Trends in breast cancer mortality rates by region of the United States, 1950-1999

Association of XPA polymorphism with breast cancer risk: A meta-analysis

BACKGROUND

The association of XPA rs1800975 polymorphism with breast cancers has been reported in several studies, but the results were conflicting. In order to analyze the association between XPA rs1800975 polymorphism and the risk of breast cancer, a meta-analysis was performed in the present study.

METHODS

The literature search for relevant studies was conducted in PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Med Online databases. The odds ratios (ORs) and their corresponding 95% confidence intervals (95% CIs) were calculated using fixed-effect/random-effects models by the STATA 12.0 software. The sources of heterogeneity were analyzed by subgroup analysis.

RESULTS

Six case-control studies involving 5069 subjects (2338 patients and 2731 healthy controls) were included in the present meta-analysis. In the pooled analysis, no obvious association was found between XPA rs1800975 polymorphism and the risk of breast cancer in all genetic models. However, in subgroup analysis based on ethnicity, XPA rs1800975 polymorphism was found to be related to decreased breast cancer risk in non-Asians in the recessive model (OR = 0.80, 95% CI = 0.64-1.00, P = .045). Moreover, source of control subgroup analysis demonstrated that XPA rs1800975 polymorphism might decrease the risk of breast cancer in population-based group in the recessive model (OR = 0.80, 95% CI = 0.64-1.00, P = .045).

CONCLUSION

XPA rs1800975 polymorphism may decrease the risk of breast cancer in both non-Asians and population-based patients. Large sample size and well-designed study is needed for further assessing the role of XPA polymorphism in breast cancer risk.

Regional Variation in Disparities in Breast Cancer Specific Mortality Due to Race/Ethnicity, Socioeconomic Status, and Urbanization

PURPOSE

Disparities in breast cancer mortality due to race/ethnicity, area socioeconomic status (SES), and urbanization have been documented. This study examined if disparities in the risk of breast cancer specific mortality due to race/ethnicity, SES, and urbanization varied within diverse regions of California.

METHODS

We identified 163,569 cases of first primary female invasive breast cancer from the California Cancer Registry diagnosed between January, 2000 and December, 2013. Cox regression was used to compute hazard ratios (HR) and 95 % confidence intervals for race/ethnicity, SES, and urbanization within eight regions of California.

RESULTS

Blacks had an increased risk of mortality in the San Francisco Bay Area (SFBA) (HR = 1.37; 1.22-1.55), Desert Sierra (HR = 1.27; 1.08-1.49), San Diego/Orange (HR = 1.43; 1.19-1.71), and Los Angeles (LA) (HR = 1.31; 1.20-1.44). Japanese (HR = 0.62; 0.47-0.81), Chinese (HR = 0.71; 0.58-0.87), and Filipino (HR = 0.81; 0.69-0.95) women had a decreased risk of mortality in LA. Southeast Asians had a decreased risk in San Diego/Orange (HR = 0.72; 0.57-0.90) and in the SFBA (HR = 0.81; 0.67-0.98). Hispanics had a decreased risk (HR = 0.73; 0.57-0.93) and American Indians had an increased risk (HR = 2.32; 1.08-4.98) in the Tri-County region. SES was a significant risk factor for mortality in all regions except the North and Tri-County. Urbanization was a statistically significant factor for mortality only in LA (HR = 1.32; 1.08-1.60).

CONCLUSIONS

Disparities in breast cancer mortality, due to race/ethnicity, SES, and urbanization vary by region which suggests that further research is warranted concerning the role of geographic regions and neighborhoods in cancer outcomes.

Methylenetetrahydrofolate reductase gene C677T polymorphism and breast cancer risk: Evidence for genetic susceptibility

There are several evidences supporting the role of 5–10 methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms in breast cancer (BC). Case control association studies on breast cancer have been repeatedly performed over the last two decades, but results are inconsistent. We performed a meta-analysis to confirm the association between MTHFR C677T polymorphism and BC risk.

The articles were retrieved by searching the PubMed, Google Scholar, and Springer Link databases. Crude odds ratios (OR) with 95% confidence intervals (CIs) was used to assess the strength of association between C677T polymorphism and BC. Publication bias was assessed by Egger's and Begg-Mazumdar tests. Meta-analysis was performed with Open Meta Analyst.

