Breast Cancer Research and Treatment

, Volume 129, Issue 2, pp 565–574 | Cite as

Obesity and breast cancer survival in ethnically diverse postmenopausal women: the Multiethnic Cohort Study

  • Shannon M. ConroyEmail author
  • Gertraud Maskarinec
  • Lynne R. Wilkens
  • Kami K. White
  • Brian E. Henderson
  • Laurence N. Kolonel


Breast cancer survival has been found to be lower in obese women, but few studies have evaluated ethnic variations in this association. This study examined all-cause and breast cancer-specific survival by body mass index (BMI) in the Multiethnic Cohort (MEC) study for African American, Native Hawaiian, Japanese American, Latino, and Caucasian women. Female MEC participants free of breast cancer, aged ≥50 years at cohort entry, and diagnosed with primary invasive breast cancer during follow-up were included in the analyses (n = 3,842). Cox proportional hazards regression was used to estimate the effect of pre-diagnostic adult BMI (<22.5, 22.5–24.9, 25.0–29.9, ≥30 kg/m2) on the risk of mortality. Mean age at diagnosis was 68.8 years (range 50–89 years). During a mean follow-up of 6.2 ± 3.8 years after diagnosis, there were 804 deaths that included 376 breast cancer-specific deaths. After adjustment for breast cancer characteristics, including hormone receptor status, stage at diagnosis, and treatment, obese women had a higher risk of all-cause [hazard ratio (HR) = 1.54; 95% confidence interval (CI): 1.23, 1.91] and breast cancer-specific (HR = 1.45; 95% CI: 1.05, 2.00) mortality compared to women with high-normal BMI; however, being overweight did not affect survival. There was no evidence of ethnic differences in the BMI effect on all-cause (P interaction = 0.87) or breast cancer-specific (P interaction = 0.63) mortality. Our findings are consistent with the literature that maintaining moderate weight throughout adult life may be beneficial for breast cancer survival in women and this appears to hold for all ethnic groups.


Breast carcinoma Ethnicity Obesity Survival Prognosis 



Body mass index


Confidence interval


Estrogen receptor


Hazard ratio


Hormone replacement therapy


Multiethnic cohort


Progesterone receptor


Surveillance, epidemiology, and end results



We thank all the participants in the Multiethnic Cohort Study. The Multiethnic Cohort Study has been supported by US Public Health Service (National Cancer Institute) grant R37 CA 54281. SMC was supported by a postdoctoral fellowship on grant R25 CA 90956. The tumor registries are supported by NCI contracts N01-PC-35137 and N01-PC-35139.

Conflict of interest

All authors (Conroy, Maskarinec, Wilkens, White, Henderson, Kolonel) declare that they have no conflicts of interest.


