Iranian Journal of

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Background & Objectives: Breast cancer is a common malignancy in women in many parts of the world. The incidence of breast cancer in Iranian women is growing. Iranian patients are relatively younger than their western counterparts. We conducted a case-control study to determine roles of reproductive factors for breast cancer among women in Iran.
Methods: A hospital based case-control study was conducted in 2004 at a teaching hospital in Tehran, Iran. A total of 303 cases of breast cancer and 303 healthy controls were interviewed. Cases were identified through the oncology department of a university hospital and controls were recruited from other wards or out-patients clinics at the same hospital. Controls were matched to cases on age. Demographic and reproductive data were ascertained by personal interview using a structured questionnaire. Informed consent was obtained from cases and controls. Odds ratios and 95% confidence intervals for breast cancer were derived using logistic regression analysis.
Results: Mean ±SD age of cases and controls was 48.8 ±9.8 and 50.2 ± 11.1 years, respectively (range 24-84). The final model constructed after multivariate analysis indicated that factors such as never being married, menopause, older age at first live birth, parity, use of oral contraceptives, and history of chest X-ray between adolescence and the age of 30 yrs were significantly associated with breast cancer. Variables such as higher education, early age at menarche, abortion, breast feeding and its duration did not constitute significant risk factors.
Conclusions: Marital status, history of chest X-ray between adolescence and the age of 30, number of live births, and age at first live birth, menopause, and oral contraceptive use seem to increase the risk of developing breast cancer among women in Iran.

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Background and Objectives: Logistic regression is one of the most widely used generalized linear models for analysis of the relationships between one or more explanatory variables and a categorical response. Strong correlations among explanatory variables (multicollinearity) reduce the efficiency of model to a considerable degree. In this study we used latent variables to reduce the effects of multicollinearity in the analysis of a case-control study.
Methods: Our data came from a case-control study in which 300 women with breast cancer were compared to 300 controls. Five highly correlated quantitative variables were selected to assess the effect of multicollinearity. First, an ordinary logistic regression model was fitted to the data. Then, to remove the effect of multicollinearity, two latent variables were generated using factor analysis and principal components analysis methods. Parameters of logistic regression were estimated using these latent as explanatory variables. We used the estimated standard errors of the parameters to compare the efficiency of models.
Results: The logistic regression based on five primary variables produced unusual odds ratio estimates for age at first pregnancy (OR=67960, 95%CI: 10184-453503) and for total length of breast feeding (OR=0). On the other hand, the parameters estimated for logistic regression on latent variables generated by both factor analysis and principal components analysis were statistically significant (P<0.003). The standard errors were smaller than with ordinary logistic regression on original variables. The factors and components generated by the two methods explained at least 85% of the total variance.
Conclusions: This research showed that the standard errors of the estimated parameters in logistic regression based on latent variables were considerably smaller than that of model for original variables. Therefore models including latent variables could be more efficient when there is multicollinearity among the risk factors for breast cancer.

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Background and objectives: There is growing interest in assessing gene-environment interaction in the course of case-control studies. Difficulties related to the sampling of controls have led to the development of a range of non-traditional methods that do not require controls for estimating gene-environment interaction. One of these new modalities is the case-only approach, in which the assessment of gene-environment interaction is based on information from the cases only. The present article describes the application of this approach to data from breast cancer patients and compares its efficacy with that of a traditional case-control analysis.
Methods: We used age at first pregnancy, number of live birth, menopause and the total number of post-menopausal years as the "environment" factors and family history of breast cancer as the "gene" factor. We computed standard errors, 95% confidence intervals and (-2 log likelihood) to compare efficiency between case-control and case-only analyses.
Results: We observed significant interaction between menopause and family history of breast cancer by both methods (OR=4.32 CI: 1.10-16.90 for case-control analysis & OR=3.40 CI: 1.17-9.87 for case-only analysis). There was also a significant interaction effect between total years after menopause and family history of breast cancer (OR=1.07 CI: 0.98-1.16 in case-control analysis & OR=1.07 CI: 1.01-1.12 in case-only analysis). The case-only approach yielded narrower confidence intervals for the odds ratio, and the (-2 log likelihood) values computed by this method were correspondingly smaller.
Conclusions: Comparison of confidence intervals and (-2 log likelihood) values shows that the estimation of gene-environment interaction in breast cancer would be more efficient with the case-only approach than with the traditional case-control analysis.

