Serum 25-hydroxyvitamin D levels in early and
advanced breast cancer
C Palmieri, T MacGregor, S Girgis, D Vigushin
............................................................... ............................................................... .
J Clin Pathol 2006;59:1334–1336. doi: 10.1136/jcp.2006.042747
Background: Laboratory and epidemiological studies have
implicated vitamin D deficiency in the pathogenesis of breast
cancer. 1,25-Dihydroxyvitamin D (1,25(OH)2D) promotes
differentiation and apoptosis, and potently inhibits prolifera-
tion of malignant breast epithelial cells in culture. Serum
levels of 1,25(OH)2D are higher in normal women than in
patients with primary breast cancer.
Aim: To clarify the role of vitamin D in breast cancer
progression by comparing the levels of serum vitamin D in
patients with early and in those with advanced breast cancer.
Methods: Circulating levels of 25-hydroxyvitamin D
(25(OH)D), parathyroid hormone (PTH) and calcium were
measured prospectively in 279 Caucasian women with
invasive breast cancer, 204 women with early-stage disease
and 75 women with locally advanced or metastatic disease.
Results: Patients with early-stage breast cancer had signifi-
cantly higher circulating levels of 25(OH)D (p,0.005) and
significantly lower PTH (p,0.001) levels than those with
advanced disease. Calcium levels did not differ significantly
Conclusion: Serum levels of 25(OH)D are significantly higher
in patients with early-stage breast cancer than in those with
locally advanced or metastatic disease.
inhibits the proliferation of breast cancer cell lines,1promotes
differentiation2and induces apoptosis.3Animal studies have
shown that dietary vitamin D can abrogate the tumorigenic
effects of a high-fat diet on mammary tissue4and that
1,25(OH)2D3 and its analogues can inhibit growth of breast
cancer cell lines,5prevent the development of carcinogen-
induced mammary tumours6and have a pro-apoptotic effect in
nude mice bearing MCF-7 xenografts.7
Epidemiological studies have shown a higher incidence of
breast cancer in countries at higher latitudes and in those
living at higher latitudes in the same country,8 9and an
association with an increased risk of dying from breast cancer
for those living at such latitudes.8Vitamin D sufficiency and
exposure to sunlight have been shown to reduce the risk of
developing breast cancer in the National Health and
Nutrition Survey Epidemiological Follow-up Study I.10A
case–control study of normal women and those with breast
cancer showed that blood levels of 1,25(OH)2D3 were higher
in the cohort of healthy women.11In women with breast
cancer, tumour DNA aneuploidy was associated with a low
dietary vitamin D intake,12whereas increased skin pigmenta-
tion was associated with larger-sized breast cancers and
increased frequency of nodal involvement.13In women with
aboratory and epidemiological studies implicate vitamin D
deficiency in the pathogenesis of breast cancer. In vitro
studies show that 1,25-dihydroxyvitamin D (1,25(OH)2D3)
to breastcancer, serum
1,25(OH)2D3 fell in those who developed disease progres-
sion.14To further investigate the potential role of vitamin D in
breast cancer progression, we measured circulating levels of
25-hydroxyvitamin D (25(OH)D), the major circulating form
of vitamin D and the best indicator of vitamin D status, as
well as that of parathyroid hormone (PTH) and calcium in
patients with early or advanced breast cancer.
Serum was obtained from 279 Caucasian women with
invasive breast cancer: 204 with early-stage breast cancer
(stage I or II) and 75 with locally advanced or metastatic
disease (stage III or IV). Patients were staged according to the
6th edition of the American Joint Committee on Cancer
staging system for invasive breast cancer.15Patients with
renal impairment or those receiving bisphosphonate therapy
or epilepsy drugs were excluded. Blood samples were
obtained with informed consent at the time of the clinic
appointment and analysed immediately after collection.
Serum 25(OH)D was quantified by radioimmunoassay
(ImmunoDiagnostic Systems, IDS, Boldon, UK) and PTH by
immunoradiometric assay (Nicols Institute Diagnostics, San
Clemente, California, USA). Serum calcium (corrected for
albumin binding) was measured by the automated standard
laboratory method. Normal laboratory reference ranges were
as follows: 25(OH)D 15–100 nmol/l, PTH 1.06–5.3 pmol/l and
corrected calcium 2.15–2.65 mmol/l.
The unpaired t test was used for comparative statistical
analysis of biochemical data on each group of patients. The
study had 80% power to detect a difference between mean
serum 25(OH)D concentrations of 10 nmol/l, with a sig-
nificance level (a) of 0.05 (two tailed).
