Int. J.
Cancer: 107, 268 –270 (2003)
© 2003 Wiley-Liss, Inc.
PHYSICAL ACTIVITY AND BREAST CANCER RISK AMONG FEMALE
PHYSICAL EDUCATION AND LANGUAGE TEACHERS:
A 34-YEAR FOLLOW-UP
Pirjo RINTALA1,4*, Eero PUKKALA2, Esa LÄÄRÄ3 and Veikko VIHKO1
1
LIKES Research Center for Sport and Health Sciences, Jyväskylä, Finland
2
Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
3
Department of Mathematical Sciences, University of Oulu, Oulu, Finland
4
Department of Physical Medicine and Rehabilitation, Jyväskylä Central Hospital, Jyväskylä, Finland
The cohort consisted of 1,489 Finnish female physical ed-
ucation and 8,560 language teachers born after 1920 and alive
in 1967. The 2 study populations were similar in social class
and way of living and clearly discordant in physical activity
both during their university studies and later in life. The
incidence of breast cancer among these teachers up to the
year 2000 was assessed through a record linkage with the
Finnish Cancer Registry. The number of breast cancer cases
among physical education teachers was 61 in 32,862 person-
years and among language teachers was 404 in 177,188 per-
son-years. In Poisson-regression analysis, the incidence rate
ratio—adjusted for age, calendar time, number of children
and age at first birth—for physical education vs. language
teachers was overall 0.83 (95% confidence interval 0.63–1.09).
This relative rate was 0.79 (0.46 –1.36) in ages <50 years and
0.86 (0.62–1.18) in ages >50 years. Our study is concordant
with the hypothesis that life-long physical activity may reduce
the risk of breast cancer.
© 2003 Wiley-Liss, Inc.
Key words: occupational physical load; malignant mammary tumor;
cancer registry; epidemiology; cohort study; poisson regression
There is growing evidence suggesting that physical activity may
decrease the risk of breast cancer.1 There are several mechanisms
that in theory may mediate the possible protective effect of phys-
ical activity on breast cancer risk.
Exercise has an effect on sex hormones,2,3 and estrogenic hor-
mones are involved in the aetiology of breast cancer.4 Obesity and
adult weight gain increase the risk of postmenopausal breast can-
cer,1 while physical activity reduces fat mass, especially the highly
metabolic abdominal fat mass.5 Exercise also reduces the circulat-
ing level of insulin.6 Insulin-like growth factors (IGFs) stimulate
cell turnover in most body tissues and have been associated with
an increased risk of breast cancer, although the findings have been
variable.7 The IGF is downregulated by an increased production of
its binding protein, which can result from increased exercise,
although the results have not been quite consistent.8,9 Physical
activity may also decrease the breast cancer risk via immunologic
mechanisms.10
About 10 years ago, Finnish physical education and language
teachers were compared according to their risk of breast cancer,
and a suggestive protective effect of physical activity was
found.11,12 At the same time a structured questionnaire on life
habits was sent to a random subsample of 278 physical education
and 278 language teachers. This survey proved that the 2 teacher
groups had very similar living habits except for their physical
activity, which differed markedly, especially during their univer-
sity years but also later in life.12,13 In our present study, the
follow-up of the same cohort was extended by 9 years and the data
were analysed differently than in earlier articles,11,12 now based on
individual level regression modelling.
