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Wati LR, Sargowo D, Nurseta T, Zuhriyah L, Rahardjo B. Correlations Among Maternal and Infant Factors, Lead Exposure, and Serum Prolactin Levels During Lactation: A Cross-sectional Study in Indonesia. J Prev Med Public Health 2023; 56:422-430. [PMID: 37735831 PMCID: PMC10579643 DOI: 10.3961/jpmph.23.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/28/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Prolactin is vital for breastfeeding and milk production, and its secretion is influenced by factors related to the mother, infant, and environment. To date, no study has concurrently investigated the correlation of these factors with serum prolactin levels during lactation. Therefore, the objective of this study was to investigate the correlations among maternal and infant factors, lead exposure, and serum prolactin levels during lactation. METHODS A cross-sectional approach was employed in Surabaya, Indonesia, among 110 exclusively lactating mothers. The mothers' daily diets were determined using multiple 24-hour recalls, while blood lead levels were measured with inductively coupled plasma mass spectrometry. Serum prolactin levels were assessed using the electrochemiluminescence immunoassay. For bivariate analysis, we employed the Spearman correlation, Mann-Whitney, and Kruskal-Wallis tests, while for multivariate analysis, we utilized multiple linear regression. RESULTS The average serum prolactin level of the lactating mothers was 129.19±88.96 ng/mL. Positive correlations were found between serum prolactin levels and breastfeeding frequency (p < 0.001), protein intake (p < 0.001), and calcium intake (p = 0.011) but had negative correlation with blood lead levels (p < 0.001) and vitamin B6 intake (p = 0.003). Additionally, prolactin levels were not significantly associated with maternal age; parity; intake of calories, vitamin D, vitamin E, zinc, folic acid, magnesium, or iron; infant age; or infant sex. CONCLUSIONS Breastfeeding frequency had a stronger positive relationship with serum prolactin levels than protein and calcium intake. However, lead exposure was associated with reduced serum prolactin levels during lactation. Consequently, specific interventions from policymakers are necessary to manage breastfeeding in mothers exposed to lead.
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Affiliation(s)
- Linda Ratna Wati
- Doctoral Study Program in Medical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
- Department of Midwifery, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Djanggan Sargowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya/Universitas Brawijaya Hospital, Malang, Indonesia
| | - Tatit Nurseta
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Lilik Zuhriyah
- Department of Public Health, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Bambang Rahardjo
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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Hathaway CA, Rice MS, Townsend MK, Hankinson SE, Arslan AA, Buring JE, Hallmans G, Idahl A, Kubzansky LD, Lee IM, Lundin EA, Sluss PM, Zeleniuch-Jacquotte A, Tworoger SS. Prolactin and Risk of Epithelial Ovarian Cancer. Cancer Epidemiol Biomarkers Prev 2021; 30:1652-1659. [PMID: 34244157 DOI: 10.1158/1055-9965.epi-21-0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prolactin is synthesized in the ovaries and may play a role in ovarian cancer etiology. One prior prospective study observed a suggestive positive association between prolactin levels and risk of ovarian cancer. METHODS We conducted a pooled case-control study of 703 cases and 864 matched controls nested within five prospective cohorts. We used unconditional logistic regression to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between prolactin and ovarian cancer risk. We examined heterogeneity by menopausal status at blood collection, body mass index (BMI), age, and histotype. RESULTS Among women with known menopausal status, we observed a positive trend in the association between prolactin and ovarian cancer risk (P trend = 0.045; OR, quartile 4 vs. 1 = 1.34; 95% CI = 0.97-1.85), but no significant association was observed for premenopausal or postmenopausal women individually (corresponding OR = 1.38; 95% CI = 0.74-2.58; P trend = 0.32 and OR = 1.41; 95% CI = 0.93-2.13; P trend = 0.08, respectively; P heterogeneity = 0.91). In stratified analyses, we observed a positive association between prolactin and risk for women with BMI ≥ 25 kg/m2, but not BMI < 25 kg/m2 (corresponding OR = 2.68; 95% CI = 1.56-4.59; P trend < 0.01 and OR = 0.90; 95% CI = 0.58-1.40; P trend = 0.98, respectively; P heterogeneity < 0.01). Associations did not vary by age, postmenopausal hormone therapy use, histotype, or time between blood draw and diagnosis. CONCLUSIONS We found a trend between higher prolactin levels and increased ovarian cancer risk, especially among women with a BMI ≥ 25 kg/m2. IMPACT This work supports a previous study linking higher prolactin with ovarian carcinogenesis in a high adiposity setting. Future work is needed to understand the mechanism underlying this association.