Patients with early-stage breast cancer were found to have
circulating concentrations of 25(OH)D ranging from 15.0 to
184.0 nmol/l (mean 57 nmol/l, 95% confidence interval (CI)
52.7 to 60.5 nmol/l) as compared with levels of 16–146 nmol/l
(mean 46.0 nmol/l, 95% CI 40.9 to 51.8 nmol/l) in patients with
locally advanced or metastatic breast cancer. Comparison of the
two groups yielded a significant difference in vitamin D levels
(p=0.048). PTH levels ranged from 1.2 to 11.3 pmol/l (mean
3.91 pmol/l, 95% CI 3.7 to 4.2 pmol/l) in the early-stage breast
cancer group as compared with a range of 1.05–14.1 pmol/l
(mean 5.06 pmol/l, 95% CI 4.4 to 5.8 pmol/l) in the locally
advanced/metastatic cancer group; there was a significant
difference between these two groups with regard to PTH levels,
(p,0.001). We found no significant difference between these
two groups with regard to calcium levels (p=0.74). Table 1
summarises these results.
Abbreviations: 1,25(OH)2D, 1,25-dihydroxyvitamin D; 25(OH)D, 25-
hydroxyvitamin D; PTH, parathyroid hormone
This study has shown that serum levels of 25(OH)D were
markedly higher and that PTH levels were considerably lower
in patients with early-stage breast cancer than in those with
locally advanced or metastatic disease. The notably higher
serum PTH in patients with metastatic disease than that in
those with early-stage disease is presumably due to the lower
vitamin D level, resulting in a lower serum calcium and
therefore a rise in serum PTH. The raised PTH level can
therefore account for the lack of any difference in serum
calcium between these two groups. Epidemiological studies
have previously shown that maintenance of adequate levels
of vitamin D via exposure to sunlight is associated with a
reduced incidence and mortality of breast cancer.8 9 11This
may reflect the fundamental importance of vitamin D in
regulating aspects of cellular behaviour such as cell growth.
This is supported by in vitro data in breast cancer cell lines, as
well as in vivo animal studies,6 7which have shown the
ability of 1,25(OH)2D3 to inhibit proliferation and promote
differentiation and apoptosis.1–4In addition, an observational
study showed lower levels of 1,25(OH)2D3 in women
diagnosed with primary breast cancer compared with a
healthy cohort,11and a decrease in vitamin D in patients with
breast cancer with bone metastasis that progressed.14The
results of this study showing lower levels of 25(OH)D in
women with advanced breast cancer lends weight to the
hypothesis that the growth of breast cancer in vivo is
inhibited by vitamin D. The exact reason for the deranged
and low 25(OH)D levels in patients with advanced cancer as
compared with those with early-stage breast cancer is
unclear, and also whether the decrease in 25(OH)D is
causative for the advanced disease or is a direct consequence
of the advanced disease as a result of cancer-related reduced
dietary intake or altered synthesis in the skin due to reduced
24-Hydroxylase inactivates 1,25(OH)3and is involved in
the homeostasis of serum levels of 1,25(OH)3, and it is
suggested to be an oncogene.16The expression of 24-
hydroxylase is shown to be higher in primary breast tumours
than in normal breast tissue,17and the levels of 1,24,25(OH)3
were considerably higher in malignant breast tumours. It is
also known that 1,24,25(OH)3 does not induce an anti-
proliferative response in breast cancer cell lines. This can be
reversed by antisense inhibition of 24-hydroxylase in vitro.17
Therefore, a resistance mechanism to the potential effects of
vitamin D—namely, via the dysregulation of 24-hydroxylase
activity—seems to exist in breast tumours. How this
advanced or metastatic breast cancer is not known, given
the previously normal tissue was compared with primary
breast tumours.17Possibly, in advanced breast cancer, a
further dysregulation in the metabolism of vitamin D may
result from some paracrine tumour effect, or tumours that
have high 24-hydroxylase levels may have a greater
propensity to progress to advanced stage disease.
Vitamin D binds to the vitamin D receptor, which is a ligand-
activated transcription factor that controls gene transcription
via binding to vitamin D response elements in DNA. Microarray
analysis has shown that several key genes are up regulated or
down regulated as a result of vitamin D treatment. One such
key gene that is up regulated is the cyclin-dependent kinase
inhibitor p21, which has an important role in controlling cell
cycle progression.18Whatever the cause for the change in
vitamin D levels,it can potentially have a marked effect on gene
transcription and therefore on cellular phenotype. Lower serum
vitamin D levelsmight therefore have some causative role inthe
progression from early-stage to advanced disease as a result of
altered gene transcription.
In summary, these findings lend support to the hypothesis
that vitamin D has a role in the pathogenesis and progression
of breast cancer. This report, while being an observational
study, clearly shows that circulating vitamin D levels are
lower in patients with advanced breast cancer than in those
with early breast cancer. However, several questions remain
unanswered. These include the potential causes and mechan-
isms underlying this dysregulation of vitamin D regulation,
their precise molecular consequences and the potential
clinical implications of monitoring or maintaining high
circulating vitamin D levels in patients diagnosed with breast
cancer. Answering these questions offers the potential of
improving the risk stratification, surveillance and treatment
of women with breast cancer.
This work is dedicated to the memory of Dr David Vigushin, a much
respected friend, colleague and mentor, whose tireless care and
dedication will always be remembered by his patients.
parathyroid hormone and vitamin D between patients
with early-stage breast cancer and locally advanced or
metastatic breast cancer
Comparison of the serum levels of calcium,
Total number of patients 204
Age range (years)
Parathyroid hormone (pmol/l)
25(OH)D, 25-hydroxyvitamin D.
