There are limited data on awareness of cervical cancer risk factors and symptoms among refugee populations living in Uganda. In this study, we sought to determine the awareness and knowledge of cervical cancer risk factors and symptoms among women in Palabek refugee settlement, northern Uganda.We conducted a cross-sectional study. 815 women (aged 18–60 years) were randomly selected using multistage sampling in Palabek refugee settlement. Data were collected using pre-tested, structured questionnaires. Logistic regression models were used to determine magnitudes of association between socio-demographic and health system factors, and knowledge on cervical cancer risk factors and symptoms.n = 433) were young (18–29 years), married , and did not have formal employment . Less than half  had heard of cervical cancer. Of those who had heard, most recognized multiple male sexual partners, early onset of sexual intercourse and HPV infections as risk factors for cervical cancer . Median knowledge score for risk factor recognition = 7 (IQR: 3–9). Median knowledge score for symptoms recognition = 7 (IQR: 1–10). Half of women  correctly recognized 7 to 11 symptoms of cervical cancer, with vaginal bleeding between menstrual periods, pelvic pain, and vaginal bleeding during/after sexual intercourse recognized by 58, 52 and 54% respectively. Single women (OR = 0.59 (95%CI: 0.38–0.94), and women that lived farther than 1 kilo meter from nearest health facility in South Sudan (OR = 0.36–0.49 (95%CI: 0.26–0.84) were less likely to be knowledgeable of symptoms of cervical cancer.The majority of participants (53%, A significant proportion of women in Palabek refugee settlement had not heard about cervical cancer. Refugee health services providers could increase awareness of cervical cancer risk factors and symptoms through health education in order to promote risk reduction behaviours and guide women during symptoms appraisal. Single women and those who lived more than one kilo metre from nearest health facility in home country could be a priority group for awareness intervention in the settlement. Worldwide, there were 569,847 new cases of cervical cancer diagnosed in 2018; and there were 311,365 cancer deaths. 85% of the new cases and deaths from cervical cancer occurred in low- and middle-income countries (LMICs) [The incidence and mortality from cervical cancer in Sub-Sahara African refugee settings are likely higher than in the host population. Generally, refugees and people in internally displaced persons camps (IDPs) have poorer health and higher incidence of sexually transmiited infections including HIV and hepatitis B –13. RefuThere are several refugee settelments in Sub-Saharan Africa with very large populations of women and children . For exaThis study was conducted in Palabek refugee settlement, northern Uganda. Palabek refugee settlement is one of the newest refugee settlements in Uganda established in April 2017 . It is dThis was a cross-sectional survey. We used a multilevel sampling approach to select the study participants. We obtained the updated list of zones and blocks within the settlement with their respective population sizes from the settlement commandant at the Office of the Prime Minister (OPM). This list was used as the sampling frame. The number of women selected from each zone was based on probability proportionate to sizes of the blocks. Two blocks were randomly selected from each of the 7 zones. The number of women selected per block was obtained by dividing the total population in each block with the total population of all the blocks in the zone then multiplied by the sample size calculated per zone. Systematic random sampling of every “10th”  household was done until the required number of participants from each selected block was achieved. The beginning household was selected by simple random sampling of one out of 10 listed households in every selected blocks. We identified eligible households with the help of village health teams and the local leaders in the zones/blocks. Data collection was conducted during May 2019. In each household, one woman aged 18–60 years was selected by simple random sampling from a list of eligible women within the household. Potential particpants (20 households) who were never found home on two visits during field data collection were replaced. Women with self-reported or documented diagnosis of cervical cancer or those reported by family members and or judged by research assistants as not mentally sound or with speech impairments were to be excluded. 30 women declined to participate for various reasons. No woman fulfilled the exclusion criteria.www.awacan.online) was used to collect data [A standardised pretested questionnaire adapted from the African Women Awareness of CANcer (AWACAN) tool (ect data . Data fr(i) Cervical cancer risk factors: 10 risk factors were assessed. A participant scored 1 or 0 if she responded “Yes” or “No” respectively to a known cervical cancer risk factor. The highest expected knowledge score for any one participant = 10, while the lowest score = 0. The calculated median knowledge score was 7. Participants with knowledge scores of 0–6 were considered to have low knowledge (less knowledgeable) while those with scores of 7 and above were considered to have high knowledge (highly knowledgeable). (ii) Cervical cancer symptoms: 11 symptoms were assessed. A participant scored 1 or 0 if she responded “Yes” or “No” respectively to a symptom known to be associated with cervical cancer. The highest expected knowledge score for any one participant = 11, while the lowest score = 0. The calculated median knowledge score was 7. Participants with knowledge scores of 0–6 were considered to have low knowledge (less knowledgeable) while those with scores of 7 and above were considered to have high knowledge (highly knowledgeable).At the end of each workday, WA uploaded data collected from the ODK into Epidata 3.1 and reviewed the data for completeness, accuracy and consistency. In seven instances, the RAs revisited the households where data were not complete and or aspects of the data not clear. The biostatistician (GOG) reviewed data from 10% of randomly selected participants to ensure data quality. There were no significant inconsistencies detected in data entry and capture. Knowledge of cervical cancer risk factors and symptoms was assessed based on scores developed from the list of risk factors and symptoms presented to the participants for recognition: p-value < 0.05. Odds ratios and accompanying 95% confidence intervals have been reported.Univariate analysis was used to obtain the descriptive statistics (demographic characteristics) of participants. Measures on knowledge scores included median and interquartile ranges. Knowledge scores were categorized into binary outcome around the median scores as less knowledgable (below median) and highly knowledgeable (median and above). Bivariate analysis using Chi square tests were conducted to determine assocations between the binary knowledge scores on risk factors and symptoms of cervical cancer with socio-demographic correlates. Multivariate logistic regression models were applied on categorical variables with binary outcomes (split around the median scores) to determine the magnitudes of associations between knowledge of risk factors and symptoms of cervical cancer with selected independent variables. Statistical significance was set at n = 433) were young (18–29 years), and were married . Most participants were not formally employed . Less than half of the women  self-reported having heard of cervical cancer before this study  who self-reported they had heard of cervical cancer before this study. Recognition of cervical cancer risk factors was quite good; 93% (295/319) recognized that having multiple sexual partners (> 3 men) increases a woman’s risk of developing cervical cancer. Similarly, 87% (271/314) recognized infection with the human papilloma virus (HPV) as a risk factor for cervical cancer. However, less than half of participants recognized smoking cigarettes  as risk factor for cervical cancer . 11% could correctly recognize 7 risk factors, while 40% recognized 8–10 risk factors correctly (Table n = 532) symptom of cervical cancer. Other symptoms recognized by more than half of participants included persistent smelly vaginal discharge , vaginal bleeding after menopause  and vaginal bleeding between menstrual periods  . 5% could correctly recognize 7 cervical cancer symptoms, while 51.2% correctly recognized 7–11 cervical cancer symptoms Table . Upon adOn adjusting for age, level of education, employment status, tribe, and distance to the nearest health facility back in South Sudan, single participants were 41% less likely to be knowledgeable about cervical cancer symptoms compared to participants who were married . Similarly, on adjusting for participants’ sociodemographic charateristics, those who lived farther than 1 km from the nearest health facility back in South Sudan were 51–64% less likely to be knowledgeable of cervical cancer symptoms compared to participants who lived within 1 km  had not heard of cervical cancer before this study. Of the women who had heard, the majority could recognize most of the cervical cancer risk factors. HPV infections, multiple male sexual partners (> 3), and early sexual debut were well recognized as risk factors for cervical cancer. However, less than half of participants recognized smoking cigarettes (38%) as a risk factor. Recogntion of risk factors was only associated with being formally employed. All participants were assessed for recognition of cervical cancer symptoms; recognition was generally low among the women: Persistent lower abdominal pain (65%) was the most recognized cervical cancer symptom, followed by persistent smelly vaginal discharge (63%) and vaginal bleeding after menopause (60%). Recognition of cervical cancer symptoms was statistically significantly associated with being married, formally employed and residing within 1 kilo meter of the the nearest health facility back in South Sudan.n = 36) and Liberia , had significantly lower levels of knowledge of cervical cancer compared to other non-refugee immigrant women [Our findings are similar to results of a study from a neighbouring host community; recognition of smoking and delivery of three or more children as risk factors for cervical cancer were also low in the neighbouring host community of Gulu . Other snt women . Poor reIn this study, we found that only about half of the participants could correctly recognize cervical cancer symptoms. Our result is similar to findings from a number of studies in Sub-Saharan Africa that show low awareness of symptoms of cervical cancer in the general population , 41. TheMajority of the participants in this study spoke Acoli, the local language of the host community. The questionnaire used was in Acoli, and the RAs were also ethnic Acoli; therefore, the questions could have been well understood. The findings perhaps reflect the true cervical cancer knowledge among women in the settlement. However, the study has some limitations. First, although the knowledge assessment approach applied in this research has been validated in the AWACAN tool referred to earlier, there is possibility that prompted items addressing recognition of symptoms/risks factors may overestimate awareness while unprompted questions on cancer awareness may underestimate awareness. Second, this was a cross sectional study that depended on self-report by the participants. Recall bias and social desirability bias could affect their responses. Third, the settlemnet commandants were strict on access to available health services and limited our access to what was in our protocol. We therefore can not tease out the contributions of health programmes conducted in the settlement to the knowledge enhancement of the participants. Finally, generalization of findings from this study to inform health services intervention in South Sudan or other refugee settings need to take into considerations knowledge and behavioural changes that could have been introduced by different actors during encampment in this settlement.More than half of the refugee women from South Sudan had not heard of cervical cancer before this study. These women are therefore unlikely to undertake preventive measures including cervical screening and or seek appropriate care when symptomatic. There is need for deliberate public awareness interventions to improve recognition of cervical cancer risk factors and symptoms, and to increase awareness of the benefits of treatment when cervical cancer is detected in early stages. Single women and women who lived farther than one kilo meter from the nearest health facility in South Sudan are a particular target group for health education interventions regarding cervical risk factors and symptoms.


