELISA, enzyme-linked immunosorbent assay; HPLC, high performance liquid chromatography; IGF-BP, insulin-like growth factor binding protein; MRI, magnetic resonance imaging; MS, mass spectrometry; NAF, nipple aspirate fluid; NCI, National Cancer Institute; PCOS, polycystic ovary syndrome; QC, quality control; SAE, serious adverse event; SD, standard deviation; UACC, University of Arizona Cancer Center


The type of silhouette and quantity of fat tissue are correlated with hormonal imbalance which plays a substantial role in breast carcinogenesis. The goal of the study was to investigate the association between various anthropometric characteristics and breast cancer risk.t test and Mann-Whitney’s test. Models of logistic regression for selected data were built to estimate the odds ratio. Results were considered statistically significant when the P value was less than 0.05.Detailed anthropometric assessment was conducted on 487 women of whom 193 had diagnosed breast cancer and were consecutive patients in the Oncology Center, Cracow, Poland between 2002 and 2004. Measurements were divided into four categories: overall body size , regional body sizes , thickness of the skeleton , and body proportions. Additionally, results were analyzed in regard to menopausal status. Differences between groups were assessed using Student’s The BMI in both groups was negatively associated with the risk of cancer. Among premenopausal women, WHR increased the risk of breast cancer . Anthropometric indices of hip-to-shoulder ratio in postmenopausal  and trunk-to-height ratio in both premenopausal women  and postmenopausal women  were strongly related to a decreased risk of breast cancer. Thicknesses of the triceps and subscapular skinfolds increased the risk of breast cancer.Women with breast cancer present with an obese type of silhouette with a specific concentration of fat tissue in the central and upper parts of the body. There are many studies which confirm that breast cancer is strongly associated with body size –7. CharaNotably, peripheral fat tissue plays a substantial role in the synthesis of sex steroid hormones in women. Thus, after menopausal transition, obesity leads to a higher level of estrogen and androgens which are mitogenic agents for breast cells. Equally, it has been found that the moment of diagnosis of breast cancer in obese women is delayed and chemotherapy is less efficient . MoreoveThe question remains whether there are any different features in the body silhouette which may exemplify hormonal imbalance in women with breast cancer. In this aim, we conducted detailed anthropometric studies of 488 women of whom 193 had diagnosed breast cancer. The parameters which we considered may be divided into four categories: overall body size , regional body sizes , thickness of the skeleton , and body proportions.We compared our results with different studies; however, thickness of the skeleton and body proportions have not hitherto been described in the literature. We also hypothesized that body composition differences in breast cancer women are only a symptom of different metabolic and biochemical disturbances. Therefore, certain anthropometric measurements could be helpful in identifying women at a higher risk of developing breast cancer in the future.We performed a case-control population study based on 488 women—193 cases and 295 control subjects. The manuscript submitted for publication contains an experiment which complies with the current law of Poland where it was performed and was approved by the Ethics Committee Board in Cracow, Poland.All cases were collected from the Oncology Center, Cracow, Poland. We included patients aged between 35 and 80 years old with newly diagnosed breast cancer and who were qualified for radical mastectomy during the period of 2002–2004. Each patient’s diagnosis was confirmed by pathologists. We excluded patients with a previous history of cancer, after neoadjuvant treatment, pregnant, breastfeeding, or with liver disease. Female controls were chosen randomly from local industry companies, public education institutes, and social service workers. Cancer-free participants were matched to patients by age and sex to eliminate the most important confounding factors.Data were collected anonymously and consent from all participants was obtained orally. After taking all measurements, each patient signed up on a questionnaire as an approval of participation in the study.All participants were interviewed by students and the authors in person at the hospital and workplace and via a structured questionnaire to obtain such information as demographic factors, menstrual status, reproductive history with a detailed history of breast feeding, and family history of cancer. Menopause was defined as no menses for 12 months or bilateral oophorectomy or hysterectomy.Anthropometric measurements were directly taken in accordance with International Standards for Anthropometric Assessment  by trainTo estimate body proportion, we calculated body mass index (BMI by dividing weight [kg] with the square of height [m]), waist-to-hip ratio (WHR), and additional anthropometric indexes such as the length of the trunk , hip-to-shoulder ratio, hip-to-height ratio, shoulder-to-height ratio, and trunk-to-height ratio.t test and Mann-Whitney’s test were conducted for demographic factors, reproductive history and all taken anthropometric measurements. We performed the analysis for normal distribution for every single measurement, and then, we used a t test for parameters presenting normal distribution  and Mann-Whitney U test for these parameters which did not qualify for the t test (the rest of the parameters). Furthermore, logistic regression analysis was performed for the following anthropometric factors: hip-to-shoulder ratio; trunk-to-height ratio; suprailiac, triceps, and subscapular skinfold thicknesses; and wrist circumference and for BMI and WHR ratios to obtain the odds ratios (OR) with 95 % confidence intervals. To observe the dose-response effect, we categorized all these variables into quartile groups. Additionally, we adjusted each analysis for age, education status, and potential confounders: positive family history of breast cancer, age at menarche, number of parity, and age of menopause for the postmenopausal group. All analyses were performed using STATISTICA 10.0. Results were considered statistically significant when the P value was less than 0.05.All statistical analyses were stratified according to menopausal status. To evaluate differences between cases and control participants, Student’s P < 0.01) and were older at the time of the birth of their last offspring . They had a greater number of parity  and more episodes of miscarriages . A positive family history of breast cancer in first-degree relatives was reported more often by healthy individuals . We did not observe any statistical differences regarding age at menarche, age at first birth, education, and age at menopause.Analysis of the baseline characteristic of the groups Table  showed sP < 0.01). In postmenopausal participants, there were no differences in age and the only statistically significant differences were connected with the number of parity  and with a positive family history of breast cancer .In the group of premenopausal participants, significant differences were observed only in age at enrollment because of the greater number of participants in the control group . However, in postmenopausal women, there was no linear association between WHR value and cancer risk. BMI in both groups was negatively associated with cancer risk; nevertheless, OR values were not statistically significant . Furthermore, increased trunk-to-height ratio was also significantly associated with a decreased risk of breast cancer among both premenopausal women  and postmenopausal women . Thicknesses of triceps and subscapular skinfolds were associated with an increased risk of breast cancer, and wrist circumference was associated with a decreased risk; however, these factors did not reach statistical significance (Table The link between anthropometric measurements and breast cancer risk in different studies remains uncertain –7. In ad2) without statistically significant differences between groups. According to our investigations, central obesity increases the risk of developing breast cancer in premenopausal women—these data are consistent with previous studies [In our data, pre- and postmenopausal women are overweight -1, and fatty acids , 8, 21. In regard to body shape, women with breast cancer present an android type of silhouette with the distribution of fat tissue in the central and upper parts of the body which is revealed by increased shoulder width, waist circumference, skinfold thickness of the triceps and scapula, and differences in body proportions. Anthropometric indicators showed that women with breast cancer have narrower hips and shorter trunks and are shorter with broader arms—features which are typical for men. In premenopausal women, such characteristics are not so evident; however, they deteriorate after menopause. This is due to the high level of androgens postmenopause caused by a stimulation of androgen synthesis by IGF-1 in ovarian theca cells and