Physical activity in association with mortality among Black women diagnosed with breast cancer in the Southern Community Cohort Study

PURPOSE

Physical activity (PA) is associated with many health benefits. While PA has been associated with reduced mortality after breast cancer diagnosis in many studies, few studies have examined the role of PA in breast cancer survival among underserved and minority populations, including Black women. We investigated PA in association with mortality among Black predominantly low-income breast cancer survivors in the Southern Community Cohort Study (SCCS).

METHODS

Study participants were women diagnosed with incident breast cancer (n = 949) in the SCCS, which is a prospective cohort study of predominantly low-income adults aged 40-79 years recruited from 12 Southeastern states between 2002 and 2009. Participants completed a detailed baseline questionnaire, with annual follow-up for mortality via registry linkages. Cox regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of pre-diagnosis PA (measured via a validated questionnaire) with all-cause and breast cancer-specific mortality.

RESULTS

Breast cancer survivors had a mean age of 61.1 years and most (79.3%) had a household income of < $25,000. In adjusted models, higher levels of total PA (MET-hours/day) were inversely associated with all-cause mortality with HRs (95% CIs): 0.79 (0.59-1.06), 0.66 (0.49-0.90), and 0.60 (0.43-0.84), for Q2, Q3, and Q4 (reference: Q1), respectively, ptrend ≤ 0.01. A similar inverse association was found for breast cancer-specific mortality.

CONCLUSION

Higher levels of pre-diagnosis PA were associated with improved survival among low-income Black breast cancer survivors. Resources to reduce barriers to PA participation and increase support for education and intervention efforts to promote PA among Black women are needed.

A population-based descriptive study of neonatal abstinence syndrome using hospital discharge and birth certificate data

BACKGROUND

Neonatal abstinence syndrome (NAS), largely a consequence of prenatal opioid exposure, results in substantial morbidity. Population-based studies of NAS going beyond Medicaid populations and hospital discharge data (HDD) alone are limited. Using statewide Tennessee (TN) HDD and birth certificate (BC) data, we examined trends and evaluated maternal and infant factors associated with NAS.

METHODS

We conducted a population-based descriptive study during 2013-2017 in TN. NAS infants were identified with International Classification of Diseases (ICD)-9-Clinical Modification (CM) and ICD-10-CM codes in HDD and linked to BC data using iterative deterministic matching algorithms. Descriptive analyses were conducted for infant and maternal factors (exposures) by NAS (outcome). Multivariable logistic regression models were used to estimate adjusted ORs and 95% CIs.

RESULTS

NAS incidence increased from 13.4 to 15.4 per 1,000 live births between 2013-2017 (15% increase; ptrend<0.001), but remained stable in 2017. In adjusted models, maternal factors associated with reduced odds of NAS included breastfeeding (OR:0.55, 95%CI:0.52-0.59) and prenatal care (OR:0.36, 95%CI:0.32-0.41). Smoking, preterm birth and lower birthweight were associated with increased odds of NAS.

CONCLUSIONS

This study highlights the value of utilizing surveillance data to monitor trends and correlates of NAS to inform prevention efforts and targeting of public health resources.

Prescribing patterns before and after a non-fatal drug overdose using Tennessee's controlled substance monitoring database linked to hospital discharge data

We performed a statewide evaluation of prescribing patterns of controlled substances (CS) before and after an overdose, using Tennessee's Hospital Discharge Data System and the Controlled Substance Monitoring Database (CSMD). Adults' first non-fatal overdose discharges either from the emergency department (ED) or inpatient (IP) stay occurring between 2013 and 2016 were linked to prescriptions in the CSMD. The difference in the proportion of patients filling a prescription before versus after an overdose was calculated. Included were 49,398 patients with an overdose and a prescription record; most (60.5%) were treated in the ED. Among any drug type overdose the percentage of patients who filled a CS prescription within a year of experiencing an overdose was as follows: opioid analgesics: 59.1%, benzodiazepines: 37.3%, stimulants: 5.0%, muscle relaxants: 3.4%, concurrent opioid-benzodiazepines: 24.0% with the percent difference from before to after similar in both settings. Among patients treated for an opioid overdose, this represented a decrease in opioid analgesics filled by 9.7% (95%CI: -11.2, -8.3) among those treated in the ED, and by 7.1% (95% CI: -8.3, -5.9) among treated inpatients. Among patients treated for a heroin overdose, 12.2% (95%CI: -15.2, -9.3) fewer of those treated in the ED and 8.8% (95%CI: -15.0, -2.7%) fewer of treated inpatients filled a CS prescription in that year. The most common opioid analgesics included hydrocodone and oxycodone. The number of patients filling buprenorphine for treatment increased in the year after overdoses associated with any drug or opioids but decreased among those treated for a heroin overdose.

Sociodemographic factors, prescription history and opioid overdose deaths: a statewide analysis using linked PDMP and mortality data

BACKGROUND

Opioid overdose deaths have continued to rise in Tennessee (TN) with fentanyl emerging as a major contributor. Current data are needed to identify at-risk populations to guide prevention strategies. We conducted a large statewide observational study among TN adult decedents (2013-2016) to evaluate the association of sociodemographic factors and prescribing patterns with opioid overdose deaths.

