Vitamin D insufficiency in a multiethnic cohort of breast cancer survivors

Evaluation of some proinflammatory cytokines and biochemical parameters in pre and postmenopausal breast cancer women

The study was planned to evaluate the differences in certain proinflammatory cytokines(IL-6, TNF-α) with CRP and biochemical parameters (E2, D3, LDH, GGT, TSB, Ca, Ph, uric acid), between women with pre- and postmenopausal breast cancer and seemingly healthy women in Iraqi women as controls; at medical city in teaching Oncology hospital,70 breast cancer patients women their ages ranged (47.51 ± 1.18) and 20 healthy women with age (44.45 ± 2.66) begun from September (2020) to February (2021). The aims of this study to investigate the evaluation of chemotherapy effects especially doxorubicin and cyclophosphamide only use in this study in pre and postmenopausal breast cancer women on proinflammatory cytokines(IL-6, TNF-α) with CRP and on biochemical parameters(E2, D3, LDH, GGT, TSB, Ca, Ph, uric acid) in pre and postmenapausal breast cancer women. The patients were divided into five groups and each group contains 14 patients women with breast cancer during pre and postmenopausal periods. The control groups were divided into 10 pre and 10 postmenopausal women(Fig. 1). The results of proinflammatory cytokines of and biochemical parameters in premenopausal groups were as the levels of IL-6 (pg/ml),TNF-α(pg/ml) and CRP (ng/ml) showed significant increase differences (P < 0.01)among breast cancer treated (BCT) groups in comparison with control groups,While the Liver enzymes GGT,LDH and TSB showed highly significant increase (P < 0.01) in BCT groups, Estrogen levels (pg/ml) and D3(ng/ml) increased significantly (P < 0.01)among BCT groups. Blood serum calcium and phosphorus with uric acid levels (mg/dl) showed significant difference (P < 0.01); While the result in postmenopausal of IL-6(pg/ml), TNF-α (pg/ml) and CRP (ng/ml) showed highly significant differences (P < 0.01)among BCT groups.While GGT(IU/L), LDH(IU/L) and TSB (mg/dl) enzymes were increased significantly (p < 0.01), Estrogen (pg/ml) and D3(ng/ml) levels showed significant increase (P < 0.01) among BCT groups.Blood calcium and phosphorus showed significant increase (P < 0.01) while uric acid was non-significant increase (P > 0.05).

Effect of vitamin D supplementation on inflammatory markers and total antioxidant capacity in breast cancer women using a machine learning technique

Aim

This study aimed to establish a learning system using an artificial neural network (ANN) to predict the effects of vitamin D supplementation on the serum levels of vitamin D, inflammatory factors, and total antioxidant capacity (TAC) in women with breast cancer.

Methods

The data set of the current project was created from women with breast cancer who were referred to the Shafa State Hospital of Patients with Cancers in Ahvaz city, Iran. Modeling was implemented using the data set at the serum levels of vitamin D, tumor necrosis factor-α (TNF-α), transforming growth factor β (TGF-β), and TAC, before and after vitamin D3 supplement therapy. A prediction ANN model was designed to detect the effects of vitamin D3 supplementation on the serum level changes of vitamin D, inflammatory factors and TAC.

Results

The results showed that the ANN model could predict the effect of vitamin D3 supplementation on the serum level changes of vitamin D, TNF-α, TGF-β1, and TAC with an accuracy average of 85%, 40%, 89.5%, and 88.1%, respectively.

Conclusions

According to the findings of the study, the ANN method could accurately predict the effect of vitamin D3 supplementation on the serum levels of vitamin D, TNF-α, TGF-β1, and TAC. The results showed that the proposed ANN method can help specialists to improve the treatment process more confidently in terms of time and accuracy of predicting the influence of vitamin D supplementation on the factors affecting the progression of breast cancer (https://www.irct.ir/ identifier: IRCT2015090623924N1).

FokI polymorphism of Vitamin D receptor gene and deficiency of serum Vitamin D increases the risk of breast cancer in North Indian women

INTRODUCTION

Breast cancer is a leading cause of cancer morbidity and mortality in females. Decreased availability of Vitamin D within breast cells, contributed by deficiency of serum Vitamin D and polymorphisms of Vitamin D receptor genes are possible risk factors for breast cancer.

OBJECTIVES

To study the association of FokI polymorphism of the Vitamin D Receptor gene with breast cancer in females and to study the levels of Vitamin D in breast cancer patients.

MATERIALS AND METHODS

VDR gene FokI genotyping was done by PCR-RFLP method and levels of serum Vitamin D were estimated by ELISA. Statistical analysis was done with SPSS v.21.

RESULTS

Serum Vitamin D was significantly lower in newly diagnosed breast cancer patients than in healthy controls (P = 0.016). Females with serum Vitamin D levels in the highest quartile have a lesser risk of breast cancer than those with serum Vitamin D levels in the lowest quartile (O. R = 2.4421, C.I = 1.09-5.45, P = 0.029). The risk of developing breast cancer is higher in women with the polymorphic T allele for VDR FokI genotype (CT/TT) than those homozygous for the wild C allele (CC). (O.R. = 4.295, C.I. = 2.2110-8.3451, p-value = <0.0001). Levels of serum Vitamin D were significantly higher (p < 0.001) in ER + patients and significantly low in those presenting with higher stages of cancer (p = 0.009).

CONCLUSIONS

FokI polymorphism of VDR gene and low circulating Vitamin D levels increase the risk of developing breast cancer in North Indian females. Serum Vitamin D can be used as a prognostic factor.

Advances in the Prevention and Treatment of Obesity-Driven Effects in Breast Cancers

Obesity and associated chronic inflammation were shown to facilitate breast cancer (BC) growth and metastasis. Leptin, adiponectin, estrogen, and several pro-inflammatory cytokines are involved in the development of obesity-driven BC through the activation of multiple oncogenic and pro-inflammatory pathways. The aim of this study was to assess the reported mechanisms of obesity-induced breast carcinogenesis and effectiveness of conventional and complementary BC therapies. We screened published original articles, reviews, and meta-analyses that addressed the involvement of obesity-related signaling mechanisms in BC development, BC treatment/prevention approaches, and posttreatment complications. PubMed, Medline, eMedicine, National Library of Medicine (NLM), and ReleMed databases were used to retrieve relevant studies using a set of keywords, including "obesity," "oncogenic signaling pathways," "inflammation," "surgery," "radiotherapy," "conventional therapies," and "diet." Multiple studies indicated that effective BC treatment requires the involvement of diet- and exercise-based approaches in obese postmenopausal women. Furthermore, active lifestyle and diet-related interventions improved the patients' overall quality of life and minimized adverse side effects after traditional BC treatment, including postsurgical lymphedema, post-chemo nausea, vomiting, and fatigue. Further investigation of beneficial effects of diet and physical activity may help improve obesity-linked cancer therapies.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

A Phase II Multicenter Trial on High-Dose Vitamin D Supplementation for the Correction of Vitamin D Insufficiency in Patients with Breast Cancer Receiving Adjuvant Chemotherapy

Breast cancer (BC) treatments induce vitamin D (VD) insufficiency and bone metabolism changes, resulting in osteoporosis and skeletal morbidity risk. We report the results of a bicentric phase II trial (ClinicalTrials.gov Identifier: NCT04091178) on the safety and efficacy of high-dose oral VD supplementation for VD deficiency correction in 44 patients with early BC treated with adjuvant chemotherapies. Patients received one dose of 100,000 IU 25-OH VD every 3 weeks from day 1 of cycle 1 to day 1 of cycle 5. The primary endpoint was the percentage of patients achieving serum 25-OH VD concentration normalization on day 1 of cycle 6 (D1C6). Secondary endpoints were safety, VD and calcium parameters at baseline and during chemotherapy, and identification of predictive biomarkers of VD normalization on D1C6. On D1C6, 21 patients (47.7%, 95% CI: 33.0–62.8) achieved VD normalization. No VD-related clinical toxicity was reported. However, 13 patients (29.5%) presented asymptomatic grade 1 hypercalciuria, leading to interruption of the high-dose oral VD supplementation in 10, followed by a rapid reduction in serum VD concentration. No baseline clinical factor was predictive of VD normalization on D1C6. This high-dose VD supplementation appears safe and efficient in patients with early BC receiving adjuvant chemotherapy.

