Systemic and Local Strategies for Primary Prevention of Breast Cancer

One in eight women will develop breast cancer in the US. For women with moderate (15-20%) to average (12.5%) risk of breast cancer, there are few options available for risk reduction. For high-risk (>20%) women, such as BRCA mutation carriers, primary prevention strategies are limited to evidence-based surgical removal of breasts and/or ovaries and anti-estrogen treatment. Despite their effectiveness in risk reduction, not many high-risk individuals opt for surgical or hormonal interventions due to severe side effects and potentially life-changing outcomes as key deterrents. Thus, better communication about the benefits of existing strategies and the development of new strategies with minimal side effects are needed to offer women adequate risk-reducing interventions. We extensively review and discuss innovative investigational strategies for primary prevention. Most of these investigational strategies are at the pre-clinical stage, but some are already being evaluated in clinical trials and others are expected to lead to first-in-human clinical trials within 5 years. Likely, these strategies would be initially tested in high-risk individuals but may be applicable to lower-risk women, if shown to decrease risk at a similar rate to existing strategies, but with minimal side effects.

Breathe

This is a personal essay about breasts. It focuses on my experiences as a young girl, moving through adolescence to a history of breast cancer in my family, including my mother's breast cancer diagnosis. As a physician, patient, and wife, I reflect on the choices that I have to make and what this means for my identity as a woman and mother.

A Narrative Review of the Carcinogenic Effect of Night Shift and the Potential Protective Role of Melatonin

Since the IARC (International Agency for Research on Cancer) announcement in 2007 indicating the possibility of night-shift work carrying carcinogenesis risk, multiple studies on a global level have been conducted to investigate the correlation between night-shift work and cancer development. Circadian rhythm disruption and decreased melatonin production have been postulated as potential contributing factors. There is also growing evidence that night-shift workers tend to adopt unhealthier lifestyles which contribute to poorer health and increase the risk of developing diseases such as cancer. No experimental study has been specifically dedicated to testing specific methods that could decrease cancer risk in night-shift workers. While there are a few studies that investigate melatonin's concurrent use with chemotherapy in cancer patients, there is yet to be seen for studies that investigate melatonin specifically as a cancer prevention method. This narrative review aims to examine current evidence of healthcare night-shift work's risk in cancer incidence, potential pathogenesis, and its significance in clinical practice.

Evaluation of a Polymeric Topical Formulation of Endoxifen in an Estrogen Receptor Positive Breast Cancer Murine Model

Breast cancer (BC) has surpassed lung cancer as the most diagnosed cancer and, in terms of mortality, is the fifth leading cause with 684,996 new deaths (6.7% of all cancer-related deaths) and the highest mortality amongst all cancers (15.5%) in women. Selective estrogen-receptor modulators (SERMs) have been used for the last thirty years for estrogen receptor-positive (ER+) breast cancer prevention and treatment. Tamoxifen (TAM), the most widely used SERM, is orally administered and its long-term oral administration has been associated to toxicity and adverse side effects. Endoxifen (EDX) is one of the known active metabolites of TAM, with an affinity to ERα 100 times higher than TAM. Furthermore, EDX has shown antiproliferative activity against the ER+ breast cancer cell line MCF-7. Alternative administration routes that avoid the metabolic processing of TAM seem an appealing alternative to its oral administration. With this aim, we have prepared a polymeric gel-like solution of Pluronic® F127 as vehicle for topical administration of EDX. In order to shed light on the potential clinical use of this formulation we have compare it with the standard pharmaceutical form, i.e. orally administered TAM. The biodistribution, antitumor efficacy and toxic effects of topical EDX and oral TAM were evaluated in ER+ tumor xenograft athymic nu/nu mouse models. The results showed a statistically significant antitumor effect and reduced toxicity of topical EDX as compared to oral TAM or empty F127 gel. This novel administration route of SERMs could also have a strong impact in the prevention of BC at early development stages and could help to ameliorate the mortality and morbidity related to this disease.

Response to "Knowledge and Practice of Breast Self-Examination: A Cross-Sectional Study of Women at Selected Health Centers in Oyo State, Nigeria"

I would like to thank Faleti et al. (2023) for describing the practice patterns of breast self-examination (BSE) in Nigeria. Early identification of the symptoms of breast cancer is important in the effort to improve quality.

Promising Effects of N-Docosahexaenoyl Ethanolamine in Breast Cancer: Molecular and Cellular Insights

Unhealthy dietary habits have been identified as a risk factor for the development and progression of cancer. Therefore, adopting a healthy eating pattern is currently recommended to prevent the onset of different types of cancers, including breast carcinoma. In particular, the Mediterranean diet, based on high consumption of omega-3 polyunsaturated fatty acids (N-3 PUFAs), such as those found in cold-water fish and other seafood, nuts, and seeds, is recommended to reduce the incidence of several chronic-degenerative diseases. Indeed, the consumption of N-3 PUFAs, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), reduced the risk of different types of cancer, including breast cancer. Moreover, they can counteract breast cancer progression and reduce the side effects of chemotherapy in breast cancer survival. Studies have demonstrated that DHA, exhibiting greater antitumor activity than EPA in breast cancer, can be attributed to its direct impact on breast cancer cells and also due to its conversion into various metabolites. N-docosahexaenoyl ethanolamine, DHEA, is the most studied DHA derivative for its therapeutic potential in breast cancer. In this review, we emphasize the significance of dietary habits and the consumption of N-3 polyunsaturated fatty acids, particularly DHA, and we describe the current knowledge on the antitumoral action of DHA and its derivative DHEA in the treatment of breast cancer.

A Hybrid Algorithm of ML and XAI to Prevent Breast Cancer: A Strategy to Support Decision Making

Worldwide, the coronavirus has intensified the management problems of health services, significantly harming patients. Some of the most affected processes have been cancer patients' prevention, diagnosis, and treatment. Breast cancer is the most affected, with more than 20 million cases and at least 10 million deaths by 2020. Various studies have been carried out to support the management of this disease globally. This paper presents a decision support strategy for health teams based on machine learning (ML) tools and explainability algorithms (XAI). The main methodological contributions are: first, the evaluation of different ML algorithms that allow classifying patients with and without cancer from the available dataset; and second, an ML methodology mixed with an XAI algorithm, which makes it possible to predict the disease and interpret the variables and how they affect the health of patients. The results show that first, the XGBoost Algorithm has a better predictive capacity, with an accuracy of 0.813 for the train data and 0.81 for the test data; and second, with the SHAP algorithm, it is possible to know the relevant variables and their level of significance in the prediction, and to quantify the impact on the clinical condition of the patients, which will allow health teams to offer early and personalized alerts for each patient.

Knowledge and Practice of Breast Self-Examination: A Cross-Sectional Study of Women at Selected Health Centers in Oyo State, Nigeria

Breast cancer is the leading cause of death for women in sub-Saharan Africa. However, knowledge and practice of breast self-examination (BSE) remains low. This project examined if there is an association between BSE knowledge.

