Results from epidemiologic studies on the relationship between vitamin D and breast cancer risk are inconclusive. It is possible that vitamin D may be effective in reducing risk only of specific subtypes due to disease heterogeneity.In case-control and case-series analyses, we examined serum concentrations of 25-hydroxyvitamin D (25OHD) in relation to breast cancer prognostic characteristics, including histologic grade, estrogen receptor (ER), and molecular subtypes defined by ER, progesterone receptor (PR) and HER2, among 579 women with incident breast cancer and 574 controls matched on age and time of blood draw enrolled in the Roswell Park Cancer Institute from 2003 to 2008. We found that breast cancer cases had significantly lower 25OHD concentrations than controls . Among premenopausal women, 25OHD concentrations were lower in those with high- versus low-grade tumors, and ER negative versus ER positive tumors (p≤0.03). Levels were lowest among women with triple-negative cancer (17.5 ng/mL), significantly different from those with luminal A cancer . In case-control analyses, premenopausal women with 25OHD concentrations above the median had significantly lower odds of having triple-negative cancer  than those with levels below the median; and every 10 ng/mL increase in serum 25OHD concentrations was associated with a 64% lower odds of having triple-negative cancer . The differential associations by tumor subtypes among premenopausal women were confirmed in case-series analyses.In our analyses, higher serum levels of 25OHD were associated with reduced risk of breast cancer, with associations strongest for high grade, ER negative or triple negative cancers in premenopausal women. With further confirmation in large prospective studies, these findings could warrant vitamin D supplementation for reducing breast cancer risk, particularly those with poor prognostic characteristics among premenopausal women. Vitamin D is a secosteroid hormone critical to bone health and other biological pathways It is possible that tumor heterogeneity in breast cancer may mask associations. Clinical markers including estrogen receptor (ER), progesterone receptor (PR) and tumor grade have long been used to classify breast cancer subtypes associated with differential prognosis and response to cancer therapy. These crude subtypes were refined by recent gene expression microarray studies, which clustered breast tumors into five major molecular subtypes The definition of breast tumors that are ‘triple negative’, i.e., lack of expression of ER, PR and HER2, largely overlap with that of basal-like tumors and is sometimes used as a proxy for the latter. Basal-like or triple negative tumors pose a major challenge for breast cancer treatment, because it does not repond to hormonal therapy targeting ER or trastuzumab targeting HER2. In a recent case-series study, women with triple negative breast cancer had the lowest serum 25OHD concentrations compared to those with other molecular cancer subtypes Data and specimens from women with breast cancer and healthy controls were obtained from the Data Bank and Biorepository (DBBR) at Roswell Park Cancer Institute (RPCI). The DBBR, as previously described Inclusion criteria for breast cancer cases in the study were: self-identified as non-Hispanic white, histologically confirmed primary, incident, female breast cancer, and no prior cancer history except non-melanoma skin cancer. Healthy controls were identified from family members and friends of the patients and other visitors to RPCI or from volunteers recruited from community events, and blood was drawn and processed at RPCI in the same manner as the cases. For this study, controls were matched to cases on five year age category and month of blood collection. Those who were family members or friends of the breast cancer cases were not included in the study. Self-administered questionnaires were used to collect data on demographics, reproduction, medical history, family histories of cancer, and lifestyle factors including physical activity. Self-reported physical activity compared to same age peers was used as an estimate for sun exposure. In addition, questionnaire data on activities including walking, running, cycling, and golfing were included as alternative estimates for sun exposure. A food frequency questionnaire was administered, and questions on supplement use were included. Ninety-two percent (92%) of the women in this study had questionnaires returned. Postmenopausal status in the study was defined as women who experienced 12 consecutive months of amenorrhea, or women who underwent bilateral salpingo-oophorectomy. This study was approved by the Institutional Review Board at RPCI.HER2 gene was tested by fluorescence in situ hybridization (FISH) when IHC scored 2+. Histologic grade, ER status and molecular subtypes defined by ER, PR and HER2 were used as three independent prognostic characteristics for breast cancer. In addition, tumor stage was also included for analysis.Patients' clinical data, including tumor stage, histologic grade and ER, PR and HER2 status, were obtained from a clinical database maintained by the RPCI breast program, and supplemented with data from abstracted medical records and the RPCI Tumor Registry. Because IHC of CK 5/6 or EGFR was not routinely performed in pathology, we instead defined four molecular subtypes in our study based on ER, PR and HER2 as follows: luminal A , luminal B , non-luminal HER2+ , and triple negative . As such, we were not able to distinguish the basal-like and unclassified subtypes, both of which were included in the triple negative group in our study. However, it has been shown that the prognostic significance of the triple negative subtype is similar to that of the basal-like subtype Considering the potential variability of 25OHD assays, we first tested assay performance on pilot samples in two different laboratories both running the immunochemiluminometric assay on the DiaSorin Liasion automated instrument. At one laboratory, the coefficient of variation (CV) was 19%, which was considered inappropriate for the purpose of this study. At another laboratory , the CV was 6.5%, and this laboratory was chosen. For the entire batch of samples analyzed for cases and controls, the CV was 8.8%.For univariate analysis, we first compared serum 25OHD concentrations in the healthy controls by a number of selected factors that might affect vitamin D levels, using non-parametric tests. To compare serum 25OHD concentrations by case-control status or by tumor prognostic characteristics, we used a generalized linear model controlling for age, body mass index (BMI) and season of blood collection, which had independent effects on serum 25OHD concentrations (p<0.05). Least square means and standard errors of 25OHD concentrations were derived separately for each of the tumor characteristics. Physical activity was not associated with serum 25OHD levels after control for BMI, and adding it to the models had little impact on the results. Thus, results without additional adjustment for physical activity are presented.in situ (CIS) were excluded. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) associated with 25OHD levels. When outcomes had more than two levels, multinomial logistic regression models were fitted. Considering large seasonal variations of 25OHD concentrations due to change of solar ultra-violet B intensity in the Northeastern United States through a year, we computed season-standardized 25OHD concentrations by locally weighted multinomial regression to determine the cut-off points of vitamin D levels for logistic regression, following the approach described by Ahn and colleagues To examine serum 25OHD levels in relation to breast cancer prognostic characteristics, we performed two types of analyses, including case-control analysis, where healthy controls were used as a referent group, and case-series analysis, where women with better prognostic characteristics  were used as a referent group and women with carcinoma For case-control analysis, season-standardized vitamin D levels were defined as follows: deficient (<20.0 ng/mL), insufficient (20.0–29.9 ng/mL), and sufficient (≥30.0 ng/mL). For case-series analysis of prognostic characteristics, because the number of cases was limited in some categories, we dichotomized season-standardized 25OHD concentrations based on the medians in healthy controls. In addition, we also treated season-standardized 25OHD concentrations as a continuous variable in the regression models and computed the ORs and 95% CIs associated with an incremental increase of 10 ng/mL of 25OHD. Because etiologic pathways of breast cancer may differ between premenopausal and postmenopausal women, we first performed analyses for all women, and then stratified the analyses by menopausal status. All analyses were performed using SAS 9.2 with two-sided significance level of 0.05 .The median of serum 25OHD concentrations in breast cancer cases and controls were 22.8 ng/mL and 26.2 ng/mL, respectively. After control for seasonal variations, a majority of the controls were either vitamin D deficient (25.8%) or insufficient (35.7%), and only 38.5% of them had a sufficient level of 30 ng/mL or higher. The proportion of vitamin D deficiency was even higher in cases (38.5%), and only a small proportion of them were considered vitamin D sufficient (21.4%) (p<0.001). As shown in When pre- and postmenopausal women with invasive breast cancer were considered together, there were no significant differences in serum 25OHD concentrations by histologic grade or ER status (data not shown). However, women with triple negative breast cancer had the lowest vitamin D concentrations among the 4 molecular subtypes after control for age, BMI and season of blood collection . In addition, there was an inverse relationship between serum 25OHD concentrations and tumor stage .When stratifying by menopausal status, serum 25OHD levels did not differ by tumor characteristics among postmenopausal women, but there were notable differences among premenopausal women . Those dIn case-control analyses, ORs and 95% CIs of breast cancer by menopausal status and tumor prognostic characteristics are plotted in In case-series analyses, high levels of serum 25OHD were less likely to be associated with premenopausal breast cancer with poor prognostic characteristics than low levels  . SimilarWe found that higher serum 25OHD concentrations were associated with significantly reduced odds of both premenopausal and postmenopausal breast cancer. Among premenopausal women only, 25OHD concentrations were significantly lower in women with tumors with poor prognostic characteristics  than among those with cancers with better prognostic features. The findings support the hypothesis that vitamin D may reduce risk of the development of a subset of tumors with more aggressive characteristics and poorer prognosis.Existing evidence supports a link between vitamin D and prognostic characteristics of breast cancer. In clinical studies, serum 25OHD concentrations have been inversely associated with breast cancer stage The inconsistency in results across studies could be explained by heterogeneity in study populations, in classification of HR status, and/or in assessment of vitamin D status (dietary intake versus circulating 25OHD). Our patient population represents a more contemporary patient cohort (2003–2008) with data available on ER, PR and HER2, allowing us to refine tumor subtype classification and to distinguish the triple negative subtype. However, we were not able to classify the basal-like subtype due to lack of data on basal markers CK5/6 or EGFR. Although basal-like and triple negative phenotypes largely overlap and share a poor prognosis, the former definition represents a more refined group by excluding the unclassified subtype, which may behave differently in prognosis from the basal-like subtype. Our findings warrant validation in large prospective studies where complete data on molecular subtypes are available.Vdr knockout mice gavaged with the carcinogen dimethylbenzanthracene (DMBA) were more likely to develop ER-/PR- mammary tumors than wild type littermates VDR expression were remarkably lower in ER- than in ER+ breast tumors 2D down-regulated the abundance