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Mei J, Qian M, Hou Y, Liang M, Chen Y, Wang C, Zhang J. Association of saturated fatty acids with cancer risk: a systematic review and meta-analysis. Lipids Health Dis 2024; 23:32. [PMID: 38291432 PMCID: PMC10826095 DOI: 10.1186/s12944-024-02025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE Extensive research has explored the link between saturated fatty acids (SFAs) and cardiovascular diseases, alongside other biological dysfunctions. Yet, their association with cancer risk remains a topic of debate among scholars. The present study aimed to elucidate this association through a robust meta-analysis. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were searched systematically to identify relevant studies published until December 2023. The Newcastle-Ottawa Scale was used as the primary metric for evaluating the quality of the included studies. Further, fixed- or random-effects models were adopted to determine the ORs and the associated confidence intervals using the Stata15.1 software. The subsequent subgroup analysis revealed the source of detection and the cancer types, accompanied by sensitivity analyses and publication bias evaluations. RESULTS The meta-analysis incorporated 55 studies, comprising 38 case-control studies and 17 cohort studies. It revealed a significant positive correlation between elevated levels of total SFAs and the cancer risk (OR of 1.294; 95% CI: 1.182-1.416; P-value less than 0.001). Moreover, elevated levels of C14:0, C16:0, and C18:0 were implicated in the augmentation of the risk of cancer. However, no statistically significant correlation of the risk of cancer was observed with the elevated levels of C4:0, C6:0, C8:0, C10:0, C12:0, C15:0, C17:0, C20:0, C22:0, and C24:0. Subgroup analysis showed a significant relationship between excessive dietary SFA intake, elevated blood SFA levels, and heightened cancer risk. Increased total SFA levels correlated with higher risks of breast, prostate, and colorectal cancers, but not with lung, pancreatic, ovarian, or stomach cancers. CONCLUSION High total SFA levels were correlated with an increased cancer risk, particularly affecting breast, prostate, and colorectal cancers. Higher levels of specific SFA subtypes (C14:0, C16:0, and C18:0) are also linked to an increased cancer risk. The findings of the present study would assist in providing dietary recommendations for cancer prevention, thereby contributing to the development of potential strategies for clinical trials in which diet-related interventions would be used in combination with immunotherapy to alter the levels of SFAs in patients and thereby improve the outcomes in cancer patients. Nonetheless, further high-quality studies are warranted to confirm these associations.
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Affiliation(s)
- Jin Mei
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Meiyu Qian
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Yanting Hou
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Maodi Liang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Yao Chen
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Cuizhe Wang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Jun Zhang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China.
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Wu Q, Shi D, Dong T, Zhang Z, Ou Q, Fang Y, Zhang C. Serum Saturated Fatty Acids including Very Long-Chain Saturated Fatty Acids and Colorectal Cancer Risk among Chinese Population. Nutrients 2023; 15:nu15081917. [PMID: 37111137 PMCID: PMC10141165 DOI: 10.3390/nu15081917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
The association between circulating saturated fatty acids (SFAs) including very long-chain SFAs (VLCSFAs) and colorectal cancer (CRC) risk has not been clearly established. To investigate the association between serum SFAs and CRC risk in Chinese population, 680 CRC cases and 680 sex and age-matched (5-year interval) controls were recruited in our study. Serum levels of SFAs were detected by gas chromatography. Unconditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between serum SFAs and CRC risk. Results showed that total SFAs were positively associated with the risk of CRC (adjusted OR quartile 4 vs. 1 = 2.64, 95%CI: 1.47-4.74). However, VLCSFAs were inversely associated with CRC risk (adjusted OR quartile 4 vs. 1 = 0.51, 95%CI: 0.36-0.72). Specifically, lauric acid, myristic acid, palmitic acid, heptadecanoic acid, and arachidic acid were positively associated with CRC risk, while behenic acid and lignoceric acid were inversely associated with CRC risk. This study indicates that higher levels of total serum SFAs and lower levels of serum VLCSFAs were associated with an increased risk of CRC in Chinese population. To reduce the risk of CRC, we recommend reducing the intake of foods containing palmitic acid and heptadecanoic acid such as animal products and dairy products, and moderately increasing the intake of foods containing VLCSFAs such as peanuts and canola oil.
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Affiliation(s)
- Qixin Wu
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Dandan Shi
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Ting Dong
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhuolin Zhang
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Qingjian Ou
- Department of Experimental Research, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou 510060, China
| | - Yujing Fang
- Department of Experimental Research, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou 510060, China
| | - Caixia Zhang
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
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Matta M, Deubler E, Chajes V, Vozar B, Gunter MJ, Murphy N, Gaudet MM. Circulating plasma phospholipid fatty acid levels and breast cancer risk in the Cancer Prevention Study-II Nutrition Cohort. Int J Cancer 2022; 151:2082-2094. [PMID: 35849437 DOI: 10.1002/ijc.34216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/09/2022]
Abstract
Prospective studies that objectively measure circulating levels of fatty acids are needed to clarify their role in the etiology of breast cancer. Thirty-eight phospholipid fatty acids were measured using gas chromatograph in the plasma fraction of blood samples collected prospectively from 2718 postmenopausal women (905 breast cancer cases) enrolled in the Cancer Prevention Study II Nutrition Cohort. Associations of 28 fatty acids that passed quality control metrics (modeled as per 1-SD increase) with breast cancer risk were assessed using multiple variable conditional logistic regression models to compute odds ratios (OR) and 95% confidence intervals (CI). The false discovery rate (q value) was computed to account for multiple comparisons. Myristic acid levels were positively associated with breast cancer risk (OR, 1.17, 95% CI: 1.07-1.28; q value = 0.03). Borderline associations were also found for palmitoleic acid (OR, 1.14, 95% CI: 1.04-1.24) and desaturation index16 (OR, 1.10, 95% CI: 1.01-1.20) at nominal P values (<.03) (q values>0.05). These findings suggest that higher circulating levels of myristic acid, sourced from dietary intake of palm kernel oils along with increased de novo synthesis of fatty acids, may increase breast cancer risk. Additional studies are needed to investigate de novo synthesis of fatty acid in breast cancer tissues.