METHODS

Among drug overdose decedents identified using death certificate data (n = 5483), we used logistic regression to estimate adjusted odds ratios and 95% confidence intervals for characteristics associated with prescription opioid (PO) (excluding fentanyl), fentanyl, and heroin alone overdoses. Among decedents linked to TN's Prescription Drug Monitoring Database using deterministic algorithms, we obtained prescription history in the year before death (n = 3971), which was evaluated by type of overdose using descriptive statistics.

RESULTS

Younger, non-White decedents had lower odds of PO overdose, while females and benzodiazepines as a contributing cause were associated with increased odds of PO overdose. Younger age, Non-Hispanic Black race/ethnicity, greater than high school education, and cocaine/other stimulants as a contributing cause were associated with increased odds of fentanyl or heroin overdoses. Over 55% of PO, 39.2% of fentanyl, and 20.7% of heroin overdoses had an active opioid prescription at death. For PO, fentanyl, and heroin decedents, respectively, 46.0%, 30.5%, and 26.2% had an active prescription for benzodiazepines at death.

CONCLUSIONS

Prescription opioid overdose deaths were associated with different sociodemographic profiles and prescribing history compared to fentanyl and heroin overdose deaths in TN. Data can guide prevention strategies to reduce opioid overdose mortality.

The Role of Biomarkers of Oxidative Stress in Breast Cancer Risk and Prognosis: A Systematic Review of the Epidemiologic Literature

BACKGROUND

Oxidative stress may play an important role in both initiation and progression of breast cancer. We conducted the first systematic epidemiologic review to summarize the published literature on oxidative stress biomarkers and breast cancer.

MATERIALS AND METHODS

We implemented systematic search strategies to identify published studies of oxidative stress biomarkers and (1) risk of developing breast cancer and (2) breast cancer prognosis using the PRISMA statement guidelines.

RESULTS

We identified eleven case-control studies of oxidative stress biomarkers and breast cancer. Biomarkers utilized varied and menopausal status was a key modifying factor. Across three nested case-control studies with biomarkers measured before diagnosis, one reported increased risk of postmenopausal breast cancer in association with 8-oxodG (DNA damage biomarker), while two (one of F₂-isoprostanes and one of fluorescent oxidation products) reported inverse associations for premenopausal breast cancer only. We identified eight prognostic studies. Two reported associations for lipid peroxidation and breast cancer prognosis; results for other studies were null.

CONCLUSIONS

DNA damage may increase risk of breast cancer among postmenopausal women, while lipid peroxidation may be inversely associated with premenopausal breast cancer. Lipid peroxidation may be associated with survival after breast cancer diagnosis; however, results require evaluation in large, prospective cohort studies.

Adolescent exercise in association with mortality from all causes, cardiovascular disease, and cancer among middle-aged and older Chinese women

BACKGROUND

Little is known regarding the role of early-life exercise, a potentially modifiable factor, in long-term adult morbidity and mortality. We utilized the Shanghai Women's Health Study (SWHS) to investigate adolescent exercise in association with cancer, cardiovascular disease (CVD), and all-cause mortality among middle-aged and older women.

METHODS

The SWHS is a prospective cohort of 74,941 Chinese women ages 40 to 70 years recruited from 1996 to 2000. In-person interviews at enrollment assessed adolescent and adult exercise history, medical and reproductive history, and other lifestyle and socioeconomic (SES) factors. Mortality follow-up occurs via annual linkage to the Shanghai Vital Statistics Registry. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) were derived from Cox regression models.

RESULTS

Adjusting for birth year and other adolescent factors, adolescent exercise was associated with reduced risk of cancer, CVD, and total mortality [HRs (95% CI), 0.83 (0.72-0.95), 0.83 (0.70-0.98), and 0.78 (0.71-0.85), respectively for ≤1.33 hours (h)/week, and 0.83 (0.74-0.93), 0.62 (0.53-0.72), and 0.71 (0.66-0.77), respectively for >1.33 h/week (reference = none)]. Results were attenuated after adjustment for adult SES and lifestyle factors. Participation in sports teams was inversely associated with cancer mortality [HR (95% CI), 0.86 (0.76-0.97)]. Joint adolescent and adult exercise was associated with reduced risk of all-cause, CVD, and cancer mortality [HRs (95% CIs), 0.80 (0.72-0.89), 0.83 (0.69-1.00), and 0.87 (0.74-1.01), respectively], adjusting for adult/adolescent factors, and adolescence exercise only was inversely associated with cancer mortality [HR (95% CI), 0.84 (0.71-0.98)].

CONCLUSIONS

Adolescent exercise participation, independent of adult exercise, was associated with reduced risk of cancer, CVD, and all-cause mortality.

IMPACT

Results support promotion of exercise in adolescence to reduce mortality in later life.

