Recent trends and patterns in breast cancer incidence among Eastern and Southeastern Asian women

Trends in breast density and other risk factors for breast cancer and associations with trends in the incidence of breast cancer in Korean women

INTRODUCTION

This study investigated the trends in breast density in Korean women and their association with the incidence of breast cancer, incorporating the trends in the known risk factors for breast cancer from an ecological perspective.

METHODS

The prevalence of risk factors for breast cancer from the National Health and Nutrition Survey, breast density from Korea's national breast cancer screening program, and breast cancer incidence from the Korea Central Cancer Registry during 2010-2018 were applied after age-standardization to the population at the middle of the year 2000. The association between the prevalence of risk factors for breast cancer, the prevalence of dense breast, and the incidence rate of breast cancer was estimated using linear regression.

RESULTS

The proportion of age-standardized dense breasts steadily increased from 45.8 % in 2010 to 51.5 % in 2018. The increased prevalence of dense breasts in women was positively related to the prevalence of smoking, drinking, lack of exercise, early menarche age (<15 years old), premenopausal status, nulliparity, and no history of breastfeeding, and negatively related to the prevalence of obesity. The increased prevalence of the dense breast was associated with an increase in the incidence of breast cancer, and 96 % of the variation in breast cancer incidence could be explained by the variation in the prevalence of dense breast. The factors associated with dense breast and breast cancer incidence overlapped.

CONCLUSIONS

Trends in breast cancer risk factors were associated with an increased prevalence of dense breast, which, in turn, was associated with an increased incidence of breast cancer in Korea.

Hormone replacement therapy and breast cancer incidence in Korean women

OBJECTIVES

After the 2002 Women's Health Initiative (WHI) study, the global use of menopausal hormone therapy (MHT) declined, and despite subsequent studies indicating a low risk of breast cancer, concerns about MHT usage persist. We examined the relationship between changes in MHT use and changes in the incidence of breast cancer from 2002 to 2020 in South Korea.

STUDY DESIGN

This study used tumor registry information from 2002 to 2020 from the Korean Statistical Information Service and analyzed the incidence rate of invasive breast cancer in women, who were divided into two age groups: <50 and >50 years. The numbers of MHT prescriptions in Korea between 2002 and 2020 was determined from pharmacy data.

RESULTS

The incidence of breast cancer per 100,000 women in South Korea increased from 34.3 in 2002 to 96.4 in 2020. Breast cancer incidence rates increased annually in both groups of women (those aged under and over 50 years), with no significant difference between the two (p = 0.614). Prescriptions for estrogen therapy (ET) in 2020 were 52.7 % lower than those in 2002. Prescriptions for estrogen-progesterone therapy (EPT) decreased by 27.9 % over the same period. Conversely, tibolone prescriptions, which had initially decreased by 25.4 % in 2004, subsequently showed a steady increase and were 93.6 % higher in 2020 than in 2002.

CONCLUSION

The incidence of breast cancer increased annually in Korean women of all ages; however, the use of ET and EPT for MHT has declined since 2002, particularly the use of EPT after 2010. MHT, especially EPT, did not significantly increase the incidence of breast cancer in Korean women.

Changes in Breast Cancer Risk and Risk Factor Profiles among U.S.-Born and Immigrant Asian American Women Residing in the San Francisco Bay Area

BACKGROUND

Breast cancer incidence rates in women of Asian descent have been increasing in the United States and Asia.

METHODS

In a case-control study of Asian American women from the San Francisco Bay Area, we assessed associations with birthplace and migration-related characteristics and compared risk factors between Asian American and non-Hispanic White women by birthplace and birth cohort.

RESULTS

Birthplace and migration-related characteristics were associated with breast cancer risk only among women in the younger birth cohort (1951-1984) that comprised 355 cases diagnosed at age ≤55 years and 276 sister and population controls. Breast cancer risk was marginally increased among foreign-born women [OR = 1.40; 95% confidence interval (CI), 0.97-2.03] and two-fold among foreign-born Chinese women (OR = 2.16; 95% CI, 1.21-3.88). Two-fold increased risks were associated with migration at age ≥40 years and longer U.S. residence (≥30 years or ≥75% of life). The education level was high among both cases and controls. Differences in the prevalence of risk factors by birthplace and birth cohort suggest temporal changes in reproductive and lifestyle-related factors. The prevalence in risk factors was similar between foreign-born and U.S.-born women in the younger birth cohort, and did not fully explain the observed associations with birthplace and other migration characteristics.

CONCLUSIONS

In contrast to studies from earlier decades, younger foreign-born Asian American women had a higher risk of breast cancer than U.S.-born Asian American women.

IMPACT

It is important and urgent to understand what factors drive the increasing burden of breast cancer in women of Asian descent and implement effective prevention programs.

Urban-Rural Disparity in Birth Cohort Effects on Breast Cancer Incidence

Breast cancer is the most commonly diagnosed cancer among women worldwide. Studies have reported minimal birth cohort effects on the incidence rates of breast cancer in Western countries but have reported notable birth cohort effects in some Asian countries. The risks of breast cancer may also vary within a country. In the present study, we abstracted female invasive breast cancer data from the Taiwan Cancer Registry for the period 1997-2016. We used the age-period-cohort model to compare birth cohort effects on breast cancer incidence rates between urban and rural regions in Taiwan. We identified a notable urban-rural disparity in birth cohort effects on breast cancer incidence rates in women in Taiwan. The incidence rates in the urban regions were higher than those in the rural regions across all cohorts. However, the incidence rates rose faster in the rural regions than in the urban regions across the cohorts. The risks of breast cancer observed for women born in 1992 were approximately 22 and 11 times than those observed for women born in 1917 in rural and urban regions, respectively. The observed gap in breast cancer incidence rates between the urban and rural regions gradually disappeared across the cohorts. Accordingly, we speculate that urbanization and westernization in Taiwan may be the drivers of female breast cancer incidence rates across birth cohorts.

What Is Known about Breast Cancer in Young Women?

Breast cancer (BC) is the second leading cause of cancer-related death in women under the age of 40 years worldwide. In addition, the incidence of breast cancer in young women (BCYW) has been rising. Young women are not the focus of screening programs and BC in younger women tends to be diagnosed in more advanced stages. Such patients have worse clinical outcomes and treatment complications compared to older patients. BCYW has been associated with distinct tumour biology that confers a worse prognosis, including poor tumour differentiation, increased Ki-67 expression, and more hormone-receptor negative tumours compared to women >50 years of age. Pathogenic variants in cancer predisposition genes such as BRCA1/2 are more common in early-onset BC compared to late-onset BC. Despite all these differences, BCYW remains poorly understood with a gap in research regarding the risk factors, diagnosis, prognosis, and treatment. Age-specific clinical characteristics or outcomes data for young women are lacking, and most of the standard treatments used in this subpopulation currently are derived from older patients. More age-specific clinical data and treatment options are required. In this review, we discuss the epidemiology, clinicopathologic characteristics, outcomes, treatments, and special considerations of breast cancer in young women. We also underline future directions and highlight areas that require more attention in future studies.

Incidence of second primary malignancies in women with different stages of breast cancer

Introduction

Breast cancer (BC) is the most common cancer in women worldwide. Because of the extended survival of patients with BC, the occurrence of second primary malignancies (SPMs) after BC is an important issue.

Methods

We identified female patients with BC in the Breast Cancer Health Database of Taiwan, which includes four cancer registry datasets between 2002 and 2014 from Taiwan Cancer Registry. We compared the incidence of SPM between patients who received chemotherapy and/or radiotherapy with those who did not. Stratified analyses were performed according to the American Joint Committee on Cancer (AJCC) stage. The Cox regression model was used to identify the risk factors for SPM and evaluate their effects.

Results

We enrolled 85,947 eligible patients with BC, and 2,656 (3.09%) patients developed SPM. The median duration of SPM was 2.70 (1.14-5.14) years. Radiotherapy was administered in 40,946 (47.64%) patients, and chemotherapy was administered in 52,120 (60.64%). The most common SPMs were digestive tract cancers (876, 31.89%). The risk factors for SPM included the AJCC stage, chemotherapy, radiotherapy, age, and underlying comorbidities. Neither chemotherapy nor radiotherapy was associated with an increased risk of SPM in any stage. In contrast, after adjusting for other risk factors, patients at stage III/IV who received both therapies had lower risks of SPM compared with those who did not (p = 0.047).

Conclusion

The risk of SPM was different across BC stages. Neither chemotherapy nor radiotherapy was associated with an increased risk of SPM in women with BC.