Total 75 studies with 31,315 cases and 35, 608 controls were found suitable for the inclusion in the present meta-analysis. The results of meta-analysis suggested that there were moderate significant association between C677T polymorphism and BC risk using overall comparisons in five genetic models (T vs. C: OR = 1.08, 95% CI = 1.03–1.13, p = < 0.001; TT + CT vs. CC: OR = 1.06, 95% CI = 1.02–1.09, p = < 0.001; TT vs. CC: OR = 1.17, 95% CI = 1.06–1.28, p = 0.001; CT vs. CC OR = 1.05, 95% CI = 1.01–1.08, p = 0.005; TT vs. CT + CC: OR = 1.12, 95% CI = 1.03–1.22, p = 0.005). In conclusion, results of present meta-analysis showed modest association between MTHFR C677T polymorphism with breast cancer in total studies. However, sub-group analysis results based on ethnicity showed strong significant association between TT genotype and breast cancer (TT vs. CC; OR°=°1.26; 95% CI: 1.06–1.51; p = 0.009) in Asian population but in Caucasian population such association was not observed (TT vs. CC; OR°=°1.08; 95% CI: 0.99–1.14; p = 0.05).

The methylenetetrahydrofolate reductase C677T polymorphism and breast cancer risk in Asian populations

BACKGROUND

Methylenetetrahydrofolate (MTHFR) is the key enzyme of the folate metabolic pathway and several studies have pointed to association between the MTHFR C677T polymorphism and breast cancer risk. Although significant association was observed in some studies, in others no clear link could be established.

OBJECTIVE

A meta-analysis of published Asian case control studies was therefor carried out to shed further light on any C677T breast cancer association.

MATERIALS AND METHODS

PubMed, Springer Link, Google Scholar and Elsevier databases were searched for case control studies of associations between MTHFR C677T polymorphism and breast cancer risk. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated to assess the association. A total of 36 studies including 8,040 cases and 10,008 controls were included in the present meta-analysis.

RESULTS

Overall, a significantly elevated breast cancer risk was associated with the T allele and TT genotype in homozygote comparison and dominant genetic models when all studies were pooled into the meta-analysis (T vs C (allele contrast model): OR=1,23, 95%CI=1.13-1.37, p=0.000 ; TT vs CC(homozygote model): OR=1.38, 95%CI=1.16-1.63, p=0.0003; TT+CT vs CC (dominant model): OR=1.12, 95%CI=1.01-1.23, p=0.02).

CONCLUSIONS

The present meta-analysis strongly suggested a significant association between the MTHFR C677T polymorphism and risk of breast cancer in Asian populations.

Methylenetetrahydrofolate reductase polymorphisms and breast cancer risk in Chinese population: a meta-analysis of 22 case-control studies

The association between methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms and breast cancer risk in the Chinese population has been widely reported, but results were inconsistent. In order to derive a more precise estimation of the relationship, a meta-analysis was performed. Eligible articles were identified through search of databases including Medline, PubMed, Web of Science, Embase, Chinese Biomedical Literature Database (CBM, Chinese), China National Knowledge Infrastructure (CNKI, Chinese), and Wangfang Database (Chinese). The association between the MTHFR polymorphism and breast cancer risk was conducted using odds ratios (ORs) and 95 % confidence intervals (95 % CIs). Finally, a total of 22 studies with 6,103 cases and 7,913 controls were included in our meta-analysis: 13 studies with 3,273 cases and 4,419 controls for C677T polymorphism and 9 studies with 2,830 cases and 3,494 controls for A1298C polymorphism. With regard to C677T polymorphism, significant association was found with breast cancer risk under three models (T vs. C: OR = 1.12, 95 % CI = 1.02-1.23, P = 0.015; TT vs. CC: OR = 1.35, 95 % CI = 1.10-1.67, P = 0.005; TT vs.

