JOURNAL ARTICLE

CRITIQUE
PRESENTATION
Submitted To submitted by
Vijayakumari S Athira PS
Asst.professor 1st year MSc Nursing
Govt. college of Nursing Govt. college of Nursing
Thrissur Thrissur
TITLE
The international journal of cancer epidemiology, detection and prevention
STUDY
Risk factors for breast cancer in the breast cancer risk model study of Guam and Saipan
Rachael T. Leon Guerreroa
Rachel Novotnyb
Lynne R. Wilkensc
Marie Chongc Kami K.
Whitec Yurii B. Shvetsovc
Arielle Buyumd
Grazyna Badowskia
Michelle Blas-Laguaña
INTRODUCTION
Chamorro Pacific Islanders in the Mariana Islands have breast cancer incidence rates
similar to, but mortality rates higher than, those of U.S. women. As breast cancer risk factors
of women of the Mariana Islands may be unique because of ethnic and cultural differences.In
the United States (U.S.), breast cancer is the second most common cause of cancer mortality
among women, and it has also been the second leading cause of cancer mortality among
women on Guam .over the last three decades. Many risk factors for breast cancer have been
established. Its etiology involves both genetic and behavioral factors. Increasing age is a
major risk factor. Risk increases with inherited genetic mutations, such as in the BRCA1 and
BRCA2 genes, and a personal or family history of breast cancer .Other risk factors include
never having children, greater height, benign breast disease, early menarche, late menopause
(after age 54), ionizing-radiation exposure, postmenopausal obesity, physical inactivity, and
alcohol intake .Breastfeeding, moderate/vigorous physical activity, and maintaining a healthy
body weight decrease breast cancer risk .High breast tissue density and high circulating levels
of estrogens have also been associated with higher breast cancer incidence. Abdominal
adiposity, as measured by waist circumference and waist-to-height ratio, are also considered
risk factors.To study the reasons for the disparate rates of breast cancer in different ethnic
groups in the Mariana Islands the BRISK (Breast Cancer Risk Model) Project was conducted
to improve under-standing of the risk factors for breast cancer in this region. Here, we discuss
established and suspected risk factors for breast cancer in this population, including
demographics, reproductive factors, body size, and alcohol intake.
STATEMENT OF THE PROBLEM
A retrospective case control study to assess the risk factor for breast cancer in the breast
cancer risk model study of Guam and Saipan.
MATERIAL AND METHODS
RESEARCH APPROACH
• It is a quantitative study
RESEARCH DESIGN
• it is a retrospective case control study
SETTING OF THE STUDY
the University of Guam and the University of Hawaii Cancer Center at the CNMI department
of public health.
POPULATION AND SAMPLE SIZE
• Population: women among mariana island • Sample size:290 women
TOOL AND TECHNIQUES
TECHNIQUE
Interview method
TOOLS