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Affiliation(s)
- Michèle Matta
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Emily Deubler
- Department of Population Science, American Cancer Society, Atlanta, Georgia, USA
| | - Veronique Chajes
- Office of the Director, International Agency for Research on Cancer, Lyon, France
| | - Beatrice Vozar
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Marc J Gunter
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Neil Murphy
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Mia M Gaudet
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
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Jiang H, Wang L, Wang D, Yan N, Li C, Wu M, Wang F, Mi B, Chen F, Jia W, Liu X, Lv J, Liu Y, Lin J, Ma L. Omega-3 polyunsaturated fatty acid biomarkers and risk of type 2 diabetes, cardiovascular disease, cancer, and mortality. Clin Nutr 2022; 41:1798-1807. [PMID: 35830775 DOI: 10.1016/j.clnu.2022.06.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND & AIMS Considerable attention has focused on the role of omega-3 polyunsaturated fatty acids (PUFA) in the prevention of cardiometabolic diseases, which has led to dietary recommendations to increase omega-3 fatty acid intake. A meta-analysis was conducted to summarize evidence from prospective studies regarding associations between omega-3 PUFA biomarkers and risk of developing major chronic diseases. METHODS Four electronic databases were searched for articles from inception to March 1, 2022. Random-effects model was used to estimate the pooled relative risk (RR) and 95% confidence intervals (CIs) for the association of omega-3 PUFAs, including α-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA), with risk of developing type 2 diabetes (T2D), cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, cancer, and mortality. The Grades of Recommendation, Assessment, Development and Evaluation assessment tool was used to rates the confidence in estimates. RESULTS A total of 67 prospective studies comprised of 310,955 participants were identified. Individual omega-3 PUFAs showed divergent associations with the study outcomes of interest. A significant inverse association with T2D risk was observed across categories of ALA (relative risk [RR]: 0.89, 95% confidence interval [CI]: 0.82-0.96), EPA (RR: 0.85, 95% CI: 0.72-0.99) and DPA (RR: 0.84, 95% CI: 0.73-0.96) biomarkers. The marine-origin omega-3 fatty acids biomarkers but not ALA was significantly associated with lower risks of total CVD, CHD, and overall mortality, with RRs ranging from 0.70 for DHA-CHD association to 0.85 for EPA-CHD association. A lower risk of colorectal cancer was observed at higher levels of DPA (RR: 0.76, 95% CI: 0.59-0.98) and DHA (RR: 0.80; 95% CI: 0.65-0.99), whereas no association was noted for other outcomes. In addition, a dose-response relationship was observed between an increasing level of EPA, DPA, or DHA biomarker and lower risk of CVD. CONCLUSIONS Higher concentrations of marine-derived omega-3 PUFA biomarkers were associated with a significantly reduced risk of total CVD, CHD, and total mortality. Levels of ALA were inversely associated with a lower risk of T2D but not CVD-related outcomes. These data support the dietary recommendations advocating the role of omega-3 PUFAs in maintaining an overall lower risk of developing cardiovascular disease and premature deaths.
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Affiliation(s)
- Hong Jiang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Lina Wang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ni Yan
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Chao Li
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Min Wu
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fan Wang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Baibing Mi
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fangyao Chen
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Wanru Jia
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xi Liu
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jiaxin Lv
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yan Liu
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jing Lin
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China.
| | - Le Ma
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, China.
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Michels N, Specht IO, Heitmann BL, Chajès V, Huybrechts I. Dietary trans-fatty acid intake in relation to cancer risk: a systematic review and meta-analysis. Nutr Rev 2021; 79:758-776. [PMID: 34104953 DOI: 10.1093/nutrit/nuaa061] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Apart from ruminant fat, trans-fatty acids are produced during the partial hydrogenation of vegetable oils, (eg, in the production of ultraprocessed foods). Harmful cardiovascular effects of trans-fatty acids are already proven, but the link with cancer risk has not yet been summarized. OBJECTIVE A systematic review (following PRISMA guidelines) - including observational studies on the association of trans-fatty acid intake with any cancer risk - was conducted, with no limitations on population types. DATA SOURCES The electronic databases PubMed and Embase were searched to identify relevant studies. DATA EXTRACTION This systematic review included 46 articles. Quality was assessed via the Newcastle-Ottawa scale. Meta-analyses were conducted if at least 4 articles exploring the same transfat-cancer pairings were found. DATA ANALYSIS Nineteen cancer types have been researched in cohort and case-control studies on trans-fatty acids, with breast cancer (n = 17), prostate cancer (n = 11), and colorectal cancer (n = 9) as the most researched. The meta-analyses on total trans-fat showed a significant positive association for prostate cancer (odds ratio [OR] 1.49; 95%CI, 1.13-1.95) and colorectal cancer (OR 1.26; 95%CI, 1.08-1.46) but not for breast cancer (OR 1.12; 95%CI, 0.99-1.26), ovarian cancer (OR 1.10; 95%CI, 0.94-1.28), or non-Hodgkin lymphoma (OR 1.32; 95%CI, 0.99-1.76). Results were dependent on the fatty acid subtype, with even cancer-protective associations for some partially hydrogenated vegetable oils. Enhancing moderators in the positive transfat-cancer relation were gender (direction was cancer-site specific), European ancestry, menopause, older age, and overweight. CONCLUSION Despite heterogeneity, higher risk of prostate and colorectal cancer by high consumption of trans-fatty acids was found. Future studies need methodological improvements (eg, using long-term follow-up cancer data and intake biomarkers). Owing to the lack of studies testing trans-fatty acid subtypes in standardized ways, it is not clear which subtypes (eg, ruminant sources) are more carcinogenic. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42018105899.
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Affiliation(s)
- Nathalie Michels
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Ina Olmer Specht
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Berit L Heitmann
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Veronique Chajès
- International Agency for Research on Cancer, Nutrition and Metabolism Section, Lyon, France
| | - Inge Huybrechts
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- International Agency for Research on Cancer, Nutrition and Metabolism Section, Lyon, France
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Newell M, Ghosh S, Goruk S, Pakseresht M, Vena JE, Dummer TJB, Field CJ. A Prospective Analysis of Plasma Phospholipid Fatty Acids and Breast Cancer Risk in 2 Provinces in Canada. Curr Dev Nutr 2021; 5:nzab022. [PMID: 33889794 PMCID: PMC8049855 DOI: 10.1093/cdn/nzab022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Studies suggest that fatty acid status influences breast cancer etiology, yet the roles of individual fatty acids in breast cancer risk are unclear, specifically when central adiposity and menopausal status are considered. OBJECTIVES This study examined the associations of fatty acid status with breast cancer risk including location, menopausal status, and waist-to-hip ratio as key variables. METHODS Prediagnostic plasma phospholipid fatty acids were measured in women with breast cancer (n = 393) and age-matched controls (n = 786) from a nested case-control prospective study within Alberta's Tomorrow Project (ATP) and British Columbia Generations Project (BCGP) cohorts. Binary logistic regression models were used to evaluate associations of fatty acids and breast cancer risk with subgroup analysis for menopausal status and waist-to-hip ratio. RESULTS Women from BCGP had a higher n-3 (ɷ-3) fatty acid status compared with the ATP (6.4% ± 0.08% vs. 5.3% ± 0.06%; P < 0.001), so subsequent analysis was blocked by cohort. Overall, fatty acids had inconsistent associations with risk. In the ATP among premenopausal women, total long-chain n-3 fatty acids (ORQ4vsQ1 = 1.78; 95% CI: 0.58, 5.43; P-trend = 0.007, P-interaction = 0.07) were positively associated with breast cancer risk, whereas in BCGP, DHA (ORQ4vsQ1 = 0.66; 95% CI: 0.28, 1.53; P-trend = 0.03, P-interaction = 0.05) and total long-chain n-3 fatty acids (ORQ4vsQ1 = 0.66; 95% CI: 0.28, 1.54; P-trend = 0.03) were associated with decreased cancer risk when the waist-to-hip ratio was <0.85. CONCLUSIONS Our findings suggest that regional variations in fatty acid status influence breast cancer risk, resulting in positive associations of total long-chain n-3 fatty acids in premenopausal ATP women and negative associations of these fatty acids in BCGP women with a waist-to-hip ratio below guidelines. This study highlights the complexity and difficulty in using fatty acid status to predict breast cancer risk in diverse populations without the consideration of other risk factors.
