Int J Clin Exp Pathol 2015;8(4):4074-4082 www.ijcep.com /ISSN:1936-2625/IJCEP0006007
Original Article Significance of serum levels of vitamin D and some related minerals in breast cancer patients Iman A Abdelgawad1, Rawya H El-Mously2, Magdy M Saber3, Ossama A Mansour4, Samia A Shouman5 Department of Clinical & Chemical Pathology, NCI, Cairo University, Cairo, Egypt; 2Department of Oncology, NCI, Cairo University, Cairo, Egypt; 3Pharmaceutical Sciences, Cairo, Egypt; 4Departement of Biochemitry, Faculty of Pharmacy, Alazhar University, Cairo, Egypt; 5Department of Biochemitry, Faculty of Pharmacy, Cairo University, Cairo, Egypt 1
Received January 16, 2015; Accepted March 19, 2015; Epub April 1, 2015; Published April 15, 2015 Abstract: Vitamin D and calcium are involved in a wide range of proliferation, apoptosis and cell signaling activities in the body. Suboptimal concentrations may lead to cancer development. The role of phosphate in cancer metabolism is particularly relevant in breast cancer while, magnesium deficiency favors DNA mutations leading to carcinogenesis. Objectives: To determine serum levels of vitamin D, calcium, phosphorus, magnesium, and parathormone in female breast cancer patients and to assess their association with some prognostic factors in breast cancer. Design and methods: This study is done on 98 newly diagnosed female breast cancer patients and 49 age matched apparently healthy female volunteers as controls. Serum samples from all patients and controls were subjected to 25-OH Vit D, calcium, phosphorus, magnesium, and parathormone measurements. Results: In the breast cancer group, the median serum levels of 25-OH Vit D were 15 ng/ml, while it was 21 ng/ml in the control group. Levels of 25-OH Vit D and other tested minerals were significantly lower while calcium: magnesium (Ca:Mg) ratio, and calcium : phosphorus (Ca:P) ratio were significantly higher in the breast cancer group. Significant negative correlation was detected between phosphorus and calcium, ionized calcium , calcium magnesium ratio, and calcium phosphorus ratio. Conclusion: It is not only the deficient levels of Vit D and other related minerals, but the combination of the abnormal levels of all the studied parameters that might contribute to the development of cancer. Further studies with larger number of patient are needed. Keywords: Vitamin D, calcium, phosphorus, magnesium, breast cancer
Introduction Breast cancer was estimated one of the most commonly diagnosed cancers worldwide (11.9%). Among women, it is the most common cause of cancer death and the most frequently diagnosed cancer in 140 out of 184 countries worldwide [1] including Egypt, where there were an estimated 49.5 cases of breast cancer per 100,000 adults in 2012, and an estimated 18,660 cases in total [2]. Many factors have been claimed to increase breast cancer risk, from which are; weight gain and body mass index; age at menarche and menopause, previous benign breast lesions and family history of breast cancer, and exposure to ionizing radiation and alcohol consumption [3]. Because the epidemiology of breast cancer is not fully explained by these factors,
there is still a need for investigating more etiological factors for breast cancer. Vitamin D (Vit D), through its binding to vitamin D receptors (VDR) which are located in the nuclei of the breast cells among other tissues of the body, exerts a variety of immunogenic and antiproliferative activities [4]. That is why suboptimal Vit D levels might lead to cancer development through impairment of cell proliferation, differentiation, apoptosis, and angiogenesis [5]. Interestingly, it has been found that people with higher sun exposure, higher intake, or higher serum levels of vitamin D showed reduced incidence of breast, colon, and prostate cancers [6]. In the liver, vitamin D is metabolized to 25-hydroxy vitamin D (25 (OH) D), then further
Vitamin D and some minerals in breast cancer Table 1. Clinical characteristics of the 98 breast cancer patients in the study Characteristic Age Menopausal Status Pathological type Grade Distant metastasis LN involvement ER PR
N (98) Percentage 50 (30-80) Premenopause Postmenopause IDC Other types Grade 2 Grade 1 & 3 Presence Absence Positive Negative Positive Negative Positive Negative
36 62 83 15 89 9 16 82 51 47 55 43 49 49
37 63 85 15 91 9 16 84 52 48 56 44 50 50
IDC: invasive duct carcinoma; ER: estrogen receptor; PR: progesterone receptor; LN: Lymph node; Age: Median and interquartile range in parenthesis.