Impact of very low physical activity, BMI, and comorbidities on mortality among breast cancer survivors

The purpose of this study was to examine post-diagnosis BMI, very low physical activity, and comorbidities, as predictors of breast cancer-specific and all-cause mortality. Data from three female US breast cancer survivor cohorts were harmonized in the After Breast Cancer Pooling Project (n = 9513). Delayed entry Cox proportional hazards models were used to examine the impact of three post-diagnosis lifestyle factors: body mass index (BMI), select comorbidities (diabetes only, hypertension only, or both), and very low physical activity (defined as physical activity <1.5 MET h/week) in individual models and together in multivariate models for breast cancer and all-cause mortality. For breast cancer mortality, the individual lifestyle models demonstrated a significant association with very low physical activity but not with the selected comorbidities or BMI. In the model that included all three lifestyle variables, very low physical activity was associated with a 22 % increased risk of breast cancer mortality (HR 1.22, 95 % CI 1.05, 1.42). For all-cause mortality, the three individual models demonstrated significant associations for all three lifestyle predictors. In the combined model, the strength and significance of the association of comorbidities (both hypertension and diabetes versus neither: HR 2.16, 95 % CI 1.79, 2.60) and very low physical activity (HR 1.35, 95 % CI 1.22, 1.51) remained unchanged, but the association with obesity was completely attenuated. These data indicate that after active treatment, very low physical activity, consistent with a sedentary lifestyle (and comorbidities for all-cause mortality), may account for the increased risk of mortality, with higher BMI, that is seen in other studies.

Abstract 2182: Lifestyle factors are associated with late breast cancer outcomes among 5-year survivors of estrogen-receptor positive breast cancer

Background: Estrogen-receptor (ER)+ breast cancers have a favorable prognosis in the first several years after diagnosis, with adjuvant endocrine therapies for treatment. However, in later years, ER+ breast cancer is associated with poorer prognosis compared to ER- breast cancer. Predictors of late recurrence in women with ER+ breast cancer, and in particular lifestyle factors, have been little studied. Using data from a pooling project of breast cancer survivor cohorts (After Breast Cancer Pooling Project), we prospectively evaluated the association of post-diagnosis lifestyle factors and comorbidities with late breast cancer outcomes.

Methods: Analyses included 6,129 women diagnosed with stage I-III invasive ER+ breast cancer (1990-2004) from three US prospective cohorts, who survived disease-free for five years. Pooled and harmonized data were available for post-diagnosis lifestyle factors, comorbidities, cancer treatment, tumor characteristics, and socio-demographics. Late outcomes (defined as &gt;5 years post-diagnosis) included breast cancer recurrence, breast cancer specific-mortality (BCSM), and all-cause mortality. Lifestyle factors and comorbidities were assessed at a mean of about 2 years post-diagnosis. Study heterogeneity was evaluated by the Q statistic. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models stratified by study.

Results: After a median follow-up of 6.9 years (11.9 years post-diagnosis), 645 deaths and 564 recurrences were documented. Five-year recurrence and all-cause mortality rates were 7.2% and 6.1%, respectively. Ten-year recurrence and all-causes mortality rates were 12.1% and 15.4%, respectively. In multivariable models, recreational physical activity (PA) of 10-MET h/wk was associated with reduced all-cause mortality (HR: 0.71, 95% CI: 0.60-0.84) and BCSM (HR: 0.77, 95% CI: 0.61-0.99), and non-significantly reduced recurrence risk (HR: 0.87, 95% CI: 0.73-1.03). Multivitamin and antioxidant vitamin supplement use were inversely associated with recurrence (HRs (95% CIs): 0.74 (0.62-0.87) and 0.75 (0.61-0.91), respectively). Current smoking was associated with increased risk of all-cause and BCSM ((HRs (95% CIs): 2.58 (1.99-3.35)) and 1.87 (1.22-2.88), respectively). Women with diabetes had increased risk of late outcomes (HRs 95% CIs: 1.35 (0.95-1.92) for recurrence, 1.86 (1.45-2.40) for all-cause mortality, and 1.75 (1.12-2.73) for BCSM. Hypertension was significantly associated with all-cause mortality only (HR: 1.42, 95% CI: 1.19-1.70). Obesity (BMI ≥30 kg/m2) was not associated with late outcomes.

Conclusion: In this large study, post-diagnosis lifestyle factors were important predictors of late breast cancer outcomes. Our findings suggest PA and multivitamin use may improve long-term prognosis for ER-positive breast cancer.

Citation Format: Sarah J. Nechuta, Wendy Y. Chen, Marilyn L. Kwan, Elizabeth M. Poole, Shirley W. Flatt, John P. Pierce, Bette J. Caan, Xiao Ou Shu. Lifestyle factors are associated with late breast cancer outcomes among 5-year survivors of estrogen-receptor positive breast cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2182. doi:10.1158/1538-7445.AM2014-2182

Lifetime cigarette smoking and breast cancer prognosis in the After Breast Cancer Pooling Project

BACKGROUND

There is controversy on whether former smokers have increased risk for breast cancer recurrence or all-cause mortality, regardless of how much they smoked.

METHODS

Data were from three US cohorts in the After Breast Cancer Pooling Project, with detailed information on smoking among 9975 breast cancer survivors. Smoking was assessed an average of 2 years after diagnosis. Delayed entry Cox proportional hazards models were used to examine the relationships of smoking status, cigarettes per day, years of smoking, and pack years with breast cancer prognosis. Endpoints included breast cancer recurrence (n = 1727), breast cancer mortality (n = 1059), and overall mortality (n = 1803).