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Affiliation(s)
- Marnie Newell
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Sunita Ghosh
- Department of Medical Oncology, University of Alberta, Edmonton, Canada
| | - Susan Goruk
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Mohammedreza Pakseresht
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Jennifer E Vena
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
- Alberta's Tomorrow Project, CancerCare Alberta, Alberta Health Services, Calgary, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Catherine J Field
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
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Serum Phospholipids Fatty Acids and Breast Cancer Risk by Pathological Subtype. Nutrients 2020; 12:nu12103132. [PMID: 33066483 PMCID: PMC7602197 DOI: 10.3390/nu12103132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 12/16/2022] Open
Abstract
This study evaluates whether serum phospholipids fatty acids (PL-FAs) and markers of their endogenous metabolism are associated with breast cancer (BC) subtypes. EpiGEICAM is a Spanish multicenter matched case-control study. A lifestyle and food frequency questionnaire was completed by 1017 BC cases and healthy women pairs. Serum PL-FA percentages were measured by gas chromatography-mass spectrometry. Conditional and multinomial logistic regression models were used to quantify the association of PL-FA tertiles with BC risk, overall and by pathological subtype (luminal, HER2+ and triple negative). Stratified analyses by body mass index and menopausal status were also performed. Serum PL-FAs were measured in 795 (78%) pairs. Women with high serum levels of stearic acid (odds ratio (OR)T3vsT1 = 0.44; 95% confidence interval (CI) = 0.30–0.66), linoleic acid (ORT3vsT1 = 0.66; 95% CI = 0.49–0.90) and arachidonic to dihomo-γ-linolenic acid ratio (OR T3vsT1 = 0.64; 95% CI = 0.48–0.84) presented lower BC risk. Participants with high concentrations of palmitoleic acid (ORT3vsT1 = 1.65; 95% CI = 1.20–2.26), trans-ruminant palmitelaidic acid (ORT3vsT1 = 1.51; 95% CI = 1.12–2.02), trans-industrial elaidic acid (ORT3vsT1 = 1.52; 95% CI = 1.14–2.03), and high oleic to stearic acid ratio (ORT3vsT1 = 2.04; 95% CI = 1.45–2.87) showed higher risk. These associations were similar in all BC pathological subtypes. Our results emphasize the importance of analyzing fatty acids individually, as well as the desaturase activity indices.
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N-6 Polyunsaturated Fatty Acids and Risk of Cancer: Accumulating Evidence from Prospective Studies. Nutrients 2020; 12:nu12092523. [PMID: 32825393 PMCID: PMC7551408 DOI: 10.3390/nu12092523] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
Previous studies on the association between polyunsaturated fatty acids (PUFAs) and cancer have focused on n-3 PUFAs. To investigate the association between intake or blood levels of n-6 PUFAs and cancer, we searched the PubMed and Embase databases up to March 2020 and conducted a meta-analysis. A total of 70 articles were identified. High blood levels of n-6 PUFAs were associated with an 8% lower risk of all cancers (relative risk (RR) = 0.92; 95% confidence interval (CI): 0.86-0.98) compared to low blood levels of n-6 PUFAs. In the subgroup analyses by cancer site, type of n-6 PUFAs, and sex, the inverse associations were strong for breast cancer (RR = 0.87; 95% CI: 0.77-0.98), linoleic acid (LA) (RR = 0.91; 95% CI: 0.82-1.00), and women (RR = 0.88; 95% CI: 0.79-0.97). In the dose-response analysis, a 2% and 3% decrease in the risk of cancer was observed with a 5% increase in blood levels of n-6 PUFAs and LA, respectively. Thus, there was no significant association between n-6 PUFA intake and the risk of cancer. The pooled RR of cancer for the highest versus lowest category of n-6 PUFA intake was 1.02 (95% CI: 0.99-1.05). Evidence from prospective studies indicated that intake of n-6 PUFAs was not significantly associated with risk of cancer, but blood levels of n-6 PUFAs were inversely associated with risk of cancer.
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McGee EE, Kim CH, Wang M, Spiegelman D, Stover DG, Heng YJ, Collins LC, Baker GM, Farvid MS, Schedin P, Jindal S, Tamimi RM, Eliassen AH. Erythrocyte membrane fatty acids and breast cancer risk by tumor tissue expression of immuno-inflammatory markers and fatty acid synthase: a nested case-control study. Breast Cancer Res 2020; 22:78. [PMID: 32698885 PMCID: PMC7374956 DOI: 10.1186/s13058-020-01316-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/08/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Previous studies of fatty acids and breast cancer risk have shown mixed results, which may be due in part to tumor heterogeneity. Prior research has also illustrated an important role of specific fatty acids in immune regulation, T cell function, and inflammation, indicating that the effects of specific fatty acids on breast cancer risk may vary by tumor expression of immuno-inflammatory markers. We therefore aimed to evaluate the relationships between prediagnostic erythrocyte membrane fatty acids and breast cancer risk by tumor tissue expression of immuno-inflammatory markers (CD4, CD8, CD20, CD163, COX-2) and fatty acid synthase (FAS). METHODS We conducted a matched case-control study nested within the Nurses' Health Study II (n = 235 cases and 235 controls). Blood samples were collected from 1996 to 1999. Tumor tissue blocks were collected for cases diagnosed after blood collection and through 2006. Unconditional nominal polytomous logistic regression adjusted for matching factors and potential confounders was used to assess whether associations between fatty acids and breast cancer risk varied by tumor expression subtype, ascertained via immunohistochemistry. Odds ratios (OR) and 95% confidence intervals (CI) were estimated separately by tumor expression subtype using unconditional logistic regression. RESULTS Associations between fatty acids and breast cancer risk did not vary substantially by tumor CD4, CD20, CD163, or COX-2. However, n-3 polyunsaturated fatty acids (PUFAs) were inversely associated with CD8low but not CD8high cancers (CD8low ORT3 vs T1 = 0.45, 95% CI 0.23-0.87, Ptrend = 0.02; CD8high ORT3 vs T1 = 1.19, 95% CI 0.62-2.26, Ptrend = 0.62; Phet = 0.04). n-6 PUFAs were suggestively inversely associated with CD8high but not CD8low cancers (CD8high ORT3 vs T1 = 0.61, 95% CI 0.32-1.14, Ptrend = 0.11; CD8low ORT3 vs T1 = 1.63, 95% CI 0.87-3.04, Ptrend = 0.12; Phet = 0.02). Trans fatty acids were positively associated with FAShigh but not FASlow tumors (FAShigh ORT3 vs T1 = 2.94, 95% CI 1.46-5.91, Ptrend = 0.002; FASlow ORT3 vs T1 = 0.99, 95% CI 0.52-1.92, Ptrend = 0.97; Phet = 0.01). CONCLUSION Results indicate that the effects of n-3 PUFAs, n-6 PUFAs, and trans fatty acids on breast cancer risk may vary by tumor tissue expression subtypes. Findings suggest potential immuno-modulatory and FAS-mediated mechanisms.
