Body mass and breast cancer. Relationship between method of detection and stage of disease

Breast Cancer Method of Detection: 5-Year Outcomes Across a Multisite Health Care Enterprise

PURPOSE

To investigate the feasibility and accuracy of radiologists categorizing the method of detection (MOD) when performing image-guided breast biopsies.

METHODS

This retrospective, observational study was conducted across a health care enterprise that provides breast imaging services at 18 imaging sites across four US states. Radiologists used standardized templates to categorize the MOD, defined as the first test, sign, or symptom that triggered the subsequent workup and recommendation for biopsy. All image-guided breast biopsies since the implementation of the MOD-inclusive standardized template-from October 31, 2017 to July 6, 2023-were extracted. A random sample of biopsy reports was manually reviewed to evaluate the accuracy of MOD categorization.

RESULTS

A total of 29,999 biopsies were analyzed. MOD was reported in 29,423 biopsies (98.1%) at a sustained rate that improved over time. The 10 MOD categories in this study included the following: 15,184 mammograms (51.6%); 4,561 MRIs (15.5%); 3,473 ultrasounds (11.8%); 2,382 self-examinations (8.1%); 2,073 tomosynthesis studies (7.0%); 432 clinical examinations (1.5%); 421 molecular breast imaging studies (1.4%); 357 other studies (1.2%); 338 contrast-enhanced digital mammograms (1.1%); and 202 PET studies (0.7%). Original assignments of the MOD agreed with author assignments in 87% of manually reviewed biopsies (n = 100, 95% confidence interval: [80.4%, 93.6%]).

CONCLUSIONS

This study demonstrates that US radiologists can consistently and accurately categorize the MOD over an extended time across a health care enterprise.

The efficacy of mindfulness-based stress reduction vs. standard or usual care in patients with breast cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Mindfulness-based stress reduction (MBSR) has become an alternative intervention for cancer patients, but its impact on depression and quality of life (QOL) of breast cancer patients remains controversial. The aim of this study was to evaluate the effects of MBSR vs. standard or usual care to relieve psychological stress in patients with breast cancer.

METHODS

According to the PICOS principles, databases [PubMed, Cochrane Database, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), China Scientific Journal Database (VIP), and Wanfang Database] were searched for randomized controlled trials (RCTs) on the evaluation of MBSR vs. standard or usual care for patients with breast cancer, the outcome variables included depression, stress, anxiety, fatigue, sleep and QOL. Review Manager 5.4 was used to evaluate the effects of the results among selected articles. Forest plots and funnel plots were also performed. The risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

The final analysis included 14 studies with a total of 2,224 patients (1,138 in the MBSR group and 1,086 in the control group). The overall results of risk of bias assessment showed that the reporting bias among articles was high, and other bias was relatively moderate. Funnel plots and Egger's tests showed that there was no significant publication bias. Compared with standard or usual care, MBSR effectively relieved the psychological stress [mean difference (MD), -1.72; 95% confidence interval (CI): (-2.53, -0.92); P<0.0001] and anxiety [standardized mean difference (SMD), -1.36; 95% CI: (-2.13, -0.60); P=0.0005] of breast cancer patients, and improved depression [SMD, -0.62; 95% CI: (-1.20, -0.03); P=0.04] and sleep status [MD, -0.42; 95% CI: (-0.73, -0.10), P=0.009]. However, it had no significant effect on fatigue [SMD, -0.97; 95% CI: (-2.24, 0.31); P=0.14] or QOL [MD, 1.95; 95% CI: (-3.15, 7.05); P=0.45].

CONCLUSIONS

MBSR was better than standard or usual care for relieving psychological stress, anxiety, depression, and sleep in patients with breast cancer. Considering the limitations of this article, such as high risk of bias and high heterogeneity of included studies, the interpretation of this conclusion should be cautious.

The Effect of Body Mass Index on Initial Breast Cancer Stage Among Korean Women

BACKGROUND

The relationship between obesity and breast cancer stage is not well-known in the Korean population. This study aimed to identify the effect of body mass index (BMI) on initial breast cancer stage.

PATIENTS AND METHODS

Among patients who underwent surgery for breast cancer (stages 0-III) from June 2003 to December 2018, we analyzed 4510 patients for whom there were BMI data.

RESULTS

The average BMI of our patients was 23.5 (14.2-44.9). In total, 4.6% and 24.2% of the patients had a BMI of ≥30 and 25-29.9, respectively. In the patients with obesity, the proportion of T2 to T4 was 41.4%, which was higher than that in patients with a BMI of 25 to 29 (28.4%; P = .001) or a BMI of <25 (23.3%; P < .001). There was no difference in positive rates of estrogen receptor and progesterone receptor with BMI, but obese patients were less likely to be human epidermal growth factor receptor 2 positive. Patients with higher stages were more likely to have a higher BMI. The effect of BMI on stage was stronger in patients <50 years (odds ratio, 2.439; 95% CI, 1.783-3.335). Although there was no statistical significance, tumors >2 cm were less likely to be palpable in obese patients than in patients of normal weight (nonpalpable in 33.8% and 27.0%, respectively).

CONCLUSION

Our study suggests that obesity is associated with a more advanced breast cancer stage, which represents a poor prognosis, and large tumors tend to be less palpable in women with obesity.

Weight-lowering Effects of Glucagon-like Peptide-1 Receptor Agonists and Detection of Breast Cancer Among Obese Women with Diabetes

BACKGROUND

It has been proposed that the weight loss associated with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may improve detection of breast cancer in patients undergoing this treatment. We aimed to determine whether the weight-lowering effects of GLP-1 RAs are associated with an increased detection of breast cancer among obese women with type 2 diabetes.

METHODS

Using the UK Clinical Practice Research Datalink, we conducted a propensity score-matched cohort study among female obese patients with type 2 diabetes newly treated with antidiabetic drugs between 1 January 2007 and 31 January 2018. New users of GLP-1 RAs (n = 5,510) were matched to new users of second- to third-line noninsulin antidiabetic drugs (n = 5,510). We used time-dependent Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer associated with different GLP-1 RA maximal weight loss categories (<5%, 5%-10%, >10%).

RESULTS

Breast cancer incidence gradually increased with GLP-1 RA maximal weight loss categories, with the highest HR observed for patients achieving at least 10% weight loss (HR = 1.8, 95% CI = 1.1, 2.8). In secondary analyses, the HR for >10% weight loss was highest in the 2-3 years since treatment initiation (HR = 2.9, 95% CI = 1.2, 6.9).

CONCLUSIONS

In this population-based study, the detection of breast cancer gradually increased with GLP-1 RA weight loss categories, particularly among those achieving >10% weight loss. These results are consistent with the hypothesis that substantial weight loss with GLP-1 RAs may improve detection of breast cancer among obese patients with type 2 diabetes.

Overall and Estrogen Receptor-Positive Breast Cancer Incidences Are Decreased Following Bariatric Surgery

INTRODUCTION

Bariatric surgery treats morbid obesity resulting in long-lasting weight loss. Elevated body mass index (BMI) increases breast cancer risk. We hypothesized that patients undergoing bariatric surgery would have decreased overall and estrogen receptor (ER)-positive breast cancer incidences compared to a propensity-matched non-surgical cohort.

METHODS

The bariatric population included all female patients who underwent weight loss surgery at a single institution from 1985 to 2015. Patients from all outpatient visits were propensity score matched 1:1 with bariatric patients using BMI, comorbidities, demographics, and insurance status. The primary outcome was breast cancer incidence. Univariate analyses compared the groups.

RESULTS

A total of 4860 patients were included, with 2430 in both groups. Median follow-up time from date of surgery or morbid obesity diagnosis was 5.7 years. There were no differences in age or comorbidities aside from gastroesophageal reflux disease. Seventeen (0.7%) patients in the surgery group were subsequently diagnosed with breast cancer versus 32 (1.3%) in the non-surgery group (p = 0.03). The non-surgery group had more ER-positive tumors [4 (36.4%) vs. 22 (71.0%); p = 0.04].

