Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta-analysis

Umbilical cord-derived mesenchymal stem cells promote proliferation and migration in MCF-7 and MDA-MB-231 breast cancer cells through activation of the ERK pathway

Mesenchymal stem cells (MSCs) are known to migrate to tumor tissues and to play an important role in cancer progression. However, the effects of MSCs on tumor progression remain controversial. The purpose of the present study was to detect the effects of human umbilical cord-derived MSCs (hUC‑MSCs) on the human breast cancer cell lines MDA-MB‑231 and MCF-7 in vitro and the underlying mechanisms. MSCs were isolated and identified from umbilical cord tissues. MDA-MB‑231 and MCF-7 cells were treated with conditioned medium (CM) from 10 and 20% umbilical cord MSCs (UC-MSCs), and the resulting changes in proliferation and migration were investigated. The 3-(4,5-dimethyl-2-thiazolyl)‑2,5-diphenyl‑2-H-tetrazolium bromide (MTT) and plate clone formation assays were used to assess the effect on proliferation, and the effects of CM on MDA-MB-231 and MCF-7 migration were assessed through scratch wound and Transwell migration assays. The expression of cell proliferation- and metastasis-related genes and proteins and activation of the ERK signaling pathway were analyzed by RT-PCR and western blot assays. UC-MSCs are characteristically similar to bone marrow MSCs (BM-MSCs) and exhibit multipotential differentiation capability (i.e., osteoblasts and adipocytes). The MTT, plate clone formation, scratch wound and Transwell migration assay results revealed that 10 and 20% CM promoted the proliferation and migration to higher levels than those observed in the control group. Our findings showed that UC-MSC-CM inhibited E-cadherin expression, increased the expression of N-cadherin and proliferating cell nuclear antigen (PCNA) and enhanced the expression of ZEB1, a transcription factor involved in epithelial‑to‑mesenchymal transition (EMT), through activation of the ERK pathway. U0126, an inhibitor of ERK, reversed the effects of UC-MSC-CM on breast cancer cell proliferation and migration. We conclude that UC-MSCs promote the proliferation and migration of breast cancer cell lines via activation of the ERK pathway.

Nomegestrol acetate/17-beta estradiol: a review of efficacy, safety, and patient acceptability

Nomegestrol acetate (NOMAC) 2.5 mg with 17-beta estradiol (E2) 1.5 mg is a new combined oral contraceptive (COC) formulation and is the first monophasic E2 pill to be marketed, having been licensed for use in Europe in 2011. It is available to be taken daily in a regimen of 24 active pills followed by four placebo pills. NOMAC is a highly selective 19-nor progestogen derivative with specific binding to progesterone receptors, anti-estrogenic activity and no androgenic, mineralocorticoid nor glucocorticoid effects. E2 is an estrogen that is identical to endogenous estrogen. While it has been in use for only a short period of time, current evidence suggests that NOMAC/E2 is just as effective, safe, and acceptable as existing COC preparations. Two large Phase III trials conducted in the Americas and across Europe, Australia, and Asia showed lower cumulative pregnancy rates in the NOMAC/E2 groups compared to the drospirenone (DRSP) 3 mg in combination with ethinyl estradiol (EE) 30 µg (DRSP/EE) groups but this difference was not statistically significant. NOMAC/E2 exhibits a good safety profile and has less effects on cardiovascular risk, hemostatic, metabolic, and endocrine factors in comparison to COCs containing EE in combination with levonorgestrel (LNG) or DRSP. NOMAC/E2 has also been found to cause less breast cell proliferation when compared to E2 alone and has some anti-proliferative effect on human breast cancer cells. NOMAC/E2 is considered acceptable as its compliance, continuation rates, and bleeding patterns were similar to COCs containing DRSP/EE and LNG 150 µg combined with EE 30 µg or LNG 100 µg combined with EE 20 µg (LNG/EE). However, discontinuation was found to be slightly higher in the NOMAC/E2 groups in the two large Phase III trials comparing NOMAC/E2 use with DRSP/EE. As the scientific literature has limited information on NOMAC/E2, further experience with NOMAC/E2 is required.

Hormone therapy and young-onset breast cancer

Estrogen plus progestin hormone therapy (HT) is associated with an increased risk of postmenopausal breast cancer, but few studies have examined the impact of HT use on the risk of breast cancer in younger women. We assessed the association between estrogen plus progestin HT or unopposed estrogen HT and young-onset breast cancer using data from the Two Sister Study (2008-2010), a sister-matched study of 1,419 cases diagnosed with breast cancer before the age of 50 years and 1,665 controls. We assessed exposures up to a family-specific index age to ensure comparable opportunities for exposures and used propensity scores to control for birth cohort effects on HT use. Ever HT use was uncommon (7% and 11% in cases and controls, respectively). Use of estrogen plus progestin was not associated with an increased risk of young-onset breast cancer (odds ratio = 0.80, 95% confidence interval: 0.41, 1.59). Unopposed estrogen use was inversely associated with the risk of young-onset breast cancer (odds ratio = 0.58, 95% confidence interval: 0.34, 0.99). Duration of use, age at first use, and recency of use did not modify these associations.

Impact of an educational intervention on provider knowledge, attitudes, and comfort level regarding counseling women ages 40-49 about breast cancer screening

Background

Mammography screening for women under the age of 50 is controversial. Groups such as the US Preventive Services Task Force recommend counseling women 40–49 years of age about mammography risks and benefits in order to incorporate the individual patient’s values in decisions regarding screening. We assessed the impact of a brief educational intervention on the knowledge and attitudes of clinicians regarding breast cancer screening.

Methods

The educational intervention included a review of the risks and benefits of screening, individual risk assessment, and counseling methods. Sessions were led by a physician expert in breast cancer screening. Participants were physicians and nurses in 13 US Department of Veterans Affairs primary care clinics in Alabama. Outcomes were as follows: 1) knowledge assessment of mammogram screening recommendations; 2) counseling practices on the risks and benefits of screening; and 3) comfort level with counseling about screening. Outcomes were assessed by survey before and after the intervention.

Results

After the intervention, significant changes in attitudes about breast cancer screening were seen. There was a decrease in the percentage of participants who reported that they would screen all women ages 40–49 years (82% before the intervention, 9% afterward). There was an increase in the percentage of participants who reported that they would wait until the patient was 50 years old before beginning to screen (12% before the intervention, 38% afterward). More participants (5% before, 53% after; P<0.001) said that they would discuss the patient’s preferences. Attitudes favoring discussion of screening benefits increased, though not significantly, from 94% to 99% (P=0.076). Attitudes favoring discussion of screening risks increased from 34% to 90% (P<0.001). The comfort level with discussing benefits increased from a mean of 3.8 to a mean of 4.5 (P<0.001); the comfort level with discussing screening risks increased from 2.7 to 4.3 (P<0.001); and the comfort level with discussing cancer risks and screening preferences with patients increased from 3.2 to 4.3 (P<0.001). (The comfort levels measurements were assessed by using a Likert scale, for which 1= not comfortable and 5= very comfortable.)

Conclusion

Most clinicians in the US Department of Veterans Affairs ambulatory practices in Alabama reported that they routinely discuss mammography benefits but not potential harms with patients. An educational intervention detailing recommendations and counseling methods affected the knowledge and attitudes about breast cancer screening. Participants expressed greater likelihood of discussing screening options in the future.

Association between four MMP-9 polymorphisms and breast cancer risk: a meta-analysis

BACKGROUND

The role of matrix metalloproteinase 9 (MMP-9) polymorphisms in breast cancer risk remains unclear. The purpose of this study was to evaluate the association between MMP-9 variants and breast cancer susceptibility.

MATERIAL AND METHODS

Case-control studies were searched on electronic databases to retrieve related articles published between 2000 and 2014 concerning the role of MMP-9 variants in breast cancer risk. Pooled odds ratios (OR) with correlative 95% confidence intervals (CI) were employed to assess this association.