a lower level of SHBG. It has been stated that the level of free testosterone increases with BMI , 10, 13 Statistically significant differences in the thickness of the skeleton between premenopausal and postmenopausal women with breast cancer are an unusual finding which has previously not been described in the literature. Compared to healthy individuals, breast cancer women had elevated widths of the wrist, elbow, knee, arm, and ankle and a bigger thorax. The most substantial event during menopausal transition is decreasing ovarian activity resulting in deficient estrogen levels. The latter causes many menopausal symptoms such as a loss of bone mass . It is hThe anthropometric measures used in the present study have some limitations. Firstly, BMI is not a homogenous parameter especially in comparison to modern techniques used in order to assess fat distribution such as the following: dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), or air displacement plethysmography. It may be misleading in individuals with normal BMI but a high content of body fat. Secondly, WHR may be also an inadequate index as it is under the influence of confounding factors such as age-related variation in muscle mass and tone.Anthropometric measurements may be miscalculated due to bias during examination . The present results are confounded by variables such as differences in age between groups, different stage of the disease, and the method used for selecting the control group. Nonetheless, the present results highlight significant body parameter changes which could be of great value in assessing breast cancer risk.The present study highlighted some interesting avenues of future research. The bone strengths between overweight breast cancer women are another area which has yet to be explored in depth. Furthermore, the influence of testosterone on breast tissue is an interesting issue particularly after consideration of its estrogen-independent role which merits further investigation.Obesity has reached an epidemic level. It should be a matter of great concern due to the negative health complications it is associated with such as higher cancer rates. Our study revealed that women with breast cancer present with a typical android silhouette and visceral obesity, which is more common in men, along with altered body proportions and increased thickness of the skeleton. Some simple anthropometric characteristics  and the estimation of body proportions may be a valuable tool for women assessment in order to disclose groups at a higher risk of developing breast cancer in the future.


The average area under the curve for the diurnal and reactive profiles was 631.54 ± 66.94 SEM and 1238.78 ± 111.84 SEM, respectively. This is in sharp contrast to their cortisol results, which showed normal diurnal and blunted acute patterns. The complexity of the stress system necessitates further investigation to understand the synergistic relationship of the HPA and SAM axes.The two main components of the stress system are the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) axes. While cortisol has been commonly used as a biomarker of HPA functioning, much less attention has been paid to the role of the SAM in this context. Studies have shown that long-term breast cancer survivors display abnormal reactive cortisol patterns, suggesting a dysregulation of their HPA axis. To fully understand the integrity of the stress response in this population, this paper explored the diurnal and acute alpha-amylase profiles of 22 breast cancer survivors and 26 women with no history of cancer. Results revealed that breast cancer survivors displayed identical but elevated patterns of alpha-amylase concentrations in both diurnal and acute profiles relative to that of healthy women, F  = 17.95,  It has been estimated that one in nine women will develop breast cancer during her lifetime . In 2013Stress is an influential factor in psychological and physical wellbeing. Breast cancer survivors, defined in this study as individuals with a diagnosis of breast cancer and currently in remission, may experience various stressors throughout the cancer trajectory. Stressors may be punctual—associated with the diagnosis, anxiety over the reactions of loved ones, or the treatment itself ,6; or chThe two main components of the stress system, the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) axes, operate in tandem to maintain homeostasis and prepare the organism to deal with environmental challenges . One wayCortisol, one of a class of glucocorticoid hormones, is associated with the HPA axis and is an essential steroid hormone for regulating bodily functions . CortisoIt has been demonstrated that approximately 10% of the healthy population exhibits abnormal diurnal cortisol, also referred to as dysregulated cortisol patterns . Such paet al. [et al. [Abercrombie et al.  noted th [et al.  showed t [et al. . In our  [et al. .et al. [Recently, investigators have become interested in exploring biomarkers that reflect SNS activity as a way of understanding the synergistic relationship between the HPA and SAM systems as adaptive stress mechanisms. Alpha-amylase, a salivary enzyme that is modulated by the autonomic nervous system (ANS), controls various visceral functions, such as salivation. Studies exploring the involvement of the ANS in the secretion of alpha-amylase first began in the early 1970s. In a series of studies examining the parotid gland in rats ,24, Batzet al.  and Askiet al.  evaluateet al. ,26. Moreet al. [While animal studies provided evidence for ANS involvement in alpha-amylase production, Speirs et al.  publisheBy the late 1970s, numerous researchers had begun to investigate the relationship between alpha-amylase and stress; the evidence generated since then suggests that alpha-amylase is a SNS biomarker and a reliable measure of both physical and psychological stress in humans ,29,30,31Alpha-amylase has been measured in response to a variety of acute stressors including writing a test , skydiviThe TSST is now considered the gold standard for inducing an acute stress response in the laboratory . AlthougThe aim of the current study was to compare the circadian and reactive profiles of alpha-amylase in the same breast cancer survivors and in women with no history of breast cancer. Although researchers have begun examining alpha-amylase profiles in individuals with chronic illnesses , to our A community sample of 22 female breast cancer survivors was recruited through printed advertisements and various cancer support groups. For complete participant demographics and medical characteristics, see Eligible participants were between the ages of 29 and 80 who understood English. Inclusion criteria for the breast cancer survivor group were as follows: A prior diagnosis of breast cancer (more than one year earlier) and completion of all local and/or systemic adjuvant therapy at least six months earlier. Individuals were ineligible if they had a previous history of other cancers , substance abuse, or any major disabling conditions that would interfere with their quality of life. Women who were breast feeding or pregnant were also excluded from the current study. All eligible participants received $50 to compensate for any travel costs incurred and were entered into a draw for one of four $250 prizes. The study received ethical approval from the University of Ottawa Research Ethics Board (file number 04-09-04). All participants gave their written informed consent prior to inclusion in the study.Commercially available kinetic reaction assay kits were used to assay saliva samples for alpha-amylase, using protocols designed by Salimetrics, State College, PA, USA .The TSST  protocolnot at all to 100 equaling very much based on the statement “I feel stressed”. Scores were determined by measuring the distance from the left end to the appraisal mark.A visual analog scale (VAS)  was usedParticipants completed a series of questionnaires designed to provide socio-demographic information, and to assess their perception of stress. These included the Daily Stress Inventory , the PerFinally we also assessed the breast cancer survivors’ fear of recurrence using the Concerns About Recurrence Scale , a 30-itOnce participants were deemed eligible by telephone, they were scheduled at their convenience for two laboratory visits at the University of Ottawa. The first visit, approximately 30 min in length, served to obtain informed consent, and provide specific instructions on the correct method of collecting saliva samples at home. Afterwards, participants were given pre-labeled salivettes (synthetic swabs) to use at home at each time point—waking, 30 min after waking, 12:00 p.m., 4:00 p.m., and 9:00 p.m. They were instructed to rinse their mouths with water 10 min prior to collection (to avoid sample dilution), to place the salivette directly under their tongues for three minutes, and to store the salivettes in the refrigerator until delivery to the laboratory. Participants were also provided an insulated lunch bag with freezable ice packs to keep the samples cool in the event that they did not have access to a refrigerator and/or during their commute to the laboratory. They were also asked to avoid