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Affiliation(s)
| | - Megan S Rice
- Clinical and Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mary K Townsend
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Susan E Hankinson
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Alan A Arslan
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York.,Department of Population Health, New York University Langone Health, New York, New York.,NYU Perlmutter Comprehensive Cancer Center, New York, New York
| | - Julie E Buring
- Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Göran Hallmans
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Annika Idahl
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Laura D Kubzansky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - I-Min Lee
- Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Eva A Lundin
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Patrick M Sluss
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne Zeleniuch-Jacquotte
- Department of Population Health, New York University Langone Health, New York, New York.,NYU Perlmutter Comprehensive Cancer Center, New York, New York
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Katz TA, Wu AH, Stanczyk FZ, Wang R, Koh WP, Yuan JM, Oesterreich S, Butler LM. Determinants of prolactin in postmenopausal Chinese women in Singapore. Cancer Causes Control 2018; 29:51-62. [PMID: 29124543 PMCID: PMC5962355 DOI: 10.1007/s10552-017-0978-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Mechanistic and observational data together support a role for prolactin in breast cancer development. Determinants of prolactin in Asian populations have not been meaningfully explored, despite the lower risk of breast cancer in Asian populations. METHODS Determinants of plasma prolactin were evaluated in 442 postmenopausal women enrolled in the Singapore Chinese Health Study, a population-based prospective cohort study. At baseline all cohort members completed an in-person interview that elicited information on diet, menstrual and reproductive history, and lifestyle factors. One year after cohort initiation we began collecting blood samples. Quantified were plasma concentrations of prolactin, estrone, estradiol, testosterone, androstenedione, and sex hormone-binding globulin (SHBG). Analysis of covariance method was used for statistical analyses with age at blood draw, time since last meal, and time at blood draw as covariates. RESULTS Mean prolactin levels were 25.1% lower with older age at menarche (p value = 0.001), and 27.6% higher with greater years between menarche and menopause (p value = 0.009). Prolactin levels were also positively associated with increased sleep duration (p value = 0.005). The independent determinants of prolactin were years from menarche to menopause, hours of sleep, and the plasma hormones estrone and SHBG (all p values < 0.01). CONCLUSION The role of prolactin in breast cancer development may involve reproductive and lifestyle factors, such as a longer duration of menstrual cycling and sleep patterns.
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Affiliation(s)
- Tiffany A Katz
- Department of Pharmacology and Chemical Biology, Women's Cancer Research Center, Magee Women's Research Institute, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Department of Molecular and Cellular Biology, The Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, USA
| | - Anna H Wu
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Frank Z Stanczyk
- Department of Urology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Renwei Wang
- Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Woon-Puay Koh
- Duke-NUS Medical School, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Jian-Min Yuan
- Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Steffi Oesterreich
- Department of Pharmacology and Chemical Biology, Women's Cancer Research Center, Magee Women's Research Institute, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Lesley M Butler
- Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA.