RESULTS

Compared with never smokers, former smokers with less than 20 pack-years of exposure had no increased risk of any outcome. However, former smokers with 20 to less than 34.9 pack-years of exposure had a 22% increased risk of breast cancer recurrence (hazard ratio [HR] = 1.22; 95% confidence interval [CI] = 1.01 to 1.48) and a 26% increased risk of all-cause mortality (HR = 1.26; 95% CI = 1.07 to 1.48). For former smokers with 35 or more pack-years of exposure, the probability of recurrence increased by 37% (HR = 1.37; 95% CI = 1.13 to 1.66), breast cancer mortality increased by 54% (HR = 1.54; 95% CI = 1.24 to 1.91), and all-cause mortality increased by 68% (HR = 1.68; 95% CI = 1.44 to 1.96). Current smoking increased the probability of recurrence by 41% (HR = 1.41; 95% CI = 1.16 to 1.71), increased breast cancer mortality by 60% (HR = 1.61; 95% CI = 1.28 to 2.03), and doubled the risk of all-cause mortality (HR = 2.17; 95% CI = 1.85 to 2.54).

CONCLUSIONS

Lifetime cigarette smoking was statistically significantly associated with a poor prognosis among women diagnosed with breast cancer, dose-dependent increased risks of recurrence, and breast cancer and all-cause mortality.

Postdiagnosis supplement use and breast cancer prognosis in the After Breast Cancer Pooling Project

Vitamin supplement use after breast cancer diagnosis is common, but little is known about long-term effects on recurrence and survival. We examined postdiagnosis supplement use and risk of death or recurrence in the After Breast Cancer Pooling Project, a consortium of four cohorts of 12,019 breast cancer survivors from the United States and China. Post-treatment supplement use (vitamins A, B, C, D, E, and multivitamins) was assessed 1-5 years postdiagnosis. Associations with risk of recurrence, breast cancer-specific mortality, or total mortality were analyzed in Cox proportional hazards models separately by cohort. Individual cohort results were combined using random effects meta-analysis. Interactions with smoking, treatment, and hormonal status were examined. In multivariate models, vitamin E was associated with a decreased risk of recurrence (RR: 0.88; 95 % CI 0.79-0.99), and vitamin C with decreased risk of death (RR: 0.81; 95 % CI 0.72-0.92). However, when supplements were mutually adjusted, all associations were attenuated. There were no statistically significant associations with breast cancer mortality. The use of antioxidant supplements (multivitamins, vitamin C, or E) was not associated with recurrence, but was associated with a 16 % decreased risk of death (95 % CI 0.72-0.99). In addition, vitamin D was associated with decreased risk of recurrence among ER positive, but not ER negative tumors (p-interaction = 0.01). In this large consortium of breast cancer survivors, post-treatment use of vitamin supplements was not associated with increased risk of recurrence or death. Post-treatment use of antioxidant supplements was associated with improved survival, but the associations with individual supplement were difficult to determine. Stratification by ER status and considering antioxidants as a group may be more clinically relevant when evaluating associations with cancer risk and mortality.

Abstract 119: Urinary biomarkers of oxidative stress and breast cancer survival among Chinese breast cancer survivors

Background: Systemic oxidative stress has been implicated in the pathogenesis and progression of many chronic diseases, including breast cancer. To our knowledge, no study has investigated the association of biomarkers of systemic oxidative stress after cancer treatment and breast cancer prognosis.

Methods: We conducted a pilot study to investigate the association of systemic oxidative stress after primary cancer treatment with mortality in a nested case-control study in the Shanghai Breast Cancer Survival Study (SBCSS). Urinary levels of 15-F(2t)-isoprostane (15-F(2t)-IsoP) and one of its major metabolites (2,3-dinor-5,6-dihydro-15-F(2t)-IsoP (15-F(2t)-IsoP-M)), two well-studied biomarkers of systemic oxidative stress, were measured using gas chromatography/negative ion chemical ionization mass spectrometry for 57 deceased breast cancer patients (cases; 88% due to breast cancer) and 103 matched surviving breast cancer patients (controls) in the SBCSS with available post-cancer treatment urinary samples. Cases and controls were aged 26-70 years and were matched approximately 1:2 on age at diagnosis (+/- 1 year), stage (I-III), and year of diagnosis (2003-2004). Biomarkers were adjusted for creatinine concentrations and expressed as ng/mg of creatinine. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were derived from conditional logistic regression models, conditioned on age, stage, and year of diagnosis.

Results: Elevated 15-F(2t)-IsoP levels, categorized based on the median level (≥1.73;&lt;1.73(reference)), were inversely associated with mortality (adjusted OR = 0.36, 95% CI: 0.14-0.96) after adjustment for known clinical prognostic factors (including cancer treatment and tumor characteristics), body mass index, vitamin supplement use, and weeks between breast cancer diagnosis and urine collection. The inverse association was marginally significant when 15-F(2t)-IsoP was categorized based on tertiles (p for trend = 0.08). In contrast, elevated 15-F(2t)-IsoPM levels, categorized based on the median level (≥0.91;&lt;0.91 (reference)), were associated with a statistically non-significant increased risk of mortality (adjusted OR = 1.39, 95% CI: 0.62-3.09).

Conclusion: These preliminary results suggest differing associations for 15-F(2t)-IsoP and 15-F(2t)-IsoPM with mortality among breast cancer survivors. To our knowledge, this is the first study to investigate the association between 15-F(2t)-IsoP or 15-F(2t)-IsoP-M levels and breast cancer survival. Results from this pilot study require conformation in future larger studies.

