Cancer Causes & Control

, Volume 24, Issue 2, pp 305–312 | Cite as

Body mass index, tumor characteristics, and prognosis following diagnosis of early-stage breast cancer in a mammographically screened population

  • Aruna Kamineni
  • Melissa L. Anderson
  • Emily White
  • Stephen H. Taplin
  • Peggy Porter
  • Rachel Ballard-Barbash
  • Kathleen Malone
  • Diana S. M. Buist
Original paper



Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment.


Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use.


Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34–4.41) and breast cancer death (HR 2.41; 95 % CI 1.00–5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67.


Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.


Breast cancer recurrence Breast cancer-specific mortality Tumor characteristics Obesity Body mass index 



This work was supported by a grant from the American Cancer Society (CRTG-03-024-01-CCE) and a cooperative agreement (U01CA63731) and grant (K05CA154337) from the National Cancer Institute.

Conflict of interest

All authors listed on the manuscript have met all three requirements for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals and the authors declare that they have no conflicts of interest regarding this work.


  1. 1.
    Goodwin PJ, Boyd NF (1990) Body size and breast cancer prognosis: a critical review of the evidence. Breast Cancer Res Treat 16:205–214PubMedCrossRefGoogle Scholar
  2. 2.
    Greenberg ER, Vessey MP, McPherson K, Doll R, Yeates D (1985) Body size and survival in premenopausal breast cancer. Br J Cancer 51:691–697PubMedCrossRefGoogle Scholar
  3. 3.
    Holmberg L, Lund E, Bergstrom R, Adami HO, Meirik O (1994) Oral contraceptives and prognosis in breast cancer: effects of duration, latency, recency, age at first use and relation to parity and body mass index in young women with breast cancer. Eur J Cancer 30A:351–354PubMedCrossRefGoogle Scholar
  4. 4.
    Daling JR, Malone KE, Doody DR, Johnson LG, Gralow JR, Porter PL (2001) Relation of body mass index to tumor markers and survival among young women with invasive ductal breast carcinoma. Cancer 92:720–729PubMedCrossRefGoogle Scholar
  5. 5.
    Zhang S, Folsom AR, Sellers TA, Kushi LH, Potter JD (1995) Better breast cancer survival for postmenopausal women who are less overweight and eat less fat. The Iowa Women’s Health Study. Cancer 76:275–283PubMedCrossRefGoogle Scholar
  6. 6.
    Chang S, Alderfer JR, Asmar L, Buzdar AU (2000) Inflammatory breast cancer survival: the role of obesity and menopausal status at diagnosis. Breast Cancer Res Treat 64:157–163PubMedCrossRefGoogle Scholar
  7. 7.
    Ewertz M, Jensen MB, Gunnarsdottir KA et al (2011) Effect of obesity on prognosis after early-stage breast cancer. J Clin Oncol 29:25–31PubMedCrossRefGoogle Scholar
  8. 8.
    Senie RT, Rosen PP, Rhodes P, Lesser ML, Kinne DW (1992) Obesity at diagnosis of breast carcinoma influences duration of disease-free survival. Ann Intern Med 116:26–32PubMedGoogle Scholar
  9. 9.
    Chlebowski RT, Aiello E, McTiernan A (2002) Weight loss in breast cancer patient management. J Clin Oncol 20:1128–1143PubMedCrossRefGoogle Scholar
  10. 10.
    Maehle BO, Tretli S (1996) Pre-morbid body-mass-index in breast cancer: reversed effect on survival in hormone receptor negative patients. Breast Cancer Res Treat 41:123–130PubMedCrossRefGoogle Scholar
  11. 11.
    Newman SC, Lees AW, Jenkins HJ (1997) The effect of body mass index and oestrogen receptor level on survival of breast cancer patients. Int J Epidemiol 26:484–490PubMedCrossRefGoogle Scholar
  12. 12.
    Williams G, Howell A, Jones M (1988) The relationship of body weight to response to endocrine therapy, steroid hormone receptors and survival of patients with advanced cancer of the breast. Br J Cancer 58:631–634PubMedCrossRefGoogle Scholar
  13. 13.
