Recent trends in U.S. breast cancer incidence, survival, and mortality rates

Power and Sample Size Calculations for the Restricted Mean Time Analysis of Prioritized Composite Endpoints

As a new way of reporting treatment effect, the restricted mean time in favor (RMT-IF) of treatment measures the net average time the treated have had a less serious outcome than the untreated over a specified time window. With multiple outcomes of differing severity, this offers a more interpretable and data-efficient alternative to the prototypical restricted mean (event-free) survival time. To facilitate its adoption in actual trials, we develop simple approaches to power and sample size calculations and implement them in user-friendly R programs. In doing so we model the bivariate outcomes of death and a nonfatal event using a Gumbel-Hougaard copula with component-wise proportional hazards structures, under which the RMT-IF estimand is derived in closed form. In a standard set-up for censoring, the variance of the nonparametric effect-size estimator is simplified and computed via a hybrid of numerical and Monte Carlo integrations, allowing us to compute the power and sample size as functions of component-wise hazard ratios. Simulation studies show that these formulas provide accurate approximations in realistic settings. To illustrate our methods, we consider designing a new trial to evaluate treatment effect on the composite outcomes of death and cancer relapse in lymph node-positive breast cancer patients, with baseline parameters calculated from a previous study.

Campania and cancer mortality: An inseparable pair? The role of environmental quality and socio-economic deprivation

The region of Campania in Southern Italy features high levels of socio-economic deprivation and low levels of environmental quality. A vast strand of the scientific literature has tried to verify whether poor environmental quality and widespread socio-economic deprivation might explain the high cancer mortality rates (CMRs) observed, especially in the municipalities - infamously labelled as the 'Land of Fires' - that were hit most severely by the crisis. While some studies managed to identify links between these two confounding factors and cancer mortality, the evidence is overall mixed. Interesting information may be drawn from the observation of municipal data: in spite of previous claims, some municipalities featuring high environmental quality and low socio-economic deprivation also display high CMRs, while other Campanian municipalities facing disastrous environmental and socio-economic conditions are characterised by low CMRs. These figures, in contrast to common sentiment and previous studies, need to be investigated thoroughly in order to assess the exact role of the confounding factors. In this work, we aim to identify the municipalities where confounding factors act as driving forces in the determination of high CMRs through an original multi-step analysis based on frequentist and Bayesian analysis. Pinpointing these municipalities could allow policymakers to design targeted and effective policy measures aimed at reducing cancer mortality.

Impact of Birth Cohorts in Breast Cancer Risk Among South Korean Women

BACKGROUND

The incidence of breast cancer among South Korean women, a historically low-risk population, has increased over the past 3 decades, with marked changes in socioeconomic environment by birth cohort.

OBJECTIVES

We investigated associations between breast cancer risk and reproductive factors as well as the impact of birth cohort in those associations.

METHOD

This was a cross-sectional study of data from the Korea National Health and Nutrition Examination Survey for 2013-2016. Data from 10 012 parous women 30 years or older were analyzed using descriptive statistics and Cox multivariate regression after adjusting for socioeconomic status, educational level, occupation, and birth cohort.

RESULTS

Of the reproductive factors considered-age at menarche, number of pregnancies, age at first birth, age at last birth, breastfeeding duration, and use of oral contraceptives-only age at menarche was associated with breast cancer risk. Higher educational level, not having an occupation, and younger birth cohort were also associated with increased risk of breast cancer, with birth cohort the strongest of these impact factors.

CONCLUSION

Whereas the relationship between reproductive factors and breast cancer risk was relatively weak, birth cohort was the most important risk factor for breast cancer.

IMPLICATIONS FOR PRACTICE

The results provide a basis and a rationale for developing birth cohort-based clinical guidelines for breast cancer prevention and early detection, treatment, and survivorship. These findings should also be useful to researchers in other countries experiencing rapid changes in breast cancer incidence.

Adherence to endocrine therapy and its relation to disease-free survival among breast cancer patients visiting an out-patient clinic at Khartoum Oncology Hospital, Sudan

RATIONALE

Adherence to endocrine therapy provides substantial reduction in breast cancer (BC) relapses and improve survival. Hence, non-adherence remains an under reported issue mainly in developing countries.

AIMS AND OBJECTIVES

The aim of this study is to evaluate the adherence to endocrine therapy (tamoxifen [TAM] and aromatase inhibitors [AIs]) among BC patients visiting an out-patient clinic (2015-2016) in Khartoum Oncology Hospital, Sudan.

METHODS

Adherence was assessed using pills count and self-reporting methods. A total of 172 patients were interviewed. Also, records were reviewed for demographic and other cancer characteristics.

RESULTS

The patients' mean age at diagnosis was 53 years, with the highest frequency at (41-60) years. Invasive ductal carcinoma 69.2% formed the main pathological diagnosis. T2 tumour size (51.2%) and lymph node involvement (N1) (31.4%) were most evident. Also, the majority of patients were stage III (45.9%) and grade II (48%). The studied women were postmenopausal (49.4%) and premenopausal (47.7%). Regarding hormonal receptors, about 68% were oestrogen (ER)+/progesterone (PR)+ and 23.3% were ER+/PR-. Studying adherence, almost (93%) of the studied group were ≥80% adherent to TAM and AIs. The hormonal therapy persistence mean was 27.2 ± 22.5 months (40-96). While adherence percentage mean was 93.7 ± 13.6% (0%-100%). Also disease-free survival (DFS) mean was 36.3 ± 32.7 months (4-312). Adherence to hormonal therapy and persistence were significantly correlated (P < .000). Also, statistically significant association was found between hormonal therapy adherence (≥80%) and patient poor to average economic status (P = .006), and the marital status "married" (P = .008).

CONCLUSIONS

A high rate of adherence (93%) to endocrine therapy was estimated in the present study. Also, a positive association was found between the hormonal therapy persistence, and the DFS year's groups (P = .000), and the hormonal therapy types (P = .000). Adherence to hormonal therapy and persistence were significantly correlated (P < .000).