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Affiliation(s)
- Emma E McGee
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Claire H Kim
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Molin Wang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Center on Methods for Implementation and Prevention Science (CMIPS), Yale School of Public Health, New Haven, CT, USA.,Department of Statistics and Data Science, Yale University, New Haven, CT, USA
| | - Daniel G Stover
- Medical Oncology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Yujing J Heng
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Laura C Collins
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Gabrielle M Baker
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Maryam S Farvid
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Pepper Schedin
- Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Sonali Jindal
- Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Rulla M Tamimi
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Division of Epidemiology, Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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10
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Nindrea RD, Aryandono T, Lazuardi L, Dwiprahasto I. Association of Dietary Intake Ratio of n-3/n-6 Polyunsaturated Fatty Acids with Breast Cancer Risk in Western and Asian Countries: A Meta-Analysis. Asian Pac J Cancer Prev 2019; 20:1321-1327. [PMID: 31127884 PMCID: PMC6857870 DOI: 10.31557/apjcp.2019.20.5.1321] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: This systematic review and meta-analysis were performed to determine association of dietary intake ratio of n-3/n-6 polyunsaturated fatty acids with breast cancer risk in Western and Asian countries. Methods: The authors conducted a meta-analysis of published research articles on association of dietary intake ratio of n-3/n-6 polyunsaturated fatty acids (PUFAs) with breast cancer risk in Western and Asian countries published between January 2000 and February 2019 in online article databases of PubMed, ProQuest and EBSCO. Pooled risk ratios (RR) were calculated using fixed and random-effect models. Publication bias was visually evaluated by performing funnel plots and statistically assessed by Egger’s and Begg’s tests. Data were processed by using Stata version 14.2 (Stata Corporation). Results: This study reviewed 913 articles. There were 13 studies included in systematic review continued by meta-analysis of relevant data with total number of samples: 275,264 patients. The results showed dietary intake ratio of n-3/n-6 PUFAs with breast cancer risk in Western and Asian countries (RR = 0.99; 95%CI: 0.92-1.07). Dietary intake ratio of n-3/n-6 PUFAs with breast cancer risk in Western countries reached (RR = 0.98; 95%CI: 0.91-1.06) and there was any significant publication bias for studies included. Dietary intake ratio of n-3/n-6 PUFAs with breast cancer risk in Asian countries reached (RR = 1.18; 95%CI: 0.94-1.47) and there was not any significant publication bias for studies included. Conclusion: This analysis confirmed association of dietary intake ratio of n-3/n-6 PUFAs with breast cancer risk in Western and Asian countries. Higher dietary intake ratio is associated with lower risk of breast cancer in Asian countries rather than Western countries. This study suggests increasing dietary intake ratio n-3/n-6 PUFAs will provide benefit for breast cancer prevention.
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Affiliation(s)
- Ricvan Dana Nindrea
- Doctoral Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta City, Indonesia. ,Department of Public Health, Faculty of Medicine, Universitas Andalas, Padang City, Indonesia
| | - Teguh Aryandono
- Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta City, Indonesia
| | - Lutfan Lazuardi
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta City, Indonesia
| | - Iwan Dwiprahasto
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta City, Indonesia
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11
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Anjom-Shoae J, Sadeghi O, Larijani B, Esmaillzadeh A. Dietary intake and serum levels of trans fatty acids and risk of breast cancer: A systematic review and dose-response meta-analysis of prospective studies. Clin Nutr 2019; 39:755-764. [PMID: 30954361 DOI: 10.1016/j.clnu.2019.03.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/21/2019] [Accepted: 03/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Although the relationship between dietary intake and serum levels of trans fatty acids and risk of breast cancer has been investigated extensively, findings are inconsistent. To summarize earlier findings on the association of dietary intake and serum levels of trans fatty acids with risk of breast cancer through a dose-response meta-analysis. METHODS The online databases of PubMed, ISI Web of Science, Scopus, ProQuest, Science Direct and Embase were searched for relevant publications up to June 2018, using MeSH and non-MeSH keywords. In total, 7 prospective studies [6 cohort studies and one nested case-control study] were included on total dietary trans fat intake, and five studies [1 cohort study and 4 nested case-control studies] were included about serum trans fatty acids. Assessment of study quality was conducted using the Newcastle-Ottawa scale. Study-specific RRs were combined via fixed-effects model to compute overall RRs. RESULTS Participants were apparently healthy aged 26 years or older. We observed no significant relationship between dietary intake of total trans fatty acids and risk of breast cancer (pooled effect size: 1.02, 95% CI: 0.95-1.10, P = 0.403). Combining 3 effect sizes from 2 prospective and one nested case-control study, no significant relation was seen between dietary intake of CLA and risk of breast cancer (pooled effect size: 1.05, 95% CI: 0.95-1.17, P = 0.513). Based on 5 effect sizes, each additional 1 g/day dietary intake of total trans fats was not significantly associated with risk of breast cancer (RR = 1.00; 95% CI = 0.99-1.01). In addition, it seems that serum levels of trans fats might be associated with an increased risk of breast cancer only among postmenopausal women (Pooled effect size: 1.37, 95% CI: 1.04-1.81, P = 0.02). CONCLUSIONS In conclusion, dietary intake of trans fatty acids was not associated with risk of breast cancer; however, a significant positive association was seen between serum trans fats and risk of breast cancer in postmenopausal women.
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Affiliation(s)
- Javad Anjom-Shoae
- Students' Scientific Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Sadeghi
- Students' Scientific Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran; Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular - Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran; Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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12
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Yang B, Ren XL, Wang ZY, Wang L, Zhao F, Guo XJ, Li D. Biomarker of long-chain n-3 fatty acid intake and breast cancer: Accumulative evidence from an updated meta-analysis of epidemiological studies. Crit Rev Food Sci Nutr 2018; 59:3152-3164. [PMID: 29902077 DOI: 10.1080/10408398.2018.1485133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: We aimed to summarize the up-to-date epidemiology evidence on biomarkers of long-chain (LC) n-3 fatty acid (FA) intake in relation to breast cancer (BC).Methods: Epidemiology studies determining FA levels in biospecimen (circulating blood or adipose tissue (AT)) were identified from PubMed, EMBASE, and Cochrane Library databases until March 2018. Multivariate-adjusted risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effect model. Difference in biospecimen proportions of LC n-3 FA between BC cases and non-cases were analyzed as a standardized mean difference (SMD).Results: Thirteen cohort and eleven case-control studies were eligible for the present meta-analysis. The estimated SMD was -0.14 (95% CI: -0.27, -0.11) for LC n-3 FA and -0.27 (95% CI: -0.42, -0.11) for LC n-3/n-6 FA ratio. When comparing the top tertiles with the bottom baseline levels, circulating LC n-3 FA was significantly associated with a lower risk of BC (RR: 0.84, 95% CI: 0.74, 0.96), but not AT (RR: 1.02, 95% CI: 0.70, 1.48). Significant inverse dose-response associations were observed for each 1% increment of circulating 20:5n-3 and 22:6n-3.Conclusion: This meta-analysis highlights that circulating LC n-3 FA as a biomarker of intake may be an independent predictive factor for BC, especially 20:5n-3 and 22:6n-3.