Vitamin D Regulates CXCL12/CXCR4 and Epithelial-to-Mesenchymal Transition in a Model of Breast Cancer Metastasis to Lung

Vitamin D deficiency is associated with poor cancer outcome in humans, and administration of vitamin D or its analogs decreases tumor progression and metastasis in animal models. Using the mouse mammary tumor virus-polyoma middle T antigen (MMTV-PyMT) model of mammary cancer, we previously demonstrated a significant acceleration of carcinogenesis in animals on a low vitamin D diet and a reduction in spontaneous lung metastases when mice received vitamin D through perfusion. We investigate here the action mechanism for vitamin D in lung metastasis in the same non-immunodeficient model and demonstrate that it involves the control of epithelial to mesenchymal transition as well as interactions between chemokine C-X-C motif chemokine 12 (CXCL12) and its receptor C-X-C chemokine receptor type 4 (CXCR4). In vitro, 10-9M vitamin D treatment modifies the phenotype of MMTV-PyMT primary mammary tumor cells and significantly decreases their invasiveness and mammosphere formation capacity by 40% and 50%, respectively. Vitamin D treatment also inhibits phospho-signal transducer and activator of transcription 3 (p-STAT3), zinc finger E-box-binding homeobox 1 (Zeb1), and vimentin by 52%, 75%, and 77%, respectively, and increases E-cadherin by 87%. In vivo, dietary vitamin D deficiency maintains high levels of Zeb1 and p-STAT3 in cells from primary mammary tumors and increases CXCL12 expression in lung stroma by 64%. In lung metastases, vitamin D deficiency increases CXCL12/CXCR4 co-localization by a factor of 2.5. These findings indicate an involvement of vitamin D in mammary cancer "seed" (primary tumor cell) and "soil" (metastatic site) and link vitamin D deficiency to epithelial-to-mesenchymal transition (EMT), CXCL12/CXCR4 signaling, and accelerated metastasis, suggesting vitamin D repleteness in breast cancer patients could enhance the efficacy of co-administered therapies in preventing spread to distant organs.

Vitamin D Receptor (VDR) Allelic Variants Correlating with Response to Vitamin D3 Supplementation in Breast Cancer Survivors

We investigated how vitamin D receptor (VDR) allelic variants affect breast cancer survivors' responses to vitamin D3 supplementation to increase circulating 25-hydroxy vitamin D (25(OH)D) levels. Two hundred and fourteen patients who were diagnosed with breast cancer at least 6 mo, prior to the study and had completed all treatment regimens were assigned to consume 4000 IU of vitamin D3 daily for 12 weeks. Linear and multinomial logistic regression analyses were used to analyze the association of VDR single nucleotide polymorphism (SNPs) with changes in circulating 25(OH)D. The TaqI and BsmI VDR sequence variants modified the effect of vitamin D3 treatment on the plasma 25(OH)D changes (P value = 0.008 for TaqI and P value = 0.0005 for BsmI). Patients with the bb [Q4 vs. Q1 odds ratio(OR) 8.04, 95% confidence interval (CI) 1.55-41.57] and tt [Q4 vs. Q1 OR 4.64 95%CI 1.02-21.02] genotype of BsmI and TaqI had larger increases in plasma 25(OH)D levels compared to those with BB and TT genotype respectively after adjustment for potential confounders. Haplotype analyses suggested the existence of specific combination of alleles that might be associated with circulating 25(OH)D changes. VDR allelic variants modulate vitamin D3 supplementation to increase plasma 25(OH) levels in breast cancer survivors.

Medication-Related Osteonecrosis of the Jaw (MRONJ): Are Antiresorptive Drugs the Main Culprits or Only Accomplices? The Triggering Role of Vitamin D Deficiency

Osteonecrosis of the jaw (ONJ) is a severe clinical condition characterized mostly but not exclusively by an area of exposed bone in the mandible and/or maxilla that typically does not heal over a period of 6-8 weeks. The diagnosis is first of all clinical, but an imaging feedback such as Magnetic Resonance is essential to confirm clinical suspicions. In the last few decades, medication-related osteonecrosis of the jaw (MRONJ) has been widely discussed. From the first case reported in 2003, many case series and reviews have appeared in the scientific literature. Almost all papers concerning this topic conclude that bisphosphonates (BPs) can induce this severe clinical condition, particularly in cancer patients. Nevertheless, the exact mechanism by which amino-BPs would be responsible for ONJ is still debatable. Recent findings suggest a possible alternative explanation for BPs role in this pattern. In the present work we discuss how a condition of osteomalacia and low vitamin D levels might be determinant factors.

Challenges in Preventing Bone Loss Induced by Aromatase Inhibitors

CONTEXT

Aromatase inhibitors have become a mainstay in the adjuvant treatment regimen in postmenopausal women with hormone receptor-positive breast cancer. While many of these patients have an excellent long-term prognosis, adverse effects on bone represent an emerging complication of aromatase inhibitor treatment, resulting in substantial bone loss and fragility fractures. Treatment approaches to prevent aromatase inhibitor-induced bone loss typically consist of an antiresorptive approach with bisphosphonates or the RANKL antibody denosumab. However, different guidelines vary with respect to treatment thresholds, duration, and dosing. The choice of antiresorptive regime is further complicated by comorbidities and potential disease-modifying effects of individual agents.

OBJECTIVE

This review summarizes the evidence of how aromatase inhibitors affect bone health and provides an update of clinical approaches to preserve bone strength in affected women. (J Clin Endocrinol Metab XX: 0-0, 2020).

Variants in SNAI1, AMDHD1 and CUBN in vitamin D pathway genes are associated with breast cancer risk: a large-scale analysis of 14 GWASs in the DRIVE study

Vitamin D has a potential anticarcinogenic role, possibly through regulation of cell proliferation and differentiation, stimulation of apoptosis, immune modulation and regulation of estrogen receptor levels. Because breast cancer (BC) risk varies among individuals exposed to similar risk factors, we hypothesize that genetic variants in the vitamin D pathway genes are associated with BC risk. To test this hypothesis, we performed a larger meta-analysis using 14 published GWAS datasets in the Discovery, Biology, and Risk of Inherited Variants in Breast Cancer (DRIVE) Study. We assessed associations between 2,994 (237 genotyped in the DRIVE study and 2,757 imputed from the 1000 Genomes Project) single nucleotide polymorphisms (SNPs) in 33 vitamin D pathway genes and BC risk. In unconditional logistic regression analysis, we found 11 noteworthy SNPs to be associated with BC risk after multiple comparison correction by the Bayesian false-discovery probability method (<0.80). In stepwise logistic regression analysis, with adjustment for age, principal components and previously published SNPs in the same study populations, we identified three independent SNPs (SNAI1 rs1047920 C>T, AMDHD1 rs11826 C>T and CUBN rs3914238 C>T) to be associated with BC risk (P = 0.0014, 0.0020 and 0.0022, respectively). Additional expression quantitative trait loci analysis revealed that the rs73276407 A allele, in a high LD with the rs1047920 T allele, was associated with decreased SNAI1 mRNA expression levels, while the rs11826 T allele was significantly associated with elevated AMDHD1 mRNA expression levels. Once replicated by other investigators and additional mechanistic studies, these genetic variants may serve as new biomarkers for susceptibility to BC.

Low Plasmatic 25-hydroxyvitamin D at Diagnosis is Associated with Axillary Invasion, Chemoresistance and Metastasis in Women with Breast Cancer

PURPOSE

In this study, we investigated the circulating levels of 25-hydroxyvitamin D (25[OH]D) in Brazilian women with breast cancer in samples collected at diagnosis, and correlated these with clinicopathological parameters relevant to disease prognosis.

METHODS

This study involved 147 women diagnosed with infiltrative ductal carcinoma whose peripheral blood samples were collected, to have 25(OH)D levels measured in plasma.

RESULTS

Our findings indicated that circulating 25(OH)D levels at diagnosis were insufficient in patients with breast cancer. Further, 25(OH)D reduced plasmatic levels at diagnosis correlated significantly with poor prognosis parameters, including axillar positivity, chemoresistance and metastasis. Patients bearing triple-negative tumors also presented reduced 25(OH)D in plasma when compared to those who carried Luminal tumors. Our data suggest relevant correlations when 25(OH)D is reduced in plasma at diagnosis, such as advanced disease with axillar positivity, chemoresistance with advanced disease, early age at diagnosis with high histological grade and dead with axilla positivity.

CONCLUSIONS

Altogether, our findings reinforce that 25(OH)D reduction can be a plausible marker of disease prognosis in breast cancer.