Globally, more than 2 million new cases of breast cancer are reported annually. The United States alone has more than 496,000 new cases every year. The worldwide prevalence is approximately 6.8 million cases. Although many risk factors for breast cancer are not modifiable, understanding the role of the factors that can be altered is critical. Alcohol consumption is a modifiable factor. Studies of alcohol in relation to breast cancer incidence have included hundreds of thousands of women. Evidence is consistent that intake, even intake of less than 10–15 grams per day, is associated with increased risk of this disease. In addition, evidence, although less extensive, shows that possible early indicators of risk, such as benign breast disease and increased breast density, are associated with alcohol consumption. Evidence is less strong for differences based on geographic region, beverage type, drinking pattern, or breast cancer subtype. Some studies have examined the association between alcohol and recurrence or survival after a breast cancer diagnosis. These findings are less consistent. Public awareness of alcohol as a risk factor for breast cancer is low, and public health measures to increase that awareness are warranted. New England Journal of Medicine published two reports about alcohol consumption and breast cancer risk.In 1987, the Breast cancer affects more than 2 million women each year around the world.A large body of research provides evidence that alcohol is a risk factor for incidence of breast cancer. The World Cancer Research Fund and the American Institute for Cancer Research (WCRF-AICR) collaborated to organize a continuous systematic review of dietary factors in relation to cancer.6New England Journal of Medicine, an association between alcohol and breast cancer was found across geographic locations for a range of beverage types consumed and for a variety of drinking patterns.As noted in the 1987 editorial in the The WCRF-AICR meta-analysis reported some differences by location.In a study that pooled data from 20 cohorts in the United States, Canada, Europe, Australia, and Japan, no significant heterogeneity was found among studies, although the association between alcohol and breast cancer was stronger for the North American cohorts than for the others.8Studies of individual European countries, including Italy,20Few studies have examined the association between alcohol and breast cancer by race/ethnicity. The African American Breast Cancer Epidemiology and Risk (AMBER) Consortium, a pooled analysis of studies of African American women, found a J-shaped association between alcohol consumption and breast cancer risk.Overall, there is strong evidence that alcohol increases breast cancer risk. Evidence is strongest for North America and Europe, where more studies have been conducted, but other regions also show some evidence of a similar association. Much additional research has been done regarding the details of the alcohol consumption  and the details of the breast cancer . These findings are less consistent.Variability in findings may be a function of the small sample size of some studies, for instance, in those studies that examined associations between alcohol consumption for breast cancer by subtype . In addition, alcohol consumption can be difficult to assess for a variety of reasons, including difficulty recalling usual intake, change in consumption over the lifetime, and response bias. In this context, the consistency of the findings regarding overall risk of breast cancer associated with alcohol consumption is noteworthy.Several studies of alcohol and risk examined whether there are differences depending on the beverage consumed: wine, beer, or spirits. The pooled analysis of 20 cohorts reported no difference in risk based on the beverage type.When examining the effects of alcohol consumption on health and disease, how participants consumed the alcohol must be considered. Not only the absolute quantity consumed, but also the intensity of consumption may have biological effects. For example, the effects of an average consumption of seven drinks per week may differ for consumption of one drink daily and for seven drinks on one day once per week.Just a few studies have examined drinking intensity. In the Nurses’ Health Study I (NHS), binge drinking (defined as six or more drinks in one day) was associated with increased risk, even after adjusting for total consumption.Even among people who drink lightly, evidence of increased risk has been reported. In a systematic review of light drinking, which used the World Health Organization definition of less than 21 grams of alcohol consumed per day, Shield and colleagues found consistent evidence of increased risk.Breast cancer can be classified into subtypes by tumor markers. The subtypes may have different risk factors, and they are different in terms of aggressiveness, treatment, and prognosis. A number of studies have examined the association between alcohol consumption and invasive breast cancer by subtype.In the European Prospective Investigation into Cancer and Nutrition (EPIC) study, which examined a cohort of more than 360,000 women from 23 centers in 10 countries in Europe, the association between alcohol consumption and risk was stronger for women with estrogen receptor–positive tumors than for those with estrogen receptor–negative tumors.5In one study, alcohol consumption and risk of human epidermal growth factor receptor 2 (HER2)–positive and triple-negative breast cancers were compared to risk of estrogen receptor–positive tumors.Alcohol consumption patterns generally vary during the life span, and effects of exposures may differ depending on the stage of breast development when the drinking occurred. A number of studies have examined risk associated with alcohol consumption at particular time periods, especially during adolescence and early adulthood.The NHS II, a prospective study of women ages 24 to 44 at baseline, reported an 11% increase in breast cancer risk associated with consumption of 10 grams of alcohol per day between menarche and first pregnancy, adjusting for subsequent intake.Benign breast disease is associated with increased breast cancer risk and may be an early indicator of risk. In the NHS II, evidence indicated a 15% increase in risk of benign breast disease for each additional 10 grams per day of alcohol consumed during adolescence.32in utero may predispose to increased risk. Evidence from animal models indicates that ethanol exposure in utero can lead to increased breast tumorigenesis in the adult offspring when exposed to carcinogens.33The EPIC cohort study examined the association between risk and alcohol consumption for parous women before their first, full-term pregnancy compared with women who did not begin drinking until after their first pregnancy.These studies indicate that the association of lifetime alcohol consumption with breast cancer risk may be different depending on when the alcohol was consumed. Evidence shows, with some inconsistency among studies, that consumption in adolescence and before a first pregnancy may particularly affect risk.Breast density is a measure of breast tissue from radiography. It is associated with subsequent breast cancer and is one of the strongest breast cancer risk factors.41In some studies, the association between alcohol consumption and risk varied depending on other breast cancer risk factors. In the Swedish study, the association was strongest for the group that also had other factors that predicted increased risk of breast cancer.A number of studies have examined alcohol consumption in concert with other known breast cancer risk factors. In particular, there has been study of interactions of alcohol with other dietary factors such as folate and other B vitamins, which play a role in alcohol metabolism. Alcohol negatively affects folate status, impacting folate absorption and metabolism and increasing folate excretion.Several recent studies examined plasma folate as a measure of vitamin status. In the NHS II, there was an interaction between alcohol and plasma vitamin concentrations, with a trend toward plasma folate being protective for breast cancer risk among individuals who consumed greater amounts, but not among those consuming lesser amounts of alcohol.4712 consumption in relation to breast cancer risk; vitamin B12 also is a cofactor in one-carbon metabolism. A study that examined the Women’s Health Study cohort found no interaction between plasma concentrations of B vitamins and alcohol consumption in relation to risk.Further, in the EPIC cohort study in Europe, no interaction was found for alcohol and plasma folate consumption in relation to breast cancer risk.Several studies have examined genetic variation in the association between alcohol consumption and breast cancer risk. There have been several studies of the genes that code for the alcohol dehydrogenases (ADH), which are critical enzymes for alcohol metabolism. In a cohort in the Netherlands, variants in the genes for ADH were not associated with breast cancer risk nor did they modify the risk associated with alcohol consumption.CYP19A1 gene, which codes for aromatase, an enzyme important to estrogen metabolism.BRCA1 or BRCA2 genes, mutations that confer a particularly elevated risk of breast cancer, alcohol was not associated with breast cancer risk.A Danish cohort study examined variation in the Understanding of whether other factors modify the observed association between alcohol consumption and breast cancer is another area of active research. In a pooled analysis, alcohol was positively associated with risk among both nulliparous and parous women.Although most of the research regarding the association between consuming alcohol and the risk for breast cancer has focused on incidence, some studies have examined the effects of alcohol on survival after a breast cancer diagnosis. Studies used different time frames (before or after diagnosis) for the alcohol consumption and different outcome measures, such as breast cancer recurrence, breast cancer–specific survival, and all-cause mortality. Most studies did not distinguish by breast cancer subtype, which can affect prognosis.A meta-analysis of 11 studies found evidence of improved survival after breast cancer diagnosis among individuals who reported any prediagnostic alcohol consumption, when compared with those who reported none.59In the National Institutes of Health (NIH)-AARP Diet and Health Study cohort, alcohol consumption at the study baseline was not statistically significantly associated with breast cancer–specific survival.63Alcohol consumption pattern may affect mortality as well as incidence. In a study in western New York among women who had postmenopausal breast cancer, drinking intensity before diagnosis was associated with prognosis.Few studies have examined alcohol consumption following a breast cancer diagnosis. One study reported an increased risk of breast cancer recurrence with alcohol consumption after diagnosis among premenopausal but not postmenopausal women.More analyses regarding breast cancer subtype and treatment are required to better understand a possible role of alcohol consumption following diagnosis. Recent studies examining alcohol consumption and the efficacy of breast cancer treatments have not found any effect of alcohol consumption on radiotherapyThe role of alcohol consumption in breast carcinogenesis is a complex process likely acting through a number of mechanisms. Although alcoholic beverages contain a variety of compounds, for breast