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Background & Objectives: Today, the quality of life study has an important role in health care especially in chronic diseases, in clinical judgment and in medical resources supplying. Malignancies have a clinical and health importance in the world and Iran. Breast cancer has first order among women’s malignancies. Now, survival rate for this cancer is long. However Breast cancer has several complications that affected patient’s life. It is necessary that we studying the quality of life and related factors among this patients.
Methods: We conducted a cross-sectional study on 119 breast cancer patients that admitted and treated in chemotherapy ward of Namazi hospital in Shiraz.We used QLQ-C30 & QLQ-BR23 to assessment quality of life in these patients. We used univariate nonparametric tests and multiple linear regression model to identify associations between dependent variables and the quality of life and it’s different scales.All calculation performed by using SPSS.V.13.
Results: Mean age of patients was 48.27±11.42 with quality of life total score 64.92±24.28. Univariate analysis showed that occupation,duration of disease,grade of tumor,physical,emotional and cognitive functioning, also, symptoms such as fatigue,pain, nausea and vomiting , insomnia , constipation and financial difficulties, perspective were associated to quality of life. (P< 0.05). But in multivariate analysis, only occupation, menopause status, dyspnea , grade of tumor and financial difficulties perspective were related to quality of life (p<0.05).
Conclusions: With this finding, It is recommended that financial supports, also early detection are necessary for improvement of quality of life in these patients

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Background & Objectives: The repression of retinoic acid receptor-β2 (RARβ2) expression is a concerning aspect of breast cancer, which is often induced by hypermethylation at promoter of the gene. We aimed to explore the correlation of plasma folate, vitamin B12 and total homocysteine (tHcy) levels with hypermethylation status of RARβ2 gene among Iranian breast cancer patients.
Methods: The hypermethylation status was investigated in 137 specimens tissues from primary breast cancer patients aged 28-85 years thorough methylation-specific PCR.
Results: Hypermethylation at RARβ2 gene was observed in 36.5 %. The hypermthylated RARβ2 associated with younger age at diagnosis and negative family history of breast cancer. The plasma level of folate was found lower in cases aged ≥48 years with hypermethylated RARβ2 gene (P<0.05). In contrast the level of tHcy was shown higher in cases aged <48 y (P<0.05). The risk of hypermethylation at RARβ2 gene increased with low plasma levels of folate (OR=0.21, 95%CI: 0.05-0.88) and vitamin B12 (OR=0.04, 95%CI: 0.01-0.92) and high plasma level of tHcy (OR=7.55, 95%CI: 1.07-25.7) in cases older than 48y.
Conclusions: Low plasma levels of folate, Vitamin B12 and high plasma level of total homocysteine could have important roles as prognostic factors in hypermethylation status of RARβ2 gene in breast cancer.

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Background & Objectives: The experience of patients with breast cancer may vary in different cultures. The aim of this qualitative study was to explore the experiences of women with breast cancer in Iran.
Methods: Fifty one participants were recruited from a university-affiliated breast clinic in Tehran. In-depth interviews each lasting approximately one hour per participant were scheduled and conducted in a private room. The interviews intended to motivate the participants to reflect on their life experiences since the cancer diagnosis. The interviews were tape-recorded and were transcribed to elucidate the major themes encountered in the interviews.
Results: The mean age of patients was 48.8 years (SD = 10.5), 44 were married, one was single, and six were widowed or divorced. Forty-eight participants underwent radical mastectomy and 13 patients received breast-conserving surgery. Thirty-five (69%) patients received chemotherapy. Overall eight major themes emerged from the analysis. These were: importance of God and spiritual beliefs, importance of family support especially husbands and children during the diagnosis and treatment, difficult times during receiving mammography results, experiencing an ambiguous condition while losing their breasts, fear of recurrence, concerns about children, and chemotherapy as the worst experience during the course of treatment.

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  Background & Objectives: Breast cancer is the most common cancer among women. Numerous factors are effective in the improvement of patients undergoing surgery in terms of preventing relapse or need for repeated treatment during 6 months after the surgery. This study aimed to determine the factors affecting improvement of patients undergoing surgery for breast cancer using a logistic regression model.

  Methods: In this study information of 150 patients were extracted from the surgical records of patients underwent surgery at the Cancer Institute of Tehran Imam Khomeini Hospital. Data were analyzed through SPSS software and using logistic regression models .

  Results: Of 150 studied patients, 18 patients (12%) were not fully recovered while 132 (88%) had complete remission. The mean age of the patients was 43 ± 7.5 years, 92.8% were married, and 87.3% had children. According to the results, the odds of non recovery increased by 1.26 times with each one-year increase in age, 5.3 times with each one lymph node involvement, and 8.67 times in the case of metastasis. Other variables, such as marital status, number of children, tumor size, and location of the metastasis showed no significant relationship.

  Conclusion : The Results showed that age at diagnosis, due to its relationship with metastases and number of involved lymph nodes can be directly or indirectly affect the outcome. Therefore, increasing the women's awareness about breast cancer seems to be necessary for early diagnosis which requires planning a sufficient screening program by health policy makers of the country.

