Association between the Adherence to the International Guidelines for Cancer Prevention and Mammographic Density

RESEARCH ARTICLE Association between the Adherence to the International Guidelines for Cancer Prevention and Mammographic Density Adela Castelló1,2,3*, Leandro Prieto1, María Ederra4, Dolores Salas-Trejo5, Carmen Vidal6, Carmen Sánchez-Contador7, Carmen Santamariña8, Carmen Pedraz9, Pilar Moreo10, Nuria Aragonés1,2,3, Beatriz Pérez-Gómez1,2,3, Virginia Lope1,2,3, Jesús Vioque2,11, Marina Pollán1,2,3, DDM-Spain research group¶ OPEN ACCESS Citation: Castelló A, Prieto L, Ederra M, Salas-Trejo D, Vidal C, Sánchez-Contador C, et al. (2015) Association between the Adherence to the International Guidelines for Cancer Prevention and Mammographic Density. PLoS ONE 10(7): e0132684. doi:10.1371/journal.pone.0132684 Editor: Aamir Ahmad, Wayne State University School of Medicine, UNITED STATES Received: March 23, 2015 Accepted: June 17, 2015 Published: July 24, 2015 Copyright: © 2015 Castelló et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data are available in the paper and its Supporting Information files. Funding: This study was supported by FIS PI060386 FIS (Health Research Fund) Research Grant; EC11273 Research Grant from the Spanish Ministy of Health; CD110/00018 FIS Sara Borrell contract; FECMA 485 EPY 1170-10 grant from the Spanish Federation of Breast Cancer Patients. Competing Interests: The authors have declared that no competing interests exist. 1 Cancer Epidemiology Unit, National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain, 2 Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain, 3 Cancer Epidemiology Research Group, Oncology and Hematology Area, IIS Puerta de Hierro (IDIPHIM), Madrid, Spain, 4 Navarre Breast Cancer Screening Program, Public Health Institute, Pamplona, Spain, 5 Valencian Breast Cancer Screening Program, General Directorate of Public Health, Valencia, Spain, 6 Cancer Prevention and Control Unit, Catalonian Institute of Oncology (ICO. Barcelona, Spain, 7 Balearic Islands Breast Cancer Screening Program, Regional Authority for Health & Consumer Affairs, Palma de Mallorca, Islas Baleares, 8 Galician Breast Cancer Screening Program, Galician Regional Health Authority, A Coruña, Spain, 9 Castile-León Breast Cancer Screening Program, General Directorate of Public Health, Burgos, Spain, 10 Aragón Breast Cancer Screening Program, Aragon Health Service, Zaragoza, Spain, 11 Universidad Miguel Hernandez, Sant Joan D'Alacant, Spain ¶ Membership of the DDM-Spain research group is provided in the acknowledgments section. * Abstract Introduction Mammographic density (MD) is considered a strong predictor of Breast Cancer (BC). The objective of the present study is to explore the association between MD and the compliance with the World Cancer Research Fund and the American Institute for Cancer Research (WCRF/AICR) recommendations for cancer prevention. Methods Data of 3584 women attending screening from a population-based multicenter cross-sectional study (DDM-Spain) collected from October 7, 2007 through July 14, 2008, was used to calculate a score that measures the level of compliance with the WCRF/AICR recommendations: R1)Maintain adequate body weight; R2)Be physically active; 3R)Limit the intake of high density foods; R4)Eat mostly plant foods; R5)Limit the intake of animal foods; R6)Limit alcohol intake; R7)Limit salt and salt preserved food intake; R8)Meet nutritional needs through diet. The association between the score and MD (assessed by a single radiologist using a semi-quantitative scale) was evaluated using ordinal logistic models with random center-specific intercepts adjusted for the main determinants of MD. Stratified analyses by menopausal status and smoking status were also carried out. PLOS ONE | DOI:10.1371/journal.pone.0132684 July 24, 2015 1 / 16 WCRF/AICR Recommendations and Mammographic Density Results A higher compliance with the WCRF/AICR recommendations was associated with lower MD (OR1-unit increase = 0.93 95%CI:0.86;0.99). The association was stronger in postmenopausal women (OR = 0.91 95%CI:0.84;0.99) and nonsmokers (OR = 0.87;95%CI:0.80;0.96 for nonsmokers, OR = 1.01 95%CI:0.91;1.12 for smokers, P-interaction = 0.042). Among nonsmokers, maintaining adequate body weight (OR = 0.81 95%CI:0.65;1.01), practicing physical activity (OR = 0.68 95%CI:0.48;0.96) and moderating the intake of high-density foods (OR = 0.58 95%CI:0.40;0.86) and alcoholic beverages (OR = 0.76 95%CI:0.55;1.05) were the recommendations showing the strongest associations with MD. Conclusions postmenopausal women and non-smokers with greater compliance with the WCRF/AICR guidelines have lower MD. These results may provide guidance to design specific recommendations for screening attendants with high MD and therefore at higher risk of developing BC. Introduction The World Cancer Research Fund and the American Institute of Cancer Research (WCRF/ AICR) estimate that around one fourth of cancer cases from high and medium income countries are preventable by adopting healthier lifestyles concerning diet, physical activity and body fatness. Regarding Breast Cancer (BC), published evidence indicates that between 20% and 42% of cases could be prevented in countries such as the USA, the UK, Brazil and China [1]. Taking into account that breast tumours are the most common cancer among women and one of the main causes of adult female mortality in developed countries [2], preventive strategies are of special importance. The WCRF/AICR issued in 2007, 8 general and 2 special recommendations on diet, physical activity and weight management for cancer prevention based on the available evidence [3, 4]. Five studies have already explored the association between compliance with such recommendations and BC risk, showing a beneficial effect [5–9]. A high mammographic density (MD), i.e. a high percentage of dense breast tissue, is considered a strong risk factor for BC [10, 11]. MD has also been associated with some of the WCRF/ AICR recommendations such as body fatness [12, 13], diet[14, 15] and other obstetric and gynecological factors [16, 17], although, to our knowledge, no studies have investigated the relationship between adherence to the WCRF/AICR guidelines and MD. In this paper, the association between compliance with these recommendations and MD was explored in a group of Spanish women attending population-based BC screening programs, globally and separately according to their menopausal status. Finally, given the antiestrogenic effect of tobacco [18, 19], we hypothesized that this association might be different in smokers and nonsmokers. Therefore, we also explored the relationship between these recommendations and MD by smoking status. Methods Study p (...truncated)