Look how far we have come: BREAST cancer detection education on the international stage

The development of screening mammography over 30 years has remarkedly reduced breast cancer-associated mortality by 20%-30% through detection of small cancer lesions at early stages. Yet breast screening programmes may function differently in each nation depending on the incidence rate, national legislation, local health infrastructure and training opportunities including feedback on performance. Mammography has been the frontline breast cancer screening tool for several decades; however, it is estimated that there are 15% to 35% of cancers missed on screening which are owing to perceptual and decision-making errors by radiologists and other readers. Furthermore, mammography screening is not available in all countries and the increased speed in the number of new breast cancer cases among less developed countries exceeds that of the developed world in recent decades. Studies conducted through the BreastScreen Reader Assessment Strategy (BREAST) training tools for breast screening readers have documented benchmarking and significant variation in diagnostic performances in screening mammogram test sets in different countries. The performance of the radiologists from less well-established breast screening countries such as China, Mongolia and Vietnam were significant lower in detecting early-stage cancers than radiologists from developed countries such as Australia, USA, Singapore, Italy. Differences in breast features and cancer presentations, discrepancies in the level of experiences in reading screening mammograms, the availability of high-quality national breast screening program and breast image interpretation training courses between developed and less developed countries are likely to have impact on the variation of readers' performances. Hence dedicated education training programs with the ability to tailor to different reader cohorts and different population presentations are suggested to ameliorate challenges in exposure to a range of cancer cases and improve the interpretation skills of local radiologists. Findings from this review provide a good understanding of the radiologist' performances and their improvement using the education interventions, primarily the BREAST program, which has been deployed in a large range of developing and developed countries in the last decade. Self-testing and immediate feedback loops have been shown to have important implications for benchmarking and improving the diagnostic accuracy in radiology worldwide for better breast cancer control.

Characteristics and chronologically changing patterns of late-onset breast cancer in Korean women of age ≥ 70 years: A hospital based-registry study

BACKGROUND

Women from Asian and western countries have vastly different ages of onset of breast cancer, with the disease tending to occur at an older age in the West. Through an investigation of the patterns of old-onset breast cancer (OBC) in Korean women, we aimed to identify the characteristics of Korean OBC and evaluate whether these patterns are changing in relation to increasing westernization.

METHODS

This study retrospectively evaluated 102,379 patients who underwent surgical treatment of primary breast cancer between January 1, 2000 and December 31, 2013 in Korea. We used hospital -based breast cancer registry and analyzed data from these patients using multiple linear regression analysis to compare the characteristics and chronologically changing patterns between OBC (70 years of age or older) and non-OBC (40-69 years of age) patients in Korea.

RESULTS

A total of 6% of the 102,379 patients had OBC. Overall, OBC had more favorable biological features, such as a higher incidence of luminal A subtype, than did non-OBC, except for a higher incidence rate of triple-negative breast cancer (TNBC). However, OBC also presented with a higher overall disease stage, including higher T and M stages. Although the incidence rates of both OBC and non-OBC have increased overtime, the relative proportion of OBC patients has slightly increased, whereas that of non-OBC has slightly decreased. The increase in the incidence of both OBC and non-OBC was primarily due to the luminal A subtype.

CONCLUSIONS

Based on a hospital-based registry, overall, Korean OBC had favorable biological features but showed a higher rate of TNBC and advanced cancer stages. The incidence trend of breast cancer in Korea is slowly shifting toward an older age at onset, largely due to the luminal A subtype. Our results may provide novel insights into OBC in Asia, and aid in the development of optimal management of the disease in Asia.

TRIAL REGISTRATION

Retrospectively registered.

Birth Cohort Effects in Breast Cancer Incidence: Global Patterns and Trends

Breast cancer is the most common neoplasm in the world among women. The age-specific incidences and onset ages vary widely between Asian and Western countries/regions. Invasive breast cancer cases among women from 1997 to 2011 were abstracted from the International Agency for Research on Cancer and the Taiwan Cancer Registry. Age-period-cohort analysis was performed to examine the trends. The cohort effect was prominent in South Korea, Taiwan, Japan, and Thailand, possibly related to the timing of westernization. The risk of breast cancer initially rose with the birth cohorts in Hong Kong and India (both former British colonies), peaked, and then declined in recent birth cohorts. Unlike other Asian countries/regions, virtually no birth cohort effect was identified in the Philippines (a Spanish colony in 1565 and the first Asian country to adopt Western cultural aspects). Moreover, an at-most negligible birth cohort effect was identified for all ethnic groups (including Asian immigrants) in the United States. This global study identified birth cohort effects in most Asian countries/regions but virtually no impact in Western countries/regions. The timing of westernization was associated with the birth cohort effect.

Forecast of a future leveling of the incidence trends of female breast cancer in Taiwan: an age-period-cohort analysis

Breast cancer is the most common cancer among women in Taiwan. The age-standardized incidence rate has doubled in just 20 years, causing considerable concern to health professionals and the general public. This study used an ensemble of age-period-cohort models to estimate breast cancer incidence trends in Taiwan from 1997 to 2016 and project trends up to 2035. The (truncated) world standard population (World Health Organization 2000) proportions (age groups: 25–29, 30–34, …, 80–84, and older than 85 years) were used to calculate age-standardized incidence rates. The age-standardized incidence rate from 1997 (60.33/100,000 population) to 2016 (128.20/100,000 population) increased rapidly. The projection is that the increase in the age-standardized incidence will subsequently slow and exhibit a plateau in 2031 (151.32/100,000 population). From 2026 to 2035, the age-specific incidence rates for women older than 55 years old (postmenopausal breast cancer) are projected to increase with larger percentage increments for older women. A future leveling of female breast cancer incidence trends in Taiwan is anticipated. The majority of the patients with breast cancer in the future will be women aged 55 years and older. Education on lifestyle recommendations and mammography screening is required to reduce the burden of breast cancer. The results should have implications for other countries which are also confronted with the same public health problem of rapidly increasing breast cancer incidences.

Potential Pro-Tumorigenic Effect of Bisphenol A in Breast Cancer via Altering the Tumor Microenvironment

Simple Summary

Bisphenol A (BPA) is primarily used to produce polycarbonate plastics, such as water bottles. Exposure to BPA has been shown to increase the growth of breast cancer cells that depend on estrogen for growth due to its ability to mimic estrogen. More recent studies have suggested that BPA also affects the cellular and non-cellular components that compose tumor microenvironments (TMEs), namely the environment around a tumor, thereby potentially promoting breast cancer growth via altering the TME. The TME plays an essential role in cancer development and promotion. Therefore, it is crucial to understand the effect of BPA on breast TMEs to assess its role in the risk of breast cancer adequately. This review examines the potential effects of BPA on immune cells, fibroblasts, extracellular matrices, and adipocytes to highlight their roles in mediating the carcinogenic effect of BPA, and thereby proposes considerations for the risk assessment of BPA exposure.

Abstract

BPA, a chemical used in the preparation of polycarbonate plastics, is an endocrine disruptor. Exposure to BPA has been suggested to be a risk factor for breast cancer because of its potential to induce estrogen receptor signaling in breast cancer cells. More recently, it has been recognized that BPA also binds to the G protein-coupled estrogen receptor and other nuclear receptors, in addition to estrogen receptors, and acts on immune cells, adipocytes, and fibroblasts, potentially modulating the TME. The TME significantly impacts the behavior of cancer cells. Therefore, understanding how BPA affects stromal components in breast cancer is imperative to adequately assess the association between exposure to BPA and the risk of breast cancer. This review examines the effects of BPA on stromal components of tumors to highlight their potential role in the carcinogenic effect of BPA. As a result, I propose considerations for the risk assessment of BPA exposure and studies needed to improve understanding of the TME-mediated, breast cancer-promoting effect of BPA.

Relationship between the type of hormone replacement therapy and incidence of breast cancer in Korea

OBJECTIVE

This study aimed to investigate the relationship between hormone replacement therapy (HRT) types and breast cancer (BC) incidence in postmenopausal women in Korea.

METHODS

The nested case-control study used data from the National Health Insurance Service database. Among the women aged ≥50 years who menopaused between 2004 and 2007, BC incidence up to 2017 was analyzed in 36,446 women using or having used HRT for >1 year and in 36,446 women who did not use any HRT for more than 1 year. HRT types and duration were classified into three categories.

RESULTS

BC risk (BCR) decreased with tibolone use for all ages. With HRT initiation in women aged ≥50 years, BCR was lower with tibolone and estrogen-progestogen therapy. HRT for <3 years showed lower BCR with tibolone, while higher BCR was observed with estrogen-only therapy. BCR was lower in women of all ages on HRT for >5 years than in the control group.

CONCLUSIONS

For women in their 50s, tibolone use lowers BCR; for all ages, the use of any HRT for >5 years showed lower BCR in Korea. These divergent results from western countries could be associated with the specific characteristics of BC in Korea.

Breast cancer incidence and predictions (Monastir, Tunisia: 2002–2030): A registry-based study

Introduction

Breast cancer is a major public health problem worldwide. It is the leading cause of cancer deaths in females. In developing countries like Tunisia, the frequency of this cancer is still growing. The aim of this study was to determine the crude and standardized incidence rates, trends and predictions until 2030 of breast cancer incidence rates in a Tunisian governorate.

