Association between menopausal hormone therapy, mammographic density and breast cancer risk: results from the E3N cohort study

BACKGROUND

Menopausal hormone therapy (MHT) is a risk factor for breast cancer (BC). Evidence suggests that its effect on BC risk could be partly mediated by mammographic density. The aim of this study was to investigate the relationship between MHT, mammographic density and BC risk using data from a prospective study.

METHODS

We used data from a case-control study nested within the French cohort E3N including 453 cases and 453 matched controls. Measures of mammographic density, history of MHT use during follow-up and information on potential confounders were available for all women. The association between MHT and mammographic density was evaluated by linear regression models. We applied mediation modelling techniques to estimate, under the hypothesis of a causal model, the proportion of the effect of MHT on BC risk mediated by percent mammographic density (PMD) for BC overall and by hormone receptor status.

RESULTS

Among MHT users, 4.2% used exclusively oestrogen alone compared with 68.3% who used exclusively oestrogens plus progestogens. Mammographic density was higher in current users (for a 60-year-old woman, mean PMD 33%; 95% CI 31 to 35%) than in past (29%; 27 to 31%) and never users (24%; 22 to 26%). No statistically significant association was observed between duration of MHT and mammographic density. In past MHT users, mammographic density was negatively associated with time since last use; values similar to those of never users were observed in women who had stopped MHT at least 8 years earlier. The odds ratio of BC for current versus never MHT users, adjusted for age, year of birth, menopausal status at baseline and BMI, was 1.67 (95% CI, 1.04 to 2.68). The proportion of effect mediated by PMD was 34% for any BC and became 48% when the correlation between BMI and PMD was accounted for. These effects were limited to hormone receptor-positive BC.

CONCLUSIONS

Our results suggest that, under a causal model, nearly half of the effect of MHT on hormone receptor-positive BC risk is mediated by mammographic density, which appears to be modified by MHT for up to 8 years after MHT termination.

Abstract P3-02-03: Accurate and reliable automated breast density measurements with no ionizing radiation using fat-water decomposition MRI

Objective Breast density(BD) is a measure of the distribution of variable tissue types within the breast and higher BD has been shown to positively correlate with breast cancer risk. As such, the accurate measurement of BD has become a priority for risk assessment and for evaluating the effects of prevention strategies aimed at reducing BD. Mammography(MG) is the most common method of BD determination but is limited by the exposure to ionizing radiation, particularly for studies requiring repeated measures. BD derived from fat-water decomposition magnetic resonance imaging(FWMRI-BD) has been proposed as an alternative, safe, and quantitative method for BD. To optimize its use, we developed a new FWMRI-BD that is automated, more accurate and reliable. In this study, we compare our automated method to digital MG and a previous reported algorithm for MRI derived BD.

Methods From a completed prevention trial, 42 pre- and post-menopausal patients receiving tamoxifen therapy for early stage breast cancer or as primary chemoprevention were identified. Patients had undergone prior digital MG within 6 months from the date of MRI scan and MG-BD was calculated using a well-established method(Cumulus). MRI scans were performed on a 1.5T GE Signa NV-CV/i scanner using an axial radial IDEAL-GRASE sequence to generate quantitative fat fraction maps of the entire breast. Total acquisition time was < 5 min and automated breast segmentation was applied to all scans. Only the contralateral, unaffected breast was analyzed. Pearson correlation analysis compared BD as measured by MG(range 0-100%) and FWMRI based methods. BD by FWMRI was initially calculated as the ratio of breast voxels with<80% apparent fat fraction(Fra80). Fra80 had been previously shown by our group to correlate with MG-BD(Spearman ρ=0.86, p<0.001). Here, BD was calculated using a new algorithm(FraG+W) that accounts for the total amount of fibroglandular tissue and water content in the breast after correction for fat-water signal intensity bias and fat-water signal shine-through. Reliability of FWMRI measurements was tested in 24 repeated scans from 9 patients and evaluated using intra-class correlation(ICC) analysis.

Results Table 1 shows the correlation and reliability analysis results between MG-BD and FWMRI-BD. Both FWMRI-BD measures(Fra80 and FraG+W) were strongly correlated with MG-BD. More importantly, they exhibit superior test-retest reliability(ICC>0.98) compared to MG-BD values from the literature(reported ICC range 0.91-0.95). FraG+W showed improvement over Fra80 in all measures tested including correlation to MG-BD, dynamic range, standard errors and ICC.

Table 1. Accuracy and Reliability of the FWMRI-BD measuresFWMRI-BDFra80FraG+WPearson correlation coefficient* with MG-BDR=0.86R=0.94Test-retest reliabilitystandard error0.02300.0134dynamic range0.0902 – 0.65370.0736 – 0.6588standard error/ dynamic range4.1%2.3%ICC [95% confidence interval]0.985 [0.966,0.993]0.990 [0.976,0.995]* All P-values < 1e-10

Conclusion The refined and automated FWMRI-BD that quantifies the entire fibroglandular and water content of the breast(FraG+W) strongly correlates with MG-BD and is more accurate and reliable than previous FWMRI-BD method.

Acknowledgement NIH grants CA149417, CA161534.

Citation Format: Ding J, Thompson PA, Gao Y, Marron MT, Wertheim BC, Altbach MI, Galons J-P, Roe DJ, Wang F, Maskarinec G, Thomson CA, Stopeck A, Huang C. Accurate and reliable automated breast density measurements with no ionizing radiation using fat-water decomposition MRI [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-03.

