Etiology of Breast Cancer: with special attention to
environmental factors By: Saad Almasoud, Lamya Alomair, Amir Shams
George Mason University Spring 2013
Slide 2
Breast anatomy I 1-ribs: 2-pectoralis muscle 3-chest wall
4-coopers ligaments 5-small ducts and acini 6-major ducts 7-nipple
8-lobule
Slide 3
Breast Anatomy II The lymph node bearing area has been divided
into three axillary regions: Level 1: Lymph nodes lateral and
inferior to the pectoralis minor muscle Level 2: Lymph nodes under
the pectoralis minor muscle Level 3: Lymph nodes under and deep to
the pectoralis minor muscle
Slide 4
Vascular and nervous system: Vascular and nervous system: 1-The
lateral border of the Pectoralis Minor and Major muscle 2-The
Latissimus Dorsi Muscle 3-The Axillary Vein 4-The Long Thoracic
Nerve which innervates the Serratus Anterior Muscle 5-The
Thoraco-Dorsal Nerve which innervates the Latissimus Dorsi Muscle
6-The Intercostal Brachial Nerve which is a sensory nerve for the
inferior aspect of the arm and the posterior aspect of the axilla
7-The Lateral Pectoral Nerve which innervates portions of the
pectoralis muscle
Slide 5
Breast Development: Pre and post pubertal development
Slide 6
CHANGES ASSOCIATED WITH PREGNANCY As the output of oestrogen
and progesterone produced first by the corpus luteum and later by
the placenta rises during pregnancy, the intralobular ductal
epithelium proliferates and the cells increase in size: the number
and length of the ductal branches therefore increase. Alveoli
develop at their termini and expand as their cells and lumina fill
with newly synthesized and secreted milk. The myoepithelial cells,
which are initially spindle-shaped, become highly branched stellate
cells, especially around the alveoli. Adjacent myoepithelial cells
intermesh to form a basket-like network around the alveoli and
ducts, interposed between the basal lamina and the luminal cells.
Their cytoplasm contains actin and myosin filaments and they are
contractile. There is a concomitant reduction in adipose tissue in
the stroma. The numbers of lymphocytes, including plasma cells, and
eosinophils increase greatly. Blood flow through the breast
increases. Secretory activity in the alveolar cells rises
progressively in the latter half of pregnancy. In late pregnancy,
and for a few days after parturition, their product is different
from later milk and is known as colostrum, which is low in lipid
but rich in protein and immunoglobulins. Colostrum confers a
measure of passive immunity to the neonatal alimentary tract; it
also has laxative properties. Proliferation of the glandular breast
parenchyma results in an overall increase in breast size through
gestation.
Slide 7
CHANGES ASSOCIATED WITH LACTATION True milk secretion begins a
few days after parturition as a result of a reduction in
circulating oestrogen and progesterone, a change which appears to
stimulate production of prolactin by the anterior hypophysis. Milk
distends the alveoli so that the cells flatten as secretion
increases. The alveolar cell cytoplasm accumulates membrane-bound
granules of casein and other milk proteins, and these are released
from the apical plasma membrane by membrane fusion (merocrine
secretion; see Ch. 2). Lipid vacuoles are formed directly in the
apical cytoplasm as small lipid droplets which fuse with each other
to create large milk vacuoles' up to 10 m across, that frequently
protrude from the cell surface. These are released as intact lipid
droplets with a thin surround of apical plasma membrane and
adjacent cytoplasm (apocrine secretion). On hormonal stimulation by
oxytocin, myoepithelial cells contract to expel alveolar secretions
into the ductal system in readiness for suckling. After the onset
of lactation there is a gradual reduction in the numbers of
lymphocytes and eosinophils in the stroma, although plasma cells
continue to synthesize IgA for secretion into the milk. Alveolar
cells take up IgA synthesized by adjacent plasma cells by
endocytosis at their basal surfaces and secrete it apically, as
dimers complexed to epithelial secretory component. Engorged Vs.
Non lactating
Slide 8
Breast abnormalities Part I: non-proliferative lesion
Slide 9
What is mastalgia (breast pain)? Mastalgia is breast pain and
is generally classified as either cyclical (associated with
menstrual periods) or noncyclic. Noncyclic pain may come from the
breast or may come from somewhere else, such as nearby muscles or
joints, and may be felt in the breast. Pain can range from minor
discomfort to severely incapacitating pain in some cases. Many
women with mastalgia worry more about the consequences of cancer
than about the pain itself.