smoking and alcohol consumption 24 h before sample collection and eating or drinking caffeinated products and exercising one hour prior to sample collection. As a test of compliance, they entered the collection time in a recording book. Saliva samples were collected for two consecutive days. A second laboratory visit was scheduled within seven days following the home-based saliva collection.On the day of the visit, participants were asked to collect three saliva samples at home at waking, 30 min after waking, and at noon. The laboratory component lasted approximately two hours during which a total of seven saliva samples were collected; at each of the seven time points, participants were also asked to indicate their subjective stress level on the VAS. The first saliva sample, labeled “arrival”, was retrieved upon arrival to the laboratory. The participant was then escorted to a testing room and introduced to a mock panel of committee members and in their presence, explained the task instructions. These were to prepare a five-minute speech about her suitability for a mock job position and deliver it to the panel. No aids, such as notes, were permitted during the speech delivery. The arithmetic task immediately followed the speech presentation. Saliva samples were collected after the speech preparation (labeled “anticipation”) and, upon completion of the arithmetic task (labeled “arithmetic”).Afterwards, the participant was asked to relax in the room for one hour and to complete a series of questionnaires assessing perceived stress, feelings of anxiety, and fear of recurrence. During this phase, four additional saliva samples were collected at 10 min, 20 min, 40 min, and 60 min. The participant was then debriefed and explained the purpose of the TSST. All saliva samples were transferred to Eppendorf tubes and stored in a freezer at −80 °C until assayed for alpha-amylase.et al. [p = 0.488), the number of women with postmenopausal status was similar (χ2 group difference p = 0.147), and roughly 90% self-identified as White. See Details of the participant demographics and characteristics were reported in Couture-Lalande et al. . Brieflyet al. [To our knowledge, there were no serious or untreated medical conditions in participants in either group. There were, however, a few cases of hypertension, diabetes (one or two per group), and osteoarthritis (in breast cancer survivors only); please refer to Couture-Lalande et al.  for moreet al. [et al. , for addMissing values were imputed using the EM algorithm in SPSS V22  for participants with up to two missing saliva samples of a total of 10  for their home-based saliva collection, and for participants with up to three missing samples out of the seven samples collected during the laboratory session. We imputed 4.6% of the diurnal and 5.7% of the TSST data related to alpha-amylase. For comparison to salivary cortisol, 3.8% and 5.7% were imputed for the same participants .A series of mixed-design Analysis of Variance (ANOVA) were conducted to assess the diurnal and acute reactive profiles of alpha-amylase. In the event that Mauchly’s Test of Sphericity was significant, the Huynh–Feldt correction was applied, which adjusts the degrees of freedom .group (breast cancer survivor or control) and the repeated factor was time .A 2 × 5 mixed-design Analysis of Variance (ANOVA) was used to assess differences in mean alpha-amylase concentrations over two consecutive days. The between-subject factor was p < 0.001, ηp2 = 0.269) and group  = 17.95, p < 0.001, ηp2 = 0.315) and no significant interaction between the two factors (p = 0.094). Across all time points, Bonferroni corrected main comparisons revealed that the mean alpha-amylase level at 30 min after waking was significantly lower than that associated with all other time points (p ranged from <0.001 to 0.038). Moreover, mean sAA levels were significantly lower at waking or shortly afterwards compared to that at the end of the day at 9:00 p.m. (p = 0.021).As shown in An additional analysis was performed to assess the relationship between time since diagnosis (in years) and diurnal alpha-amylase concentrations; no significant correlations were found at any of the five time points.et al. 2014). A 2 × 7 mixed-design ANOVA was used to assess salivary alpha-amylase levels in this phase of the study. The between-group factor was group (breast cancer survivor or control participants) and the repeated factor was time .p < 0.001, ηp2 = 0.313, and group, F  = 7.29, p = 0.010, ηp2 = 0.165, but no interaction (p = 0.563). Bonferroni corrected follow-up analysis revealed that sAA levels at Time 3 (“Arithmetic”) differed significantly from all other time points (p varied from <0.001 to 0.002). Furthermore, alpha-amylase concentrations did not differ significantly between Time 1  and Time 7 (60 min following the TSST), suggesting that all participants returned to baseline within one hour following the TSST (p = 1.00).The analysis revealed a significant main effect of time, F  = 16.85, Similar to their sAA diurnal profile, breast cancer survivors had a higher basal level of alpha-amylase in comparison to the control group and a parallel time course, despite the difference in concentrations. This pattern contrasts with their acute cortisol patterns, shown in the inset graph of We also examined the correlation between time since diagnosis (in years) with alpha-amylase concentrations at all seven time points to assess whether sAA responses to an acute stressor were associated with the passage of time since diagnosis and found no significant relationships.t-Test results revealed significant group differences in both the diurnal t (29.5) = −4.19, p < 0.001, d = 1.356, and reactive stress profiles t (37) = −2.74, p = 0.009, d = 0.88, due to consistently higher values in breast cancer survivors versus those of the control participants. Note that the group difference, averaged across all time points, was similar overall for both diurnal (36%) and reactive patterns (34%).Finally, we determined the area under the curve (auc) using trapezoidal integration for mean diurnal and reactive sAA levels in both groups. The auc for both groups was calculated with respect to the ground. The average auc for the diurnal and reactive sAA levels for breast cancer survivors was 631.54 ± 66.94 SEM and 1238.78 ± 111.84 SEM respectively. For diurnal and reactive sAA profiles in control participants, the values were 306.42 ± 39.23 SEM and 813.67 ± 107.02 SEM respectively. et al. [p < 0.001, due to increased subjective stress during the anticipation, arithmetic, and 20 min time points, but there were no group or interaction effects. Indeed, the group patterns were virtually identical.Results regarding subjective levels of stress were reported in a previously published study based on the same subjects; please see Couture-Lalande et al.  for an iWe also correlated each group’s scores from the three stress scales  ,44,45 wir values ranged from 0.024 to 0.324 and p values ranged from 0.238 to 0.931); reactive data .Finally, for breast cancer survivors, we correlated their scores from the Concerns About Recurrence Scale (CARS)  with theIn a previous paper, we explored the diurnal and reactive patterns of cortisol in breast cancer survivors and women without a diagnosis of breast cancer . Those dM = 4.6 ± 3 years), but we did not find a correlation between “time since diagnosis” and cortisol or alpha-amylase concentrations at any of the collected time points. We reasoned that the apparent HPA dysregulation to an acute stressor in breast cancer survivors, as interpreted from cortisol patterns, would be accompanied by SNS impairments. To better understand the synergistic relationship between the HPA axis and SNS, it was therefore important to explore the diurnal and acute sAA profiles in the same individuals.The goal of the current study was to complement the cortisol findings by exploring diurnal stress and reactivity profiles based on sAA concentrations in the same participants. The breast cancer survivors varied from one to 11 years since diagnosis . The Life Experiences Survey only addressed the frequency and impact of perceived major stressful events that occurred in the past year; most participants did not indicate having such experiences. It would be important to explore in this context the influences of experiences over the lifetime and not limited to a particular time frame.In the current study, we did not find atypical sAA profiles in breast cancer survivors. Rather, we found that breast cancer survivors exhibited elevated basal sAA levels, but the patterns paralleled the alpha-amylase reactivity of healthy women. The patterns were not related to the occurrence of stressful events in either group. More research is needed to determine the factors that influence the relationship between disease and stress biomarker patterns. Other routes could include the moderating effects of coping and social seeking behavior, fear of recurrence, and lifestyle habits. The relationship between HPA and SAM axes in maintaining homeostasis and managing stress is an important area of investigation, in order to understand their synergistic mechanisms and the consequences of their functioning in chronic disease.


