Vitamin D and mammographic breast density: a systematic review

Multivitamin Use and Mammographic Breast Density

BACKGROUND

The association of multivitamin use with mammographic breast density (MBD) is unclear, with 2 studies reporting conflicting findings.

OBJECTIVES

We aimed to investigate the associations of multivitamin use with volumetric measures of MBD-volumetric percent density (VPD), dense volume (DV), and nondense volume (NDV)-in a diverse population of women.

METHODS

This cross-sectional study included 1083 women recruited during their annual screening mammograms at the Joanne Knight Breast Health Center, Washington University School of Medicine, St. Louis, MO. Participants were classified based on self-reported multivitamin use into nonusers, <1, 1-3, and 4-6 d/wk, and daily users. MBD was assessed as VPD, DV, and NDV using Volpara 1.5. Data were analyzed using general linear modeling and adjusted for potential confounders, including age, BMI, race, menopausal status, education, age at menarche, a family history of breast cancer, parity and age at first birth, oral contraceptive use, menopausal hormone therapy use, and alcohol intake. Statistical significance was set at P < 0.05.

RESULTS

Multivitamin use was not associated with VPD. The adjusted mean VPD was 7.0% (95% CI: 6.6%, 7.2%) for nonusers, 7.1% (95% CI: 6.4%, 8.0%) for women who used multivitamins <1 d/wk, 7.4% (95% CI: 6.6%, 8.3%) for women who used multivitamins 1-3 d/wk, 7.1% (95% CI: 6.3%, 7.7%) for women who used multivitamins 4-6 d/wk, and 6.9% (95% CI: 6.6%, 7.3%) for daily users (P = 0.794). Similar null associations were observed between multivitamin use and DV and NDV. Race and menopausal status did not modify the associations.

CONCLUSIONS

There is no association between multivitamin use and MBD, regardless of the frequency of use. Studies evaluating the potential interactions among dietary patterns, specific nutrients, and MBD are needed to enhance our understanding of how dietary factors impact MBD.

Breast Density: Current Knowledge, Assessment Methods, and Clinical Implications

Breast density is an accepted independent risk factor for the future development of breast cancer, and greater breast density has the potential to mask malignancies on mammography, thus lowering the sensitivity of screening mammography. The risk associated with dense breast tissue has been shown to be modifiable with changes in breast density. Numerous studies have sought to identify factors that influence breast density, including age, genetic, racial/ethnic, prepubertal, adolescent, lifestyle, environmental, hormonal, and reproductive history factors. Qualitative, semiquantitative, and quantitative methods of breast density assessment have been developed, but to date there is no consensus assessment method or reference standard for breast density. Breast density has been incorporated into breast cancer risk models, and there is growing consciousness of the clinical implications of dense breast tissue in both the medical community and public arena. Efforts to improve breast cancer screening sensitivity for women with dense breasts have led to increased attention to supplemental screening methods in recent years, prompting the American College of Radiology to publish Appropriateness Criteria for supplemental screening based on breast density.

Air pollution exposure and mammographic breast density in Tehran, Iran: a cross-sectional study

BACKGROUND

Air pollution is one of the major public health challenges in many parts of the world possibly has an association with breast cancer. However, the mechanism is still unclear. This study aimed to find an association between exposure to six criteria ambient air pollutants (PM_2.5, PM₁₀, SO₂, NO₂, O₃, and CO) and mammographic breast density (MBD), as one of the strongest predictors for developing breast cancer, in women living in Tehran, Iran.

METHODS

Participants were selected from women attending two university hospitals for screening mammography from 2019 to 2021. Breast density was rated by two expert radiologists. Individual exposures to 3-year ambient air pollution levels at the residence were estimated.

RESULTS

The final analysis in 791 eligible women showed that low and high breast density was detected in 34.8 and 62.2 of participants, respectively. Logistic regression analysis after considering all possible confounding factors represented that an increase in each unit of NO₂ (ppb) exposure was associated with an increased risk of breast density with an OR equal to 1.04 (95CI: 1.01 to 1.07). Furthermore, CO level was associated with a decreasing breast density (OR = 0.40, 95CI = 0.19 to 0.86). None of the other pollutants were associated with breast density.

