Annals of Agricultural and Environmental Medicine, Vol 24, No 4, 549–553

ORIGINAL ARTICLE www.aaem.pl

Primary and secondaryprevention of breast cancer

Agnieszka Kolak1, Marzena Kamińska2, Katarzyna Sygit3, Agnieszka Budny1, Dariusz Surdyka1,
Bożena Kukiełka-Budny2, Franciszek Burdan4
1
St. John’s Cancer Center, Department of Radiotherapy, Lublin, Poland
2
St. John’s Cancer Center, Department of Oncology, Lublin, Poland
3
University of Szczecin, Faculty of Physical Education and Health Promotion, Szczecin, Poland
4
Human Anatomy Department, Medical Univeristy of Lublin, Poland
Kolak A, Kamińska M, Sygit K, Budny A, Surdyka D, Kukiełka-Budny B, Burdan F. Primary and secondary prevention of breast cancer. Ann
Agric Environ Med. 2017; 24(4): 549–553. doi: 10.26444/aaem/75943

Abstract
Introduction. Breast cancer is the most common cancer among women and is the second cancer frequently occurring
worldwide of newly-diagnosed cancers. There is much evidence showing the influence of life style and environmental
factors on the development of mammary gland cancer (high-fat diet, alcohol consumption, lack of physical exercise), the
elimination of which (primary prevention) may contribute to a decrease in morbidity and mortality. Secondary prevention,
comprising diagnostic tests (e.g. mammography, ultrasonography, magnetic resonance imaging, breast self-examination, as
well as modern and more precise imaging methods) help the early detection of tumours or lesions predisposing to tumours.
Objective. The aim of this study paper is to review current knowledge and reports regarding primary and secondary
prevention of breast cancer.
State of knowledge. It is estimated that nearly 70% of malign tumours are caused by environmental factors, whereas
in breast cancer this percentage reaches 90–95%. There are national programmes established in many countries to fight
cancer, where both types of prevention are stressed as serving to decrease morbidity and mortality due to cancers.
Conclusions. Cancer prevention is currently playing a key role in the fight against the disease. Behaviour modification,
as well as greater awareness among women regarding breast cancer, may significantly contribute towards reducing the
incidence of this cancer. Another important aspect is the number of women undergoing diagnostic tests, which still remains
at an unsatisfactory level.
Key words
breast cancer, primary and secondary prevention, risk factors, life style, mammography, modern diagnostics methods

INTRODUCTION cancer burden in family, especially breast cancer burden [9].

This cancer occurs most frequently among women in the
In 2012, regardless of gender, breast cancer was the menopausal transition (80% of disease recognitions among
second most frequently diagnosed cancer worldwide, women aged 50 or older) [10].
with a frequency adding up to 11.9%. It is also the first
most frequently occurring cancer among women [1, 2, 3], Primary prevention. Primary prevention consists of
comprising 25.2% of all newly-diagnosed cancers [1]. It is eliminating the causes leading to the disease occurrence,
assumed that one in eight women in the world will develop and increasing or enhancing the immune system in the
mammary gland cancer [4], and that only 5–10% of all cases population [11].
of this cancer are caused by genetic disorders, whereas the
remaining 90–95% of cases are connected to environmental Diet. In 2007, World Cancer Research Fund / American
factors and life style [5]. Therefore, an essential element of Institute for Cancer Research (WCRF/AICR) analyzed a lot
modern medicine is to conduct multidisciplinary research of research regarding the impact of diet and physical activity
targeted at the enhancing efficiency of health prevention by on cancer development, confirming that there is a connection
focusing on primary prevention, risk factors modification to between the two. According to recommendations, a healthy
early detection of the disease, quick beginning of treatment diet in cancer prevention is a diet that helps maintain proper
(secondary prevention), as well as observation. The main goal body weight, is rich in fruit, vegetables, cereals and legumes,
is to reduce continuously increasing morbidity, mortality, contains little red meat and little salt, and does not consist
and economic costs as a result of breast cancer [6]. of processed meat. Moreover, it is characterized by avoiding
Various genetic and environmental factors, especially sweet beverages and reducing the consumption of high-
those co-existing, increase the risk of morbidity and re- calories food and alcohol beverages [12, 13]. Food factors (e.g.
activation of gland mammary cancer. Environmental and life edible fats) may also cause reversible epigenetic changes (DNA
style factors include: ionizing radiation, hormonal therapy, hypomethylation, hypermethylation of promoter region of
reproductive behaviours (preferences) of women (e.g. late age tumour suppressor genes and abnormal modification of
of first labour), alcohol [6], as well as other dietary factors, histones) leading to oncogenesis [14].
