General and Abdominal Obesity and Survival among
Young Women with Breast Cancer
Page E. Abrahamson,1Marilie D. Gammon,1Mary Jo Lund,3,4Elaine W. Flagg,5
Peggy L. Porter,7June Stevens,1,2Christine A. Swanson,8Louise A. Brinton,9
J. William Eley,4and Ralph J. Coates6
Epidemiology, Rollins School of Public Health and
Division of Global Migration and Quarantine, National Center for Infectious Diseases and
National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention,
8Office of Disease Prevention, Office of Dietary Supplements;
National Cancer Institute, NIH, Bethesda, Maryland
2Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
4Winship Cancer Institute, Emory University;
5Surveillance and Epidemiology Branch,
6Division of Cancer Prevention and Control,
7Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington; and
9Division of Cancer Epidemiology and Genetics,
Among postmenopausal women, obesity is linked to
increased risk of breast cancer and poorer subsequent
survival. For premenopausal women, obesity may reduce
incidence, but less is known about its effect on prognosis,
particularly for abdominal obesity. This study investigated
whether general or abdominal obesity at diagnosis influ-
enced survival in a cohort of young women with breast
cancer. A population-based follow-up study was conducted
among 1,254 women ages 20 to 54 who were diagnosed with
invasive breast cancer between 1990 and 1992 in Atlanta or
New Jersey. Women were interviewed within several months
of diagnosis and asked about their weight and height at age
20 and in the year before diagnosis. Study personnel did
anthropometric measures at the interview. With 8 to 10 years
of follow-up, all-cause mortality status was determined
using the National Death Index (n = 290 deaths). Increased
mortality was observed for women who were obese [body
mass index (BMI), z30] at the time of interview compared
with women of ideal weight [BMI, 18.5-24.9; stage- and
income-adjusted hazard ratio (HR), 1.48; 95% confidence
interval (95% CI), 1.09-2.01]. A similar result was seen for the
highest versus lowest quartile of waist-to-hip ratio (HR, 1.52;
95% CI, 1.05-2.19). Strong associations with mortality were
found for women who were obese at age 20 (HR, 2.49; 95%
CI, 1.15-5.37) or who were overweight/obese (BMI, z25)
at both age 20 and the time of interview (HR, 2.22; 95% CI,
1.45-3.40). This study provides evidence that breast cancer
survival is reduced among younger women with general or
(Cancer Epidemiol Biomarkers Prev
Women under age 45, who comprise <25% of all breast
cancer cases, have survival rates considerably lower than
those for older women even after controlling for stage of
disease (1). Although results are not consistent across studies,
the poorer prognosis for young women may be explained in
part by a greater likelihood of lymph node involvement,
larger tumors, higher histologic grade, estrogen receptor
negativity, overexpression of p53, and poorly differentiated
Younger women may present with more advanced or
aggressive disease due to delayed diagnosis, as they are not
generally recommended for mammography and typically
have denser breasts, making it more difficult to detect cancer
through self-exam, clinical exams, or mammographic screen-
ing (7). Other hypotheses offered to explain their poorer
survival include higher estrogen concentrations, which may
induce a more rapid tumor growth rate or a different biology
of the cancer, compared with older women (8).
Although clinical markers are generally considered to be the
most important prognostic factors for women with breast
cancer, stage and grade have been estimated to explain only
f20% of the observed variation in survival (9). Age, race,
and socioeconomic status have been found to influence
survival (10, 11), but modifiable factors have generally
not been well studied in relation to surviving breast cancer.
Body weight is one of the few potentially modifiable factors
to receive extensive attention. For postmenopausal women,
high body mass index (BMI) or weight is well established
as adversely affecting both the incidence of breast cancer (12)
and its prognosis (13, 14). In contrast, obesity seems to reduce
the risk of developing breast cancer among premenopausal
women (15); less is understood about the effects of obesity on
prognosis in these younger women (16).
In addition to general obesity, as indexed by the BMI, there
is growing interest in the adverse health effects of abdominal
fat because of its relationship with visceral fat (17) and unique
hormonal profiles (18). Women with an elevated waist-to-hip
ratio (WHR) or a large waist circumference, two markers of
abdominal fat distribution (19), are reported to have a higher
risk of several cancers (including postmenopausal breast
cancer) as well as stroke, hypertension, atherosclerosis,
hirsutism, insulin resistance, and type 2 diabetes mellitus
(20-22) presumably due to elevated concentrations of estrogen,
insulin, and triglycerides (18, 23). The effect of abdominal fat
on the prognosis for breast cancer has not been well studied
in either premenopausal or postmenopausal women (24, 25).
In this population-based follow-up study, we investigated
whether general or abdominal obesity before or near the time
of diagnosis influenced survival among a cohort of younger
Cancer Epidemiol Biomarkers Prev 2006;15(10). October 2006
Received 5/3/06; revised 7/5/06; accepted 8/10/06.