carcinogenesis, alcohol itself appears to be the more important carcinogen,Alcohol likely contributes to carcinogenesis partly through oxidation from alcohol metabolism and through oxidative stress from production of the alpha-hydroxyethyl radical, a reactive oxygen species.There is in vivo evidence that acetaldehyde can concentrate in mammary cells following a single exposure. In an animal model, acetaldehyde accumulated and persisted in higher concentrations in breast tissue than in blood.In addition to the carcinogenic effects of alcohol consumption and acetaldehyde on breast tissue, alcohol consumption’s effects on hormones also may contribute to cancer in the breast. There are both acute and chronic effects of alcohol on steroid hormone level. At doses of even 15 to 30 grams of alcohol per day, serum estrogens increase.72Altered DNA methylation also contributes to carcinogenesis. Alcohol significantly affects one-carbon metabolism, including DNA methylation, in part by effects on folate status, as discussed previously. Studies that examined DNA methylation in breast tumors made comparisons based on drinking history and found differences by the amount of alcohol consumption.24Other possible mechanisms for an effect of alcohol on carcinogenesis in general and breast cancer in particular are still emerging. For example, the microbiome in the mouth and gut may affect breast cancer risk,80Alcohol’s effects on oxidative stress, cell proliferation, steroid hormones, and one-carbon metabolism may explain, in part, the observed associations with breast cancer risk. Additional research is needed regarding these and other mechanisms, including research on those specific to tumor subtypes and mechanisms for exposures following a breast cancer diagnosis.A limited number of studies have examined public understanding of alcohol and breast cancer. In a study of women attending a breast screening clinic in the United Kingdom, only 19% were aware that alcohol consumption is a breast cancer risk factor.Awareness tends to be greater among women who have been diagnosed with breast cancer, with resulting lower alcohol intake in that group. In a systematic review, 62% to 97% of participants adhered to recommendations to limit alcohol consumption in a study of women completing initial treatment for breast cancer.Reduction of alcohol consumption could measurably affect the burden of disease related to breast cancer. Based on global data of the prevalence of alcohol consumption and of the incidence rate of breast cancer, an estimated 144,000 new cases of breast cancer and 38,000 breast cancer deaths annually are accounted for by alcohol consumption, which is 8.6% of all incidence and 7.3% of mortality.85in utero exposure, is warranted. Examination of how other breast cancer risk factors  interact with alcohol consumption in relation to both breast cancer risk and prognosis is needed. More studies of the association by race/ethnicity, by age at diagnosis, and conducted in regions outside of Europe and North America would contribute to our understanding. Additional research linking epidemiological information with biological information regarding the role of alcohol in carcinogenesis could enhance the ability to leverage this important relationship toward prevention efforts.Although the evidence is strong for an increase in breast cancer with alcohol consumption, some areas of research still require further attention. A better understanding of the roles of drinking pattern, or drinking intensity, in relation to total consumption is needed. More studies of alcohol consumption and breast cancer subtypes would help increase insight into the relationship. A clearer understanding of the effects of exposures in early life, including Given the strength of the evidence linking alcohol to breast cancer, increasing awareness of risk is critical. It is time for a clear public health message identifying the role of alcohol in breast carcinogenesis and indicating that that there is no apparent lower threshold of effect. Consumption levels of less than one drink per day are associated with increased risk. Further, drinking alcohol affects risk at all phases of life, including early and late life. The science is consistent and clear, but awareness is low. It is time for a focus on developing public understanding of alcohol, which is a very common exposure, and its connection with increased risk of breast cancer.


Among breast cancer survivors age > 50 years, deaths due to cardiovascular disease account for 35% of non-cancer related deaths. The increases in cardiovascular disease among breast cancer survivors is due to the cardiotoxic effects of breast cancer treatment and to overlapping risk factors for breast cancer and cardiovascular disease.We conducted a study of a sample of 164 breast cancer patients in order to examine the frequency of cardiovascular disease. The overall objective was to examine the frequency of high blood pressure, myocardial infarction, cardiomyopathy, congestive heart failure, stroke, and venous thrombosis/thromboembolism among women who have been diagnosed with stage I-IV breast cancer and who had completed primary therapy for the disease. Data were collected by postal survey and abstraction of electronic medical records.A high percentage of the women (62.8%) had a reported history of high blood pressure. Fifty percent of the women had a reported history of high cholesterol. About 8.3% of the women were current smokers and 36.0% were former smokers. About 23.8% of the women had a reported history of diabetes. About 4.9% of the women had a reported history of congestive heart failure and 6.1% had a history of stroke.Additional studies are needed of cardiovascular risk factors and adverse cardiovascular events among breast cancer survivors. Of particular concern is whether patients with hypertension, hypercholesterolemia, and diabetes are receiving appropriate therapy to reduce their cardiovascular risk and prevent morbidity and mortality from adverse cardiovascular events. Cardiovascular disease is the leading cause of death in women in general and among breast cancer survivors in particular , 2. AmonAs a result, doses of anthracycline such as doxorubicin have decreased. Trastuzumab, a biological therapy that targets the HER-2 receptor can lead to reversible congestive heart failure -7. TamoxData are from the Cardiovascular Disease outcomes among Breast Cancer Survivors study (CVDBCS), a cross-sectional study among breast cancer survivors. Non-institutionalized women were eligible to take part in the study if they had been diagnosed with breast cancer and completed primary therapy at Augusta University Health or the Georgia Cancer Center; and resided in Augusta-Richmond County or Columbia County, GA, or in Aiken County, SC. Data were collected using postal survey questionnaires and abstraction of electronic medical records.The mailings were sent to 1,000 potential research participants. A sequential mailing protocol was followed using a modified Dillman method. An advance letter was mailed to the women by the study principal investigator (SSC). The letter provided information about the study . Three weeks later, a survey consent letter was mailed to those who had not opted out along with a copy of the survey questionnaire and a pre-addressed, stamped return envelope. Women who had not opted out or returned a completed questionnaire were sent a reminder postcard four weeks later.Information about cardiovascular risk factors and diseases , breast cancer , and breast cancer treatment) was collected via postal survey and abstracted from electronic medical records. Survey responses were checked for completeness and then coded and entered into an electronic database.Descriptive analyses and logistic regression methods were used to examine predictors of congestive heart failure, using a forward-selection model building strategy. We present adjusted odds ratios (OR) and 95% confidence Intervals (95% CI). Significance level was set at α = 0.05. Levels of statistical significance were determined using Wald chi-square tests and Log-likelihood ratio tests. The goodness-of-fit of the model model was examined using the Log-likelihood ratio test.A total of 164 women completed the study questions (response rate 16.4%). The mean age of the women was 67 years . Among aA high percentage of the study participants (62.8%) reported a history of high blood pressure; 50% had high cholesterol; and 8.3% were current cigarette smokers . About 2In this study of breast cancer survivors treated at a large academic medical center in the southern United States, a high percentage of patients had one or more cardiovascular risk factors. Almost two-thirds of the women had a history of high blood pressure and half had a history of high cholesterol. About one in five had a history of diabetes. Forty-four percent were current or former cigarette smokers. The prevalence of cardiovascular risk factors in this population is of concern both because it may increase risk of adverse cardiovascular events such as congestive heart failure and stroke, and because breast cancer survivors have an increased risk of adverse cardiovascular events due to primary treatment for the disease. Aside from hypertension, the most common adverse cardiovascular disease outcomes were stroke (5.1%), venous thrombosis (5.1%), congestive heart failure (4.4%), and cardiomyopathy (4.4%). Only 1.3% of the women had a recorded history of heart attack. Breast cancer survivors who receive tamoxifen therapy have an increased risk of deep vein thrombosis and pulmonary embolism .Women who had received chemotherapy were more likely to have a history of congestive heart failure. This is consistent with the well-established link between anthracycline chemotherapy and congestive heart failure , 2. HoweOver half of the patients in the current study were over 60 years of age. Older breast cancer survivors cope with health issues related to cancer treatment and the aging process, including comorbidities, symptoms, physical functioning, nutrition, and physical activity . AdditioIt is important to develop early markers of cardiotoxicity to prevent irreversible damage. This can be accomplished by detecting early heart function derangement than relying on ejection fraction which is less sensitive to capture subtle heart malfunction. Monitoring diastolic function has been proved to be more sensitive to effect of these medications in the increasing numbers cancer survivors. Such effort will encompass using Doppler and strain rate imaging, cardiac MRI, and biomarkers  in a large population to identify precursors of cardiac malfunction in breast cancer treated patients and determine who should be treated at an early stage.With respect to limitations, misclassification bias is a possibility due to the use of self-reported information. However, recorded information about cardiovascular risk factors and adverse cardiovascular outcomes was also obtained from electronic medical records. The results of this study may not be generalizable to other populations of breast cancer survivors. However, the sample was diverse by race, socioeconomic factors, and history of breast cancer diagnosis and treatment. Additional studies are needed of cardiovascular risk factors and adverse cardiovascular events among breast cancer survivors. Of particular concern is whether patients with hypertension, hypercholesterolemia, and diabetes are receiving appropriate therapy to reduce their cardiovascular risk and prevent morbidity and mortality from adverse cardiovascular events.


