Aspirin (ASA) use has been associated with improved breast cancer survival in several prospective studies.We conducted a nested case–control study of ASA use after a breast cancer diagnosis among women using Swedish National Registries. We assessed prospectively recorded ASA exposure during several different time windows following cancer diagnosis using conditional logistic regression with breast cancer death as the main outcome. Within each six-month period of follow-up, we categorized dispensed ASA doses into three groups: 0, less than 1, and 1 or more daily doses.increased risk of breast cancer death: HR (95% CI) = 1.43 (1.09-1.87).We included 27,426 women diagnosed with breast cancer between 2005 and 2009; 1,661 died of breast cancer when followed until Dec 31, 2010. There was no association between ASA use and breast cancer death when exposure was assessed either shortly after diagnosis, or 3–12 months before the end of follow-up. Only during the period 0–6 months before the end of follow-up was ASA use at least daily compared with non-use associated with a decreased risk of breast cancer death: HR (95% CI) = 0.69 (0.56-0.86). However, in the same time-frame, those using ASA less than daily had an Contrary to other studies, we did not find that ASA use was associated with a lower risk of death from breast cancer, except when assessed short term with no delay to death/end of follow-up, which may reflect discontinuation of ASA during terminal illness. Postulated mechanisms include the inhibition of prostaglandins which stimulate angiogenesis, inhibit apoptosis, and stimulate aromatase activity and thus increase estrogen levels; ASA may also inhibit platelet-induced adhesion of circulating tumor cells that initiate metastases [In Western countries, increasingly effective adjuvant systemic treatment has entailed a gradual improvement in breast cancer survival . Neverthtastases . UltimatIn the absence of randomized trials, large prospective observational studies remain important to advance this field of research. To this end, we used unique Swedish population-based registers allowing a prospective nation-wide study with drug intake ascertained through a prescription register. We hypothesized that women with breast cancer who took ASA would experience a lower risk of death from breast cancer compared to similar women not taking ASA.Using the Swedish National Cancer Register, we identified 33,697 female patients with a first incident breast cancer diagnosis between April 1, 2005 and December 31, 2009. We excluded 6,244 patients who had a record of another cancer diagnosis (except non-melanoma skin cancer) prior to breast cancer, 22 cases diagnosed at autopsy, and 5 individuals with erroneous coding of dates of last follow up. Reporting of cancers by clinicians and pathologists has been required by Swedish law since 1958, and the completeness of the Cancer Registry is now approaching 100% for breast cancer. Using the National Registration Numbers assigned to all Swedish residents, the cohort was further linked with other nation-wide registers including the Prescribed drug Registry, the Cause of death Registry, the Patient Registry and the LISA  registry including information on highest achieved educational level  [Linkage to the Population Registry allowed us to censor the 44 women who were lost to follow-up because they moved out of the country. Linkage to the death registry allowed us to achieve virtually complete follow-up with regard to vital status and to ascertain date of death as well as cause of death up to Dec 31, 2010.The study was approved by the Regional Ethics Committee, Karolinska Institutet, Stockholm Sweden (2007/1335-31/4). No patient consent was needed.Within the final cohort of 27,424 patients with a first incident breast cancer diagnosed during the study period, we used a nested case–control design to investigate the association between the dispensing of ASA at different time intervals after breast cancer diagnosis and risk of breast cancer death. In the main analysis, cases were all individuals in the cohort experiencing death due to breast cancer during the study period starting from 3 months following breast cancer diagnosis. We did not consider exposure or outcome events during the first three months after diagnosis since most women are expected to use pain killers including ASA immediately following surgery. Death due to breast cancer was defined as having breast cancer as the main cause of death.. The end of follow-up for each matched risk set was considered to be the time of death for the case. In analyses stratified by stage at breast cancer diagnosis , new controls were sampled to the cases in each stratum and additionally matched on breast cancer stage. In a secondary analysis, cases were defined as breast cancer patients who died of non-breast-cancer related causes, and controls were sampled from within the cohort using a similar procedure as described above.For each case we randomly selected 2 controls via risk-set sampling using time since diagnosis as the time scale. Additionally, cases and controls were matched on age and calendar year of breast cancer diagnosis. Since we sampled controls at the time of the event of the case, we took drop outs and other deaths into accountst of July 2005 [The Swedish Prescription registry has recorded all prescriptions dispensed at Swedish pharmacies prospectively beginning from 1uly 2005 . In the We classified drug intake according to the following principles: within each six-month period of follow-up, we added up the total number of dispensed ASA and categorized drug intake into three different groups; unexposed individuals (0 daily doses), partially exposed individuals (less than 1 daily dose) and fully exposed individuals (1 or more daily doses of either 75 or 160 mg). To account for possible variation in the dispensing of drugs during follow-up, exposure was assessed during different time windows; 3–9 months following diagnosis, 6–12 months before end of follow-up, 3–9 months before end of follow-up and, 0–6 months before end of follow-up. Furthermore, we examined cumulative exposure as the percentage of follow-up time as exposed in three different analyses. The date of entry (i.e. 3 months following diagnosis) was used as starting point in all three analyses, and the proportion of follow-up time as exposed was summed up to 6 months before end of follow-up, 3 months before end of follow-up, or up to the end of follow-up, respectively.Non-aspirin NSAIDs may also affect breast cancer survival, and NSAID use may correlate with ASA use. Therefore, since NSAID use may confound the association tested, we assessed NSAID dispensings (ATC codes starting with M01A) in a similar fashion to ASA, as described above, in order to be able to adjust for NSAID use as a covariate (yes/no in each time window investigated).th Revision. Since 2001, this register also records visits in specialized outpatient care. Because of concern that underlying diseases might confound an association between drug intake and breast cancer survival, we linked the entire study cohort to the Patient registry for the period 1987 to 2009. Co-morbidity was assessed in two major groups: diseases for which ASA use is recommended  and diseases where ASA may be counter-indicated . Since the Patient Registry is confined to records of hospital admissions and/or specialized outpatient visits and not visits to the general practitioner, we consider the comorbidity assessment to represent severe disorders.The Swedish National Board of Health and Welfare has compiled data on individual hospital discharges in its Patient registry which has had nation-wide coverage since 1987 as previously described [We analyzed the association between low-dose ASA and risk of breast cancer death, using conditional logistic regression, with one analysis for each exposure window investigated. All models were adjusted for co-morbid diseases and educational level as a proxy for socioeconomic status. For each analysis the co-morbid diseases status was evaluated before the start of each exposure window, thus allowing co-morbid status to vary between analyses. For analysis per each time window, only cases (and the respective controls) that were followed-up long enough to experience the whole exposure window were included. For example, to be included in the analysis of exposure 3–9 months before end of follow-up the case had to survive at least 9 months from entry. Since we use a nested case–control design with risk-set sampling of controls, we were in fact measuring the same quantity as in a time-to-event analysis. By sampling controls among those at risk at each time of an event, we have controlled for follow-up time, and the estimated odds ratios from the conditional logistic regression were therefore regarded and reported as hazard ratios .Table Overall survival in the group was 94% at 2 years and 83% at 5 years after diagnosis.  = 1.43 (1.09-1.87).There was no association between ASA use and breast cancer death in Exposure Periods A, B, and C. For Exposure Period D only (6 to 0 months before end of follow-up), was there a decreased risk of breast cancer death among those using ASA at least daily compared to non-users; HR (95% CI) = 0.69 (0.56-0.86). However, we found no evidence of a dose–response association in this time-window, as those using ASA less than daily had an In Table The analyses in Tables In secondary analyses, we assessed whether results differed by stage at diagnosis. We repeated the analysis in Table We assessed whether ASA intake was associated with non-breast cancer causes of death in an analysis similar to that of Table In this nested case–control study using linked prospectively recorded Swedish cancer registry, death registry, and national pharmacy data, we found little evidence that ASA intake among women diagnosed with breast cancer reduces risk of breast cancer death. After assessing ASA exposure multiple different ways, we found that only when ASA intake was assessed short term without any delay  was it associated with a reduced risk of breast cancer death similar in magnitude to that reported in most other studies assessing ASA and/or NSAIDs -13. ThisLimitations of our study include the following: ASA is available over-the-counter in Sweden as in all countries. Since we relied on pharmacy records, we undoubtedly misclassified ASA use as many categorized as non-users by pharmacy records were likely users. However, low-dose ASA (for example to prevent heart disease) constitutes close to 90% of all ASA sold in Sweden, and low-dose forms are only available through prescription . With thWe must consider why our results differ from other prospective studies of the same question. Of the four published studies, The Iowa Women’s Health Study reported a RR 95% CI) of breast-cancer death, 0.53 (0.30-0.93) for women with breast cancer using ASA compared to nonusers , and the5% CI of Firstly, misclassification of ASA use mentioned in the limitations above  would tend to underestimate any ASA