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Breast Cancer and the Environment: A Life Course Approach (2012)

Chapter:Appendix D: Summary Table on Estimates of Population Attributable Risk

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Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
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Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×

TABLE D-1 Summary of Estimates of Population Attributable Risk for Risk Factors for Breast Cancer

Source Study Location and Type Study Population Characteristics
United States
Madigan et al. (1995) U.S.

Cohort
NHANES I Epidemiologic Follow-up Study (NHEFS) (1971-1987)
Women, ages 25-74 at initial examination

7,508 in analytic cohort
193 breast cancer cases

Rockhill et al. (1998)

U.S.

Unmatched case-control with randomized recruitment

Carolina Breast Cancer Study (1993-1996)

Women, ages 20-74 (white women for PAR analysis)

513 cases
445 controls

Tseng et al. (1999)

U.S.

Survey data for risk factor prevalence

Adjusted RR from meta-analysis

Incidence rates from SEER data (1990-1994)

NHANES III (1988-1994)

No age restrictions

U.S. women

Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Risk Factors and Relative Risk Estimatesa Population Attributable Risk in Percentb (95% CI, where available) Impact on Absolute Risk
 

History of breast cancer in 1st degree relative = 2.6
Income in upper two thirds of U.S. population = 1.7
Age at first birth > than 29 yrs = 1.9
Nulliparity = 1.8
Estimates for U.S.
All factors: 41 (1.6-80.0)
Family history: 9 (3.0-15.2)
Higher income: 19 (-4.3-42.1)
Later age at first birth or nulliparity: 30 (5.6-53.3)

Estimates for NHEFS
All factors: 47 (16.7-76.7)
Family history: 8 (2.3-13.9)
Higher income: 23 (5.4-39.9)
Later age at first birth or nulliparity: 30 (8.9-51.4)

NHEFS age adjusted baseline incidence per 100,000 (standardized to 1970 U.S. population)

History of breast cancer in 1st degree relative = 470
Income in upper two thirds of U.S. population = 259
Age at first birth > than 29 = 260
Nulliparity = 259
Early menarche (< age 12 = 1.24; age 12-13 = 1.08)
Later age of first full-term pregnancy (≥ age 20) 1.08 to 1.53, depending on age group
Breast cancer in mother or sister = 1.36
History of benign breast biopsy = 1.06
All: 25 (6-48)
With menarche at < age 14 and first birth at ≥ age 20, or nulliparity

All: 15 ( ̴5-20) With menarche at < age 12 and first birth at ≥ age 30, or nulliparity
Not reported
Alcohol consumption
None = 1.0
Light (0.1-6.4 g/day) = 1.0
Moderate (6.5-25.9 g/day) = 1.1
Heavy (≥ 26 g/day) = 1.3
Alcohol consumption: 2 ( ̴1.2-2.9) Not reported
Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Source Study Location and Type Study Population Characteristics
Clarke et al. (2006) U.S.

Survey data for risk factor prevalence

Published literature for RRs

Incidence from California Cancer Registry (1998-2002)
California Health Interview Survey, 2001

White, non-Hispanic women, ages 40-79

Analysis for counties and hypothetical populations

3,781,621 women
13,019 breast cancer cases
Sprague et al. (2008) U.S.

Unmatched case-control

Cases from cancer registries; population-based controls
Collaborative Breast Cancer Study—
Wisconsin, Massachusetts, New Hampshire (1996?2000)

Women, ages 20?69 (95% white, non-Hispanic)


3,499 cases
4,213 controls
Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Risk Factors and Relative Risk Estimatesa Population Attributable Risk in Percentb (95% CI, where available) Impact on Absolute Risk
Alcohol (2+ drinks/day on 10+ days/mo) = 1.4
HT (E+P) = 1.26
Physical inactivity (no vigorous/moderate activity in past month) = 1.3
Alcohol: 3.5
HT (E+P): 4.4
Physical inactivity: 7.5
Alcohol: 450 cases/yr
HT (E+P): 567 cases/yr
Physical inactivity: 1,422 cases/yr
       

Not modifiable
Age at menarche (< age 15 yrs) = 1.20-1.37
Age at menopause (≥ age 45 yrs) = 1.22-1.40
Age at first full-term pregnancy (< age 20 yrs, parous women only) = 1.02-1.42
Parity (< 4 births) = 1.13-1.35
1st degree family history = 1.66
History of benign breast disease = 1.53
Height at age 25 (≥ 1.6 m) = 1.11-1.27

Modifiable
Alcohol (≥ 1 drink/wk) = 1.12-1.43
HT, current use (E, E+P, or other) = 0.96-1.31
Physical inactivity (≤ 5 hrs/ wk) = 1.17-1.26
Weight gain (since age 18, > 5 kg) = 1.27-1.57

Not modifiable 57.3 (47.5-65.4)
Age at menarche: 18.8 (7.9-29.0)
Age at menopause: 13.7 (6.6-19.6)
Age at first full-term pregnancy: 5.2 (-3.2-13.9)
Parity: 13.3 (6.9-19.8)
1st degree family history: 8.5 (6.5-10.5)
History of benign breast disease: 9.7 (7.3-12.0)
Height at age 25: 11.0 (3.5-18.5)

Modifiable 40.7 (23.0-55.1)
Alcohol: 6.1 (2.1-10.3),
HT, current use: 4.6 (-3.5-11.9)
Physical activity: 15.7 (-6.5-33.7)
Weight gain: 21.3 (13.1-29.3)

Not reported

Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Source Study Location and Type Study Population Characteristics
Europe and Canada
Mezzetti et al. (1998) Italy
Case-control
Unmatched hospital cases (ages 23-74, median 55 yrs) and controls (ages 20-74, median 56 yrs) (1991-1994)

2,569 cases
2,588 controls
Bakken et al. (2004) Norway

Cohort

Cases identified from national cancer registry
Norwegian Women and Cancer study

Postmenopausal women, ages 45-64, recruited in 1991-1992 or 1996-1997

31,451 in cohort

Neutel and Morrison (2010)

Canada

Survey data for risk factor prevalence

Published literature for RRs

National age-adjusted cancer incidence rates

National Population Health Survey (1994-2006)

Canadian women ages 50-69

Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Risk Factors and Relative Risk Estimatesa Population Attributable Risk in Percentb (95% CI, where available) Impact on Absolute Risk
 
Low levels of physical activity = 1.5
Alcohol consumption (> 20 g/day) = 1.25
Aggregate: 19.2 (1.5-36.8)
Physical activity: 11.6 (-0.1-23.3)
Alcohol: 10.7 (4.4-17.0)
Not reported
HT, ever used = 1.9
HT, current use = 2.1

(HT formulations different from those in U.S.)
Current use of HT: 27 300 cases/yr
Modifiable risk factors:

Alcohol (> 9 drinks/wk) = 1.4
HT use = 1.4
Obesity (BMI ≥ 30 kg/m(2)) = 1.4
Physical inactivity = 1.15
Smoking, current = 1.25
2000
All: 28.9
Alcohol: 1.8
HT use: 11.5
Obesity: 7.6
Physical inactivity: 8.0
Smoking: 3.8

2006
All: 23.6
Alcohol: 2.6
HT use: 5.2
Obesity: 8.8
Physical inactivity: 6.4
Smoking: 3.1
Not reported
Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Source Study Location and Type Study Population Characteristics
Barnes et al. (2010) Germany

Case-control
Mammary carcinoma Risk factor Investigation (MARIE) (2001-2005)

Postmenopausal women, ages 50-74

3,074 cases
6,386 controls
     
Friedenreich et al. (2010) Europe (15 countries)

Survey data for risk factor prevalence

Review of published literature for RR

Incidence from estimates by IARC
Eurobarometer, Wave 58.2 (2002)

