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Role of a Plant-based Diet In the Prevention of Breast Cancer

Rachel OConnor
May 5th, 2015

I. Abstract
Breast cancer is the most common type of invasive cancer in American women, with
40,200 deaths occurring in 2001. Many studies have examined the protective effects a
plant-based diet has on breast cancer. One study compared an alcohol/Western diet to a
healthy/Mediterranean diet in relation to breast cancer risk. In this prospective cohort study,
65,374 postmenopausal French women were involved in the E3N-EPIC cohort, and 2,381 of
these women developed invasive breast cancer between 1993 and 2005. The study concluded
that participants consuming more of an alcohol/Western diet show a positive association with
breast cancer risk. A second study examined the relationship between cancer risk in obese adults
and healthy behaviors outlined by the World Cancer Research Fund (WCRF) and the American
Institute for Cancer Research (AICR). Data on food intake was collected in 1991 to make a 7component score based on recommendations for things like body fat, physical activity, foods that
contribute to weight gain, plant foods, animal foods, alcohol, as well as food preservation,
processing, and preparation. This study concluded that overall adherence to the WCRD and
AICR guidelines contributes to a lower risk of obesity-related cancers, including breast cancer.
The final study determined how overall diet - not simply individual foods or nutrients - relates
to breast cancer risk in women. The major dietary patterns were identified: plant-based, highprotein/high-fat, high-carbohydrate, ethnic, and salad and wine. The study concluded that

those who followed the plant-based diet showed a reduction in breast cancer risk, while those
who followed the salad and wine diet were shown to have an increased risk.
II. Introduction
Breast cancer is a disease that is characterized by malignant, or cancerous, cells forming
in breast tissues1. Risk factors for this type of cancer include a family history of the disease,
changes in the BRCA1 and BRCA2 genes, consumption of alcohol, dense breast tissue, excess
estrogen, use of oral contraceptives, obesity, lack of physical activity, a history of invasive breast
cancer, ductal carcinoma, or lobular carcinoma, a history of a noncancerous breast disease, being
white, and radiation treatment to the breast or chest2. These are risk factors that have all been
well researched, but since they are just that: risk factors, they are merely correlated to breast
cancer, not the cause of it. Preventative measures are less researched than treatment regarding
breast cancer, but intake of vitamin D, calcium, dairy and soy products has been shown to be
negatively correlated with breast density8. In addition, consumption of dietary fiber from fruits
and cereals is associated with a ~50% lower risk of PR+ER+ tumors. The reason for this
correlation is because fiber reduces circulating estrogen levels9. Therefore, one preventative
measure that is important to consider is consumption of a plant-based diet.
A plant-based diet is made up of fruits, vegetables, whole grains, legumes, and little or no
animal products. It is believed to play a protective role in the body. It is a topic that has been
less researched regarding breast cancer. Obesity is a known breast cancer risk factor, and one
obviously related to nutrition. However, nutrition related to obesity does not include benefits
different food sources provide. A BMI greater than 30 has a plethora of different problems
associated with it; it is going to be a risk factor in nearly every disease that is not solely genetic.
It is hard to say whether excess fat is the main factor contributing to breast cancer, or if it is the

lack of key nutrients. In 17 of 26 studies exploring the relationship between nutrition and breast
cancer progression/recurrence, an increased body mass index was associated with a significant
risk factor for breast cancer or a lower survival rate7.
Phytochemicals are prevalent in a plant-based diet and are important to consider in
studying the correlation between consumption of plant foods and breast cancer prevention.
Antioxidants are a type of phytochemical found in foods such as berries and broccoli. They rid
the body of free radicals, which can damage a cell and eventually trigger cancer. Isoflavones are
another type of phytochemical, found mainly in soybeans and soy-based products. They are
believed to be a preventative nutrient in that they bind to estrogen receptors instead of estrogen
produced by your body. Isoflavones are a weaker source of estrogen, so contribute less to
estrogen-dependent tumors10.
Diets of those living in more developed countries, such as the United States, are
composed of many animal products and energy dense food, as well as less plant foods than diets
of people living in countries with lower risks of breast cancer6.
In a study performed by Hernandez-Valero, et al., breast cancer survivors participated in
the Womens Healthy Eating and Living study. The purpose of this study was to determine if a
diet comprised of fiber, fruit, and vegetables, and low in fat extended survival rate. This study
resulted in breast cancer survival rate not being affected (neither positively nor negatively) by the
healthy diet, though further research is needed5. Eating nutritious foods is a necessity humans
must realize in order for their bodies to thrive. Because of this, nutrition, specifically a plantbased diet, plays an important role in the prevention of breast cancer.
III. Review of Research Studies
a. Article One

