High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients
Background: Breast cancer (BC) is the most common cancer among women. A high body-mass index (BMI) is related to increased incidence of BC with poorer prognosis. Aim: The aim of the study was to evaluate the association in patients with BC between BMI at the time of diagnosis and biological characte...
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| Zitieren: | High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients / Y. Kemal, G. Demirag, F. Teker, E. Kut, M. Kefeli, K. Ekiz, I. Yucel // Experimental Oncology. — 2015. — Т. 37, № 4. — С. 281-284. — Бібліогр.: 24 назв. — англ. |
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irk-123456789-1455572019-01-24T01:23:07Z High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients Kemal, Y. Demirag, G. Teker, F. Kut, E. Kefeli, M. Ekiz, K. Yucel, I. Original contributions Background: Breast cancer (BC) is the most common cancer among women. A high body-mass index (BMI) is related to increased incidence of BC with poorer prognosis. Aim: The aim of the study was to evaluate the association in patients with BC between BMI at the time of diagnosis and biological characteristics, according to the menopausal status. Materials and Methods: This retrospective study comprised a total of 318 women with BC. Clinicopathological differences between normal, overweight and obese patients according to menopausal status were evaluated. Results: Premenopausal women had a significantly lower BMI than postmenopausal patients (28.7 vs. 31.5, respectively; p = 0.00001). No statistically significant association was determined between BMI and clinicopathological characteristics in either the premenopausal or the postmenopausal group (all p values are > 0.05). Conclusions: There are many conflicting results in literature on this relationship. The results of this study showed that a high BMI is not associated with worse clinicopathological characteristics in a predominantly obese population. In current medical oncology practice, BC should be evaluated on an individual patient basis and the impact of obesity on BC prognosis seems to be difficult to estimate especially in an obese population. Key Words: breast cancer, body-mass index, prognosis. 2015 High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients / Y. Kemal, G. Demirag, F. Teker, E. Kut, M. Kefeli, K. Ekiz, I. Yucel // Experimental Oncology. — 2015. — Т. 37, № 4. — С. 281-284. — Бібліогр.: 24 назв. — англ. http://dspace.nbuv.gov.ua/handle/123456789/145557 Experimental Oncology Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
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Original contributions Original contributions |
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Original contributions Original contributions Kemal, Y. Demirag, G. Teker, F. Kut, E. Kefeli, M. Ekiz, K. Yucel, I. High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients Experimental Oncology |
| description |
Background: Breast cancer (BC) is the most common cancer among women. A high body-mass index (BMI) is related to increased incidence of BC with poorer prognosis. Aim: The aim of the study was to evaluate the association in patients with BC between BMI at the time of diagnosis and biological characteristics, according to the menopausal status. Materials and Methods: This retrospective study comprised a total of 318 women with BC. Clinicopathological differences between normal, overweight and obese patients according to menopausal status were evaluated. Results: Premenopausal women had a significantly lower BMI than postmenopausal patients (28.7 vs. 31.5, respectively; p = 0.00001). No statistically significant association was determined between BMI and clinicopathological characteristics in either the premenopausal or the postmenopausal group (all p values are > 0.05). Conclusions: There are many conflicting results in literature on this relationship. The results of this study showed that a high BMI is not associated with worse clinicopathological characteristics in a predominantly obese population. In current medical oncology practice, BC should be evaluated on an individual patient basis and the impact of obesity on BC prognosis seems to be difficult to estimate especially in an obese population. Key Words: breast cancer, body-mass index, prognosis. |
| author |
Kemal, Y. Demirag, G. Teker, F. Kut, E. Kefeli, M. Ekiz, K. Yucel, I. |
| author_facet |
Kemal, Y. Demirag, G. Teker, F. Kut, E. Kefeli, M. Ekiz, K. Yucel, I. |
| author_sort |
Kemal, Y. |
