Patterns of Physical Activity and the Role of Obesity and Comorbidities Among Long-term African American Breast Cancer Survivors

PURPOSE

Physical activity (PA) has many health benefits for cancer survivors, but little research has examined patterns and correlates in African American women, who have a higher burden of comorbidities and obesity. We examined PA types and patterns overall and by obesity and comorbidities among long-term (> 5 years) breast cancer survivors.

METHODS

This cross-sectional study included 323 women who were previous participants of a case-only study in three southeastern states. Women completed a survivorship-focused questionnaire using validated measures to collect data on cancer treatment, PA (recreational, household, transportation) and other lifestyle factors, and comorbidities. Logistic regression models estimated adjusted ORs and 95% CIs for total PA (all three types, categorized as tertiles) and meeting PA guidelines (> 150 min/week of exercise).

RESULTS

The mean age of women was 59.1 years (range 27.9-79.5). The most frequent PA types (≥ 1/month) included routine household cleaning (92.9%), shopping (94.7%), walking slowly (42.1%), and walking briskly (40.6%). Less than 40% met PA guidelines. Women with more total comorbidities, arthritis, and obesity had lower levels of total PA (minutes/week) and/or recreational PA. In adjusted models, BMI ≥ 35 kg/m2 was associated with reduced odds of total PA (OR = 0.33, 95% CI 0.12-0.88, highest tertile). Arthritis was associated with reduced odds of meeting PA guidelines (OR = 0.61, 95% CI 36-1.05).

CONCLUSIONS

Close to 60% of African American breast cancer survivors did not meet PA guidelines based on recreational PA participation. Household PA was an important source of PA. Comorbidities and obesity were associated with both reduced total PA and not meeting PA guidelines.

The Role of Spirituality on Physical Activity and Sleep Among African American Long-Term Breast Cancer Survivors

BACKGROUND

African Americans with chronic conditions have reported the importance of spirituality in their lives. Aspects of spirituality have been shown to be related to physical activity (PA) and sleep, and PA and sleep affect quality of life (QOL). This study examined the association between spirituality, PA, and sleep in long-term African American breast cancer survivors.

METHODS

This cross-sectional study included 323 breast cancer survivors who previously participated in a case-only study. During 2015-2016, participants completed a questionnaire focused on survivorship that used validated measures for spirituality, PA, and sleep. Adjusted binary and multinomial logistic regression models estimated odds ratios (aORs) and 95% confidence intervals (CIs) for the associations of spirituality with total PA, meeting PA guidelines, sleep duration, and sleep medication.

RESULTS

The mean age at diagnosis was 54.8 (SD = 9.89) years. The range of spirituality scores was 7-48 (median = 44). Among participants who had a score ≥ 44, 59% had high total PA, 61% met PA guidelines, 59% had high sleep duration, and 55% did not use sleep medication. Higher spirituality score was associated with higher total PA (aOR for ≥ 681 min/week: 1.90, 95% CI: 1.03-3.50), meeting PA guidelines (aOR: 1.78, 95% CI: 1.06-2.98), sleep duration > 7 h/night (aOR: 1.72, 95% CI 1.05-2.83), and lack of sleep medication use (aOR: 0.45, 95% CI: 0.24-0.84).

CONCLUSION

In African American long-term breast cancer survivors, a higher spirituality score increased the likelihood of greater PA and high sleep duration. These results indicate that interventions surrounding spirituality may benefit the QOL of African American breast cancer survivors.

Female fertility treatment and adverse birth outcomes: a multistate analysis of pregnancy risk assessment monitoring system data

OBJECTIVE

The popularity of fertility treatments has continued to rise, however, the potential health risks of these treatments for both mother and infant are not fully known. Our objective was to determine the association between fertility treatments and adverse birth outcomes of intended pregnancies using the Pregnancy Risk Assessment Monitoring System (PRAMS) data.

METHODS

Data from 27,018 intended pregnancies, collected from 2009 to 2018 in the United States, were included in our analysis. PRAMS data consisted of questionnaire and birth certificate data. SAS 9.4 was used for analyses accounting for complex survey weights. All analyses were conducted separately for singleton and twin births. Weighted percentages with 95% confidence intervals (CIs) were estimated for maternal characteristics and birth outcomes. Multivariable logistic regression was used to determine adjusted odds ratios (OR) and 95% CIs for associations of fertility treatment use and adverse birth outcomes.

RESULTS

Close to 12% of women reported the use of any fertility treatment. Among those using fertility treatments, the most common type was assisted reproductive technology (ART) for both twin (68.7%, 95% CI: 62.3, 75.2) and singleton births (45.1%, 95% CI: 42.0, 48.1). Use of any type of fertility treatment for singleton births was associated with increased odds of a cesarean delivery (OR: 1.31, 95% CI: 1.16, 1.47), preterm birth (OR: 1.42, 95% CI: 1.20, 1.67), a small-for-gestational age infant (OR: 1.20, 95% CI: 1.00, 1.44), and an infant hospital stay >5 days (OR: 1.34, 95% CI: 1.11, 1.62). Use of fertility treatment for twin births was associated with cesarean delivery only. In analyses examining associations for specific types of treatment (medication alone, ART, insemination) with birth outcomes, results varied by treatment type.

CONCLUSIONS

In this large population-based sample of women who intended to become pregnant and had a live birth, fertility treatment was associated with adverse birth outcomes. Patients seeking fertility treatment should be appropriately counseled on the risks of adverse maternal and infant birth outcomes overall and by treatment type. Maternal support and resources to prevent adverse birth outcomes among women using fertility treatments are warranted.

Trends, patterns, and maternal characteristics of opioid prescribing during pregnancy in a large population-based cohort study

BACKGROUND

Opioid use during pregnancy has been associated with adverse maternal and infant health outcomes. Prescription drug monitoring programs (PDMP) provide a population-based source of prescription data. We linked statewide PDMP and birth certificate data in Tennessee (TN) to determine patterns of prescription opioid and benzodiazepine use during pregnancy.

METHODS

We constructed a cohort of 311,217 live singleton births from 2013 to 2016 with prescription history from 90 days before pregnancy to birth. Descriptive statistics were used to describe opioid prescription patterns during pregnancy overall, by maternal characteristics and by year. Multivariable logistic regression models estimated adjusted odds ratios and 95% confidence intervals for factors associated with prescription use.

RESULTS

The prevalence of prescription use during pregnancy was 14.1% for opioid analgesics, 1.6% buprenorphine for medication-assisted treatment, and 2.6% for benzodiazepines. The prevalence of opioid analgesic use decreased from 16.6% (2013) to 11.8% (2016) (ptrend< 0.001). About 25% used for > 7 and 9.7% for > 30 days' supply. The most common types were hydrocodone (9.3%), codeine (3.4%), and oxycodone (2.9%). In adjusted models, lower education, lower income, pre-pregnancy obesity and smoking during pregnancy were associated with increased odds of any opioid and opioid analgesic use.

