Abstract B99: Hot flashes, hormone therapy, and breast cancer risk: The Women's Health Initiative Clinical Trials

Background: New onset of hot flashes with anti-estrogen therapy was found to predict breast cancer prognosis. Hot flashes were also observed to modify the effects of dietary interventions on breast cancer risk and prognosis. We investigated whether hot flashes 1) predict breast cancer risk (Aim 1), and 2) modify the effects of estrogen plus progestin (E+P) and E-alone therapy on breast cancer risk (Aim 2).

Methods: We performed a prospective analysis within the Women's Health Initiative randomized, placebo-controlled clinical trials of E+P (0.625 mg/day conjugated equine estrogens [CEE] plus 2.5 mg/day medroxyprogesterone acetate) and E-alone (0.625 mg/day CEE). The cohort included 27,347 postmenopausal women (mean age: 63.4 ± 7.2 years; 81% white; no history of breast cancer). During an average follow-up of 7.8 years, 752 incident breast cancer cases were diagnosed and confirmed. The occurrence of hot flashes (HF-status) was self-reported at the baseline visit and categorized as: none, mild (symptom not interfering with usual activities), and moderate (interfering somewhat with usual activities) or severe (so bothersome that usual activities could not be performed). Cox proportional hazards regression was used for analysis. Hazard ratios (HR) and 95% confidence intervals (CI) were obtained. Models were adjusted for the following confounders: age, race, age at menarche, body mass index, prior breast needle aspiration, and prior use of oral contraceptives or E+P therapy. For Aim 1, the analysis combined the placebo groups of both trials and the cohort was followed through September 2005. For Aim 2, the E+P and E-alone trials were analyzed separately and the cohort was followed through each trial's termination date.

Results: Twenty one percent of participants reported mild hot flashes, and 11% reported moderate/ severe symptoms. Aim 1: Baseline HF-status was not significantly associated with breast cancer risk (HRs [95% CIs]: mild HF= 1.06 [0.79-1.42]; moderate/severe HF= 0.96 [0.64-1.44]; no HF= reference).

Aim 2: No significant interactions were observed for HF-status with E+P or E-alone therapy. Breast cancer risk associated with E+P or E-alone treatment did not vary significantly according to baseline HF-status (effect of E+P in: no HF= 1.14 [0.87-1.50], mild HF= 1.26 [0.76-2.09], moderate/severe HF= 1.86 [0.87-3.97]. Effect of E-alone in: no HF=0.73 [0.52-1.03], mild HF= 0.61 [0.32-1.16], moderate/severe HF= 1.02 [0.46-2.26]).

Conclusion: Among postmenopausal women, hot flashes were not associated with breast cancer risk, and they did not significantly modify the effects of E+P or E-alone therapy on breast cancer risk. The possibility that women with moderate/severe hot flashes have different effects of hormone therapy needs to be investigated in a larger study.

Citation Information: Cancer Prev Res 2010;3(12 Suppl):B99.

25-hydroxyvitamin D concentration, vitamin D intake and joint symptoms in postmenopausal women

INTRODUCTION

Low 25-hydroxyvitamin D (25(OH) D) concentrations have been associated with radiologic worsening of osteoarthritis in some reports. However, the results are mixed and few studies have evaluated associations between 25(OH) D concentrations and both total vitamin D intake and clinical joint symptoms.

STUDY DESIGN

Cross-sectional analyses of information from a subset of 1993 postmenopausal women obtained at baseline entry in the Women's Health Initiative Calcium plus Vitamin D clinical trial.

MAIN OUTCOME MEASURES

25(OH) D concentration, total vitamin D intake (diet plus supplements), presence and severity of joint pain and joint swelling.

RESULTS

The 25(OH) D levels were commonly low with 53% having deficient (<50 nmol/L) and only 17% having sufficient (>72 nmol/L) levels. Joint pain (reported by 74%) and joint swelling (reported by 34%) were also commonly reported. 25(OH) D concentrations were modestly correlated with total vitamin D intake (R=0.29, p<0.0001); however, considerable variability in 25(OH) D concentrations for a given vitamin D intake was seen. In adjusted linear regression models, lower serum 25(OH) D concentrations were associated with higher average joint pain score (P=0.01 for trend) with differences most apparent in the lowest 25(OH) D levels sextile.

CONCLUSIONS

Relatively low 25(OH) D levels and a high frequency of joint symptoms were common in this population of postmenopausal women. Total vitamin D intake was only modestly associated with 25(OH) D. Low serum 25(OH) D concentrations were associated with higher joint pain scores. These findings can inform the design of future intervention trials.