RESULTS

Ten articles were screened out, including 6177 breast cancer patients and 6726 matched-controls. For rs3918242 (-1562 C/T), 6 studies contained 1435 patients and 1446 controls. Although the frequency of risk allele C was higher in breast cancer patients than in controls, only TT genotype in recessive model was significantly associated with increased risk of breast cancer (TT vs. CT+CC: OR=1.55, 95% CI=1.12-2.16, P=0.009) in a fixed-effects model. This significant relationship was not observed in other genetic models (P>0.05). No significant association was found between breast cancer risk and rs17576, rs2250889, and rs3787268 under any genetic models.

CONCLUSIONS

Our results show that TT genotype of MMP-9-1562 C/T polymorphism might be a risk factor for breast cancer. More studies are needed to further explore this association.

Stress hormones reduce the efficacy of paclitaxel in triple negative breast cancer through induction of DNA damage

Background:

The mechanisms by which stress hormones impact triple-negative breast cancer (TNBC) etiology and treatment are unclear. We have previously shown that stress hormones, cortisol, and catecholamines induce rapid DNA damage and impact DNA repair in NIH 3T3 fibroblasts. This study investigates whether stress hormones increase DNA damage in breast cancer cells and if this impacts drug efficacy.

Methods:

We first screened a panel of 39 breast cancer cell lines for expression of adrenergic and glucocorticoid receptors and examined if stress hormones induce DNA damage and alter cell cycle regulation in vitro. A TNBC xenograft model was used to assess the impact of restraint stress on tumour growth and chemosensitivity to paclitaxel.

Results:

We found that stress hormones induced DNA damage, phosphorylation of ATR, which was accompanied by an up-regulation of the G1 cell kinase inhibitor p21 and a cell cycle halt of TNBCs in the G1 phase. p21 knockdown abrogated G1 arrest by stress hormones. We also demonstrated that stress significantly decreased efficacy of paclitaxel.

Conclusion:

We describe a novel mechanism through which stress hormones can induce drug resistance to paclitaxel, which may have profound implications for treating drug resistance in patients with TNBC.

General Practitioners and Breast Surgeons in France, Germany, Netherlands and the UK show variable breast cancer risk communication profiles

BACKGROUND

No information is available on the attitudes of General Practitioners (GPs) and Breast Surgeons (BSs) to their delivery of genetic, environmental and lifestyle risk factor information about breast cancer. The aim of this study was to describe the Breast Cancer Risk Communication Behaviours (RCBs) reported by GPs and BSs in four European countries and to determine the relationships between their RCBs and their socio-occupational characteristics.

METHODS

Self-administered questionnaires assessing breast cancer risk communication behaviours using vignettes were mailed to a sample of Breast Surgeons (BS) and General Practitioners (GP) working in France, Germany, the Netherlands, and the UK (N = 7292). Their responses to questions about the risk factors were first ordered and compared by specialty and country after making multivariate adjustments. Rather than defining a standard Risk Presentation Format (RPF) a priori, the various RPFs used by the respondents were analyzed using cluster analysis.

RESULTS

Family history and hormonal replacement therapy were the risk factors most frequently mentioned by the 2094 respondents included in this study. Lifestyle BC risk factors such as obesity and alcohol were rarely/occasionally mentioned, but this point differed (p < 0.001) depending on the country and the specialty of the providers involved. Five distinct RPF profiles including the numerical/verbal presentation of absolute/relative risks were identified. The most frequently encountered RPF (34.2%) was characterized by the fact that it included no negative framing of the risks, i.e., the probability of not developing cancer was not mentioned. Age, specialty and country of practice were all found to be significant determinants of the RPF clusters.

CONCLUSIONS

The increasing trend for GPs and BSs to discuss lifestyle risk factors with their patients suggests that this may be a relevant means of improving breast cancer prevention. Physicians' risk communication skills should be improved during their initial and vocational training.

An integrated breast cancer risk assessment and management model based on fuzzy cognitive maps

BACKGROUND

There is a growing demand for women to be classified into different risk groups of developing breast cancer (BC). The focus of the reported work is on the development of an integrated risk prediction model using a two-level fuzzy cognitive map (FCM) model. The proposed model combines the results of the initial screening mammogram of the given woman with her demographic risk factors to predict the post-screening risk of developing BC.

METHODS

The level-1 FCM models the demographic risk profile. A nonlinear Hebbian learning algorithm is used to train this model and thus to help on predicting the BC risk grade based on demographic risk factors identified by domain experts. The risk grades estimated by the proposed model are validated using two standard BC risk assessment models viz. Gail and Tyrer-Cuzick. The level-2 FCM models the features of the screening mammogram concerning normal, benign and malignant cases. The data driven Hebbian learning algorithm (DDNHL) is used to train this model in order to predict the BC risk grade based on these mammographic image features. An overall risk grade is calculated by combining the outcomes of these two FCMs.

RESULTS

The main limitation of the Gail model of underestimating the risk level of women with strong family history is overcome by the proposed model. IBIS is a hard computing tool based on the Tyrer-Cuzick model that is comprehensive enough in covering a wide range of demographic risk factors including family history, but it generates results in terms of numeric risk score based on predefined formulae. Thus the outcome is difficult to interpret by naive users. Besides these models are based only on the demographic details and do not take into account the findings of the screening mammogram. The proposed integrated model overcomes the above described limitations of the existing models and predicts the risk level in terms of qualitative grades. The predictions of the proposed NHL-FCM model comply with the Tyrer-Cuzick model for 36 out of 40 patient cases. With respect to tumor grading, the overall classification accuracy of DDNHL-FCM using 70 real mammogram screening images is 94.3%. The testing accuracy of the proposed model using 10-fold cross validation technique outperforms other standard machine learning based inference engines.

CONCLUSION

In the perspective of clinical oncologists, this is a comprehensive front-end medical decision support system that assists them in efficiently assessing the expected post-screening BC risk level of the given individual and hence prescribing individualized preventive interventions and more intensive surveillance for high risk women.

Trends in breast biopsy pathology diagnoses among women undergoing mammography in the United States: a report from the Breast Cancer Surveillance Consortium

BACKGROUND

Current data on the pathologic diagnoses of breast biopsy after mammography can inform patients, clinicians, and researchers about important population trends.

METHODS

Breast Cancer Surveillance Consortium data on 4,020,140 mammograms between 1996 and 2008 were linked to 76,567 pathology specimens. Trends in diagnoses in biopsies by time and risk factors (patient age, breast density, and family history of breast cancer) were examined for screening and diagnostic mammography (performed for a breast symptom or short-interval follow-up).

RESULTS

Of the total mammograms, 88.5% were screening and 11.5% diagnostic; 1.2% of screening and 6.8% of diagnostic mammograms were followed by biopsies. The frequency of biopsies over time was stable after screening mammograms, but increased after diagnostic mammograms. For biopsies obtained after screening, frequencies of invasive carcinoma increased over time for women ages 40-49 and 60-69, Ductal carcinoma in situ (DCIS) increased for those ages 40-69, whereas benign diagnoses decreased for all ages. No trends in pathology diagnoses were found following diagnostic mammograms. Dense breast tissue was associated with high-risk lesions and DCIS relative to nondense breast tissue. Family history of breast cancer was associated with DCIS and invasive cancer.

CONCLUSIONS

Although the frequency of breast biopsy after screening mammography has not changed over time, the percentages of biopsies with DCIS and invasive cancer diagnoses have increased. Among biopsies following mammography, women with dense breasts or family history of breast cancer were more likely to have high-risk lesions or invasive cancer. These findings are relevant to breast cancer screening and diagnostic practices.

Clinical use of fertility agents and risk of breast cancer: a recent update for an old problem

PURPOSE OF REVIEW

Female infertility is today a very common, expanding problem and therefore restoring fertility strategies are increasing in the last few years. An association between ovarian stimulation and breast cancer risk has been hypothesized, but the question has not yet been clarified.