CC/CT

OR = 1.37, 95 % CI = 1.11-1.70, P = 0.004). There was no significant association found between A1298C polymorphism and breast cancer risk under all genetic models (C vs. A: OR = 0.96, 95 % CI = 0.89-1.03, P = 0.268; CC vs. AA: OR = 0.98, 95 % CI = 0.77-1.26, P = 0.899; AC vs. AA: OR = 0.95, 95 % CI = 0.88-1.02, P = 0.174; CC vs. AC/AA: OR = 1.00, 95 % CI = 0.78-1.28, P = 0.996, CC/AC vs. AA: OR = 0.96, 95 % CI = 0.89-1.02, P = 0.196). In summary, during this meta-analysis, we found that MTHFR C677T polymorphism was significantly associated with breast cancer risk in the Chinese population. Meanwhile, MTHFR A1298C polymorphism was not associated with breast cancer risk in the Chinese population.

Vascular endothelial growth factor +936C/T polymorphism and breast cancer risk: a meta-analysis of 13 case-control studies

The association between vascular endothelial growth factor (VEGF) +936C/T polymorphism and breast cancer risk has been widely reported, but results were inconsistent. In order to derive a more precise estimation of the relationship, a meta-analysis was performed. Eligible articles were identified through search of databases including PubMed, Embase, and Chinese Biomedical Literature Database (CBM). The association between the VEGF +936C/T polymorphism and breast cancer risk was conducted by odds ratios (ORs) and 95 % confidence intervals (95 % CIs). Finally, a total of 13 studies with 6,879 cases and 7,219 controls were included in our meta-analysis. Overall, a significant association was found between VEGF +936C/T polymorphisms and the risk of breast cancer in overall populations under five models (T vs. C: OR = 0.83, 95 % CI = 0.73–0.94, P = 0.002; TT vs. CC: OR = 0.74, 95 % CI = 0.61–0.91, P = 0.004, Fig. 1a; TC vs. CC: OR = 0.83, 95 % CI = 0.71–0.96, P = 0.014; TT vs. CC/CT: OR = 0.77, 95 % CI = 0.62–0.94, P = 0.010; TT/TC vs. CC: OR = 0.82, 95 % CI = 0.72–0.95, P = 0.006). In the subgroup analysis by ethnicity, there were also significant associations found between VEGF +936C/T polymorphism and breast cancer risk in Asians and Caucasians. In conclusion, the results of our meta-analysis suggest that the VEGF +936C/T polymorphism is significantly associated with breast cancer development and the VEGF 936T allele carriers may be associated with decreased breast cancer risk.

XPD Asp312Asn and Lys751Gln polymorphisms and breast cancer susceptibility: a meta-analysis

The association between xeroderma pigmentosum complementation group D (XPD) Asp312Asn and Lys751Gln gene polymorphisms and breast cancer risk has been widely reported, but the results were inconsistent. In order to derive a more precise estimation of the relationship, a meta-analysis was performed. A comprehensive search strategy was conducted towards the electronic databases including Medline, PubMed, Web of Science, Embase, and Chinese Biomedical Literature Database (Chinese). The association between the XPD polymorphism and breast cancer risk was conducted by odds ratios (ORs) and 95 % confidence intervals (95 % CIs). A total of 22 studies with 18,136 cases and 18,351 controls were included in our meta-analysis. Among these, 12 studies with 7,667 cases and 7,480 controls for Asp312Asn polymorphism and 20 studies with 10,469 cases and 10,871 controls for Lys751Gln polymorphism. With regard to Asp312Asn polymorphism, no significantly associated was found with breast cancer risk. However, significant association was found between Lys751Gln polymorphism and breast cancer risk under all genetic models in overall populations (C vs. A—OR = 1.10, 95 % CI = 1.04–1.17, P = 0.002; CC vs. AA—OR = 1.17, 95 % CI = 1.06–1.30, P = 0.003; AC vs. AA—OR = 1.06, 95 % CI = 1.01–1.12, P = 0.032; CC vs. AC/AA—OR = 1.17, 95 % CI = 1.04–1.32, P = 0.009; CC/AC vs. AA—OR = 1.07, 95 % CI = 1.02–1.12, P = 0.005). In subgroup analysis base on ethnicity, significance was found in Caucasians and mix. The results suggest that XPD Asp312Asn polymorphism was not associated with breast cancer. The XPD Lys751Gln polymorphism significantly increased breast cancer risk, especially for Caucasian and mix.

