Breast cancer is the leading cause of death from cancer among women, accounting for 23% of the total cancer cases and 14% of cancer deaths in 2008. As dietary fat is thought to be one of the main risk factors, this webinar will focus on the opposing effects of the omega-6 fatty acid arachidonic acid (AA) and the omega-3 fatty acid eicosapentaenoic acid (EPA) on factors related to breast cancer risk, development and prognosis, including their influence on cyclooxygenase activity and prostaglandin production, the impact of inflammation within the tissue microenvironment, impact on aromatase and oestrogen production and impact on genetic aspects of breast cancer such as modulation of BRAC1 and BRAC2 genes.
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Modulating Breast Cancer Risk: The AA:EPA Ratio - webinar - Igennus
1. Fatty acids and breast cancer
Dr Nina Bailey
BSc MSc PhD ANutr
2. Common cancers (males vs females) UK, 2010
25%
31%
47%
46%
14%
Prostate
Breast
12%
Lung
14%
Bowel
Other sites
http://www.cancerresearchuk.org/cancer-info/cancerstats/incidence/commoncancers
11%
Lung
Bowel
Other sites
3. Breast cancer is one of the most commonly diagnosed cancers and the
leading cause of death from cancer among women,
Breast cancer accounted for 31% of the total cancer cases in 2010
Risk factors:
Gender
Hormones
Aging
Reproductive history
HRT/birth control
Breast density
Genetic risk factors
Family history
Alcohol consumption
Obesity
Sedentary lifestyle
Dietary factors
4. Diet and lifestyle
For the past few decades, epidemiological studies have suggested
that a healthy diet and lifestyle is critical for the prevention of breast
cancer
For women living in low-risk countries, the risk of developing breast
cancer increases upon immigration to a high-risk country (exposure to
Western lifestyle), which suggests that this cancer is influenced by
modifiable lifestyle or environmental factors (Ziegler et al., 1993)
Dietary fat is one of the most intensively studied dietary factors
closely related with risk
5. Dietary fat
Dietary fat is thought to be one of the main risk factors, on the basis of reports
of positive correlations between dietary fat intake and increased risks for cancers
of the breast, colon and prostate
Epidemiological and in particular experimental studies have shown the link
between dietary fat and breast cancer (Rose 1997)
The effect of a high fat diet on the risk of breast cancer may not be as
important as the effect of the different kinds of dietary fat, including
saturated, monounsaturated and polyunsaturated fat
Evidence suggests that the polyunsaturated fatty acids affect breast cancer
proliferation, differentiation and prognosis
The omega-6 to omega-3 ratio
6. •
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•
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Cell fluidity
Metabolism
Growth and development
Brain structure and function
• Eicosanoid production
Immunity
Cardiovascular health
Inflammation
• Cell cycle control
7. AA, EPA and the cell cycle
A high rate of cell proliferation rate and a low rate of apoptosis are
the hallmark of abnormal cell growth
AA and EPA have opposing effects on the
proliferation, differentiation and apoptosis of genetically altered cells
and therefore the disposal/accumulation of DNA damaged tissue
(Cathcart et al, 2011)
The antiproliferative effects of EPA combined with the ability to
induce programmed cell death suggests that E-EPA supplementation
may have a significant impact on halting disease progression
(Hawcroft et al., 2010; Hawcroft et al., 2012)
8. A new biomarker in cancer patients: the AA to EPA ratio
Aim To evaluate the potential value of tumour risk assessment in colon and breast
cancer patients by determining the AA to EPA ratio in plasma in a case-control study
against healthy patients (Garassino et al., 2006)
Findings
Colorectal cancer
AA/EPA ratio was 22.232+1.852 compared to 14.25+1.083 for healthy
subjects (median age 70; range 53 - 81)
Breast cancer
The AA/EPA ratio was 21.029+2.584 compared to 12.10+1.414 in healthy
subjects (median age 77; range 44 - 86)