effect.Secondly, follow-up time in the two previous studies null for ASA intake ,15, and Our lack of finding a cumulative dose or duration effect was similar to one other published study . The facRecently published data from randomized trials provide intriguing evidence for the effect of ASA on cancer recurrence. Data was pooled from 5 large United Kingdom trials of ASA to prevent vascular disease and examined for the effect of ASA on cancer metastases presenting during the trials or after they ended. Those subjects treated with ASA had a substantially reduced risk of metastatic adenocarcinoma (of any site) . Although it was difficult to examine individual cancer sites because of small numbers, there was a suggestion of reduced case-fatality for breast cancer  .We found an increased risk of non-breast cancer death for ASA users. This makes sense because ASA users are most likely taking it as secondary prevention for cardiovascular disease. It may also indicate that we could not fully adjust for co-morbidity. However, the extent to which co-morbidity is associated with breast cancer survival, potentially leading to residual confounding in our data, is unclear. We also found an increased risk of breast cancer death among patients taking less than 1 dose/day on average, during the 6 months prior to death (or corresponding date for matched controls). However, this may be due to reverse causation, as terminally ill breast cancer patients might stop secondary prevention for cardiovascular disease or be admitted to hospital for terminal care, and consequently their medication would not be recorded in the Swedish prescription registry, since the register does not cover drugs distributed in hospitals.In conclusion, in this population-based Swedish register study, we did not find that use of ASA among women with breast cancer was associated with a lower risk of death from breast cancer. This is contrary to results from some but not all other prospective cohort studies. We found that ASA intake was associated with a reduced risk of breast cancer death only when it was assessed short term with no delay to death or end of follow-up, and also that non-breast cancer deaths were higher among ASA users. Because of these two findings, we speculate that the phenomenon of confounding by indication may be contributing to the conflicting results from prospective studies.We suggest a randomized trial of ASA in women with breast cancer specifically with breast cancer death as the outcome, for efficiency limited to women with stages II and III tumors at higher risk of recurrence. Because of the risk of serious gastrointestinal bleeding or hemorrhagic stroke, ASA is currently recommended to prevent heart disease only among those women considered to be high risk . Such women for whom ASA is indicated would ethically have to be excluded from a trial of ASA for breast cancer survival. A randomized trial will be the only way to sort out the issues of confounding by indication, balance the risk of mortality from bleeding versus a potential benefit on breast cancer survival, and determine a causal relationship between breast cancer prognosis and ASA.ASA: Aspirin, acetylsalicylic acid; CI: Confidence interval; HR: Hazard ratio; LACE: Life after cancer epidemiology; LISA: Longitudinal integration database for health insurance and labor market studies; NSAID: Non-steroidal anti-inflammatory drug; OR: Odds ratio.The authors declare that they have no competing interests.Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. MDH contributed to the conception and design of the study, the analysis and interpretation of the data, drafting the manuscript, revised the manuscript critically for intellectual content, and approved the final manuscript. HO contributed to the conception and design of the study, the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. YP contributed to the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. JH contributed to the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. CL contributed to the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. TM-LA contributed to the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. H-OA contributed to the conception and design of the study, the analysis and interpretation of the data, revised the manuscript critically for intellectual content, and approved the final manuscript. JA contributed to the conception and design of the study, the analysis and interpretation of the data, drafting the manuscript, revised the manuscript critically for intellectual content, and approved the final manuscript. KES contributed to the conception and design of the study, acquisition of the data, the analysis and interpretation of the data, drafting the manuscript, revised the manuscript critically for intellectual content, and approved the final manuscript.Johan Askling and Karin Ekström Smedby shared senior author position.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/14/391/prepubKaplan-Meier estimates of all-cause survival.Click here for fileTable S2. Relative risk  of other causes of death (non-breast cancer causes) in association with dispensed ASA dose at different time periods following breast cancer diagnosis using a nested case–control design. Table S3. Relative risk  of breast cancer death in association with dispensed NSAID dose at different time periods following breast cancer diagnosis using a nested case–control design.Relative risk  of breast cancer death in association with dispensed ASA dose at different time periods following breast cancer diagnosis stratified by cancer stage at diagnosis. Click here for file


Terminal duct lobular units (TDLUs) are the primary structures from which breast cancers and their precursors arise. Decreased age-related TDLU involution and elevated mammographic density are both correlated and independently associated with increased breast cancer risk, suggesting that these characteristics of breast parenchyma might be linked to a common factor. Given data suggesting that increased circulating levels of insulin-like growth factors (IGFs) factors are related to reduced TDLU involution and increased mammographic density, we assessed these relationships using validated quantitative methods in a cross-sectional study of women with benign breast disease.Serum IGF-I, IGFBP-3 and IGF-I:IGFBP-3 molar ratios were measured in 228 women, ages 40-64, who underwent diagnostic breast biopsies yielding benign diagnoses at University of Vermont affiliated centers. Biopsies were assessed for three separate measures inversely related to TDLU involution: numbers of TDLUs per unit of tissue area (“TDLU count”), median TDLU diameter (“TDLU span”), and number of acini per TDLU (“acini count”). Regression models, stratified by menopausal status and adjusted for potential confounders, were used to assess the associations of TDLU count, median TDLU span and median acini count per TDLU with tertiles of circulating IGFs. Given that mammographic density is associated with both IGF levels and breast cancer risk, we also stratified these associations by mammographic density.P-trend = 0.009 and <0.0001, respectively); these associations were strongest among women with elevated mammographic density (P-interaction <0.01). Circulating IGF levels were not significantly associated with TDLU span or acini count per TDLU.Higher IGF-I levels among postmenopausal women and an elevated IGF-I:IGFBP-3 ratio among all women were associated with higher TDLU counts, a marker of decreased lobular involution  contains supplementary material, which is available to authorized users. Terminal duct lobular units (TDLUs) comprise the secretory units of the breast and are the structures from which most breast cancers and their precursors arise. Microscopically, TDLUs consist of terminal ducts and substructures referred to as acini. With aging, TDLUs involute, which results in reduced acini content per TDLU , shorter TDLU span and eventually lower TDLU numbers. Data suggest that reduced age-related TDLU involution among women with benign breast disease is a marker of increased breast cancer risk –5. HowevIn rodent models, the IGF system interacts with hormonal and non-hormonal pathways to influence normal breast development over time, including breast development during puberty, pregnancy, and the post-lactational involution that accompanies weaning –9. In woIn the Nurses’ Health Study, elevated IGF-I and a higher IGF-I:IGFBP-3 ratio were associated with decreased TDLU involution, based on visual assessment . In the To assess the possible associations between the IGF system and TDLU involution, we evaluated serum levels of IGF-I, IGFBP-3 and the molar ratio of IGF-I:IGFBP-3 among women with benign breast disease in relation to three standardized, reproducible quantitative measures that are inversely related to TDLU involution : numbersThe Breast Radiology Evaluation and Study of Tissues (BREAST) Stamp Project is a cross-sectional molecular epidemiologic study of mammographic density in 465 women ages 40 to 65 years, referred for diagnostic biopsy from 2007 through 2010 at the University of Vermont (UVM) College of Medicine and its affiliated academic medical center, the UVM Medical Center  . The curWomen were referred for image-guided breast biopsy following an abnormal breast imaging examination. Digital mammographic examinations were performed with a density phantom, permitting measurement of percent volumetric mammographic density using single x-ray absorptiometry (SXA) . For thehttp://breastscreening.cancer.gov/ [2) was computed from measures of height and weight obtained on the day of the breast biopsy. Whole blood samples were collected prior to breast biopsy using standard techniques, allowed to clot for 30 minutes, and processed at the UVM General Clinical Research Center. Samples were centrifuged at 3,000 rpm for 15 minutes, and the serum and clot fractions were frozen at –80 °C until shipment to SeraCare Life Sciences , where they were stored in liquid nitrogen.Demographic and breast cancer risk factor information was collected using a self-administered questionnaire (see sample questionnaire at cer.gov/ ) and a scer.gov/ . Body maIGF-I and IGFBP-3 levels were measured in duplicate in masked serum samples by enzyme-linked immunosorbent assay (ELISA) ) as described previously . Three q, or invasive breast carcinoma based on review of microscopic sections and surgical pathology reports. The present analysis was restricted to women whose biopsy diagnoses were benign  or stereotactic-guided vacuum-assisted (9-gauge needle) breast biopsies were routinely processed as formalin-fixed paraffin-embedded blocks, which were sectioned and stained with hematoxylin and eosin (H&E) for diagnosis. For study purposes, final diagnoses were categorized as non-proliferative benign breast disease, proliferative , proliferative with atypia , in-situ2) per section. For women who had multiple benign biopsy targets, measures from the first biopsy were used (n = 5). Sections were visually