Nutrition 27 (2011) 912918

Contents lists available at ScienceDirect

Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Evaluation of dietary factors in relation to the biomarkers of oxidative stress

and inammation in breast cancer risk
Jee-Young Yeon Ph.D. a, Young-Jin Suh Ph.D. b, Sang-Wook Kim Ph.D. c, Hyun-Wook Baik Ph.D. d,
Chung-Ja Sung Ph.D. a, Hyun-Sook Kim Ph.D. a, Mi-Kyung Sung Ph.D. a, *
a

Department of Food and Nutrition, Sookmyung Womens University, Seoul, Korea

Department of Surgical Oncology St. Vincents Hospital, The Catholic University College of Medicine, Suwon, Korea
Department of Surgery, Bundang Jaesaeng Hospital, Seongnam, Korea
d
Department of Gastroenterology, Bundang Jaesaeng Hospital, Seongnam, Korea
b
c

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 16 October 2009
Accepted 2 October 2010

Objective: This study was conducted to evaluate blood concentrations of inammatory cytokines
and oxidative stress-related biomarkers as risk factors of breast cancer and to determine the
relation between these markers and antioxidant nutrient intake.
Methods: Study subjects were 134 patients with breast cancer and 149 controls. Total antioxidant
capacity and concentrations of 8-isoprostane, 8-hydroxy-20 -deoxyguanosine, interleukin (IL)-1b,
IL-6, and IL-8 of blood samples were determined. A food-frequency questionnaire was used to
assess nutrient intake.
Results: Patients with breast cancer had signicantly higher blood levels of oxidative stress markers
compared with control subjects. Plasma concentrations of IL-1b and IL-6 were signicantly higher
in patients with breast cancer compared with those of control subjects. In the pooled analysis, total
antioxidant capacity was signicantly decreased with increasing quartiles of carbohydrate intake
but was increased with increasing quartiles of total vitamin A intake and vitamin C intake. In
addition, 8-hydroxy-20 -deoxyguanosine concentration was decreased with increasing quartiles of
vitamin A and b-carotene. No signicant association was found between nutrient intake and
cytokine concentrations.
Conclusions: These results suggest that oxidative stress and inammation may be associated with
the risk of breast cancer. Total vitamin A intake was negatively related to oxidative stresses,
possibly modifying the risk of breast cancer.
2011 Elsevier Inc. All rights reserved.

Keywords:
Antioxidant capacity
Proinammatory cytokines
Food-frequency questionnaire
Antioxidant vitamins
Mammary tumors

Introduction
Breast cancer is the most prevalent cancer in women. Lifestyle
factors, including dietary habits and physical activity levels, are
seen as important contributors to the rapidly growing incidence
of breast cancer in Asian countries including Korea [1].
Oxidative stress is closely associated with carcinogenesis [2,3].
Blood oxidative stress-related markers such as 8-isoprostane and
8-hydroxy-20 -deoxyguanosine (8-OHdG), a major oxidative DNA

This work was supported by the SRC Research Center for Womens Diseases of
Sookmyung Womens University and by the Basic Science Research Program
through the National Research Foundation of Korea funded by the Ministry of
Education, Science and Technology (2010-0001886).
* Corresponding author. Tel.: 82-2-710-9395; fax: 82-2-710-9453.
E-mail address: mksung@sm.ac.kr (M.-K. Sung).
0899-9007/$ - see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.nut.2010.10.012

adduct, are signicantly increased in patients with breast cancer

[4,5]. Oxidative DNA damage may lead to structural modications
in DNA, resulting in modication of the DNA base [6,7], and disrupt
the normal reciprocal interactions between the cell types, thus
increasing breast cancer risk. Over time and without DNA repair,
DNA damage can lead to an increased incidence of cancer [8]. Lipid
peroxidation may be used to examine free radical-induced and
reactive oxygen species (ROS)-related processes [9]. Patients with
breast cancer have been reported to exhibit an increased plasma
level of lipid peroxides [1012]. The marker 8-isoprostane is a free
radical-catalyzed lipid peroxide that originates from arachidonic
acid, and increased 8-isoprostane concentrations in plasma and
urine have been associated with several human diseases [13,14].
Increased oxidative stress is an important player in the
initiation and progression of cancer, possibly through inammatory responses [15]. It has been reported that ROS stimulate

