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Research Articles

Better Postdiagnosis Diet Quality Is Associated with Reduced Risk of Death among Postmenopausal Women with Invasive Breast Cancer in the Women's Health Initiative

Stephanie M. George, Rachel Ballard-Barbash, James M. Shikany, Bette J. Caan, Jo L. Freudenheim, Candyce H. Kroenke, Mara Z. Vitolins, Shirley A. Beresford and Marian L. Neuhouser
Stephanie M. George
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Rachel Ballard-Barbash
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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James M. Shikany
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Bette J. Caan
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Jo L. Freudenheim
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Candyce H. Kroenke
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Mara Z. Vitolins
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Shirley A. Beresford
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Marian L. Neuhouser
Authors' Affiliations: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Research, Kaiser Permanente of Northern California, Oakland, California; Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina; and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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DOI: 10.1158/1055-9965.EPI-13-1162 Published April 2014
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Tables

  • Table 1.

    Demographic, clinical, and lifestyle characteristics of 2,317 women with invasive breast cancer in the WHI by HEI-2005 quartiles

    Poor-quality dietsMixed-quality dietsBetter-quality diets
    Healthy Eating Index-2005 Score Quartile 1 (34–63)Healthy Eating Index-2005 Score Quartile 2 (63–71)Healthy Eating Index-2005 Score Quartile 3 (71–77)Healthy Eating Index-2005 Score Quartile 4 (77–91)
    N(%)N(%)N(%)N(%)Pa
    Number of participants579579580579
    Age at screening for WHI
     Mean (SE)63.6 (0.3)63.6 (0.3)63.4 (0.3)63.9 (0.3)0.639
    Years since diagnosis
     Mean (SE)1.6 (0.4)1.5 (0.05)1.4 (0.04)1.6 (0.04)0.366
    Calories (kcals/day)
     Mean (SE)1665 (27.1)1558.7 (23.7)1454.4 (21.0)1470.2 (19.8)<0.0001
    Alcohol servings/wk
     Mean (SE)3.3 (0.3)2.6 (0.2)1.7 (0.1)1.0 (0.1)<0.0001
    MET-hours/week of MVPAb
     Mean (SE)8.1 (0.5)9.9 (0.5)10.6 (0.5)13.3 (0.7)<0.0001
    BMIc
     Mean (SE)29.3 (0.3)28.6 (0.2)27.8 (0.2)27.0 (0.2)<0.0001
    Race/ethnicity0.773
     White51088505875168952290
     Black417387285244
     Hispanic122163132132
     Other153203203193
     Unknown10102010
    Education0.002
     High school or less12121941686158615
     Some college23641214372213818933
     College6511751379147713
     Postgraduate15226190331893322539
     Missing51625120
    Income0.029
     ≥$50,00019934228392504324943
     $20,000–49,99925945257442374123841
     <$20,0008114691266115610
     Missing407254275366
    WHI component/arm<0.0001
     WHI Observational Study26446247432784832356
     WHI-DM-control25344222381512611420
     WHI-DM-intervention6211111191502614225
    Stage0.974
     Localized43675427744367544377
     Regional13223142251362312822
     Distant61413131
     Unknown51615151
    Estrogen receptor status0.197
     Positive42974455794517842373
     Negative9016651172129015
     Unknown6010591057106611
    Progesterone receptor status0.751
     Positive35862357623716434960
     Negative15326153261352315026
     Unknown6812691274138014
    Postmenopausal hormone therapy0.122
     Never21337195371923318933
     Past8615911771126912
     Current28048293513175532155
    • ↵aP for χ2 test for categorical variables or trend test for continuous variables.

    • ↵bFor 2,149 of 2,317 participants with known MVPA.

    • ↵cFor 2,297 of 2,317 participants with known measured BMI.

  • Table 2.

    Postdiagnosis diet quality, risk of death from any cause, and risk of death from breast cancer among 2,317 postmenopausal women diagnosed with invasive breast cancer in the WHI