Citation Format: Sarah J. Nechuta, Qiuyin Cai, Ying Zheng, Ginger L. Milne, Hui Cai, Qi Dai, Gong Yang, Wei Zheng, Wei Lu, Xiao Ou Shu. Urinary biomarkers of oxidative stress and breast cancer survival among Chinese breast cancer survivors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 119. doi:10.1158/1538-7445.AM2013-119

Postdiagnosis alcohol consumption and breast cancer prognosis in the after breast cancer pooling project

BACKGROUND

Alcohol consumption is an established risk factor for incident breast cancer. However, its role in breast cancer prognosis remains unclear.

METHODS

We conducted an investigation of postdiagnosis alcohol consumption with recurrence and mortality among 9,329 breast cancer patients in the After Breast Cancer Pooling Project. Women were diagnosed from 1990 to 2006 with AJCC Stage I-III breast tumors from three prospective US cohorts. Alcohol intake was assessed at cohort entry (mean 2.1 years postdiagnosis) using a food frequency questionnaire. HR and 95% confidence intervals (CI) were estimated using delayed entry Cox proportional hazards models with adjustment for known prognostic factors.

RESULTS

After a mean follow-up of 10.3 years, 1,646 recurrences and 1,543 deaths were ascertained. 5,422 women (58%) were considered drinkers (≥0.36 g/day of alcohol, ≥0.25 drinks/week) with a median of 5.3 g/day. Overall, compared with nondrinking, regular alcohol intake (≥6.0 g/day) was not associated with risk of recurrence (HR for 6 to less than 12 g/day, 1.03; 95% CI, 0.86-1.24; HR for 12 to less than 24 g/day, 1.12; 95% CI, 0.93-1.34; HR for ≥24 g/day, 1.04; 95% CI, 0.84-1.31). However, risk varied significantly by menopausal status (P for interaction < 0.05). Postmenopausal women who regularly consumed alcohol (≥6.0 g/day) had increased risk of recurrence (HR, 1.19; 95% CI, 1.01-1.40). Alcohol intake was not associated with mortality.

CONCLUSIONS

Regular alcohol consumption was not associated with breast cancer recurrence and total mortality overall, yet recurrence risk was only elevated in postmenopausal women.

IMPACT

The association between alcohol intake and recurrence may depend on menopausal status at breast cancer diagnosis.

Soy food intake after diagnosis of breast cancer and survival: an in-depth analysis of combined evidence from cohort studies of US and Chinese women

BACKGROUND

Soy isoflavones have antiestrogenic and anticancer properties but also possess estrogen-like properties, which has raised concern about soy food consumption among breast cancer survivors.

OBJECTIVE

We prospectively evaluated the association between postdiagnosis soy food consumption and breast cancer outcomes among US and Chinese women by using data from the After Breast Cancer Pooling Project.

DESIGN

The analysis included 9514 breast cancer survivors with a diagnosis of invasive breast cancer between 1991 and 2006 from 2 US cohorts and 1 Chinese cohort. Soy isoflavone intake (mg/d) was measured with validated food-frequency questionnaires. HRs and 95% CIs were estimated by using delayed-entry Cox regression models, adjusted for sociodemographic, clinical, and lifestyle factors.

RESULTS

After a mean follow-up of 7.4 y, we identified 1171 total deaths (881 from breast cancer) and 1348 recurrences. Despite large differences in soy isoflavone intake by country, isoflavone consumption was inversely associated with recurrence among both US and Chinese women, regardless of whether data were analyzed separately by country or combined. No heterogeneity was observed. In the pooled analysis, consumption of ≥10 mg isoflavones/d was associated with a nonsignificant reduced risk of all-cause (HR: 0.87; 95% CI: 0.70, 1.10) and breast cancer-specific (HR: 0.83; 95% CI: 0.64, 1.07) mortality and a statistically significant reduced risk of recurrence (HR: 0.75; 95% CI: 0.61, 0.92).

CONCLUSION

In this large study of combined data on US and Chinese women, postdiagnosis soy food consumption of ≥10 mg isoflavones/d was associated with a nonsignificant reduced risk of breast cancer-specific mortality and a statistically significant reduced risk of recurrence.

Weight change and survival after breast cancer in the after breast cancer pooling project

BACKGROUND

Weight change after a breast cancer diagnosis has been linked to lower survival. To further understand effects of postdiagnostic weight variation on survival, we examined the relationship by comorbid status and initial body mass index (BMI).

METHODS

The current analysis included 12,915 patients with breast cancer diagnosed between 1990 and 2006 with stage I-III tumors from four prospective cohorts in the United States and China. HRs and 95% confidence intervals (CI) representing the associations of five weight change categories [within <5% (reference); 5%-<10% and ≥10% loss and gain] with mortality were estimated using Cox proportional hazards models.

RESULTS

Mean weight change was 1.6 kg. About 14.7% women lost and 34.7% gained weight. Weight stability in the early years postdiagnosis was associated with the lowest overall mortality risk. Weight loss ≥10% was related to a 40% increased risk of death (HR, 1.41; 95% CI, 1.14-1.75) in the United States and over three times the risk of death (HR, 3.25; 95% CI: 2.24, 4.73) in Shanghai. This association varied by prediagnosis BMI, and in the United States, lower survival was seen for women who lost weight and had comorbid conditions. Weight gain ≥10% was associated with a nonsignificant increased risk of death.

CONCLUSIONS

Prevention of excessive weight gain is a valid public health goal for breast cancer survivors. Although intentionality of weight loss could not be determined, women with comorbid conditions may be particularly at risk of weight loss and mortality.