Breast cancer is the most common cancer in women, but its incidence can only be partially explained through established risk factors. Our aim was to use metabolomics to identify novel risk factors for breast cancer and to validate recently reported metabolite-breast cancer findings. We measured levels of 1275 metabolites in prediagnostic serum in a nested case-control study of 782 postmenopausal breast cancer cases and 782 matched controls. Metabolomics analysis was performed by Metabolon Inc using ultra-performance liquid chromatography and a Q-Exactive high resolution/accurate mass spectrometer. Controls were matched by birth date, date of blood draw, and race/ethnicity. Odds ratios (ORs) and 95% confidence intervals (CIs) of breast cancer at the 90th versus 10th percentile (modeled on a continuous basis) of metabolite levels were estimated using conditional logistic regression, with adjustment for age. Twenty-four metabolites were significantly associated with breast cancer risk at a false discovery rate <0.20. For the nine metabolites positively associated with risk, the ORs ranged from 1.75 (95% CI: 1.29–2.36) to 1.45 (95% CI: 1.13–1.85), and for the 15 metabolites inversely associated with risk, ORs ranged from 0.59 (95% CI: 0.43–0.79) to 0.69 (95% CI: 0.55–0.87). These metabolites largely comprised carnitines, glycerolipids, and sex steroid metabolites. Associations for three sex steroid metabolites validated findings from recent studies and the remainder were novel. These findings contribute to growing data on metabolite-breast cancer associations by confirming prior findings and identifying novel leads for future validation efforts. Breast cancer is the most frequently diagnosed cancer among women, with 2 million cases globally in 2018, and rates rising rapidly . By the Several lines of evidence indicate that metabolism may be important to breast cancer etiology, including the established associations of physical inactivity and obesity with breast cancer risk ,7, and tIn the present study, we examined levels of 1256 metabolites in prediagnostic serum in a nested case-control study of 782 postmenopausal breast cancer cases and 782 matched controls in the Cancer Prevention Study-II (CPS-II) Nutrition Cohort. The broad span of metabolites examined allowed us to simultaneously evaluate prior metabolic findings for replication and to search for novel metabolic risk factors that may not have been examined in studies preceding the advent of metabolomics.Study participants were an average (mean) 68 years of age and 98% were white . The estTwenty-four of the 1275 metabolites were statistically significantly associated with breast cancer at a false discovery rate <0.20 in conditional logistic regression models (one below the Bonferroni threshold of 0.00004) . These mheterogeneity = 7.34 × 10−6; qheterogeneity = 0.07). In our analysis of estrogen receptor-positive (ER+) cases, no associations met the FDR threshold for statistical significance. Results for the 20 metabolites most significantly associated with breast cancer among non-hormone-users and ER+ breast cancer are shown in After confirming that results for unconditional models were like those of conditional models (the median absolute difference in OR between models was 0.01), we further examined associations between metabolites and breast cancer among non-hormone-users. We found that five metabolites were associated with breast cancer risk in this group at FDR < 0.2 (one below the Bonferroni threshold). The metabolite X-11795 was associated with breast cancer only in non-hormone-users, while the other four metabolites were associated with risk in both non-hormone-users and in all participants , Androstenediol  monosulfate (2), and 4-allylphenol sulfate) . The resage-adjusted = 1.75 vs ORmultivariable = 1.58).Adjusting for additional covariates in our statistical models had little effect on the magnitude of metabolite-breast cancer associations, suggesting that associations are largely independent of known breast cancer risk factors . Fifteen16alpha-hydroxy DHEA 3-sulfate and three other androgen metabolites are biochemically related to the hormone DHEA and, in our study, each of these metabolites was highly correlated with DHEA-sulfate, the body’s major reservoir of DHEA. The Pearson correlation of 16alpha-hydroxy DHEA 3-sulfate with DHEA-sulfate, for example, was 0.71. To test whether the associations of these metabolites with breast cancer risk were independent of DHEA, we added DHEA-sulfate to models but found little attenuation of associations. For example, the OR for 16alpha-hydroxy DHEA 3-sulfate was 1.54 (95% CI: 1.09–2.19) after adding DHEA-Sulfate, when compared with 1.45 (95% CI: 1.13–1.85) previously. In contrast, adding 16alpha-hydroxy DHEA 3-sulfate to models did affect the association of DHEA sulfate with breast cancer risk. The OR for DHEA sulfate was 0.91 (95% CI: 0.64–1.30) when 16alpha-hydroxy DHEA 3-sulfate was in the model, but 1.24 (95% CI: 0.97–1.60) when 16alpha-hydroxy DHEA 3-sulfate was not in the model.In a metabolite correlation heatmap, we identified four distinct metabolite clusters encompassing 17 of the 24 breast cancer-associated metabolites . The firAfter controlling for multiple testing, we found that levels of 24 distinct metabolites were associated with the risk of postmenopausal breast cancer. Findings for three of the metabolites—16alpha-hydroxy DHEA 3-sulfate, androstenediol  monosulfate (2), and androstenediol  disulfate (1)—replicate results from recent studies ,14, suggThe three metabolites with replicating associations each share a common feature, namely DHEA as a precursor. While DHEA has previously been linked with breast cancer risk DHEA ,17,18, tEighteen other associations were novel to the literature and generally involved metabolites whose biological function is understood incompletely. One cluster included the metabolites of linoleoylcarnitine and linolenoylcarnitine, which are long-chain acyl fatty acid derivative esters of carnitines. Levels of such derivatives in serum can reflect shifts in mitochondrial metabolism of fats and proteins ,24. Two p < 0.05)—namely threonate, a marker for dietary supplement use [In total, five prospective studies on metabolomics and breast cancer preceded our own and they reported that an aggregate of 51 metabolites was associated with risk of breast cancer at the FDR < 0.2 level of statistical significance ,13,14,15ment use ,28,29.Strengths of our study include a large number of cases and controls, prospective collection of serum, the detailed data on breast cancer risk factors, and the use of a reliable and robust metabolomics platform. The large number of metabolites we assessed made it possible to both identify novel associations and to attempt replication of previously reported findings.Our study also has several limitations. We analyzed blood samples from a single point in time for each participant. Since metabolite levels can change over time, this may cause attenuation of odds ratios . We did In summary, our metabolomics analysis delivered a strong replication of associations between DHEA metabolites and risk of breast cancer and identified novel associations that, if replicated, may provide important clues about breast cancer’s mechanistic basis. The study also provided some limited support for the notion that branched-chain amino acids and alcohol-related metabolites are associated with the risk of breast cancer. Future studies are needed to corroborate these findings and to further expand our understanding of the role of metabolism in breast cancer etiology.The CPS-II Nutrition Cohort is a large, well-characterized prospective cohort established in 1992 by the American Cancer Society (ACS) that enrolled 184,185 men and women residing in 21 states with population-based state cancer registries . The CPSOur nested case-control analysis includes all 782 of the breast cancer cases (ICD-O C50) that occurred among the postmenopausal women who donated blood from 1998 to 2001. Cases were first self-reported on biennial questionnaires and then verified through medical records (90%) or through state cancer registries (10%) and they occurred a median of five years after blood donation. Stage data were available for 99.6% of cases and 172 cases were at a regional/distant stage. Estrogen receptor status data were available on ~94% of participants and 644 cases were estrogen receptor-positive (ER+). Controls with no history of breast cancer or other cancer (except for nonmelanoma skin cancer) were selected by incidence density sampling and 1:1 matched to cases by birth date (±6 months), race/ethnicity , and date of blood draw (±6 months). Controls were alive and had no history of cancer as of the date of diagnosis for the matched case. All aspects of the CPS-II Nutrition Cohort were approved by the Emory University  Institutional Review Board.Metabolomics analysis was performed by Metabolon , whose platform and analytical process have been previously detailed ,32. BrieMetabolon quantified the relative concentrations of 1385 metabolites in their analysis. Of these, 110 metabolites (primarily drug metabolites) had no detectable level in ≥90% of samples and we excluded them from analyses. Among the remaining 1275 metabolites, 61% of metabolites had fewer than 5% of their values below the limit of detection. Any values below the limit of detection were assigned the lowest value observed for that metabolite in subsequent analyses. To minimize batch variability and account for non-normal distributions, each metabolite’s value was divided by its daily median then log-transformed for statistical analyses.Triplicates of 46 samples and duplicates of five samples were used as quality controls to assess the reproducibility of the platform. Across the 1275 metabolites, the median intraclass correlation coefficient (ICC) was 0.93 , indicating a high level of technical reliability comparable to that observed in previous analyses ,28. The eβ(X90-X10) where β is the coefficient for the metabolite modeled continuously and X90 and X10 are metabolite values at the 90th and 10th percentiles). Associations were also separately estimated for cases among non-hormone-users and for ER+ cases, as prior studies suggest that metabolite associations may be evident predominantly in non-hormone users and/or for the ER+ cancer subtype [p-values were less than the false discovery rate threshold of 0.2.For each metabolite, we estimated the age-adjusted odds ratio (OR) and 95% confidence intervals (CIs) of breast cancer risk using conditional logistic regression to account for matching. Odds ratios for metabolites were scaled so that they represent risk at the 90th percentile of metabolite values when compared with risk at the 10th percentile  and RStudio version 1.1.453 .