Sociodemographic and clinical characteristics associated with vitamin D status in newly diagnosed pediatric cancer patients

Vitamin D deficiency and insufficiency are associated with serious sequelae in childhood cancer survivors. However, data on vitamin D deficiency in children with newly diagnosed cancer are scarce and the role of sociodemographic factors and vitamin D supplementation is largely unknown. We assessed vitamin D status and its socio-demographic and clinical correlates in 163 children with newly diagnosed cancer, using 25-hydroxy vitamin D (25(OH)D) concentrations and assessed longitudinal changes following vitamin D supplementation. Sixty-five percent of the patients with newly diagnosed cancer had low 25(OH)D concentrations. Fifty-two patients (32%) were vitamin D deficient (≤20 ng/mL 25(OH)D concentration), and 53(33%) were insufficient (21-29 ng/mL 25(OH)D concentration). Age over 10 (P = 0.019), Hispanic ethnicity (P = 0.002), and female sex (P = 0.008) were significantly associated with lower 25(OH)D concentration at diagnosis. Vitamin D supplementation resulted in significant increase in 25(OH)D concentrations (P < 0.001). However, following supplementation in the longitudinal analysis, this increase was less pronounced in Hispanic patients vs. non-Hispanic (P = 0.007), and in children with solid tumors vs. hematological malignancies (P = 0.003). Vitamin D deficiency and insufficiency are common in children with newly diagnosed cancer. Hispanic patients, females and older children were at higher risk for vitamin D deficiency and insufficiency. Although supplementation appeared to increase 25(OH)D concentrations over time, this increase was not as pronounced in certain subsets of patients. Prospective trials of the effects of vitamin D supplementation on bone health in children with newly diagnosed cancer are warranted, particularly in Hispanics and patients with solid tumors.

Low pretreatment serum concentration of vitamin D at breast cancer diagnosis in postmenopausal women

OBJECTIVE

The aim of the study was to evaluate the rate of and risk factors for low pretreatment vitamin D (VitD) levels in postmenopausal breast cancer (BC) women, compared with postmenopausal women without BC.

METHODS

A cross-sectional clinical study was conducted to compare 209 women with BC (case group) to 418 women without BC (control group), age range: 45 to 75 years. The case group consisted of women diagnosed with BC, amenorrhea ≥12 months, aged ≥45 years, without use of medication or clinical conditions that might interfere with VitD levels. The control group consisted of women with amenorrhea ≥12 months, aged ≥45 years, without BC. The groups were matched for age and time since menopause, at a case: control ratio of 1:2. Serum 25-hydroxyvitamin-D [25(OH)D] concentration was measured in all women 10 to 20 days after BC diagnosis and before the proposed treatment. Serum levels ≥30 ng/mL were defined as sufficient. The Student's t test or gamma distribution, χ test, and logistic regression (odds ratio, OR) were used for statistical analysis.

RESULTS

The BC group had a higher body mass index (BMI) and higher percentage of obesity than the control group (57.4% vs 40.2%, P < 0.0001). In addition, rates of insufficient (20-29 ng/mL) and deficient (<20 ng/mL) 25(OH)D levels were higher in BC patients than in controls (55.6% vs 49.3%, P = 0.039 and 26.2% vs 20.3%, P = 0.018), respectively. In risk analysis (adjusted for age, time since menopause, and BMI), BC patients had a 1.5-fold higher risk of developing low VitD levels (OR = 1.52, 95% CI, 1.04-2.22, P = 0.029) than women without BC.

CONCLUSIONS

Postmenopausal women had an increased risk of VitD deficiency at the time of BC diagnosis, associated with a higher rate of obesity, than women of the same age group without cancer.

Genetic Variations in VDR could Modulate the Efficacy of Vitamin D3 Supplementation on Inflammatory Markers and Total Antioxidant Capacity among Breast Cancer Women: A Randomized Double Blind Controlled Trial

Background:

Low levels of vitamin D are found in a great part of breast cancer women. Study subjects using vitamin D₃ supplement had lower rates of cancers and fewer markers of inflammation. Additionally, recent studies demonstrate the power of vitamin D supplementation to lower inflammation and oxidative stress biomarkers associate with VDR polymorphism to reduce inflammation. This study was aimed to assess the impact of vitamin D₃ supplementation on the serum concentration of inflammatory markers and antioxidant capacity with regard to VDR polymorphism in the VDR gene in breast cancer women.

Methods:

A randomized, double-blind, placebo-controlled trial was conducted on 56 breast cancer women. Participants were assigned to 2 treatment arms: placebo and vitamin D₃ for 2 months intervention. Supplementation group received 50,000 IU of vitamin weekly. Blood samples were collected at baseline and after the intervention to measure the 25(OH) D₃, TNF-α, TGF- β and TAC. Genotyping was performed for FokI, BsmI, ApaI, and TaqI polymorphism.

Results:

After eight weeks supplementation, the intervention group showed a significant increase in the serum concentration of 25(OH) D₃ (28±2.6 to 39±3.5; p=0.004 and TAC (48.9±13.3 to 63.5±13.3; p= 0.017). Changes in TNF-α, TGF- β1 were not significant. Serum TAC levels of participants with the TT/Tt, Ff genotypes were more responsive to supplementation.

Conclusions:

Supplementation with a vitamin D₃ increased the TAC in breast cancer women, although it had no effect on inflammatory markers. Serum TAC in the TT/Tt, Ff were more responsive to vitamin D supplement compared with those with the FF/ff and tt genotypes.

Vitamin D and breast cancer: A systematic review and meta-analysis of observational studies

CONTEXT

Breast cancer (BC) is the most common malignancy among women in the US. Vitamin D status and intakes are thought to be inversely associated with BC occurrence.

OBJECTIVES

In our systematic review and meta-analysis, we evaluated evidence linking serum 25(OH)D (both in serum and diet) with breast cancer (BC) occurrence.

DATA SOURCES AND EXTRACTION

Only observational studies from databases such as PubMed and Cochrane (January 1st 2000 through March 15th, 2018) were included using PRISMA guidelines. Publication bias and consistency upon replication were assessed, while harmonizing risk ratios (RR, 95% CI) of BC, per fixed increment of 5 exposures [10 ng/mL of 25(OH)D; 100 IU/d for total/dietary vitamin D intakes; vitamin D deficiency; supplement use). RRs were pooled using random effect models.

DATA ANALYSIS

Pooled findings from 22 studies suggested a net direct association between 25(OH)D deficiency and BC, with RR_pooled = 1.91, 95% CI: 1.51-2.41, P < 0.001). Total vitamin D intake (RR_pooled = 0.99, 95% CI: 0.97-1.00, P = 0.022, per 100 IU/d) and supplemental vitamin D (RR_pooled = 0.97, 95% CI:0.95-1.00, P = 0.026) were inversely associated with BC. No evidence of publication bias was found; all 5 exposures of interest were consistent upon replication.

CONCLUSIONS

25(OH)D deficiency was directly related to BC while total vitamin D and supplemental vitamin D intakes had an inverse relationship with this outcome. Randomized clinical trials are warranted pending further evidence from primary meta-analyses of observational studies.

Assessment and management of bone health in women with oestrogen receptor-positive breast cancer receiving endocrine therapy: Position statement of the Endocrine Society of Australia, the Australian and New Zealand Bone & Mineral Society, the Australasian Menopause Society and the Clinical Oncology Society of Australia

To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is ≥5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.

Circulating Vitamin D and Overall Survival in Breast Cancer Patients: A Dose-Response Meta-Analysis of Cohort Studies

Studies have shown that vitamin D could have a role in breast cancer survival; however, the evidence of the relationship between patients' vitamin D levels and their survival has been inconsistent. This meta-analysis explores possible dose-response relationships between vitamin D levels and overall survival by allowing for differences in vitamin D levels among populations of the various studies. Studies relating vitamin D (25-OH-D [25-hydroxyvitamin D]) levels in breast cancer patients with their survival were identified by searching PubMed and Embase. A pooled HR (hazard ratio) comparing the highest with the lowest category of circulating 25-OH-D levels were synthesized using the Mantel-Haenszel method under a fixed-effects model. A two-stage fixed-effects dose-response model including both linear (a log-linear dose-response regression) and nonlinear (a restricted cubic spline regression) models were used to further explore possible dose-response relationships. Six studies with a total number of 5984 patients were identified. A pooled HR comparing the highest with the lowest category of circulating 25-OH-D levels under a fixed-effects model was 0.67 (95% confidence interval = 0.56-0.79, P < .001). Utilizing a dose-response meta-analysis, the pooled HR for overall survival in breast cancer patients was 0.994 (per 1 nmol/L), Pfor linear trend < .001. At or above a 23.3 nmol/L threshold, for a 10 nmol/L, 20 nmol/L, or 25 nmol/L increment in circulating 25-OH-D levels, the risk of breast cancer overall mortality decreased by 6%, 12%, and 14%, respectively. There was no significant nonlinearity in the relationship between overall survival and circulating 25-OH-D levels. Our findings suggest that there is a highly significant linear dose-response relationship between circulating 25-OH-D levels and overall survival in patients with breast cancer. However, better designed prospective cohort studies and clinical trials are needed to further confirm these findings.