Nutritional factors and non-Hodgkin lymphoma survival in an ethnically diverse population: the Multiethnic Cohort

Background/Objectives

To understand the possible effect of modifiable health behaviors on the prognosis of the increasing number of non-Hodgkin lymphoma (NHL) survivors, we examined the pre-diagnostic intake of major food groups with all-cause and NHL-specific survival in the Multiethnic Cohort (MEC).

Subjects/Methods

This analysis included 2,339 participants free of NHL at cohort entry and diagnosed with NHL as identified b cancer registries during follow-up. Deaths were ascertained through routine linkages to state and national death registries. Cox proportional hazards regression was applied to estimate hazard ratios (HR) and 95% confidence intervals (CI) for overall and NHL-specific mortality according to prediagnostic intake of vegetables, fruits, red meat, processed meat, fish, legumes, dietary fiber, dairy products, and soy foods assessed by food frequency questionnaire.

Results

The mean age at diagnosis was 71.8±8.5 years. During 4.5±4.1 years of follow-up, 1,348 deaths, including 903 NHL-specific deaths, occurred. In multivariable models, dairy intake was associated with higher all-cause mortality (highest vs. lowest tertile: HR=1.14, 95% CI 1.00–1.31, p_trend=0.03) and NHL-specific (HR=1.16, 95% CI 0.98–1.37) mortality. Legume intake above the lowest tertile was related to significant 13–16% lower all-cause and NHL-specific mortality, while red meat and fish intake in the intermediate tertiles was associated with lower NHL-specific mortality. No association with survival was detected for the other food groups.

Conclusion

These data suggest that pre-diagnostic dietary intake may not appreciably contribute to NHL survival although the higher mortality for dairy products and the better prognosis associated with legumes agree with known biologic effects of these foods.

Urinary estrogen metabolites in two soy trials with premenopausal women

Background

Soy consumption may protect against breast cancer through modification of estrogen metabolism.

Objective

We examined the effect of soy foods on urinary estrogens and the 2-hydroxy (OH)/16α-OH estrone (E₁) ratio in 2 dietary interventions with premenopausal women.

Methods

BEAN1 was a 2-year randomized trial and BEAN2 a 13-month randomized crossover study. In both interventions, study participants consumed a high-soy diet with 2 soy food servings/day and a low-soy diet with <3 servings of soy/week. Urine samples were collected at baseline and at the end of the diet periods, analyzed for 9 estrogen metabolites by liquid chromatography mass spectrometry, and adjusted for creatinine levels. For BEAN1, 2 samples for 188 participants and for BEAN2, 3 samples for 79 women were analyzed. We applied mixed-effects regression models with log-transformed values of estrogen metabolites and soy intake as the exposure variable.

Results

In BEAN1, no effect of the high-soy diet on individual estrogen metabolites or hydroxylation pathways was observed. The median 2-OH/16α-OH E₁ ratio decreased non-significantly in the intervention group from 6.2 to 5.2 as compared to 6.8 and 7.2 in the control group (p=0.63). In BEAN2, only 4-OHE₁ was significantly lower after the high-soy diet. Interaction terms of the high-soy diet with equol producer status, ethnicity, and weight status revealed no significant effect modification.

Conclusions

Contrary to our hypothesis and some previous reports, the results from 2 well controlled dietary interventions do not support an effect of a high-soy diet on a panel of urinary estrogen metabolites and the 2-OH/16α-OHE₁ ratio.

Food intake of individuals with and without diabetes across different countries and ethnic groups

BACKGROUND/OBJECTIVES

Given the importance of nutrition therapy in diabetes management, we hypothesized that food intake differs between individuals with and without diabetes. We investigated this hypothesis in two large prospective studies including different countries and ethnic groups.

SUBJECTS/METHODS

Study populations were the European Prospective Investigation into Cancer and Nutrition Study (EPIC) and the Multiethnic Cohort Study (MEC). Dietary intake was assessed by food frequency questionnaires, and calibrated using 24h-recall information for the EPIC Study. Only confirmed self-reports of diabetes at cohort entry were included: 6192 diabetes patients in EPIC and 13 776 in the MEC. For the cross-sectional comparison of food intake and lifestyle variables at baseline, individuals with and without diabetes were matched 1:1 on sex, age in 5-year categories, body mass index in 2.5 kg/m(2) categories and country.

RESULTS

Higher intake of soft drinks (by 13 and 44% in the EPIC and MEC), and lower consumption of sweets, juice, wine and beer (>10% difference) were observed in participants with diabetes compared with those without. Consumption of vegetables, fish and meat was slightly higher in individuals with diabetes in both studies, but the differences were <10%. Findings were more consistent across different ethnic groups than countries, but generally showed largely similar patterns.

CONCLUSIONS

Although diabetes patients are expected to undergo nutritional education, we found only small differences in dietary behavior in comparison with cohort members without diabetes. These findings suggest that emphasis on education is needed to improve the current behaviors to assist in the prevention of complications.

Urinary isoflavonoid excretion and soy consumption in three generations of Japanese women in Hawaii

OBJECTIVE

To explore soy intake and urinary isoflavonoid excretion within several generations of American-Japanese women based on the hypothesis that earlier generations excrete higher levels of urinary isoflavonoids, in particular the metabolite equol, than later generations.

SUBJECTS

A convenience sample of 43 women from 19 families aged 18-78 years, all of whom reported at least 50% Japanese ancestry.

INTERVENTIONS

Each woman collected overnight urine samples at baseline and after consuming one serving of soymilk, both samples were analyzed for the isoflavonoids daidzein, genistein and equol using liquid chromatography-mass spectrometry.