RECENT FINDINGS

In the last 2 years, many important studies have been published on this topic. A lot of new combinations of drugs are in experimentation and other recent drugs are already in current use, such as aromatase inhibitors. Furthermore, the data from older studies were investigated by two recent meta-analyses.

SUMMARY

Infertility affects many couples in western countries and the use of fertility stimulation techniques is widespread in the last few years, determining personal anxiety, social costs, and organizing difficulties. It is well known that one of the most important causative agents for the development of breast cancer is the proliferative activity of endogenous and exogenous female hormones. Therefore, it seems appropriate to investigate the risk of breast cancer derived from the use of hormonal therapies in infertile women. The final clarification of this question is very important so that all women can realize their dream of having children, with the certainty of not being exposed to an increased risk of breast cancer.

Incidence and mortality of female breast cancer in Jiangsu, China

OBJECTIVES

The aim of this study was to describe and analyze the incidence and mortality of female breast cancer in Jiangsu Province of China.

METHODS

Incidence and mortality data for female breast cancer and corresponding population statistics from eligible cancer registries in Jiangsu from 2006 to 2010 were collected and analyzed. Crude rates, age-specific rates and age-standardized rates of incidence and mortality were calculated, and annual present changes (APCs) were estimated to describe the time trends.

RESULTS

From 2006 to 2010, 11,013 new cases and 3,068 deaths of female breast cancer were identified in selected cancer registry areas of Jiangsu. The annual average crude incidence and age-standardized incidence by world population (ASW) were 25.2/ and 17.9/100,000 respectively. The annual average crude and ASW for mortality rates were 7.03/ and 4.81/100,000. The incidence was higher in urban areas than that in rural areas, and this was consistent in all age groups. No significant difference was observed in mortality between urban and rural areas. Two peaks were observed when looking at age-specific rates, one at 50-59 years and another at over 85 years. During the 5 years, incidence and mortality increased with APCs of 4.47% and 6.89%, respectively. Compared to the national level, Jiangsu is an area with relatively low risk of female breast cancer.

CONCLUSION

Breast cancer has become a main public health problem among Chinese females. More prevention and control activities should be conducted to reduce the burden of this disease, even in relatively low risk areas like Jiangsu.

MicroRNA signatures highlight new breast cancer subtypes

MicroRNAs (miRNAs) are a kind of short non-coding RNAs, of about 22 nucleotides in length, which modulate and sometimes degrade the target mRNAs thereby regulating a number of cellular functions. Recent research in this area establishes the involvement of miRNAs in various disease progressions, including certain types of cancer development. Further, genome-wide expression profiling of miRNAs has been proven to be useful for differentiating various cancer types. In this paper, we have used miRNA expression profiles over a large set of breast cancer tumor samples for identifying subtypes of breast cancers. The experimental results demonstrate that miRNAs carry a unique signature that distinguishes cancer subtypes and reveal new cancer subtypes. Additional survival analyses based on clinical data also strengthen this claim.

Older women's experience with a benign breast biopsy—a mixed methods study

BACKGROUND

Little is known about older women's experience with a benign breast biopsy.

OBJECTIVES

To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy.

DESIGN

Prospective cohort study using quantitative and qualitative methods.

SETTING

Three Boston-based breast imaging centers.

PARTICIPANTS

Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy.

MEASUREMENTS

We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes.

RESULTS

Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms.

CONCLUSIONS

The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.

Combined associations of genetic and environmental risk factors: implications for prevention of breast cancer

Genome-wide association studies (GWAS) have identified hundreds of genetic susceptibility loci for cancers and other complex diseases. However, the public health and clinical relevance of these discoveries is unclear. Evaluating the combined associations of genetic and environmental risk factors, particularly those that can be modified, will be critical in assessing the utility of genetic information for risk stratified prevention. In this commentary, using breast cancer as a model, we show that genetic information in combination with other risk factors can provide levels of risk stratification that could be useful for individual decision-making or population-based prevention programs. Our projections are theoretical and rely on a number of assumptions, including multiplicative models for the combined associations of the different risk factors, which need confirmation. Thus, analyses of epidemiological studies with high-quality risk factor information, as well as prevention trials, are needed to empirically assess the impact of genetics in risk stratified prevention.

Understanding patient options, utilization patterns, and burdens associated with breast cancer screening

Despite ongoing awareness, educational campaigns, and advances in technology, breast cancer screening remains a complex topic for women and for the health care system. Lack of consensus among organizations developing screening guidelines has caused confusion for patients and providers. The psychosocial factors related to breast cancer screening are not well understood. The prevailing algorithm for screening results in significant rates of patient recall for further diagnostic imaging or procedures, the majority of which rule out breast cancer rather than confirming it. For women, the consequences of the status quo range from unnecessary stress to additional out-of-pocket expenses to indirect costs that are more difficult to quantify. A more thoughtful approach to breast cancer screening, coupled with a research agenda that recognizes the indirect and intangible costs that women bear, is needed to improve cost and quality outcomes in this area.

Symptomatic breast cancer diagnosis and multimodal management in women aged 40 to 50 years; consequences of current mammographic screening programs

INTRODUCTION

Consensus exists that screening mammography is appropriate for women aged 50 to 69 years. However, the effectiveness of such screening for women aged 40 to 50 years is still questioned. The aim of our study was to analyze breast cancer management in the 40- to 50-year age group. We also wished to determine the proportion of patients with a significant family history and whether this was associated with more advanced disease.

PATIENTS AND METHODS

All female patients with primary breast cancer diagnosed between 40 and 50 years of age were included over a 4-year period. The database of the National Breast Cancer Research Institute was interrogated, and a chart and radiology review carried out to obtain relevant details of clinical presentation, family history, radiological findings, and treatments undertaken.

RESULTS

Three hundred thirty-four patients were diagnosed in this cohort during the study period. Twenty-two percent of those diagnosed had a family history of breast cancer with 1.8% having a genetically confirmed predisposition to breast cancer. A significant proportion of patients presented with advanced disease, with 50% of patients having nodal involvement and 3% who presented with distant metastases. The overall rate of mastectomy was 47%, with minimal variation between the surgeons who performed the surgeries. More than half of the patients in our analysis underwent axillary clearance (51%).

CONCLUSION

Our results indicate that a large proportion of patients in the 40- to 50-year age group presented with advanced disease and required aggressive surgical and adjuvant treatment. The presence of a family history did not identify a subgroup with more advanced disease at presentation.

Effectiveness of population-based service screening with mammography for women ages 40 to 49 years with a high or low risk of breast cancer: socioeconomic status, parity, and age at birth of first child

BACKGROUND

Invitation to mammography screening of women aged 40 to 49 years is a matter of debate in many countries and a cost-effective alternative in countries without screening among women aged 40 to 49 years could be inviting those at higher risk. The relative effectiveness of mammography screening was estimated for subgroups based on the breast cancer risk factors parity, age at time of birth of first child, and socioeconomic status (SES).

METHODS

The SCReening of Young Women (SCRY) database consists of all women aged 40 to 49 years in Sweden between 1986 and 2005 and was split into a study and control group. The study group consisted of women residing in areas in which women aged 40 to 49 years were invited to screening and the control group of women in areas in which women aged 40 to 49 years were not invited to screening. Rate ratio (RR) estimates were calculated for 2 exposures: invitation and attendance.

RESULTS

There were striking similarities noted in the RR pattern for women invited to and attending screening and no statistically significant difference or trend in the RR was noted by risk group. The RR estimates increased by increasing parity for parity of 0 to 2 and ranged from 0.55 (95% confidence interval [95% CI], 0.38-0.79) to 0.79 (95% CI, 0.65-0.95) for attending women. The RR for women with high SES was lower than that for women with low SES (RR, 0.72 [95% CI, 0.60-0.86] and RR, 0.79 [95% CI, 0.63-0.99], respectively). For women aged 20 to 24 years at the time of the birth of their first child, the RR was 0.73 (95% CI, 0.58-0.91) and estimates for other ages were similar.