The Assessment and Comparison of the Knowledge of Breast Self-Examination and Breast Carcinoma Among Health Care Workers and the General Population in an Urban Setting

Background Breast cancer is one of the common causes of cancer related mortality in women. Early detection and treatment can combat the morbidity and mortality of breast cancer. Most first-world countries have a screening program to facilitate early detection of breast malignancy. A lack of similar programs in developing countries, compounded with ignorance and financial crunch, often leaves women vulnerable due to late detection and complications. Identification of early physical changes in breasts through regular breast self-examination (BSE) can potentially aid in the early detection of breast lumps. Ideally, all women should have access to screening programs, although, practically, it is difficult to achieve mass screening in resource-poor areas. BSE cannot completely bridge this gap in health care; however, it can undoubtedly aid in increased awareness, identification of danger signs, and timely approach to the health care center for intervention. Materials and method A cross-sectional study was conducted at Bharati Vidyapeeth Medical College, Pune, India. The participants were administered a pretested questionnaire to collect information about their understanding of BSE. The data were analyzed using the Statistical Package for Social Sciences (SPSS) statistical software, Version 25. Mean and frequencies were used to compare participants from various backgrounds. Results The total sample consisted of 1,649 women from various educational backgrounds. Every doctor had heard about BSE compared to 81% of women from the general population; 84% of doctors and less than 40% of women representing the general population were taught to perform BSE; however, only around 34% of all women perform BSE. Women from the general population were largely unaware of the correct age to begin BSE, the frequency of performance, its correlation with the menstrual cycle, and the steps necessary to perform it. Women employed in the health care industry were better informed than the general population but still needed to be aware of BSE's details. Conclusion The study highlighted the lack of information regarding breast malignancy and self-examination among women from all educational and professional backgrounds. Women in the health care sector are better informed about the topic than the general population but still lack adequate information. There is a dire need to train women about the procedure, frequency, and correct time of conducting BSE and the telltale signs of breast carcinoma. Women in the health care industry can be educated and trained as educators on the topic, who can further disseminate the information to the general population to promote early detection of breast malignancy.

Predicting breast cancer risk in a racially diverse, community-based sample of potentially high-risk women

BACKGROUND

Identifying women with high risk of breast cancer is necessary to study high-risk experiences and deliver risk-management care. Risk prediction models estimate individuals' lifetime risk but have rarely been applied in community-based settings among women not yet receiving specialized care. Therefore, we aimed: (1) to apply three breast cancer risk prediction models (i.e., Gail, Claus, and IBIS) to a racially diverse, community-based sample of women, and (2) to assess risk prediction estimates using survey data.

METHODS

An online survey was administered to women who were determined by a screening instrument to have potentially high risk for breast cancer. Risk prediction models were applied using their self-reported family and medical history information. Inclusion in the high-risk subsample required ≥20% lifetime risk per ≥1 model. Descriptive statistics were used to compare the proportions of women identified as high risk by each model.

RESULTS

N = 1053 women were initially eligible and completed the survey. All women, except one, self-reported the information necessary to run at least one model; 90% had sufficient information for >1 model. The high-risk subsample included 717 women, of which 75% were identified by one model only; 96% were identified by IBIS, 3% by Claus, <1% by Gail. In the high-risk subsample, 20% were identified by two models and 3% by all three models.

CONCLUSIONS

Assessing breast cancer risk using self-reported data in a community-based sample was feasible. Different models identify substantially different groups of women who may be at high risk for breast cancer; use of multiple models may be beneficial for research and clinical care.

Korean American Immigrant Women's Perceived Breast Cancer Risk and Prevention Beliefs: A Qualitative Study

INTRODUCTION

With the goal of informing culturally appropriate intervention strategies, the purpose of this qualitative study was to understand the Korean American immigrant women's (KAIW) perceptions of breast cancer risk and how their perceived risk, along with normative breast cancer prevention beliefs, shaped their attitudes toward mammography.

METHOD

Semi-structured individual interviews were conducted with 30 Korean women in Los Angeles County, Los Angeles, California. Braun and Clarke's thematic analysis was used to code and analyze interview data.

RESULTS

Two major themes were identified: (a) perceived risk of breast cancer and attitudes to prevention (e.g., worried and using all means of prevention) and (b) influences on attitudes to breast cancer prevention (e.g., family members and friends' cancer experiences).

DISCUSSION

Breast cancer prevention interventions for KAIW should target perceived breast cancer risk, social factors such as women's family roles and social networks, and health information evaluation skills.

Rapid Escalation of High-Volume Exercise during Caloric Restriction; Change in Visceral Adipose Tissue and Adipocytokines in Obese Sedentary Breast Cancer Survivors

Simple Summary

Aerobic exercise reduces risk for developing breast cancer or for breast cancer recurrence. In obese women exercise can significantly augment the effects of caloric restriction on visceral fat, reducing metabolic abnormalities and cancer. Women who are older, obese, and sedentary, especially those who have been treated for breast cancer, find it difficult to initiate and achieve the minimum or optimum levels of exercise. In a two-part pilot we found that by providing older, obese, sedentary breast cancer survivors 12 weeks of twice weekly personal training sessions, they could safely increase exercise to ≥200 min/week by 9 weeks during caloric restriction. At 24 weeks, high levels of exercise were still observed with continued behavioral support and study-provided exercise facility. Substantial improvement in visceral fat and breast cancer risk biomarkers were observed with this affordable intervention that is readily exportable to the community.

Abstract

Aerobic exercise reduces risk for breast cancer and recurrence and promotes visceral adipose tissue (VAT) loss in obesity. However, few breast cancer survivors achieve recommended levels of moderate to vigorous physical activity (MVPA) without supervision. In a two-cohort study, feasibility of 12 weeks of partially supervised exercise was started concomitantly with caloric restriction and effects on body composition and systemic risk biomarkers were explored. In total, 22 obese postmenopausal sedentary women (including 18 breast cancer survivors) with median age of 60 and BMI of 37 kg/m² were enrolled. Using personal trainers twice weekly at area YMCAs, MVPA was escalated to ≥200 min/week over 9 weeks. For cohort 2, maintenance of effect was assessed when study provided trainer services were stopped but monitoring, group counseling sessions, and access to the exercise facility were continued. Median post-escalation MVPA was 219 min/week with median 12-week mass and VAT loss of 8 and 19%. MVPA was associated with VAT loss which was associated with improved adiponectin:leptin ratio. In total, 9/11 of cohort-2 women continued the behavioral intervention for another 12 weeks without trainers. High MVPA continued with median 24-week mass and VAT loss of 12 and 29%. This intervention should be further studied in obese sedentary women.

The Influence of Vitamin D on Mammographic Density: Results from CALGB 70806 (Alliance) a Randomized Clinical Trial

Current therapies for breast cancer prevention only prevent estrogen receptor positive (ER+) disease and toxicity limits use of these agents. Vitamin D is a potential prevention therapy for both ER+ and ER- disease and is safe with few side effects. This study evaluates the effect of 1-year of vitamin D supplementation on mammographic density (MD), a biomarker of breast cancer risk in a multicenter randomized controlled trial. Premenopausal women with ≥25% MD and no history of cancer were randomly assigned to 2,000 international units (IU) of vitamin D or placebo orally daily for 1 year. Change in percent MD was evaluated using Cumulus software after all participants completed treatment. Three hundred women enrolled between January 2011 and December 2013 with a mean age of 43 and diverse ethnicity [14% Hispanic, 12% African American (AA)]. Supplementation significantly increased vitamin D levels compared with placebo (14.5 ng/mL vs. -1.6 ng/mL; P < 0.0001) with all participants on the vitamin D arm achieving vitamin D sufficiency at 12 months. Vitamin D was safe and well tolerated. After adjustment for baseline MD, the mean between-arm difference (vitamin D vs. placebo) at 1 year was -0.75 (-0.26, 1.76; P = 0.56). A greater effect was seen for women with ≥50% MD and AA women, although neither reached significance. This randomized controlled trial demonstrated significant improvement in vitamin D levels with 2,000 IU for 1 year, with 100% of supplemented women achieving sufficiency. However, a null effect was seen regarding change in MD for premenopausal women (the primary outcome of the study). PREVENTION RELEVANCE: Current therapies for breast cancer prevention only prevent estrogen receptor positive (ER+) disease and are underutilized due to toxicity and side effects. Vitamin D is a potential prevention therapy for both ER+ and ER- disease and is safe with few side effects.