| title |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| title_short |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| title_full |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| title_fullStr |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| title_full_unstemmed |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| title_sort |
high body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients |
| publisher |
Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
| publishDate |
2015 |
| topic_facet |
Original contributions |
| url |
http://dspace.nbuv.gov.ua/handle/123456789/145557 |
| citation_txt |
High body-mass index is not associated with worse clinicopathological characteristics in predominantly obese breast cancer patients / Y. Kemal, G. Demirag, F. Teker, E. Kut, M. Kefeli, K. Ekiz, I. Yucel // Experimental Oncology. — 2015. — Т. 37, № 4. — С. 281-284. — Бібліогр.: 24 назв. — англ. |
| series |
Experimental Oncology |
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2025-07-10T21:57:14Z |
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| fulltext |
Experimental Oncology 37, 281–284, 2015 (December) 281
HIGH BODY-MASS INDEX IS NOT ASSOCIATED WITH WORSE
CLINICOPATHOLOGICAL CHARACTERISTICS IN PREDOMINANTLY
OBESE BREAST CANCER PATIENTS
Y. Kemal1,*, G. Demirag2, F. Teker2, E. Kut2, M. Kefeli4, K. Ekiz3, I. Yucel2
1Samsun Education and Research Hospital, Department of Medical Oncology, Samsun 55100, Turkey
219 Mayis University, Faculty of Medicine, Department of Medical Oncology, Samsun 55270, Turkey
319 Mayis University, Faculty of Medicine, Department of Internal Medicine, Samsun 55270, Turkey
419 Mayis University, Faculty of Medicine, Department of Pathology, Samsun 55270, Turkey
Background: Breast cancer (BC) is the most common cancer among women. A high body-mass index (BMI) is related to increased in-
cidence of BC with poorer prognosis. Aim: The aim of the study was to evaluate the association in patients with BC between BMI at the
time of diagnosis and biological characteristics, according to the menopausal status. Materials and Methods: This retrospective study
comprised a total of 318 women with BC. Clinicopathological differences between normal, overweight and obese patients according
to menopausal status were evaluated. Results: Premenopausal women had a significantly lower BMI than postmenopausal patients (28.7 vs.
31.5, respectively; p = 0.00001). No statistically significant association was determined between BMI and clinicopathological charac-
teristics in either the premenopausal or the postmenopausal group (all p values are > 0.05). Conclusions: There are many conflicting results
in literature on this relationship. The results of this study showed that a high BMI is not associated with worse clinicopathological cha-
racteristics in a predominantly obese population. In current medical oncology practice, BC should be evaluated on an individual patient
basis and the impact of obesity on BC prognosis seems to be difficult to estimate especially in an obese population.
Key Words: breast cancer, body-mass index, prognosis.
Breast cancer (BC) is the most frequent invasive neo-
plasm in women. It has been estimated that by 2015 the
annual global incidence of BC will be 1.6 million wo-
men [1]. The impact of both genetic and environmental
risk factors on BC etiology has been well established.
Positive associations of reproductive risk factors such
as early menarche, late menopause, nulliparity, hormone
replacement therapy and postmenopausal obesity are
reportedly stronger for estrogen receptor (ER)-positive
(ER+) than for ER-negative (ER−) BC [2, 3]. However, the
prevelance of obesity has increased dramatically and
if current trends continue, over 50% of the world’s popu-
lation will be obese by the year 2030 [4].
Besides its established role as a risk factor, there
is now widespread consensus on the importance
of obesity as a negative prognostic factor for BC [5, 6].
BC is, however, a biologically heterogeneous disease
and definitive evidence is still lacking on the impact
of obesity on prognosis. Some authors [7] have found
that obese women develop BC with a significantly
higher proliferation index, nuclear grade and larger
size compared to normal and underweight women.
It has also been suggested that obesity at diagnosis
is associated with a higher number of metastatic axil-
lary nodes [8]. According to the data from an ATAC
(anastrozole, tamoxifen, alone, or in combination) trial,
postmenopausal women with high body-mass index
(BMI) treated with anastrozole showed significantly
more distant recurrences than those with a low BMI [9].