CONCLUSION

Higher MBD was associated with an increased level of NO₂, as a marker of traffic-related air pollution. Furthermore, CO concentration was associated with a lower MBD, while other criteria air pollutants were not related to MBD. Further studies are needed to evaluate the association between ambient air pollutants with MBD.

OUP accepted manuscript

In screening for breast cancer (BC), mammographic breast density (MBD) is a powerful risk factor that increases breast carcinogenesis and synergistically reduces the sensitivity of mammography. It also reduces specificity of lesion identification, leading to recalls, additional testing, and delayed and later-stage diagnoses, which result in increased health care costs. These findings provide the foundation for dense breast notification laws and lead to the increase in patient and provider interest in MBD. However, unlike other risk factors for BC, MBD is dynamic through a woman’s lifetime and is modifiable. Although MBD is known to change as a result of factors such as reproductive history and hormonal status, few conclusions have been reached for lifestyle factors such as alcohol, diet, physical activity, smoking, body mass index (BMI), and some commonly used medications. Our review examines the emerging evidence for the association of modifiable factors on MBD and the influence of MBD on BC risk. There are clear associations between alcohol use and menopausal hormone therapy and increased MBD. Physical activity and the Mediterranean diet lower the risk of BC without significant effect on MBD. Although high BMI and smoking are known risk factors for BC, they have been found to decrease MBD. The influence of several other factors, including caffeine intake, nonhormonal medications, and vitamins, on MBD is unclear. We recommend counseling patients on these modifiable risk factors and using this knowledge to help with informed decision making for tailored BC prevention strategies.

Insights into the perspective correlation between vitamin D and regulation of hormones: sex hormones and prolactin

Aim. Vitamin D is currently an exciting research target, besides its obvious role in calcium homeostasis and bone health, enormous work is being directed at examining the effects of this vitamin on various biological functions and pathological conditions.

Material and methods. The review of the literature and the analysis took about six months and was carried out through PubMed. This is a search engine opening mainly the MEDLINE database of trusted references. We called up all studies written in English that were published between the years 2004 to 2021 and that came through using the applied search terms, and analysed all those that met the criteria.

Results. The endocrine system with its many glands and hormones and their essential roles in the maintenance of normal body functioning cannot be far from interactions with vitamin D. Male and female sex hormones are no exceptions and many studies have investigated the correlations between these hormones and vitamin D. As such, direct and indirect relationships have been found between vitamin D, its receptors or one of its metabolising enzymes with sex hormones and the development of reproductive organs in males and females.

Conclusion. This review summarises the research investigating the associations of vitamin D with sex hormones and reproductive organs in males and females, and thus may pave the road for future studies that will investigate the clinical significance of vitamin D in the management of reproductive system disorders. Despite some conflicting results about the relationship between VD and the effectiveness of the reproductive system, many studies confirm the presence of receptors for this vitamin in the reproductive system, and this supports the direct or indirect relationship between VD and prolactin or VD and testosterone through PO4 and Ca2+ homeostasis, or production of osteocalcin. Therefore, VD is positively associated with semen quality and androgen status. Furthermore, a direct relationship between VD and the production of progesterone, estrogen and estrone in human ovarian cells has been supported by many studies.