Cottet V, Touvier M, Fournier A, et al. Postmenopausal breast cancer risk and dietary
patterns in the E3N-EPIC prospective cohort study. American journal of epidemiology.
Nov 15 2009;170(10):1257-1267.
The purpose of this study was to compare an alcohol/Western diet to a
healthy/Mediterranean diet in relation to breast cancer risk. The Japanese have always had a
relatively low risk of breast cancer, but as Japan has begun to adopt a more Westernized diet,
breast cancer incidence has increased.
In this prospective cohort study, 65,374 postmenopausal French women were involved in
the E3N-EPIC cohort, and 2,381 of these women developed invasive breast cancer between 1993
and 2005. Each woman completed a diet history questionnaire that assessed the consumption of
208 different foods and beverages. A follow-up started upon the completion of the diet
questionnaire. A technique called principal-components analysis produced dietary patterns
based on certain food groups. This analysis groups together similar foods, and calls these groups
factor loadings. If a factor loading is positive, a food group is positively correlated with a
dietary pattern, while a negative factor loading shows a negative correlation. A factor score was
calculated for each participant. The factor score measures the adherence of a womans diet to the
pattern.
Two dietary patterns were identified: alcohol/Western (correlated with the
consumption of foods such as processed meat, pizza, cakes, and alcoholic beverages) and
healthy/Mediterranean (correlated with the consumption of fish, fruits, vegetables, and olive
oil). A higher alcohol/Western score is associated with people who are younger, overweight, or
have a stronger history of relatives with breast cancer. A higher healthy/Mediterranean score is
associated with people who are older, exercise, or have a higher personal history of benign breast
disease. Participants consuming more of an alcohol/Western diet show a positive association

with breast cancer risk. This dietary pattern and breast cancer risk was statistically significant,
but only for ER+/PR+ tumors1.
Table 1 Hazard Ratios for Alcohol/Western

Table 2 Hazard Ratios for Healthy/Mediterranean

There were a number of pros to this study. One pro is that the sample size was very large,
providing the study with copious amounts of data. A second pro is that the dietary data was
validated. Some studies only choose foods to put on a questionnaire that are only relevant to their
study and arent accurate depictions of a participants total diet. Because this studys dietary data
was validated, it means it was an accurate depiction of diet as a whole. A third pro is that the
cases of prevalent tumors at baseline were excluded, so only dietary patterns from cancer-free
subjects were produced.
There were also cons to this study. It was difficult to determine which specific
components of the healthy diet explained the inverse association with breast cancer. It was also
unclear whether it was the specific diet or the excess fat correlating with breast cancer, as obesity
is a known risk factor for the disease.
b. Article Two
Makarem N, Lin Y, Bandera EV, Jacques PF, Parekh N. Concordance with World
Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR)
guidelines for cancer prevention and obesity-related cancer risk in the Framingham
Offspring cohort (1991-2008). Cancer causes & control : CCC. Feb 2015;26(2):277-286.
The purpose of this study was to examine the relationship between cancer risk in obese
adults and healthy behaviors outlined by the World Cancer Research Fund (WCRF) and the
American Institute for Cancer Research (AICR). This is a prospective cohort study with the
sample being made up of 2,983 men and women from the Offspring generation of the
Framingham Heart Study. Every four years, clinical and medical exams were conducted between
1991 and 2008. Data on food intake was collected in 1991 to make a 7-component score based
on recommendations for things like body fat, physical activity, foods that contribute to weight
gain, plant foods, animal foods, alcohol, as well as food preservation, processing, and

records provided researchers with cancer types, specifically the obesity-related ones they were
interested in. 124 breast, 153 prostate, and 63 colorectal cancers were identified from the records.
Table 3 Cancer Prevention Recommendations and Adherence Levels
WCFR/AICR
recommendations
1. Body fatness: be as lean
as possible w/o being
underweight

Personal
recommendations
1a. ensure that bodyweight
throughout childhood and
adolescent growth

Operationalization

Scoring

Insufficient data

N/A

2. Physical activity: be
physically active every
day

2a. be moderately
physically active

3. Foods and drinks that


promote weight gain: limit
consumption of energydense foods; avoid sugary
drinks
4. Plant foods: eat mostly
foods of plant origin

3a. consume energy-dense


foods sparingly

PAI
>33 (high level)
3033 (moderate level)
<30 (low level)
ED foods (servings/week)
Tertile 1 (<29.8)
Tertile 2 (29.848.8)
Tertile 3 (48.9)

5. Animal foods: limit


intake of red meat and
avoid processed meat

4a. eat 5 portions of a


variety of non-starchy
vegetables and fruit every
day
5a. people who eat red
meat should consume <
500 g/week and very few,
if any, processed meats