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

the nuclear factor-kB family of transcription factors involved in

innate immune or inammation responses [16,17]. The activation
of nuclear factor-kB upregulates the expression of many
inammation-related genes, including tumor necrosis factor-a,
interleukin (IL)-6, IL-8, and vascular endothelial growth factor.
Tumor necrosis factor-a and IL-1 in turn bind to tumor necrosis
factor receptors and IL-1 receptors, thereby further activating the
nuclear factor-kB pathway and repeating the cycle. Inammatory
chemokines act on inammatory cells to increase their protumorigenic properties and act directly on tumor cells through
specic receptors expressed by those cells [18,19]. Therefore,
a loss of balance between pro-oxidant and antioxidant statuses,
due to an inadequate intake of nutrients and/or an altered
metabolic response, may increase oxidative stress and induce
chronic inammatory conditions that result in abnormal cell
growth.
The objectives of this study were 1) to compare the circulating inammatory cytokines and oxidative stress-related
markers in patients with breast cancer at initial diagnosis with
those in healthy counterparts and 2) to relate these biomarkers
to antioxidant nutrient intakes.
Materials and methods
Study population
Participants were enrolled from June 30, 2006 to September 6, 2007. Subjects
were recruited from St. Vincents Hospital (Suwon, Korea) and Bundang Jaesaeng
Hospital (Bundang, Korea). The study was approved by the medical ethical
committees of St. Vincents Hospital and Bundang Jaesaeng Hospital. The purpose
of the study was explained to the participants, and informed consent was
obtained. Histologically conrmed cases of breast cancer without previous
treatment were identied in women 20 to 69 y old who visited the hospitals
gynecologic clinics for breast lump biopsy. Only women with biopsy-conrmed
breast cancer diagnoses (134 cases) were included in the study. Control
subjects matched by age were recruited from healthy female outpatients who
received routine health examination at the same hospitals during the study
period. Exclusion criteria for the controls and cases were known malignant
diseases, diabetes mellitus, and cardiovascular diseases. All case and control
subjects were interviewed by a trained dietitian. A questionnaire including
questions on lifestyle, maternal factors, drinking and smoking habits, multiplevitamin supplement intake, and family history of breast cancer was administered. Anthropometric measurements included height, weight, and calculated
body mass index (BMI). Physical activity was measured as hours per week spent
pursuing common leisure-time physical activities. Alcohol intake was calculated
by summing the consumption frequency and amounts consumed of beer, wine,
and soju as reported by the participants on a food-frequency questionnaire (FFQ).
Alcohol consumption was measured as mean daily ethanol intake (grams).
Diet assessment
A quantitative FFQ reported in a previous study [20] was used to estimate
nutrient intake during the 1-y period before the breast cancer diagnosis for the
cases and 1 y before the interview for the control subjects. The FFQ included a list
of 101 food items. Selection grouping criteria were 1) most frequently consumed
food items, 2) food items consumed in largest amounts, and 3) major food items
supplying each nutrient, especially antioxidant vitamins. Selections were based
on the Korean National Health and Nutrition Survey Report by the Ministry of
Health and Welfare. Selected food items were categorized according to food
groups and subdivided by food preparation methods, nutrient content, and
portion sizes. The FFQ included 14 food consumption categories: cereals and
starches, 8 items; soups, 6 items; meats, 9 items; egg, 1 item, sh and other
seafoods, 10 items; legumes, 4 items; milk and dairy products, 4 items; vegetables, 23 items; fruits, 12 items; seasonings, 4 items; oils, 6 items; nuts, 5 items;
hot beverages and soft drink, 7 items; and snacks, 2 items. Subjects were asked to
state the average frequency of consumption of each food item using the following
frequency categories: never or less than once per month; once per month; two or
three times per month; once per week; twice per week; three or four times per
week; ve or six times per week; once per day; twice per day; or three times per
day. The portion sizes were set as 0.5, 1, and 1.5 serving sizes. The interviewer
showed food models and photographs of the standard serving sizes and asked
the subjects to refer to those portion sizes when determining the amounts of
foods consumed. The FFQ data were numerically coded and then analyzed using

913

a computer-aided nutrient analysis program for professionals (CAN-PRO, APAC

Intelligence, Seoul, Korea).
Blood sample preparation
Blood samples were obtained by venipuncture and were immediately placed
in ice. Subsequently, blood and plasma and serum were separated by centrifugation at 2500  g for 15 min at 4 C. All samples were collected in the morning
and were stored frozen at 80 C until analyzed.
Biochemical analysis
Total antioxidant capacity
Serum total antioxidant capacity (TAC) was measured using 96-well enzymelinked immunosorbent assay (ELISA) kits (Northwest, Vancouver, BC, Canada).
This assay is based on the ability of serum to reduce Cu2 to Cu. Because Cu
reacts with bathocuproine to form a complex with maximal absorbance at 480 to
490 nm, measurement at 490 nm before and after addition of bathocuproine
generates an estimate of net absorbance proportional to the reductive capacity of
the serum. The net absorbance values obtained for samples were compared with
a standard curve generated using uric acid.
Lipid peroxidation
The 8-isoprostane was measured in the puried plasma sample using ELISA kits
(Cayman Chemical Company, Ann Arbor, MI, USA) [21]. This assay determines
the amount of antibody competition between 8-isoprostane and an 8-isoacetylcholinesterase tracer. The 8-isoprostane antibody bound to the immunoglobulin G mouse monoclonal antibody that was previously attached to the test
wells. After washing, color was developed using Ellmans reagent, and absorbance
was measured at 405 nm.
DNA damage
Plasma concentrations of 8-OHdG were measured using 96-well ELISA kits
(JaICA, Fukuroi, Japan). Samples and standards were added to the microtiter plate
wells that had been previously coated with 8-OHdG. The 8-OHdG monoclonal
antibody reacts competitively with the 8-OHdG bound on the plate and the
8-OHdG in the sample solution. Plates were washed, leaving only the antibody
that had bound to the 8-OHdG coating the wells. A secondary antibody, which is
then added to the plate, binds to the monoclonal antibody remaining on the
plate. A chromatic solution was added after another washing, color was developed, and absorbance was measured at 450 nm.
Cytokine assay
Plasma concentrations of IL-1b, IL-6, and IL-8 were analyzed using 96-well
ELISA kits (R&D Systems, Minneapolis, MN, USA) as used previously [22]. In these
assays, wells were coated with antibodies, and the samples were pipetted into
the wells and incubated for 2 h at room temperature. After washing with wash
buffer to remove any unbound substances, an enzyme-linked polyclonal antibody was added to the wells. A substrate solution was added to plates for color
development, and the plates were incubated for 30 min. A stop solution was then
added, and absorbance was read on a plate reader (Biotech Instruments, Inc.,
Winooski, VT, USA) at 490 nm.
Statistical analysis
Data were expressed as mean  standard deviation or percentage. To test for
differences between cases and controls, Students t test was used for logtransformed plasma biomarker levels, and a difference was considered statistically signicant at P < 0.05. To determine the associations between nutrient
intakes and blood biomarkers, nutrient intakes were ranked into quartiles of
calorie-adjusted nutrient intakes of the control subjects. Analysis of covariance,
using blood biomarkers as the dependent variables, quartiles of dietary nutrient
intakes, and the covariates, age, BMI, physical activity, and alcohol consumption,
as independent variables, was performed. All analyses were performed using SAS
9.1 (SAS Institute, Cary, NC, USA).