Hot flashes in breast cancer survivors and an association with calcium supplement use

AIMS

In breast cancer survivors, we aimed to describe the frequency of hot flashes and night sweats, frequency and type of treatment, and the association of hot flashes and use of calcium supplements.

METHODS

Charts of breast cancer survivors were reviewed for information about hot flashes, treatment for hot flashes, and calcium supplementation. Associations between variables were explored using the Chi-square test and Fisher's Exact test.

RESULTS

Eighty-six charts were reviewed. Mean age of the women was 58 years and 79% were postmenopausal. Forty-two (49%) of women had hot flashes and 18 (21%) had night sweats. Thirty-one (36%) were treated for hot flashes. Treatment included selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (n = 19), clonidine (n = 7), Bellergal-S(®) (n = 8), sleep-aid (n = 7), and other (n = 5). Calcium supplementation was recorded in 31%. Of women with hot flashes, 44% took calcium supplements; of women without hot flashes, 18% took calcium supplements (Chi-square P = 0.02).

CONCLUSION

Hot flashes were recorded in 49% of this group of primarily postmenopausal breast cancer survivors. Women with hot flashes were more likely to be taking calcium supplements. Further exploration of the association between hot flashes and calcium supplementation is warranted.

Sex Hormones and Risk of Estrogen Receptor (ER)-Positive and ER-Negative Breast Cancer

Background: There is a need for improved breast cancer risk prediction by tumor estrogen receptor (ER) status. Endogenous sex hormone levels are associated with risk of overall breast cancer and the ER-positive subtype. However, the role of estradiol (E2) and testosterone (T) in the development of ER-negative tumors remains unclear. We investigated the associations of circulating levels of endogenous E2 and T with the risk of ER-positive as well as ER-negative breast cancer in postmenopausal women.Methods: We performed a case-cohort study within the Women's Health Initiative- Observational Study of postmenopausal women not taking exogenous hormones (age range: 50-79 years). Baseline endogenous levels of bioavailable E2 and T were measured using radioimmunoassays (University of Southern California, LA, CA) in 196 cases of invasive ER-positive breast cancer, 107 cases of invasive ER-negative cancer, and 560 randomly selected controls. The average follow-up time was 7.3 years.Results: After adjustment for putative risk factors, women with E2 levels in the upper three quartiles had an approximately 2-fold increased risk of ER-positive breast cancer, compared to those with E2 in the lowest quartile. These associations were only modestly decreased after adjustment for T. Higher T levels also indicated increased risk of ER-positive breast cancer; women in the third quartile of T had a 1.7-fold significantly higher risk, compared to those in the first quartile. However, this association was substantially diminished and not significant after controlling for E2.No association was observed between E2 levels and ER-negative cancer. However, women with T levels in the second, third, and fourth quartiles had lower risks of ER-negative cancer in the order of 54% (p= 0.018), 38% (p= 0.13), and 46% (p= 0.05), respectively, compared to women with T in the lowest quartile. These associations did not change materially after adjusting for E2.Table 1. Risk (Hazard Ratio (HR) and 95% CI) of ER-positive and ER-negative breast cancer by E2 and T quartiles ER-positive (HR (95% CI))ER-negative (HR (95% CI)) Model 1*Model 2**Model 1*Model 2*E2    Q11.001.001.001.00Q22.19 (1.25-3.84)2.12 (1.16-3.87)0.57 (0.29-1.12)0.72 (0.34-1.53)Q31.92 (1.10-3.35)1.74 (0.92-3.33)0.75 (0.40-1.42)1.09 (0.51-2.3)Q42.11 (1.21-3.68)1.86 (0.97-3.56)0.88 (0.48-1.62)1.36 (0.60-3.08)P for trend0.020.150.840.44T    Q11.001.001.001.00Q21.01 (0.57-1.78)0.82 (0.44-1.53)0.46 (0.24-0.88)0.45 (0.22-0.92)Q31.72 (1.04-2.84)1.36 (0.75-2.48)0.62 (0.34-1.15)0.56 (0.27-1.18)Q41.45 (0.85-2.46)1.16 (0.62-2.17)0.54 (0.29-1.00)0.44 (0.20-1.00)P for trend0.050.280.100.09*Model1: adjusted for age, race, age at menopause, alcohol use, physical activity, history of needle aspiration, lifetime use of estrogen+progestin, and time since quitting hormone therapy use. **Model2: adjusted for Model1 + sex hormones.Conclusion: Higher endogenous E2 levels were associated with increased risk of ER-positive breast cancer, independent of risk factors and T. In contrast, higher concentrations of endogenous T were related to lower risk of ER-negative breast cancer, independent of risk factors and E2. This is the first study to report an association of testosterone with ER-negative breast cancer. Further studies are needed to confirm this association.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 907.