obesity and lack of physical activity [6, 7, 8]. Other commonly Essential diet ingredients increasing the risk of mammary
recognized and documented risk factors include age and gland cancer include trans-fatty acids; their detrimental
influence is exercised through disorders in metabolic
Address for correspondence: Agnieszka Kolak, St. John’s Cancer Center, Department
of Radiotherapy, Lublin, Poland processes and signal pathways, increase in the level of lipids
E-mail: [email protected] in blood, inflammation stimulation, dysfunction of vascular
Received: 4 February 2017; accepted: 18 May 2017; first published on June 30, 2017 endothelium, increase in abdominal obesity, body weight and
AAEM Annals of Agricultural and Environmental Medicine 2017, Vol 24, No 4
Agnieszka Kolak, Marzena Kamińska, Katarzyna Sygit, Agnieszka Budny, Dariusz Surdyka, Bożena Kukiełka-Budny, Franciszek Burdan. Primary and secondary…

insulin resistance. Increased consumption of high glycaemic of 82 examinations carried out by Chan et al. [2014], since
index products also significantly influences the risk increase worse overall survival among patients with breast cancer is
of cancer [12, 13]. recognized among women with higher BMI (≥30.0 kg/m2).
A very important and favourable diet ingredient is vegetable According to the authors’ observations, maintaining normal
fibre, which stimulates bacterial anaerobic fermentation in body weigh reduces the risk of breast cancer development,
the large intestine, leading to the production of short-chain improves prognosis and reduces the possibility of occurrence
fatty acids: acetate, propionate and butyrate. In scientific of oncological treatment complications [28]. It was also
research on cellular lines, butyrate decreases cell proliferation shown that patients with normal body weight are less prone
and intensifies apoptosis. Moreover, decrease in the level of to cancer relapse, diabetes and cardiovascular diseases [6].
circulating estrogen and androstenedione among people Overweight and obesity aggravate the prognosis for the
consuming a lot of fibre was also reported. Furthermore, long-term follow-up period among women who received
products rich in fibre are an essential source of phytoestrogens anti-cancer therapy [29].
(working in the human body like estrogens), changing the
activity of estrogen receptors and interacting with them, Alcohol. The risk of cancer increases depending on alcohol
thus contributing to reducing the risk of developing tumour dose in combination with biological mechanisms, where
diseases dependent on the endocrine system, especially ethanol and its genotoxide metabolism and acetaldehyde
breast cancer [12, 13]. In meta-analysis of 16 prospective play an important role [30]. When consuming 10g of
examinations related to fibre consumption and breast ethanol daily the risk of breast cancer increases by 8% in the
cancer risk, Aune et al. [2012] proved that there is a reverse postmenopausal period, by 9% before menopause and by 10%
relation between fibre occurring in diet and the frequency in general [31]. It is suggested that there are 3 mechanisms
of tumour prevalence [15]. Moreover, another study [Aune that explain alcohol influence on the development of
et  al.] proved a correlation between the concentration of mammary gland cancer: impact on the level of estrogens,
beta-carotene, alpha-carotene and lutein, and the risk estrogen receptors and development of alcohol metabolism
decrease of breast cancer morbidity. These observations are by-products [32, 33]. Alcohol has also an impact on estrogen
crucial from the practical point of view since the source of pathway through activating aromatase. Additionally, it
carotenoids in diet are commonly consumed vegetables and can exert influence on the menstrual cycle by decreasing
fruit. Epidemiological research shows that the consumption changeability and frequency of cycle length. Big alcohol
of carrots and broccoli, as well as green and fresh vegetables, consumption is connected to the elevated level of estrogen in
correlates with the most with the concentration of alpha- and the luteal phase, whereas a large amount of consumed alcohol
beta-carotene, as well lutein / zeaxanthin, whereas citrus during weekends is related to very high level of estrogen in
fruit are related to the concentration of lutein in blood [16]. blood. One of the hypotheses suggests alcohol impact on
mammary gland cancer development through the cumulative
Obesity. Excessive consumption of high-calorie meals leads level of endogenous estrogen throughout the whole life.
