Dietary Antioxidant Vitamins and Minerals and Breast Cancer Risk: Prospective Results from the SUN Cohort

There is growing interest in natural antioxidants and their potential effects on breast cancer (BC). Epidemiological evidence, however, is inconsistent. We prospectively evaluated the association between dietary intake of vitamins A, C, and E, selenium, and zinc and BC among 9983 female participants from the SUN Project, a Mediterranean cohort of university graduates. Participants completed a food frequency questionnaire at baseline, and biennial follow-up information about incident BC diagnosis was collected. Cases were ascertained through revision of medical charts and consultation of the National Death Index. Cox proportional hazards models were used to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CI). During an average follow-up of 11.3 years, 107 incident BC cases were confirmed. The multivariable HRs (95% CI) for BC comparing extreme tertiles of energy-adjusted dietary intakes were 1.07 (0.64–1.77; Ptrend = 0.673) for vitamin A, 1.00 (0.58–1.71; Ptrend = 0.846) for vitamin C, 0.92 (0.55–1.54; Ptrend = 0.728) for vitamin E, 1.37 (0.85–2.20; Ptrend = 0.135) for selenium, and 1.01 (0.61–1.69; Ptrend = 0.939) for zinc. Stratified analyses showed an inverse association between vitamin E intake and postmenopausal BC (HRT3 vs. T1 = 0.35; 95% CI, 0.14–0.86; Ptrend = 0.027). Our results did not suggest significant protective associations between dietary vitamins A, C, and E, selenium, or zinc and BC risk.

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Association between overall diet quality and postmenopausal breast cancer risk in five Finnish cohort studies

Scientific Reports ◽

10.1038/s41598-021-95773-2 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Satu Männistö ◽

Kennet Harald ◽

Tommi Härkänen ◽

Mirkka Maukonen ◽

Johan G. Eriksson ◽

...

Keyword(s):

Breast Cancer ◽

Diet Quality ◽

Proportional Hazards ◽

Postmenopausal Breast Cancer ◽

Healthy Eating Index ◽

Cox Proportional Hazards ◽

Healthy Diet ◽

Food Culture ◽

Alternative Healthy Eating Index

AbstractThere is limited evidence for any dietary factor, except alcohol, in breast cancer (BC) risk. Therefore, studies on a whole diet, using diet quality indices, can broaden our insight. We examined associations of the Nordic Diet (mNDI), Mediterranean diet (mMEDI) and Alternative Healthy Eating Index (mAHEI) with postmenopausal BC risk. Five Finnish cohorts were combined including 6374 postmenopausal women with dietary information. In all, 8–9 dietary components were aggregated in each index, higher total score indicating higher adherence to a healthy diet. Cox proportional hazards regression was used to estimate the combined hazard ratio (HR) and 95% confidence interval (CI) for BC risk. During an average 10-year follow-up period, 274 incident postmenopausal BC cases were diagnosed. In multivariable models, the HR for highest vs. lowest quintile of index was 0.67 (95 %CI 0.48–1.01) for mNDI, 0.88 (0.59–1.30) for mMEDI and 0.89 (0.60–1.32) for mAHEI. In this combined dataset, a borderline preventive finding of high adherence to mNDI on postmenopausal BC risk was found. Of the indices, mNDI was more based on the local food culture than the others. Although a healthy diet has beneficially been related to several chronic diseases, the link with the etiology of postmenopausal BC does not seem to be that obvious.

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Relationship of lycopene intake and consumption of tomato products to incident CVD

British Journal Of Nutrition ◽

10.1017/s0007114512005417 ◽

2013 ◽

Vol 110 (3) ◽

pp. 545-551 ◽

Cited By ~ 54

Author(s):

Paul F. Jacques ◽

Asya Lyass ◽

Joseph M. Massaro ◽

Ramachandran S. Vasan ◽

Ralph B. D'Agostino Sr

Keyword(s):

Repeated Measures ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Supporting Evidence ◽

