To evaluate association of sociodemographic, anthropometric, and epidemiological factors with result of mammogram in women undergoing breast cancer screening.Hospital de Câncer de Barretos, Brazil, in 2014. The results of these examinations in the BI-RADS categories 1 and 2 were grouped and classified in this study as normal mammogram outcome, and those of BI-RADS categories 3, 4A, 4B, 4C, and 5 were grouped and classified as altered mammogram outcome. The statistical analysis included the Student's t-test to compare means, as well as odds ratios (OR), with their corresponding 95% confidence intervals (95%CI), to verify an association by means of the multivariate analysis.This is a cross-sectional study with data obtained through interviews, anthropometric measurements, and mammography of 600 women aged 40 to 69 years at the Preventive Medicine Department of Of 600 women evaluated, 45% belonged to the age group of 40–49 years-old and 60.2% were classified as BI-RADS category 2. The multivariate analysis showed that women with blood hypertension  were more likely to present changes in the mammography, while physical activity was associated with lower chances .Hypertensive women undergoing screening mammography are more likely to present mammographic changes, whereas women practicing physical activity have lower chances (70%) of presenting changes in the breast compared with sedentary individuals. Risk factors include age, genetics, family history, endocrine and reproductive factors, alcohol consumption, fat-rich diet, obesity, sedentarism, exposition to ionizing radiation, pre-malignant injuries of the breast and high density of breast tissue. The factors associated with women's reproductive life and longer exposition to endogen estrogens, such as early menarche, nulliparity, use of hormone replacement therapy for more than five years and late age at first delivery are among most important risk factors for breast cancer.e.g. healthy eating, regular exercise, adequate weight, moderate alcohol consumption, and non-smoking. Age remains one of the most important risk factors, and incidence growth rapidly up to 50 years and, after this age range, the increase is more moderately.Some factors are inevitable, such as age and family history, however, in almost 30% of cases of breast cancer factors can be avoided by adoption of some habits, ,2 Although not incorporated in routine of public health service, the annual mammography is ensured as right in Brazilian Public Health Services (SUS - Sistema Único de Saúde) to all women aged 40 years or older according to the Federal Law nº 11,664, April 29, 2008, that come into effect in 2009. A study suggests annual mammography before diagnosis of breast cancer as a predictor of higher global survival, and, therefore, the screening results in real benefits to the patient with decrease in mortality for this type of cancer.,6Mammography is currently considered one of the most reliable techniques to early detection of breast cancer, comprising an ideal method to identify subclinical injuries. Among actions that favor early detection of disease, there are clinical breast exams and screening mammography in routine of integral health care for women. According to the outcome, the exam can be classified in screening mammography that is directed to asymptomatic women, and diagnostic mammography recommended for those with signs and symptoms of breast cancer.–9 The American College of Sports Medicine recommends for general population, a total of 150 minutes weekly of cardiorespiratory exercises in order to reduce mortality and enhance quality of life. However, recommendations regarding level of physical activity (LPA) to reduce breast cancer risk are little longer, the suggestion is 180 minutes of exercises with moderate intensity weekly to reduce risk approximately in 3%.Regular exercise is associated with better prognosis and survival in women with breast cancer, in addition it has a protective role against several types of cancer, because it prevents obesity, which is one of the risk factors for the disease. Studies on exercises and their biologic mechanisms shown them as protective factor for breast cancer and this result have increased considerably in the last years.To evaluate association of sociodemographic, anthropometric and epidemiologic factors with results of mammograms of women who underwent breast cancer screening.Hospital de Câncer de Barretos (HCB) from July 1, 2014 to November 3, 2014.This cross-sectional study obtained data from interviews, anthropometric assessments and results of mammograms of women assisted at Department of Prevention of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto at Universidade de São Paulo and Ethical Committee of HCB, under protocol number 1.169.686 CAAE: 24514413.1.0000.5440. Participants signed the Consent Form, authorized data collection, and publication of results.The study was approved by the Ethical and Research Committee of the In the HCB women aged 40 years or older underwent screening mammograms. In this sense, considering simple random sample with limited population, based in number of exams conducted in the mentioned service  and prevalence of obesity in Brazil in adult women of 16.9%, estimating a tolerable absolute error of 3% and significance level of 5%, our total sample was composed by 583 women. However, we evaluated 600 women aged between 40 and 69 years who were previously identified to perform screening mammography.deficit.We excluded pregnant women who had pacemakers and who had positive diagnosis for any other type of cancer and presented some type of physical impairment and cognitive ®) of the American College of Radiology.Interview was carried out in the same day of the mammography using a structured questionnaire. The assessment of level of physical activity practice was applied based in International Physical Activity Questionnaire that measures level of activity and classifies individuals as inactive, irregular active, active and very active. We classified anthropometrical assessment including height measure, body weight, body mass index (BMI) and waist and hip circumference. After finishing data collection, anthropometric assessments and mammography exam, we initiated the follow-up and analysis of report of the exam in which results of breast density and mammography classification were obtained. Result of this exam was interpreted by radiologists according to standardized system known as Breast Imaging Reporting and Data System Mammography , in which there was need of additional assessment of image or previous mammograms for comparison and complete assessment , involving BI-RADS 1–5.Results of mammograms in categories BI-RADS 1 and 2 were grouped and classified as “normal mammography finding”. These referred to exams without mammographic findings or those with benign (however with some change). But results of categories BI-RADS 3, 4A, 4B, 4C and 5 were grouped and classified as “altered mammogram finding”, in which entailed benign results (however with need of follow-up exams), findings with low suspicion of malignity, intermediate suspicion of malignancy, moderate and high suspicion of malignancy. using four patterns: N1 – primarily fat, all breast composed almost with fat; P1 – fibroglandular tissue pattern with prominent ducts occupying up to one-third of the breast volume; P2 -fibroglandular tissue pattern with prominent ducts occupying more than one-fourth of breast volume, DY; fibroglandular pattern occupying almost all the breast. Patterns N1 and P1, characterized in this study as fat breast and primarily fat breast were considered low density, whereas P2 and DY were considered as dense and predominantly dense with high risk for development of breast cancer.Classification of breast density was based in proportion of tissues that composed breast that was described by Wolfe2 test was used to analyze data concerning differences among categorical variables.Responses related to sociodemographic, epidemiologic, clinical and anthropometric parameters were analyzed in relation to association among independent variables such as BMI and breast density, and dependents . To measure and compare degree of linear correlation between variables of BMI and waist-hip circumference ratio, we applied coefficient of Pearson correlation. The χt test for independent or dependent samples, when indicated. Parameters without normal distribution or with unknown distribution were compared using the Mann-Whitney test. To evaluate association among obesity, excessive weight, socioeconomic, epidemiologic, anthropometric variables and health we employed univariated and multivariated analyses, considering altered mammogram finding as dependent variable and applying prevalence ratio and odds ratio (OR) with respective confidence interval of 95% (CI95%). The level of significant adopted in all analyses was 5%.Comparisons between normal distribution parameters were analyzed by Student's 2, whereas waist circumference was 93.0 (±12.57) cm and hip circumference was 103.7 (±9.84) cm. The mean of waist-hip circumference ratio was 0.89 (±0.08) cm. Most of participants were aged between 40 to 49 years (45.0%), followed by 50 to 59 years (34.8%). The majority of women selected were irregularly activity (47.5%) whereas those active or very active represented a total of 34.7% and 3.6%, respectively. We also verified a predominance of women with primarily dense breasts (60.7%).The age of the 600 women included in the study ranged from 40 to 69 years, mean of 51.7 years (±7.99). Participants' mean weight was 72.2 (±14.40) kg and mean height was 1.57 (±0.06) m. Concerning obesity classified by BMI, the mean was 29.38 (±5.62) kg/mIn relation to BMI , a highe® classification. We also observed that only 7.4% of exams were classified in BI-RADS 0 category, suggesting an additional evaluation with other complementary exam. Among women who underwent mammography in the period of investigation, 94.8% had their exams classified as normal in BI-RADS 1 and 2 classification, after reclassification of BI-RADS 0. Other categories of BI-RADS entailed 5.2% of the sample.In Comparison of women's mean age among those with normal mammographic findings and altered mammogram finding of right breast , did notIn ,15Breast cancer is one of the neoplasia that more affects women in Brazil, excluding non-melanoma skin cancer, and it is one of the main causes of death from cancer in developed and under developing countries. Although enhancements in breast cancer screening service had occurred, and advances in development of early diagnosis methods and treatment in developed countries, this disease represents the main cause of death among women affected by cancer in many countries, mainly in less developed ones. Screening with mammography test is adopted as a public health strategy, and it is considered the best method for early diagnosis of breast cancer. Studies suggest that annual mammography before diagnosis of breast cancer is a predictor of increase in global survival, however, these studies highligth that methods and programs to early detection of breast cancer do not reduce the disease incidence, but they can reduce the disease mortality.,18Population screening program are important and efficient to reduce breast cancer mortality because it might detect potential diseases in early stages. study about a screening based program in mammography reported strategies on adherence and better optimization in breast cancer detection using this initiative. For these authors, administrators of public health institutions must be always encouraged to adhere to population level program, which might consequently increase participation of these women.The Haikel et al.i.e., excessive weight was seen in 78.0% of the sample. A study including 145 women without breast cancer who participated in a screening program in South Brazil found a prevalence of obesity of 39.3% and excessive weight of 76.5%. The study emphasized