CONCLUSION(S)

Despite the encouraging trend of decreasing use of prescription opioid analgesics, the overall prevalence remained close to 12% with many women using for long durations. Use was associated with lower socioeconomic status, obesity, and prenatal smoking. Findings highlight the need for maternal education and resources, and provider support for implementation of evidence-based care.

Characteristics of fatal opioid overdoses with stimulant involvement in Tennessee: A descriptive study using 2018 State Unintentional Drug Overdose Reporting System Data

PURPOSE

Opioid overdose deaths involving stimulants are on the rise. Demographic characteristics for these deaths to be used in prevention efforts have not been established.

METHODS

We conducted a statewide retrospective study to evaluate the characteristics of fatal opioid overdoses with stimulant involvement using 2018 Tennessee State Unintentional Drug Overdose Reporting System data. Data sources included death certificates, autopsy reports, toxicology, and prescription drug monitoring program data. Frequencies were generated to compare demographics, circumstances, opioid history, death scene information, bystander intervention, and toxicology between fatal opioid overdoses with and without stimulant involvement.

RESULTS

A total of 1183 SUDORS opioid overdose deaths occurred in Tennessee in 2018 of which 434 (36.7%) involved a stimulant. Fatal opioid overdoses involving stimulants had higher frequencies of illicit drugs on toxicology specifically marijuana, fentanyl, and heroin compared to fatal opioid overdoses without stimulants. Fatal opioid overdoses involving stimulants had higher frequencies of scene indications of injection drug use compared to fatal opioid overdoses without stimulant involvement.

CONCLUSIONS

Fatal overdoses are shifting from mainly opioid to multidrug involvement and over one-third include use of stimulants. This analysis can help public health practitioners understand the circumstances around fatal opioid overdoses involving stimulants to inform tailored prevention strategies.

Prediction models for breast cancer prognosis among Asian women

BACKGROUND

Robust and reliable prognosis prediction models have not been developed and validated for Asian patients with breast cancer, a rapidly growing yet understudied population in the United States.

METHODS

We used longitudinal data from the Shanghai Breast Cancer Survival Study, a population-based prospective cohort study (n = 5042), to develop prediction models for 5- and 10-year disease-free survival (DFS) and overall survival (OS). The initial models considered age at diagnosis, tumor grade, tumor size, number of positive nodes, TNM stage, chemotherapy, tamoxifen therapy, and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status. We then evaluated whether the addition of modifiable lifestyle factors (physical activity, soy isoflavones intake, and postdiagnostic weight change) improved the models. All final models have been validated internally and externally in the National Cancer Database when applicable.

RESULTS

Our final models included age at diagnosis, tumor grade, tumor size, number of positive nodes, TNM stage, chemotherapy, tamoxifen therapy, ER status, PR status, 6-month postdiagnostic weight change, interaction between ER status and tamoxifen therapy, and interaction between age and TNM stage. The internal validation yielded C-statistics of 0.76, 0.74, 0.78, and 0.75 for 5-year DFS, 10-year DFS, 5-year OS, and 10-year OS, respectively. The external validation yielded C-statistics of 5- and 10-year OS both at 0.78 for Chinese ethnicity, 0.79 for East Asian ethnicity, and 0.75 and 0.76 for all ethnic groups combined.

CONCLUSION

We developed prediction models for breast cancer prognosis from a large prospective study. Our prognostic models performed very well in women from the United States-particularly in Asian American women-and demonstrated high prediction accuracy and generalizability.

Descriptive exploration of overdose codes in hospital and emergency department discharge data to inform development of drug overdose morbidity surveillance indicator definitions in ICD-10-CM

Background

In October 2015, discharge data coding in the USA shifted to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), necessitating new indicator definitions for drug overdose morbidity. Amid the drug overdose crisis, characterising discharge records that have ICD-10-CM drug overdose codes can inform the development of standardised drug overdose morbidity indicator definitions for epidemiological surveillance.

Methods

Eight states submitted aggregated data involving hospital and emergency department (ED) discharge records with ICD-10-CM codes starting with T36–T50, for visits occurring from October 2015 to December 2016. Frequencies were calculated for (1) the position within the diagnosis billing fields where the drug overdose code occurred; (2) primary diagnosis code grouped by ICD-10-CM chapter; (3) encounter types; and (4) intents, underdosing and adverse effects.

Results

Among all records with a drug overdose code, the primary diagnosis field captured 70.6% of hospitalisations (median=69.5%, range=66.2%–76.8%) and 79.9% of ED visits (median=80.7%; range=69.8%–88.0%) on average across participating states. The most frequent primary diagnosis chapters included injury and mental disorder chapters. Among visits with codes for drug overdose initial encounters, subsequent encounters and sequelae, on average 94.6% of hospitalisation records (median=98.3%; range=68.8%–98.8%) and 95.5% of ED records (median=99.5%; range=79.2%–99.8%), represented initial encounters. Among records with drug overdose of any intent, adverse effect and underdosing codes, adverse effects comprised an average of 74.9% of hospitalisation records (median=76.3%; range=57.6%–81.1%) and 50.8% of ED records (median=48.9%; range=42.3%–66.8%), while unintentional intent comprised an average of 11.1% of hospitalisation records (median=11.0%; range=8.3%–14.5%) and 28.2% of ED records (median=25.6%; range=20.8%–40.7%).

Conclusion

Results highlight considerations for adapting and standardising drug overdose indicator definitions in ICD-10-CM.

Interrupted time series analysis to evaluate the performance of drug overdose morbidity indicators shows discontinuities across the ICD-9-CM to ICD-10-CM transition

INTRODUCTION

On 1 October 2015, the USA transitioned from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision (ICD-10-CM). Considering the major changes to drug overdose coding, we examined how using different approaches to define all-drug overdose and opioid overdose morbidity indicators in ICD-9-CM impacts longitudinal analyses that span the transition, using emergency department (ED) and hospitalisation data from six states' hospital discharge data systems.

METHODS

We calculated monthly all-drug and opioid overdose ED visit rates and hospitalisation rates (per 100 000 population) by state, starting in January 2010. We applied three ICD-9-CM indicator definitions that included identical all-drug or opioid-related codes but restricted the number of fields searched to varying degrees. Under ICD-10-CM, all fields were searched for relevant codes. Adjusting for seasonality and autocorrelation, we used interrupted time series models with level and slope change parameters in October 2015 to compare trend continuity when employing different ICD-9-CM definitions.

RESULTS

Most states observed consistent or increased capture of all-drug and opioid overdose cases in ICD-10-CM coded hospital discharge data compared with ICD-9-CM. More inclusive ICD-9-CM indicator definitions reduced the magnitude of significant level changes, but the effect of the transition was not eliminated.