Relationship of vitamin D deficiency with mammographic breast density and triple-negative breast cancer: A cross-sectional study

Background As breast epithelium is affected by vitamin D, it may have a direct effect on breast density and the risk of breast cancer. Our aim was to study the serum levels of vitamin D in patients with malignant and benign breast disease, and to study the association, if any, between vitamin D levels, mammographic breast density (MD) and molecular subtypes of breast cancer. Methods In this cross-sectional, observational study, we enrolled 162 consecutive adult women with benign and malignant breast masses subjected to mammography and core-needle biopsy. Serum levels of vitamin D were estimated and correlated with MD and with immunohistochemical subtyping of breast cancer. Results The mean vitamin D level in these 162 patients was 12.44 (5.88) ng/ml, with vitamin D deficiency seen in 98%. The mean (SD) vitamin D level in MD type 1 was 16.19 (4.62) ng/ml and it decreased to 7.54 (2.58) ng/ml in MD type 4. High MD was associated with significantly lower vitamin D levels. The mean vitamin D level in patients with benign breast disease (n=102) was 13.73 (5.68) ng/ml, while it was significantly lower in patients with breast cancer (n=60) at 10.26 (5.61) ng/ml. Among patients with breast cancer, the good prognosis luminal A molecular subtype had mean vitamin D level of 12.94 (6.16) ng/ml, whereas the poor prognosis triple-negative subtype had a significantly lower value of 7.68 (3.42) ng/ml. Conclusion Our study shows that vitamin D deficiency has a significant relationship with breast cancer (v. benign breast disease), high MD (showing increased breast cancer risk) and poor prognosis triple-negative breast cancer. Vitamin D deficiency could be an important, potentially modifiable, risk factor for the prevention of breast cancer in susceptible populations.

Association between skeletal muscle mass and mammographic breast density

Mammographic density (MD) of the breast and body mass index (BMI) are inversely associated with each other, but have inconsistent associations with respect to the risk of breast cancer. Skeletal muscle mass index (SMI) has been considered to reflect a relatively accurate fat and muscle percentage in the body. So, we evaluated the relation between SMI and MD. A cross-sectional study was performed in 143,456 women who underwent comprehensive examinations from 2012 to 2016. BMI was adjusted to analyze whether SMI is an independent factor predicting dense breast. After adjustment for confounding factors including BMI, the odds ratios for MD for the dense breasts was between the highest and lowest quartiles of SMI at 2.65 for premenopausal women and at 2.39 for postmenopausal women. SMI was a significant predictor for MD, which could be due to the similar growth mechanism of the skeletal muscle and breast parenchymal tissue. Further studies are needed to understand the causal link between muscularity, MD and breast cancer risk.

Chemoprevention Agents to Reduce Mammographic Breast Density in Premenopausal Women: A Systematic Review of Clinical Trials

Background

Higher mammographic breast density (MBD) is associated with an increased risk of breast cancer when compared with lower MBD, especially in premenopausal women. However, little is known about the effectiveness of chemoprevention agents in reducing MBD in premenopausal women without a history of breast cancer. Findings from this review should provide insight on how to target MBD in breast cancer prevention in premenopausal women with dense breasts.

Methods

We searched 9 electronic databases for clinical trials in English, Spanish, French, or German published until January 2020. Articles evaluating the association of pharmacological agents and MBD were included. Data were extracted on methods, type and dose of intervention, outcomes, side effects, and follow up. Quality of the studies was assessed using the US Preventive Services Task Force criteria.

Results

We identified 7 clinical trials evaluating the associations of 6 chemoprevention agents with changes in MBD in premenopausal women without history of breast cancer. The studies evaluated selective estrogen-receptor modulators (n = 1); gonadotropin-releasing hormone agonists (n = 2); isoflavones (n = 1); vitamin D (n = 1); and Boswellia, betaine, and mayo-inositol compound (n = 1). Hormonal interventions were associated with net reductions in percent density (tamoxifen [13.4%], leuprolide acetate [8.9%], and goserelin [2.7%]), whereas nonhormonal (vitamin D and isoflavone) interventions were not. However, MBD returned to preintervention baseline levels after cessation of gonadotropin-releasing hormone agonists.

Conclusions

A limited number of chemoprevention agents have been shown to reduce MBD in premenopausal women. Identification of new and well-tolerated chemoprevention agents targeting MBD and larger studies to confirm agents that have been studied in small trials are urgent priorities for primary breast cancer prevention in premenopausal women with dense breasts.

