Vitamin D and

Breast Cancer
Prevention
Practical
Guidelines
for
Clinicians

Tara Bergren, MS, RD

Roschelle Heuberger, PhD, RD
 Vitamin D deficiency has been hypothetically linked to a number of
diseases (Gissel, Rejnmark, Mosekilde, & Vestergaard, 2008), including
cancer (Grant, 2002, 2003), and recent research has shown that adequate
amounts of vitamin D may help prevent breast cancer (Crew et al., 2009).
One theory regarding the protective properties of vitamin D centers on the
biologically active form of the vitamin, 1,25 dihydroxyvitamin D. Vitamin
D is converted to this active form mostly in the kidneys, but also in target
tissues, such as breast tissue (Tangpricha et al., 2001; Zehnder et al., 2001). In
addition, data from clinical studies suggest that the biologically active form of
vitamin D prevents rapid cell growth in breast tissue that could lead to cancer
(Christakos, Ravil-Pandya, Wernyj, & Yang, 1996; Danielsson et al., 1997;
Love-Schimenti, Gibson, Ratnam, & Bikle, 1996). When a woman is deficient
in vitamin D these effects are limited, which may increase her risk of
cancer. The focus of this article is to provide practical guidelines for
clinicians regarding vitamin D deficiency and breast cancer risk.
Vitamin D: tHe BasiCs
Vitamin D comprises a group of fat-soluble compounds found
naturally only in a few foods, including fish-liver oils, fatty fish,
mushrooms, egg yolks and liver. The two major physiologi-
cally relevant forms of vitamin D are D2 (ergocalciferol) and
D3 (cholecalciferol). Vitamin D3 is photosynthesized in the skin
of vertebrates by ultraviolet B (UVB) radiation on a precursor
(7-dehydrocholesterol); vitamin D2 is produced by UV irradia-
tion of ergosterol, which occurs in molds, yeast and higher-or-
der plants. Vitamin D from either source circulates in the blood
for 1 to 2 days, and is then stored in fat cells or metabolized in
the liver. In the liver, it is converted to 25-hydroxyvitamin D,
which must be further activated in the kidneys (and to a small
extent in the breast and other tissues) to 1,25-dihydroxyvita-
min D. This is the form thought to be responsible for most, if
not all, of the biologic functions of vitamin D.
Active vitamin D functions as a hormone, and its main
function is to maintain serum calcium and phosphorus con-
centrations within the normal range by enhancing the efficien-
Bottom Line
• Recent research suggests
an inverse association between vitamin D intake
and breast cancer risk.
• Current recommendations for vitamin D intake
are likely too low with regard to chemoprevention.
• Strategies for increasing vitamin D intake include
the consumption of fatty fish and fortified foods,
supplementation and sensible exposure to sunlight.
cy of the small intestine to absorb these minerals from the diet.
While it’s too early to draw any definitive conclusions, the vi-
tamin that was once best known for building strong bones also
appears to be associated with a number of cancers, as well as
cognitive changes, autoimmune diseases and the development
of heart disease (Nagpal, Na, & Rathnachalam, 2005).
WHat tHe Data teLL Us aBoUt CanCer
Animal research provided initial evidence for the inverse as-
sociation between vitamin D and breast cancer. Removal of the
vitamin D receptor caused an abnormal increase in breast cells
in studies conducted on animals (Zinser, Suckow, & Welsh,
Tara Bergren, MS, RD, is a clinical dietitian and diabetes educator at
Mercy Hospital in Cadillac, MI. Roschelle Heuberger, PhD, RD, is a
professor at Central Michigan University in Mount Pleasant, MI. The
authors report no conflicts of interest or relevant financial relationships.
There is no discussion of off-label drug or device use in this article.
Address correspondence to: taraj711@hotmail.com.
DOI: 10.1111/j.1751-486X.2010.01575.x
370 © 2010, AWHONN
2005; Zinser & Welsh, 2004). An animal study conducted in
2008 examined whether supplementing a Western diet with
increased vitamin D and calcium would have an effect on the
mammary glands of mice (Kurihara, Fan, Thaler, Yang, & Lip-
kin, 2008). The mice fed the standard Western diet showed an
accumulation of cells in ducts of the mammary gland and in-
creased duct cell growth (see Box 1). Additional animal studies
provided similar findings (Lipkin & Newmark, 1999).
Over the past decade, most of the research on vitamin D