SNP rs17506395 in TP63 gene locus has been associated with the development of breast cancer in Asian women, no investigation has been undertaken within African population. We investigated the impact of this polymorphism in a representative African population. Breast cancer (BC) is a leading female cancer worldwide and cause of cancer-related death, especially in developing countries. Genetic predispositions to BC development in African population is poorly studied, and meanwhile the TP63 gene at rs17506395 locus. Unconditional logistic regression was used to study the association between the TP63 gene polymorphism and risk of BC development. After stratification into different age and ethno-linguistic groups as well as menopausal status, the Cochran-Mantel-Haenszel test was used to measure significance of the associations. We undertook a case-control study including 335 women, of which 111 were breast cancer patients and 224 controls. Using blood-derived germline DNA, PCR-RFLP was used to investigate the polymorphism of Comparing cases with controls, no significant associations between genotype and disease development was observed. Similarly, when cases were stratified according to menopausal status and ethno-linguistic groups, no significant association was observed between genotype and disease development. However, in women of 40 years and below, TT and TG genotypes were associated with breast cancer development. The minor G allele seems to protective against early breast cancer onset OR of 0.5 . Our data revealed an association between rs15706395 and the risk of early breast cancer onset. The GG genotype seems to reduce the risk of early breast cancer. Larger studies are needed to confirm the potential of this SNP as biomarker for breast cancer prognostic. Breast cancer (BC) is one of the most common invasive malignancies among women worldwide and is the leading cause of cancer-related-deaths among women . It constitutes about 25% of cancers diagnosed in women , and its annual incidence has increased from approximately 1.67 million in 2012 to 2.1 million new cases in 2018 . In 2012, nearly 60% of BC-related deaths were reported in low-income countries . According to the International Agency for Cancer Research (IARC), breast cancer incidence range from 28 per 100, 000 women in central Africa to more than 37 per 100, 000 women in Western Africa . Although BC is relatively less prevalent in Sub-Saharan Africa (SSA), survival is also generally poor in this region with high mortality recorded in many settings .Currently, African women under the age of 40 years with poor prognostic features are increasingly being diagnosed than older women in sub-Saharan Africa . The age at first diagnosis lies between 20 and 50 years in sub-Saharan Africa  compared with 60 to 70 years in most western societies . In Sub-Saharan Africa, most patients die within one year from diagnosis as a result of disease complications and aggressiveness . Although the clinic-pathological underpinnings of disease outcomes is still poorly understood, several factors including the poor health infrastructures, the lack of screening programs in some African countries, the late diagnosis, lack of patient support programs and poor clinical among others, may explain the differences observed in breast cancer outcomes in various populations .Current evidence suggests that early BC onset in patients below 40 years is clinically and etiologically distinct from breast cancer in older women . For instance, early onset of BC has specific characteristics such as worse prognosis, high aggressiveness, the higher proportions of high-grade and later-stage tumors, and lower expression of hormone receptor genes . Additionally, the “triple-negative” phenotype  of breast cancer, which seems to be more prevalent in young indigenous African and African-American women is very aggressive, lethal and recurrent . Although the role of accumulated driver and passenger mutations is undisputable, the importance of germline genetic variants in the development of BC is becoming an area of great interest . Identification of genotypes associated with early disease onset holds the promise of well-tailored surveillance schemes. TP63 gene is located on chromosome 3q27 and encode for the protein p63 that plays a crucial role in the maintenance of a stem cell population of several epithelial tissues. Although p63 is necessary for the normal development of epithelial organs including mammary glands , its tissue expression patterns have been shown to be associated with syncytial growth pattern in triple negative breast cancer . Moreover, a positive association has been reported between the percentages of p63-positive cells with a marked nuclear pleomorphism . At the genetic level, a functional SNP rs17506395 (T>G) located in the TP63 gene, which was initially associated with fertility  has recently been associated with several cancers including breast cancer in Asian populations . The TT genotype is associated with poor survival, suggesting that this genotype could be a biomarker of adverse prognosis in breast cancer . Despite the aforementioned associations between p63 expression and/or TP63 gene polymorphism with BC development and patient outcome, very little, if all any study has addressed this crucial factors on BC development or patient outcome in African women. With this in mind, and mindful of the socio-economic and clinical impacts of BC in developing countries, this study was designed to understand the impact of TP63 gene polymorphism on the incidence and/or development of BC within an African context.Genetic variants in the TP63 gene locus has been reported to be associated with BC development in Asian populations . The Ethical approval and consent to participate This study was approved by the Ethics Review and Consultancy Committee (ERCC) of the Cameroon Bioethics Initiative (CAMBIN) under the reference number CBI/395/ERCC/CAMBIN and Protocol number 1086. All participants voluntarily signed written informed consent forms prior to their inclusion into the study and the analysis of participant data was fully anonymized. Study populationThe Cameroonian population is made up of more than 250 ethno-linguistic subgroups from three major ethno-linguistic groups: Bantu , Semi Bantu  and Sudano-Sao  . These different ethno-linguistic groups are spread over several African countries and thus provide an excellent opportunity of studying some global aspects of human genetics research in sub-Saharan Africa . For this study, a total of 335 women including 111 patients and 224 controls were prospectively recruited between October 2015 and December 2016 at the oncology and radiotherapy unit of the Douala General Hospital and the St. Joseph clinic cancer center of Yaoundé. All patients were histologically confirmed with invasive breast cancer, but without other clinically detectable neoplasm (case group). Controls were randomly recruited women who had no form of cancer as determined from their medical histories and general physical examination. Women who were below 21 years old and/or not Cameroonian and/or had another type of cancer and/or refused to participate in the study were excluded. Participant information was recorded by means of a structured questionnaire that was provided to the participants after consent was given. Clinical and pathological data for all cases was obtained from the physician and/or collected from hospital records. Blood sampling and DNA ExtractionAbout 5 ml of blood sample was taken by vein-puncture into EDTA coated tubes. After centrifugation of each tube at 3000xg for 5 minutes, the buffy coat was collected. From each buffy coat, DNA was extracted using phenol–chloroform-isoamylic alcohol (25:24:1) and then, precipitated with isopropanol. DNA pellets were re-suspended in 50µl of sterile ultrapure water and stored at -20°C until use.Genotyping of TP63 gene at rs17506395 TP63 gene was amplified and thereafter, the PCR products were digested with restriction enzyme before their resolution on a 2% agarose gel. Genotyping was carried out by the Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) where the Amplification of TP63 geneTP63 gene, the primer pair Rb395F (5-ACAGATAAATTGGTGGAGAGAGAT-3) and Rb395R (5-CACTGTTTGGACCCTGGAA-3) flanking the region containing the SNP rs17506395 were designed using Primer-BLAST Software . The PCR reactions were carried out in a DNA thermal cycler . Each amplification reaction was performed in total volume of 25µL containing 1X PCR buffer 2SO4, 1.5 mM MgCl2), 1X Q-Solution , 20 pmol/L of each primers, 200 nmol/L of each dNTP, 1.5 mM MgCl2, 0.25 U Hot star Taq DNA polymerase (Qiagen), and 5µL of genomic DNA diluted 10 fold. The amplification reactions included a denaturation step at 95°C for 15 min followed by 40 amplification cycles comprising a denaturation step at 95°C for 30s, an annealing step at 58°C for 45s and an extension step at 72°C for 1min. This was followed by a final extension step at 72°C for 10 min. For every PCR reaction, a negative control was included where the nuclease free water was used instead of the DNA. The amplified products were resolved by electrophoresis at 135 volts for 30 min on 2% agarose gel containing ethidium bromide. The gels were visualized under ultraviolet light and then photographed using a gel documentation system . Samples with a successful amplification of the target region (450bp fragment) were selected and subjected to digestion with restriction enzyme. For the amplification of Digestion of PCR productsFor this digestion, 10µL of PCR product were mixed with 10 units (1µL) of MboII restriction enzyme . The digestion was performed for 18 hours at 37°C. The digested products were subsequently resolved on a 2% agarose gel containing ethidium bromide. Samples presenting two DNA fragments of 235 and 215bp were considered as homozygote wild type with genotype TT while those showing a single DNA fragment of 450bp were considered as homozygous mutant with genotype GG. A profile showing three DNA fragments of 235, 215, and 450bp were considered as heterozygote with genotype TG.Power calculation2) for linkage disequilibrium (LD) of 1.0 and the sampling size. This later was estimated as described by Kasiulevicius et al., (2006) using the independent case-control sampling size formula. For this estimation, we assumed an expected exposure proportions in control of 20%, a disease prevalence of 25%  and a case-control ratio of 1:2. With the independent case-control sampling size formula, the sampling size to detect a real odds ratio or case exposure rate with power and two-sided type I error of 5% risk was 195 including 65 breast cancer patients and 130 controls.For this study, we assumed an additive genetic model where two risk alleles of an SNP (homozygous) have twice the effect of one risk allele (heterozygous) . Power calculations were undertaken using the PGA modeller package in MATLAB . For this