Results
The characteristics of the study population and the potential
confounders are presented in Table 1. The mean ages of subjects
were 48.5  8.1 y for cases and 49.2  8.6 y for controls. Patients
with breast cancer showed a slightly higher BMI compared with
control subjects, although no statistical signicance was found.
However, in postmenopausal women, BMI was signicantly
higher in cases than in controls (P 0.0029). The mean age at

914

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

Table 1
Differences in general characteristics of patients with breast cancer (cases) and their age-matched controls*
Characteristic

Controls
(n 149)

Cases
(n 134)

Signicancey

Age (y)
Height (cm)
Weight (kg)
Body mass index (kg/m2)
Premenopausal
Postmenopausal
Age at menarche (y)
Age at rst live birth (y)
Number of births
Menopausal age (y)
Menopausal status
Premenopausal
Postmenopausal
Family history of breast cancer
No
Yes
Hormone replacement therapy use
Non-user
User
Oral contraceptive use
No
Yes
Smoking
Never
Previous
Current
Alcohol consumption (g/d)
Physical activity
No
Yes
Hormonal receptor status of tumor
Estrogen receptor
Positive
Negative
Progesterone receptor
Positive
Negative
Stage
0
I
II
III
IV

49.27  8.63
157.79  4.86
56.78  6.83
22.83  2.73
22.36  2.72
23.52  2.63
14.95  1.76
26.02  3.87
2.11  0.84
48.76  5.84

48.58  8.14
156.91  4.86
57.65  6.96
23.43  2.77
22.22  2.47
24.94  2.46
14.35  1.66
26.34  4.01
2.12  0.90
47.90  5.20

0.4931
0.1301
0.2873
0.0666
0.7486
0.0029
0.0563
0.5186
0.9894
0.4098

*
y

84 (57.14)
63 (42.86)

74 (56.06)
58 (43.94)

0.8555

146 (97.99)
3 (2.01)

125 (93.98)
8 (6.02)

0.0832

43 (67.19)
21 (32.81)

54 (77.14)
16 (22.86)

0.1979

118 (79.19)
31 (20.81)

113 (85.61)
19 (14.39)

0.1608

145 (97.32)
1 (0.67)
3 (2.01)
2.71  7.44

118 (88.06)
4 (2.99)
12 (8.96)
7.82  21.53

0.0100
0.0099

66 (44.30)
83 (55.70)

89 (66.42)
45 (33.58)

d
d

67 (60.36)
44 (39.54)

d
d

66 (59.46)
45 (40.54)

d
d
d
d
d

21
47
48
12
4

0.0002

(15.91)
(35.61)
(9.09)
(9.09)
(3.03)

Data are presented as mean  SD or number of subjects (percentage).

Determined by independent-sample t test of equality of the means or by chi-square tests of differences in proportions.

menarche was slightly younger in cases than in controls (P

0.0563). A signicantly larger proportion (P 0.0100) of cases
were current smokers, but there was no difference between the
two groups in previous smokers and those who never smoked.
Cases consumed signicantly more (P 0.0099) alcohol than
control subjects. A higher level of physical activity was observed
in the control group (P 0.0002). However, the use of oral
contraceptives and hormone replacement therapy status were
not signicantly different between the two groups.
As presented in Table 2, the plasma TAC was signicantly
lower in cases (geometric mean levels of 3.02 versus 2.95 mM in
controls versus cases), whereas the 8-OHdG level was signicantly higher in cases (geometric mean levels of 5.60 versus 5.67
pg/mL in controls versus cases) compared with those of the
control subjects. Furthermore, patients with breast cancer had
signicantly higher plasma concentrations of IL-1b (geometric
mean levels of 0.88 versus 1.08 pg/mL in controls versus cases)
and IL-6 (geometric mean levels of 1.40 versus 1.68 pg/mL in
controls versus cases) compared with the controls. However, the
plasma concentration of IL-8 was not statistically different

between the two groups (geometric mean levels of 2.93 versus

3.02 pg/mL in controls versus cases).
Plasma biomarker levels allocated by the quartile distribution
of nutrient intakes for the combined cases and control subjects
are listed in Table 3. The TAC was signicantly decreased with
increasing quartiles of carbohydrate intake but was increased
with increasing quartiles of ber, vitamin A, b-carotene,
vitamin C, and vitamin E intake. The 8-OHdG level was signicantly decreased with increasing quartiles of vitamin A and
b-carotene intake. The IL-1b level was signicantly decreased
with increasing quartiles of b-carotene intake. No signicant
associations between nutrient intakes and 8-isoprostane, IL-6, or
IL-8 levels were found.
Discussion
Carcinogenesis is a multistep process that includes initiation,
proliferation, and progression. Oxidative cellular damage, especially DNA damage, is considered a main contributor to cancer
initiation. Under normal circumstances, the damaged DNA is

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

Table 2
Levels of oxidative stress markers and proinammatory cytokines in plasma
samples of patients with breast cancer (cases) and their age-matched controls*
Controls
(n 149)
TAC (mM)
8-Isoprostane (pg/mL)
8-OHdG (pg/mL)
IL-1b (pg/mL)
IL-6 (pg/mL)
IL-8 (pg/mL)

3.02
2.80
5.60
0.88
1.40
2.93

(2.98,
(2.69,
(5.57,
(0.82,
(1.35,
(2.87,

3.06)
2.90)
5.62)
0.95)
1.45)
2.99)

Cases
(n 134)

P for
differencey

2.95
2.70
5.67
1.08
1.68
3.02

0.0077
0.0915
<0.0001
<0.0001
<0.0001
0.122

(2.92, 2.99)
(2.60,2.80)
(5.65, 5.69)
(1.01, 1.14)
(1.61, 1.76)
(2.93, 3.11)