Single nucleotide polymorphism 6q25.1 rs2046210 and increased risk of breast cancer

The onset and development of breast cancer (BC) are influenced by many factors, including the single nucleotide polymorphism (SNP) rs2046210 at 6q25.1. However, studies of the potential association between rs2046210 at 6q25.1 and risk of BC have given inconsistent results. We performed a meta-analysis to address this controversy. PubMed, EMBASE, and Web of Science were systematically searched to identify relevant studies. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to assess the strength of the association between this SNP and risk of BC. A total of 14 studies are included in the meta-analysis, involving 123,085 cases and 120,761 controls. The A-allele, AA/GA, and AA genotypes were significantly associated with increased risk of BC (A-allele vs. G-allele: OR = 1.20, 95%CI = 1.15-1.25, P for heterogeneity < 0.0001; AA/GA vs. GG: OR = 1.22, 95%CI = 1.16-1.28, P for heterogeneity < 0.0001; AA vs.

GA/GG

OR = 1.18, 95%CI = 1.13-1.24, P for heterogeneity = 0.064). In further stratified analysis by ethnicity, the elevated risks were found in Europeans and Asians, while there was no significant association detected in African population. In the subgroup analysis based on sample size and source of control, significant results were observed in all the subgroups. There was evidence of heterogeneity (P < 0.10), which largely disappeared after stratification by ethnicity. In summary, this meta-analysis suggests the participation of rs2046210 at 6q25.1 in the susceptibility for BC, especially in Europeans and Asians.

Single nucleotide polymorphism 8q24 rs13281615 and risk of breast cancer: meta-analysis of more than 100,000 cases

Background

The onset and progression of breast cancer (BC) is influenced by many factors, including the single nucleotide polymorphism (SNP) rs13281615 at 8q24. However, studies of the potential association between rs13281615 at 8q24 and risk of BC have given inconsistent results. We performed a meta-analysis to address this controversy.

Methods

PubMed, EMBASE and the Chinese National Knowledge Infrastructure databases were systematically searched to identify relevant studies. Two curators independently extracted data, and odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated to assess the strength of the association between rs13281615 at 8q24 and risk of BC.

Results

Fourteen studies are included in the meta-analysis, involving 44,283 cases (5,170 Chinese and 39,113 mixed) and 55,756 controls (5,589 Chinese and 50,167 mixed). The GG and G-allele genotypes of rs13281615 at 8q24 are significantly associated with increased risk of BC (GG vs. AG+AA, OR 1.13, 95% CI 1.08–1.19, P<0.001; G-allele vs. A-allele, OR 1.10, 95% CI 1.06–1.14, P<0.001; GG vs. AA, OR 1.20, 95% CI 1.12–1.29, P<0.001). Conversely, the AA genotype is significantly associated with decreased risk of BC (AA vs. AG+GG, OR 0.89, 95% CI 0.84–0.93, P<0.001).

Conclusion

G-allele genotypes of rs13281615 at 8q24 polymorphism are a risk factor for developing BC, while the AA genotype is a protective factor. Further large and well-designed studies are required to confirm this conclusion.

Identifying risk factors for disparities in breast cancer mortality among African-American and Hispanic women

BACKGROUND

This study evaluated the risk factors associated with racial disparities in female breast cancer mortality for African-American and Hispanic women at the census tract level in Texas from 1995 to 2005.

METHODS

Data on female breast cancer cases were obtained from the Texas Cancer Registry. Socioeconomic and demographic data were collected from Census 2000. Network distance and driving times to mammography facilities were estimated using Geographic Information System techniques. Demographic, poverty and spatial accessibility factors were constructed using principal component analysis. Logistic regression models were developed to predict the census tracts with significant racial disparities in breast cancer mortality based on racial disparities in late-stage diagnosis and structured factors from the principal component analysis.

RESULTS

Late-stage diagnosis, poverty factors, and demographic factors were found to be significant predictors of a census tract showing significant racial disparities in breast cancer mortality. Census tracts with higher poverty status were more likely to display significant racial disparities in breast cancer mortality for both African Americans (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.95-3.04) and Hispanics (OR, 5.30; 95% CI, 4.26-6.59). Spatial accessibility was not a consistent predictor of racial disparities in breast cancer mortality for African-American and Hispanic women.

