Association between menopausal hormone therapy, mammographic density and breast cancer risk: results from the E3N cohort study.

BACKGROUND: Menopausal hormone therapy (MHT) is a risk factor for breast cancer (BC). Evidence suggests that its effect on BC risk could be partly mediated by mammographic density. The aim of this study was to investigate the relationship between MHT, mammographic density and BC risk using data from a prospective study. METHODS: We used data from a case-control study nested within the French cohort E3N including 453 cases and 453 matched controls. Measures of mammographic density, history of MHT use during follow-up and information on potential confounders were available for all women. The association between MHT and mammographic density was evaluated by linear regression models. We applied mediation modelling techniques to estimate, under the hypothesis of a causal model, the proportion of the effect of MHT on BC risk mediated by percent mammographic density (PMD) for BC overall and by hormone receptor status. RESULTS: Among MHT users, 4.2% used exclusively oestrogen alone compared with 68.3% who used exclusively oestrogens plus progestogens. Mammographic density was higher in current users (for a 60-year-old woman, mean PMD 33%; 95% CI 31 to 35%) than in past (29%; 27 to 31%) and never users (24%; 22 to 26%). No statistically significant association was observed between duration of MHT and mammographic density. In past MHT users, mammographic density was negatively associated with time since last use; values similar to those of never users were observed in women who had stopped MHT at least 8 years earlier. The odds ratio of BC for current versus never MHT users, adjusted for age, year of birth, menopausal status at baseline and BMI, was 1.67 (95% CI, 1.04 to 2.68). The proportion of effect mediated by PMD was 34% for any BC and became 48% when the correlation between BMI and PMD was accounted for. These effects were limited to hormone receptor-positive BC. CONCLUSIONS: Our results suggest that, under a causal model, nearly half of the effect of MHT on hormone receptor-positive BC risk is mediated by mammographic density, which appears to be modified by MHT for up to 8 years after MHT termination.

Weight change in older adults and mortality: the Multiethnic Cohort Study.

OBJECTIVE: To investigate the association between weight change in older adults and mortality in a multiethnic population. METHODS: We performed a prospective analysis using data on weight change between the baseline (1993-1996) and the 10-year follow-up (2003-2007) surveys in relation to subsequent mortality among 63 040 participants in the Multiethnic Cohort Study in Hawaii and California. The participants were African American, Native Hawaiian, Japanese American, Latino and white, aged 45-75 years at baseline, and did not report heart disease or cancer at either survey. RESULTS: During an average of 7.3 years of follow-up after the 10-year survey, 6623 deaths were identified. Compared with individuals whose weight remained stable (±2.5 kg), those who lost weight and those with the highest weight gain (>10 kg) were at increased risk of all-cause mortality, with the risks greater for the weight loss (hazard ratios (HR): 2.86; 95% confidence interval (95% CI): 2.62-3.11 for >10 kg) than the weight-gain group (HR: 1.25; 95% CI: 1.11-1.41 for >10 kg), thus resulting in a reverse J-shaped curve. Japanese Americans and Latinos had stronger associations of weight loss >10 kg with mortality than did African Americans, Native Hawaiians and whites. The increase in risk with weight gain >10 kg was greater for older (⩾55 years at baseline) than younger individuals, whereas the increase in mortality associated with weight loss was greater for the normal weight (<25 kg m-2 at baseline) participants and never smokers, compared with overweight/obese persons and current smokers, respectively. CONCLUSIONS: Our findings confirm the association between weight change and a higher mortality in a healthy, multiethnic population, with higher risks for weight loss than weight gain. On the basis of these observations, public health recommendation should focus on the prevention of weight loss, as well as weight stability within the non-obese range, for middle-aged and older adults.

Ethnic admixture affects diabetes risk in native Hawaiians: the Multiethnic Cohort.