of ER and suppressed estrogen activity in breast cancer cells Although the exact biological mechanisms are not clear, data from animal experiments are concordant with our findings. A limitation of our study is that only a single measurement of vitamin D at diagnosis was used, which may not necessarily represent vitamin D levels at the time of cancer initiation or progression. However, in a recent study, the correlation coefficient for measurement of 25OHD concentrations in serum samples collected in 1994 and 2008 ranged from 0.42 to 0.52, and was 0.80 when measured 12 months apart In conclusion, our study provides compelling evidence that endogenous vitamin D levels may be associated with the etiology of breast cancer, particularly the triple negative subtype leading to poor prognosis among premenopausal women. Because the risk of triple negative breast cancer peaks before menopause, and because vitamin D deficiency can be easily corrected by increasing sun exposure and/or supplement intake, if our findings are confirmed in large prospective studies for temporal causality, vitamin D may be used as a potential cancer preventive agent against triple negative cancers among young women.Figure S1Case-control analysis of breast cancer risk by 10 ng/ml increase of vitamin D levels. Season-standardized serum 25-hydroxyvitamin D (25OHD) concentrations were entered into the regression models as a continuous variable. Odds ratios (OR) and 95% confidence intervals (CI) of an incremental increase of 10 ng/mL 25OHD were derived from multinomial logistic regression with adjustment for age at diagnosis and BMI, and presented in groups of tumor characteristics, where healthy controls were used as a referent group. Further adjustment for physical activity did not significantly change the results (data not shown). The lengths of horizontal lines are indicative of confidence intervals and the dots are indicative of odds ratios, with the corresponding odds ratios and 95% confidence interval given in numbers on the right of the Y-axis.(TIF)Click here for additional data file.Figure S2Case-only analysis of breast cancer risk by 10 ng/ml increase of vitamin D levels. Season-standardized serum 25-hydroxyvitamin D (25OHD) concentrations were entered into the regression models as a continuous variable. Odds ratios (OR) and 95% confidence intervals (CI) of an incremental increase of 10 ng/mL 25OHD were derived from multinomial logistic regression with adjustment for age at diagnosis and BMI, and presented in groups of tumor characteristics, where women with better prognostic characteristics  were used as a referent group and women with carcinoma in situ (CIS) were excluded. Further adjustment for physical activity did not significantly change the results (data not shown). The lengths of horizontal lines are indicative of confidence intervals and the dots are indicative of odds ratios, with the corresponding odds ratios and 95% confidence interval given in numbers on the right of the Y-axis.(TIF)Click here for additional data file.


Chronic internal inflammation secondary to adiposity is a risk factor for sporadic breast cancer and Post-Menopausal Breast Cancer (PMBC) is largely defined as such. Adiposity is one of the clinical criteria for the diagnosis of Metabolic Syndrome (MetS) and is a risk factor for PMBC. We examined SNPs of eight genes implicated in adiposity, inflammation and cell proliferation in a Prospective-specimen-collection, Retrospective-Blinded-Evaluation (PRoBE) design approach. A total of 180 cases and 732 age-matched controls were identified from the MyCode prospective biobank database and then linked to the Clinical Decision Information System, an enterprise-wide data warehouse, to retrieve clinico-demographic data. Samples were analyzed in a core laboratory where the personnel were masked to their status. Results from multivariate logistic regression yielded one SNP (rs2922126) in the GHSR as protective against PMBC among homozygotes for the minor allele (A/A) ; homozygosity for the minor allele (C/C) of the SNP (rs889312) of the gene MAP3K1 was associated with the risk of PMBC . Advanced age was protective against PMBC . Family history of breast cancer , HRT , and MetS  and interaction between HRT and MetS  were associated with the risk of PMBC. We did not detected significant interactions between SNPs or between the SNPs and the clinico-demographic risk factors. Our study further confirms that MetS increases the risk of PMBC and argues in favor of reducing exposure to HRT. Our findings are another confirmation that low penetrance genes involved in the inflammatory pathway, i.e. MAP3KI gene, may have a plausible causative role in PMBC. Given the fact that genetic constitutionality of individuals cannot be changed, efforts should be focused on life style modification. Of all identified modifiable risk factors for PMBC, adiposity has been known to have the strongest (Risk ratio = 1.67) and the largest population attributable risk (>20%)  is an amalgamation of several clinical signs and symptoms of which a minimum of three of the five risk factors, insulin resistance, hypertension, hyperlipidemia and low serum levels of HDL cholesterol, and obesity are required for diagnosis of this syndrome  design approach . The MyCode database was linked to medical record numbers and subsequently to the electronic health records (EHR). Women whose diagnoses pre-dated 1/1/2001, women with diagnosis of malignancies of other organs sites except for squamous and/or basal cell carcinoma were excluded, women with medical conditions that required chronic intake of steroids and women younger than age 40 or older than 79 years were excluded.Members of the cohort with no history of breast or other organ site malignancies or chronic prescription of steroids comprised the control group. We applied a ratio of one case to four controls, matched by age (± 5 years) and year of entry into the cohort. Date of blood donation to the MyCode prospective biobanking was considered the entry point for each person into the cohort.Demographic and clinical data were retrieved from CDIS, an enterprise-wide data warehouse. Data were downloaded into the databases that were created for the purpose of this study.We developed a standard operational procedure for manual review of data from EHR. One of the study personnel with training in medical abstraction reviewed the EHRs over a period of nine months. The validity of electronically downloaded data was evaluated against the manually reviewed and retrieved data  criteria of 1999 to classify women with or without MetS.In selecting the genes and their SNPs we reviewed findings from GWAS and other independent studies and applied minor allele frequency filtering approach and function prediction method to select a total of 64 SNPs of eight genes  according to the manufacturer’s protocol. Quantification of extracted DNA was performed using a NanoDrop ND-1000 spectrophotometer .Single nucleotide polymorphism genotyping was performed on TaqMan® OpenArray System with assay kit (64 assay format) and Genotyping Master Mix purchased from Life Technologies , according to the manufacturer’s protocol. Briefly, 10 ul of each DNA samples  plated in 384 well plate were loaded on OpenArray assay slide with Life Technologies OpenArray® AccuFill™ System  then performed PCR on GeneAmp PCR System 9700  as follows: 93°C for 10 minutes followed by 50 cycles at 95°C for 45 seconds, 94°C for 13 seconds, and 53°C for 2 minutes 14 seconds. The post-PCR OppenArray assay slides were then scanned with OpenArray scanner and analyzed using TaqMan genotyper Software v1.3 . We took a two-step quality control measure to remove poor quality genotype data. First, 10% samples were replicated to test the concordance and reliability of the genotyping result. We excluded discordant SNPs. This step was followed by excluding SNPs with a recall rate of < 85% for genotyping; this step was followed by manual recall for the remaining SNPs. A total of 40 SNPs passed the two-step quality control requirement.The observed frequencies for all selected SNPs in our sample were compared with and were in agreement with the Hardy-Weinberg-Equilibrium. We then evaluated the linkage disequilibrium structure of the SNPs in our sample using the Gabriel algorithm  and the interaction between MetS and HRT. In our next analysis, we restricted the reference group to controls with no history of exposure to HRT or smoking and no clinical documentation of MetS The final model included age, family history of breast cancer, HRT, MetS and the interaction between HRT and MetS. The estimated risk of PMBC was not significantly different from our first approach where all controls were inclusive. Therefore, we use this reference group to estimate the relative risk contributions of genetic polymorphism to PMBC in presence of clinico-demographic risk factors. For each SNP, testing each SNP individually for its association with PMBC, we used the Cockerham genetic model additive coding scheme and dominant coding scheme Cordell . For theThis study was approved the Institutional Review Board and is in full compliance with the U.S. Congress Health Insurance Portability and Accountability Act (HIPAA) of 1996.We identified a total of 4,075 women between ages of 40 and 79 years from the MyCode database. Figure  A total Frequency distributions of SNPs of the eight genes stratified by disease status are presented in Table Results from our final multivariate risk estimation analysis for SNPs combined with the clinico-demographic characteristics are presented in Table Findings from the present study further support results from previous studies that metabolic syndrome (MetS) increases the risk of postmenopausal breast cancer (PMBC)  and MAP3K1 (rs889312) were associated with the risk of PMBC independent of clinico-demographic risk factors. Our results suggest homozygotes for minor allele of GHSR (rs2922126) carried a lower risk for PMBC relative to carriers of major alleles. Dossus et al. reported a 2-fold increase in the risk of breast cancer for homozygote carriers of the GHSR (rs2948694) but did not find a statistically significant association with GHSR (rs2922126) and risk of breast cancer . The disWe detected polymorphism of MAP3K1 (rs889312) was associated with an elevated risk of PMBC, independent of clinico-demographic risk factors. Our findings concur with previous studies suggesting polymorphism of MAP3KI (rs889312) was associated with the increased risk of hormone receptor positive breast cancer (Rebbeck et al. The main strength of our study was the availability of longitudinal body weight and height data. The median stay with our health care system is 18 years. Therefore, the availability of long-term data enabled us to estimate the mean body weight for each study participant which is a better reflection of the “true” body weight as oppose to a one-point-in-time measurement or self-reported body weight. Also, our study benefited from clinically documented signs and symptoms of MetS and medically documented use of HRT therapy over the period of stay of each study participant with the health care system. Therefore, the likelihood of recall bias was reduced in this study. Our study had its limitations. First, the relatively small sample size reduced the statistical power to adequately discern the association between SNPs of genes and MetS. Also, it prevented us from stratifying women by their breast cancer subtype. Also, our study sample was derived from a population relatively homogenous with respect to its genetic pool and life style risk factors. Never-the-less, our study further sheds light on the associate between prolonged MetS and the risk of PMBC.In summary, findings from our study further confirm that MetS increases the risk of PMBC and argues in favor of reducing the exposure to HRT. In addition, our finding is another independent confirmation that low penetrance genes involved in the inflammatory pathway, i.e. MAP3KI gene, may have a plausible causative role in sporadic breast cancers. Given the fact that genetic constitutionality of individuals cannot be changed, at least at the present level of science and technology, our effort should be focused on reducing the risk of PMBC through life style modification.