to weight gain and eventually to obesity, which is related to Research conducted by Frydenberg et  al. on 202 women
higher cancer risk [13, 17, 18]. Obesity is a result of long-term showed that daily consumption of beverages containing
increased energy consumption against energy expenditure >10g of alcohol for a week increases the concentration of
[19]. A commonly used index determining underweight, 17β-estradiol, on average by 18% during the menstrual cycle,
overweight and obesity is the body mass index (BMI), which compared to women reporting the consumption of <10g of
is calculated by dividing body weight in kilograms by the alcohol, which confirms a positive relationship between this
square of height in meters (kg/m2). BMI range include: <18.50 sex hormone and breast cancer development [34]. Between
(underweight), 18.5–24.99 (normal body weight), ≥25.00 1980–2010, Cao et al. conducted 2 prospective observation
(overweight), ≥30.00 (obesity) [20, 21]. A lot of scientific examinations on 88,084 women and 47,881 men in the United
research showed that calorie limitation impedes the process States, examining alcohol impact on cancer development.
of neoplasia. Mechanisms combining obesity with cancer risk Breast cancer was the main and most frequently occurring
include hyperinsulinaemia and insulin resistance, increased malign tumour related to alcohol consumption. Collected
production of insulin-like growth factors (IGF), change of data proved that an alcohol consumption of 5–14.9g daily
sex hormone metabolism, chronic inflammation, change increases the risk of breast cancer (relative risk 1.13) [35].
in production by fatty tissue adipocytokines and vascular
endothelial growth factors (VEGF), oxidative stress and Physical activity. Physical activity has a positive impact
changes in immune response [13]. Protani et  al. carried on mental health among patients suffering from malign
out between 1963–2005, meta-analysis of 43 examinations tumours [36], and is defined as each body movement made
among women diagnosed with cancer. The group of women by the skeletal muscles that results in energy consumption
who were already obese when the disease was recognized was [37]. The connection between breast cancer and physical
characterized by a 33% higher mortality risk than women activity is stronger among women who have undergone the
with normal body weight [22, 23]. Hauner et  al. came to menopause [5], have a negative family history regarding this
similar conclusions by assessing examinations and meta- cancer and maintain proper body weight, as well as among
analyses which were published between 1996–2010 [24]. women who have given birth to at least one healthy baby
The significance of obesity as a risk factor is increasing with [38]. Epidemiological research suggests that the intensity
age, especially after menopause [6, 25, 26], since tumours of exercises, starting from moderate to energetic, reduces
are characterized by worse response to treatment and great the risk of breast cancer by roughly 10–25%, compared to
risk of relapse in this period [6, 27], whereas women before inactive women. A precise plan and amount of exercises
and after menopause are characterized by worse survival required to prevent this cancer have not been determined;
[28]. Similar conclusions were drawn from a meta-analysis however, risk decrease is observed along with the increase
Annals of Agricultural and Environmental Medicine 2017, Vol 24, No 4 551
Agnieszka Kolak, Marzena Kamińska, Katarzyna Sygit, Agnieszka Budny, Dariusz Surdyka, Bożena Kukiełka-Budny, Franciszek Burdan. Primary and secondary…

of workout length and intensity [39]. WCRF recommends at of lesions in the pre-operative period and during the follow-
least 30 minutes of moderate physical activity undertaken up period, after termination of the treatment process. USG is
daily and the equivalent to a quick walk in the prevention a valuable examination among women at high risk, as well as
of any cancer [12, 39], and reducing sedentary activity, such at breast evaluation of high density (especially among young
as watching TV [12]. Lahart et  al. report about reverse a women) [43, 49], since MMG is limited [43].
relationship between physical activity and risk of death and
development of mammary gland cancer in every case of Magnetic Resonance Imaging (MRI). Mammary gland
this disease. Nonetheless, physical activity after cancer has examination by means of magnetic resonance imaging is
been diagnosed is connected to greater reduction of death similarly to USG – non-invasive and safe (no X-radiation).
risk among women who have undergone the menopause, It mostly complements mammography by increasing the
compared to women who are not yet facing it [40]. detection of malignant lesions [43, 50]. However, MRI is a
more invasive examination compared to MMG since it is
Secondary prevention. Secondary prevention aims at conducted using an intravenous contrast agent, although
terminating the process of disease development before its full this agent is less sensitizing than that administered during
symptoms are diagnosed, which may impede or prevent the computed tomography (CT) [43]. MR sensitivity amounts
development of a malign tumour [11]. Screening is the main to 88.1% [48]. Its advantage is incredibly precise imaging of
example of such a prevention, and is targeted at specified soft tissues, which cannot be completed using other methods
groups of the healthy population characterized by a greater [43]. The presence of gene mutation among young women
risk, for instance [41]: mammography in breast cancer or is an indication to carry out diagnosis by means of MR
colonoscopy in colon cancer [11, 41]. The main result of such [48] (BRCA1, BRCA2) [51]. Breast examination using this
prevention should be a decrease in mortality due to cancer method does not always allow differentiation between a
thanks to its early detection [41, 42]. malignant lesion and a benign lesion (e.g. fibroadenoma),
which may lead to false positive results. MR is still an
Mammography. Mammography screening in Poland expensive examination and not available in every medical
(MMG) is a screening testing for mammary gland cancer, centre. Moreover, the combination of MMG and breast MR
to which women in the age group 50–69 are subject once is not currently recommended [43].