The Relationship between Body Mass Index and Mammographic Density during a Premenopausal Weight Loss Intervention Study

We evaluated the association between short-term change in body mass index (BMI) and breast density during a 1 year weight-loss intervention (Manchester, UK). We included 65 premenopausal women (35-45 years, ≥7 kg adult weight gain, family history of breast cancer). BMI and breast density (semi-automated area-based, automated volume-based) were measured at baseline, 1 year, and 2 years after study entry (1 year post intervention). Cross-sectional (between-women) and short-term change (within-women) associations between BMI and breast density were measured using repeated-measures correlation coefficients and multivariable linear mixed models. BMI was positively correlated with dense volume between-women (r = 0.41, 95%CI: 0.17, 0.61), but less so within-women (r = 0.08, 95%CI: -0.16, 0.28). There was little association with dense area (between-women r = -0.12, 95%CI: -0.38, 0.16; within-women r = 0.01, 95%CI: -0.24, 0.25). BMI and breast fat were positively correlated (volume: between r = 0.77, 95%CI: 0.69, 0.84, within r = 0.58, 95%CI: 0.36, 0.75; area: between r = 0.74, 95%CI: 0.63, 0.82, within r = 0.45, 95%CI: 0.23, 0.63). Multivariable models reported similar associations. Exploratory analysis suggested associations between BMI gain from 20 years and density measures (standard deviation change per +5 kg/m² BMI: dense area: +0.61 (95%CI: 0.12, 1.09); fat volume: -0.31 (95%CI: -0.62, 0.00)). Short-term BMI change is likely to be positively associated with breast fat, but we found little association with dense tissue, although power was limited by small sample size.

Epigenetic Reprogramming Mediated by Maternal Diet Rich in Omega-3 Fatty Acids Protects From Breast Cancer Development in F1 Offspring

Diets rich in omega-3 fatty acids (FA) have been associated with lowered risks of developing certain types of cancers. We earlier reported that in transgenic mice prone to develop breast cancer (BCa), a diet supplemented with canola oil, rich in omega-3-rich FA (as opposed to an omega-6-rich diet containing corn oil), reduced the risk of developing BCa, and also significantly reduced the incidence of BCa in F1 offspring. To investigate the underlying mechanisms of the cancer protective effect of canola oil in the F1 generation, we designed and performed the present study with the same diets using BALB/c mice to remove any possible effect of the transgene. First, we observed epigenetic changes at the genome-wide scale in F1 offspring of mothers fed diets containing omega-3 FAs, including a significant increase in acetylation of H3K18 histone mark and a decrease in H3K4me2 mark on nucleosomes around transcription start sites. These epigenetic modifications contribute to differential gene expressions associated with various pathways and molecular mechanisms involved in preventing cancer development, including p53 pathway, G2M checkpoint, DNA repair, inflammatory response, and apoptosis. When offspring mice were exposed to 7,12-Dimethylbenz(a)anthracene (DMBA), the group of mice exposed to a canola oil (with omega 3 FAs)-rich maternal diet showed delayed mortality, increased survival, reduced lateral tumor growth, and smaller tumor size. Remarkably, various genes, including BRCA genes, appear to be epigenetically re-programmed to poise genes to be ready for a rapid transcriptional activation due to the canola oil-rich maternal diet. This ability to respond rapidly due to epigenetic potentiation appeared to contribute to and promote protection against breast cancer after carcinogen exposure.

Prolonged recombinant pregnancy hormone use in BRCA1 and BRCA2 mutation carriers

BACKGROUND

An early first full-time pregnancy substantially reduces the risk of developing breast cancer later in life. Extensive studies indicate that this protective effect is mediated by the pregnancy hormone human chorionic gonadotrophin (hCG).

METHODS

In this proof-of-concept study 33 women with a BRCA mutation received recombinant-hCG (r-hCG). A 4-mm breast biopsy was obtained before (T1) and after 12 weeks of r-hCG injections (T2), as well as 6 months later (T3). The tissue was examined using RNA-sequencing methodology to determine if the 'high-risk' transcriptomic signature was converted to a 'low-risk' signature as in an early first full-time pregnancy. A stringent clinical safety monitoring was performed.

RESULTS

The r-hCG administration was well tolerated in all participants. No clinically relevant changes were observed. In 25 women, the RNA quality was good for RNA sequencing in all three breast tissue biopsies. In response to the r-hCG, we observed 1907 differentially expressed genes (DEGs) (1032 up, 875 down) at T2 vs. T1 and 1065 DEGs (897 up, 168 down) at T3 vs. T1 in the group of women (n = 11) not using any hormonal contraceptives during the study. There was no response at T2 vs. T1 and a small number of DEGs, 260 (214 up, 46 down) at T3 vs. T1 in the group of 14 women using contraceptives.

CONCLUSIONS

In summary, r-hCG has a remarkable effect on the gene expression profile of breast tissues from BRCA1/2 carriers who did not use any contraception. This opens an opportunity for a novel preventive strategy to reduce the incidence of breast cancer.

Prevalence of Known Risk Factors in Uruguayan Women Treated for Breast Cancer at a University Hospital

Introduction

In Uruguay, breast cancer has the highest incidence and mortality of all cancer in women. Knowledge of the distribution of risk factors related to disease development supports the implementation of prevention strategies in routine clinical practice. This study aimed to determine the epidemiological profile for breast cancer and the frequency of mammographic surveillance in the surveyed population.

Materials and Methods

A survey was conducted among Uruguayan women diagnosed with breast cancer who were assisted in the mastology unit of the oncology service of the Hospital de Clínicas in Montevideo, Uruguay, from September 1, 2018, to March 1, 2020.

Results

This study included 398 respondents, with a median (SD) age at diagnosis of 61 (34-86) years. A total of 310 respondents (78.0%) had 1 or more risk factors. Most women aged over 50 years (264 out of a total of 338 [78.1%]) underwent mammographic surveillance at least biennially.

Conclusions

Consistent with international reports, most respondents had a risk factor. Among the group of respondents aged over 50 years, most underwent mammographic and clinical surveillance at least biennially. Although it is only possible to formulate conclusions about the surveyed women because of the study design, the obtained data further our understanding of the epidemiological profile of the Uruguayan population, which can contribute to prevention practices.

Factors Associated with Women's Unwillingness to Decrease Alcohol Intake to Decrease Breast Cancer Risk

OBJECTIVE

Alcohol intake is a known risk factor for breast cancer. National organizations recommend that women consume no more than one serving of alcohol per day, if at all; however, many women exceed this recommendation, and some are unwilling to decrease consumption. Our study sought to identify factors associated with women's unwillingness to decrease their alcohol intake to decrease their breast cancer risk.

METHODS

942 women in a screening mammography cohort were asked questions about their demographics, personal and family health history, lifestyle factors, and willingness/unwillingness to decrease alcohol intake to decrease their breast cancer risk. Univariate and multivariate analyzes of their responses were performed.