❖Questionnaire ❖Marianas food frequency questionnaire

STATISTICAL ANALYSIS

➢The goal of the present analysis was to examine established or suspected risk and
protective factors for breast cancer in this population. ➢Breast cancer cases were identified
through the Guam Cancer Registry, CNMI Department of Public Health, and health clinics
on Guam.
Eligibility criteria for cases were (1) primary, invasive breast cancer newly diagnosed
between 2009 and 2012; (2) no prior history of cancer (other than skin cancer); (3) residence
on Guam or Saipan for at least 5 years; (4) ability to provide consent for the study; and (5)
age between 25 and 80 years.
Eligibility criteria for controls were (1) no prior history of cancer (other than skin cancer); (2)
residence on Guam or Saipan for at least 5 years; (3) ability to provide consent for the study;
and (4) age between 25 and 80 years. The questionnaire included demo-graphic information
such as age, date of birth, date of diagnosis (cases), education level, place of birth, and
number of years living in the Mariana Islands. ➢Breast cancer baseline characteristics were
first summarized using descriptive statistics. ➢The association of established and suspected
risk factors for breast cancer with breast cancer risk was assessed using a multivariable
logistic regression model, adjusting for baseline patient characteristics, with results expressed
as odds ratios (ORs) with 95% confidence intervals (CIs).ORs were calculated for each of the
following 19 lifestyle-related factors in all women combined and in pre- and post-menopausal
women separately: education, age at menarche, number of live births, age at first live birth,
ever breastfed, firstdegree family history of breast cancer, hormone use, type of menopause,
age at menopause, BMI, WC, WHtR, physical activity, daily energy intake, alcohol intake,
betel-nut use, smoking tobacco, height, and weight change.
RESULTS AND DISCUSSION
RESULTS
Of the medical and reproductive factors considered — age at menarche, breastfeeding,
number of live births, age at first live birth, hormone use, and menopause — only age at first
live birth was confirmed. Age at first live birth, among parous women, was higher among
cases (mean 24.9 years) than controls (mean 23.2 years); with increased breast cancer risk
(OR = 2.53; 95% CI,1.04–6.19 for age 30y compared to 40%), as indicated by BMI’s of 30
and above, and they were at risk for cardiometabolic disease, as indicated by high WC
measures and WHtR calculations. Age at first live birth above 30 years is a well-known risk
factor for breast cancer and women in the present study who had a higher age at first birth
had a significantly greater breast cancer risk. This population of women residing in the
Mariana Islands has a relatively low age at first live birth. In the U.S., the age at first birth has
risen to 26.0 years .In the BRISK study, the mean age at first birth was 24. If these women
are representative of the women living in the Mariana Islands, this difference may explain
why the overall rates of breast cancer on Guam are lower than those among U.S.
women.Filipino women with high waist circumference were at a higher risk of developing
breast cancer.
LIMITATIONS
The small sample size of approximately 290 women has made statistical significance for
many of the known risk factors difficult to attain. Recall bias for both cases and controls may
have affected the associations for dietary, reproductive, and physical- activity factors. The
interview was conducted after the cases had been diagnosed, although within 24 months after
diagnosis. We measured weight and height after cancer diagnosis and treatment, and, for
breast cancer cases, body-size associations with risk may have been biased because the body
size we recorded may not have reflected body size before diagnosis, although the results for
self reported body size before diagnosis were similar. Control subjects were a convenience
sample of volunteers and may not be representative of the population from which they were
recruited, although the participation rate was good among controls at 74%.
STRENGTH
this retrospective case-control study provides the first assessment of breast cancer risk
factors in the multiethnic populations of Guam and Saipan.
CONCLUSION
The results provide a basis for cancer prevention guidance for women in the Mariana Islands.
 CRITICAL ANALYSIS
1.TITLE AND AUTHORS CREDENTIALS,DETAILS OF JOURNAL
Title, authors credentials and details of the journal mentioned.
TITLE:Risk factors for breast cancer in the breast cancer risk model study of Guam and
Saipan.
Details of the journal mentioned- The international journal of cancer epidemiology , detection
and prevention
• Editor in chief is Eve Roman, university of York, United kingdom . Cite score is 4.5 .
Impact factor is 2.1792.
ABSTRACT/SUMMARY-SUMMERISES ARTICLES
Background: Chamorro Pacific Islanders in the Mariana Islands have breast cancer incidence
rates similar to, but mortality rates higher than, those of U.S. women. As breast cancer risk
factors of women of the Mariana Islands may be unique because of ethnic and cultural
differences, we studied established and suspected risk factors for breast cancer in this
unstudied population. • Methods: retrospective case-control study of female breast cancer
(104 cases and 185 controls) among women in the Mariana Islands. • Results: Of the medical
and reproductive factors considered — age at menarche, breastfeeding, number of live births,
age at first live birth, hormone use, and menopause — only age at first live birth was
confirmed.Age at first live birth, among parous women, was higher among cases (mean 24.9
years) than controls (mean 23.2 years); with increased breast cancer risk (OR = 2.53; 95%
CI,1.04–6.19 for age 30y compared .
the abstract include only the data that are presented in the paper. the abstract includes the
materials that can be substantiated. the conclusion is clear and reflects the results.
Conclusion: The results provide a basis for cancer prevention guidance for women in the
Mariana Islands
they are appropriate Key Words: Breast cancer , BRISK, risk factors , Guam , Saipan
INTRODUCTION
• Did the authors indicate why the study is important/justification for the study?
Yes , the author indicates why the study is important
Does the review identify the current knowledge and gaps?
Yes, the review identifies the current knowledge and gaps. According to the most recent
Guam Cancer Facts and Figures (2008–2012) breast cancer accounts for 30% of new cancer
cases among women on Guam and for 14% of cancer deaths. The age-adjusted incidence rate
of breast cancer for 2008–2012 on Guam was 97 per 100,000 for Chamorro women and 77
for Filipino women The breast cancer mortality rate for this period was 20.8 for Chamorro
women and 21.9 for women in the U.S.CONT…
• Does the review of literature provide rational and direction for the present study?
No . the review of literature is inadequate.
• Does the literature review provides the basis for study conducted?
No , the literature review not provides the basis for the study conducted.
• Was the background information provided adequate to understand the aims of the study?
Yes , the background information was adequate. Background: Chamorro Pacific Islanders in
the Mariana Islands have breast cancer incidence rates similar to, but mortality rates higher
than, those of U.S. women. As breast cancer risk factors of women of the Mariana Islands
may be unique because of ethnic and cultural differences, we studied established and
suspected risk factors for breast cancer in this unstudied population.
• Is there a logical connection to the aim?
Yes, there is a logical connection to the aim of the study. It assess the reasons for the
disparate rates of breast cancer in different ethnic groups in the Mariana Islands [15,16,29],
the BRISK (Breast Cancer Risk Model) Project was conducted to improve under-standing of
the risk factors for breast cancer in this region. Here, we discuss established and suspected
risk factors for breast cancer in this population, including demographics, reproductive factors,
body size, and alcohol intake.
• Are the objectives clear, unbiased, specific, consistent and important and logically relate to
research purpose, aims, and theory?
The objectives are clear, unbiased, specific and consistent and also important and logically
related to the purpose, aims and theory.
• Does the introduction creates interest to read the article?
Yes, it creates an interest to read the article. It discuss about the rates of breast cancer in
different ethnic groups in mariana islands. It also explains the major risk factor involved
cancer.
4.MATERIALS AND METHODS
it states what the researcher did and how it was done. BRISK is a retrospective case-control
study that was designed to assess breast cancer risk factors and to develop a model for
predicting breast cancer risk in Pacific populations of Asians and Pacific Islanders living on
Guam and Saipan. The study was conducted from 2010 to 2013 by researchers at the
University of Guam and the University of Hawaii Cancer Center under the auspices of an
NCI-sponsored partnership (U54-CA-143727) and was approved by Institutional Review
Boards at both institutions. The University of Guam lead investigator and project staff
members were of Chamorro heritage. Recruitment required identification of women
diagnosed with breast cancer (cases) and women of similar age and ethnicity without a
diagnosis of breast cancer (controls) who were willing to participate. Breast cancer cases
were identified through the Guam Cancer Registry, CNMI Department of Public Health, and
health clinics on Guam. the patients are selected and enrolled in the trial appropriately.
• Is the study designed according to appropriate standards?
a)Inclusion and exclusion criteria: It has the inclusion criteria: Eligibility criteria for cases
were (1) primary, invasive breast cancer newly diagnosed between 2009 and 2012; (2) no
prior history of cancer (other than skin cancer); (3) residence on Guam or Saipan for at least 5
years; (4) ability to provide consent for the study; and (5) age between 25 and 80 years.
Eligibility criteria for controls were (1) no prior history of cancer (other than skin cancer); (2)
residence on Guam or Saipan for at least 5 years; (3) ability to provide consent for the study;
and (4) age between 25 and 80 years. .b)Sample size calculation: it is not done. They were
selected according to the inclusion criteria. c)Randomization procedure: there is no
randomization. Breast cancer cases were identified through the Guam Cancer Registry,
CNMI Department of Public Health, and health clinics on Guam. d)Blinding : there is no
blinding in this study; it’s a retrospective cohort study.
e)Appropriateness of the outcome measures: appropriate
f)Adequate intervals to measure outcomes?
No. The interview was conducted after the cases had been diagnosed, although within 24
months after diagnosis.
g)Is the sample represent the population?
Yes, the sample represent the population.
Is the sampling method described? Yes.
• Are potential sampling biases identified?
No any potential sampling biases identified.
• Details od any drop out, if any. yes. Of the 275 cases contacted, 38% agreed to participate,
21% were ineligible, and 41% refused; 48% of the eligible cases participated. The
corresponding percentages for the 250 controls contacted were 74%, 20% and 6%; 93% of
the eligible controls participated. The study included 104 breast cancer cases (83 from Guam
and 21 from CNMI) and 185 controls (140 from Guam and 45 from CNMI) between 27 and
80 years of age.
• Does the investigator mentioned ethical consideration and data collection process.
Investigator mentioned about the consent from participants and discuss about the data
collection process well.
• Does the study describes details of measurements, instructions, mode of administration,
validity, reliability, scoring details?
Yes, the study describes the details of measurements, instructions, modes of administration.
Details of measurements : Age at first live birth, among parous women, was higher among
cases (mean 24.9 years) than controls (mean 23.2 years); with increased breast cancer risk
(OR = 2.53; 95% CI,1.04–6.19 for age 30y compared
Validity and reliability:

