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• W1769722598 abstract "At the outset of their reproductive careers, today’s women face significant health challenges from two relatively common conditions, namely preeclampsia and breast cancer. Depending on the definition used, preeclampsia affects up to 5% of women in their first pregnancy,1.North R.A. McCowan L.M. Dekker G.A. Poston L. Chan E.H. Stewart A.W. et al.Clinical risk prediction for preeclampsia in nulliparous women:development of model in international prospective cohort.BMJ. 2011; 342: d1875Crossref PubMed Scopus (301) Google Scholar while today's cohort of young women face an approximate 10% lifetime risk of breast cancer.2.Howlader N. Noone A.M. Krapcho M. Neyman N. Aminou R. Waldron W. SEER cancer statistics review, 1975-2009 (Vintage 2009 Populations). National Cancer Institute, Bethesda (MD)2011Google Scholar An emerging body of evidence suggests an interaction between these conditions, in that women appear to have a reduced risk of breast cancer following a pregnancy that has been complicated by hypertension, including preeclampsia. Substantial efforts have been made in the past decade to understand the placental basis of transient hypertension and multi-organ dysfunction in preeclampsia, and to identify biomarkers to predict preeclampsia. This knowledge may thus prove invaluable in the fight against breast cancer. In 1983, Polednak and Janerich were the first to describe this epidemiological relationship in a case-control study by linking cancer records to New York State birth records. They found that women who had preeclampsia in their first pregnancy had a lower rate of breast cancer diagnosed before the age of 45.3.Polednak A.P. Janerich D.T. Characteristics of first pregnancy in relation to early breast cancer. A case-control study.J Reprod Med. 1983; 28: 314-318PubMed Google Scholar Since this landmark study, many research groups have also investigated this potential association. In 2009, the ensuing research was summarized in a systematic review4.Kim J.S. Kang E.J. Woo O.H. Park K.H. Woo S.U. Yang D.S. et al.The relationship between preeclampsia, pregnancy-induced hypertension and maternal risk of breast cancer: a meta-analysis.Acta Oncol. 2013; 52: 1643-1648Crossref PubMed Scopus (36) Google Scholar and a meta-analysis.5.Nechuta S. Paneth N. Velie E.M. Pregnancy characteristics and maternal breast cancer risk: a review of the epidemiologic literature.Cancer Causes Control. 2010; 21: 967-989Crossref PubMed Scopus (65) Google Scholar Collectively, approximately 70% of the reported studies supported a decreased risk of breast cancer in women who were hypertensive during pregnancy, while 30% supported an increased risk.4.Kim J.S. Kang E.J. Woo O.H. Park K.H. Woo S.U. Yang D.S. et al.The relationship between preeclampsia, pregnancy-induced hypertension and maternal risk of breast cancer: a meta-analysis.Acta Oncol. 2013; 52: 1643-1648Crossref PubMed Scopus (36) Google Scholar Although the consensus from the 2009 reviews was inconclusive, there was a suggestion that hypertension in pregnancy confers a modest 20% to 30% reduction in breast cancer risk. Since 2009, further research has attempted to clarify this important question by assessing increased cohort sizes and stratifying the data to address potentially confounding factors such as age, parity, age at menarche, age at first birth, BMI, and family history.6.Ma H. Henderson K.D. Sullivan-Halley J. Duan L. Marshall S.F. Ursin G. et al.Pregnancy-related factors and the risk of breast carcinoma in situ and invasive breast cancer among postmenopausal women in the California Teachers Study cohort.Breast Cancer Res. 2010; 12: R35Crossref PubMed Scopus (70) Google Scholar, 7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar, 8.Brasky T.M. Li Y. Jaworowicz D.J. Potischman N. Ambrosone C.B. Hutson A.D. et al.Pregnancy-related characteristics and breast cancer risk.Cancer Causes Control. 2013; 24: 1675-1685Crossref PubMed Scopus (25) Google Scholar, 9.Terry M.B. Perrin M. Salafia C.M. Zhang F.F. Neugut A.I. Teitelbaum S.L. et al.Preeclampsia, pregnancy-related hypertension, and breast cancer risk.Am J Epidemiol. 