Randomized Double-Blind Placebo-Controlled Biomarker Modulation Study of Vitamin D Supplementation in Premenopausal Women at High Risk for Breast Cancer (SWOG S0812)

Observational studies have reported an inverse association between vitamin D intake and breast cancer risk. We examined whether vitamin D supplementation in high-risk premenopausal women reduces mammographic density (MD), an established breast cancer risk factor. We conducted a multicenter randomized double-blind placebo-controlled trial in premenopausal women at high risk for breast cancer [5-year risk ≥ 1.67%, lifetime risk ≥ 20%, lobular carcinoma in situ, prior stage 0-II breast cancer, hereditary breast cancer syndrome, or high MD (heterogeneously/extremely dense)], with a baseline serum 25-hydroxyvitamin D [25(OH)D] ≤ 32 ng/mL. Participants were randomized to 12 months of vitamin D3 20,000 IU/week or matching placebo. The primary endpoint was change in MD from baseline to 12 months using the Cumulus technique. Secondary endpoints included serial blood biomarkers [25(OH)D, 1,25-dihydroxyvitamin D (1,25(OH)D), insulin-like growth factor (IGF)-1, IGF-binding protein-3] and MD change at 24 months. Among 208 women randomized, median age was 44.6 years, 84% were white, 33% had baseline 25(OH)D < 20 ng/mL, and 78% had high baseline MD. Comparing the active and placebo groups at 12 months, MD changes were small and did not significantly differ. Mean MD changes at 12 and 24 months were -0.3% and -1.2%, respectively, in the active arm and +1.5% and +1.6% with placebo (P > 0.05). We observed a mean change in serum 25(OH)D of +18.9 versus +2.8 ng/mL (P < 0.01) and IGF-1 of -9.8 versus -1.8 ng/mL (P = 0.28), respectively. At 12 months, MD was positively correlated with serum IGF-1 and IGF-1/IGFBP-3 (P < 0.01). This trial does not support the use of vitamin D supplementation for breast cancer risk reduction.

Serum 25-hydroxyvitamin D and mammographic density in premenopausal Spanish women

The role of vitamin D in mammographic density is still unclear. This study examines the association between serum 25-hydroxyvitamin D (25(OH)D) and mammographic density, overall and by specific women characteristics. DDM-Madrid is a cross-sectional study that recruited 1403 premenopausal women in a breast radiodiagnosis unit of Madrid City Council. Information was collected with a questionnaire and plasma 25(OH)D was measured by solid-phase extraction on-line coupled to liquid chromatography-tandem mass spectrometry. Percent mammographic density was assessed using a semi-automated computer tool (DM-Scan). Multivariable linear regression models were used to quantify the associations, categorizing 25(OH)D levels (nmol/L) into 3 groups according to the cut-offs established by the US Endocrine Society. Models were adjusted for age, education, body mass index, age at menarche, parity, previous breast biopsies, family history of breast cancer, physical activity, energy intake, use of corticoids, hypercholesterolemia and day of sample extraction. Mean serum 25(OH)D level was 49.4 + 18.9 nmol/L. Women with sufficient concentrations of 25(OH)D showed a slight decrease in mammographic density (β _>75nmol/L=-3.40; p = 0.037). No differences were observed according to women characteristics except for parity, where the protective effect of 25(OH)D was only seen among nulliparous (β _>75nmol/L=-13.00; p-heterogeneity = 0.006). In light of the protective effect of vitamin D on mammographic density and the high prevalence of vitamin D insufficiency in our population, improving these levels could be an effective measure for the prevention of health problems related to the lack of this essential vitamin.

Adjuvant Therapy and Mammographic Density Changes in Women With Breast Cancer

Background

Tamoxifen decreases mammographic density. Whether compliance affects this relationship is unclear as is the relationship between other types of adjuvant treatment and changes in mammographic density.

