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Breast cancer is the most commonly diagnosed cancer among women in many Western populations (American Cancer Society, 2004), although in Asian countries this disease is comparatively less frequent (Parkin et al, 1992). For example, breast cancer incidence rates historically have been four to seven times higher among women in the United States than those in China or Japan (Kelsey and Horn-Ross, 1993), yet the underlying reasons for this disparity are not entirely clear (Kelsey and Horn-Ross, 1993; Ziegler et al, 1993). The geographic variation in risk does not appear to be due to large genetic differences between ethnicities, because breast cancer incidence rates among Asian-American women shifts substantially toward those of white American women within a few generations after migration (Chie et al, 1995; Stanford et al, 1995; Wu et al, 1998). These international variations in incidence rates coupled with the results from migration studies suggest breast cancer risk is influenced by environmental exposures, reproductive history, and lifestyle choices, including diet (Kelsey and Horn-Ross, 1993; Ziegler et al, 1993). Some researchers attribute the international heterogeneity in risk to the higher consumption of soy products in Asian countries (Ren et al, 2003). Since Americans and other Western populations tend to consume less flavonoid-rich foods compared to Asians and Asian-Americans (Dai et al, 2002), it is possible that compounds in these products with known biologic anti-cancer activity may decrease breast cancer risk and improve survival after diagnosis. Flavonoids, of which soy-based isoflavones are the most intensely studied, lower endogenous hormone levels in pre- (Dai et al, 2002; Ren et al, 2003) and post-menopausal women (Murkies et al, 1995), and inhibit transcriptional factors involved in cancer metastasis (Valachovicova et al, 2004; Slivova et al, 2005), including vascular endothelial growth factor, which is strongly associated with tumour angiogenesis (Masuda et al, 2002). These findings provide support for a biologically plausible association between dietary intake of flavonoids, particularly isoflavones, on breast cancer risk and prognosis. Unfortunately, the multiple investigations conducted to date among human populations to evaluate a possible soy–breast cancer link appear to be inconsistent and interpretation is not straightforward. The meta-analysis presented by Wu et al in this issue of BMJ was undertaken to obtain a summary effect estimate of the association in epidemiologic studies. Their approach brings clarity to the heated debate on this controversial issue. One of the most important contributions of the meta-analysis undertaken by Wu et al is the separation of the epidemiologic studies conducted among Asian populations from those conducted among Western populations. This simple stratified approach elegantly demonstrates that a higher intake of isoflavones—about 20 mg per day or more as compared with a lower intake of about 5 mg per day—among Asian populations is associated with a consistent 29% reduction in the risk of developing breast cancer. Importantly, an inverse dose–response relation was evident; modest intake of about 10 mg per day of isoflavones was associated with a modest 12% decrease in breast cancer risk. Further, the risk reductions among Asian women were observed for both pre-and postmenopausal breast cancer. Moreover, the effect appeared to be stronger among those consuming soy during adolescence than among those who had only consumed soy as an adult, although research on early-life consumption patterns is sparse. In contrast, isoflavone intake of about 0.8 mg per day, which Wu et al reported as the higher level of consumption among Western populations (but which is obviously far below even the lower levels of intake for Asian populations), was not associated with breast cancer risk. In all, these exciting findings by Wu et al underscore the importance of considering exposure dose and timing when evaluating the effects of soy intake on breast cancer risk. Other concerns have also contributed to the difficulty in interpreting the numerous population studies on the soy–breast cancer association, and again the thoughtful methodologic approach of Wu et al sheds light on these issues. For example, many of the investigations conducted to date have used the case–control study design, which may yield biased effect estimates due to possible differential recall of exposure based on the subjects' case–control status. However, as shown by Wu et al, results among Asian populations from both cohort and case–control studies yielded nearly identical summary effect estimates. Further, if recall bias was the underlying reason for the inverse association noted in the meta-analysis presented by Wu et al, then the risk reduction associated with isoflavone intake should have been evident among case–control studies conducted among Asian and Western populations, which was not the case. Thus, recall bias does not appear to be the reason for the observed risk reductions associated with soy intake among Asian populations. An important issue that still remains unclear is whether any of the biologically active anti-cancer flavonoid compounds influence breast cancer risk among Western populations. Most previous epidemiologic studies have been hampered by focusing solely on intake of isoflavones, which are usually consumed by Westerners through intake of soy-based products such as processed foods. Challenges associated with assessing intake of isoflavones from these types of products could perhaps be overcome by utilising a biomarker of exposure, although single measures common to epidemiologic studies are not easily interpreted. Instead, it may be more productive to consider intake of a broader range of flavonoids, many of which occur in foods more frequently consumed by Western populations (such as tomatoes, green peppers, berries, and citrus fruits (Fink et al, 2006)). These other flavonoid classes can then be assessed using more conventional nutritional epidemiology methods (Fink et al, 2006). Recent studies conducted in Greece (Peterson et al, 2003), Italy (Bosetti et al, 2005), and the United States (Fink et al, 2007b) using this alternative approach consistently report a modest decrease in the risk of breast cancer in relation to intake of flavones. Thus, further exploration of the potential chemo-preventive effects of additional flavonoid classes on breast cancer appears warranted. The review by Wu et al also highlights other understudied soy–breast cancer issues. In particular, the authors note that few investigators have formally evaluated the effects of soy intake on survival among women diagnosed with breast cancer. For example, one study conducted among a cohort of women with breast cancer in Shanghai (Boyapati et al, 2005) observed no association between consumption of isoflavones at diagnosis and subsequent mortality. In contrast, in a recent publication by our own group (Fink et al, 2007a) a reduction in all-cause and breast cancer-specific mortality was observed among a cohort of breast cancer survivors in the United States, who reported consuming higher levels of total flavonoids, and particularly flavones. To the best of our knowledge, no other reports on this subject have been published to date. In sum, the meta-analysis by Wu et al notably demonstrate that relatively high intake of 10–20 mg per day of isoflavones, a consumption level frequently found among Asian populations, is inversely associated with a 10–30% reduction in risk of breast cancer. Lower isoflavone intake of