BACKGROUND/OBJECTIVES: Obesity and diabetes rates are high in Native Hawaiians (NHs) who commonly have mixed ancestries. People of Asian ancestry experience a high risk of type 2 diabetes despite the relatively low body weight. We evaluated the impact of ethnic admixture on diabetes risk among NHs in the Multiethnic Cohort (MEC). SUBJECTS/METHODS: On the basis of self-reports, 11 521 eligible men and women were categorized into NH/white, NH/other, NH alone, NH/Asian and the most common three ancestry admixture, NH/Chinese/white. Cox proportional hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with the NH/white category as the reference group; covariates included known confounders-that is, body mass index (BMI), dietary and other lifestyle factors. RESULTS: The NH alone category had the highest proportion of overweight and obese individuals and the NH/Asian category the lowest proportion. During 12 years of follow-up after cohort entry at 56 years, 2072 incident cases were ascertained through questionnaires and health plan linkages. All NH categories had higher HRs than the NH/white category before and after adjustment for BMI. In the fully adjusted models, the NH/Asian category showed the highest risk (HR=1.45; 95% CI: 1.27-1.65), followed by NH/other (HR=1.20; 95% CI: 1.03-1.39), NH/Chinese/white (HR=1.19; 95% CI: 1.04-1.37) and NH alone (HR=1.19; 95% CI: 1.03-1.37). The elevated risk by Asian admixture was more pronounced in normal weight than overweight/obese individuals. CONCLUSIONS: These findings indicate that Asian admixture in NHs is associated with a higher risk for type 2 diabetes independent of known risk factors and suggest a role for ethnicity-related genetic factors in the development of this disease.

Nutritional factors and non-Hodgkin lymphoma survival in an ethnically diverse population: the Multiethnic Cohort.

BACKGROUND/OBJECTIVES: To understand the possible effect of modifiable health behaviors on the prognosis of the increasing number of non-Hodgkin lymphoma (NHL) survivors, we examined the pre-diagnostic intake of major food groups with all-cause and NHL-specific survival in the Multiethnic Cohort (MEC). SUBJECTS/METHODS: This analysis included 2339 participants free of NHL at cohort entry and diagnosed with NHL as identified by cancer registries during follow-up. Deaths were ascertained through routine linkages to state and national death registries. Cox proportional hazards regression was applied to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and NHL-specific mortality according to pre-diagnostic intake of vegetables, fruits, red meat, processed meat, fish, legumes, dietary fiber, dairy products and soy foods assessed by food frequency questionnaire. RESULTS: The mean age at diagnosis was 71.8±8.5 years. During 4.5±4.1 years of follow-up, 1348 deaths, including 903 NHL-specific deaths, occurred. In multivariable models, dairy intake was associated with higher all-cause mortality (highest vs lowest tertile: HR=1.14, 95% CI 1.00-1.31, Ptrend=0.03) and NHL-specific (HR=1.16, 95% CI 0.98-1.37) mortality. Legume intake above the lowest tertile was related to significant 13-16% lower all-cause and NHL-specific mortality, whereas red meat and fish intake in the intermediate tertiles was associated with lower NHL-specific mortality. No association with survival was detected for the other food groups. CONCLUSIONS: These data suggest that pre-diagnostic dietary intake may not appreciably contribute to NHL survival, although the higher mortality for dairy products and the better prognosis associated with legumes agree with known biologic effects of these foods.

Ethnic differences in serum adipokine and C-reactive protein levels: the multiethnic cohort.