in 2 years. This programme has been in operation since
2005 in the whole country [41]. Mammography is not Breast Self-Examination (BSE). Breast self-examination
recommended for women at moderate risk of breast cancer, applied as a self-method is not a sufficient, but still an
under 40-years-old since ionizing radiation may induce the important element in helping detect cancer at an early
process of tumour development, and the risk is higher for stage. It is a cheap method, generally available and does not
younger women, especially if they had been exposed before demand any complex technical training [52], and can be
they turned 30-years-old. The disease latency period lasts performed in the home environment [48]. BSE allows woman
10 years, whereas increased risk lasts throughout the whole to learn about proper breast structure which helps later detect
life. The main disadvantage of MMG is over-recognition, untypical lesions in mammary gland tissue [52]. Experts from
which adds up to around 33% of all breast cancer detections (Population Programme for Early Breast Cancer Detection
[43], defined as detection of malign tumour by means of (Populacyjny Program Wczesnego Wykrywania Raka Piersi)
imaging, then confirmed histologically, which would not conducted as part of a national programme to fight cancer
develop into a full symptom disease during the patient’s in Poland, recommend performing breast self-examination
lifetime [44]. Additionally, over 75% of lesions detected in once a month by every woman above the age of 20, preferably
mammography are detected as pathologically mild [45]. on the first day after the termination of menstruation.
MMG sensitivity in mammary gland where glandular Women who have undergone the menopause should also
tissue dominates amounts to 90–95%, whereas in tissue of examine their breasts once in a month, preferably on the
high density it amounts to 60–75% [46]. In spite of these same day every month [53]. BSE sensitivity is low (12–14%). Its
observations, mammographic assessment is still considered disadvantage is also a high index of false positive results and
the best tool for diagnosing breast cancer at its early stage, over-recognition; thus, BSE should always be complemented
when the chance of survival treatment possibilities are the by objective imaging examination [48].
best [44]. Moreover, mammography performed currently
uses digital quality by receiving an image directly on a Modern and non-standard imaging methods. High-
computer (digital mammography) [43]. It may also help in definition digital mammography is one of the modern imaging
thoroughly evaluating the local disease stage and reaction to methods of mammary glands and is used in combination with
treatment, as well being used to conduct biopsy under MMG iodinated contrast agents. Images before and after contrast
control [47]. This imaging method decreases death risk by administration are obtained during one examination. Its
15–20%, which proves these observations [48]. advantage is in obtaining many after-contrast phases in
order to examine the potential capture and washing of the
Ultrasonography (USG). Breast examination by means of contrast agent by suspicious changes Its disadvantage is the
ultrasonography is safe – there is no ionizing radiation – necessity to keep pressure on the breast for a long time during
and non-invasive. It is mostly used to complement other the examination (5–10 minutes), resulting in discomfort for
diagnostic examinations, as well as to conduct biopsy under the patient, and the great possibility that the patient may
USG control. Its disadvantage is low specificity [43]. USG move, which causes a false image recording and necessity to
sensitivity in detecting neoplastic lesions amounts to only administer an additional intravenous contrast agent.