CONCLUSIONS

There was no statistically significant difference noted in the relative effectiveness of mammography screening by parity, age at the time of birth of the first child, or SES.

EMAS position statement: individualized breast cancer screening versus population-based mammography screening programmes

INTRODUCTION

Breast cancer is the most prevalent cancer in women, with slightly more than ten percent developing the disease in Western countries. Mammography screening is a well established method to detect breast cancer.

AIMS

The aim of the position statement is to review critically the advantages and shortcomings of population based mammography screening.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

RESULTS AND CONCLUSION

Mammography screening programmes vary worldwide. Thus there are differences in the age at which screening is started and stopped and in the screening interval. Furthermore differences in screening quality (such as equipment, technique, resolution, single or double reading, recall rates) result in a sensitivity varying from 70% to 94% between studies. Reporting results of screening is subject to different types of bias such as overdiagnosis. Thus because of the limitations of population-based mammography screening programmes an algorithm for individualized screening is proposed.

Cross-sectional study to assess the association of population density with predicted breast cancer risk

The Gail and CARE models estimate breast cancer risk for white and African-American (AA) women, respectively. The aims of this study were to compare metropolitan and nonmetropolitan women with respect to predicted breast cancer risks based on known risk factors, and to determine if population density was an independent risk factor for breast cancer risk. A cross-sectional survey was completed by 15,582 women between 35 and 85 years of age with no history of breast cancer. Metropolitan and nonmetropolitan women were compared with respect to risk factors, and breast cancer risk estimates, using general linear models adjusted for age. For both white and AA women, tisk factors used to estimate breast cancer risk included age at menarche, history of breast biopsies, and family history. For white women, age at first childbirth was an additional risk factor. In comparison to their nonmetropolitan counterparts, metropolitan white women were more likely to report having a breast biopsy, have family history of breast cancer, and delay childbirth. Among white metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.44% and 1.32% (p < 0.001), and lifetime risks of breast cancer were 10.81% and 10.01% (p < 0.001), respectively. AA metropolitan residents were more likely than those from nonmetropolitan areas to have had a breast biopsy. Among AA metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.16% and 1.12% (p = 0.039) and lifetime risks were 8.94%, and 8.85% (p = 0.344). Metropolitan residence was associated with higher predicted breast cancer risks for white women. Among AA women, metropolitan residence was associated with a higher predicted breast cancer risk at 5 years, but not over a lifetime. Population density was not an independent risk factor for breast cancer.

Physician adherence to U.S. Preventive Services Task Force mammography guidelines

BACKGROUND

In 2009, the U.S. Preventive Services Task Force (USPSTF) guidelines for screening mammography changed significantly, and are now in direct conflict with screening guidelines of other major national organizations. The extent to which physicians in different primary care specialties adhere to current USPSTF guidelines is unknown.

METHODS

We conducted a cross-sectional web-based survey completed by 316 physicians in internal medicine, family medicine (FM), and gynecology (GYN) from February to April 2012. Survey items assessed respondents' breast cancer screening recommendations in women of different ages at average risk for breast cancer. We used descriptive statistics to generate response distribution for survey items, and logistic regression models to compare responses among specialties.

FINDINGS

The response rate was 55.0% (316/575). A majority of providers in internal medicine (65%), FM (64%), and GYN (92%) recommended breast cancer screening starting at age 40 versus 50. A majority of providers in internal medicine (77%), FM (74%), and GYN (98%) recommended annual versus biennial screening. Gynecologists were significantly more likely than both internists and family physicians to recommend initial mammography at age 40 (p ≤ .0001) and yearly mammography (p = .0003). There were no other differences by respondent demographic.

CONCLUSIONS

Primary care providers, especially gynecologists, have not implemented USPSTF guidelines. The extent to which these findings may be driven by patient versus provider preferences should be explored. These findings suggest that patients are likely to receive conflicting breast cancer screening recommendations from different providers.

Risk of breast cancer following fertility treatment--a registry based cohort study of parous women in Norway

Despite increasing numbers of women availing themselves of assisted reproductive technology (ART), effects on cancer risk remain unresolved. Given hormonal exposures, breast cancer risk is of particular concern. The aim of this study is to investigate breast cancer risk amongst women giving birth following ART as compared to that amongst women who gave birth without ART. Data on all women who gave birth in Norway with or without ART, between 1984 and 2010 were obtained from the Medical Birth Registry of Norway (MBRN). 808,834 women eligible for study were linked to the Cancer Registry of Norway. Cox proportional models computed hazard ratios (HR) and 95% confidence intervals (CI) of breast cancer between the two groups, adjusting for age, parity, age at first birth, calendar period and region of residence. In total, 8,037 women were diagnosed with breast cancer during the study period, 138 ART women and 7,899 unexposed. Total follow-up time was 12,401,121 person-years (median 16.0); median age at entry was 32.5 years (range 18.6-49.9) for ART women and 26.3 (range 10.5-54.6) for unexposed. Women exposed to ART had an elevated risk of breast cancer (adjusted HR 1.20, 95% CI 1.01-1.42). Subgroup analyses gave an HR of 1.30 (95% CI 1.07-1.57) for women treated with IVF and 1.35 (95 % CI 1.07-1.71) for women with follow-up >10 years, compared with controls. Our findings of increased risk in the study population warrant continued monitoring of women treated with ART as this population advances into more typical cancer age ranges.

[Update of breast cancer in primary care (I/V)]

Breast cancer is a prevalent disease affecting all areas of the patients' lives. Therefore, family physicians should have a thorough knowledge of this disease in order to optimize the health care services for these patients, and making the best use of available resources. A series of 5 articles on breast cancer is presented below. It is based on a review of the scientific literature over the last 10 years. The first article reviews the epidemiology, risk factors, and protective factors in this disease This summary report aims to provide a current and practical review on breast cancer, providing answers to family doctors and helping them to support the patients for their benefit throughout their illness.

Changes in breast cancer risk distribution among Vermont women using screening mammography

BACKGROUND

Screening mammography utilization in Vermont has declined since 2009 during a time of changing screening guidelines and increased interest in personalized screening regimens. This study evaluates whether the breast cancer risk distribution of the state's screened population changed during the observed decline.

METHODS

We examined the breast cancer risk distribution among screened women between 2001 and 2012 using data from the Vermont Breast Cancer Surveillance System. We estimated each screened woman's 5-year risk of breast cancer using the Breast Cancer Surveillance Consortium risk calculator. Annual screening counts by risk group were normalized and age-adjusted to the Vermont female population by direct standardization.

RESULTS

The normalized rate of low-risk (5-year breast cancer risk of <1%) women screened increased 8.3% per year (95% confidence interval [CI] = 4.8 to 11.9) between 2003 and 2008 and then declined by -5.4% per year (95% CI = -8.1 to -2.6) until 2012. When stratified by age group, the rate of low-risk women screened declined -4.4% per year (95% CI = -8.8 to 0.1; not statistically significant) for ages 40 to 49 years and declined a statistically significant -7.1% per year (95% CI = -12.1 to -2.0) for ages 50 to 74 years during 2008 to 2012. These declines represented the bulk of overall decreases in screening after 2008, with rates for women categorized in higher risk levels generally exhibiting small annual changes.

CONCLUSIONS

The observed decline in women screened in Vermont in recent years is largely attributable to reductions in screening visits by women who are at low risk of developing breast cancer.