RESULTS

13.2% of women in our cohort indicated they were unwilling to decrease their alcohol intake to reduce their breast cancer risk. After adjusting for potential confounders, women who were 60 years and older were more than twice as unwilling to decrease their alcohol intake compared to their younger counterparts (P = .0002). Women who had an annual household income of more than $200,000 were 1.75 times more unwilling to decrease their alcohol intake compared to their less affluent counterparts (P = .033). Unwillingness was not significantly associated with race/ethnicity, education, having a first-degree family member with cancer, health perception, breast cancer risk perception, or BMI.

CONCLUSIONS

Levels of unwillingness to decrease alcohol intake differed by age and household income. An opportunity is present to potentially decrease breast cancer risk in the community by educating women, especially older and more affluent women, about alcohol as a risk factor for breast cancer and the importance of limiting one's alcohol intake.

Night Work and Breast Cancer Risk in Nurses: Multifactorial Risk Analysis

Night work has been highlighted by the International Agency for Research on Cancer (IARC) as a likely carcinogenic factor for humans, associated with breast cancer and professions that require continuity of work. Knowing the impact that short and long-term night work has on the nurses' collective seems a priority, therefore, this study aims to analyse the relationship between night work and the development of breast cancer risk factors in nurses. For this, a cross-sectional study through an online questionnaire on breast cancer risk variables and working life was designed. The study was conducted in Spain and the sample consisted of 966 nurses, of whom 502 were healthy participants and 56 were breast cancer patients. These two groups were compared in the analyses. A descriptive analysis was performed, and the relationship was tested using χ2 independence test and OR calculation. The CHAID (Chi Square Automatic Interaction Detection) data mining method allowed for the creation of a segmentation tree for the main risk variables. The most significant risk variables related to working life have been the number of years worked, nights worked throughout life, and years working more than 3 nights per month. Exceeding 16 years of work has been significant for women and men. When the time worked is less than 16 years, the number of cases increases if there is a family history of cancer and if there have been more than 500 nights of work. High-intensity night work seems more harmful at an early age. The accumulation of years and nights worked increase the risk of breast cancer when factors such as sleep disturbance, physical stress, or family responsibilities come together.

The Effects of Diet and Exercise on Endogenous Estrogens and Subsequent Breast Cancer Risk in Postmenopausal Women

Endogenous estrogens have been associated with overall breast cancer risk, particularly for postmenopausal women, and ways to reduce these estrogens have served as a primary means to decrease overall risk. This narrative review of clinical studies details how various nutritional and exercise lifestyle interventions have been used to modify estrogen levels and metabolism to provide a protective impact against breast cancer incidence. We also summarized the evidence supporting the efficacy of interventions, outcomes of interest and identified emerging research themes. A systematic PubMed MEDLINE search identified scholarly articles or reviews published between 2000-2020 that contained either a cohort, cross-sectional, or interventional study design and focused on the relationships between diet and/or exercise and overall levels of different forms of estrogen and breast cancer risk and occurrence. Screening and data extraction was undertaken by two researchers. Data synthesis was narrative due to the heterogeneous nature of studies. A total of 1625 titles/abstracts were screened, 198 full texts reviewed; and 43 met eligibility criteria. Of the 43 studies, 28 were randomized controlled trials, and 15 were observational studies. Overall, studies that incorporated both diet and exercise interventions demonstrated better control of detrimental estrogen forms and levels and thus likely represent the best strategies for preventing breast cancer development for postmenopausal women. Some of the strongest associations included weight loss via diet and diet + exercise interventions, reducing alcohol consumption, and consuming a varied dietary pattern, similar to the Mediterranean diet. More research should be done on the effects of specific nutritional components on endogenous estrogen levels to understand the effect that the components have on their own and in combination within the diet.

Targeted Transdermal Delivery of Curcumin for Breast Cancer Prevention

N.B. This manuscript is based on the research concept submitted to the "Global Challenge to Prevent Breast Cancer" idea showcase and competition, launched in 2018 by the California Breast Cancer Research Program (CBCRP), which was subsequently selected for publication. The hypothesis, methods, and discussion put forth here are thus proposed concept studies, which could eventually be elucidated in the future. Curcumin is an herbal supplement, shown in preclinical studies to have antioxidant, anti-inflammatory, and antitumoral properties that we believe can be harnessed for breast cancer prevention. However, due to its poor absorption when consumed orally, curcumin's anticancer effects have not yet been exploited to their full therapeutic potential. Incorporating existing research that focuses on the optimization of curcumin's bioavailability and the latest transdermal delivery technology, we propose, below, a hypothetical in vivo study to test whether a targeted daily dose of bioavailable curcumin has a cytotoxic effect on cancer cells, potentially reducing the incidence of breast cancer over time. Our ultimate objective is to adopt innovative methods to create curcumin-infused bio-textiles offering transdermal, targeted drug delivery, simply through contact with the skin. We would use this fabric to create disposable bra inserts for an effortless, daily breast cancer prevention regimen for healthy women. It would be essential that the cost of these inserts remain reasonable, but if successful, curcumin is readily available, affordable and non-toxic, and could thus be a preventive measure that would be beneficial for women from all socio-economic backgrounds.

Mammary stem cells and progenitors: targeting the roots of breast cancer for prevention

Breast cancer prevention is daunting, yet not an unsurmountable goal. Mammary stem and progenitors have been proposed as the cells-of-origin in breast cancer. Here, we present the concept of limiting these breast cancer precursors as a risk reduction approach in high-risk women. A wealth of information now exists for phenotypic and functional characterization of mammary stem and progenitor cells in mouse and human. Recent work has also revealed the hormonal regulation of stem/progenitor dynamics as well as intrinsic lineage distinctions between mammary epithelial populations. Leveraging these insights, molecular marker-guided chemoprevention is an achievable reality.

The Breast-Cancer Education and Wellness (BE Well) Intervention: Congregants' Intended Participation, Actual Participation, and Perceived Health Outcomes

Objective. To evaluate a health leader-focused church-based breast cancer prevention intervention in relation to congregants' intended participation, congregants' actual participation, and perceived health outcomes at both individual and church levels using socio-ecological and theory of planned behavior frameworks. Method. Participants for the study were African American adults (n = 52) from six churches in a North Florida county involved in implementing the 9-month, three-phase intervention. Using a pre/post without comparison group design, data were collected via self-administered surveys and analyzed using qualitative and quantitative (descriptive, analysis of variance, linear regression) procedures. Results. There was general alignment between congregants' intended and actual participation when analyzed by content, especially in the areas of food and nutrition and health education. Regarding the number of intended versus actual activities, there was a significant, negative change in physical activity, a slight decline in health education activities, but a slight increase in food and nutrition activities. No significant relationships were found between extent of participation and the individual health outcomes (health ratings, health status), but significant relationships were found between extent of participation and church health outcomes (perceived role of church in improving health, p < .001; perceived role of the pastor in improving health, p < .001). Conclusions. The findings demonstrate that (1) congregants may follow through and participate in church-based health activities in which they express interest and that are made available and (2) the extent of their participation may be influenced by the perceived role of both the church and the pastor in improving their health.

Research-Tested Mobile Apps for Breast Cancer Care: Systematic Review

BACKGROUND

The use of mobile health (mHealth) apps in clinical settings is increasing widely. mHealth has been used to promote prevention, improve early detection, manage care, and support survivors and chronic patients. However, data on the efficacy and utility of mHealth apps are limited.

OBJECTIVE

The main objective of this review was to provide an overview of the available research-tested interventions using mHealth apps and their impact on breast cancer care.

METHODS

A systematic search of Medline, PsycINFO, Embase, and Scopus was performed to identify relevant studies. From the selected studies, the following information was extracted: authors, publication date, study objectives, study population, study design, interventions' features, outcome measures, and results.