36% [48]. Ultrasonography allows differentiation between Contrast-enhanced spectral mammography (CESM)
cystic lesions and solid lesions, and is useful in the evaluation allows a number of images to be received from both breasts
AAEM Annals of Agricultural and Environmental Medicine 2017, Vol 24, No 4
Agnieszka Kolak, Marzena Kamińska, Katarzyna Sygit, Agnieszka Budny, Dariusz Surdyka, Bożena Kukiełka-Budny, Franciszek Burdan. Primary and secondary…

after a one-off administration of the contrast agent. In this CONCLUSIONS

examination, after intravenous marker administration,
every image consists of a quickly-received pair of images Primary and secondary prevention has a significant impact
of low and high energy. Low-energy images are made using on morbidity and the detection of cancer. Modern life-style
the same dose as in digital mammography, while high- and various easily accessible stimulants contribute to the
energy images have only around 20% of this dose. CESM fact that life-style and environmental factors are playing
enables the demonstration of lesions characterized by bigger a greater role in breast cancer development. Living in big
vascularization and extracellular leakage of the contrast urban agglomerations causes the situation where women
agent. It is also characterized by high negative predictive do not have time to properly take care of their health, or
value and is similar to the index value of false positive results await diagnostic examinations for a long time. On the other
of MRI [47]. hand, there is worse accessibility to imaging examinations in
Optical mammography uses the range of wave lengths smaller cities. Extending women’s knowledge regarding the
close to infrared (650–1,000  nm), providing structural impact of their behaviour on breast cancer development and
and functional information. Image contrast is made by educating them about the possibilities to gain control over
haemoglobin absorption and other dominant tissues, such this disease by implementing modifications of their habits
as water and lipids. Functional information is received is an important aspect. Although the awareness of Polish
by means of spectroscopic methods that detect oxygen society on the subject of cancer is increasing, the number
saturation in tissues, which help assess the metabolism of of women reporting for diagnostic examinations is still too
breast tissue. The main advantages of this examination is low, which leads to constantly increasing mortality caused
lack of ionizing radiation, non-invasiveness, low performance by cancer. Nonetheless, every method of mammary gland
cost, relatively cheap equipment [43], shorter imaging time imaging demands further research conducted on bigger
compared to magnetic resonance imaging, and perfect time- groups of patients before they are applied in daily diagnostic
resolution [48]. The elementary limitation of optical breast practice.
imaging is relatively low spatial resolution in comparison to
traditional techniques, such as mammography using ionizing
radiation. Nowadays, this method is used by means of digital REFERENCES
technologies [43].
Radiothermometry mammography (RTM) is based on a 1. Worldwide cancer statistics (WCRF) [Internet]. 2015 [cited 2015
November 5]. Available from: http://www.wcrf.org/cancer_statistics/
thermal imaging system that measures and analyses the world_cancer_statistics.php.
breast surface and internal temperature. RTM is a sensitive 2. Mermer G, Turk M. Assessment of the Effects of Breast Cancer Training
method supporting breast cancer diagnosis. RTM equipment on Women Between the Ages of 50 and 70 in Kemalpasa, Turkey. Asian
measures electro-magnetic waves sent by the breast tissue Pac J Cancer Prev. 2014; 15(24): 10749–10755. [Crossref]
in order to identify a specific area. It is possible to diagnose 3. Leśniczak B, Krasomski G, Oszukowski P, Stetkiewicz T, Woźniak
P. Incidence of and mortality from breast cancer among women in
cancer by means of this method using thermal activity of Poland in the years 2001–2010. Prz Menopauzalny. 2014; 13(6): 344–347.
cancerous cells before structural lesions in breast tissue [Crossref]
occur. RTM allows to differentiate dysplasia from neoplastic 4. Ferrini K, Ghelfi F, Mannucci R, Titta L. Lifestyle, nutrition
lesions. It is a safe examination since it is performed without and breast cancer: facts and presumptions for consideration.
Ecancermedicalscience. 2015; 9: 1–11. [Crossref]
ionizing radiation and may encompass the imaging area to 5. Castelló A, Martín M, Ruiz A, Casas AM, Baena- Cañada JM, Lope V
include the axillary cavity [45]. et al. Lower Breast Cancer Risk among Women following the World
Scintimammography (SMM) is an imaging technique, Cancer Research Fund and American Institute for Cancer Research
in which non-specific radio-markers are used to identify Lifestyle Recommendations: EpiGEICAM Case-Control Study. PLoS
malignant lesions. SMM usually helps verify lesions noticed One. 2015; 10(5): 1–15. [Crossref]
6. Coughlin SS, Smith SA. The Impact of the Natural, Social, Built, and
in mammography. This examination is also useful after Policy Environments on Breast Cancer. J Environ Health Sci. 2015;
primary therapy and adjuvant treatment in order to evaluate 1(3): 1–7. [Crossref]
response to treatment and early detection of disease relapse, 7. Podkowa N, Komasińska P, Roszak M, Gryczka R, Grodecka-Gazdecka
as well as necrosis in the examined area. SMM is more specific S, Łacka K. Health behaviours among women diagnosed with breast
tumours. Pol Merkur Lekarski. 2014; 37(219):153–158.
than MRI and, as a result, is used to detect lesions bigger that 8. Howell A, Anderson AS, Clarke RB, Duffy SW, Evans DG, Garcia-
onr centimeter diameter. Closas M et al. Risk determination and prevention of breast cancer.