DISCUSSION

The coding change appears to have introduced systematic differences in measurement of drug overdoses before and after 1 October 2015. When using hospital discharge data for drug overdose surveillance, researchers and decision makers should be aware that trends spanning the transition may not reflect actual changes in drug overdose rates.

Impact of benzodiazepines and polysubstance status on repeat non-fatal drug overdoses

Research has shown that benzodiazepines and mental health disorders can increase the likelihood of repeat overdose, but researchers have not explored this association in Tennessee (TN). We examined benzodiazepines, polysubstance overdose status with/without benzodiazepines, and mental health comorbidities with repeat overdose using statewide data in TN. This study analyzed TN hospital discharge data on nonfatal overdoses for patients ages 18-64 from 2012 to 2016 for 21,066 patients with an initial inpatient visit and 36,244 patients with an initial outpatient visit. The study assessed each patient at one year after initial overdose to determine likelihood of repeat overdose. We used a Cox proportional hazards model to compute hazard ratios (HRs) and 95% confidence intervals (CIs) to determine the factors associated with repeat nonfatal overdose. Repeat overdose rates, by one year after index overdose, were 12.9% of the sample for inpatients and 13.9% of the sample for outpatients. The visit factors (overdose characteristics and comorbidities determined from the initial visit) that the study found to be independently associated with repeat overdoses among inpatients were polysubstance status (HR: 0.88, 95% CI 0.78-0.99), benzodiazepine/polysubstance interaction (HR: 1.29, 95% CI 1.02-1.64), and presence of any mental health disorder (HR: 1.28, 95% CI: 1.18-1.39). For outpatients, the benzodiazepine/polysubstance interaction (HR: 1.21, 95% CI 1.01-1.44) was significant without adjusting for demographic factors. We found evidence that benzodiazepine/polysubstance status and mental health disorders were associated with repeat overdose for inpatients, and that benzodiazepine/polysubstance status was associated with repeat overdose for outpatients. Findings support the need to include polysubstance status and mental health in overdose prevention efforts.

Record Linkage Approaches Using Prescription Drug Monitoring Program and Mortality Data for Public Health Analyses and Epidemiologic Studies

BACKGROUND

The use of Prescription Drug Monitoring Program (PDMP) data has greatly increased in recent years as these data have accumulated as part of the response to the opioid epidemic in the United States. We evaluated the accuracy of record linkage approaches using the Controlled Substance Monitoring Database (Tennessee's [TN] PDMP, 2012-2016) and mortality data on all drug overdose decedents in Tennessee (2013-2016).

METHODS

We compared total, missed, and false positive (FP) matches (with manual verification of all FPs) across approaches that included a variety of data cleaning and matching methods (probabilistic/fuzzy vs. deterministic) for patient and death linkages, and prescription history. We evaluated the influence of linkage approaches on key prescription measures used in public health analyses. We evaluated characteristics (e.g., age, education, sex) of missed matches and incorrect matches to consider potential bias.

RESULTS

The most accurate probabilistic/fuzzy matching approach identified 4,714 overdose deaths (vs. the deterministic approach, n = 4,572), with a low FP linkage error (<1%) and high correct match proportion (95% vs. 92% and ~90% for probabilistic approaches not using comprehensive data cleaning). Estimation of all prescription measures improved (vs. deterministic approach). For example, frequency (%) of decedents filling an oxycodone prescription in the last 60 days (n = 1,371 [32%] vs. n = 1,443 [33%]). Missed overdose decedents were more likely to be younger, male, nonwhite, and of higher education.

CONCLUSION

Implications of study findings include underreporting, prescribing and outcome misclassification, and reduced generalizability to population risk groups, information of importance to epidemiologists and researchers using PDMP data.

Prevalence and Risk Factors Associated With Long-term Opioid Use After Injury Among Previously Opioid-Free Workers

IMPORTANCE

Using opioids for acute pain can lead to long-term use and associated morbidity and mortality. Injury has been documented as a gateway to long-term opioid use in some populations, but data are limited for injured workers.

OBJECTIVE

To evaluate the prevalence and risk factors of long-term opioid use after injury among workers in Tennessee who were opioid free at the time of injury.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study identified injured workers aged 15 to 99 years who reported only 1 injury to the Tennessee Bureau of Workers' Compensation from March 2013 to December 2015 and had no opioid prescription in the 60 days before injury. Participants were matched to their prescription history in Tennessee's prescription drug monitoring program. Analysis was conducted from November 2017 to March 2018. Logistic regression models were used to calculate adjusted odds ratios (ORs) and 95% CIs for associations of demographic, injury, and opioid use variables with long-term use.

MAIN OUTCOMES AND MEASURES

The primary outcome was long-term opioid use, defined as having an opioid supplied for 45 or more days in the 90 days after injury.

RESULTS

Among 58 278 injured workers who received opioids after injury (18 977 [32.5%] aged 15-34 years, 27 514 [47.2%] aged 35-54 years, and 11 787 [20.2%] aged 55-99 years; 32 607 [56.0%] men), 46 399 (79.6%) were opioid free at the time of injury. Among opioid-free injured workers, 1843 (4.0%) began long-term opioid use. After controlling for covariates, long-term use was associated with receiving 20 or more days' supply in the initial opioid prescription compared with receiving less than 5 days' supply (OR, 28.94; 95% CI, 23.44-35.72) and visiting 3 or more prescribers in the 90 days after injury compared with visiting 1 prescriber (OR, 14.91; 95% CI, 12.15-18.29). However, even just 5 days' to 9 days' supply was associated with an increase in the odds of long-term use compared with less than 5 days' supply (OR, 1.83; 95% CI, 1.56-2.14).

CONCLUSIONS AND RELEVANCE

In this study of injured workers, injury was associated with long-term opioid use. The number of days' supply of the initial opioid prescription was the strongest risk factor of developing long-term use, highlighting the importance of careful prescribing for initial opioid prescriptions.

Prescription opioid use by injured workers in Tennessee: a descriptive study using linked statewide databases

PURPOSE

This is the first study in Tennessee to measure opioid use in injured workers and among the first nationally to use a prescription drug monitoring program to do so. We conducted a retrospective cohort study to evaluate the prevalence of opioid use after injury and associated characteristics among workers reporting one injury to Tennessee Workers' Compensation.

METHODS

Injured workers identified in Workers' Compensation records 2013-2015 were linked to their prescription history in Tennessee's prescription drug monitoring database.