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Affiliation(s)
- Bo Yang
- Institute of Lipids Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Xiao L Ren
- Institute of Lipids Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Zhi Y Wang
- Department of Emergency Medicine, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liang Wang
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Feng Zhao
- Institute of Nutrition and Health, Qingdao University, Qingdao, China
| | - Xiao J Guo
- Institute of Lipids Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Duo Li
- Institute of Nutrition and Health, Qingdao University, Qingdao, China
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13
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Hirko KA, Chai B, Spiegelman D, Campos H, Farvid MS, Hankinson SE, Willett WC, Eliassen AH. Erythrocyte membrane fatty acids and breast cancer risk: a prospective analysis in the nurses' health study II. Int J Cancer 2017; 142:1116-1129. [PMID: 29071721 DOI: 10.1002/ijc.31133] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/12/2017] [Accepted: 10/04/2017] [Indexed: 01/07/2023]
Abstract
The roles of specific fatty acids in breast cancer etiology are unclear, particularly among premenopausal women. We examined 34 individual fatty acids, measured in blood erythrocytes collected between 1996 and 1999, and breast cancer risk in a nested case-control study of primarily premenopausal women in the Nurses' Health Study II. Breast cancer cases diagnosed after blood collection and before June 2010 (n = 794) were matched to controls and conditional logistic regression was used to estimate OR's (95% CI's) for associations of fatty acids with breast cancer; unconditional logistic regression was used for stratified analyses. Fatty acids were not significantly associated with breast cancer risk overall; however, heterogeneity by body mass index (BMI) was observed. Among overweight/obese women (BMI ≥ 25), several odd-chain saturated (SFA, e.g. 17:0, ORQ4vsQ1 (95% CI) =1.85 (1.18-2.88), ptrend =0.006 pint <0.001), trans (TFA, e.g. 18:1, ORQ4vsQ1 (95% CI) =2.33 (1.45-3.77), ptrend <0.001, pint =0.007) and dairy-derived fatty acids (SFA 15:0 + 17:0 + TFA 16:1n-7t; ORQ4vsQ1 (95% CI) =1.83(1.16-2.89), ptrend =0.005, pint <0.001) were positively associated, and n-3 polyunsaturated fatty acids (n-3 PUFA, e.g. alpha-linolenic acid; ORQ4vsQ1 (95% CI) =0.57 (0.36-0.89), ptrend =0.017, pint =0.03) were inversely associated with breast cancer. Total SFA were inversely associated with breast cancer among women with BMI < 25 (ORQ4vsQ1 (95% CI) =0.68 (0.46-0.98), ptrend =0.05, pint =0.01). Thus, while specific fatty acids were not associated with breast cancer overall, our findings suggest positive associations of several SFA, TFA and dairy-derived fatty acids and inverse associations of n-3 PUFA with breast cancer among overweight/obese women. Given these fatty acids are influenced by diet, and therefore are potentially modifiable, further investigation of these associations among overweight/obese women is warranted.
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Affiliation(s)
- Kelly A Hirko
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Boyang Chai
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hannia Campos
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Centro de Investigación e Innovación en Nutrición Translacional y Salud, Universidad Hispanoamericana, San José, Costa Rica
| | - Maryam S Farvid
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Susan E Hankinson
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA, USA
| | - Walter C Willett
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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14
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Cao Y, Hou L, Wang W. Dietary total fat and fatty acids intake, serum fatty acids and risk of breast cancer: A meta-analysis of prospective cohort studies. Int J Cancer 2015; 138:1894-904. [PMID: 26595162 DOI: 10.1002/ijc.29938] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 10/25/2015] [Accepted: 11/18/2015] [Indexed: 01/01/2023]
Abstract
Results from prospective cohort studies on the association between dietary total fat and fatty acids intake and risk of breast cancer remain controversial. Pertinent prospective cohort studies were identified by a search of Embase and PubMed from inception to September 2015. Study-specific relative risks (RRs) with 95% confidence intervals were pooled using a random-effect model. Between-study heterogeneity and publication bias were assessed, and sensitivity analysis was conducted. Twenty-four independent studies on dietary total fat and fatty acids intake and seven studies on serum fatty acids were included. The pooled RR of breast cancer for the highest vs. lowest category of dietary total fat intake was 1.10 (1.02-1.19); however, no association was observed in studies adjusting for traditional risk factors of breast cancer. No association was observed between animal fat, vegetable fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), n-3 PUFA, n-6 PUFA, eicosapentaenoic acid, docosahexaenoic acid, alpha-linolenic acid, oleic acid, linoleic acid and arachidonic acid and risk of breast cancer. The pooled RRs of breast cancer for the highest vs. lowest category of serum SFA, MUFA, PUFA, n-3 PUFA and n-6 PUFA were 1.00 (0.78-1.28), 1.41 (0.99-2.03), 0.59 (0.27-1.30), 0.81 (0.60-1.10) and 0.84 (0.60-1.18), respectively. Results from this meta-analysis suggested that dietary total fat and fatty acids might be not associated with risk of breast cancer.
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Affiliation(s)
- Yi Cao
- Department of Biochemistry, Qingdao University Medical College, Qingdao, China
| | - Lin Hou
- Department of Biochemistry, Qingdao University Medical College, Qingdao, China
| | - Weijing Wang
- Department of Epidemiology and Health Statistics, Qingdao University Medical College, Qingdao, China
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15
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Abstract
AbstractObjectivePrior studies on linoleic acid, the predominant n-6 fatty acid, and breast cancer risk have generated inconsistent results. We performed a meta-analysis to summarize the evidence regarding the relationship of dietary and serum linoleic acid with breast cancer risk.DesignPertinent studies were identified by a search of PubMed and EMBASE. The fixed- or random-effect pooled measure was selected based on between-study heterogeneity.ResultsEight prospective cohort studies and four prospective nested case–control studies, involving 10 410 breast cancer events from 358 955 adult females across different countries, were included in present study. Compared with the lowest level of linoleic acid, the pooled relative risk (RR; 95 % CI) of breast cancer was 0·98 (0·93, 1·04) for the highest level of linoleic acid. The pooled RR (95 % CI) for dietary and serum linoleic acid were 0·99 (0·92, 1·06) and 0·98 (0·88, 1·08), respectively. The RR (95 % CI) of breast cancer was 0·97 (0·91, 1·04), 0·95 (0·85, 1·07), 0·96 (0·86, 1·07), 0·98 (0·87, 1·10) and 0·99 (0·85, 1·14) for linoleic acid intake of 5, 10, 15, 20 and 25 g/d, respectively. The risk of breast cancer decreased by 1 % (RR=0·99; 95 % CI 0·93, 1·05) for every 10 g/d increment in linoleic acid intake.ConclusionsThis meta-analysis indicated that both dietary linoleic acid intake and serum linoleic acid level were associated with decreased risk of breast cancer, although none of the associations were statistically significant. Further investigations are warranted.