Positron emission tomography (PET) is an examination Breast Cancer Research. 2014; 16(5): 1–19. [Crossref]
where the most frequently used radio-marker is 9. Kruk J. Intensity of recreational physical activity in different life periods
18F-fluorodeoxyglucose. In PET examination, glucose in relation to breast cancer among women in the region of Western
Pomerania. Contemp Oncol (Pozn). 2012; 16(6): 576–581. [Crossref]
metabolism is used in order to detect malignant and metastatic 10. Kamińska M, Ciszewski T, Łopacka-Szatan K, Miotła P, Starosławska
lesions, especially from solid tumours. Advanced usage of E. Breast cancer risk factors. Prz Menopauzalny. 2015; 14(3): 196–202.
breast imaging by means of nuclear energy include positron [Crossref]
emission mammography (PEM) and PET/CT. PEM is used 11. Katz D, Ather A. Preventive Medicine, Integrative Medicine & The
Health of The Public. Commissioned for the IOM Summit on Integrative
to illustrate only mammary gland tissues, in contrast to PET Medicine and the Health of the Public. 2009. [cited 2015 November 8].
examination which encompass the whole body and is the best Available from: http://www.iom.edu/~/media/Files/Activity%20Files/
screening tool among women characterized by high risk. Quality/IntegrativeMed/Preventive%20Medicine%20Integrative%20
PET / CT is an imaging method combining PET (providing Medicine%20and%20the%20Health%20of%20the%20Public.pdf.
functional information) and computed tomography that 12. World Cancer Research Fund/American Institute for Cancer Research.
Food, nutrition, physical activity and the prevention of cancer: a
provides anatomic information [48]. global perspective. Washington, DC: World Cancer Research Fund/
American Institute for Cancer Research. 2007.[Internet]. 2015 [cited
Annals of Agricultural and Environmental Medicine 2017, Vol 24, No 4 553
Agnieszka Kolak, Marzena Kamińska, Katarzyna Sygit, Agnieszka Budny, Dariusz Surdyka, Bożena Kukiełka-Budny, Franciszek Burdan. Primary and secondary…

2015 November 9]. Available from: http://www.aicr.org/assets/docs/ 32. Liu Y, Nguyen N, Colditz GA. Links between alcohol consumption
pdf/reports/Second_Expert_Report.pdf. and breast cancer: a look at the evidence.Womens Health. 2015; 11(1):
13. Norata T, Scocciantib C, Boutron-Ruaultc M-C, Andersond A, Berrino 65–77. [Crossref]
F, Cecchini M et al. European Code against Cancer 4th Edition: Diet 33. Castro GD, Castro JA. Alcohol drinking and mammary cancer:
and cancer. Cancer Epidemiology. 2015. [cited 2015 November 8]. pathogenesis and potential dietary preventive alternatives. World J
Available from: http://www.cancerepidemiology.net/article/S1877– Clin Oncol. 2014; 5(4): 713–729. [Crossref]
7821(15)00070–3/pdf. [Crossref] 34. Frydenberg H, Flote VG, Larsson IM, Barrett ES, Furberg AS, Ursin G
14. Rodríguez-Miguel C, Moral R, Escrich R, Vela E, Solanas M, Escrich et al. Alcohol consumption, endogenous estrogen and mammographic
E. The Role of Dietary Extra Virgin Olive Oil and Corn Oil on the density among premenopausal women. Breast Cancer Research. 2015;
Alteration of Epigenetic Patterns in the Rat DMBA-Induced Breast 17: 1–12. [Crossref]
Cancer Model. PLoS One. 2015; 10(9): 1–16. [Crossref] 35. Cao Y, Willett WC, Rimm EB, Stampfer MJ, Giovannucci EL. Light to
15. Aune D, Chan DSM, Greenwood DC, Vieira AR, Navarro Rosenblatt moderate intake of alcohol, drinking patterns, and risk of cancer: results
DA, Vieira R et al. Dietary fiber and breast cancer risk: a systematic from two prospective US cohort studies. BMJ. 2015; 351: 1–8. [Crossref]
review and meta-analysis of prospective studies. Ann Oncol. 2012; 36. Milecki P, Hojan K, Ozga-Majchrzak O, Molińska-Glura M. Exercise
23(6): 1394–1402. [Crossref] tolerance in breast cancer patients during radiotherapy after aerobic
16. Aune D, Chan DSM, Vieira AR, Navarro Rosenblatt DA, Vieira R, training. Contemp Oncol (Pozn). 2013; 17(2): 205–209.
Greenwood DC et  al. Dietary compared with blood concentrations 37. Kruk J. Lifestyle Components and Primary Breast Cancer Prevention.