Methods

This prospective cohort study included 2490 women diagnosed with breast cancer during 2001-2015 in Sweden. Mammographic density was assessed within 3 months of diagnosis and 6-36 months post diagnosis. Logistic regression was performed to study the association between each respective adjuvant treatment and mammographic density reduction (annual dense area decrease >15%).

Results

Intention-to-treat analyses using treatment information from the regional cancer registries showed that tamoxifen-treated patients more frequently experienced mammographic density reductions compared with nontreated patients (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.25 to 1.99), as did chemotherapy-treated patients (OR = 1.28, 95% CI = 1.06 to 1.54). For chemotherapy, the association was mainly seen in premenopausal women. Neither aromatase inhibitors nor radiotherapy was associated with density change. Tamoxifen use based on prescription and dispensation data from the Swedish Prescribed Drug Register showed that users were more likely to have density reductions compared with nonusers (adjusted OR = 2.24, 95% CI = 1.40 to 3.59). Moreover, among tamoxifen users, tamoxifen continuers were more likely than discontinuers to experience density reductions (adjusted OR = 1.50, 95% CI = 1.04 to 2.17).

Conclusions

Our results indicate that adherence influences the association between tamoxifen and mammographic density reduction. We further found that chemotherapy was associated with density reductions and propose that this is largely secondary to chemotherapy-induced ovarian failure.

The Effect of Vitamin D Supplementation on Breast Density Changes: A Clinical Trial Study

The aim of this study was to determine the effect of supplementation with 50,000 IU/monthly vitamin D for 1 yr on breast density in Iranian women.

METHODS

This double-blind, placebo-controlled, single center clinical trial was conducted among 400 women aged 40 yr and older. Participants were allocated to 2 groups. Group 1 received vitamin D (Cholecalciferol) 50,000 IU in tablet form, monthly, for 1 yr. Group 2 received vitamin E 400 IU in tablet form, monthly, for the same period of time. Participants had follow-up clinic visits every 6 mo and received an annual mammogram.

RESULTS

Final data were evaluated based on 216 and 194 women in the vitamin D and control groups. The mean decrease in mammographic density was -5.01%(95% CI, -9.9% to -0.01%) and -2.34 %(95% CI, -6.84% to -2.15%) in the vitamin D and control groups, respectively. There was no significant association between vitamin D consumption and breast density after 1 yr (OR = 0.7, 95% CI, 0.46 to 1.06; P = 0.1).Similar results were observed when multivariate model of logistic regression analysis was performed.

CONCLUSIONS

This study showed that monthly consumption of 50,000 IU of vitamin D supplementation for 1 yr did not affect breast density.

Serum 25-Hydroxyvitamin D3 and Mammography Density among Mexican Women

Low circulating levels of vitamin D and high mammographic density (MD) have been associated with higher risk of breast cancer. Although some evidence suggested an inverse association between circulating vitamin D and MD, no studies have investigated this association among Mexican women. We examined whether serum 25-hydroxyvitamin D3 [25(OH)D3] levels were associated with MD in a cross-sectional study nested within the large Mexican Teacher's Cohort. This study included 491 premenopausal women with a mean age of 42.9 years. Serum 25(OH)D3 levels were measured by liquid chromatography/tandem mass spectrometry. Linear regression and non-linear adjusted models were used to estimate the association of MD with serum 25(OH)D3. Median serum 25(OH)D3 level was 27.3 (23.3-32.8) (ng/ml). Forty one (8%) women had 25(OH)D3 levels in the deficient range (< 20 ng/ml). Body mass index (BMI) and total physical activity were significantly correlated with 25(OH)D3 (r = -0.109, P = 0.019 and r = 0.095, P = 0.003, respectively). In the multivariable linear regression, no significant association was observed between 25(OH)D3 levels and MD overall. However, in stratified analyses, higher serum 25(OH)D3 levels (≥27.3 ng/ml) were significantly inversely associated with percent MD among women with BMI below the median (β = -0.52, P = 0.047). Although no significant association was observed between serum 25(OH)D3 and percent MD in the overall population, specific subgroups of women may benefit from higher serum 25(OH)D3 levels.