Vasomotor symptoms, adoption of a low-fat dietary pattern, and risk of invasive breast cancer: a secondary analysis of the Women's Health Initiative randomized controlled dietary modification trial

PURPOSE

To assess whether the effect of a low-fat dietary pattern on breast cancer incidence varied by report of baseline vasomotor symptoms.

METHODS

Postmenopausal women age 50 to 79 years enrolled onto the Women's Health Initiative (WHI) Dietary Modification trial from 1993 to 1998 were randomly assigned to a low-fat dietary intervention (n = 19,541) or comparison (n = 29,294). Presence of vasomotor symptoms at baseline was ascertained from a 34-item self-report symptom inventory. Women were queried semi-annually for a new diagnosis of breast cancer. Each case report was verified by medical record and pathology report review by centrally trained WHI physician adjudicators.

RESULTS

Among participants who reported hot flashes (HFs) at baseline (n = 3,375), those assigned to the low-fat diet had a breast cancer rate of 0.27 compared with their counterparts in the control group who had a rate of 0.41 (hazard ratio [HR] = 0.65; 95% CI, 0.42 to 1.01). Among women reporting no HFs (n = 45,160), the breast cancer rate was 0.42 in those assigned to the low-fat diet compared with 0.46 in the control group (HR = 0.93; 95% CI, 0.84 to 1.03; P for interaction = .12 by HF status). Furthermore, the dietary benefits observed seemed to be specific to estrogen receptor (ER) -positive/progesterone receptor (PR) -positive tumors (ER positive/PR positive v other, P for risk = .03). Although women with and without HFs differed with regard to breast cancer risk factors, the effect of the diet intervention on breast cancer incidence by HF status was consistent across risk factor strata.

CONCLUSION

The results of this trial, which are hypothesis generating, suggest that HFs may identify a subgroup of postmenopausal women whose risk of invasive breast cancer might be reduced with the adoption of a low-fat eating pattern.

Calcium plus vitamin D supplementation and the risk of breast cancer

BACKGROUND

Although some observational studies have associated higher calcium intake and especially higher vitamin D intake and 25-hydroxyvitamin D levels with lower breast cancer risk, no randomized trial has evaluated these relationships.

METHODS

Postmenopausal women (N = 36 282) who were enrolled in a Women's Health Initiative clinical trial were randomly assigned to 1000 mg of elemental calcium with 400 IU of vitamin D(3) daily or placebo for a mean of 7.0 years to determine the effects of supplement use on incidence of hip fracture. Mammograms and breast exams were serially conducted. Invasive breast cancer was a secondary outcome. Baseline serum 25-hydroxyvitamin D levels were assessed in a nested case-control study of 1067 case patients and 1067 control subjects. A Cox proportional hazards model was used to estimate the risk of breast cancer associated with random assignment to calcium with vitamin D(3). Associations between 25-hydroxyvitamin D serum levels and total vitamin D intake, body mass index (BMI), recreational physical activity, and breast cancer risks were evaluated using logistic regression models. Statistical tests were two-sided.

RESULTS

Invasive breast cancer incidence was similar in the two groups (528 supplement vs 546 placebo; hazard ratio = 0.96; 95% confidence interval = 0.85 to 1.09). In the nested case-control study, no effect of supplement group assignment on breast cancer risk was seen. Baseline 25-hydroxyvitamin D levels were modestly correlated with total vitamin D intake (diet and supplements) (r = 0.19, P < .001) and were higher among women with lower BMI and higher recreational physical activity (both P < .001). Baseline 25-hydroxyvitamin D levels were not associated with breast cancer risk in analyses that were adjusted for BMI and physical activity (P(trend) = .20).

CONCLUSIONS

Calcium and vitamin D supplementation did not reduce invasive breast cancer incidence in postmenopausal women. In addition, 25-hydroxyvitamin D levels were not associated with subsequent breast cancer risk. These findings do not support a relationship between total vitamin D intake and 25-hydroxyvitamin D levels with breast cancer risk.

A survey of cancer patient preferences: which types of snacks do they prefer during treatment?