RESULTS

Among 172,256 injured workers, the prevalence of receiving an opioid after injury was 22.8% in 1 week, 29.7% in 1 month, and 33.3% in 6 months. Receiving an opioid was associated with having a fracture (odds ratio, 4.9; 95% confidence interval, 4.64-5.11 vs. other injuries). Hydrocodone short-acting was the most commonly received opioid (69.5% of injured workers), and the mean of each worker's maximum dose was 42.8 morphine milligram equivalents (SD 39.26). Ten percent of injured workers who received opioids also received a benzodiazepine.

CONCLUSIONS

Injured workers have a high prevalence of opioid use after injury, but prescribing patterns generally tend to follow Tennessee prescribing guidelines.

Postdiagnosis social networks and breast cancer mortality in the After Breast Cancer Pooling Project

BACKGROUND

Large social networks have been associated with better overall survival, though not consistently with breast cancer (BC)-specific outcomes. This study evaluated associations of postdiagnosis social networks and BC outcomes in a large cohort.

METHODS

Women from the After Breast Cancer Pooling Project (n = 9267) provided data on social networks within approximately 2 years of their diagnosis. A social network index was derived from information about the presence of a spouse/partner, religious ties, community ties, friendship ties, and numbers of living first-degree relatives. Cox models were used to evaluate associations, and a meta-analysis was used to determine whether effect estimates differed by cohort. Stratification by demographic, social, tumor, and treatment factors was performed.

RESULTS

There were 1448 recurrences and 1521 deaths (990 due to BC). Associations were similar in 3 of 4 cohorts. After covariate adjustments, socially isolated women (small networks) had higher risks of recurrence (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.15-1.77), BC-specific mortality (HR, 1.64; 95% CI, 1.33-2.03), and total mortality (HR, 1.69; 95% CI, 1.43-1.99) than socially integrated women; associations were stronger in those with stage I/II cancer. In the fourth cohort, there were no significant associations with BC-specific outcomes. A lack of a spouse/partner (P = .02) and community ties (P = .04) predicted higher BC-specific mortality in older white women but not in other women. However, a lack of relatives (P = .02) and friendship ties (P = .01) predicted higher BC-specific mortality in nonwhite women only.

CONCLUSIONS

In a large pooled cohort, larger social networks were associated with better BC-specific and overall survival. Clinicians should assess social network information as a marker of prognosis because critical supports may differ with sociodemographic factors. Cancer 2017;123:1228-1237. © 2016 American Cancer Society.

ALDH1A1 mRNA expression in association with prognosis of triple-negative breast cancer

ALDH1 is a crucial element in the retinoic acid signaling pathway regulating the self-renewal and differentiation of normal stem cells, and may play an important role in cancer progression. However, research on ALDH1 gene expressionand breast cancer prognosis has yielded conflicting results. We evaluated the association between tumor tissue ALDH1A1/ALDH1A3 mRNA expression and triple-negative breast cancer (TNBC) prognosis in the Shanghai Breast Cancer Survival Study (SBCSS, N=463), Nashville Breast Health Study (NBHS, N=86), and Southern Community Cohort Study (SCCS, N=47). Gene expression was measured in RNA isolated from breast cancer tissues. In the SBCSS, higher ALDH1A1 mRNA level was associated with improved disease-free (HR=0.87, 95% CI: 0.80-0.95, per log unit change) and overall survival (HR=0.85, 95% CI: 0.78-0.93 per log unit change) independent of age at diagnosis, TNM stage and treatment. We replicated the findings for overall survival in the NBHS and SCCS (HR = 0.27, 95% CI: 0.10-0.73) and for disease-free survival by a meta-analysis of four publicly-available gene expression datasets (HR = 0.86, 95% CI: 0.76-0.97). No significant association was found for ALDH1A3. Our study suggests high expression of ALDH1A1 mRNA in tumor tissues may be an independent predictor of a favorable TNBC outcome.

Abstract A58: Interaction of diabetes and obesity in postmenopausal breast cancer risk among black women

Purpose: Meta-analyses of the association between diabetes and postmenopausal breast cancer have been conducted primarily among white women with summary relative risks [RR] of approximately 1.15 (95% confidence interval (CI) 1.07-1.24). The only related prospective cohort study among black women reported a RR of 0.93 (95% CI 0.73-1.19). We conducted a case-control study to examine whether diabetes was associated with subsequent breast cancer among postmenopausal black women and whether obesity modified this association.

Methods: Women diagnosed with incident postmenopausal breast cancer between September 2009 and December 2012 were identified through statewide cancer registries in Georgia, South Carolina and Tennessee. One control per case, individually matched on age at enrollment, state and household income, were selected from Southern Community Cohort Study participants. Women whose breast cancer and diabetes were diagnosed within one year of each other were excluded to minimize detection bias resulting in 839 cases and 839 controls for analysis. Data on diabetes (cases n=244, controls n=336) and obesity (cases n=468, controls n=466) were obtained from baseline surveys; data on breast cancer histologic subtype (estrogen receptor (ER) positive n=556, ER negative n=216) were from cancer registry records.

Results: Using conditional logistic regression with further adjustment for educational level and health insurance coverage, there was a reduced risk of breast cancer associated with self-reported diabetes (odds ratio (OR) 0.63, 95% CI 0.49-0.80). Obesity did not significantly modify the effect of diabetes on breast cancer, but there was a stronger risk reduction among non-obese women (OR 0.51, 95% CI 0.34-0.77) than obese women (OR 0.69, 95% CI 0.50-0.94) (p for interaction=0.25). The inverse association was more pronounced for ER positive breast cancer (OR 0.51, 95% CI 0.37-0.70) than ER negative breast cancer (OR 0.84, 95% CI 0.51-1.37). However, the difference was not statistically significant.

Conclusions: In this large case-control study among black women, we found the first evidence suggesting a significant inverse association between diabetes and postmenopausal breast cancer risk. Future studies are needed to confirm our findings and to evaluate the underlying mechanisms, particularly regarding metformin use.

Citation Format: Maureen Sanderson, Loren Lipworth, David Shen-Miller, Martha J. Shrubsole, Alicia Beeghly-Fadiel, Sarah Nechuta, Xiao-ou Shu, Wei Zheng. Interaction of diabetes and obesity in postmenopausal breast cancer risk among black women. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A58.

Post-diagnosis social networks, and lifestyle and treatment factors in the After Breast Cancer Pooling Project

OBJECTIVE

Larger social networks have been associated with better breast cancer survival. To investigate potential mediators, we evaluated associations of social network size and diversity with lifestyle and treatment factors associated with prognosis.

METHODS

We included 9331 women from the After Breast Cancer Pooling Project who provided data on social networks within approximately two years following diagnosis. A social network index was derived from information about the presence of a spouse or intimate partner, religious ties, community participation, friendship ties, and numbers of living relatives. Diversity was assessed as variety of ties, independent of size. We used logistic regression to evaluate associations with outcomes and evaluated whether effect estimates differed using meta-analytic techniques.