these alarming rates and highlighted as a possible explanation for high prevalence of excessive weight other associated factors such as low education level and no exercise. Of note is that some studies report categorical data that excessive body fat represents a risk factor to increase incidence of breast cancer, particularly among women in postmenopausal period.,22The analysis of obesity prevalence in our sample revealed that most of women were classified as obese (40.5%), and 37.5% as overweight,  One of this changes is the increase of circulating estrogen levels: an aromatase enzyme found in adipocytes and responsible for conversion of androstenedione into estrogen. Other studies have demonstrated that most of mediating effect of estrogen represent the association of BMI and breast cancer in such a way that estrogen stimulate the division of epithelial breast cells, therefore increasing the risk for mutation, and for this reason, favoring and inducing breast cancer. In addition, hyperinsulinemia which is closely related with obesity, reduces level of sexual hormones binding globulin, and cause an increase in levels of estradiol and testosterone.Based on this fact, it is necessary to identify how obesity can affect and change organism of these women. Obesity is correlated with a number of changes in the organism and, therefore, can affect prognosis of breast cancer. Although results did not show a relationship among obesity with changes and prevalence of changes in the breast, the lifestyle, exercise, and eating habits are considered important factors to prevent and reduce breast cancer risks.In our study, the sample was characterized by LPA such as inactive, irregularly active, active and very active participants. We observed a predominance of women categorized and classified as sedentary . By multivariate analysis, we observed an association of LPA with mammography finding, active women present 70% lower chance of presenting changes in breast compared with sedentary patients. Based on this fact, physical activity seems to be associated with a protective factor against changes in the breast. According to some international agencies such as World Cancer Research Fund and American Institute of Cancer Research, the regular practice of exercise at least 30 minutes a day is considered a protective factor for breast cancer in postmenopausal period, in addition to help to maintain the healthy level of some hormones. However, evidences of protective effect of this variable are still limited for women in pre-menopause period. Another large study on metabolic syndrome and initial stages of breast cancer identified higher risk of general mortality attributed to SAH, however, it was not possible to find the same association for breast cancer.Among findings we highlight the SAH in which found an association with change in breast, suggesting that women with hypertension have 2.6 times more chance of presenting changes in the breast compared with normotensive women. A recent study including women with breast cancer found similar prevalence of comorbidities, and it was higher in SAH with 32.8%, thyroid 22.4% and hypercoloesterolemia with 12.7%. However, policies and national programs must be implemented to increase conscience and reduce exposition to risk factors of cancer, and also guarantee provision of information for individuals and support they would need to adopt healthy life habits.Contribution of several modifiable risk factors for global load of breast cancer, except the reproductive, was calculated by some authors, and they conclude that 21% of all deaths by breast cancer around the world are attributed to alcohol consumption, overweight, obesity and physical inactivity. This proportion was higher in countries with high income (27%), and the most important influencers are overweight and obesity. In countries with mean and low income the proportion of breast cancer attributed to these findings was 18%, and physical inactivity was the most important determinant (10%).Systemic arterial hypertension variables and level of physical activity had significant association with changed mammographic finding. Results showed that although prevalence of overweight and obesity among women in the sample was above the expected for this population, the body mass index did not show significant difference in association with mammographic findings. In relation to level of physical activity, this finding suggested that women considered active had 70% lower chance of presenting change in the breast compared with sedentary women.


With advances in breast cancer (BC) gene panel testing, risk counseling has become increasingly complex, potentially leading to unmet psychosocial needs. We assessed psychosocial needs and correlates in women initiating testing for high genetic BC risk in clinics in France and Germany, and compared these results with data from a literature review. Among the 442 counselees consecutively approached, 212 (83%) in France and 180 (97%) in Germany, mostly BC patients , returned the ‘Psychosocial Assessment in Hereditary Cancer’ questionnaire. Based on the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) BC risk estimation model, the mean BC lifetime risk estimates were 19% and 18% in France and Germany, respectively. In both countries, the most prevalent needs clustered around the “living with cancer” and “children-related issues” domains. In multivariate analyses, a higher number of psychosocial needs were significantly associated with younger age (b = −0.05), higher anxiety (b = 0.78), and having children (b = 1.51), but not with country, educational level, marital status, depression, or loss of a family member due to hereditary cancer. These results are in line with the literature review data. However, this review identified only seven studies that quantitatively addressed psychosocial needs in the BC genetic counseling setting. Current data lack understandings of how cancer risk counseling affects psychosocial needs, and improves patient-centered care in that setting. BRCA1 and BRCA2 were identified as major BC susceptibility genes [BRCA1 or BRCA2 gene face up to a 72% and 44% risk of developing breast or ovarian cancer, respectively, by the age of 80 [Breast cancer (BC) is a major public health concern for women, with almost 1.7 million new BC diagnoses worldwide in 2012 [ge of 80 . When alge of 80 . BRCA1 or BRCA2 provides options for early detection or prevention. There is evidence that a risk-reducing bilateral mastectomy decreases the risk of BC by 85% to 100% [The identification of a pathogenic variant in highly penetrant genes such as  to 100% , and tha to 100% . When a CHEK2, ATM, BARD1 and RAD51D) to “high” (PALB2) BC risk [BRCA1 and BRCA2 genes alone, panels of genes may now be simultaneously tested, at a reduced cost and faster turnaround [Recently, additional genetic factors have been identified, including rare variants with “moderate” , an incAssessing psychosocial needs during the care trajectory allows for clarifying what type of interventions  or for which population  the provision of specific health care resources is necessary . VariatiPsychosocial needs may also reveal based on counselees’ sociodemographic, family history, and clinical or psychosocial characteristics. If their psychosocial needs are similar across counselees’ characteristics, but are different across countries, this implies that the mode of counseling delivery is associated with needs, and this may have implications for clinical practice according to specific settings .To our knowledge, only two United States (US) studies ,30 repor(1)Assess the prevalence of moderate and high psychosocial needs in women undergoing genetic counseling and testing for BC risk in a French and a German cancer genetic clinic, and compare them between the two countries;(2)Explore sociodemographic, clinical, psychological, and geographical  factors associated with the number of moderate and high psychosocial needs in these women; and(3)Compare these results with empirical data extracted from a literature review addressing the domains and specific items of psychosocial needs that are most frequently reported along the cancer genetic counseling and testing process.Specifically, we aimed to:This study protocol was approved in France by the Comité consultatif sur le traitement de l’information en matière de recherche dans le domaine de la santé , and by the Commission Nationale Informatique et Libertés (CNIL: French Information Technology and Privacy Commission), and in Germany by the Ethics Committee of the University Hospital of Cologne. All of the recruited women provided written informed consent.From October 2016 to July 2017, women over the age of 18 years, who were either healthy or affected with a primary non-metastatic breast cancer, and eligible for BC gene panel testing, were consecutively recruited at the cancer genetic units of the Institut Curie  and the University Hospital of Cologne . A minimum sample size of 200 was required to allow for comparisons between the two country cancer genetic services. Women with a recurrent BC, a personal history of ovarian cancer, or a major psychiatric disorder were not included.The study objectives were explained to the women on the day of the initial cancer genetic counseling visit, and when they agreed to participate, they were given questionnaires to fill in at home, either in paper or online, and to return within the next two weeks. Questionnaires not completed or received within 28 days after the genetics consultation were considered missing. If necessary, 14 days after the consultation, one reminder was made by telephone call.The ‘Psychosocial Aspects of Hereditary Cancer’ (PAHC) questionnaire is comprised of 26 items organized into six problem domains, i.e., needs related to hereditary predisposition, practical issues, family and social issues, living with cancer, emotions, and children-related issues . ParticiGeneral distress  was measured by the Hospital Anxiety and Depression Scale. This scale comprises anxiety (HADS-Anxiety) and depression (HADS-Depression) subscales, and has French  and GermWomen were also asked if they had lost family member(s) due to breast or ovarian cancer.To compute the objective risk estimates of breast and of ovarian cancer up to the age of 80 years, the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) web application   was usedAdditional data were collected on the sociodemographic characteristics provided by the patient, and the clinical data obtained from the medical record.t-test for quantitative data and the Chi-square test for categorical data to compare study participants among the French and the German respondents, and between the age of overall respondents and non-respondents. Response frequencies were computed for each PAHC item. We computed the frequency (percent) of individuals reporting moderate to high needs (at least “quite a bit” responses) per item. A Chi-square test was performed to compare the percentage of patients with a moderate to high need per item between the two countries.Baseline sociodemographic and clinical characteristics of the participants were described using the mean (standard deviation) or median (range) for continuous variables, and the number (percentage) for qualitative variables. We used the Student Multivariate regression analyses were performed on the number of needs (rated at least “quite a bit”) per individual, as a dependent variable. Psychosocial needs were taken as a whole, considering that the PAHC structural validity was not yet confirmed in these PAHC language versions (work in process). The country sample, age, educational level (secondary school or below versus superior education), marital status , parental status (having children or not), HADS-anxiety and HADS-depression scores (continuous variables), health status (affected or not with a present or past BC diagnosis), and family history (having lost a blood family member from