IMPACT

Weight control strategies for breast cancer survivors should be personalized to the individual's medical history.

Abstract LB-322: Cruciferous vegetable intake after diagnosis of breast cancer and survival: a report from the shanghai breast cancer survival study

BACKGROUND: Cruciferous vegetables are a major source of glucosinolate-derived bioactive compounds, such as isothiocyanates and indoles, which have been shown in animal studies and in vitro to inhibit cancer growth and progression. However, little is known regarding the role of cruciferous vegetables in breast cancer prognosis. Using resources from the Shanghai Breast Cancer Survival, a large population-based prospective cohort study of Chinese breast cancer survivors, we evaluated the association of cruciferous vegetable consumption after cancer diagnosis and breast cancer outcomes with repeated dietary assessments after diagnosis. METHODS: Women with incident breast cancer aged 20-75 years were recruited within 6-months of diagnosis during 2002-2006. In-person baseline interviews collected detailed data on clinic characteristics, socio-demographics, and lifestyle factors. Medical records were used to verify clinical data. The cohort has been followed-up by a combination of in-person follow-up surveys and record linkage to the Shanghai Vital Statistics Registry. Cruciferous vegetable intake (g/day) was reassessed at 18- and 36-months. Cox regression models were used to derive hazard ratios (HR) and 95% confidence intervals (CIs) for the associations of cruciferous vegetables and breast cancer outcomes. Analyses include 4,886 women with stage I-IV breast cancer. RESULTS: After a median follow-up of 5.2 years, 587 deaths (496 breast cancer deaths) and 615 recurrences occurred. Cruciferous vegetable intake increased after diagnosis (mean (SD)=62.5 (44.5) at 6-months and 133.8 (93.3) at 36-months). After adjustment for socio-demographics, clinical characteristics including treatment and tumor characteristics, and lifestyle factors, cruciferous vegetable intake was associated with improved breast cancer survival in a dose-response pattern (P for trend &lt; 0.01). The multivariable hazard ratios (95% confidence intervals) across increasing quartiles (vs. Q1) were 0.73 (0.60-0.90), 0.51 (0.41-0.64), and 0.38 (0.29-0.49) for total mortality; 0.78 (0.62-0.97), 0.53 (0.41-0.68), and 0.38 (0.29-0.51) for breast cancer-specific mortality; 0.79 (0.63-0.98), 0.71 (0.57-0.88), and 0.65 (0.52-0.81) for recurrence. These associations persisted after excluding the first year of observation, although the association for recurrence was no longer statistically significant. CONCLUSION: Cruciferous vegetable intake after breast cancer diagnosis was associated with improved prognosis among Chinese women.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-322. doi:1538-7445.AM2012-LB-322

Pre-diagnosis body mass index and survival after breast cancer in the After Breast Cancer Pooling Project

Obese and underweight women who develop breast cancer may have poorer survival compared with normal-weight women. However, the optimal weight for best prognosis is still under study. We conducted a prospective investigation of pre-diagnosis body mass index (BMI) and mortality among 14,948 breast cancer patients in the After Breast Cancer Pooling Project. Breast cancer patients diagnosed from 1990 to 2006 with AJCC Stage I-III breast tumors were drawn from four prospective cohorts. Hazard ratios (HR) and 95% confidence intervals (CI) representing the associations of BMI categories (World Health Organization international classifications) with recurrence and mortality were estimated using delayed entry Cox proportional hazards models. Obese (30 to < 35 kg/m(2)), severely obese (35 to < 40 kg/m(2)), and morbidly obese (≥ 40 kg/m(2)) were examined. After a mean follow-up of 7.8 years, 2,140 deaths and 2,065 recurrences were documented. Both underweight (HR = 1.59; 95% CI: 1.18, 2.13) and morbidly obese women (HR = 1.81; 95% CI: 1.42, 2.32) had the greatest risk of overall mortality compared with normal weight (18.5-24.9 kg/m(2)) women. Severe obesity (HR = 1.09; 95% CI: 0.88, 1.36) and obesity (HR = 1.11; 95% CI: 0.97, 1.27) were related to small non-significant increased risks. Overweight (25.0-29.9 kg/m(2)) was not associated with any excess risk compared with normal weight. Similar associations were found for breast cancer death and non-breast cancer death but not recurrence. Women who were underweight and morbidly obese before breast cancer diagnosis were at the greatest risk of all-cause mortality. Morbidly obese women were also at increased risk of death from breast cancer. These results suggest that degree of obesity confers differential risk on survival.