RESULTS

We identified 29 empirical studies that described a health care intervention using an mHealth app in breast cancer care. Of these, 7 studies were about the use of an mHealth application in an intervention for breast cancer prevention and early detection, 12 targeted care management, and 10 focused on breast cancer survivors.

CONCLUSIONS

Our results indicate consistent and promising findings of interventions using mHealth apps that target care management in breast cancer. Among the categories of mHealth apps focusing on survivorship, mHealth-based interventions showed a positive effect by promoting weight loss, improving the quality of life, and decreasing stress. There is conflicting and less conclusive data on the effect of mHealth apps on psychological dimensions. We advocate further investigation to confirm and strengthen these findings. No consistent evidence for the impact of interventions using mHealth apps in breast cancer prevention and early detection was identified due to the limited number of studies identified by our search. Future research should continue to explore the impact of mHealth apps on breast cancer care to build on these initial recommendations.

Peroxisome proliferator-activated receptor gamma and BRCA1

Peroxisome proliferator-activated receptor gamma agonists have been proposed as breast cancer preventives. Individuals who carry a mutated copy of BRCA1, DNA repair-associated gene, are at increased risk for development of breast cancer. Published data in the field suggest there could be interactions between peroxisome proliferator-activated receptor gamma and BRCA1 that could influence the activity of peroxisome proliferator-activated receptor gamma agonists for prevention. This review explores these possible interactions between peroxisome proliferator-activated receptor gamma, peroxisome proliferator-activated receptor gamma agonists and BRCA1 and discusses feasible experimental directions to provide more definitive information on the potential connections.

Genetic ablation of mammary ducts through foxa1 prevents breast cancer occurrence

Risk reducing mastectomy is the only surgical approach for the prevention of breast cancer in women with deleterious genetic mutations or in those deemed to be at extremely high risk. However, up to 10.5% of these women still developed breast cancer. Thus, developing new strategies for complete prevention of breast cancer is imperative. Mammary ducts were ablated by mammary-specific ablation of forkhead box protein A1 (Foxa1). Mammary tumorigenesis was induced in control and mammary-specific Foxa1 knockout mice using carcinogens. No mammary tumors were observed in these knockout mice compared to four types of breast tumors induced in control mice. We present a promising novel strategy for the prevention of breast cancer by genetic ablation of mammary ducts via targeting Foxa1.

Trends in Use of Risk-Reducing Mastectomy in a Context of Celebrity Decisions and Media Coverage: An Observational Study in the United States and Australia

OBJECTIVE

To examine trends in risk-reducing mastectomy (RRM) and immediate breast reconstruction in New York State and New South Wales, especially before and after Angelina Jolie's announcement of her surgery in 2013.

DATA SOURCE

Hospital discharge data, 2004-2014.

STUDY DESIGN

Trends in procedures were assessed using Poisson regression and the Cochrane-Armitage test.

DATA EXTRACTION METHODS

Extracted using procedure codes.

PRINCIPAL FINDINGS

There was an increase in RRM procedures after May 2013 in both regions, with a peak during late 2013-early 2014. The average bimonthly RRM procedures were significantly higher after Jolie's announcement than before.

CONCLUSIONS

In both countries, we found a substantial increase of RRM after Jolie's announcement, highlighting the impact of celebrity health care coverage on preventive surgical choice and the need for decision aids to assist patients.

'No Pink Ribbons': How Women's Lived Experiences With Breast Atypia Inform Decisions Involving Risk-Reducing Medications

Purpose

Atypical hyperplasia (AH) is associated with a nearly 4-fold elevation of lifetime risk for breast cancer, and lobular carcinoma in situ (LCIS) is associated with a 7- to 8-fold risk. Women with AH/LCIS make numerous decisions in the course of treatment, including whether to take a risk-reducing medication, an option relatively few women pursue. We explored women's decision-making processes through patient narratives in an effort to inform decision supports for AH/LCIS.

Methods

We conducted in-depth interviews with 20 English-speaking women with AH/LCIS and no subsequent diagnosis of invasive breast cancer who had enrolled in the Rays of Hope Center for Breast Cancer Research patient registry between April 5, 2012, and March 31, 2016. Interviews were audiotaped, professionally transcribed, and qualitatively analyzed using thematic qualitative content analysis.

Results

We identified three major narrative themes: 1) experiences with medical care; 2) decision-making; and 3) making sense of AH/LCIS. Each major theme had several subthemes, many of which map onto existing decisional theories and heuristics. Subthemes included the impact of life context on diagnosis meaning, emotional responses, changes in self-concept and body image, and understanding of the risk-benefit of risk-reducing medications.

Conclusions

This narrative analysis offers important insights into how lived experience may influence decision-making for women with AH/LCIS. Decision supports that focus not only on analytic decisional processes, but also patients' subjectivities and decisional heuristics, could prove useful for women and their health care providers.

Reproducible automated breast density measure with no ionizing radiation using fat-water decomposition MRI

BACKGROUND

Increased breast density is a significant independent risk factor for breast cancer, and recent studies show that this risk is modifiable. Hence, breast density measures sensitive to small changes are desired.

PURPOSE

Utilizing fat-water decomposition MRI, we propose an automated, reproducible breast density measurement, which is nonionizing and directly comparable to mammographic density (MD).

STUDY TYPE

Retrospective study.

POPULATION

The study included two sample sets of breast cancer patients enrolled in a clinical trial, for concordance analysis with MD (40 patients) and reproducibility analysis (10 patients).

FIELD STRENGTH/SEQUENCE

The majority of MRI scans (59 scans) were performed with a 1.5T GE Signa scanner using radial IDEAL-GRASE sequence, while the remaining (seven scans) were performed with a 3T Siemens Skyra using 3D Cartesian 6-echo GRE sequence with a similar fat-water separation technique.

ASSESSMENT

After automated breast segmentation, breast density was calculated using FraGW, a new measure developed to reliably reflect the amount of fibroglandular tissue and total water content in the entire breast. Based on its concordance with MD, FraGW was calibrated to MR-based breast density (MRD) to be comparable to MD. A previous breast density measurement, Fra80-the ratio of breast voxels with <80% fat fraction-was also calculated for comparison with FraGW.

STATISTICAL TESTS

Pearson correlation was performed between MD (reference standard) and FraGW (and Fra80). Test-retest reproducibility of MRD was evaluated using the difference between test-retest measures (Δ_1-2 ) and intraclass correlation coefficient (ICC).

RESULTS

Both FraGW and Fra80 were strongly correlated with MD (Pearson ρ: 0.96 vs. 0.90, both P < 0.0001). MRD converted from FraGW showed higher test-retest reproducibility (Δ_1-2 variation: 1.1% ± 1.2%; ICC: 0.99) compared to MD itself (literature intrareader ICC ≤0.96) and Fra80.

DATA CONCLUSION

The proposed MRD is directly comparable with MD and highly reproducible, which enables the early detection of small breast density changes and treatment response.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;48:971-981.