Grant support: Public Health Service grants P30ES10126 and R25 CA94880 and Intramural
Research Program of the NIH, National Cancer Institute.
The costs of publication of this article were defrayed in part by the payment of page charges.
This article must therefore be hereby marked advertisement in accordance with 18 U.S.C.
Section 1734 solely to indicate this fact.
Note: The findings and conclusions in this report are those of the authors and do not
necessarily represent the views of the Centers for Disease Control and Prevention.
Requests for reprints: Page E. Abrahamson, Fred Hutchinson Cancer Research Center,
1100 Fairview Avenue North, M4-B402, Seattle, WA 98109-1024. Phone: 206-667-5491;
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Copyright D 2006 American Association for Cancer Research.
39. Demark-Wahnefried W, Rimer BK, Winer EP. Weight gain in women
diagnosed with breast cancer. J Am Diet Assoc 1997;97:519–26.
40. Lees AW, Jenkins HJ, May CL, et al. Risk factors and 10-year breast cancer
survival in northern Alberta. Breast Cancer Res Treat 1989;13:143–51.
41. Mohle-Boetani JC, Grosser S, Whittemore AS, et al. Body size, reproductive
factors, and breast cancer survival. Prev Med 1988;17:634–42.
42. Kroenke CH, Chen WY, Rosner B, et al. Weight, weight gain, and survival
after breast cancer diagnosis. J Clin Oncol 2005;23:1–9.
43. Dignam JJ, Wieand K, Johnson KA, et al. Obesity, tamoxifen use, and
outcomes in women with estrogen receptor-positive early-stage breast
cancer. J Natl Cancer Inst 2003;95:1467–76.
44. Greenberg ER, Vessey MP, McPherson K, et al. Body size and survival in
premenopausal breast cancer. Br J Cancer 1985;51:691–7.
45. Daling JR, Malone KE, Doody DR, et al. Relation of body mass index to
tumor markers and survival among young women with invasive ductal
breast carcinomas. Cancer 2001;92:720–9.
46. Whiteman MK, Hillis SD, Curtis KM, et al. Body mass and mortality
after breast cancer diagnosis. Cancer Epidemiol Biomarkers Prev 2005;14:
47. Tretli S, Haldorsen T, Ottestad L. The effect of pre-morbid height and weight
on the survival of breast cancer patients. Br J Cancer 1990;62:299–303.
48. Haybittle J, Houghton J, Baum M. Social class and weight as prognostic
factors in early breast cancer. Br J Cancer 1997;75:729–33.
49. Chang S, Alderfer JR, Asmar L, et al. Inflammatory breast cancer survival:
the role of obesity and menopausal status at diagnosis. Breast Cancer Res
50. Tornberg S, Carstensen J. Serum h-lipoprotein, serum-cholesterol, and
Quetelet’s index as predictors for survival of breast cancer patients. Eur J
51. Stephenson GD, Rose DP. Breast cancer and obesity: an update. Nutr Cancer
52. den Tonkelaar I, de Waard F, Seidell JC, et al. Obesity and subcutaneous fat
patterning in relation to survival of postmenopausal breast cancer patients
participating in the DOM-project. Breast Cancer Res Treat 1995;34:129–37.
53. Kumar NB, Cantor A, Allen K, et al. Android obesity at diagnosis and breast
carcinoma survival: evaluation of the effects of anthropometric variables at
diagnosis, including body composition and body fat distribution and weight
gain during life span, and survival from breast carcinoma. Cancer 2000;88:
54. Ballard-Barbash R. Anthropometry and breast cancer. Body size—a moving
target. Cancer 1994;74:1090–100.
55. Stallone DD. The influence of obesity and its treatment on the immune
system. Nutr Rev 1994;52:37–52.
56. Madarnas Y, Sawka CA, Franssen E, et al. Are medical oncologists biased in
their treatment of the large woman with breast cancer? Breast Cancer Res
57. Bruning PF, Bonfrer JM, van Noord PA, et al. Insulin resistance and breast-
cancer risk. Int J Cancer 1992;52:511–6.
58. Keizer HA, Rogol AD. Physical activity and menstrual cycle alterations.
What are the mechanisms? Sports Med 1990;10:218–35.
59. Irwin ML, McTiernan A, Baumgartner RN, et al. Changes in body fat and
weight after a breast cancer diagnosis: influence of demographic, prognostic,
and lifestyle factors. J Clin Oncol 2005;23:774–82.
60. Patterson RE, Neuhouser ML, Hedderson MM, et al. Changes in diet,
physical activity, and supplement use among adults diagnosed with cancer.
J Am Diet Assoc 2003;103:323–8.
61. Rich-Edwards JW, Corsano KA, Stampfer MJ. Test of the National Death Index
and Equifax Nationwide Death Search. Am J Epidemiol 1994;140:1016–9.
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