Software, the power was calculated by considering an odd ratio (OR) or relative risk (RR) ≥ 2 for locus with disease allele frequency of 0.1612-0.205 with one locus genotyped. Other factors taken into consideration include the disease prevalence estimated at 25% according to GlOBOCAN 2012 , a type 1 error of 5% risk, a complete linkage parameter  was undertaken not only on the entire population, but also on different subpopulations stratified by ages, menopausal status and ethno-linguistic subgroups. SNP rs17506395 of TP63 gene and the risk of breast cancer development, the association analysis were firstly performed on the entire population made up of 111 patients and 224 controls. For these association studies, the unconditional logistic regression models were used to estimate odds ratio (OR) at 95% confidence intervals (CI) in the entire population without any stratification as well as in each stratified population.When the absence of one genotype or allele (represented by zero) has led to problems with the computation of the odds ratio (standard error), 0.5 was added to all cells  as supposed by Deeks and Higgins (2010) . Pearson chi-square (χ2) tests and the Fisher’s exact test were used to compare categorical variables between the participants while the student t-test was used to compare the mean values for continuous variables between groups. The test was considered significant for a P value below 0.05.To test if there was any association between polymorphism at To see if the heterogeneous nature of our study population, made up of women having different menopausal status or belonging to different age groups or various ethno-linguistic subgroups, could have an effect on the results of association studies, additional analyses were undertaken on different subpopulations. Each subpopulation was considered here as all women belonging to the same ethno-linguistic group or the same age group or having the same menopausal status. These analyses were performed when the participants were subdivided according to their menopausal status, their ethno-linguistic groups  and their age group (women ≤ 40 years old and those above 40). For these stratified population, the Cochran-Mantel-Haenszel (CMH) test implemented in PLINKv1.9 package  was performed with the allelic frequencies because this test can only be done with binary vars. The CMH test enabled not only to estimate the odds ratio and 95% confidence interval across the stratified population, but also to test the associations between alleles and the probability to develop a breast cancer in each stratum. Moreover, the CMH2 test, also implemented in PLINKv1.9 package, was used to determine if there were significant differences between the allele frequencies of different subpopulations. The genotype-based Cochran-Armitage trend test with high power and two degrees of freedom (in the 2 x 3 crosstab) was performed to test the association between rs17506395 and the susceptibility to breast cancer. The statistical analyses were conducted using SPSS Software 22.0  and PLINK v1.9 package. The chi-squared test was used to compare the allelic and genotypic frequencies between breast cancer patients and controls.Socio-demographic and clinical characteristics of the study populationIn our study, 335 Cameroonian women were recruited: 111 breast cancer patients who were histologically confirmed with infiltrating ductal carcinomas and 224 controls . AmongstFrom the 111 breast cancer patients, 77 (69.37 %) were premenopausal and 53 (47.7%) were below 40 years. About 91.89% (102/111) all patients were either at stage III or IV while only 8.11% (9/111) were either at stage I or II. Seventy one (63.96%) patients had lymph node involvement. Grouping the patients according to lymph node status and tumor size, significant different (p <0.0001) were observed . About 3Of the 224 controls, 195 (87%) were premenopausal and 12.95% postmenopausal women. About 58.04 % (130/224) of these controls were 40 years or less . With a LD r2 of 1.0, a disease prevalence of 25%, the disease allele frequencies range from 0.1612-0.205 for one locus genotyped, and a sampling size of 335 individuals including 111 breast cancer patients and 224 controls, the power of this study was estimated at 95%.Genotyping results SNP rs17506395 locus of TP63 was investigated on 111 breast cancer patients and 224 controls belonging to three ethno-linguistic groups. The primers designed in this study successfully amplified all the 335 samples. The polymorphism at Allelic frequenciesFor the entire population, the allelic frequency was 83.9% (562/670) for T allele and 16.1% (108/670) for G. In breast cancer patients, the allelic frequencies for T and G alleles were 86.9% (193/222) and 13.1% (29/222) respectively. In the controls, the allelic frequency was 82.4% (369/448) and 17.6% (79/448) for T and G allele, respectively . BetweenIn patients of 40 years or less, the allelic frequencies were respectively 86.79% (92/106) and 13.21% (14/106) for T and G alleles. In controls of the same age group, the frequencies of T and G alleles were respectively 76.54% (199/260) and 23.46 (61/260). Between controls and patients of 40 years or less, a significant difference  was observed in allelic distribution. These frequencies were 87.07% (101/116) and 12.93% (15/116) respectively for T and G alleles in patients above 40 years. For controls of the same group of ages, the frequency of the T allele was 90.43% (170/188) while that of G was 9.57% (18/188). In women above 40 years, no significant difference  was observed.In premenopausal patients, the allelic frequency was 87.66% (135/154) for T allele and 12.34% (19/154) for G. In controls with the same status, the allelic frequencies for T and G alleles were respectively 81.03% (316/390) and 18.97% (74/390). For postmenopausal patients, the T allele has an allelic frequency of 85.29% (58/68) while that of G allele was 14.71% (10/68) . In contThe distribution of T and G alleles among the different ethno-linguistic groups is summarized in Genotypic frequenciesFor the entire population, the genotypic frequencies were 24.5% (92/335) for TG genotype (heterozygote), 2.4% (8/335) for GG genotype (homozygote mutant) and 67.2% (235/335) for TT genotype (homozygote wild type) . In patiThe GG genotype was present only in controls of 40 years or less . About 7From the 77 premenopausal patients, the genotypic frequencies were 75.32% (58/77) for TT genotype and 24.68% (19/77) for TG genotype. None of these women was found with GG genotype. In 195 controls of the same menopausal status, the genotypic frequencies were 66.15% (129/195) for TT genotype, 29.74% (58/195) for TG genotype and 4.10% (8/195) for GG genotype. In postmenopausal patients, the genotypic frequencies were 70.59% (24/34) for the TT genotype and 29.41% (10/34) for TG genotype. For controls having the same menopausal status, the genotypic frequencies were 82.76% (24/29) for TT genotype and 17.24% (5/29) for TG genotype . No postThe GG genotype was only found in controls of the Bantu and semi-Bantu ethno-linguistic groups with respective genotypic frequencies of 7.32% (3/41) and 2.75% (5/182). In contrast, other genotypes were present in all ethno-linguistic groups . In factAmong the Bantu group, the TT and TG genotypes have respective genotypic frequencies of 66.67% (22/33) and 33.33% (11/33) for patients; and 65.85% (27/41) and 26.83% (11/41) for controls. The genotypic frequencies for TT and TG genotypes were respectively 83.33% (5/6) and 16.67 (1/6) for patients in the Sudano-sao group. The only one control of this group has TT genotype. Whatever, the ethno-linguistic group, no significant difference was observed in the genotypic frequencies between patients and controls.. Association between polymorphism at SNP rs17506395 and the risk of developing breast cancer in the whole population SNP rs17506395 and the risk of developing breast cancer in our study population . The Cochran-Armitage trend test performed using the genotypic frequencies of the overall study population revealed no significant association (p = 0.1269) between the polymorphism at pulation . These rpulation . Whatevepulation .To see if these results could be bias by the heterogeneity of the study population, additional analyses were carried out on the populations stratified on the basic of their menopausal status, ethno-linguistic groups as well as age groups. Association between polymorphism at SNP rs17506395 and the risk of developing breast cancer in women of different SubpopulationsX2 = 10.55) was observed in allele frequencies between the age groups. The odds ratio at 95% confidence intervals estimated using the unconditional logistic regression models are reported in Data from the Cochran-Mantel-Haenszel (CMH) and CMH2 tests reported in Association between polymorphism at SNP rs17506395 of TP63 and the risk of developing breast cancer in women of different age groupsThe Cochran-Armitage trend test found an association  between genotype combinations ([TT + TG] versus [GG]) and the risk of breast cancer development in women of 40 years and less . The GG Association between polymorphism at rs17506395 and the risk of developing breast cancer in women of different menopausal status For this association study, the participants were subdivided into 272 premenopausal women (77 breast cancer patients and 195 controls) and 63 postmenopausal women (34 patients and 29 controls). Using the unconditional logistic regression analysis, no association  was observed for the allelic frequencies in premenopausal women . The CocAssociation between polymorphism at rs17506395 and the risk of developing breast cancer in different to ethno-linguistic groupsBetween patients and controls, and within the different ethno-linguistic groups, no significant difference was found in the allelic frequencies when the unconditional logistic regression model was used . The Coc SNP rs17506395 of TP63 gene and the risk of developing breast cancer in women presenting different clinico-pathological features of the disease , all women of 40 years and below were considered in our study as young, otherwise they were of old age. Our classification is in agreement with age stratifications that have recently been used in several studies .The evaluation of genetic variants associated with the risk of BC development has led to a better understanding of the relationship between genomics and cancer development. Such relationships have been fundamentally based on SNPs, which generally carry the most common pattern of genetic variation in the human genome . Zhang et al., (2014) have shown an association between polymorphism at SNP rs17506395 with breast cancer is not yet understood, this allele seems to be able to alter the regulator power of TP63 gene, which could contribute to breast cancer development . It was suggested that the T allele, which is mostly observed in breast cancer patients, may enhance the expression of TP63 