Slide 10
What is mastitis? Mastitis is inflammation of the breast. It is
most often caused by a breast infection that affects women who are
breast-feeding, but it can happen in any woman. A break in the skin
or an opening in the nipple can allow bacteria to enter the breast
duct, where they can grow. The body's white blood cells release
substances to fight the infection. This causes swelling and
increased blood flow. The area may become painful, red, and warm to
the touch. Other symptoms can include fever and a headache.
Mastitis is treated with antibiotics. In some cases, a breast
abscess (a collection of pus) may form. Abscesses are treated by
draining the pus, either by surgery or by using a needle (often
guided by ultrasound), and then giving antibiotics. Having mastitis
does not raise a woman's risk of developing breast cancer. But an
uncommon type of cancer known as inflammatory breast cancer has
symptoms that are a lot like mastitis and can be mistaken for an
infection. If you are diagnosed with mastitis but antibiotic
treatment does not help, a biopsy of the skin may be needed to be
sure it is not cancer. Inflammatory breast cancer can spread
quickly, so do not put off going back to the doctor if you still
have symptoms after antibiotic treatment.
Slide 11
What is chronic sub areolar abscess? Chronic sub areolar
abscess is a breast infection that occurs infrequently. Surgery may
be needed to stop this repeating infection.
Slide 12
Duct ectasia Duct ectasia is also known as mammary duct
ectasia. It is a common condition that tends to affect women in
their 40s and 50s. It occurs when a breast duct widens and its
walls thicken, which can cause it to become blocked and lead to
fluid build-up. Duct ectasia may cause a sticky green or black
discharge, which is often thick. The nipple and nearby breast
tissue may be tender and red. The nipple may be pulled inward.
Sometimes scar tissue around the abnormal duct causes a hard lump
that may be confused with cancer. This condition sometimes improves
without treatment, or with warm compresses and antibiotics. If the
symptoms do not go away, the abnormal duct can be removed through
an incision (cut) at the edge of the areola (the darker colored
area around the nipple). Duct ectasia does not increase breast
cancer risk.
Slide 13
What is fat necrosis? Fat necrosis is a condition in which
painless, round, firm lumps caused by damaged and disintegrating
fatty tissues form in the breast tissue. Fat necrosis often occurs
in women with very large breasts or in response to a bruise or blow
to the breast. This condition may also be the result of a
lumpectomy and radiation from a previous cancerous lump. In some
cases, physicians/care providers will watch the lump through
several menstrual cycles, and may perform a mammogram before
deciding whether or not to remove it. These lumps are not malignant
and there is no reason to believe that they increase a woman's risk
of cancer.
Slide 14
What is a cyst? A cyst is a fluid-filled sac that develops in
the breast tissue. Such cysts typically occur in women between the
ages of 35 and 50 and are most common in those approaching
menopause. They often enlarge and become tender and painful just
before the menstrual period and may seem to appear overnight. Cysts
are rarely malignant and may be caused by a blockage of breast
glands. Cysts can feel either soft or hard. When close to the
surface of the breast, cysts can feel like a large blister, smooth
on the outside, but fluid-filled on the inside. However, when they
are deeply imbedded in breast tissue, cysts will feel like hard
lumps because they are covered with tissue.
Slide 15
Breast abnormalities Type II: proliferative lesion without
atypia
Slide 16
What is a Fibroadenoma? Fibroadenomas are solid, smooth, firm,
benign lumps that are most commonly found in women in their 20s and
30s. They are the most common benign lumps that occur in women and
can occur in women of any age. Increasingly, they are being seen in
postmenopausal women who are taking hormone therapy. The painless
lump feels rubbery and moves around freely and very often is found
by the woman herself. Fibroadenomas vary in size and can grow
anywhere in the breast tissue.
Slide 17
What is Sclerosing Adenosis? Sclerosing adenosis is a breast
condition that involves excessive growth of tissues in the breast's
lobules, often resulting in breast pain. While these changes in the
breast tissue are microscopic, they may show up on mammograms as
calcifications and can produce lumps. Usually a biopsy is necessary
to distinguish this condition from cancer. In addition, because the
condition can be mistaken for cancer, the lumps are usually removed
through surgical biopsy.