Determinants of Plasma 25-Hydroxyvitamin D Concentrations among Breast Cancer Survivors in Korea

We identified demographic, lifestyle, and clinical factors associated with vitamin D status among breast cancer survivors. The vitamin D prediction model may be a useful surrogate of circulating 25-hydroxvitamin D (25(OH)D) concentrations when this measure was not available. We included a total of 216 Korean breast cancer survivors aged 21–79 years who had been diagnosed with stage I to III primary breast cancer and had breast cancer surgery at least 6 months before enrolment. We used linear and logistic regressions to identify determinants for the plasma 25(OH)D concentrations and vitamin D insufficiency (plasma 25(OH)D concentration < 50 nmol/L). We observed that 48.85% of breast cancer survivors had a plasma 25(OH)D concentration less than 50 nmol/L. We identified the following determinants for plasma 25(OH)D concentrations: time since diagnosis (β = −0.005 for 1 month increment), supplementary vitamin D intake (β = 0.06 for 10 μg/day increment), season of the blood draw (β = 0.35 for summer; β = 0.32 for fall; β = 0.26 for winter vs. spring), smoking status (β = 0.28 for former vs. never), use of any supplement (β = −0.35 for non-use vs. use), and the parity number (β = −0.30 for three or more vs. one) were associated with the plasma 25(OH)D concentrations. In addition to the aforementioned variables, body mass index (BMI) was associated with the prevalence of vitamin D insufficiency. We identified the determinants for the plasma 25(OH)D concentrations among Korean breast cancer survivors. Future studies are needed to investigate the role of vitamin D in the progression of breast cancer among Korean breast cancer survivors.

Prognostic Significance of Serum Vitamin D Levels in Egyptian Females with Breast Cancer

Objective:

To determine the frequency and prognostic significance of vitamin D deficiency in Egyptian women with breast cancer (BC).

Methods:

This prospective study included 50 women with primary invasive, non-metastatic BC. The serum level of 25-hydroxy vitamin D [25(OH)D was measured by ELISA at diagnosis, before any cancer treatment. Vitamin D deficiency was defined as 25(OH) D<20 ng/mL. Patients were followed up for a median of 30 months (range: 18-48).

Results:

The median level of 25(OH)D was 29.0 ng/mL (range: 10.0-55.0 ng/mL). Fifteen patients (30%) had vitamin D deficiency, which was positively associated with larger tumor size (p < 0.001), higher grade (p = 0.014), advanced stage (p = 0.001), lymph node positivity (p = 0.012), and HER2/neureceptor expression (p = 0.002). It was also linked with worse overall survival (OS) and disease free survival (DFS) (p = 0.026, and p = 0.004, respectively). On multivariate analysis, DFS was independently affected by vitamin D deficiency with an HR of 2.8 (95%CI: 1.6-7.0, p = 0.022) and advanced stage, i.e. stage II had worse survival compared to stage I with an HR of 4.8 (95%CI:1.1-21.7, p = 0.042).

Conclusion:

Vitamin D deficiency had a negative effect on overall and disease-free survival in our breast cancer cases, being related to tumor size, stage, grade, nodal status and HER2/neu receptor expression.

Prevalence and Predictors of Low Serum 25-Hydroxyvitamin D among Female African-American Breast Cancer Survivors

BACKGROUND

African-American breast cancer survivors commonly demonstrate low serum 25-hydroxyvitamin D (25(OH)D). Decreased cutaneous conversion, high levels of adiposity, and even breast cancer treatment may influence vitamin D status. Previous investigations have analyzed African-American women in aggregate with other breast cancer survivors and have not comprehensively addressed these influential factors.

OBJECTIVES

To determine the prevalence of low serum 25(OH)D in an exclusively African-American cohort of female breast cancer survivors with overweight/obesity and to evaluate the role of ultraviolet (UV) light exposure, body composition, and dietary sources of vitamin D on serum 25(OH)D levels.

DESIGN

Cross-sectional.

PARTICIPANTS

Pre- and postmenopausal African-American breast cancer survivors (n=244) were recruited from various neighborhoods in the city of Chicago, IL, between September 2011 and September 2014 for a larger weight loss trial.

MAIN OUTCOME MEASURES

Demographic, clinical, anthropometric (body mass index [calculated as kg/m²], waist circumference, and hip circumference), blood specimen, dietary intake (food frequency questionnaire), and sun behavior data were collected by trained study personnel before trial participation. Dual-energy x-ray absorptiometry was used to quantify adiposity (total, percentage, regional, visceral) and lean mass. Serum 25(OH)D was used as the biomarker reflective of vitamin D status.

STATISTICAL ANALYSES

Mean (±standard deviation), frequencies, and multivariate linear regression modeling.

RESULTS

The average participant was 57.4 years old (±10.0), 6.9 years (±5.2) from initial breast cancer diagnosis with a body mass index of 36.2 (±6.2). The majority of participants (60%) reported habitual oral vitamin D supplementation with mean intake of 327 IU (±169). Vitamin D deficiency was prevalent in 81% and 43%, when the cut points of the Endocrine Society (<30 ng/mL or <75 nmol/L) and the Institute of Medicine (<20 ng/mL or <50 nmol/L) were applied, respectively. A multivariate model adjusting for age, seasonality of blood draw, total energy intake, use of supplemental vitamin D, darker skin pigmentation, breast cancer stage, and waist-to-hip ratio was able to explain 28.8% of the observed variance in serum 25(OH)D concentrations. No significant associations were detected for body mass index or any dual-energy x-ray absorptiometry measures of body composition.

CONCLUSIONS

Considering the number of women who endorsed use of vitamin D supplementation, the prevalence of vitamin D deficiency among these African-American breast cancer survivors was high. Vitamin D supplementation, sun behavior, and waist-to-hip ratio may serve as future points of intervention to improve the vitamin D status of this minority survivor population.

Vitamin D deficiency is associated with poor breast cancer prognostic features in postmenopausal women

This study aimed to evaluate the association between pretreatment vitamin D (VD) deficiency with breast cancer prognostic features in Brazilian postmenopausal women. An analytical cross sectional study was conducted with 192 women, aged 45-75 years, attended at University Hospital. Women with recent diagnosis of breast cancer, in amenorrhea >12months and age ≥45 years, without medication use or clinical conditions that interfere with VD values were included. Clinical and anthropometric data were collected. Serum level of 25 hydroxyvitamin D [25(OH)D] was measured in all patients until 20days after breast cancer diagnosis, and was classified as normal (≥30ng/mL), insufficiency (20-29ng/mL) and deficiency (<20ng/mL). Data on breast cancer (histopathological type, grade, tumor stage, lymph node status), hormone status (estrogen receptor, ER, progesterone receptor, PR), human epidermal growth factor receptor type 2 (HER2) and epithelial proliferative activity (Ki-67) were collected. For statistical analysis, the t-student test, the Gamma Distribution (asymmetric variables), the chi-square test and the logistic regression (OR-odds ratio) were used. The median 25(OH)D level was 25.8ng/mL (range 12.0-59.2ng/mL). Sufficient vitamin D levels were detected in 65 patients (33.9%), whereas insufficient levels in 92 patients (47.9%), and deficient levels in 35 patients (18.2%). Participants with insufficient and deficient 25(OH)D levels had a higher proportion of tumors with a high grade and locally advanced and metastatic disease, more positive lymph node, a lower proportion of ER, PR positives tumors and higher Ki-67(p<0.05). Patients with normal vitamin D had a higher frequency of luminal A (47.7%) and luminal B (32.2%) tumors when compared to patients with vitamin D insufficiency or deficiency. Furthermore, all cases of triple negative were detected in women with low VD levels. Multivariate analysis, after adjusting for age, time since menopause and BMI, showed that insufficient and deficient level of vitamin D were significantly associated with negative estrogen receptor (OR 3.77 CI 95% 1.76-8.09 and OR 3.99 CI 95% 1.83-8.68), high Ki-67 (OR 2.50, CI 95% 1.35-4.63, and OR 2.62, CI 95% 1.40-4.98), and positive axillary lymph node status (OR 1.59, CI 95% 1.03-2.33, and OR 1.58, CI 95% 1.02-2.92) respectively. In Brazilian postmenopausal women with breast cancer, there was an association between vitamin D insufficiency or deficiency and tumors with worse prognostic features. Low vitamin D levels were shown to be a risk factor for ER negative tumors, with positive axilla and a higher rate of cell proliferation.