Methods

This is a descriptive study including all female patients diagnosed with breast cancer in Monastir between 2002 and 2013. The data were collected from the cancer register of the center. Tumors were coded according to the 10^th version of international classification of disease (ICD-10). Trends and predictions until 2030 were calculated using Poisson linear regression.

Results

A total of 1028 cases of female breast cancer were recorded. The median age of patients was 49 years (IQR: 41–59 years) with a minimum of 16 years and a maximum of 93 years. The age-standardized incidence rate (ASR) was of 39.12 per 100000 inhabitants. It increased significantly between 2002 and 2013 with APC of 8.4% (95% CI: 4.9; 11.9). Prediction until 2030 showed that ASR would reach 108.77 (95% CI: 57.13–209.10) per 100000 inhabitants.

Conclusion

The incidence and the chronological trends of breast cancer highlighted that this disease is of a serious concern in Tunisia. Strengthening preventive measures is a primary step to restrain its burden.

Improvement of survival in Korean breast cancer patients over a 14-year period: A large-scale single-center study

Purpose

The aim of this study was to evaluate the chronological changes over 14 years in the survival of Korean patients with breast cancer. We also sought to investigate the factors that may have influenced the changes in survival rate.

Materials and methods

We retrospectively analyzed 17,776 breast cancer patients who were treated at Asan Medical Center between January 2000 and December 2013. Patient information was collected from the Asan database, including age at diagnosis, clinical manifestation, pathology report, types of treatment and modality, types of recurrence, and follow-up period. We classified the patients into two cohorts according to the year of their surgery (P1: 2000–2007 and P2: 2008–2013) and compared survival and recurrence between both cohorts.

Results

We observed that patients treated more recently had better survival outcomes. The 5-year breast cancer-specific survival increased from 94.0% in P1 to 96.6% in P2 (p<0.001), and the 5-year disease-free survival increased from 87.9% in P1 to 91.2% in P2 (p<0.001). When analyzed by type of recurrence, distant metastasis-free survival increased to a significant degree. In subgroup analysis by the subtypes of breast cancer, the survival rates improved in all of the subtypes except triple negative breast cancer, and the improvement was more prominent in subtypes with overexpressed human epidermal growth factor receptor 2.

Conclusion

This study showed improvement in breast cancer survival over the succeeding years, which is consistent with the advancement in systemic therapy.

Breast cancer incidence trends in Asian women aged 20 or older as compared to other ethnic women in the United States from 2000 to 2018 by time period, age and tumor stage

BACKGROUND

After new cancer data are released in April 2021, it is important to update the incidence trend in breast cancer from 2000 to 2018 and focus on ethnic disparities in the risk of developing breast cancer.

METHODS

We identified 1129,564 women who were diagnosed with incident breast cancer at age ≥ 20 in 2000-2018 from 18 SEER (Surveillance, Epidemiology, and End Results) registries. We utilized the SEER*Stat software to calculate age-adjusted incidence rates.

RESULTS

Overall age-adjusted incidence rate of breast cancer was the highest in non-Hispanic white (NHW) women (190.4 cases per 100,000 women), followed by NH-black (NHB) (178.4), Asian/Pacific-Islanders (API) (141.3), Hispanic (133.3) and American-Indians/Alaska-Native (AIAN) women (128.8). Annual percentage change (APC) from 2000 to 2018 showed that annual increase was statistically significant for API (APC: 1.0, 95% CI: 0.8-1.3), NHB (APC: 0.5, 0.2-0.7), AIAN (1.6, 1.1-2.2), and Hispanic women (0.4, 0.2-0.7), but annual percentage of incidence did not significantly decrease for NHW (-0.1, -0.4 to -0.1). Incidence rates of hormone-receptor positive breast cancer increased from 2000 to 2018 in all ethnic women, while incidence rates of hormone-receptor negative breast cancer decreased. NHW and NHB women had a significantly higher risk of having breast cancer than API women. In 2012-2018, the risks of having local stage and distant stage breast cancer for NHW (1.31, 1.29-1.33 and 1.19, 1.16-1.21) and NHB (1.09, 1.07-1.11 and 1.31, 1.28-1.35) women were significantly higher than that of API women.

CONCLUSIONS

The incidence of hormone-receptor positive breast cancer increased in all ethnic women from 2000 to 2018 while the incidence of hormone-receptor negative breast cancer decreased. There were still substantial racial disparities in breast cancer incidences.

Clinicopathological characteristics and treatment outcomes of luminal B1 breast cancer in Taiwan

BACKGROUND

Hormone receptor-positive, human epidermal growth factor receptor II (HER2)-negative luminal B1 breast cancer is associated with a higher risk of disease relapse than luminal A breast cancer. Therefore, we assessed and compared the distant metastasis pattern and clinical outcomes associated with luminal B1 and luminal A breast cancer in an Asian population.

METHODS

In this observational study, we assessed patients with estrogen receptor-positive, HER2-negative breast cancer who underwent surgery from 2009 to 2016. Patients were classified into luminal A or luminal B1 subsets via immunohistochemical analysis. Disease-free survival, post-metastasis survival, and overall survival were estimated; time to disease relapse and patterns of distant metastasis were compared. Risk of relapse and mortality were assessed using Cox proportional hazards model.

RESULTS

Patients with luminal B1 breast cancer (n = 677) were significantly younger and had larger tumors and a higher degree of affected axillary lymph nodes, lymphovascular invasion, and tumor necrosis than those with luminal A breast cancer (n = 630). Higher rates of local recurrence and distant metastasis were observed for luminal B1 (both p < 0.05); however, no difference was observed in the specific distant metastatic sites. We observed a significant increase in disease relapse risk in luminal B1 patients compared with that in luminal A (hazard ratio: 2.157, 95% CI: 1.340-3.473, p < 0.05). Patient age, tumor size, stage, lymphovascular invasion, and receiving chemotherapy and hormone therapy were independent risk factors for metastasis and recurrence. Only the luminal B1 subtype (hazard ratio: 5.653, 95% CI: 1.166-27.409, p < 0.05) and stage (hazard ratio: 3.400, 95% CI: 1.512-7.649, p < 0.05) were identified as independent risk factors for post metastatic mortality.

CONCLUSION

Luminal B1 breast cancer has aggressive tumor biology compared with luminal A breast cancer in the follow-up period. However, there was no significant difference in the disease relapse pattern between the groups.

Comparison of clinicopathological characteristics and prognosis in breast cancer patients with different Breast Imaging Reporting and Data System categories

Purpose

The Breast Imaging Reporting and Data System (BI-RADS) is a systematic and standardized scheme of the radiological findings of breast. However, there were different BI-RADS categories between breast cancers as the clinical characteristics in previous studies. We analyzed the association of BI-RADS categories with the clinicopathological characteristics and prognosis of breast cancer.

Methods

A total of 44,184 patients with invasive breast cancers assigned to BI-RADS category 3, 4, or 5 in preoperative mammography or ultrasonography were analyzed retrospectively using large-scale data from the Korean Breast Cancer Society registration system. The difference in the clinicopathological factors and prognoses according to the BI-RADS categories (BI-RADS 3–4 and BI-RADS 5) were compared between the mammography and ultrasonography groups. Comparisons of the clinicopathological factors in both groups were made using logistic regression analysis, while the prognoses were based on the breast cancer-specific survival using the Kaplan-Meier method and Cox proportional hazards model.

Results

The factors associated with BI-RADS were T stage, N stage, palpability, histology grade, and lymphovascular invasion in the mammography group; and N stage, palpability, histology grade, and lymphovascular invasion in the ultrasonography group. In the survival analysis, there were significant differences in the breast cancer-specific survival of the BI-RADS category groups in both of the mammography (hazard ratio [HR], 3.366; P < 0.001) and ultrasonography (HR, 2.877; P < 0.001) groups.

Conclusion

In this study, the BI-RADS categories of preoperative mammography and ultrasonography of patients with invasive breast cancer were associated with prognosis and could be an important factor in making treatment decisions.

Increasing Mortality in Korean Patients With Breast Cancer: High Mortality Rate in Elderly Breast Cancer Population Due to Suboptimal Treatment and Other Diseases

Background

The incidence of breast cancer in Asia, including Korea, has rapidly increased. Each country has shown different clinical features. This study presents a comprehensive understanding of breast cancer in different age groups in Korea and determines potential measures for improving patient survival.

Methods

Patients diagnosed with invasive breast cancer stages I to III with available clinicopathologic and follow-up data were included in the study. Kaplan–Meier survival graphs were generated for each group and compared using log-rank test. The hazard ratio for each risk factor was calculated using the Cox regression model and the 95% confidence interval.

Results

The final cohort included 833 patients with a mean age of 51.3±11.3 years (range, 22–89 years), and 191 (22.9%) of them were aged >60 years. Patients aged ≥60 years had worse overall survival (OS) and distant disease-free survival than those aged <60 years. Although no difference was observed in the tumor biology, elderly patients showed significant differences in practice patterns: they tended to undergo mastectomy (40.2% vs 62.8%, P<0.001), did not receive the standard chemotherapy (88.4% vs 69.3%, P < 0.001), and had a higher risk of developing second primary cancer or diseases other than breast cancer (1.2% vs 6.8%, P < 0.001), which significantly correlated with poor survival in elderly patients.