RESULTS

Associations were similar across cohorts though analyses of smoking and alcohol included US cohorts only because of low prevalence of these behaviors in the Shanghai cohort. Socially isolated women were more likely to be obese (OR = 1.21, 95% CI:1.03-1.42), have low physical activity (<10 MET-hours/week, OR = 1.55, 95% CI:1.36-1.78), be current smokers (OR = 2.77, 95% CI:2.09-3.68), and have high alcohol intake (≥15 g/d, OR = 1.23, 95% CI:1.00-1.51), compared with socially integrated women. Among node positive cases from three cohorts, socially isolated women were more likely not to receive chemotherapy (OR = 2.10, 95% CI:1.30-3.39); associations differed in a fourth cohort. Other associations (nonsignificant) were consistent with less intensive treatment in socially isolated women. Low social network diversity was independently associated with more adverse lifestyle, but not clinical, factors.

CONCLUSIONS

Small, less diverse social networks measured post-diagnosis were associated with more adverse lifestyle factors and less intensive cancer treatment. Copyright © 2016 John Wiley & Sons, Ltd.

A pooled analysis of post-diagnosis lifestyle factors in association with late estrogen-receptor-positive breast cancer prognosis

Lifestyle factors have been well studied in relation to breast cancer prognosis overall; however, associations of lifestyle and late outcomes (>5 years after diagnosis) have been much less studied, and no studies have focused on estrogen receptor-positive (ER+) breast cancer survivors, who may have high risk of late recurrence and mortality. We utilized a large prospective pooling study to evaluate the associations of lifestyle factors with late recurrence and all-cause mortality among 6,295 5-year ER+ Stage I-III breast cancer survivors. Pooled and harmonized data were available on clinical factors and lifestyle factors (pre- to post-diagnosis weight change, body mass index (BMI) (kg/m(2)), recreational physical activity, alcohol intake and smoking history), measured on average 2.1 years after diagnosis. Updated information for weight only was available. Study heterogeneity was evaluated by the Q-statistic. Multivariable Cox regression models were stratified by study. Adjusting for clinical factors and potential confounders, ≥ 10% weight gain and obesity (BMI, 30-34.99 and ≥ 35) were associated with increased risk of late recurrence (hazard ratios (95% confidence intervals): 1.24 (1.00-1.53), 1.40 (1.05-1.86) and 1.41 (1.02-1.93), respectively). Daily alcohol intake was associated with late recurrence, 1.28 (1.01-1.62). Physical activity was inversely associated with late all-cause mortality (0.81 (0.71-0.93) and 0.71 (0.61-0.82) for 4.9 to <17.4 and ≥ 17.4 metabolic equivalent-hr/week). A U-shaped association was observed for late all-cause mortality and BMI using updated weight (1.42 (1.15-1.74) and 1.40 (1.09-1.81), <21.5 and ≥ 35, respectively). Smoking was associated with increased risk of late outcomes. In this large prospective pooling project, modifiable lifestyle factors were associated with late outcomes among long-term ER+ breast cancer survivors.

Abstract 2773: Association of ALDH1A1 gene expression with survival of triple-negative breast cancer

Aldehyde dehydrogenases (ALDH) are a family of enzymes that catalyze aldehyde into carboxylic acids via the NAD(P)+-dependent oxidation. Several ALDH family members have been identified in humans, including ALDH1A1, ALDH1A3, ALDH2, ALDH3A1, and ALDH4A1.

ALDH1A1 is a crucial element in the retinoic acid signaling pathway regulating the self-renewal and differentiation of normal stem cells. It ALDH1A1 has been suggested as one of breast cancer stem cell markers and may play an important role in breast cancer prognosis. However, previous research on ALDH1A1 and breast cancer prognosis has yielded conflicting results. We analyzed the association between mRNA expression of ALDH1A1 in tumor tissues and survival of triple-negative breast cancer (TNBC: ER-/PR-/HER2-) using data and samples from three cohorts of breast cancer patients, including 469 cases from the Shanghai Breast Cancer Survival Study (SBCSS), 86 cases from the Nashville Breast Health Study (NBHS), and 47 cases from the Southern Community Cohort Study (SCCS).

Gene expression levels were measured in total RNA isolated from microdissected archival formalin-fixed paraffin-embedded breast cancer tissues using Nanostring nCounter assays. The associations between ALDH1A1 mRNA expression levels and recurrence/breast cancer mortality and overall mortality were evaluated by multivariate survival analysis using the Cox regression model. Data from the SCCS and NBHS were combined in the analysis because both studies were conducted among US women and had a small sample size.

The levels of ALDH1A1 mRNA expression were consistently and positively associated with disease free and overall survival independent of age at diagnosis and TNM stage in both Chinese and US women with TNBC. Compared to those with ALDH1A1 mRNA expression below the median, TNBC patients with ALDH1A1 mRNA expression above the median had a reduced risk of recurrence/breast cancer mortality (HR = 0.60, 95% CI: 0.39-0.92) and overall mortality (HR = 0.70, 95% CI: 0.47-1.05) in the SBCSS and reduced overall mortality in the SCCS/NBHS (HR = 0.27,95% CI: 0.10-0.74). Additional analyses of the SBCSS cohort stratified by basal-like breast cancer subtype showed that ALDH1A1 mRNA expression was similarly associated with reduced risk of recurrence/breast cancer mortality and total mortality in both basal-like and non-basal like TNBC patients, although the point estimates were not significant due to the smaller sample size. In addition, we found that patients with a higher tumor grade had a lower level of ALDH1A1 mRNA expression but did not observe an association with TNM stage. Our study suggests that the mRNA expression of ALDH1A1 in tumor tissue may be associated with favorable clinical outcomes in patients with TNBC. Further investigations are needed to understand the biological mechanism(s) underlying the observed association.

Citation Format: Yan Liu, Qiuyin Cai, Ying Zheng, Michelle L. Baglia, Yinghao Su, Sarah Nechuta, Ping-Ping Bao, William Blot, Wei Zheng, Xiao-Ou Shu. Association of ALDH1A1 gene expression with survival of triple-negative breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2773. doi:10.1158/1538-7445.AM2015-2773

Energy-Related Indicators and Breast Cancer Risk among White and Black Women

Energy-related indicators, including physical activity, energy intake, body mass index (BMI) and adult weight change, have been linked to breast cancer risk. Very few studies of these associations have been conducted among black women, therefore we used the Nashville Breast Health Study (NBHS) to determine whether similar effects were seen in black and white women. The NBHS is a population-based case-control study of breast cancer among women age 25 to 75 years conducted between 2001 and 2010 in and around the Nashville Metropolitan area. Telephone interviews and self-administered food frequency questionnaires were completed with 2,614 incident breast cancer cases ascertained through hospitals and the statewide cancer registry, and 2,306 controls selected using random digit dialing. Among premenopausal white and black women, there was little effect of adult exercise or other energy-related indicators on breast cancer risk, regardless of tumor estrogen receptor (ER) status. The beneficial effect of adult exercise on postmenopausal breast cancer appeared to be comparable between white and black women (highest tertile relative to none - white odds ratio [OR] 0.8, 95% confidence interval [CI] 0.6-1.0, p for trend=0.05; black OR 0.7, 95% CI 0.4-1.1, p for trend=0.07); however, among black women the reduction was limited to those with ER-positive disease. White and black women should be encouraged to engage in more physical activity to reduce their risk of postmenopausal breast cancer.