Aberrant promoter methylation of the CHD1 gene may contribute to the pathogenesis of breast cancer: a meta-analysis

Cadherin-1 (CHD1), as an invasion suppressor gene, could suppress tumor cell invasion and metastasis in various tumors, but reduced CHD1 levels, resulting from epigenetic silencing, are common in poorly differentiated, advanced stage carcinomas. This meta-analysis was performed to evaluate the relationships between promoter methylation of CHD1 and breast cancer. Relevant studies were retrieved from the Web of Science (1945 ~ 2013), the Cochrane Library (Issue 12, 2013), PubMed (1966 ~ 2013), EMBASE (1980 ~ 2013), CINAHL (1982 ~ 2013), and the Chinese Biomedical Database (CBM) (1982 ~ 2013) using a systematic literature search. Results were summarized by meta-analyses, conducted using the STATA software (version 12.0, Stata Corporation, College Station, TX, USA). Odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were calculated. In the present meta-analysis, 9 cohort studies with a total of 425 patients with breast cancer were included. Our meta-analysis results demonstrated that the frequency of CHD1 promoter methylation in cancer tissues was significantly higher than that in normal tissues, adjacent tissues, and benign tissues (cancer tissue vs. normal tissue OR = 30.87, 95 % CI = 16.76 ~ 56.86, P < 0.001; cancer tissue vs. adjacent tissue OR = 23.30, 95 % CI = 12.85 ~ 42.26, P < 0.001; cancer tissue vs. benign tissue OR = 2.94, 95 % CI = 1.60 ~ 5.40, P < 0.001; respectively). Ethnicity-stratified analysis indicated that aberrant CHD1 promoter methylation was strongly correlated with breast cancer among both Asians and Caucasians in the majority of subgroups. Our results suggest that aberrant promoter methylation of the CHD1 gene may have a high frequency in breast cancer tissues. Thus, CHD1 methylation could be correlated with the pathogenesis of breast cancer.

Correlations of common polymorphism of EVI-1 gene targeted by miRNA-206/133b with the pathogenesis of breast cancer

The aim of this study was to identify the correlations of a common polymorphism (rs6774494 A > G) in the EVI-1 gene targeted by micro-RNA (miRNA)-206/133b with the pathogenesis of breast cancer (BC). A total of 196 unrelated ethnic Han Chinese women diagnosed with primary BC were consecutively recruited and 200 healthy controls were randomly selected from the same population-based cohort. Direct PCR sequencing assay was used to detection of rs6774494 A > G polymorphism in the EVI-1 gene. Real-time quantitative PCR (RT-PCR) analysis was performed to verify the alterations of the EVI1 messenger RNA (mRNA) levels. Kaplan-Meier analysis was used to investigate and to estimate the survival outcomes for each endpoint. All statistical analyses were performed with SPSS software (version 18.0, SPSS, Chicago, IL). Our results demonstrated that the carriers of EVI-1 AG genotype were more likely to develop BC when compared with the EVI-1 GG genotype (P = 0.034, OR = 1.26, 95% CI = 1.02 ∼ 1.57). In addition, it was found that patients with the G (AG + GG) allele of EVI-1 genetic variants were associated with higher risk of BC compared with the EVI-1 AA genotype (OR = 1.26, 95% CI = 1.02 ∼ 1.54, P = 0.028). The results of a subgroup analysis stratified by menopause revealed that in female post-menopause subgroup patients with the EVI-1 G allele were correlated with a higher risk of BC than those with the EVI-1 AA genotype (OR = 1.31, 95% CI = 1.00 ∼ 1.72, P = 0.054). Kaplan-Meier analyses suggested that carriers of the G allele (AG + GG) were associated with poorer overall survival (OS) and progression-free survival (PFS) compared with those with AA genotype (OS P = 0.042; PFS P = 0.036, respectively). The correlation analysis showed that EVI-1 mRNA levels were negatively associated with miRNA-206/133b levels in the carriers of the G allele (AG + GG) (r = -1.274, P < 0.05). Our findings provide evidence that the EVI-1 rs6774494 G > A polymorphism targeted by miRNA-206/133b may contribute to the pathogenesis of BC.

Aberrant promoter methylation of HIN-1 gene may contribute to the pathogenesis of breast cancer: a meta-analysis

We conducted the present meta-analysis of relevant cohort studies to evaluate whether promoter methylation of the high in normal-1 (HIN-1) gene contributes to breast cancer. The MEDLINE (1966 ~ 2013), Cochrane Library (Issue 12, 2013), EMBASE (1980 ~ 2013), CINAHL (1982 ~ 2013), Web of Science (1945 ~ 2013), and Chinese Biomedical (CBM) (1982 ~ 2013) databases were searched without any language restrictions. Meta-analyses were conducted using Stata software (version 12.0; Stata Corporation, College Station, TX, USA). Crude odds ratios (ORs) with their 95 % confidence interval (CI) were calculated. Nine clinical cohort studies that enrolled a total of 693 breast cancer patients were included in the meta-analysis. The results of our meta-analysis demonstrated that HIN-1 methylation frequency in cancer tissue was significantly higher than that of normal and benign tissues (cancer tissue vs. normal tissue: OR = 52.60, 95 % CI = 33.77 ~ 81.92, P < 0.001; cancer tissue vs. benign tissue: OR = 2.38, 95 % CI = 1.53 ~ 3.70, P < 0.001; respectively). Ethnicity-stratified analysis indicated that HIN-1 promoter methylation was correlated with the pathogenesis of breast cancer among both Asians and Caucasians (all P < 0.05). Our findings provide empirical evidence that aberrant HIN-1 promoter methylation may contribute to the pathogenesis of breast cancer. Thus, aberrant HIN-1 promoter methylation could be an independent and important biomarker used in predicting the prognosis and progression of breast cancer.

Association between computed tissue density asymmetry in bilateral mammograms and near-term breast cancer risk

This study investigated association between bilateral mammographic density asymmetry and near-term breast cancer risk. A data base of digital mammograms acquired from 690 women was retrospectively collected. All images were originally interpreted as negative by radiologists. During the next subsequent screening examinations (between 12 and 36 months later), 230 women were diagnosed positive for cancer, 230 were recalled for additional diagnostic workups and proved to be benign, and 230 remained negative (not recalled). We applied a computerized scheme to compute the differences of five image features between the left and right mammograms, and trained an artificial neural network (ANN) to compute a bilateral mammographic density asymmetry score. Odds ratios (ORs) were used to assess associations between the ANN-generated scores and risk of women having detectable cancers during the next screening examinations. A logistic regression method was applied to test for trend as a function of the increase in ANN-generated scores. The results were also compared with ORs computed using other existing cancer risk factors. The ORs showed an increasing risk trend with the increase in ANN-generated scores (from 1.00 to 9.07 between positive and negative case groups). The regression analysis also showed a significant increase trend in slope (p < 0.05). No significant increase trends of the ORs were found when using woman's age, subjectively rated breast density, or family history of breast cancer. This study demonstrated that the computed bilateral mammographic density asymmetry had potential to be used as a new risk factor to improve discriminatory power in predicting near-term risk of women developing breast cancer.

The relationship between seven common polymorphisms from five DNA repair genes and the risk for breast cancer in northern Chinese women

BACKGROUND

Converging evidence supports the central role of DNA damage in progression to breast cancer. We therefore in this study aimed to assess the potential interactions of seven common polymorphisms from five DNA repair genes (XRCC1, XRCC2, XRCC3, XPA and APEX1) in association with breast cancer among Han Chinese women.

METHODOLOGY/PRINCIPAL FINDINGS

This was a case-control study involving 606 patients diagnosed with sporadic breast cancer and 633 age- and ethnicity-matched cancer-free controls. The polymerase chain reaction-ligase detection reaction method was used to determine genotypes. All seven polymorphisms were in accordance with Hardy-Weinberg equilibrium in controls. Differences in the genotypes and alleles of XRCC1 gene rs25487 and XPA gene rs1800975 were statistically significant between patients and controls, even after the Bonferroni correction (P<0.05/7). Accordingly, the risk for breast cancer was remarkably increased for rs25487 (OR = 1.28; 95% CI: 1.07-1.51; P = 0.006), but decreased for rs1800975 (OR = 0.77; 95% CI: 0.67-0.90; P = 0.001) under an additive model at a Bonferroni corrected alpha of 0.05/7. Allele combination analysis showed higher frequencies of the most common combination C-G-G-C-G-G-G (alleles in order of rs1799782, rs25487, rs3218536, rs861539, rs1800975, rs1760944 and rs1130409) in controls than in patients (PSim = 0.002). In further interaction analysis, two-locus model including rs1800975 and rs25487 was deemed as the overall best model with the maximal testing accuracy of 0.654 and the cross-validation consistency of 10 out of 10 (P = 0.001).