Association of Vitamin D3 Level with Breast Cancer Risk and Prognosis in African-American and Hispanic Women

Background: This study investigated the association of vitamin D3 levels with breast cancer risk and progression in African-Americans and Hispanics. Methods: A total of 237 African-American (Cases = 119, Control = 118) and 423 Hispanic women (Cases = 124, Control = 299) were recruited in the study. Blood samples were collected at the time of breast cancer screening and prior to cancer treatment for 4 weeks on average for the cases. The serum 25-hydroxyvitamin D (25(OH)D3) was measured at a Quest-Diagnostics facility. Results: The results showed that 69.2% of African-Americans and 37.8% of Hispanics had 25(OH)D3 levels below 20 ng/mL. The 25(OH)D3 level below 20 ng/mL was significantly associated with breast cancer in both African-Americans (OR = 2.5, 95% CI = 1.3-4.8) and Hispanics (OR = 1.9, 95% CI = 1.1-3.0). However, the predicted probabilities of breast cancer in African-Americans were significantly higher than in Hispanics (p < 0.001). The 25(OH)D3 below 20 ng/mL was significantly associated with triple negative breast cancer (TNBC) in African-Americans (OR = 5.4, p = 0.02, 95% CI = 1.4-15), but not in Hispanics in our cohort of participants. Levels of 25(OH)D3 below 26 ng/mL predicts a decrease in disease-free survival, but it was not an independent predictor. Conclusions: Our data shows an association between 25(OH)D3 levels and the risk of breast cancer. Further studies on the relationship between 25(OH)D3 level and breast cancer risk are warranted.

Circulating 25-Hydroxy Vitamin D Relative to Vitamin D Receptor Polymorphism after Vitamin D3 Supplementation in Breast Cancer Women: A Randomized, Double-Blind Controlled Clinical Trial

Objective: The influence of vitamin D receptor (VDR) genetic variation on serum 25-hydroxyvitamin D levels [25(OH)D] after vitamin D3 supplementation remains unclear. We aimed to investigate changes of 25(OH)D in a randomized, double-blind, placebo-controlled clinical trial, according to VDR genotype, after provision of vitamin D3 to breast cancer cases for a 2-month period. Methods: Participants were assigned to two treatment arms: placebo (n = 28) and vitamin D3 supplementation (n =28). The supplementation group received 50,000 IU of vitamin D every week for 2 months. Blood samples were collected at baseline and after intervention to measure serum 25(OH)D3. Genotypes were assessed for FokI, BsmI, ApaI, and TaqI polymorphisms. Results: After eight weeks supplementation, the intervention group showed a significant increase in the serum concentration of 25 (OH)D3 (28±2.6 to 39±3.5; p=0.004). Subjects were then classified into twelve subgroups according to different VDR genotypes. Subjects with ff/Ff, TT/Tt, and Bb genotypes had significantly higher increases in serum 25(OH)D compared to those with FF, tt, and BB/bb genotypes post-intervention. Serum vitamin D3 levels with the AA genotype were lower than with aa/ Aa. No differences were found among other subgroups. Conclusion: Vitamin D3 supplementation increases serum 25(OH)D in women with breast cancer. Serum vitamin D3 in TT/Tt, ff/Ff, and Bb carriers was more responsive to vitamin D supplementation than in those with FF/ff and tt genotypes. Other subgroups might gain less from vitamin D3 supplementation.

Pretreatment Serum Concentration of Vitamin D and Breast Cancer Characteristics: A Prospective Observational Mediterranean Study

BACKGROUND

Recent studies of the correlation between breast cancer (BC) and vitamin D yielded contrasting results. Although preclinical and clinical evidence has implicated vitamin D in BC prevention and outcome, little is known about the link between vitamin D and specific BC histologically defined subtypes. In the attempt to clarify this association we correlated vitamin D levels with BC characteristics.

PATIENTS AND METHODS

We enrolled 220 pre- and postmenopausal women with early BC in this prospective observational trial. Data on the patients' clinical and specific BC pathological characteristics were collected and related to vitamin D levels, stratified in deficient (< 20 ng/mL), insufficient (20-30 ng/mL), and sufficient (> 30 ng/mL). BC subtypes were defined according to the 14th St Gallen Breast Cancer Conference.

RESULTS

Deficient vitamin D levels were correlated with Grade 3 (P = .015) and node-positive (P = .043) BC, and with a higher body mass index (P = .017). Insufficient vitamin D levels were associated with estrogen receptor expression in the primary tumor (P = .033). Vitamin D levels were unrelated to the histological molecular subtypes of BC.

CONCLUSION

Deficient vitamin D levels were correlated with more aggressive disease, namely, node-positive high grade BC, and with obesity. Should our findings be confirmed in larger prospective studies, nutritional programs designed to reduce body weight, and vitamin D supplementation might be considered a BC prevention strategy.

Tumoral Vitamin D Synthesis by CYP27B1 1-α-Hydroxylase Delays Mammary Tumor Progression in the PyMT-MMTV Mouse Model and Its Action Involves NF-κB Modulation

Biologically active vitamin D (1,25-dihydroxycholecalciferol or 1,25(OH)2D) is synthetized from inactive prohormone 25-hydroxycholecalciferol (25(OH)D) by the enzyme CYP27B1 1-α-hydroxylase in kidney and several extrarenal tissues including breast. Although the development of breast cancer has been linked to inadequate vitamin D status, the importance of bioactive vitamin D production within tumors themselves is not fully understood. To investigate the role of tumoral vitamin D production in mammary epithelial cell progression to breast cancer, we conducted a Cre-loxP-mediated Cyp27b1 gene ablation in the mammary epithelium of the polyoma middle T antigen-mouse mammary tumor virus (PyMT-MMTV) mouse breast cancer model. Targeted ablation of Cyp27b1 was accompanied by significant acceleration in initiation of spontaneous mammary tumorigenesis. In vivo, cell proliferation, angiogenesis, cell cycle progression, and survival markers were up-regulated in tumors by Cyp27b1 ablation, and apoptosis was decreased. AK thymoma (AKT) phosphorylation and expression of several components of nuclear factor κB (NF-κB), integrin, and signal transducer and activator of transcription 3 (STAT3) signaling pathways were increased in Cyp27b1-ablated tumors compared with nonablated controls. In vitro, 1,25(OH)2D treatment induced a strong antiproliferative action on tumor cells from both ablated and nonablated mice, accompanied by rapid disappearance of NF-κB p65 from the nucleus and segregation in the cytoplasm. In contrast, treatment with the metabolic precursor 25(OH)D was only effective against cells from nonablated mice. 25(OH)D did not inhibit growth of Cyp27b1-ablated cells, and their nuclear NF-κB p65 remained abundant. Our findings demonstrate that in-tumor CYP27B1 1-α-hydroxylase activity plays a crucial role in controlling early oncogene-mediated mammary carcinogenesis events, at least in part by modulating tumoral cell NF-κB p65 nuclear translocation.

Association of Vitamin D Level with Clinicopathological Features in Breast Cancer

A population-based relationship between low vitamin D status and increased cancer risk is now generally accepted. However there were only few studies reported on prognostic impact. To determine the effect of low vitamin D on progression of breast cancer, we conducted a cross-sectional analysis of vitamin D levels and clinico- pathological characteristics in 200 cases of breast cancer diagnosed during 2011-2012 at the National Cancer Institute of Thailand. Vitamin D levels were measured by high-performance liquid chromatography (HPLC). Clinical and pathological data were accessed to examine prognostic effects of vitamin D. We found that the mean vitamin D level was 23.0±6.61 ng/ml. High vitamin D levels (≥32 ng/ml) were detected in 7% of patients, . low levels (<32 ng/ml) in 93% Mean vitamin D levels for stages 1-4 were 26.1±6.35, 22.3±6.34, 22.2±6.46 and 21.3±5.42 ng/ml respectively (P=0.016) and 24.1 and 21.3 ng/ml for lymph node negative and positive cases (P=0.006). Low vitamin D level (<32 ng/ml) was significantly found in majority of cases with advanced stage of the disease (P=0.036), positive node involvement (P=0.030) and large tumors (P=0.038). Our findings suggest that low and decreased level of vitamin D might correlate with progression and metastasis of breast cancer.

Randomized, blinded trial of vitamin D3 for treating aromatase inhibitor-associated musculoskeletal symptoms (AIMSS)

The purpose of the study was to evaluate the efficacy and safety of vitamin D3 at 4000 IU/day as a treatment option for aromatase inhibitor-associated musculoskeletal symptoms (AIMSS) when compared with the usual care dose of 600 IU D3. We conducted a single site randomized, double-blind, phase 3 clinical trial in women with AIMSS comparing change in symptoms, reproductive hormones and AI pharmacokinetics. Postmenopausal women ≥18 years with stages I-IIIA breast cancer, taking AI and experiencing AIMSS [breast cancer prevention trial symptom scale-musculoskeletal (BCPT-MS) subscale ≥1.5] were admitted. Following randomization, 116 patients had a run-in period of 1 month on 600 IU D3, then began the randomized assignment to either 600 IU D3 (n = 56) or 4000 IU D3 (n = 57) daily for 6 months. The primary endpoint was a change in AIMSS from baseline (after 1 month run-in) on the BCPT-MS (general MS pain, joint pain, muscle stiffness, range for each question: 0 = not at all to 4 = extremely). Groups had no statistically significant differences demographically or clinically. There were no discernable differences between the randomly allocated treatment groups at 6 months in measures of AIMSS, pharmacokinetics of anastrozole and letrozole, serum levels of reproductive hormones, or adverse events. We found no significant changes in AIMSS measures between women who took 4000 IU D3 daily compared with 600 IU D3. The 4000 IU D3 did not adversely affect reproductive hormone levels or the steady state pharmacokinetics of anastrozole or letrozole. In both groups, serum 25(OH)D remained in the recommended range for bone health (≥30 ng/mL) and safety (<50 ng/mL).