BACKGROUND: Ethnic disparities in metabolic disease risk may be the result of differences in circulating adipokines and inflammatory markers related to ethnic variations in obesity and body fat distribution. SUBJECTS/METHODS: In a cross-sectional design, we compared serum levels of leptin, adiponectin, C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in control subjects (321 men and 930 women) from two nested case-control studies conducted within the Multiethnic Cohort Study consisting of whites, Japanese Americans (JA), Latinos, African Americans (AA) and Native Hawaiians (NH). General linear models were applied to evaluate ethnic differences in log-transformed serum biomarker levels before and after adjusting for body mass index (BMI) at cohort entry. RESULTS: In comparison to whites, significant ethnic differences were observed for all biomarkers except TNF-α. JA men and women had significantly lower leptin and CRP levels than whites, and JA women also had lower adiponectin levels. Leptin was significantly higher in AA women (P < 0.01), adiponectin was significantly lower in AA men and women (P = 0.02 and P < 0.001), and CRP and IL-6 were significantly higher in AA men and women. Lower adiponectin (P < 0.0001) and CRP (P = 0.03) levels were the only biomarkers in NH women that differed from whites; no statistically significant differences were seen for NH men and for Latino men and women. When adjusted for BMI at cohort entry, the differences between the lowest and the highest values across ethnic groups decreased for all biomarkers except adiponectin in men indicating that ethnic differences were partially due to weight status. CONCLUSIONS: These findings demonstrate the ethnic variations in circulating adipokine and CRP levels before and after adjustment for BMI. Given the limitation of BMI as a general measure of obesity, further investigation with visceral and subcutaneous adiposity measures are warranted to elucidate ethnicity-related differences in adiposity in relation to disparities in obesity-related disease risk.

Urinary estrogen metabolites in two soy trials with premenopausal women.

BACKGROUND: Soy consumption may protect against breast cancer through modification of estrogen metabolism. OBJECTIVES: We examined the effect of soy foods on urinary estrogens and the 2-hydroxy (OH)/16α-OH estrone (E(1)) ratio in two dietary interventions with premenopausal women. SUBJECTS/METHODS: The Breast, Estrogens, And Nutrition (BEAN1) study was a 2-year randomized trial and BEAN2 a 13-month randomized crossover study. In both interventions, study participants consumed a high-soy diet with 2 soy food servings/day and a low-soy diet with <3 servings of soy/week. Urine samples were collected at baseline and at the end of the diet periods, analyzed for nine estrogen metabolites by liquid chromatography mass spectrometry, and adjusted for creatinine levels. For BEAN1, two samples for 188 participants and for BEAN2, three samples for 79 women were analyzed. We applied mixed-effects regression models with log-transformed values of estrogen metabolites and soy intake as the exposure variable. RESULTS: In BEAN1, no effect of the high-soy diet on individual estrogen metabolites or hydroxylation pathways was observed. The median 2-OH/16α-OHE(1) ratio decreased non-significantly in the intervention group from 6.2 to 5.2 as compared with 6.8 and 7.2 in the control group (P=0.63). In BEAN2, only 4-OHE(1) was significantly lower after the high-soy diet. Interaction terms of the high-soy diet with equol producer status, ethnicity and weight status revealed no significant effect modification. CONCLUSIONS: Contrary to our hypothesis and some previous reports, the results from two well-controlled dietary interventions do not support an effect of a high-soy diet on a panel of urinary estrogen metabolites and the 2-OH/16α-OHE(1) ratio.

Food intake of individuals with and without diabetes across different countries and ethnic groups.

BACKGROUND/OBJECTIVES: Given the importance of nutrition therapy in diabetes management, we hypothesized that food intake differs between individuals with and without diabetes. We investigated this hypothesis in two large prospective studies including different countries and ethnic groups. SUBJECTS/METHODS: Study populations were the European Prospective Investigation into Cancer and Nutrition Study (EPIC) and the Multiethnic Cohort Study (MEC). Dietary intake was assessed by food frequency questionnaires, and calibrated using 24h-recall information for the EPIC Study. Only confirmed self-reports of diabetes at cohort entry were included: 6192 diabetes patients in EPIC and 13 776 in the MEC. For the cross-sectional comparison of food intake and lifestyle variables at baseline, individuals with and without diabetes were matched 1:1 on sex, age in 5-year categories, body mass index in 2.5 kg/m(2) categories and country. RESULTS: Higher intake of soft drinks (by 13 and 44% in the EPIC and MEC), and lower consumption of sweets, juice, wine and beer (>10% difference) were observed in participants with diabetes compared with those without. Consumption of vegetables, fish and meat was slightly higher in individuals with diabetes in both studies, but the differences were <10%. Findings were more consistent across different ethnic groups than countries, but generally showed largely similar patterns. CONCLUSIONS: Although diabetes patients are expected to undergo nutritional education, we found only small differences in dietary behavior in comparison with cohort members without diabetes. These findings suggest that emphasis on education is needed to improve the current behaviors to assist in the prevention of complications.