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  Background and Objectives : Breast cancer is the second most common cancer among Iranian women. The peak age of breast cancer in Iran is one decade lower than the global estimates. The aim of this cross-sectional study was to estimate the burden of breast cancer in Iranian women in the country level.

 Methods: In this study, the CANMOD software was used for the calculation of DALYs as the sum of YLL and YLD. The required data was the population of the Iranian women, mortality due to breast cancer, incidence cases of breast cancer, and mean time of the stages of breast cancer that was obtained from the Mortality Registry System, Cancer Registry System, and expert panel views .

  Results : In this study, the total burden of breast cancer in Iranian women was 75811 years in 2009. Moreover, the years of life lost (YLL) was 54938 years while years lived with disability (YLD) was estimated 20873 years. The rate of DALYs per 100000 female population was 220.9 years. The peak age of breast cancer burden was in the age group 45-59 years. The incidence to mortality ratio was 3/2.

  Conclusion: The incidence rate, mortality rate, and the burden of breast cancer in Iranian women increased in 2009 when compared to a previous study in 2003. The findings of this study may provide Iranian health managers with some information on the determinants of the burden of breast cancer in order to design preventive measures as well as screening programs for early detection of breast cancer.

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Background and Objectives: Breast cancer is one of the most common cancers among women and is the second main cause of death after lung cancer. The objective of this study was to use the Bayes model to analyze the prognostic effects on the survival of the women with breast cancer after surgery in the south of Iran.

Methods: The date was collected 1192 women who had breast cancer in Namazi Hospital Research Center between 2001 and 2006. The complete information of only 1148 of them was registered. Parametric Bayes and Bayes Cox methods were used. Considering 0.05 as the level of significance, the data analysis was done using the WinBUGS14 software.

Results: The mean age of the patients (at the time of diagnosis) was 47 years in this study. Cox one-variable analysis showed a significant relationship between survival and smoking (P=0.009), bone metastasis (P=0.01), the number of lymph nodes (P=0.001), the tumoral level of malignancy (P=0.001), the surgical method (P=0.015), financial status (P=0.025), and the tumor size (P=0.001). By fitting Bayes models the variables tumor size, level of malignancy and number of lymph nodes were significant.   

Conclusion: The results showed that clinicopathological features of cancer had a significant role in the survival of the patients.

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Background and Objectives: Reproductive factors are in close relationship with breast carcinogenesis. This matched case-control study was conducted to study the association of reproductive risk factors with the risk of breast cancer (BC) among women in Tehran and northwest of Iran.

Methods: This hospital-based case-control study was performed on a total of 432 patients diagnosed with BC with confirmed histopathology who were recruited from hospitals affiliated with Shahid Beheshti and Tabriz University of Medical Sciences between 2007 and 2012, and 543 regionally matched controls without a prior history of BC.

Results: The average number of pregnancy and breast-fed children were significantly higher in cases than controls (P<0.01). The duration of breast-feeding was longer in patients (18.0±8.4 months) than controls (16.0±9.1; P<0.001). Most of the patients were diagnosed with BC above the age of 48 years old which was higher than the mean age of the recruited matched controls. Older age was associated with a 3.87 higher risks of BC development (95% CI: 2.94-5.10). The higher frequency of lactation in patients was significantly associated with the elevated risk (OR=2.22, 95% CI 1.62-3.04). The duration of breast-feeding within14-24 months was correlated with OR=0.52 to protect BC development during the reproductive age
(<48 years) (95% CI: 0.32-0.86). 

Conclusion: High frequency of pregnancy, lactation, and older ages at first pregnancy are associated with the risk of BC, while older age at puberty, menopause, and longer duration of breast-feeding (age above 48 years) have inverse associations with the risk of BC.

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Background and Objectives: Breast cancer is one of the most common malignancies in women which accounts for the highest number of deaths after lung cancer. The aim of the current study was to compare the logistic regression and classification tree models in determining the risk factors and prediction of breast cancer.

Methods: We used from the data of a case-control study conducted on 303 patients with breast cancer and 303 controls. In the first step, we included 16 potential risk factors of breast cancer in both the logistic regression and classification tree models. Then, the area under the ROC curve (AUC), sensitivity, and specificity indexes were used for comparing these models.

Results: From 16 variables included in the models, 5 variables were statistically significant in both models. Sensitivity, specificity, and AUC was 71%, 69%, and 74.7% for the logistic regression and 63.3%, 68.8%, and 71.1% for the classification tree, respectively.

Conclusion: The obtained results suggest that the classification tree has more power for separating patients from healthy people. Menopausal status, number of breast cancer cases in the family, and maternal age at the first live birth were significant indicators in both models.