CONCLUSION

Female patients who underwent bariatric surgery were less frequently diagnosed with any breast cancer and ER-positive breast cancer versus a propensity-matched cohort suggesting a possible oncologic benefit to weight loss surgery.

Obesity and breast cancer screening: Cross-sectional survey results from the behavioral risk factor surveillance system

BACKGROUND

Postmenopausal obese women demonstrate an elevated breast cancer risk and experience increased breast cancer morbidity and mortality compared with women with a normal body mass index (BMI). However, to the authors' knowledge, prior studies have yielded inconclusive results regarding the effects of obesity on mammography screening adherence. Using national cross-sectional survey data, the objective of the current study was to assess the current association between increasing BMI and use of mammography screening.

METHODS

Cross-sectional survey data from the 2016 Behavioral Risk Factor Surveillance System, a state-based national telephone survey of noninstitutionalized adults in the United States, was used to identify the association between mammography screening use and increasing incremental BMI categories, including normal (18.5-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), obese class I (30-34.9 kg/m2 ), obese class II (35-39.9 kg/m2 ), and obese class III (>40 kg/m2 ), with adjustments for potential confounders. A multivariable logistic regression model was used to evaluate the effect of each BMI category on self-reported mammography use, using unadjusted and adjusted odds ratios. Effect modification by race/ethnicity was determined by testing interaction terms using Wald tests.

RESULTS

Of 116,343 survey respondents, 33.5% (38,984 respondents) had a normal BMI, 32.6% (37,969 respondents) were overweight, 19.3% (22,416 respondents) were classified as obese class I, 8.4% (9791 respondents) were classified as obese class II, and 6.2% (7183 respondents) were classified as obese class III. There was no statistically significant difference (P < .05) observed with regard to mammography use between women with a normal BMI and obese women from each obese class (classes I-III) when compared individually. There also was no evidence of effect modification by race (P = .53).

CONCLUSIONS

In contrast to prior reports, the results of the current study demonstrated no association between obesity and adherence to screening mammography. These findings may relate to the increasing social acceptance of obesity among women from all racial/ethnic groups and the removal of weight-related facility-level barriers over time.

Factors Associated with Initial Mode of Breast Cancer Detection among Black Women in the Women's Circle of Health Study

Mammogram-detected breast cancers have a better prognosis than those identified through clinical breast exam (CBE) or through self-detection, primarily because tumors detected by mammography are more likely to be smaller and do not involve regional nodes. In a sample of 1,322 Black women, aged 40-75 years, diagnosed with breast cancer between 2002 and 2016, we evaluated factors associated with CBE and self-detection versus screening mammogram as the initial mode of breast cancer detection, using multivariable logistic regression models. Compared with screening mammogram, history of routine screening mammogram (OR 0.20, 95% CI: 0.07, 0.54) and performance of breast self-examination (BSE) (OR 0.31, 95% CI: 0.13, 0.74) before diagnosis were associated with lower odds of CBE as the initial mode of detection, while performance of CBEs before diagnosis (OR 11.04, 95% CI: 2.24, 54.55) was positively associated. Lower body mass index (<25.0 kg/m² vs. ≥35.0 kg/m²: OR 2.46, 95% CI: 1.52, 3.98), performance of BSEs before diagnosis (less than once per month: OR 4.08, 95% CI: 2.45, 6.78; at least monthly: OR 4.99, 95% CI: 3.13, 7.97), and larger tumor size (1.0-2.0 cm vs. <1.0 cm: OR 2.92, 95% CI: 1.84, 4.64; >2.0 cm vs. <1.0 cm: OR 6.41, 95% CI: 3.30, 12.46) were associated with increased odds of self-detection relative to screening mammogram. The odds of CBE and self-detection as initial modes of breast cancer detection among Black women are independently associated with breast care and breast cancer screening services before diagnosis and with larger tumors at diagnosis.

The impact of bariatric surgery on qualitative and quantitative breast density

BACKGROUND

Obesity and breast density are associated with breast cancer in postmenopausal women. Bariatric surgery effectively treats morbid obesity, with sustainable weight loss and reductions in cancer incidence. We evaluated changes in qualitative and quantitative density; hypothesizing breast density would increase following bariatric surgery.

METHODS

Women undergoing bariatric surgery from 1990 to 2015 were identified, excluding patients without a mammogram performed both before and after surgery. Changes in body mass index (BMI), time between mammograms and surgery, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) scores were assessed. VolparaDensity™ automated software calculated volumetric breast density (VBD), fibroglandular volume (FGV), and total breast volume for the 82 women with digital data available. Differences between pre- and postsurgery values were assessed.

RESULTS

One hundred eighty women were included. Median age at surgery was 50.0 years, with 8.8 months between presurgery mammogram and surgery and 62.3 months between surgery and postsurgery mammogram. Median BMI significantly decreased over the study period (46.0 vs 35.4 kg/m² ; P < 0.001). No change in BI-RADS scores was seen between the pre- and postsurgery mammograms. Eighty-two women had VolparaDensity™ data available. While VBD increased in these patients, FGV and total breast volume both decreased following bariatric surgery.

CONCLUSIONS

Increased VBD, decreased FGV, and decreased total breast volume were seen following bariatric surgery-induced weight loss. There was no difference in qualitative breast density, highlighting the discrepancy between BI-RADS and VolparaDensity™ measurements. Further investigation will be required to determine how differential changes in components of breast density may affect breast cancer risk.

Breast cancer detection method, diagnostic interval and use of specialized diagnostic assessment units across Ontario, Canada

INTRODUCTION

Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario.

METHODS

The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women's residence.

RESULTS

In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties.

CONCLUSION

The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.

Causal effect of obesity on gynecologic malignancies

INTRODUCTION

Gynecologic malignancies are estimated to affect 110,070 women and will be the cause of death in approximately 32,120 in 2018. Endometrial cancer is among the most prevalent with 63,320 estimated new cases and approximately 11,350 deaths, followed by ovarian cancer with an estimate of 22,000 new cases and 14,000 deaths annually. Obesity is one of the most modifiable risk factors. Providers should engage in a multifaceted approach to patient education and healthcare to decrease the projected cases of obesity-related cancers.

BACKGROUND

The literature demonstrates a significant link between obesity and the development of certain malignancies such as endometrial, pancreatic, and renal cancer. Specific mechanisms found to play a role in the development of these malignancies include alterations of the metabolic pathway attributed to lipid accumulation as well as a chronic inflammatory process. Obesity also predisposes patients to other medical comorbidities as well as a poorer prognosis once a diagnosis of cancer is established. Factors contributing to poorer prognosis include challenges with treatment planning, specifically pertaining to inappropriate chemotherapy dosing and delivery of radiation therapy. Surgical approach and perioperative management are similarly challenging in obese patients and are associated with increased risk of complications.

CONCLUSION

Obesity is a modifiable factor which is associated with an increased risk of cancer and poorer outcomes. Providers should educate patients on all health hazards of obesity, including increased risk of cancer, and encourage them to participate in a structured weight loss plan.

Does Bariatric Surgery Affect the Incidence of Breast Cancer Development? A Systematic Review

We reviewed the evidence for bariatric surgery reducing the risk of breast cancer. Data was extracted from multiple libraries, including PubMed, EMBASE, and Medline, to perform a systematic review. Abstracts were reviewed by two independent reviewers. Thirty-eight full-text articles were identified from 1171 abstracts. Four studies were included for meta-analysis; 114 of 10,533 (1.1%) patients receiving bariatric surgery versus 516 of 20,130 (2.6%) controls developed breast cancer, odds ratio 0.564 (95% CI 0.453 to 0.702) using a fixed effects model (P < 0.001) and odds ratio 0.585 (95% CI 0.247 to 1.386) using a random effects model (P 0.223). Bariatric surgery may reduce the risk of breast cancer. More research is required due to heterogeneity of studies, difficulty in identifying accurate controls, and limited follow-up.