9. Cancer – an inflammatory disease?
The link between non-resolving inflammation and cancer is well
documented, with epidemiological evidence supporting that approximately 25%
of all human cancer worldwide is caused by non-resolving inflammation
Inflammatory cells are found in the microenvironment of most, if not all
tumours
High AA content of cells indicates a pro-inflammatory microenvironment
Products derived from inflammatory cells influence almost every aspect
of cancer
Vendramini-Costa & Carvalho 2012
10. Inflammatory response
Resoleomics - the process of inflammation resolution
Eicosanoid switch
Stop signal
Pro-inflammatory reduced
LTB4
PGE2
Anti-inflammatory increased
Time
Initiation
Resolution
Bosma-den Boer et al., 2013
Termination
11. Inflammation and omega-3 & omega-6 fatty acid intake among
breast cancer survivors
The Health, Eating, Activity and Lifestyle Study (HEAL)
Investigated the correlation between inflammation and fatigue and the
intake of omega-6 and omega-3 PUFAs among breast cancer survivors
Six hundred thirty-three particiants (mean age, 56 years; stage I to IIIA)
Higher intake of omega-6 relative to omega-3 PUFAs was associated with
higher levels of the inflammatory marker C-reactive protein
Survivors with the highest C-reactive protein had the highest levels of
fatigue
Alfano et al., 2012
12. Inflammation and tumour development
Inflammation causes cellular stress and may trigger DNA damage or
genetic instability
Chronic inflammation may contribute to primary genetic mutations
leading to malignant cell transformation
Inflammation has an important role in all phases of tumour
development:
• Initiation
• Promotion
• Invasion
• Metastatic dissemination
Thus, suppression of pro-inflammatory pathways may provide
opportunities for both prevention and treatment of cancer
14. The role of COX
Before the discovery of COX-2 it was known that prostaglandin synthesis
could be stimulated by a variety of substances including cytokines, growth factor
and tumour promoters
These effects were due to activation of phospholipases which supply
arachidonic acid to COX
The two COX enzymes are regulated independently:
COX-1 is constitutively expressed
COX-2 is inducible and expressed only in response to certain stimuli
COX-2 is over-expressed in cancer
16. COX-2 over-expression plays an important role in the pathogenesis of
malignant breast cancer in humans
COX-2 plays a key role in tumourigenesis through
•
•
•
•
•
•
stimulating epithelial cell proliferation
inhibiting apoptosis
stimulating angiogenesis
enhancing cell invasiveness
mediating immune suppression
increasing the production of mutagens
Singh-Ranger et al., 2002
17. COX-2 expression in aggressive breast cancer
HER-2 (human epidermal growth factor 2)
Over-expression (HER-2/neu-positive) of this gene has been shown to play an
important role in the development and progression of certain aggressive types
of breast cancer (15-30% of breast cancers)
Strongly associated with increased disease recurrence and a poor prognosis
Of 29 micro-dissected breast cancers:
high levels of COX-2 protein in 14 our of 15 (93%) HER-2/neu-positive samples
high levels of COX-2 protein in 4 our of 14 (29%) HER-2/neu-negative
tumours
Subbaramaiah et al., 1999
18. COX-2 expression and breast cancer prognosis
Cancer group: 57 primary breast cancer patients
Control group: 27 patients consisting of fibro-adenoma and benign breast disease
Control group COX-2 was over-expressed in 0%
Cancer group COX-2 was over-expressed in 74% breast carcinoma patients
COX-2 expression is directly correlated with ER negative (88.1%, p = 0.001) and also
associated with higher NPI value (78.6%, p = 0.006).
COX-2 over-expression was found to correlate with aggressive phenotypic
features, such as high histological grade, large tumour size, higher NPI value, ER
negativity and HER-2/neu positivity
Jana et al., 2012
19. COX-2, aromatase and oestrogen
About 75% of breast cancers are ER positive
Oestrogens are produced from androgens by the action of the enzyme aromatase
In postmenopausal women, plasma oestrogens result from peripheral
aromatisation, particularly in adipose tissue
Many breast cancers, also contain aromatase with certain breast cancers able to
synthesise oestrogens by intratumoural aromatase activity
COX-2 expression has been found to correlate with aromatase expression within
human breast cancer tissue
Inflammation is a major activator of aromatase activity
Brueggemeier et al., 2006
21. Women’s Health Initiative (WHI) Observational Study designed to address
some of the major causes of morbidity and mortality in an ethnically and
geographically diverse sample of postmenopausal women
Examined the effects of regular use of aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) on breast cancer risk