hydroxylated by 1- alpha hydroxylase enzyme in kidneys and other tissues like breast , prostate, and colon cells to 1, 25- dihydroxy vitamin D (1, 25 (OH) D), the most biologically active form and the natural ligand for VDR [7]. Circulating 25 (OH) D concentration is considered to be the best indicator of vitamin D status and the major storage form and varies with dietary intake and exposure to sunlight [8]. On the other hand, the circulating concentration of 1, 25 (OH) D is tightly regulated by renal 1-α-hydroxylase , so its level is maintained in a relatively narrow range [9]. Vitamin D deficiency is also associated with secondary elevation in PTH serum levels which has carcinogenic and tumor promoting effects [10] hence, may lead to an increased risk of breast cancer. Altered cell metabolism is regarded as a hallmark of cancer. As phosphate is an essential nutrient for the synthesis of nucleic acids, phospholipids and high energy metabolites such as adenosine triphosphate (ATP), rapidly dividing cells should require a continuous supply of it. The role of phosphate in cancer metabolism is particularly relevant in breast cancer and bone metastasis. Additionally, the high local phosphate concentration during osteoly-
4075
sis represents a potential factor contributing to the cell’s prolific microenvironment [11]. Being an important intracellular messenger, calcium is involved in proliferation, apoptosis and cell signaling [12]. Magnesium (Mg) is the fourth most abundant cation in the body [13], plays an essential role in more than 300 biological activities and is essential for deoxyribonucleic acid (DNA) duplication and repair, so Mg deficiency leads to carcinogenesis by favoring DNA mutations. It was also postulated that alterations in Ca:Mg ratio could lead to increased development of new and recurrent breast cancer [14]. Aim of the work was to evaluate the association between abnormal serum levels of 25-OH vitamin D and other related minerals in adult female patients with breast cancer and to compare their levels to the normal control group, also to assess their association with some prognostic factors in breast cancer. Patients and methods All newly diagnosed adult female patients with breast cancer who were presented to the Medical Oncology Department over a period of consecutive 6 months from January till June 2012 (98 patients) were recruited into the study as “cases” after informed consent. Forty nine age-matched healthy female volunteers were enrolled as the “control group”. The histopathological diagnosis of breast cancer, grade of the tumor, and hormone receptor status (estrogen receptor - ER, and progesterone receptor - PR) was recorded from the pathology reports of breast cancer patients. The study protocol was approved by the Scientific Research Committee and Institutional Review Board at the National Cancer Institute, Cairo University, Egypt. Methods Five ml of blood was withdrawn from each patient, left to clot then centrifuged; serum was collected and kept at -20°. Serum 25-(OH) D levels were measured by ELISA technique, using DRG ELISA kit (EIA-5396)-USA. Parathormone was determined using a solid-phase,
Int J Clin Exp Pathol 2015;8(4):4074-4082
Vitamin D and some minerals in breast cancer Table 2. Comparison of 25-OH Vit D, parathormone & other tested minerals’ levels in the breast cancer & normal control groups using Mann-Whitney test Breast Cancer Control group group (n:98) (n:49) 25-OH Vit D (20-100 ng/ml) 15 (8.8-24) 21 (12.5-31) Parathormone (10-70 pg/ml) 58 (41-87) 45.4 (33-72) Phosphorus (2.5-4.5 mg/dl) 3.8 (3.3-4.3) 4.6 (3.9-5.3) Ca Total (2.2-2.7 mmol/L) 2.2 (1.9-2.3) 2.2 (2-2.3) Ionized calcium (1.15-1.35 mmol/L) 1 (0.9-1.1) 1.1 (1-1.2) Mg (1.8-2.6 mg/dl) 1.8 (1.5-2.1) 2.3 (2-2.6) Ca:Mg ratio (3.1:1) 1.2 (0.9-1.5) 0.92 (0.8-1.1) Ca:P ratio (2.63:1) 0.56 (0.46-0.68) 0.45 (0.4-0.56) Parameter
P value 0.044* 0.102