gene. If we assume that, it is likely that the high frequency of T allele among young patients may promote high expression of TP63, which in tune drive the aggressiveness of basal-like breast cancer. Previous studies highlight that the total percentage of p63-positive cells was related to a marked nuclear pleomorphism and that the intensity of p63 staining was associated with a syncytial growth pattern in triple negative breast cancer . Moreover, higher expression of p63 was reported in the cytoplasm cells of basal-like subtype breast cancer compared to non-basal-like of Indonesian women . Results obtained in young Cameroonian patients highlighting the high allelic frequency for T allele could be linked to aggressiveness of breast cancer in the young black women because breast cancer in women of below 40 years is more aggressive with a worse clinical outcome compared to older group . The exact mechanism underlying the function of this polymorphism has not been unveiled and functional studies are required in order to understand the biological function related to the polymorphism observed at SNP of rs17506395 of TP63 gene.Our results showing that the T allele seems to be widely spread in Cameroonian Women are in agreement with those obtained from the 1000 Genomes project where the T allele represents 89% against 11% for G allele . However, the present study shows a significant difference (p = 0.03) in the allelic frequencies of T allele between patients and controls for women of age 40 years and or less. On the other hand, no significant difference was observed between controls and patients of above 40 years as well as in the entire population or participants grouped according to their ethno-linguistic groups or menopausal status. The presence of T allele seems to have an impact on breast cancer outcome in women of 40 years and less. This hypothesis is in line with observation of Zhang et al. (2014) reporting high frequency of T allele in breast cancer patients. In Asian women for instance, Zhang et al., (2014) observed 70.33% of T allele in controls against 78.69% in patients. In our study, such difference was observed only in participants of 40 years and less (86.79% for patients versus 76.54% for controls). From the differences in the allelic frequencies, it was inferred that the single present of T allele seems sufficient to increase the risk of developing breast cancer in Asian women. The presence of T allele seems therefore to be associated with the risk of developing breast cancer in women of 40 years and less. Although the mechanism associating the presence of T allele at In our study, the G allele seems to be predominant in the young population because its allelic frequency was 23.46% and 13.21% in controls and patients of 40 years and less against 9.57% and 12.93% in those above 40 years. These results are in agreement with those obtained in Asian women where Zhang et al., (2014) reported 50.4% of young women (below 48 years) carrying G allele against 17.3% in patients above 48 years although the grouping by age was different. In the present study, the allelic frequency for G allele was significantly high in controls than patients of 40 years and less. However, no significant difference was observed for the allelic frequencies between controls and patients when all participants or the ethno-linguistic groups or the menopausal status were taken into consideration. These results suggest the implication of G allele in the breast cancer outcome in participants of 40 years and less. For this allele, an odds ratio of 0.5 and a significant p value of 0.03 suggest that the presence of G allele could reduce the risk of developing breast cancer in the young Cameroonian women. This allele may have a protecting effect against breast cancer in Cameroonian women of 40 years and less; this effect has been reported elsewhere by Zhang et al., (2014).TP63 mRNA compared with other genotypes in breast cancer tissues, indicating that rs17506395 may be a functional single nucleotide polymorphism in breast cancer. The presence of TT genotype was statistically correlated with increased risk for breast cancer, compared with genotypes containing the G allele (GG and GT). If the presence of T allele may enhance the expression of the TP63 gene, such phenomenon may subsequently drive tumorigenesis than the GG and GT genotypes could do . Moreover, an increase in the expression level of TP63 gene is generally observed in less differentiated or more aggressive tumors, which would indicate the correlation between an increase in p63 expression and a poor prognosis . Therefore, the association of this functional variant rs17506395 of the TP63 gene in young Cameroonian women would partially justify the aggressiveness of cancer among young black women in sub-Saharan Africa. The Cochran–Armitage test for trend revealed an association between the combination of TT and TG genotypes with the risk of developing breast cancer in of women of 40 years and less. These results are in agreement with those of Zhang et al., (2014). These authors reported the TT genotype to be associated with unfavorable survival of breast cancer; suggesting this genotype as potential biomarker for adverse prognosis of breast cancer in Asian women. According to results of Cochran-Armitage trend test on the group of women of 40 years and less, the GG genotype seems to be associated (p=0.03) with a decreasing risk of developing breast cancer. These results are in agreement with those obtained by Zhang et al., (2014) who found that breast tumors with TT genotype exhibited higher level of rs15706395 of TP63 gene and risk of developing breast cancer in different ethno-linguistic groups. These results suggest that the rs15706395 variant of the TP63 gene could exert its effect regardless of ethno-linguistic groups. Although the power of our study is 95%, it is important to point out that the low sample size of the sudano-soa ethno-linguistic group might have an impact on the outcome of this study. This low sample size of women belonging to the Sudano-sao group could partially be explained by some cultural behavior and believes. Indeed, women belonging to this ethno-linguistic group are generally reluctant to participate in Breast and cervical cancer screening programs . Additional studies need to be conducted in larger sample sizes to validate these findings.Our study failed to find significant association between polymorphism at SNP rs15706395 of TP63 gene and the risk of developing breast cancer among Cameroonian women of 40 years and less. The GG genotype seems to reduce the risk of developing breast cancer in young Cameroonian women. Further studies using larger sample sizes are needed to provide more conclusive evidences. Such studies could enable to confirm the potential of this SNP as biomarker for breast cancer prognostic. In conclusion, results of this study revealed an association between polymorphism at


Insulin-like growth factor 1 (IGF-1) and binding protein 3 (IGFBP-3) are associated with breast cancer in women at average risk of cancer. Less is known whether these biomarkers also predict risk in women with breast cancer family history.n = 80 cases, 156 controls), a cohort enriched for breast cancer family history. Using conditional logistic regression, we estimated the association between IGF-1 and IGFBP-3 levels and breast cancer risk and examined whether this risk differed by predicted absolute breast cancer risk based on pedigree models.We conducted a nested case-control study within the New York site of the Breast Cancer Family Registry  and breast cancer risk was elevated, but not statistically significant . Women with elevated predicted absolute 10-year risk ≥ 3.4% and elevated IGFBP-3 (≥ median) had more than a 3-fold increased risk compared to women with lower predicted absolute 10-year risk (< 3.4%) and low IGFBP-3 (OR = 3.47 95% CI = 1.04–11.6).These data offer some support that the overall magnitude of the associations between IGF-1 and IGFBP3 seen in average risk cohorts may be similar in women enriched with a strong breast cancer family history. Insulin-like growth factor IGF-1) and its primary binding protein IGFBP-3) are known risk factors for breast cancer due to their ability to stimulate mitosis and suppress programmed cell death  and its , 3. To d are knowWithin the New York site of the Breast Cancer Family Registry (BCFR), we prospectively followed a sub-cohort of women unaffected with breast cancer at study entry. The New York site of the BCFR recruited family members with multiple instances of breast or ovarian cancer to construct a family-based registry to assess risk due to a woman’s familial risk profile (FRP) . In tWe collected a 30-mL blood sample at baseline, which was processed and stored at the New York site of the BCFR . To asseWe calculated each woman’s 10-year absolute risk of breast cancer using the BOADICEA  risk model , 8. In o2), smoking and alcohol consumption, menopausal status, and BOADICEA score.We performed conditional logistic regression on the 1:2 matched sets of cases and controls to estimate the breast cancer risk for women with high circulating IGF-1 or IGFBP-3 biomarker levels compared to women with low levels. We defined elevated biomarkers as greater than or equal to the median value in controls  and assessed risk for both elevated and continuous log-transformed biomarker levels. To test for the interaction between biomarker levels and BOADICEA score, we first tested for linearity of the biomarker level. We then used a cross-product term to assess multiplicative interaction and examined interaction on the additive scale using relative excess risk due to interaction (RERI). We adjusted for baseline covariates including obesity , with an OR of 1.28 (1.14–1.44) for women in the highest IGF-1 quintile [p trend = 0.062), with an OR of 1.13 (0.99–1.28) at the highest IGFBP-3 quintile [We found an overall increased breast cancer risk for IGF-1 or IGFBP-3 elevation, although it was not statistically significant . The magnitude of these associations is consistent with results from pooled analyses comparing women with the highest and lowest biomarker concentrations [Study limitations include the cohort sample size; despite the consistency of our effect estimates with prior literature, we had low power, particularly for subgroup analyses. None of the women in this sample had IGF-1 or IGFBP-3 levels outside the normal range; there were therefore no clinically defined thresholds to indicate abnormal elevation. In addition, we obtained a single baseline measure of IGF-1 and IGFBP-3. Intra-individual variability exists for IGF-1, and diet can modify non-fasted IGFBP-3 levels; single biomarker measures should be interpreted with caution .The results of this study offer some support that blood biomarkers, particularly IGFBP-3, may be useful in improving risk stratification, especially if replicated in larger enriched cohorts , 11–13.