  1. 1.
    Rosenberg J, Chia YL, Plevritis S (2005) The effect of age, race, tumor size, tumor grade, and disease stage on invasive ductal breast cancer survival in the U.S. SEER database. Breast Cancer Res Treat 89:47–54PubMedCrossRefGoogle Scholar
  2. 2.
    Altekruse SF, Kosary CL, Krapcho M et al (eds) (2010) SEER cancer statistics review, 1975–2007, National Cancer Institute. Bethesda, MD, Accessed 15 March 2010
  3. 3.
    Dunnwald LK, Rossing MA, Li CI (2007) Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients. Breast Cancer Res 9:R6PubMedCrossRefGoogle Scholar
  4. 4.
    Patterson RE, Cadmus LA, Emond JA, Pierce JP (2010) Physical activity, diet, adiposity and female breast cancer prognosis: a review of the epidemiologic literature. Maturitas 66:5–15PubMedCrossRefGoogle Scholar
  5. 5.
    Flegal KM, Carroll MD, Ogden CL, Curtin LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. JAMA 303:235–241PubMedCrossRefGoogle Scholar
  6. 6.
    Protani M, Coory M, Martin JH (2010) Effect of obesity on survival of women with breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat 123:627–635PubMedCrossRefGoogle Scholar
  7. 7.
    Maskarinec G, Pagano I, Lurie G, Bantum E, Gotay CC, Issell BF (2011) Factors affecting survival among women with breast cancer in Hawaii. J Womens Health (Larchmt) 20:231–237CrossRefGoogle Scholar
  8. 8.
    Petrelli JM, Calle EE, Rodriguez C, Thun MJ (2002) Body mass index, height, and postmenopausal breast cancer mortality in a prospective cohort of US women. Cancer Causes Control 13:325–332PubMedCrossRefGoogle Scholar
  9. 9.
    Dignam JJ, Wieand K, Johnson KA et al (2006) Effects of obesity and race on prognosis in lymph node-negative, estrogen receptor-negative breast cancer. Breast Cancer Res Treat 97:245–254PubMedCrossRefGoogle Scholar
  10. 10.
    Rose DP, Gilhooly EM, Nixon DW (2002) Adverse effects of obesity on breast cancer prognosis, and the biological actions of leptin (review). Int J Oncol 21:1285–1292PubMedGoogle Scholar
  11. 11.
    Calle EE, Kaaks R (2004) Overweight, obesity and cancer: epidemiological evidence and proposed mechanisms. Nat Rev Cancer 4:579–591PubMedCrossRefGoogle Scholar
  12. 12.
    Griggs JJ, Sorbero ME, Lyman GH (2005) Undertreatment of obese women receiving breast cancer chemotherapy. Arch Intern Med 165:1267–1273PubMedCrossRefGoogle Scholar
  13. 13.
    Kolonel LN, Henderson BE, Hankin JH et al (2000) A multiethnic cohort in Hawaii and Los Angeles: baseline characteristics. Am J Epidemiol 151:346–357PubMedGoogle Scholar
  14. 14.
    Hankey BF, Ries LA, Edwards BK (1999) The surveillance, epidemiology, and end results program: a national resource. Cancer Epidemiol Biomarkers Prev 8:1117–1121PubMedGoogle Scholar
  15. 15.
    Henderson SO, Haiman CA, Wilkens LR, Kolonel LN, Wan P, Pike MC (2007) Established risk factors account for most of the racial differences in cardiovascular disease mortality. PLoS One 2:e377PubMedCrossRefGoogle Scholar
  16. 16.
    Peairs KS, Barone BB, Snyder CF et al (2011) Diabetes mellitus and breast cancer outcomes: a systematic review and meta-analysis. J Clin Oncol 29:40–46PubMedCrossRefGoogle Scholar
  17. 17.
    Durrleman S, Simon R (1989) Flexible regression models with cubic splines. Stat Med 8:551–561PubMedCrossRefGoogle Scholar
  18. 18.
    Dal Maso L, Zucchetto A, Talamini R et al (2008) Effect of obesity and other lifestyle factors on mortality in women with breast cancer. Int J Cancer 123:2188–2194PubMedCrossRefGoogle Scholar
  19. 19.
    Imkampe AK, Bates T (2010) Impact of a raised body mass index on breast cancer survival in relation to age and disease extent at diagnosis. Breast J 16:156–161PubMedCrossRefGoogle Scholar
  20. 20.
    Caan BJ, Kwan ML, Hartzell G et al (2008) Pre-diagnosis body mass index, post-diagnosis weight change, and prognosis among women with early stage breast cancer. Cancer Causes Control 19:1319–1328PubMedCrossRefGoogle Scholar
  21. 21.
    Chen X, Lu W, Zheng W et al (2010) Obesity and weight change in relation to breast cancer survival. Breast Cancer Res Treat 122:823–833PubMedCrossRefGoogle Scholar
  22. 22.
    Patterson RE, Flatt SW, Saquib N et al (2010) Medical comorbidities predict mortality in women with a history of early stage breast cancer. Breast Cancer Res Treat 122:859–865PubMedCrossRefGoogle Scholar