Biomarker profiling for breast cancer detection: translational research to determine acceptance of a novel breast cancer screening technique

The current study seeks to determine how the psychosocial predictors of the health belief model are related to willingness to adopt biomarker screening practices among women above and below current screening age recommendations, as biomarker profiling can potentially detect cancer much earlier than current breast cancer detection methods. Patients (N = 205) at an Obstetrician/Gynaecology office in a mid-sized Midwest city. Participants completed a survey in the waiting room before their doctor appointment. Results revealed that benefits (p < .001), barriers (p = .02), cancer worry severity (p = .01), and self-efficacy (p = .002) were significant predictors of willingness to adopt biomarker profiling, and susceptibility was marginally related (p = .09). The direct effects are qualified by two interactions between psychosocial predictors of the health belief model and participants' age. The model predicted willingness to adopt biomarker screening well (R ² = 28%), and may be used successfully as a framework to assess the diffusion of biomarker screening acceptability.

Experiencing the cancer of a loved one influences decision-making for breast cancer prevention

Prior research demonstrates that family history influences breast cancer prevention decisions among healthy women at elevated risk of the disease. Drawing on in-depth interviews with 50 African American and White women, this study reveals an important psychological mechanism of this relationship: exposure to cancer among loved ones. Four distinct categories of cancer exposure (Abstract, Generalized, Practical, and Traumatic), distinguished by the characteristics of women's experiences with cancer among family members and close friends, are associated with differences in knowledge and decisions about breast cancer prevention options. Racial differences and distinct experiences among those with BRCA mutations are also discussed.

Feasibility of collecting tumor samples of breast cancer patients diagnosed up to 50 years ago in the Child Health and Development Studies

Environmental exposures during pregnancy may increase breast cancer risk for mothers and female offspring. Tumor tissue assays may provide insight regarding the mechanisms. This study assessed the feasibility of obtaining tumor samples and pathology reports from mothers (F0) who were enrolled in the Child Health and Development Studies during pregnancy from 1959 to 1967 and their daughters (F1) who developed breast cancer over more than 50 years of follow-up. Breast cancer cases were identified through linkage to the California Cancer Registry and self-report. Written consent was obtained from 116 F0 and 95 F1 breast cancer survivors to access their pathology reports and tumor blocks. Of those contacted, 62% consented, 13% refused and 24% did not respond. We obtained tissue samples for 57% and pathology reports for 75%, and if diagnosis was made ⩽10 years we obtained tissue samples and pathology reports for 91% and 79%, respectively. Obtaining pathology reports and tumor tissues of two generations is feasible and will support investigation of the relationship between early-life exposures and molecular tumor markers. However, we found that more recent diagnosis increased the accessibility of tumor tissue. We recommend that cohorts request consent for obtaining future tumor tissues at study enrollment and implement real-time tissue collection to enhance success of collecting tumor samples and data.

Correlation of mammographic density and serum calcium levels in patients with primary breast cancer

Percentage mammographic breast density (PMD) is one of the most important risk factors for breast cancer (BC). Calcium, vitamin D, bisphosphonates, and denosumab have been considered and partly confirmed as factors potentially influencing the risk of BC. This retrospective observational study investigated the association between serum calcium level and PMD. A total of 982 BC patients identified in the research database at the University Breast Center for Franconia with unilateral BC, calcium and albumin values, and mammogram at the time of first diagnosis were included. PMD was assessed, using a semiautomated method by two readers. Linear regression analyses were conducted to investigate the impact on PMD of the parameters of serum calcium level adjusted for albumin level, and well‐known clinical predictors such as age, body mass index (BMI), menopausal status and confounder for serum calcium like season in which the BC was diagnosed. Increased calcium levels were associated with reduced PMD (P = 0.024). Furthermore, PMD was inversely associated with BMI (P < 0.001) and age (P < 0.001). There was also an association between PMD and menopausal status (P < 0.001). The goodness‐of‐fit of the regression model was moderate. This is the first study assessing the association between serum calcium level and PMD. An inverse association with adjusted serum calcium levels was observed. These findings add to previously published data relating to vitamin D, bisphosphonates, denosumab, and the RANK/RANKL signaling pathway in breast cancer risk and prevention.

Pregnancy at early age is associated with a reduction of progesterone-responsive cells and epithelial Wnt signaling in human breast tissue

BACKGROUND

Pregnancy at early age is the most significant modifiable factor which consistently decreases lifetime breast cancer risk. However, the underlying mechanisms haven't been conclusively identified. Studies in mice suggest a reduction in progesterone-receptor (PR) sensitive epithelial cells as well as a downregulation of the Wnt signaling pathway as being one of the main mechanisms for the protective effect of early pregnancy. The aim of our study was to validate these findings in humans.

METHODS

We collected benign breast tissue of 125 women who had been stratified according to age at first pregnancy and the occurrence of subsequent breast cancer, and performed immunohistochemistry for PR, Wnt4 and the Wnt-target Versican.

RESULTS

The number of PR positive epithelial cells was significantly lower in the group of women with early pregnancy and no subsequent breast cancer compared to the group of nulliparous women with subsequent invasive breast cancer (p = 0.0135). In women with early pregnancy, expression of Versican and Wnt4 was significantly lower compared to nulliparous women (p = 0.0036 and p = 0.0241 respectively), and Versican expression was also significant lower compared to women with late pregnancy (p < 0.0001).

DISCUSSION

Our results confirm prior observations in mice and suggest a role of downregulation of epithelial Wnt signaling in the protective effect of early pregnancy in humans. This results in a decreased proliferation of stem/progenitor cells; therefore, the Wnt signaling pathway may represent a potential target for breast cancer prevention in humans.

Potential Mechanisms underlying the Protective Effect of Pregnancy against Breast Cancer: A Focus on the IGF Pathway

A first full-term birth at an early age protects women against breast cancer by reducing lifetime risk by up to 50%. The underlying mechanism resulting in this protective effect remains unclear, but many avenues have been investigated, including lobular differentiation, cell fate, and stromal composition. A single pregnancy at an early age protects women for 30-40 years, and this long-term protection is likely regulated by a relatively stable yet still modifiable method, such as epigenetic reprograming. Long-lasting epigenetic modifications have been shown to be induced by pregnancy and to target the IGF pathway. Understanding how an early first full-term pregnancy protects against breast cancer and the role of epigenetic reprograming of the IGF system may aid in developing new preventative strategies for young healthy women in the future.

Effect of Vitamin D Supplementation on Breast Cancer Biomarkers: CALGB 70806 (Alliance) Study Design and Baseline Data

One in eight women will develop breast cancer over their lifetime with 230,000 women diagnosed in 2015. For this reason, breast cancer prevention efforts are essential. Vitamin D, with anticancer properties, may have a role in prevention of some cancers, including breast cancer. This report discusses the rationale, study protocol, and baseline data for a clinical trial of vitamin D and its effects on breast cancer biomarkers. This study was a randomized controlled trial designed to evaluate the effect of a fixed dose of vitamin D on specfic breast cancer biomarkers. Study participants were randomized to take either vitamin D or placebo for a period of 1 year. All participants had mammograms and blood drawn for serum biomarkers. A subset of participants underwent random periareolar fine needle aspiration to draw tissue for biomarkers. From January 2011 to December 2013, 300 premenopausal women, aged 59 or younger, were recruited from 41 institutions across the United States. A total of 102 women underwent random periareolar fine needle aspiration. The last subject completed the trial in January 2015. Baseline vitamin D levels for all participants ranged from 4-72 ng/mL, with 62% of participants being vitamin D deficient at enrollment (≥30 ng/mL or ≥75 nmo-l/L). The mean body mass index was 27.0 kg/m² (range 15.1-53.6 kg/m²). 14% and 11.7% of participants were Hispanic or African American, respectively. Accrual and enrollment of participants is feasible for this type of multi-center prevention trial, and it can readily be carried out in a cooperative group setting.