P1-08-02: Pre-Diagnosis Body Mass Index and Breast Cancer Prognosis and Survival: Report from the after Breast Cancer Pooling Project

Background: A large body of evidence dating back over 30 years suggests that obese women have poorer survival after a breast cancer (BC) diagnosis compared to non-obese women. Despite most studies supporting an association of elevated risk of overall mortality with obesity, the relationship of obesity with risk of BC recurrence, BC mortality and non-BC mortality remains unclear. Furthermore, reports suggest that the association of BMI with BC outcomes may be U or J shaped, prompting the necessity of examining underweight and more severely obese women as independent groups. We conducted a pooled investigation of pre-diagnosis BMI and BC recurrence and survival using data from the After Breast Cancer Pooling Project (ABCPP). Materials and Methods: The ABCPP includes 14,950 BC survivors from four prospective cohorts (three US and one Shanghai, China) diagnosed from 1990–2006 with invasive primary AJCC Stage I-III BC at ages 20–83 years. A random effects meta-analysis was conducted to assess heterogeneity across studies and poolability of data. Delayed entry Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the associations of pre-diagnosis BMI (underweight &lt;18.5 kg/m2, normal 18.5-&lt;25 kg/m2, overweight 25-&lt;30 kg/m2, obese ≥30 kg/m2) with BC recurrence, BC death, non-BC death, and overall death, adjusted for age at diagnosis, stage, race/ethnicity, menopausal status, hormone receptor status, number of positive lymph nodes, treatment, smoking history, and comorbidity (diabetes, hypertension, and/or CVD). Subgroup analyses further divided the obesity group into obese (30-&lt;35 kg/m2), severely obese (35-&lt;40 kg/m2), and morbidly obese (≥40 kg/m2) categories.

Results: No heterogeneity in effect estimates by study was found. 2104 deaths (1416 BC-related) and 2320 recurrences were observed after a mean (SD) of 7.66 (3.95) years of follow-up. Both underweight and obese women had a statistically significant increased risk of overall death compared to normal-weight women (underweight HR=1.69; 95% CI: 1.25, 2.28 and obese HR=1.22; 95% CI: 1.08, 1.38; p for nonlinear association&lt;0.01). Similar associations were found for non-BC death. Obese but not underweight was associated with increased risk of BC death (HR=1.17; 95% CI: 1.01, 1.36) and recurrence (HR=1.11; 95% CI: 0.98, 1.26). When examining finer obesity categories, the morbidly obese women had the greatest risk for all outcomes (overall death HR=1.90; 95% CI: 1.48, 2.45; non-BC death HR= 3.27; 95% CI: 2.25, 4.77; BC death HR = 1.47; 95% CI: 1.05, 2.06; recurrence HR = 1.27; 95% CI: 0.95, 1.71). No effect modification was observed by menopausal status, hormone receptor status, chemotherapy, and smoking. In all analyses, overweight women had similar risk of outcomes compared to normal-weight women.

Discussion: In this large pooling study of nearly 15,000 BC survivors, we found that the association between BMI and BC outcomes, specifically overall death and non-BC death, was U shaped with both underweight and obese women at greatest risk. Morbidly obese women were at even greater risk compared to other obesity groups. Maintaining a healthy weight throughout adult life may be beneficial for BC prognosis and survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-02.

Meeting the physical activity guidelines and survival after breast cancer: findings from the after breast cancer pooling project

The 2008 Physical Activity (PA) Guidelines recommend engaging in at least 2.5 h (10 MET-hours/week) of moderate intensity PA per week (defined as 4 METs) to reduce risk of morbidity and mortality. This analysis was conducted to investigate whether this recommendation can be extended to breast cancer survivors. Data from four studies of breast cancer survivors measuring recreational PA from semi-quantitative questionnaires a median of 23 months post-diagnosis (interquartile range 18-32 months) were pooled in the After Breast Cancer Pooling Project (n = 13,302). Delayed entry Cox proportional hazards models were applied in data analysis with adjustment for age, post-diagnosis body mass index, race/ethnicity, menopausal status, TNM stage, cancer treatment, and smoking history. Engaging in at least 10 MET-hours/week of PA was associated with a 27% reduction in all-cause mortality (n = 1,468 events, Hazard Ratio (HR) = 0.73, 95% CI, 0.66-0.82) and a 25% reduction in breast cancer mortality (n = 971 events, HR = 0.75, 95% CI 0.65-0.85) compared with women who did not meet the PA Guidelines (<10 MET-hours/week). Risk of breast cancer recurrence (n = 1,421 events) was not associated with meeting the PA Guidelines (HR = 0.96, 95% CI, 0.86-1.06). These data suggest that adhering to the PA guidelines may be an important intervention target for reducing mortality among breast cancer survivors.

The After Breast Cancer Pooling Project: rationale, methodology, and breast cancer survivor characteristics

The After Breast Cancer Pooling Project was established to examine the role of physical activity, adiposity, dietary factors, supplement use, and quality of life (QOL) in breast cancer prognosis. This paper presents pooled and harmonized data on post-diagnosis lifestyle factors, clinical prognostic factors, and breast cancer outcomes from four prospective cohorts of breast cancer survivors (three US-based and one from Shanghai, China) for 18,314 invasive breast cancer cases diagnosed between 1976 and 2006. Most participants were diagnosed with stage I-II breast cancer (84.7%). About 60% of breast tumors were estrogen receptor (ER)+/progesterone receptor (PR)+; 21% were ER-/PR-. Among 8,118 participants with information on HER-2 tumor status, 74.8% were HER-2- and 18.5% were HER-2+. At 1-2 years post-diagnosis (on average), 17.9% of participants were obese (BMI ≥ 30 kg/m2), 32.6% were overweight (BMI 25-29 kg/m2), and 59.9% met the 2008 Physical Activity Guidelines for Americans (≥ 2.5 h per week of moderate activity). During follow-up (mean = 8.4 years), 3,736 deaths (2,614 from breast cancer) and 3,564 recurrences have been documented. After accounting for differences in year of diagnosis and timing of post-diagnosis enrollment, five-year overall survival estimates were similar across cohorts. This pooling project of 18,000 breast cancer survivors enables the evaluation of associations of post-diagnosis lifestyle factors, QOL, and breast cancer outcomes with an adequate sample size for investigation of heterogeneity by hormone receptor status and other clinical predictors. The project sets the stage for international collaborations for the investigation of modifiable predictors for breast cancer outcomes.

