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JAMA Oncology 2017年2月2日，《美国医学会杂志·肿瘤学分册》在线发表加利福尼亚大学旧金山分校、加利福尼亚大学戴维斯分校、华盛顿州集团医疗协作组织、佛蒙特大学起草的二十万女性人群病例对照研究，发现两大乳腺癌临床风险因素：乳腺密度、体重指数。 该研究将乳腺癌监测联盟（BCSC）社区医疗机构乳腺钼靶检查登记数据库的202746位女性（绝经前58146位，绝经后144600位），根据年龄、风险因素评估年份按1∶10进行匹配，其中18437位浸润性乳腺癌或导管原位癌女性为病例组（绝经前、后女性的平均年龄分别为46.3±3.7、61.7±7.2岁）、184309位无乳腺癌女性为对照组，于1996年1月1日～2012年10月31日前瞻性收集乳腺癌相关临床风险因素数据，包括乳腺成像报告与数据系统（BI-RADS）乳腺密度（不均匀或极度致密，对比纤维腺体密度分散）、乳腺癌一级家族史、体重指数（＞25，对比18.5～25）、良性乳腺活检史、未育或生育第一胎时年龄（≥30岁，对比＜30岁）。衡量指标为人群归因风险比重（PARP）。 结果发现，4747位绝经前（89.8%）和12502位绝经后（95.1%）乳腺癌女性至少有1个乳腺癌风险因素。绝经前、后女性的所有风险因素综合PARP分别为52.7%、54.7%（95%置信区间：49.1～56.3%、46.5～54.7%）。 乳腺密度是绝经前、后女性最普遍的风险因素，对PARP的影响最大。体重指数对绝经后女性的影响较大。 乳腺密度不均匀或极度致密的女性，与纤维腺体密度分散的女性相比，绝经前、后乳腺癌的风险分别增加39.3%、26.2%（95%置信区间：36.6～42.0%、24.4～28.0%）。 体重指数＞25的超重和肥胖女性，与体重指数为18.5～25的女性相比，绝经后乳腺癌的风险增加22.8%（95%置信区间：18.3～27.3%）。 因此，大多数乳腺癌女性在常规乳腺钼靶检查时被发现至少有1个乳腺癌风险因素，这些因素可以解释超过一半的绝经前、后乳腺癌。这些容易评估的风险因素应被纳入风险预测模型，对乳腺癌临床风险进行分层，并促进风险筛查（例如乳腺密度、体重指数）和有针对性的预防措施（例如减重或减肥）。 JAMA Oncol. 2017 Feb 2. [Epub ahead of print] Population-Attributable Risk Proportion of Clinical Risk Factors for Breast Cancer. Natalie J. Engmann; Marzieh K. Golmakani; Diana L. Miglioretti; Brian L. Sprague; Karla Kerlikowske; for the Breast Cancer Surveillance Consortium. University of California, San Francisco; University of California, Davis; Group Health Cooperative, Seattle, Washington; University of Vermont, Burlington. This population-based, case-control, cohort study uses data from the Breast Cancer Surveillance Consortium to assess risk factors associated with breast cancer in premenopausal and postmenopausal women. KEY POINTS QUESTION: What proportion of premenopausal and postmenopausal breast cancers are attributed to commonly collected clinical risk factors? FINDINGS: In this population-based, case-control, cohort study of 202,746 women, breast density and body mass index had the largest individual population-attributable risk proportion. Thirty-nine percent of premenopausal and 26% of postmenopausal breast cancers could be prevented if breast density in women with dense breasts was reduced to scattered fibroglandular densities on the Breast Imaging Reporting and Data System scale, and postmenopausal breast cancer incidence would be reduced by 23% if all women achieved a body mass index less than 25. MEANING: Clinical breast cancer risk factors explain a large proportion of breast cancer incidence and should be used in the clinical setting for risk stratification and targeted screening and prevention efforts. ABSTRACT IMPORTANCE: Many established breast cancer risk factors are used in clinical risk prediction models, although the proportion of breast cancers explained by these factors is unknown. OBJECTIVE: To determine the population-attributable risk proportion (PARP) for breast cancer associated with clinical breast cancer risk factors among premenopausal and postmenopausal women. DESIGN, SETTING, AND PARTICIPANTS: Case-control study with 1:10 matching on age, year of risk factor assessment, and Breast Cancer Surveillance Consortium (BCSC) registry. Risk factor data were collected prospectively from January 1, 1996, through October 31, 2012, from BCSC community-based breast imaging facilities. A total of 18,437 women with invasive breast cancer or ductal carcinoma in situ were enrolled as cases and matched to 184,309 women without breast cancer, with a total of 58,146 premenopausal and 144,600 postmenopausal women enrolled in the study. EXPOSURES: Breast Imaging Reporting and Data System (BI-RADS) breast density (heterogeneously or extremely dense vs scattered fibroglandular densities), first-degree family history of breast cancer, body mass index (>25 vs 18.5-25), history of benign breast biopsy, and nulliparity or age at first birth (≥30 years vs <30 years). MAIN OUTCOMES AND MEASURES: Population-attributable risk proportion of breast cancer. RESULTS: Of the 18,437 women with breast cancer, the mean (SD) age was 46.3 (3.7) years among premenopausal women and 61.7 (7.2) years among the postmenopausal women. Overall, 4747 (89.8%) premenopausal and 12,502 (95.1%) postmenopausal women with breast cancer had at least 1 breast cancer risk factor. The combined PARP of all risk factors was 52.7% (95% CI, 49.1%-56.3%) among premenopausal women and 54.7% (95% CI, 46.5%-54.7%) among postmenopausal women. Breast density was the most prevalent risk factor for both premenopausal and postmenopausal women and had the largest effect on the PARP; 39.3% (95% CI, 36.6%-42.0%) of premenopausal and 26.2% (95% CI, 24.4%-28.0%) of postmenopausal breast cancers could potentially be averted if all women with heterogeneously or extremely dense breasts shifted to scattered fibroglandular breast density. Among postmenopausal women, 22.8% (95% CI, 18.3%-27.3%) of breast cancers could potentially be averted if all overweight and obese women attained a body mass index of less than 25. CONCLUSIONS AND RELEVANCE: Most women with breast cancer have at least 1 breast cancer risk factor routinely documented at the time of mammography, and more than half of premenopausal and postmenopausal breast cancers are explained by these factors. These easily assessed risk factors should be incorporated into risk prediction models to stratify breast cancer risk and promote risk-based screening and targeted prevention efforts. DOI: 10.1001/jamaoncol.2016.6326 |
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