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

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

Safety, Feasibility, and Biomarker Effects of High-Dose Vitamin D Supplementation Among Women at High Risk for Breast Cancer

Vitamin D deficiency is a potentially modifiable risk factor that may be targeted for breast cancer prevention. We examined the safety, feasibility, and biomarker effects of high-dose vitamin D among women at high risk for breast cancer. Forty high-risk women, defined as a 5-year breast cancer risk ≥1.67% per the Gail model, lobular or ductal carcinoma in situ, were assigned to a 1-year intervention of vitamin D3 20,000 IU or 30,000 IU weekly. Participants were monitored for toxicity every 3 months, underwent serial blood draws at baseline, 6 and 12 months, and a digital mammogram at baseline and 12 months. Biomarker endpoints included serum 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)₂D], parathyroid hormone (PTH), insulin-like growth factor (IGF-1), IGF binding protein (IGFBP-3), and mammographic density (MD) using Cumulus software. From November 2007 to January 2011, we enrolled 40 women; 37 were evaluable at 6 months and 30 at 12 months. One patient was taken off study for hypercalciuria; otherwise, the intervention was well tolerated. From baseline to 12 months, mean serum 25(OH)D and 1,25(OH)₂D rose from 20.0 to 46.9 ng/ml and 69.7 to 98.1 pg/ml, respectively (p<0.01). Serum PTH decreased by 12% at 6 months and IGF-1/IGFBP-3 ratio decreased by 4.3% at 12 months (p<0.05). There was no significant change in MD regardless of menopausal status or dose level. We demonstrated that 1 year of high-dose vitamin D3 was associated with a significant increase in circulating vitamin D levels and favorable effects on IGF signaling, but no significant change in MD.

Premenopausal plasma 25-hydroxyvitamin D, mammographic density, and risk of breast cancer

Epidemiologic evidence for an association between plasma 25-hydroxyvitamin D [25(OH)D] and breast cancer is inconsistent. Data are especially limited for premenopausal women and for associations with mammographic density. To test the hypothesis that plasma concentration of 25(OH)D is associated with mammographic density, we conducted a cross-sectional study among 835 premenopausal women in the Nurses' Health Studies. We measured 25(OH)D in blood samples and used multivariable linear regression to quantify the association of average percent density by quartile of plasma 25(OH)D. In a nested case-control analysis including 493 breast cancer cases, we evaluated risk of breast cancer associated with vitamin D status within tertiles of mammographic density. Women in the top quartile of plasma 25(OH)D levels had an average percent breast density 5.2 percentage points higher than women in the bottom quartile (95 % confidence interval: 1.8, 8.7; P trend <0.01), after adjusting for predictors of 25(OH)D and established breast cancer risk factors. Plasma 25(OH)D concentration was significantly inversely associated with breast cancer risk among women with high mammographic density (P trend < 0.01) but not among women in lower tertiles of mammographic density (P-interaction < 0.01). These results do not support the hypothesis that vitamin D is inversely associated with percent mammographic density in premenopausal women. There was evidence that the association between premenopausal 25(OH)D and breast cancer risk varies by mammographic density, with an inverse association apparent only among women with high mammographic density.

Mammographic density and serum 25-hydroxyvitamin D levels

Background

Vitamin D, which influences cellular proliferation and breast tissue characteristics, has been inversely correlated with breast cancer risk. Dietary vitamin D intake has been associated with lower mammographic density (MD), a strong intermediate marker of breast cancer risk.

