Background: Breast cancer risk assessment is a helpful method for estimating development of breast cancer at the population level. Materials and Methods: In this cross-sectional study, participants consisted of a group of 3,847 volunteers (mean Â± SD age: 463 Â± 7.59 years) in a convenience sample of women referred to health centers affiliated to Tehran University of Medical Sciences in Tehran, Iran. The risk of breast cancer was estimated by applying the National Cancer Institute's online version of the Gail Risk Assessment Tool. Results: Some 24.9 of women reported having one first-degree female relative with breast cancer, with 8.05 of them having two or more first-degree relatives with breast cancer. The mean five-year risk of breast cancer for all participants was 1.61Â±0.73, and 9.36 of them had a five-year risk of breast cancer > 1.66. The mean lifetime risk of breast cancer was 11.7Â±3.91. Conclusions: The Gail model is useful for assessing probability of breast cancer in Iranian women. Based on the their breast cancer risk, women may decide to accept further screening services

Janani, L.

Khazaee-Pool, M.

Majlessi, F.

Montazeri, A.

Nedjat, S.

Pashaei, T.

English

eprints Iran University of Medical Sciences

Asian Pacific Journal of Cancer Prevention, Vol 17, 2016 375910.14456/apjcp.2016.166/APJCP.2016.17.8.3759Assessing the Breast Cancer Risk among Iranian Women Using the Gail ModelAsian Pac J Cancer Prev, 17 (8), 3759-3762 IntroductionThe rate of breast cancer in Iran is continually increasing due to the variations in reproductive patterns such as delayed marriage, having fewer kids, changes in lifestyle behaviours. Additionally, due to the improving women’s health literacy, the rate of early detection has increased. While the incidence rate of breast cancer in Iranian women over 30 years is still fairly low (about 23 per 100,000), the number of patients with just detected breast cancer is increasing, and it is ranked first common cancer among Iranian women (Montazeri, 2008; Khazaee-pool, 2014; Khazaee-Pool, 2014). This emphasizes the importance of breast cancer preventing and screening program in Iran.Breast cancer screening is effective approach for prevention and early detection in women. Early detection is enhanced by a follow-up screening program for “high risk” women. Consequently, it is essential to describe what is meant by “high risk” women (Bevers, 2009). Although there are a number of tools for assessing risk of breast 1Department of Health Education and Promotion, School of Health, Zanjan University of Medical Sciences, Zanjan, 2School of Public Health, Knowledge Utilization Research Center, 3Department of Health Education and Promotion, School of Health, 4Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, 5Mental Health Research Group, Health Metrics Research Center, Institute for Health Sciences Research, ACECR, 6Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, 7Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, 8Department of public health, School of Health, Kurdistan University of Medical Sciences, Sanandaj, Iran  *For correspondence: dr_f_majlessi@yahoo.comAbstract Background: Breast cancer risk assessment is a helpful method for estimating development of breast cancer at the population level. Materials and Methods: In this cross-sectional study, participants consisted of a group of 3,847 volunteers (mean ± SD age: 463 ± 7.59 years) in a convenience sample of women referred to health centers affiliated to Tehran University of Medical Sciences in Tehran, Iran. The risk of breast cancer was estimated by applying the National Cancer Institute’s online version of the Gail Risk Assessment Tool. Results: Some 24.9% of women reported having one first-degree female relative with breast cancer, with 8.05% of them having two or more first-degree relatives with breast cancer. The mean five-year risk of breast cancer for all participants was 1.61±0.73%, and 9.36% of them had a five-year risk of breast cancer >1.66%. The mean lifetime risk of breast cancer was 11.7±3.91%. Conclusions: The Gail model is useful for assessing probability of breast cancer in Iranian women. Based on the their breast cancer risk, women may decide to accept further screening services. Keywords: Breast cancer - Gail model - risk assessment - Iranian womenRESEARCH ARTICLEAssessing Breast Cancer Risk among Iranian Women Using the Gail ModelMaryam Khazaee-Pool1, Fereshteh Majlessi2,3*, Saharnaz Nedjat4,2 Ali Montazeri5, leila Janani6, Tahereh Pashaei7,8cancer, Gail model is most commonly tool in order to predict the risk of developing breast cancer for women aged 35 and above in the next five years and within her lifetime (Gail, 1989). It was improved by the National Surgical Adjuvant Breast and Bowel Project (NSABP) to design the developing invasive breast cancer risk, which is accessible on the National Cancer Institute (NCI) website (Costantino, 1999). The main difficulty of the Gail model is that it estimates only risk of developing breast cancer in people who have a history of breast cancer in their first-degree relatives.It is suggested having clinical breast examinations every 6-12 months and annual mammography in women aged 35 years or above with a 5-year risk of 1.7% or more (Andreeva, 2013). One helpful procedure to maximize advantages and reduce burden of disease is applying the screening program for only the women who are at a high risk of developing breast cancer. Therefore, the aim of the present study was to determine the percentage of Iranian women at high risk of developing