CONCLUSION

Our findings provide clear evidence that XRCC1 gene rs25487 and XPA gene rs1800975 might exert both independent and interactive effects on the development of breast cancer among northern Chinese women.

Targeting FASN in Breast Cancer and the Discovery of Promising Inhibitors from Natural Products Derived from Traditional Chinese Medicine

Molecular targeted therapy has been developed for cancer chemoprevention and treatment. Cancer cells process a fundamental change in its bioenergetic metabolism from normal cells on an altered lipid metabolism, also known as the de novo fatty acid synthesis, for sustaining their high proliferation rates. Fatty acid synthesis is now associated with clinically aggressive tumor behavior and tumor cell growth and has become a novel target pathway for chemotherapy development. Although the underlying mechanisms of the altered de novo fatty acid synthesis still remains unclear, recent progress has shown that by targeting Fatty acid synthase (FASN), a key enzyme that catalyzes the synthesis of endogenous long chain fatty acid could be a critical target for drug discovery. However, relatively few FASN inhibitors have been discovered. With the long history of clinical practices and numerous histological case study reports, traditional Chinese medicine enjoys an important role in seeking bioactive anticancer natural compounds. Herein, we will give an overall picture of the current progress of molecular targeted therapy in cancer fatty acid synthesis, describe the advances in the research on natural products-derived FASN inhibitors and their potential for enhancing our understanding of fatty acids in tumor biology, and may provide new therapeutic moieties for breast cancer patient care.

Hyperresistinemia is associated with postmenopausal breast cancer

OBJECTIVE

The constellation of obesity, insulin resistance, and serum adipocytokine levels is associated with the risk and prognosis of postmenopausal breast cancer (PBC). Altered secretion of resistin may underlie the association between overweight/obesity and PBC. We thus explored the association of serum resistin with PBC, taking into account established risk factors, including adipokines and anthropometric, metabolic, and inflammatory markers.

METHODS

In a case-control study, we studied 102 postmenopausal women with pathologically confirmed, incident invasive breast cancer and 102 control participants matched on age and time of diagnosis between 2003 and 2010 at the Veterans' Administration General Hospital of Athens (NIMTS Hospital). Serum resistin, adiponectin, leptin, metabolic (homeostasis model assessment score of insulin resistance) and inflammatory (tumor necrosis factor-α, interleukin-6, and high-sensitivity C-reactive protein) parameters, and tumor markers (carcinoembryonic antigen and CA 15-3) were determined.

RESULTS

The mean serum resistin level was significantly higher in case participants than in control participants (P < 0.001) in both univariate and multivariable analyses, adjusting for age, date of diagnosis, education, family history of cancer, use of exogenous hormones, alcohol consumption, smoking status, physical activity, reproductive markers, metabolic markers, anthropometric (body mass index and weight circumference) markers, inflammatory markers, and adipokines (odds ratio, 1.17; 95% CI, 1.03-1.34; P = 0.02). In case participants, resistin level correlated significantly with tumor markers and inflammatory parameters, but not with metabolic and anthropometric variables.

CONCLUSIONS

Further prospective, longitudinal, and mechanistic studies are needed to determine whether hyperresistinemia is involved in the development of PBC or reflects changes during PBC progression and therefore could be used as a biomarker for PBC. Targeting resistin inhibition could be an effective therapeutic strategy in breast cancer by down-regulating the inflammatory microenvironment in breast tissue.

Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines

BACKGROUND

Controversy exists over how often and at what age mammography screening should be implemented. Given that evidence supports less frequent screening, the cost differences among advocated screening policies should be better understood.

OBJECTIVE

To estimate the aggregate cost of mammography screening in the United States in 2010 and compare the costs of policy recommendations by professional organizations.

DESIGN

A model was developed to estimate the cost of mammography screening in 2010 and 3 screening strategies: annual (ages 40 to 84 years), biennial (ages 50 to 69 years), and U.S. Preventive Services Task Force (USPSTF) guidelines (biennial for those aged 50 to 74 years and personalized based on risk for those younger than 50 years and based on comorbid conditions for those 75 years and older).

SETTING

United States.

PATIENTS

Women aged 40 to 85 years.

INTERVENTION

Mammography annually, biennially, or following USPSTF guidelines.

MEASUREMENTS

Cost of screening per year, using Medicare reimbursements.

RESULTS

The estimated cost of mammography screening in the United States in 2010 was $7.8 billion, with approximately 70% of women screened. The simulated cost of screening 85% of women was $10.1 billion, $2.6 billion, and $3.5 billion for annual, biennial, and USPSTF guidelines, respectively. The largest drivers of cost (in order) were screening frequency, percentage of women screened, cost of mammography, percentage of women screened with digital mammography, and percentage of mammography recalls.

LIMITATION

Cost estimates and assumptions used in the model were conservative.

CONCLUSION

The cost of mammography varies by at least $8 billion per year on the basis of screening strategy. The USPSTF guidelines are based on the scientific evidence to date to maximize patient benefit and minimize harm but also result in far more effective use of resources.

PRIMARY FUNDING SOURCE

University of California and the Safeway Foundation.

Confronting confirmation bias about breast cancer screening with the four Cs

The tendency to resist evidence that doesn't support our own beliefs is a type of confirmation bias. Recent changes to recommendations for breast cancer screening underscore the need for nurses to maintain awareness of most recent and reliable evidence, evaluate women's family histories and encourage women to mitigate modifiable risks and make well-informed decisions. When advising women about breast cancer screening, nurses can employ an approach based on the four Cs: (1) commit to staying up-to-date with evidence; (2) convey understanding; (3) communicate the evidence and answer questions; and (4) collaborate with women on their plan for breast cancer screening.

Timing of oral contraceptive use and the risk of breast cancer in BRCA1 mutation carriers

It is not clear if early oral contraceptive use increases the risk of breast cancer among young women with a breast cancer susceptibility gene 1 (BRCA1) mutation. Given the benefit of oral contraceptives for the prevention of ovarian cancer, estimating age-specific risk ratios for oral contraceptive use and breast cancer is important. We conducted a case-control study of 2,492 matched pairs of women with a deleterious BRCA1 mutation. Breast cancer cases and unaffected controls were matched on year of birth and country of residence. Detailed information about oral contraceptive use was collected from a routinely administered questionnaire. Conditional logistic regression was used to estimate the odds ratios (OR) and 95 % confidence intervals (CI) for the association between oral contraceptive and breast cancer, by age at first use and by age at diagnosis. Among BRCA1 mutation carriers, oral contraceptive use was significantly associated with an increased risk of breast cancer for women who started the pill prior to age 20 (OR 1.45; 95 % CI 1.20-1.75; P = 0.0001) and possibly between ages 20 and 25 as well (OR 1.19; 95 % CI 0.99-1.42; P = 0.06). The effect was limited to breast cancers diagnosed before age 40 (OR 1.40; 95 % CI 1.14-1.70; P = 0.001); the risk of early-onset breast cancer increased by 11 % with each additional year of pill use when initiated prior to age 20 (OR 1.11; 95 % CI 1.03-1.20; P = 0.008). There was no observed increase for women diagnosed at or after the age of 40 (OR 0.97; 95 % CI 0.79-1.20; P = 0.81). Oral contraceptive use before age 25 increases the risk of early-onset breast cancer among women with a BRCA1 mutation and the risk increases with duration of use. Caution should be taken when advising women with a BRCA1 mutation to take an oral contraceptive prior to age 25.

Prediction of near-term breast cancer risk based on bilateral mammographic feature asymmetry

RATIONALE AND OBJECTIVES

The objective of this study is to investigate the feasibility of predicting near-term risk of breast cancer development in women after a negative mammography screening examination. It is based on a statistical learning model that combines computerized image features related to bilateral mammographic tissue asymmetry and other clinical factors.