Background and Objective. Breast cancer (BC) continues to be a major cause of morbidity and mortality among women throughout the world and in Iran. Lack of awareness and early detection program in developing country is a main reason for escalating the mortality. The present research was conducted to assess the Iranian women's level of knowledge about breast cancer risk factors, early warning signs, and therapeutic and screening approaches, and their correlated determinants. Methods. In a cross-sectional study, 2250 women before participating at a community based screening and public educational program in an institute of cancer research in Isfahan, Iran, in 2012 were investigated using a self-administered questionnaire about risk factors, early warning signs, and therapeutic and screening approaches of BC. Latent class regression as a comprehensive statistical method was used for evaluating the level of knowledge and its correlated determinants. Results. Only 33.2%, 31.9%, 26.7%, and 35.8% of study participants had high awareness levels about screening approaches, risk factors, early warning signs and therapeutic modalities of breast cancer, respectively, and majority had poor to moderate knowledge levels. Most effective predictors of high level of awareness were higher educational qualifications, attending in screening and public educational programs, personal problem, and family history of BC, respectively. Conclusion. Results of current study indicated that the levels of awareness among study population about key elements of BC are low. These findings reenforce the continuing need for more BC education through conducting public and professional programs that are intended to raise awareness among younger, single women and those with low educational attainments and without family history.  Breast cancer (BC) as a multifactorial disease is one of the most common cancers and the second leading cause of deaths among women worldwide . Global Breast cancer is a major public health problem in developed nations and is becoming an increasingly predominant problem in low and middle income countries, where incidence rates have been increased by up to 5% per year , 5. AccoIn Eastern Mediterranean countries, breast cancer is the most common cancer and in Iran, breast cancer ranks first among cancers diagnosed in women, in which 76% of common malignancies among Iranian women are breast cancer comprising 1200 deaths per year with a crude incidence rate and age specific rate of 17.4 and 23.1 per 100,000 of female population, respectively . In IranThe etiology of the majority of breast cancers is not known carefully, in which only about 25% to 40% of them may be attributed to well known risk factors . The risMany of the breast cancer cases, in developing country, including Iran, are diagnosed in advanced stages, attributable to low level of awareness about early warning signs and screening methods among general women population and poor prognosis of the patients.Various epidemiologic studies have shown that the increased women's knowledge about early diagnosis and screening of breast cancer can change people's screening seeking behavior , 17.Early diagnosis of cancer can effectively improve the chance of early detection of breast cancer in early stages and successful treatment resulting in improvement survival rate and quality of life. In this regard, early detection of disease through clinical breast exams such as mammography and breast self-examination as simple and inexpensive approaches provides the best approaches for reducing the risk of dying from breast cancer. Accordingly, correct knowledge about early warning signs and screening methods of disease plays an effective role towards developing and employing early detection programs in a community .Although biological factors consistently can be considered as key elements of final outcome, in the absence of breast screening programs, stage at presentation remains the most important prognostic indicator in regard to detecting breast cancer at a preclinical stage. This is more important when there is no established national screening registry and program for breast cancer .In a community such as Iran where late presentation is predominant and majority of breast cancer patients are diagnosed at advanced stages of disease there is an urgent need for improving the levels of awareness about breast cancer and its early detection measures. The awareness about breast cancer among Iranian women is not well documented particularly among general public. Some limited studies in Iran have shown that the awareness level about risk factors and early detection measures of breast cancer such as clinical breast examination (CBE) and breast self-examination (BSE) is low , 11. TheThe aims of current large population based survey among Iranian adult women were to evaluate the levels of knowledge about risk factors, early warning signs, screening approaches, and therapeutic methods of breast cancer and to determine which women are most at risk of less knowledgeable. There has previously been disagreement in the literature regarding the best ways to measure cancer's awareness, making it difficult to determine levels of awareness reliably. In current study, we applied a comprehensive and relevant analytical statistical method, that is, latent class analysis (LCA) and its extended form, that is, latent class regression (LCR) , 19 thatThis large population-based cross-sectional study carried out among 2250 women interested in participating at a community based screening and public educational program about breast cancer in the cancer research institute in Isfahan, Iran, since January to March, 2012. The cancer research institute in Isfahan, Iran, using different invitation methods  invited people to participate in a planned comprehensive cancer control program. As a part of this population based program, the women's awareness levels about different aspects of breast cancer including risk factors, early warning signs, and therapeutic and screening approaches were evaluated. During the study period, a well face and content validated questionnaire see  was distA self-administered well face and content validated structured questionnaire was used for data collection. The questionnaire was organized in five distinct sections; each one documented with appropriate heading indicating its content, as follows: first section contained sociodemographic variables such as age, educational status , personal breast problems history (Yes/No), first relatives' family history and marital status (Married/Single) attending in screening and public educational programs (Yes/No). The majority of the questions in other four sections of our study questionnaire were considered based on the American cancer society .Second section contained questions about 10 well-established breast cancer's risk factors including: infertility, age at menarche, age at menopause, breastfeeding, family history of breast cancer, obesity, smoking, alcohol consumption, diet, and trauma; third section included 7 early warning signs including: lump in breast, nipple retraction, breast or nipple pain, discharge other than breast milk in nipple, breast asymmetry, lump or swelling under the armpit, redness, and scaliness or thickening of the nipple or breast skin; fourth section addressed questions about breast cancer screening methods including: biopsy, sonography or CT scan, mammography, monthly self-examination, and biannually breast examination by a physician; and fifth section requested information on evaluating the level of awareness about breast cancer therapeutic methods including: “surgery or removal of whole or part of