While post-treatment breast cancer survivors face up to twice the cancer risk of the general population, modifiable health behaviors may somewhat reduce this risk. We sought to better understand health behaviors that early stage breast cancer survivors engage in to reduce recurrence risk.type DX) during their clinical care. Study outcomes were meeting health behavior recommendations ).Data came from a cross-sectional multi-site survey of 186 early-stage breast cancer survivors who received genomic testing for breast cancer recurrence risk (OncoApproximately three-quarters of survivors we surveyed believed the 3 behaviors might reduce their cancer risk but many did not engage in these behaviors for this purpose: 62% for BMI, 36% for fruit and vegetable consumption, and 37% for physical activity. Survivors with higher recurrence risk, as indicated by their genomic test results, were no more likely to meet any of the three health behavior recommendations. Adherence to health behavior recommendations was higher for women who were white, college-educated, and had higher incomes.Many nonadherent breast cancer survivors wish to use these behavioral strategies to reduce their risk for recurrence, suggesting an important opportunity for intervention. Improving BMI, which has the largest association with cancer risk, is an especially promising target. The numbers of women in the US Modifiable health behaviors may offer additional reductions in the risk of recurrence and comorbid conditions among cancer survivors, as well as counter the negative impacts of treatment Despite this, some breast cancer survivors have poor adherence to these health behavior recommendations. Breast cancer survivors experience obesity at the same high rate as the general U.S. population type DX, a test that predicts 10-year risk of recurrence among women with early stage breast cancer by examining the activity of a group of 21 genes within a woman's tumor Information on recurrence risk may increase women's motivation to follow health behavior recommendations. Women newly diagnosed with breast cancer receive increasingly sophisticated risk information. One example of this includes results of Oncotype DX test results, who perceived higher recurrence risk and who had more breast cancer worry.Our study sought to characterize early stage breast cancer survivors' awareness of the potential cancer risk reduction offered by three health behaviors . A second goal was to understand whether this awareness was associated with adoption of the behaviors . Based on previous research, we expected adherence to these behaviors would be low, but no published research we are aware of has documented whether awareness of the guidelines is a central problem. Last, we also sought to assess variables associated with engaging in these recommended health behaviors. We predicted greater adherence by women who had higher recurrence risk according to their Oncotype DX testing between the time the test was first available in June 2004 through March 2009. Oncotype DX testing, which analyzes breast tumor tissue removed during surgery, estimates the 10-year risk for distant breast cancer recurrence assuming the woman receives adjuvant hormone therapy. Women eligible for Oncotype DX had stages I or II, hormone-receptor positive breast cancer. All but one participant had node-negative disease; we included this woman because the test has proven clinically useful for node-positive breast cancers of the type that she had. Exclusion criteria included being male, not being English-speaking, or under age 18. Study sites included: University of North Carolina (UNC) Breast Center in Chapel Hill, North Carolina; National Naval Medical Center (NNMC) in Bethesda, Maryland; and Georgetown University (GU) in Washington, DC. Participation rates were 75% (78/104), 74% (59/80) and 63% (50/80) for these three sites respectively. We excluded a participant who had an outlier of 194 months since diagnosis, resulting in a combined sample of 186 participants.Participants were women who were previously treated for early-stage breast cancer at one of three study sites and whose records indicated they received OncoResearchers mailed study questionnaires to eligible women between December 2008 and May 2010. The Institutional Review Boards of the University of North Carolina, National Naval Medical Center, and Georgetown University approved the study protocol and materials.We calculated survivors' body mass indexes using their self-reported height and weight and categorized them as adherent (BMI 18.5–24.9) or non-adherent (25.0 and over or under 18.5). The survey measured adherence to recommendations to consume 5 servings of fruits and vegetables daily: “How many servings of fruits do you usually eat or drink each day? Think of a serving as being about 1 medium piece, or ½ cup of fruit, or ¾ cup of fruit juice,” and “How many servings of vegetables do you usually eat or drink each day? Think of a serving as being about 1 cup of raw leafy vegetables, ½ cup of other cooked or raw vegetables, or ¾ cup vegetable juice.” We categorized respondents who reported consuming 5 or more daily servings across the two measures as adherent. We adapted these items and the physical activity items from The Health Information National Trends Survey (HINTS) We measures cancer risk-reduction awareness by asking survivors to indicate how each of the following behaviors affect chances of getting cancer: 1) having a healthy body weight, 2) eating 5 or more fruits and vegetables each day, and 3) engaging in at least 30 minutes of moderate to vigorous physical activity on 5 or more days each week. Response options were “decreases chances,” “makes no difference,” “increases chances,” and “don't know.” We categorized women who indicated that these behaviors decreased chances as “aware” with the latter responses constituting the “unaware” group.We assessed engagement in cancer risk-reduction behaviors  by asking survivors for each of the three health behaviors, whether they engaged in any of those behaviors to specifically reduce their chances of getting cancer or a recurrence. Response options were “Yes,” “No,” and “No, but I want to.”We assess stage of change as has been done in previous research on health behavior in other populations type DX test as “low” “intermediate” or “high” risk. We collapsed the intermediate and high risk groups for analyses due to small numbers who reported their risk was high. We previously have found these self-reports match clinical records with a high degree of accuracy The survey assessed survivors' recollection of the likelihood of their cancer coming back based on results of their OncoThe survey assessed how often women worried during the past few weeks about their breast cancer recurring, measured on a 4-point response scale ranging from “not at all” to “all of the time” p<.10 in bivariate analyses. We analyzed data with two-tailed statistical tests with a critical alpha of .05 in SAS.We generated descriptive statistics to characterize the sample and the proportions of survivors in each stage of behavior change for each of the three health behaviors. We conducted bivariate analyses to identify demographic, medical and psychosocial variables associated with meeting each of the three health behavior outcomes (yes/no) using logistic regression. We then conducted separate multivariate logistic regression analyses for meeting each BMI, diet, and physical activity outcome, including variables identified as statistically significant at type score, while fewer reported intermediate (24%) or high (4%) scores. Women's mean perceived recurrence risk was 16% and their overall breast cancer worry was low (M = 1.8).On average, women were 57 years old (range 30–84) and were 23 months since diagnosis (range 4–68). Most were Caucasian (80%), college educated (61%), and had a household income of at least $60,000 (69%) . Most   . About oIn bivariate analyses, women who received chemotherapy as part of their care were less adherent to BMI recommendations compared to women who did not receive chemotherapy but more adherent to recommendations related to fruit and vegetable consumption. White women were more likely to be adherent to BMI recommendations when compared to non-White women . Women wp<.05), education , and chemotherapy  remained statistically significant. In the multivariate model for fruit and vegetable consumption, education , chemotherapy , and awareness  remained statistically significant. In the multivariate model for physical activity, adherence had no statistically significant correlates.In the multivariate model for BMI adherence, race  as they are no more likely to engage in these health behaviors. Survivors with high recurrence risk would additionally benefit from improved adherence to health behavior recommendations given the high rate of chemotherapy use in this population, as these health behaviors could ameliorate some sequelae of chemohormonal therapy type DX test and thus positioned us to ask novel questions about the influence of genomic testing on health behaviors. Further, to our knowledge, this is the largest study to date to include self-report data from women who have received this testing. Despite these strengths, we were limited by our cross-sectional, self-report data and that women were, on average, almost two years from diagnosis. We also do not know the degree to which lifestyle counseling was part of the care received by the participants in this study. Finally, though findings for fruit and vegetable consumption's effect on recurrence risk are equivocal, eating these foods regularly substantially reduces cardiovascular risk Strengths of our study are its multi-site sample of breast cancer survivors for whom the findings are clinically relevant. Women in our study were among the first to receive the OncoOur findings corroborate previous research with cancer survivors suggesting that adherence to health behaviors for this population is less than optimal and that there are significant disparities in adherence. While cancer survivors are aware that health behaviors may play some role in reducing cancer recurrence, this awareness often does not translate to action. Interventions should focus on strategies to facilitate actions, such as providing survivors with the appropriate skills and resources to achieve a healthy lifestyle, with a special focus on BMI reduction