assessed to estimate percentage fat . Normal TDLUs per section were enumerated, and up to 10 TDLUs were evaluated for maximum diameter as TDLU span (measured with an electronic ruler in microns) and categories of acini counts per TDLU  to provide reliable estimates, as previously described [r >0.90) for the study pathologist (MES) for the TDLU measures [H&E-stained tissue sections were digitized at × 20 magnification , and prepared for web-based viewing and annotation with Digital Image Hub software . The lasso tool in Digital Image Hub was used to manually outline and measure total tissue area , parity and percent fat on the tissue slide. Final models for each analysis are included within the respective table footnotes.Among women with at least one TDLU, ordinal logistic regression models were used to estimate odds ratios (ORs) and 95 % CIs for associations between circulating IGF levels  and the outcomes of median TDLU span and median category of acini count per TDLU . For these analyses, adjustment factors were identified by stepwise selection with an inclusion/exclusion criterion of P value for interaction (P-int). Sensitivity analyses using percent dense mammographic area yielded similar conclusions (data not shown). In sensitivity analyses, we also restricted analyses of premenopausal women to those with available hormone data, excluding potentially perimenopausal women. In addition, we mutually adjusted models relating IGF-I and IGFBP-3 to TDLU counts for IGFBP-3 and IGF-I, respectively. Statistical analyses were conducted using Stata version 11.2 , with the exception of the tests for interaction which were conducted in R version 2.14.1 [We tested for effect modification of the association between IGF levels and TDLU count by stratifying models on mammographic density . Stratified analyses were adjusted for the confounders identified in the main analysis with the exception of the interaction between BMI and percent fat on the tissue slide, as its inclusion yielded similar results, and age at menarche in the stratum of the highest mammographic density tertile among postmenopausal women, in order to improve model convergence. We used the Wald test to compare the estimates from models stratified by tertiles of mammographic density to obtain a n 2.14.1 .P = 0.01, Table Overall, 94 % of subjects were white and 68 % were premenopausal. The median age at biopsy for premenopausal women was 47 years and for postmenopausal women was 57 years Table . ApproxiP ≤0.001; Table P = 0.44). Correlations between TDLU count, TDLU span and acini count were generally similar by menopausal status, such that TDLU span and acini count were correlated , whereas TDLU count was not significantly correlated with either acini count or TDLU span . IGF-I:IGFBP-3 ratio levels in the highest tertile versus the lowest were associated with higher TDLU counts  and the IGF-I:IGFBP-3 ratio . IGF-I and IGFBP-3 and their ratio were not significantly related to TDLU span or number of acini per TDLU  were consistent with those observed among all premenopausal/perimenopausal women combined, such that those in the highest tertile of IGF-I:IGFBP-3 ratio levels had higher TDLU counts (data not shown). In addition, patterns of association between IGF-I or IGFBP-3 and TDLU counts were similar to and somewhat stronger than those reported in Table r = –0.22 and r = 0.27, respectively; P <0.05; Table P-int = 0.006). For postmenopausal women . Patterns of association were similar, though stronger, following mutual adjustment for IGFBP-3 and IGF-I (Additional file IGFBP-3 was inversely correlated with mammographic density and the IGF-I:IGFBP-3 ratio was positively correlated with mammographic density, but only significantly so among premenopausal women (men Fig. , mammogrOur study demonstrates that elevated IGF-I:IGFBP-3 ratios among women with biopsy-proven benign breast disease were associated with higher TDLU counts, a measure of decreased TDLU involution, which has been linked to increased breast cancer risk. The associations between the IGF-I:IGFBP-3 ratio and TDLU count were strongest among postmenopausal women who had high mammographic density. In conjunction with mechanistic studies performed in animal models, our results suggest that studies assessing IGF levels and TDLU involution as markers of breast cancer risk are warranted. In addition, our findings further highlight the influence of the growth factor milieu on breast tissue architecture and pliability in the carcinogenic process.Relationships between IGF-I, IGFBP-3 and the ratio of the two with TDLU measures differed by menopausal status. TDLU count was associated with IGF-I, IGFBP-3 and their ratio in postmenopausal women; however, only the IGF-I:IGFBP-3 ratio was associated with TDLU count in premenopausal women. The degree to which circulating hormones and growth factors interact within the tissue microenvironment –34 may pConsistent with our findings, prior work suggests that increased mammographic density is associated with less TDLU involution , 16, andAssessing whether adding IGF levels, TDLU involution and mammographic density enhance prediction of developing breast cancer among women with biopsy-proven benign breast disease may be useful. We hypothesize a parallel role for the IGF system among women, whereby this pathway and its related networks influence breast cancer risk by altering parenchymal composition, organization and function Fig. . InteresTo our knowledge, we are the first to demonstrate an association between circulating IGF levels and TDLU count as a measure of lobular involution. Rice and colleagues found that higher IGF-I levels and IGF-I:IGFBP-3 ratios were associated with less involuted TDLU categories, based on visual evaluation, which in turn was related to increased risk of breast cancer among women with benign breast disease . In a trWe did not identify any significant associations between IGFs and TDLU span or acini count per TDLU, two additional measures of TDLU involution. TDLU span and acini count are highly correlated, whereas TDLU count is weakly correlated with either measure. Thus, TDLU span and acini count may reflect biological processes distinct from TDLU counts. Alternatively, associations may vary with TDLU metrics secondary to measurement and analysis. In prior analyses , 25, we A major strength of our study was the utilization of highly reproducible measures of TDLU involution. A recent study found that TDLU counts were positively associated with number of live births and family history of breast cancer, and inversely associated with older age at menarche among postmenopausal women . Also, aA limitation of our study is that circulating levels of growth hormones were used, and analysis of tissue levels might prove more informative. In an analysis of healthy women, plasma and breast tissue levels of IGF-I and IGFBP-3 were not associated; however, breast cancer risk factors associated with plasma IGF-I and IGFBP-3 were similarly associated with breast concentrations of IGF-I and IGFBP-3 . AnotherIn summary, we demonstrated that circulating levels of serum IGF-I and IGFBP-3 are associated with TDLU count among women with benign breast disease, and that the strongest associations are found among women who have high mammographic density. Our findings contribute to the body of knowledge that supports the evaluation of TDLU involution and mammographic density as possible intermediate endpoints in breast carcinogenesis. Expanding this analysis to a study of breast cancer risk may further contribute to an improved understanding of the role of TDLU involution, or lack thereof, in the mammary carcinogenic process, which could have value for improving risk prediction and prevention.


It is critical, therefore, to determine if the increased risk is driven by epigenetic alterations in genes that increase susceptibility to breast cancer and if these alterations are reversible.The idea that susceptibility to breast cancer is determined not only through inherited germline mutations but also by epigenetic changes induced by alterations in hormonal environment during fetal development is gaining increasing support. Using findings obtained in human and animal studies, this review addresses the mechanisms that may explain why daughters of mothers who took synthetic estrogen diethylstilbestrol (DES) during pregnancy have two times higher breast cancer risk than women who were not exposed to it. The mechanisms likely involve epigenetic alterations, such as increased DNA methylation and modifications in histones and microRNA expression. Further, these alterations may target genes that regulate stem cells and prevent differentiation of their daughter cells. Recent findings in a preclinical model suggest that not only are women exposed to DES  Both hyin utero estrogen levels increase later breast cancer risk is that data must be available for both fetal hormonal environment and breast cancer incidence approximately 50 years later. These data can be obtained from daughters whose mothers took the synthetic estrogen diethylstilbestrol (DES) during pregnancy.The reason why high birth weight is linked to increased breast cancer risk may be due to elevated pregnancy estrogenic environment , but alsin utero for Continuation of Follow-up of DES-Exposed Cohorts trial .In the early 1940s, physicians started prescribing DES to pregnant women who exhibited signs of being in danger of having a miscarriage. The rationale for this practice was that miscarriage is preceded by a drop in estrogen levels, and providing women with estrogen might help to sustain the pregnancy. However, Herbst and colleagues  discoverin utero DES exposure and breast cancer are discussed for the purpose of weighing evidence as to whether fetal hormonal environment can impact breast cancer risk in women several decades later. Since causal studies can readily be performed using animal models, findings obtained in DES-exposed mouse and rat offspring also are discussed. Importantly, animal studies were done prior to any epidemiological studies addressing a possible link between maternal DES exposure and breast cancer risk among daughters could be performed. By the 1980s, exposed daughters in the cohorts began to be old enough to develop breast cancer and several human studies have been performed since to determine if maternal exposure to DES during pregnancy increases an offspring’s breast cancer risk.In this review, findings related to The idea that DES prevents miscarriage was tested in the 1940s by Smith and Smith ,7 in a cDES Timeline [The exact number of women who used DES is not known, but it is estimated to have been between 5 to 10 million women worldwide. These numbers may be an underestimation, as DES was marketed by several drug companies and under several different trade names and was included in some prenatal vitamin preparations. Further, in 1954 DES use was approved for livestock to promote growth, and two years later approximately two-thirds of US beef cattle were treated with DES [Timeline , DES prein utero or neonatal DES exposure on mammary gland development [Since estrogens are linked to increased breast cancer risk, and since maternal DES exposure induces cancers in the offspring’s reproductive tissues, a concern rose that daughters exposed to DES might exhibit increased risk of developing breast cancer. Animal studies were first done to investigate the effect of elopment -15 and lelopment -21; theyThe animal studies show that the doses of DES relevant to pregnant women increased later risk of developing mammary tumors. Specifically, female offspring of rat dams exposed to a total of 1.2 μg DES either on gestation week 2 or 3 , to 0.6 in utero estrogenic environment impacts the development of the mammary gland, which begins with the formation of the mammary lines on gestational day 10 in the mouse and rat [in utero exposure to DES leads to an increase in TEB numbers [In addition to an increase in mammary tumorigenesis in animal models, high  and rat . Ductal  and rat ,26. At p and rat . TEBs gi and rat , and cor and rat . Further and rat ,29. Afte and rat ,31. Impo numbers ,32. It iSeveral published studies have investigated breast cancer risk in the daughters of DES mothers, the majority of which were cohort studies done in the US. As the women in the cohorts aged, their breast cancer risk grew higher, compared with matched non-exposed controls ,33-36. Tin utero DES exposure and mammographic density. However, since a surrogate marker of having been exposed to elevated pregnancy hormonal environment - high birth weight - is associated with increased mammographic density [Density of TEBs in rodents might be modeling mammographic density in women. Mammographic density is determined as a ratio between epithelial area containing the epithelial and stromal/connective tissue cells, and the whole breast . Mammographic density thus reflects the number of epithelial cells, especially terminal ductal lobular units , and it  density , it is pin utero estrogen-exposed females is caused by a high number of mammary stem cells or an increase in their potential to generate daughter cells. Our unpublished data support this conclusion and show that in utero exposure to the synthetic estrogen ethinyl estradiol increases the stem-cell like population in the developing mammary gland.To summarize, animal and human studies have generated similar findings and indicate that there is a causal link between maternal exposure to DES during pregnancy and increased breast cancer risk among female offspring. According to animal studies, the increase in risk may reflect the presence of a higher number of TEBs in the mammary epithelium in the DES offspring. Baik and colleagues  have proin utero DES exposure would induce mutations in the mammary tissue [When determining how maternal exposure to DES during pregnancy can impact mammary gland development and breast cancer risk, several questions need to be answered. First, what are the changes in the fetal mammary gland caused by DES? Second, how are these changes maintained to adult life? The second point is especially important, since there is no evidence that y tissue , or thaty tissue ,35.in utero or neonatal exposure to estrogens, including DES, alters fetal and neonatal mammary gland development in humans [Several signaling factors, expressed in the epithelial cells and mesenchyma, have been identified that are critical for fetal mammary gland development ,26. Inten humans  and micen humans . A likeln humans -50.in utero. Umekita and colleagues [Relatively little is known about long-term changes in the transcriptome of the mammary glands in animals exposed to estrogenic compounds lleagues  investiglleagues . The moslleagues . NF-kB illeagues  and antilleagues , and amolleagues .in utero environment are likely to have been epigenetically induced. This is because the epigenetic signature in all fetal cells, including germ cells, is established during early development and the signature then interprets the information in the genetic code that is inherited from both parents by means that do not involve a change in DNA sequence [There is general agreement that the changes in the transcriptome of adult tissues found to be affected by alterations in the sequence .Gene expression can be altered as a consequence of mutations or epigenetic changes. In contrast to gene mutations within the DNA, epigenetic changes involve post-transcriptional modifications; that is, methylation of gene promoter regions, histone modifications, deposition of certain histone variants along specific gene sequences and microRNA (miRNA) expression. Although both changes are heritable, an important distinction between the two is that mutations are not reversible, but epigenetic modifications generally are.3) onto the 5-carbon of the cytosine ring within CpG dinucleotides. Histone modifications are complex, as they involve not just histone methylation but also acetylation, deacetylation and other post-translational changes. These modifications occur in the amino-terminal tails of histones and affect the 'openness' of the chromatin, which determines whether a gene is expressed or silenced  [Probably the most common mechanism of epigenetic gene silencing is methylation , and it ription) ,57. Trimription) ,59. PcG/ription) ,61, and ription) . Over 2,ription)  and theyription) -66. As dDNMTs may be key players in regulating histones and the entire epigenomic machinery, since DNA methylation events often precede histone modifications . UpregulIn utero exposure to DES is reported to increase the expression of DNMT1 in the epididymis [in utero.We and others have observed that the expression of DNMTs is persistently altered in estrogen-regulated tissues following estrogenic exposures during early life. ididymis  and uterididymis . We founididymis . These cIn utero DES exposure alters methylation patterns of several genes in estrogen’s target tissues, including Hox genes [in utero to the synthetic estrogen ethinyl estradiol using global sequencing approaches [ox genes ,73, c-foox genes , and Nsbox genes , but it proaches . Among tin utero has been reported [As an increase in EZH2 expression in the mammary glands of mice exposed to DES reported , histonereported  recentlyreported . Similarreported  and exprreported  in the uin utero exposure to ethinyl estradiol lowers the expression of many of the same miRNAs in the adult mammary gland [in utero DES-exposed offspring may be a result of epigenetic silencing of miRNAs that target them.Maternal exposures during pregnancy have been found to induce persistent changes in miRNA expression in the offspring. miRNAs are short non-coding single-stranded RNAs composed of approximately 21 to 22 nucleotides that regulate gene expression by sequence-specific base-pairing with the 3’ untranslated region of target mRNAs. miRNA binding induces post-transcriptional repression of target genes , either ry gland  as are dry gland . Since mry gland ,84 or asry gland , and thery gland ,87, the BRCA1 or BRCA2 mutations, are those encoding RARB, ER-α, INK4a/ARF, BRCA1, PRA, PRB, RASSF1A, HIN-1, and CRBP1. Many of these genes also are PcG target genes. Methylation of many other, 'non-tumor suppressor' PcG target genes also are observed in cancer [in utero exposure to synthetic estrogen causes hypermethylation of PcG target genes [Methylation of PcG target genes and tumor suppressor genes in peripheral blood cells, detected years before diagnosis, is associated with increased breast cancer risk, particularly in women with a high familial risk -90. Simin cancer ,92. It hn cancer . Since iet genes  and incret genes , in somein utero estrogenic environment.Several miRNAs are altered in breast tumors in women, compared with normal tissue . There iDeveloping germ cells undergo epigenetic erasure when they, as primordial germ cells, enter into the fetal gonads around embryonic day 10 to 11 (in mice and rats), and then undergo gender-specific reprogramming as germ cells . It is nSkinner’s group  has inveWe have investigated changes in the methylation patterns of the mammary glands in three generations of female offspring of rat dams exposed to ethinyl estradiol or vehicle during pregnancy . A totalDNMT1, DNMT3A and DNMT3B were all downregulated. Effects on female germ cells were not studied, but we and others have found increased DNMT expression in the breast and reproductive tissues in in utero ethinyl estradiol- or DES-exposed animals [in utero.In addition to changes in histones and DNA methylation, miRNA expression may be affected in germ cells by hormonal exposures during early development. Meunier and colleagues  investig animals -71. It iSome researchers have begun to investigate whether the effects of maternal DES exposure during pregnancy extend to the third generation in humans. Although there is no evidence that DES granddaughters have cervical and ovarian abnormalities similar to DES daughters, there is evidence that they may have more menstrual irregularities and a higher rate of infertility than non-exposed granddaughters . In addiMillions of women in the US, Europe and Australia have been exposed to DES in the womb, and consequently exhibit about a two times higher breast cancer risk than unexposed women. The increase in risk may not be limited to the DES-exposed daughters, but could also increase breast cancer risk in granddaughters and great granddaughters. Such outcome would be consistent with the findings we obtained in studies using a synthetic estrogen ethinyl estradiol (EE2) . If DES in utero DES exposure induces epigenetic changes in reproductive tract tissues [in utero. Second, we should investigate whether the transgenerational increase in breast cancer risk can be prevented with drugs that reverse epigenetic modifications. Our preliminary studies in mice suggest that this is achievable in daughters by using the well-tolerated and non-toxic histone deacetylase inhibitor valproic acid and DNMT inhibitor hydralazine. However, whether these compounds also prevent an increase in granddaughters and great granddaughters in experimental models remains to be investigated.To achieve this goal, we need to understand how maternal DES exposure during pregnancy increases a daughter’s breast cancer risk. A plausible model is proposed in Figure  tissues ,72-75,77 tissues . DES expin utero are destined to be at an increased risk of developing breast cancer, and this risk may extend to their daughters and granddaughters as well. It is of critical importance to determine if the increased risk is driven by epigenetic alterations in genes that increase susceptibility to breast cancer and if these alterations are reversible.In summary, women exposed to DES DES: Diethylstilbestrol; DNMT: DNA methyltransferase; ER: Estrogen receptor; EZH2: Protein enhancer of Zeste-2; miRNA: microRNA; NF: Nuclear factor; PcG: Polycomb group; Six1: Sine oculis homeobox 1; TEB: Terminal end bud.LH-C has served as an expert witness in a case concerning daughters of DES-exposed mothers on behalf of the plaintiffs.