F and V intake
5 servings/day
2.5 - <5 servings/day
<2.5 servings/day
Red and processed meat
intake
<500 g/week and <3 g/day
<500 g/week and 3 to <50
g/day
500 g/week or 50 g/day

1
0.5
0
1
0.5
0

1
0.5
0

1
0.5
0

6. Alcoholic drinks: limit


alcoholic drinks

6a. if alcoholic drinks are


consumed, limit
consumption to 2
drinks/day for men and 1
drink/day for women

Ethanol intake (g/day)


28 (men)
14 (women)
28-42 (men)
14-21 (women)
> 42 (men)
> 21 (women)

1
1
0.5
0.5
0
0

7. Preservation,
processing, preparation:
limit consumption of salt

7a. avoid salt-preserved,


salted, or salty foods

Salty foods
(servings/week)
Tertile 1 (<41.1)
Tertile 2 (41.1-62.7)
Tertile 3 (62.7)

1
0.5
0

This study resulted in recommendations made from the 7-component score with all
recommendations contributing 1 point to the total score, as shown in Table 1. A higher score (1)
shows a better adherence to the WCRD and AICR guidelines. At the end of the study, the
average age of participants was 66, the average BMI was 28.3 kg/m2, the average PAI was 35.7.
The average daily caloric intake was 1,858 kcal/day, half of the energy from carbohydrates and a
third of it from fats. Upon evaluating the total score, for every unit increment, there was a
marginally significant lower risk of breast cancer, at 13%. For every unit increase in the
alcohol score, there was a statistically significant decrease in risk of breast cancer, at 49%.
Overall adherence to the WCRD and AICR guidelines contribute to a lower risk of obesityrelated cancers, including breast cancer3.
Pros of this study were that it was a prospective design and there was a two-decade
follow-up. This is good because they were able to follow the women for a prolonged period of
time. The food frequency questionnaire was validated, making the study more reliable. The
researchers also used medical records to determine cancer incidence.
Cons of this study were that it was not specific to breast cancer, it did not only include
women, and all participants were Caucasian. These all contribute to less reliable data.
c. Article Three
Link LB, Canchola AJ, Bernstein L, et al. Dietary patterns and breast cancer risk in the
California Teachers Study cohort. The American journal of clinical nutrition. Dec
2013;98(6):1524-1532.
The purpose of this study was to determine how overall diet - not simply individual foods
or nutrients - relates to breast cancer risk in women. The study consisted of 91,779 active or
retired female teachers in California. 4,140 of the 91,1779 were diagnosed with invasive breast
cancer after joining the study. A baseline questionnaire was administered to gain information on

potential breast cancer risk factors and personal and lifestyle characteristics in each of the
women. A food-frequency questionnaire was also administered to gather dietary intake over the
past year before baseline.
Principal components factor analysis (PCFA) was used to recognize dietary patterns, and
further reduce foods, beverages, and dietary supplements into fewer variables. A factor score was
developed for each participants dietary pattern by multiplying the consumption of
food/beverage by the weight and adding up the values for all foods/beverages consumed. Women
in the study were followed from the time they did their baseline questionnaire until diagnosis
with breast cancer, death, leaving California, or the last day of 2009.
The major dietary patterns were identified: plant-based, high-protein/high-fat, highcarbohydrate, ethnic, and salad and wine. Those who followed the plant-based diet showed a
reduction in breast cancer risk, while those who followed the salad and wine diet were shown to
have an increased risk. Both trends were statistically significant. Specifically, the plant-based
diet was associated with a reduced risk of ER-PR- tumors, and the salad and wine diet was
associated with an increased risk of ER+PR+ tumors. Table 2 shows how each dietary pattern is
related to breast cancer risk4.

Table 4 Dietary Patterns and Breast Cancer Risk


Dietary
Pattern
Plant-based
# of cases
RR
95% CI
Highprotein, high
fat
# of cases
RR
95% CI
Highcarbohydrate
# of cases
RR
95% CI
Ethnic
# of cases
RR
95% CI
Salad and
wine
# of cases
RR
95% CI