The effect of pre-diagnostic vitamin D supplementation on cancer survival in women: a cohort study within the UK Clinical Practice Research Datalink

BACKGROUND

There remains uncertainty in whether vitamin D status affects cancer survival. We investigated whether vitamin D (± calcium) supplementation affects cancer survival in women.

METHODS

Participants were women aged ≥55 years identified from the UK Clinical Practice Research Datalink (CPRD) with a first diagnosis of breast, colorectal, lung, ovarian or uterine cancer between 2002 and 2009, and at least 5 years of CPRD data prior to diagnosis. Cox proportional hazards were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) of the relationship between pre-diagnostic vitamin D supplementation and all-cause mortality. To avoid confounding by indication, the primary analysis compared women with 3+ to 1-2 (but no more) vitamin D prescriptions. Models were adjusted for pre-diagnostic body mass index, smoking, alcohol and deprivation. A sensitivity analysis excluded supplements prescribed in the year prior to diagnosis.

RESULTS

Exposure to 3 or more versus 1 to 2 prescriptions of vitamin D was not associated with survival from any of the cancers studied. Any vitamin D prescription, compared to never having been prescribed one, was associated with a better survival from breast cancer (HR 0.78, 95 % CI 0.70 to 0.88). The sensitivity analysis suggested a possible detrimental effect of vitamin D supplementation on lung cancer outcomes (HR for 3 versus 1 or 2 prescriptions 1.22 (95 % CI 0.94 to 1.57); HR for any versus no prescriptions 1.09 (0.98 to 1.22)).

CONCLUSIONS

We found no evidence that vitamin D supplementation is associated with survival among women with cancer. Previous observational findings of beneficial effects of vitamin D supplementation on cancer survival may be confounded.

Increased vitamin D and calcium intake associated with reduced mammographic breast density among premenopausal women

Vitamin D has been identified as a weak protective factor for postmenopausal breast cancer (relative risk, ~0.9), whereas high breast density has been identified as a strong risk factor (relative risk, ~4-6). To test the hypothesis that there is an association between vitamin D intake, but not circulating vitamin D levels, and mammographic breast density among women in our study, we conducted a cross-sectional study of 165 screening mammography patients at Nashville General Hospital's Breast Health Center, a public facility serving medically indigent and underserved women. Dietary and total (dietary plus supplements) vitamin D and calcium intakes were estimated by the Harvard African American Food Frequency Questionnaire, and blood samples were analyzed for 25-hydroxyvitamin D. Average percent breast density for the left and right breasts combined was estimated from digitized films using an interactive thresholding method available through Cumulus software. After statistical adjustment for age, race, and body mass index, the results revealed that there were significant trends of decreasing breast density with increasing vitamin D and calcium intake among premenopausal but not among postmenopausal women. There was no association between serum vitamin D and breast density in premenopausal or postmenopausal women. Confirmation of our findings in larger studies may assist in clarifying the role of vitamin D in breast density.

The Prevalence of Vitamin D Deficiency among Cancer Survivors in a Nationwide Survey of the Korean Population

Background

Recent studies have shown that inadequate vitamin D levels are associated with a poor cancer prognosis, but data regarding actual vitamin D levels in cancer survivors are limited. This study investigated the vitamin D levels and prevalence of vitamin D deficiency among Korean cancer survivors compared with non-cancer controls, and identified the factors associated with vitamin D deficiency.

Methods

Using the Korea National Health and Nutrition Examination Survey (KNHANES), 915 cancer survivors and 29,694 controls without a history of cancer were selected. Serum 25(OH)D levels were measured; vitamin D deficiency was defined as 25(OH)D levels less than 20 ng/mL. Chi-square tests and multiple logistic regression analyses were used to evaluate the prevalence of vitamin D deficiency and associated factors.

Results

Vitamin D deficiency was observed in 62.7% of cancer survivors and 67.1% of controls. Among cancer survivors, vitamin D deficiency was most prevalent among 19–44 year olds (76.2%) and among managers, professionals, and related workers (79.3%). Multiple logistic regression analysis revealed that younger cancer survivors and those who work indoors were predisposed to vitamin D deficiency.

Conclusion

Vitamin D deficiency was prevalent among both cancer survivors and controls in Korea. The regular evaluation and management of vitamin D levels is needed for both bone health and general health in cancer survivors.

Assessing the prevalence of compromised bone health among overweight and obese African-American breast cancer survivors: a case-control study

PURPOSE

Osteoporosis increases the risk of fracture and is often considered a late effect of breast cancer treatment. We examined the prevalence of compromised bone health in a sample of exclusively African-American (AA) breast cancer survivors since bone mineral density (BMD) varies by race/ethnicity in healthy populations.

METHODS

Using a case-control design, AA women in a weight loss intervention previously diagnosed and treated for stages I-IIIa breast cancer were matched 1:1 on age, race, sex, and BMI with non-cancer population controls (n = 101 pairs) from National Health and Nutrition Examination Survey (NHANES). Questionnaires and dual-energy x-ray absorptiometry (DXA) scanning were completed, and participants were categorized as having normal bone density, low bone mass, or osteoporosis using the World Health Organization (WHO) definition for femoral neck T-scores.

RESULTS

The majority of these overweight/obese survivors were 6.6 (±4.7) years post-diagnosis, had stage II (n = 46) or stage III (n = 16) disease, and treated with chemotherapy (76 %), radiation (72 %), and/or adjuvant hormone therapies (45 %). Mean femoral neck BMD was significantly lower in cases vs. matched non-cancer population controls (0.85 ± 0.15 vs. 0.91 ± 0.14 g/cm(2), respectively; p = 0.007). However, the prevalence of low bone mass and osteoporosis was low and did not significantly differ between groups (n = 101 pairs; p = 0.26), even when restricted to those on adjuvant hormone therapies (n = 45 pairs; p = 0.75). Using conditional logistic regression, controlling for dietary factors and education, the odds of developing compromised bone health in AA breast cancer survivors was insignificant (OR 1.5, 95 % CI 0.52, 5.56).

CONCLUSIONS

These null case-control findings challenge the clinical assumption that osteoporosis is highly prevalent among all breast cancer survivors, providing foundational evidence to support differences by race/ethnicity and body weight.

IMPLICATIONS FOR CANCER SURVIVORS

Routine bone density testing and regular patient-provider dialogue is critical in overweight/obese AA breast cancer survivors to ensure that healthy lifestyle factors (e.g., ideal weight, regular weight-bearing exercises, dietary adequacy of calcium and vitamin D) support optimal skeletal health.

Management of menopause in women with breast cancer

Increasing breast cancer incidence and decreasing mortality have highlighted the importance of survivorship issues related to breast cancer. A consideration of the issues related to menopause is therefore of great importance to both women and clinicians. Menopause/menopausal symptoms, with significant negative effects on quality of life and potential long-term health impacts, may in women with breast cancer be associated with: (1) natural menopause occurring concurrently with a breast cancer diagnosis; (2) recurrence of menopausal symptoms following cessation of hormone replacement therapy; (3) treatment-induced menopause (chemotherapy, ovarian ablation/suppression) and adjuvant endocrine therapy. A variety of non-hormonal pharmacological and non-pharmacological therapies have been investigated as therapeutic options for menopausal symptoms with mixed results, and ongoing research is required. This review presents a summary of the causes, common problematic symptoms of menopause (vasomotor, genitourinary and sexual dysfunction), and longer-term consequences (cardiovascular disease and osteoporosis) related to menopause. It proposes an evidenced-based multidisciplinary approach to the management of menopause/menopausal symptoms in women with breast cancer.

Vitamin D levels in patients with breast cancer: importance of dressing style

BACKGROUND

Vitamin D deficiency is a potentially modifiable risk factor that may be targeted for breast cancer (BC) prevention. It may also be related to prognosis after diagnosis and treatment. The aim of our study was to determine the prevalence of vitamin D deficiency as measured by serum 25-hydroxy vitamin D (25-OHD) levels in patients with BC and to evaluate its correlations with life-style and treatments.