Ethnic differences in weight gain and diabetes risk: the Multiethnic Cohort Study.

AIM: To improve our understanding of excess body weight and risk for diabetes type 2, the study examined the influence of weight change in the Hawaii component, including 78,006 Caucasians, Japanese Americans and Native Hawaiians, of the Multiethnic Cohort Study. METHODS: Participants aged 58.5±9.2 years completed a questionnaire at cohort entry (Qx1), including weight at age 21, and a follow-up questionnaire 5 years later (Qx2). After 14 years of follow-up, 8892 incident diabetes cases were identified through self-reports or linkups with the major health plans in Hawaii. Cox regression analysis was applied, stratified by age and adjusted for confounders, to estimate hazard ratios (HRs). RESULTS: The mean weight gain from age 21 to Qx1 was 10.5±11.0 kg and, between Qx1 and Qx2, 0.8±5.6 kg. Diabetes risk showed a significant dose-response relationship with weight gain from age 21 (P<0.0001). The respective HRs for a weight gain of 5-10 kg and greater or equal to 25 kg were 1.8 (95% CI: 1.7-2.0) and 7.7 (95% CI: 7.1-8.4), while weight loss of greater than 5 kg significantly reduced diabetes risk (HR=0.7; 95% CI: 0.6-0.9). The interaction term of weight change since age 21 with ethnicity was also highly significant (P<0.0001). Compared with stable-weight Caucasians, the adverse effects of weight gain were more pronounced in those of Japanese and Native Hawaiian descent. Weight change between Qx1 and Qx2 conferred a smaller risk. CONCLUSION: These findings support the current public-health recommendations for weight control and particularly among ethnic groups at high risk for diabetes.

Soy consumption is not protective against diabetes in Hawaii: the Multiethnic Cohort.

Based on the hypothesis that soy consumption may improve glucose tolerance, we examined the association of soy intake with diabetes risk in the Hawaii component of the Multiethnic Cohort. Among 29 719 Caucasian, 35 141 Japanese American and 10 484 Native Hawaiian men and women, 8564 incident diabetes cases were identified during 14 years of follow-up. Cox regression was used to calculate hazard ratios while adjusting for known confounders with stratifications by sex, ethnicity and weight status. We observed no protective effect of soy food consumption on diabetes risk in this population, which has a wide range of soy intakes though lower than in Asian populations. Indeed, higher soy food intake was associated with a weakly elevated diabetes risk across ethnic groups; the higher risk was limited to overweight and obese individuals. The current findings do not support a protective effect of modest levels of soy food consumption against diabetes.

Meat consumption and risk of type 2 diabetes: the Multiethnic Cohort.

OBJECTIVE: To examine the association of meat consumption with diabetes risk in the Hawaii component of the Multiethnic Cohort and to assess effect modification by ethnicity. DESIGN: A prospective cohort study. Baseline information on diet and lifestyle was assessed by questionnaire. The cohort was followed up for incident cases of diabetes, which were identified through self-reports, medication questionnaires, or health plan linkages. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals for diabetes associated with quintile of meat consumption. SETTING: Hawaii, USA. SUBJECTS: A total of 29,759 Caucasian, 35,244 Japanese-American and 10,509 Native Hawaiian men and women, aged 45-75 years at baseline. RESULTS: During a mean follow-up time of 14 years, 8587 incident diabetes cases were identified. Intake of red meat was positively associated with diabetes risk in men (fifth v. first quintile: HR=1.43; 95% CI 1.29, 1.59) and women (fifth v. first quintile: HR=1.30; 95% CI 1.17, 1.45) in adjusted models. The respective HR for processed red meat intake were 1.57 (95% CI 1.42, 1.75) and 1.45 (95% CI 1.30, 1.62). The association for processed poultry was weaker than for processed red meat, and fresh poultry intake was not associated with diabetes risk. For men only, we observed significant interactions of ethnicity with the red and processed red meat associations, with Caucasians experiencing slightly higher risks than Japanese-Americans. CONCLUSIONS: Our findings support the growing evidence that red and processed meat intake increase risk for diabetes irrespective of ethnicity and level of BMI.