The present study assessed more than 800 potential risk factors to identify new predictors of breast cancer and compare the independence and relative importance of established risk factors.Data were collected by the Women's Health Initiative and included 147,202 women ages 50 to 79 who were enrolled from 1993 to 1998 and followed for 8 years. Analyses performed in 2011 and 2012 used the Cox proportional hazard regression to test the association between more than 800 baseline risk factors and incident breast cancer.Baseline factors independently associated with subsequent breast cancer at the p<0.001 level  were breast aspiration, family history, age, weight, history of breast biopsies, estrogen and progestin use, fewer live births, greater age at menopause, history of thyroid cancer, breast tenderness, digitalis use, alcohol intake, white race, not restless, no vaginal dryness, relative with prostate cancer, colon polyps, smoking, no breast augmentation, and no osteoporosis. Risk factors previously reported that were not independently associated with breast cancer in the present study included socioeconomic status, months of breast feeding, age at first birth, adiposity measures, adult weight gain, timing of initiation of hormone therapy, and several dietary, psychological, and exercise variables. Family history was not found to alter the risk associated with other factors.These results suggest that some risk factors not commonly studied may be important for breast cancer and some frequently cited risk factors may be relatively unimportant or secondary. Breast cancer risk factors have been studied often. The present study has the advantage of simultaneously considering many risk factors. This makes it possible to find new risk factors, assess the relative importance of risk factors, and assess which risk factors are secondary (their association is removed by adjusting for other risk factors). The data for the present study were collected by the Women's Health Initiative (WHI). Because the WHI is a prospective study with a large, comprehensive, meticulously collected database, it is especially well-suited for evaluating risk factors.The WHI study design has been described in detail . In brieParticipants available for analysis included 161,807 WHI participants: 93,675 from the OS, 16,608 from the RCT of estrogen plus progesterone (E+P), 10,739 from the RCT of estrogen only , and 40,785 additional women who were in the diet study and not in a RCT of hormone therapy. To minimize the inclusion of participants with a history of breast cancer, we excluded from the present analysis those who reported a history of breast cancer, a breast removed, or current antineoplastic therapy. Of the 161,807 participants in the dataset we excluded 7,906 because of a possible history of breast cancer and 825 patients who could not influence the analysis because they did not have follow-up. An additional 5,874 participants were excluded from the final analyses because they did not have data on all factors independently associated at the p<0.001 level with the development of breast cancer. There were 147,202 women included in the final analyses.Several data sources were used to determine breast cancer recurrence and the date of this recurrence . For folThere were 869 factors that characterized subjects at baseline that were evaluated for an association with the risk of breast cancer for all participants and an additional 102 factors were evaluated for an association with participants in the OS. Types of information included demographic, general health, clinical and anthropometric, functional status, healthcare behaviors, reproductive, medical history, family history, personal habits, thoughts and feelings, therapeutic class of medication, hormones, supplements, and dietary intake. Scales used in this study that we anticipated might be important included stressful life events , optimism  and depression .Analyses were performed in 2011 and 2012 using the Cox proportional hazard regression model to find the hazard ratio of breast cancer associated with a factor after adjusting for other risk factors. We first tested the statistical significance of each potential risk factor after adjusting for only the study that recruited the patient, age, and race. All variables that were statistically significant at the p<0.05 level were then included in a backwards stepwise Cox proportional hazard regression analysis, and variables that were statistically significant at the p<0.001 level were retained in the model. We then retested the statistical significance of all variables not in the model to determine if any should be added because they would be significant at the p<0.001 level. The significance level of the variables was not adjusted for multiple comparisons because this might obscure meaningful results.The hazard ratio was usually reported for a one unit increase in the risk factor. For age risk was measured for a 10 year increase, and where noted the hazard ratio was for an increase in one standard deviation of the risk factor. For categorical variables a reference category was chosen, and the hazard ratios were shown for other categories compared to the reference category. Some ordinal variables were also divided into categories, and in addition to an overall hazard ratio and significance test for the ordinal variable there was a hazard ratio comparing a given category to the reference category.To test whether the risks associated with some variables were influenced by others, we tested pairs of the statistically significant independent variables for interaction.In addition to testing the variables in the complete dataset, we also tested the results for participants in each of three subsets: 1) the OS, 2) the RCT of diet, and 3) the combination of the two RCTs of hormone therapy that were each relatively small.Missing data for variables that were not independently significant were imputed prior to the analysis of these variables by the mean value for ordinal or binary variables and the mode value for categorical variables.Statistical analyses were performed using SAS version 9.0 .The demographic characteristics of the participants are shown in As shown in The highest chi-squared values in The best way to show how hazard ratios for continuous variables varied across data sets was to compare the hazard ratio for the continuous form of variable. The confidence intervals for categories of continuous variables in the individual datasets were wide and comparisons were less meaningful. The number of years of hormone use had a stronger association with subsequent breast cancer in the observational and RCT for diet datasets than it did in the RCTs for hormone therapy in these RCTs the past use of hormones had no association with the future use, which was determined by random assignment. The hazard ratios were similar for the observational study and the RCT for baseline use of estrogen plus progesterone but not for baseline use of estrogen alone.The risk of breast cancer decreased for women as they had more children, up to a 39% reduction for women who had seven or more births. Later age at menopause, breast tenderness and benign breast disease were associated with a higher risk, while vaginal dryness and breast augmentation were associated with lower risk.Participants who had a mammogram were at higher risk for breast cancer although this was greatly reduced after taking into account the variables that were independently significant. There may have been a protective effect of having an oophorectomy prior to age 40. Neither first birth after age 30 nor breast feeding for at least 2 years had a statistically significant independent association with breast cancer. Later age at menarche had a protective but weak association with breast cancer.As shown in The risk of breast cancer also increased with history of thyroid cancer, the use of cardiotonic medications , greater alcohol consumption, a history of colon polyps, greater smoking, and a relative with prostate cancer. It decreased for women who reported themselves to be restless and fidgety or having a history of osteoporosis. Although the hazard ratios for some risk factors  varied considerably among the datasets, this variation was not statistically significant.Factors previously evaluated in the literature that were not associated with breast cancer at the p<0.001 level after adjusting for age, race, and study are shown in Not shown in A large, diverse study population with long follow-up and comprehensive participant information was used to evaluate numerous potential risk factors for breast cancer in postmenopausal women. The study found many factors associated with breast cancer and 20 independently associated at the p<0.001 level of statistical significance. The large sample size made it possible to detect relatively weak associations and to precisely estimate the strength of association between the risk factor and breast cancer. Because numerous factors were examined, it was possible to show that some factors mediated the risk associated with others. Associations between a risk factor and outcome disappeared after adjusting for mediating risk factors.The statistically significant independent risk factors in decreasing order of their chi-squared values for one degree of freedom were number of previous breast aspirations, breast cancer in first degree relatives, age, weight, a previous breast biopsy, years using estrogen and progesterone, fewer live births, use of estrogen and progesterone at baseline, age at menopause, a history of thyroid cancer, breast tenderness, digitalis use, at least one drink per week, less restlessness, lack of vaginal dryness, relative with prostate cancer, colon polyps, no breast augmentation, smoking more than 15 cigarettes a day, and no osteoporosis.Factors of little importance after adjusting for the independent risk factors included socioeconomic status, breast feeding, age at first birth, obesity measures, adult weight gain after adjusting for current weight, and several dietary, psychological, and exercise variables. There was no evidence that family history influenced the association of breast cancer with the number of live births or alcohol consumption. There was also no evidence that greater weight reduced the risk associated with estrogen plus progesterone.Greater weight may be associated with breast cancer because it is associated with hormone levels likely to contribute to breast cancer including higher leptin levels, lower adiponectin levels, and higher estrogen levels . Weight Some variables highly associated with breast cancer in this study directly increase exogenous hormone levels. Others such as number of births and age at menopause indirectly influence hormone levels by influencing the number of lifetime menstrual cycles . The risOne of the highest hazard ratios was seen with thyroid cancer. This might have been secondary to the radiation exposure in the treatment for thyroid cancer. It is also possible that both the thyroid cancer and the breast cancer may have been increased by medical radiation as treatment for benign conditions such as acne or for medical or dental diagnostic tests that used excessive radiation .A well established set of risk factors commonly used in studies of breast cancer  include Some risk factors found in previous literature were weaker in this study  some weWe found evidence of a weak association between breast cancer and smoking that had been found in other studies  althoughWe are unaware of studies that evaluated some risk factors that were independently significant in this study: number of breast aspirations, vaginal dryness, breast augmentation, and restlessness.This study assessed the relative importance of several risk factors for breast cancer and identified some new risk factors. Some previously identified factors were only weakly associated with breast cancer after adjusting for other risk factors.