Furthermore, Berclaz et al. [10] demonstrated that
elevated BMI is significantly associated with a worse
prognosis, especially for pre- and perimenopausal
patients. Consistent with these studies, Kawai et al. [11]
found that higher BMI was associated with an increase
in morta lity for premenopausal patients. Their analysis
of subgroups showed a positive association between
higher BMI and a worse prognosis for patients with hor-
monal receptor-positive tumors. Thus, the effect of BMI
on BC incidence and prognosis seems to be restricted
to ER-positive BC. However, it is not yet clear why prog-
nosis mostly correlates with the BMI of premenopausal
patients. If the occurrence of BC in patients with high
BMI is the result of an increase in estrogen status,
these tumors must be highly estrogen dependent, thus
resulting in a favorable prognosis. However, a poorer
prognosis for patients with high BMI may indicate that
BMI plays a significant part in BC etiology and prognosis
by mediation through various mechanisms.
The exact reason remains unclear, but different
hypotheses have been suggested to explain the
poorer survival in obese women. For example, obese
women undergo less screening [12] so tend to have
more advanced disease at presentation, they have
an increased risk of developing second primary can-
cer [13], obese women develop more complications
and toxicity due to chemotherapy [14] and have more
aggressive tumors [15]. To determine the crucial role
of BMI, the relationship between tumor biological cha-
racteristics and the BMI of patients, therefore needs
more attention, as to date there have been very few
studies on this subject in literature.
The aim of this study was to analyze the association
between BMI at the time of diagnosis and biological
Submitted: July 02, 2015.
*Correspondence: E-mail: drturkmen@yahoo.com
Tel.: 090362316000–1135; Fax: 0903622330917.
Abbreviations used: BC — breast cancer; BMI — body-mass index;
ER — estrogen receptor; PR — progesterone receptor.
Exp Oncol 2015
37, 4, 281–284
282 Experimental Oncology 37, 281–284, 2015 (December)
characteristics in BC patients, focusing specifically
on ER, PR, and stage according to menopausal status.
MATERIALS AND METHODS
The study comprised 318 cases of invasive
BC treated with mastectomy or breast-conserving sur-
gery at 19 Mayis University Hospital between 2008 and
2012. Approval for the study was granted by the Ethics
Committee of 19 Mayis University; approval number:
2012/502. Detailed information was obtained from the
electronic database of the patient archives.
Patient weight and height were recorded before
surgery and the BMI is calculated based on the fol-
lowing formula:
BMI = bodyweight (kg)/height2 (m2).
Women were categorized according to the WHO
criteria: underweight — BMI < 19 kg/m2; normal —
BMI ≥ 19 and < 25 kg/m2; overweight — BMI ≥ 25 and
<30 kg/m2; obese — BMI ≥ 30 kg/m2.
Menopausal status was defined by 1 year of ame-
norrhea, or previous bilateral oophorectomy. Patholo-
gic tumor grade, estrogen and progesterone receptor
(ER and PR) expression, tumor size, lymph node me-
tastasis and HER-2/neu status were recorded from the
electronic patient database for statistical evaluation.
Immunohistochemical staining. All the tumor
tissues were fixed in formalin and then embedded
in paraffin. Tissue sections were cut at 3–4 μm for
immunohistochemical staining. Immunohistochemi-
cal staining and in situ hybridisation were performed
using the Ventana BenchMark XT autostaining system
(Ventana Medical Systems, Tucson, AZ, USA). ER
(Clone 6F11, Novocastra) and PR (Clone 16, Novo-
castra) antibodies were used and a value of > 1%
was accepted as positive. For HER-2 positivity, 3+
HER-2 (Clone CB-11, Biogenex) immunohistochemical
staining or a positive HER-2 silver in situ hybridization
(SISH) test was accepted as HER-2 positive.
Statistical analysis. Statistical analysis were per-
formed using SPSS software for Windows, version 15.
In all tests, p < 0.05 was considered statistically sig-
nificant. The association between BMI and BC charac-
teristics (nuclear grade, ER and PR expression, tumor
size, lymph node metastasis and HER-2/neu status)
was determined using the χ2 test (we hypothesized
the effect of BMI on prognostic and predicting clini-
copathological tumor features).