8-OHdG, 8-hydroxy-20 -deoxyguanosine; IL, interleukin; TAC, total antioxidant

capacity
* Data are presented as geometric mean (95% condence interval).
y
Independent-sample t test of equality of log-transformed mean concentrations.

repaired by inherent damage-control mechanisms; however,

excess oxidative stress may result in non-repairable DNA
damage, which may lead to mutations in critical genes involved
in the normal control of cell growth. ROS act as signaling molecules to initiate inammatory responses, which can affect cell
proliferation and apoptosis. Therefore, oxidative stress and
inammatory responses may be related to abnormal cell growth
during breast cancer development. However, few studies have
evaluated oxidative stress and inammation biomarkers as
breast cancer risk factors and related those factors to nutrient
intake.
It is well accepted that breast cancer risk is positively related
to body fatness, especially in postmenopausal women [23]. In
this study, BMI was a similarly found to be signicant breast
cancer risk factor (P 0.0029) in postmenopausal women. A
meta-analysis of a cohort study showed a 15% increase in the risk
of breast cancer with each 5-kg/m2 increase in BMI in postmenopausal women [23]. In addition, a higher BMI has been
related to a detection of a more advanced stage (i.e., larger
tumor) of breast cancer at diagnosis [24]. Furthermore, survivors
of breast cancer have a greater chance of cancer recurrence when
their BMI increases after initial treatment [25]. A possible
explanation for the relation includes increases in circulating
levels of estrogen and adipokines due to an increase in body fat
mass [26]. Among adipokines, leptin is known to affect the
signaling pathway to induce abnormal cell growth [27]. Obesity
has been associated with oxidative stress, and there is evidence
suggesting that a cluster of oxidative stress sources such as
hyperglycemia, hyperleptinemia, increased tissue lipid levels
and increased rates of free radical formation [28] exist in obesity.
The 8-OHdG plasma level was signicantly higher in patients
with breast cancer than in the control subjects. The 8-OHdG has
been used as a reliable biomarker to measure the level of
oxidative stress. Previous studies have also indicated that breast
carcinomas show higher 8-OHdG levels than non-malignant
tissues [29,30], and the level of 8-OHdG has been reported to
be signicantly higher in estrogen receptor-positive tissue than
in estrogen receptor-negative tissue [5]. Possible explanations
for higher DNA damages in carcinoma tissue include higher
production of ROS, depletion of antioxidant enzymes [31], and
defects in the DNA repair system.
The TAC was signicantly lower in patients with breast cancer
than in the controls, which agrees with other studies [6,32,33].
Casecontrol studies have measured antioxidant blood levels as
indicators of protective factors in breast cancer cases; however,
the results were inconsistent [6,34]. Most casecontrol studies
measure one or two antioxidants in blood, but dietary antioxidants include not only antioxidant vitamins but also nonnutrients such as polyphenols. Therefore, TAC determination

915

may be a better measurement of overall antioxidant status than

measuring only a limited number of antioxidant vitamins in the
blood as indicators of antioxidant status.
In contrast to a previous report [35], the plasma 8-isoprostane
levels in control subjects and patients with breast cancer were
not different in our study. The 8-isoprostanes can be assessed in
various biological uids, including urine, plasma, and cerebrospinal uid; however, extensive auto-oxidation may occur
in blood plasma and tissues [36]. This low stability of
8-isoprostanes affects its usefulness as a biomarker and may
produce such contrasting results.
Chronic inammation has been linked to the development of
cancer [37,38]. We found that proinammatory IL-1b and IL-6
levels were signicantly higher in cases than in controls.
Several studies have reported that patients with breast cancer
have increased serum levels of cytokines, such as IL-6, IL-8, and
IL-10, compared with levels in healthy controls [3942]. These
cytokines stimulate various signaling pathways, resulting in the
transcriptional regulation of target genes involved in cell
proliferation, differentiation, and survival [38]. Furthermore,
IL-1b and IL-6 have been shown to promote tumor growth
through upregulation of antiapoptotic and angiogenic proteins in
breast tumor cells [43,44]. In addition, increased IL-1b and IL-6
levels may result in increased estrogen production and stimulate the proliferation of breast tumor cells [45]. Tumor cells in
turn produce various cytokines and chemokines that attract
leukocytes, resulting in chronic inammatory responses in the
tumor microenvironment [46]. Various leukocytes populations
are also capable of producing cytokines and ROS, thus resulting
in a repetitive cycle of chronic inammation in tumor tissue.
Limited evidence, however, has indicated a possible association
between inammatory cytokines and breast cancer. Our results
support the possibility that increased levels of IL-1b and IL-6 are
associated with breast cancer risk.
As far as we know, this is the rst study to report increased
oxidative stress and inammatory biomarker concentrations in
Korean patients with breast cancer who exhibit different breast
tumor physiology from those in other areas. The age distribution
of breast cancer in Korea is skewed to a much younger generation than in Western women [1]. Also, Korean women have
greater mammographic density with less fat tissue compared
with Western women [47]. The mammographic density has been
associated with an increased risk of breast cancer, with 1.8- to
6.0-fold differences in women of the same age but with different
densities [48]. An inverse association between mammographic
density and age in Korean women [47], therefore, may explain
the higher rate of breast cancer incidence in young women.
Despite these differences in breast physiology, we found that
many oxidative and inammation biomarkers are signicantly
increased in these subjects. Furthermore, these markers may be
sensitive enough to detect the risk in this patient group with
early-stage breast cancer. These results suggest that these
markers may be sensitive markers that are closely associated
with cancer development, particularly in Korean women.
We also measured dietary intake of macronutrients and
antioxidant vitamins to evaluate their associations with these
biomarkers. Diets composed of carbohydrates with an associated
high insulin response have produced circulating proinammatory cytokine levels compared with a low insulin
response produced by carbohydrate diets in subjects with
metabolic syndrome [49]. Also, postprandial hyperglycemia and
hyperinsulinemia increase the circulating level of ROS [50] and
increase inammatory responses by activating the nuclear
factor-kB signaling pathway [51]. Glucose challenges in healthy