RESULTS

Median isoflavone intakes during the last year were 7.2 mg/day for the first generation, 7.3 mg/day for the second generation and 6.3 mg/day for the third generation (P=0.36). At baseline, the median isoflavonoid excretion for the first generation was nonsignificantly higher than for later generations (190, 86 and 42 nmol/h; P=0.20) but after intervention, the median urinary isoflavonoid excretion was very similar for the three groups: 2465, 1895 and 2775 nmol/h (P=0.70). Following intervention, a nonsignificantly higher proportion of older than younger women (53 vs 32 and 33%; P=0.41) excreted the metabolite equol. The respective median equol excretion rates by generation following intervention were 39.5, 4.2 and 3.5 nmol/h (P=0.04).

CONCLUSIONS

This small investigation among three generations of Japanese-Americans detected a higher equol production among older women after a soy challenge, but no difference in the excretion of total isoflavonoids after a standardized dose of soymilk was observed.

Serum prostate-specific antigen but not testosterone levels decrease in a randomized soy intervention among men

BACKGROUND

Low prostate cancer incidence and high soy intake in Asian countries suggest a possible protective effect of soy foods against prostate cancer. The goal of this pilot study was to evaluate the feasibility of a randomized, crossover soy trial among men and to investigate the effects of daily soy intake on serum prostate-specific antigen (PSA) and testosterone levels.

METHODS

We randomized 24 men to a high or a low soy diet for 3 months. After a 1-month washout period, the men crossed over to the other treatment. During the high soy diet, the men consumed two daily soy servings; during the low soy diet, they maintained their usual diet. During the entire study each man donated four blood samples and five overnight urine samples. Dietary compliance was assessed by soy calendars, 24-h dietary recalls, and urinary isoflavone excretion measured by high-pressure liquid chromatography with photodiode array detection. Blood samples were analyzed for serum testosterone and PSA by radioimmunoassay. When necessary, variables were log transformed. Two sample t-tests compared the two groups before each study period. Mixed models incorporating the repeated measurements were used to evaluate the effect of the soy diet on urinary isoflavone excretion and serum analytes.

RESULTS

Twenty-three men aged 58.7+/-7.2 years completed the study. The compliance with the study regimen was high according to self-reported soy food intake and urinary isoflavone excretion. No significant between-group and within-group differences were detected. During the high soy diet, dietary isoflavone intake and urinary isoflavone excretion increased significantly as compared to the low soy diet. A 14% decline in serum PSA levels (P=0.10), but no change in testosterone (P=0.70), was observed during the high soy diet in contrast to the low soy diet.

CONCLUSION

The high adherence as shown by three measures of compliance in this pilot trial demonstrated the feasibility of an intervention based on soy foods among free-living men.

Urinary isoflavone excretion as a compliance measure in a soy intervention among young girls: a pilot study

OBJECTIVE

To investigate the compliance of young girls with a soy intervention.

DESIGN

An 8-week dietary intervention and urine sample collection.

SETTING

Free-living girls.

SUBJECTS

A convenience sample of 8- to 14-y-old girls (20 started and 17 finished the study) recruited through flyers distributed to staff members and previous study participants.

INTERVENTION

The girls consumed one daily serving of soymilk, soy nuts, or tofu, completed 3-day food records, kept daily soy intake logs, and collected weekly urine samples.

MAIN OUTCOME MEASURES

Compliance with the intervention was evaluated by daily soy intake logs, 3-day food records analyzed by the center's Food Composition and Food Groups Servings Databases, and weekly urinary isoflavone excretion using high-pressure liquid chromatography. The statistical analysis included paired t-tests, analysis of variance, and Spearman's rank-order correlation coefficients.

RESULTS

Daily soy intake logs indicated a mean intake of 6.28 servings out of a maximum of 7.0 servings per week. The food records revealed a six-fold increase in isoflavone intake during the study period (P<0.01) which was confirmed by an increase in urinary isoflavone excretion of similar magnitude (23.3-142.1 nmol/mg creatinine, P=0.02).

CONCLUSIONS

This study demonstrated the ability of young girls to consume one daily soy serving and the usefulness of urinary isoflavones as a primary compliance measure. The high urinary isoflavone excretion levels detected in girls as compared to adult women suggest less intestinal degradation and/or greater absorption of isoflavones in nonadult populations. This finding requires further investigations into the pharmacokinetics of isoflavones.

Nutritional changes among premenopausal women undertaking a soya based dietary intervention study in Hawaii

BACKGROUND

We conducted a 2-year nutritional intervention among premenopausal women. The goal was to incorporate two daily servings of soya into the regular diet. This report describes the dietary modifications and assesses their nutritional adequacy with regard to major nutrients.

METHODS

In this analysis of 100 intervention and 106 control subjects, women completed a validated food-frequency questionnaire at baseline; throughout the study, they participated in at least three unannounced 24-h recalls.

RESULTS

At randomization, both groups were similar in age and body weight, reported low soya intake, and did not differ by intake of major nutrients and foods. According to the 24-h recalls, women in the intervention group consumed nearly two servings of soya per day, while the control women remained at 0.2 servings. In comparison with the control group, the intervention group consumed fewer dairy products, primarily milk, but also less meat, nuts and seeds. As a result of the dietary modification, the intervention women consumed less-saturated fat and cholesterol and more protein, dietary fibre, calcium and vitamins than the control group.

CONCLUSION

These results suggest that women in the intervention group improved the overall quality of their diet by adding two servings of soya per day.