What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors

BACKGROUND

Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage.

METHODS

The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses.

RESULTS

Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results.

CONCLUSIONS

Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer.

IMPACT

Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.

Rural-urban disparities in stage of breast cancer at diagnosis in Australian women

OBJECTIVE

To examine urban-rural differences and individual risk factors for a late stage of breast cancer at diagnosis in Australian women.

DESIGN

Individual-level longitudinal data were linked with cancer registry data from New South Wales (New South Wales Cancer Registry linked by the Centre for Health Record Linkage (CHeReL)), Queensland (Queensland Cancer Registry) and Victoria (The Cancer Council Victoria).

SETTING

Participants were drawn from the Australian Longitudinal Study on Women's Health 1946-1951 cohort (n = 13 715).

PARTICIPANTS

The sample included 195 women identified from the linked cancer registry data with a breast cancer diagnosis.

INTERVENTIONS

Rural or urban residence was measured using Accessibility/Remoteness Index of Australia Plus (ARIA+). Individual characteristics and socio-demographic variables examined included survey year, menopausal status, country of birth, education and marital status.

MAIN OUTCOME MEASURES

A late stage of breast cancer at diagnosis was defined based on the TNM Classification of Malignant Tumours.

RESULTS

A late stage of breast cancer diagnosis was observed in 36% of women residing in urban areas and 40% of women residing in rural areas. After adjusting for individual characteristics, we found that obesity was the strongest risk factor for a late stage of breast cancer at diagnosis.

CONCLUSIONS

Given that women are becoming increasingly obese, and that the rate of obesity is higher in the Australian rural population, this paper provides further evidence for targeting interventions for obesity, particularly in rural Australia, as a public health priority.

Pathophysiology of obesity on knee joint homeostasis: contributions of the infrapatellar fat pad

Osteoarthritis (OA) is a debilitating condition characterized by inflammation, breakdown, and consequent loss of cartilage of the joints. Epidemiological studies indicate obesity is an important risk factor involved in OA initiation and progression. Traditional views propose OA to be a biomechanical consequence of excess weight on weight-bearing joints; however, emerging data demonstrates that systemic and local factors released from white adipose depots play a role. Hence, current views characterize OA as a condition exacerbated by a metabolic link related to adipose tissue, and not solely related to redistributed/altered weight load. Factors demonstrated to influence cartilage and bone homeostasis include adipocyte-derived hormones (“adipokines”) and adipose depot released cytokines. Epidemiological studies demonstrate a positive relation between systemic circulating cytokines, leptin, and resistin with OA types, while the association with adiponectin is controversial. Local factors in joints have also been shown to play a role in OA. In particular, this includes the knee, a weight-bearing joint that encloses a relatively large adipose depot, the infrapatellar fat pad (IFP), which serves as a source of local inflammatory factors. This review summarizes the relation of obesity and OA as it specifically relates to the IFP and other integral supporting structures. Overall, studies support the concept that metabolic effects associated with systemic obesity also extend to the IFP, which promotes inflammation, pain, and cartilage destruction within the local knee joint environment, thus contributing to development and progression of OA.

The impact of overweight and obesity on breast cancer: data from Switzerland, so far a country little affected by the current global obesity epidemic

This review presents results from the project "The Impact of Overweight/Obesity on Breast Cancer: data from Switzerland". Swiss data is interesting because the general female population is distinctive in two areas when compared to that of most other industrialized countries: Switzerland has comparatively low rates of overweight (22-23%) and obesity (7-8%) and has rather stable rates of overweight and obesity. The entire project comprised three major issues: (I) etiology of breast cancer (BC). There is a consistently shown association between obesity and postmenopausal BC risk in countries with high obesity prevalence rates in the literature. In our Swiss study group, however, we did not find higher rates of overweight and obesity in postmenopausal BC cases than in the general population. A possible explanation for this observation may be a curvilinear dose-response relationship between BMI and postmenopausal BC risk, so that an increased risk may only be observed in populations with a high prevalence of obese/very obese women; (II) tumor characteristics. BMI was significantly associated with tumor size; this applied not only to the cases where the tumor was found by self-detection, but also to lesions detected by radiological breast examinations. In addition, a higher BMI was positively correlated with advanced TNM stage, unfavorable grading and a higher St. Gallen risk score. No associations were observed between BMI and histological subtype, estrogen receptor status, HER2 status and triple negative BC; (III) patient compliance and persistence towards adjuvant BC therapy. Many studies found that the prognosis of overweight/obese BC patients was significantly lower than that of normal weight patients. However, failure of compliance and persistence towards therapy on the part of the patient is not a contributing factor for this observed unfavorable prognosis. In most therapy modes, patients with increasing BMI demonstrated greater motivation and perseverance towards the recommended treatment.

Impact of body mass index on prognostically relevant breast cancer tumor characteristics

BACKGROUND

This study analyzes the association of body mass index (BMI) and prognostically relevant breast cancer (BC) characteristics in a country that has been rather spared of the global obesity epidemic.

PATIENTS AND METHODS

Based on 20-year data (1999-2009, n = 1,414) of the prospective relational BC database of the University Hospital Basel, Switzerland, the associations between BMI, tumor size and stage, histological subtype, grading, hormonal receptor status, HER2 status and 'triple-negative' status were evaluated. Multivariate analysis considered BMI and patient's age.

RESULTS

The association between increasing BMI and the above-mentioned variables were as follows (results described in each case: Beta-coefficient or odds ratio, 95% confidence interval, p value): tumor size, (1) entire cohort: 0.03 (0.01-0.05), p < 0.001, (2) tumor found by self-palpation: 0.05 (0.03-0.07), p < 0.001, (3) tumor found by radiological examination: 0.03 (0-0.07), p = 0.044; advanced TNM stage: 1.16 (1.02-1.31), p = 0.022; histological subtype: 1.04 (0.89-1.22), p = 0.602; unfavorable grading: 1.11 (1.00-1.25), p = 0.057; positive estrogen receptor status: 0.95 (0.83-1.09), p = 0.459; positive HER2 status: 0.92 (0.74-1.15), p = 0.467; presence of a 'triple-negative' carcinoma: 1.19 (0.93-1.52), p = 0.165. Consideration of only postmenopausal BC patients (n = 1,063) did attenuate the results, but did not change the direction of the associations with BMI.

CONCLUSION

BMI was positively associated with TNM stage, grading and tumor size for tumors that were found by self-detection, as well as for those lesions detected by radiological breast examinations.

Weight change during chemotherapy changes the prognosis in non metastatic breast cancer for the worse

Background

Weight change during chemotherapy is reported to be associated with a worse prognosis in breast cancer patients, both with weight gain and weight loss. However, most studies were conducted prior to the common use of anthracycline-base chemotherapy and on North American populations with a mean BMI classified as overweight. Our study was aimed to evaluate the prognostic value of weight change during anthracycline-based chemotherapy on non metastatic breast cancer (European population) with a long term follow-up.

Methods

Patients included 111 women diagnosed with early stage breast cancer and locally advanced breast cancer who have been treated by anthracycline-based chemotherapy regimen between 1976 and 1989. The relative percent weight variation (WV) between baseline and postchemotherapy treatment was calculated and categorized into either weight change (WV > 5%) or stable (WV < 5%). The median follow-up was 20.4 years [19.4 - 27.6]. Cox proportional hazard models were used to evaluate any potential association of weight change and known prognostic factors with the time to recurrence and overall survival.

Results

Baseline BMI was 24.4 kg/m2 [17.1 - 40.5]. During chemotherapy treatment, 31% of patients presented a notable weight variation which was greater than 5% of their initial weight.

In multivariate analyses, weight change (> 5%) was positively associated with an increased risk of both recurrence (RR 2.28; 95% CI: 1.29-4.03) and death (RR 2.11; 95% CI: 1.21-3.66).