As the risks and benefits of early detection and primary prevention strategies for breast cancer are beginning to be quantified, the risk perception of women has become increasingly important as may affect their screening behaviors. This study evaluated the women’s breast cancer risk perception and their accuracy, and determined the factors that can affect their risk perception accuracy.Data was collected in a cross-sectional survey design. Questionnaire, including breast cancer risk factors, risk perceptions and screening behaviors, answered by 624 women visiting primary health care center (PHCC). “Perceived risk” investigated with numeric and verbal measures. Accuracy of risk perception was determined by women’s Gail 5-year risk scores.The mean age of the participants was 59.62 ± 1.97 years. Of the women 6.7% had a first-degree relative with breast cancer, 68.9% performed breast self-examination and 62.3% had a mammography, and 82.9% expressed their breast cancer worry as “low”. The numeric measure correlated better with worry and Gail scores. Of the women 65.5% perceived their breast cancer risk accurately. Among the women in “high risk” group 65.7% underestimated, while in “average risk” group 25.4% overestimated their risk.Turkish women visiting PHCC are overtly and overly optimistic. This was especially obvious with the result that nearly one third had had no mammography. There is a need for further studies to understand why and how this optimism is maintained so that better screening strategies can be applied at PHCC. All health workers working at PHCC have to be aware of this optimism to prevent missed opportunities for cancer screening. Breast cancer is by far the most frequent cancer among women with an estimation 1.383,5 million newly diagnosed cases in 2008 globally , and also is the most frequent cause of cancer death in women in both developing and developed countries [Despite some recent controversy, most of the current literature confirms that breast cancer screening is an effective tool for reducing breast cancer mortality -6. Gaps Gail model, widely used as a risk-prediction method for estimating and calculating breast cancer risk, has been tested for different populations including diverse race and ethnic groups, and also validated for European women -12. ThisThere are conflicting results about the perceptions of women, either optimistic or pessimistic, and the effects of concern and risk perception about cancer on their screening behaviors. Women with optimistic perception, underestimating their own risk, may feel invulnerable to breast cancer and mistakenly forgo the potential benefits of screening. Moreover, if a woman is underestimating her risk but is in “high risk” group can also miss the opportunity to benefit from advances of chemoprevention in breast cancer ,18,19. CTogether with this, it is also an interesting result that the majority of women at high risk of developing breast cancer may underestimate their risk, and a substantial proportion of women at average risk may perceive that they are at increased risk . But somAs the U.S. Preventive Services Task Force (USPSTF) and American Cancer Society recommend screening mammography, they consider the clinical breast exam and the breast self-examination (BSE) as a complimentary method to mammography in the context of a shared decision making and breast self-awareness of the women at average risk. Primary health care centers are the critical point of access for breast cancer screening and play a significant role in consultancy of breast health and using shared decision-making approach for cancer screening preferences of their patients .The aim of the study was to evaluate the women’s breast cancer risk perception and their accuracy determined by using an objective measure, Gail model, and to investigate factors that can affect their risk perception including their socio-demographic characteristics; concerns in relation to having breast cancer, and to evaluate their screening attitudes including breast self-examination and mammography.Data was collected in a cross-sectional survey design that examined breast cancer risk factors, risk perceptions and screening behaviors, monthly regular breast-self examination and mammography at least once within a minimum period of five years, from cancer-free women aged over 45 years.Women, during their visits to their primary health care center (PHCC), for any reason between March-June 2011, were invited to participate in the survey. The PHCC constitutes of 10 physicians and 11 nurses and midwives working together as a group practice. The exclusion criteria were ages below 45 and any previous personal history of breast cancer. The study was completed by 624 women having face-to-face interviews after their oral consent was taken in PHCC. Ethical approval was obtained from Dokuz Eylul University Faculty of Clinical and Laboratory Research Ethics Committee while written official permission was obtained from the Provincial Health Directorates of Izmir.A questionnaire completed by the participants included the following: socio-demographic  and health related characteristics , risk factors included in Gail model, and screening behaviors including regular monthly BSE and mammography performance at least once within last 5 years, and breast cancer concern.“Perceived risk” was investigated with regards to numeric and verbal measures. The numeric measure was displayed with pie charts showing risk as simple fractions, risk 1 out of 3 women (1/3), 1 out of 10 women (1/10), 1 out of 50 women (1/50), 1 out of 100 women (1/100) and 1 out of 1000 women (1/1000) as shown in Figure Actual breast cancer risk was calculated by National Cancer Institute’s Breast Cancer Risk Assessment Tool (BCRAT), also known as the Gail Model. After entering the necessary information, calculation of the women’s breast cancer risk over the next five year was calculated with this tool available at the web site immediately . The mod“underestimate” if women with Gail 5-year risk ≥1.67 responded as “low risk”;“accurate”, if women with Gail 5-year risk ≥1.67 responded as “high risk”, or women with Gail 5-year risk <1.67 responded as “low risk”; and“overestimate” if women with Gail 5-year risk <1.67 responded as “high risk”.Accuracy of risk perception addressed according to Gail groups, and perceived risk measures. Perceived risk categories were defined as;Breast cancer concern was evaluated with two items that inquired the frequency of worry and its effect on the daily life of the woman. It is scaled from 1 to 7, 1 representing “not at all” and 7 being “all the time”. Cronbach’s alpha for the study group was 0.74. The total score of the two items was grouped as low, average and high.Descriptive statistics were mentioned as number and percentage, while Spearman’s correlations were calculated for perceived breast cancer risks with numeric and verbal measures and objective breast cancer risk calculated with Gail model, and breast cancer concern and bivariate analysis between accuracy of perceived breast cancer risk and factors that can affect them were conducted using Pearson’s chi-square and Fisher’s exact test where appropriate using the Statistical Package for Social Sciences version 15. A two-sided alpha level was accepted as 0.05 for significance.The age of the participants ranged from 45 to 85 years (mean age: 59.62 ± 1.97 years). About one-third of the participants  had graduated from primary school, most of them were not working , and about two-third were married/living with partner . Most of the women described their health as fair or good . Of the women, 6.7% (n = 42) had a first-degree relative with breast cancer, 52.9% (n = 330) defined the “contribution of family history to risk” as strong. Women who performed regular monthly BSE and had a mammography at least once within last 5 year constituted 68.9% (n = 430) and 62.3% (n = 389) of the participants, respectively. Most of the women,  expressed their breast cancer worry as “low” .Breast cancer risk perceptions of the women were assessed by a numeric and verbal measures. The lowest risk value of numeric measure, “1/1000”, was mentioned by the 51.0% (n = 318) of the women as their perceived risk while 40.2% (n = 251) mentioned their risk as “very low” in verbal measure  perceived their breast cancer risk accurately. Among the women in “increased-high risk” group according to Gail score for 5 year breast cancer risk 65.7% (n = 92) underestimated their risk, while 25.4% n = 123) of women in “average risk” group overestimated their risk . Women who had an education level equal to a university degree and above and who worked overestimated their risk more than the other groups . Higher proportion 34.4%) of the single women underestimated their risk (p = 0.001). The accuracy of breast cancer risk estimation was not affected by presence of a first-degree relative with breast cancer, health status of the women, monthly BSE and mammography performance at least once within last 5 years (p > 0.05). Women who described the “contribution of family history to risk” as weak were statistically inclined to significantly less overestimate their risk (p = 0.008). Women with “low” breast cancer worry have less overestimated their risk than other groups (p < 0.001) (Table 4.4% of tThe purpose of the study was to determine the breast cancer risk perception in women and their accuracy according to the Gail model, and to examine factors that can affect their risk perception. The results revealed that, although most of the Turkish women visiting PHCC perceived their breast cancer risk accurately, the ones determined as “increased risk” were more likely to be optimistic. The women working, having higher education levels and aged between 45-54 years were overestimating their risk.Different measures were used for risk perception including numeric, verbal, and comparative. The accuracy of risk perception is an issue that can be affected by the measure used. It was shown that numerical measure of absolute risk was more highly correlated than measures of comparative risks . In thisThe current literature shows that women have difficulty in estimating their breast cancer risk accurately with regards to different measures used in different forms ,20-23,29It is obvious that women’s socio-demographic characteristics can have an impact on their risk perception. There are pros and cons in the results of studies for younger women’s risk perception for breast cancer. While most of the studies reported younger ages were inversely associated with risk perception or in other words to overestimate their risk like we found ,20,32,33Presence of a first-degree relative with breast cancer and the concern levels of women are the other important issues that can have affect on screening behaviors of the women. In different study populations, the percentage of first-degree relative with breast cancer changes between 2.9% and 11% -30. The All studies showed that women who had risk factors for breast cancer such as previous personal history of breast disease, presence of family history of breast cancer, and being of an age over 40, having their first menstrual period at a young age, history of abnormal mammography, history of breast biopsy or morbid obesity were more likely to rate their perceived risk as “moderate-strong” or “increased” ,30-32,36There are also conflicting results reported about the perceived risk and screening behaviors of women including adherence to BSE and mammography. Studies showed that the increased perceived cancer risk was related to increased regular breast cancer screening or mammography use ,32,37. HGreater worries about breast cancer were found to be associated with higher perceived verbal/numerical absolute risk . In our To our knowledge, this is one of few studies which investigated the risk perception of Turkish women, and factors that can have effect on the perception of risk. However, the study has some limitations. As it has the design of a cross-sectional study, a causal relationship cannot be identified. Secondly, all study participants were recruited from a PHCC which means the results may not be generalizable to their peers in Turkey. Finally, there may have been some information bias in terms of the risk perception and worry levels because these variables were measured using self-reported questionnaires.In conclusion, the current study revealed that, Turkish women, especially those in the “increased risk” group, visiting the PHCCs were more likely to underestimate their risk for breast cancer and it was found that nearly one third did not have a mammography at least once within last 5 years. Not only physicians, but also nurses and midwives working at PHCCs have to be aware of this optimism in order to prevent missed opportunities of diagnosis while consulting and managing their cancer screening. There is also a need for further studies that aim to understand why and how this optimism is maintained so that better screening strategies can be applied at PHCCs.