Quality-of-life effects of screening mammography in Norway

Mammography screening may save women from dying of breast cancer, although it has not been shown to reduce all-cause mortality. Screening also leads to overdiagnosis and many false positive mammograms aggravating women's quality-of-life. Quality adjusted life years (QALY) analyses of mammography screening have so far, calculated life years gained assuming that all prevented breast cancer deaths translate into a reduction in all-cause mortality. We calculated net QALYs in two hypothesized cohorts of 100,000 Norwegian women; one screened biennially from age 50 to 69 years and one not screened. We followed both cohorts to age 85 years. We used EQ-5D and an alternative equity weighted QALY instrument to estimate utility losses. In the screening cohort, we assumed 20% false positive tests during screening, different levels of overdiagnosis (20-75%) and different levels of breast cancer mortality reduction (10-30%). We assumed that reductions in breast cancer mortality only to a limited extent (20, 50 or 80%), resulted in reductions in all-cause mortality. We calculated both undiscounted and discounted (4%) QALYs. Assuming that 50% of the reduction in breast cancer mortality translated to a reduction in all-cause mortality and using estimated levels of benefits and harms in modern screening programs (50-75% overdiagnosis and 10% reduction in breast cancer mortality), undiscounted equity weighted QALY loss varied from 437 to 875 per 100,000 women. Using the levels of benefit and harms as reported in 30-40 years old randomized trials (30% overdiagnosis and 15% reduction in breast cancer mortality), undiscounted equity weighted QALY gain was 535 per 100,000. Net QALY in modern mammography screening in Norway is negative. Results could also be representative for Sweden, Denmark, UK and the US.

Label-Free Surface-Enhanced Raman Spectroscopy Biosensor for On-Site Breast Cancer Detection Using Human Tears

Surface-enhanced Raman scattering (SERS) is an ultrasensitive molecular screening technique with greatly enhanced Raman scattering signals from trace amounts of analytes near plasmonic nanostructures. However, research on the development of a sensor that balances signal enhancement, reproducibility, and uniformity has not yet been proposed for practical applications. In this study, we demonstrate the potential of the practical application for detecting or predicting asymptomatic breast cancer from human tears using a portable Raman spectrometer with an identification algorithm based on multivariate statistics. This potentiality was realized through the fabrication of a plasmonic SERS substrate equipped with a well-aligned, gold-decorated, hexagonal-close-packed polystyrene (Au/HCP-PS) nanosphere monolayer that provided femtomole-scale detection, giga-scale enhancement, and <5% relative standard deviation for reliability and reproducibility, regardless of the measuring site. Our results can provide a first step toward developing a noninvasive, real-time screening technology for detecting asymptomatic tumors and preventing tumor recurrence.

Prospective Decision Analysis Study of Clinical Genomic Testing in Metastatic Breast Cancer: Impact on Outcomes and Patient Perceptions

PURPOSE

To evaluate the impact of targeted DNA sequencing on selection of cancer therapy for patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

In this prospective, single-center, single-arm trial, patients with MBC were enrolled within 10 weeks of starting a new therapy. At enrollment, tumor samples underwent next-generation sequencing for any of 315 cancer-related genes to high depth (> 500×) using FoundationOne CDx. Sequencing results were released to providers at the time of disease progression, and physician treatment recommendations were assessed via questionnaire. We evaluated three prespecified questions to assess patients' perceptions of genomic testing.

RESULTS

In all, 100 patients underwent genomic testing, with a median of five mutations (range, 0 to 13 mutations) detected per patient. Genomic testing revealed one or more potential therapies in 98% of patients (98 of 100), and 60% of patients (60 of 100) had one or more recommended treatments with level I/II evidence for actionability. Among the 94 genomic text reports that were released, there was physician questionnaire data for 87 patients (response rate, 92.6%) and 31.0% of patients (27 of 87) had treatment change recommended by their physician. Of these, 37.0% (10 of 27) received the treatment supported by genomic testing. We did not detect a statistically significant difference in time-to-treatment failure (log-rank P = .87) or overall survival (P = .71) among patients who had treatment change supported by genomic testing versus those who had no treatment change. For patients who completed surveys before and after genomic testing, there was a significant decrease in confidence of treatment success, specifically among patients who did not have treatment change supported by genomic testing (McNemar's test of agreement P = .001).

CONCLUSION

In this prospective study, genomic profiling of tumors in patients with MBC frequently identified potential treatments and resulted in treatment change in a minority of patients. Patients whose therapy was not changed on the basis of genomic testing seemed to have a decrease in confidence of treatment success.

Partitioning of time trends in prevalence and mortality of lung cancer

BACKGROUND

Time trends of lung cancer prevalence and mortality are the result of three competing processes: changes in the incidence rate, stage-specific survival, and ascertainment at early stages. Improvements in these measures act concordantly to improve disease-related mortality, but push the prevalence rate in opposite directions making a qualitative interpretation difficult. The goal of this paper is to evaluate the relative contributions of these components to changes in lung cancer prevalence and mortality.

METHODS

Partitioning of prevalence and mortality trends into their components using SEER data for 1973-2013.

RESULTS

The prevalence of lung cancer increases for females and decreases for males. In 1998, the former was due to increased incidence (45%-50% of total trend), improved survival (40%-45%), and increased ascertainment at early stages (10%-15%). In males, a rapidly declining incidence rate overpowered the effects of survival and ascertainment resulting in an overall decrease in prevalence over time. Trends in lung cancer mortality are determined by incidence during 1993-2002 with noticeable contribution of survival after 2002.

CONCLUSION

Lung cancer incidence was the main driving force behind trends in prevalence and mortality. Improved survival played essential role from 2000 onwards. Trends in stage ascertainment played a small but adverse role. Our results suggest that further improvement in lung cancer mortality can be achieved through advances in early stage ascertainment, especially for males, and that in spite of success in treatment, adenocarcinoma continues to exhibit adverse trends (especially in female incidence) and its role among other histology-specific lung cancers will increase in the near future.

Prognostic impact of AnxA1 and AnxA2 gene expression in triple-negative breast cancer

Objective

Previous studies have shown Annexin A1 (AnxA1) and Annexin A2 (AnxA2) association with the aggressive behavior of Triple Negative Breast Cancer (TNBC). Our aim was to determine the correlation of AnxA1 and AnxA2 with poor prognosis of TNBC patients.

Methods

We analyzed the gene expression of the human annexin family from microarray datasets and correlated with clinical outcomes to determine their ability to predict prognosis.