MATERIAL AND METHODS
The source population consisted of all Finnish female language
and physical education teachers born since 1920. Altogether, 8,634
Publication of the International Union Against Cancer
language and 1,503 physical education teachers were collected
from various registries: Physical Education Teachers’ rosters and
the registry of the Trade Union of Education in Finland founded in
1983.14 –17 The registers have close to full coverage. Data on the
age at the first live birth and the number of children were obtained
by record linkage with The National Population Registry. For each
person, the follow-up for cancer started after completion of each
register, at the age 25 years or on January 1, 1967, whichever was
latest. Women with breast cancer were identified from The Finnish
Cancer Registry through record linkage using the official personal
identification code. The final study cohort size included 8,560
language teachers and 1,489 physical education teachers (Table I)
after the exclusion of those who had emigrated or died (39 lan-
guage and 8 physical education teachers), who already had had
breast cancer at the beginning of the follow-up (33 language and 6
physical education teachers) or whose personal identification code
was incomplete (2 language teachers). For the follow-up person-
years at risk were calculated until the date of diagnosis of breast
cancer, emigration, death or the closing date (31 December 2000),
whichever was first.
The breast cancer risk among both of the teacher groups was
compared to that of the whole Finnish female population: the
observed numbers of breast cancer cases were divided by the
expected numbers to get the standardized incidence ratios (SIRs).
The expected numbers were based on the age and calendar time-
specific incidence rates of breast cancer in women in Finland
during the follow-up period in question (1967–2000).
Poisson regression modelling18 was used to analyze the inci-
dence density or incidence rate according to the teacher group and
the variables for which to be adjusted. The adjusted estimates of
the incidence rate ratio between physical education teachers and
language teachers were obtained from fitting a Poisson model
using the logarithmic link function and also including 3 categorical
covariates: (i) age (grouped as 25–39, 40 – 49, 50 –59, 60 – 69,
70 –79 years and ⱖ80 years old); (ii) calendar period of follow-up
(1967– 81, 1982–91, 1992–2000); and (iii) number of children
(none, 1, 2, 3 or more) and age at the first birth (⬍25 years, 25–29
years, ⱖ30 years). Possible modification of the effect of teacher
group by age, calendar period, number of children and age at first
Grant sponsor: LIKES-Foundation for Promotion of Sport and Health
Sciences; Grant sponsor: Finnish Ministry of Education.
*Correspondence to: LIKES Research Center, Rautpohjankatu 10,
FIN-40 700 Jyväskylä, Finland. Fax: ⫹358-14-260-1571.
E-mail: Pirjo.Rintala@likes.fi
Received 6 February 2003; Revised 9 April 2003; Accepted 24 April
2003
DOI 10.1002/ijc.11390
 10970215, 2003, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ijc.11390 by CAPES, Wiley Online Library on [23/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PHYSICAL ACTIVITY AND BREAST CANCER RISK 269
TABLE I – NUMBERS OF CASES, PERSON-YEARS AT RISK AND INCIDENCE RATES (PER 10,000 PERSON-YEARS) OF BREAST CANCER IN PHYSICAL
EDUCATION TEACHERS AND LANGUAGE TEACHERS BY SELECTED DETERMINANTS
Physical education teachers Language teachers
Determinant
No. Person-years Rate No. Person-years Rate