RESULTS
A total of 318 women with BC were enrolled in this
retrospective study. The mean age of the study partici-
pants was 50.0 ± 9.7 years (range 27–77 years). Of the
total patients, 156 were premenopausal and 162 were
postmenopausal. The premenopausal women had
a significantly lower BMI than the postmenopausal
women (28.7 vs. 31.5, respectively; p = 0.00001)
(Table 1). A total of 78% of premenopausal women
were classified as overweight/obese, while, in the
postmenopausal group, nearly all the patients (92%)
were overweight/obese (Table 2).
Table 1. Relationship between BMI and menopausal status of BC patients
Characteristics Premenopausal, n (%)
N = 156
Postmenopausal, n (%)
N = 162 p value
Age¹ (years) 43.1 (6.2) 56.5 (7.8) 0.00001BMI (kg/m2) 28.7 (4.9) 31.5 (5.3)
Note: ¹Mean (Standard deviation).
Table 2. BMI distribution
BMI distribution
Premenopausal
women, n (%)
N = 156
Postmenopausal
women, n (%)
N = 162
p value (χ2 test)
Normal weight
(19 < BMI < 24.9) 36 (22.1) 13 (8.0)
0.001Overweight
(25 < BMI < 29.9) 54 (35.0) 51 (31.5)
Obese
(BMI > 30) 66 (42.9) 98 (60.5)
Correlation between BMI and clinicopathologi-
cal characteristics of BC. The patients were divided
into three groups based on BMI; the normal weight group
(BMI smaller than 24.9 kg/m2) comprised 49 patients,
the overweight group (BMI between 25 and 30 kg/m2)
105 patients and the obese group (BMI > 30 kg/m2)
164 patients.
In both the premenopausal and the postmeno-
pausal group no statistically significant association
was determined between BMI and clinicopathological
characteristics (all p > 0.05) (Table 3, 4).
Table 3. Relationship between BMI and clinicopathological characteristics
in premenopausal patients
Characteristics
Normal
weight, n (%)
N = 34*
Overweight,
n (%)
N = 54
Obese,
n (%)
N = 66
p value
Nuclear grade
1
2
3
1 (2.9)
27 (79.4)
6 (17.6)
5 (9.3)
32 (59.3)
17 (31.5)
8 (12.1)
45 (68.2)
13 (19.7)
0.221
Tumor size
1
2
3
4
8 (23.5)
20 (58.8)
4 (11.8)
2 (5.9)
20 (37.0)
25 (46.3)
7 (13.0)
2 (3.7)
26 (39.4)
29 (43.9)
9 (13.6)
2 (3.0)
0.767
Lymph node metastasis
Negative
Positive
13 (38.2)
21 (61.8)
20 (37.0)
34 (63.0)
30 (45.5)
36 (54.5)
0.627
ER
ER+
ER−
28 (82.4)
6 (17.6)
36 (66.7)
18 (33.3)
49 (74.2)
17 (25.8)
0.263
PR
PR+
PR−
21 (61.8)
13 (38.2)
31 (57.4)
23 (42.6)
42 (63.6)
24 (36.4)
0.781
HER2
Positive
Negative
8 (23.5)
26 (76.5)
21 (38.9)
33 (61.1)
14 (21.2)
52 (78.8)
0.081
Note: *grade and other characteristics are reached 34 of 36 patients.
DISCUSSION
Consistent with many previous studies, the results
of this study have shown that the BMI of postmeno-
pausal patients was significantly higher than that
of premenopausal patients. The strength of this study
is the homogeneity in patient management as all the
patients were treated and detected in a single institu-
tion. However, no significant association was deter-
mined between BC characteristics and the BMI of the
patients in the study group.