Results

Within a mean follow-up time of 57.2 months in our TNBC cohort, high AnxA1 expression was an independent indicator of poor overall survival (OS) [hazard ratio (HR), 2.14; 95% confidence interval (CI), 1.22-3.78] and relapse-free survival (RFS) prognosis [HR, 1.66; 95% CI, 1.28-2.17]. Additionally, high AnxA2 expression was an independent indicator of poor OS [HR, 2.66; 95% CI, 1.14-6.25], RFS [HR, 1.45; 95% CI, 1.12-1.89], RFS [HR, 1.45; 95% CI, 1.12-1.89), and distant metastasis free survival (DMFS) prognosis [HR, 1.5; 95% CI, 1.16-1.95]. Analyses of TNBC patients with both high AnxA1 and AnxA2, demonstrates a significant decrease in OS (P=0.0017) and RFS (P=0.0002) when compared to the expression of genes independently. Furthermore, AnxA1 prognostic impact relies on high AnxA2 expression and both are preferential for TNBC when compared to other breast cancer subtypes.

Conclusion

Together these findings indicate that AnxA1 and AnxA2 are preferential dual prognostic predictors among TNBC patients.

Measuring Light at Night and Melatonin Levels in Shift Workers: A Review of the Literature

Shift work, especially that involving rotating and night shifts, is associated with an increased risk of diseases, including cancer. Attempts to explain the association between shift work and cancer in particular have focused on the processes of melatonin production and suppression. One hypothesis postulates that exposure to light at night (LAN) suppresses melatonin, whose production is known to slow the development of cancerous cells, while another proposes that circadian disruption associated with shift work, and not just LAN, increases health risks. This review focuses on six studies that employed quantitative measurement of LAN and melatonin levels to assess cancer risks in shift workers. These studies were identified via searching the PubMed database for peer-reviewed, English-language articles examining the links between shift work, LAN, and disease using the terms light at night, circadian disruption, health, risk, cancer, shift work, or rotating shift. While the results indicate a growing consensus on the relationship between disease risks (particularly cancer) and circadian disruption associated with shift work, the establishment of a direct link between LAN and disease has been impeded by contradictory studies and a lack of consistent, quantitative methods for measuring LAN in the research to date. Better protocols for assessing personal LAN exposure are required, particularly those employing calibrated devices that measure and sample exposure to workplace light conditions, to accurately assess LAN's effects on the circadian system and disease. Other methodologies, such as measuring circadian disruption and melatonin levels in the field, may also help to resolve discrepancies in the findings.

Serum antioxidant capacity, biochemical profile and body composition of breast cancer survivors in a randomized Mediterranean dietary intervention study

PURPOSE

Increasing evidence suggests that Mediterranean Diet (MD) is correlated with reduced risk of breast cancer (BC) and cancer mortality, since it modifies patients' serum antioxidant capacity, body composition and biochemical parameters. The aim of the study was to investigate whether a dietary intervention based on MD has a beneficial effect on these factors.

METHODS

In this intervention study, seventy female BC survivors were randomly assigned to (1) the intervention group (personalized dietary intervention based on MD) and (2) the control group (received the updated American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention and ad libitum diet). Both groups were assessed twice [beginning, end of study (after 6 months)] regarding their anthropometric and biochemical parameters, serum vitamin C, vitamin A, a-tocopherol and CoQ10 levels, dietary intake and adherence to MD. An additional intermediate analysis was conducted on participants' body composition and biochemical profile.

RESULTS

Concerning the intervention group, body weight, body fat mass, waist circumference, body mass index as well as HDL-cholesterol were significantly decreased (P < 0.2%). An increase was observed in the vitamin C levels in blood (P < 0.2%). In the control group, body weight, body fat mass and serum total cholesterol rose (P < 0.2%). At the end of the study the two groups were significantly different considering blood glucose, vitamin C, polyunsaturated fatty acids, vitamin A and a-tocopherol levels.

CONCLUSIONS

This randomized dietary intervention based on MD managed to ameliorate serum antioxidant capacity, body composition, adherence to MD and glycemic profile of postmenopausal BC survivors.

Barriers to early presentation and diagnosis of breast cancer among African women living in sub-Saharan Africa

Background

Breast cancer (BC) has been described as the leading cause of cancer deaths among women especially in the developing world including sub Saharan Africa (SSA). Delayed presentation and late diagnosis at health facilities are parts of the contributing factors of high BC mortality in Africa. This review aimed to appraise the contributing factors to delayed breast cancer presentation and diagnosis among SSA women.

Methods

Five databases encompassing medical and social sciences were systematically searched using predefined search terms linked with breast cancer presentation and diagnosis and sub Saharan Africa. Reference lists of relevant papers were also hand searched. Quality of quantitative and qualitative articles were assessed using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Critical Appraisal Skills Programme (CASP) quality appraisal checklist. Thematic analysis was used to synthesize the qualitative studies to integrate findings.

Results

Fourteen (14) quantitative studies, two (2) qualitative studies and one (1) mixed method study merited inclusion for analysis. This review identified low knowledge of breast cancer among SSA women. This review also found lack of awareness of early detection treatment, poor perception of BC, socio-cultural factors such as belief, traditions and fear as factors impacting African women’s health seeking behavior in relation to breast cancer.

Conclusion

Improving African women’s knowledge and understanding will improve behaviors related to breast cancer and facilitate early presentation and detection and enhance proper management and treatment of breast cancer.

The Evaluation of p53 Polymorphism at Codon 72 and Association With Breast Cancer in Iran: A Systematic Review and Meta-analysis

Background

Breast cancer is the most common cancer among women in Iran and the world. Multiple environmental factors and genetic variations such as genetic polymorphisms are of its main causes. p53 gene plays an important role in conserving and sustaining the genome as a tumor suppressing gene. Change and polymorphism at codon 72 of p53 gene are correlated with increased risk of lung, mouth, endometrial, prostate, and colorectal cancers, and could be considered an indicator of susceptibility to breast cancer.

Methods

Twelve studies (1,190 cases and 1,145 control studies with evaluation of three types of Arg/Arg, Arg/Pro, and Pro/Pro genotypes) have been conducted using keywords, such as polymorphism at codon 72, gene p53 polymorphisms, and the relation between polymorphisms and breast cancer, from databases in Iran, including Magiran, Medlibe, Sid, and Iranmedex, as well as Latin databases such as PubMed, Google Scholar, Science Direct, and Scopus.

Results

The OR for Arg/Arg is 1.58 (95% CI: 2.45 to 1.01), the OR for Arg/Pro is 0.75 (95% CI: 1.10 to 0.51), and the OR for Pro/Pro is 0.62 (95% CI: 0.93 to 0.42). p53 gene polymorphism at codon 72 is statistically significant in Arg/Arg and Pro/Pro genotypes.