and breast cancer has been done using case-control and cohort
studies. A recent large, population-based case-control investi-
gation by Crew et al. (2009) examined the association between
levels of 25-hydroxyvitamin D and breast cancer incidence.
The study utilized in-person interviews and blood samples
of 25-hydroxyvitamin D from more than 1,000 breast cancer
cases and controls. Women with 25-hydroxyvitamin D levels
above 40 ng/mL were less likely to develop breast cancer than
women with a vitamin D deficiency, defined as 25-hydroxyvi-
tamin D levels <20 ng/mL—suggesting that optimal levels of
25-hydroxyvitamin D for breast cancer prevention may be ≥40
ng/mL (Crew et al.). Other studies have also provided evidence
of an inverse relationship between active vitamin D levels and
breast cancer risk (John, Schwartz, Dreon, & Koo, 1999; Mc-
Cullough et al., 2005; Nunez, Carbajal, Belmonte, Moreiras, &
Varela, 1996; Shin et al., 2002).
Lin et al. (2007) used a prospective study to evaluate the
association between calcium and vitamin D relative to breast
cancer occurrence in pre- and postmenopausal women. The
women were at least 45 years old and did not have cancer at
the beginning of the study. Food frequency questionnaires were
used to assess dietary intake. The premenopausal women who
consumed more calcium and vitamin D were found to have a
lower risk of premenopausal breast cancer. This inverse rela-
tionship was not seen in the postmenopausal women. Another
study found that women were less likely to die of breast cancer
if they had 25-hydroxyvitamin D levels ≥25 ng/mL (Garland,
Gorham, Baggerly, & Garland, 2008).
CUrrent Vitamin D reCommenDations
Recommendations for vitamin D intake are available as Dietary
Reference Intakes (DRI), published by the Institute of Medicine
of the National Academies (Institute of Medicine [IOM], 1997).
From birth to age 50, the adequate intake (AI) is 200 interna-
tional units (IU) with no increased need during pregnancy or
lactation. The AI increases to 400 IU for adults over age 50 and
to 600 IU for those over 70 years of age. However, recent re-
search suggests that levels of vitamin D above 400 IU may aid
in prevention of breast cancer. A meta-analysis by Gissel et al.
(2008) reviewed studies that contained original data on the as-
sociation between vitamin D intake and breast cancer risk. The
researchers concluded that although there appears to be a trend
toward a lower incidence of breast cancer with increased intake
http://nwh.awhonn.org
of vitamin D ≥400 IU/day, many of the studies included in the
meta-analysis were of poor quality.
To date, the exact amount of vitamin D needed for chemo-
prevention is still unknown. However, some experts believe that
at least 1,000 IU/day is needed by most adults (Holick, 2008).
Currently, the tolerable upper intake levels (ULs) are 1,000 IU
from birth to 12 months and 2,000 IU for all others. The IOM
defines the UL as “the maximum level of daily nutrient intake
that is likely to pose no risk of adverse effects” (IOM, 1997).
WHo’s at risK?
Monitoring vitamin D should become the standard of
care among primary care practitioners. Measurement of
25-hydroxyvitamin D is the best indicator of one’s overall
vitamin D status (Moyad, 2009) as it reflects vitamin D levels
in the body from all sources, including diet, supplements, and
sunlight (Moyad; Rajakumar, Greenspan, Thomas, & Holick,
2007). The test should ideally be ordered in the winter when
vitamin D levels are typically lower due to limited sun exposure
(Moyad). There is currently disagreement about the lower limit
of optimal vitamin D levels, but most experts believe that levels
lower than 20 ng/mL are undesirable and that the lower limit
is likely <30 ng/mL (Weng, Shults, Leonard, Stallings, & Zemel,
2007). Note that the IOM has defined vitamin D deficiency as a
concentration less than 12 ng/mL (IOM, 1997).
Those at risk for vitamin D deficiency include older adults,
those with limited sun exposure, individuals with dark skin,
people with fat absorption disorders and individuals with a
body mass index (BMI) ≥30 (Vilarrasa et al., 2007). In women,
the risk for breast cancer should also be taken into account.
The Breast Cancer Risk Assessment Tool may also be useful in
determining current risk for breast cancer. The tool was devel-
oped at the National Cancer Institute as part of the National