21% decrease in the risk of breast cancer among women who took NSAIDs
at least twice a week for at least 5 years
28% decrease in the risk for women who used them for at least 10 years
statistically significant inverse linear trend of breast cancer incidence with
the duration of NSAID use (P < 0.01)
Harris et al., 2003
22. Data from 91 epidemiological studies examined the dose response of relative
risk and level of NSAID intake for ten human malignancies
Results showed a significant exponential decline in the risk with increasing
intake of NSAIDs (primarily aspirin or ibuprofen) for 7-10 malignancies
Daily intake of NSAIDs, primarily aspirin, produced risk reductions of 63%
for colon, 39% for breast, 36% for lung, and 39% for prostate cancer
Significant risk reductions were also observed for oesophageal
(73%), stomach (62%), and ovarian cancer (47%)
NSAID effects became apparent after five or more years of use and were
stronger with longer duration
Harris et al., 2005
23. Use of COX-2 inhibitors and breast cancer risk
Meta-analysis of 6 cohort studies (number of cases ranged from 14 to 2414) and 8
case-control studies (number of cases ranged from 252 to 5882)
(Khuder & Mutqi 2001)
• Regular use of NSAID associated with 18% reduced risk of breast cancer
Meta-analysis of 38 studies (16 case-control studies, 18 cohort studies, 3 casecontrol studies nested in well-defined cohorts, and 1 clinical trial) that included
2,788,715 subjects
(Takkouch et al., 2008)
• Regular use of aspirin associated with 13% reduced risk of breast cancer
• Regular use of ibuprofen associated with 21% reduced risk of breast cancer
24. Use of COX-2 inhibitors and breast cancer risk
Meta-analysis of 26 studies with 528,705 participants
(Zhao et al., 2009)
• Regular use of aspirin associated with 17% reduced risk of breast cancer
• Regular use of ibuprofen associated with 19% reduced risk of breast cancer
Meta-analysis of 33 studies (19 cohort studies, 13 case-control studies, and 1
randomized controlled trial ) that included 1,916,448 subjects
(Luo et al., 2012)
• Regular use of aspirin associated with 14% reduced risk of breast cancer
26. Selective vs non-selective NSAIDS
Non-selective NSAIDs block both COX-1 and COX-2 [aspirin, ibuprofen
(Brufen, Nurofen), naproxen (Naprosyn), diclofenac (Voltarol), etodolac
(Lodine), and meloxicam (Mobic)]
Duel acting NSAIDS (COX/5-lipoxygenase inhibitors) [tepoxalin
(Zubrin), meloxicam (Metacam)]
Selective COX-2 inhibitors – ‘coxibs’ [celecoxib (Celebrex), etoricoxib (Arcoxia)]
Main side effects associated with NSAIDs
gastrointestinal and renal effects (Lanas & Ferrandez 2013)
increased risk of heart attack, stroke heart failure or other thrombotic
events or cardiovascular complications (Fanelli et al., 2013)
27. Selective COX-2 inhibitor drugs still have side effects
Merck & Co withdraws Rofecoxib (Vioxx, Vioxxacute) in September 2004
because evidence of an increased risk of confirmed serious thrombotic
events (including myocardial infarction and stroke) compared to
placebo, following long-term use
Pfizer withdraws Valdecoxib (Bextra) from the EU market in April 2005
because serious and potentially fatal skin reaction associated with its use
outweighed the benefits
What are the non- pharmacutical alternatives?
29. The role of EPA as a competitive inhibitor
High arachidonic acid
levels
COX-2
Pro-inflammatory ‘cancer
driving’ prostaglandins
Increased EPA lowers
arachidonic acid levels
COX-2
Anti-inflammatory
‘cancer-suppressing
prostaglandins
Increased EPA lowers
arachidonic acid levels
EPA competes with AA
for COX-2
Anti-inflammatory
‘cancer-suppressing
prostaglandins
30. Intake of fish and marine n-3 polyunsaturated fatty acids and risk of breast
cancer: meta-analysis of data from 21 independent prospective cohort studies
Twenty six publications, including 20,905 cases of breast cancer and 883,585
participants from 21 independent prospective cohort studies were eligible
• 11 articles (13,323 breast cancer events and 687,770 participants)
investigated fish intake
• 17 articles investigated marine n-3 PUFA (16,178 breast cancer events and
527,392 participants)
• 12 articles investigated ALA (14,284 breast cancer events and 405,592
participants)
Zheng et al., 2013
31. Intake of fish and marine n-3 polyunsaturated fatty acids and risk of breast
cancer: meta-analysis of data from 21 independent prospective cohort studies
Main findings:
• No significant association was observed for fish intake or for short-chain
omega-3 ALA intake
• Marine omega-3 PUFA was associated with 14% reduction of risk of breast
cancer (relative risk for highest v lowest category 0.86 (95% confidence interval
0.78 to 0.94), I(2)=54)
• Dose-response analysis indicated that risk of breast cancer is reduced by 5%