Conclusions

Arg/Arg genotype can be considered as a risk factor for breast cancer, and Pro/Pro genotype can be accounted for as a protective factor against breast cancer.

The Urtica dioica extract enhances sensitivity of paclitaxel drug to MDA-MB-468 breast cancer cells

INTRODUCTION

Due to the chemo resistant nature of cancer cells and adverse effects of current therapies, researchers are looking for the most efficient therapeutic approach which has the lowest side effects and the highest toxicity on cancer cells. The aim of the present study was to investigate the synergic effect of Urtica dioica extract in combination with paclitaxel on cell death and invasion of human breast cancer MDA-MB-468 cell line.

MATERIALS AND METHODS

To determine the cytotoxic effects of Urtica dioica extract with paclitaxel, MTT assay was performed. The scratch test was exploited to assess the effects of Urtica dioica, Paclitaxel alone and combination on migration of cancer cells. The expression levels of snail-1, ZEB1, ZEB2, twist, Cdc2, cyclin B1 and Wee1 genes were quantified using qRT-PCR and western blot performed for snail-1expression. The effects of plant extract, Paclitaxel alone and combination on different phases of cell cycle was analyzed using flow cytometry.

RESULTS

Results of MTT assay showed that Urtica dioica significantly destroyed cancer cells. Interestingly, Concurrent use of Urtica dioica extract with paclitaxel resulted in decreased IC50 dose of paclitaxel. Moreover, findings of scratch assay exhibited the inhibitory effects of Urtica dioica, Paclitaxel alone and combination on migration of MDA-MB-468 cell line. Our findings also demonstrated that the extract substantially decreased the Snail-1 and related gene expression. Ultimately, Cell cycle arrest occurred at G2/M phase post-treatment by deregulating Cdc2 and wee1.

CONCLUSIONS

Our results demonstrated that the dichloromethane extract of Urtica dioica inhibit cell growth and migration. Also, Urtica dioica extract substantially increased sensitivity of breast cancer cells to paclitaxel. Therefore, it can be used as a potential candidate for treatment of breast cancer with paclitaxel.

Risk of breast cancer associated with hormone replacement therapy

Purpose. The primary objective of this paper is to provide a brief overview of the risk of breast cancer associated with hormone replacement therapy (HRT) in healthy postmenopausal women, in breast cancer survivors, and in women at increased risk for breast cancer.

Data Sources. The literature was reviewed through a MEDLINE search covering the years 1988 to 1999. Relevant articles cited in the literature obtained by MEDLINE searching were also considered. The following terms were searched: estrogen, progesterone, breast cancer, and HRT. The search was restricted to the English language.

Data Extraction. The current literature is reviewed with regard to the risk of breast cancer associated with HRT in healthy postmenopausal women, in breast cancer survivors, and in women at increased risk for breast cancer.

Data Synthesis. HRT is used commonly in post-menopausal women to alleviate both climacteric menopausal symptoms such as hot flashes and urogenital atrophy and to reduce the degree and frequency of osteoporosis. However, exposure to estrogen is one of the most important risk factors for breast cancer, and HRT is a relative contraindication in women with a personal history of breast cancer. The majority of epidemiological literature indicates that healthy women taking short-term HRT are not at increased risk of developing breast cancer. In breast cancer survivors, HRT does not appear to increase the risk of relapse. Some epidemiological studies show that women with a family history of breast cancer are at a substantially increased risk of developing breast cancer when receiving HRT. The decision to use HRT should be made individually by each woman and her health care provider by weighing the expected benefits and potential risks of therapy.

Mammography Screening for Older Minority Women

This project facilitated access to mammography screening for older ethnic minority women through health education and coordination of service networks for aging and health care services. Health education sessions were held in senior centers, followed by a mammography screening in a mammography van or at a health care facility. Of the participants in the education sessions, 38% received a mammogram. More women who did not obtain a mammogram believed that cancer treatments were worse than the disease. Also, more African American and White women than Hispanic women did not recognize age as a risk factor for cancer Of the Hispanic women, 30% believed that early diagnosis did not make a difference in one's outcome, compared with 20% of White women and 8% of African American women.

Alcohol Use and Breast Cancer: A Critical Review

The objective of this study was to outline the biological pathways of alcohol-attributable breast cancer, the epidemiological risk relationship between alcohol consumption and breast cancer, and the global burden of breast cancer incidence and mortality attributable to alcohol consumption, with a focus on light drinking. First, the literature regarding the biological mechanisms of how alcohol affects the risk of breast cancer was reviewed and summarized. Second, a search of meta-analyses that evaluated the risk relationship between alcohol consumption and breast cancer was conducted. Last, the burden of alcohol-attributable breast cancer incidence and mortality was estimated by means of a Population-Attributable Fraction methodology. Data on alcohol consumption were obtained from the Global Information System on Alcohol and Health, and data on cancer incidence and mortality were obtained from the GLOBOCAN database. Alcohol consumption affects breast cancer risk through the alteration in hormone levels and the associated biological pathways, the metabolism of ethanol resulting in carcinogens, and the inhibition of the one carbon metabolism pathway. The systematic review found 15 meta-analyses on the risk relationship between alcohol consumption (also light consumption) and the risk of breast cancer. All but 2 of these analyses showed a dose-response relationship between alcohol consumption and the risk of breast cancer. An estimated 144,000 (95% confidence interval [CI]: 88,000 to 200,000) breast cancer cases and 38,000 (95% CI: 2,400 to 53,000) breast cancer deaths globally in 2012 were attributable to alcohol, with 18.8% of these cases and 17.5% of these deaths affecting women who were light alcohol consumers. All levels of evidence showed a risk relationship between alcohol consumption and the risk of breast cancer, even at low levels of consumption. Due to this strong relationship, and to the amount of alcohol consumed globally, the incidence of and mortality from alcohol-attributable breast cancer is large.

Providing Supportive Care for Young Breast Cancer Patients: Exploring the Comfort Level and Educational Needs of the Interprofessional Health Care Team at a Comprehensive Cancer Centre

INTRODUCTION

Younger patients diagnosed with breast cancer have unique issues compared with their older counterparts, including premature menopause, body image, and fertility/relationship concerns. However, breast cancer information tends to focus on older patients. The interprofessional team at a large hospital was surveyed to assess comfort level and knowledge of supportive care for the younger population.

METHODS

A one-time, cross-sectional survey was distributed to oncologists, nurses, radiation therapists, and other supportive care professionals. The survey included multiple-choice, Likert scale, and open-ended questions asking participants to assess their knowledge and comfort level around the issues faced by younger breast cancer patients. Demographic information was collected, and results were analyzed using descriptive statistics.