  23. 23.
    Suissa S, Pollak M, Spitzer WO, Margolese R (1989) Body size and breast cancer prognosis: a statistical explanation of the discrepancies. Cancer Res 49:3113–3116PubMedGoogle Scholar
  24. 24.
    Moon HG, Han W, Noh DY (2009) Underweight and breast cancer recurrence and death: a report from the Korean Breast Cancer Society. J Clin Oncol 27:5899–5905PubMedCrossRefGoogle Scholar
  25. 25.
    Bessonova L, Marshall SF, Ziogas A et al (2011) The association of body mass index with mortality in the California Teachers Study. Int J Cancer. doi: 10.1002/ijc.25905
  26. 26.
    Whitlock G, Lewington S, Sherliker P et al (2009) Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 373:1083–1096PubMedCrossRefGoogle Scholar
  27. 27.
    McTiernan A, Rajan KB, Tworoger SS et al (2003) Adiposity and sex hormones in postmenopausal breast cancer survivors. J Clin Oncol 21:1961–1966PubMedCrossRefGoogle Scholar
  28. 28.
    Lonning PE, Helle H, Duong NK, Ekse D, Aas T, Geisler J (2009) Tissue estradiol is selectively elevated in receptor positive breast cancers while tumour estrone is reduced independent of receptor status. J Steroid Biochem Mol Biol 117:31–41PubMedCrossRefGoogle Scholar
  29. 29.
    Brakenhielm E, Veitonmaki N, Cao R et al (2004) Adiponectin-induced antiangiogenesis and antitumor activity involve caspase-mediated endothelial cell apoptosis. Proc Natl Acad Sci USA 101:2476–2481PubMedCrossRefGoogle Scholar
  30. 30.
    Rene Gonzalez R, Watters A, Xu Y et al (2009) Leptin-signaling inhibition results in efficient anti-tumor activity in estrogen receptor positive or negative breast cancer. Breast Cancer Res 11:R36PubMedCrossRefGoogle Scholar
  31. 31.
    Lann D, LeRoith D (2008) The role of endocrine insulin-like growth factor-I and insulin in breast cancer. J Mammary Gland Biol Neoplasia 13:371–379PubMedCrossRefGoogle Scholar
  32. 32.
    Duggan C, Irwin ML, Xiao L et al (2011) Associations of insulin resistance and adiponectin with mortality in women with breast cancer. J Clin Oncol 29:32–39PubMedCrossRefGoogle Scholar
  33. 33.
    Sparreboom A, Wolff AC, Mathijssen RH et al (2007) Evaluation of alternate size descriptors for dose calculation of anticancer drugs in the obese. J Clin Oncol 25:4707–4713PubMedCrossRefGoogle Scholar
  34. 34.
    Srokowski TP, Fang S, Hortobagyi GN, Giordano SH (2009) Impact of diabetes mellitus on complications and outcomes of adjuvant chemotherapy in older patients with breast cancer. J Clin Oncol 27:2170–2176PubMedCrossRefGoogle Scholar
  35. 35.
    van de Poll-Franse LV, Houterman S, Janssen-Heijnen ML, Dercksen MW, Coebergh JW, Haak HR (2007) Less aggressive treatment and worse overall survival in cancer patients with diabetes: a large population based analysis. Int J Cancer 120:1986–1992PubMedCrossRefGoogle Scholar
  36. 36.
    Stommel M, Schoenborn CA (2009) Accuracy and usefulness of BMI measures based on self-reported weight and height: findings from the NHANES & NHIS 2001–2006. BMC Public Health 9:421PubMedCrossRefGoogle Scholar
  37. 37.
    Cowper DC, Kubal JD, Maynard C, Hynes DM (2002) A primer and comparative review of major US mortality databases. Ann Epidemiol 12:462–468PubMedCrossRefGoogle Scholar
  38. 38.
    Goodwin PJ, Ennis M, Pritchard KI et al (1999) Adjuvant treatment and onset of menopause predict weight gain after breast cancer diagnosis. J Clin Oncol 17:120–129PubMedGoogle Scholar
  39. 39.
    Kroenke CH, Chen WY, Rosner B, Holmes MD (2005) Weight, weight gain, and survival after breast cancer diagnosis. J Clin Oncol 23:1370–1378PubMedCrossRefGoogle Scholar
  40. 40.
    Nichols HB, Trentham-Dietz A, Egan KM et al (2009) Body mass index before and after breast cancer diagnosis: associations with all-cause, breast cancer, and cardiovascular disease mortality. Cancer Epidemiol Biomarkers Prev 18:1403–1409PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2011

Authors and Affiliations

  • Shannon M. Conroy
    • 1
    Email author
  • Gertraud Maskarinec
    • 1
  • Lynne R. Wilkens
    • 1
  • Kami K. White
    • 1
  • Brian E. Henderson
    • 2
  • Laurence N. Kolonel
    • 1
  1. 1.Epidemiology ProgramUniversity of Hawaii Cancer CenterHonoluluUSA
  2. 2.Department of Preventive Medicine, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA

Personalised recommendations