breast” and “chemical or radiotherapy” and third item was “it depends on disease's stage.” All questions in above four study's instrument sections were recorded as “yes” and “no” options.Summary statistics were reported for study participants as mean ± SD for quantitative variables and percent for qualitative variables.To analyze the level of “knowledge” about each studied domain of breast cancer, it was considered as a latent construct and was evaluated based on having knowledge or lack of knowledge about each item included in each domain using latent class analysis (LCA) and the determinants of knowledge were evaluated using extended form of LCA, that is, “latent class regression” analysis (LCR). Latent class analysis (LCA) examines the pattern of relations among a set of observed categorical variables and identifies and classifies similar individuals into latent classes . This leR” (version 3.0.2): an open source comprehensive statistical package.All descriptive and analytical analyses in the present study were performed with “The mean (±SD) and range of age for the study participants were 36.8 (±9.1) and 15–67 yrs. 51.9% of study participants had university educational attainment and 81.9% of them were married. 92.5% and 81.9% of study participants had no personal breast problems history and first relatives' family history, respectively.P < 0.05). As can be seen from P < 0.01), personal history , and attending in educational and screening programs  were significantly related with high levels of awareness. Married and older women were marginally more aware (P < 0.1).Applying latent class analysis for evaluating of knowledge levels about 10 well known breast cancer risk factors lead to three classes see . AccordiP < 0.01), educational attainment level , personal  and family  history, and marital status .P < 0.0001), attending in screening and educational programs . Personal and family history was marginally positively correlated with high levels of awareness.In current research, awareness about three major therapeutic approaches see  for breaBreast cancer as a multi-etiology disease has created a significant health problem worldwide. Breast cancer is the third common of all female cancer in Iran , 20. ItsThis study was conducted to evaluate levels of awareness and their correlated determinants about risk factors, early warning signs, screening methods for early detection, and treatment of breast cancer in a large representative sample of Iranian women.Results of current study showed that the level of awareness about breast cancer screening methods among study population was low, in which only 33.2% had high knowledge and remaining had mixed or weak awareness level. Also our study showed inadequate knowledge about well-known risk factors for breast cancer among study population, in which only about 32% of participants had high knowledge and majority of them (about 43%) had moderate and the remaining had low awareness levels. Age at menarche and infertility were the least frequently identified correctly as the risk factors for breast cancer in our study. The current study's results revealed that the participants had inadequate knowledge about breast cancer early warning signs in which the vast majority of them 71.3%) were in class with low levels of awareness. Although we evaluated awareness about well-known and widely used therapeutic methods, the results clearly indicated that knowledge levels among study population were low, in which only about 36% of them were in class with high levels of awareness. Although previous studies in this field did not provide aggregate and reliable features of awareness as we did in current study using latent class analysis, however they have shown poor knowledge, but slightly higher, about screening methods .3% were , 21, 22 In terms of individual specific items in the area of breast cancer risk factors, some earlier studies provided similar results to our findings –26 and sGenerally, comparing the findings obtained in developed and developing nations did not clearly suggest obvious differences; although, in average, levels of awareness were higher in former ones. Majority of the observed differences about knowledge of all aspects of breast cancer can be attributed to specific sociocultural characteristics of studied populations.The most effective predictors of knowledge level about breast cancer risk factors, screening methods, early warning sign, and therapeutic modalities were educational qualification, personal history and contributing in educational and screening public programs, respectively. The educational qualification was the common significant predictor for high awareness levels about all four studied domains. The observed important role of educational status on awareness level were in agreement with previous studies in screening approaches , 33–36, Our results in line with other previous studies showed a positive association (OR > 1) between high awareness levels about screening methods , 33–36, The present study found marginally significant association between age and awareness about BC's screening methods and risk factors, also results indicated that unmarried women had marginally lower knowledge about BS's risk factors while significantly lower knowledge about BC's screening methods. Similar results with our finding in these regards were found in some previous studies –36, 46. The present study can be considered as the first comprehensive research established in not only Iran but also over the world in order to investigating the public knowledge level about the various aspect of breast cancer. The second and most important strength aspect of current study was applying a sophisticated statistical method that provides a real and reliable descriptive perspective about women public awareness about breast cancer and its determinants. Previous studies, in our view, suffer from the partiality of the models and frameworks regarding to the evaluating of actual knowledge and its determinants among general public.An apparent limitation of the current study was that the awareness levels of those people who are interested in attending at a public screening and educational programs about breast cancer in an cancer research institute was investigated which could reflect selection bias and resulting an over estimate of awareness levels about breast cancer's key issues. However, it should be noted that the awareness levels assessment was conducted before participating of responders in public screening and educational programs.In conclusion, the results of present study revealed low levels of awareness regarding breast cancer risk factors, early warning signs, and its screening and therapeutic approaches among a relatively large sample of Iranian adult women. The results also indicated that the women with higher educational attainments, attending screening and public educational programs, personal problem, and family history of breast cancer, had higher levels of awareness. These findings emphasis on raising awareness about breast cancer among Iranian women as an effective way to overcome a challenging important problem in Iran's public health scope, that is, increasing trend and burden of breast cancer disease. Awareness would lead to early detection and reduce the stage at diagnosis, potentially improving the odds of survival and cure with simpler and more cost effective treatment. Also, our findings will help in directing breast cancer public educational programs. Developing of public screening and educational program through health care system more emphasis on low educated, single, younger women and those without family history are needed among Iranian women.