Slide 18
What is intraductal papilloma? An intraductal papilloma is a
small, wart-like growth that projects into the breast ducts near
the nipple. This causes a bloody or sticky discharge. In addition,
any slight bump or bruise near the nipple can cause the papilloma
to bleed. If the discharge becomes bothersome, the duct can be
surgically removed, often without changing the appearance of the
breast. While single papillomas most often affect women nearing
menopause, multiple intraductal papillomas -- which often occur in
both breasts -- are more common in younger women. Multiple
intraductal papillomas are more likely to be associated with a lump
than with nipple discharge. Any papilloma associated with a lump is
surgically removed. Bloody discharge
Slide 19
Uncontrolled Cell growth What is plasia? What is benign growth?
What is malignant growth? What is tumor? What is cancer?
Slide 20
What is Anaplasia? Reversion of cells to an immature or a less
differentiated form, as occurs in most malignant tumors.
Slide 21
What is Hypoplasia? 1. Incomplete or arrested development of an
organ or part. 2. Atrophy due to destruction of some of the
elements of a tissue or organ.
Slide 22
What is Hyperplasia? abnormal increase in the number of normal
cells in normal arrangement in an organ or tissue, which increases
its volume.
Slide 23
What is Dysplasia? 1. abnormality of development. 2. in
pathology, alteration in size, shape, and organization of adult
cells.
Slide 24
What is metaplasia? the change in the type of adult cells in a
tissue to a form abnormal for that tissue
Slide 25
What is Desmoplasia? The formation and proliferation of
fibroblasts and fibrous connective tissue, especially in
tumors.
Slide 26
Last but not least : Neoplasia Neoplasm is an abnormal mass of
tissue as a result of neoplasia. neoplasm means new growth without
qualifying the nature of that growth. What is neoplasm? any new and
abnormal growth, specifically one in which cell multiplication is
uncontrolled and progressive. Neoplasms may be benign or malignant.
A neoplasm can be benign, potentially malignant (pre-cancer), or
malignant (cancer).benignpre-cancercancer
Slide 27
Types of neoplasm Benign :do not transform into cancer.cancer
Potentially malignant: They do not invade and destroy but, given
enough time, will transform into a cancer.cancer Malignant
neoplasms are commonly called cancer. They invade and destroy the
surrounding tissue, may form metastases and eventually kill the
host. cancermetastases
Slide 28
What is tumor? In modern medicine, the term tumor means a
neoplasm that has formed a lump.
Slide 29
Metastasis
Slide 30
Breast abnormalities Type III: Atypical proliferative
lesion
Slide 31
Ductal Carcinoma In-Situ (DCIS) DCIS is a type of early breast
cancer confined to the inside of the ductal system.
Slide 32
Infiltrating(invasive) Ductal Carcinoma (IDC) IDC is the most
common type of breast cancer representing 78% of all malignancies.
These lesions appear as stellate (star like) or well-circumscribed
(rounded) areas on mammograms. The stellate lesions generally have
a poorer prognosis.
Slide 33
Infiltrating Lobular Carcinoma (ILC) Infiltrating lobular
carcinoma is a type of breast cancer that usually appears as a
subtle thickening in the upper-outer quadrant of the breast. This
breast cancer type represents 5% of all diagnosis. Often positive
for estrogen and progesterone receptors, these tumors respond well
to hormone therapy.
Slide 34
Rare breast cancer What is Paget disease of the breast? Paget
disease of the breast (also known as Paget disease of the nipple
and mammary Paget disease) is a rare type of cancer involving the
skin of the nipple and, usually, the darker circle of skin around
it, which is called the areola. Most people with Paget disease of
the breast also have one or more tumors inside the same breast.
These breast tumors are either ductal carcinoma in situ or invasive
breast cancerductal carcinoma in situinvasive breast cancer
Slide 35
Inflammatory Breast Cancer (IBC) Inflammatory breast cancer is
a rare and very aggressive type of breast cancer that causes the
lymph vessels in the skin of the breast to become blocked. This
type of breast cancer is called "inflammatory" because the breast
often looks swollen and red, or "inflamed". IBC accounts for 1% to
5% of all breast cancer cases in the United States.