916

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

Table 3
Plasma concentrations of biomarkers by quartile distribution of nutrient intakes*

Protein
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Py
Fat
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Carbohydrate
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Fiber
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Vitamin A
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Retinol
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
b-Carotene
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Vitamin C
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P
Vitamin E
Quartile 1
Quartile 2
Quartile 3
Quartile 4
P

8-Isoprostane

8-OHdG

IL-1b

IL-6

IL-8

0.60
0.72
0.72
0.81

16.88 
18.32 
16.15 
19.72 
0.2692

1.10
1.37
1.30
1.49

0.28  0.00
0.28  0.00
0.28  0.00
0.28  0.01
0.7576

2.80  0.17
2.68  0.20
3.15  0.20
3.00  0.22
0.3637

4.95  0.27
5.02  0.33
4.78  0.33
5.12  0.37
0.9106

20.24 
20.13 
20.86 
22.46 
0.5641

1.03
1.22
1.22
1.37

19.00 
20.06 
21.68 
21.69 
0.0592

0.66
0.71
0.72
0.78

16.43 
16.98 
20.00 
16.97 
0.1932

1.19
1.29
1.30
1.48

0.28  0.00
0.28  0.00
0.28  0.00
0.28  0.01
0.4949

2.59  0.18
3.28  0.19
2.89  0.20
2.88  0.21
0.0745

4.64  0.30
5.24  0.32
5.05  0.32
5.00  0.35
0.5746

19.17 
19.99 
23.93 
20.41 
0.0844

1.08
1.20
1.20
1.30

22/38
21/36
38/37
53/38

21.86 
21.00 
20.69 
19.08 
0.0439

0.79
0.78
0.69
0.63

18.73 
17.75 
18.24 
16.20 
0.5193

1.50
1.41
1.26
1.15

0.28  0.01
0.28  0.01
0.28  0.00
0.28  0.00
0.8359

2.93  0.21
2.86  0.21
3.23  0.19
2.62  0.17
0.1324

4.97  0.35
4.94  0.35
5.13  0.32
4.84  0.28
0.9277

20.83 
22.74 
21.62 
18.84 
0.1075

1.32
1.30
1.17
1.05

67/38
42/37
17/36
8/38

19.66 
20.29 
22.61 
20.25 
0.0385

0.59
0.68
0.83
0.88

18.71 
16.68 
17.98 
15.85 
0.4202

1.07
1.23
1.51
1.60

0.29  0.00
0.28  0.00
0.28  0.01
0.27  0.01
0.5041

3.01  0.16
2.70  0.19
3.06  0.23
2.80  0.24
0.5121

5.02  0.27
4.62  0.30
4.91  0.38
5.04  0.39
0.5475

20.67 
20.42 
21.10 
21.28 
0.9642

0.99
1.14
1.40
1.48

68/38
33/37
27/37
6/37

19.04 
20.43 
21.09 
23.25 
0.0012

0.56
0.70
0.73
0.91

18.47 
15.30 
16.88 
20.15 
0.0918

1.04
1.28
1.35
1.71

0.29  0.00
0.28  0.00
0.28  0.00
0.27  0.01
0.0163

3.23  0.16
2.76  0.19
2.59  0.20
2.76  0.25
0.0582

5.21  0.26
4.51  0.33
4.93  0.33
5.07  0.41
0.3872

21.06 
20.28 
20.24 
22.03 
0.7395

0.97
1.20
1.24
1.55

32/37
26/37
31/37
45/38

19.95 
20.92 
19.80 
21.14 
0.4480

0.73
0.77
0.73
0.67

16.50 
16.60 
17.60 
19.09 
0.4657

1.33
1.40
1.30
1.21

0.28  0.00
0.28  0.00
0.28  0.00
0.29  0.00
0.6263

2.81  0.20
3.22  0.21
2.71  0.20
2.88  0.18
0.3211

4.79  0.33
5.11  0.34
5.06  0.32
4.91  0.30
0.9031

21.68 
19.76 
20.47 
21.04 
0.7293

1.22
1.28
1.22
1.11

73/37
33/38
23/37
5/37

19.14 
20.64 
20.92 
23.20 
0.0023

0.56
0.70
0.76
0.91

18.33 
15.23 
16.95 
20.58 
0.0650

1.02
1.26
1.38
1.71

0.29  0.00
0.28  0.00
0.28  0.01
0.26  0.01
0.0004

3.27  0.15
2.65  0.19
2.53  0.21
2.93  0.25
0.0140

5.32  0.25
4.34  0.32
5.00  0.34
4.94  0.41
0.1242

21.51 
19.16 
20.55 
21.98 
0.3750

0.95
1.18
1.27
1.55

68/38
29/37
23/36
14/38

19.30 
21.03 
20.53 
22.06 
0.0435

0.59
0.73
0.81
0.81

18.61 
18.54 
16.08 
15.82 
0.3086

1.08
1.33
1.51
1.47

0.29  0.00
0.28  0.00
0.28  0.01
0.28  0.01
0.5101

3.05  0.16
2.57  0.20
3.27  0.22
2.58  0.22
0.1580

5.09  0.27
0.84  0.33
5.03  0.36
4.79  0.37
0.8899

21.40 
21.17 
20.82 
19.03 
0.5552

0.99
1.23
1.38
1.37

63/37
29/38
27/36
15/38

19.06 
20.23 
21.62 
22.17 
0.0095

0.60
0.72
0.75
0.982

18.02 
17.06 
16.30 
18.82 
0.6131

1.09
1.33
1.38
1.57

0.28  0.00
0.28  0.00
0.28  0.01
0.28  0.01
0.9430

3.11  0.17
2.95  0.20
2.61  0.21
2.76  0.23
0.2947

4.79  0.27
5.04  0.33
4.89  0.34
5.30  0.37
0.7260

19.94 
19.29 
22.39 
22.32 
0.1837

1.01
1.22
1.27
1.37

Cases/controls

TAC

59/37
28/38
31/36
16/38

19.26 
21.74 
19.76 
22.00 
0.1633

47/38
34/36
31/37
22/38

8-OHdG, 8-hydroxy-20 -deoxyguanosine; IL, interleukin; TAC, total antioxidant capacity