2007; 165: 1007-1014Crossref PubMed Scopus (41) Google Scholar In a 2010 analysis of approximately 50 000 postmenopausal women, 624 subsequently developed breast carcinoma in situ (CIS), and 2828 developed invasive breast cancer.6.Ma H. Henderson K.D. Sullivan-Halley J. Duan L. Marshall S.F. Ursin G. et al.Pregnancy-related factors and the risk of breast carcinoma in situ and invasive breast cancer among postmenopausal women in the California Teachers Study cohort.Breast Cancer Res. 2010; 12: R35Crossref PubMed Scopus (70) Google Scholar This analysis revealed that a diagnosis of preeclampsia in the most recent pregnancy was associated with an increased risk of breast CIS (RR 1.72; 95% CI 1.05 to 2.81), although preeclampsia in any previous pregnancy was not significantly associated with the risk of either breast CIS or invasive breast cancer. Of note, the association between breast cancer risk and pregnancy-induced hypertension was not assessed in this cohort, as women only self-reported whether they had preeclampsia defined as elevated blood pressure, proteinuria, and fluid retention upon enrolment in the study. A subsequent analysis of approximately one million women from two Norwegian national registries (2012) concluded that women with preeclampsia or isolated gestational hypertension in their first pregnancy had a 17% reduction (HR 0.83; 95% CI 0.77 to 0.90) in the risk of breast cancer when compared with women who were normotensive during their first pregnancy.7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar The association was strongest for women delivering infants with normal birth weight compared with those delivering low birth weight infants, and also in full term deliveries compared with preterm deliveries. In contrast to both of these studies, a smaller cohort study of 2812 women reported in 2013 failed to identify an association between gestational hypertension or preeclampsia and a subsequent risk of breast cancer.8.Brasky T.M. Li Y. Jaworowicz D.J. Potischman N. Ambrosone C.B. Hutson A.D. et al.Pregnancy-related characteristics and breast cancer risk.Cancer Causes Control. 2013; 24: 1675-1685Crossref PubMed Scopus (25) Google Scholar Collectively, these epidemiologic data suggest a modest protective effect of preeclampsia on the subsequent risk of breast cancer. Pregnancy per se reduces the risk of breast cancer, and each additional successful normal pregnancy confers a further reduction in lifetime risk.10.Trichopoulos D. Hsieh C.C. MacMahon B. Lin T.M. Lowe C.R. Mirra A.P. et al.Age at any birth and breast cancer risk.Int J Cancer. 1983; 31: 701-704Crossref PubMed Scopus (208) Google Scholar The converse may also be true. A population-based case-control study of 1310 women with breast cancer and 1385 age- and parity-matched controls (adjusted for potential confounders listed above) demonstrated incremental protection for women who had two or more preeclamptic pregnancies.9.Terry M.B. Perrin M. Salafia C.M. Zhang F.F. Neugut A.I. Teitelbaum S.L. et al.Preeclampsia, pregnancy-related hypertension, and breast cancer risk.Am J Epidemiol. 2007; 165: 1007-1014Crossref PubMed Scopus (41) Google Scholar Currently there is no evidence to suggest that greater severity of preeclampsia confers any advantage in protecting against breast cancer.7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar An important consideration in the potential relationship between preeclampsia and breast cancer is age at menopause. Two studies reported that age at menopause is not a confounding variable, since cohorts of women having their menopause before, at, or after age 50 did not show a difference in the strength of the association between preeclampsia and the subsequent diagnosis of breast cancer.7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar, 11.Vatten L.J. Forman M.R. Nilsen T.I.L. Barrett J.C. Romundstad P.R. The negative association between pre-eclampsia and breast cancer risk may depend on the offspring’s gender.Br J Cancer. 