Although considerable evidence has demonstrated that physical activity is associated with breast cancer prevention, few studies have assessed the level of awareness of this association. Awareness is a key first step to successful of behavior change. Increasing awareness may contribute to promote physical activity and prevent breast cancer at the population level. The present study examined the prevalence and correlates of awareness about the role of physical activity in breast cancer prevention among Japanese women.1,000 Japanese women aged 20–69 years (mean age: 44.3 ± 13.4 years) who responded to an internet-based cross-sectional survey. Awareness of the role of physical activity in breast cancer prevention, knowledge of breast cancer , exposure to information about physical activity and cancer, a self-reported physical activity, and sociodemographic variables  were obtained. Force-entry logistic regression analysis was used.The prevalence of awareness was 31.5% (95% CI: 28.6-34.4). Factors significantly associated with awareness included sociodemographic variables, exposure to information, and knowledge of breast cancer. Being married  was positively related to awareness, while having children  was negatively related. College graduates or those with higher levels of education  were significantly more likely to be aware than those who had not graduated high school. Moreover, exposure to information , and high knowledge of symptoms  were positively associated with awareness. Finally, low knowledge of risk factors  was negatively associated with awareness.Japanese women through internet-based study were poorly aware of the role of physical activity in breast cancer prevention. Awareness was especially low among individuals with children and higher knowledge of risk factors whereas high in married women, those with higher educational level, exposure to information, and greater knowledge of symptoms. The findings suggest that strategies to increase the awareness about the preventive role of physical activity are needed for breast cancer prevention in consideration of subgroups with low awareness. Breast cancer is the most common cancer among women. The morAwareness is the first key step to successful behavior change,10. RaisBetter understanding of the correlates of awareness about the role of physical activity in breast cancer prevention is essential to identifying targeted individuals and developing tailored interventions. Recent research observed that awareness of the role of physical activity in colon cancer was positively related to higher educational level, engagement in physical activity, previous exposure to information about cancer and physical activity, and higher knowledge about cancer,17.However, no study examined for breast cancer. Thus, the aim of the present study was to examine the prevalence and correlates of awareness about the role of physical activity in breast cancer prevention among Japanese women.The participants were 1,000 Japanese women aged 20–69 years (44.3 ± 13.4 years) who responded to an internet-based cross-sectional survey conducted through a Japanese social research company . This research company offers full-scale marketing research services, owned approximately 260,000 voluntarily registered samples across Japan, and had detailed sample sociodemographic data. Thus, the company was able to select specific sociodemographic group(s) from registered population according to requirements of each survey ordered. The participants in the present study were stratified into five age brackets  and allocated equally to five sample groups . Potential respondents  were randomly and blindly invited to participate in the internet-based survey via e-mail. The invitation e-mail contained an URL directing them to a protected area of the website using their unique log-on ID and password. After 200 participants in each group voluntarily clicked on the “agree” button at the end of an online informed consent form and completed the questionnaire, acceptance of further participants was closed for each group. As an incentive for participation, the internet research service company offered reward points valued at 120 yen . The response rate was 24.6% . The study was approved by the Research Ethics Committee, Waseda University, Japan.Knowledge of breast cancer was measured by a 31-item questionnaire consisting of three subsections regarding symptoms 14 items), risk factors (13 items), and a screening test (4 items) for breast cancer. For each item, the participants responded by answering either true (1) or false (0). This questionnaire was adapted from previous studies of knowledge and attitudes about cancer items, r,17. The Age was classified according to five categories: 20–29, 30–39, 40–49, 50–59 and 60–69 years. Marital status was categorized as either currently married or unmarried. Having children was categorized into having children or no child. Education level was classified as high school graduate or less, junior college graduate or equivalent, and college graduate or higher. Employment status was categorized as working full time or not. Household income was classified into five categories: less than 3 million yen, 3–5 million yen, 5–7 million yen, 7–10 million yen and 10 million yen or more. Personal or familial history of breast cancer was categorized as having a history of breast cancer or not. Menopause status was categorized as postmenopausal or not.Respondents were asked about previous exposure to information about physical activity and cancer. They were categorized into two groups: ‘exposure to information’ or ‘no exposure to information’.Physical activity was assessed with a short version of the International Physical Activity Questionnaire (IPAQ-SV). The IPAQ-SV was designed to identify the frequency and duration of walking, moderate physical activity, vigorous physical activity, and sitting time in the previous week. The Japanese version of the IPAQ-SV has been observed to have acceptable validity and reliability. Total pData were analyzed for 985 adults who provided complete information for the study variable. Fifteen respondents with missing data were excluded from analyses. Chi-square tests were performed to examine proportional differences between sociodemographic characteristics and the awareness of the role of physical activity in breast cancer prevention. Moreover, forced-entry logistic regression analysis was conducted to examine the independent relationships between sociodemographic variables, knowledge, exposure to information, level of physical activity and awareness of the role of physical activity in breast cancer prevention adjusted for all independent variables. Adjusted Odds Ratios (AORs) and their 95% confidence intervals (CIs) were calculated. Statistical analyses were performed using the SPSS for Windows version 21.0 J for Windows .Table The median of knowledge score about breast cancer symptoms was 10.2 (out of 14), and 55.6% of the respondents were classified as belonging to the high level of knowledge group on this basis. The median of knowledge score about breast cancer risk factors was 6.8 (out of 12), and 58.6% were classified as belonging to the high level group. The median knowledge score about breast cancer screening was 3.8 (out of 4), and 82.0% of participants were classified as belonging to the high level group. More than 60 percent (62.7%) of the participants reported that they were exposed to information about physical activity and cancer from some information source. Overall, 57.4% of the respondents were sufficiently active, whereas 24.3% were inactive.The prevalence of awareness about the preventive role of physical activity in breast cancer among Japanese women was 31.5% 95% CI: 28.6-34.4). Table 8.6-34.4.This is the first study to identify the prevalence and correlates of awareness for the preventive effect of physical activity on breast cancer among adult women through internet-based study. The prevalence of awareness was approximately 30%. Compared with previous studies examining colon cancer across 21 European countries (30%) and in tThe present study found several sociodemographic factors related to awareness of the role of physical activity in breast cancer prevention. Individuals having children were less likely to be aware of this role. The result imply that women having children may be unable to take enough time and access information because they spend more time on child care than do men. On the Respondents who had greater knowledge about breast cancer risk factors had lower awareness of the connection to physical activity than respondents with less knowledge. The result suggests that the role of physical activity in breast cancer prevention may not have been disseminated widely enough, even if individuals had high knowledge about breast cancer risk. In contrast, respondents who had previous exposure to information and higher knowledge about breast cancer symptoms had higher awareness than their counterparts with less exposure and less knowledge of symptoms. These findings may indicate that providing clearer cancer information and, more specifically, information about the effect of physical activity in reducing cancer risk may be necessary for increasing