The present study aimed to determine knowledge of breast cancer risk factors, symptoms and early detection methods and to identify knowledge and practice of breast self-examination among Ain Shams University female students. This is a descriptive cross sectional study. Most study participants had low level of knowledge of breast cancer risk factors. The most widely known risk factors by the students were smoking 66.9%, followed by radiation to the chest 63.7% and genetic factors 63.7%. Most of the students (81.6%) identified breast lump as a symptom for breast cancer. However, non lump symptoms were less known and less than half were aware of other warning signs. Mass media such as TV and/or radio were identified as the main source of information on breast cancer by 89.1% of students followed by relatives 39.2%. Only 8.8% of students identified correctly the appropriate time to perform breast self examination and 1.3% reported performing it regularly every month. The most common reasons for not practicing BSE were” did not know how to perform it” (47.7%) and lack of interest (35%). The findings of this study showed that there is low level of knowledge on breast cancer risk factors, early warning signs and BSE among female university students and that only few students practice BSE monthly. Health care workers should develop effective breast health programs targeting youth to help females to gain healthy habits starting very early during their formative years. Breast cancer is the most commonly diagnosed cancer and worldwide it is considered the leading cause of cancer death in females, accounting for 23% (1.38 million) of the total new cancer cases and 14%  of the total cancer deaths in 2008. Approximately half of the breast cancer cases and 60% of the deaths are estimated to take place in developing countries .According to the official statistics of the Egyptian National Cancer Institute, breast cancer represents 18.9% of total cancer cases (35.1% in women and 2.2% in men) . In Egypt, the median age at diagnosis for breast cancer is ten years younger than in the United States and Europe . Cancer Although the importance of Breast Self Examination (BSE) is controversial , the AmeAlthough there were scarcity of studies on knowledge of breast cancer and practice of BSE among Egyptian females , to our The present study aimed to determine knowledge of breast cancer risk factors, symptoms and early detection methods and to identify knowledge and practice of breast self-examination among Ain Shams University female students.This is a descriptive cross sectional study.Undergraduate students at non health related disciplines were included based on a belief that they possess less health information compared to the general public. The study sample included 543 female students at non health related disciplines, who were available on the day of data collection, who agreed to participate in the study and who returned a completely filled questionnaires (Response rate=89.8%).A self administered questionnaire in Arabic language was distributed by fourth year medical students to study participants in order to clarify any item if needed A Clinical oncology consultant evaluated content and face validity of the questionnaire. Moreover, the questionnaire was pilot tested on 20 students (not included in study sample) to check the clarity of the questions. Results of the pilot test were used to adjust the wording of some questions in order to make them easier to understand. The Cronbach's alpha of study questionnaire is 0.805. The questionnaire covered the following itemsSocio-demographic data such as age, marital status, discipline, academic year.Knowledge of risk factors for breast cancer was determined with 13 questions. The answers were "true", "false" and "don’t know". This part assessed the knowledge of breast cancer risk factors using the guidelines of the American Cancer Society (2008)Knowledge of early warning signs, of methods of early detection and of different lines of treatment of breast cancerKnowledge of Breast Self Examination (BSE) term and correct time to perform itPracticing BSE and reasons for not performingSource of information on breast cancerApproval of study conduction was obtained from the ethical review Committee at the faculty of Medicine Ain Shams University. In addition, the purpose of the study was explained to all participants and confidentiality was assured, an oral informed consent was obtained and the survey tool was anonymous.Data collected were revised, coded and computerized. Data entry using Statistical Package for Social Science (SPSS) version 18 was used. Frequency tables and a chart were utilized to describe nominal variables. Continuous variables were described using distributions, means and standard deviation.Participants in this study ranged in age from 17 to 23 years with a mean of 19.3 (SD=1.1). Of 543 participants 43.1% were students at commerce school. More than one third of study participants 36.7% were second year faculty students, 31.7% were fourth year and 25.7% were third year and only 5.9% were first year faculty students. The majority of participants 90.4% were single. Only 16.1% of students reported a family history of breast cancer. Nearly all study participants 98.7% believe that early detection improves treatment outcome and as many as 87.7% believe that there is an effective treatment for breast Cancer .Most students had low level of knowledge of breast cancer risk factors. The most widely known risk factors by the students were smoking 66.9%, radiation to the chest 63.7% and genetic factors 63.7%. Age at first full term pregnancy >30 years and never being pregnant were not known as risk factors for breast cancer by most of the students .Most of the students 81.6% identified breast lump as a symptom for breast cancer. However, non lump symptoms were less known and less than half were aware of other warning signs such as change in shape/or retraction of nipple and bloody nipple discharge accounting for 25.6% and 24.7% respectively. Further, as many as 74.2% of students identified breast self examination as an early detection measure for breast cancer. The most widely known lines of treatment were surgery followed by chemotherapy accounting for 71.8% and 67.7% respectively .Mass media such as TV and/or radio were identified as the main source of information on breast cancer by 89.1% of students followed by relatives 39.2% .More than half of the students (63.4%) heard about BSE. Only 8.8% of students identified correctly the appropriate time to perform BSE. The percentage of students performing BSE regularly every month was 1.3% and 6.1% reported that they performed it irregularly. The most common reasons for not practicing BSE were “did not know how to perform it” (47.7%) and lack of interest (35%) .Informing youth about breast cancer is both a challenge and key investment in the health of future generations of women  as it isIn the current study more than half of the students (63.4%) heard about BSE. This study showed that female university students may not have adequate knowledge about BSE as only 8.8% of the students had knowledge about appropriate time to perform BSE. Our findings are comparable to a study of Yemeni University students in which 76.9% of participants heard about BSE . The curIn the current study only 1.3% practice BSE regularly every month and 6.1% reported that they performed it irregularly. Our findings are lower than  study inStudies from Egypt have revealed that the percentage of older women performing BSE monthly ranged from 2.7% to 18.8 % .It is anticipated that a higher percentage of women in older age groups perform BSE because they are at higher risk of breast cancer. However, studies from Egypt have shown low percentages of both young and older women performing BSE. This may be due to the fact that health education programs organized to increase breast health awareness are not satisfactory. Such education programs should start very early in the formative years.In the present study mass media such as TV and/or radio were identified as the main source of information on breast cancer by 89.1% of students followed by relatives 39.2% and 36.8% acknowledged books, magazines and newspapers as the leading source of information. This is consistent with Similarly media was acknowledged as the main source of information on breast cancer by 48.6% of female high school students in Turkey while 44.4% of the sample mentioned health professionals as a source of information . In anotNot knowing how to perform BSE was the primary reason for not practicing BSE as reported by 47.7% of Nigerian female students, lack of interest was identified by 35% and only 7.4% mentioned fear of a positive finding as a reason . This agIn the current study nearly all study participants (98.7%) believe that early detection improves treatment outcome and as many as 87.7% believe that there is an effective treatment for breast Cancer. However, most students had poor knowledge of breast cancer risk factors. The most widely known risk factors by the students were smoking (66.9%), radiation to the chest (63.7%), genetic factors (63.7%) and Family history of breast cancer (47.5%). Age at first full term pregnancy >30 years and never being pregnant were not known as risk factors for breast cancer by most of the study participants.Similarly a study carried out to determine the awareness of breast cancer risk factors and practice of breast self- examination among female students of the University of Nigeria Enugu Campus showed that the only risk factors that are widely known are family history of breast cancer (50%), and tobacco smoking (36%). The findings also showed that very few students had knowledge of other risk factors  and family history of breast cancer (67.0%). In other words, students know that breast cancer was associated with genetic factors .Most of the students (81.6%) in the present study identified breast lump as a symptom for breast cancer followed by pain in breast as reported by 74.2%. However they were less knowledgeable about non lump symptoms and less than half were aware of other warning signs such as change in shape/or retraction of nipple and bloody nipple discharge accounting for 25.6% and 24.7% respectively. Further, as many as 74.2% of students identified breast self- examination as an early detection measure for breast cancer. The most widely known lines of treatment were surgery followed by chemotherapy accounting for 71.8% and 67.7% respectively.In concordance with the current study a cross-sectional survey of Angola university students using a self-administered questionnaire, showed that almost all study participants (80%) reported that breast lumps that are cancerous would be painful . Powe etKnowledge of symptoms and methods of diagnosis of breast cancer was mostly above (60%)among nurses working in a general hospital in Lagos, Nigeria and the most widely reported symptom identified by(93.6%) of the m was breast lump .The present research is as a cross sectional study on female university students in one of the most eminent governmental universities in the capital of Egypt as a result it does not represent Egyptian female youth population as a whole also the results of the current study do not represent the entire population of Egyptian female university students all over Egypt. In addition, the study participants were relatively homogenous as a group so sociodemographic comparisons were not performed.Health behaviors acquired early in life have an influence on future health. The findings of this study showed that there is low level of knowledge on breast cancer risk factors, early warning signs and BSE among female Ain Shams University students and that only few students practice BSE monthly. There is a need to raise the knowledge of university students about the risks of breast cancer and benefits of early detection. Health care workers should develop effective breast health programs targeting youth to help females to gain healthy habits starting very early during their formative years.