Endocrine therapy for breast cancer prevention in high-risk women: clinical and economic considerations

The global burden of breast cancer highlights the need for primary prevention strategies that demonstrate both favorable clinical benefit/risk profile and good value for money. Endocrine therapy with selective estrogen-receptor modulators (SERMs) or aromatase inhibitors (AIs) has been associated with a favorable clinical benefit/risk profile in the prevention of breast cancer in women at high risk of developing the disease. The available endocrine therapy strategies differ in terms of their relative reductions of breast cancer risk, potential side effects, and upfront drug acquisition costs, among others. This review highlights the clinical trials of SERMs and AIs for the primary prevention of breast cancer, and the cost-effectiveness /cost-utility studies that have examined their "value for money" in various health care jurisdictions.

Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial

BACKGROUND

Ductal carcinoma in situ is currently managed with excision, radiotherapy, and adjuvant hormone therapy, usually tamoxifen. We postulated that an aromatase inhibitor would be safer and more effective. We therefore undertook this trial to compare anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy.

METHODS

The double-blind, randomised, phase 3 National Surgical Adjuvant Breast and Bowel Project (NSABP) B-35 trial was done in 333 participating NSABP centres in the USA and Canada. Postmenopausal women with hormone-positive ductal carcinoma in situ treated by lumpectomy with clear resection margins and whole-breast irradiation were enrolled and randomly assigned (1:1) to receive either oral tamoxifen 20 mg per day (with matching placebo in place of anastrozole) or oral anastrozole 1 mg per day (with matching placebo in place of tamoxifen) for 5 years. Randomisation was stratified by age (<60 vs ≥60 years) and patients and investigators were masked to treatment allocation. The primary outcome was breast cancer-free interval, defined as time from randomisation to any breast cancer event (local, regional, or distant recurrence, or contralateral breast cancer, invasive disease, or ductal carcinoma in situ), analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00053898, and is complete.

FINDINGS

Between Jan 1, 2003, and June 15, 2006, 3104 eligible patients were enrolled and randomly assigned to the two treatment groups (1552 to tamoxifen and 1552 to anastrozole). As of Feb 28, 2015, follow-up information was available for 3083 patients for overall survival and 3077 for all other disease-free endpoints, with median follow-up of 9·0 years (IQR 8·2-10·0). In total, 212 breast cancer-free interval events occurred: 122 in the tamoxifen group and 90 in the anastrozole group (HR 0·73 [95% CI 0·56-0·96], p=0·0234). A significant time-by-treatment interaction (p=0·0410) became evident later in the study. There was also a significant interaction between treatment and age group (p=0·0379), showing that anastrozole is superior only in women younger than 60 years of age. Adverse events did not differ between the groups, except for thrombosis or embolism--a known side-effect of tamoxifen-for which there were 17 grade 4 or worse events in the tamoxifen group versus four in the anastrozole group.

INTERPRETATION

Compared with tamoxifen, anastrozole treatment provided a significant improvement in breast cancer-free interval, mainly in women younger than 60 years of age. This finding means that women will benefit from having a choice of effective agents for ductal carcinoma in situ.

FUNDING

US National Cancer Institute and AstraZeneca Pharmaceuticals LP.

Vitamin D favorably alters the cancer promoting prostaglandin cascade

BACKGROUND

Preclinical studies suggest that 1,25-dihydroxyvitamin D [1,25(OH)2D] and celecoxib inhibit prostaglandins (PGs) associated with cancer through different mechanisms. We determined if there was synergy in their use.

PATIENTS AND METHODS

A total of 36 healthy women received daily for one month/menstrual cycle: placebo, 400 international units (IU) vitamin D-3, 2,000 IU vitamin D-3, or 2,000 IU vitamin D-3 plus 400 mg celecoxib. Serum and nipple aspirate fluid (NAF) were analyzed for PGE2 and transforming growth factor (TGF)β1 and -2; serum for 25(OH)D (total, -D-2, -D-3), plasma for celecoxib; and mammary duct RNA for cyclooxygenase (COX)2.

RESULTS

25(OH)D-3 increased (p<0.01) only in the groups receiving 2,000 IU vitamin D-3. PGE2 decreased in the breast (p=0.01) only after receiving 2,000 IU vitamin D-3; 2,000 IU vitamin D-3 alone was more effective in decreasing PGE2 than 2,000 IU vitamin D-3 plus celecoxib (p=0.018). COX2 expression decreased only in the breasts of women taking 2,000 IU vitamin D-3. Change in circulating 25(OH)D-3 correlated with change in TGFβ2 in the breast.

CONCLUSION

Vitamin D-3 reduces the PG cascade and increases TGFβ2 in a dose-dependent fashion. Adding celecoxib did not provide synergy.

Results from a randomized trial of a web-based, tailored decision aid for women at high risk for breast cancer

OBJECTIVE

To assess the impact of Guide to Decide (GtD), a web-based, personally-tailored decision aid designed to inform women's decisions about prophylactic tamoxifen and raloxifene use.

METHODS

Postmenopausal women, age 46-74, with BCRAT 5-year risk ≥ 1.66% and no prior history of breast cancer were randomized to one of three study arms:intervention (n=690), Time 1 control (n=160), or 3-month control (n=162). Intervention participants viewed GtD prior to completing a post-test and 3 month follow-up assessment. Controls did not. We assessed the impact of GtD on women's decisional conflict levels and treatment decision behavior at post-test and at 3 months, respectively.

RESULTS

Intervention participants had significantly lower decisional conflict levels at post-test (p<0.001) and significantly higher odds of making a decision about whether or not to take prophylactic tamoxifen or raloxifene at 3-month follow-up (p<0.001) compared to control participants.

CONCLUSION

GtD lowered decisional conflict and helped women at high risk of breast cancer decide whether to take prophylactic tamoxifen or raloxifene to reduce their cancer risk.

PRACTICE IMPLICATIONS

Web-based, tailored decision aids should be used more routinely to facilitate informed medical decisions, reduce patients' decisional conflict, and empower patients to choose the treatment strategy that best reflects their own values.

Evaluation of serum estrogen-DNA adducts as potential biomarkers for breast cancer risk

This study was conducted to determine whether the ratio of estrogen-DNA adducts to their respective metabolites and conjugates in serum differed between women with early-onset breast cancer and those with average or high risk of developing breast cancer. Serum samples from women at average risk (n=63) or high risk (n=80) for breast cancer (using Gail model) and women newly diagnosed with early breast cancer (n=79) were analyzed using UPLC-MS/MS. Adduct ratios were statistically compared among the three groups, and the Area Under the Receiver Operating Characteristic Curve (AUC) was used to identify a diagnostic cut-off point. The median adduct ratio in the average-risk group was significantly lower than that of both the high-risk group and the breast cancer group (p values<0.0001), and provided good discrimination between those at average versus high risk of breast cancer (AUC=0.84, 95% CI 0.77-0.90). Sensitivity and specificity were maximized at an adduct ratio of 77. For women in the same age and BMI group, the odds of being at high risk for breast cancer was 8.03 (95% CI 3.46-18.7) times higher for those with a ratio of at least 77 compared to those with a ratio less than 77. The likelihood of being at high risk for breast cancer was significantly increased for those with a high adduct ratio relative to those with a low adduct ratio. These findings suggest that estrogen-DNA adducts deserve further study as potential biomarkers for risk of developing breast cancer.