Conclusions

Our results suggest that weight change during breast-cancer chemotherapy treatment may be related to poorer prognosis with higher reccurence and higher mortality in comparison to women who maintained their weight.

Cancer and obesity: effect of bariatric surgery

Recent international cancer prevention guidelines recommend weight loss, where appropriate, for the purpose of cancer risk reduction. However, limited research associates voluntary weight loss to subsequent cancer incidence because of the difficulty of achieving long-term weight loss maintenance among large participant groups. Bariatric surgery has demonstrated long-term sustained weight loss, and as a result, patients after bariatric surgery represent an ideal population to explore the relationship between long-term, voluntary weight loss and cancer incidence. This paper briefly reviews cancers that have shown to be associated with overweight and obesity and looks at studies that demonstrate reduced total mortality after bariatric surgery. Reduced cancer mortality and incidence as well as reduced cancer-related physician visits after bariatric surgery are presented. Study limitations and future research questions related to cancer and bariatric surgery are briefly discussed.

Impact of obesity on diagnosis and treatment of breast cancer

In this population-based study, we evaluated the impact of obesity on presentation, diagnosis and treatment of breast cancer. Among all women diagnosed with invasive breast cancer in the canton Geneva (Switzerland) between 2003 and 2005, we identified those with information on body mass index (BMI) and categorized them into normal/underweight (BMI <25 kg/m(2)), overweight (BMI > or =-<30 kg/m(2)) and obese (BMI > or =30 kg/m(2)) women. Using multivariate logistic regression, we compared tumour, diagnosis and treatment characteristics between groups. Obese women presented significantly more often with stage III-IV disease (adjusted odds ratio [OR(adj)]: 1.8, 95% CI: 1.0-3.3). Tumours > or =1 cm and pN2-N3 lymph nodes were significantly more often impalpable in obese than in normal/underweight patients (OR(adj) 2.4, [1.1-5.3] and OR(adj) 5.1, [1.0-25.4], respectively). Obese women were less likely to have undergone ultrasound (OR(adj) 0.5, [0.3-0.9]) and MRI (OR(adj) 0.3, [0.1-0.6]) and were at increased risk of prolonged hospital stay (OR(adj) 4.7, [2.0-10.9]). This study finds important diagnostic and therapeutic differences between obese and lean women, which may impair survival of obese women with breast cancer. Specific strategies are needed to optimize the care of obese women with or at risk of breast cancer.

Cancer incidence and mortality after gastric bypass surgery

Despite weight loss recommendations to prevent cancer, cancer outcome studies after intentional weight loss are limited. Recently, reduced cancer mortality following bariatric surgery has been reported. This study tested whether reduced cancer mortality following gastric bypass was due to decreased incidence. Cancer incidence and mortality data through 2007 from the Utah Cancer Registry (UCR) were compared between 6,596 Utah patients who had gastric bypass (1984-2002) and 9,442 severely obese persons who had applied for Utah Driver's Licenses (1984-2002). Study outcomes included incidence, case-fatality, and mortality for cancer by site and stage at diagnosis of all gastric bypass patients, compared to nonoperated severely obese controls. Follow-up was over a 24-year period (mean 12.5 years). Total cancer incidence was significantly lower in the surgical group compared to controls (hazard ratio (HR) = 0.76; confidence interval (CI) 95%, 0.65-0.89; P = 0.0006). Lower incidence in surgery patients vs. controls was primarily due to decreased incidence of cancer diagnosed at regional or distant stages. Cancer mortality was 46% lower in the surgery group compared to controls (HR = 0.54; CI 95%, 0.37-0.78; P = 0.001). Although the apparent protective effect of surgery on risk of developing cancer was limited to cancers likely known to be obesity related, the inverse association for mortality was seen for all cancers. Significant reduction in total cancer mortality in gastric bypass patients compared with severely obese controls was associated with decreased incidence, primarily among subjects with advanced cancers. These findings suggest gastric bypass results in lower cancer risk, presumably related to weight loss, supporting recommendations for reducing weight to lower cancer risk.

Radiologist characteristics associated with interpretive performance of diagnostic mammography

BACKGROUND

Extensive variability has been noted in the interpretive performance of screening mammography; however, less is known about variability in diagnostic mammography performance.

METHODS

We examined the performance of 123 radiologists who interpreted 35895 diagnostic mammography examinations that were obtained to evaluate a breast problem from January 1, 1996, through December 31, 2003, at 72 facilities that contribute data to the Breast Cancer Surveillance Consortium. We modeled the influence of radiologist characteristics on the sensitivity and false-positive rate of diagnostic mammography, adjusting for patient characteristics by use of a Bayesian hierarchical logistic regression model.

RESULTS

The median sensitivity was 79% (range = 27%-100%) and the median false-positive rate was 4.3% (range = 0%-16%). Radiologists in academic medical centers, compared with other radiologists, had higher sensitivity (88%, 95% confidence interval [CI] = 77% to 94%, versus 76%, 95% CI = 72% to 79%; odds ratio [OR] = 5.41, 95% Bayesian posterior credible interval [BPCI] = 1.55 to 21.51) with a smaller increase in their false-positive rates (7.8%, 95% CI = 4.8% to 12.7%, versus 4.2%, 95% CI = 3.8% to 4.7%; OR = 1.73, 95% BPCI = 1.05 to 2.67) and a borderline statistically significant improvement in accuracy (OR = 3.01, 95% BPCI = 0.97 to 12.15). Radiologists spending 20% or more of their time on breast imaging had statistically significantly higher sensitivity than those spending less time on breast imaging (80%, 95% CI = 76% to 83%, versus 70%, 95% CI = 64% to 75%; OR = 1.60, 95% BPCI = 1.05 to 2.44) with non-statistically significant increased false-positive rates (4.6%, 95% CI = 4.0% to 5.3%, versus 3.9%, 95% CI = 3.3% to 4.6%; OR = 1.17, 95% BPCI = 0.92 to 1.51). More recent training in mammography and more experience performing breast biopsy examinations were associated with a decreased threshold for recalling patients, resulting in similar statistically significant increases in both sensitivity and false-positive rates.

CONCLUSIONS

We found considerable variation in the interpretive performance of diagnostic mammography across radiologists that was not explained by the characteristics of the patients whose mammograms were interpreted. This variability is concerning and likely affects many women with and without breast cancer.

Emergency physicians do not use more resources to evaluate obese patients with acute abdominal pain

OBJECTIVE

We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients.

METHODS

We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m2), obese (BMI = 30-40 kg/m2), and morbidly obese (BMI > 40 mg/m2). The main outcome measure was laboratory and radiographic testing. chi2 Tests and analysis of variance were used as appropriate.

RESULTS

Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], -0.26 to 0.27), physicians' pre-computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, -0.13; 95% CI, -0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, -0.17; 95% CI, -0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis (P > .05).

CONCLUSIONS

Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.

Body Mass Index Influences Palpability but not Stage of Breast Cancer at Diagnosis

Body mass index (BMI) is associated with breast cancer risk, but its relationship with stage at diagnosis is unclear. BMI was calculated for patients in the North American Fareston and Tamoxifen Adjuvant trial, and was correlated with clinicopathologic factors, including stage at diagnosis. One thousand eight hundred fourteen patients were enrolled in the North American Fareston and Tamoxifen Adjuvant study; height and weight were recorded in 1451 (80%) of them. The median BMI was 27.1 kg/m2 (range, 14.7–60.7). The median patient age was 68 years (range, 42–100); median tumor size was 1.3 cm (range, 0.1–14 cm). One thousand seven hundred ninety-three (99.0%) patients were estrogen receptor positive, and 1519 (84.7%) were progesterone receptor positive. There was no significant relationship between BMI (as a continuous variable) and nodal status ( P = 0.469), tumor size ( P = 0.497), American Joint Committee on Cancer stage ( P = 0.167), grade ( P = 0.675), histologic subtype ( P = 0.179), or estrogen receptor status ( P = 0.962). Patients with palpable tumors, however, had a lower BMI than those with nonpalpable tumors (median 26.4 kg/m2 vs 27.5 kg/m2, P < 0.001). Similar results were found when BMI was classified as a categorical variable (<25 vs 25–29.9 vs ≥30). Increased BMI does not lead to a worse stage at presentation. Obese patients, however, tend to have nonpalpable tumors. Mammography in this population is especially important.