Conclusion

Less-than-the-standard treatment of care or development of a second primary disease resulted in poor prognosis in elderly patients in Korea. A multi-institutional and multinational study is warranted to elucidate the clinical features of breast cancer in Asian patients.

Impact of Birth Cohorts in Breast Cancer Risk Among South Korean Women

BACKGROUND

The incidence of breast cancer among South Korean women, a historically low-risk population, has increased over the past 3 decades, with marked changes in socioeconomic environment by birth cohort.

OBJECTIVES

We investigated associations between breast cancer risk and reproductive factors as well as the impact of birth cohort in those associations.

METHOD

This was a cross-sectional study of data from the Korea National Health and Nutrition Examination Survey for 2013-2016. Data from 10 012 parous women 30 years or older were analyzed using descriptive statistics and Cox multivariate regression after adjusting for socioeconomic status, educational level, occupation, and birth cohort.

RESULTS

Of the reproductive factors considered-age at menarche, number of pregnancies, age at first birth, age at last birth, breastfeeding duration, and use of oral contraceptives-only age at menarche was associated with breast cancer risk. Higher educational level, not having an occupation, and younger birth cohort were also associated with increased risk of breast cancer, with birth cohort the strongest of these impact factors.

CONCLUSION

Whereas the relationship between reproductive factors and breast cancer risk was relatively weak, birth cohort was the most important risk factor for breast cancer.

IMPLICATIONS FOR PRACTICE

The results provide a basis and a rationale for developing birth cohort-based clinical guidelines for breast cancer prevention and early detection, treatment, and survivorship. These findings should also be useful to researchers in other countries experiencing rapid changes in breast cancer incidence.

Age-specific incidence rates of breast cancer among Japanese women increasing in a conspicuous bimodal distribution pattern

Breast cancer incidence rates are increasing in East and Southeast Asia, along with the westernisation of reproductive and lifestyle patterns. Such westernisation is thought to be involved in the cumulative exposure of breast tissue to both endogenous and exogenous oestrogen. Immigrant studies among Asian American women indicate that risk factors for breast cancer can be modified. When breast cancer incidence rates were compared with those of corpus uteri and colon among Japanese women in 2005, 2010 and 2015, it is of note that age-specific incidence rates of breast cancer in 5-year age groups clearly increased during the 10-year period in a bimodal distribution pattern, with two peaks in the 45–49 and 60–64 years age groups. From the relevant literature, it is inferred that the low prevalence of obesity and the intake of soy products or isoflavones among Japanese women may contribute to the bimodal distribution pattern by suppressing the extent of increase in breast cancer incidence rates among Japanese postmenopausal women. With regard to dietary habits relating to obesity, it has been globally reported that the intake of high-calorie foods is associated with the incidence of oestrogen receptor-positive breast cancer in both pre- and postmenopausal women, while high-carbohydrate or -milk intake that can enhance the secretion of insulin or insulin-like growth factor 1 is associated with that of oestrogen receptor-negative breast cancer mostly in postmenopausal women. Studies are needed to clarify the aetiology or modifiable factors behind the bimodal incidence rates of breast cancer among Japanese women.

Clinicopathological and Molecular Analysis of 45 Cases of Pure Mucinous Breast Cancer

Pure mucinous breast carcinoma (PMBC) is characterized by clusters of tumor cells floating in abundant extracellular mucin and can be classified into paucicellular (Type A) and hypercellular (Type B) subtypes. However, the clinicopathological and genomic differences between these two subtypes have not been well characterized. We retrospectively investigated the clinicopathologic features of 45 cases of surgically removed PMBC (31 Type A and 14 Type B). We also performed whole-exome sequencing (WES) in eight cases of PMBC. We found that Type B PMBC occurs at an older age and shows more aggressive clinical behavior than Type A. WES analysis revealed that HYDIN was the most frequently mutated gene in both types of PMBC. Although Type B PMBC showed a tendency toward more frequent genetic alterations, there were no statistically significant differences between the two subtypes in single nucleotide variants or insertions or deletions of bases associated with moderate or high effects. Our results provide additional evidence that PMBCs are clinicopathologically and genetically heterogeneous and lack pathognomonic genetic alterations. Further, Type B PMBC is more frequently associated with lymph node metastasis than Type A.

The Vascular Effects of Isolated Isoflavones-A Focus on the Determinants of Blood Pressure Regulation

Isoflavones are phytoestrogen compounds with important biological activities, including improvement of cardiovascular health. This activity is most evident in populations with a high isoflavone dietary intake, essentially from soybean-based products. The major isoflavones known to display the most important cardiovascular effects are genistein, daidzein, glycitein, formononetin, and biochanin A, although the closely related metabolite equol is also relevant. Most clinical studies have been focused on the impact of dietary intake or supplementation with mixtures of compounds, with only a few addressing the effect of isolated compounds. This paper reviews the main actions of isolated isoflavones on the vasculature, with particular focus given to their effect on the determinants of blood pressure regulation. Isoflavones exert vasorelaxation due to a multitude of pathways in different vascular beds. They can act in the endothelium to potentiate the release of NO and endothelium-derived hyperpolarization factors. In the vascular smooth muscle, isoflavones modulate calcium and potassium channels, leading to hyperpolarization and relaxation. Some of these effects are influenced by the binding of isoflavones to estrogen receptors and to the inhibition of specific kinase enzymes. The vasorelaxation effects of isoflavones are mostly obtained with plasma concentrations in the micromolar range, which are only attained through supplementation. This paper highlights isolated isoflavones as potentially suitable alternatives to soy-based foodstuffs and supplements and which could enlarge the current therapeutic arsenal. Nonetheless, more studies are needed to better establish their safety profile and elect the most useful applications.

Impact of Educational Level and Family income on Breast Cancer Awareness among College-Going Girls in Shillong (Meghalaya), India

Background:

Breast cancer (BC) is the most common cancer among women in India and shows an increasing trend. The mammography screening seems unfeasible as a public health service in India. Thus, breast self-examination (BSE), followed by clinical breast examination (CBE), is the affordable method to downstage BC. A cross-sectional study was conducted with senior school and college-going girls in Shillong (Meghalaya) to study the impact of girls’ academic level and family income on breast cancer knowledge and the prevalence of BC’s known risk factors in girls.

Methods:

A self-administered questionnaire was employed to collect relevant information. The data were analysed using statistical software SPSS version 22. The categorical data presented as frequency (%) and the comparison made using Chi-square or Fisher exact test.

Results:

(i) 78.2% girls knew about breast cancer, 19.2% of these were aware of BSE, and 22.9% of BSE knowing ever performed it (ii) Awareness of breast cancer and BSE, and its practice is significantly associated with their academic level and family income (iii) The consumption of alcohol beverages and physical activity of girls was positively associated with educational level and family income (iv) Body mass index (BMI) was weakly associated with family income with an insignificant relationship with academic level (v) oily food consumption related inversely with the level of education irrespective of family income (vi) there was a positive correlation between parents education and family income.

Conclusions:

The results show a severe lack of breast cancer knowledge in senior school and college-going girls under the survey. To spread community awareness, we suggest a public health policy-driven educational intervention through culturally relevant mass/social media on the risk factors of breast cancer and practice of BSE. It is also recommended that dedicated facilities be created for breast cancer early diagnosis in the public health system.

Contrasting Epidemiology and Clinicopathology of Female Breast Cancer in Asians vs the US Population

BACKGROUND

The incidence of breast cancer among younger East Asian women has been increasing rapidly over recent decades. This international collaborative study systemically compared the differences in age-specific incidences and pathological characteristics of breast cancer in East Asian women and women of predominantly European ancestry.

METHODS

We excerpted analytic data from six national cancer registries (979 675 cases) and eight hospitals (18 008 cases) in East Asian countries and/or regions and, for comparisons, from the US Surveillance, Epidemiology, and End Results program database. Linear regression analyses of age-specific incidences of female breast cancer and logistic regression analyses of age-specific pathological characteristics of breast cancer were performed. All statistical tests were two-sided.

RESULTS

Unlike female colorectal cancer, the age-specific incidences of breast cancer among East Asian women aged 59 years and younger increased disproportionally over recent decades relative to rates in US contemporaries. For years 2010-2014, the estimated age-specific probability of estrogen receptor positivity increased with age in American patients, whereas that of triple-negative breast cancer (TNBC) declined with age. No similar trends were evident in East Asian patients; their probability of estrogen receptor positivity at age 40-49 years was statistically significantly higher (odd ratio [OR] = 1.50, 95% confidence interval [CI] = 1.36 to 1.67, P < .001) and of TNBC was statistically significantly lower (OR = 0.79, 95% CI = 0.71 to 0.88, P < .001), whereas the probability of ER positivity at age 50-59 years was statistically significantly lower (OR = 0.88, 95% CI = 0.828 to 0.95, P < .001). Subgroup analyses of US Surveillance, Epidemiology, and End Results data showed similarly distinct patterns between East Asian American and white American patients.