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
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O'Leary KA, Shea MP, Salituro S, Blohm CE, Schuler LA. Prolactin Alters the Mammary Epithelial Hierarchy, Increasing Progenitors and Facilitating Ovarian Steroid Action. Stem Cell Reports 2017; 9:1167-1179. [PMID: 28919264 PMCID: PMC5639259 DOI: 10.1016/j.stemcr.2017.08.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 01/01/2023] Open
Abstract
Hormones drive mammary development and function and play critical roles in breast cancer. Epidemiologic studies link prolactin (PRL) to increased risk for aggressive cancers that express estrogen receptor α (ERα). However, in contrast to ovarian steroids, PRL actions on the mammary gland outside of pregnancy are poorly understood. We employed the transgenic NRL-PRL model to examine the effects of PRL alone and with defined estrogen/progesterone exposure on stem/progenitor activity and regulatory networks that drive epithelial differentiation. PRL increased progenitors and modulated transcriptional programs, even without ovarian steroids, and with steroids further raised stem cell activity associated with elevated canonical Wnt signaling. However, despite facilitating some steroid actions, PRL opposed steroid-driven luminal maturation and increased CD61+ luminal cells. Our findings demonstrate that PRL can powerfully influence the epithelial hierarchy alone and temper the actions of ovarian steroids, which may underlie its role in the development of breast cancer.
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Affiliation(s)
- Kathleen A O'Leary
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Michael P Shea
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA; Molecular and Environmental Toxicology Graduate Program, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Stephanie Salituro
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Courtney E Blohm
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Linda A Schuler
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA; UW Comprehensive Cancer Center, University of Wisconsin-Madison, Madison, WI 53792, USA; Molecular and Environmental Toxicology Graduate Program, University of Wisconsin-Madison, Madison, WI 53706, USA.
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Tikk K, Sookthai D, Fortner RT, Johnson T, Rinaldi S, Romieu I, Tjønneland A, Olsen A, Overvad K, Clavel-Chapelon F, Baglietto L, Boeing H, Trichopoulou A, Lagiou P, Trichopoulos D, Masala G, Krogh V, Tumino R, Ricceri F, Mattiello A, Agudo A, Menéndez V, Sánchez MJ, Amiano P, Chirlaque MD, Barricarte A, Bueno-de-Mesquita HB, Monninkhof EM, Onland-Moret NC, Andresson A, Sund M, Weiderpass E, Khaw KT, Key TJ, Travis RC, Merritt MA, Riboli E, Dossus L, Kaaks R. Circulating prolactin and in situ breast cancer risk in the European EPIC cohort: a case-control study. Breast Cancer Res 2015; 17:49. [PMID: 25887963 PMCID: PMC4413538 DOI: 10.1186/s13058-015-0563-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/17/2015] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION The relationship between circulating prolactin and invasive breast cancer has been investigated previously, but the association between prolactin levels and in situ breast cancer risk has received less attention. METHODS We analysed the relationship between pre-diagnostic prolactin levels and the risk of in situ breast cancer overall, and by menopausal status and use of postmenopausal hormone therapy (HT) at blood donation. Conditional logistic regression was used to assess this association in a case-control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, including 307 in situ breast cancer cases and their matched control subjects. RESULTS We found a significant positive association between higher circulating prolactin levels and risk of in situ breast cancer among all women [pre-and postmenopausal combined, ORlog2=1.35 (95% CI 1.04-1.76), Ptrend=0.03]. No statistically significant heterogeneity was found between prolactin levels and in situ cancer risk by menopausal status (Phet=0.98) or baseline HT use (Phet=0.20), although the observed association was more pronounced among postmenopausal women using HT compared to non-users (Ptrend=0.06 vs Ptrend=0.35). In subgroup analyses, the observed positive association was strongest in women diagnosed with in situ breast tumors<4 years compared to ≥4 years after blood donation (Ptrend=0.01 vs Ptrend=0.63; Phet=0.04) and among nulliparous women compared to parous women (Ptrend=0.03 vs Ptrend=0.15; Phet=0.07). CONCLUSIONS Our data extends prior research linking prolactin and invasive breast cancer to the outcome of in situ breast tumours and shows that higher circulating prolactin is associated with increased risk of in situ breast cancer.
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Affiliation(s)
- Kaja Tikk
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 581, D-69120, Heidelberg, Germany.
| | - Disorn Sookthai
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Renée T Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Theron Johnson
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Sabina Rinaldi
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC), Lyon, France.
| | - Isabelle Romieu
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC), Lyon, France.
| | | | - Anja Olsen
- Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Kim Overvad
- Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark.
| | - Françoise Clavel-Chapelon
- INSERM, Centre for Research in Epidemiology and Population Health [CESP], U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France.