2007; 96: 1436-1438PubMed Google Scholar However, there have been contradictory reports suggesting the effect of preeclampsia in reducing the subsequent risk of breast cancer is more pronounced in postmenopausal women.9.Terry M.B. Perrin M. Salafia C.M. Zhang F.F. Neugut A.I. Teitelbaum S.L. et al.Preeclampsia, pregnancy-related hypertension, and breast cancer risk.Am J Epidemiol. 2007; 165: 1007-1014Crossref PubMed Scopus (41) Google Scholar At present, it is difficult to conclude whether or not maternal age at diagnosis of breast cancer or menopausal status at diagnosis influence the relative association between the two conditions. Interestingly, epidemiologic data further suggest that the sex of the fetus appears to play an important role in mediating the phenomenon of reducing the risk of breast cancer in women with preeclampsia. Two studies demonstrated a greater risk reduction in women who delivered male babies following preeclampsia.7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar, 11.Vatten L.J. Forman M.R. Nilsen T.I.L. Barrett J.C. Romundstad P.R. The negative association between pre-eclampsia and breast cancer risk may depend on the offspring’s gender.Br J Cancer. 2007; 96: 1436-1438PubMed Google Scholar Vatten et al. (2007) found a substantial risk reduction in primiparous mothers who delivered a male baby compared with women who delivered a female baby.11.Vatten L.J. Forman M.R. Nilsen T.I.L. Barrett J.C. Romundstad P.R. The negative association between pre-eclampsia and breast cancer risk may depend on the offspring’s gender.Br J Cancer. 2007; 96: 1436-1438PubMed Google Scholar Further examining the role of fetal sex, a subsequent study found that the risk reduction for delivering a male fetus was statistically significant only in hypertensive women delivering preterm infants.7.Opdahl S. Romundstad P.R. Alsaker M.D. Vatten L.J. Hypertensive diseases in pregnancy and breast cancer risk.Br J Cancer. 2012; 107: 176-182Crossref PubMed Scopus (30) Google Scholar It is widely known that having a male fetus increases the risk of preterm birth and is associated with inflammatory disorders in the placenta.12.Di Renzo G.C. Rosati A. Sarti R.D. Cruciani L. Cutuli A.M. Does fetal sex affect pregnancy outcome?.Gend Med. 2007; 4: 19-30Abstract Full Text PDF PubMed Scopus (301) Google Scholar Recent data exploring the placental pathology in cases of severe preeclampsia and intrauterine growth restriction have demonstrated similar sex-specific differences, with maternal leukocyte infiltration (deciduitis, villitis) being more common in the placentas of males than in the placentas of females.13.Walker M.G. Fitzgerald B. Keating S. Ray J.G. Windrim R. Kingdom J.C.P. Sex-specific basis of severe placental dysfunction leading to extreme preterm delivery.Placenta. 2012; 33: 568-571Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Severe preeclampsia is known to be a disorder characterized by severe systemic inflammation14.Pinheiro M.B. Martins-Filho O.A. Mota A.P.L. Alpoim P.N. Godoi L.C. Silveira A.C.O. et al.Severe preeclampsia goes along with a cytokine network disturbance towards a systemic inflammatory state.Cytokine. 2013; 62: 165-173Crossref PubMed Scopus (95) Google Scholar and enhanced shedding of placentally derived micro-particles from the syncytiotrophoblast into maternal blood.15.Orozco A.F. Jorgez C.J. Ramos-Perez W.D. Popek E.J. Yu X. Kozinetz C.A. et al.Placental release of distinct DNA-associated microparticles into maternal circulation: reflective of gestation time and preeclampsia.Placenta. 2009; 30: 891-897Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar In addition, maternal blood from the placentas of women with severe preeclampsia is intensely anti-angiogenic,16.Sobel M.L. Kingdom J. Drewlo S. Angiogenic response of placental villi to heparin.Obstet Gynecol. 