Inverse Association ◽

Cvd Risk ◽

Stroke Incidence ◽

Hazard Ratios ◽

Increased Risk

Evidence for cardioprotective effects of lycopene is inconsistent. Studies of circulating lycopene generally report inverse associations with CVD risk, but studies based on lycopene intake do not. The failure of dietary studies to support the findings based on biomarkers may be due in part to misclassification of lycopene intakes. To address this potential misclassification, we used repeated measures of intake obtained over 10 years to characterise the relationship between lycopene intake and the incidence of CVD (n314), CHD (n171) and stroke (n99) in the Framingham Offspring Study. Hazard ratios (HR) for incident outcomes were derived from Cox proportional hazards regression models using logarithmically transformed lycopene intake adjusted for CVD risk factors and correlates of lycopene intake. HR were interpreted as the increased risk for a 2·7-fold difference in lycopene intake, a difference approximately equal to its interquartile range. Using an average of three intake measures with a 9-year follow-up, lycopene intake was inversely associated with CVD incidence (HR 0·83, 95 % CI 0·70, 0·98). Using an average of two intake measures and 11 years of follow-up, lycopene intake was inversely associated with CHD incidence (HR 0·74, 95 % CI 0·58, 0·94). Lycopene intake was unrelated to stroke incidence. The present study of lycopene intake and CVD provides supporting evidence for an inverse association between lycopene and CVD risk; however, additional research is needed to determine whether lycopene or other components of tomatoes, the major dietary source of lycopene, are responsible for the observed association.

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Adjuvant endocrine monotherapy (ET) versus adjuvant breast radiation (RT) alone in healthy older women with stage I, estrogen receptor-positive (ER+) breast cancer: An analysis of the National Cancer Database (NCDB).

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.519 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 519-519

Author(s):

Anthony H. Bui ◽

Manjeet Chadha ◽

Theresa H. Shao ◽

Naamit K. Gerber ◽

Sarah P. Cate ◽

...

Keyword(s):

Breast Cancer ◽

Older Women ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Stage I ◽

Nccn Guidelines ◽

Treatment Groups ◽

Distant Relapse ◽

Demographic Covariates

519 Background: The NCCN guidelines state that breast RT may be omitted in patients > 70 years of age with ER+, clinically node-negative, T1 breast cancer (BC) who receive adjuvant ET. Available data on older patients notes that local relapses are the most frequent site of failure, and distant relapse rates are low. The side effects of ET are not inconsequential and negatively affect QOL. The objectives of this study are to examine clinical outcomes including overall survival (OS) in women ≥70 years of age treated by lumpectomy(L)+ET and L+RT in the NCDB. Methods: The 2004-2013 NCDB includes 76,431 women ≥70 years with ER+ stage I BC who underwent L, and had a minimum one year follow up. Women who received no adjuvant therapy, both ET+RT, or any chemotherapy were excluded. To limit the analysis to healthy women, we excluded subjects with a Charlson comorbidity index > 0. We identified 24,572 patients who received either adjuvant ET monotherapy or adjuvant RT alone. Among these, 46% (11,313) received ET and 54% (13,259) breast RT. Overall median follow up was 57 months (range: 12-143 months). Analysis of OS between the 2 treatment groups was performed using Kaplan-Meier statistics and Cox proportional hazards regression; propensity weighting was used to balance covariates across the 2 treatment groups. Results: After propensity weighting, demographic covariates including age, race, insurance, and facility type were balanced between the 2 treatment groups. The median OS for ET was 125.9 months (95% CI 120.1-131.8), and 127.2 months for RT (95% CI 124.5-131.7) (p < 0.0001). The weighted hazard of death was 11.7% less in women receiving RT compared to ET (HR 0.883, 95% CI 0.834-0.936, p < 0.0001). Conclusions: To our knowledge, this is the first large study comparing RT and ET monotherapy in healthy older women with stage I, ER+ BC. The OS with RT alone is not inferior to ET alone, and in this study population is noted to be better. While this analysis has various limitations not dissimilar from other NCDB database studies, our observations are encouraging and warrant further research with prospective studies.