CONCLUSIONS

Contrasting age-specific incidences and pathological characteristics of breast cancer between East Asian and American women, as well as between East Asian Americans and white Americans, suggests racial differences in the biology.

Association of physical activity, body mass index and reproductive history with breast cancer by menopausal status in Iranian women

BACKGROUND

The incidence rate of breast cancer (BC) is increasing in low- and middle-income countries (LMICs), including Iran. We investigated the association between BC risk and physical activity (PA), body mass index (BMI), and reproductive history among Iranian women.

METHODS

We conducted a large hospital-based case-control study and compared 958 BC cases with 967 controls at the Cancer Institute of Iran during 2011-2016. We used multiple logistic regression models and adjusted for potential confounders to estimate odds ratios (ORs) and 95% confidence intervals (95%CIs) for the associations between BC and different risk factors, including low physical activity.

RESULTS

Women with high levels of physical activity had a lower risk of BC compared to those who were inactive (OR = 0.55, 95%CI: 0.41, 0.75). In premenopausal women, the association was observed only in normal-weight women (OR = 0.31, 95%CI: 0.13, 0.75), while it was limited to obese women in the postmenopausal group (OR = 0.29, 95%CI: 0.12, 0.66). We found a high risk of postmenopausal BC among overweight (OR = 1.69; 95%CI: 1.01, 2.81) and obese women (OR = 1.9; 95%CI: 1.14, 3.14) compared to women with a normal BMI. We observed an inverse association among postmenopausal women who had between three and five children (OR = 0.31, 95%CI 0.14, 0.64) and more than six children (OR = 0.21, 95%CI 0.12, 0.42) compared to nulliparous women.

CONCLUSIONS

Low levels of physical activity, low parity, and being overweight or obese were major risk factors for BC. For the first time, we report a strong association between physical activity and BC risk in Iranian women.

History of Diabetes Mellitus and Risk of Breast Cancer in Asian Women: A Meta-Epidemiological Analysis of Population-Based Cohort Studies

Objectives

Previous quantitative systematic reviews conducting subgroup analyses by race have reported that the association between diabetes and breast cancer in Asian women was inconclusive. The aim of this meta-epidemiological study (MES) was to evaluate this association from additional population-based cohort studies.

Methods

The potential subjects of this MES were six Asian cohort studies selected by previous systematic reviews. Additional reports were found from the selected articles using citation discovery tools. The study with the longest follow-up period was selected among prospective studies of the same cohorts. A summary relative risk (sRR) and its 95% confidence intervals (CI) were calculated using random effect models.

Results

Four cohort studies on Asian women were finally selected. The participants were from the women population of Korea, Japan, China, and Taiwan and included a total of 1,448,254 women. The sRR (95% CI) (I-squared value) was 1.20 (0.98–1.46) (63.1%).

Conclusions

This MES found that the history of diabetes mellitus was not associated with the risk of breast cancer in Asian women. As breast cancer in this population develops at a younger age, additional cohort studies are necessary to conduct a subgroup analysis by menopausal status at diagnosis of breast cancer in Asian women.

Hormone Replacement Therapy, Breast Cancer Risk Factors, and Breast Cancer Risk: A Nationwide Population-Based Cohort

BACKGROUND

Hormone replacement therapy (HRT) increases the risk of breast cancer, but the association may vary according to patient factors. We investigated the association between HRT and breast cancer in a nationwide cohort with risk stratification according to risk factors for breast cancer.

METHODS

Using the Korean National Health Insurance Service database, 4,558,376 postmenopausal women who underwent breast cancer screening and regular health checkups from 2009 to 2014 were analyzed.

RESULTS

A total of 696,084 (15.3%) women reported current or previous HRT use. Breast cancer was newly diagnosed in 26,797 (0.6%) women during a median follow-up of 5.35 years. The HR of the risk of breast cancer in HRT users was 1.25 [95% confidence interval (CI), 1.22-1.29] compared with HRT nonusers. The risk of breast cancer increased according to HRT duration [adjusted HR = 1.08; 95% CI, 1.04-1.12, for <2 years; adjusted HR = 1.33; 95% CI, 1.25-1.40, for 2 to <5 years; and adjusted HR = 1.72; 95% CI, 1.63-1.82, for ≥5 years). The effects of HRT on breast cancer risk applied to both invasive and in situ cancer. The HRT-related risk of breast cancer was higher in women who were leaner and those who had dense breasts.

CONCLUSIONS

This nationwide population-based study confirms the association between HRT use and breast cancer risk. The risk increased proportionally with duration of HRT and differed according to body weight and breast density.

IMPACTS

Risk stratification would be useful when deciding whether to apply HRT for relief of menopausal symptoms.

Disparity in Tumor Immune Microenvironment of Breast Cancer and Prognostic Impact: Asian Versus Western Populations

BACKGROUND

The clinicopathological features and prognosis of breast cancer in Asia are different from those in the Western countries. Tumor-infiltrating immune cells can influence the outcome of patients with breast cancer, but they have not been systemically evaluated in Asian patients with breast cancer.

METHODS

We compared the immune score, composition, and prognostic impact of infiltrating immune cells between Asian and Western patients with breast cancer by analyzing gene expression profiles from eight Gene Expression Omnibus data sets and The Cancer Genome Atlas data set. The Estimation of Stromal and Immune Cells in Malignant Tumours Using Expression Data (ESTIMATE) and Cell Type Identification by Estimating Relative Subsets of Known RNA Transcripts (CIBERSORT) algorithms were used to determine the immune score and composition of tumor-infiltrating immune cells, respectively.

FINDINGS

This study included 462 Asian patients and 2,186 Western patients. Tumors of Asian patients had significantly higher immune score, particularly in the luminal B and HER2-enriched subtypes. High immune score was associated with favorable prognosis in both Asian and Western patients, and Asian race with a high ESTIMATE immune score provided additional power to predict longer disease-free survival. Activated CD4 T cells and M2 macrophages were the most strongly associated with survival in both Asian and Western patients.

INTERPRETATION

Our study highlights the difference in tumor immune microenvironments between Asian and Western patients. The higher ESTIMATE immune score, which represents more abundant tumor-infiltrating immune cells, in tumors of Asian patients partly explains their favorable prognosis.

IMPLICATIONS FOR PRACTICE

The tumor microenvironment serves as an interface that affects the human body's reaction to cancer cells. Evidence has revealed that tumor-infiltrating immune cells were associated with patient prognosis. This study demonstrated the disparity of tumor microenvironments and their prognostic impact between Asian and Western patients with breast cancer. The differences in immune score partially explained the racial survival differences noted in recent studies. Integrated analysis of tumor cells, tumor microenvironment, and racial effect may significantly improve recurrence risk prediction for patients with stage I-III breast cancer. Because the effect of tumor microenvironment varies across different populations, a model of interaction between immune score and race/ethnicity is recommended in accessing the risk of patients with cancer.

Post-traumatic stress symptoms and social constraints in the communication with family caregivers among Chinese-speaking breast cancer survivors

PURPOSE

The consequences of breast cancer on physical and psychological well-being have been extensively studied. One of the long-term effects of the disease is Post-Traumatic Stress Symptoms (PTSS). However, only a small number of studies examined PTSS among Chinese-speaking breast cancer survivors. This study investigated interpersonal and physical health predictors of PTSS and explored sociodemographic and clinical factors linked to PTSS in this group. We hypothesized that higher levels of social constraints and lower levels of social support, relationship closeness, and physical health would be associated with higher levels of PTSS.

METHODS

A sample of 96 Chinese-speaking breast cancer survivors completed measures of PTSS, social constraints, social support, closeness, health-related quality of life, and acculturation. Bivariate correlation examined association between variables of interest. Then, a hierarchical multiple regression analysis was conducted to examine predictors of PTSS.

RESULTS

Participants reported an average score of 14.7 (SD = 10.46, range 0-44) on the severity of PTSS, with 54.2% (N = 52) meeting the criteria for likelihood of PTSD. PTSS were positively associated with social constraints and negatively associated with social support, closeness, and physical health. More medication usage was linked to worse PTSS. Only social constraints in the ability to communicate cancer-related concerns to the caregiver predicted worse PTSS severity.

CONCLUSIONS

The study unveils the role of interpersonal factors in mental health outcomes of Chinese-speaking breast cancer survivors. Future research should be conducted on larger samples and culturally relevant psychosocial interventions should be developed.

Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: an Example from Tanzania

While more than 90% of breast cancer patients in western countries survive for at least 5 years, the survival rate in Tanzania is less than 45% because of late stage at presentation. The aim of this study was to identify patient and health system factors related to early or late stages of a breast cancer diagnosis. The study was conducted at the Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania, and included interviews with 196 breast cancer patients diagnosed with early (stage I/II, n = 44) or late (stage III/IV, n = 152) stage who were referred to ORCI from January 2016 to August 2018. The questionnaire elicited information regarding disease history, sociodemographics, barriers to navigating the health system, and patient attitudes towards breast cancer. More early-stage patients (54.5%) stated history of previous breast examinations before their initial diagnosis compared to late-stage patients (19.7%) (p = < 0.001). Financial restraints were cited more often as barriers to diagnosis among late-stage presentation patients (55.7%) compared to early-stage patients (35.5%) (p = 0.047). Patients who were diagnosed at late-stage (47.5%) were also more likely to state time restraints as significant barriers to their diagnosis than early-stage patients (25.8%) (p = 0.041). Although the late diagnosis of breast cancer will take immense efforts of policy workers to resolve, this study offers significant opportunities for making immediate health system changes through patient and physician education that can aid in reducing diagnosis delay in Tanzania other low-income developing countries, and low-income communities within the USA.

Prevalence of Molecular Subtypes of Breast Cancer: A Single Institutional Experience of 2062 Patients

Objective

The aim of the study was to analyze the prevalence of molecular subtypes of all breast cancer patients treated at tertiary cancer centre in West India in 12 years.

Materials and Methods

A retrospective observational study carried out in Tertiary Cancer Care Centre in Western India. Electronic medical records of all breast cancer patients were retrieved from the hospital database between March 2007 to March 2019. Patient's characteristic, histological features and molecular subtypes were collected and analyzed.

Results

A total of 2062 women fulfilled the criteria for this study and were analyzed. The median age of study population was 51 years (range 22-100 years). Among these, 1357 (65.8%) were of ≤55 years and 705 (34.2%) were over 55 years. The overall incidence of Hormonal Receptor-positive patients (either estrogen-receptor (ER) or progesterone-receptor (PR) or both) was 1162 (56.4%). The Mean tumor size was 3.8cm (range 0-18cm). The most common histology was IDC (96%). Axillary nodes were positive in 62.5%. Luminal type A was positive in 762 (37%) patients while Luminal type B was present in 157 (7.6%) patients. Basal-like subtype was observed in 537 (26%) patients while HER2 rich subtype was seen in 229 (11.1%). The incidence of Luminal A subtype increased with age. The highest observed among patients (72%) aged 70 years or more. Incidence of Basal like subtype was highest in patients less than 30 years (52%).

Conclusion

Luminal-like disease is the most common molecular subtype in India. Identification of Basal like breast cancer, a highly aggressive, biologically and clinically distinct subtype different than its non-basal variant, is important for treatment planning and target therapy.

Comparison of GenesWell BCT Score With Oncotype DX Recurrence Score for Risk Classification in Asian Women With Hormone Receptor-Positive, HER2-Negative Early Breast Cancer

Introduction: The GenesWell Breast Cancer Test (BCT) is a recently developed multigene assay that predicts the risk of distant recurrence in patients with early breast cancer. Here, we analyzed the concordance of the BCT score with the Oncotype DX recurrence score (RS) for risk stratification in Asian patients with pN0-N1, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer.

Methods: Formalin-fixed, paraffin-embedded breast cancer tissues previously analyzed using the Oncotype DX test were assessed using the GenesWell BCT test. The risk stratification by the two tests was then compared.

Results: A total of 771 patients from five institutions in Korea were analyzed. According to the BCT score, 527 (68.4%) patients were classified as low risk, and 244 (31.6%) as high risk. Meanwhile, 134 (17.4%), 516 (66.9%), and 121 (15.7%) patients were categorized into the low-, intermediate-, and high-risk groups, respectively, according to the RS ranges used in the TAILORx. The BCT high-risk group was significantly associated with advanced lymph node status, whereas no association between RS risk groups and nodal status was observed. The concordance between the two risk stratification methods in the overall population was 71.9% when the RS low-risk, and intermediate-risk groups were combined into one group. However, poor concordance was observed in patients aged ≤50 years and in those with lymph node-positive breast cancer.

Conclusions: The concordance between the BCT score and RS was low in women aged ≤50 years or with lymph node-positive breast cancer. Further studies are necessary to identify more accurate tests for predicting prognosis and chemotherapy benefit in this subpopulation.

Marked increase in breast cancer incidence in young women: A 10-year study from Northern Iran, 2004-2013

INTRODUCTION

Breast cancer is the most frequent cancer among women worldwide. Breast cancer incidence in young women is a health issue of concern, especially in middle-income countries such as Iran. The aim of this study is to report the breast cancer incidence variations in Golestan province, Iran, over a 10-year period (2004-2013).

METHODS

We analyzed data from the Golestan Population-based Cancer Registry (GPCR), which is a high-quality cancer registry collecting data on primary cancers based on standard protocols throughout the Golestan province. Age-standardized incidence rates (ASRs) and age-specific incidence rates per 100,000 person-years were calculated. Time trends in ASRs and age-specific rates were evaluated using Joinpoint regressions. The average annual percentage change (AAPC) with correspondence 95% confidence intervals (95%CIs) were calculated.

RESULTS

A total of 2106 new breast cancer cases were diagnosed during the study period. Most cases occurred in women living in urban areas: 1449 cases (68%) versus 657 cases (31%) in rural areas. Statistically significant increasing trends were observed over the 10-year study period amongst women of all ages (AAPC = 4.4; 95%CI: 1.2-7.8) as well as amongst women in the age groups 20-29 years (AAPC = 10.0; 95%CI: 1.7-19.0) and 30-39 years (AAPC = 5.1; 95%CI: 1.4-9.0).

CONCLUSION

The incidence of breast cancer increased between 2004 and 2013 in Golestan province amongst all age groups, and in particular amongst women aged 20-39 years. Breast cancer should be considered a high priority for health policy making in our community.

Study of Gene Expression Profiles of Breast Cancers in Indian Women

Breast cancer is the most common cancer among women globally. In India, the incidence of breast cancer has increased significantly during the last two decades with a higher proportion of the disease at a young age compared to the west. To understand the molecular processes underlying breast cancer in Indian women, we analysed gene expression profiles of 29 tumours and 9 controls using microarray. In the present study, we obtained 2413 differentially expressed genes, consisting of overexpressed genes such as COL10A1, COL11A1, MMP1, MMP13, MMP11, GJB2, and CST1 and underexpressed genes such as PLIN1, FABP4, LIPE, AQP7, LEP, ADH1A, ADH1B, and CIDEC. The deregulated pathways include cell cycle, focal adhesion and metastasis, DNA replication, PPAR signaling, and lipid metabolism. Using PAM50 classifier, we demonstrated the existence of molecular subtypes in Indian women. In addition, qPCR validation of expression of metalloproteinase genes, MMP1, MMP3, MMP11, MMP13, MMP14, ADAMTS1, and ADAMTS5 showed concordance with that of the microarray data; wherein we found a significant association of ADAMTS5 down-regulation with older age (≥55 years) of patients. Together, this study reports gene expression profiles of breast tumours from the Indian subcontinent, throwing light on the pathways and genes associated with the breast tumourigenesis in Indian women.

BioPATH: A Biomarker Study in Asian Patients with HER2+ Advanced Breast Cancer Treated with Lapatinib and Other Anti-HER2 Therapy

PURPOSE

BioPATH is a non-interventional study evaluating the relationship of molecular biomarkers (PTEN deletion/downregulation, PIK3CA mutation, truncated HER2 receptor [p95HER2], and tumor HER2 mRNA levels) to treatment responses in Asian patients with HER2+ advanced breast cancer treated with lapatinib and other HER2-targeted agents.

Materials and Methods

Female Asian HER2+ breast cancer patients (n=154) who were candidates for lapatinib-based treatment following metastasis and having an available primary tumor biopsy specimen were included. The primary endpoint was progression-free survival (PFS). Secondary endpoints were response rate, overall survival on lapatinib, correlation between biomarker status and PFS for any previous trastuzumab-based treatment, and conversion/conservation rates of the biomarker status between tissue samples collected at primary diagnosis and at recurrence/metastasis. Potential relationships between tumor mRNA levels of HER2 and response to lapatinib-based therapy were also explored.

RESULTS

p95HER2, PTEN deletion/downregulation, and PIK3CA mutation did not demonstrate any significant co-occurrence pattern and were not predictive of clinical outcomes on either lapatinib-based treatment or any previous trastuzumab-based therapy in the metastatic setting. Proportions of tumors positive for p95HER2 expression, PIK3CA mutation, and PTEN deletion/down-regulation at primary diagnosis were 32%, 31.2%, and 56.2%, respectively. Despite limited availability of paired samples, biomarker status patterns were conserved in most samples. HER2 mRNA levels were not predictive of PFS on lapatinib.