2011; 117: 1375-1383Crossref PubMed Scopus (44) Google Scholar in part mediated by anti-angiogenic proteins secreted from the placental syncytiotrophoblast, such as soluble fms-like tyrosine kinase-1 (sFlt-1).17.Karumanchi S.A. Maynard S.E. Stillman I.E. Epstein F.H. Sukhatme V.P. Preeclampsia: a renal perspective.Kidney Int. 2005; 67: 2101-2113Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar Any of these systemic processes could, in theory, function in breast tissue, either to prevent the formation or induce the regression of tumorigenic lesions that otherwise might progress over time to overt disease. Focusing on the breast pathology, two studies to date have addressed the potential difference in risk by breast cancer subtypes.6.Ma H. Henderson K.D. Sullivan-Halley J. Duan L. Marshall S.F. Ursin G. et al.Pregnancy-related factors and the risk of breast carcinoma in situ and invasive breast cancer among postmenopausal women in the California Teachers Study cohort.Breast Cancer Res. 2010; 12: R35Crossref PubMed Scopus (70) Google Scholar, 8.Brasky T.M. Li Y. Jaworowicz D.J. Potischman N. Ambrosone C.B. Hutson A.D. et al.Pregnancy-related characteristics and breast cancer risk.Cancer Causes Control. 2013; 24: 1675-1685Crossref PubMed Scopus (25) Google Scholar However, neither study found an overall association of breast cancer risk with preeclampsia or gestational hypertension that was associated with estrogen receptor or HER2 expression subtype. To date, no studies that show a positive risk reduction have assessed whether differences are present in outcome based on receptor subtype. Therefore, current studies on breast cancer tissue will require phenotyping to determine the potentially protective effects of preeclampsia. Given the multifactorial and systemic nature of severe preeclampsia, such studies are likely to offer important insights into the components within preeclamptic serum that could interact with breast tissue to suppress cancer, and could provide novel preventative or chemotherapeutic strategies to improve the fight against breast cancer. While the mechanisms linking preeclampsia to reduced risk of breast cancer remain unknown, evidence suggests that genetics,18.Louwen F. Muschol-Steinmetz C. Reinhard J. Reitter A. Yuan J. A lesson for cancer research: placental microarray gene analysis in preeclampsia.Oncotarget. 2012; 3: 759-773Crossref PubMed Scopus (88) Google Scholar environmental factors, and preeclampsia-specific factors such as placental ischemia19.Gingery A. Nelson A.M. Soldner E.L.B. Gilbert J.S. Soluble endoglin inhibits breast cancer cell proliferation.FASEB J 2010: Meeting Abstract Supplement. 2010; 816: 4Google Scholar and hormone milieu20.Tamimi R. Lagiou P. Vatten L.J. Mucci L. Trichopoulos D. Hellerstein S. et al.Pregnancy hormones, pre-eclampsia, and implications for breast cancer risk in the offspring.Cancer Epidemiol Biomarkers Prev. 2003; 12: 647-650PubMed Google Scholar play a prominent role. Furthermore, malignancies also adapt physiological processes that are critical for normal pregnancy, such as proliferation, invasion, and immune tolerance.21.Holtan S.G. Creedon D.J. Haluska P. Markovié S.N. Cancer and pregnancy: parallels in growth, invasion, and immune modulation and implications for cancer therapeutic agents.Mayo Clin Proc. 2009; 84: 985-1000Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar For example, placental extravillous trophoblast cells are able to proliferate, migrate, and develop their own blood supply; these are similar to the characteristics required for tumour formation. In addition, while inadequate trophoblast invasion leading to incomplete remodelling of the uterine spiral arteries is the major cause of placental ischemia, it is the increased release of sFlt-1, soluble endoglin (sEng), and pro-inflammatory cytokines, together with a complex range of secreted micro-particles that is likely responsible for much of the pathogenesis of the preeclamptic syndrome. These factors may therefore interact with breast tissue during pregnancy, either to directly suppress tumour-initiating pathways or to drive a tumour- suppre s sive microenvironment. In support of such a hypothesis, serum from pregnant rats with placental ischemia and preeclamptic-like symptoms inhibit proliferation of several human and murine breast cancer cell lines in vitro.19.Gingery A. Nelson A.M. Soldner E.L.B. Gilbert J.S. Soluble endoglin inhibits breast cancer cell proliferation.FASEB J 2010: Meeting Abstract Supplement. 