    Obermair A, Kurz C, Hanzal E et al (1995) The influence of obesity on the disease-free survival in primary breast cancer. Anticancer Res 15:2265–2269PubMedGoogle Scholar
  14. 14.
    Dignam JJ, Wieand K, Johnson KA, Fisher B, Xu L, Mamounas EP (2003) Obesity, tamoxifen use, and outcomes in women with estrogen receptor-positive early-stage breast cancer. J Natl Cancer Inst 95:1467–1476PubMedCrossRefGoogle Scholar
  15. 15.
    den Tonkelaar I, de Waard F, Seidell JC, Fracheboud J (1995) Obesity and subcutaneous fat patterning in relation to survival of postmenopausal breast cancer patients participating in the DOM-project. Breast Cancer Res Treat 34:129–137CrossRefGoogle Scholar
  16. 16.
    Katoh A, Watzlaf VJ, D’Amico F (1994) An examination of obesity and breast cancer survival in post-menopausal women. Br J Cancer 70:928–933PubMedCrossRefGoogle Scholar
  17. 17.
    Carmichael AR, Bendall S, Lockerbie L, Prescott RJ, Bates T (2004) Does obesity compromise survival in women with breast cancer? Breast 13:93–96PubMedCrossRefGoogle Scholar
  18. 18.
    Caan BJ, Emond JA, Natarajan L et al (2006) Post-diagnosis weight gain and breast cancer recurrence in women with early stage breast cancer. Breast Cancer Res Treat 99:47–57PubMedCrossRefGoogle Scholar
  19. 19.
    Taplin SH, Mandelson MT, Anderman C et al (1997) Mammography diffusion and trends in late-stage breast cancer: evaluating outcomes in a population. Cancer Epidemiol Biomarkers Prev 6:625–631PubMedGoogle Scholar
  20. 20.
    Taplin SH, Thompson RS, Schnitzer F, Anderman C, Immanuel V (1990) Revisions in the risk-based Breast Cancer Screening Program at Group Health Cooperative. Cancer 66:812–818PubMedCrossRefGoogle Scholar
  21. 21.
    Taplin SH, Ichikawa L, Yood MU et al (2004) Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow-up? J Natl Cancer Inst 96:1518–1527PubMedCrossRefGoogle Scholar
  22. 22.
    Fleming ID, Cooper JS, Henson DE et al (eds) (1997) AJCC Cancer Staging Manual, 5th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  23. 23.
    Buist DS, Porter PL, Lehman C, Taplin SH, White E (2004) Factors contributing to mammography failure in women aged 40–49 years. J Natl Cancer Inst 96:1432–1440PubMedCrossRefGoogle Scholar
  24. 24.
    Porter PL, El-Bastawissi AY, Mandelson MT et al (1999) Breast tumor characteristics as predictors of mammographic detection: comparison of interval- and screen-detected cancers. J Natl Cancer Inst 91:2020–2028PubMedCrossRefGoogle Scholar
  25. 25.
    WHO (2000) Obesity: preventing and managing the global epidemic. World Health Organization, Geneva (Switzerland)Google Scholar
  26. 26.
    American College of Radiology (ACR) (2003) ACR BI-RADS—mammography ACR Breast Imaging and Reporting and Data System, Breast Imaging Atlas, 4th edn. American College of Radiology, RestonGoogle Scholar
  27. 27.
    Rutter CM, Mandelson MT, Laya MB, Seger DJ, Taplin S (2001) Changes in breast density associated with initiation, discontinuation, and continuing use of hormone replacement therapy. JAMA 285:171–176PubMedCrossRefGoogle Scholar
  28. 28.
    Buist DS, Chubak J, Prout M et al (2009) Referral, receipt, and completion of chemotherapy in patients with early-stage breast cancer older than 65 years and at high risk of breast cancer recurrence. J Clin Oncol 27:4508–4514PubMedCrossRefGoogle Scholar
  29. 29.
    Geiger AM, Thwin SS, Lash TL et al (2007) Recurrences and second primary breast cancers in older women with initial early-stage disease. Cancer 109:966–974PubMedCrossRefGoogle Scholar
  30. 30.
    Yood MU, Owusu C, Buist DS et al (2008) Mortality impact of less-than-standard therapy in older breast cancer patients. J Am Coll Surg 206:66–75PubMedCrossRefGoogle Scholar
  31. 31.
    Zou G (2004) A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 159:702–706PubMedCrossRefGoogle Scholar
  32. 32.