RESULTS

In total, 67 questionnaires were returned (22% response rate); 92% of respondents felt comfortable providing care to young breast cancer patients, whereas 72% were confident in their ability to provide support for their psychosocial needs. However, most participants rated their knowledge of issues specific to these patients higher than their comfort level. Disparity between the professions occurred, with oncologists and nurses reporting a higher comfort level than other professions.

CONCLUSIONS

Although most professionals felt they had good knowledge of the issues faced by young breast cancer patients, many felt less confident addressing these issues with their patients. This informational needs gap presents an opportunity for the emergence of champions to heighten awareness and educate colleagues in the supportive care of this patient population.

An open letter to panels that are deciding guidelines for breast cancer screening

Panels are presently reviewing breast cancer screening guidelines. It is critical that they understand which publications are scientifically valid, and which analyses are methodologically flawed and not valid. The scientific evidence clearly supports annual mammography screening beginning at the age of 40. The analyses that suggest that screening leads to overdiagnosis of invasive breast cancers are flawed and incorrect. There is little if any overdiagnosis of these cancers. The vast majority of breast cancers occur in women who are not at elevated risk so that excluding them from screening and only screening high risk women will deny the benefits of early detection to most women who develop breast cancer. Guidelines panels should not make decisions that exclude women from screening. Women should be provided with accurate information so that they can make informed decisions and have unimpeded access to screening if that is their preference.

Racial differences in breast cancer, cardiovascular disease, and all-cause mortality among women with ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast represents 15-20% of new breast cancer diagnoses in the US annually. However, long-term competing risks of mortality, as well as racial differences in outcomes among US women with DCIS, are unknown. Case data from the years 1978-2010 were obtained using SEER*Stat software available through the National Cancer Institute from the 2010 SEER registries. Included were all women aged 40 and over with newly diagnosed DCIS. There were 67,514 women in the analysis, including 54,518 white women and 6,113 black women. A total of 12,173 deaths were observed over 607,287 person-years of follow-up. The 20-year cumulative incidence of all-cause death among women with DCIS was 39.6% (CI 38.9-40.3). The corresponding 20-year rates for breast cancer death and CVD death were 3.2% (CI 3.0-3.4) and 13.2% (CI 12.8-13.7), respectively. Black women with DCIS had a higher risk of death compared to white women, with these hazard ratios elevated throughout the entire study period. For example, between 1990 and 2010, black women had a higher risk of all-cause death (HR 3.06, CI 2.39-3.91), breast cancer death (HR 5.78, CI 3.16-10.57), and CVD death (HR 6.43, CI 3.61-11.45) compared to white women diagnosed between 50 and 59 years of age. The risk of all-cause and CVD death was greater than breast cancer death among women diagnosed with DCIS over 20 years. Black women had higher risks of dying from all-causes compared to white women. These differences persisted into the modern treatment era.

Important Factors Affecting Adjuvant Treatment Decision in Stage IA Breast Cancer Patients in Turkey

INTRODUCTION

In Turkey, the gene expression profile test is not standard, so adjuvant treatment is planned according to clinicopathological factors. Therefore, we retrospectively analyzed important parameters that affect the decision on adjuvant chemotherapy, and also factors related to survival in stage IA breast cancer patients in Turkey.

METHODS

We retrospectively evaluated 347 stage IA patients. The relationship between the clinicopathological parameters and adjuvant chemotherapy was analyzed.

RESULTS

The median age and follow-up time were 52 years (range: 25-86) and 22.6 months (range: 1-113), respectively. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 87.9% and 98.7%, respectively, but the median DFS was not reached. Age, estrogen receptor (ER) status, human epidermal growth factor receptor 2 (HER2) status, and the presence of triple-negative breast tumor (TNBC) were related to DFS, and lymphovascular invasion (LVI), perineural invasion (PNI), HER2 status, the presence of TNBC, and recurrence were related to OS (p > 0.05). Furthermore, age, menopausal status, multicentricity, grade, tumor size, necrosis, ER, the presence of TNBC, and HER2 were found to be related to adjuvant therapy decision (p > 0.05). All these parameters, in addition to LVI and PNI, were independent factors for chemotherapy by logistic regression analysis.

CONCLUSIONS

In decisions about adjuvant therapy in stage IA breast cancer patients, clinicopathological factors should be kept in mind.

Breast cancer incidence and mortality in women under 50 years of age in Brazil

Many countries have reported an increase in breast cancer incidence in young women. The current study's objective was to explore breast cancer distribution in women less than 50 years of age in Brazil. A descriptive study on breast cancer incidence (selected cities) and mortality (Brazil and selected cities) in 2002-2004 was carried out, and the results were compared with those from other countries. The study also analyzed the trend in hospital morbidity and incidence rates for breast cancer. Porto Alegre (Rio Grande do Sul State) showed the highest incidence rates (17.9 and 165.5/100,000 in the 15-39 and 40-49-year age strata, respectively). Regarding mortality, Belo Horizonte (Minas Gerais State) showed the highest rate in the 15-39-year group and Porto Alegre in the 40-49-year group (2.8 and 25.5/100,000). Hospital admissions and incidence rates for breast cancer suggest a change in epidemiological distribution. The results reveal an epidemiological pattern of breast cancer in young Brazilian women with regional distribution characteristics.

Gastrointestinal tract metastasis from tubulolobular carcinoma of the breast: a case report and review of the literature

Metastasis of breast cancer into the gastrointestinal tract happens rarely. The diagnosis of this kind of disease is difficult because of the nonspecific symptoms and the long interval between primary manifestations and recurrence. Awareness of this condition may lead to an accurate diagnosis and an earlier initiation of systemic treatment, thus avoiding unnecessary surgical intervention. In this paper, we report a rare case of a patient with tubulolobular carcinoma metastases to the colon, presenting with abdominal pain, discomfort, and weight loss. The patient underwent radical mastectomy and received postoperative radiotherapy and chemotherapy. Ten years later, she presented with gastrointestinal tract symptoms. Surgery combined with systemic treatment was chosen for the colon lesion. Immunohistochemical staining suggested a breast origin. The patient was still living 24 months after the diagnosis of the metastasis. This is the fourth case report in our literature review.