Abstract 4665: Postdiagnosis soy food intake and breast cancer survival: Report from the After Breast Cancer Pooling Project

Background: Soy constituents possess anti-estrogenic and other anti-cancer properties. Soy food consumption has been associated with lower risk of development of breast cancer. However, the ability of soy isoflavones to bind to estrogen receptors, stimulate cell proliferation, and potentially interact with tamoxifen therapy, has raised concern about soy food consumption among breast cancer survivors. Two recent reports from China and one report from the US have suggested that postdiagnosis soy intake may improve prognosis among breast cancer survivors. Methods: We evaluated postdiagnosis soy food intake and breast cancer outcomes using data from the After Breast Cancer Pooling Project, which includes 18,312 women diagnosed with invasive primary breast cancer between ages 20 and 83 years and who participated in four prospective cohorts, three from the US and one from Shanghai, China. In two cohorts, information on soy food intake was assessed using food frequency questionnaires designed to capture soy food intake; two cohorts only collected information on two soy foods (tofu and soy milk), and multiple imputation was applied to derive total isoflavone intake based on information gathered by the US study with comprehensive assessment of soy intake. Delayed entry Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of isoflavones with total mortality and breast cancer recurrence, adjusted for age at diagnosis, estrogen receptor/progesterone receptor status, stage, chemotherapy, radiotherapy, hormonal therapy, smoking, body mass index, exercise, race/ethnicity, and education and stratified by study. Analyses included 16,048 women with information on soy food intake. Results: After an average follow-up of 9.2 years, a total of 2,592 deaths and 2,622 recurrences were documented. Mean soy isoflavone intake (mg), as assessed at an average of 13 months postdiagnosis (range: 1-48 months), was 3.2 (standard deviation (SD)=5.8) for US women and 45.9 (SD=38.3) for Chinese women. Pooled analyses based on study-specific deciles showed that, compared with the lowest deciles, higher isoflavone intakes were associated with HRs in the range of 0.85-0.89 for mortality and 0.85-0.83 for recurrence (not all HRs were significant). Corresponding HRs restricted to only US cohorts ranged from 0.84-1.04 for mortality and 0.87-0.88 for recurrence, although none were significant. Using common cut-points for the pooled data including all cohorts, HRs (95% CIs) for the highest intake category (&gt;23 mg/day) vs. the lowest (≤0.48 mg/day) were 0.91 (0.70-1.19) for mortality and 0.85 (0.66-1.11) for recurrence. Additional analyses conducted among non-Asian US women showed a similar pattern. Conclusions: Soy food consumption was not associated with an increased risk of mortality or cancer recurrence among breast cancer survivors.

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 4665. doi:10.1158/1538-7445.AM2011-4665

Combined impact of lifestyle-related factors on total and cause-specific mortality among Chinese women: prospective cohort study

BACKGROUND

Although cigarette smoking, excessive alcohol drinking, obesity, and several other well-studied unhealthy lifestyle-related factors each have been linked to the risk of multiple chronic diseases and premature death, little is known about the combined impact on mortality outcomes, in particular among Chinese and other non-Western populations. The objective of this study was to quantify the overall impact of lifestyle-related factors beyond that of active cigarette smoking and alcohol consumption on all-cause and cause-specific mortality in Chinese women.

METHODS AND FINDINGS

We used data from the Shanghai Women's Health Study, an ongoing population-based prospective cohort study in China. Participants included 71,243 women aged 40 to 70 years enrolled during 1996-2000 who never smoked or drank alcohol regularly. A healthy lifestyle score was created on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes (normal weight, lower waist-hip ratio, daily exercise, never exposed to spouse's smoking, higher daily fruit and vegetable intake). The score ranged from zero (least healthy) to five (most healthy) points. During an average follow-up of 9 years, 2,860 deaths occurred, including 775 from cardiovascular disease (CVD) and 1,351 from cancer. Adjusted hazard ratios for mortality decreased progressively with an increasing number of healthy lifestyle factors. Compared to women with a score of zero, hazard ratios (95% confidence intervals) for women with four to five factors were 0.57 (0.44-0.74) for total mortality, 0.29 (0.16-0.54) for CVD mortality, and 0.76 (0.54-1.06) for cancer mortality. The inverse association between the healthy lifestyle score and mortality was seen consistently regardless of chronic disease status at baseline. The population attributable risks for not having 4-5 healthy lifestyle factors were 33% for total deaths, 59% for CVD deaths, and 19% for cancer deaths.

CONCLUSIONS

In this first study, to our knowledge, to quantify the combined impact of lifestyle-related factors on mortality outcomes in Chinese women, a healthier lifestyle pattern-including being of normal weight, lower central adiposity, participation in physical activity, nonexposure to spousal smoking, and higher fruit and vegetable intake-was associated with reductions in total and cause-specific mortality among lifetime nonsmoking and nondrinking women, supporting the importance of overall lifestyle modification in disease prevention. Please see later in the article for the Editors' Summary.