Obesity as a risk factor for development and poor prognosis of breast cancer

The evidence that obesity adversely affects women's health is overwhelming and indisputable. The risk of postmenopausal breast cancer increases with obesity; measured as weight gain, body mass index, waist-hip ratio or percent body fat. It is also established that obesity is associated with poor prognosis of breast cancer. This review examines in detail the possible mechanisms by which obesity causes poor prognosis of breast cancer such as estrogenic activity, advanced or more aggressive disease at diagnosis and high likelihood of both local and systemic treatment failure. After careful consideration of the available evidence, the author concludes that obesity contributes towards development and poor prognosis of breast cancer; therefore, weight management should be an integral part of any strategy to prevent and improve the outcome of breast cancer.

Established breast cancer risk factors by clinically important tumour characteristics

Breast cancer is a morphologically and clinically heterogeneous disease; however, it is less clear how risk factors relate to tumour features. We evaluated risk factors by tumour characteristics (histopathologic type, grade, size, and nodal status) in a population-based case-control of 2386 breast cancers and 2502 controls in Poland. Use of a novel extension of the polytomous logistic regression permitted simultaneous modelling of multiple tumour characteristics. Late age at first full-term birth was associated with increased risk of large (> 2 cm) tumours (odds ratios (95% confidence intervals) 1.19 (1.07-1.33) for a 5-year increase in age), but not smaller tumours (P for heterogeneity adjusting for other tumour features (Phet) = 0.007). On the other hand, multiparity was associated with reduced risk for small tumours (0.76 (0.68-0.86) per additional birth; Phet = 0.004). Consideration of all tumour characteristics simultaneously revealed that current or recent use of combined hormone replacement therapy was associated with risk of small (2.29 (1.66-3.15)) and grade 1 (3.36 (2.22-5.08)) tumours (Phet = 0.05 for size and 0.0008 for grade 1 vs 3), rather than specific histopathologic types (Phet = 0.63 for ductal vs lobular). Finally, elevated body mass index was associated with larger tumour size among both pre- and postmenopausal women (Phet = 0.05 and 0.0001, respectively). None of these relationships were explained by hormone receptor status of the tumours. In conclusion, these data support distinctive risk factor relationships by tumour characteristics of prognostic relevance. These findings might be useful in developing targeted prevention efforts.

Adult weight gain and histopathologic characteristics of breast cancer among postmenopausal women

BACKGROUND

Although the link between postmenopausal breast cancer and adiposity is well established, the association between weight gain and specific histopathologic characteristics of breast carcinoma has not been studied carefully.

METHODS

Using 1200 incident invasive breast cancers among 44,161 postmenopausal women who were not taking hormone therapy in the American Cancer Society's Cancer Prevention Study II Nutrition Cohort, the authors computed age-adjusted rates and rate ratios (RR) for breast cancer by histology, stage, grade, and estrogen receptor (ER) and progesterone receptor (PR) status by categories of adult weight gain.

RESULTS

Age-adjusted rates of breast cancer were highest for women who reported the most weight gain, regardless of histologic type. For weight gain >60 pounds, compared with weight gain < or =20 pounds the RR for ductal carcinoma was 1.89 (95% confidence interval [95%CI], 1.53-2.34), and the RR for lobular carcinoma was 1.54 (95%CI. 1.01-2.33). Weight gain was associated with increased risk at every tumor stage and grade. The risk for regional or distant stage was elevated significantly in every category of weight gain and was 3 times higher among women who had the greatest weight gain (RR, 3.15; 95%CI, 2.21-4.48). Weight gain was associated with increased risk of ER-positive/PR-positive tumors (P for trend <.0001) but not ER-negative/PR-negative tumors (P for trend = .09). The results essentially remained unchanged when the analysis was restricted to women who had regular screening mammograms.

CONCLUSIONS

Excess adiposity is an important contributor to breast cancer risk among postmenopausal women, regardless of histologic type, and especially for tumors of advanced stage and high grade.

Body Size and Composition and Risk of Postmenopausal Breast Cancer

Background: Studies of postmenopausal breast cancer have reported positive associations with body size and composition but it is uncertain whether these are due to non-adipose, adipose mass, or central adiposity, and whether they are limited to subgroups defined by age or tumor characteristics.

Methods: In a prospective cohort study of women ages 27 to 75, body measurements were taken directly; fat mass and fat-free mass being estimated by bioelectrical impedance analysis, and central adiposity by waist circumference. Among 13,598 women followed on average for 9.1 years, 357 invasive breast cancers were ascertained via the population cancer registry. Data were obtained on estrogen receptor and progesterone receptor status, grade, and stage.

Results: Estimates of body size such as fat-free mass [hazard ratio per 10 kg increase = 1.45, 95% confidence interval (CI) 1.16-1.82], fat mass (hazard ratio per 10 kg increase = 1.18, 95% CI, 1.06-1.31), and waist circumference (hazard ratio per 10 cm increase = 1.13, 95% CI, 1.03-1.24) were associated with breast cancer risk. There was no association with risk before 15 years postmenopause. About 15 years after menopause, risk increased sharply and remained elevated. There was some evidence that this association might be stronger for estrogen receptor-positive and poorly differentiated tumors but no evidence that it differed by stage.

Conclusion: Given that elements of body size and composition are positively associated with breast cancer risk, although not until 15 or more years postmenopause, it is possible that women could reduce risk by maintaining ideal body weight after menopause.

Obesity and cancer

Large prospective studies show a significant association with obesity for several cancers, and the International Agency for Research on Cancer has classified the evidence of a causal link as 'sufficient' for cancers of the colon, female breast (postmenopausal), endometrium, kidney (renal cell), and esophagus (adenocarcinoma). These data, and the rising worldwide trend in obesity, suggest that overeating may be the largest avoidable cause of cancer in nonsmokers. Few obese people are successful in long-term weight reduction, and thus there is little direct evidence regarding the impact of weight reduction on cancer risk. If the correlation between obesity and cancer mortality is entirely causal, we estimate that overweight and obesity now account for one in seven of cancer deaths in men and one in five in women in the US.

The association between obesity and screening mammography accuracy

BACKGROUND

Obesity is increasing among American women, especially as they age. The influence of obesity on the accuracy of screening mammography has not been studied extensively.

METHODS

We analyzed 100 622 screening mammography examinations performed on members of a nonprofit health plan. The relationship between body mass index (weight in kilograms divided by the square of height in meters) and measures of screening accuracy was assessed. Body mass index was categorized as underweight or normal weight (<25), overweight (25-29), obesity class I (30-34), and obesity classes II to III (> or =35).

RESULTS

Compared with underweight or normal weight women, overweight and obese women were more likely to be recalled for additional tests after adjusting for important covariates, including age and breast density (overweight odds ratio [OR], 1.17; 95% confidence interval [CI], 1.11-1.23); obesity class I OR, 1.27; 95% CI, 1.19-1.35; obesity classes II-III OR, 1.31; 95% CI, 1.22-1.41). As body mass index increased, women were more likely to have lower specificity (overweight OR, 0.86; 95% CI, 0.81-0.90; obesity class I OR, 0.79; 95% CI, 0.74-0.84; and obesity classes II-III OR, 0.77; 95% CI, 0.71-0.82). No statistically significant differences were noted in sensitivity. Adjusted receiver operating characteristic analysis showed statistically significant improvement in the area under the curve (AUC) for underweight or normal weight women (AUC = 0.941) vs overweight women (AUC = 0.916, P =.02) and underweight or normal weight women vs obesity classes II and III women (AUC = 0.904, P =.02).