it is not mentioned in the study, but discuss about the tools used to measure the variables.

logistic regression models were used to assess the associations.

• Were the methods described in sufficient details for others to repeat or extend the study?

Yes , the methods described are sufficient for others to repeat or extend the study.

• Have the authors indicated the details of protocol and the reasons why particular procedures
were used?

No, the author didn’t indicated the details of protocol and the reason why particular procedures
were used.

DATA ANALYSIS

• Have the author specified the statistical procedures used?

Yes. baseline characteristics were first summarized using descriptive statistics. The association
determined using a multivariable logistic regression model adjusting for baseline patient
characteristics, with results expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

• Are the statistical methods used appropriate? • Yes, here descriptive statistics is used and it is
appropriate.

DISCUSSION

• Does the study evaluate and interpret the results in relation to research question were there any
suggestion for future research?

Yes, the study evaluate and interpret the results in relation to the research question and also
provides suggestions for the future research. only waist circumference (OR = 1.65; 95% CI 0.87– 3.14
for the highest tertile group compared to the lowest, P for trend = 0.04) was significantly associated
with breast cancer risk and only in Filipino women. The association with many other established risk
factors, such as BMI, hormone use and physical activity, were in the expected direction but were not
significant. Associations for family history of breast cancer and alcohol intake were not evident

• Suggestions: Future prospective studies are needed to establish a causal relationship between
established and suspected risk factors for breast cancer with breast cancer risk.