Breast cancer incidence varies between social groups, but differences have not been thoroughly examined in New Zealand. The objectives of this study are to determine whether trends in breast cancer incidence varied by ethnicity and socioeconomic position between 1981 and 2004 in New Zealand, and to assess possible risk factor explanations.Five cohorts of the entire New Zealand population for 1981-86, 1986-1991, 1991-1996, 1996-2001, and 2001-2004 were created, and probabilistically linked to cancer registry records, allowing direct determination of ethnic and socioeconomic trends in breast cancer incidence.Breast cancer rates increased across all ethnic and socioeconomic groups between 1981 and 2004. Māori women consistently had the highest age standardised rates, and the difference between Māori and European/Other women increased from 7% in 1981-6 to 24% in 2001-4. Pacific and Asian women had consistently lower rates of breast cancer than European/Other women over the time period studied (12% and 28% lower respectively when pooled over time), although young Pacific women had slightly higher incidence rates than young European/other women. A gradient between high and low income women was evident, with high income women having breast cancer rates approximately 10% higher and this difference did not change significantly over time.Differences in breast cancer incidence between European and Pacific women and between socioeconomic groups are explicable in terms of known risk factors. However no straightforward explanation for the relatively high incidence amongst Māori is apparent. Further research to explore high Māori breast cancer rates may contribute to reducing the burden of breast cancer amongst Māori women, as well as improving our understanding of the aetiology of breast cancer. Breast cancer is the most commonly diagnosed non-skin cancer and the leading cause of cancer death for New Zealand women . Rates oBreast cancer incidence varies between social groups. In general groups with higher income and education have higher rates of breast cancer ,4. WhiteEpidemiological studies suggest that reproductive factors play a major role in determining breast cancer risk. Older age at first birth, lower parity, lack of breast feeding, younger age at menarche, older age at menopause and use of menopausal hormone therapy (HT) are all related to increases in breast cancer risk , and canDifferences in breast cancer incidence between social groups vary by age ,16. ThisThis paper examines variation in breast cancer incidence by socioeconomic status and ethnicity in New Zealand over 25 years from 1981. There are a number of reasons for investigating this issue. Firstly, there are known differences between social groups in New Zealand in terms of risk factor patterns and screening, and so differences in breast cancer incidence between groups are expected. Moreover, reproductive patterns and other important risk factors are changing over time and differentially between socioeconomic and ethnic groups. We would therefore expect that ethnic and socioeconomic patterns in breast cancer incidence may also be changing over time. These differences may also vary with age, as they do between social groups in other countries. Secondly, "expected" patterns of breast cancer incidence between social groups based on risk factor distribution are not always seen, pointing to alternative aetiological explanations ,22. In NThirdly, recent work in New Zealand suggests an emerging trend of higher breast cancer mortality among Māori women and women of lower socioeconomic status , but it The aims of this paper are:To examine differences in breast cancer incidence between ethnic and socioeconomic groupsTo examine whether differences in incidence between social groups in New Zealand vary over time and by ageThe datasets were created through linking records from the New Zealand Cancer Registry  and records from a 5 yearly census of population and dwellings. Five closed cohorts were created of the New Zealand usual resident population  on census night 1981, 1986, 1991, 1996, 2001, followed up for incident cancer(s) until the subsequent census or in the case of the 2001 cohort, until 31 December 2004 (the most recent data available at the time of the study's record linkage). Cohorts were created using probabilistic record linkage software  to anonymously link census and cancer register records within a geographic area (meshblock or census area unit) on sex, date of birth, ethnicity, and country of birth. Details on the linkage methods, process and outputs are detailed elsewhere ,28.Briefly, 73.2% (1981-86) to 81.7% (2001-04) of eligible cancer registry records were linked to a census record, with 95.2% (1981-86) to 96.9% (2001-04) of these linked census-cancer records estimated to be true links. To adjust for underestimation of rates using the linked datasets, and to correct for any linkage bias whereby the percentage of eligible cancer records linked varied by socio-demographic characteristics, we calculated weights for strata of age, sex, ethnicity, region, small area deprivation, and time since census. All analyses presented in this report use these weights.Approval was granted for this project under the Statistics New Zealand Data Integration Policy , and theThere are four main ethnic groups in New Zealand: 1. the Indigenous people (Māori) who migrated to New Zealand c.1000 AD; 2. those of European origin who commenced migration in the 1800s; 3. people from islands in the Pacific region, with the main migration occurring between 1945 and 1980; and 4. a substantial 'Asian' ethnic group, mostly from a recent wave of migrants -32. By tA modified total ethnicity approach was used for this work. Total ethnicity places an individual in all ethnic groups that they identify with, thus capturing (most) multiple ethnic affiliations of individuals . If indiHousehold equivalised income was calculated and assigned to each individual within the household. Personal incomes were CPI adjusted to 2001, summed over the household and adjusted for number of individuals within the household, using the New Zealand-specific Jensen equivalisation index [on index . EquivalAnalyses were also performed using education as a measure of socioeconomic position, and are available from the authors on request.Cancer outcome was assessed by having a cancer registered on the NZ Cancer Registry. All breast cancers (ICD-10 code C50) were included. Ductal carcinoma in situ (DCIS) was excluded. Cancers prior to 2000 were forward mapped from ICD-9 to ICD-10 codes using mapping codes provided by New Zealand Health Information Service.For the analyses presented here, data were restricted to adults aged 25 and over who were in their usual residence on census night. All analyses were conducted in SAS v8.2 or v9.Person time was censored after development of the first breast cancer. Incidence rates, rate ratios and rate differences  were calculated after direct standardisation of the cohorts to the age structure of the WHO World Standard population , and to Statistical tests of trend were conducted for rates, and rate differences, and of the log transformed rate ratios. All measures were also calculated for all five cohorts pooled .Table Figure Both the relative and absolute differences between Māori and European/other women increased between 1981 and 2004 , are comparable to breast cancer rates in European women in other developed countries. For example, in the US non-Hispanic white women have an annual age standardised rate of 189/100,000 for women 25+,  [The incidence pattern for breast cancer amongst Pacific women is consistent with our knowledge of breast cancer risk factor distribution in this group. Pacific women are more likely than European women to have children, to commence child bearing earlier and to have more children . Lower aRates of breast cancer amongst Asian women were consistently lower than those of European and Māori women. This "Asian" group is diverse both in terms of country of origin and time in New Zealand, and so is likely to be diverse in terms of reproductive patterns and other risk factors for breast cancer, making the results for Asian women hard to interpret. However despite small numbers, the relatively low rates seen are consistent with the low rates seen in Asian countries. For example IARC's Cancer Incidence in Five Continents IX reports age standardised rates per 100,000 for those aged 25+ of 52 in India, 67 in China, 45 in Korea, and 56 in Malaysia for the period 1998-2002  [The high incidence of breast cancer amongst Māori women is however not easily explained, as Māori women have a more favourable (known) risk factor profile than European women. Māori women tend to start having children younger and have more children compared to European women . Māori wThe timing of menarche has previously been postulated as a possible reason for the difference in breast cancer rates between Māori and European women . HoweverSeveral recent studies have suggested that cigarette smoking initiation shortly after menarche and before first full term pregnancy may increase the risk of breast cancer -50. EarlThere is some evidence that there are differences in tumour biology between ethnic groups. For example, there are differences in tumour grade and estrogen and progesterone receptor (ER and PR) positivity between black, Hispanic and white women in the US . In New Indigenous Hawaiian women also have surprisingly high rates of breast cancer given their distribution of risk factors, and it has been postulated that genetic polymorphisms in the sex steroid and gonadotropin metabolism pathways, causing high endogenous hormone levels, are responsible for their high rates . DietaryThe above discussion has been orientated mainly at trying to explain differences between ethnic groups' rates on average, but our study also finds a more rapidly increasing Māori breast cancer rate than European/Other.  