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16
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Roy S, Brasky TM, Belury MA, Krishnan S, Cole RM, Marian C, Yee LD, Llanos AA, Freudenheim JL, Shields PG. Associations of erythrocyte ω-3 fatty acids with biomarkers of ω-3 fatty acids and inflammation in breast tissue. Int J Cancer 2015; 137:2934-46. [PMID: 26137879 DOI: 10.1002/ijc.29675] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/15/2015] [Indexed: 12/31/2022]
Abstract
There is increasing evidence that chronic inflammation is associated with increased breast cancer risk. Long-chain omega-3 polyunsaturated fatty acids (LCω-3PUFA) may reduce circulating biomarkers of inflammation; however associations of blood LCω-3PUFA with breast tissue LCω-3PUFA and breast tissue biomarkers of inflammation are not well understood. We conducted a cross-sectional analysis of breast tissue and blood samples from n = 85 women with no history of breast cancer, who underwent breast reduction surgery. Fatty acids of erythrocytes and undissected breast tissues were analyzed by gas chromatography; C-reactive protein (CRP), interleukin (IL)-6 and IL-8 in plasma and tissue were measured by ELISA. Multivariable-adjusted regression models were used to estimate associations between erythrocyte LCω-3PUFA and breast tissue biomarkers. Women in the highest erythrocyte LCω-3PUFA tertile had LCω-3PUFA concentrations in the breast 73% (95% CI: 31-128%; p trend < 0.0001) higher than women in the lowest tertile. Associations for each individual LCω-3PUFA were similar in magnitude. No significant association was found for the shorter ω-3 PUFA, α-linolenic acid. Although compatible with no association, women in the highest tertile of erythrocyte eicosapentaenoic acid had a nonsignificant 32% (95% CI: -23 to 62%) reduced breast tissue CRP. No correlation was observed between erythrocyte ω-3 PUFA and tissue IL-6 or IL-8 concentrations. Our findings provide evidence that erythrocyte ω-3 fatty acids are valid measures of breast tissue concentrations, and limited evidence that inverse associations from prospective epidemiologic studies of blood LCω-3PUFA and breast cancer risk may be partly explained by reductions in breast tissue inflammation; however, these findings require replication.
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Affiliation(s)
- Shuvro Roy
- Department of Internal Medicine, Division of Cancer Prevention and Control, The Ohio State University College of Medicine, Columbus, OH
| | - Theodore M Brasky
- Department of Internal Medicine, Division of Cancer Prevention and Control, The Ohio State University College of Medicine, Columbus, OH.,The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Martha A Belury
- The Ohio State University Comprehensive Cancer Center, Columbus, OH.,Department of Human Sciences, The Ohio State University College of Education and Human Ecology, Columbus, OH
| | - Shiva Krishnan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Rachel M Cole
- Department of Human Sciences, The Ohio State University College of Education and Human Ecology, Columbus, OH
| | - Catalin Marian
- Department of Internal Medicine, Division of Cancer Prevention and Control, The Ohio State University College of Medicine, Columbus, OH.,The Ohio State University Comprehensive Cancer Center, Columbus, OH.,Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Lisa D Yee
- The Ohio State University Comprehensive Cancer Center, Columbus, OH.,Department of Surgical Oncology, The Ohio State University College of Medicine, Columbus, OH
| | - Adana A Llanos
- RBHS-School of Public Health and Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Jo L Freudenheim
- Department of Epidemiology and Environmental Health, The State University of New York at Buffalo, School of Public Health and Health Professions, Buffalo, NY
| | - Peter G Shields
- Department of Internal Medicine, Division of Cancer Prevention and Control, The Ohio State University College of Medicine, Columbus, OH.,The Ohio State University Comprehensive Cancer Center, Columbus, OH
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17
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Wiggins AKA, Kharotia S, Mason JK, Thompson LU. α-Linolenic Acid Reduces Growth of Both Triple Negative and Luminal Breast Cancer Cells in High and Low Estrogen Environments. Nutr Cancer 2015; 67:1001-9. [PMID: 26134471 DOI: 10.1080/01635581.2015.1053496] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Flaxseed, rich in α-linolenic acid (ALA), is a complementary breast cancer (BC) therapy; however ALA effectiveness and mechanism are unclear. Variation in cellular expression of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and estrogen (E2) levels may alter ALA effectiveness. This research determined the effect of ALA on growth, apoptosis, and phospholipid fatty acids of 4 BC cell lines with varying receptor expression ± E2. MCF-7 (ER+/PR+/HER2-), BT-474 (ER+/PR+/HER2+), MDA-MB-231 (ER-/PR-/HER2-) and MDA-MB-468 (ER-/PR-/HER2-) cells were incubated with ALA (50-200 μM) ± 1 nM E2 for 48-72 h. ALA dose-dependently reduced growth, measured by trypan blue exclusion, of all cells (55-80% with 75 μM), and this effect was not altered by E2. ALA (75 μM)+E2 induced apoptosis, measured by flow cytometry (up to 111.2%). Decreased growth and increased apoptosis is related to increased cell phospholipid % ALA (up to 25.1%), measured by gas chromatography. ALA is shown for the first time to reduce cell growth and induce apoptosis regardless of receptor expression and E2 environment, by incorporating into BC phospholipids, supporting the use of ALA and ALA-rich foods as a safe, inexpensive complementary therapy for a wide range of BC.