P-trend2

749
1.0

807
0.97
0.88, 1.07

847
0.95
0.86, 1.05

887
0.93
0.84, 1.04

850
0.85
0.76, 095

0.003

779
1.0

763
0.94
0.85, 1.04

849
1.01
0.91, 1.12

865
1.02
0.91, 1.13

884
1.00
0.88, 1.14

1,013
1.0

906
0.93
0.84, 1.02

853
0.94
0.85, 1.04

716
0.86
0.77, 0.97

652
0.91
0.79, 1.05

907
1.0

854
0.99
0.90, 1.09

831
0.99
0.90, 1.09

788
0.97
0.88, 1.07

760
0.94
0.85, 1.05

0.24

581
1.0

692
0.95
0.85, 1.06

856
1.03
0.92, 1.14

891
0.98
0.88, 1.09

1,120
1.12
1.01, 1.25

0.010

0.60

0.11

Pros of this study were that it had a large sample size, so the results were more accurate
and generalizable. Dietary data was collected before actual breast cancer diagnosis, which is
important in the validity of the research. The article discusses specific components of a plantbased diet that could reduce breast cancer risk, such as fiber, antioxidants, and phytochemicals in
general. The dietary patterns evaluated were unique, providing the field with novel research.
Cons of this study were that the dietary data was collected an entire year before it began.
Women could have changed their diet in that timespan. The researchers also did not separate
cooked from raw vegetables, which is only important to note because raw vegetables have been
shown to be inversely related to breast cancer risk.

IV. Conclusions
Cottet et al. concluded that breast cancer risk may be reduced in postmenopausal women
who adopt a more healthy/Mediterranean diet, avoid a Western/alcohol diet, and maintain
caloric intake within the recommended amount.
Makarem et al. concluded that certain health behaviors, in particular reduction of alcohol
and adequate consumption of non-starchy plant foods, are the strongest predictors of cancer risk
reduction.
Link et al. concluded that a plant-based diet is associated with a reduction in ER-PRtumors; a salad and wine diet is associated with an increase in ER+PR+ tumors.
These three articles all support the hypothesis that a plant-based diet contributes to the
prevention of breast cancer.
V. Future Research
Further research is needed to determine just how strong the role of a plant-based diet is in
the prevention of breast cancer. It would be interesting to perform research clarifying the role of
a plant-based diet versus simply having a low body fat percentage. Since obesity is a risk factor
for breast cancer, it is hard to differentiate between the positive impact of plants versus the
impact of not having excess fat, which would be likely in someone consuming a plant-based diet.
Another idea for further research would be to do a longitudinal study starting on a younger age
group to see how consumption of foods changes or remains the same over time, and determine if
length of consumption makes a difference.

VII. References
1.
2.
3.

4.
5.

6.
7.
8.

9.

10.

Cottet V, Touvier M, Fournier A, et al. Postmenopausal breast cancer risk and dietary
patterns in the E3N-EPIC prospective cohort study. American journal of epidemiology.
Nov 15 2009;170(10):1257-1267.
National Cancer Institute: PDQ Breast Cancer Treatment. Bethesda, MD: National
Cancer Institute. Date last modified <03/04/2015>. Available at:
http://cancer.gov/cancertopics/pdq/treatment/breast/Patient. Accessed <03/18/2015>.
Makarem N, Lin Y, Bandera EV, Jacques PF, Parekh N. Concordance with World Cancer
Research Fund/American Institute for Cancer Research (WCRF/AICR) guidelines for
cancer prevention and obesity-related cancer risk in the Framingham Offspring cohort
(1991-2008). Cancer causes & control : CCC. Feb 2015;26(2):277-286.
Link LB, Canchola AJ, Bernstein L, et al. Dietary patterns and breast cancer risk in the
California Teachers Study cohort. The American journal of clinical nutrition. Dec
2013;98(6):1524-1532.
Hernandez-Valero MA, Thomson CA, Hernandez M, et al. Comparison of baseline
dietary intake of Hispanic and matched non-Hispanic white breast cancer survivors
enrolled in the Women's Healthy Eating and Living study. Journal of the American
Dietetic Association. Aug 2008;108(8):1323-1329.
Pierce JP, Faerber S, Wright FA, et al. A randomized trial of the effect of a plant-based
dietary pattern on additional breast cancer events and survival: the Women's Healthy
Eating and Living (WHEL) Study. Controlled clinical trials. Dec 2002;23(6):728-756.
Rock CL, Demark-Wahnefried W. Can lifestyle modification increase survival in women
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Takata Y, Maskarinec G, Park SY, Murphy SP, Wilkens LR, Kolonel LN.
Mammographic density and dietary patterns: the multiethnic cohort. European journal of
cancer prevention : the official journal of the European Cancer Prevention Organisation.
Oct 2007;16(5):409-414.
Suzuki R, Rylander-Rudqvist T, Ye W, Saji S, Adlercreutz H, Wolk A. Dietary fiber
intake and risk of postmenopausal breast cancer defined by estrogen and progesterone
receptor status--a prospective cohort study among Swedish women. International journal
of cancer. Journal international du cancer. Jan 15 2008;122(2):403-412.
Wang Y, Gapstur SM, Gaudet MM, Peterson JJ, Dwyer JT, McCullough ML. Evidence
for an association of dietary flavonoid intake with breast cancer risk by estrogen receptor
status is limited. The Journal of nutrition. Oct 2014;144(10):1603-1611.