This divergence over time may be due to changes in the factors which are driving the underlying differences between Māori and European/Other rates . Alternatively, this change may be due to changes in the distribution of established risk factors amongst the Māori population, overlying the already higher risk for Māori. For example there is some evidence that Māori fertility rates are dropping more quickly than among European women, with a convergence on similar fertility patterns ,59. RapiFinally, it is important to note that breast cancer mortality differences between Māori and non-Māori remain more significant  and are The pattern of higher breast cancer rates amongst women of higher socioeconomic status seen here is consistent with that found internationally -62, and This study is a series of five short-duration cohort studies of the entire New Zealand population, followed up for breast cancer over a 24 year period. By using data from the entire New Zealand (census night) population as well as data from New Zealand's population based cancer registry, it was possible to overcome numerator/denominator bias and misclassification of ethnicity and socioeconomic group. Self identified ethnic affiliation from census forms was used to define the numerator and denominator populations, and therefore produce more reliable estimates of differences between ethnic groups. Individual measures of socioeconomic position were also able to be used rather than relying on area-based measures. Considering trends over 24 years also provides a good basis for understanding evolving differences between population groups.However the study is not without limitations. Statistical imprecision becomes a problem when stratifying by ethnicity or socioeconomic position. This is particular problem for the Asian and Pacific groups where numbers are small. It was not possible to link all cancer records back to the census, and so weighting for linkage bias was undertaken; we are confident that this will have eliminated most bias due to misclassification of outcome. The Cancer Registry Act, which came into effect in 1995, required mandatory registration of all cancers, and there may have been a small artefactual increase in breast cancer registrations following its introduction, but this is not thought to have a had a major effect on breast cancer rates and probably impacted ethnic groups and income groups in a similar manner.Household income is presented as an indicator of individual socioeconomic status. While education measures socioeconomic status closer to the time of reproductive choices which are important for breast cancer risk, more proximal exposures such as post menopausal obesity, screening, and HT use are also important for breast cancer risk and so both measures are relevant. Education also lacks discriminatory power in older women in the earlier cohorts, as the majority of these women fall into the category of no qualifications. As similar results were found for both education and household income a decision was made to only present the results for household income in this paper.Finally, the lack of good information about risk factor distribution in the population, particularly in the relevant time period, makes it difficult to fully interpret the differences found between ethnic and socioeconomic groups; rather, these breast cancer rates over time might provide clues about unmeasured risk factors back in time.Patterns of breast cancer incidence in Pacific women and between socioeconomic groups are probably explicable in terms of the known risk factors for breast cancer. However no straightforward explanation for the relatively high incidence amongst Māori is apparent. Biological explanations put forward for unexpectedly high rates amongst Hawaiian women may provide a clue, but little is known about biological differences in breast tumours or risk factors between Māori and non-Māori and much more work needs to be done in this area. Even if underlying biological or genetic differences explain some of the difference in rates, the faster increase in rates amongst Māori women may in fact be the result of changes in risk factor distribution.Further research should focus on the role of known and new risk factors and the biological characteristics of breast tumours as determinants of the pattern of breast cancer incidence amongst Māori women. It may be that the currently inexplicable differences between Māori and European/Other women at any one point in time, and diverging trends over time, provide a chance for research that can provide new insights into the aetiology of breast cancer. Moreover, such insights may contribute to reducing the burden of breast cancer amongst Māori women.The authors declare that they have no competing interests.CS and TB were responsible for the inception and design of the study. JA participated in the design of the study and was responsible for the analysis of data. RC was responsible for the interpretation of data and drafted the manuscript. CS, DS and TB provided comments on drafts of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/674/prepub


SHMT, MS, MTRR and CBS gene can affect plasma Hcy levels and are associated with breast cancer risk.Folate plays a pivotal role in DNA synthesis, repair, methylation and homocysteine (Hcy) metabolism. Therefore, alterations in the folate-mediated one-carbon metabolism may lead to abnormal methylation proliferation, increases of tumor/neoplasia and vein thrombosis/cardiovascular risk. The serine hydroxymethyhransferase (SHMT), methionine synthase (MS), methionine synthase reductase (MTRR) and cystathionine beta synthase (CBS) regulate key reactions in the folate and Hcy metabolism. Therefore, we investigated whether the genetic variants of the Genotyping was performed by PCR-RFLP method. Plasma Hcy levels were measured by the fluorescence polarization immunoassay on samples of 96 cases and 85 controls.SHMT 1420 T, MS 2756G, MTRR 66G allele frequency distribution showed significant difference between case and controls (p < 0.01 ~ 0.05). (b) The concentration of plasma Hcy levels of SHMT 1420TT was significantly lower than that of the wild type, while the plasma Hcy levels of MS 2756GG, CBS 699TT/1080TT significantly higher than that of the wild type both in case and controls. The plasma Hcy levels of MTRR 66GG was significantly higher than that of wild type in cases. The plasma Hcy levels of the same genotype in cases were significantly higher than those of controls except SHMT 1420CC, MS 2756AA, MTRR 66GG; (c) Multivariate Logistic regression analysis showed that SHMT C1420T , MS A2756G , MTRR A66G  polymorphism is significantly associated with breast cancer risk. And elevated plasma Hcy levels were significantly linked to increased risk of breast cancer .(a) The HMT C1420T mutation may be negatively correlated with breast cancer susceptibility; while MS A2756G and MTRR A66G mutation may be positively associated with breast cancer risk. SHMT C1420T, MS A2756G, MTRR A66G, CBS C1080T, CBS C699T locus mutation may be factors affecting plasma levels of Hcy. The plasma Hcy levels could be metabolic risk factor for breast cancer risk to a certain extent.The current study results seem to suggest a possibility that S St. St26]. Eligible patients with breast cancer were randomly selected from 2010 January to 2011 April in the Third Affiliated Hospital of Kunming Medical College , Yunnan, China. Based on the hospital chart number, cases involved 96 women consecutively selected from subjects with a first confirmed histopathologic diagnosis of breast carcinoma in the age range of 30–77 years. The each types of cancers including infiltrating ductal carcinoma , papillary carcinoma , invasive ductal intraductal carcinoma , smooth cribriform carcinoma , medullary carcinoma , fibrosarcoma , non invasive ductal intraductal carcinoma  and accessory breast malignant tumor . Eighty-five Control subjects comprising individuals without a history of cancer in the age range of 18–76 years were simultaneously recruited form the health examination clinics of same hospital during the same study period. Eventually, the controls were individually matched for age (±3 years) and menopausal status (premenopause or postmenopause) to cases with a 1: 1 case–control ratio.Approval for the present study was obtained from the National Natural Sciences Foundation of China (NSFC) and the Yunnan Scientific and Technological Committee. Once case patients and control subjects agree to participate, written informed consent was obtained from all subjects. Pathology tests were performed and the number of active manifestations recorded for each patient. The pathology tests included morphological pathological examination of breast, nipple discharge cytology, cytological smear, biopsy, endoscopic examination and so on. Data were collected on sociodemographic characteristics, menstrual and reproductive history, menopausal status, lifestyle behaviors and medical history as well as family history of breast and other cancers. More specifically, in this study, menopausal status was defined as last menstruation after one year free of menstrual cycle and no attempt was made to distinguish between women with artificial and those with natural menopause. Subjects taking vitamin supplements in the previous 6 months were excluded from the study.μmol/L. Five cc blood samples were drawn using a 25 gauge needle from a peripheral vein, avoiding haemolysis in the morning hours after an overnight fasting and 30 minutes of supine rest and collected into 10 mL empty evacuated tubes without EDTA, heparin, or clot activators. Samples were centrifuged at 1000 × g for 10 minutes. The plasma was separated in aliquots and immediately frozen and stored at −80°C within 60 minutes until use.Plasma Hcy concentrations  were determined by fluorescence polarization immunoassay (FPIA) technique . FPIA was run on an IMx analyzer . The 95% confidence interval of plasma Hcy level suggested by the manufacturer for healthy individuals is 4.45–12.42 Genomic DNA was extracted from peripheral leukocytes isolated from acid-citrate-dextrose-anti-coagulated blood using a commercially available FlexiGen DNA isolation kit .MS A2756G were determined by polymerase chain reaction (PCR) followed by restriction fragment length polymorphisms (RFLP) ; plasma Hcy level of MTRR 66GG homozygote genotype was significantly higher than that of wild type AA in cases , Due to GG gene was only one in controls, there was no significant difference between three kinds of genotypes; plasma Hcy levels of CBS 699TT genotype was significantly higher than of wild type CC in cases and controls (19.52 ± 15.89) vs. (14.47 ± 3.32) μ mol/L in cases, p < 0.01; (15.47 ± 6.82) vs. (10.36 ± 5.12) μ mol/L in controls, p < 0.01]; plasma Hcy levels of CBS 1080TT genotype was significantly higher than that of wild type CC in cases and controls .Table SHMT 1420CT/TT, CBS 699CC/CT/TT, CBS 1080CC/CT/TT, MS 2756AG/GG, MTRR 66AG/GG group in cases were significantly higher than those in the controls (p < 0.001 ~ 0.01).As shown in Table SHMT 1420TT genotype is inversely associated with breast cancer risk; (ii) the MS 2756GG or MTRR A66G genotype is positively associated with breast cancer risk; (iii) SHMT 1420CC, MS 2756GG, MTRR 66GG, CBS 1080TT, CBS 699TT genotype may be a factor in reducing plasma Hcy levels, and (iv) plasma Hcy level is positively associated with breast cancer risk.The results of the present study of associations between one-carbon metabolism-related gene polymorphisms or plasma Hcy levels and breast cancer risk suggested that (i) Many observational studies have highlighted the importance of adequate folate intake in breast cancer prevention, as reviewed in a recent meta-analysis, but the results were inconsistent . Almost The folate metabolism pathway is complex and involves various enzymes that regulate DNA synthesis and DNA methylation. Among others, SHMT catalyzes the reversible conversion of serine and tetrahydrofolate to glycine and methylene tetrahydrofolate; MS supports methionine homeostasis by catalyzing the remethylation of homocysteine to methionine in a cobalamine-dependent reaction that utilizes 5,10-methylenetetrahydrofolate