Adherence to adjuvant endocrine therapy in estrogen receptor-positive breast cancer patients with regular follow-up

BACKGROUND

Adjuvant hormonal therapy is crucial in the treatment of estrogen receptor-positive breast cancer. The nonadherence rate to hormonal treatment is reported to be as high as 60%. The goal of this study was to evaluate the factors evoked by the patients as well as the demographic and disease-related factors that could be associated with nonadherence to adjuvant hormonal therapy.

METHODS

All consecutive patients treated for an estrogen receptor-positive breast cancer who showed up for regular follow-up with a single breast specialist between November 2008 and April 2009 were included in the study. We assessed adherence to hormonal therapy (either with tamoxifen or aromatase inhibitor). Reasons for adherence and nonadherence were collected. Records were also reviewed for demographic and cancer characteristics and for treatment components.

RESULTS

We included 161 patients in the study; 150 (93.2%) adhered to hormonal treatment. Side effects and absence of conviction were the main reasons for nonadherence. The importance of the diagnosis of cancer, fear of recurrence and regular follow-up were reported as the main reasons for adherence.

CONCLUSION

Severity of disease and side effects are associated with nonadherence to treatment. Strict follow-up appears to be a necessary adjunct in the adherence to treatment. The association between demographic and cancer characteristics and treatment components needs further investigation. However, these factors may help identify patients at risk of nonadherence and help the oncology team.

Trends in breast cancer stage and mortality in Michigan (1992-2009) by race, socioeconomic status, and area healthcare resources

The long-term effect of socioeconomic status (SES) and healthcare resources availability (HCA) on breast cancer stage of presentation and mortality rates among patients in Michigan is unclear. Using data from the Michigan Department of Community Health (MDCH) between 1992 and 2009, we calculated annual proportions of late-stage diagnosis and age-adjusted breast cancer mortality rates by race and zip code in Michigan. SES and HCA were defined at the zip-code level. Joinpoint regression was used to compare the Average Annual Percent Change (AAPC) in the median zip-code level percent late stage diagnosis and mortality rate for blacks and whites and for each level of SES and HCA. Between 1992 and 2009, the proportion of late stage diagnosis increased among white women [AAPC = 1.0 (0.4, 1.6)], but was statistically unchanged among black women [AAPC = −0.5 (−1.9, 0.8)]. The breast cancer mortality rate declined among whites [AAPC = −1.3% (−1.8,−0.8)], but remained statistically unchanged among blacks [AAPC = −0.3% (−0.3, 1.0)]. In all SES and HCA area types, disparities in percent late stage between blacks and whites appeared to narrow over time, while the differences in breast cancer mortality rates between blacks and whites appeared to increase over time.

Pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis

We reported on a rare case of pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. A 65-year-old woman was admitted to our department complaining of progressive dysphagia to solids and liquids. Her medical history revealed a surgery for left breast tumour, which had been performed 11 years, previously, with adjuvant treatment based on hormonal therapy and radiotherapy. The presenting symptoms had started 1 year before her admission, with progressive paradoxical medio chest dysphagia. The patient had lost 7 kg in weight without prominent anorexia. The endoscopic, radiological, histological and manometric appearance was in favor pseudoachalasia associated with stenosis of the esophagus. The esophageal mucosa covering the lumen of the stricture after the dilation was smooth and neoplasm was not detected by another repeated biopsy. We could not obtain the diagnosis for the stricture. The most likely diagnosis was a pseudoachalasia associated with esophagus stenosis complicating probably radiotherapy. The patient had received four pneumatic dilatations with several normal biopsies. At the last one (4 months later), pathological examination of the biopsy specimen revealed infiltrating lobular breast carcinoma. The final diagnosis was pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. Treatment was based mainly on tamoxifen.

Identification and validation of new autoantibodies for the diagnosis of DCIS and node negative early-stage breast cancers

Evidence of circulating autoantibodies in cancer patient sera has created opportunities for exploiting them as biomarkers. We report the identification and the clinical validation of an autoantibody panel in newly diagnosed patients with early-stage breast cancer. Proteomic approach and serological screening of a discovery set of sera (n = 80) were performed to identify tumor-associated antigens (TAAs). Autoantibody levels were then measured in an independent validation set (n = 182) against a panel of five TAAs by enzyme-linked immunosorbent assay. Sixty-seven antigens that elicited a specific humoral response in breast cancer were identified and five antigens (GAL3, PAK2, PHB2, RACK1 and RUVBL1) were selected for validation. GAL3 and RACK1 showed significantly increased reactivity in early-stage breast cancer. When combined, the five markers significantly discriminated early-stage cancer from healthy individuals (AUC = 0.81; 95% CI [0.74-0.86]). Interestingly, this value was high in both node-negative early-stage primary breast cancer (AUC = 0.81; 95% CI [0.72-0.88]) and ductal carcinoma in situ (AUC = 0.85; 95% CI [0.76-0.95]) populations. This autoantibody panel could be useful as a diagnostic tool in a screening strategy of early-stage invasive breast cancer and preinvasive breast cancer. It could be particularly appropriate in complement to mammography for women with high breast density.

Multimodal optical imaging for detecting breast cancer

The goal of the study was to evaluate wide-field and high-resolution multimodal optical imaging, including polarization, reflectance, and fluorescence for the intraoperative detection of breast cancer. Lumpectomy specimens were stained with 0.05 mg/ml aqueous solution of methylene blue (MB) and imaged. Wide-field reflectance images were acquired between 390 and 750 nm. Wide-field fluorescence images were excited at 640 nm and registered between 660 and 750 nm. High resolution confocal reflectance and fluorescence images were excited at 642 nm. Confocal fluorescence images were acquired between 670 nm and 710 nm. After imaging, the specimens were processed for hematoxylin and eosin (H&E) histopathology. Histological slides were compared with wide-field and high-resolution optical images to evaluate correlation of tumor boundaries and cellular morphology, respectively. Fluorescence polarization imaging identified the location, size, and shape of the tumor in all the cases investigated. Averaged fluorescence polarization values of tumor were higher as compared to normal tissue. Statistical analysis confirmed the significance of these differences. Fluorescence confocal imaging enabled cellular-level resolution. Evaluation and statistical analysis of MB fluorescence polarization values registered from single tumor and normal cells demonstrated higher fluorescence polarization from cancer. Wide-field high-resolution fluorescence and fluorescence polarization imaging shows promise for intraoperative delineation of breast cancers.

Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women

OBJECTIVES

To describe the effect of multidisciplinary care on survival in women treated for breast cancer.