breast or ovarian cancer) were assessed as potential predictors in univariate analyses. The collinearity between variables was tested in univariate analysis; variables presenting collinearity were not simultaneously included in the same multivariate model. A stepwise selection approach was then used to select the final multivariate model.BRCA1/2 psychosocial outcomes were mainly addressed on researched cohorts rather than in “real” clinical practice [A systematic search of the PubMed/Medline database was conducted. We selected papers published between January 2000  to 17 OAll of the titles and abstracts were inspected for relevance, excluding papers such as protocol descriptions, literature reviews, studies addressing the period of referral or following cancer risk management decision-making, men only, healthcare professionals, genetic testing for breast or ovarian treatment decision-making, or controlled (randomized) trials. Thirteen papers were rejected on full text as they only addressed a specific outcome  (11 papers) or generic difficulties/needs measures such as the SF-36 (two papers). The two remaining papers  were anaTwo authors (Anne Brédart and Jean-Luc Kop) extracted the study descriptive data , and presented a higher level of education (p < 0.0001) and a lower depression level (p = 0.03).Overall respondents’ and non-respondents’ mean (standard deviation) age was 47.8 (11.2) and 45.5 (11.9), respectively . Compared to the German respondents, the French respondents were significantly less often affected with BC (p < 0.01).Out of the over 26 potential psychosocial needs assessed with the PAHC, seven needs were reported by more than 50% of the French women, and five needs were reported by more than 50% of the German women  . Among tp = 0.01), as well as in those with a higher level of anxiety  and those with children  (p = 0.08). The sample country, marital status, education level, depression level, and loss of family members due to breast or ovarian cancer showed no statistically significant association. The variance in the number of needs explained by the regression model was 40%.In multivariate analyses, a significantly higher number of needs was observed in younger women  . A trendThe seven studies available were from different Western countries . Around two years after the BRCA1/2 test disclosure, Farrelly et al. [BRCA1/2 tested women, whatever the BRCA1/2 test result [After the disclosure of the ionnaire , BjØrnslionnaire  reportedy et al.  found thy et al. , uncertaA significant increase in needs was found in younger counselees , women wA number of tested factors, including demographics ,41, clinAspects of the cancer genetic counseling delivery  in relation to psychosocial needs were not investigated in the selected reviewed studies .This study primarily aimed to assess the prevalence of psychosocial needs in women initiating genetic counseling for high BC risk in a French and a German cancer genetic clinic, and explore correlates of increased needs, including the country setting. We compared these results to data extracted from a literature review in order to shed light on implications for research and clinical applications.A substantial proportion of women in both countries perceived significant difficulties in the “living with cancer” domain, which referred to living with both actual cancer as well as the threat of personal or familial cancer diagnoses. In addition, they also experienced concerns in the “family and social issues” domain, representing the interpersonal aspects of the cancer genetic risk. Interventions should thus focus on these particular difficulties in both institutions. Besides, independently from the country, the overall number of needs was found to be higher in younger women, in those having children, or those presenting increased anxiety; therefore, attention should be given to the needs of these women in particular.Specific differences were also observed between the two country samples. For instance, compared to the German sample, a higher proportion in the French sample worried about children-related issues. For example, women attending the French cancer genetic clinic more frequently expressed “guilt about the chance of passing on genetic alterations to their children” than the German sample; this may suggest that women in the French genetic clinic may need additional counseling for dealing with this feeling of guilt. In contrast, women attending the German cancer genetic clinic more frequently expressed preoccupations related to the hereditary predisposition, such as “worries about the choice of possible preventive options (screening versus surgery)”, which points to the need for additional support in decision-making with regard to management options in the German clinic.Significant differences  between the two country samples may require specific clinical implications by clinic setting. As only the actual BC diagnosis status appeared to be (to some extent) related to a higher number of needs, interventions should predominantly emphasize the needs of women affected with BC.Our results are in line with the information obtained from the literature review, confirming a high prevalence of psychosocial needs following genetic counseling, including aspects in relation to the cancer diagnosis  or familBRCA1/2 carriers and 69% of non-carriers “worried about their risk of getting cancer/again” [BRCA1/2 carriers “dealt with fears about developing cancer” at about two years after the genetic test result disclosure [Other reviewed studies investigated the prevalence of these needs over time, showing that these needs may remain high (above 50%), independent of the genetic test result: 59% of women worried about the “implications of being at increased risk of cancer for other family members” one month after the initial genetic consultation ; 84% of r/again” ; 57% of sclosure ; and 59%sclosure . This unThe literature review data found that younger age , having This report comprises a number of limitations. Our study samples mainly comprised BC patients; therefore, the results may not reflect the psychosocial needs of healthy women that are at a high BC genetic risk  undergoing genetic counseling. Moreover, we assessed a limited number of needs correlates, thus potentially missing out on other relevant needs. Further, so far, our data is cross-sectional, i.e., no causal conclusions can be drawn. Hence, in order to provide more specific clinical recommendations, further research should address additional factors in longitudinal study designs. The impact of recent advances in BC risk genetic testing and counseling requires the monitoring of counselees’ well-being. Future research should address the effects of different genetic counseling delivery models, such as the risk communication style on counselees’ psychosocial needs.Only two quantitative studies that addressed overall psychosocial needs were identified from the literature review based on the chosen databases and keywords. In fact, the psychometric assessment of needs happens to be a relatively new area of research in the cancer field . In the Among the seven studies selected, the population samples varied , and so, beyond general observations such as high needs prevalence regarding the cancer experience or in relation to younger age and anxiety, making comparisons and drawing conclusions on more specific observations between studies remain problematic. Moreover, four different needs questionnaires were employed. Most of them assessed the severity of difficulties, concerns or worries ,40, and A high prevalence of psychosocial needs clustering around the personal and familial experience of cancer, and the interpersonal aspects of hereditary cancer, were observed among women undergoing BC genetic counseling in a cancer genetic clinic in France and Germany. An increased number of needs were observed in younger, more anxious women, and in those having children, independently from the country setting. This suggests that these younger women in particular may need additional counseling during the course of BC genetic testing. Specific needs were also observed in each country clinic, underlying the relevance of needs assessment in the clinical care setting. A literature review supported these findings, and also pointed at future research directions with regards to BC genetic counseling practices. We should move forward to provide standardized and valid instruments that allowing unambiguous scoring and reporting of counselees’ psychosocial needs within and across cancer genetic clinics. Moreover, in line with recent advances in cancer genetics and risk counseling, future research should focus on the genetic service delivery examining different models of risk communication and counseling that may influence psychosocial needs. Health care specialists, like physicians, nurses, counselors, and psychologists who attend to women at high genetic risk of breast cancer should be trained to identify and respond to their psychosocial needs. In this way the benefits expected from new cancer genetics discoveries and technologies may also manifest in clinical genetics settings by optimally responding to counselees’ needs and ensure a patient-centered care in that setting.


Overweight and weight gain throughout adult life have been associated with increased risk of breast cancer after the menopause. However the role of body weight at a young age and of the timing of weight gain over the lifetime in postmenopausal breast cancer is not well documented.We conducted a population-based case-control study on breast cancer in France that included 739 cases and 815 population controls in postmenopausal women. Height, weight at age 20, 40 and 50 as well as weight one year before diagnosis were obtained during in-person interviews.No association between body mass index at the age of 20 years and breast cancer after the menopause was detected. However, we found that postmenopausal breast cancer was associated with weight gain between ages 40 and 50 years (OR per 5 kg/m2 increase in BMI: 1.45 [95%ci 1.06−1.98]). The increased risk of breast cancer associated with weight gain was more consistent in leaner women at age 20, in older postmenopausal women (>65 years), and in women who did not use menopausal hormone therapy.These findings point to the importance of controlling for weight gain in middle aged-women. The role of low body weight in young adulthood in breast cancer risk after the menopause should be further scrutinized.The online version of this article (doi:10.1186/s12885-016-2793-0) contains supplementary material, which is available to authorized users. With over 1.5 million new cases each year across the world, breast cancer is the leading cause of cancer among women. Despite a recent decrease attributed to the reduction of menopausal hormone therapy, incidence rates of postmenopausal breast cancer in wealthy countries has grown steadily over the last decades. Rising incidence rates are also observed in emerging countries as high calorie intake and sedentary life become more common, pointing to the role of overweight and lack of physical activity as major modifiable causes of breast cancer among postmenopausal women.The relationship between adiposity and breast cancer is complex and varies during lifetime. Before menopause, adiposity reduces the risk of breast cancer. This inverse association has been attributed to a decreased number of ovulations in overweight women and alteration of circulating hormone levels, which play a key role in breast cancer etiology, but other mechanisms may also account for the protective effect of high BMI before the menopause . After tInvestigating weight changes during lifetime, particularly in the period around the menopause, when the effect of BMI in breast cancer changes from a protective to a deleterious effect, is thus important to improve our understanding of the relationship between adiposity and breast cancer. However, most studies on