Original Article Significance of serum levels of vitamin D and some related minerals in breast cancer patients Iman A Abdelgawad1, Rawya H El-Mously2, Magdy M Saber3, Ossama A Mansour4, Samia A Shouman5 Department of Clinical & Chemical Pathology, NCI, Cairo University, Cairo, Egypt; 2Department of Oncology, NCI, Cairo University, Cairo, Egypt; 3Pharmaceutical Sciences, Cairo, Egypt; 4Departement of Biochemitry, Faculty of Pharmacy, Alazhar University, Cairo, Egypt; 5Department of Biochemitry, Faculty of Pharmacy, Cairo University, Cairo, Egypt 1
Received January 16, 2015; Accepted March 19, 2015; Epub April 1, 2015; Published April 15, 2015 Abstract: Vitamin D and calcium are involved in a wide range of proliferation, apoptosis and cell signaling activities in the body. Suboptimal concentrations may lead to cancer development. The role of phosphate in cancer metabolism is particularly relevant in breast cancer while, magnesium deficiency favors DNA mutations leading to carcinogenesis. Objectives: To determine serum levels of vitamin D, calcium, phosphorus, magnesium, and parathormone in female breast cancer patients and to assess their association with some prognostic factors in breast cancer. Design and methods: This study is done on 98 newly diagnosed female breast cancer patients and 49 age matched apparently healthy female volunteers as controls. Serum samples from all patients and controls were subjected to 25-OH Vit D, calcium, phosphorus, magnesium, and parathormone measurements. Results: In the breast cancer group, the median serum levels of 25-OH Vit D were 15 ng/ml, while it was 21 ng/ml in the control group. Levels of 25-OH Vit D and other tested minerals were significantly lower while calcium: magnesium (Ca:Mg) ratio, and calcium : phosphorus (Ca:P) ratio were significantly higher in the breast cancer group. Significant negative correlation was detected between phosphorus and calcium, ionized calcium , calcium magnesium ratio, and calcium phosphorus ratio. Conclusion: It is not only the deficient levels of Vit D and other related minerals, but the combination of the abnormal levels of all the studied parameters that might contribute to the development of cancer. Further studies with larger number of patient are needed. Keywords: Vitamin D, calcium, phosphorus, magnesium, breast cancer
Introduction Breast cancer was estimated one of the most commonly diagnosed cancers worldwide (11.9%). Among women, it is the most common cause of cancer death and the most frequently diagnosed cancer in 140 out of 184 countries worldwide [1] including Egypt, where there were an estimated 49.5 cases of breast cancer per 100,000 adults in 2012, and an estimated 18,660 cases in total [2]. Many factors have been claimed to increase breast cancer risk, from which are; weight gain and body mass index; age at menarche and menopause, previous benign breast lesions and family history of breast cancer, and exposure to ionizing radiation and alcohol consumption [3]. Because the epidemiology of breast cancer is not fully explained by these factors,
there is still a need for investigating more etiological factors for breast cancer. Vitamin D (Vit D), through its binding to vitamin D receptors (VDR) which are located in the nuclei of the breast cells among other tissues of the body, exerts a variety of immunogenic and antiproliferative activities [4]. That is why suboptimal Vit D levels might lead to cancer development through impairment of cell proliferation, differentiation, apoptosis, and angiogenesis [5]. Interestingly, it has been found that people with higher sun exposure, higher intake, or higher serum levels of vitamin D showed reduced incidence of breast, colon, and prostate cancers [6]. In the liver, vitamin D is metabolized to 25-hydroxy vitamin D (25 (OH) D), then further
Vitamin D and some minerals in breast cancer Table 1. Clinical characteristics of the 98 breast cancer patients in the study Characteristic Age Menopausal Status Pathological type Grade Distant metastasis LN involvement ER PR
N (98) Percentage 50 (30-80) Premenopause Postmenopause IDC Other types Grade 2 Grade 1 & 3 Presence Absence Positive Negative Positive Negative Positive Negative
36 62 83 15 89 9 16 82 51 47 55 43 49 49
37 63 85 15 91 9 16 84 52 48 56 44 50 50
IDC: invasive duct carcinoma; ER: estrogen receptor; PR: progesterone receptor; LN: Lymph node; Age: Median and interquartile range in parenthesis.