Cancer patients undergoing treatment may find it difficult to maintain proper caloric intake. This survey sought to characterize food/beverage preferences and services related to nutritional needs for oncology outpatients. A total of 222 adult oncology patients completed surveys while in an oncology clinic for treatment or for a medical appointment. Data were collected on demographic characteristics, cancer diagnosis/treatment, general health behaviours, preferences for various foods and beverages that could feasibly be offered in the clinic setting and interest in nutrition-related services. Foods requested by at least 50% of the respondents included several types of crackers, doughnuts, fruit cups, cookies, applesauce and gelatin cups. Beverages requested by at least 50% of the respondents included filtered water, coffee, soft drinks and various juices. Nearly 50% requested caffeine-free beverages, and nearly 40% requested sugar-free food choices. Regarding nutrition-related services, respondents were most interested in recipes for persons with cancer, nutrition information/brochures and nutrition counselling. We found that assessing patients' nutritional preferences through survey methodology in the oncology clinic setting was feasible. It is important to aid patients' ability to consume food and beverages that they consider most palatable in order to maintain sufficient caloric intake during active treatment.

Phytanic acid, AMACR and prostate cancer risk

The growing body of knowledge in cancer prevention demonstrates that for many cancers, risk must be defined in terms of both environmental and genetic factors. In prostate cancer, there is increasing evidence linking risk with polymorphisms in the alpha-methylacyl-CoA racemase (AMACR) gene and branched-chain fatty acids derived from specific sources of dietary fats. We are now at the point where we can begin to conceptualize possible inter-relationships between dietary and genetic risk as applied to prostate cancer, with the goal of generating testable hypotheses amenable to coordinated examinations. A greater understanding of such relationships should provide better ways to establish overall risk, to screen for the disease and perhaps to offer specific opportunities for prevention and treatment.

Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial

CONTEXT

Obesity in the United States has increased dramatically during the past several decades. There is debate about optimum calorie balance for prevention of weight gain, and proponents of some low-carbohydrate diet regimens have suggested that the increasing obesity may be attributed, in part, to low-fat, high-carbohydrate diets.

OBJECTIVES

To report data on body weight in a long-term, low-fat diet trial for which the primary end points were breast and colorectal cancer and to examine the relationships between weight changes and changes in dietary components.

DESIGN, SETTING, AND PARTICIPANTS

Randomized intervention trial of 48,835 postmenopausal women in the United States who were of diverse backgrounds and ethnicities and participated in the Women's Health Initiative Dietary Modification Trial; 40% (19,541) were randomized to the intervention and 60% (29,294) to a control group. Study enrollment was between 1993 and 1998, and this analysis includes a mean follow-up of 7.5 years (through August 31, 2004).

INTERVENTIONS

The intervention included group and individual sessions to promote a decrease in fat intake and increases in vegetable, fruit, and grain consumption and did not include weight loss or caloric restriction goals. The control group received diet-related education materials.

MAIN OUTCOME MEASURE

Change in body weight from baseline to follow-up.

RESULTS

Women in the intervention group lost weight in the first year (mean of 2.2 kg, P<.001) and maintained lower weight than control women during an average 7.5 years of follow-up (difference, 1.9 kg, P<.001 at 1 year and 0.4 kg, P = .01 at 7.5 years). No tendency toward weight gain was observed in intervention group women overall or when stratified by age, ethnicity, or body mass index. Weight loss was greatest among women in either group who decreased their percentage of energy from fat. A similar but lesser trend was observed with increases in vegetable and fruit servings, and a nonsignificant trend toward weight loss occurred with increasing intake of fiber.

CONCLUSION

A low-fat eating pattern does not result in weight gain in postmenopausal women. Clinical Trial Registration ClinicalTrials.gov, NCT00000611.

Serum levels of phytanic acid are associated with prostate cancer risk

BACKGROUND

Recent findings of over-expression of the AMACR gene in prostate cancer and association between sequence variants in the AMACR gene and prostate cancer risk, along with the well established findings of association between prostate cancer risk and over-consumption of dairy products and red meat, indirectly suggest that phytanic acid, which primarily comes from dietary intake of dairy and red meat and requires the AMACR enzyme for its metabolism, may be associated with prostate cancer risk. In this small case-control study, we assessed the association between phytanic acid levels and prostate cancer risk.

METHODS

One hundred and four prostate cancer patients and controls were recruited in North Carolina. Serum levels of phytanic acid were measured using a gas liquid chromatography/mass spectroscopy analysis, and a food frequency questionnaire was administered to each individual to assess dietary intake.

RESULTS

Three key findings are reported. First, there was a high correlation between two independent measurements of phytanic acid levels from the same individuals and the levels of phytanic acid were within the expected range, suggesting that serum levels of phytanic acid levels can be reliably measured in large epidemiological studies. Second, serum levels of phytanic acid among prostate cancer patients were significantly higher than that of unaffected controls, suggesting an association between phytanic acid and prostate cancer risk. Lastly, there was a significantly positive correlation between serum levels of phytanic acid and dietary intake of dairy and red meat servings during the year prior to the serum measurement.