Calendar period
1967-1981 13 9,447 14 50 40,426 12
1982-1991 21 12,148 17 133 68,652 19
1992-2000 27 11,267 24 221 68,110 32
Age (years)
25-49 15 16,486 9 108 94,697 11
50-59 20 7,302 27 150 43,894 34
60⫹ 26 9,075 29 146 38,597 38
No. of children
Nulliparous 7 5,446 13 146 58,793 25
1 7 3,366 21 57 25,660 22
2 25 11,295 22 119 53,045 22
ⱖ3 22 12,756 17 82 39,690 21
Age (years) at first birth (parous only)
⬍25 years 6 5,172 12 42 23,513 18
25–29 years 34 15,400 22 112 52,769 21
ⱖ30 years 14 6,846 20 104 42,113 25
Overall 61 32,863 19 404 177,188 23

TABLE II – NUMBER OF BREAST CANCER CASES AND RELATIVE RISK (RR) WITH 95% CONFIDENCE INTERVAL (CI) FOR PHYSICAL EDUCATION
TEACHERS BY AGE, PARITY AND AGE AT FIRST BIRTH (PAROUS ONLY)
Age ⬍ 50 years Age ⱖ 50 years
Determinant
No. RR (95% CI) No. RR (95% CI)

Teacher
Physical education 15 0.79 (0.46–1.36) 46 0.86 (0.62–1.18)
Language 108 1.0 (ref.) 296 1.0 (ref.)
Parity; age at first birth
Nulliparous 28 1.0 (ref.) 125 1.0 (ref.)
1–2 children; ⬍25 years 5 0.63 (0.24–1.63) 20 0.83 (0.51–1.32)
ⱖ3 children; ⬍25 years 5 0.74 (0.28–1.91) 18 0.65 (0.39–1.06)
1–2 children; ⱖ25 years 61 1.35 (0.86–2.12) 122 1.02 (0.79–1.31)
ⱖ3 children; ⱖ25 years 24 1.44 (0.83–2.49) 57 0.81 (0.59–1.11)

birth, respectively, were investigated by including the correspond-
ing product or interaction terms in the model. The analyses were
also performed separately for “premenopausal” breast cancers (the
follow-up ending at the age of 49 years) and “postmenopausal”
(the follow-up starting at the age of 50 years).
The computations were performed using the SAS software,19
particularly its GENMOD procedure for model fitting and the
macro %LEXIS supplied by Dr. Bendix Carstensen (Steno Diabe-
tes Center, Copenhagen, Denmark) for person-year calculations.
RESULTS
The total number of cases among physical education teachers
was 61 in 32,862 person-years and among language teachers was
404 in 177,188 person years (Table I). The SIR in relation to the
whole Finnish female population during the follow-up 1967–2000
was for physical education teachers 1.35 (95% confidence interval
0.88 –1.83) and for language teachers 1.58 (95% confidence inter-
val 1.38 –1.79). The ratio of these SIRs was 0.85 (0.65–1.11).
From the fitted Poisson regression model, the incidence rate ratio
(RR) of physical education teachers vs. language teachers was 0.83
(0.63–1.09) during the follow-up 1967–2000 adjusted for age,
calendar time and age at first birth and the number of children. No
difference could be observed in the rate ratio associated with
cancer diagnosed before 50 years of age and after 50 years of age,
respectively (Table II).
DISCUSSION
The comparison of the 2 teacher groups, similar in social class
and life habits but discordant in physical activity, showed that
physical education teachers had a somewhat lower breast cancer
risk than the language teachers both in the age ⬍50 years old and
in the age ⱖ50 years. The statistical precision of our estimates,
however, is rather low because of small number of cases among
physical education teachers.
The incidence of breast cancer in both of the teacher groups
clearly exceeded the average of the Finnish female population.
Teachers, the most highly educated stratum, belong to the highest
social class with the highest breast cancer risk.20 Lifestyle factors
typical for women with high socioeconomic status in Finland
include late age at first birth,21 low-fat diet with a higher consump-
tion of fruits and vegetables22 and resistance to overweight and
obesity.23 These factors also characterise the teachers in our study.
The mean age at first birth was ⬎25 years in both teacher groups.
Their diet was healthy: the vegetable and fruit consumption was
equally high, but physical education teachers ate fish more often
and low-fat milk products less often than language teachers.12,13
The proportion of regular cigarette smokers was 20% for language
teachers and 18% for physical education teachers. The physical
education teachers consumed slightly more alcohol than the lan-
guage teachers. Lifestyle factors related both to the socioeconomic
status and breast cancer24 are likely to explain the increased
incidence of both teacher categories in comparison to the general
population but do not explain the difference in breast cancer risk
between the teacher groups found in our study.
The 2 teacher groups differed from each other in the level of
physical activity during their university years because physical
education teachers had obligatory physical exercises as a major
part of their studies. Later in life, according to the subsample of
185 language and 202 physical education teachers,12,13 the teach-
ers were different in both their leisure and occupational physical
activity level. During leisure time, 30% of the physical education

270 RINTALA ET AL.
teachers were highly active compared to the 10% of the language
teachers. High physical activity was determined as exercise 2–3
times a week with duration of ⬎1 hr each time. The most popular
sport was swimming in summer and cross-country skiing in winter.
The proportion of physical education teachers who felt their work
was at least moderately physically demanding was 62%, whereas
that of language teachers was 3%. The physical workload for the
profession of physical education teachers consists of demonstrat-
ing the execution of movements, assisting the pupils physically to
do the movements, moving gymnastic equipment and moving from
one activity site to another.25
Hormone replacement therapy has been found to contribute to a
markedly increased risk of breast cancer, also in the Finnish
population.26 High social class was related to the use of hormone
replacement therapy for menopausal disorders among Finnish
women in the 1980s but not any more in the 1990s.27 We do not
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