29 Background: In 2010 the National Comprehensive Cancer Network recommended a 21-gene assay recurrence score (RS) to aid in the adjuvant treatment decision among patients with estrogen receptor positive, lymph node negative early stage breast cancer. Early-decision impact studies show that the RS can reduce overall chemotherapy use by 27%. This study was performed to assess the cost-benefit of the test for the patients diagnosed and treated an academic institute before 2010. Methods: Data from early breast cancer estrogen-receptor–positive and lymph-node–negative patients (n = 87), who were diagnosed and treated at our center from 2004-2010 were analyzed. All patients had the 21-gene recurrence test done to guide in their management. Cost of chemotherapy, adverse effects, and supportive care costs were calculated from previously published articles. Results: 66 patients with stage I breast cancer and 21 patients with stage II were analyzed. All but one patient had a tumor size more than 5mm. In total, 27 patients received chemotherapy. Characteristics of patients receiving chemotherapy are shown in the table. Cost of 21 gene recurrence score assay was $4,000. Savings for each patient who did not receive chemotherapy was $21,715 after accounting for cost of the test. The total savings for 60 patients who did not receive chemotherapy was $1,302,900. Conclusions: Use of the 21-gene assay in patients with early stage lymph node negative breast cancer improves health outcomes by avoiding chemotherapy-related adverse events. It also appears to add no incremental costs. This study emphasizes the cost-saving potential of the Oncotype Dx 21 gene assay. [Table: see text]

Background: Breast cancer education programs while abundant tend to focus on young and middle age women. However, the median age of breast cancer diagnosis is 61 years of age. With increasing debate on when to begin mammography, the risk of being diagnosed at a later age also increases. As the senior breast cancer survivor and at-risk population continues to grow, their need to be educated regarding breast cancer and other health and legal-related issues of aging is key to reducing risk, finding breast cancer early, and improving the quality of life for survivors. This pilot program was designed to educate seniors about breast cancer in relation to healthy aging and nutrition, elder law, patient advocacy, and occupational and physical therapy. The intent is to improve senior confidence and knowledge pertaining to these issues in order to create a sustainable population of seniors that can help themselves and each other. Methods and Materials: Two senior centers located in Northwest Ohio agreed to host the four individual workshops of From Gray to Pink during September and October 2011, respectively. Senior breast cancer survivors (age ≤ 60), their family and friends, and women at risk were welcome to attend. The workshops covered breast cancer and issues related to diet, aging, elder law, patient advocacy and navigation, and physical therapy and occupational therapy. Participant knowledge and confidence were assessed using pre- and post-surveys and the Student's paired t-test was used to compare mean pre- and post-test knowledge and confidence scores. Results: Among the 25 total participants, there were statistically significant differences between pre- and post-test knowledge for the aging and nutrition (p = 0.01), elder law (p < 0.01), physical and occupational therapy (p = 0.03) workshops. Conclusion: Senior breast cancer survivors and those at risk scored higher in both topic knowledge and confidence on post-surveys compared to pre-surveys. This pilot study has provided sufficient data to apply for funding to bring this program to additional rural Ohio counties. While improvements in confidence were not statistically significant, most participants did have the same level of or greater confidence following each workshop. Given the aging of our population and increasing health care costs and needs, breast cancer education for seniors at risk and senior survivors is crucial. The knowledge and confidence gained by seniors can be shared among all to provide an ever-growing network of people who can educate and help each other improve their quality of life. Further implementation will help in determining if this educational methodology may be useful in other parts of the country for seniors who have or are at risk for breast cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4440. doi:1538-7445.AM2012-4440

Background The favorable prognosis for early stage breast cancer survivors may be a reason for the minimal research regarding their quality of life. Prior research has observed more long-term weight gain among early stage survivors compared to cancer-free women of a similar age. It would be useful to study survivors’ perceptions and reported behaviors regarding diet and exercise to see if there is a correlation with previous studies. Methods A sample of 700 breast cancer survivors from Ohio and Michigan was randomly selected from the Northwest Ohio affiliate of the Susan G. Komen For the Cure mailing list and sent a survey for completion. Results 389 survivors completed the survey and among Stage 1 (50/197 = 25.4%) and Stage 2 survivors (24/105 = 22.9%), a small proportion had a positive correlation between self-reported dietary behaviors and their perceived benefits of eating fruits and vegetables. Similar correlations were observed between their self-reported exercise behaviors and their perceived benefits of exercise (Stage 1: 36/197 = 18.3%, Stage 2: 18/105 = 17.1%). Conclusions Regardless of stage, a small proportion of survivors’ self-reported dietary and exercise behaviors match their perceived benefits of diet and exercise. Factors such as access, motivation, and lack of co-morbidities among early stage survivors may prevent them from living healthier post-diagnosis. More thorough dietary and clinical measurements will provide greater certainty. Thus, innovative, sustainable programs must be accessible and provide motivation and social support from family, friends, and other survivors to truly improve quality of life.