title: Obesity, mammography use and accuracy, and advanced breast cancer risk.
abstract: BACKGROUND
  Being overweight or obese is associated with increased breast cancer risk and disease severity among postmenopausal women, but whether extent of mammography use and accuracy modify this association and further contribute to increases in disease severity at diagnosis among overweight and obese women is unclear.
  
  
  METHODS
  We prospectively collected data during 1996-2005 on 287,115 postmenopausal women not using hormone therapy (HT) who underwent 614,562 mammography examinations; 4,446 women were diagnosed with breast cancer within 12 months of a mammography examination. We calculated rates per 1,000 mammography examinations of large (>15 mm), advanced-stage (IIb, III, or IV), high-grade (3 or 4), estrogen receptor (ER)-positive and -negative, and screen-detected and non-screen-detected breast cancer across body mass index (BMI, kg/m(2)) groups defined as normal (18.5-24.9), overweight (25.0-29.9), obese class I (30.0-34.9), and obese class II/III (> or =35.0), adjusting for age, race/ethnicity, and mammography registry and use. All statistical tests were two-sided.
  
  
  RESULTS
  Adjusted rates per 1000 mammography examinations of overall breast cancer increased across BMI groups (6.6 normal, 7.4 overweight, 7.9 obese I, 8.5 obese II/III; P(trend) < .001), as did rates of advanced disease, including large invasive (2.3 normal, 2.6 overweight, 2.9 obese I, 3.2 obese II/III; P(trend) < .001), advanced-stage (0.8 normal, 0.9 overweight, 1.3 obese I, 1.5 obese II/III; P(trend) < .001), and high nuclear grade (1.5 normal, 1.7 overweight, 1.7 obese I, 1.9 obese II/III; P(trend) = .10) tumors. Rates of ER-positive tumors increased across BMI groups (P(trend) < .001); rates of ER-negative tumors did not. Rates of screen-detected cancers were higher among overweight and obese women than normal and underweight women, but rates of non-screen-detected (false-negative) cancers were similar. Rates of advanced breast cancer increased across BMI groups regardless of extent of mammography use.
  
  
  CONCLUSIONS
  Patterns of mammography use and mammography accuracy are not the primary reasons for higher rates of advanced breast cancer among overweight and obese postmenopausal women not using HT; thus, biologic differences in breast tumor development and/or progression may be important.
authors.affiliation: Department of Epidemiology and Biostatistics, General Internal Medicine Section, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA 94121, USA. karla.kerlikowske@ucsf.edu
authors.forename: Karla
authors.initials: K
authors.lastname: Kerlikowske
authors.forename: Rod
authors.initials: R
authors.lastname: Walker
authors.forename: Diana L
authors.initials: DL
authors.lastname: Miglioretti
authors.forename: Arati
authors.initials: A
authors.lastname: Desai
authors.forename: Rachel
authors.initials: R
authors.lastname: Ballard-Barbash
authors.forename: Diana S M
authors.initials: DS
authors.lastname: Buist
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology* / Q000473:pathology / Q000517:prevention & control; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D016015:Logistic Models; D008327:Mammography; D008875:Middle Aged; D009367:Neoplasm Staging; D009765:Obesity / Q000150:complications* / Q000175:diagnosis; D016017:Odds Ratio; D050177:Overweight / Q000150:complications; D017698:Postmenopause; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology