Excess body weight and sub-optimal lifestyle are modifiable causes of breast cancer and other diseases. There is little evidence that behaviour change is possible within screening programmes and ...whether this is influenced by prior knowledge of disease risk. We determined whether breast cancer risk influences uptake, retention and efficacy of a weight control programme in the UK National Health Service Breast Screening Programme, and whether additional cardiovascular disease and type 2 diabetes risk information improves uptake and retention further.
Overweight/obese women in the UK National Health Service Breast Screening Programme identified at high, moderately increased, average and low-risk of breast cancer were randomised to receive individualised breast cancer risk information (breast cancer prevention programme), or individualised breast cancer, cardiovascular disease (QRISK2) and type 2 diabetes (QDiabetes, HbA1c) information (multiple disease prevention programme). Personalised breast cancer risk feedback was given before randomisation in Study-1, and after randomisation in Study-2.
Recruitment was 9% (126/1356) in Study-1 and 7% (52/738) in Study-2. With respect to breast cancer risk, odds ratio of uptake for high/moderately increased vs low risk women was 1.99 (95% CI 1.24-3.17, P = 0.004) in Study-1 and 3.58 (95% CI 1.59-8.07, P = 0.002) in Study-2. Odds ratio of retention for high/moderately increased -risk vs. low risk women was 2.98 (95% CI 1.05-8.47, P = 0.041) in Study-1 and 3.88 (95% CI 1.07-14.04, P = 0.039) in Study-2. Weight loss of ≥5% at 12 months was achieved by 63% high/moderate vs. 43% low-risk women in Study-1 (P = 0.083) and 39% vs. 8% in Study-2 (P = 0.008). Uptake, retention and weight loss were equivalent in both the breast cancer prevention programme and the multiple disease prevention programme in both studies.
Women who are informed that they are at increased breast cancer risk were significantly more likely to join and remain in the programmes and consequently lose more weight across both studies. High risk women are more likely engage in a lifetyle prevention programme and also have the greatest potential benefit fom risk reduction strategies.
ISRCTN91372184 Registered 28 September 2014.
Excess weight (BMI ≥25.0 kg/m
) and weight gain during adult life increase the risk of postmenopausal breast cancer in women who are already at increased risk of the disease. Reasons for weight gain ...in this population can inform strategies for weight gain prevention.
Baseline data from six weight loss studies for women at increased risk of breast cancer (age 31-74 years) were collated. Self-reported patterns of adult weight gain and attributed reasons for weight gain before joining the weight loss study were reported for the whole population and secondary analyses reported the different reasons given by women with/without children, pre-/peri- or postmenopausal, and moderate/high risk of breast cancer.
Five hundred and one women with a mean age of 47.6 (SD 8.4) years and median BMI of 29.9 (IQR 27.0-34.7) kg/m
were included in the analyses. The median weight gain since young adulthood (18-20 years) was 20.5 (IQR 14.0-29.7) kg or 33.7 (23.4-50.2) % and median annual weight gain was 0.73 (IQR 0.51-1.08) kg. Four hundred and one women were included in analysis of weight gain reasons. The main five self-reported reasons for weight gain were children / childcare / pregnancy (stated by 55.9% of participants), followed by inactivity (41.9%), comfort or boredom eating (38.2%), portion size (32.4%), and stress (27.4%). Reasons appeared broadly similar between the different groups in the secondary analyses.
We have highlighted common reasons for weight gain in women at increased risk of breast cancer. This will inform future interventions to support women to avoid weight gain in adulthood which would reduce the burden of breast cancer.
NIHR NRR N0226132725, ISRCTN52913838, ISRCTN77916487, ISRCTN91372184, ISRCTN10803394 and ISRCTN16431108.
Obesity in early adulthood is associated with lower breast cancer rates in later life. This could be interpreted as a positive reinforcement of excess weight amongst younger women however, the wider ...implications of higher weights are less well known. This study examined the association between both obesity in early adulthood and body mass index (BMI) change through adulthood, and all-cause mortality.
The Predicting Risk of Cancer At Screening (PROCAS) study recruited 57,902 women aged 46-73 years (median age 57.2, IQR 51.8-63.7 years) from the Greater Manchester National Health Service breast screening programme in North West England between 2009 and 2015. It was used to assess associations between BMI at 20 years and cohort entry with all-cause mortality ascertained via deaths recorded on the National Breast Screening System to June 2020. Hazard ratios were estimated using proportional hazards (Cox) regression adjusted for factors at entry to the cohort: age, deprivation, bilateral oophorectomy, hormone-replacement therapy, menopausal status, ethnicity, alcohol intake, physical activity, and BMI.
The prevalence of overweight (25-30 kg/m
) and obesity (> 30 kg/m
) were 10.4% and 2.5% respectively at 20 years, increasing to 35.2% and 25.9% respectively at cohort entry. After a mean 8.7 years follow-up we observed that overweight (HR = 1.27, 95%CI = 1.10-1.47) and obesity (HR = 2.11, 95%CI = 1.67-2.66) at 20 years had a higher mortality rate compared with healthy weight. Women who were underweight/healthy weight at 20 years and gained weight to obesity at entry had a slightly increased mortality rate compared with women who were underweight/healthy weight at both time points (HR 1.16, 95%CI = 1.02-1.32). Women with overweight (HR = 1.36, 95%CI = 1.06-1.75) or obesity (HR = 1.90, 95%CI = 1.45-2.48) at both 20 years and entry had a higher mortality rate than women who were underweight/healthy weight at both points.
Women who self-reported overweight and obesity at 20 years had a shorter life expectancy in this cohort of women attending breast cancer screening. Weight gain from 20 years was common in this group. Girls and women should be supported to maintain a healthy weight throughout the lifespan to help increase life expectancy. Trial registration number NCT04359420, retrospectively registered 24/04/2020.
Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of ...1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987-2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17-29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in
and
but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14-27% entered various lifestyle studies. From 1992-2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013-2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.
Excess weight and unhealthy behaviours (e.g. sedentariness, high alcohol) are common amongst women including those attending breast screening. These factors increase the risk of breast cancer and ...other diseases. We tested the feasibility and acceptability of a weight loss/behaviour change programme framed to reduce breast cancer risk (breast cancer prevention programme, BCPP) compared to one framed to reduce risk of breast cancer, cardiovascular disease (CVD) and diabetes (T2D) (multiple disease prevention programme, MDPP).
Women aged 47-73 years with overweight or obesity (n = 1356) in the NHS Breast Screening Programme (NHSBSP) were randomised (1:2) to be invited to join a BCPP or a MDPP. The BCPP included personalised information on breast cancer risk and a web and phone weight loss/behaviour change intervention. The MDPP also included an NHS Health Check (lipids, blood pressure, HbA1c and personalised feedback for risk of CVD QRISK2 and T2D QDiabetes and HbA1c). Primary outcomes were uptake and retention and other feasibility outcomes which include intervention fidelity and prevalence of high CVD and T2D risk. Secondary outcomes included change in weight.
The BCPP and MDPP had comparable rates of uptake: 45/508 (9%) vs. 81/848 (10%) and 12-month retention; 33/45 (73%) vs. 53/81 (65%). Both programmes had a high fidelity of delivery with receipt of mean (95% CI) 90 (88-98% of scheduled calls, 91 (86-95%) of scheduled e-mails and 89 (76-102) website entries per woman over the 12-month period. The MDPP identified 15% of women with a previously unknown 10-year CVD QRISK2 of ≥ 10% and 56% with 10-year Qdiabetes risk of ≥ 10%. Both groups experienced good comparable weight loss: BCPP 26/45 (58%) and MDPP 46/81 (57%) with greater than 5% weight loss at 12 months using baseline observation carried forward imputation.
Both programmes appeared feasible. The MDPP identified previously unknown CVD and T2D risk factors but does not appear to increase engagement with behaviour change beyond a standard BCPP amongst women attending breast screening. A future definitive effectiveness trial of BCPP is supported by acceptable uptake and retention, and good weight loss.
ISRCTN91372184 , registered 28 September 2014.
Breast cancer is the most common form of cancer in women, and around 20% of cases are associated with factors such as adult weight gain, overweight and obesity, and potentially modifiable health ...behaviors including high alcohol intake, smoking, lack of physical activity, and breastfeeding. Significant weight gain occurs between the ages of 18 and 35 years; hence, this age group could benefit from weight gain prevention interventions. Population studies have reported that women at increased risk of breast cancer account for a disproportionate amount of cases. Thus, there is a particular need to target weight gain prevention and other health behavior interventions for women at increased risk. A literature review identified no evidence-based apps that cover all relevant health behaviors. With patient and participant involvement from the target population, we have developed a new app to promote healthy behaviors among young women at increased risk of breast cancer. Alongside the app, a Facebook group provides peer support, and a virtual welcome event provides an overview of the project and the opportunity to meet the research team and other study participants. The aim of the intervention is to prevent weight gain via changes to eating habits and physical activity levels, and improve other health behaviors associated with breast cancer. The app includes goal setting and self-monitoring of health behaviors and provides education about breast cancer.
This study aims to assess the acceptability and usability of the app in young women at increased risk of breast cancer, and the feasibility of the study procedures for a future, larger efficacy study.
Young women (n=35, age 18-35 years) at increased risk of breast cancer (>17% lifetime risk) will be recruited via 2 recruitment procedures: mailed invite from the local breast cancer family history, risk and prevention clinic, and advertisements on social media and websites. Participants will have access to the app and the private Facebook group for 2 months. They will complete questionnaires regarding their health behaviors and breast cancer risk belief at the start and end of the study, complete app rating scales in the middle and at the end of the study, and be invited to give feedback on the app during the study period. Approximately 20 participants will have a semistructured interview at the end of the study regarding their views on the app and trial procedures.
The trial is ongoing, and the publication of results is anticipated in 2023.
The trial will provide evidence regarding the acceptability and usability of the newly developed app for young women at increased risk of breast cancer. Feedback obtained will be used to improve the app. The trial will also assess the feasibility of the study procedures and how these can be refined for a future efficacy study.
ClinicalTrials.gov NCT05460650; https://clinicaltrials.gov/ct2/show/NCT05460650.
PRR1-10.2196/41246.
Excess weight at breast cancer diagnosis and weight gain during treatment are linked to increased breast cancer specific and all-cause mortality. The Breast—Activity and Healthy Eating After ...Diagnosis (B-AHEAD) trial tested 2 weight loss diet and exercise programmes versus a control receiving standard written advice during adjuvant treatment. This article identifies differences in characteristics between patients recruited from the main trial site to those of the whole population from that site during the recruitment period and identifies barriers to recruitment. A total of 409 patients with operable breast cancer were recruited within 12 weeks of surgery. We compared demographic and treatment factors between women recruited from the main trial coordinating site (n = 300) to the whole breast cancer population in the center (n = 532). Uptake at the coordinating site was 42%, comparable to treatment trials in the unit (47%). Women recruited were younger (55.9 vs 61.2 years, P < .001), more likely to live in least deprived postcode areas (41.7% vs 31.6%, P = .004), and more likely to have screen-detected cancers (55.3% vs 48.7%, P = .026) than the whole breast cancer population. The good uptake highlights the interest in lifestyle change around the time of diagnosis, a challenging time in the patient pathway, and shows that recruitment at this time is feasible. Barriers to uptake among older women and women with a lower socioeconomic status should be understood and overcome in order to improve recruitment to future lifestyle intervention programs.
