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Breast Cancer Prevention (PDQ®)

  • Last Modified: 04/04/2014

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Overview

Factors Associated With Increased Risk of Breast Cancer
        Combination hormone therapy
        Ionizing radiation
        Obesity
        Alcohol
        Major inheritance susceptibility
Factors Associated With Decreased Risk of Breast Cancer
        Estrogen-only use among women with a hysterectomy
        Exercise
        Early pregnancy
        Breast-feeding
Interventions Associated With Decreased Risk of Breast Cancer
         Selective estrogen receptor modulators (SERMs): Benefits
        Selective estrogen receptor modulators (SERMs): Harms
        Aromatase inhibitors or inactivators: Benefits
        Aromatase inhibitors or inactivators: Harms
        Prophylactic mastectomy: Benefits
        Prophylactic mastectomy: Harms
        Prophylactic oophorectomy or ovarian ablation: Benefits
        Prophylactic oophorectomy or ovarian ablation: Harms

Note: Separate PDQ summaries on Breast Cancer Screening; Breast Cancer Treatment; Male Breast Cancer Treatment; Breast Cancer Treatment and Pregnancy; and Levels of Evidence for Cancer Screening and Prevention Studies are also available.

Factors Associated With Increased Risk of Breast Cancer

Combination hormone therapy

Based on solid evidence, combination hormone therapy (HT; estrogen-progestin) is associated with an increased risk of developing breast cancer.

Magnitude of Effect for Combination Therapy: Approximately a 26% increase in incidence of invasive breast cancer; number needed to harm for every 237 patients participating in the Women’s Health Initiative (WHI) trial and randomly assigned to the combination HT arm: one invasive breast cancer occurred beyond those that happened in the placebo arm of the trial.

Study Design: Randomized, controlled trial (RCT) supported by evidence from cohort and ecological studies showing withdrawal of combination HT is associated with a decrease in the rates of breast cancer.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Ionizing radiation

Based on solid evidence, exposure of the breast to ionizing radiation is associated with an increased risk of developing breast cancer, starting 10 years after exposure and persisting lifelong. Risk depends on dose and age at exposure, with the highest risk occurring during puberty.

Magnitude of Effect: Variable, but approximately a six-fold increase in incidence overall.

Study Design: Cohort or case-control studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Obesity

Based on solid evidence, obesity is associated with an increased breast cancer risk in postmenopausal women who have not used HT. It is uncertain whether reducing weight would decrease the risk of breast cancer.

Magnitude of Effect: The WHI observational study of 85,917 postmenopausal women found body weight to be associated with breast cancer. Comparing women weighing more than 82.2 kg with those weighing less than 58.7 kg, the relative risk (RR) was 2.85 (95% confidence interval [CI], 1.81–4.49).

Study Design: Observational study.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Alcohol

Based on solid evidence, exposure to alcohol is associated with an increased breast cancer risk in a dose-dependent fashion. It is uncertain whether decreasing alcohol exposure would decrease the risk of breast cancer.

Magnitude of Effect: The RR for women consuming approximately four alcoholic drinks per day compared with nondrinkers is 1.32 (95% CI, 1.19–1.45). The RR increases by 7% (95% CI, 5.5%–8.7%) for each drink per day.

Study Design: Case-control and cohort studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Major inheritance susceptibility

Based on solid evidence, women who inherit gene mutations associated with breast cancer have an increased risk.

Magnitude of Effect: Variable, depending on gene mutation, family history, and other risk factors affecting gene expression.

Study Design: Cohort or case-control studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Factors Associated With Decreased Risk of Breast Cancer

Estrogen-only use among women with a hysterectomy

Based on fair evidence, estrogen-only use after menopause among women with a hysterectomy is associated with a decreased risk of breast cancer incidence and mortality.

Magnitude of effect: Based on one RCT of estrogen-only therapy with conjugated equine estrogen, there was a 23% decrease in incidence of invasive breast cancer (0.27% per year with a median of 5.9 years of use, compared with 0.35% per year among those taking a placebo).

Study Design: RCT and cohort studies.
Internal Validity: Good.
Consistency: Mixed.
External Validity: Good.
Exercise

Based on solid evidence, exercising strenuously for more than 4 hours per week is associated with reduced breast cancer risk.

Magnitude of Effect: Average RR reduction is 30% to 40%. The effect may be greatest for premenopausal women of normal or low body weight.

Study Design: Prospective observational and case-control studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Early pregnancy

Based on solid evidence, women who have a full-term pregnancy before age 20 years have decreased breast cancer risk.

Magnitude of Effect: 50% decrease in breast cancer compared with nulliparous women or those who give birth after age 35 years.

Study Design: Cohort and case-control studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Breast-feeding

Based on solid evidence, women who breast-feed have a decreased risk of breast cancer.

Magnitude of Effect: The RR of breast cancer is decreased 4.3% for every 12 months of breast-feeding, in addition to 7% for each birth.[1]

Study Design: Cohort and case-control studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Interventions Associated With Decreased Risk of Breast Cancer

Selective estrogen receptor modulators (SERMs): Benefits

Based on solid evidence for tamoxifen and fair evidence for raloxifene, treatment reduces the incidence of breast cancer in postmenopausal women. Tamoxifen also reduces the risk of breast cancer in high-risk premenopausal women. The effects observed for tamoxifen and raloxifene show persistence several years after discontinuing active treatment, with longer duration of effect noted for tamoxifen than for raloxifene.[2]

All fractures were reduced with decreases primarily noted for raloxifene but not for tamoxifen. Reduction in vertebral fractures (34% reduction) and small reduction in nonvertebral fractures (7%) were noted.[2]