breast cancer, using the Gail risk assessment model. It is also important knowing Maryam Khazaee-Pool et alAsian Pacific Journal of Cancer Prevention, Vol 17, 20163760the women at high risk of developing breast cancer that is a valuable support for making a decision in health care and accepting the effect of different prevention policies.Materials and MethodsThis was a descriptive and cross-sectional study. A convenience sample of 3,847 women referred to Health cancers affiliated to Tehran University of Medical Sciences in Tehran, Iran, was recruited to participate in the study between August 2014 and October 2015. Inclusion criteria contained being 35 years or above (based on the Gail model).The risk factors used were age, the number of previous breast biopsies, the presence of atypical hyperplasia in any previous breast biopsy specimen, age at first period, age at the first live birth of a child, the history of breast cancer among her first-degree relatives (mother, sisters, daughters), and the individual’s age and race. The calculation was done by using Gail model prediction from the NCI’s breast cancer Risk Assessment Tool website (which is available at http://www.cancer.gov/bcrisktool/). This model estimated the five-year and lifetime breast cancer risk for women aged 35 years and older (Gail, 1989).Statistics: Statistical software, namely, SPSS 22.0, was used to perform descriptive statistics counting the mean, median, standard deviation, frequency distributions, and percentage.Ethics of studyThis project was accepted by the ethics committee of Tehran University of Medical Sciences. Informed written consent was received from all the study participants. An effort was made to observe the ethics of the study, proposing the women the choice to give up whenever they wish, and by keeping their private information. The women were assured about the unanimity of their identities.Results In total, 3,847 women participated in this study. The average age of participants in the present study was 46.27±7.59 years (range 35-71 years). It was specified that the majority of women (46.5%) where higher education, 51.86% of them were housewives, 43.44% of them had medical insurance, 46.9% of them had “middle level” family income, and 76.6% of them married (see Table 1). Additionally, results determined that the majority of them (49.96%) stated their menarche at age 7 to 11; 35.7% of women had their first live birth at the ages of 30 and over; 24.85% of participants reported having one first degree relatives affected breast cancer; 8.05% of participants stated having two or more first-degree relative with breast cancer; and 11.1% of them had one previous breast biopsies (See Table 1).The result of the present study also shown that the Table 1. Distribution of Women Based on Socio Demographic Characteristics and Risk Factors Using the Gail Model (n=3847)Socio demographic characteristics of women N %Marital status   Married 2947 76.6   Single 649 16.88   Divorced/widowed 251 6.52Occupation   Housewife 1995 51.86   Employed 1852 48.14Education   Primary 318 8.3   Secondary 1739 45.2   Higher 1790 46.5Family income   High 914 23.78   Middle 1804 46.9   Low 1129 29.32Insurance   Medical insurance 1671 43.44   Social insurance 1069 27.8   No insurance 1107 28.76Risk Factors the Gail model of womenAge group (years)   35-40 639 16.6   41-46 792 20.6   47-52 1610 41.85   53 and above 806 20.95Age at menarche (years)   Unknown 37 0.96   7 years old-11 years old 1922 49.96   12 years old-13 years old 1081 28.1   ≥14 807 20.98Age at first live birth (years)   No children 327 8.5   ≤20 217 5.63   20-24 502 13.05   25-29 1428 37.12   ≥30 1373 35.7Number of first-degree relatives with breast cancer   Zero relatives 2581 67.1   One relative 956 24.85   More than one 310 8.05Biopsy   No 3371 87.62   Yes (one biopsy) 427 11.1   Yes (more than one biopsy) 49 1.28Figure 1. Five-year Risk of Breast Cancer in Women Based on the Gail Model (%)Asian Pacific Journal of Cancer Prevention, Vol 17, 2016 376110.14456/apjcp.2016.166/APJCP.2016.17.8.3759Assessing the Breast Cancer Risk among Iranian Women Using the Gail Modelmean five-year risk of breast cancer for all participants was 1.608±0.729% (range 0.2±13.8%).The mean lifetime risk of breast cancer was 11.705±3.91% (range 0.6 54.7%) (See Table 2). In addition, 9.36% (360 women) of them had a five-year risk of breast cancer >1.66% (See Figure 1).DiscussionAs the incidence rate of breast cancer is increasing in Iran, it is important to find women with a high risk of breast cancer in order to timely function for treatment. Although there are some risk assessment tools in the area of breast cancer, such as Claus model, Tyrer–Cuzick model, and several others; we applied the Gail model to estimate the risk of breast cancer for Iranian women.  