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Background and Objectives: Breast cancer is the leading cause of death from cancer among women. In developing countries, the patients’ survival is less than developed countries. Metastasis, as an intermediate event, affects the survival of breast cancer patients. This study aimed to evaluate the survival of patients after surgery considering metastasis, as the intermediate event, using the illness-death model.
Methods: In this study, 165 cases of Iranian breast cancer patients who underwent surgery during 2006-2014 were investigated. The patients’ characteristics and their intermediate and final status were collected from their medical records. The illness-death model was used to assess prognostic factors in all stages of disease.
Results: The risk of metastasis in patients with tumor size between 2-5 cm was 3.8 times higher than patients whose tumors were below 2 cm (P=0.009). Patients who had 3 to 6 lymph nodes involved were 3.1 times more likely to have metastases that those with less than 2 lymph nodes (P=0.003). Also, the grade of tumor and HER-2 had a significant role in metastasis (P=0.04).
Conclusion: Using the illness-death model that is suitable for the analysis of such data, it was found that lymph node involved and tumor size had a significant role in metastasis. So, early detection of cancer is required to prevent metastasis and death.

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Background and Objectives: Breast cancer is the most common cancer in Iran. It can be prevented by rapid diagnosis of the disease. Thus, it is necessary to determine the causal relationships between variables related to breast cancer. Bayesian network is a data mining tool that shows the causal relationship between different variables. In this paper, a Bayesian network was applied to find causal relationships between breast cancer variables using a genetic algorithm in a graphical model. 
 
Methods: in this applied study, data were collected from 900 breast cancer patients in Kerman Province from 1999 to 2008. For data analysis, we used a probabilistic graphical model representing the causal relationship between variables.
 
Results: The results showed that surgery was the most important treatment for breast cancer. Based on the conditional and marginal probabilities, the women who underwent surgery had higher hopes of living longer. Moreover, 81% of the patients who did not undergo surgery only received chemotherapy or radiotherapy were less likely to have long lives.
 
Conclusion: People aged 40-65 years are more likely to have breast cancer. Moreover, the variables of age, surgery, chemotherapy, and radiotherapy had a direct effect on the status of the patients and there were direct edges from these variables to the status of the patients.

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Background and Objectives: Accurate assessment of patients' death depression requires a specific tool that is appropriate to the culture of each community. Therefore, the aim of this study was to evaluate the psychometric properties of the Death Depression Scale in women with breast cancer.
 
Methods: In this methodological study, 246 breast cancer patients presenting to Qazvin Provincial Hospital completed the 17-item Templar Death Depression Scale. Psychometric properties of this scale were evaluated by exploratory and confirmatory factor analysis. Reliability was also assessed using Cronbach's alpha, omega and composite reliability.
 
Results: Exploratory factor analysis showed that six items in the Persian version did not acquire the required loading factor, and were omitted. The remaining eleven items as a single factor accounted for 66.91% of the variance of this concept. In confirmatory factor analysis, 11 items had appropriate fit indices (χ2 = 97.664, p <.001, χ2 / df = 2.504, GFI = .932, CFI = .972, IFI = .973, TLI = .961, SRMR = .030, and RMSEA = .079). A Cronbach's alpha coefficient of 0.95, Omega coefficient of 0.95, and composite reliability coefficient of 0.96 indicated the acceptable reliability of the 11-item version.
 
Conclusion: The results of this study showed that the 11-item Death Depression Scale was valid and reliable in Iranian patients with breast cancer. Given the appropriate psychometric parameters, this scale can be used to assess death depression in future studies.

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Background and Objectives: Breast cancer has the highest incidence in the Iranian women.

Methods: A cross-sectional study was conducted. All female with breast cancer during 2008-2015 were enrolled. Breast cancer registration is based on the pathology method in Iran. The information about female with breast cancer was collected from their files in the cancer registry department of Hamadan Health Center. The samples were divided into four groups according to age (<50 and> 50) and location (city, village). GeoBUGS was used to generate a map of high-risk areas in Hamedan Province based on the adjusted relative risk estimate (RR*) in OpenBUGS v 3.2.3 software.

Results: This study included 1316 females with breast cancer. The mean age of the patients was 50.38±12.98 years. The results of the study showed that high-risk areas of breast cancer for were Assadabad urban females aged over 50 years (RR*(i)=1.32, CI= 0.99,1.79) and Tuyserkan (RR*(i)=1.09, CI= 1.08,1.38) and Razan (RR*(i)=1.09, CI= 0.85,1.40) for females below 50 years. In addition, Razan for rural females over 50 years old (RR*(i)=1.18, CI=0.82,1.73) and Malayer for females below 50 years old (RR*(i)=1.08, CI= 0.81,1.45) were high risk areas for breast cancer in Hamadan Province.

Conclusion: The distribution of breast cancer is different at different ages and in the cities of Hamadan Province. Asadabad, Tuyserkan, Razan and Malayer were high risk areas for breast cancer in Hamadan Province.