MATERIALS AND METHODS

A database of negative digital mammograms acquired from 994 women was retrospectively collected. In the next sequential screening examination (12 to 36 months later), 283 women were diagnosed positive for cancer, 349 were recalled for additional diagnostic workups and later proved to be benign, and 362 remain negative (not recalled). From an initial pool of 183 features, we applied a Sequential Forward Floating Selection feature selection method to search for effective features. Using 10 selected features, we developed and trained a support vector machine classification model to compute a cancer risk or probability score for each case. The area under the receiver operating characteristic curve and odds ratios (ORs) were used as the two performance assessment indices.

RESULTS

The area under the receiver operating characteristic curve = 0.725 ± 0.018 was obtained for positive and negative/benign case classification. The ORs showed an increasing risk trend with increasing model-generated risk scores (from 1.00 to 12.34, between positive and negative/benign case groups). Regression analysis of ORs also indicated a significant increase trend in slope (P = .006).

CONCLUSIONS

This study demonstrates that the risk scores computed by a new support vector machine model involving bilateral mammographic feature asymmetry have potential to assist the prediction of near-term risk of women for developing breast cancer.

Hormonal therapy and risk of breast cancer in mexican women

The use of hormonal therapies, including hormonal contraceptives (HC) and postmenopausal hormone replacement therapy (HRT) have been shown to influence breast cancer (BC) risk. However, the variations of these effects among populations and ethnic groups are not completely documented, especially among Hispanic women. We evaluated the association between HC and premenopausal BC risk, and between HRT and postmenopausal BC risk in Mexican women. Data from a Mexican multi-center population-based case–control study ofwomen aged 35 to 69 years were analysed. A total of 1000 cases and 1074 matched controls were recruited between 2004 and 2007. Information on hormonal therapy was collected through a structured questionnaire. Results were analysed using conditional logistic regression models. Overall, HC were used by 422/891 (47.3%) premenopausal women and HRT was used by 220/1117 (19.7%) postmenopausal women. For HC, odds ratios (ORs) for BC were 1.11 (95% confidence interval (CI): 0.82, 1.49) for current users and 1.68 (95% CI: 0.67, 4.21) for ever-users. No clear effect of duration of use was observed. For HRT, the OR for BC was significantly increased in ever users (OR: 1.45; 95% CI: 1.01, 2.08). A non-significant increased risk was observed for combined estrogen/progestin, (OR =  1.85; 95% CI: 0.84, 4.07) whereas no effect was observed for the use of estrogen alone (OR = 1.14; 95% CI: 0.68, 1.91). Our results indicate that, HC had a non-significant effect on the risk of pre-menopausal BC, but suggested that injected contraceptives may slightly increase the risk, whereas HRT had a significant effect on post-menopausal BC in this population. This study provides new information about the effects of HC and HRT on BC risk in a Mexican population, which may be of relevance for the population of Latin America as a whole.

Altered features and increased chemosensitivity of human breast cancer cells mediated by adipose tissue-derived mesenchymal stromal cells

Background

Mesenchymal stromal cells (MSCs) represent heterogeneous cell population suitable for cell therapies in regenerative medicine. MSCs can also substantially affect tumor biology due to their ability to be recruited to the tumor stroma and interact with malignant cells via direct contacts and paracrine signaling. The aim of our study was to characterize molecular changes dictated by adipose tissue-derived mesenchymal stromal cells (AT-MSCs) and the effects on drug responses in human breast cancer cells SKBR3.

Methods

The tumor cells were either directly cocultured with AT-MSCs or exposed to MSCs-conditioned medium (MSC-CM). Changes in cell biology were evaluated by kinetic live cell imaging, fluorescent microscopy, scratch wound assay, expression analysis, cytokine secretion profiling, ATP-based viability and apoptosis assays. The efficiency of cytotoxic treatment in the presence of AT-MSCs or MSCs-CM was analyzed.

Results

The AT-MSCs altered tumor cell morphology, induced epithelial-to-mesenchymal transition, increased mammosphere formation, cell confluence and migration of SKBR3. These features were attributed to molecular changes induced by MSCs-secreted cytokines and chemokines in breast cancer cells. AT-MSCs significantly inhibited the proliferation of SKBR3 cells in direct cocultures which was shown to be dependent on the SDF-1α/CXCR4 signaling axis. MSC-CM-exposed SKBR3 or SKBR3 in direct coculture with AT-MSCs exhibited increased chemosensitivity and induction of apoptosis in response to doxorubicin and 5-fluorouracil.

Conclusions

Our work further highlights the multi-level nature of tumor-stromal cell interplay and demonstrates the capability of AT-MSCs and MSC-secreted factors to alter the anti-tumor drug responses.

Impact of mammography screening interval on breast cancer diagnosis by menopausal status and BMI

BACKGROUND

Controversy remains regarding the frequency of screening mammography. Women with different risks for developing breast cancer because of body mass index (BMI) may benefit from tailored recommendations.

OBJECTIVE

To determine the impact of mammography screening interval for women who are normal weight (BMI < 25), overweight (BMI 25-29.9), or obese (BMI ≥ 30), stratified by menopausal status.

DESIGN

Two cohorts selected from the Breast Cancer Surveillance Consortium. Patient and mammography data were linked to pathology databases and tumor registries.

PARTICIPANTS

The cohort included 4,432 women aged 40-74 with breast cancer; the false-positive analysis included a cohort of 553,343 women aged 40-74 without breast cancer.

MAIN MEASURES

Stage, tumor size and lymph node status by BMI and screening interval (biennial vs. annual). Cumulative probability of false-positive recall or biopsy by BMI and screening interval. Analyses were stratified by menopausal status.

KEY RESULTS

Premenopausal obese women undergoing biennial screening had a non-significantly increased odds of a tumor size > 20 mm relative to annual screeners (odds ratio [OR] = 2.07; 95 % confidence interval [CI] 0.997 to 4.30). Across all BMI categories from normal to obese, postmenopausal women with breast cancer did not present with higher stage, larger tumor size or node positive tumors if they received biennial rather than annual screening. False-positive recall and biopsy recommendations were more common among annually screened women.

CONCLUSION

The only negative outcome identified for biennial vs. annual screening was a larger tumor size (> 20 mm) among obese premenopausal women. Since annual mammography does not improve stage at diagnosis compared to biennial screening and false-positive recall/biopsy rates are higher with annual screening, women and their primary care providers should weigh the harms and benefits when deciding on annual versus biennial screening.

Does and should breast cancer genetic counselling include lifestyle advice?

To optimally inform counselees about their and their relatives' risks, information about lifestyle risk factors, e.g. physical activity and alcohol consumption, might be discussed in breast cancer genetic counselling. This study explored whether lifestyle was discussed, on whose initiative, whether information and/or advice was given, and whether discussion of lifestyle was related to counselees' characteristics and their causal attributions. First and follow-up consultations with 192 consecutive counselees for breast cancer genetic counselling were videotaped and coded for discussion of lifestyle topics. Counselees completed web-based questionnaires before the initial and after the final consultation. With 52 (27%) counselees lifestyle was discussed, either in the first, or the final consultation, or both. Counselees mostly raised the topic (60%). Counsellors provided information about lifestyle risk factors to 19% and lifestyle advice to 6% of the counselees. Discussion of lifestyle was not associated with counselees' characteristics or causal attributions. Post-counselling, more affected counselees considered lifestyle as a cause of their breast cancer (29%) compared to pre-counselling (15%; p = 0.003). Information and advice about lifestyle risk factors was infrequently provided, both with breast cancer unaffected and affected counselees and with those who did and did not consider their lifestyle as a cause of their breast cancer. Modifiable lifestyle factors could be discussed more frequently to optimally inform counselees about possible ways to reduce their risk. Counsellors should be educated about effects of lifestyle and research should be conducted on how to best integrate lifestyle information in breast cancer genetic counselling.