Mammographic densities in a one-year isoflavone intervention

The estrogenic and antiestrogenic effects of isoflavones, phytoestrogens contained in soy foods, have been proposed as mechanisms for the possible involvement of soy products in the development of breast cancer. We investigated the hypothesis that isoflavones reduce mammographic density, a predictor of breast cancer risk. We conducted a double-blind randomized trial in premenopausal women who received a daily 100 mg isoflavone supplement or a placebo over 12 months. Compliance with the study regimen was confirmed by urinary isoflavones and tablet counts. We used a computer-assisted method to measure mammographic density and paired t-tests to assess changes in mammographic characteristics from baseline to follow-up mammogram. Complete sets of mammograms were available for 30 women. The two groups differed by age and mammographic density at baseline, but were similar in body weight and nutritional intakes. We detected no significant changes either in the size of the dense areas or in the per cent densities. A non-significant decrease in breast area among intervention group subjects was probably the result of methodological issues in comparing mammograms taken under different conditions. In conclusion, our findings do not support the hypothesis that isoflavones decrease mammographic density during a one-year intervention. Although this exploratory study had limited power, it appears that isoflavones do not exert an estrogenic effect similar to hormone replacement therapy on mammographic density.

Why some cancer patients choose complementary and alternative medicine instead of conventional treatment

OBJECTIVES

We examined cancer patients' reasons for declining all or part of recommended cancer treatment and choosing complementary and alternative medicine (CAM).

STUDY DESIGN

This was a qualitative interview study.

POPULATION

Fourteen cancer survivors who reported having declined all or part of the recommended conventional treatment (surgery, chemotherapy, or radiation) were included. The participants were a subset from a multi-ethnic (Asian, Native Hawaiian, and white) group of 143 adults diagnosed with cancer in 1995 or 1996 who were recruited through a population-based tumor registry and interviewed about CAM.

OUTCOMES MEASURED

We performed semistructured interviews regarding experience with conventional cancer treatment and providers, use of CAM, and beliefs about disease.

RESULTS

All participants used 3 or more types of CAM, most commonly herbal or nutritional supplements. Across the board, participants stated that their reason for declining conventional treatment was to avoid damage or harm to the body. The majority of participants also felt that conventional treatment would not make a difference in disease outcome, and some but not all participants perceived an unsatisfactory or alienating relationship with health care providers. Some participants reported that their discovery of CAM contributed to their decision to decline conventional treatment, and participants generally perceived CAM as an effective and less harmful alternative to conventional treatment.

CONCLUSIONS

Cancer patients may benefit from interventions (eg, patient education, improvements in physician-patient communication, and psychologic therapy) to facilitate treatment decision making through increased understanding of conventional and CAM treatments and to identify barriers to treatment for individual patients.

Ethnic differences in mammographic densities

BACKGROUND

Breast cancer incidence is considerably lower among Japanese and Chinese women than among Caucasian and Native Hawaiian even in second and third generation migrants. Mammographic densities, which refer to the radiological appearance of the healthy female breast, are related to breast cancer risk. The purpose of this project was to explore the hypothesis that women from ethnic groups at high breast cancer risk are more likely to have high levels of densities than women from low breast cancer risk groups.

METHODS

In a cross-sectional design, 514 pre- and post-menopausal women recruited at mammography screening clinics completed a self-administered questionnaire. We used a computer-assisted method to measure the dense and the total areas of the breast and to compute per cent breast density. Student's t-tests and multiple linear regression were applied to examine ethnic differences and to explore determinants of mammographic densities, respectively.

RESULTS

The unadjusted mean dense area was 15% smaller in Chinese and Japanese women than in the Caucasian/Hawaiian group. However, because of their smaller breast size, the per cent of the breast occupied by dense tissue in Chinese and Japanese women was 20% higher than in Caucasian women. Body mass index, age, menopausal status, parity, and oestrogen therapy were associated with mammographic densities, but they did not account for all ethnic differences.

CONCLUSIONS

Whereas this study detected some ethnic differences in mammographic densities, the importance of dense areas and per cent densities as indicators of breast cancer risk in ethnically diverse populations remains to be clarified.

Association of tocopherols with circulating autoantibody levels against an oxidized DNA nucleoside in humans

Autoantibodies against oxidized DNA bases are found in vivo and have been used as an indicator of oxidative damage, yet little is known concerning their individual variation and relation to serum micronutrients. Human plasma anti-5-hydroxymethyl-2'-deoxyuridine (HMdU) autoantibody (aAb) levels were repeatedly determined in 41 women and 11 men, and found to have small within-individual variation over time, but large between-individual differences. A positive association in both women (r = .5762, p = .0001) and men (r = .415, p = .2) between plasma total tocopherols and antibody levels was observed. Autoantibody levels were lower in postmenopausal women (8.37 +/- 1.61 vs. 17.18 +/- 2.85 in premenopausal women, p < .01), independently of plasma tocopherol. However, aAb titers in postmenopausal women were still significantly associated with plasma tocopherol levels and adjustment for menopausal status in women yielded a highly significant correlation between HMdU aAb levels and total tocopherol (r = .7342, p = .0001). Plasma malondialdehyde equivalents (MDA), a measure of lipid peroxidation, were also higher in individuals with either high plasma alpha-tocopherol or high beta+gamma-tocopherol levels. The positive association of tocopherols with markers of oxidative damage may reflect a response to the generation of endogenous oxidants associated with enhanced immune function. The decrease in aAb level in postmenopausal women may similarly reflect decreased immune function associated with decreased estrogen levels.