CONCLUSION

Physical access to mammography facilities does not necessarily reflect a greater utilization of mammogram screening, possibly owing to financial constraints. Therefore, a metric measuring access to health care facilities is needed to capture all aspects of access to preventive care. Despite easier physical access to mammography facilities in metropolitan areas, great resources and efforts should also be devoted to these areas where racial disparities in breast cancer mortality are often found.

Spatial association of racial/ethnic disparities between late-stage diagnosis and mortality for female breast cancer: where to intervene?

Background

Over the past twenty years, racial/ethnic disparities between late-stage diagnoses and mortality outcomes have widened due to disproportionate medical benefits that different racial/ethnic groups have received. Few studies to date have examined the spatial relationships of racial/ethnic disparities between breast cancer late-stage diagnosis and mortality as well as the impact of socioeconomic status (SES) on these two disparities at finer geographic scales.

Methods

Three methods were implemented to assess the spatial relationship between racial/ethnic disparities of breast cancer late-stage diagnosis and morality. First, this study used rate difference measure to test for racial/ethnic disparities in both late-stage diagnosis and mortality of female breast cancer in Texas during 1995-2005. Second, we used linear and logistic regression models to determine if there was a correlation between these two racial/ethnic disparities at the census tract level. Third, a geographically-weighted regression analysis was performed to evaluate if this correlation occurred after weighting for local neighbors.

Results

The spatial association of racial disparities was found to be significant between late-stage diagnosis and breast cancer mortality with odds ratios of 33.76 (CI: 23.96-47.57) for African Americans and 30.39 (CI: 22.09-41.82) for Hispanics. After adjusting for a SES cofounder, logistic regression models revealed a reduced, although still highly significant, odds ratio of 18.39 (CI: 12.79-26.44) for African-American women and 11.64 (CI: 8.29-16.34) for Hispanic women. Results of the logistic regression analysis indicated that census tracts with low and middle SES were more likely to show significant racial disparities of breast cancer late-stage diagnosis and mortality rates. However, values of local correlation coefficients suggested that the association of these two types of racial/ethnic disparities varied across geographic regions.

Conclusions

This study may have health-policy implications that can help early detection of breast cancer among disadvantaged minority groups through implementing effective intervention programs in targeted regions.

Identification of racial disparities in breast cancer mortality: does scale matter?

Background

This paper investigates the impact of geographic scale (census tract, zip code, and county) on the detection of disparities in breast cancer mortality among three ethnic groups in Texas (period 1995-2005). Racial disparities were quantified using both relative (RR) and absolute (RD) statistics that account for the population size and correct for unreliable rates typically observed for minority groups and smaller geographic units. Results were then correlated with socio-economic status measured by the percentage of habitants living below the poverty level.

Results

African-American and Hispanic women generally experience higher mortality than White non-Hispanics, and these differences are especially significant in the southeast metropolitan areas and southwest border of Texas. The proportion and location of significant racial disparities however changed depending on the type of statistic (RR versus RD) and the geographic level. The largest proportion of significant results was observed for the RD statistic and census tract data. Geographic regions with significant racial disparities for African-Americans and Hispanics frequently had a poverty rate above 10.00%.

Conclusions

This study investigates both relative and absolute racial disparities in breast cancer mortality between White non-Hispanic and African-American/Hispanic women at the census tract, zip code and county levels. Analysis at the census tract level generally led to a larger proportion of geographical units experiencing significantly higher mortality rates for minority groups, although results varied depending on the use of the relative versus absolute statistics. Additional research is needed before general conclusions can be formulated regarding the choice of optimal geographic regions for the detection of racial disparities.

Female breast cancer mortality clusters within racial groups in the United States

Although breast cancer is the second leading cause of cancer deaths among women in the Unites States, to date there have been no nationwide studies systematically analyzing geographic variation and clustering. An assessment of spatial-temporal clusters of cancer mortality by age and race at the county level in the lower 48 United States indicated a primary cluster in the Northeast US for both younger (RR = 1.349; all RR are p < or = 0.001) and older (RR = 1.283) women in the all-race category. Similar cluster patterns in the North were detected for younger (RR = 1.390) and older (RR = 1.292) white women. The cluster for both younger (RR = 1.337) and older (RR = 1.251) black women was found in the Midwest. The clusters for all other racial groups combined were in the West for both younger (RR = 1.682) and older (RR = 1.542) groups. Regression model results suggest that lower socioeconomic status (SES) was more protective than higher status at every quartile step (Medium-high SES, OR = 0.374; Medium-low, OR = 0.137; Low, OR = 0.061). This study may provide insight to aid in identifying geographic areas and subpopulations at increased risk for breast cancer.