Postdiagnosis social networks and lifestyle and treatment mechanisms in the Ater Breast Cancer Pooling Project (ABCPP)

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Background: Larger social networks have been associated with better breast cancer survival. To investigate potential mediators, we evaluated associations of social network size and diversity with lifestyle and treatment factors associated with prognosis. Methods: We included 9,331 women from the After Breast Cancer Pooling Project who provided data on social networks within two years following diagnosis. A social network index was derived from information about the presence of a spouse or intimate partner, religious ties, community participation, friendship ties, and numbers of relatives. Diversity was assessed as variety of ties, independent of size. We used logistic regression to evaluate associations with outcomes and evaluated whether effect estimates differed using meta-analytic techniques. Results: Associations of social networks and outcomes generally did not differ by cohort. Because of the low prevalence of smoking and alcohol consumption in the Shanghai cohort, however, analyses of smoking and alcohol included US cohorts only. Women who were socially isolated (small networks) were more likely to be obese (body mass index>30 kg/m2, OR=1.21, 95% CI:1.03-1.42) and have low physical activity (<10 MET-h/wk, OR=1.53, 95% CI:1.34-1.75) compared to socially integrated women. Women with low network diversity were more likely to be current smokers (OR=3.68, 95% CI:2.19-6.19) and have high alcohol consumption (>15 g/d alcohol, OR=2.43, 95% CI:1.60-3.69). Among node positive cases, socially isolated women were more likely not to receive chemotherapy (OR=1.52, 95% CI:1.03-2.25). By contrast, low network diversity, but not social network size, was associated with greater odds of not receiving adjuvant hormonal therapy (OR=1.52, 95% CI:1.03-2.23). Associations with surgery were nonsignificant. Conclusions: In a large pooled cohort, small, less diverse social networks measured post-diagnosis were associated with more adverse lifestyle factors and less intensive cancer treatment, which may help to explain poorer breast cancer prognosis in socially isolated women.

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.

Postdiagnosis cruciferous vegetable consumption and breast cancer outcomes: a report from the After Breast Cancer Pooling Project

Cruciferous vegetables are a major source of glucosinolate-derived bioactive compounds such as isothiocyanates, which have been shown in animal and in vitro studies to inhibit cancer growth and progression. Few studies have investigated cruciferous vegetable intake after diagnosis and breast cancer outcomes. Using data from the After Breast Cancer Pooling Project, which includes prospective data from U.S. and Chinese breast cancer survivors, we evaluated the association of cruciferous vegetables with breast cancer outcomes. Analyses included 11,390 women diagnosed with stage I-III invasive breast cancer (1990-2006) from four cohorts. Cruciferous vegetable intake (g/day) was assessed using food frequency questionnaires (mean of 22 months postdiagnosis). Study heterogeneity was evaluated by the Q statistic; hazard ratios (HRs) and 95% confidence intervals (CI) were estimated using delayed-entry Cox regression models stratified by study. After a median follow-up of 9.0 years, 1,725 deaths and 1,421 recurrences were documented. In pooled analyses using study-specific quartiles, cruciferous vegetable intake was not associated with breast cancer outcomes, adjusting for known clinical prognostic factors and selected lifestyle factors. HRs (95% CIs) by increasing quartiles (reference = lowest quartile) were 1.08 (0.93-1.25), 1.01 (0.87-1.18), and 1.10 (0.95-1.28) for recurrence (P(trend) = 0.34) and 1.01 (0.88-1.15), 0.97 (0.84-1.11), and 0.99 (0.86-1.13) for total mortality (P(trend) = 0.84). No associations were observed for subgroups defined by estrogen receptor status, stage, or tamoxifen therapy. Cruciferous vegetable intake at approximately two years after diagnosis was not associated with recurrence or mortality. Our results do not support an association between postdiagnosis cruciferous vegetable intake and breast cancer outcomes.

Comorbidities and breast cancer survival: a report from the Shanghai Breast Cancer Survival Study

We investigated the association of major comorbidities with breast cancer outcomes using the Shanghai Breast Cancer Survival Study, a population-based, prospective cohort study of Chinese women diagnosed with breast cancer. Analyses included 4,664 women diagnosed with stage I-III incident breast cancer aged 20-75 years (median age = 51) during 2002-2006. Women were interviewed at 3-11 months post-diagnosis (median = 6.4) and followed up by in-person interviews and linkage with the vital statistics registry. Multivariable hazard ratios (HRs) and (95 % confidence intervals (CIs)) for the associations of comorbidities with breast cancer outcomes were estimated using Cox regression models. After a median follow-up of 5.3 years (range: 0.64-8.9), 647 women died (516 from breast cancer) and 632 recurrence/metastases were documented. The main comorbidities reported included: hypertension (22.4 %), chronic gastritis (14.3 %), diabetes mellitus (6.2 %), chronic bronchitis/asthma (5.8 %), coronary heart disease (5.0 %), and stroke (2.2 %). Diabetes was associated with increased risk of total mortality (adjusted HR: 1.40 (1.06-1.85)) and non-breast cancer mortality (adjusted HR: 2.64 (1.63-4.27)), but not breast cancer-specific mortality (adjusted HR: 0.98 (0.68-1.41)), adjusting for socio-demographics, clinical characteristics, selected lifestyle factors, and other comorbidities. Women with a history of stroke had a non-significant increased risk of total mortality (adjusted HR: 1.42 (0.91-2.22)) and a significant increased risk of non-breast cancer mortality (adjusted HR: 2.52 (1.33-4.78)), but not breast cancer-specific mortality (adjusted HR: 0.78 (0.38-1.62)). Overall, none of the comorbidities investigated were significantly associated with recurrence. In this large prospective cohort of breast cancer survivors, diabetes was significantly associated with increased risk of total and non-breast cancer mortality, and history of stroke was associated with increased risk of non-breast cancer mortality.

Prospective cohort study of tea consumption and risk of digestive system cancers: results from the Shanghai Women's Health Study

BACKGROUND

Data from in vitro and animal studies support a protective role for tea in the etiology of digestive system cancers; however, results from prospective cohort studies have been inconsistent. In addition, to our knowledge, no study has investigated the association of tea consumption with the incidence of all digestive system cancers in Chinese women.