per 0.1g/day increment of dietary marine n-3 PUFA intake
Zheng et al., 2013
32. Fish consumption patterns
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Type (oily vs white; farmed vs wild)
Omega-3 content/omega-6 content
EPA to DHA ratio
Cooking method
Frequency of consumption
Welch et al., 2002
Cod
Tuna
Salmon
Haddock
Plaice
Herring
Mackerel
29.9%
16.4%
14.2%
13.0%
7.6%
6.0%
3.0%
33. Dietary polyunsaturated fatty acids and breast cancer risk in Chinese women:
a prospective cohort study (Shanghai Women’s Health Study) (Murff et al., 2011)
72,571 cancer free woman at recruitment (1996 to 2000) with 712 cancer cases reported at
follow-up (2007)
Women who consumed the highest levels of omega-6 with the lowest amounts of marine
derived omega-3 had 2-fold increased risk for breast cancer compared to women consuming
the lowest amounts of omega-6 and highest amount of omega-3 PUFA intake
There was a statistically significant interaction between total omega-6 intake, marine-derived
omega-3 intake and breast cancer risk
34. Specialty supplements and breast cancer risk in the VITamins And Lifestyle
(VITAL) Cohort
Postmenopausal women (n = 35,016) recruited 2000-2002
Incident invasive breast cancers (n = 880) from 2000 to 2007
Data on supplement use (current versus
past), frequency (days/week), and duration
(years)
Current use of fish oil was associated with a
32% reduced risk of breast cancer with a
ten-year average use suggestive of
reduced risk (P trend = 0.09)
Brasky et al., 2010
35. •
Dietary intake of specific fatty acids and breast cancer risk among postmenopausal
women in the VITAL cohort
Association between fatty acid intake and breast cancer risk (diet and supplements)
Total SFA was suggestive of an increased risk (HR = 1.47, 95% CI: 1.00-2.15, P = 0.09)
Total PUFA intake was not associated with increased risk of breast cancer risk (HR =
0.84, 95% CI: 0.65-1.09, P = 0.27)
Intake of eicosapentaenoic (HR = 0.70, 95% CI: 0.54-0.90, P = 0.04) and docosahexaenoic
acid (HR = 0.67, 95% CI: 0.52-0.87, P = 0.01) were inversely associated with risk
Sczaniecka et al., 2012
36. Modulating eicosanoids
Products (eicosanoids) derived from AA and EPA play a central role in
inflammation and tissue homeostasis, and are directly implicated in cancer
Chronic inflammation is one of the foremost risk factors for different types of
malignancies, including breast cancer
Inflammation in the tumour microenvironment is now recognised as one of the
hallmarks of cancer
Regulating eicosanoid production may serve as a method to reduce risk as well as
serve as a therapeutic target for inhibiting tumour growth
37. Modulation of angiogenesis by AA and EPA
The formation of new blood vessels (angiogenesis), a critical process that affects
tumour growth and dissemination (Szymczak et al., 2008)
EPA inhibit and AA stimulates major pro-angiogenic processes in human
endothelial cells:
angiopoietin-2 (Ang-2)
vascular endothelial growth factor (VEGF)
basic fibroblast growth factor (bFGF)
insulin-like growth factor-1
matrix metalloproteases (MMPs) that degrade the extracellular
matrix, and play an important role in the migration of endothelial cells
during angiogenesis
38. BRCA (breast cancer susceptibility protein) genes
BRCA1 and BRCA2 are human genes that belong to a class of genes
known as tumour suppressors
As human caretaker genes they produce a protein responsible for
repairing DNA or destroying cells if DNA cannot be repaired
Mutations in BRCA1 and BRCA2 damaged DNA is not repaired properly
and this increases risks for cancers
39. Omega fatty acids and BRCA genes
EPA in vitro has been shown to mediate gene expression in human cells
AA down-regulates BRCA1 and BRCA2 expression which increases
proliferation and anchorage independent growth of tumour cells
EPA increases BRCA1 and BRCA2 expression which decreases
proliferation and increases apoptosis of tumour cells
Bernard-Gallon et al., 2002
40. Arachidonic acid and eicosapentaenoic acid metabolism contribute to cancer
risk and progression through pro-and anti-inflammatory lipid metabolites that
stimulate cell proliferation, angiogenesis, and migration
Azrad et al., 2013
41. EPA and cancer cachexia
Cachexia is a form of muscle wasting often associated with advanced stage
cancer
Inflammatory cytokines appear to tilt the body's metabolism toward
catabolism, the breakdown of muscle proteins and fat ultimately lead to a
chronic state of wasting and malnourishment
Cachexia is a complication responsible for around 20% of cancer deaths
EPA supplementation decreases weight loss, promotes weight gain and
increases survival times in patients affected with cancer cachexia
(Kanat et al., 2013)
Not all intervention studies show improvements and EPA supplementation