MATERIALS AND METHODS

This study included 186 patients with stage 0-III BC treated in our breast center between 2010-2013. The correlation between serum baseline 25-OHD levels and supplement usage, age, menopausal status, diabetes mellitus, usage of bisphosphonates, body-mass index (BMI), season, dressing style, administration of systemic treatments and radiotherapy were investigated. The distribution of serum 25-OHD levels was categorized as deficient (<10ng/ ml), insufficient (10-24 ng/ml), and sufficient (25-80 ng/ml).

RESULTS

The median age of the patients was 51 years (range: 27-79 years) and 70% of them had deficient/insufficient 25-OHD levels. On univariate analysis, vitamin D deficiency/insufficiency was more common in patients with none or low dose vitamin D supplementation at the baseline, high BMI (≥25), no bisphosphonate usage, and a conservative dressing style. On multivariate analysis, none or low dose vitamin D supplementation, and decreased sun-exposure due to a conservative dressing style were found as independent factors increasing risk of vitamin D deficiency/insufficiency 28.7 (p=0.002) and 13.4 (p=0.003) fold, respectively.

CONCLUSIONS

The prevalence of serum 25-OHD deficiency/insufficiency is high in our BC survivors. Vitamin D status should be routinely evaluated for all women, especially those with a conservative dressing style, as part of regular preventive care, and they should take supplemental vitamin D.

Association of nutritional status with quality of life in breast cancer survivors

Nutritional status and dietary intake play a significant role in the prognosis of breast cancer and may modify the progression of disease. The aim of this study was to determine the influence of nutritional status on the quality of life of Iranian breast cancer survivors. Cross-sectional data were collected for 100 Iranian breast cancer survivors, aged 32 to 61 years, attending the oncology outpatient clinic at Golestan Hospital, Ahvaz, Iran. Nutritional status of subjects was assessed by anthropometric measurements, Patient-Generated Subjective Global Assessment (PG-SGA) and three non-consecutive 24-hour diet recalls. The European Organization of Research and Treatment of Cancer Quality of Life form (EORTC QLQ-C30) was used to assess quality of life. Ninety-four percent of the survivors were well-nourished, 6% were moderately malnourished or suspected of being malnourished while none were severely malnourished. Prevalence of overweight and obesity was 86%. Overall, participants had an inadequate intake of vitamin D, E, iron and magnesium according to dietary reference intake (DRI) recommendations. Survivors with better nutritional status had better functioning scales and experienced fewer clinical symptoms. It appears important to provide educational and nutritional screening programs to improve cancer survivor quality of life.

Review: the impacts of circulating 25-hydroxyvitamin D levels on cancer patient outcomes: a systematic review and meta-analysis

CONTEXT

Circulating levels of 25-hydroxyvitamin D [25(OH)D] may affect the prognosis of cancer patients; however, the epidemiological results are not consistent.

OBJECTIVE

To perform a meta-analysis of all published studies to assess the associations of circulating 25(OH)D levels measured at or near the time of diagnosis and outcomes for cancer patients.

DATA SOURCES

Searches of the PubMed and MEDLINE databases were performed and updated to December 2013.

STUDY SELECTION

Studies reporting an association between circulating 25(OH)D levels at or near the time of diagnosis and outcomes for the patients were included.

DATA EXTRACTION

Data extraction was performed independently by two authors, and conflicts were resolved by a third investigator.

DATA SYNTHESIS

Included in the meta-analysis were 25 studies with 17 332 cases. Significant associations between circulating 25(OH)D levels at or near the time of diagnosis and the outcomes for cancer patients were found. The pooled hazard ratio for the highest vs the lowest quartile of circulating 25(OH)D levels was 0.55 (95% confidence interval [CI] = 0.33-0.91) for overall survival of colorectal cancer patients, 0.63 (95% CI = 0.51-0.77) for breast cancer patients, and 0.48 (95% CI = 0.36-0.64) for lymphoma patients. Higher 25(OH)D levels were significantly associated with reduced cancer-specific mortality for patients with colorectal cancer (P = .005) and lymphoma (P < .001) and improved disease-free survival for patients with breast cancer (P < .001) or lymphoma (P < .05). A 10-nmol/L increment in circulating 25(OH)D levels conferred a hazard ratio of 0.96 (95% CI = 0.95-0.97) for overall survival of the cancer patients.

CONCLUSIONS

The results indicate that cancer patients with higher circulating 25(OH)D levels at or near the time of diagnosis have better outcomes.

Vitamin D intake, blood 25(OH)D levels, and breast cancer risk or mortality: a meta-analysis

Background:

Experimental studies suggest potential anti-carcinogenic properties of vitamin D against breast cancer risk, but the epidemiological evidence to date is inconsistent.

Methods:

We searched MEDLINE and EMBASE databases along with a hand search for eligible studies to examine the association between vitamin D status (based on diet and blood 25-hydroxyvitamin D (25(OH)D)) and breast cancer risk or mortality in a meta-analysis. A random-effect model was used to calculate a pooled adjusted relative risk (RR).

Results:

A total of 30 prospective studies (nested case-control or cohort) were included for breast cancer incidence (n=24 studies; 31 867 cases) or mortality (n=6 studies; 870 deaths) among 6092 breast cancer patients. The pooled RRs of breast cancer incidence for the highest vs the lowest vitamin D intake and blood 25(OH)D levels were 0.95 (95% CI: 0.88–1.01) and 0.92 (95% CI: 0.83–1.02), respectively. Among breast cancer patients, high blood 25(OH)D levels were significantly associated with lower breast cancer mortality (pooled RR=0.58, 95% CI: 0.40–0.85) and overall mortality (pooled RR=0.61, 95% CI: 0.48–0.79). There was no evidence of heterogeneity and publication bias.

Conclusions:

Our findings suggest that high vitamin D status is weakly associated with low breast cancer risk but strongly associated with better breast cancer survival.

The association between postdiagnosis dietary supplement use and total mortality differs by diet quality among older female cancer survivors

BACKGROUND

Dietary supplements are widely used by cancer survivors. However, health effects among older cancer survivors are unclear.

METHODS

We used the Iowa Women's Health Study, a prospective cohort study with 2,118 postmenopausal women with a confirmed cancer diagnosis (1986-2002), to evaluate the association between postdiagnosis dietary supplement use assessed in 2004 and subsequent all-cause mortality. Risk of death was evaluated using multivariable-adjusted Cox proportional hazards regression. We performed stratified analyses by diet quality score, dietary micronutrient intake, and perceived general health.

RESULTS

Through 2010, 608 deaths were identified. Approximately 85% of the cancer survivors used dietary supplements. Overall supplement use and multivitamin use were not associated with mortality. Iron supplement use was associated with 39% higher risk of death [95% confidence interval (CI), 1.09-1.77]. This association was stronger among survivors with deteriorating general health. Folic acid supplement use was associated with higher risk of death, only among survivors reporting low-quality diets (HR, 2.33; 95% CI, 1.33-4.08; P interaction = 0.006). Multivitamin use and using a greater number of supplements was associated with a trend towards higher mortality only among those with poor diet quality. Using vitamin E supplements in combination with multivitamin was associated with lower risk of death only among survivors with higher dietary vitamin E intake (HR, 0.61; 95% CI, 0.39-0.94; P interaction = 0.02).

CONCLUSIONS

Postdiagnosis supplement use was associated with higher mortality among older female cancer survivors with poor general health and/or poor dietary intake.

IMPACT

The association between postdiagnosis dietary supplement use and mortality may differ by diet quality and health status among older female cancer survivors.

Low 25-hydroxyvitamin D levels in people with a solid tumor cancer diagnosis: the tip of the iceberg?

PURPOSE

Low serum 25-hydroxyvitamin D [25(OH)D] levels have been linked to both cancer incidence and poor prognosis. The frequency of 25(OH)D tests and clinical factors associated with low levels in cancer patients are unknown.

PATIENTS AND METHODS

Electronic medical records from 2006 to 2007 of 39,252 adult solid tumor patients were reviewed. Data included demographics, cancer sites (primary and metastatic), and first serum 25(OH)D level during the study period. Laboratory data, comorbidities, selected medications, and anticancer treatment within the prior 2 months were recorded. Data were compared between (1) those tested and not tested and (2) 25(OH)D levels≤10 ng/ml (deficient), 11-30 ng/ml (insufficient), and ≥31 ng/ml (sufficient). Stepwise logistic regression identified independent predictors of low serum 25(OH)D levels.