* Intake distributions were adjusted for age, body mass index, hormone replacement therapy, family history of breast cancer, menopausal status, age at menarche,
smoking, and alcohol consumption and were adjusted for kilocalories consumed. Data are presented as number of subjects or mean  SD.
y
P value calculated from analysis of covariance.

subjects have increased ROS generation by stimulation of

reduced nicotinamide adenine dinucleotide phosphate oxidase
related protein expression in polymorphonuclear leukocytes and
mononuclear cells [50]. High-carbohydrate diets may also result
in higher concentrations of the plasma-soluble E-selectin and
inammatory markers [52]. Our study results show that carbohydrate intake is negatively related to blood TAC, an indicator of
oxidative stress and a breast cancer risk factor.
Contrary to expectations, dietary fat was not signicantly
associated with oxidative stress or the inammatory biomarkers
measured. The energy intake from fat in these study subjects was

20.3% of their total energy supply, which is much lower than that
of the Western populations. Lee et al. [53] reported that high-fat
intake levels lowered the risk of breast cancer in Korean women
who obtained a large proportion of the fat from plant sources.
Other studies have failed to show dietary fat as a risk factor for
breast cancer. Martin-Moreno et al. [54] indicated that breast
cancer risk is associated with fat quality but not with total fat
intake. In support of that observation, increased intake of dietary
a-linolenic acid has been shown to inhibit production of proinammatory cytokines [55], implying that a large proportion of
plant fat within total fat consumption may be benecial.

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

Our results showed that the plasma TAC signicantly increased

as the quartile value of dietary ber and antioxidant vitamins,
such as vitamin A, b-carotene, vitamin C, and vitamin E increased,
whereas 8-OHdG level was negatively associated with vitamin A
and b-carotene intake. Dietary vitamin A measured in this study
included retinol and its precursor carotenoids; however, neither
retinol nor carotenoids was signicantly associated with the
breast cancer risk when these were independently analyzed.
Therefore, a combined effect should be considered anticarcinogenic, and further studies are required to interpret this result.
A previous study has indicated that fruit and vegetable
consumption, by the associated increase in TAC, may be important for the prevention of breast cancer [56]. TAC has been
reported to be increased with increasing intakes of antioxidants
[57]. Furthermore, antioxidants have been reported to decrease
oxidative DNA damage in cultured cells and in humans [58]. Also,
decreased levels of 8-OHdG and IL-1b have been demonstrated
in subjects with increased intakes of antioxidant-rich vegetables
and fruits [59]. This is supported by our previous study, which
showed that a polyphenol-rich diet suppressed leukocyte DNA
damage [60]. The present study also showed that dietary intake
of antioxidants including vitamin A, b-carotene, vitamin C and
vitamin E was signicantly associated with oxidative stress.
Other studies, however, have created doubt about whether
dietary antioxidants delay carcinogenesis due to discrepancies
in results between observational and intervention studies [61].
Further investigations on the adequate dosage to exert benecial
effects and other possible confounding factors are required.
Conclusion
In summary, patients with breast cancer exhibit increased
concentrations of 8-OHdG, IL-1b, and IL-6, indicating that
oxidative stress and inammation may be associated with the
disease. Dietary antioxidant intake may be related to breast
cancer risk, possibly through modifying oxidative stress levels.
This is a cross-sectional casecontrol study, which makes interpretation of biomarker changes difcult. At this point, it is not
clear whether changes in these oxidative stress and inammatory markers develop with disease progression or whether these
changes contribute to disease initiation. It is also possible to
assume that a cause-and-effect relation between these markers
and breast cancer are present, and further studies are required to
understand their associations.
References
[1] The Ministry of Health, Welfare and Family Affairs of Korea/National Cancer
Control Institute, Division of Cancer Statistics and Registry. Annual report
on national cancer incidence statistics. 2008.
[2] Benz CC, Atsriku C, Yau C, Britton D, Schilling B, Gibson BW, et al. Novel
pathways associated with quinone-induced stress in breast cancer cells.
Drug Metab Rev 2006;38:60113.
[3] Malins DC, Anderson KM, Jaruga P, Ramsey CR, Gilman NK, Green VM, et al.
Oxidative changes in the DNA of stroma and epithelium from the female
breast: potential implications for breast cancer. Cell Cycle 2006;5:162932.
[4] Huang YL, Sheu JY, Lin TH. Association between oxidative stress and
changes of trace elements in patients with breast cancer. Clin Biochem
1999;32:1316.
[5] Musarrat J, Arezina-Wilson J, Wani AA. Prognostic and aetiological relevance of 8-hydroxyguanosine in human breast carcinogenesis. Eur J Cancer
1996;32A:120914.
[6] Cerutti PA. Prooxidant states and tumor promotion. Science 1985;227:
37581.
[7] Olinski R, Gackowski D, Foksinski M, Rozalski R, Roszkowski K, Jaruga P.
Oxidative DNA damage: assessment of the role in carcinogenesis, atherosclerosis, and acquired immunodeciency syndrome. Free Radic Biol Med
2002;33:192200.