Determinants of mammographic densities among women of Asian, Native Hawaiian, and Caucasian ancestry

This cross-sectional study explored the relation between mammographic densities (a predictor of breast cancer risk), ethnicity, and dietary factors among women in Hawaii. Thirty-nine postmenopausal women with Japanese, Chinese, Caucasian, and Native Hawaiian ancestry who had received a screening mammogram completed a medical, reproductive, and dietary history. Using a computerized method, we determined the total and the dense area of the breast and calculated the ratio between the two. Blood lipids were measured using standard methods. For statistical analysis, we applied analysis of variance and multiple linear regression. Whereas the mean dense area of the breast was one third smaller in Asian than in Caucasian and Native Hawaiian women, the percent of the breast occupied by dense tissue in the Asian women was slightly higher than in the Caucasian/Hawaiian group, possibly a result of the Asian women's smaller breast size. The exploratory analysis indicated inverse relations of body mass index, high-density lipoprotein cholesterol (HDLC), age at menarche, and soy intake with mammographic densities, as well as direct relations of estrogen use and family history with mammographic densities. The results of this study suggest that variations in these factors may be responsible for ethnic differences in mammographic densities and in breast cancer risk.

Perceived cancer causes: use of complementary and alternative therapy

PURPOSE

The objectives of this report are to describe beliefs about general and personal cancer causes among patients with cancer who use and do not use complementary and alternative medicine (CAM), to compare these beliefs with current epidemiologic knowledge, and to explore associations between these beliefs and choice of CAMs. DESCRIPTION OF INTERVIEWS: The authors conducted a semistructured interview with 143 patients with cancer, who were identified via the Hawaii Tumor Registry and had participated in a survey on CAM use. By design, the majority of interviewees (85%) were CAM users. A qualitative data analysis was performed.

RESULTS

Genetics, environment, and diet were among the most common perceived general causes of cancer, whereas psychosocial factors were by far the most common perceived personal causes. CAM users were more likely than nonusers to name environment, immune system, and stress as cancer causes. Compared with the epidemiologic literature, study participants were less likely to mention tobacco use and more likely to consider environmental exposures, psychosocial factors, immunologic mechanisms, and physical injury as causes of cancer. Furthermore, the interviews suggest that causal thinking may be related to the type of CAM used.

CLINICAL IMPLICATIONS

Given the discrepancy between popular cancer theories and current scientific knowledge, the challenge for the healthcare provider is to listen and try to understand the patient's beliefs about cancer etiology. Understanding the patient's beliefs about their disease is important in providing the support and information they need to make effective decisions about their medical care.

Dietary changes among cancer survivors

Given the limited scientific knowledge about dietary factors that affect cancer recurrence, dietary guidelines for cancer survivors are similar to general recommendations on healthy eating. This study explored the patterns of and motivation for, dietary changes among cancer patients. We conducted in-person interviews with 143 cancer survivors who were chosen from a mail survey on complementary and alternative medicine among cancer patients. We applied qualitative analysis using the software package NUD*IST to sort and code the transcribed interviews. The majority of dietary changes reported by 69 cancer patients agreed with current nutritional recommendations, such as decreasing meat and fat intake and increasing the consumption of vegetables and fruits. However, many diet changers also reported the intake of herbal and vitamin supplements, many with unproven effects. The major themes for changing diet were hopes that nutrition would increase well-being, maintain health and prevent cancer recurrence and beliefs that foods that cause or prevent cancer should be avoided and increased, respectively. Many cancer patients use non-scientific reasons when deciding on dietary changes and supplement use. Increasing communication with health care providers may prevent the use of extreme diets, unproven and possibly harmful supplements and reduce exaggerated hopes related to the benefits of a particular dietary regimen.

An investigation of soy intake and mammographic characteristics in Hawaii

This cross-sectional investigation in Hawaii explored the relation between soy foods and mammographic characteristics using two food frequency questionnaires and a computer-assisted density assessment method. Japanese and Chinese women reported significantly greater soy food intake than Caucasian women. Whereas soy intake and the size of the dense areas were not related, soy intake and percent mammographic densities were positively associated. The size of the entire breast and the nondense area (ie the fatty part of the breast) were inversely related to soy intake. These results suggest the hypothesis that soy foods by themselves or as part of an Asian dietary pattern may affect the growth of the female breast before adulthood, but the possible mechanisms of action have to be explored in future studies.

Dietary patterns are associated with body mass index in multiethnic women

This cross-sectional study investigated the relationship between dietary patterns and body mass index among 514 women with different ethnic backgrounds who completed a validated food-frequency questionnaire. An exploratory factor analysis with orthogonal rotation started with 23 food items and resulted in four factors that accounted for 93% of the total variance. Confirmatory factor analysis with the 16 items that had factor loadings of at least 0.60 validated the four dietary patterns. The most significant dietary pattern, "meat," was characterized by high intake of processed and red meats, fish, poultry, eggs, fats and oils, and condiments. The "vegetable" pattern loaded high on different vegetables, whereas the third pattern named "bean" was high in legumes, tofu and soy protein. The major components of the "cold foods" pattern were fruit, fruit juice and cold breakfast cereals. Although the "meat" pattern was predominant among Hawaiians and the "bean" pattern very common among Chinese and Japanese women, factors two and four were not related to ethnicity. After adjustment for daily energy intake, the "meat" pattern was positively associated with body mass index (r = 0.17, P: = 0.0001), whereas the other three patterns showed negative relationships to body mass index (r = -0.076, P: = 0.084, r = -0.13, P: = 0.003, and r = -0.13, P: = 0.003) for vegetables, beans and cold foods, respectively. The associations were similar in direction and magnitude for all ethnic groups. The study results support the ideas that choosing the right foods may be important in weight control and that food-based dietary patterns may be useful in dietary counseling.

Ethnic differences in complementary and alternative medicine use among cancer patients

OBJECTIVES

This study estimated the prevalence of complementary and alternative medicine (CAM) use and its relation to quality of life (QOL) among cancer patients from diverse ethnic backgrounds. Given the ethnically diverse population in Hawaii, we hypothesized that CAM use may be related to the ancestry and the cultural heritage of cancer patients.