N Epidemiological studies, as well as in vitro and in vivo
data, suggest a role for vitamin D in the pathogenesis
of breast cancer.
N Vitamin D levels have been shown to be higher in
normal women compared with those who have
primary breast cancer, and decrease with the progres-
sion of bone metastases.
N This study shows a significantly higher level of
25-hydroxyvitamin D in women with early breast
cancer compared with those with advanced disease.
Further work is required to determine the precise
mechanism for the dysregulation of vitamin D levels in
advanced breast cancer.
25(OH)D levels in breast cancer 1335
C Palmieri, T MacGregor, D Vigushin, Cancer Research UK
Laboratories, Department of Cancer Medicine, Faculty of Medicine,
Imperial College, Hammersmith Hospital, London, UK
S Girgis, Department of Metabolic Medicine, Faculty of Medicine,
Imperial College London, London, UK
Competing interests: None declared.
Correspondence to: C Palmieri, Cancer Research UK Laboratories,
Department of Cancer Medicine, MRC Cyclotron Building, Faculty of
Medicine, Imperial College, Hammersmith Hospital, Du Cane Road,
London W12 ONN, UK; email@example.com
Accepted 23 August 2006
Published Online First
17 October 2006
1 Chouvet C, Vicard E, Devonee M, et al. 1,25-Dihydroxyvitamin D3inhibitory
effect on growth of two human breast cancer cell lines (MCF-7, BT-20).
J Steroid Biochem 1986;24:373–6.
2 Frappart L, Falette N, Lefebvre MF, et al. In vitro study of effects of 1,25
dihydroxyvitamin D3 on the morphology of human breast cancer cell line
BT20. Differentiation 1989;40:63–9.
3 James SY, Mackay AG, Colston KW. Effects of 1,25 dihydroxyvitamin D3 and
its analogues on induction of apoptosis in breast cancer cells. J Steroid
Biochem Mol Biol 1996;58:395–401.
4 Jacobson E, James K, Newmark H, et al. Effects of dietary fat, calcium, and
vitamin D on growth and mammary tumorigenesis induced by 7,12-
dimethylbenz(a)anthracene in female Sprague-Dawley rats. Cancer Res
5 Colston KW, Chander SK, Mackay AG, et al. Effects of synthetic vitamin D
analogues on breast cancer cell proliferation in vivo and in vitro. Biochem
6 Anzano MA, Smith JM, Uskokoviv MR, et al. 1a-Dihydroxy-16-ene-23-yne-
26,27-hexafluorocholecalciferol (Ro24–5531), a new deltanoid (vitamin D
analogue) for prevention of breast cancer in the rat. Cancer Res
7 Van Weelden K, Flanagan L, Binderup L, et al. Apoptotic regression of MCF-7
xenografts in nude mice treated with the vitamin D3 analog EB1089.
8 Garland CF, Garland FC, Gorham ED, et al. Geographic variation in breast
cancer mortality in the United States: a hypothesis involving exposure to solar
radiation. Prev Med 1990;19:614–22.
9 Gorham ED, Garland FC, Garland CF. Sunlight and breast cancer incidence
in the USSR. Int J Epidemiol 1990;19:820–4.
10 John EM, Schwartz GG, Dreon DM, et al. Vitamin D and breast cancer risk:
the NHANES I Epidemiologic Follow-up Study, 1971–1975 to 1992. Cancer
Epidemiol Biomarkers Prev 1999;8:399–406.
11 Janowsky EC, Lester GE, Weinberg, et al. Association between low levels of
1,25-dihydroxyvitamin D and breast cancer risk. Public Health Nutr
12 Furst CJ, Auer G, Nordevang E, et al. DNA pattern and dietary habits in
patients with breast cancer. Eur J Cancer 1993;29:1285–8.
13 Elledge RM, Clark GM, Chamness GC, et al. Tumour biologic factors and
breast cancer prognosis among white, Hispanic, and black women in the
United States. J Natl Cancer Inst 1994;86:704–12.
14 Mawer EB, Walls J, Howell A, et al. Serum 1,25-dihydroxyvitamin D may be
related inversely to disease activity in breast cancer patients with bone
metastases. J Clin Endocrinol Metab 1997;82:118–22.
15 Thor A. A revised staging system for breast cancer. Breast J
16 Albertson DG, Ylstra, Seagraves R, et al. Quantitative mapping of amplicon
structure by array CGH identifies CYP24 as a candidate oncogene. Nat Genet
17 Townsend K, Banwell CM, Guy M, et al. Autocrine metabolism of
vitamin D in normal and malignant breast tissue. Clin Cancer Res
18 Swami S, Raghavachari N, Muller UR, et al. Vitamin D growth inhibition of
breast cancer cells gene expression patterns assessed by cDNA microarray.
Breast Cancer Res Treat 2003;80:49–62.
1336 Palmieri, MacGregor, Girgis, et al