hydroxylated by 1- alpha hydroxylase enzyme in kidneys and other tissues like breast , prostate, and colon cells to 1, 25- dihydroxy vitamin D (1, 25 (OH) D), the most biologically active form and the natural ligand for VDR [7]. Circulating 25 (OH) D concentration is considered to be the best indicator of vitamin D status and the major storage form and varies with dietary intake and exposure to sunlight [8]. On the other hand, the circulating concentration of 1, 25 (OH) D is tightly regulated by renal 1-α-hydroxylase , so its level is maintained in a relatively narrow range [9]. Vitamin D deficiency is also associated with secondary elevation in PTH serum levels which has carcinogenic and tumor promoting effects [10] hence, may lead to an increased risk of breast cancer. Altered cell metabolism is regarded as a hallmark of cancer. As phosphate is an essential nutrient for the synthesis of nucleic acids, phospholipids and high energy metabolites such as adenosine triphosphate (ATP), rapidly dividing cells should require a continuous supply of it. The role of phosphate in cancer metabolism is particularly relevant in breast cancer and bone metastasis. Additionally, the high local phosphate concentration during osteoly-
4075
sis represents a potential factor contributing to the cell’s prolific microenvironment [11]. Being an important intracellular messenger, calcium is involved in proliferation, apoptosis and cell signaling [12]. Magnesium (Mg) is the fourth most abundant cation in the body [13], plays an essential role in more than 300 biological activities and is essential for deoxyribonucleic acid (DNA) duplication and repair, so Mg deficiency leads to carcinogenesis by favoring DNA mutations. It was also postulated that alterations in Ca:Mg ratio could lead to increased development of new and recurrent breast cancer [14]. Aim of the work was to evaluate the association between abnormal serum levels of 25-OH vitamin D and other related minerals in adult female patients with breast cancer and to compare their levels to the normal control group, also to assess their association with some prognostic factors in breast cancer. Patients and methods All newly diagnosed adult female patients with breast cancer who were presented to the Medical Oncology Department over a period of consecutive 6 months from January till June 2012 (98 patients) were recruited into the study as “cases” after informed consent. Forty nine age-matched healthy female volunteers were enrolled as the “control group”. The histopathological diagnosis of breast cancer, grade of the tumor, and hormone receptor status (estrogen receptor - ER, and progesterone receptor - PR) was recorded from the pathology reports of breast cancer patients. The study protocol was approved by the Scientific Research Committee and Institutional Review Board at the National Cancer Institute, Cairo University, Egypt. Methods Five ml of blood was withdrawn from each patient, left to clot then centrifuged; serum was collected and kept at -20°. Serum 25-(OH) D levels were measured by ELISA technique, using DRG ELISA kit (EIA-5396)-USA. Parathormone was determined using a solid-phase,
Int J Clin Exp Pathol 2015;8(4):4074-4082
Vitamin D and some minerals in breast cancer Table 2. Comparison of 25-OH Vit D, parathormone & other tested minerals’ levels in the breast cancer & normal control groups using Mann-Whitney test Breast Cancer Control group group (n:98) (n:49) 25-OH Vit D (20-100 ng/ml) 15 (8.8-24) 21 (12.5-31) Parathormone (10-70 pg/ml) 58 (41-87) 45.4 (33-72) Phosphorus (2.5-4.5 mg/dl) 3.8 (3.3-4.3) 4.6 (3.9-5.3) Ca Total (2.2-2.7 mmol/L) 2.2 (1.9-2.3) 2.2 (2-2.3) Ionized calcium (1.15-1.35 mmol/L) 1 (0.9-1.1) 1.1 (1-1.2) Mg (1.8-2.6 mg/dl) 1.8 (1.5-2.1) 2.3 (2-2.6) Ca:Mg ratio (3.1:1) 1.2 (0.9-1.5) 0.92 (0.8-1.1) Ca:P ratio (2.63:1) 0.56 (0.46-0.68) 0.45 (0.4-0.56) Parameter
P value 0.044* 0.102