Slide 36
End of breast abnormalities
Slide 37
Hormone effects on breast development 1-growth hormone(LH-FSH)
2-estrogen(E1-E2-E3) 3-progestrone 4-prolactin 5-oxytocin
6-testostrone
Slide 38
Luetinizing hormone Luteinizing hormone (LH, also known as
lutropin [1] and sometimes lutrophin [2] ) is a hormone produced by
the anterior pituitary gland. In females, an acute rise of LH ("LH
surge") triggers ovulation [3] and development of the corpus
luteum. In males, where LH had also been called interstitial cell-
stimulating hormone (ICSH), [4] it stimulates Leydig cell
production of testosterone. [3] It acts synergistically with FSH.
[1] [2]hormoneanterior pituitary glandovulation [3] corpus luteum
[4]Leydig cell testosterone [3]FSH
Slide 39
Follicle-stimulating hormone (FSH) Follicle-stimulating hormone
(FSH) is a hormone found in humans and other animals. It is
synthesized and secreted by gonadotrophs of the anterior pituitary
gland. [1] FSH regulates the development, growth, pubertal
maturation, and reproductive processes of the body. FSH and
luteinizing hormone (LH) act synergistically in reproduction.
Specifically, an increase in FSH secretion by the anterior
pituitary causes ovulation.hormonegonadotrophsanterior pituitary
gland [1]luteinizing hormonereproductionovulation
Slide 40
Progesteron Progesterone also known as P4
(pregn-4-ene-3,20-dione) is a C-21 steroid hormone involved in the
female menstrual cycle, pregnancy (supports gestation) and
embryogenesis of humans and other species. Progesterone belongs to
a class of hormones called progestogens, and is the major naturally
occurring human progestogen.steroid hormonefemalemenstrual
cyclepregnancygestationembryogenesis progestogens
Slide 41
prolactin Prolactin (PRL) also known as luteotropic hormone
(LTH) is a protein that in humans is encoded by the PRL gene.
[1]proteingene [1] Prolactin is a peptide hormone discovered by
Henry Friesen. Although it is perhaps best known for its role in
lactation, prolactin already existed in the oldest known
vertebratesfishwhere its most important functions were probably
related to control of water and salt balance.peptide hormone Henry
Friesenlactationvertebrates
Slide 42
Estradiol during menstrual cycle
Slide 43
LOOKING FOR CLUES : Very briefly
Slide 44
Epidemiology of breast cancer Studying the factors that are
thought to increase the risk of breast cancer by Statistics
Slide 45
1-Gender A-From the available evidence, breast cancer is
predominantly a disease, which develops in women although in rare
circumstances the condition can be diagnosed in males. B-It seems
likely that estrogen has some role in the development of breast
cancer, which would explain why there is almost a 100 -fold
difference in breast cancer incidence between males and females.
C-However the difference in incidence may be because in females
estradiol is able to exert a direct biological effect on breast
cells, whereas in males testosterone needs to be converted to
estradiol before exerting any biologic effect
Slide 46
2-Age A-breast cancer is relatively rare in young women who are
younger than 40 years of age. Some 161 cases were diagnosed in
women under the age of 40 years during 1996, and the incidence
increases with increasing age.
Slide 47
3-Menarche-establishment of regularity A-The establishment of
regular menstrual cycles within one year of the first menstrual
cycle has been found to double the risk of breast cancer, compared
to a situation where menstrual cycles establish regularity in five
or more years rapid establishment of regularity in menstrual cycles
increased the risk of developing breast cancer four-fold (Henderson
et ah, 1981).
Slide 48
4-Menarche-Length A-The length of the menstrual cycle and the
duration of menstrual activity have been positively correlated with
breast cancer risk. B-regular menstrual cycle of 28 days is not
only associated with the regular cycling of estrogen and
progesterone but also the cycle of cell multiplication (mitosis)
and cell death (apoptosis).
Slide 49
5-Parity-Age at full term pregnancy The same researchers also
found that if a woman gave birth to her first child under the age
of eighteen, that she would only have 40 percent of the breast
cancer risk of a nulliparous woman (MacMahon et al., 1970). This
decrease in risk, (compared to the risk for a woman with a first
full term birth after the age of thirty years), is widely supported
throughout the literature, even though the strength of the
association varies from one study to another (MacMahon et aI.,
1970; Kelsey et al., 1993).
Slide 50
6-Parity-high number of birth A-high parity (or a high number
of births) provides additional protection against the risk of
developing breast cancer, independent of the age at first birth.