CONCLUSIONS

Obese women had more than a 20% increased risk of having false-positive mammography results compared with underweight and normal weight women, although sensitivity was unchanged. Achieving a normal weight may improve screening mammography performance.

Obesity and breast cancer screening

BACKGROUND

Compared to normal weight women, women with obesity have higher mortality from breast cancer but are less often screened.

OBJECTIVES

To examine the relation between mammography use and weight category and to examine the influence of race, illness burden, and other factors on this relationship.

DESIGN AND SETTING

The 1998 National Health Interview Survey, a U.S. civilian population-based survey.

PARTICIPANTS

Five thousand, two hundred, and seventy-seven women ages 50 to 75 years who responded to the Sample Adult and Prevention questionnaires.

MEASUREMENTS

Mammogram use in the preceding 2 years.

RESULTS

Among 5277 eligible women, 72% reported mammography use. The rate was 74% among white women and 70% among black women. Among white women, mammogram use was lowest in women with a body mass index (BMI) greater than 35 kg/m(2) (64% to 67%). After adjusting for sociodemographic factors, health care access, medical conditions, hospitalizations, and mobility status, higher BMI was associated with lower screening among white women, P =.02 for trend; the relative risk (RR) for screening in moderately obese white women (BMI, 35 to 40 kg/m(2)) was 0.83 (95% confidence interval [CI], 0.68 to 0.96) compared to normal weight white women. Compared to normal weight black women, mammography use was similar or higher in overweight (BMI, 25 to 30 kg/m(2); RR, 1.19; 95% CI, 1.01 to 1.32), mildly obese (BMI, 30 to 35 kg/m(2); RR, 1.22; 95% CI, 0.98 to 1.39), and moderately obese black women (RR, 1.37; 95% CI, 1.37 to 1.50) after adjustment. The P value for the race-BMI interaction was.001. Results for white and black women were unchanged after additional adjustment for psychological functioning and health habits.

CONCLUSION

Among white women, those with higher BMI were less likely to undergo breast cancer screening than normal weight women. This relationship was not seen in black women. Our findings were not explained by differences in sociodemographic factors, health care access, illness burden, or health habits. More research is needed to determine the reasons for these disparities so that appropriate efforts can be made to improve screening.

Effects of obesity on breast cancer stage at diagnosis in Korean women

This study was carried out to test the hypothesis that palpation for lumps may be more difficult in large breasts than in small breasts, resulting in a delay in the detection and diagnosis of breast cancer, and to determine whether this hypothesis is confirmed in Asian women. Of 833 new breast cancer patients registered in the Daegu Cancer Registry in 1997-1999, 579 were used in the final data analysis, after excluding patient records containing many missing data on study variables related with cancer staging. There was no difference in means of body mass index (BMI) according to tumour, either in all cases or in those under 49 years of age. In the 50+ age group, the means+/-standard deviations of BMI of T1, T2 and T3 were 23.7+/-2.8, 24.2+/-3.0, and 26.2+/-4.3, respectively (P=0.01). In univariate logistic regression of tumour characteristics with BMI, no statistically significant odds ratios were found either by continuous or quartiles of BMI. In conclusion, these results suggest that the hypothesis is partially confirmed in Korean breast cancer patients and further studies are needed to clarify the relationship between BMI and tumour stage at diagnosis.

Breast cancer and obesity: an update

Obesity has a complicated relationship to both breast cancer risk and the clinical behavior of the established disease. In postmenopausal women, particularly the elderly, various measures of obesity have been positively associated with risk. However, before menopause increased body weight is inversely related to breast cancer risk. In both premenopausal and postmenopausal breast cancer, the mechanisms by which body weight and obesity affect risk have been related to estrogenic activity. Obesity has also been related to advanced disease at diagnosis and with a poor prognosis in both premenopausal and postmenopausal breast cancer. Breast cancer in African-American women, considering its relationship to obesity, exhibits some important differences from those described in white women, although the high prevalence of obesity in African-American women may contribute to the relatively poor prognosis compared with white American women. Despite the emphasis on estrogens to explain the effects of obesity on breast cancer, other factors may prove to be equally or more important, particularly as they relate to expression of an aggressive tumor phenotype. Among these, this review serves to stress insulin, insulin-like growth factor-I, and leptin, and their relationship to angiogenesis, and transcriptional factors.

Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults

BACKGROUND

The influence of excess body weight on the risk of death from cancer has not been fully characterized.

METHODS

In a prospectively studied population of more than 900,000 U.S. adults (404,576 men and 495,477 women) who were free of cancer at enrollment in 1982, there were 57,145 deaths from cancer during 16 years of follow-up. We examined the relation in men and women between the body-mass index in 1982 and the risk of death from all cancers and from cancers at individual sites, while controlling for other risk factors in multivariate proportional-hazards models. We calculated the proportion of all deaths from cancer that was attributable to overweight and obesity in the U.S. population on the basis of risk estimates from the current study and national estimates of the prevalence of overweight and obesity in the U.S. adult population.

RESULTS

The heaviest members of this cohort (those with a body-mass index [the weight in kilograms divided by the square of the height in meters] of at least 40) had death rates from all cancers combined that were 52 percent higher (for men) and 62 percent higher (for women) than the rates in men and women of normal weight. For men, the relative risk of death was 1.52 (95 percent confidence interval, 1.13 to 2.05); for women, the relative risk was 1.62 (95 percent confidence interval, 1.40 to 1.87). In both men and women, body-mass index was also significantly associated with higher rates of death due to cancer of the esophagus, colon and rectum, liver, gallbladder, pancreas, and kidney; the same was true for death due to non-Hodgkin's lymphoma and multiple myeloma. Significant trends of increasing risk with higher body-mass-index values were observed for death from cancers of the stomach and prostate in men and for death from cancers of the breast, uterus, cervix, and ovary in women. On the basis of associations observed in this study, we estimate that current patterns of overweight and obesity in the United States could account for 14 percent of all deaths from cancer in men and 20 percent of those in women.

CONCLUSIONS

Increased body weight was associated with increased death rates for all cancers combined and for cancers at multiple specific sites.

Mammography screening in African American women: evaluating the research

BACKGROUND

Notwithstanding some controversy regarding the benefits of screening mammography, it is generally assumed that the effects are the same for women of all race/ethnic groups. Yet evidence for its efficacy from clinical trial studies comes primarily from the study of white women. It is likely that mammography is equally efficacious in white and African American women when applied under relatively optimal clinical trial conditions, but in actual practice African Americans may not be receiving equal benefit, as reflected in their later stage at diagnosis and greater mortality.

METHODS

Initial searches of Medline using search terms related to screening mammography, race, and other selected topics were supplemented with national data that are routinely published for cancer surveillance. Factors that potentially compromise the benefits of mammography as it is delivered in the current health care system to African American women were examined.

RESULTS

While there have been significant improvements in mammography screening utilization, observational data suggest that African American women may still not be receiving the full benefit. Potential explanatory factors include low use of repeat screening, inadequate followup for abnormal exams, higher prevalence of obesity and, possibly, breast density, and other biologic factors that contribute to younger age at diagnosis.

CONCLUSIONS

Further study of biologic factors that may contribute to limited mammography efficacy and poorer breast cancer outcomes in African American women is needed. In addition, strategies to increase repeat mammography screening and to ensure that women obtain needed followup of abnormal mammograms may increase early detection and improve survival among African Americans. Notwithstanding earlier age at diagnosis for African American women, mammography screening before age 40 years is not recommended, but screening of women aged 40-49 years is particularly critical.

Detection method and breast carcinoma histology

BACKGROUND

The association between method of detection and breast carcinoma histopathology has not been assessed adequately in a population-based setting.