917

[8] Jackson JH. Potential molecular mechanisms of oxidant-induced carcinogenesis. Environ Health Perspect 1994;102:1557.
[9] Mannello F, Tonti GA, Pagliarani S, Benedetti S, Canestrari F, Zhu W, et al.
The 8-epimer of prostaglandin F(2alpha), a marker of lipid peroxidation
and oxidative stress, is decreased in the nipple aspirate uid of women
with breast cancer. Int J Cancer 2007;120:19716.
[10] Sener DE, Gonenc A, Akinci M, Torun M. Lipid peroxidation and total
antioxidant status in patients with breast cancer. Cell Biochem Funct
2007;25:37782.
[11] Gonenc A, Ozkan Y, Torun M, Simsek B. Plasma malondialdehyde (MDA)
levels in breast and lung cancer patients. J Clin Pharm Ther 2001;26:1414.
[12] Khanzode SS, Muddeshwar MG, Khanzode SD, Dakhale GN. Antioxidant
enzymes and lipid peroxidation in different stages of breast cancer. Free
Radic Res 2004;38:815.
[13] Fam SS, Morrow JD. The isoprostanes: unique products of arachidonic acid
oxidation-a review. Curr Med Chem 2003;10:172340.
[14] Morrow JD. The isoprostanes: their quantication as an index of oxidant
stress status in vivo. Drug Metab Rev 2000;32:37785.
[15] Trush MA, Kensler TW. An overview of the relationship between oxidative
stress and chemical carcinogenesis. Free Radic Biol Med 1991;10:2019.
[16] Pham CG, Bubici C, Zazzeroni F, Papa S, Jones J, Alvarez K, et al. Ferritin
heavy chain upregulation by NF-kappaB inhibits TNFalpha-induced
apoptosis by suppressing reactive oxygen species. Cell 2004;119:52942.
[17] Karin M. Nuclear factor-kappaB in cancer development and progression.
Nature 2006;441:4316.
[18] Youngs SJ, Ali SA, Taub DD, Rees RC. Chemokines induce migrational
responses in human breast carcinoma cell lines. Int J Cancer 1997;71:25766.
[19] Azenshtein E, Luboshits G, Shina S, Neumark E, Shahbazian D, Weil M, et al.
The CC chemokine RANTES in breast carcinoma progression: regulation of
expression and potential mechanisms of promalignant activity. Cancer Res
2002;62:1093102.
[20] Kim E-Y, Jeon H-M, Sung M-K, Sung C-J. Comparisons of food intake
between breast cancer patients and controls in Korean women. Nutr Res
Pract 2007;1:23742.
[21] Dillon SA, Lowe GM, Billington D, Rahman K. Dietary supplementation with
aged garlic extract reduces plasma and urine concentrations of 8-isoprostaglandin F(2 alpha) in smoking and nonsmoking men and women.
J Nutr 2002;132:16871.
[22] Bae SC, Jung WJ, Lee EJ, Yu R, Sung MK. Effects of antioxidant supplements
intervention on the level of plasma inammatory molecules and disease
severity of rheumatoid arthritis patients. J Am Coll Nutr 2009;28:5662.
[23] World Cancer Research Fund/American Institute for Cancer Research. Food,
nutrition, physical activity, and the prevention of cancer: a global
perspective. Washington, DC: AICR; 2007. p. 292293.
[24] Carmichael AR, Bates T. Obesity and breast cancer: a review of the literature. Breast 2004;13:8592.
[25] Saquib N, Flatt SW, Natarajan L, Thomson CA, Bardwell WA, Caan B, et al.
Weight gain and recovery of pre-cancer weight after breast cancer treatments: evidence from the Womens Healthy Eating and Living (WHEL)
study. Breast Cancer Res Treat 2007;105:17786.
[26] Judd HL, Shamonki IM, Frumar AM, Lagasse LD. Origin of serum estradiol in
postmenopausal women. Obstet Gynecol 1982;59:6806.
[27] Cirillo D, Rachiglio AM, la Montagna R, Giordano A, Normanno N. Leptin
signaling in breast cancer: an overview. J Cell Biochem 2008;105:95664.
[28] Vincent HK, Taylor AG. Biomarkers and potential mechanisms of obesityinduced oxidant stress in humans. Int J Obes (Lond) 2006;30:40018.
[29] Loft S, Moller P, Cooke MS, Rozalski R, Olinski R. Antioxidant vitamins and
cancer risk: is oxidative damage to DNA a relevant biomarker? Eur J Nutr
2008;47:1928.
[30] Toyokuni S, Okamoto K, Yodoi J, Hiai H. Persistent oxidative stress in cancer.
FEBS Lett 1995;358:13.
[31] Kasapovic J, Pejic S, Todorovic A, Stojiljkovic V, Pajovic SB. Antioxidant
status and lipid peroxidation in the blood of breast cancer patients of
different ages. Cell Biochem Funct 2008;26:72330.
[32] Liu X, Zhao J, Zheng R. DNA damage of tumor-associated lymphocytes and
total antioxidant capacity in cancerous patients. Mutat Res 2003;539:18.
[33] Ching S, Ingram D, Hahnel R, Beilby J, Rossi E. Serum levels of micronutrients, antioxidants and total antioxidant status predict risk of breast
cancer in a case control study. J Nutr 2002;132:3036.
[34] Michels KB, Mohllajee AP, Roset-Bahmanyar E, Beehler GP, Moysich KB.
Diet and breast cancer: a review of the prospective observational studies.
Cancer 2007;109:271249.
[35] Ray G, Batra S, Shukla NK, Deo S, Raina V, Ashok S, Husain SA. Lipid peroxidation, free radical production and antioxidant status in breast cancer.
Breast Cancer Res Treat 2000;59:16370.
[36] Pratico D, Barry OP, Lawson JA, Adiyaman M, Hwang SW, Khanapure SP,
et al. IPF2alpha-I: an index of lipid peroxidation in humans. Proc Natl Acad
Sci U S A 1998;95:344954.
[37] Ohshima H, Bartsch H. Chronic infections and inammatory processes as
cancer risk factors: possible role of nitric oxide in carcinogenesis. Mutat Res
1994;305:25364.
[38] Balkwill F, Mantovani A. Inammation and cancer: back to Virchow? Lancet
2001;357:53945.