awareness of the role of physical activity in breast cancer prevention. Jorgensen, Wayman, Green, and Gelb suggesteThe present study did not find an association between awareness and the level of physical activity engaged in by the participants. However, this finding is consistent with a previous study that found that mass media campaigns increased awareness and knowledge of physical activity, but had less impact on changes in physical activity levels. PreviouThe present study has several limitations. First, these data were cross-sectional, thereby making it impossible to determine cause and effect. Second, the level of physical activity was assessed using only the self-reported questionnaire. Thus, inaccurate estimation of physical activity level and recall bias were unavoidable. Moreover, the outcome variable for this study—awareness of the role of physical activity in breast cancer prevention—was measured using a single item. Although it was adapted from previous studies,15,17, oJapanese women through internet based study were poorly aware of the role of physical activity in breast cancer prevention. Awareness was especially low among individuals with children and higher knowledge of breast cancer risk factors whereas high in married women, those with higher educational level, exposure to information about physical activity and cancer, and higher knowledge of breast cancer symptoms. The findings suggest that the development of communication strategies to increase the awareness of the preventive role of physical activity on breast cancer is needed for cancer prevention. Further identification of the specific psychological and behavioral characteristics of subgroups with low awareness would help in developing more effective and targeted communication strategies.The authors declare that they have no competing interests.RM was involved in the design of the study, analysis and interpretation of the data, and drafting the manuscript. AS, KI, and KO involved in the design and coordination of the study and helped in drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/80/prepub


It has been estimated that at least a third of the most common cancers are related to lifestyle and as such are preventable. Key modifiable lifestyle factors have been individually associated with cancer risk; however, less is known about the combined effects of these factors.This study generated a healthy lifestyle index score (HLIS) to investigate the joint effect of modifiable factors on the risk of overall cancers, alcohol-related cancers, tobacco-related cancers, obesity-related cancers, and reproductive-related cancers. The study included 391,608 men and women from the multinational European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. The HLIS was constructed from 5 factors assessed at baseline  by assigning scores of 0 to 4 to categories of each factor, for which higher values indicate healthier behaviors. Hazard ratios (HR) were estimated by Cox proportional regression and population attributable fractions (PAFs) estimated from the adjusted models.There was a 5% lower risk : 0.946, 0.958) of all cancers per point score of the index for men and 4%  for women. The fourth versus the second category of the HLIS was associated with a 28% and 24% lower risk for men and women respectively across all cancers, 41% and 33% for alcohol-related, 49% and 46% for tobacco-related, 41% and 26% for obesity-related, and 21% for female reproductive cancers.Findings suggest simple behavior modifications could have a sizeable impact on cancer prevention, especially for men. In order to examine specific risk-related cancer subgroupings  within EPIC, an a priori healthy lifestyle index was created based on posited dietary components as previously proposed.14 Fiber, carbohydrates, fruits and vegetables, red and processed meats, and different fatty acids have all been posited to affect cancer risks.16 The healthy lifestyle index and its 5 components: smoking status, physical activity, alcohol consumption, diet, and body mass index (BMI), were used to assess associations with all cancer, and the alcohol-, tobacco-, obesity-, and reproductive-related cancer groupings.There is evidence mounting on the association of patterns of behavior, or combined lifestyle factors, to cardiovascular disease17 The cohort of 521,330 healthy men and women were recruited from 1992 to 2000, to investigate the relationship between nutrition, dietary habits and lifestyle, and cancer incidence. Participants were aged between 25 and 70 years and enrolled from the general population, with exceptions for France , Utrecht and Florence (breast cancer screening participants), Oxford , and some centers from Italy and Spain (blood donor participants). The rationale, study design, and methods for EPIC have been described in detail elsewhere.17 Ethical approval was obtained from participating centers and IARC ethics committees. All study participants gave informed consent.EPIC is a prospective cohort study conducted in 23 centers across 10 European countries .18 The harmonized EPIC nutrient database was used to estimate energy intake.19 Sociodemographic data, smoking history, alcohol consumption, and physical activity were obtained from lifestyle questionnaires, and anthropometric measurements taken, except for Oxford and France where measurements were self-reported.17Participants completed validated country-specific questionnaires at baseline, including interviewer-administered diet histories or self-administered semi-quantitative food frequency questionnaires to measure usual intakes.In Denmark, Italy, the Netherlands, Norway, Spain, Sweden, and the UK follow-up was performed through cancer registries. In France, Germany, and Greece, follow-up was performed through health insurance records, cancer/pathology registrations, and via participants and their next-of-kin. Follow-up commenced at date of enrolment and finished at date of cancer diagnosis, death, or at last complete follow-up , whichever came first. Cancer incident cases were defined as first primary invasive tumors .3Colorectal cancer [C18–C20], female breast cancer [C50], upper aero-digestive (UADT) cancers , and liver cancer [C22–C24].3Upper aero-digestive cancers , liver [C22–C24], pancreas [C25], bladder [C67], kidney , cervix [C53], stomach [C16], trachea [C33], lung [C34], acute myeloid leukemia [C92], and colorectum [C18–C20].2Esophagus [C15], pancreas [C25], colorectum [C18-C20], breast (after menopause) [C50], endometrium (lining of the uterus) [C54], kidney , thyroid [C73], and gallbladder [C23].Breast (after menopause) [C50], vulva [C51], vagina [C52], cervix [C53], uterine [C54–C55], ovary [C56] and other female genital organs [C57–C58].The original EPIC cohort comprised 521,330 men and women; 477,312 after the exclusion of participants with prevalent cancers  or missing follow-up information (4380), missing dietary or lifestyle questionnaires (6253), and those in the top or bottom 1% of the ratio of energy intake to energy requirement (9600). The present study was based on data from 391,608 men and women, following exclusions of those that were not primary malignant cancers , and those with missing data for the components of the lifestyle index , including all participants from Umea in Sweden, and Norway, where information on physical activity was not collected.11Intakes of 6 dietary factors were combined for the diet score: cereal fiber, red and processed meat, the ratio of polyunsaturated to saturated fat, margarine , glycemic load, and fruits and vegetables. The linear regression residuals of each dietary component on total energy intake were grouped into country-specific deciles and scored from 0 to 9 , with 0 being least healthy consumption (for margarine there was a non-consumers category). The individual scores were summed to a total diet score, and then categorized into quintiles.11 The healthy lifestyle index ranged from 0 to 20. Healthiest behavior was defined as never smoking , low consumption of alcohol , top quintile of physical activity based on recreational and household metabolic equivalent tasks , a healthy BMI , and a healthy diet, that is, high in cereal fiber, with a high ratio of polyunsaturated to saturated fat, high intake of fruits and vegetables, and low in red/processed meat, margarine/trans-fat and glycemic load .The overall healthy lifestyle index was determined by assigning scores of 0 to 4 to each individual variable category, for which a higher point value indicates a healthier behavior.All analyses are sex-specific. Descriptive statistics are provided by cross tabulations with medians and interquartile ranges for continuous variables, and percentages for categorical variables. Cox proportional hazard regression models were used to estimate associations between the healthy lifestyle index and risk factor related cancer groupings. Age was used as the primary time variable, with entry time defined as age at study entry, and exit time as age at diagnosis of first primary cancer or censoring (which ever occurred first).P-values are provided with statistical significance set at P < 0.05. All models were tested for and satisfied the proportional hazards assumption.Hazard ratios (HR) and 