Surgical Adjuvant Breast and Bowel Project and is useful in de-
termining breast cancer risk (see Get the Facts).
BOX 1
Measurements of Epithelial Cells in Ducts
Western Diet With Increased
Calcium and Vitamin D in Dried
Diet group Western Diet—Mean Yogurt Powder—Mean
Small 13.6 10.6
Medium 28.8 24.6
Large 95.4 80.0
Average 33.2 27.4
October November 2010
Monitoring vitamin D should
become the standard
of care among primary
care practitioners
GettinG enoUGH Vitamin D
Food Sources
Helping patients achieve optimal vitamin D status requires that
they understand the various sources of vitamin D, starting with
food sources (see Box 2). Very few foods in nature contain vi-
tamin D. The flesh of fish (such as salmon, tuna, and mack-
erel) and fish liver oils are among the best sources, with small
amounts of vitamin D found in beef liver and egg yolks.
Fortified foods provide most of the vitamin D in the Ameri-
can diet. For example, almost all of the U.S. milk supply is
fortified with 100 IU/cup of vitamin D (50 percent of the AI
level for ages 14-50 years). Other dairy products made from
milk, such as cheese and ice cream, are generally not fortified.
Ready-to-eat breakfast cereals may contain added vitamin D,
as do some brands of orange juice, yogurt, and margarine. In
the United States, foods allowed to be fortified with vitamin D
include cereal flours and related products, milk and products
made from milk, and calcium-fortified fruit juices and drinks.
Maximum levels of added vitamin D are specified by law.
Sunlight
Sunlight is another source of vitamin D. Known for years as the
“sunshine vitamin,” vitamin D is partially activated when UVB
Western Diet With Increased
Calcium and Vitamin D as
Elemental Calcium Carbonate
and Vitamin D3—Mean
11.1
25.0
78.4
27.8
Source: Kurihara et al. (2008).
Nursing for Women’s Health 371
radiation from sunlight hits cholesterol compounds in the skin,
converting them to vitamin D precursors. These precursors
travel to the liver and kidneys, where they are converted to the
active form of vitamin D. The total amount of vitamin D synthe-
sized depends not only on sun exposure, but also on the season
(winter is less desirable than summer), skin color (darker tones
absorb less UVB) and residence (the farther from the equator,
the less UVB is available). In fact, North Americans who live
north of 42 degrees latitude—which would include residents of
Boston, Milwaukee and Seattle—don’t get enough UVB from
roughly mid-October to mid-March, regardless of how much
time they spend outdoors (Looker, Dawson-Hughes, Calvo,
Gunter, & Sayhoun, 2002).
According to Moyad (2009), a 21-year-old who spends 15 to
20 minutes exposed to summer UVB rays will produce 10,000
IU of vitamin D; continued exposure beyond 20 minutes will
not produce additional vitamin D. This assumes that the sun
exposure occurs without sunscreen, as even low levels of sun
protection factor in sunscreen may block the synthesis of vi-
tamin D. Other factors that affect the skin’s ability to produce
vitamin D include age, skin color, latitude, time of day, season,
and cloud/pollution cover (Litchford, 2009).
Past studies have shown that some sun exposure may be a
beneficial approach to preventing breast cancer. An inverse re-
lationship has been found between sunlight exposure and death
from breast cancer (Garland, Garland, Gorham, & Young,
1990). Another study showed that breast cancer incidence de-
creased as sun exposure increased (Gorham, Garland, & Gar-
land, 1990). Recent research shows similar findings. Data from
the Women’s Health Initiative Observational Study (WHIOS)
showed that women who reported limited sun exposure were
20 percent more likely to have breast cancer compared with
those who spent much time outside each day (Millen et al.,
2009).
Another recent study looking at large groups of people
found an inverse relationship between high levels of UVB
rays and age-standardized breast cancer rates in 107 countries
(Mohr, Garland, Gorham, Grant, & Garland, 2008). These re-
search conclusions are supported by others as well, who agree
that the minimum requirement to maintain a circulating level
of 25-hyroxyvitamin D of more than 20 ng/mL is 1,000 IU/
day, a level that is difficult to achieve from diet alone (Holick,
2008). But even this level is well below the >40 ng/mL thought
to be necessary for chemoprevention. While 15 to 20 minutes