    Rosner GL, Hargis JB, Hollis DR et al (1996) Relationship between toxicity and obesity in women receiving adjuvant chemotherapy for breast cancer: results from cancer and leukemia group B study 8541. J Clin Oncol 14:3000–3008PubMedGoogle Scholar
  33. 33.
    Griggs JJ, Culakova E, Sorbero ME et al (2007) Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy. J Clin Oncol 25:277–284PubMedCrossRefGoogle Scholar
  34. 34.
    Mannisto S, Pietinen P, Pyy M, Palmgren J, Eskelinen M, Uusitupa M (1996) Body-size indicators and risk of breast cancer according to menopause and estrogen-receptor status. Int J Cancer 68:8–13PubMedCrossRefGoogle Scholar
  35. 35.
    Ruder AM, Lubin F, Wax Y, Geier A, Alfundary E, Chetrit A (1989) Estrogen and progesterone receptors in breast cancer patients. Epidemiologic characteristics and survival differences. Cancer 64:196–202PubMedCrossRefGoogle Scholar
  36. 36.
    Giuffrida D, Lupo L, La Porta GA et al (1992) Relation between steroid receptor status and body weight in breast cancer patients. Eur J Cancer 28:112–115PubMedCrossRefGoogle Scholar
  37. 37.
    Howson CP, Kinne D, Wynder EL (1986) Body weight, serum cholesterol, and stage of primary breast cancer. Cancer 58:2372–2381PubMedCrossRefGoogle Scholar
  38. 38.
    Enger SM, Ross RK, Paganini-Hill A, Carpenter CL, Bernstein L (2000) Body size, physical activity, and breast cancer hormone receptor status: results from two case-control studies. Cancer Epidemiol Biomarkers Prev 9:681–687PubMedGoogle Scholar
  39. 39.
    Elmore JG, Carney PA, Abraham LA et al (2004) The association between obesity and screening mammography accuracy. Arch Intern Med 164:1140–1147PubMedCrossRefGoogle Scholar
  40. 40.
    Carney PA, Harwood BG, Weiss JE, Eliassen MS, Goodrich ME (2002) Factors associated with interval adherence to mammography screening in a population-based sample of New Hampshire women. Cancer 95:219–227PubMedCrossRefGoogle Scholar
  41. 41.
    Fontaine KR, Heo M, Allison DB (2001) Body weight and cancer screening among women. J Womens Health Gend Based Med 10:463–470PubMedCrossRefGoogle Scholar
  42. 42.
    Wee CC, McCarthy EP, Davis RB, Phillips RS (2000) Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Ann Intern Med 132:697–704PubMedGoogle Scholar
  43. 43.
    Caan BJ, Aragaki A, Thomson CA et al (2009) Vasomotor symptoms, adoption of a low-fat dietary pattern, and risk of invasive breast cancer: a secondary analysis of the Women’s Health Initiative randomized controlled dietary modification trial. J Clin Oncol 27:4500–4507PubMedCrossRefGoogle Scholar
  44. 44.
    Kaplan MA, Pekkolay Z, Kucukoner M et al (2012) Type 2 diabetes mellitus and prognosis in early stage breast cancer women. Med Oncol 29:1576–1580PubMedCrossRefGoogle Scholar
  45. 45.
    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
  46. 46.
    Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin JR, Hux JE (2008) The impact of diabetes on survival following breast cancer. Breast Cancer Res Treat 109:389–395PubMedCrossRefGoogle Scholar
  47. 47.
    National Comprehensive Cancer Network (2012) NCCN clinical practice guidelines in oncology (NCCN guidelines) breast cancer version 3, 2012th edn. National Comprehensive Cancer Network, Fort WashingtonGoogle Scholar
  48. 48.
    Nekhlyudov L, Li L, Ross-Degnan D, Wagner AK (2011) Five-year patterns of adjuvant hormonal therapy use, persistence, and adherence among insured women with early-stage breast cancer. Breast Cancer Res Treat 130:681–689PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Aruna Kamineni
    • 1
  • Melissa L. Anderson
    • 1
  • Emily White
    • 2
    • 3
  • Stephen H. Taplin
    • 4
  • Peggy Porter
    • 2
  • Rachel Ballard-Barbash
    • 4
  • Kathleen Malone
    • 2
    • 3
  • Diana S. M. Buist
    • 1
  1. 1.Group Health Research InstituteSeattleUSA
  2. 2.Fred Hutchinson Cancer Research CenterSeattleUSA
  3. 3.School of Public HealthUniversity of WashingtonSeattleUSA
  4. 4.National Cancer InstituteBethesdaUSA

Personalised recommendations