OBJECTIVE

We investigated the association of regular tea intake (≥3 times/wk for >6 mo) with risk of digestive system cancers.

DESIGN

We used the Shanghai Women's Health Study, a population-based prospective cohort study of middle-aged and older Chinese women who were recruited in 1996-2000. Adjusted HRs and associated 95% CIs were derived from Cox regression models.

RESULTS

After a mean follow-up of 11 y, 1255 digestive system cancers occurred (stomach, esophagus, colorectal, liver, pancreas, and gallbladder/bile duct cancers) in 69,310 nonsmoking and non-alcohol-drinking women. In comparison with women who never drank tea, regular tea intake (mostly green tea) was associated with reduced risk of all digestive system cancers combined (HR: 0.86; 95% CI: 0.74, 0.98), and the reduction in risk increased as the amount and years of tea consumption increased (P-trend = 0.01 and P-trend < 0.01, respectively). For example, women who consumed ≥150 g tea/mo (∼2-3 cups/d) had a 21% reduced risk of digestive system cancers combined (HR: 0.79; 95% CI: 0.63, 0.99). The inverse association was found primarily for colorectal and stomach/esophageal cancers.

CONCLUSION

In this large prospective cohort study, tea consumption was associated with reduced risk of colorectal and stomach/esophageal cancers in Chinese women.

Attitudes of pregnant women towards collection of biological specimens during pregnancy and at birth

Epidemiological investigations of maternal and child health may involve the collection of biological specimens, including cord blood and the placenta; however, the attitudes of pregnant women towards participation in the collection of biological specimens have been studied rarely. We evaluated attitudes towards collection and storage of biological specimens, and determined whether attitudes differed by maternal characteristics, in a cross-sectional study of pregnant women residing in Kent County, Michigan. Women were interviewed at their first visit for prenatal care between April and October 2006 (n = 311). Willingness to participate was highest for maternal blood collection (72%), followed by storage of biological specimens (68%), placenta collection (64%), and cord blood collection (63%). About one-quarter of women (25-28% by procedure) would not participate even if compensated. Hispanic ethnicity was associated with unwillingness to participate in maternal blood collection (OR = 2.16 [95% CI 1.15, 4.04]). Primiparity was associated with unwillingness to participate in cord blood collection (OR = 1.72 [95% CI 1.23, 2.42]). Among women willing to participate, Hispanic women were less likely to require compensation; while higher educated, married and primiparous women were more likely to require compensation. In conclusion, while many pregnant women were willing to participate in biological specimen collection, some women were more resistant, in particular Hispanic and primiparous women. Targeting these groups of women for enhanced recruitment efforts may improve overall participation rates and the representativeness of participants in future studies of maternal and child health.

Marital status and mortality among middle age and elderly men and women in urban Shanghai

BACKGROUND

Previous studies have suggested that marital status is associated with mortality, but few studies have been conducted in China where increasing aging population and divorce rates may have major impact on health and total mortality.

METHODS

We examined the association of marital status with mortality using data from the Shanghai Women's Health Study (1996-2009) and Shanghai Men's Health Study (2002-2009), two population-based cohort studies of 74,942 women aged 40-70 years and 61,500 men aged 40-74 years at the study enrollment. Deaths were identified by biennial home visits and record linkage with the vital statistics registry. Marital status was categorized as married, never married, divorced, widowed, and all unmarried categories combined. Cox regression models were used to derive hazard ratios (HR) and 95% confidence interval (CI).

RESULTS

Unmarried and widowed women had an increased all-cause HR = 1.11, 95% CI: 1.03, 1.21 and HR = 1.10, 95% CI: 1.02, 1.20 respectively) and cancer (HR = 1.17, 95% CI: 1.04, 1.32 and HR = 1.18, 95% CI: 1.04, 1.34 respectively) mortality. Never married women had excess all-cause mortality (HR = 1.46, 95% CI: 1.03, 2.09). Divorce was associated with elevated cardiovascular disease (CVD) mortality in women (HR = 1.47, 95% CI: 1.01, 2.13) and elevated all-cause mortality (HR = 2.45, 95% CI: 1.55, 3.86) in men. Amongst men, not being married was associated with excess all-cause (HR = 1.45, 95% CI: 1.12, 1.88) and CVD (HR = 1.65, 95% CI: 1.07, 2.54) mortality.

CONCLUSIONS

Marriage is associated with decreased all cause mortality and CVD mortality, in particular, among both Chinese men and women.

Abstract 5021: Physical health scores and breast cancer outcomes in the ABC Pooling Project

Background: Of the two health-related quality of life domains measured by the SF-36 (mental health and physical health), the physical health score (PHS) has been associated with all cause mortality, and recently with additional breast cancer events. This PHS includes subscales for self-perceived physical functioning, general health, bodily pain, and role limitations due to physical problems and is known to be a marker for a number of co-morbidities. Methods: Three of the four cohorts that form the After Breast Cancer (ABC) Pooling Project measured health-related quality of life using the SF-36 after cancer diagnosis. These cohorts were the Women's Healthy Eating and Living (WHEL) Study, the Nurses’ Health Study (NHS), and the Shanghai Breast Cancer Survival Study (SBCSS). Using Cox proportional hazards models controlled for cancer stage and grade, we examined the relationship between PHS with disease-free and overall survival in 9387 early stage (I-III) breast cancer survivors. The post-diagnosis SF-36 measurement took place between 1991 and 2006 and the median follow-up time was 7.8 years. Poor physical health was defined as a non-normalized score of 76.4 as previously published by the WHEL study. We also report the association between PH and co-morbidities. Results: The pooled HR (95% CI) for additional breast cancer events was 1.27(1.12, 1.44) with significant findings in each of the two US cohorts: Nurses’ Health Study 1.31(1.07-1.61) and WHEL study 1.28(1.08-1.51). A similar effect size was seen in SBCSS only, with the measurement taken during or immediately after cancer treatment. However, mostly likely due to the much shorter follow-up in this study, it did not reach statistical significance (HR=1.22 95% CI 0.80-1.86). In all cohorts, low PHS was strongly associated with higher BMI. In overweight/obese WHEL participants, low compared to adequate PHS scores were significantly associated with much lower levels of physical activity (p&lt;.0001), 64% higher reported insomnia, a 50% higher prevalence of hypertension and diabetes, and a twofold higher prevalence of arthritis. Conclusion: The importance of the PHS as a predictor of future breast cancer events and overall survival appears to be confirmed in these observational studies. Interventions to improve the PHS and prognosis might target weight control, physical activity and sleep management.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5021. doi:10.1158/1538-7445.AM2011-5021

Vitamin supplement use during breast cancer treatment and survival: a prospective cohort study

BACKGROUND

Antioxidants may protect normal cells from the oxidative damage that occurs during radiotherapy and certain chemotherapy regimens; however, the same mechanism could protect tumor cells and potentially reduce effectiveness of cancer treatments. We evaluated the association of vitamin supplement use in the first 6 months after breast cancer diagnosis and during cancer treatment with total mortality and recurrence.