Pro-angiogenic factors are positively associated with breast tumor staging and poorer prognosis, but their role in the etiology of breast cancer has not been assessed.We measured serum levels of the pro-angiogenic vascular endothelial growth factor A (VEGF), and placental growth factor (PlGF) and anti-angiogenic soluble fms-like tyrosine kinase-1 (sFlt-1) in 352 incident breast cancer cases [mean age at diagnosis 67 (range 55–83)] and 352 non-cases in the prostate, lung, colorectal, and ovarian screening trial  matched on age and date of enrollment. Cases were followed on average 4.2 years from blood draw to diagnosis, range 3.9–12.8 years; 53 % were estrogen receptor positive/progesterone receptor positive (ER+/PR+), and 13 % were ER−/PR−. Quartile-specific hazard ratios (HR) and 95 % confidence intervals (CI) were estimated using weighted Cox proportional hazards regression models adjusted for known breast cancer risk factors. An ordinal variable for the angiogenic markers was used to test for trend in the HR.p trend = 0.88), 1.38 for sFlt-1 , and 0.62 for PlGF . Risk patterns were not altered when all angiogenic markers were included in the model simultaneously, or by restricting analyses to invasive breast cancers, to cases diagnosed two or more years after blood collection or to ER+ tumors.Comparing the highest to lowest quartile, multivariable HR were 0.90 for VEGF  contains supplementary material, which is available to authorized users. Numerous studies show poorer survival in women with breast cancer tumors that overexpress angiogenesis-promoting proteins including VEGF  –4 and PlWhile angiogenesis is a quiescent process in most adult tissues, it is critical to normal physiologic processes such as inflammation, wound healing, embryogenesis, and the menstrual cycle, as well as to the pathologic processes of tumor growth and metastasis. It entails a complex coordination between pro- and anti-angiogenic factors, and increasing evidence suggests that sex steroids may regulate their production in a tissue-specific manner. Additionally, women with a history of preeclampsia, who during their pregnancy experience pronounced elevations in the anti-angiogenic factor sFlt-1  along with low circulating VEGF and PlGF, have a reduced risk of subsequent breast cancer –16. ElevIncident breast cancer cases and non-cases were drawn from the 39, 116 female participants, aged 55–74 years, who were randomly assigned from 1993 through 2001, to the screening arm of the multicenter prostate, lung, colorectal, and ovarian cancer screening trial (PLCO) . This stParticipants were contacted annually by mail regarding cancer diagnoses occurring within the previous year. Breast cancers obtained from self-reports, next-of-kin, physicians, death certificates, and National Death Index linkage were confirmed by medical records, and tumor characteristics, including histology and hormone receptor status, were abstracted. Only confirmed cases were included in the analysis. Cases were grouped as ductal  , lobular 8,520), and tubular/other/unknown. When quantitative immunohistochemical results were available, tumors were considered estrogen receptor (ER) or progesterone receptor (PR) positive if at least 1 % of cells stained positive [, and tub165. The limits of detection were 5, 7, and 6 pg/ml for VEGF, PlGF, and sFlt-1, respectively. To monitor the assay reliability, duplicate blinded quality control samples were included in each batch. Within and between batch, CVs were ≤15 % for all markers.Measurement of VEGF, sFlt-1, and PlGF in sera of non-pregnant women is limited, and in preliminary efforts, commercially available assays could not detect PlGF in sera of healthy postmenopausal women. We obtained a more sensitive assay (available for research purposes only) and measured these proteins at the Clinical and Epidemiologic Research Laboratory, Children’s Hospital, Boston, as follows: sFlt-1 was measured via Elecsys chemiluminescent immunoassay  , and VEGp values <0.05 were considered statistically significant; no adjustment for multiple comparisons was made.Differences between cases and non-cases in baseline characteristics and angiogenic factors were assessed by t tests or Wilcoxon rank sum tests, with VEGF, sFlt-1, and PlGF analyzed on the natural logarithmic scale. To evaluate the association between quartiles of levels of each marker and breast cancer risk, HR and 95 % confidence intervals (CI) were estimated using weighted Cox proportional hazards regression models. Quartile cutpoints of marker concentrations were based on the non-case distribution. Non-cases were weighted by the inverse sample fraction to represent the study cohort; cases were given a weight of 1.0 because no sampling occurred, i.e., all women diagnosed with breast cancer who met the inclusion criteria were selected. Tests for trend were calculated using an ordinal variable for the quartiles. To assess potential confounding, we assessed whether inclusion of known or suspected breast cancer risk factors altered HR from the full model by more than 10 %, using a backwards elimination strategy. All factors meeting this criterion remained in the final model. Variables considered included age at study entry ; family history of breast cancer; personal history of benign breast disease; ages at menarche , first birth , and menopause ; and body mass index (BMI). Sensitivity analyses assessed potential tumor influences on marker levels by excluding women diagnosed with breast cancer within 2 years of blood donation. For women with available pathology information, we evaluated whether HR varied by breast tumor characteristics, including estrogen and progesterone receptor status, histology, and invasive vs in situ behavior. Analyses were performed with SAS Version 9, and proportional hazards ratios were calculated using Proc Surveyphreg . All tesp = 0.045), and of smoking (p = 0.008), to have higher BMI at blood draw (p = 0.015), and were less likely to report regular aspirin use (p = 0.006). Cases were somewhat younger at menarche (p = 0.060), and used postmenopausal hormones for a longer duration than non-cases (p = 0.066). When the analysis was limited to invasive breast cancers, similar patterns of results were observed.Table n = 277), 62.5 % were ER+/PR+ and 15.2 %, ER−/PR−  or lobular (10.5 %) histology and diagnosed with stage 1 or in situ disease (71.9 %). Overall, 52.8 % were ER+/PR+, 13.1 % ER−/PR−, and 8.2 % ER+/PR−; among invasive cancers , VEGF (pg/ml) , and sFlt-1 (pg/ml) . No trends in HR were observed for any of the markers  were similar for cases and non-cases (mentclass2pt{minimp = 0.099). On average, levels in those diagnosed within the first year after blood donation were 250 pg/ml; this increased to 350 pg/ml in women diagnosed eight or more years after blood donation. sFlt-1 and PlGF did not vary consistently by recency of blood collection , no discernible pattern was observed between VEGF and recency of blood donation, and overall, VEGF levels were comparable among women with invasive and in situ disease. Since the majority of women with invasive cancer were diagnosed with stage 1 disease, our study does not support a role for serum VEGF as a marker of early progression from DCIS to invasive breast cancer. No studies have evaluated a similar role for sFlt-1 and PlGF in breast cancer etiology, in part because previous assays have not been sensitive enough to detect the low levels found in postmenopausal or non-pregnant women.This first study to evaluate pre-diagnostic serum levels of pro- and anti-angiogenic factors did not demonstrate a link between these biomarkers and postmenopausal breast cancer risk. Circulating angiogenic markers have been used for breast cancer staging and prognosis , but effThe close physiologic relationship between endocrine function and angiogenesis, and suggestions that sex steroids regulate the balance of angiogenic factors, particularly VEGF, in a tissue-specific manner , 27, proWhy pregnancies complicated by preeclampsia attenuate maternal breast cancer risk later in life is not fully understood , 15, butReasons for our lack of findings are not clear, but the ongoing debate regarding the clinical utility of circulating VEGF as a prognostic marker in breast cancer may provide some insight , 37–39. This study had notable strengths, including that the study population was drawn from the PLCO cohort, which provided prospectively collected serum samples, and angiogenic markers were measured using assays available for research purposes that can detect the low values, particularly of PlGF and sFlt-1, found in postmenopausal women. This study also had several weaknesses. The measurement of angiogenic factors occurred at one point in time, which is a common limitation in studies of circulating biomarkers, and the representativeness and stability of these markers over time is not known. We did not have the opportunity to evaluate temporal changes in these markers in individual women; however, our finding of little differences in marker levels in non-cases across the age groups provides some confidence of the stability of these markers in the postmenopause. Additionally, inferences from this study are limited, since only women who were postmenopausal and not using menopausal hormone therapy at the time of blood collection were eligible for study. Finally, as discussed earlier, both the study population and specimen used may not be optimal for assessing the role of angiogenic markers in breast cancer risk, particularly in women who experienced pregnancy complications. Nevertheless, this study does not support the proposition that a pro-angiogenic profile is associated with excess breast cancer risk.Box-plots of Angiogenic Factors by Age Group  (PPTX 43 kb)Supplementary material 2 (DOCX 16 kb)Below is the link to the electronic supplementary material.