CONCLUSIONS

Although the results from our study suggest phytanic acid levels may be associated with prostate cancer risk, they were based on a study with a small sample size. Much larger studies are required to confirm these important findings.

Dietary adherence: characteristics and interventions

This paper reviews issues regarding dietary adherence. Issues and barriers unique to dietary adherence, in contrast to adherence to physical activity or medication regimens, are discussed. These include decision making, social and cultural contexts, perceptions and preferences, and environmental barriers. We review factors known to increase adherence in dietary interventions, including education, motivation, behavioral skills, new and modified foods, and supportive interactions. We conclude with directions for future study, such as improved measurement of diet-related behavior and longitudinal, culturally sensitive interventions. Control Clin Trials 2000;21:206S-211S

A randomized trial comparing the effect of casein with that of soy protein containing varying amounts of isoflavones on plasma concentrations of lipids and lipoproteins

CONTEXT

Isolated soy protein reduces plasma concentrations of total and low-density lipoprotein (LDL) cholesterol.

OBJECTIVE

To identify the agent(s) responsible for the cholesterol-lowering effect of soy in mildly hypercholesterolemic volunteers: isoflavones isolated together with soy protein or soy protein itself.

DESIGN

Double-blind randomized parallel trial.

SETTING

Single-center study.

PARTICIPANTS

A total of 156 healthy men and women with LDL cholesterol levels between 3.62 mmol/L (140 mg/dL) and 5.17 mmol/L (200 mg/dL) after instruction in a National Cholesterol Education Program Step I diet and recruited by advertisement from the community.

INTERVENTION

One of 5 daily diets (25 g of casein [for isoflavone-free comparison] or 25 g of isolated soy protein containing 3, 27, 37, or 62 mg of isoflavones).

MAIN OUTCOME MEASURES

Change and percent change from baseline in plasma concentrations of triglycerides and total, LDL, and high-density lipoprotein cholesterol after 9 weeks.

RESULTS

Compared with casein, isolated soy protein with 62 mg of isoflavones lowered total and LDL cholesterol levels by 4% (P = .04) and 6% (P = .01), respectively. In patients with LDL cholesterol levels in the top half of the population studied (>4.24 mmol/L [>164 mg/dL]), comparable reductions were 9% (P<.001) and 10% (P = 001), respectively; in this group, isolated soy protein with 37 mg of isoflavones reduced total (P = .007) and LDL (P = .02) cholesterol levels by 8%, and there was a dose-response effect of increasing amounts of isoflavones on total and LDL cholesterol levels. Plasma concentrations of triglycerides and high-density lipoprotein cholesterol were unaffected. Ethanol-extracted isolated soy protein containing 3 mg of isoflavones did not significantly reduce plasma concentrations of total or LDL cholesterol.

CONCLUSIONS

Naturally occurring isoflavones isolated with soy protein reduce the plasma concentrations of total and LDL cholesterol without affecting concentrations of triglycerides or high-density lipoprotein cholesterol in mildly hypercholesterolemic volunteers consuming a National Cholesterol Education Program Step I diet. Ethanol-extracted isolated soy protein did not significantly reduce plasma concentrations of total or LDL cholesterol.

Accuracy of a piezoelectric crystal microphone interfaced through an audio amplifier board for use in an automated blood pressure device

Two certified blood pressure technicians and a computerized blood pressure monitor from Computerized Screening, Inc., model 2000 (CSI 2000) obtained 900 blood pressure (BP) readings from 100 subjects aged 15 to 85 years (mean = 44.1 +/- 1.8 SEM). Measurements were obtained simultaneously on the same limb by the observers and the CSI 2000 three times per subject within a 30-minute period). Pressures obtained from the CSI 2000, which uses a piezoelectric crystal microphone interfaced through a newly designed audio amplifier board, were compared with the results of indirect cuff mercury sphygmomanometry. Correlations between the CSI 2000 readings and simultaneous readings obtained by two certified BP technicians for systolic and diastolic BP were r = 0.96 (p less than 0.001) and r = 0.91 (p less than 0.001), respectively. For systolic BP readings, the estimating equation (least-squares) based on a linear relationship between measurements from the test and reference methods was: CSI 2000 systolic BP = -3.454 + [1.015 x (observers' systolic BP)]. For diastolic BP readings, the estimating equation (least squares) was: CSI 2000 = 5.997 + [0.906 x (observers' diastolic BP)]. Close agreement was found between the readings obtained by the CSI 2000 and the average of those obtained by the two certified BP technicians.