CONCLUSION

The prevalence of p95HER2 expression, PIK3CA mutation, and PTEN deletion/downregulation at primary diagnosis were similar to previous reports. Importantly, no difference was observed in clinical outcome based on the status of these biomarkers, consistent with reports from other studies.

Integrative molecular profiling identifies a novel cluster of estrogen receptor-positive breast cancer in very young women

Very young breast cancer patients are more common in Asian countries than Western countries and are thought to have worse prognosis than older patients. The aim of the current study was to identify molecular characteristics of young patients with estrogen receptor (ER)-positive breast cancer by analyzing mutations and copy number variants (CNV), and by applying expression profiling. The whole exome and transcriptome of 47 Korean young breast cancer (KYBR) patients (age <35) were analyzed. Genomic profiles were constructed using mutations, CNV and differential gene expression from sequencing data. Pathway analyses were also performed using gene sets to identify biological processes. Our data were compared with young ER+ breast cancer patients in The Cancer Genome Atlas (TCGA) dataset. TP53, PIK3CA and GATA3 were highly recurrent somatic mutation genes. APOBEC-associated mutation signature was more frequent in KYBR compared with young TCGA patients. Integrative profiling was used to classify our patients into 3 subgroups based on molecular characteristics. Group A showed luminal A-like subtype and IGF1R signal dysregulation. Luminal B patients were classified into groups B and C, which showed chromosomal instability and enrichment for APOBEC3A/B deletions, respectively. Group B was characterized by 11q13 (CCND1) amplification and activation of the ubiquitin-mediated proteolysis pathway. Group C showed 17q12 (ERBB2) amplification and lower ER and progesterone receptor expression. Group C was also distinguished by immune activation and lower epithelial-mesenchyme transition (EMT) degree compared with group B. This study showed that integrative genomic profiling could classify very young patients with breast cancer into molecular subgroups that are potentially linked to different clinical characteristics.

Suppressing glucose metabolism with epigallocatechin-3-gallate (EGCG) reduces breast cancer cell growth in preclinical models

Numerous studies propose that epigallocatechin-3-gallate (EGCG), an abundant polyphenol in green tea, has anti-cancer properties. However, its mechanism of action in breast cancer remains unclear. This study investigated the capacity of EGCG to suppress breast cancer cell growth in vitro and in vivo, characterizing the underlying mechanisms, focusing on the effect of EGCG on glucose metabolism. EGCG reduced breast cancer 4T1 cell growth in a concentration- (10-320 μM) and time- (12-48 h) dependent manner. EGCG induced breast cancer apoptotic cell death at 24 h, as evidenced by annexin V/PI, caspase 3, caspase 8 and caspase 9 activation. Furthermore, EGCG affected the expression of 16 apoptosis-related genes, and promoted mitochondrial depolarization. EGCG induced autophagy concentration-dependently in 4T1 cells by modulating the levels of the autophagy-related proteins Beclin1, ATG5 and LC3B. Moreover, EGCG affected glucose, lactate and ATP levels. Mechanistically, EGCG significantly inhibited the activities and mRNA levels of the glycolytic enzymes hexokinase (HK), phosphofructokinase (PFK), and lactic dehydrogenase (LDH), and to a lesser extent the activity of pyruvate kinase (PK). In addition, EGCG decreased the expression of hypoxia-inducible factor 1α (HIF1α) and glucose transporter 1 (GLUT1), critical players in regulating glycolysis. In vivo, EGCG reduced breast tumor weight in a dose-dependent manner, reduced glucose and lactic acid levels and reduced the expression of the vascular endothelial growth factor (VEGF). In conclusion, EGCG exerts an anti-tumor effect through the inhibition of key enzymes that participate in the glycolytic pathway and the suppression of glucose metabolism.

Isoflavones

Phytoestrogens are naturally occurring nonsteroidal phenolic plant compounds that, due to their molecular structure and size, resemble vertebrate steroids estrogens. This review is focused on plant flavonoids isoflavones, which are ranked among the most estrogenic compounds. The main dietary sources of isoflavones for humans are soybean and soybean products, which contain mainly daidzein and genistein. When they are consumed, they exert estrogenic and/or antiestrogenic effects. Isoflavones are considered chemoprotective and can be used as an alternative therapy for a wide range of hormonal disorders, including several cancer types, namely breast cancer and prostate cancer, cardiovascular diseases, osteoporosis, or menopausal symptoms. On the other hand, isoflavones may also be considered endocrine disruptors with possible negative influences on the state of health in a certain part of the population or on the environment. This review deals with isoflavone classification, structure, and occurrence, with their metabolism, biological, and health effects in humans and animals, and with their utilization and potential risks.

Change of HER2 status during disease recurrence predicts good prognosis for primary squamous cell carcinoma of the breast: A case report

RATIONALE

Primary squamous cell carcinoma (PSCC) of the breast is one of the least common types of breast cancer. Adjuvant treatment for PSCC remains an unresolved issue.

PATIENT CONCERNS

We reported a case of a 48-year-old postmenopausal female patients with a 2 × 2.5 cm lump presented with no symptoms.

DIAGNOSES

This patient was diagnosed as PSCC of the breast. The original tumor and first recurrence exhibited triple negative phenotype, whereas the second recurrence was HER2-positive.

INTERVENTIONS

A tumorectomy with latissimus dorsi flap reconstruction for the second recurrence was performed followed by targeted therapy with trastuzumab.

OUTCOMES

The patient had a complete remission, which was sustained over the 25 months of follow-up after the tumorectomy.

LESSONS

This is the first reported case in literature of a breast PSCC patient with switched immunohistochemical phenotypes during disease recurrence. Surgical resection with flap reconstruction and targeted therapy successfully treated the recurrence.

Higher Breast Cancer Risk Among Immigrant Asian American Women Than Among US-Born Asian American Women

INTRODUCTION

Given rising rates of breast cancer in parts of Asia, immigrant Asian American women in the United States may have higher rates of breast cancer than previously anticipated. This study examined breast cancer risk among Asian American women by nativity and percentage of life lived in the United States, accounting for established breast cancer risk factors.

METHODS

We analyzed a breast cancer case-control data set of Asian American women living in the San Francisco Bay Area; this data set included 132 cases of women with breast cancer selected from a Surveillance, Epidemiology, and End Results cancer registry and 438 Asian American women without diagnosed breast cancer matched to cases by age and country of origin. We used logistic regression to compare 3 Asian American groups: US-born, immigrants who lived 50% or more of their life in the United States, and immigrants who lived less than 50% of their life in the United States.

RESULTS

In the minimally adjusted and fully adjusted models, both groups of immigrant Asian American women had higher risk of breast cancer than US-born Asian American women. In the fully adjusted model, compared with US-born Asian American women, immigrant Asian American women who lived more than 50% of their life in United States were on average 3 times as likely (odds ratio = 3.00; 95% confidence interval, 1.56-5.75) and immigrants who lived less than 50% of their life in United States were on average 2.46 times as likely (odds ratio = 2.46; 95% confidence interval, 1.21-4.99) to have breast cancer. We found no difference in fully adjusted odds ratios of having breast cancer between the 2 immigrant groups.

CONCLUSION

This study provides preliminary evidence that breast cancer risk among immigrant Asian American women may be higher than among their US-born counterparts.

Dietary patterns and breast cancer risk among Iranian women: A case-control study

AIM

Breast cancer is the most common cancer among women worldwide. Most previous studies focused on individual nutrients or foods rather than overall dietary patterns. We aimed to assess the association between major dietary patterns and breast cancer risk.

METHOD

In a hospital-based case-control study, 134 women diagnosed as breast cancer and 267 controls were recruited from referral hospitals in Tehran, Iran. Dietary intakes were evaluated by using a validated 168-item food frequency questionnaire. Dietary pattern were identified by factor analysis. Odds ratios (OR) were estimated using logistic regression.

RESULTS

Two dietary patterns were extracted: healthy and unhealthy. The "Healthy" dietary pattern was loaded for high consumptions of fruits, vegetables, seeds, legume, fish and sea foods, whole grains, liquid oils, olive oils and olive and lack of salt intake. "Unhealthy" dietary pattern was characterized by high factor loadings for sweets, soft drinks, mayonnaise, solid oils, processed meat, fried and boiled potato and salt intake. In multivariate logistic regression analyses, the healthy dietary pattern was not associated with breast cancer risk (OR: 0.83; 95%CI: 0.36, 1.89; P-trend = 0.50), while women in the highest quartile of the unhealthy dietary pattern had a significantly increased breast cancer risk (OR: 2.21; 95%CI: 1.04, 4.690; P-trend = 0.009). When stratified by menopausal status, unhealthy dietary pattern showed inverse association with breast cancer risk only among post-menopausal women (OR: 3.56; 95%CI: 1.16, 10.95; P-trend = 0.008).

CONCLUSIONS

Our findings showed that an unhealthy dietary pattern might be associated with higher risk of breast among Iranian women.