Serum 25-hydroxyvitamin D levels and mammographic density among premenopausal women in a multiethnic population.

Although some evidence suggests a protective role of vitamin D against breast cancer, epidemiological findings are inconsistent. The current study investigated the relation of serum 25-hydroxyvitamin D (25(OH)D) levels with mammographic density. Baseline serum samples from 182 premenopausal women including 67 Caucasians and 74 Asians from a nutritional trial were analyzed for 25(OH)D. Mammographic density was assessed using a computer-assisted method. Serum 25(OH)D was not associated with mammographic density after adjustment for confounders (body mass index (BMI), age at mammogram, Asian ethnicity, age at first birth, parity and age at menarche). 25(OH)D levels were significantly lower in Asians than in Caucasians, but no significant ethnic differences in mammographic density were observed after adjusting for BMI. Although the current results indicate that serum 25(OH)D levels were not associated with mammographic density among premenopausal women, a possible protective effect of vitamin D against breast cancer may be mediated through other pathways.

Urinary isoflavonoid excretion and soy consumption in three generations of Japanese women in Hawaii.

OBJECTIVE: To explore soy intake and urinary isoflavonoid excretion within several generations of American-Japanese women based on the hypothesis that earlier generations excrete higher levels of urinary isoflavonoids, in particular the metabolite equol, than later generations. SUBJECTS: A convenience sample of 43 women from 19 families aged 18-78 years, all of whom reported at least 50% Japanese ancestry. INTERVENTIONS: Each woman collected overnight urine samples at baseline and after consuming one serving of soymilk, both samples were analyzed for the isoflavonoids daidzein, genistein and equol using liquid chromatography-mass spectrometry. RESULTS: Median isoflavone intakes during the last year were 7.2 mg/day for the first generation, 7.3 mg/day for the second generation and 6.3 mg/day for the third generation (P=0.36). At baseline, the median isoflavonoid excretion for the first generation was nonsignificantly higher than for later generations (190, 86 and 42 nmol/h; P=0.20) but after intervention, the median urinary isoflavonoid excretion was very similar for the three groups: 2465, 1895 and 2775 nmol/h (P=0.70). Following intervention, a nonsignificantly higher proportion of older than younger women (53 vs 32 and 33%; P=0.41) excreted the metabolite equol. The respective median equol excretion rates by generation following intervention were 39.5, 4.2 and 3.5 nmol/h (P=0.04). CONCLUSIONS: This small investigation among three generations of Japanese-Americans detected a higher equol production among older women after a soy challenge, but no difference in the excretion of total isoflavonoids after a standardized dose of soymilk was observed.

Serum prostate-specific antigen but not testosterone levels decrease in a randomized soy intervention among men.