95% confidence intervals (CI) were stratified by center, to control for center-specific effects, and 1-year age bands (age at study entry). Models were adjusted by height (continuous), education , and total energy intake excluding alcohol (continuous). The healthy index was modeled as a continuous and categorical variable , using the second lowest score group as the reference category as some strata contained low numbers of healthiest group. The test for trend was performed by assigning median values of each of the four categories of the index, which was then modeled as a continuous variable. Two-sided The population attributable fractions (PAFs) of cancer cases that might be associated with the lifestyle index score were estimated, with the assumption of a causal relationship, using the following equation: p(RR − 1)/p(RR − 1) + 1, where p is the proportion of the cohort without cancer in the lowest three categories of the index (<16 on the index score) and RR is the association between the exposure and cancer, estimated by the adjusted HR comparing risk in the lowest categories to the highest of lifestyle index score.Sensitivity analyses were performed to assess the robustness of the findings. Models were run separately for Northern, Central, and Southern European based centers. The healthy lifestyle index was recalculated with the highest/healthiest score assigned to the second BMI category (22–23.9). Models were run separately for tobacco-related cancers among never smokers. Reverse causality was tested through the exclusion of those whose cancer diagnosis was within their first 2 years of follow-up.Analyses were performed using Stata version 11.2 and SAS version 9.3.The overall cohort of 391,608 comprised 121,200 men and 270,408 women. Among men there were 10,950 first primary incident cancer cases recorded during a median follow-up time of 11.6 years and 1,339,718 accumulated person-years. Among women there were 17,564 first primary incident cancer cases recorded during a median follow-up time of 11.8 years and 3,006,119 accumulated person-years.Table Table Modeled as a continuous variable, there was a 5% lower risk  of all cancers per point score of the index for men and 4% lower risk  for women. Table PAFs were calculated for men and women to estimate the proportions of cancers that hypothetically would not have occurred if everyone had a healthy lifestyle score within the highest category of the study cohort. Figure Sensitivity analyses were performed to assess the robustness of the findings. Models were run separately for Northern, Central, and Southern European based centers and no material difference in results (not shown) was observed. Reverse causality was tested through the exclusion of those whose cancer diagnosis was within their first 2 years of follow-up; these results (not shown) did not differ from those of the entire cohort. For tobacco-related cancers, the healthy lifestyle index still showed a protective effect among never smokers: there was a 2% lower risk  per point score of the index for men and 3%  for women. None of the sensitivity analyses materially altered results or changed interpretation of findings.This study based on a large prospective cohort has found a lower risk of cancer in men and women with healthier lifestyles. The findings suggest modification of behavior resulting in a single point increase in the healthy lifestyle index score (HLIS) corresponds to a 5% and 4% lower overall cancer risk, for men and women, respectively, with even lower risks associated with alcohol- and tobacco-related cancers. If the associations were causal, 26% of the cancer cases in men, and 15% in women, would have been prevented if the entire cohort had been in the highest scoring category of the healthy lifestyle index.All individual components of the healthy lifestyle index were associated with cancer risk for women; for men, all components except physical activity and BMI, which did not reach conventional significance. However, the physical activity component used in this study combines a measure of recreational activity with household activity, which is notably lower among men than women within the EPIC cohort.2 compared to the lowest category .10 The components of this index for all cancer were: degree of adiposity, physical activity, foods that promote weight gain, plant foods, red and processed meat, alcohol intake, and breastfeeding.10 Similarly, a Women's Health Initiative study used the American Cancer Society Nutrition and Physical Activity Cancer Prevention Guidelines to assess cancer risk in postmenopausal women and found lowest to highest category of their score had lower risk of any cancer .20 Whereas, a Framingham Offspring cohort study used a score based on seven components: body fatness, physical activity, foods that promote weight gain, plant foods, animal foods, alcohol, and food preservation/processing/preparation, to assess adherence to WCRF/AICR recommendations21; this study found no association with the overall score and obesity-related cancer risk. A simpler index was used in the women only E3N cohort in France, which used the five lifestyle factors: BMI, physical activity, smoking, alcohol consumption, and fruit and vegetable consumption, and found lower risk of all-site cancer for women associated with higher healthy lifestyle index categories .22 A postmenopausal breast cancer specific healthy index previously used for the EPIC cohort included identical components to the present study, although the factors included within the diet component differed slightly; this combined seven dietary factors: cereal fiber, folate, the ratio of polyunsaturated to saturated fat, fatty fish (as a marker for omega-3 fatty acids), margarine , glycemic load, and fruits and vegetables.11 This study found breast cancer risk was inversely associated with a high index score .Findings for the present study are consistent with previous reported studies, which found protective associations between cancer and healthy lifestyle indexes. One study based on the EPIC cohort found a lower cancer risk for men and women in the highest scoring category of a score based on adherence to WCRF/AICR recommendations23 Margarine has been related to plasma elaidic acid (a biomarker for trans-fat intake) within EPIC showing the strongest correlation among numerous food groups investigated.24The present study has several strengths, including the large size and prospective design of the cohort, and the long follow-up for EPIC participants. Detailed dietary and lifestyle information was collected before cancer diagnosis, thereby eliminating risk of recall bias, and ensuring any misclassification for these variables would most likely be nondifferential, underestimating the observed associations. Nevertheless, as information was not available for trans-fat in the dataset, margarine was used as an indicator; this food group has been described in the literature as the main source for industrially produced trans fatty acids.25Even though the index components were equally weighted, there is likely to be unintentional weighting because some of the factors are “recommended” items or items perceived as positive such as physical activity; while others are “moderation” items, viewed as negative such as smoking. Index components which are recommended are those behaviors which are encouraged, and as such, they may be weighted unintentionally through their promotion more so than discouraged behaviors, like the negative moderation components.EPIC participants are volunteers, and as such this is not an ordinary population-based cohort. Participants are more likely to be healthier than the general population, and therefore the estimates may be attenuated, providing an underestimation of PAFs that could be expected in the general population. A further consideration in the interpretation of results is that all PAF estimates are based on an assumption that the relationship between exposure and cancer is actually a causal relationship.In order to avoid high correlations within and between food groups, the number of indicator foods for an index should be restricted to as few as possible, while still capturing risk-related components. Many healthy lifestyle indices have been used in recent studies to assess cancer risk, and many of these studies have had similar results, further validating the use of scores and their underlying concept of combined lifestyle modifications. Nevertheless, prospective work should investigate and compare these indices for a balance of simplicity and effectiveness to guide the future research in this area.In conclusion, we evaluated the association between a healthy lifestyle index  and the risk of cancer among men and women, and found a protective association of a healthy lifestyle among all cancer groupings. The combined healthy lifestyle index was overall more strongly associated with cancer risk for men. Cancer is a complex multifactorial disease; nevertheless, these findings add further weight to the suggestion that simple behavior modifications could have a major impact on cancer incidence. Cancer prevention policies should include strategies to engage men and women in lasting healthy diet and lifestyle habits.