Comparison of Random Periareolar Fine Needle Aspirate versus Ductal Lavage for Risk Assessment and Prevention of Breast Cancer

Random periareolar fine needle aspiration (RPFNA) and ductal lavage (DL) are research techniques developed to (1) assess short-term breast cancer risk in asymptomatic women who are at increased risk for breast cancer and (2) track cytological response to risk reduction strategies. RPFNA and DL provide minimally invasive methods to repeatedly sample epithelial cells and research tools to investigate the biological origins of breast cancer in high-risk women. This review gives an overview of the strengths and limitations of both RPFNA and DL for risk assessment and breast cancer prevention in asymptomatic high-risk women.

Ethanol exposure induces the cancer-associated fibroblast phenotype and lethal tumor metabolism: implications for breast cancer prevention

Little is known about how alcohol consumption promotes the onset of human breast cancer(s). One hypothesis is that ethanol induces metabolic changes in the tumor microenvironment, which then enhances epithelial tumor growth. To experimentally test this hypothesis, we used a co-culture system consisting of human breast cancer cells (MCF7) and hTERT-immortalized fibroblasts. Here, we show that ethanol treatment (100 mM) promotes ROS production and oxidative stress in cancer-associated fibroblasts, which is sufficient to induce myofibroblastic differentiation. Oxidative stress in stromal fibroblasts also results in the onset of autophagy/mitophagy, driving the induction of ketone body production in the tumor microenvironment. Interestingly, ethanol has just the opposite effect in epithelial cancer cells, where it confers autophagy resistance, elevates mitochondrial biogenesis and induces key enzymes associated with ketone re-utilization (ACAT1/OXCT1). During co-culture, ethanol treatment also converts MCF7 cells from an ER(+) to an ER(-) status, which is thought to be associated with "stemness," more aggressive behavior and a worse prognosis. Thus, ethanol treatment induces ketone production in cancer-associated fibroblasts and ketone re-utilization in epithelial cancer cells, fueling tumor cell growth via oxidative mitochondrial metabolism (OXPHOS). This "two-compartment" metabolic model is consistent with previous historical observations that ethanol is first converted to acetaldehyde (which induces oxidative stress) and then ultimately to acetyl-CoA (a high-energy mitochondrial fuel), or can be used to synthesize ketone bodies. As such, our results provide a novel mechanism by which alcohol consumption could metabolically convert "low-risk" breast cancer patients to "high-risk" status, explaining tumor recurrence or disease progression. Hence, our findings have clear implications for both breast cancer prevention and therapy. Remarkably, our results also show that antioxidants [such as N-acetyl cysteine (NAC)] can effectively reverse or prevent ethanol-induced oxidative stress in cancer-associated fibroblasts, suggesting a novel strategy for cancer prevention. We also show that caveolin-1 and MCT4 protein expression can be effectively used as new biomarkers to monitor oxidative stress induced by ethanol.

In vitro human skin permeation of endoxifen: potential for local transdermal therapy for primary prevention and carcinoma in situ of the breast

PURPOSE

Oral tamoxifen, a triphenylethylene (TPE), is useful for breast cancer prevention, but its adverse effects limit acceptance by women. Tamoxifen efficacy is related to its major metabolites 4-hydroxytamoxifen (4-OHT) and N-desmethyl-4-hydroxytamoxifen (endoxifen [ENX]). Transdermal delivery of these to the breast may avert the toxicity of oral tamoxifen while maintaining efficacy. We evaluated the relative effciency of skin permeation of 4-OHT and ENX in vitro, and tested oleic acid (OA) as a permeation-enhancer.

METHODS

4-OHT, ENX, and estradiol (E2) (0.2 mg/mL of 0.5 μCi (3)H/mg) were dissolved in 60% ethanol-phosphate buffer, ±OA (0.1%-5%). Permeation through EpiDerm™ (Matek Corp, Ashland, MA) and split-thickness human skin was calculated based on the amount of the agents recovered from the receiver fluid and skin using liquid scintillation counting over 24 hours.

RESULTS

In the EpiDerm model, the absorption of 4-OHT and ENX was 10%-11%; total penetration (TP) was 26%-29% at 24 hours and was decreased by OA. In normal human skin, the absorption of 4-OHT and ENX was 0.3%; TP was 2%-4% at 24 hours. The addition of 1% OA improved the permeation of ENX significantly more than that of 4-OHT (P < 0.004); further titration of OA at 0.25%-0.5% further improved the permeation of ENX to a level similar to that of estradiol.

CONCLUSION

The addition of OA to ENX results in a favorable rapid delivery equivalent to that of estradiol, a widely used transdermal hormone. The transdermal delivery of ENX to the breast should be further developed in preclinical and clinical studies.

Women's interest in taking tamoxifen and raloxifene for breast cancer prevention: response to a tailored decision aid

Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women's interest in tamoxifen and raloxifene after reading a decision aid (DA) describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥ 1.66 from two large health maintenance organizations were randomized to receive a DA versus usual care. After reading an on-line DA that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions, and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs, and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug.

Action tendency emotions evoked by memorable breast cancer messages and their association with prevention and detection behaviors

Memorable messages about breast cancer sent by different sources, such as friends and family members, were analyzed for the action tendency emotions that they evoked. Negative emotions of fear, sadness, and anger, and positive emotions of hope and relief were analyzed for their associations with prevention and detection breast cancer behaviors. Messages that evoked fear were significantly more likely to be associated with detection behaviors, whereas messages that evoked relief were significantly less likely to be associated with detection behaviors than messages that did not evoke these emotions. These results are consistent with control theory and also show that friends and family are important sources of memorable messages about breast cancer.

Development and evaluation of a breast cancer prevention decision aid for higher-risk women

OBJECTIVE

To develop and evaluate the effectiveness of a breast cancer prevention decision aid for women aged 50 and older at higher risk of breast cancer.

DESIGN

Pre-test-post-test study using decision aid alone and in combination with counselling.

SETTING

Breast Cancer Risk Assessment Clinic.

PARTICIPANTS

Twenty-seven women aged 50-69 with 1.66% or higher 5-year risk of breast cancer.

INTERVENTION

Self-administered breast cancer prevention decision aid.

MAIN OUTCOME MEASURES

Acceptability; decisional conflict; knowledge; realistic expectations; choice predisposition; intention to improve life-style practices; psychological distress; and satisfaction with preparation for consultation.

RESULTS

The decision aid alone, or in combination with counselling, decreased some dimensions of decisional conflict, increased knowledge (P < 0.01), and created more realistic expectations (P < 0.01). The aid in combination with counselling, significantly reduced decisional conflict (P < 0.01) and psychological distress (P < 0.02), helped the uncertain become certain (P < 0.02), and increased intentions to adopt healthier life-style practices (P < 0.03). Women rated the aid as acceptable, and both women and practitioners were satisfied with the effect it had on the counselling session.

CONCLUSION

The decision aid shows promise as a useful decision support tool. Further research should compare the effect of the decision aid in combination with counselling to counselling alone.

Effect of raloxifene on IGF-I and IGFBP-3 in postmenopausal women with breast cancer

The effect on the IGF system of 60 mg and 600 mg daily of raloxifene administered for 2 weeks prior to surgery was investigated in 37 postmenopausal women with breast cancer. Raloxifene significantly decreased insulin-like growth factor (IGF-I) as compared to placebo (P < 0.05) with no dose-response relationship. No significant change was observed in IGFBP-3, while the IGF-I/IGFBP-3 molar ratio was decreased by treatment, with a statistically significant effect only for the higher dose. Given that high plasma levels of IGF-I have been suggested as a risk factor for breast cancer, these findings provide further support for the potential activity of raloxifene in breast cancer prevention.