BACKGROUND: Low prostate cancer incidence and high soy intake in Asian countries suggest a possible protective effect of soy foods against prostate cancer. The goal of this pilot study was to evaluate the feasibility of a randomized, crossover soy trial among men and to investigate the effects of daily soy intake on serum prostate-specific antigen (PSA) and testosterone levels. METHODS: We randomized 24 men to a high or a low soy diet for 3 months. After a 1-month washout period, the men crossed over to the other treatment. During the high soy diet, the men consumed two daily soy servings; during the low soy diet, they maintained their usual diet. During the entire study each man donated four blood samples and five overnight urine samples. Dietary compliance was assessed by soy calendars, 24-h dietary recalls, and urinary isoflavone excretion measured by high-pressure liquid chromatography with photodiode array detection. Blood samples were analyzed for serum testosterone and PSA by radioimmunoassay. When necessary, variables were log transformed. Two sample t-tests compared the two groups before each study period. Mixed models incorporating the repeated measurements were used to evaluate the effect of the soy diet on urinary isoflavone excretion and serum analytes. RESULTS: Twenty-three men aged 58.7+/-7.2 years completed the study. The compliance with the study regimen was high according to self-reported soy food intake and urinary isoflavone excretion. No significant between-group and within-group differences were detected. During the high soy diet, dietary isoflavone intake and urinary isoflavone excretion increased significantly as compared to the low soy diet. A 14% decline in serum PSA levels (P=0.10), but no change in testosterone (P=0.70), was observed during the high soy diet in contrast to the low soy diet. CONCLUSION: The high adherence as shown by three measures of compliance in this pilot trial demonstrated the feasibility of an intervention based on soy foods among free-living men.

Urinary isoflavone excretion as a compliance measure in a soy intervention among young girls: a pilot study.

OBJECTIVE: To investigate the compliance of young girls with a soy intervention. DESIGN: An 8-week dietary intervention and urine sample collection. SETTING: Free-living girls. SUBJECTS: A convenience sample of 8- to 14-y-old girls (20 started and 17 finished the study) recruited through flyers distributed to staff members and previous study participants. INTERVENTION: The girls consumed one daily serving of soymilk, soy nuts, or tofu, completed 3-day food records, kept daily soy intake logs, and collected weekly urine samples. MAIN OUTCOME MEASURES: Compliance with the intervention was evaluated by daily soy intake logs, 3-day food records analyzed by the center's Food Composition and Food Groups Servings Databases, and weekly urinary isoflavone excretion using high-pressure liquid chromatography. The statistical analysis included paired t-tests, analysis of variance, and Spearman's rank-order correlation coefficients. RESULTS: Daily soy intake logs indicated a mean intake of 6.28 servings out of a maximum of 7.0 servings per week. The food records revealed a six-fold increase in isoflavone intake during the study period (P<0.01) which was confirmed by an increase in urinary isoflavone excretion of similar magnitude (23.3-142.1 nmol/mg creatinine, P=0.02). CONCLUSIONS: This study demonstrated the ability of young girls to consume one daily soy serving and the usefulness of urinary isoflavones as a primary compliance measure. The high urinary isoflavone excretion levels detected in girls as compared to adult women suggest less intestinal degradation and/or greater absorption of isoflavones in nonadult populations. This finding requires further investigations into the pharmacokinetics of isoflavones.

Nutritional changes among premenopausal women undertaking a soya based dietary intervention study in Hawaii.

BACKGROUND: We conducted a 2-year nutritional intervention among premenopausal women. The goal was to incorporate two daily servings of soya into the regular diet. This report describes the dietary modifications and assesses their nutritional adequacy with regard to major nutrients. METHODS: In this analysis of 100 intervention and 106 control subjects, women completed a validated food-frequency questionnaire at baseline; throughout the study, they participated in at least three unannounced 24-h recalls. RESULTS: At randomization, both groups were similar in age and body weight, reported low soya intake, and did not differ by intake of major nutrients and foods. According to the 24-h recalls, women in the intervention group consumed nearly two servings of soya per day, while the control women remained at 0.2 servings. In comparison with the control group, the intervention group consumed fewer dairy products, primarily milk, but also less meat, nuts and seeds. As a result of the dietary modification, the intervention women consumed less-saturated fat and cholesterol and more protein, dietary fibre, calcium and vitamins than the control group. CONCLUSION: These results suggest that women in the intervention group improved the overall quality of their diet by adding two servings of soya per day.

Mammographic densities in a one-year isoflavone intervention.