The impact of an expressive writing intervention on quality of life among Chinese breast cancer patients undergoing chemotherapy

BACKGROUND

Expressive writing interventions are shown to confer physical and psychological benefits for Caucasian cancer survivors. This study evaluated the health benefits of an expressive writing intervention among breast cancer patients in mainland China.

METHODS

Stage I-III Chinese breast cancer survivors undergoing chemotherapy were recruited in Shanghai, China. They (n = 90) were randomly assigned to one of three conditions: a positive thinking group (PTC) to write about the positive aspects of their cancer experience; a self-regulation condition (SRC) to write about their stress and coping efforts, deepest feelings, and positive aspects of their cancer experience; or a cancer-fact group (CFC) to write about facts relevant to their cancer experience. All groups wrote for 30 min every week for 4 weeks. Quality of life (QOL) was assessed using the FACT-B at baseline and 1- and 2-month follow-ups. Linear mixed effects models were used to test the hypotheses that the SRC and PTC would improve QOL compared to the CFC.

RESULTS

QOL improved overtime in the whole sample. Contrary to hypotheses, the CFC had increased QOL compared with the SRC from baseline to both the 1- and 2-month follow-ups (ΔQOL = 9.31, p = 0.01, d = 0.44; ΔQOL = 9.45, p = 0.025, d = 0.49). The PTC did not differ from cancer-fact writing but had increased QOL compared with the SRC from baseline to both the 1- and 2-month follow-ups (ΔQOL = 7.44, p = 0.04, d = 0.35; ΔQOL = 11.72, p = 0.06, d = 0.61).

CONCLUSION

Interventions through expressive writing about positive experience and cancer facts are feasible and can benefit Chinese cancer patients undergoing chemotherapy.

Development of a Quality of Sexual Life Questionnaire for Breast Cancer Survivors in Mainland China

BACKGROUND There is a great need for a quality of sexual life questionnaire (QVS) in breast cancer survivors (BCSs) based on the Chinese social culture since the imported tools lack localization verification. To develop a QVS in BCSs and determine its validity and reliability. MATERIAL AND METHODS In the qualitative study, a total of 21 BCSs were interviewed by purposive sampling and snowball sampling; and in the quantitative study, a total of 249 BCSs, who were admitted and received outpatient follow-up, were investigated. Regarding construct validity, factor analysis was performed. The female sexual function index (FSFI), self-rating depression scale (SDS), and Locke-Wallace marital adjustment test (LWMAT) were used to evaluate criterion validity. Cronbach's alpha coefficient was used as an index of internal consistency. To evaluate test-retest reliability, 50 patients were re-evaluated after 1 week. RESULTS We put 28 items in the factor analysis model: (1) 5 factors were extracted by exploratory factor analysis (EFA), with a cumulative contribution of 60.37%; (2) the confirmatory factor analysis (CFA) showed that the path coefficients among the factors were all above 0.5, and the standardized load coefficients of the most items were above 0.5; (3) the Cronbach's alpha coefficient was 0.929 for the overall questionnaire, and ranged from 0.571 to 0.869 for the 5 factors; (4) the correlation coefficients between the overall questionnaire and the FSFI, SDS, and LWMAT were 0.582, -0.456 and 0.515, respectively (P<0.01); and (5) the test-retest correlation coefficient was 0.816, and the split-half-reliability coefficient was 0.899. CONCLUSIONS The QVS in BCSs has good reliability and validity, and can be used to assess the quality of sexual life among BCSs in Mainland China.

Effect of mammography screening on stage at breast cancer diagnosis: results from the Korea National Cancer Screening Program

In Asian countries, breast densities and the proportion of younger women with breast cancer are higher than those in Western countries. This study was designed to determine differences in stage at diagnosis of breast cancer among Korean women according to screening history. The study population was derived from the Korea National Cancer Screening Program (KNCSP). The study cohort comprised 17,689 women who were newly diagnosed with breast cancer in 2011 and were invited to undergo breast cancer screening via the KNCSP between 2002 and 2011. Ductal carcinoma in situ (DCIS) and localized breast cancer were most frequent in both ever-screened and never-screened patients. Late stage cancer was significantly more frequent in never-screened patients, compared with ever-screened patients. Compared to never-screened women, the odds ratio (OR) for being diagnosed with early stage breast cancer among screened women was 1.41 (95% Confidence Interval [CI] = 1.28–1.55). The OR for being diagnosed with early stage breast cancer was highest among patients who underwent screening three times or more (aOR = 1.89, 95% CI = 1.57–2.29). Screening by mammography was associated with diagnosis of early stage breast cancer in Korean women. However, significant increases in the diagnosis of DCIS and localized breast cancers among ever-screened patients suggest the possibility of overdiagnosis due to screening.

Towards Prevention of Breast Cancer: What Are the Clinical Challenges?

The dramatic increase in breast cancer incidence compels a paradigm shift in our preventive efforts. There are several barriers to overcome before prevention becomes an established part of breast cancer management. The objective of this review is to identify the clinical challenges for improved breast cancer prevention and discuss current knowledge on breast cancer risk assessment methods, risk communication, ethics, and interventional efforts with the aim of covering the aspects relevant for a breast cancer prevention trial. Herein, the following five areas are discussed: (i) Adequate tools for identification of women at high risk of breast cancer suggestively entitled Prevent! Online. (ii) Consensus on the definition of high risk, which is regarded as mandatory for all risk communication and potential prophylactic interventions. (iii) Risk perception and communication regarding risk information. (iv) Potential ethical concerns relevant for future breast cancer prevention programs. (v) Risk-reducing programs involving multileveled prevention depending on identified risk. Taken together, devoted efforts from both policy makers and health care providers are warranted to improve risk assessment and risk counseling in women at risk for breast cancer to optimize the prevention of breast cancer. Cancer Prev Res; 11(5); 255-64. ©2018 AACR.

Chronological Improvement in Survival of Patients with Breast Cancer: A Large-Scale, Single-Center Study

Purpose

This study aimed to chronologically evaluate survival of patients with breast cancer in Korea and investigate the observed changes during the last 20 years. We also sought to determine factors that may influence outcomes and changes in the duration of survival over time.

Methods

We retrospectively analyzed a total of 10,988 patients with breast cancer who were treated at our institution between January 1993 and December 2008. We divided the study period into three periods (P1, 1993–1997; P2, 1998–2002; and P3, 2003–2008). We retrospectively reviewed the collected data from the Asan database, including age at diagnosis, clinical manifestations, pathology report, surgical methods, types of adjuvant treatment modalities, type of recurrence, and follow-up period.

Results

At a median follow-up of 8.2 years, we observed that survival outcomes have improved recently. The 5-year breast cancer-specific survival (BCSS) rate also increased from 82.8% in P1 to 92.6% in P3 (p<0.001). The survival rate in patients with tumors at each stage increased in similar patterns in all patients, and, remarkably, there was a significant survival improvement in patients with stage III breast cancer (P1 vs. P3: 5-year BCSS, 57.4% vs. 80.0%, p<0.001). The time period was a significant prognostic factor in multivariate analysis (P1 vs. P2: hazard ratio [HR], 0.83, p=0.035; P1 vs. P3: HR, 0.75, p=0.015).

Conclusion

The study results suggest an improvement in breast cancer survival in Korea, which is consistent with the development of treatments and early detection.

Establishment of two basal-like breast cancer cell lines with extremely low tumorigenicity from Taiwanese premenopausal women

The research of carcinogenetic mechanisms of breast cancer in different ethnic backgrounds is an interesting field, as clinical features of breast cancers vary among races. High premenopausal incidence is distinctive in East-Asian breast cancer. However, human cell lines derived from Asian primary breast tumor are rare. To provide alternative cell line models with a relevant genetic background, we aimed to establish breast cancer cell lines from Taiwanese patients of Han-Chinese ethnicity. Fresh tissue from mammary tumors were digested into organoids, plated and grown in basal serum-free medium of human mammary epithelial cells (HuMEC) with supplements. Cells were further enriched by positive selection with CD326 (epithelial cell adhesion molecule; EpCAM)-coated micro-magnetic beads. Two breast cancer cell lines derived from premenopausal women were successfully established by this method, and named Chang-Gung Breast Cancer 01 (CGBC 01) and 02 (CGBC 02). These two cell lines had a similar phenotype with weak expression of estrogen receptor (ER), progesterone receptor (PR), and without amplification of receptor tyrosine protein kinase erbB-2 (HER2/neu). Genome-wide Single Nucleotide Polymorphism (SNP) array showed multiple copy number alterations in both cell lines. Based on gene expression profiles, CGBC 01 and 02 were clustered into basal-like subtype with reference to the breast cancer cell line gene expression database. The tumorigenicity of both cell lines was extremely low in both anchorage-independence assay and transplantation into the mammary fat pads of nude mice. CGBC 01 and CGBC 02 are low tumorigenic breast cancer cell lines, established from Han-Chinese premenopausal breast cancer patients, which serve as in vitro models in studying the biological features of Asian breast cancer.