Patient compliance based on genetic medicine: a literature review

For this literature review, medical literature data bases were searched for studies on patient compliance after genetic risk assessment. The review focused on conditions where secondary or tertiary preventive options exist, namely cancer syndromes (BRCA-related cancer, HNPCC/colon cancer), hemochromatosis, thrombophilia, smoking cessation, and obesity. As a counterpart, patient compliance was assessed regarding medication adherence and medical advice in some of the most epidemiologically important conditions (including high blood pressure, metabolic syndrome, and coronary heart disease) after receiving medical advice based on nongenetic risk information or a combination of genetic and nongenetic risk information. In the majority of studies based on genetic risk assessments, patients were confronted with predictive rather than diagnostic genetic profiles. Most of the studies started from a knowledge base around 10 years ago when DNA testing was at an early stage, limited in scope and specificity, and costly. The major result is that overall compliance of patients after receiving a high-risk estimate from genetic testing for a given condition is high. However, significant behavior change does not take place just because the analyte is "genetic." Many more factors play a role in the complex process of behavioral tuning. Without adequate counseling and guidance, patients may interpret risk estimates of predictive genetic testing with an increase in fear and anxiety.

The Athena Breast Health Network: developing a rapid learning system in breast cancer prevention, screening, treatment, and care

The term breast cancer covers many different conditions, whose clinical course ranges from indolent to aggressive. However, current practice in breast cancer prevention and care, and in breast cancer epidemiology, does not take into account the heterogeneity of the disease. A comprehensive understanding of the etiology and progression of different breast cancer subtypes would enable a more patient-centered approach to breast health care: assessing an individual's risk of getting specific subtypes of the disease, providing risk-based screening and prevention recommendations, and, for those diagnosed with the disease, tailored treatment options based on risk and timing of progression and mortality. The Athena Breast Health Network is an initiative of the five University of California medical and cancer centers to prototype this approach and to enable the development of a rapid learning system-connecting risk and outcome information from a heterogeneous patient population in real time and using new knowledge from research to continuously improve the quality of care. The Network is based on integrating clinical and research processes to create a comprehensive approach to accelerating patient-centered breast health care. Since its inception in 2009, the Network has developed a multi-site, transdisciplinary collaboration that enables the learning system. The five-campus collaboration has implemented a shared informatics platform, standardized electronic patient intake questionnaires, and common biospecimen protocols, as well as new clinical programs and multi-center research projects. The Athena Breast Health Network can serve as a model of a rapid learning system that integrates epidemiologic, behavioral, and clinical research with clinical care improvements.

IVF and breast cancer: a systematic review and meta-analysis

BACKGROUND

The effects of controlled ovarian hyperstimulation (COH) for IVF in terms of breast cancer risk remain controversial, despite the hormone-dependent nature of the latter.

METHODS

Eligible studies up to 15 February 2013 were identified and pooled effect estimates for relative risk (RR) were calculated separately for the investigations using the general population and those using infertile women, as a reference group. Fixed- or random-effects models were implemented and subgroup analyses were performed, as appropriate.

RESULTS

Eight cohort studies were synthesized, yielding a total cohort size of 1,554,332 women among whom 14,961 incident breast cancer cases occurred, encompassing 576 incident breast cancer cases among women exposed to IVF. No significant association between IVF and breast cancer was observed either in the group of studies treating the general population (RR = 0.91, 95% confidence interval (CI): 0.74-1.11) or infertile women (RR = 1.02, 95% CI: 0.88-1.18), as a reference group. Of note were the marginal associations, protective for pregnant and/or parous women after IVF (pooled effect estimate = 0.86, 95% CI: 0.73-1.01) and adverse for women <30 years at first IVF treatment (pooled effect estimate = 1.64, 95% CI: 0.96-2.80).

CONCLUSIONS

At present, COH for IVF does not seem to impart increased breast cancer risk. Longer follow-up periods, comparisons versus infertile women, subgroup analyses aiming to trace vulnerable subgroups, adjustment for various confounders and larger informative data sets are needed before conclusive statements for the safety of the procedure are reached.

Chemoprevention of breast cancer

The development of pharmacologic agents for the prevention of breast cancer is a significant milestone in medical and laboratory research. Despite these advances, the endorsement of preventive options has become challenging and complex, as physicians are expected to counsel and tailor their recommendations using a personalized approach taking into account medical comorbidities, degree of risk and patient preferences. This article provides a comprehensive overview of the major breast cancer prevention trials, review of the pharmacologic options available for breast cancer prevention, and strategies for integrating chemoprevention of breast cancer in high-risk women into clinical practice.

Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy

IMPORTANCE

Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

OBJECTIVE

To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

DESIGN

Prospective cohort.

SETTING

Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

PARTICIPANTS

Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

MAIN OUTCOMES AND MEASURES

We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

RESULTS

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

CONCLUSIONS AND RELEVANCE

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Exposures to synthetic estrogens at different times during the life, and their effect on breast cancer risk

Women are using estrogens for many purposes, such as to prevent pregnancy or miscarriage, or to treat menopausal symptoms. Estrogens also have been used to treat breast cancer which seems puzzling, since there is convincing evidence to support a link between high lifetime estrogen exposure and increased breast cancer risk. In this review, we discuss the findings that maternal exposure to the synthetic estrogen diethylstilbestrol during pregnancy increases breast cancer risk in both exposed mothers and their daughters. In addition, we review data regarding the use of estrogens in oral contraceptives and as postmenopausal hormone therapy and discuss the opposing effects on breast cancer risk based upon timing of exposure. We place particular emphasis on studies investigating how maternal estrogenic exposures during pregnancy increase breast cancer risk among daughters. New data suggest that these exposures induce epigenetic modifications in the mammary gland and germ cells, thereby causing an inheritable increase in breast cancer risk for multiple generations.

Mammographic density and risk of breast cancer according to tumor characteristics and mode of detection: a Spanish population-based case-control study

INTRODUCTION

It is not clear whether high mammographic density (MD) is equally associated with all subtypes of breast cancer (BC). We investigated the association between MD and subsequent BC, considering invasiveness, means of detection, pathologic subtype, and the time elapsed since mammographic exploration and BC diagnosis.

METHODS

BC cases occurring in the population of women who attended screening from 1997 through 2004 in Navarre, a Spanish region with a fully consolidated screening program, were identified via record linkage with the Navarre Cancer Registry (n = 1,172). Information was extracted from the records of their first attendance at screening in that period. For each case, we randomly selected four controls, matched by screening round, year of birth, and place of residence. Cases were classified according to invasiveness (ductal carcinoma in situ (DCIS) versus invasive tumors), pathologic subtype (considering hormonal receptors and HER2), and type of diagnosis (screen-detected versus interval cases). MD was evaluated by a single, experienced radiologist by using a semiquantitative scale. Data on BC risk factors were obtained by the screening program in the corresponding round. The association between MD and tumor subtype was assessed by using conditional logistic regression.

RESULTS

MD was clearly associated with subsequent BC. The odds ratio (OR) for the highest MD category (MD >75%) compared with the reference category (MD <10%) was similar for DCIS (OR = 3.47; 95% CI = 1.46 to 8.27) and invasive tumors (OR = 2.95; 95% CI = 2.01 to 4.35). The excess risk was particularly high for interval cases (OR = 7.72; 95% CI = 4.02 to 14.81) in comparison with screened detected tumors (OR = 2.17; 95% CI = 1.40 to 3.36). Sensitivity analyses excluding interval cases diagnosed in the first year after MD assessment or immediately after an early recall to screening yielded similar results. No differences were seen regarding pathologic subtypes. The excess risk associated with MD persisted for at least 7 to 8 years after mammographic exploration.

CONCLUSIONS

Our results confirm that MD is an important risk factor for all types of breast cancer. High breast density strongly increases the risk of developing an interval tumor, and this excess risk is not completely explained by a possible masking effect.