    Poor-quality dietMixed-quality dietBetter-quality diet
    Healthy Eating Index-2005 Score Quartile 1 (34–63)Healthy Eating Index-2005 Score Quartile 2 (63–71)Healthy Eating Index-2005 Score Quartile 3 (71–77)Healthy Eating Index-2005 Score Quartile 4 (77–91)Ptrend
    N579579580579
    Death from any cause (n)11710510291
     Unadjusted HR (95% CI)1.000.84 (0.65–1.09)0.79 (0.61–1.03)0.67 (0.51–0.88)0.004
     Age and energy-adjusted HR (95% CI)1.000.83 (0.64–1.08)0.77 (0.59–1.01)0.63 (0.48–0.83)0.0009
     Multivariate-adjusted HR (95% CI)a1.000.93 (0.71–1.22)0.86 (0.65–1.14)0.74 (0.55–0.99)0.043
    Death from breast cancer (n)51484445
     Unadjusted HR (95% CI)1.000.89 (0.60–1.32)0.79 (0.53–1.19)0.78 (0.52–1.17)0.178
     Age and energy-adjusted HR (95% CI)1.000.89 (0.60–1.32)0.79 (0.53–1.19)0.78 (0.52–1.16)0.173
     Multivariate-adjusted HR (95% CI)a1.000.99 (0.66–1.50)0.93 (0.61–1.43)0.91 (0.60–1.40)0.627
    Death from causes other than breast cancer (n)66575846
     Unadjusted HR (95% CI)1.000.80 (0.56–1.14)0.79 (0.56–1.13)0.59 (0.40–0.86)0.008
     Age and energy-adjusted HR (95% CI)1.000.79 (0.55–1.12)0.77 (0.54–1.10)0.52 (0.36–0.76)0.001
     Multivariate-adjusted HR (95% CI)a1.000.83 (0.58–1.20)0.79 (0.54–1.15)0.58 (0.38–0.87)0.011
    • ↵aAdjusted for age at screening visit (continuous), WHI component (WHI-DM-intervention, WHI-DM-control, or OS), ethnicity (White non-Hispanic, Black/African American, Hispanic/Latino, other, missing), income (<20,000, 20,000–49,999, ≥50,000, missing), education (high school or below, some college, college, postgraduate, missing), stage (localized, regional, distant, unknown), estrogen receptor status (positive, negative, unknown), progesterone receptor status (positive, negative, unknown), time since diagnosis (continuous), energy intake in kcals (continuous), physical activity in MET-h/wk (0, 0.1–3, 3.1–8.9, 9+, unknown), servings of alcohol per week (continuous), and use of postmenopausal hormone therapy (never, former, current).

  • Table 3.

    Multivariate associations between diet quality and death from any cause, stratified analysis by ER status

    Poor-quality dietMixed-quality dietBetter-quality diet
    Healthy Eating Index-2005 Score Quartile 1 (34–63)Healthy Eating Index-2005 Score Quartile 2 (63–71)Healthy Eating Index-2005 Score Quartile 3 (71–77)Healthy Eating Index-2005 Score Quartile 4 (77–91)PtrendPinteraction
    ER-positive
     N429455451423
     Death from any cause (n)81747157
     Multivariate-adjusted HR of all-cause mortality (95% CI)a1.000.82 (0.59–1.13)0.71 (0.51–0.99)0.55 (0.38–0.79)0.0009
    ER-negative0.449
     N90657290
     Death from any cause (n)25161520
     Multivariate-adjusted HR of all-cause mortality (95% CI)a1.000.90 (0.46–1.76)0.92 (0.46–1.83)1.14 (0.58–2.23)0.811

    NOTE: For 2,075 participants with known ER status.

    • ↵aAdjusted for age at screening visit (continuous), WHI component (WHI-DM-intervention, WHI-DM-control, or OS), ethnicity (White non-Hispanic, Black/African American, Hispanic/Latino, other, missing), income (<20,000, 20,000–49,999, ≥50,000, missing), education (high school or below, some college, college, postgraduate, missing), stage (localized, regional, distant, unknown), progesterone receptor status (positive, negative, unknown), time since diagnosis (continuous), energy intake in kcals (continuous), physical activity in MET-h/wk (0, 0.1–3, 3.1–8.9, 9+, unknown), servings of alcohol per week (continuous), and use of postmenopausal hormone therapy (never, former, current).

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Cancer Epidemiology Biomarkers & Prevention: 23 (4)
April 2014
Volume 23, Issue 4
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Better Postdiagnosis Diet Quality Is Associated with Reduced Risk of Death among Postmenopausal Women with Invasive Breast Cancer in the Women's Health Initiative
Stephanie M. George, Rachel Ballard-Barbash, James M. Shikany, Bette J. Caan, Jo L. Freudenheim, Candyce H. Kroenke, Mara Z. Vitolins, Shirley A. Beresford and Marian L. Neuhouser
Cancer Epidemiol Biomarkers Prev April 1 2014 (23) (4) 575-583; DOI: 10.1158/1055-9965.EPI-13-1162

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Better Postdiagnosis Diet Quality Is Associated with Reduced Risk of Death among Postmenopausal Women with Invasive Breast Cancer in the Women's Health Initiative
Stephanie M. George, Rachel Ballard-Barbash, James M. Shikany, Bette J. Caan, Jo L. Freudenheim, Candyce H. Kroenke, Mara Z. Vitolins, Shirley A. Beresford and Marian L. Neuhouser
Cancer Epidemiol Biomarkers Prev April 1 2014 (23) (4) 575-583; DOI: 10.1158/1055-9965.EPI-13-1162
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