918

J.-Y. Yeon et al. / Nutrition 27 (2011) 912918

[39] Hussein MZ, Al Fikky A, Abdel Bar I, Attia O. Serum IL-6 and IL-12 levels in
breast cancer patients. Egypt J Immunol 2004;11:16570.
[40] Zakrzewska I, Kozlowski L, Wojtukiewicz M. [Assessment of changes in
levels of interleukin 6 and C reactive protein in patients with breast
tumors]. Pol Merkur Lekarski 2003;15:1157.
[41] Kozlowski L, Zakrzewska I, Tokajuk P, Wojtukiewicz MZ. Concentration of
interleukin-6 (IL-6), interleukin-8 (IL-8) and interleukin-10 (IL-10) in blood
serum of breast cancer patients. Rocz Akad Med Bialymst 2003;48:824.
[42] Ahmed OI, Adel AM, Diab DR, Gobran NS. Prognostic value of serum level of
interleukin-6 and interleukin-8 in metastatic breast cancer patients. Egypt
J Immunol 2006;13:618.
[43] Nicolini A, Carpi A, Rossi G. Cytokines in breast cancer. Cytokine Growth
Factor Rev 2006;17:32537.
[44] Pantschenko AG, Pushkar I, Anderson KH, Wang Y, Miller LJ,
Kurtzman SH, et al. The interleukin-1 family of cytokines and receptors
in human breast cancer: implications for tumor progression. Int J Oncol
2003;23:26984.
[45] Honma S, Shimodaira K, Shimizu Y, Tsuchiya N, Saito H, Yanaihara T, Okai T.
The inuence of inammatory cytokines on estrogen production and cell
proliferation in human breast cancer cells. Endocr J 2002;49:3717.
[46] Coussens LM, Werb Z. Inammation and cancer. Nature 2002;420:8607.
[47] Cho JJ, Koh EY, Song YM, Han BK, Yun YS, Park HA, et al. Mammographic
breast density and risk factors of breast cancer in Korean women using
multicenter study. J Korean Acad Fam Med 2006;27:3341.
[48] Boyd NF, Dite GS, Stone J, Gunasekara A, English DR, McCredie MR, et al.
Heritability of mammographic density, a risk factor for breast cancer. N
Engl J Med 2002;347:88694.
[49] Kallio P, Kolehmainen M, Laaksonen DE, Pulkkinen L, Atalay M,
Mykkanen H, et al. Inammation markers are modulated by responses to
diets differing in postprandial insulin responses in individuals with the
metabolic syndrome. Am J Clin Nutr 2008;87:1497503.
[50] Mohanty P, Hamouda W, Garg R, Aljada A, Ghanim H, Dandona P. Glucose
challenge stimulates reactive oxygen species (ROS) generation by leucocytes. J Clin Endocrinol Metab 2000;85:29703.
[51] Aljada A, Mohanty P, Ghanim H, Abdo T, Tripathy D, Chaudhuri A,
Dandona P. Increase in intranuclear nuclear factor kappaB and decrease in

[52]

[53]
[54]

[55]

[56]

[57]

[58]

[59]

[60]

[61]

inhibitor kappaB in mononuclear cells after a mixed meal: evidence for

a proinammatory effect. Am J Clin Nutr 2004;79:68290.
Lopez-Garcia E, Schulze MB, Fung TT, Meigs JB, Rifai N, Manson JE,
Hu FB. Major dietary patterns are related to plasma concentrations of
markers of inammation and endothelial dysfunction. Am J Clin Nutr
2004;80:102935.
Lee E-J, Lee W-K, Suh S, Suh B-H, Lee H-S. Intakes of energy and nutrients
and risk of breast cancer. Korean J Nutr 2008;41:75466.
Martin-Moreno JM, Willett WC, Gorgojo L, Banegas JR, RodriguezArtalejo F, Fernandez-Rodriguez JC, et al. Dietary fat, olive oil intake and
breast cancer risk. Int J Cancer 1994;58:77480.
Zhao G, Etherton TD, Martin KR, Gillies PJ, West SG, Kris-Etherton PM.
Dietary alpha-linolenic acid inhibits proinammatory cytokine production
by peripheral blood mononuclear cells in hypercholesterolemic subjects.
Am J Clin Nutr 2007;85:38591.
Valtuena S, Pellegrini N, Franzini L, Bianchi MA, Ardigo D, Del Rio D, et al.
Food selection based on total antioxidant capacity can modify antioxidant
intake, systemic inammation, and liver function without altering markers
of oxidative stress. Am J Clin Nutr 2008;87:12907.
Freudenheim JL, Marshall JR, Vena JE, Laughlin R, Brasure JR, Swanson MK,
et al. Premenopausal breast cancer risk and intake of vegetables, fruits, and
related nutrients. J Natl Cancer Inst 1996;88:3408.
Sweetman SF, Strain JJ, McKelvey-Martin VJ. Effect of antioxidant vitamin
supplementation on DNA damage and repair in human lymphoblastoid
cells. Nutr Cancer 1997;27:12230.
Thompson HJ, Heimendinger J, Haegele A, Sedlacek SM, Gillette C, ONeill C,
et al. Effect of increased vegetable and fruit consumption on markers of
oxidative cellular damage. Carcinogenesis 1999;20:22616.
Kim HY, Kim OH, Sung MK. Effects of phenol-depleted and phenol-rich
diets on blood markers of oxidative stress, and urinary excretion of quercetin and kaempferol in healthy volunteers. J Am Coll Nutr 2003;22:
21723.
Blot WJ, Li JY, Taylor PR, Guo W, Dawsey S, Wang GQ, et al. Nutrition
intervention trials in Linxian, China: supplementation with specic
vitamin/mineral combinations, cancer incidence, and disease-specic
mortality in the general population. J Natl Cancer Inst 1993;85:148392.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.