METHODS

Among women who were included in a population-based, case-control study of breast cancer, patients who were newly diagnosed with invasive breast carcinoma were identified from Wisconsin's statewide tumor registry. Only women age > or = 50 years were analyzed, because screening by mammography was not recommended before age 50 years at the time of the study. The breast tumors among these women (n = 2341 tumors) included the following histopathologies: lobular carcinoma (n = 206 tumors); ductal carcinoma, not otherwise specified (n = 1920 tumors); papillary carcinoma (n = 15 tumors); medullary carcinoma (n = 36 tumors); mucinous adenocarcinoma (n = 56 tumors); tubular adenocarcinoma (n = 41 tumors); invasive comedocarcinoma (n = 24 tumors); scirrhous adenocarcinoma (n = 15 tumors); and mixed ductal/lobular carcinoma (n = 28 tumors).

RESULTS

Overall, women reported that 41% of tumors were detected by mammography, 48% of tumors were self detected, and 11% of tumors were detected by clinical breast examination (CBE). Detection by mammography was significantly more likely for women who had tubular carcinoma (83%; P < 0.001) and invasive comedocarcinoma (67%; P = 0.23) compared with women who had ductal carcinoma (40%). Mammography was significantly less likely to detect medullary carcinoma (17%) than ductal carcinoma (40%; P = 0.01). Lobular carcinoma was the only histopathology that, compared with ductal carcinoma, was detected significantly more often by CBE than by self detection. Mammography detected lobular carcinoma (42%) as frequently as ductal carcinoma (40%). However, the use of postmenopausal hormones may have modified these detection patterns: Among current users, mammography discovered a greater percentage of ductal carcinomas (51%) and fewer lobular carcinomas (36%) than nonusers.

CONCLUSIONS

Among women age > or = 50 years, breast cancer detection by mammography, self detection, and CBE varied according to tumor histopathology.

Can obesity explain the racial difference in stage of breast cancer at diagnosis between black and white women?

OBJECTIVE

Black women are more likely to be diagnosed at a more advanced stage of breast cancer than are white women. Traditionally, this has been attributed in part to social or cultural factors. Given that black women are more likely to be obese than white women and that being obese is associated with a more advanced stage at diagnosis, this study aims to assess to what extent the racial difference in stage at diagnosis can be explained by racial differences in obesity.

METHODS

Incident cases of breast cancer between 1991 and 1997 (white, n = 585; black, n = 381) were identified from hospitals in the Baltimore metropolitan area. Information, including age, race, weight, height, and pathology reports, was obtained from hospital medical records.

RESULTS

Black women were more likely than white women to be diagnosed with breast cancer at tumor-node-metastasis (TNM) stage II or greater (age-adjusted odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.15-1.99). Further, black women were more likely than white women to be overweight or obese. A high body mass index (BMI) was significantly associated with an advanced stage of breast cancer at diagnosis. Adjustment for the higher prevalence of obesity in black women attenuated the risk estimate of more advanced stage of breast cancer at diagnosis in black women compared with white women by approximately 30%.

CONCLUSIONS

Our results suggest that the higher prevalence of obesity among black women plays an important role in explaining their relative disadvantage in stage at diagnosis of breast cancer. Nonetheless, a racial difference in stage of breast cancer at diagnosis persists after adjustment for obesity.

Patient delay and stage of diagnosis among breast cancer patients in Germany -- a population based study

Early diagnosis is a tenet in oncology and should enable early treatment with the expectation of improved outcome. Extent and determinants of patient delay of diagnosis in breast cancer patients and its impact on stage of disease were examined in a population based study among female breast cancer patients in Germany. Two hundred and eighty-seven women, aged 18 to 80 years with newly diagnosed invasive symptomatic breast cancer, were interviewed with respect to the diagnostic process. Patient delay was defined as time from onset of first symptoms to first consultation of a doctor. Median patient delay was 16 days among symptomatic patients. Eighteen per cent of all breast cancer patients waited longer than 3 months before consulting a physician. Long patient delay was associated with old age, history of a benign mastopathy, obesity, and indices of health behaviour such as not knowing a gynaecologist for out-patient care and non-participation in general health screening examinations. A strong association between patient delay and stage at diagnosis was observed for poorly differentiated tumours. These results suggest that at risk groups for delaying consultation can be identified and that a substantial proportion of late stage diagnoses of poorly differentiated breast cancer cases could be avoided if all patients with breast cancer symptoms would present to a doctor within 1 month.

Body mass and stage of breast cancer at diagnosis

Obesity is a well-known risk factor for postmenopausal breast cancer. In contrast, the relationship between obesity and stage of breast cancer at diagnosis is less clear. We hypothesized that increased breast size in obese women may delay discovery of breast tumors. Thus, the purpose of our study was to examine whether there is an association between body mass and stage of breast cancer at diagnosis using hospital medical records. Newly diagnosed breast cancer cases (n = 966) in the Baltimore metropolitan area from 1991 to 1997 were included in our study. Patient information including age, ethnicity, weight, height and pathology data were obtained from hospital medical records. High body mass was significantly associated with late stage of breast cancer at diagnosis. Women who were obese (body mass index [BMI] > or = 27.3) were more likely to be at an advanced stage at diagnosis compared with women with a BMI of < 27.3 (multivariate-adjusted odds ratio [OR] 1.57, 95% confidence interval [CI] 1.15-2.14). The association between body mass and stage at diagnosis was stronger among women younger than 50 years (OR 2.34, 95% CI 1.34-4.08) compared with women 50 years or older (OR 1.30, 95% CI 0.89-1.91). Our study suggests that higher body mass is associated with advanced stage of breast cancer at diagnosis. This finding may be of considerable concern, given the increasing prevalence of obesity in women in the United States and the poor prognosis associated with late-stage tumors.

Socio-demographic factors, health behavior and late-stage diagnosis of breast cancer in Germany: a population-based study

Late-stage diagnosis of breast cancer is associated with poor survival. Identification of individuals at high risk of late-stage diagnosis could be an effective step to reduce breast cancer mortality. We examined the association of socio-demographic factors and health behavior with breast cancer stage in a population-based sample of 380 female breast cancer patients in Saarland, Germany. Overall, 182 women (47.9%) were diagnosed with late-stage (regional or distant) breast cancer. After control for potential confounding by multivariate logistic regression, an increased risk of late-stage diagnosis was observed for older age (OR = 1.8; 95% CI 1.0-3.2), foreign nationality (OR = 3.9; 95% CI 0.7-20.8), living in large households (OR = 1.7; 95% CI 1.0-2.9), non-participation in general health check-up (OR = 1.5; 95% CI 0.9-2.4) and low interest in health care (OR = 1.6; 95% CI 1.0-2.7). The proportion of late-stage cancer was clearly decreased when tumors were detected by screening (OR = 0.4; 95% CI 0.2-0.8). Certain socio-demographic factors and characteristics of health behavior seem to represent independent risk indicators of late-stage diagnosis.

Race, anthropometric factors, and stage at diagnosis of breast cancer

A recent study suggested that the greater prevalence of severe obesity among African-American women explained almost one third of the observed differences between African-American and White women in stage at diagnosis of breast cancer. The objective of this investigation was to attempt to replicate these findings in a second, larger population and to expand the analyses by including a measure of body fat distribution, the waist:hip ratio. The authors used data from a population-based study in North Carolina comprising 791 breast cancer cases (302 in African-American women and 489 in White women) diagnosed between 1993 and 1996. African-American women were more likely to have later-stage (TNM stage >/=II) breast cancer (odds ratio (OR) = 2.2; 95% confidence interval (CI): 1.6, 2.9). They also were much more likely to be severely obese (body mass index >/=32.3) (OR = 9.7; 95% CI: 6.5, 14.5) and to be in the highest tertile of waist:hip ratio (OR = 5.7; 95% CI: 3.8, 8.6). In multivariate logistic regression models, adjustment for waist:hip ratio reduced the odds ratio for later-stage disease in African-American women by 20%; adjustment for both waist:hip ratio and severe obesity reduced the odds ratio by 27%. These observations suggest that obesity and body fat distribution, in addition to socioeconomic and medical care factors, contribute to racial differences in stage at breast cancer diagnosis.