- University Paris Sud, UMRS 1018, F-94805, Villejuif, France.
- IGR, F-94805, Villejuif, France.
| | - Laura Baglietto
- Cancer Epidemiology Centre, Cancer Council Victoria, 3053, Melbourne, Australia.
- Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology, The University of Melbourne, 3010, Melbourne, Australia.
| | - Heiner Boeing
- Department of Epidemiology, German Institute of Human Nutrition (DIfE) Potsdam-Rehbrücke, Nuthetal, Germany.
| | - Antonia Trichopoulou
- Hellenic Health Foundation, 13 Kaisareias Street, GR-115 27, Athens, Greece.
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, 75 M. Asias Street, Goudi, GR-115 27, Athens, Greece.
- Bureau of Epidemiologic Research, Academy of Athens, 23 Alexandroupoleos Street, Athens, GR-115 27, Greece.
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, 75 M. Asias Street, Goudi, GR-115 27, Athens, Greece.
- Bureau of Epidemiologic Research, Academy of Athens, 23 Alexandroupoleos Street, Athens, GR-115 27, Greece.
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, USA.
| | - Dimitrios Trichopoulos
- Hellenic Health Foundation, 13 Kaisareias Street, GR-115 27, Athens, Greece.
- Bureau of Epidemiologic Research, Academy of Athens, 23 Alexandroupoleos Street, Athens, GR-115 27, Greece.
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, USA.
| | - Giovanna Masala
- Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy.
| | - Vittorio Krogh
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milano, Italy.
| | - Rosario Tumino
- Cancer Registry and Histopathology Unit, "Civic - M.P.Arezzo" Hospital ASP, Ragusa, Italy.
| | - Fulvio Ricceri
- Unit of Cancer Epidemiology, AO Citta' della Salute e della Scienza, University of Turin, Torino, Italy.
- Center for Cancer Prevention (CPO), Via Santena 7, 10126, Torino, Italy.
| | - Amalia Mattiello
- Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy.
| | - Antonio Agudo
- Unit of Nutrition, Environment and Cancer, Catalan Institute of Oncology-ICO, IDIBELL, L'Hospitalet de Llobregat, Barcelona, 08908, Spain.
| | | | - María-José Sánchez
- Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitario de Granada (Granada.ibs), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP)), Madrid, Spain.
| | - Pilar Amiano
- Public Health Division of Gipuzkoa, BioDonostia Reserach Institute, San Sebastian, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP)), Madrid, Spain.
| | - Maria-Dolores Chirlaque
- Department of Epidemiology, Murcia Regional Health Authority, Murcia, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP)), Madrid, Spain.
| | - Aurelio Barricarte
- Navarre Public Health Institute, Pamplona, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP)), Madrid, Spain.
| | - H Bas Bueno-de-Mesquita
- Department for Determinants of Chronic Diseases (DCD), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
- Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands.
- Department of Epidemiology and Biostatistics, The School of Public Health, Imperial College, London, UK.
- Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Evelyn M Monninkhof
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - N Charlotte Onland-Moret
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Anne Andresson
- Department of Radiation Sciences, University of Umeå, Umeå, Sweden.
| | - Malin Sund
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Elisabete Weiderpass
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
- Department of Research, Cancer Registry of Norway, Oslo, Norway.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
- Samfundet Folkhälsan, Helsinki, Finland.
| | - Kay-Tee Khaw
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Timothy J Key
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Ruth C Travis
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Melissa A Merritt
- Department of Epidemiology and Biostatistics, The School of Public Health, Imperial College, London, UK.
| | - Elio Riboli
- Department of Epidemiology and Biostatistics, The School of Public Health, Imperial College, London, UK.
| | - Laure Dossus
- INSERM, Centre for Research in Epidemiology and Population Health [CESP], U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France.
- University Paris Sud, UMRS 1018, F-94805, Villejuif, France.
- IGR, F-94805, Villejuif, France.
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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