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Affiliation(s)
- Ashleigh K A Wiggins
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto , Toronto , Ontario , Canada
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18
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Hidaka BH, Li S, Harvey KE, Carlson SE, Sullivan DK, Kimler BF, Zalles CM, Fabian CJ. Omega-3 and omega-6 Fatty acids in blood and breast tissue of high-risk women and association with atypical cytomorphology. Cancer Prev Res (Phila) 2015; 8:359-64. [PMID: 25712053 DOI: 10.1158/1940-6207.capr-14-0351] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/16/2015] [Indexed: 11/16/2022]
Abstract
The ratio of omega-3 to omega-6 fatty acids, especially the long-chain eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) to arachidonic acid (AA) ratio, is inversely associated with breast cancer risk. We measured the association between cytologic atypia, a biomarker for short-term risk of breast cancer development, and omega-3 and omega-6 fatty acid intake and levels in blood and breast tissue. Blood and benign breast tissue, sampled by random periareolar fine-needle aspiration (RPFNA), was obtained from 70 women at elevated risk for breast cancer. Self-reported dietary intake was assessed by the NCI's Food Frequency Questionnaire. The fatty acid composition of five lipid compartments, red blood cell, plasma and breast phospholipids, and plasma and breast triaclyglycerides (TAG), was analyzed by gas chromatography as weight percent. Median daily intakes of EPA+DHA and total omega-3 fatty acids were 80 mg and 1.1 g, respectively. The median total omega-3:6 intake ratio was 1:10. Compared with women without atypia, those with cytologic atypia had lower total omega-3 fatty acids in red blood cell and plasma phospholipids and lower omega-3:6 ratios in plasma TAGs and breast TAGs (P < 0.05). The EPA+DHA:AA ratio in plasma TAGs was also lower among women with atypia. This is the first report of associations between tissue levels of omega-3 and omega-6 fatty acids and a reversible tissue biomarker of breast cancer risk. RPFNA cytomorphology could serve as a surrogate endpoint for breast cancer prevention trials of omega-3 fatty acid supplementation.
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Affiliation(s)
- Brandon H Hidaka
- Department of Dietetics and Nutrition University of Kansas Medical Center, Kansas City, Kansas
| | - Shengqi Li
- Department of Dietetics and Nutrition University of Kansas Medical Center, Kansas City, Kansas
| | - Katherine E Harvey
- Department of Dietetics and Nutrition University of Kansas Medical Center, Kansas City, Kansas
| | - Susan E Carlson
- Department of Dietetics and Nutrition University of Kansas Medical Center, Kansas City, Kansas
| | - Debra K Sullivan
- Department of Dietetics and Nutrition University of Kansas Medical Center, Kansas City, Kansas
| | - Bruce F Kimler
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Carol J Fabian
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas.
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19
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Pouchieu C, Chajès V, Laporte F, Kesse-Guyot E, Galan P, Hercberg S, Latino-Martel P, Touvier M. Prospective associations between plasma saturated, monounsaturated and polyunsaturated fatty acids and overall and breast cancer risk - modulation by antioxidants: a nested case-control study. PLoS One 2014; 9:e90442. [PMID: 24587366 PMCID: PMC3937383 DOI: 10.1371/journal.pone.0090442] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/30/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Mechanistic data suggest that different types of fatty acids play a role in carcinogenesis and that antioxidants may modulate this relationship but epidemiologic evidence is lacking. Our aim was to investigate the association between plasma saturated, monounsaturated and polyunsaturated fatty acids (SFAs, MUFAs and PUFAs) and overall and breast cancer risk and to evaluate the potential modulatory effect of an antioxidant supplementation on these relationships. METHODS A nested case-control study included all first incident cancer cases diagnosed in the SU.VI.MAX study between 1994 and 2002 (n=250 cases, one matched control/case). Participants to the SU.VI.MAX randomized controlled trial received either vitamin/mineral antioxidants or placebo during this intervention period. Baseline fatty acid composition of plasma total lipids was measured by gas chromatography. Conditional logistic regression was performed overall and stratified by intervention group. RESULTS Dihomo-γ-linolenic acid (Ptrend=0.002), the dihomo-γ-linolenic/linoleic acids ratio (Ptrend=0.001), mead acid (Ptrend=0.0004), and palmitoleic acid (Ptrend=0.02) were inversely associated with overall cancer risk. The arachidonic/dihomo-γ-linolenic acids ratio (Ptrend=0.02) and linoleic acid (Ptrend=0.02) were directly associated with overall cancer risk. Similar results were observed for breast cancer specifically. In stratified analyses, associations were only observed in the placebo group. Notably, total PUFAs were directly associated with overall (Ptrend=0.02) and breast cancer risk in the placebo group only. CONCLUSION Specific SFAs, MUFAs and PUFAs were prospectively differentially associated with cancer risk. In addition, this study suggests that antioxidants may modulate these associations by counteracting the potential effects of these fatty acids on carcinogenesis.
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Affiliation(s)
- Camille Pouchieu
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
| | - Véronique Chajès
- Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
| | - François Laporte
- Department of Integrated Biology, University Hospital of Grenoble, Grenoble, France
| | - Emmanuelle Kesse-Guyot
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
| | - Pilar Galan
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
| | - Serge Hercberg
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
- Public Health Department, Avicenne Hospital, Bobigny, France
| | - Paule Latino-Martel
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
| | - Mathilde Touvier
- Sorbonne Paris Cité, Nutritional Epidemiology Research Team (EREN), Epidemiology and Biostatistics Center, Inserm U1153, Inra U1125, Cnam, University Paris 13, University Paris 5, University Paris 7, Bobigny, France
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Yang B, Ren XL, Fu YQ, Gao JL, Li D. Ratio of n-3/n-6 PUFAs and risk of breast cancer: a meta-analysis of 274135 adult females from 11 independent prospective studies. BMC Cancer 2014; 14:105. [PMID: 24548731 PMCID: PMC4016587 DOI: 10.1186/1471-2407-14-105] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/18/2013] [Indexed: 12/31/2022] Open
Abstract
Background Increased ratio of n-3/n-6 polyunsaturated fatty acids (PUFAs) in diet or serum may have a protective effect on the risk of breast cancer (BC); however, the conclusions from prospective studies are still controversial. The purpose of this study is to ascertain the relationship between intake ratio of n-3/n-6 PUFAs and the risk of BC, and estimate the potential summarized dose–response trend. Methods Relevant English-language studies were identified through Cochrane Library, PubMed and EMBASE database till April 2013. Eligible prospective studies reporting the multivariate adjusted risk ratios (RRs) for association of n-3/n-6 PUFAs ratio in diet or serum with BC risk. Data extraction was conducted independently by 2 investigators; disagreements were reconciled by consensus. Study quality was assessed using the Newcastle-Ottawa scale. Study-specific RRs were combined via a random-effects model. Results Six prospective nested case–control and 5 cohort studies, involving 8,331 BC events from 274,135 adult females across different countries, were included in present study. Subjects with higher dietary intake ratio of n-3/n-6 PUFAs have a significantly lower risk of BC among study populations (pooled RR = 0.90; 95% CI: 0.82, 0.99), and per 1/10 increment of ratio in diet was associated with a 6% reduction of BC risk (pooled RR = 0.94; 95% CI: 0.90, 0.99; P for linear trend = 0.012). USA subjects with higher ratio of n-3/n-6 in serum phospholipids (PL) have a significantly lower risk of BC (pooled RR = 0.62; 95% CI: 0.39, 0.97; I2 = 0.00%; P for metaregression = 0.103; P for a permutation test = 0.100), and per 1/10 increment of ratio in serum PL was associated with 27% reduction of BC risk (pooled RR = 0.73; 95% CI: 0.59, 0.91; P for linear trend = 0.004; P for metaregression = 0.082; P for a permutation test = 0.116). Conclusions Higher intake ratio of n-3/n-6 PUFAs is associated with lower risk of BC among females, which implies an important evidence for BC prevention and treatment is by increasing dietary intake ratio of n-3/n-6 PUFA. No firm conclusions from USA populations could be obtained, due to the limited numbers of USA studies.