may be more effective if provided earlier rather than later, when muscle
loss is accelerated
(Murphy et al., 2011)
42. GLA and breast cancer
GLA is metabolised to DGLA to produce anti-inflammatory eicosanoids
Addition of GLA to EPA reduces accumulation of AA (Barham et
al., 2000)
GLA has a number of anti-tumour properties:
GLA reduces the secretion of SPARC and Ang-1 and inhibits the
growth and metastasis of a variety of tumour cells (Cai et
al., 1999; Watkins et al., 2005)
GLA significant reduces tumour ER expression and enhances
tamoxifen efficacy in human breast cancer cells (Kenny et
al., 2000)
43. EPA and breast cancer
EPA displaces AA and reduces the production of inflammatory products
EPA blocks the activity of cyclooxygenase-2 (COX-2) and the production of
prostaglandin E2 (PGE2) inhibiting tumourigenesis
EPA reduces the production of pro-inflammatory cytokines TNF- , IL- 1
EPA increases BRCA1 and BRCA2 expression, inhibits proliferation and
induces apoptosis (programmed cell death)
EPA down-regulates aromatase activity and decreases oestrogen production
EPA inhibits major pro-angiogenic processes
EPA may have potential in the treatment of cancer cachexia
Combining EPA with GLA offers synergistic benefits
44. AA and breast cancer
AA gives rise to key pro-inflammatory mediators involved in orchestrating
cross-talk between tumour epithelial cells and immune cells
AA drives inflammation within the tumour environment
Cyclooxygenase-2 (COX-2) is an enzyme over-expressed in many human
cancers and converts AA to prostaglandin E2 (PGE2), which drives
tumourigenesis
AA down-regulates BRCA1 and BRCA2 and promotes the
proliferation, migration and invasiveness of cancer cells
AA stimulates aromatase activity and increases oestrogen production
AA stimulates major pro-angiogenic processes
45. Shifting the balance
AA and EPA content of cell membranes can be altered through
consumption of omega-3 EPA (marine products/marine oils)
Changing the fatty acid composition of cell membranes affects
• changes in membrane structure
• products involved in immune function and the inflammatory
cascade
• cell signalling
• gene expression and cell cycle control
47. RBC content of EPA (%)
The effect of EPA supplementation on red blood cell (RBC)
membranes EPA content
Maki & Rains, 2012
Time (weeks)
48. Fatty acid levels ( g/g)
Changes in erythrocyte membrane omega-3 fatty acid levels
following 12 weeks treatment with 1g ethyl-EPA
Base line
Boston et al., 2004
Week 12
49. References
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Alfano, C. M., I. Imayama, et al. (2012). "Fatigue, inflammation, and omega-3 and omega-6 fatty acid intake among breast cancer
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serum arachidonic acid accumulation in humans." The Journal of nutrition 130(8): 1925-1931.
Bernard-Gallon, D. J., C. Vissac-Sabatier, et al. (2002). "Differential effects of n-3 and n-6 polyunsaturated fatty acids on BRCA1 and
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Boston, P. F., A. Bennett, et al. (2004). "Ethyl-EPA in Alzheimer's disease--a pilot study." Prostaglandins, leukotrienes, and essential
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novel approaches for prevention/intervention." Cancer metastasis reviews 30(3-4): 363-385.
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50. References
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Harris, R. E., R. T. Chlebowski, et al. (2003). "Breast cancer and nonsteroidal anti-inflammatory drugs: prospective results from the
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Hawcroft, G., M. Volpato, et al. (2012). "The omega-3 polyunsaturated fatty acid eicosapentaenoic acid inhibits mouse MC-26
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51. References
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Rose, D. P. (1997). "Dietary Fat, Fatty Acids and Breast Cancer." Breast cancer 4(1): 7-16.
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52. References
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Ziegler, R. G., R. N. Hoover, et al. (1993). "Migration patterns and breast cancer risk in Asian-American women." Journal of the
National Cancer Institute 85(22): 1819-1827.
Editor's Notes
2008
2008
Not pancreatic, urinary bladder, or renal cancer
Not pancreatic, urinary bladder, or renal cancer
Not pancreatic, urinary bladder, or renal cancer
Adjusted for age, body mass index, total energy, family history of breast cancer, alcohol use, tobacco use, education, use of hormone replacementtherapy, personal history of diabetes, menopausal status, age at menopause, age at menarche, parity, age at first pregnancy, level of physical activity,red meat intake, fish intake and vitamin E intake.