Temporal trends in breast cancer mortality by state and race

OBJECTIVE

To examine how temporal trends in age-standardized female breast cancer death rates vary by state and race.

METHODS

We analyzed mortality data from the National Center for Health Statistics (NCHS) for the years 1975 through 2004 by state and race using joinpoint analyses.

RESULTS

By 2004, breast cancer death rates in white women were decreasing in all 50 states and the District of Columbia (DC), with the onset of decline varying by state. In contrast, among African American women, breast cancer death rates increased in two states (Arkansas and Mississippi) of the 37 states analyzed, were level in 24 states, and decreased in 11 states. In general, states that showed little progress in reducing breast cancer mortality rates over time had higher death rates in 2003-2004.

CONCLUSION

Trends in breast cancer death rates vary widely by state and are considerably less favorable in African American than in white women. State cancer control efforts should ensure that all women have access to high-quality early detection and treatment services.

U.S. congressional district cancer death rates

BACKGROUND

Geographic patterns of cancer death rates in the U.S. have customarily been presented by county or aggregated into state economic or health service areas. Herein, we present the geographic patterns of cancer death rates in the U.S. by congressional district. Many congressional districts do not follow state or county boundaries. However, counties are the smallest geographical units for which death rates are available. Thus, a method based on the hierarchical relationship of census geographic units was developed to estimate age-adjusted death rates for congressional districts using data obtained at county level. These rates may be useful in communicating to legislators and policy makers about the cancer burden and potential impact of cancer control in their jurisdictions.

RESULTS

Mortality data were obtained from the National Center for Health Statistics (NCHS) for 1990-2001 for 50 states, the District of Columbia, and all counties. We computed annual average age-adjusted death rates for all cancer sites combined, the four major cancers (lung and bronchus, prostate, female breast, and colorectal cancer) and cervical cancer. Cancer death rates varied widely across congressional districts for all cancer sites combined, for the four major cancers, and for cervical cancer. When examined at the national level, broad patterns of mortality by sex, race and region were generally similar with those previously observed based on county and state economic area.

CONCLUSION

We developed a method to generate cancer death rates by congressional district using county-level mortality data. Characterizing the cancer burden by congressional district may be useful in promoting cancer control and prevention programs, and persuading legislators to enact new cancer control programs and/or strengthening existing ones. The method can be applied to state legislative districts and other analyses that involve data aggregation from different geographic units.

Comparisons of Estimated Economic Burdens due to Insufficient Solar Ultraviolet Irradiance and Vitamin D and Excess Solar UV Irradiance for the United States

Vitamin D sufficiency is required for optimal health, and solar ultraviolet B (UVB) irradiance is an important source of vitamin D. UVB and/or vitamin D have been found in observational studies to be associated with reduced risk for over a dozen forms of cancer, multiple sclerosis, osteoporotic fractures, and several other diseases. On the other hand, excess UV irradiance is associated with adverse health outcomes such as cataracts, melanoma, and nonmelanoma skin cancer. Ecologic analyses are used to estimate the fraction of cancer mortality, multiple sclerosis prevalence, and cataract formation that can be prevented or delayed. Estimates from the literature are used for other diseases attributed to excess UV irradiation, additional cancer estimates, and osteoporotic fractures. These results are used to estimate the economic burdens of insufficient UVB irradiation and vitamin D insufficiency as well as excess UV irradiation in the United States for these diseases and conditions. We estimate that 50,000-63,000 individuals in the United States and 19,000-25,000 in the UK die prematurely from cancer annually due to insufficient vitamin D. The U.S. economic burden due to vitamin D insufficiency from inadequate exposure to solar UVB irradiance, diet, and supplements was estimated at $40-56 billion in 2004, whereas the economic burden for excess UV irradiance was estimated at $6-7 billion. These results suggest that increased vitamin D through UVB irradiance, fortification of food, and supplementation could reduce the health care burden in the United States, UK, and elsewhere. Further research is required to confirm these estimates.