B-If a woman's second birth occurred under the age of 25 years, the
risk of developing breast cancer was only one third of that of a
woman who had only one birth under the same age (MacMahon et al.,
1982).
Slide 51
7-Parity-Incomplete pregnancy A-Some researchers have
investigated the link between incomplete pregnancies, arising from
spontaneous or induced abortions, and breast cancer. B-Their
research is based on the assumption that the risk of breast cancer
may be increased because the birth does not go to term, and would
no longer have a protective effect (pike et al., 1981; Hadjimichael
et al., 1986; Parazzini et al., 1991). C-women who had at least one
abortion before their first full term pregnancy, had approximately
20% greater risk of developing breast cancer, than women who did
not have any incomplete pregnancies.
Slide 52
8- 8-pregnancies not followed by breastfeeding A-The fact that
these women did not breastfeed when their breasts had developed for
nursing, resulted in a greater likelihood of breast cancer
development (Wainwright, 1931).
Slide 53
9-Early menstrual and late Menopause A combination of early age
at menarche and a late age at menopause would therefore prolong the
time o f the menstrual cycling o f sex hormones, and thus would
substantially increase a woman's risk of breast cancer development
(Henderson et al., 1985; Rosner et al., 1994).
Slide 54
10-Family History-Kinship A-Data from the Nurse's Health Study,
which began in 1976 and recruited biannually until 1990, suggested
that the degree of kinship and the number of closely affected
relatives forms a strong relationship with breast cancer
development (Colditz et al., 1996). B-there was a 2.3 fold higher
risk (relative risk; 1.9 - 2.7, 95% confidence intervals) of
developing breast cancer if the participant had a first degree
relative affected, as compared to women with no family history of
the disease.
11-Oral Contraceptive A-The very long use of oral
contraceptives by young women before first full term pregnancy may
be a very important factor that puts them at great risk of breast
cancer. B-For a pill containing a combination of progesteron and
greater than 50micro.g of estrogen, the relative risk of breast
cancer is lower than if the combination pill contains less than
50microg of estrogen
Slide 57
12-hormone replacement therapy A-studies have suggested that
HRT use may increase the risk of some cancers, especially
endometrial, ovarian, cervical, and breast cancers (
ARONSON-et.al)
Slide 58
13-Life style-weight A-In women there are three main lifetime
periods in which substantial weight gain occurs; during menarche
fatty deposits accumulate in the hips and buttocks; and during
pregnancy and menopause there is an increase in body fat
distribution centrally and in the breasts. B-Some researchers
suspect that a greater weight gain during adolescence, accompanied
by little physical activity, is related to a greater risk of breast
cancer.
Slide 59
14-Life style-Alcohol Consumption A-Alcohol consumption is one
of the only established dietary factors that has been associated
with breast cancer risk. B-light alcohol intake was associated with
a weak to modest correlation with breast cancer risk, whilst
intakes of 24 grams per day or more, was associated with a
significant increased risk.
Slide 60
End of Part two
Slide 61
What did we describe so far Breast Anatomy & Breast
Development Breast Abnormalities & Breast Cancer Looking for
clues NEXT Step : Cure and Prevention
Slide 62
How Bad is it? 2009 Estimated US Cancer Deaths* ONS=Other
nervous system. Source: American Cancer Society, 2009. Men 292,540
Women 269,800 26%Lung & bronchus 15%Breast 9%Colon & rectum
6%Pancreas 5%Ovary 4%Non-Hodgkin lymphoma 3%Leukemia 3%Uterine
corpus 2% Liver & intrahepatic bile duct 2%Brain/ONS 25% All
other sites Lung & bronchus30% Prostate9% Colon & rectum 9%
Pancreas6% Leukemia4% Liver & intrahepatic4% bile duct
Esophagus4% Urinary bladder3% Non-Hodgkin 3% lymphoma Kidney &
renal pelvis3% All other sites 25%
Slide 63
Trends in the Number of Cancer Deaths Among Men and Women, US,
1930-2006 Women Men Number of Cancer Deaths Men Women Source: US
Mortality Data, 1930-2006, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2009.
Slide 64
Very complex disease No one single factor associated with
causing the disease Breast cancer develops over a long period of
time, usually 10 to 30 years The puzzle of breast cancer
Slide 65
Risks related to breast cancer
Slide 66
Slide 67
Slide 68
Therapy and Drug
Slide 69
Drugs which target Breast Cancer all drugs that have been
approved by the U.S. Food and Drug Administration for use as a
breast cancer treatment.