To compare the epidemiological characteristics of a breast cancer screening program of patients between 40–69 years of age and ≥70 years of age, we calculated the age-standardized detection rate of the breast cancer screening program and compared it with the age-standardized incidence rate from the Korea Central Cancer Registry. The data of the breast cancer screening program from January 2009 to December 2016 and the data of the health insurance claims from January 2006 to August 2017 were used. In the 40–69 year age group, the age-standardized detection rate of breast cancer increased annually from 106.1 in 2009 to 158.6 in 2015 and did not differ from the age-standardized incidence rate. In the ≥70 year age group, the age-standardized detection rate of breast cancer increased annually from 65.7 in 2009 to 120.3 in 2015 and was 1.9 to 2.7 fold of the age-standardized incidence rate. It shows that the early detection effect of breast cancer screening was greater for patients over 70 years old. Further studies are needed to evaluate the effect of breast cancer detection in the ≥70 year age group on all-cause mortality or breast cancer mortality. Affecting 1.7 million women each year, breast cancer is the most common women’s cancer worldwide. Furthermore, it is also the only type of women’s cancer where its rates are increasing . AccordiTo reduce the social costs associated with cancer, many countries have adopted screening test-programs which promote early detection and early treatment. Mammography screening is one of the screening test-programs which is specific to breast cancer . DespiteIn this study, we aimed to compare the differences in epidemiological characteristics on breast cancer screening programs between two age groups. Especially, the age-standardized breast cancer detection rate of the breast cancer screening program was compared with the age-standardized incidence rate from the Korea Central Cancer Registry (KCCR) in order to discuss how we have to consider age factor, in view of the trend of detection rate, in determining the upper age limit for breast cancer screening.In this study, two data set of the National Health Insurance Service (NHIS) were used; (1) The data of the breast cancer screening program from January 2009 to December 2016 and (2) the data of health insurance claims from January 2006 to August 2017. This study used a secondary data analysis to compare cancer detections within 6 months from the time of screening by dividing the breast cancer screening participants into the age groups of 40–69 years and 70 years and older.The subjects screening results were classified as normal, benign lesion, suspected breast cancer, and deferred. Suspected and deferred breast cancer diagnoses were defined as positive screening outcomes. The subjects were limited to participants in breast cancer screening not diagnosed with breast cancer. Screening participants who made insurance claims for the code for breast cancer (C50) and the code for special case (V193) from 1 January 2006, until the day of breast cancer screening were excluded. The code for special case aimed to ameliorate the economic burden on patients with cancer, cerebrovascular or cardiovascular disease, severe burns, or other intractable disease by reducing the copayment for 5 years .The subjects’ identification, age, screening date, result notification date, and screening results were obtained from the breast cancer screening data and the subjects’ identification, sex, breast cancer diagnostic code, code for special case, and dates of visits to medical institutions from the insurance claims data. The subjects were categorized according to age at the time of screening into the 40–69 year age group or the ≥70 year age group. The results of breast cancer screening were classified as ‘normal’, ‘benign lesion’, or ‘suspected breast cancer’. A finding of ‘normal’ or ‘benign lesion’ was categorized as a negative result; a finding of ‘suspected breast cancer’ was considered a positive result. A diagnosis of breast cancer was determined for subjects assigned the code for malignant breast cancer (C50 in the Korean Standard Classification of Diseases) and that for cancer special cases (V193). Therefore, the date of diagnosis of breast cancer was defined as that of the first claim for a code of V193 and C50.The participation rate, positivity rate, positive predictive value (PPV), and detection rate of breast cancer screening were evaluated. The participation rate of screening for breast cancer was defined as the number of breast cancer screening participants who underwent mammography for breast cancer during a particular year per 100 of all women over 40 years old of breast cancer screening subjects.The positivity rate of screening for breast cancer was defined as the number of positive tests per 100 breast cancer screening participants.The PPV is the proportion of subjects diagnosed with a disease among those who tested positive for that disease. In this study, the PPV was defined as patients with insurance claims (C50 + V193) for breast cancer codes within 180 days of screening notification among those with positive results of breast cancer screening per 1000 who tested positive.Among the participants in breast cancer screening, the definition was detection by breast cancer screening if treatment for breast cancer (C50 + V193) occurred within 180 days from the notification date of the breast cancer screening result. Thus, the detection rate of screening for breast cancer was defined as the number of participants in breast cancer screening who tested positive for breast cancer and were treated within 180 days of their notification date per 1000 breast cancer screening participants.To compare the detection rate of the breast cancer screening program with the incidence rate from KCCR of the 40–69 year age group and ≥70 year age group, the detection rate and incidence rate were standardized with the 2009 population in Korea.Age-standardized detection rate. Females >40 years of age in 2009 who participated in breast cancer screening were defined as the standardized population for calculation of the annual age-standardized detection rate of breast cancer .Age-standardized incidence rate. The age-standardized incidence rate of breast cancer according to the KCCR after 2009  was calculated using the number of women >40 years of age in the middle of 2009 according to the National Statistics Office as the standardized population.SAS  statistical software and Microsoft Excel  were used for data analysis. The significance of differences in the PPV and the rate of detection of breast cancer between the two groups was evaluated by calculating the 95% confidence internal (CI).This study used secondary data provided by the National Health Insurance Service (NHIS-2019-1-115) and was exempted from review by the Institutional Review Board of Konkuk University because no personal information was analyzed .In the 40–69 year age group, the number of subjects and participants in breast cancer screening and the rate of participation fluctuated from 2009 to 2016 . SimilarThe PPV of the ≥70 year age group was significantly higher than that of the 40–69 year age group from 2009 to 2016 . The PPVThe detection rate of breast cancer in the group increased from 1.06  in 2009 to 1.66  in 2016 . The ratIn the 40–69 year age group, the NHIS’s age-standardized detection rate of breast cancer increased annually from 106.1 in 2009 to 158.6 in 2015, and did not differ from the KCCR’s age-standardized incidence rate A.In the ≥70 year age group, the NHIS’s age-standardized detection rate of breast cancer increased annually from 65.7 in 2009 to 120.3 in 2015, and was 1.9 to 2.7 fold of the KCCR’s age-standardized incidence rate of breast cancer B.The purpose of this study was to present the differences in epidemiological characteristics on a breast cancer screening program between the 40–69 year age group and the ≥70 year age group. The number of subjects and participants in breast cancer screening in the ≥70 year age group increased. This is probably due to the increased number of participants from the aging population and expanded average lifespan. Participation rates in breast cancer screening increased from 2009 to 2016 in both age groups, reflecting the ongoing publicity of the need and importance of cancer screening along with the need for public health . In addiThe positivity rate in the 40–69 age group was higher than that in the ≥70 age group, which is likely to be due to the higher incidence of breast cancer in the former . The posThe PPV for breast cancer of the ≥70 age group increased over time and was higher than that of the 40–69 age group. The PPV was affected by the prevalence of breast cancer, sensitivity, and specificity of the screening tool . The higThe detection rate of breast cancer per 1000 in the ≥70 year age group increased annually after 2009. This is similar to the case in the United Kingdom, where the number of women at the age of >73 diagnosed with breast cancer has increased consistently . In addiTo set the upper age limit for breast cancer screening, all-cause mortality, cancer specific mortality and stage shift are generally considered . AlthougBecause the data of this study used the whole data of breast cancer screening and the whole data of claims for breast cancer, the effect of breast cancer screening such as detection rate could be evaluated. However, there is no formal guideline for monitoring breast screening program performance in Korea. Especially, the interval cancer of breast cancer has increased 41.8 in 2009 to 58.5 in 2014 among 100,000 negative screening participants . In addiThe comparison between the age-standardized detection rate of breast cancer from the data of NHIS and the age-standardized incidence rate of breast cancer from KCCR showed that the early detection effect of breast cancer screening was greater in women over 70 years old. Further studies on cost effectiveness, mortality rate, and stage shifts are needed to set the upper age limit for breast cancer screening.