DESIGN

Retrospective, comparative, non-randomised, interventional cohort study.

SETTING

NHS hospitals, health boards in the west of Scotland, UK.

PARTICIPANTS

14,358 patients diagnosed with symptomatic invasive breast cancer between 1990 and 2000, residing in health board areas in the west of Scotland. 13,722 (95.6%) patients were eligible (excluding 16 diagnoses of inflammatory cancers and 620 diagnoses of breast cancer at death).

INTERVENTION

In 1995, multidisciplinary team working was introduced in hospitals throughout one health board area (Greater Glasgow; intervention area), but not in other health board areas in the west of Scotland (non-intervention area).

MAIN OUTCOME MEASURES

Breast cancer specific mortality and all cause mortality.

RESULTS

Before the introduction of multidisciplinary care (analysed time period January 1990 to September 1995), breast cancer mortality was 11% higher in the intervention area than in the non-intervention area (hazard ratio adjusted for year of incidence, age at diagnosis, and deprivation, 1.11; 95% confidence interval 1.00 to 1.20). After multidisciplinary care was introduced (time period October 1995 to December 2000), breast cancer mortality was 18% lower in the intervention area than in the non-intervention area (0.82, 0.74 to 0.91). All cause mortality did not differ significantly between populations in the earlier period, but was 11% lower in the intervention area than in the non-interventional area in the later period (0.89, 0.82 to 0.97). Interrupted time series analyses showed a significant improvement in breast cancer survival in the intervention area in 1996, compared with the expected survival in the same year had the pre-intervention trend continued (P=0.004). This improvement was maintained after the intervention was introduced.

CONCLUSION

Introduction of multidisciplinary care was associated with improved survival and reduced variation in survival among hospitals. Further analysis of clinical audit data for multidisciplinary care could identify which aspects of care are most associated with survival benefits.

Identifying risk factors for disparities in breast cancer mortality among African-American and Hispanic women

BACKGROUND

This study evaluated the risk factors associated with racial disparities in female breast cancer mortality for African-American and Hispanic women at the census tract level in Texas from 1995 to 2005.

METHODS

Data on female breast cancer cases were obtained from the Texas Cancer Registry. Socioeconomic and demographic data were collected from Census 2000. Network distance and driving times to mammography facilities were estimated using Geographic Information System techniques. Demographic, poverty and spatial accessibility factors were constructed using principal component analysis. Logistic regression models were developed to predict the census tracts with significant racial disparities in breast cancer mortality based on racial disparities in late-stage diagnosis and structured factors from the principal component analysis.

RESULTS

Late-stage diagnosis, poverty factors, and demographic factors were found to be significant predictors of a census tract showing significant racial disparities in breast cancer mortality. Census tracts with higher poverty status were more likely to display significant racial disparities in breast cancer mortality for both African Americans (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.95-3.04) and Hispanics (OR, 5.30; 95% CI, 4.26-6.59). Spatial accessibility was not a consistent predictor of racial disparities in breast cancer mortality for African-American and Hispanic women.

CONCLUSION

Physical access to mammography facilities does not necessarily reflect a greater utilization of mammogram screening, possibly owing to financial constraints. Therefore, a metric measuring access to health care facilities is needed to capture all aspects of access to preventive care. Despite easier physical access to mammography facilities in metropolitan areas, great resources and efforts should also be devoted to these areas where racial disparities in breast cancer mortality are often found.

Adjuvant therapy for older women with early-stage breast cancer: treatment selection in a complex population

Breast cancer is a disease of aging. However, older women with breast cancer are less likely to participate in clinical trials or to receive recommended treatment. This undertreatment has contributed to a lag in breast cancer survival outcomes for older women compared with that for their younger counterparts. The principles that govern recommendations for adjuvant treatment of breast cancer are the same for younger and older women. Systemic adjuvant treatment recommendations should be offered on the basis of tumor characteristics that divide patients into three distinct subgroups. These include (1) older women with hormone receptor (HR)-positive and human epidermal growth factor 2 (HER2)-negative breast cancer who should be offered endocrine therapy; (2) older women with HR-negative and HER2-negative breast cancer who should be offered adjuvant chemotherapy; and (3) older women with HER2-positive disease who should be offered chemotherapy with trastuzumab. Exceptions to these guidelines may be made for older women with small node-negative tumors or frail older women with limited life expectancy, where close surveillance may be a reasonable alternative. Addressing the current age-related disparities in breast cancer survival will require that older women are offered the same state-of-the-art-treatment as their younger counterparts, with a careful weighing of the risks and benefits of each treatment in the context of the individual's preferences. In addition, older women should be encouraged to participate in breast cancer clinical trials to generate additional chemotherapy efficacy, toxicity, and quality of life data.

Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis

BACKGROUND

Breast and cervical cancer are important causes of mortality in women aged ≥15 years. We undertook annual age-specific assessments of breast and cervical cancer in 187 countries.

METHODS

We systematically collected cancer registry data on mortality and incidence, vital registration, and verbal autopsy data for the period 1980-2010. We modelled the mortality-to-incidence (MI) ratio using a hierarchical model. Vital registration and verbal autopsy were supplemented with incidence multiplied by the MI ratio to yield a comprehensive database of mortality rates. We used Gaussian process regression to develop estimates of mortality with uncertainty by age, sex, country, and year. We used out-of-sample predictive validity to select the final model. Estimates of incidence with uncertainty were also generated with mortality and MI ratios.

FINDINGS

Global breast cancer incidence increased from 641,000 (95% uncertainty intervals 610,000-750,000) cases in 1980 to 1,643,000 (1,421,000-1,782,000) cases in 2010, an annual rate of increase of 3·1%. Global cervical cancer incidence increased from 378,000 (256,000-489,000) cases per year in 1980 to 454,000 (318,000-620,000) cases per year in 2010-a 0·6% annual rate of increase. Breast cancer killed 425,000 (359,000-453,000) women in 2010, of whom 68,000 (62,000-74,000) were aged 15-49 years in developing countries. Cervical cancer death rates have been decreasing but the disease still killed 200,000 (139,000-276,000) women in 2010, of whom 46,000 (33,000-64,000) were aged 15-49 years in developing countries. We recorded pronounced variation in the trend in breast cancer mortality across regions and countries.

INTERPRETATION

More policy attention is needed to strengthen established health-system responses to reduce breast and cervical cancer, especially in developing countries.

FUNDING

Susan G Komen for the Cure and the Bill & Melinda Gates Foundation.