DESIGN AND SETTING

Participants for this mail survey were identified through the Hawaii Tumor Registry, a state-wide population-based cancer registry.

SUBJECTS

Patients with invasive cancer diagnosed 1995-1996. Of the 2,452 questionnaires received, 1,168 (47.6%) were returned.

OUTCOME MEASURES

Prevalence of CAM use and QOL measures.

RESULTS

One in four respondents reported at least one CAM therapy since cancer diagnosis. CAM use was highest among Filipino and Caucasian patients, intermediate for Native Hawaiians and Chinese, and significantly lower among Japanese. Some ethnic preferences for CAM followed ethnic folk medicine traditions, e.g., herbal medicines by Chinese, Hawaiian healing by Native Hawaiians, and religious healing or prayer by Filipinos. CAM users reported lower emotional functioning scores, higher symptom scores, and more financial difficulties than nonusers.

CONCLUSIONS

This study detected ethnic differences in CAM use, in particular a low use among Japanese patients, and supports the importance of cultural factors in determining the frequency and type of CAM therapies chosen. Consideration of patients' cultural heritage may facilitate communication between physicians and patients about CAM with the goal to achieve optimal cancer care.

A case-control study of mammographic densities in Hawaii

Epidemiologic evidence suggests that mammographic densities are markers of breast cancer risk. This project investigated the relation between breast cancer and densities in women of Chinese, Japanese, Filipino, Native Hawaiian, and Caucasian ancestry. Mammograms from breast cancer cases and from healthy controls were compared using a computer-assisted method of mammographic density assessment. From 1991 to 1997, 935 cases of breast cancer were diagnosed at Kaiser Permanente in Hawaii; for 647 (69%) subjects, a control woman matched by ethnicity, year of mammogram, and age was identified. Conditional multiple logistic regression was applied to estimate the relative risk of developing breast cancer. Breast cancer risk was associated with percent densities and with the size of the dense areas. Women in the category with the most densities experienced a twofold risk of developing breast cancer as compared to women with the least densities. Adjustment for risk factors reduced the strength of the association. Odds ratios were of similar magnitude in Asian women as in Caucasian/Native Hawaiian women, but they were not statistically significant. The results of this study indicate that the associations of breast cancer risk with the magnitude of the dense areas and with the percent densities are of similar strength in women of different ethnicities although density levels vary by ethnicity.

A biopsychosocial approach to finding common ground in the clinical encounter

PURPOSE

Little is known about how clinicians find common ground in conflicts with their patients or how educators can teach physicians-in-training to do so. The authors set out to create a conceptual model for the process of finding common ground.

METHOD

Students in a third-year family practice clerkship wrote up cases they had encountered in which conflicts arose in the patient-doctor relationship. The authors analyzed these cases, first independently and then collectively. After several iterations, they arrived at a model grounded in the case material.

RESULTS

The authors suggest that a modification of the biopsychosocial model first proposed by Engel and later updated by McWhinney is an appropriate and practical schema for classifying sources of conflict. This hierarchical system consists of five levels: (1) individual patient, (2) relationship between patient and physician, (3) patient's family, (4) ethnic belief systems of patient and family, and (5) political economy.

CONCLUSION

This hierarchical, multilevel biopsychosocial approach allows the clinician to identify the level in the system at which a conflict has arisen. This clarifies the strategies for resolution, making it easier for patient and doctor to find common ground. This may also be a useful heuristic model for teaching such skills to physicians-in-training.

Breast cancer--interaction between ethnicity and environment

The risk to develop breast cancer varies at least five fold around the world. Migrant women from low incidence countries to the United States experience an increase in risk over several generations. The objectives of this paper are to describe ethnic differences in breast cancer incidence and to review research related to risk factors that may explain these variations. Although ethnic differences can be partially explained by established risk factors, a large proportion of the increase in risk remains unexplained. Hormonal factors, including estrogens, insulin, and growth factors, may offer an explanatory mechanism how increasing caloric intake, decreasing physical activity, changes in nutrients, increasing height, and adiposity affect breast cancer risk. Future research on polymorphisms in genes coding for enzymes that are involved in the chemical activation and detoxification of environmental carcinogens, dietary agents, and endogenous hormones may contribute to the understanding of ethnic differences in breast cancer risk.

Exploring the feasibility and effects of a high-fruit and -vegetable diet in healthy women

Based on reports that fruits and vegetables may protect against breast cancer, this randomized intervention study tested the feasibility of increasing fruit and vegetable intake among healthy women to 9 daily servings through individual dietary counseling and group activities. Adherence to the dietary recommendations was monitored by 24-h food recalls, log sheets, and plasma carotenoid assessments. To explore possible cancer protective mechanisms of fruits and vegetables, we investigated the treatment effect on plasma phenol levels and on thiobarbituric acid-reactive substances measured as malondialdehyde equivalents, a possible marker of oxidative damage. At baseline, women in the intervention (n = 13) and control (n = 16) group reported an average daily consumption of 3.3 and 3.2 fruit and vegetable servings, respectively. After 3 and 6 months of intervention, intake in the intervention group had increased to 8.3 and 7.4 servings, whereas the control group reported an average of 4.2 and 4.1 daily servings. An increase of plasma carotenoid levels from 1249 microg/liter at baseline to 1854 and 1827 microg/liter after 3 and 6 months confirmed compliance with the dietary recommendations in the intervention group. Plasma carotenoid levels among controls changed slightly from 1165 to 1231 and 1291 microg/liter Whereas total phenol levels did not respond according to our hypothesis, malondialdehyde levels decreased slightly in the intervention group. These results suggest that motivated women can substantially increase their fruit and vegetable intake, which leads to a notable increase in plasma carotenoid levels.