of carotenoids and breast cancer risk: a systematic review and meta- Asian Pac J Cancer Prev.2015; 15 (24): 10543–10555. [Crossref]
analysis of prospective studies. Am J Clin Nutr. 2012; 96(2): 356–373. 38. Lynch BM, Neilson HK, Friedenreich CM. Physical activity and breast
[Crossref] cancer prevention. Recent Results Cancer Res. 2011; 186: 13–42.
17. Orecchioni S, Reggiani F, Talarico G, Bertolini F. Mechanisms of [Crossref]
obesity in the development of breast cancer. Discov Med. 2015; 20(109): 39. Neilson HK, Conroy SM, Friedenreich CM. The Influence of Energetic
121–128. Factors on Biomarkers of Postmenopausal Breast Cancer Risk. Curr
18. Allott EH, Hursting SD. Obesity and cancer: mechanistic insights from Nutr Rep. 2014; 3(1): 22–34. [Crossref]
transdisciplinary studies. Endocr Relat Cancer. 2015; 22(6): 365–386. 40. Lahart IM, Metsios GS, Nevill AM, Carmichael AR. Physical activity,
[Crossref] risk of death and recurrence in breast cancer survivors: A systematic
19. Davoodi SH, Malek-Shahabi T, Malekshahi-Moghadam A, Shahbazi review and meta-analysis of epidemiological studies. Acta Oncol. 2015;
R, Esmaeili S. Obesity as an Important Risk Factor for Certain Types 54(5): 635–654. [Crossref]
of Cancer. Iran J Cancer Prev. 2013; 6(4): 186–194. 41. Strategia walki z rakiem w Polsce 2015–2025. [Internet]. 14 czerwca
20. The WHO Global Database on Body Mass Index (BMI). [Internet]. 2014. [cited 2015 November 16]. Available from: http://walkazrakiem.
2015 [cited 2015 November 10]. Available from: http://apps.who.int/ pl/sites/default/files/library/files/strategia_walki_z_rakiem_w_
bmi/index.jsp?introPage=intro_3.html. polsce_2015_2024.pdf.
21. Jeon YW, Kang SH, Park MH, Lim W, Cho SH, Suh YJ. Relationship 42. Weigel S, Heindel W, Heidrich J, Heidinger O, Hense HW. Reduction
between body mass index and the expression of hormone receptors of Advanced Breast Cancer Stages at Subsequent Participation in
or human epidermal growth factor receptor 2 with respect to breast Mammography Screening. Fortschr Röntgenstr. 2015. [cited 2015
cancer survival. BMC Cancer. 2015; 15: 1–9. [Crossref] November 16]. Available from: https://www.thieme-connect.com/
22. Protani M, Coory M, Martin JH. Effect of obesity on survival of women products/ejournals/pdf/10.1055/s-0041–107835.pdf. [Crossref]
with breast cancer: systematic review and meta-analysis. Breast Cancer 43. Mehnati P, Tirtash MJ. Comparative Efficacy of Four Imaging
Res Treat. 2010; 123(3): 627–635. [Crossref] Instruments for Breast Cancer Screening. Asian Pac J Cancer Prev.
23. Thompson HJ, Sedlacek SM, Wolfe P, Paul D, Lakoski SG, Playdon 2015; 16(15): 6177–6186. [Crossref]
MC et al. Impact of Weight Loss on Plasma Leptin and Adiponectin 44. Morris E, Feig SA, Drexler M, Lehman C. Implications of Overdiagnosis:
in Overweight-to-Obese Post Menopausal Breast Cancer Survivors. Impact on Screening Mammography Practices. Popul Health Manag.
Nutrients. 2015; 7(7): 5156–5176 [Crossref] 2015; 18 (1): 3–11. [Crossref]
24. Hauner D, Janni W, Rack B, Hauner H. The Effect of Overweight and 45. Caferova S, Uysal F, Balcı P, Saydam S, Canda T. Efficacy and safety of
Nutrition on Prognosis in Breast Cancer. Dtsch Arztebl Int. 2011; breast radiothermometry in the differential diagnosis of breast lesions.