breast cancer among postmenopausal women have only measured weight gain over long periods, usually from early adulthood to the time of cancer diagnosis, making difficult to evaluate how weight changes in specific periods of life may affect breast cancer risk –8.Elevated BMI during childhood or adolescence has also been associated with a decreased risk of postmenopausal breast cancer in some studies –11. It hIn order to clarify the relationship between postmenopausal breast cancer risk and lifetime weight history, we used the data of a large population-based case-control study in France, focusing on the timing of weight changes over the lifetime and on the role of low weight (BMI <18.5 kg/m2) at a young age.The CECILE study is a population-based case-control study in Côte d'Or and Ille-et-Vilaine, two French administrative areas (départements) located in Eastern and Western part of France, respectively.The case group included incident cases of in situ or invasive breast cancer diagnosed between April 2005 and March 2007 in women aged 25–75 years who resided in the study areas. Patients were recruited in the main cancer hospital in each area (Centre Eugène Marquis in Rennes and Centre Georges-François Leclerc in Dijon), as well as from smaller public and private hospitals that also recruited breast cancer patients. Among the 1553 eligible cases identified during the study period, 163 refused to participate, 151 could not be contacted, and 7 died before the interview, leaving 1232 cases included in the study sample (participation 79.3 %).Controls were women without a previous history of breast cancer recruited in the general population of each study area. They were selected by phone and were frequency-matched to the cases by 10-year age group. To avoid selection bias that could arise from differential participation rates across categories of socioeconomic status (SES), we obtained a control group with a distribution by SES category similar to the general population, by using predefined numbers of controls by SES calculated from the census data. To recruit the controls, phone numbers of private homes were selected at random from the telephone directory completed beforehand with unlisted numbers. Phone numbers were dialed up to 15 times at different times of the day and different days of the week until contact could be established with the residents. When a woman was living in the residence reached by phone, she was invited to participate to the study, as long as the predefined number of controls in her age and SES stratum was not complete. When this number was exceeded, the woman was excluded. To obtain the desired number of controls within the limits of age and SES categories, approximately 30,000 phone numbers were dialed for identifying 1,731 eligible controls. Among 1731 controls identified by telephone fulfilling eligibility criteria, 260 declined participation and 154 could not be re-contacted for an in-person interview, leaving 1317 women available for the study (participation 76.1 %).The study was approved by the French Ethic Committee , the National Data Protection Agency (Dec 2004) and the Advisory Committee on the Treatment of Health Research Information (Apr 2004). All participants signed informed consent.n = 936), if they had had bilateral oophorectomy , or if they had used MHT  before natural cessation of menstruation (n = 352). Women with unknown menopausal status (n = 199) (hysterectomy before cessation of menstruations or unknown date of last menstruation), were considered postmenopausal if they were aged 50 or more years, the median age at menopause in women with natural menopause (n = 174). Women with unknown menopausal status below 50 years old were excluded from the analysis (n = 25). One woman reporting aberrant low weight was excluded from the analysis. In total, the analysis included 1554 postmenopausal women (739 cases and 815 controls).Only postmenopausal women were included in the analysis. Women were considered postmenopausal if they had not menstruated for twelve or more months  to avoid reporting weight loss that might be due to cancer development. We also elicited information on weight at the ages of 20, 40 and 50 years.Information on estrogen (ER) and progesterone receptor (PR) status was obtained from the pathology report. Tumors containing more than 10 % positive cells for hormonal receptors were classified as receptor-positive.2). BMI at different ages were categorized according to the WHO classification , except for BMI at age 20 where we used a single category of BMI ≥ 25 kg/m2 due to small number of young obese women ≥30 kg/m2. BMI changes during different periods of life were categorized in 3 groups. To enable comparisons between BMI gain during different periods of life, and despite uneven distributions, we sought to use the same cut points for defining BMI gain categories in different periods: BMI gain <1 kg/m2; BMI gain ≥ 1 < 3 kg/m2; and BMI gain ≥ 3 kg/m2. For BMI changes from age 20 to current age, the highest category of BMI gain was subdivided in two classes (3–6 kg/m2 and ≥ 6 kg/m2). We also fitted models using tertiles or quartiles of BMI gain distribution among controls specific to each exposure period, but the findings were very similar and are not shown. To test dose-response trends, we fitted models where BMI at different ages and BMI changes were introduced as continuous variables, assuming a linear relationship between the variable and breast cancer risk, and reported odds ratios for each increment of 5 kg/m2 of BMI or BMI change.Odds ratios (ORs) of breast cancer were calculated for BMI at age 20, BMI at age 50 and BMI at the current age, and for BMI changes from age 20 to current age, from age 20 to 40, from age 40 to 50, and from age 50 to current age. BMIs were calculated as weight in kilograms divided by height in meters squared (kg/m2), age at reference date , and use of menopausal hormone therapy (MHT) (current vs past or never) modified the association of breast cancer with BMI at different ages, and BMI changes. In these analyses, we present only the odds ratios associated with continuous variables for BMI and BMI changes. p-values for interaction between BMI or BMI changes and the stratification variables  were calculated by comparing models with and without an interaction term using the likelihood ratio test.Further analyses were conducted to examine whether low BMI at age 20  and study area, and for breast cancer risk factors in Table All analyses were also conducted using different categorization for BMI and BMI gain during lifetime, or using weight and weight changes (in kg) instead of BMI. These analyses produced similar findings and are not reported here. We also conducted analyses stratifying the case group according to hormone receptor status of the tumor  using polytomous logistic regression models, but no particular hint emerged from this analysis (not shown).All analyses were conducted using SAS computer software .Selected characteristics of cases and controls are shown in Table Table 2 BMI gain between ages 40 and 50: 1.32; 95 % ci 1.05–1.65). Further adjustment for current BMI did not modify this finding. No association was observed with BMI gain before 40 and after 50 years of age. Models were also fitted using weight changes in kg instead of BMI in kg/m2. The results are shown in Additional file After adjustment for potential confounders listed in Table 2; ≥18.5 kg/m2), current age , and MHT use  are shown in Table 2), the odds ratios for each increment of 5 kg/m2 of current BMI  and of BMI-gain between ages 40 and 50  were markedly higher than the corresponding odds ratios in women with BMI at age 20 ≥ 18.5 kg/m2. However the p-values for interaction between BMI at age 20 and current BMI or BMI gain were not statistically significant . The stratification by current age showed higher odds ratios for BMI at age 50, current BMI and BMI gain between 40 and 50 years in women ≥ 65 years than in women <65 years, with p-values for interaction 0.07, 0.08 and 0.08, respectively. Finally, the stratification on MHT use showed that the odds ratio for BMI gain between ages 40 and 50 was 1.37 (95 % ci 1.08–1.74) in MHT non-users whereas it was 1.02 (95 % ci 0.47–2.20) in current users .Results of the stratification of BMI and BMI gain variables by BMI at age 20 . No difference between tumor subtypes was observed (data not shown).We found that weight gain in the age range period 40–50 years, but not in earlier periods of life, was associated with increased risk of postmenopausal breast cancer. Conversely, our data do not confirm that postmenopausal breast cancer risk is increased in women with low BMI at a young age. However, the association between weight gain between 40 and 50 and postmenopausal breast cancer risk, was more consistent among leaner women at the age of 20, among older women (≥65 years at diagnosis) and among non-MHT users. These findings point to the importance of examining weight history over the lifetime to clarify the relationships between adiposity and breast cancer risk after the menopause.BMI gain in adulthood has been linked to the risk of postmenopausal breast cancer in previous investigations , 10, 13.We also observed that the association of breast cancer with current BMI and weight or BMI gain in the age range period 40–50 years was stronger in women above 65 years of age than in younger postmenopausal women, suggesting a relatively long induction period between weight gain and breast cancer occurrence. Alternatively, it is possible that the beneficial effect of adiposity during pre-menopause may compensate the adverse effect of overweight in early post-menopause.2). This finding should be interpreted with care as no statistically significant interaction between BMI at age 20 and BMI gain was seen. Nevertheless, it is consistent with a report from the large US Nurse’s Health Study showing that the association of postmenopausal breast cancer risk with weight gain of 25 kg or more since the age 18 years was stronger in women with BMI below 21 kg/m2 at age 18 years than in heavier women (p for interaction 0.05) [The hypothesis that weight during adolescence or young adulthood may influence breast cancer risk after the menopause is supported by several epidemiological studies reporting an inverse association between weight at a young age and postmenopausal breast cancer , 17, 18.on 0.05) . This reThe association of postmenopausal breast cancer risk with weight gain between ages 40 and 50 years was apparent only among non-current MHT users, although the interaction between BMI gain and MHT use was not significant. This is consistent with several studies that reported an association between adiposity and postmenopausal breast cancer only among women who did not use MHT , 22–24. In our study, incident breast cancers were identified on a population basis in well-defined geographical areas, using inclusion criteria similar to a cancer registry, and using active real-time search in the main cancer hospitals in each area. Controls were carefully selected from the study base controlling for possible differential participation rates across SES categories. In addition, all potentially important confounders were taken into account in the analysis.The main limitations of the study include the self-reported and recalled history of height and weight. Studies that examined the accuracy of self-reported height and weight compared to measured values consistently reported that height tended to be overestimated and weight to be underestimated by the women –28. If tWeight history throughout life appears to be a key determinant of breast cancer risk after the menopause, but interplay between age, weight, weight gain and breast cancer risk factors appears to be complex. Our findings point to the importance of controlling for weight gain in middle aged-women. The role of low body weight during early adulthood in postmenopausal breast cancer risk should be examined further.