Adverse effects of increased body weight on quantitative measures of mammographic image quality

OBJECTIVE

The purpose of our study was to show that compressed breast thickness on mammograms in overweight and obese women exceeds the thickness in normal-weight women and that increased thickness results in image degradation.

SUBJECTS AND METHODS

Three hundred consecutive routine mammograms were reviewed. Patients were categorized according to body mass index. Compression thickness, compressive force, kilovoltage, and milliampere-seconds were recorded. Geometric unsharpness and contrast degradation were calculated for each body mass index category.

RESULTS

Body mass index categories were lean (3%), normal (36%), overweight (36%), and obese (25%). Body mass index was directly correlated with compressed thickness. In the mediolateral oblique view, the mean thickness of the obese category exceeded normal thickness by 18 mm (p < 0.01), corresponding to a 32% increase in geometric unsharpness. Mean obese thickness exceeded lean thickness by 33 mm (p < 0.01), corresponding to a 79% increase in unsharpness. Similar trends were observed for the craniocaudal view. In the mediolateral oblique projection, there was an increase of 1.0 kVp (p < 0.01) for obese compared with normal and 1.7 kVp (p < 0.01) between lean and obese, corresponding, respectively, to a 16% and a 25% decrease in image contrast because of scatter and kilovoltage changes. Milliampere-seconds increased by 47% on the mediolateral oblique images in the obese category compared with normal body mass index.

CONCLUSION

An increased body mass index was associated with greater compressed breast thickness, resulting in increased geometric unsharpness, decreased image contrast, and greater potential for motion unsharpness.

Effect of obesity on screening mammography: outcomes analysis of 88,346 consecutive examinations

OBJECTIVE

We determined differences in the rates of recall, biopsy, and cancer detection for screening mammography as a function of adiposity.

MATERIALS AND METHODS

Eighty-eight thousand three hundred forty-six consecutive screening mammography examinations were performed from April 1985 to August 1997. Patient weights were normalized to ideal weight correcting for height and were subdivided into adiposity cohorts including underweight by greater than 10%; ideal weight +/- 10%; overweight by 11-24%; overweight by 25-39%; and overweight by greater than 40%. The rates of recall, biopsy, cancer detection, and cancer stage were calculated and were analyzed using the chi-square test for trend. Cancer size was analyzed using linear regression analysis.

RESULTS

Reliable (p < 0.05) and meaningful differences were seen between cohorts of increasing adiposity for rates of recall, biopsy, and cancer detection. An increase in recall rate occurred with progressively increasing adiposity (3.88%, 4.89%, 5.11%, 5.47%, 5.55% [p < 0.0001]). The rate of biopsy also increased with increasing adiposity (0.98%, 1.31%, 1.35%, 1.59%, 1.65% [p < 0.0002]), as did the rate of screening-detected cancer (number of cases of cancer per 1000 women screened) (3.74, 4.29, 5.34, 4.70, 6.04 [p < 0.015]). Finally, increased adiposity also correlated with increased median cancer size (p < 0.02) and with more advanced stage at diagnosis (p = 0.046).

CONCLUSION

Increasing adiposity correlates with progressive increases in the rates of recall, biopsy, and cancer detection for women undergoing screening mammography. Increasing adiposity also correlates with increased cancer size and stage, providing further support for obesity as a risk factor for breast cancer.

Stage of breast cancer in relation to body mass index and bra cup size

Most studies on women with breast cancer indicate that obesity is positively associated with late-stage disease. Some results have shown a similar relationship between breast size and stage. A recent study found that the association between body mass index (BMI) and stage was limited to cancers that were self-detected, suggesting that the BMI-stage relation may be due to delayed symptom recognition. We examined the relationships between stage and both BMI and breast (bra cup) size, stratified by method of detection, using data from a population-based case-control study of 1,361 women (ages 20-44 years) diagnosed with breast cancer during 1990-1992. Height and weight measurements and information on bra cup size, method of cancer detection and other factors predictive of stage at diagnosis were collected during in-person interviews. A case-case comparison was conducted using logistic regression to estimate odds of regional or distant stage rather than local stage in relation to BMI and bra size. Odds of late-stage disease were increased with higher BMI [adjusted odds ratio (OR) for highest to lowest tertile = 1.46, 95% confidence interval (CI) 1.10-1.93] and larger bra cup size (OR for cup D vs. cup A = 1.61, 95% CI 1.04-2.48). These relationships were not modified by the method of detection. Differences in etiologic effects, rather than differences in detection methods, may explain the relations observed between stage and both BMI and breast size.

Cancer among spouses: review of 195 couples

BACKGROUND

The study of cancer in spouses may play an important role in the assessment of cancer etiology.

METHODS

Patterns of occurrence of cancer in 195 couples related by marriage only and treated in a regional hospital are reported. The distribution of tumors by site was compared with national data.

RESULTS

Seven sites of cancer were found to be more frequent in married couples than in the general population, in particular carcinoma of the colon (37 observed vs. 19.5 expected in husbands [relative risk (RR) = 1.89 (95% confidence intervals [CI], 1.5-2.4); P < 0.001] and 32 vs. 16.7 in wives [RR = 1.92 (95% CI, 1.4-2.5); P < 0.001]), carcinoma of the prostate (32 vs. 20 in husbands [RR = 1.6 (95% CI, 1.19-2.09); P < 0.01]), and carcinoma of the female breast (84 vs. 55 in wives [RR = 1.53 (95% CI, 1.3-1.8); P < 0.001]). Same site tumors were observed in 13 couples versus 6.21 expected in the general population (RR = 2.09 [95% CI, 1.25-3.26]; P < 0.01). A combination of carcinoma of the prostate and female breast sites was found in 18 couples versus 5.4 expected in the general population (RR = 3.34 [95% CI, 2.19-4.84]; P < 0.001).

CONCLUSIONS

The distribution of cancer sites among spouses in those families in which both spouses have developed a cancer differs from that of the general population. These differences may be caused by shared risk factors. Increased awareness can explain only part of the excess.

Recent oral contraceptive use and risk of breast cancer (United States)

We examined the association between recent oral contraceptive (OC) use and the risk of breast cancer in data from a large population-based case-control study in the United States. Cases (n = 6,751) were women less than 75 years old who had breast cancer identified from statewide tumor registries in Wisconsin, Massachusetts, Maine, and New Hampshire. Controls (n = 9,311) were selected randomly from lists of licensed drivers (if aged under 65 years) and from lists of Medicare beneficiaries (if aged 65 through 74 years). Information on OC use, reproductive experiences, and family and medical history was obtained by telephone interview. After adjustment for parity, age at first delivery, and other risk factors, women who had ever used OCs were at similar risk of breast cancer as never-users (relative risk [RR] = 1.1, 95 percent confidence interval [CI] = 1.0-1.2). Total duration of use also was not related to risk. There was a suggestion that more recent use was associated with an increased risk of breast cancer; use less than two years ago was associated with an RR of 1.3 (CI = 0.9-1.9). However, only among women aged 35 to 45 years at diagnosis was the increase in risk among recent users statistically significantly elevated (RR = 2.0, CI = 1.1-3.9). Use prior to the first pregnancy or among nulliparous women was not associated with increased risk. Among recent users of OCs, the risk associated with use was greatest among non-obese women, e.g., among women with body mass index (kg/m2) less than 20.4, RR = 1.7, CI = 1.1-2.8. While these results suggest that, in general, breast cancer risk is not increased substantially among women who have used OCs, they also are consistent with a slight increased risk among subgroups of recent users.