RESULTS

The cohort was 86% Caucasian and 48% female with a mean age of 63±14 years (mean±SD). The most prevalent cancer was breast (19%). In total, 2,098 (5%) had a 25(OH)D test. Of those tested, 133 (6%) had levels≤10 ng/ml and 1,311 (62%) 11-30 ng/ml. Tests were more frequent in females and in those with breast, skin, and thyroid cancers (P<0.001). Low 25(OH)D levels were associated (in univariable analyses) with male gender, non-Caucasian race, gastrointestinal tumor primary sites, metastatic disease, benign liver disease, low serum albumin, and elevated liver enzymes. Significant factors in multivariable models for 25(OH)D levels≤10 and ≤30 ng/ml included non-Caucasian race, primary cancer site, and test calendar month. Vitamin D supplements and recent antineoplastic medication were associated with sufficient levels.

CONCLUSIONS

Low (deficient or insufficient) 25(OH)D serum levels were highly prevalent in people with solid tumors. Vitamin D tests were infrequent and paradoxically less often done in high-risk groups. Tests were more frequent in females and in those with breast, skin, and thyroid cancers. Further research should examine role of routine 25(OH)D tests, the clinical consequences of low levels, and therapeutic supplementation in people with cancer.

Correlates of 25-hydroxyvitamin D among Chinese breast cancer patients

Background

Few studies have investigated vitamin D status in association with modifiable lifestyle factors and clinical characteristics among breast cancer patients, with no studies among Chinese women, who may be at higher risk of vitamin D deficiency. We aimed to evaluate circulating 25-hydroxyvitamin D (25(OH)D) levels in association with clinical and lifestyle factors among 1,940 Chinese breast cancer patients.

Methods

Participants included breast cancer cases aged 22–77 from a population-based case-control study conducted in Shanghai, China during 1996–1998 (n = 1,044) and 2002–2005 (n = 896). Circulating 25(OH)D levels were measured in plasma samples (95% collected ≤6 months post-diagnosis). Prevalence ORs and 95% CIs were derived from multinomial logistic regression models, adjusting for age, season, and other factors.

Results

About 23% and 48% of women were vitamin D deficient (<30 nmol/L) or insufficient (30–50 nmol/L), respectively. Tumor characteristics were not associated with vitamin D status. Higher BMI was associated with increased odds of vitamin D deficiency (ORs (95% CIs): 1 (reference), 1.12 (0.85,1.47), and 1.57 (1.02,2.42), for <23, 23–<27.5, and ≥27.5 kg/m², respectively, P_trend <0.06). Total physical activity was associated with reduced odds of vitamin D deficiency (ORs (95% CIs):1 (reference), 0.84 (0.59,1.20), 0.65 (0.45,0.93), and 0.69 (0.48,1.00), for <7.65, 7.65–<10.6, 10.6–<13.5, ≥13.5 MET-hours/day, respectively, P_trend <0.02). Smoking was associated with vitamin D insufficiency and deficiency (ORs (95% CIs): 2.50 (1.07,5.84) and 2.78 (1.11,6.95), respectively).

Conclusions

In the largest study to date, the prevalence of low vitamin D status was high among Chinese breast cancer patients and associated with higher BMI, smoking, and lower physical activity. Our findings support careful monitoring of vitamin D status and recommendations for supplementation and other lifestyle modifications that may improve vitamin D status in breast cancer patients.

Correlates of 25-hydroxyvitamin D and breast cancer stage in the Women's Healthy Eating and Living Study

Inverse associations between circulating 25-hydroxyvitamin D [25(OH)D] and breast cancer stage have been reported, thus it is critical to understand the variables that contribute to 25(OH)D levels among women with breast cancer. Among 904 women in the Women's Healthy Eating and Living Study, plasma 25(OH)D concentrations were measured and data on demographic characteristics, diet, physical activity, and tumor characteristics were collected at study entry. Statistically significant associations with 25(OH)D concentrations were observed for body mass index (BMI), body surface area (BSA), height, smoking, total vitamin D intake, physical activity, and race or ethnicity. Of the correlates of 25(OH)D, BMI, BSA, height, physical activity, and study site were associated with stage of breast cancer; however, concentrations of 25(OH)D were not significantly related to stage. In fully adjusted logistic regression models, the ORs (95% CIs) for the association between vitamin D deficiency and Stage II and III cancers were 0.85 (0.59-1.22) and 1.23 (0.71-2.15), respectively (P trend = 0.59), compared to Stage I. This study confirms previous work regarding the correlates of 25(OH)D concentrations but does not provide support for an association between vitamin D status and breast cancer stage.

Circulating 25-hydroxyvitamin D and postmenopausal breast cancer survival: Influence of tumor characteristics and lifestyle factors?

We previously reported that lower post-diagnostic circulating 25-hydroxyvitamin D [25(OH)D] concentrations were associated with higher risk of overall mortality and distant disease in stage I-IV postmenopausal breast cancer survivors. This association was now re-examined in an extended dataset to investigate potential effect modification by tumor characteristics and lifestyle factors. A prospective cohort study was conducted in Germany including 2,177 incident stage I-IV postmenopausal breast cancer patients aged 50-74 years. Patients were diagnosed between 2001 and 2005 and median follow-up time was 5.3 years. Cox proportional hazards models were stratified by age at diagnosis, study center and season of blood collection and adjusted for other prognostic factors. A meta-analysis of studies on circulating 25(OH)D and mortality in breast cancer patients was performed to summarize evidence. Lower concentrations of 25(OH)D were significantly associated with higher risk of overall mortality [hazard ratio (HR) lowest vs. highest tertile = 1.86; 95% confidence interval (CI): 1.22, 2.82; p-trend = 0.002] and distant disease (HR = 1.76; 95% CI: 1.24, 2.49; p-trend = 0.003) in stage I-IIIa but not in stage IIIb-IV breast cancer patients. No significant interaction by lifestyle factors was observed (all p-interaction > 0.05). The meta-analysis yielded significant associations with overall and breast cancer-specific mortality (lowest vs. highest quantile: HR = 1.52; 95% CI: 1.22, 1.88 and HR = 1.74; 95% CI: 1.23, 2.40, respectively). In conclusion, post-diagnostic circulating 25(OH)D concentrations were associated with overall mortality and distant disease in stage I-IIIa postmenopausal breast cancer patients. This association was not strongly modified by lifestyle factors.

Cancer-associated bone disease

Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.

Associations between vitamin D deficiency and risk of aggressive breast cancer in African-American women

Although breast cancer incidence in the US is highest for women of European ancestry (EA), women of African ancestry (AA) have higher incidence of cancer diagnosed before age 40 and tumors with more aggressive features (high grade and negative for estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor (HER2)), which precludes targeted therapies and leads to poorer outcomes. It is unclear what underlies these disparities. It has been hypothesized that dark skin with high melanin content is the ancestral skin color of origin, with adaptation to northern environs resulting in lighter skin. Although intense sunlight in sub-Saharan Africa may compensate for low sun absorption through skin, an urban or western lifestyle may result in less synthesis of vitamin D with higher skin pigmentation. Laboratory and preclinical data indicate that vitamin D is involved in preventing breast carcinogenesis and progression. Vitamin D receptor (VDR) knock-out mice are more likely to develop tumors that are ER-negative, and we have shown that serum levels of 25OHD are lowest among EA women with triple-negative tumors (negative for ER, PR and HER2); and among non-cancer patients, vitamin D levels are lower in AAs than in EAs. Thus, it is plausible to hypothesize that low vitamin D levels could be associated with the higher prevalence of more aggressive tumors among AA women. In this paper, we review the current literature on vitamin D and aggressive breast cancer subtypes, discuss vitamin D in AA women from a perspective of evolution and adaption, and examine the potential role of vitamin D in cancer racial disparities. We present our recently published data showing two single nucleotide polymorphisms in vitamin D catabolic enzyme CYP24A1 associated with higher risk of estrogen ER-negative risk in AA than in EA women. The relationship of vitamin D with breast cancer risk may be subtype-specific, with emerging evidence of stronger effects of vitamin D for more aggressive breast cancer, particularly in women of African ancestry.

The sum of many small changes: microRNAs are specifically and potentially globally altered by vitamin D3 metabolites

Vitamin D3 deficiency is rampant which may contribute to increased risk of many diseases including cancer, cardiovascular disease and autoimmune disorders. Genomic activity of the active metabolite 1,25-dihydroxyvitamin D (1,25D) mediates most vitamin D3's actions and many gene targets of 1,25D have been characterized. As the importance of non-coding RNAs has emerged, the ability of vitamin D3via 1,25D to regulate microRNAs (miRNAs) has been demonstrated in several cancer cell lines, patient tissue and sera. In vitamin D3 intervention patient trials, significant differences in miRNAs are observed between treatment groups and/or between baseline and followup. In patient sera from population studies, specific miRNA differences associate with serum levels of 25D. The findings thus far indicate that dietary vitamin D3 in patients and 1,25D in vitro not only regulate specific miRNA(s), but may also globally upregulate miRNA levels. This article is part of a Special Issue entitled 'Vitamin D Workshop'.