Findings

We examined the relationship between MD and serum 25-hydroxyvitamin D [25(OH)D], an integrated measure of vitamin D status from dietary sources and sunlight exposure, in a multi-ethnic cohort of women undergoing screening mammography. We recruited women age 40–60 years without a history of breast cancer at the time of their routine screening mammogram, and conducted in-person interviews and collected blood specimens. We enrolled 195 women from 2007–2008, 120 gave blood, and 114 were evaluable, including 25% white, 41% African American, 18% African Caribbean, and 16% Hispanic. We digitized mammograms and calculated percent density, dense area, and non-dense area on cranial-caudal images. We measured serum 25(OH)D in batched, archived specimens. Median serum 25(OH)D was 22 ng/ml (range, 8–66 ng/ml). In univariable analysis, higher serum 25(OH)D was associated with white race, higher educational level, ever breast feeding, and blood draw during the summer. After adjusting for body mass index and other confounders, we found no association between serum 25(OH)D and different measures of MD. However, when stratified by season, 25(OH)D was inversely associated with dense area during July-December (p = 0.034).

Conclusions

Overall, our findings suggest that circulating vitamin D, a potentially modifiable breast cancer risk factor, is not associated with MD; the seasonal effects we observed need to be replicated in larger cohorts.

Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials

OBJECTIVE

To evaluate the breadth, validity, and presence of biases of the associations of vitamin D with diverse outcomes.

DESIGN

Umbrella review of the evidence across systematic reviews and meta-analyses of observational studies of plasma 25-hydroxyvitamin D or 1,25-dihydroxyvitamin D concentrations and randomised controlled trials of vitamin D supplementation.

DATA SOURCES

Medline, Embase, and screening of citations and references.

ELIGIBILITY CRITERIA

Three types of studies were eligible for the umbrella review: systematic reviews and meta-analyses that examined observational associations between circulating vitamin D concentrations and any clinical outcome; and meta-analyses of randomised controlled trials assessing supplementation with vitamin D or active compounds (both established and newer compounds of vitamin D).

RESULTS

107 systematic literature reviews and 74 meta-analyses of observational studies of plasma vitamin D concentrations and 87 meta-analyses of randomised controlled trials of vitamin D supplementation were identified. The relation between vitamin D and 137 outcomes has been explored, covering a wide range of skeletal, malignant, cardiovascular, autoimmune, infectious, metabolic, and other diseases. Ten outcomes were examined by both meta-analyses of observational studies and meta-analyses of randomised controlled trials, but the direction of the effect and level of statistical significance was concordant only for birth weight (maternal vitamin D status or supplementation). On the basis of the available evidence, an association between vitamin D concentrations and birth weight, dental caries in children, maternal vitamin D concentrations at term, and parathyroid hormone concentrations in patients with chronic kidney disease requiring dialysis is probable, but further studies and better designed trials are needed to draw firmer conclusions. In contrast to previous reports, evidence does not support the argument that vitamin D only supplementation increases bone mineral density or reduces the risk of fractures or falls in older people.

CONCLUSIONS

Despite a few hundred systematic reviews and meta-analyses, highly convincing evidence of a clear role of vitamin D does not exist for any outcome, but associations with a selection of outcomes are probable.

Vitamin d: are we ready to supplement for breast cancer prevention and treatment?

Vitamin D deficiency is a potentially modifiable risk factor that may be targeted for breast cancer prevention and treatment. Preclinical studies support various antitumor effects of vitamin D in breast cancer. Numerous observational studies have reported an inverse association between vitamin D status, including circulating 25-hydroxyvitamin D (25(OH)D) levels, and breast cancer risk. The relationship between vitamin D and mammographic density, a strong predictor of breast cancer risk, remains unclear. Studies analyzing the link between genetic polymorphisms in vitamin D pathway genes and breast cancer incidence and prognosis have yielded inconsistent results. Vitamin D deficiency among breast cancer patients has been associated with poorer clinical outcomes and increased mortality. Despite a number of clinical trials of vitamin D supplementation, the efficacy, optimal dosage of vitamin D, and target blood level of 25(OH)D for breast cancer prevention have yet to be determined. Even with substantial literature on vitamin D and breast cancer, future studies need to focus on gaining a better understanding of the biologic effects of vitamin D in breast tissue. Despite compelling data from experimental and observational studies, there is still insufficient data from clinical trials to make recommendations for vitamin D supplementation for breast cancer prevention or treatment.