reductase (MTHFR) as methyl donor ,38; and SHMT 1420TT genotype were lower at risk of breast cancer, consistent with previous studies [SHMT 1420CC genotype is lower and thus less folate is available for DNA methylation. Our study also showed a significant interaction between the MS A2756G or MTRR A66G and risk of breast cancer. The MS 2756GG and MTRR 66GG genotype increases the risk among Chinese women in the present study. While functional effects have yet to be fully established, the G allele of MS and MTRR are considered to decrease the enzyme activity compared with the A allele [MS 2756GG or MTRR 66GG may have reduced methionine levels compared with those who had other genotypes and therefore our finding of increased breast cancer risk is plausible. In our study, SHMT 1420 CC genotype carriers were found to have increased plasma Hcy levels compared to TT carriers. For the MS 2756 A → G polymorphism, decreased Hcy levels have been found for the GG genotype as compared to the AA genotype. For MTRR A66G elevated Hcy levels for carriers of the homozygote wild-type genotype (AA) as compared to other genotypes. However, the results in this study may have occurred by chance due to small size of SHMT 1420TT, MS 2756 GG and MTRR GG genotype and information on SHMT, MS and MTRR polymorphisms and breast cancer is scarce, thus further investigations are needed.Our results showed individuals with the  studies ,40. ThisA allele ,42. SubjTT genotype of the CBS gene, with increased cancer risk. Furthermore, our results showed CBS C699T/ C1080T polymorphisms can remarkably increase plasma Hcy level, suggested CBS 699 or 1080 mutation maybe make the loss of CBS expression lead to the accumulation of Hcy, which will be recycled to methionine by MS via the remethylation pathway [The gene CBS, located on chromosome 21q22.3, encodes an important enzyme involved in transulfuration of Hcy produced during methyl-group metabolism . Notably pathway . As methThere are evidence for a role of Hcy in pathogenesis of cardiovascular diseases , renal fMS, MTRR, SHMT, CBS polymorphisms, elevated plasma Hcy levels and increased risk of breast cancer. More research is needed regarding the functional effects of polymorphisms in these genes as related to effects on folate metabolism and subsequent folate availability and large populations are required to examine these gene-gene and gene-nutrient interactions using traditional epidemiologic methods. New methods of mathematical modeling developed for this pathway may provide insight into the effects of modifying components of the system to inform future studies. Additional studies are needed to replicate our findings in different racial/ ethnic groups and improve our ability to predict the effects of polymorphisms within genes in one-carbon metabolism and folate status. Future studies are needed to prove causality and provide insight on the mechanism of action of Hcy in breast tumorigenesis. In the study, there is big difference between the minimum age of cases (30y) and controls (18y) due to unequal number of cases and controls in order to ensure the average age is similar. The sample size was small and therefore the associations obtained need to be verified by prospective follow-up studies including a replication or larger number of subjects in future.In summary, we have shown a significant association among SHMT: Serine hydroxymethyhransferase; MS: Methionine synthase; MTRR: Methionine synthase reductase; Hcy: Homocysteine; CBS: Cystathionine beta synthase; MTHFR: 5,10-methylenetetrahydrofolate reductase; OR: Odds ratio; CI: Confidence interval; FPIA: Fluorescence polarization immunoassay; RFLP: Restriciton fragment length polymorphism.The authors declare that they have no competing interests.XW is responsible the majority in this work, including execution of experiments, data analysis, composition of this report and publication; TZ is responsible for providing samples; NC and JN contributed some of the work and provided instruction; WX provided some of data analysis; TZ is responsible for proofreading work; XW as the corresponding author is responsible for the general work including experiments and publication. All authors have read and approved the final manuscript.


Although few studies have linked cognitive variables with adherence to mammography screening in women with family histories of breast and/or ovarian cancer, research studies suggest cognitive phenomena can be powerful adherence predictors.This prospective study included 858 women aged 30 to 71 years from the Ontario site of the Breast Cancer Family Registry with at least one first-degree relative diagnosed with breast and/or ovarian cancer. Data on beliefs about breast cancer screening and use of mammography were obtained from annual telephone interviews spanning three consecutive years. Self-reported mammogram dates were confirmed with medical imaging reports. Associations between beliefs about breast cancer screening and adherence with annual mammography were estimated using polytomous logistic regression models corrected for familial correlation. Models compared adherers (N = 329) with late-screeners (N = 382) and never-screeners (N = 147).Women who believed mammography screening should occur annually were more likely to adhere to annual screening recommendations than women who believed it should happen less often . Women who believed mammography screening should start at or before age 50 (rather than after)  were significantly more likely to adhere when compared with never-screeners.Study results suggest that women with a family history of breast cancer should be strongly communicated recommendations about initial age of screening and screening intervals as related beliefs significantly predict adequate adherence. Given higher cancer detection rates  and incrwhen to begin screening and how long to wait between screening events.Although social cognitive studies reveal beliefs to be strong adherence predictors across a spectrum of treatments and screening procedures -10, veryFamily History Questionnaire. Respondents meeting a defined set of family history criteria and a random sample (25%) of those not meeting the criteria were asked to participate in the Ontario site of the BCFR. Of those identified at this stage as eligible, 72% (1851/2587) participated.A cohort of female relatives of incident cases of invasive breast cancer was selected from the Ontario site of the Breast Cancer Family Registry (BCFR) funded by the United States National Cancer Institute. A description of the BCFR and the Ontario site of the BCFR have been published . In brieEpidemiology Questionnaire between 1998 and 2004. Our study was conducted a few years after the initial recruitment of relatives. For our study, we identified all female relatives who had: 1) enrolled in the Ontario site of the BCFR; 2) completed an Epidemiology Questionnaire; 3) been unaffected by breast cancer at the time of the proband’s diagnosis date; and 4) were alive and between the ages of 30 and 69 years as of January 1st, 2006. Sample size for our study was limited to the number of female relatives participating in the BCFR study, so power calculations were performed assuming we would have an 80% response rate from eligible women. From the 3374 participating female relatives, 2066 (61%) were residents of Ontario and 1471 (71.2%) of these women met our study inclusion criteria. Women participating provided written informed consent and this study was approved by the Research Ethics Boards of Mount Sinai Hospital and the University Health Network.Probands identified from the OCR were asked for address information and permission to contact specific living relatives . An invitation letter to participate in the Ontario site of the BCFR was sent to relatives. Those agreeing to participate were sent an Personal History and Screening Questionnaire between November 2005 and March 2007. Those who were contacted and agreed to be interviewed were followed up annually for two years using the Year 1 and Year 2 Follow-up Personal History and Screening Questionnaire. An introductory letter and copy of each questionnaire were sent approximately two weeks before being contacted by phone. This allowed time for participants to recall specific dates and events and allowed referral to the questionnaire during the interview.Information was obtained from three questionnaires. Eligible women were sent a baseline The baseline questionnaire collected key demographic characteristics, detailed information on breast cancer screening examinations and women’s beliefs about breast cancer screening. At each follow-up interview, women were asked whether they had a mammogram since their last contact. Women who reported having a mammogram were asked to give either the dates (month and year) of, or their age at, their last mammogram and the clinic or hospital where it was performed. In addition, for women who provided written consent to access their imaging report, the date and reason for the mammogram were abstracted.Data on beliefs about breast cancer screening were obtained from questions concerning mammographic frequency  and initial age for mammographic screening . Women were also asked about the importance  of several risk factors: high fat diet, alcohol use, lack of exercise, and family history. Finally, women rated the likeliness  of screening tests  finding breast cancer.Information on time-since-last-mammogram and the reason for mammographic examination obtained from the imaging report were combined to determine adherence with an annual screening recommendation. A mammogram was considered a screening mammogram if the indication on the imaging report was given as routine or regular screening and non-screening if the mammogram was performed because of a reported symptom or breast problem. Adherence was defined as returning within 18 months of a woman’s first reported screening mammogram which may have been reported in their baseline or year 1 follow-up interview.Family History Questionnaire completed by the relative’s proband using a modified definition of previously referenced groups for familial breast cancer risk [Family history risk of breast and/or ovarian cancer was based on information collected from the cer risk ,20. WomeDemographic questions included date of birth from which age at interview was calculated , highest level of education achieved  and current marital status . Information on health practices included a question on the number of yearly visits to health professionals on average in the last two years .Polytomous logistic regression analyses were used to examine associations between demographic characteristics, health practices, familial risk, breast cancer screening beliefs and adherence with annual screening within 18 months of the first reported mammogram, adjusted for age at baseline interview. Breast cancer screening belief questions were also adjusted by education, visits to health professionals and family history risk. Adherers were compared to late-screeners and never-screeners in each model. Models including