Magnitude of Effect: Treatment with tamoxifen reduced breast cancer by about 50%. Treatment with raloxifene has a similar effect on reduction of invasive breast cancer but is less effective for prevention of noninvasive tumors. A meta-analysis showed an overall 38% risk reduction for SERMs in breast cancer incidence. With 5 years of treatment, 42 women would need to be treated to prevent one breast cancer in the first 10 years of follow-up.[2]

Study Design: RCTs.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Selective estrogen receptor modulators (SERMs): Harms

Based on solid evidence, tamoxifen treatment increases the risk of endometrial cancer, which was apparent in the first 5 years of follow-up but not beyond; thrombotic vascular events (pulmonary embolism, stroke, deep venous thrombosis); and cataracts. Many of these risks are reduced after discontinuing active treatment with tamoxifen. Based on solid evidence, raloxifene also increases venous pulmonary embolism and deep venous thrombosis but not endometrial cancer.

Magnitude of Effect: Meta-analysis showed the hazard ratio (HR) for endometrial cancer was 2.18 (95% CI, 1.39–3.42) for tamoxifen and was 1.09 (95% CI, 0.74–1.62) for raloxifene. Overall, HR for venous thromboembolic events was 1.73 (95% CI, 1.47–2.05).

Study Design: RCTs.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Aromatase inhibitors or inactivators: Benefits

Based on solid evidence, aromatase inhibitors or inactivators (AIs) reduce the incidence of new breast cancers in postmenopausal women who have an increased risk of breast cancer.

Magnitude of Effect: After a median follow-up of 35 months, women aged 35 years and older who had at least one risk factor (e.g., women aged 60 years and older or those having a Gail 5-year risk >1.66% or ductal carcinoma in situ with mastectomy) and who took 25 mg of exemestane daily were less likely to be diagnosed with invasive breast cancer (HR, 0.35; 95% CI, 0.18–0.70). The absolute risk reduction was 21 cancers avoided out of 2,280 participants over 35 months (number needed to treat [NNT], about 100).[3]

Study Design: One RCT.
Internal Validity: Good.
Consistency: One study in women with no history of breast cancer but consistent with RCTs in women with history of breast cancer.
External Validity: Good for women who meet inclusion criteria.
Aromatase inhibitors or inactivators: Harms

Based on fair evidence because of a relatively short follow-up from a single RCT of 4,560 women over 35 months, exemestane is associated with slightly increased hot flashes (absolute increase, 8%) and fatigue (absolute increase, 2%), but not with fractures, osteoporosis, or cardiovascular (CV) events compared with placebo.

Magnitude of Effect: There was a small increase in adverse effects in the exemestane group compared with placebo, primarily in hot flashes (absolute increase, 8%) and fatigue (absolute increase, 2%). There was no difference in the occurrence of fractures or CV events.

Study Design: One RCT.
Internal Validity: Good.
Consistency: Poor, as there is only one RCT in women with no history of breast cancer, but studies in women with breast cancer have shown decreased bone mineral density and increased fracture rate compared with tamoxifen.
External Validity: Good for women who meet inclusion criteria, but only for 35 months.
Prophylactic mastectomy: Benefits

Based on solid evidence, bilateral prophylactic mastectomy reduces the risk of breast cancer in women with a strong family history.

Magnitude of Effect: Risk is reduced as much as 90%, but published study designs may have produced an overestimate.

Study Design: Evidence obtained from case-control and cohort studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Prophylactic mastectomy: Harms

Based on fair evidence, physical and psychological effects include anxiety, depression, and impaired body image.

Magnitude of Effect: Of the women who chose to have a prophylactic mastectomy, usually for cosmesis, 6% were dissatisfied with their decision. Regrets about mastectomy were fewer in 185 women who opted not to have reconstruction than in 111 women who chose to have it.[4]

Study Design: Convenience sample.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Prophylactic oophorectomy or ovarian ablation: Benefits

Based on solid evidence, prophylactic oophorectomies in women with BRCA gene mutations document lower breast cancer incidence. Similarly, oophorectomy or ovarian ablation is associated with decreased breast cancer incidence in normal women or in those who received thoracic irradiation.

Magnitude of Effect: Breast cancer incidence is decreased by 50%, but published study designs may have produced an overestimate.

Study Design: Observational, case-control, and cohort studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
Prophylactic oophorectomy or ovarian ablation: Harms

Based on solid evidence, castration may cause the abrupt onset of menopausal symptoms such as hot flashes, insomnia, anxiety, and depression. Long-term effects include decreased libido, vaginal dryness, and decreased bone mineral density.

Magnitude of Effect: Nearly all women experience some sleep disturbances, mood changes, hot flashes, and bone demineralization, but the severity of these symptoms varies greatly.

Study Design: Case-control, cohort, and observational studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.
References
  1. Collaborative Group on Hormonal Factors in Breast Cancer.: Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet 360 (9328): 187-95, 2002.  [PUBMED Abstract]

  2. Cuzick J, Sestak I, Bonanni B, et al.: Selective oestrogen receptor modulators in prevention of breast cancer: an updated meta-analysis of individual participant data. Lancet 381 (9880): 1827-34, 2013.  [PUBMED Abstract]

  3. Goss PE, Ingle JN, Alés-Martínez JE, et al.: Exemestane for breast-cancer prevention in postmenopausal women. N Engl J Med 364 (25): 2381-91, 2011.  [PUBMED Abstract]

  4. Montgomery LL, Tran KN, Heelan MC, et al.: Issues of regret in women with contralateral prophylactic mastectomies. Ann Surg Oncol 6 (6): 546-52, 1999.  [PUBMED Abstract]