Appling the Gail model, we gotten that the mean five-year risk of breast cancer for all participants was 1.608±0.729% (range 0.2±13.8%), and 9.36% (360 women) of them had a five-year risk of breast cancer >1.66%. As the mean five-year risk of breast cancer is higher than the average five-year risk for the same age and race. These results are in contrast with previous findings by Erbil who reported that the mean five-year breast cancer risk for all women was 0.88±0.91% (Erbil, 2015). In Seyednoori’ study, the mean five-year breast cancer risk was 0.8%±1, and 16.2% of the women had a five-year risk higher than the average woman of the same age, and 18.2% of them had the same risk (Seyednoori, 2012). Additionally, Yilmaz reported that the breast cancer risk was lower in housewives than academic participants, both five-year and lifetime risk of breast cancer estimated by Gail model. Besides, the mean five-year and lifetime breast cancer risk was less than 1.7% for five-year risk and 15% for lifetime risk in both housewife and academic women (Yilmaz, 2011). The Ceber (2013) study found the 5-year risk rate of breast cancer as 17.6% among the women over the age of 50 (Ceber, 2013), but the study of Mermer (2011) determined the risk of breast cancer in 18.1% of women older than 40 years of age (Mermer, 2011). Present study results showed that the mean lifetime risk of breast cancer was more than the average lifetime risk for the same age and race while previous studies reported that the lifetime risk was commonly lower based on the Gail model amongst women (Ceber, 2006; Karakayali, 2007). In Seyednoori’ study, mean breast cancer lifetime risk was 9.0±3.9%; 11.1% of the them had higher lifetime risk and 1.6% had the same risk as the average woman (Seyednoori, 2012). In studies conducted by Dano, the risk of developing breast cancer reported the highest range in academic women compared to the other women (Dano, 2003; Dano, 2004). According to the report by Davis, the risk of breast cancer in women increased between 2%-46%, with a mean of 9% (Davis, 2004). The mean lifetime risk estimate can help women in seeking consultation about breast cancer screening and prevention (Gao, 2012).We found that reproductive history, women’s age at first live birth, menarche, age, and having first degree relatives had breast cancer were the factors in getting risk of developing breast cancer among Iranian women. Some factors such as reproductive history, socioeconomic situation, and lifestyle factors may affect risk of breast cancer (Yilmaz, 2011). A much higher risk of developing breast cancer was shown in women had early menarche and a first live birth at 30 years of age and above (Chay, 2012). Pregnancy at an early age relates to a considerably decreased breast cancer risk. Having 30 years of age and above at first live birth is associated with in increasing developing breast cancer risk (Nechuta, 2010). We observed that participants had the history of breast cancer in their first degree relatives. This is consistent with the previous findings reported by Ceber (2013), who stated that 7.4% of the participants had a history of breast cancer in their relatives (first degree and second degree), and in Erbil (2015)’ study about 6.1% of participants was reported having first degree relatives who had had breast cancer (Ceber, 2013; Erbil, 2015)However, having a family history of breast/ovarian cancer is associated with increasing risk of breast cancer, some factors, such as type, number, and age at the beginning of cancer in affected relative families are also important in assessing the rate of risk (Sifuentes, 2015). As Abu-Rustum study (Abu-Rustum, 2001), we found that some women had previous breast biopsies. However, in the Sayednoori study, less than 7 percent of the women had a history of the previous biopsy (Seyednoori, 2012). This could be associated with a lack of suitable comparison to participants of the same age without risk factors for those of Iranian ethnicity.Applying risk assessment models can help healthcare providers to calculate a person’s risk of developing breast cancer. It has been recommended that women should have annual mammograms starting at 40. Women with a higher risk of developing breast cancer should get extra screening procedures; as well as they might also get beginning screening at an earlier age with more repeated periods (Erbil, 2015).In conclusion, breast cancer remains a serious public health problem in women. In the present study, it was found that 9.36% of participants had a five-year risk of developing breast cancer (>1.66%). The calculating of breast cancer risk can assist people looking for screening and preventive services. Thus, it is necessary to highlight the importance of using breast cancer risk assessment tools to calculate a woman’s probability of developing breast cancer. Our study has some limitations. The researchers only determined risk of breast cancer among women at one province in Iran, and the convenience sampling technique Table 2. Mean Five-Year and Lifetime Risk of Women Based on the Gail Model (n=3847)Risk M (SD) Minimum risk Maximum riskMean five-year risk of women 1.61 (0.73) 0.2 13.8Mean five-year risk for women of the same age without risk factors 1.57 (0.69) 0.3 2.4Mean lifetime risk of women 11.71 (3.91) 0.6 54.7Mean lifetime risk of women the same age without risk factors 11.62 (2.014) 4.9 13.4Maryam Khazaee-Pool et alAsian Pacific Journal of Cancer Prevention, Vol 17, 20163762was applied to gather samples in the present study of which findings can generalize only to these samples. We also should be careful in using the Gail model as it has not been matched in the Iranian population. It seems that the validation of the Gail model to be necessary in Iranian people. This may help in the development of future screening programs in Iran.Acknowledgements The authors would like to thank all participants for coming. This study was funded by Tehran University of medical sciences, Iran [Grant number 26227]. 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Assessing breast cancer risk among Iranian women using the gail model

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Assessing breast cancer risk among Iranian women using the gail model

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