The risk of psoriasis in patients with breast cancer is largely unknown, as available evidence is limited to case findings. We systematically examined the incidence and risk factors of psoriasis in patients with breast cancer.A Swedish nationwide cohort of 56,235 breast cancer patients (2001–2012) was compared to 280,854 matched reference individuals from the general population to estimate the incidence and hazard ratio (HR) of new-onset psoriasis. We also calculated HRs for psoriasis according to treatment, genetic, and lifestyle factors in a regional cohort of 8987 patients.In the nationwide cohort, 599 patients with breast cancer were diagnosed with psoriasis during a median follow-up of 5.1 years compared to 2795 cases in the matched reference individuals. This corresponded to an incidence rate of 1.9/1000 person-years in breast cancer patients vs. 1.7/1000 person-years in matched reference individuals. Breast cancer patients were at an increased risk of psoriasis  = 1.07–1.28), especially its most common subtype . The risk of psoriasis vulgaris was highest shortly after diagnosis but remained increased up to 12 years. Treatment-specific analyses indicated a higher risk of psoriasis in patients treated with radiotherapy  and mastectomy . Apart from treatment-specific effects, we identified genetic predisposition, obesity, and smoking as independent risk factors for psoriasis in breast cancer patients.The incidence of psoriasis is slightly elevated among patients with breast cancer, with treatment, lifestyle, and genetic factors defining the individual risk profile.The online version of this article (doi:10.1186/s12916-017-0915-4) contains supplementary material, which is available to authorized users. Psoriasis is a complex autoimmune skin disorder characterized by patches of abnormal skin. The prevalence of the condition has been estimated to be between 2% to 3% in the general population of Western countries , 2. CommClinical observations suggest a potential increased risk of psoriasis in patients with breast cancer, which has mainly been attributed to skin trauma due to surgery  or radioPsoriasis is an autoimmune disease with genetic variants and lifestyle factors  influencing disease susceptibility –16. SincWe aimed to assess the relative risk and incidence rates of psoriasis in patients with breast cancer as compared to the general population, overall and by time since diagnosis. We specifically evaluated risks by radiotherapy and surgery as sources of skin trauma-triggering events. We also studied the impact of previously identified psoriasis risk factors  to comprehensively understand the factors influencing disease susceptibility in this patient population.We analyzed two population-based cohorts: a Swedish nationwide cohort of breast cancer patients and a regional breast cancer cohort . Information on breast cancer diagnoses was obtained through the Swedish Cancer Register, which was founded in 1958 and is managed by the National Board of Health and Welfare. Since the focus of our study is on the risk of new-onset psoriasis, patients who had been diagnosed with psoriasis before the date of the breast cancer diagnosis were excluded, leaving 56,235 patients in the cohort . Detailed information on tumor characteristics and treatment at baseline was available in LIBRO-1 through linkage to the Swedish breast cancer quality registers , including tumor size, estrogen receptor status, metastasis status, as well as information on intended treatment in terms of surgery, radiotherapy, chemotherapy, and endocrine therapy. The LIBRO-1 cohort was linked to the Swedish Causes of Death Register and the Swedish Migration Register to obtain information on date of death and emigration. Person-time was defined in the same way as for the nationwide cohort, except for an extension of the follow-up until 31 December 2013.LIBRO-1 is a regional breast cancer cohort including women diagnosed with primary invasive breast cancer (at age 20–80 years) between 2001 and 2008 in the Stockholm-Gotland area  codes (ICD-7 (1964–1968): 706; ICD-8 and ICD-9 (1969–1996): 696; ICD-10 (1997–present): L40). The validity of a psoriasis diagnosis in the inpatient and outpatient registers is 81% [All psoriasis cases were identified through the Swedish Patient Register , which ws (ICD-7 64–1968: 2/IMPUTE info-score ≥ 0.5), and for each individual breast cancer patient, a weighted PRS was calculated using the following formula:β is the per-allele log odds ratio (OR) for psoriasis associated with the risk allele for SNP k, xk is the number of alleles for the same SNP , and n is the total number of disease SNPs included in the profile. The SNPs and corresponding ORs (weights) used for the derivation of the PRS are summarized in Additional file A subset of 4365 breast cancer patients within LIBRO-1 who were alive in 2009 consented to participate in a questionnaire-based study and gave a blood sample for genetic analyses. Patients’ lifestyle information on cigarette smoking, body mass index (BMI), alcohol consumption, and physical activity prior to diagnosis was retrieved from the self-reported questionnaire. Genotyping was carried out using a custom Illumina iSelect array (iCOGS) comprising 211,155 single nucleotide polymorphisms (SNPs) . All SNPTo assess the risk of psoriasis in patients with breast cancer, we used stratified Cox regression models  and calculated hazard ratios (HRs) for psoriasis in patients with breast cancer, overall, and by dividing the follow-up time into periods of 0 to < 0.5 year, 0.5 to < 1 year, 1–5 years, and >5 years, and by age at diagnosis . The underlying time scale for all the analyses was time since diagnosis. The stratified Cox model has been a recommended analysis approach for matched cohort data, and it deals with the presence of potential confounders (measured and unmeasured) as well as any imbalances in the matching scheme caused by censoring –26. PoteTo identify the risk factors for psoriasis in patients with breast cancer, we analyzed associations with cancer treatment in the regional cohort of breast cancer patients. The basic model (Model 1) was adjusted for age at breast cancer diagnosis and calendar period. In the multivariable model (Model 2), all treatment variables were entered for mutual adjustment as fixed covariates. To investigate potential confounding by disease severity, a sensitivity analysis was conducted in which tumor characteristics were added to Model 2. We further studied the effect of genetic predisposition and lifestyle factors in the subcohort with questionnaire and genotyping data. These analyses were conducted in the same manner as the analysis of cancer treatments, with a basic model (Model 1) adjusting for age at breast cancer diagnosis and calendar period, and a multivariable model (Model 2) including all risk factors, including identified treatment-related risk factors. Ordinary Cox regression was used for all risk factor analyses, and the proportional hazards assumption was tested using Schoenfeld residuals.Statistical analyses were performed using SAS  and Stata software . The study was approved by the Regional Ethical Review Board in Stockholm.In total, 599 cases of psoriasis were observed during a median follow-up of 5.1 years in the nationwide breast cancer cohort compared to 2795 cases in the matched reference individuals. This corresponded to an incidence rate of 1.9/1000 person-years in breast cancer patients vs. 1.7/1000 person-years in the matched reference individuals, indicating a 0.2/1000 person-years of absolute risk increase  = 0.1/1000–0.4/1000). The most common psoriasis subtype was psoriasis vulgaris (298 out of 599), followed by palmoplantar pustulosis and arthropathic psoriasis. The 5-year cumulative incidence of psoriasis in breast cancer patients and in the matched reference individuals was 1.0% and 0.8%, respectively .Patients with breast cancer experienced a 17% increased risk of being diagnosed with psoriasis during follow-up  . In the multivariable model (Model 2), regular cigarette smoking for more than 1 year prior to diagnosis  and a BMI larger than 30 kg/m2 at diagnosis  significantly increased the risk of psoriasis in breast cancer patients. In the multivariable model, a high level of physical activity (more than 2 h per week) prior to diagnosis was shown to protect breast cancer patients from psoriasis; however, this effect was not significant .Table The incidence of psoriasis was 17% higher in breast cancer patients compared to the matched reference individuals in this study. The relative risk of psoriasis was seen within the first year after diagnosis and was mainly attributed to an increased risk of psoriasis vulgaris (33% higher). Treatment-specific analyses indicated an increased risk of psoriasis in patients treated with radiotherapy and mastectomy. Apart from treatment-specific effects, we identified genetic predisposition, obesity, and smoking as independent risk factors for psoriasis in patients with breast cancer.Previous studies have reported a higher risk of skin disorders such as dermatitis and skin infection in patients with breast cancer , 28. We The increased risk of psoriasis after breast cancer is clinically plausible, as some treatments for breast cancer can cause dermatological side effects. In the regional cohort, we found an association between radiotherapy and risk of psoriasis. Skin trauma  has been reported as a triggering factor for 43–76% of incident psoriasis cases . The higOur study further identified obesity, smoking, and a high genetic predisposition as independent risk factors of psoriasis in patients with breast cancer. Psoriasis is a highly heritable disease; the heritability rate is estimated to be 70% . PreviouThe main strength of our study is the large sample size and the population-based design using Swedish health registers, which minimizes selection and information biases. Other strengths include the abundant information of treatment, lifestyle, and genetic information in the regional breast cancer cohort. We also acknowledge several limitations. The validity  of psoriasis diagnoses in the Swedish Patient Register is about 81% , which iThe overall risk of psoriasis is slightly increased among patients with breast cancer compared to the general population. While the relative risk of psoriasis is highest within the first year of diagnosis, the risk of psoriasis vulgaris remained increased up to 12 years. Independent risk factors of psoriasis in breast cancer patients are radiotherapy, mastectomy, smoking, obesity, and a high genetic predisposition. Our findings emphasize the complex etiology of psoriasis in patients with breast cancer.