108(47): 795–801. Contemp Oncol (Pozn). 2014; 18(3): 197–203. [Crossref]
25. World Cancer Research Fund International/American Institute for 46. Çakır M, Küçükkartallar T, Tekin A, Selimoğlu N, Poyraz N, Belviranlı
Cancer Research Continuous Update Project Report: Diet, Nutrition, MM et al. Comparison of mammography sensitivity after reduction
Physical Activity, and Breast Cancer Survivors. 2014. [Internet]. 2015 mammoplasty targeting the glandular and fat tissue. Ulus Cerrahi
[cited 2015 November 8]. Available from: http://www.wcrf.org/sites/ Derg. 2015; 31(2): 68–71. [Crossref]
default/files/Breast-Cancer-Survivors-2014-Report.pdf. 47. Łuczyńska E, Heinze-Paluchowska S, Hendrick E, Dyczek S, Ryś J,
26. Rose DP, Gracheck PJ,Vona-Davis L. The Interactions of Obesity, Herman K et  al. Comparison between Breast MRI and Contrast-
Inflammation and Insulin Resistance in Breast Cancer. Cancers. 2015; Enhanced Spectral Mammography. Med Sci Monit. 2015; 21: 1358–1367.
7(4): 2147–2168. [Crossref] [Crossref]
27. Applebaum MA, Miller BT, Lopez J, Doren EL, Laronga C, Smith PD. 48. Godavarty A, Rodriguez S, Jung YJ, Gonzalez S. Optical imaging for
Change in Body Mass Index After Breast Reconstruction and Associated breast cancer prescreening. Breast Cancer: Targets and Therapy (Dove
Complications. Eplasty. 2015; 15: 406–412. Med Press). 2015; 7: 193–209. [Crossref]
28. Chan DSM, Vieira AR, Aune D, Bandera EV, Greenwood DC, 49. Hwang JY, Han BK, Ko EY, Shin JH, Hahn SY, Nam MY. Screening
McTiernan A et al. Body mass index and survival in women with breast Ultrasound in Women with Negative Mammography: Outcome
cancer- systematic literature review and meta-analysis of 82 follow-up Analysis. Yonsei Med J. 2015; 56(5): 1352–1358. [Crossref]
studies. Ann Oncol. 2014; 25(10): 1901–1914. [Crossref] 50. Yang SN, Li FJ, Liao YH, Chen YS, Shen WC, Huang TC. Identification
29. Thompson HJ, Sedlacek SM, Playdon MC, Wolfe P, McGinley JN, Paul of Breast Cancer Using Integrated Information from MRI and
D et al. Weight Loss Interventions for Breast Cancer Survivors: Impact Mammography. PLoS One. 2015; 10(6): 1–11. [Crossref]
of Dietary Pattern. PLoS One. 2015; 10(5): 1–17. [Crossref] 51. Weinstock C, Campassi C, Goloubeva O, Wooten K, Kesmodel S,
30. Schüz J, Espina C, Villain P, Herrero H, Leon ME, Minozzi S et al. Bellevance E et  al. Breast magnetic resonance imaging (MRI)
European Code against Cancer 4th Edition: 12 ways to reduce your surveillance in breast cancer survivors. SpringerPlus. 2015; 4: 1–8.
cancer risk. Cancer Epidemiology. 2015. [cited 2015 November 11]. [Crossref]
Available from: http://www.cancerepidemiology.net/article/S1877– 52. Akhtari-Zavare M, Latiff LA, Juni MH, Said SM, Ismail IZ. Knowledge
7821(15)00127–7/pdf. of Female Undergraduate Students on Breast Cancer and Breast Self-
31. Scoccianti C, Cecchini M, Anderson AS, Berrino F, Boutron-Ruault examination in Klang Valley, Malaysia. Asian Pac J Cancer Prev. 2015;
MC, Espina C et al. European Code against Cancer 4th Edition: Alcohol 16(15): 6231–6235. [Crossref]
drinking and cancer. Cancer Epidemiology. 2015. [cited 2015 November 53. Populacyjny program profilaktyki i wczesnego wykrywania raka szyjki
11]. Available from: http://www.cancerepidemiology.net/article/S1877– macicy i populacyjny program wczesnego wykrywania raka piersi.
7821(15)00023–5/pdf. Ministerstwo Zdrowia 2013. [cited 2015 November 16]. Available from:
http://profilaktykaraka.coi.waw.pl/dla-kobiet/profilaktyka-raka-piersi.