The estrogenic and antiestrogenic effects of isoflavones, phytoestrogens contained in soy foods, have been proposed as mechanisms for the possible involvement of soy products in the development of breast cancer. We investigated the hypothesis that isoflavones reduce mammographic density, a predictor of breast cancer risk. We conducted a double-blind randomized trial in premenopausal women who received a daily 100 mg isoflavone supplement or a placebo over 12 months. Compliance with the study regimen was confirmed by urinary isoflavones and tablet counts. We used a computer-assisted method to measure mammographic density and paired t-tests to assess changes in mammographic characteristics from baseline to follow-up mammogram. Complete sets of mammograms were available for 30 women. The two groups differed by age and mammographic density at baseline, but were similar in body weight and nutritional intakes. We detected no significant changes either in the size of the dense areas or in the per cent densities. A non-significant decrease in breast area among intervention group subjects was probably the result of methodological issues in comparing mammograms taken under different conditions. In conclusion, our findings do not support the hypothesis that isoflavones decrease mammographic density during a one-year intervention. Although this exploratory study had limited power, it appears that isoflavones do not exert an estrogenic effect similar to hormone replacement therapy on mammographic density.

Why some cancer patients choose complementary and alternative medicine instead of conventional treatment.

OBJECTIVES: We examined cancer patients' reasons for declining all or part of recommended cancer treatment and choosing complementary and alternative medicine (CAM). STUDY DESIGN: This was a qualitative interview study. POPULATION: Fourteen cancer survivors who reported having declined all or part of the recommended conventional treatment (surgery, chemotherapy, or radiation) were included. The participants were a subset from a multi-ethnic (Asian, Native Hawaiian, and white) group of 143 adults diagnosed with cancer in 1995 or 1996 who were recruited through a population-based tumor registry and interviewed about CAM. OUTCOMES MEASURED: We performed semistructured interviews regarding experience with conventional cancer treatment and providers, use of CAM, and beliefs about disease. RESULTS: All participants used 3 or more types of CAM, most commonly herbal or nutritional supplements. Across the board, participants stated that their reason for declining conventional treatment was to avoid damage or harm to the body. The majority of participants also felt that conventional treatment would not make a difference in disease outcome, and some but not all participants perceived an unsatisfactory or alienating relationship with health care providers. Some participants reported that their discovery of CAM contributed to their decision to decline conventional treatment, and participants generally perceived CAM as an effective and less harmful alternative to conventional treatment. CONCLUSIONS: Cancer patients may benefit from interventions (eg, patient education, improvements in physician-patient communication, and psychologic therapy) to facilitate treatment decision making through increased understanding of conventional and CAM treatments and to identify barriers to treatment for individual patients.

Ethnic differences in mammographic densities.

BACKGROUND: Breast cancer incidence is considerably lower among Japanese and Chinese women than among Caucasian and Native Hawaiian even in second and third generation migrants. Mammographic densities, which refer to the radiological appearance of the healthy female breast, are related to breast cancer risk. The purpose of this project was to explore the hypothesis that women from ethnic groups at high breast cancer risk are more likely to have high levels of densities than women from low breast cancer risk groups. METHODS: In a cross-sectional design, 514 pre- and post-menopausal women recruited at mammography screening clinics completed a self-administered questionnaire. We used a computer-assisted method to measure the dense and the total areas of the breast and to compute per cent breast density. Student's t-tests and multiple linear regression were applied to examine ethnic differences and to explore determinants of mammographic densities, respectively. RESULTS: The unadjusted mean dense area was 15% smaller in Chinese and Japanese women than in the Caucasian/Hawaiian group. However, because of their smaller breast size, the per cent of the breast occupied by dense tissue in Chinese and Japanese women was 20% higher than in Caucasian women. Body mass index, age, menopausal status, parity, and oestrogen therapy were associated with mammographic densities, but they did not account for all ethnic differences. CONCLUSIONS: Whereas this study detected some ethnic differences in mammographic densities, the importance of dense areas and per cent densities as indicators of breast cancer risk in ethnically diverse populations remains to be clarified.