Participants of both groups were assessed for health-related quality of life and the participants of the experimental group were assessed for engagement in meaningful activities. The evaluation was carried out during the nonacute period of the disease—at the beginning of the study and after 6 weeks. Women of the experimental group demonstrated statistically significantly better scores in the global quality of life, role functions, physical, emotional, cognitive, and social functions, fatigue, insomnia, financial impact, systemic therapy side effects, and breast symptoms scales compared to the control group participants (p < 0.05) after the 6 weeks, as measured by the EORTC QLQ-C30 questionnaire and its breast cancer module QLQ-BR23. Furthermore, women of the experimental group demonstrated significant greater engagement in meaningful activities when applying community-based occupational therapy (p < 0.05), as measured by using the Engagement in Meaningful Activities Survey (EMAS). The evaluation of the associations between the women's engagement in meaningful activities and changes in health-related quality of life showed that greater engagement in meaningful activities was associated with better emotional functions and a lower level of insomnia (p < 0.05). Based on the results of our study, we recommend applying occupational therapy in the field of community healthcare in order to maintain or improve breast cancer patients' health-related quality of life and suggest involving women into meaningful activities during community-based occupational therapy after clarifying which activities are important to them.We aimed to evaluate the short-term effects of community-based occupational therapy on health-related quality of life and engagement in meaningful activities among women with breast cancer. An open label randomized controlled trial study design was applied. The participants were members of various societies of women with cancer. In total, 22 women have participated in the study. Participants of the experimental group ( On the global scale, cancer causes one-seventh of all deaths. According to the most recent estimates, there have been over 14 million new cases of cancer and over 8 million deaths from cancer registered worldwide, and it is expected that, due to the increasing numbers and aging of the population, these numbers will increase to, accordingly, 21.7 million and 13 million by the year 2030 [Breast cancer, defined by the National Cancer Institute as cancer forming in breast tissues, is the most common malignant tumor among women and in as many as 19 out of 21 regions it is the leading cause of death among women in both the developed and the developing countries . Over 1.Unfortunately, the completion of breast cancer treatment does not mean the end of the disease . HealthcToday, it is the field of health-related quality of life that is being most actively developed in Lithuania as well as abroad . Over thThe impact of the diagnosis and treatment of breast cancer differs depending on the patient, resulting in varying numbers and degrees of physical and psychological sequelae. The consequences may significantly impair a woman's ability to participate in meaningful activities, including housework, return to work, and adequate performance of the main social roles and responsibilities. This, in turn, may negatively affect the economic status and disrupt interpersonal relations, thus further impairing the woman's engagement in meaningful activities as well as her psychoemotional status and the quality of life. Despite the fact that the combined effect of breast cancer and its treatment may manifest themselves at any moment and last for a very long time, it is essential for the patients to resume their daily roles as soon as possible after the completion of the treatment and this is where the role of the occupational therapist is especially important . AccordiThe theory of occupational therapy states that human subsistence is a social process, and people need meaningful activity; its absence is a major threat to human health, and thus occupational therapists in their professional practice strive to achieve their patients' maximum capacity to increase their ability to engage in activities that they see as important and meaningful , 17. AccWhen working in communities, occupational therapists have to be familiar with the characteristics of community-based activity in order to be able to pursue meaningful activities based on the community members' priorities. Active participation in community activities, social support, and engagement in meaningful activities positively affect community members' health and the quality of life . Based oNo similar research was found and we were the first in Lithuania who made a study analyzing changes in health-related quality of life, engagement in meaningful activities, and its associations among breast cancer patients when applying occupational therapy in the field of community healthcare. We hope that the results of our study will be useful for occupational therapists working with breast cancer patients' communities.Consequently, all these reasons have affected the following aim of the study: to evaluate the short-term effects of community-based occupational therapy on health-related quality of life and engagement in meaningful activities among women with breast cancer.This randomized controlled trial was conducted with the permission of the Bioethics Center of the Lithuanian University of Health Sciences (number BEC-SR(M)-186), the permission of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Group to use the quality of life questionnaire EORTC QLQ-C30 and its module EORTC QLQ-BR23 in the study, and the permission of the Associate Professor A. M. Eakman from Colorado State University to use the Engagement in Meaningful Activities Survey (EMAS) in the study. The study was performed during May–June 2016 in Kaunas city, with the mediation of the chairwomen of two societies of women who either had overcome their breast cancer or were still fighting it on the community level. (Eastern Cooperative Oncology Group) scale of performance status, were able to understand the essence of the study and simple instructions, were familiarized with the aim of the study, and volunteered to participate. Exclusion criteria were the following: refusal to participate in the study, women with severe decompensated comorbidities and mental diseases, and being incapable of independently filling out the questionnaires, and whose functional status was >2b according to the ECOG scale of performance status.Eligible women were adult (≥18 years of age) and Lithuanian-speaking, with diagnosed breast cancer and functional status being ≤2b according to the ECOGAll the participants who met the inclusion criteria were in advance familiarized with the study, its aims, objectives, and methods, the confidentiality of the data, and the possibility of withdrawing from the study at any time and provided a written consent to participate in the study.In total, 22 members of breast cancer patients' societies met the inclusion criteria. All participants had been diagnosed with breast cancer (code C50 according to the ICD-10-AM). The participants were randomly distributed into two groups: the experimental group and the control group, following simple randomization procedure (computerized random numbers). The distribution of the participants was equal in both groups. The participants were also distributed into two groups based on the analyzed characteristics: age, employment status, the duration of the disease, the stage of the disease, the location of the tumor, metastases, and functional status according to the ECOG. Detailed characteristics of the participants are presented in χ2(1) = 0, p = 1), employment status (p = 1), the duration of the disease (χ2(1) = 0, p = 1), the stage of the disease (p = 0.311), the location of the tumor (χ2(1) = 0, p = 1), metastases (p = 1), or functional status according to the ECOG (p = 1), p > 0.05.There were no significant differences in the participants' distribution between the groups concerning their age (α ≤ 0.9) and, based on the obtained results, stated that the questionnaires are suitable for studies of breast cancer patients [During the study, we evaluated changes in women health-related quality of life and experimental group participants' engagement in meaningful activities during the nonacute period of the disease. The methods used in the study were the following: a survey using a questionnaire designed by the author, testing, experiment, and statistical data analysis. During the survey, we evaluated the participants' sociodemographic data (age and employment status) and clinical factors: the duration of the disease, the stage of the disease, the location of the tumor, metastases, and functional status according to the ECOG. Testing was conducted twice: at the beginning of the study and after 6 weeks. In order to evaluate changes in the participants' health-related quality of life, we used the EORTC QLQ-C30 questionnaire and its module QLQ-BR23. The principal questionnaire, EORTC QLQ-C30, consists of 30 questions forming the global health status and quality of life scale, five functional scales, three symptom scales, and six separately evaluated components. The EORTC module QLQ-BR23 is a more specific questionnaire designed for breast cancer patients and consisting of 23 questions forming four functional scales and four symptom scales. After the calculation of the results according to the formulas presented by the authors, the score intervals in all scales and separately evaluated components ranged from 0 to 100 points. The questionnaires have been translated and adapted in many languages including Lithuanian and are suitable for the evaluation of cancer patients' health-related quality of life. In Lithuania, Banienė and Šinkariova 2015) evaluated the internal consistency of the scales of those questionnaires  and evaluated the internal consistency of the scale (α = 0.89), using the English version of this test in adult population [The testing of the experimental group participants' engagement in meaningful activities was also conducted at baseline and at the end of the study, using the Engagement in Meaningful Activities Survey. This survey has not been translated into Lithuanian and has not been adapted in Lithuania. For this reason, studies for the evaluation of the reliability and validity of the survey should be conducted. The results of the survey on engagement in meaningful activities reflect the level of the subjects' engagement in meaningful activities. The survey consists of 12 statements, each of which has the minimal value of 1 point and the maximal value of 4 points, where 1 point means “rarely”; 2 points, sometimes; 3 points, often; and 4 points, always. Engagement in meaningful activities was evaluated by a sum score. There is a growing body of scientific literature validating the psychometric properties of this test. The association of the results of this test with those of the evaluation of satisfaction with life and health-related quality of life has already been proven. Eakman with coauthors (2010) have proven the test-retest reliability of this instrument , active participation in community activities, social support, and engagement in meaningful activities have a positive effect on community members' health and quality of life . Cook anDuring the study, we applied occupational therapy in groups. During each session, purposeful activities were combined with creative techniques, and the sessions were made meaningful through voluntary assistance to others, that is, emotional help when communicating with other women who had the same problems and so forth. The experimental group participants also received individual consultations by an occupational therapist if needed.Duration of the program consisted of six meetings. The description of the program is provided in Occupational therapy sessions in groups were organized four times: once weekly at an arranged time in the evening (after work), up to 1.5 hours/day.Note that the sessions in occupational therapy groups took place in