Background: The problems of adherence to energy restriction in humans are well known. Objective: To compare the feasibility and effectiveness of intermittent continuous energy (IER) with continuous ...energy restriction (CER) for weight loss, insulin sensitivity and other metabolic disease risk markers. Design: Randomized comparison of a 25% energy restriction as IER (approximately 2710 kJ/day for 2 days/week) or CER (approximately 6276 kJ/day for 7 days/week) in 107 overweight or obese (mean (+/-s.d.) body mass index 30.6 (+/-5.1) kg m-2) premenopausal women observed over a period of 6 months. Weight, anthropometry, biomarkers for breast cancer, diabetes, cardiovascular disease and dementia risk; insulin resistance (HOMA), oxidative stress markers, leptin, adiponectin, insulin-like growth factor (IGF)-1 and IGF binding proteins 1 and 2, androgens, prolactin, inflammatory markers (high sensitivity C-reactive protein and sialic acid), lipids, blood pressure and brain-derived neurotrophic factor were assessed at baseline and after 1, 3 and 6 months. Results: Last observation carried forward analysis showed that IER and CER are equally effective for weight loss: mean (95% confidence interval ) weight change for IER was -6.4 (-7.9 to -4.8) kg vs -5.6 (-6.9 to -4.4) kg for CER (P-value for difference between groups=0.4). Both groups experienced comparable reductions in leptin, free androgen index, high-sensitivity C-reactive protein, total and LDL cholesterol, triglycerides, blood pressure and increases in sex hormone binding globulin, IGF binding proteins 1 and 2. Reductions in fasting insulin and insulin resistance were modest in both groups, but greater with IER than with CER; difference between groups for fasting insulin was -1.2 (-1.4 to -1.0) micromoll-1 and for insulin resistance was -1.2 (-1.5 to -1.0) micromol-1 l-1 (both P=0.04). Conclusion: IER is as effective as CER with regard to weight loss, insulin sensitivity and other health biomarkers, and may be offered as an alternative equivalent to CER for weight loss and reducing disease risk.
Breast cancer (BC) is the most frequent female malignancy in the UK and worldwide. Potentially modifiable factors such as adult weight gain, alcohol, smoking and lack of physical activity (PA) are ...estimated to be linked to around 20% of cases.Health behaviours increase risk to an equal or greater extent in women with a family history of BC compared to those at population risk. This PhD researches the magnitude of adult weight gain and the presence of overweight and sub-optimal health behaviours in women at increased risk. It includes eight projects culminating in development and testing of an app to prevent weight gain in young women at increased risk.Theme 1: The problem of weight gain:My narrative review showed that significant weight gain occurs in young adulthood (age 18-35 years). Key life events associated with weight gain include pregnancy and motherhood, marriage and cohabiting, mediators of weight gain include lack of knowledge, and moderators include socioeconomic status.Analysis of data from the PROCAS study (n=47,042) found that higher BMI at age 20 was inversely associated with postmenopausal BC (HR per SD 0.87, 95% CI 0.79-0.95), and that weight gain was positively associated with BC only in women with BMI at age 20 <23.4 kg/m2 (HR per SD: 1.31, 95% CI 1.21–1.42). A further analysis (n=48,604) showed that overweight and obesity at age 20 increased all-cause mortality compared with healthy weight at this age (HR 1.27, 95% CI 1.10-1.47; and 2.11, 1.67-2.66 respectively). Overall mortality was similarly increased in women with BMI <25kg/m2 at 20 years who had developed obesity by the time of PROCAS entry (median age 57.2, IQR 51.8-63.7 years) compared to women who had BMI <25kg/m2at both time points (HR 1.16, 95%CI 1.02- 1.32). Thus strengthening the need for effective weight gain prevention interventions for young adult females.Theme 2: Weight gain and health behaviours in women attending high risk clinics: Analysis of data from women at increased BC risk taking the BC-prevention drug, Tamoxifen (n=136), found high rates of overweight/obesity and low adherence to PA recommendations, which were comparable to women in the general population (59.2 vs 55.2%, p=0.709 and 30.6 vs 35.1%, p=0.229 respectively). I analysed Manchester Family, Risk and Prevention Clinic data (n=10,149 women) and showed an increase in BMI at referral over the last three decades from 23.7 (range 21.6-26.4) in 1990-4 to 24.8 (22.0- 28.5) kg/m2in 2015-9 (p<0.001). An analysis of reasons for weight gain cited by women with overweight and obesity at increased risk of BC also highlighted pregnancy and motherhood as the main reason (stated by 56% of all participants and 68.5% of those with children), followed by inactivity (41.9%), and comfort or boredom eating (38.2%).
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