interactions between each belief question and age or familial risk were examined to assess whether they were potential effect modifiers for breast cancer screening and beliefs. As no interaction was evident, no stratified analyses were performed. Since many study participants were members of the same family and could have similar cancer screening behaviors, a robust variance estimate was used to adjust for potential correlation due to family clustering ,22. AdjuPersonal History and Screening Questionnaire, 1309 (89.0%) were contacted, 1071 (81.8%) agreed to participate and 69 women were ineligible (n = 37 had a breast cancer diagnosis and n = 32 did not have a first-degree relative with breast and/or ovarian cancer). Of the 1002 women sent a Year 1 Follow-up Personal History and Screening Questionnaire, 942 (94.0%) were interviewed. Of the 936 women without breast cancer sent a Year 2 Follow-up Personal History and Screening Questionnaire, 856 (91.5%) were interviewed. Women who reported having a mammogram  were asked to provide written consent for access to their medical imaging report. In total, 776 (95.0%), 536 (96.0%) and 511 (94.6%) consented to share their mammogram report after completing the baseline, year 1 and year 2 questionnaires, respectively; and of these, 774 (99.7%), 453 (84.6%) and 497 (97.3%) reports were received.Of the 1471 eligible women sent a baseline Of the 646 eligible women with a baseline screening mammogram Figure , 420 repThe final sample size included 858 women from 569 unique families of which 381 (67.0%) had one family member, 121 (21.3%) had two family members and 67 (11.7%) had three to seven family members. The majority of adherers and late-screeners were aged 50 years or older  whereas the majority of never-screeners were under age 50 (87.8%)  than women who believed in a lesser frequency  than women who believed they should return less often. Subjects who believed they should start screening before 50 years of age (rather than afterwards) were nearly 10 times more likely to adhere than those who were never-screened.Studies of average risk women between 50-69 years participating in screening programs and two broader population surveys including women 40-75 years have shown that a high proportion believe in the appropriate frequency of screening. Between 77.2% and 94.1% reported beliefs that women should be screened every 1-2 years ,13,18,24The same association between beliefs regarding screening timeliness and adherence was supported in a previous study of average-risk women, 50-75 years, attending the Ontario Breast Screening Program. We found those who believed in less frequent than biennial screening were significantly less likely to biennially screen . These fWe found no significant association between women believing a mammogram was likely to find breast cancer and screening adherence. This contrasts with previous research that found women who believe mammograms are effective are more likely to adhere ,14. One Previous research in average risk women has shown that referring physicians have an important influence on women, in terms of both initially attending screening and subsequent screening adherence ,13,25-28To our knowledge, this is the first study to examine the impact of beliefs about breast cancer screening on screening adherence in women at high familial risk. Because our study includes a large cohort of female relatives of population-based breast cancer cases, there was sufficient power to examine associations and minimize self-referral bias. An additionally important strength is our prospective examination of the impact of beliefs on adherence. Finally, we obtained actual mammography dates to calculate adherence rather than relying on self-reported data. While self-reported mammography data has been found to be accurate for determining whether a woman has had a mammogram, it is less accurate in determining the interval since last mammogram .Our study limitations include being unable to determine adherence or non-adherence in approximately 7.0% of women who did not provide consent to access their mammogram report and in 7.4% of women who were lost to follow-up. In addition, self-reported data was used for determining family history of breast cancer. Previous research has demonstrated that patient-reported family cancer histories for first-degree relatives are accurate for breast cancer risk assessments, although accuracy is somewhat lower for second-degree relatives . FinallyAltogether, this study found that believing in the appropriate frequency and age range to begin breast screening was associated with significantly increased adherence to annual screening for women at familial risk. In contrast, beliefs about the importance of risk factors for breast cancer were not associated with adherence. Study results suggest women with a family history of breast cancer should continue to be informed about breast cancer screening benefits, but special emphasis should be placed on strongly communicating the recommended frequency and age to begin screening for women at increased familial risk. If women develop strong beliefs about optimal frequency and age to begin screening, our study indicates their breast screening adherence will be significantly improved.BCFR, Breast Cancer Family Registry; OCR, Ontario Cancer Registry; OR, Odds Ratio; CI, Confidence Interval.The authors declare that they have no competing interests.PR, AMC, GG, JAK and ILA conceived of the study and participated in its design and coordination. SAE, AMC, PR and LM performed statistical analyses and interpretation of the data. PR, SAE and AMC drafted the manuscript and GG, LM, JAK and ILA helped revise the manuscript. All authors read and approved the final manuscript.This research was supported by the Canadian Breast Cancer Research Alliance (Grant 016270). This work was also supported by the National Cancer Institute, National Institutes of Health under RFA-CA-06-503 and through cooperative agreements with members of the Breast Cancer Family Registry and Principal Investigators, including Cancer Care Ontario (U01 CA69467). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast CFR, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the Breast CFR.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/518/prepub


The study was conducted to determine the correlations between serum concentration of selected macro- and microelements, namely: magnesium (Mg), copper (Cu), zinc (Zn), arsenic (As), calcium (Ca), cadmium (Cd) chromium (Cr) and selenium (Se) with increased or decreased predisposition to breast and ovarian cancer.The subjects selected for the trial were Polish women, positive for at least one of three founder mutations in BRCA1 gene dominating in Poland . Persons with detected tumor were considered as cases and the others were considered as controls. One case and two controls were paired regarding many criteria  to achieve the maximum of similarity between them.All the elements were quantitatively measured simultaneously in diluted serum samples by inductively coupled plasma mass spectrometry (ICP-MS) using mass spectrometer  in standard mode  and in DRC mode  with methane as a reaction gas, for removing polyatomic interferences in measurement.Statistically significant differences have been found for arsenic and zinc. In case of arsenic, individuals classified in the second and fourth quartile had a significantly higher risk of breast or ovarian cancer than those in the first quartile. In case of zinc a significantly lower risk of breast or ovarian cancer was observed among individuals classified in the second quartile. The data are shown in Table Apart from the influence of single elements some interactions from combinations of arsenic, magnesium, cadmium, zinc and calcium with selenium were also analyzed. The combinations with statistically significant differences between quartiles in the disease risk are shown in Table


BRCA1 and BRCA2 in the mid 1990’s has transformed the management of breast and ovarian cancer families. As part of the Malaysian Breast Cancer Genetic Study [MyBrCa], University of Malaya and CARIF have established a genetic counseling, genetic testing and risk management clinic for high-risk breast and ovarian cancer families. We studied the uptake and acceptance of screening and prophylactic surgery amongst women who carry a BRCA1 or BRCA2 mutation.The discovery of BRCA1 and BRCA2 genes. Of these, 56 index patients (15%) were found to carry deleterious mutations. All patients and their relatives who carry mutations in these genes were offered follow-up in a dedicated risk management clinic. The clinic is run jointly by a consultant breast surgeon, gynae-oncologist, a genetic counselor and supported by a consultant radiologist.Between Jan 03 and Dec 10, a total of 384 patients in the MyBrCa Study had full sequencing and large rearrangement analysis of both Of 56 index patients, 40 (71%) chose to know their genetic test results. In addition, 18 female relatives were identified as carriers. Six had passed away. Thus, 52 female carriers are being followed-up . Of these, 25 women or 62.5% [24 previously affected by breast cancer and 1 unaffected BRCA carriers] chose to attend a dedicated risk management clinic at University Malaya Medical Centre. Of these 24 affected women, 4 (17%) already had bilateral mastectomies for bilateral breast cancers, 5 (24%) chose to have risk reducing mastectomy (RRM), the remaining 16 (76%) chose breast surveillance [only 6 had MRI] and none took up chemoprevention with Tamoxifen. Of the 19 women who did not have previous TAHBSOs, 12 (63%) chose risk reducing salpingo-oopherectomy (RRSO).The uptake of RRM was lower than RRSO. This study shows that although specialized risk management clinics are acceptable in a high proportion of clients, reasons for not wanting to attend a risk management clinic should be explored.


Women of higher socioeconomic status (SES) are at increased risk of developing breast cancer, but it is unclear to what extent this is mediated by differences in mammographic breast density, a well-established breast cancer risk factor. Here we explore the relationship between volumetric breast density and SES.Data from 6,398 perimenopausal/postmenopausal women undergoing routine NHSBSP screening were obtained from those consenting to the PROCAS (Predicting Risk Of Cancer At Screening) study. SES was assessed by obtaining the Index of Multiple Deprivation (IMD) associated with each participant's postcode. Volumetric breast density was measured using Volpara™. The association between volumetric breast density and IMD, adjusting for age, HRT use and BMI, was assessed using linear regression.P < 0.001), suggesting that increasing deprivation (lower SES) is associated with reduced breast density. A decreasing trend in IMD was seen with Volpara™ VDG breast density category  is not strongly associated with breast density. Established SES gradients in breast cancer risk are likely to be related to other SES-related factors, primarily BMI, rather than mammographic breast density.