Factors influencing loco-regional relapse in older breast cancer patients treated with tumour resection and tamoxifen

BACKGROUND

In breast cancer patients (≥70 years), tumour resection plus tamoxifen (T + T) has a higher loco-regional relapse (LR) rate than mastectomy. This study examines factors influencing local recurrence in these cases.

METHODS

Clinical records of 71 patients aged ≥70 years, randomised to the T + T arm of 2 randomised trials were reviewed. Cox Proportional Hazards model was used to determine the most significant variables.

RESULTS

After 15-years follow-up, LR relapse occurred in 29/71, of whom 5 had synchronous metastatic disease. Most tumours recurred in the index quadrant. Subsequently 21/24 patients with loco-regional recurrence only had salvage mastectomy. Three variables significantly predicted LR: lympho-vascular invasion (LVI) (HR [95% CI]: 11.18 [4.47, 27.95], p < 0.01), ER negative status (HR [95% CI]: 0.27 [0.10, 0.72] p = 0.01), and tumour necrosis (HR [95% CI]: 2.65 [1.10, 6.37], p = 0.03). Final margin status was not associated with LR.

CONCLUSIONS

Tumour resection + Tamoxifen in older patients results in long-term local control in the majority with most loco-regional failures being salvageable. Risk factors for LR are lympho-vascular invasion, ER status and tumour necrosis. Negative tumour excision margins did not significantly change local outcome in the absence of radiotherapy. In these older patients LVI significantly reduced survival time.

Age-specific incidence ratios of breast cancer (BC) in Turkey: BC in older people is increasing

Life expectancy has greatly increased in the last century. In the last decades, cancer in the older people has become an increasingly common problem owing to the prolonged life-expectancy of the general population and to the improved management of common cancers. The aim of this study was to demonstrate the age-specific incidence ratios in patients with BC. Data were collected from hospital-based registries from 1988 to 2007. A total of 10,149 patients were assessed. The median age at diagnosis was 50 years. When compared to Surveillance Epidemiology and End Results (SEER) data, these values were found to be 11 years younger than American patients. Trends consist of the median ages of patients were increased during years (p<0.001). Along the years, especially in the last years, the ratios of cancer patients of older than 70 years were significantly increased among the BC patient populations. In conclusion, BC in older person has become an increasingly common problem in the last years.

Spatial association of racial/ethnic disparities between late-stage diagnosis and mortality for female breast cancer: where to intervene?

Background

Over the past twenty years, racial/ethnic disparities between late-stage diagnoses and mortality outcomes have widened due to disproportionate medical benefits that different racial/ethnic groups have received. Few studies to date have examined the spatial relationships of racial/ethnic disparities between breast cancer late-stage diagnosis and mortality as well as the impact of socioeconomic status (SES) on these two disparities at finer geographic scales.

Methods

Three methods were implemented to assess the spatial relationship between racial/ethnic disparities of breast cancer late-stage diagnosis and morality. First, this study used rate difference measure to test for racial/ethnic disparities in both late-stage diagnosis and mortality of female breast cancer in Texas during 1995-2005. Second, we used linear and logistic regression models to determine if there was a correlation between these two racial/ethnic disparities at the census tract level. Third, a geographically-weighted regression analysis was performed to evaluate if this correlation occurred after weighting for local neighbors.

Results

The spatial association of racial disparities was found to be significant between late-stage diagnosis and breast cancer mortality with odds ratios of 33.76 (CI: 23.96-47.57) for African Americans and 30.39 (CI: 22.09-41.82) for Hispanics. After adjusting for a SES cofounder, logistic regression models revealed a reduced, although still highly significant, odds ratio of 18.39 (CI: 12.79-26.44) for African-American women and 11.64 (CI: 8.29-16.34) for Hispanic women. Results of the logistic regression analysis indicated that census tracts with low and middle SES were more likely to show significant racial disparities of breast cancer late-stage diagnosis and mortality rates. However, values of local correlation coefficients suggested that the association of these two types of racial/ethnic disparities varied across geographic regions.

Conclusions

This study may have health-policy implications that can help early detection of breast cancer among disadvantaged minority groups through implementing effective intervention programs in targeted regions.

Rhein inhibits angiogenesis and the viability of hormone-dependent and -independent cancer cells under normoxic or hypoxic conditions in vitro

Hypoxia is a hallmark of solid tumors, including breast cancer, and the extent of tumor hypoxia is associated with treatment resistance and poor prognosis. Considering the limited treatment of hypoxic tumor cells and hence a poor prognosis of breast cancer, the investigation of natural products as potential chemopreventive anti-angiogenic agents is of paramount interest. Rhein (4,5-dihydroxyanthraquinone-2-carboxylic acid), the primary anthraquinone in the roots of Cassia alata L., is a naturally occurring quinone which exhibits a variety of biologic activities including anti-cancer activity. However, the effect of rhein on endothelial or cancer cells under hypoxic conditions has never been delineated. Therefore, the aim of this study was to investigate whether rhein inhibits angiogenesis and the viability of hormone-dependent (MCF-7) or -independent (MDA-MB-435s) breast cancer cells in vitro under normoxic or hypoxic conditions. Rhein inhibited vascular endothelial growth factor (VEGF(165))-stimulated human umbilical vein endothelial cell (HUVEC) tube formation, proliferation and migration under normoxic and hypoxic conditions. In addition, rhein inhibited in vitro angiogenesis by suppressing the activation of phosphatidylinositol 3-kinase (PI3K), phosphorylated-AKT (p-AKT) and phosphorylated extracellular signal-regulated kinase (p-ERK) but showed no inhibitory effects on total AKT or ERK. Rhein dose-dependently inhibited the viability of MCF-7 and MDA-MB-435s breast cancer cells under normoxic or hypoxic conditions, and inhibited cell cycle in both cell lines. Furthermore, Western blotting demonstrated that rhein inhibited heat shock protein 90alpha (Hsp90α) activity to induce degradation of Hsp90 client proteins including nuclear factor-kappa B (NF-κB), COX-2, and HER-2. Rhein also inhibited the expression of hypoxia-inducible factor-1 alpha (HIF-1α), vascular endothelial growth factor (VEGF(165)), epidermal growth factor (EGF), and the phosphorylation of inhibitor of NF-κB (I-κB) under normoxic or hypoxic conditions. Taken together, these data indicate that rhein is a promising anti-angiogenic compound for breast cancer cell viability and growth. Therefore, further studies including in vivo and pre-clinical need to be performed.