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Affiliation(s)
| | | | | | | | - Duo Li
- Department of Food Science and Nutrition, Zhejiang University, 866 Yuhangtang Road, Hangzhou 310058, China.
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Azordegan N, Fraser V, Le K, Hillyer LM, Ma DWL, Fischer G, Moghadasian MH. Carcinogenesis alters fatty acid profile in breast tissue. Mol Cell Biochem 2012. [PMID: 23180247 DOI: 10.1007/s11010-012-1523-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cancerogenesis is associated with cell membrane changes. The aim of this study was to investigate whether breast tissues with different degrees of cancer involvement have different fatty acid profiles. Fourteen breast cancer patients with a mean age of 61 years were recruited. Morphological features of the tumoral specimens were characterized. Approximately 60 % of patients had invasive ductal carcinoma, and 80 % were ER positive; 65 % were PR positive; and 65 % were HER2 negative. The segments with confirmed cancer had significantly less amounts of total lipids as compared with the corresponding grossly normal or interface tissues. The fatty acid profile in cancer tissue was significantly different from that in other tissues. Fatty acid composition of five classes of phospholipids revealed the variations between cancer tissue and the other two segments. A transition of changes in fatty acid composition in these fractions of phospholipids was observed. The interface tissue had intermediate amounts of several fatty acids including palmitic acid, stearic acid, and arachidonic acid. Interestingly, we observed significantly higher amounts of the n-3 fatty acid DHA in cancer tissue as compared to the other two tissues. Data from this study will provide evidence that biochemical changes particularly phospholipid composition may take place well in advance prior to morphological changes. Should this theory be confirmed by larger studies, deviation of phospholipid composition from normal values can be used as markers of susceptibility of tissue to cancer development.
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Affiliation(s)
- Nazila Azordegan
- Departments of Human Nutritional Sciences, Canadian Centre for Agri-Food Research in Health and Medicine, University of Manitoba, 351 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
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Sczaniecka AK, Brasky TM, Lampe JW, Patterson RE, White E. Dietary intake of specific fatty acids and breast cancer risk among postmenopausal women in the VITAL cohort. Nutr Cancer 2012; 64:1131-42. [PMID: 23137008 PMCID: PMC3633593 DOI: 10.1080/01635581.2012.718033] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Studies of dietary fat intake and breast cancer have been inconsistent and few have examined specific fatty acids. We examined the association between specific monounsaturated (MUFA), polyunsaturated (PUFA), saturated (SFA), and trans-fatty acids (TFA) and breast cancer risk. Participants, 50-76 yr, were female members of the VITamins And Lifestyle (VITAL) Cohort, who were postmenopausal at baseline. In 2000-2002, participants completed a food frequency questionnaire. Seven hundred seventy-two incident, primary breast cancer cases were identified using a population-based cancer registry. Cox proportional hazard models estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between fatty acid intake and breast cancer risk. Intake of total MUFAs (highest vs. lowest quintile: HR = 1.61, 95% CI: 1.08-2.38, P trend = 0.02), particularly myristoleic and erucic acids, was associated with increased breast cancer risk. Whereas total SFA was suggestive of an increased risk (HR = 1.47, 95% CI: 1.00-2.15, P trend = 0.09), strong associations were observed for palmitic, margaric, and stearic acids. Total TFA and PUFA intake were not associated with breast cancer. However, among TFAs, linolelaidic acid was positively associated with risk; among PUFAs, intake of eicosapentaenoic and docosahexaenoic acids were inversely associated with risk. Our findings show that fatty acids are heterogeneous in their association with postmenopausal breast cancer risk.
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Affiliation(s)
- Anna K Sczaniecka
- The Fred Hutchinson Cancer Research Center, Cancer Prevention Program, Seattle, Washington 98109-1024, USA
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Laake I, Carlsen MH, Pedersen JI, Weiderpass E, Selmer R, Kirkhus B, Thune I, Veierød MB. Intake oftransfatty acids from partially hydrogenated vegetable and fish oils and ruminant fat in relation to cancer risk. Int J Cancer 2012; 132:1389-403. [DOI: 10.1002/ijc.27737] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 07/02/2012] [Indexed: 11/09/2022]
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Lv W, Yang T. Identification of possible biomarkers for breast cancer from free fatty acid profiles determined by GC–MS and multivariate statistical analysis. Clin Biochem 2012; 45:127-33. [DOI: 10.1016/j.clinbiochem.2011.10.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 10/08/2011] [Accepted: 10/16/2011] [Indexed: 10/15/2022]
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Murff HJ, Shu XO, Li H, Yang G, Wu X, Cai H, Wen W, Gao YT, Zheng W. Dietary polyunsaturated fatty acids and breast cancer risk in Chinese women: a prospective cohort study. Int J Cancer 2010; 128:1434-41. [PMID: 20878979 DOI: 10.1002/ijc.25703] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 09/08/2010] [Indexed: 12/14/2022]
Abstract
Breast cancer is the most common cancer in women. Controversy exists regarding the role of dietary fat in breast cancer etiology. We investigated the association of dietary polyunsaturated fatty acids (PUFAs) and the ratio of n-6 PUFAs to marine-derived n-3 PUFAs with breast cancer risk in the Shanghai Women's Health Study, a prospective cohort study including 72,571 cancer-free participants at baseline. Dietary fatty acid intake was determined using food frequency questionnaires. We used Cox proportional hazards analysis to estimate the relative risks (RRs) and 95% confidence intervals (CIs) for the association of breast cancer risk with dietary fatty acids consumption. In 583,998 person-years of follow-up, we identified 712 breast cancer cases. We found no association of breast cancer risk to dietary intake of linoleic acid, arachidonic acid, α-linolenic acid or marine-derived n-3 PUFA. We found a statistically significant interaction between n-6 PUFA intake, marine-derived n-3 PUFA intake and breast cancer risk (p = 0.008). Women with lower intake (the lowest tertile) of marine-derived n-3 PUFA and higher intake (the highest tertile) of n-6 PUFA had an increase risk for breast cancer (RR = 2.06; 95% CI = 1.27-3.34) compared to women with higher intake (the highest tertile) of marine-derived n-3 PUFAs and lower intake (the lowest tertile) of n-6 PUFAs after adjusting for potential confounders. The relative amounts of n-6 PUFA to marine-derived n-3 PUFAs may be more important for breast cancer risk than individual dietary amounts of these fatty acids.
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Affiliation(s)
- Harvey J Murff
- Department of Medicine, Vanderbilt Epidemiology Center and Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN 37203-1738, USA.
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