METHODS

We conducted a population-based prospective cohort study of 4,877 women aged 20 to 75 years diagnosed with invasive breast cancer in Shanghai, China, between March 2002 and April 2006. Women were interviewed approximately 6 months after diagnosis and followed up by in-person interviews and record linkage with the vital statistics registry.

RESULTS

During a mean follow-up of 4.1 years, 444 deaths and 532 recurrences occurred. Vitamin use shortly after breast cancer diagnosis was associated with reduced mortality and recurrence risk, adjusted for multiple lifestyle factors, sociodemographics, and known clinical prognostic factors. Women who used antioxidants (vitamin E, vitamin C, multivitamins) had 18% reduced mortality risk (HR = 0.82, 95% CI: 0.65-1.02) and 22% reduced recurrence risk (HR = 0.78, 95% CI: 0.63-0.95). The inverse association was found regardless of whether vitamin use was concurrent or nonconcurrent with chemotherapy, but was present only among patients who did not receive radiotherapy.

CONCLUSIONS

Vitamin supplement use in the first 6 months after breast cancer diagnosis may be associated with reduced risk of mortality and recurrence.

IMPACT

Our results do not support the current recommendation that breast cancer patients should avoid use of vitamin supplements.

A population-based case-control study of fetal growth, gestational age, and maternal breast cancer

Fetal growth or gestational age in a woman's pregnancies may modify pregnancy-related breast cancer risk, yet studies of these exposures are few. The authors conducted a population-based case-control study among parous Michigan women aged ≤50 years using linked Michigan Cancer Registry (1985-2004) and Michigan livebirth records (1978-2004). Breast cancer cases (n = 7,591) were matched 1:4 to controls (n = 28,382) on maternal birth year and race. Using conditional logistic regression, the authors examined the associations of gestational age (in weeks) and fetal growth (defined using birth weight percentiles for gestational age) in first and last births with breast cancer risk. Having a small-for-gestational-age or large-for-gestational-age infant at a maternal first or last birth was not associated with breast cancer risk, but having a small-for-gestational-age infant at a last birth at ≥30 years modestly reduced risk: odds ratio = 0.82 (95% confidence interval: 0.68, 0.98). First delivery at <32 or >41 weeks also modestly reduced risk: odds ratio = 0.80 (95% confidence interval: 0.62, 1.04) or 0.92 (95% confidence interval: 0.85, 0.99), respectively. In the largest case-control study to date, fetal growth was not associated with overall breast cancer risk in women aged ≤50, and there was some evidence for reduced breast cancer risk for early or late gestational age in first births only.

Attitudes of pregnant women towards participation in perinatal epidemiological research

We assessed attitudes of a multi-ethnic sample of pregnant women in regard to participation in five data collection procedures planned for use in the National Children's Study. A cross-sectional survey was conducted in nine prenatal clinics in Kent County, Michigan between April and October 2006. Women were approached in clinic waiting rooms at the time of their first prenatal visit and 311 (91.0%) participated. Women were asked about their willingness to participate, and the smallest amount of compensation required for participation in a 45-min in-person interview, a 15-min telephone interview, maternal and infant medical record abstraction, and an infant physical examination. Percentages for willingness to participate were highest for telephone interview (83%), followed by in-person interview (60%), infant examination (57%), and maternal (56%) and infant medical records (54%). About 34-48% of women reported that no compensation would be required for participation by data procedure. Some women reported unwillingness to participate in telephone (9%) or personal (17%) interview, record abstraction (34%) or infant examination (26%), even with compensation. Education greater than high school was associated with increased odds of refusal for infant physical examination, adjusted odds ratio 2.44 [95% confidence interval 1.41, 4.23]. In conclusion, 9-34% of pregnant women, depending on procedure, stated they would not participate in non-invasive research procedures such as medical record abstraction and infant examination, even with compensation. Resistance to these research procedures was especially noted among more highly educated women. Planning for the National Children's Study will have to address potential resistance to research among pregnant women.

Factors associated with women's perceptions of physical activity safety during pregnancy

Health benefits of physical activity (PA) during pregnancy have been noted, but women's perceptions of PA safety have been little studied.

OBJECTIVES

To examine associations among PA participation, safety perceptions, and demographic characteristics.

METHODS

Pregnant women were recruited from nine clinics in Grand Rapids, MI (USA) from April to October, 2006. Demographics, participation in moderate and vigorous PA, and perceived safety of both intensities (5-pt Likert scales) were reported. Logistic regression analyses were used to estimate associations.

RESULTS

Of 342 eligible women, 296 provided complete PA information. Most (88%) participated in some PA and felt moderate PA was safe (89%), but only 36% felt vigorous PA was safe. Feeling unsafe/unsure about moderate PA was associated with non-White race/ethnicity, low education, low income, not participating in moderate PA, and/or not intending to be active during pregnancy. Hispanic ethnicity, low education, nulliparity, and not participating in moderate or vigorous PA were associated with feeling unsafe/unsure about vigorous PA.

CONCLUSIONS

Pregnant women generally feel that moderate PA is safe, but are less certain about vigorous PA. More work is needed to inform pregnant women about the benefits of moderate PA, especially among non-White and low education/income populations.

Lifetime reproductive and anthropometric risk factors for breast cancer in postmenopausal women

Hormonally-linked adult reproductive and anthropometric risk factors have been well established in the etiology of postmenopausal breast cancer, though early life exposures have been evaluated only more recently. Here, we examine the evidence for associations between lifetime reproductive and anthropometric risk factors for postmenopausal breast cancer. The review finds some evidence for the hypothesis that breast cancer risk is determined by the number of susceptible stem cells, modified by the hormonal environment. The in utero experience of an infant may be associated with postmenopausal breast cancer; preeclampsia may decrease and greater birthweight increase risk, but more evidence is needed. Earlier and more rapid childhood growth appears to increase postmenopausal breast cancer risk and childhood obesity to decrease risk, but very few studies have yet examined these associations. Increased final height and earlier age at menarche are consistently associated with increased risk for postmenopausal breast cancer. Later age at first birth, decreased parity, later menopausal age, use of hormone replacement therapy (especially progestin containing), and increased postmenopausal adiposity are well-established risk factors for postmenopausal breast cancer. The effect of a woman's own pregnancy conditions and lactation are not established. Further investigation is needed to identify whether events occurring early in life modify later events or accumulate over the life course. Many aspects of this research can be conducted by examining the influence of early life events on intermediary events without the need for longitudinal data.