Hormone Therapy: prevent positive cells from being exposed to
the hormones that cause them to grow Evista / Raloxifene Fareston /
Toremifine Faslodex / Fulvestrant Nolvadex / Tamoxifen Arimidex /
Anastrozole Aromasin / Exemestane Femara / Letrozole Lupron /
Leuprolide Plenaxis / Abarelix Suprefact / Buserlin Zoladex /
Goserelin
Slide 72
Bisphosphonate Therapy treat breast cancer that has spread to
the bone. Actonel / Risedronate Aredia / Pamidronate Boniva /
Ibandronate Fosamex /Alendronate Xgeva /Denosumab Zometa /
Zoledronate
Slide 73
Targeted Biological Therapy focus on blocking the actions of
certain normal body proteins that allow cancer cells to grow and
divide. Herceptin / Trastuzumab Lapatinib / Tykerb Avastin /
Bevacizumab
Slide 74
Only Practical method
Slide 75
Prevention : One logical response to the growing breast cancer
burden is to develop effective prevention strategies [1-3]
Slide 76
Why Prevention is Virtually Impossible? What is hard to
prevent: Although many breast cancer risk factors have been
identified that might form the basis of such strategies, prevention
remains challenging, and virtually impossible due to practical
difficulties in modifying risk-increasing factors like nulliparity,
late age at first full-term pregnancy, early age at menarche, and
late age at menopause [1,2].
Slide 77
One Example is Environmental Risk Factors Do environmental
chemicals affect the risk of cancer? This is a question being asked
by scientists, cancer advocates, educators, policy makers, and
those exposed to environmental chemicals in their homes and
workplaces.[3-4]
Slide 78
One of the first publications
Slide 79
Studies in migrants have shown increases in breast cancer
incidence and mortality following migration from a lower- to a
higher-risk country.(1214) For example, Japanese immigrants in Los
Angeles County had a clearly higher rate of breast cancer than
Japanese in Japan.(12) Furthermore, the incidence of breast cancer
in first-generation Japanese immigrants in Sao Paulo from 1968 to
1978 was higher than that among Japanese living in Japan, whereas
mortality increased from 1979 to 2001 to a rate intermediate
between that of Japanese living in Japan and Brazilians living in
the state of Sao Paulo.(13,14) These findings strongly suggest that
breast cancer risk is influenced by factors associated with the
lifestyle or environment of the destination country[2].2
Slide 80
Do environmental chemicals affect the risk of cancer?
Slide 81
81 NCI will prioritize gene- environmental studies in 2002
Slide 82
Slide 83
Environment factors 1-Occupational Exposure Including nurses,
teachers, beauticians, airline attendants, lab technicians,
telephone and telegraph operators, electronic workers, agriculture
workers, leather and fur processors, glass manufacturing workers,
and metal fitters and assemblers (Aronson et al., 1999; Band et
al., 2000; Gardner et al., 2002; Peplonska et al., 2007; Teitelbaum
et al., 2003).
Slide 84
Environment factors 2- Ionizing Radiation High exposures to
ionizing radiation related to medical diagnosis or treat- ment was
associated with breast cancer (Doody et al., 2000; National Academy
of Sciences, 2005). Women with benign breast disease or a family
history of breast cancer may have increased breast cancer risk
following relatively low-level exposure to ionizing radiation (Hill
et al., 2002).
Slide 85
Environment factors 3-Environmental Contaminants
Slide 86
Old Contaminant Story :DDT
Slide 87
Deep Impact
Slide 88
The Other :Atrazine Most widely used herbicide in the US First
registered for use in 1959 Annual crop land usage Up to 77.3
million lbs active ingredient* * Source: Asplein, 1999
Systematic review of environmental risk factors of Breast
Cancer
Slide 92
Case study Analysis
Slide 93
Statistical Analysis Logistic Regression Analysis on NHANES
Questionnaire
Slide 94
Some of our results Analysis 1: Analysis of environmental Risk
Factors as predictor for Breast Cancer 2008
Slide 95
Some of our results Analysis 2: Analysis of environmental Risk
Factors as predictor for Breast Cancer 2007
Slide 96
Some of our results Analysis 3: Analysis of environmental Risk
Factors as predictor for Breast Cancer 2006
Slide 97
Thank you ! Question?
Slide 98
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