BOX 2
Selected Food Sources of Vitamin D
Food IU per serving Food IU per serving
Cod liver oil, 1 tablespoon 1,360 Sardines, canned in oil, drained, 46
Salmon (sockeye), cooked, 3oz 794 2 sardines

Mushrooms that have been 400 Liver, beef, cooked, 3.5oz 46

exposed to ultraviolet light to Ready-to-eat cereal, fortified 40
increase vitamin D, 3oz with 10% of the DV for vitamin D,
(not yet commonly available) 0.75 to 1 cup (more heavily
Mackerel, cooked, 3oz 388 fortified cereals might provide
more of the DV)
Tuna fish, canned in water, 154
drained, 3oz Egg, 1 whole (vitamin D is found 25
in yolk)
Milk, nonfat, reduced fat, and 115 to 124
whole, vitamin D-fortified, 1 cup
Orange juice fortified with 100
vitamin D, 1 cup (check product
labels, as amount of added
vitamin D varies)
Yogurt, fortified with 20% of 80
the DV for vitamin D, 6oz
(more heavily fortified yogurts
provide more of the DV)
IU = International Units DV = Daily Value
Margarine, fortified, 1 tablespoon 60
Source: U.S. Department of Agriculture,
Agricultural Research Service (2010).

372 Nursing for Women’s Health Volume 14 Issue 5


Fortified foods
provide most of the
vitamin D in the
American diet
of daily sun exposure may be of benefit, it is important not to
forget other issues such as the risk of skin cancer. It’s important
to balance the risks versus the benefits and consider all factors.
Supplementation
When considering supplementation, the amount of vitamin
D obtained from other sources such as diet and sun exposure
should be taken into account. While both vitamin D2 and D3
are available as over-the-counter supplements, D3 is the pre-
ferred form for supplementation as it is better able to bind the
receptors in human tissue and is more effective at elevating and
maintaining blood levels (Moyad, 2009). Of note is that vita-
min D2 is the only form available by prescription in the United
States (Holick, 2007).
Patient reCommenDations
The IOM is currently conducting a review of the DRIs for vi-
tamin D and calcium. Until then, clinicians should use their
judgment about prescribing supplements based on the patient’s
medical history, current 25-hydroxyvitamin D level, and cur-
rent disease state (i.e., people with conditions that interfere
with fat absorption may have higher needs). Risk for cancer
and the tolerable UL for vitamin D should also be considered
when making any recommendations. If a patient is tested and
found to be vitamin D deficient, then a health care practitioner
might prescribe a dose well above the UL, monitor the patient
for signs of toxicity, check blood levels and adjust the dose as
needed (see Box 3).
October November 2010
Patients should be advised that a circulating level of 40 ng/
mL 25-hydroxyvitamin D may be required to prevent diseases
such as breast cancer. You should explain the importance of sun
exposure to the patient, including information about the fact
that 15 to 20 minutes of sun exposure (without sunscreen) is
desirable. This exposure should be in direct sunlight and in-
clude exposure to the face and arms. It is also important to ex-
plain that vitamin D production should not extend beyond 20
minutes and that lengthy sun exposure may increase the risk of
skin cancer.
If sun exposure is not possible, vitamin D intake from diet
and supplementation will be required. It might be necessary to
prescribe levels as high as 50,000 IU once per week for 6 to
8 weeks if a mild to moderate deficiency (8-12 ng/mL) is ob-
served. The prescription may be increased to twice per week for
a severe deficiency (<8 ng/mL) (Litchford, 2009). When pre-
scription strength vitamin D is taken for any period of time, the
patient should be monitored for signs of toxicity (Joshi, 2009)
(see Box 3). Signs and symptoms of vitamin D toxicity are listed
in Box 4. Follow-up blood tests should be obtained to monitor
vitamin D status and further recommendations made accord-
ingly. Once an individual reaches the desired level, a mainte-
nance dose of 800 to 1,400 IU may be given (Shils, et al., 2005).
This can come from a multivitamin with 400 IU plus 400 to
1,000 IU from an additional vitamin D supplement.
ConCLUsion
Much of the research currently supports vitamin D deficiency
as a risk factor for breast cancer. However, more tightly control-
led randomized clinical trials are needed to substantiate this as-
sociation. Areas for further research include investigation into
the amount of vitamin D needed to have a protective benefit
against breast cancer, differential protective effects by source
of vitamin D and alterations in risk stemming from chemical
isoforms of vitamin D. As this is a public health concern, the
BOX 3
Dietary Reference Intake
for Vitamin D
Age Group (Years) Adequate Intake
0 to 1 200 IU or 5 mcg
2 to 50 200 IU or 5 mcg
51 to 70 400 IU or 10 mcg
> 70 600 IU or 15 mcg
1 mcg = 40 IU.
Source: Institute of Medicine of the National Academies (2010).
Nursing for Women’s Health 373

BOX 4
Signs and Symptoms of
Vitamin D Toxicity
Signs Symptoms
Increased thirst Dehydration
Increased urination Vomiting
High blood pressure Poor appetite
Excess blood calcium Constipation
Excess calcium Fatigue
in the urine
Source: Joshi (2009).
American Public Health Association, World Health Organiza-
tion, Public Health Foundation and several other public health
organizations will likely become involved in promoting re-
search in this area.
Lichtenstein et al. (2000) have studied the association be-
tween genetics and cancer and suggest that diet plays a stronger
role than genetics. They cite statistics showing that 33 percent
to 66 percent of cancer cases could be prevented by implement-
ing dietary changes highlighting the importance of taking a
proactive approach to cancer prevention. Clearly the reactive
nature of Western medicine clearly has not been successful, as
the United States currently has an overweight/obesity rate of
67 percent (Centers for Disease Control and Prevention, 2009).
Sufficient vitamin D and other dietary changes may be very in-
fluential in preventing cancer. It’s our job and responsibility to
help educate and aid our patients in making healthful changes
before they develop disease, whenever possible. NWH
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Nursing for Women’s Health 375