FGFR2 locus as risk factors for breast cancer. Validation studies, however, have shown inconsistent results by ethnics and pathological characteristics. To further explore this inconsistency and investigate the associations of FGFR2 variants with breast cancer according to intrinsic subtype  among Southern Han Chinese women, we genotyped rs1078806, rs1219648, rs2420946, rs2981579, and rs2981582 polymorphisms in 609 patients and 882 controls. Significant associations with breast cancer risk were observed for rs2420946, rs2981579, and rs2981582 with OR (95% CI) per risk allele of 1.19 (1.03–1.39), 1.24 (1.07–1.43), and 1.17 (1.01–1.36), respectively. In subtype specific analysis, above three SNPs were significantly associated with increased Luminal-A risk in a dose-dependent manner (Ptrend < 0.01); however, only rs2981579 was associated with Luminal-B, and none were linked to ER−&PR− subtypes (ER−&PR−&HER2+ and triple negative). Haplotype analyses also identified common haplotypes significantly associated with luminal-like subtypes , but not with ER−&PR− subtypes. Our results suggest that associations of FGFR2 SNPs with breast cancer were heterogeneous according to intrinsic subtype. Future studies stratifying patients by their intrinsic subtypes will provide new insights into the complex genetic mechanisms underlying breast cancer.GWAS have identified variation in the  FGFR2 gene is consistently the most strongly associated one [Recently, large genome-wide association studies (GWAS) have identified nearly 70 genetic susceptibility loci associated with breast cancer risk –7. Speciated one , 3, 8. Aated one  and Afriated one . These i FGFR2 may influence tumor subtype is provided by the fact that susceptibility loci in FGFR2 have stronger associations for estrogen receptor positive disease (ER+) than ER− [From another point of view, breast cancers vary greatly in clinical behavior, morphological appearance, and molecular alterations. Genomic studies have established that breast cancer can be divided into 4 major intrinsic subtypes  that differ significantly in terms of incidence, survival, and response to therapy , 12. Thethan ER− .However, the first wave of GWAS has been conducted with a predominance of ER positive disease and is unable to determine whether tumor subtypes modify the association between breast cancer risk and the susceptibility loci recently identified. Additionally, recent interest has focused on ER expression status , 14–16 a FGFR2 intron-2 polymorphisms recently identified. Without a doubt, this paper will expand and refine our previous reports on analyses only by ER status through including up to three additional tumor markers. Moreover, the detailed analyses are allowing us to verify whether definition of the genomic intrinsic subtypes of breast cancer can provide another window into the underlying heterogeneity between different studies and thus make more definite conclusions than previous reports.We therefore decided to use the data source provided by the Southern China Breast Cancer Genetics Study (SCBCGS) to evaluate the hypothesis that tumor intrinsic subtypes, in particular those defined jointly by the expression of ER, PR, HER2, and Ki-67, modify the association between breast cancer risk and the commonIndividuals included in the current analysis were Han Chinese women who participated in the SCBCGS. The SCBCGS was a multicenter, hospital-based study of breast cancer conducted among Han Chinese women from three areas of the Southern China, including Canton, Chongqing, and Nanchang. Previous reports have described the study population and enrollment process in detail –21. BrieExtensive early studies confirmed that late age of first term pregnancy (>30 years) and early menarche (<13 years) are known risk factors for breast cancer , 23. ThuThe study was approved by the institutional review boards at all participating institutes , and all participants provided written, informed consent before participating in the study.Laboratory protocols for the DNA extraction and genotyping methods used by the SCBCGS have been previously described in detail , 19. BriRecent GWAS have confirmed that all the significantly associated SNPs of FGFR2 with breast cancer risk fell in a 25 kb linkage disequilibrium (LD) block entirely within intron-2. To further replicate the GWAS findings in the Chinese women, we first identified 7 variants showing association with breast cancer in one or more GWAS , 3, 8. Ghigh), and (iv) Luminal-A (ER+ and/or PR+ and not HER2+ or Ki67high). Finally, database review identified 609 eligible patients with details on ER, PR, HER2, and Ki67 expression. Four subtypes were constructed: (i) triple negative , (ii) ER−HER2+ , (iii) Luminal-B  and 95% confidence intervals (CIs), based on unconditional logistic regression and adjusted for potential confounders. Analyses were carried out assuming a dominant, codominant, and additive allelic effect for each polymorphism. The Cochran-Armitage trend test was performed to test additive genetic effect model.For each SNP, deviation of genotype frequencies in controls from the Hardy-Weinberg-Equilibrium (HWE) was assessed by a goodness-of-fit Linkage disequilibrium (LD) pattern and population haplotype frequencies for the SNPs were estimated using the online SNPStats tool using an expectation maximization algorithm . Using tP < 0.05 was considered significant. To correct multiple testing, we estimated the adjusted significance by applying the Bonferroni correction for all the SNPs tested in the analysis. Statistical analysis was performed using SPSS version 19.0  unless otherwise specified.Stratified analysis according to intrinsic subtypes was additionally conducted. All statistical tests were two-sided, and P < 1 × 10−4) and thus was excluded from the subsequent analyses  and JPT (Japanese) population. All the observed genotype frequencies were found to be in agreement with HWE in controls except for rs1219648, which deviates from HWE . After adjusting for the abovementioned potential confounders, logistic regression analysis further confirmed these associations which remained significant in dominant model for rs2420946 (C/T + T/T: P = 7.2 × 10−3), in both codominant (T/T: P = 5.0 × 10−3) and dominant (T/C + T/T: P = 8.1 × 10−3) model for rs2981579, and in per-allele model for rs2981579/T even after Bonferroni correction (P < 1.0 × 10−2).Ptrend = 5.6 × 10−3). Significant associations were also observed between Luminal-A breast cancer risk and the homozygous minor allele genotype (T/T) for rs2981579  and rs2981582 . However, after Bonferroni correction, only rs2420946 (Pcorrection = 1.3 × 10−2) and rs2981582 (Pcorrection = 3.4 × 10−2) were found to be associated with Luminal-A breast cancer risk under dominant model.In a subgroup of Luminal-A, the association between rs2420946 and breast cancer risk was the strongest  in a dose-dependent manner  with ER−HER2+ breast cancer risk under dominant model. However, based on the multiple hypothesis testing, this association was not significant (Bonferroni-adjusted P = 2.2 × 10−1). No significant associations between selected SNPs and triple negative breast cancer risk were detected under any of the assumptions  (P = 8.1 × 10−3) (P = 1.5 × 10−3) and Luminal-B   . Estimat × 10−3)  and in s × 10−2) . Breast  × 10−2) .FGFR2 belongs to the FGFR family of tyrosine kinase receptors involved in various signaling pathways that contribute to the process of tumorigenesis through cell growth, apoptosis, and differentiation [ FGFR2 polymorphisms located in intron-2 alter the binding of two transcription factors, Oct-1/Runx2 and C/EBPb, resulting in an increase of FGFR2 gene expression both in cell lines and in breast tissue [ FGFR2 polymorphisms located in intron-2 with breast cancer susceptibility in Chinese populations [ntiation . Subsequt tissue . Specifiulations –32. Howe FGFR2 SNPs were associated with specific tumor subtypes defined by four markers. This will be the first Chinese study to validate and provide convincing evidence for heterogeneity in the strength of the association of FGFR2 susceptibility locus with the risk of specific subtype. Furthermore, stratification of tumors also provided further insights into etiological heterogeneity.To investigate this inconsistency, one important step is to study whether these common variants interact with known breast cancer intrinsic subtypes. Thus, present study investigated whether 5 common FGFR2  were significantly associated with increased risk of breast cancer, which validates earlier GWAS results [ FGFR2 gene is significantly associated with increased breast cancer risk in nonfamilial breast cancer but not in familial breast cancer in a Chinese Han population. Similarly, in our study, to explore the genetic risk factors for sporadic breast cancer, all subjects also lacked a family history of cancer and free of other malignant diseases. Therefore, it is likely that some polymorphisms in intron-2 of FGFR2 play a role in tumorigenesis in this subgroup of Chinese women.First, this study confirmed that three SNPs in the second intron of results . This re results , who in  results  reported FGFR2 with luminal-like tumors are also consistent with the involvement of FGFR2 in estrogen-related breast carcinogenesis [Further subtype stratification analyses showed that rs2981579 was associated with the increased risk of both Luminal-A and Luminal-B according to dominant or codominant polygenetic risk models. Consistent with previous reports, this study confirmed that rs2420946  and rs29ogenesis . FGFR2 (rs1078806C-rs2420946T-rs2981579T-rs2981582T) was associated with a significantly increased luminal-like breast cancer risk compared with the rs1078806T-rs2420946C-rs2981579C-rs2981582C haplotype, with no association observed for ER− and PR− tumors. Our findings on haplotype analysis are to several extents similar to previous studies due to further stratification by adding other tumor markers, not included in previous publications [ FGFR2 variants in our Southern Chinese Han population was moderate, in contrast to Caucasians from the HapMap CEU samples (r2 range from 0.97 to 1.0), but resembling other Asian populations [In haplotype analysis, the risk haplotype ofications , 38. FurTherefore, different patterns of association with specific tumor subtypes observed in our study strengthen the evidence for hypothesis that genetic factors differ by intrinsic subtype. Therefore, different patterns of association with specific tumor subtypes observed in our study strengthen the evidence for hypothesis that genetic factors differ by intrinsic subtype . To someOne strength of present study was that ER, PR, HER-2, and ki67 status were all assessed using the same processing protocols and criteria for pathology review for all cases. However, several limitations of this study must be considered. First, though this current study has sufficient power (>90%) to detect a log-additive OR of 1.30 with allele frequencies >27%, providing sufficient sensitivity to detect most of the SNPs at the significance level of 0.05 (two-sided), other SNPs with ORs < 1.3 may be affected by insufficient power afforded in this study. Furthermore, the exact powers of three SNPs  with Luminal-A and rs2981579 with Luminal-B were 79.64%, 72.46%, 92.15%, and 66.13%, respectively. However, we could not confirm that other SNPs lacked an association with specific breast cancer subtypes because we had limited samples and a lack of power to detect a true association. Larger sample sizes could help improve the power and ensure the correct conclusion regarding whether these SNPs are associated with specific breast cancer subtypes. Indeed, while this paper was in preparation, as part of the Southern China Breast Cancer Genetics Study, more participants are being recruited. We expect that the findings from the present study will be replicated. FGFR2 SNPs and subtypes of breast cancers differed by whether corresponding information were available. Another weakness is that misclassification probabilities of subtypes are likely to be independent of susceptibly loci and thus would tend to underestimate association strengths rather than creating spurious associations [Second, when we did analyses by receptor subtypes, 28.9% of cases were excluded due to unavailable information, which is similar to that reported by previous studies either conducted within the epidemiology registries  or conduciations . For exaciations . To addr FGFR2 intron-2 SNPs with breast cancer risk in Southern Han Chinese and provided strong evidence for differential susceptibility according to intrinsic subtype. Further epidemiological and experimental studies of larger datasets along with intrinsic subtype categorization are warranted to explore and confirm the role of these variants in increasing breast cancer risk, which will provide biological insights on the mechanisms of carcinogenesis and ultimately lead to improvement in prevention and treatment.In conclusion, our study revealed a significant association of