a cozy and comfortable environment, and all the tools and materials required for the activities were supplied and were of good quality. Prior to the sessions, the participants received all the necessary information, and the focus during the sessions was on the process rather than on the results. IBM SPSS Statistics 22 software. The data were described by using the standard numeral characteristics . The distributions were compared by applying the nonparametric criteria. Two dependent samples before and after the intervention were compared by applying the nonparametric Wilcoxon criterion and two independent samples by using the Mann–Whitney-Wilcoxon criterion. In order to determine the presence of a relationship between engagement in meaningful activities and health-related quality of life, we calculated Spearman's correlation coefficient. The difference or the relationship between the indices were considered to be statistically significant when p < 0.05.Statistical data analysis was conducted using theAfter six weeks, of 22 women randomized into the study, 21 completed the trial. The experimental group consisted of 10 participants and the control group consisted of 11. One woman withdrew from the study because of breast cancer recurrence. During the study, when applying occupational therapy in the community, we strove to improve the participants' engagement in meaningful activities and thus their health-related quality of life. For this reason, the women's active participation in the assignments was highly important for us, and thus, to determine the actual impact of the applied program on the aforementioned indices, we only calculated the results for women who were involved in the study.The health-related quality of life of women with breast cancer was evaluated during the nonacute period of the disease by calculating the scores in separate scales of the EORTC QLQ-C30 questionnaire and its module QLQ-BR23. The score could range from 0 to 100 points. A higher score in the global quality of life scale indicated better quality of life, a higher score in the functional scales better functioning, and a higher score in the symptom scales a greater degree of the manifestation of the symptom.p > 0.05 ), emotional functions ), cognitive functions ), and social functions ). The participants were also found to demonstrate the highest degrees of the manifestation of insomnia ) and the financial difficulties ). The results of the EORTC QLQ-BR23 questionnaire showed that the participants gave the poorest evaluations of the future perspective ) and demonstrated the highest degrees of the manifestation of breast symptoms ) such as pain, edema, tenderness, or skin problems.Among the control group participants, the poorest evaluations in the EORTC QLQ-C30 questionnaire at baseline were on the global quality of life ), and the participants were found to demonstrate the highest degrees of the manifestation of insomnia ) and financial impact ). The results of the EORTC QLQ-BR23 questionnaire showed that the participants gave the poorest evaluations of the future perspective ) and demonstrated the highest degrees of the manifestation of arm symptoms ) such as pain and edema.U = 0; p = 0.001; r = 0.85), physical functions , role functions , emotional functions , cognitive functions , social functions , fatigue , insomnia , and financial impact  scales, p < 0.05. The scores in other functional or symptom scales of the quality of life did not differ statistically significantly between the groups, p ≥ 0.05 , the experimental group demonstrated statistically significantly better results in the global quality of life  and breast symptoms  scales, p < 0.05. The scores in other functional or symptom scales did not differ statistically significantly between the groups, p ≥ 0.05 , the experimental group demonstrated statistically significantly better results in the systemic therapy side effects (p ≥ 0.05 .p < 0.05) in the scores of the global quality of life (0.85), physical (0.54), emotional (0.72), cognitive (0.72), and social (0.66) functions, fatigue (0.78), insomnia (0.59), financial impact (0.52), and systemic therapy side effects (0.68) scales.Considering the calculated strength of the effect, when a moderate effect was ≥0.5 and a strong effect was ≥0.8, we found not only statistically, but also clinically significant changes —the sum score that could range from 12 to 48 points, where <29 points indicated insufficient engagement; 29–41 points, moderate engagement; and >41 points, good engagement.Z = −2.829; p = 0.005): the median score was 36 points, the lowest score being 31 points (moderate engagement) and the highest score being 42 points (good engagement), p < 0.05  and the highest score being 35 points (moderate engagement). At the end of the study, after the application of the 6-week community-based occupational therapy program, the evaluation scores of the participants' engagement in meaningful activities changed statistically significantly (p < 0.05 .r(10) = 0.663; p = 0.037) between engagement in meaningful activities and the score in the emotional functions scale: better results of the evaluation of the engagement in meaningful activities  were associated with higher evaluation scores of emotional functions, that is, better emotional functions, p < 0.05.We also analyzed the relationship between breast cancer patients' engagement in meaningful activities and changes in their health-related quality of life. The results of the analysis showed that when evaluating the health-related quality of life on the EORTC QLQ-C30 questionnaire, the evaluation scores showed a statistically significant direct moderate relationship (r(10) = −0.658; p = 0.039) between engagement in meaningful activities and the evaluation scores in the insomnia scale: better results of the evaluation of the engagement in meaningful activities  were associated with lower evaluation scores of the insomnia scale, that is, a lesser degree of the manifestation of insomnia, p < 0.05.We also found a statistically significant inverse moderate relationship (r(10) = −0.681; p = 0.030) between engagement in meaningful activities and the evaluation scores in the constipation scale: better results of the evaluation of the engagement in meaningful activities  were associated with lower evaluation scores of the constipation scale, that is, a lesser degree of the manifestation of constipation, p < 0.05.We found a statistically significant inverse moderate relationship . The program was designed according to the guidelines provided in the only source of literature describing a study similar to ours—a project by Robinson (2015). The basis for those guidelines was a community-based occupational therapy program for women with breast cancer, aimed at maximizing their capacity for daily activities after the completion of the treatment .We evaluated health-related quality of life by using the questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Group—the global EORTC QLQ-C30 questionnaire and its module designed specifically for breast cancer, EORTC QLQ-BR23. These questionnaires have been translated into and adapted in many languages, including Lithuanian, and are suitable for the evaluation of health-related quality of life in individuals with breast cancer . In our   questionnaire [ , FACT-BSC , QLACS , SF-36 , and other instruments [EORTC questionnaires have been recommended by a number of foreign researchers , 25–28. ionnaire . Apart ftruments , 30, 31. (The Meaningful Activity Participation Assessment) test [According to literature data, active engagement in meaningful activities positively affects the quality of life, and thus, in order to improve breast cancer patients' health-related quality of life, the women were involved in meaningful activities during the occupational therapy sessions , 19. To nt) test .In this study, we strived to reveal the essence of occupational therapy in the community of women with breast cancer and the influence of this therapy on those women's health-related quality of life. The results of the study showed that occupational therapy significantly improves breast cancer patients' health-related quality of life and engagement in meaningful activities on the community level during the nonacute period of the disease.One of the limitations of this study is a small number of participants in the groups, and thus in the future, this or a similar study should be performed with a larger sample. We also think that, in further studies, it would be expedient to evaluate whether a longer period of program application or a greater number of sessions would affect the results and improve the effectiveness of the program. In addition, future studies could be expanded by involving specialists of other areas  because a successful implementation of the program requires not only the general competence of an occupational therapist, but also organizational skills, knowledge in marketing, and so forth in order to induce interest, attract, and invite the maximal possible numbers of women. The strong side of the study is that this was a new study in our country and that it provided positive emotions not only for the participants of the study, but also for hospitalized women who did not participate in the study, as voluntary assistance to others added meaningfulness to the sessions.


ERCC1 rs11615 , XPC rs2228000  and ERCC2/XPD rs50872  were associated with an increased risk of breast cancer. Stratified analysis revealed three polymorphisms  to be associated with breast cancer in menopausal females. Three polymorphisms were associated with specific breast cancer grades . Two polymorphisms (rs2228001 and rs50872) were associated with the risk of breast cancer with negative lymph node involvement. rs1800975 and rs50872 were associated with the risk of ER− and PR− breast cancer, whereas rs11615 was associated with the risk of ER+ and PR+ breast cancer. We found that carriers of the T allele of ERCC1 rs11615, XPC rs2228000 and rs50872, particularly in postmenopausal females, have an increased risk of breast cancer.Polymorphisms in nucleotide excision repair (NER) pathway genes are associated with the risk of breast cancer, but the relevance of these associations appeared to vary according to the ethnicity of the subjects. To systemically evaluate the potential associations between NER polymorphisms and breast cancer risk in a Chinese population, we carried out a case-control study on 450 breast cancer patients and 430 healthy controls. Sequenom MassARRAY was used for genotyping, and immunohistochemistry was performed to detect estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2) expression in tumor tissue. Our results showed that  Breast cancer is a complex multifactorial disease with unclear etiology. DNA damage and genomic instability, a potential risk of breast cancer, are induced by common environmental factors . HoweverNER repairs damage introduced by ultraviolet (UV) radiation, products of organic combustion, intrastrand DNA cross-links, heavy metals, and oxidative stress. Several proteins, including ERCC1, XPA, XPB/ERCC3, XPC, XPD/ERCC2, ERCC4/XPF, ERCC5/XPG, and PE/DDB1, are involved in the repair process, maintaining genome integrity to prevent carcinogenesis. The process of NER comprises several distinct steps, including DNA damage recognition, DNA damage demarcation, damaged DNA incision, repair patch synthesis, and ligation. Polymorphisms in NER pathway genes have been associated with increased risk for a number of cancers .Breast cancer patients and their relatives tend to have constitutively low NER levels in their peripheral blood lymphocytes , 10. MorNone of the tested polymorphisms deviated from Hardy-Weinberg equilibrium (HWE) in controls Table . There wERCC1 rs11615, XPC rs2228000, and ERCC2/XPD rs50872 carriers have a higher breast cancer risk in the whole study population. Stratified analysis of menopausal status revealed that XPC rs2228000 has a higher breast cancer risk in the premenopausal sub-cohort. While in the postmenopausal sub-cohort, ERCC1 rs11615 and ERCC2/XPD rs50872 were associated with increased breast cancer risk. On the contrary, XPA rs1800975 and XPC