Experimental Oncology 37, 281–284, 2015 (December) 283
Table 4. Relationship between BMI and clinicopathological characteristics
in postmenopausal patients
Characteristics
Normal
weight, n (%)
N = 13
Overweight,
n (%)
N = 51
Obese,
n (%)
N = 98
p value
Nuclear grade
1
2
3
1 (7.7)
6 (46.2)
6 (46.2)
9 (17.6)
31 (60.8)
11 (21.6)
17 (17.3)
60 (61.2)
21 (21.4)
0.375
Tumor size
1
2
3
4
3 (23.1)
8 (61.5)
1 (7.7)
1 (7.7)
19 (37.3)
28 (54.9)
3 (5.9)
1 (2.0)
42 (42.9)
45 (45.9)
8 (8.2)
3 (3.1)
0.745
Lymph node metastasis
Negative
Positive
7 (53.8)
6 (46.2)
27 (52.9)
24 (47.1)
39 (39.8)
59 (60.2)
0.249
ER
ER+
ER−
9 (69.2)
4 (30.8)
40 (78.4)
11 (21.6)
70 (71.4)
28 (28.6)
0.615
PR
PR+
PR−
4 (30.8)
9 (69.2)
25 (49.0)
26 (51.0)
53 (54.1)
45 (45.9)
0.276
HER2
Positive
Negative
5 (38.5)
8 (61.5)
11 (21.6)
40 (78.4)
28 (28.6)
70 (71.4)
0.418
Many studies in literature have investigated the as-
sociation between BMI and DC. It is well-known that
a high BMI is positively associated with increased ER(+)
BC risk in postmenopausal women due to enhanced
production of circulating estrogens [16, 17]. Recently,
new studies have focused on the importance of obesity
as a negative prognostic factor. Some authors [18, 19]
have found that obese women develop aggressive
BC with a significantly higher number of metastatic
axillary nodes, higher proliferation index, nuclear grade
and larger size compared to normal and underweight
women. If obesity results in more BC because of high
estrogen levels, these tumors must be estrogen de-
pendent with a favorable prognosis. However, various
mechanisms play a role in aggressive prognosis. Over-
weight women have high levels of insulin-like growth
factor and other growth factors such as leptin, TNF-α,
IL-6 and VEGF, which promote angiogenesis, tumor
growth, metastasis and inhibit apoptosis [20].
Although BC is a biologically heterogeneous dise-
ase, definitive evidence is still lacking on the impact
of obesity on BC prognosis. In different stu dies, dif-
ferent associations have been found between clini-
copathological characteristics and BMI with no stan-
dard result reached as yet. Recently, Yanai et al. [21]
reported that a high BMI showed significantly higher
lymph node metastasis, and Mazzarella et al. [22]
found that obesity significantly correlates with overall
survival and increases distant metastasis in ER(−)/
Her/neu-positive BC. In contrast, Biglia et al. [23]
could not find any statistically significant correla-
tion between BC subtypes and BMI in both pre- and
postmenopausal patients. When planning current
treatments according to molecular classification and
genomic characteristics, an easy to apply factor such
as BMI can be of benefit and positive research studies
in support of this are undoubtedly important as obesity
is a modifiable risk factor.
The results of this study did not support some
previous studies which have stated that a higher BMI
is associated with worse clinicopathological charac-
teristics in BC patients. The current study population
consisted of predominantly obese patients with mean
BMI of 28.7 in the premenopausal group and 31.5 in the
postmenopausal group. These values are conside-
rably higher than those of previously reported studies.
In a recent similar study by Lino-Silva et al. [24] of en-
dometrial carcinoma in obese patients, it was reported
that a high BMI is not a prognostic factor of a worse
condition. However, that study did not include a high
number of patients which may have been sufficient
to show small but significant differences.
In conclusion, obesity, which is increasing dramati-
cally and becoming a major global healthcare problem,
is a variable risk factor for BC. It is difficult to treat and
follow obese BC patients because of complications and
comorbidities. Cancer is different in each patient and
personalized treatment should be a priority. In current
clinical practice, there should be intervention against
obesity although a direct relationship between BMI and
simple clinical and pathological characteristics was not
determined. BC is a heterogeneous disease and the
impact of obesity on BC prognosis seems to be diffi-
cult to estimate. Future studies are needed to evaluate
the relationship between molecular characteristics
of BC and BMI.
ACKNOWLEDGEMENT
The authors thank Dr. Berkhan Topaktas for advice
on the statistical analyses of the study.
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