2010; 816: 4Google Scholar Wlodek et al. also found, via ligation of uterine vessels in rats, that uteroplacental insufficiency resulted in reduced alveolar proliferation in the mammary gland.22.Wlodek M.E. Ceramc V. O'Dowd R. Westcott K.T. Siebel A.L. Maternal progesterone treatment rescues the mammary impairment following uteroplacental insufficiency and improves postnatal pup growth in the rat.Reprod Sci. 2009; 16: 380-390Crossref PubMed Scopus (7) Google Scholar In addition, measurable breast and hematopoietic stem cells and proteomic profiles of human umbilical cord blood suggest possible mechanisms for a prenatal influence on breast cancer risk.23.Qiu L. Low H.P. Chang C.-I. Strohsnitter W.C. Anderson M. Edmiston K. et al.Novel measurements of mammary stem cells in human umbilical cord blood as prospective predictors of breast cancer susceptibility in later life.Ann Oncol. 2012; 23: 245-250Crossref PubMed Scopus (12) Google Scholar, 24.Qiu L. Onoyama S. Low H.P. Chang C.I. Strohsnitter W.C. Norwitz E.R. et al.Effect of preeclampsia on umbilical cord blood stem cells in relation to breast cancer susceptibility in the offspring.Carcinogenesis. 2015; 36: 94-98Crossref PubMed Scopus (13) Google Scholar, 25.Low H.P. Tiwari A. Janjanam J. Qiu L. Chang C.I. Strohsnitter W.C. Screening preeclamptic cord plasma for proteins associated with decreased breast cancer susceptibility.Genomics Proteomics Bioinformatics. 2013; 11: 335-344Crossref PubMed Scopus (8) Google Scholar The process of angiogenesis may also be a key process in the subsequent development of breast cancer. Transforming growth factor-beta (TGF-β) directly targets key angiogenic factors essential for tumour growth, including vascular endothelial growth factor (VEGF) expression. Soluble endoglin attenuates TGF-β signalling by interfering with TGF-β binding to receptors.19.Gingery A. Nelson A.M. Soldner E.L.B. Gilbert J.S. Soluble endoglin inhibits breast cancer cell proliferation.FASEB J 2010: Meeting Abstract Supplement. 2010; 816: 4Google Scholar Recently, Criswell et al. demonstrated that disruption of Eng signalling (via knockdown of the transforming growth factor-beta type III receptor) in metastatic breast cancer cells impaired motility and invasion in vitro, and impaired metastasis in an in vivo murine model of breast cancer.26.Criswell T.L. Dumont N. Barnett J.V. Arteaga C.L. Knockdown of the transforming growth factor-beta type III receptor impairs motility and invasion of metastatic cancer cells.Cancer Res. 2008; 68: 7304-7312Crossref PubMed Scopus (44) Google Scholar Similarly, Eng targeted cancer therapy has been successful in treating various cancers27.Seon B.K. Haba A. Matsuno F. Takahashi N. Tsujie M. She X. et al.Endoglin-targeted cancer therapy.Curr Drug Deliv. 2011; 8: 135-143Crossref PubMed Scopus (117) Google Scholar including mammary carcinoma.19.Gingery A. Nelson A.M. Soldner E.L.B. Gilbert J.S. Soluble endoglin inhibits breast cancer cell proliferation.FASEB J 2010: Meeting Abstract Supplement. 2010; 816: 4Google Scholar Nevertheless, further studies are needed to identify the connections between cancer cell proliferation and preeclampsia. Despite the inconclusiveness in many aspects of this subject, the possibility that an interaction between these two common and serious conditions affecting women could reveal important advances in the treatment or prevention of breast cancer should deserve the interdisciplinary attention of basic scientists, epidemiologists, and highrisk obstetrics specialists. Thus far into the 21st century, we have learned much about the pathogenesis of each disease, and have highly developed national epidemiologic resources. By combining forces we may discover a novel approach to reducing the disease burden of breast cancer. Funded by the Rose Torno Chair and CIHR grants to John Kingdom and to Jeff Wrana. Melanie Audette is funded by the CREMS scholar program, Faculty of Medicine, University of Toronto." @default.
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• W1769722598 title "Does Preeclampsia Reduce the Risk of Breast Cancer?" @default.
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