rs2228001 were associated with decreased breast cancer risk.The genotype distribution in the two groups and their subgroups of menopausal status are presented in Table XPA rs1800975. In addition, ERCC1 rs11615 carriers have a high risk of breast cancer with grade 3, while XPC rs2228000 and ERCC2/XPD rs50872 are linked to a high risk for breast cancer with grades 1 and 2, respectively. For the lymph node involvement subgroup, XPC rs2228001 and ERCC2/XPD rs50872 carriers have a high risk of breast cancer with negative lymph node involvement. While ERCC1 rs11615 and XPC rs2228000, were significantly associated with both negative and positive lymph node involvement subgroups  and expression of specific proteins in tumor tissue . Tumor size T3-T4) was associated with all polymorphisms of interest except for  was assoXPA rs1800975 and ERCC2/XPD rs50872 carriers have a high risk of breast cancer with negative expression of ER and PR. While ERCC1 rs11615 have a high risk of ER+ and PR+ breast cancer and PR. The susceptibility of XPC rs2228000 to breast cancer risk was observed in both subgroups; however, there was no significant association for XPC rs2228001 in any subgroup , XPC rs2228000  and ERCC2/XPD rs50872  were associated with increased breast cancer risk. Besides, ERCC1 rs11615 , and ERCC2/XPD rs50872  were associated with postmenopausal breast cancer, while XPC rs2228000  was associated with premenopausal breast cancer.This case-control association study revealed that XPC gene encodes a 940 amino acid protein that forms an XPC-RAD23B complex with RAD23B . Stratified analyses were performed by ethnicity. The Z test was performed to calculate the pooled OR, and a P value < 0.05 was considered as significant. The χ2 based Q statistical test was used to evaluated the heterogeneity across the enrolled studies [P value of heterogeneity (Ph) < 0.05 was considered significant. The random-effects model was used when there was marked heterogeneity across all the studies; otherwise, the fixed-effects model was used [For the meta-analysis, the overall risk associated with a polymorphism to breast cancer was measured by ORs with 95% CIs based on different genetic models [Rare allele homozygote (RR), heterozygous (WR), and RR+WR  studies , and a Pwas used . All sta


PSCA single-nucleotide polymorphisms  and breast cancer among 560 breast cancer cases and 583 controls (Chinese Han women). We found rs2294008 was significantly associated with a high risk of breast cancer . And stratification by menopausal status revealed an association of the minor allele of rs2294008 with breast cancer risk among premenopausal  and postmenopausal women . Rs2978974 influenced the breast cancer risk among postmenopausal women in heterozygote model . When stratified by clinicopathologic features, the T allele of rs2294008 was associated with progesterone receptor status , and the rs2976392 polymorphism was associated with high lymph node metastasis risk in homozygote model . Further haplotype analysis suggested that Trs2294008 Ars2976392 Grs2978974 haplotype enhances breast cancer risk . Therefore, among Chinese Han women, the PSCA rs2294008, rs2978974, and rs2976392 minor alleles are associated with increased breast cancer risk especially in progesterone receptor positive breast cancer patients, with breast cancer risk in postmenopausal women, and with high lymph node metastasis risk, respectively. Moreover, Trs2294008 Ars2976392 Grs2978974 haplotype was associated with significantly increased risk of breast cancer.This study explored the associations between common  BRCA1 (breast cancer 1), BRCA2 (breast cancer 2), PTEN (phosphatase and tensin homolog deleted on chromosome ten), and TP53 (tumor protein p53) have been identified [Breast cancer is the most common cancer and the principal cause of cancer-related deaths among Chinese women , accountentified –8.PSCA encodes a 123-amino acid immature lymphocyte cell surface maker with 30% homology to stem cell antigen type 2, a member of the Thy-1/Ly-6 family and is located on chromosome 8q24.2 [PSCA was initially identified as a prostate-specific antigen over-expressed in >80% of prostate cancers, including metastatic and hormone-related cancers [PSCA is also abnormally expressed in bladder cancer [PSCA being transfected into PSCA-negative cells caused down-regulated cell proliferation, thus affecting survival of gastric cancer cells [PSCA in a human bladder cancer cell line led to inhibition of cell growth via activation of several immune signaling pathways [PSCA polymorphisms, among which rs2294008 C>T, rs2978974 G>A, and rs2976392 G>A are the most widely studied ones and may influence susceptibility to different types of cancer [PSCA SNPs with breast cancer. A single study with small sample sizes (456 patients and 461controls) revealed that the PSCA SNPs were associated with breast cancer susceptibility among Korean women [PSCA with the risk of breast cancer among a population of Chinese women.e 8q24.2 . PSCA wa cancers , 11. Recr cancer , gastricr cancer –17, renar cancer , oesophar cancer , gallblar cancer –22, and pathways . Genome-f cancer , 27. HowP = 0.195, P = 0.164, and P = 0.179, respectively). Both the homozygote and recessive models of rs2294008 revealed an associated with a high risk of breast cancer . We further calculated the power of the rs2294008 SNP homozygote and recessive model analyses, and we were able to reject the null hypothesis that the TT frequency for case and controls is equal with probability (power) = 0.896. No significant associations with rs2976392 and rs2978974 were found in any of the models.Detailed allele frequencies and genotype distributions of the three polymorphisms are shown in Table PSCA SNPs and the risk of breast cancer   and postmenopausal women . For rs2978974, a significant association with high breast cancer risk was found among postmenopausal women in the heterozygote model . There were no significant associations with rs2976392 in any of the subgroups.Stratification analyses according to age revealed no significant associations between the three 5) Table . While, 5) Table  found thPSCA SNPs with various clinicopathological features including: tumor size, lymph node metastasis, and the expressions of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2). The T allele of rs2294008 was associated with positive PR status  (Table P = 0.04). However, rs2978974 was not significantly associated with any of the clinicopathological features.We evaluated the associations of PSCA haplotypes and the risk of breast cancer. Table rs2294008 Ars2976392 Grs2978974 haplotype was associated with a significantly increased risk of breast cancer . The “others” (haplotypes with frequency <1% were merged) were broadly distributed in cases at a low level . The significance of this result is limited given the naturally low frequencies of these haplotypes. We did not discover any associations with Crs2294008 Grs2976392 Ars2978974 and Trs2294008 Ars2976392 Ars2978974 in breast cancer.We analyzed the association between PSCA may influence a diverse group of cancers, including gastric, bladder, renal, and pancreatic cancers [PSCA and breast cancer.Genetic studies have provided insight into various diseases, including cancers. Understanding the associations between different genes and cancers can improve prevention, treatment, and prognosis estimation. Genome-wide association studies have revealed many genetic markers of different cancers. Recently numerous studies have indicated that  cancers –23, 26. PSCA and its C to T transition has been shown to reduce transcriptional activity of an upstream fragment of PSCA [Rs2294008 is located in exon 1 of  of PSCA , 29. Pre of PSCA , 27. The of PSCA , 31 and  of PSCA  and Asia of PSCA , 20 popuPSCA and has a strong linkage disequilibrium with rs2294008 C > T [PSCA rs2976392 polymorphism was significantly associated with increased overall cancer risk [PSCA showed low linkage disequilibrium with rs2294008 and the Ars2978974 allele was shown to contribute to bladder cancer susceptibility, presumably due to the loss of binding of ELK1 or other ETS proteins to the PSCA promoter [PSCA haplotype Trs2294008 Ars2978974 conferred low risk of gallbladder cancer in males, while in females, the Trs2294008 Grs2978974 haplotype was related to increased gallbladder cancer risk [Rs2976392 is located in the intron 2 of 08 C > T , 32. Thecer risk . Rs29789promoter . A studyPSCA rs2294008, rs2976392, and rs2978974 polymorphisms. Haplotype analysis indicated that the Trs2294008 Ars2976392 Grs2978974 haplotype was associated with significantly increased risk of breast cancer.It is believed that haplotypes may be more important than any single SNP analysis in influencing a clinical response , 34. To PSCA in breast cancer.This study has several limitations. First, the single-center design may preclude extrapolation of our findings to other patient populations or ethnic groups. Second, we used a hospital-based case-control design, which may involve selection bias. Third, our sample size was relatively small, which may limit the strength of our stratified analyses. Fourth, we did not consider other important risk factors , as we did not have access to these data. Therefore, a large well-designed prospective study is needed to validate our findings. Furthermore, biological function studies are crucial for elucidating the role of PSCA rs2294008 polymorphism influenced the risk of breast cancer among Chinese women and the rs2978974 polymorphism may specifically increase the risk of breast cancer in postmenopausal women. We found that rs2294008 was associated with PR-positive status and rs2976392 was associated with lymph node metastasis among Chinese women with breast cancer. Furthermore, the Trs2294008 Ars2976392 Grs2978974 haplotype may increase the susceptibility to breast cancer.Our study revealed that the P = 0.038).We included the cases with pathologically-confirmed breast cancer, without history of any cancer, were treated at the Department of Oncology  between January 2013 and October 2014. The healthy individuals who had visited the medical examination center at the Second Affiliated Hospital of Xi'an Jiaotong University for a check-up during the study period were included as controls. All individuals were Chinese Han women, and the controls were frequency-matched to the cases according to age (±5 years) and menopausal status. Finally, 560 eligible patients with an average age 49.09 ± 11.02 years and 583 healthy age-matched controls were included in the study . To achieve a power of at least 50%, only SNPs with a minor allele frequency of >0.01 were included. Three primers were designed to amplify fragments of rs2294008, rs2978974, and rs2976392. Primers and PCR product sequences are shown in Table P-values were calculated using the χ2 test, and all tests were two-tailed; a P-value of <0.05 was considered statistically significant. The exact test was used to examine the distribution of each SNP among the controls, and their accordance with the Hardy-Weinberg equilibrium. Five different genetic models were used to evaluate the risk of breast cancer, with “A” used to indicate the major allele and “a” used to indicate the minor allele: the allele model (a vs. A); the co-dominant model ; the recessive model (aa vs. AA+Aa); the dominant model (AA vs. Aa+aa); and the over-dominant model (AA+aa vs. Aa). The allelic frequencies for each SNP were compared between cases and controls in each model using the χ2 test and SNPStats software [http://biostat.mc.vanderbilt.edu/wiki/Main/PowerSampleSize). Phase2.1 software was used to conduct all common haplotypes [P = 0.038). BMI may be a confounder in the development of breast cancer. Therefore, to control for its effects, we used stratification analyses. First, we calculated OR1 and OR2 by stratification for BMI. Then, the ratio of the OR (unadjusted OR) and OR1/OR2 was calculated. If the ratio was close to 1, the results did not need to be adjusted, indicating that BMI was not a confounder. Otherwise, we would need to adjust results for BMI.Microsoft Excel and SPSS software  were used for all analyses. software , 37. Powplotypes  and SPSS