Lifestyle factors and chronic diseases: application of a composite risk index

BACKGROUND

Assessing a combination of modifiable lifestyle practices may be a practical tool to modify patients' health behavior in counseling. Therefore, we developed a chronic disease risk index (CDRI) and investigated its relation with chronic disease in a multiethnic cohort.

METHODS

A total of 15,693 men and 16,007 women in Hawaii who reported their diet and other lifestyle behaviors between 1975 and 1980 were followed until 1994. A semi-quantitative composite CDRI with scores ranging from 1 to 10 included the rankings for smoking, alcohol use, body mass index, fat intake, and fruit and vegetable consumption. Cox's proportional hazards regression was used to estimate the relative risk for chronic diseases.

RESULTS

When comparing the highest to the lowest CDRI category, the respective relative risks (RRs) for total mortality were 2.9 (95% CI 2.3-3.8) and 3.8 (95% CI 2.9-5.0) for men and women. With higher CDRIs, the RRs for cancer incidence, mortality from cancer, coronary heart disease, and stroke increased significantly. Among the five components of the CDRI, smoking had the greatest influence on chronic disease risk, followed by body mass index.

CONCLUSIONS

Positive health behavior reflected by the CDRI is associated with a lower risk of cancer and with greater longevity.

A pilot study of mammographic density patterns among Japanese women

Mammographic density patterns, which refer to the distribution of fat, connective, and epithelial tissue in the healthy female breast, have been shown to be related to breast cancer risk. We used a quantitative method to assess mammographic densities in 41 mammograms from women in Japan without a diagnosis of breast cancer. Information about reproductive behavior and family history for breast cancer was available from a questionnaire. The statistical analysis applied Spearman correlation coefficients and multiple linear regression. The breast size as measured on the cranio-caudal view of the mammogram was approximately 12% larger, the size of the dense areas was 20% smaller, and the mean percent mammographic densities were 30% greater among premenopausal than among postmenopausal women. We found a strong relation between age at menarche and mammographic densities in premenopausal women and significant associations for age, family history of breast cancer, and age at menopause with mammographic densities in postmenopausal women. These preliminary data will be used to plan a future study that will compare mammographic density patterns and the relative importance of dietary, reproductive, and anthropometric factors between women in Japan and in the United States.

Use of complementary and alternative medicine in Hawaii cancer patients

This research investigated complementary and alternative medicine (CAM) use by Hawaii cancer patients. Thirty-six percent of patients used CAM, most commonly religious/spiritual therapy and herbal treatments. CAM use was linked with younger age, female gender, Catholic religion, and more education. More research is needed to inform decision-making.

Isoflavone levels in soy foods consumed by multiethnic populations in Singapore and Hawaii

Concentrations and glucosidic conjugation patterns of isoflavones were determined in soy foods consumed by multiethnic populations in Singapore and Hawaii. Six raw and 11 cooked food groups traditionally consumed in Singapore and 8 food groups consumed in Hawaii were analyzed by reversed-phase high-pressure liquid chromatography with diode array detection. Mean total isoflavone levels varied between 35 and 7500 ppm, with the lowest values found in soy milk and burgers and the highest levels observed in soybean and its seeds and in supplements. Total isoflavone levels and conjugation patterns varied as a function of soybean variety, storage conditions, and food processing. A large contribution to the differences in total isoflavone content between food groups was due to the water content in foods and to leaching of polar analytes into the water phase during boiling. Soy protein drinks and traditional soy foods were found to possess very similar isoflavone amounts considering usual serving sizes.

Alcohol intake, body weight, and mortality in a multiethnic prospective cohort

The purpose of this analysis was to investigate the effects of alcohol intake and body weight on mortality from all causes, cancer, and cerebrovascular and coronary heart disease. A cohort of more than 40,000 persons with Caucasian, Chinese, Filipino, Japanese, and native Hawaiian ethnicity was followed for close to 20 years. We calculated mortality rates using the person-years at risk for each gender and ethnic group as denominators. We used proportional hazards regression models to adjust for confounding variables and to estimate relative risks. Men and women with low alcohol intake (1-7 drinks per week) experienced a 20% reduction in total mortality. At higher levels of alcohol intake, women and Asian men experienced no mortality benefit. The protective effect of alcohol consumption was limited to coronary heart disease mortality. The relation between body mass index and total mortality was J-shaped for all groups. In agreement with previous reports, this study found that persons with moderate alcohol intake appear to have a lower risk of dying than nondrinkers, but the possible protective levels of alcohol for women and Asian men appear to be lower than for Caucasian men.

Dietary soy intake and urinary isoflavone excretion among women from a multiethnic population

Isoflavones are present in soybeans and its products in concentrations up to 300 mg/100 g, have estrogenic and antiestrogenic properties, and may be protective against hormone-related cancers. The purpose of this cross-sectional study was to investigate the association between urinary isoflavone excretion and self-reported soy intake. A total of 102 women of Caucasian, Native Hawaiian, Chinese, Japanese, and Filipino ancestry completed a dietary questionnaire for soy products consumed during the last year and during the 24-h period before urine collection. Overnight urine samples were analyzed for coumestrol and the soy isoflavones genistein, daidzein, and glycitein and their main human metabolites by reverse-phase high-pressure liquid chromatography. Soy protein and isoflavone intake (predominantly from tofu) were estimated using published nutritional databases. Wilcoxon's rank-sum test scores and Spearman rank correlation coefficients were computed. Japanese women excreted more daidzein, genistein, and glycitein than did Caucasian women, whereas Caucasian women excreted slightly more coumestrol. Soy intake differed significantly among ethnic groups. Dietary soy protein and isoflavone intakes during the previous 24 h were positively related to urinary isoflavone excretion [rs = 0.61 (P < 0.0001) and 0.62 (P < 0.0001), respectively]. Urinary excretion of isoflavones was also related to annual dietary soy protein and isoflavone intake [rs = 0.32 (P < 0.0012) and 0.31 (P < 0.0016), respectively]. The strong correlation between urinary isoflavone excretion and self-reported soy intake validates the dietary history questionnaire that is now used in a study exploring dietary risk factors for breast cancer.

Ethnic differences and factors related to breast cancer survival in Hawaii

BACKGROUND

Previous studies have described differences in breast cancer survival among women from various ethnic backgrounds even after adjustment for stage at diagnosis. The aim of this study is to identify factors that could explain this disparity in prognosis and to update breast cancer survival patterns in Hawaii.

METHODS

The Hawaii Tumor Registry identified 3345 breast cancer cases diagnosed between 1980 and 1988. The following covariates were studied: ethnicity, stage at diagnosis, geographical residence, and menopausal, marital and socioeconomic statuses. The Kaplan-Meier method and proportional hazards regression were used to estimate survival by group.

RESULTS

Native Hawaiian and Filipino women had a higher risk of dying within 5 years than women of other ethnic groups. Japanese had the highest survival probability, followed by Chinese and Caucasians. Stage was the most important prognostic factor. Married women had better survival than widowed and divorced women. Filipinos had a much greater chance of dying from localized cancer than other women with localized disease. Geographical residence, menopausal and socioeconomic statuses were not associated with survival.

CONCLUSIONS

Despite an overall improvement in breast cancer survival, ethnic disparity in prognosis still exists. Other possible explanations for the differential prognosis, such as treatment, diet, genetics, obesity, oestrogen receptor and hormonal statuses need to be explored in future studies.

Ethnicity and conditional breast cancer survival in Hawaii

The conditional survival experience of 4502 female breast cancer cases diagnosed in Hawaii between 1960 and 1983 was studied. The calculation of conditional survival is based on patients who have already survived for a specified time period. Cox proportional hazards models were used to examine the effect of ethnicity, stage at diagnosis, and menopausal, marital, and socioeconomic statuses on conditional survival prognosis. Native Hawaiian and Filipino women showed a significantly higher risk of dying from breast cancer than any other ethnic group, followed by Chinese and Caucasian women, while Japanese women had the lowest risk. The ethnic pattern of breast cancer survival changed and ethnic survival differences decreased from 17 to 4% as time progressed. Conditional survival varied greatly with stage at first diagnosis. For localized, regional, and distant disease, the conditional survival rate increased from 92, 71, and 24% after diagnosis to 95, 85, and 65% 5 years after diagnosis, respectively, indicating that stage at diagnosis becomes less important in determining survival as time progresses. Being married and of a high socioeconomic status increased survival probability. These results suggest that considering time effect, the conditional survival rate is an informative tool to assess clinical outcome of breast cancer among ethnic groups over a long follow-up period.

Diabetes in Hawaii: estimating prevalence from insurance claims data

OBJECTIVES

The purpose of this study was to determine the prevalence of diabetes mellitus in Hawaii from insurance claims data.

METHODS

Information from two major health plans covering approximately 66% of the state's population was used to estimate prevalence rates by sex, age group, and geographic area. Weighted multiple linear regression was applied to identify predictors of diabetes prevalence.

RESULTS

The statewide diabetes prevalence was estimated at 43.8 per 1000 persons. The ethnic composition of the population and rural residence partially explained the geographic variation in diabetes prevalence.

CONCLUSIONS

Insurance claims data may be a useful tool for population-based diabetes surveillance.

Mammography screening and the increase in breast cancer incidence in Hawaii

This ecological study investigated the association between mammography utilization and breast cancer incidence in Hawaii with the hypothesis that geographic areas with high mammography use have higher breast cancer incidence than geographic areas with low mammography use. Insurance claims for mammograms received during 1992 and 1993 were combined with breast cancer incidence data from the Hawaii Tumor Registry and data from the 1990 Census ZIP File. The claims data were obtained from four private and three public health plans and covered approximately 85% of women 40 years of age and older. Age-specific breast cancer incidence rates for the 79 ZIP code areas were regressed on mammography rates and selected aggregate demographic variables using multiple linear regression. An estimated 42% of women 40 years of age and older had received at least 1 mammogram during 1992 and 1993, with the highest rate (45%) in women ages 50-64 years old. Overall, 23% of the variation in age-specific breast cancer incidence could be predicted by mammography utilization, 23% by increasing age, and 4% by higher education. The relationship between mammography use and breast cancer incidence was strongest for women 50-64 years old and for localized disease. The magnitude of the association between breast cancer incidence and mammography utilization was comparable to the increase in breast cancer rates observed in Hawaii during the mid-1980s, supporting the hypothesis that the sharp increase in breast cancer incidence was attributable to screening and early detection. However, the long-term 1% increase in breast cancer incidence requires alternate explanations.

Investigating increased incidence of events in the islands: a Hawaii department of health perspective

Despite the relatively clean environment on the islands of Hawaii, residents have been concerned about clusters of disease due to environmental exposures. Close to 40 inquiries related to perceived increases in health conditions have been examined during the last three years. The standardized incidence ratio approach was the preferred strategy to evaluate occurrence of disease. Three examples of cluster investigation are presented. Even though all investigations except one showed results within the expected range, cluster investigations appear to be useful in allaying fears, in particular about cancer, by providing comparative numbers and factual information on carcinogenesis.