Incidence (2008)
Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Risk Factors and Relative Risk Estimatesa Population Attributable Risk in Percentb (95% CI, where available) Impact on Absolute Risk
Not modifiable
Age at menarche (< age 15 yrs) = 1.11-1.16
Age at menopause (≥ age 45 yrs) = 1.12-1.36
Parity (< 3 births) = 1.08-1.30
1st degree family history = 1.49
History of benign breast disease = 1.24
Not modifiable: 37.2 (27.1-47.2)
Age at menarche: 7.7 (0.2-14.1)
Age at menopause: 12.0 (3.9-20.2)
Parity: 10.9 (1.3-18.8)
1st degree family history: 5.7 (4.1-7.5)
History of benign breast disease: 7.9 (4.4-11.6)
Not reported
Modifiable
Alcohol (≥ 1 g/day) = 0.93-0.93
BMI (> 22.4 kg/m(2)) = 0.93-1.06
HT, current use (E, E+P, or other) = 1.19-2.25
Physical activity (< 76.5 MET hrs/wk of recreational activities since age 50 yrs) = 1.16-1.23
Modifiable: 26.3 (13.7-37.5)
Alcohol: -7.6 (-21.1-3.6)
BMI: 2.4 (-2.8-7.4)
HT: 19.4 (15.9-23.2)
Physical activity: 12.8 (5.5-20.8)
Physical activity = 0.75

Sufficiently active (3,000 MET-minutes in 7 days or 1,500 MET-minutes of vigorous activity over 3 or more days)
Not sedentary (≥ 600 METminutes over 7 days)
Insufficiently active: 20
Sedentary: 10
Insufficiently active: 83,353 cases/yr
Sedentary: 42,837 cases/yr
Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×
Source Study Location and Type Study Population Characteristics
Petracci et al. (2011) Italy

Model to predict absolute risk; tested with independent data
Absolute risks: Florence cancer registry (1989-1993)

For model development: Case—control subjects (1991–1994), ages 20–74

For validation: Florence-EPIC cohort (1998–2004), ages 35–64

NOTES: Variation across studies in estimated PAR values reflects differences in the prevalence of exposure, in overlap among multiple risk factors, in susceptibility to the risk factor, and in the degree of control for confounding. For these and other reasons, the PARs should be viewed as ballpark estimates based on current science and the assumption that measured associations for these factors are primarily causal.

REFERENCES

Bakken, K., E. Alsaker, A. E. Eggen, and E. Lund. 2004. Hormone replacement therapy and incidence of hormone-dependent cancers in the Norwegian Women and Cancer study. Int J Cancer 112(1):130–134.

Barnes, B. B., K. Steindorf, R. Hein, D. Flesch-Janys, and J. Chang-Claude. 2010. Population attributable risk of invasive postmenopausal breast cancer and breast cancer subtypes for modifiable and non-modifiable risk factors. Cancer Epidemiol 35(4):345–352.

Clarke, C., D. Purdie, and S. Glaser. 2006. Population attributable risk of breast cancer in white women associated with immediately modifiable risk factors. BMC Cancer 6(1):170.

Friedenreich, C. M., H. K. Neilson, and B. M. Lynch. 2010. State of the epidemiological evidence on physical activity and cancer prevention. Eur J Cancer 46(14):2593–2604.

Madigan, M. P., R. G. Ziegler, J. Benichou, C. Byrne, and R. N. Hoover. 1995. Proportion of breast cancer cases in the United States explained by well-established risk factors. J Natl Cancer Inst 87(22):1681–1685.

Mezzetti, M., C. La Vecchia, A. Decarli, P. Boyle, R. Talamini, and S. Franceschi. 1998. Population attributable risk for breast cancer: Diet, nutrition, and physical exercise. J Natl Cancer Inst 90(5):389–394.

Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×

Risk Factors and Relative Risk Estimatesa Population Attributable Risk in Percentb (95% CI, where available) Impact on Absolute Risk
Aggregate contribution of elimination of risk factors

(no alcohol consumption, physical activity of ≥ 2 hrs per week, and BMI at age ≥ 50 yrs of < 25 kg/m2)
Entire population

10-yr period
Age 45: 20.5 (11.0-29.2)
Age 55: 24.5 (14.7-34.2)
Age 65: 24.5 (14.6-34.1)




Absolute risk reduction from elimination of risk factors, reported in percentage point change (95% CI)

Entire population

10-yr period
Age 45: 0.6 (0.3-1.0)
Age 55: 0.8 (0.5-1.1)
Age 65: 0.9 (0.5-1.3)

20-yr period
Age 45: 1.4 (0.7-2.0)
Age 55: 1.6 (0.9-2.3)
Age 65: 1.6 (0.9-2.3)

Abbreviations: BMI, body mass index; CI, confidence interval; E, estrogen-only hormone therapy; E+P, estrogen–progestin hormone therapy; EPIC, European Prospective Investigation into Cancer; HT, hormone therapy; IARC, International Agency for Research on Cancer; MET, metabolic equivalent; NHANES, National Health and Nutrition Examination Survey; PAR, population attributable risk; RR, relative risk.

aIncludes relative risks or odds ratios, when reported; range of relative risks provided when multiple risk categories were used in the original report.

bPopulation attributable risk is the fraction of all cases of breast cancer in the studied population in which the factor of interest appears to play a role.

Neutel, C. I., and H. Morrison. 2010. Could recent decreases in breast cancer incidence really be due to lower HRT use? Trends in attributable risk for modifiable breast cancer risk factors in Canadian women. Can J Public Health 101(5):405–409.

Petracci, E., A. Decarli, C. Schairer, R. M. Pfeiffer, D. Pee, G. Masala, D. Palli, M. H. Gail. 2011. Risk factor modification and projections of absolute breast cancer risk. J Natl Cancer Inst 103(13):1037–1048.

Rockhill, B., C. R. Weinberg, and B. Newman. 1998. Population attributable fraction estimation for established breast cancer risk factors: Considering the issues of high prevalence and unmodifiability. Am J Epidemiol 147(9):826–833.

Sprague, B. L., A. Trentham-Dietz, K. M. Egan, L. Titus-Ernstoff, J. M. Hampton, and P. A. Newcomb. 2008. Proportion of invasive breast cancer attributable to risk factors modifiable after menopause. Am J Epidemiol 168(4):404–411.

Tseng, M., C. R. Weinberg, D. M. Umbach, and M. P. Longnecker. 1999. Calculation of population attributable risk for alcohol and breast cancer (United States). Cancer Causes Control 10(2):119–123.

Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
×

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Suggested Citation:"Appendix D: Summary Table on Estimates of Population Attributable Risk." Institute of Medicine. 2012. Breast Cancer and the Environment: A Life Course Approach. Washington, DC: The National Academies Press. doi: 10.17226/13263.
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Breast cancer remains the most common invasive cancer among women. The primary patients of breast cancer are adult women who are approaching or have reached menopause; 90 percent of new cases in U.S. women in 2009 were diagnosed at age 45 or older. Growing knowledge of the complexity of breast cancer stimulated a transition in breast cancer research toward elucidating how external factors may influence the etiology of breast cancer.

Breast Cancer and the Environment reviews the current evidence on a selection of environmental risk factors for breast cancer, considers gene-environment interactions in breast cancer, and explores evidence-based actions that might reduce the risk of breast cancer. The book also recommends further integrative research into the elements of the biology of breast development and carcinogenesis, including the influence of exposure to a variety of environmental factors during potential windows of susceptibility during the full life course, potential interventions to reduce risk, and better tools for assessing the carcinogenicity of environmental factors. For a limited set of risk factors, evidence suggests that action can be taken in ways that may reduce risk for breast cancer for many women: avoiding unnecessary medical radiation throughout life, avoiding the use of some forms of postmenopausal hormone therapy, avoiding smoking, limiting alcohol consumption, increasing physical activity, and minimizing weight gain.

Breast Cancer and the Environment sets a direction and a focus for future research efforts. The book will be of special interest to medical researchers, patient advocacy groups, and public health professionals.

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