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Use of postmenopausal hormone therapies and risk of histology- and hormone receptor-defined breast cancer: results from a 15-year prospective analysis of NIH-AARP cohort

Breast Cancer Research ◽

10.1186/s13058-020-01365-9 ◽

2020 ◽

Vol 22 (1) ◽

Author(s):

Shao-Ming Wang ◽

Ruth M. Pfeiffer ◽

Gretchen L. Gierach ◽

Roni T. Falk

Keyword(s):

Breast Cancer ◽

Hormone Receptor ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Models ◽

Estrogen Plus Progestin ◽

Continued Use ◽

Progestin Therapy

Abstract Background Menopausal hormone therapy (MHT) increases breast cancer (BC) risk, but cohort studies largely consider use only at enrollment. Evidence is limited on how changes in MHT use alter the magnitude of risk, and whether risk varies between invasive and in situ cancer, by histology or by hormone receptor status. Methods We investigated the roles of estrogen-alone therapy (ET) and estrogen plus progestin therapy (EPT) on BC risk overall, by histology and estrogen receptor (ER) and progesterone receptor (PR) status, and on incidence of in situ disease, in the NIH-AARP cohort. Participants included 118,760 postmenopausal women (50–71 years), of whom 63.5% (n = 75,398) provided MHT use information at baseline in 1996 and in a follow-up survey in 2004, subsequent to the dissemination in 2002 of the Women’s Health Initiative trial safety concerns regarding EPT. ET analyses included 50,476 women with hysterectomy (31,439 with follow-up data); EPT analyses included 68,284 women with intact uteri (43,959 with follow-up data). Adjusted hazard ratios (HRs) were estimated using Cox proportional hazards models using age as the time metric with follow-up through 2011. Results Eight thousand three hundred thirty-three incident BC cases were accrued, 2479 in women with follow-up data. BC risk was not elevated in current ET users at baseline (HR = 1.05, 95% confidence interval [CI] CI = 0.95–1.16) but was higher in women continuing use through 2004 (HR = 1.35, 95% CI = 1.04–1.75). Ever EPT use at baseline was associated with elevated BC risk overall (HR = 1.54 (1.44–1.64), with a doubling in risk for women with 10 or more years of use, for in situ disease, and across subtypes defined by histology and ER/PR status (all p < 0.004). Risk persisted in women who continued EPT through 2004 (HR = 1.80, 95% CI = 1.39–2.32). In contrast, no association was seen in women who discontinued EPT before 2004 (HR = 1.14, 95% CI = 0.99–1.30). Conclusions ET use was not associated with BC risk in this cohort, although excess risk was suggested in women who continued use through 2004. EPT use was linked to elevated in situ and invasive BC risk, and elevated risk across invasive BC histologic and hormone receptor-defined subtypes, with the highest risk for women who continued use through the 2004 follow-up survey.

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Nut consumption and incidence of metabolic syndrome after 6-year follow-up: the SUN (Seguimiento Universidad de Navarra, University of Navarra Follow-up) cohort

Public Health Nutrition ◽

10.1017/s1368980012004442 ◽

2012 ◽

Vol 16 (11) ◽

pp. 2064-2072 ◽

Cited By ~ 33

Author(s):

Alejandro Fernández-Montero ◽

Maira Bes-Rastrollo ◽

Juan J Beunza ◽

Maria Teresa Barrio-Lopez ◽

Carmen de la Fuente-Arrillaga ◽

...

Keyword(s):

Metabolic Syndrome ◽

Lower Risk ◽

International Diabetes Federation ◽

Heart Association ◽

University Graduates ◽

Inverse Association ◽

The Sun ◽

Logistic Regression Models ◽

Blood Institute

AbstractObjectiveTo assess the long-term relationship between tree nut consumption and the risk of developing metabolic syndrome (MetS).DesignNut consumption was collected using a validated 136-item FFQ. The MetS was defined according to the International Diabetes Federation and American Heart Association/National Heart, Lung, and Blood Institute harmonizing definition. The association between nut consumption and MetS was assessed with logistic regression models adjusting for potential confounders. We compared the incidence of MetS between extreme categories of nut intake (≥2 servings/weekv. never/almost never) after 6 years of follow-up.SettingThe SUN Project (Seguimiento Universidad de Navarra, University of Navarra Follow-up) is a prospective cohort study, formed of Spanish university graduates. Information is gathered by mailed questionnaires collected biennially. Nut consumption and MetS information was collected by self-reported data.SubjectsParticipants (n9887) initially free of MetS or diabetes and followed up for a minimum of 6 years were included.ResultsWe observed 567 new cases of MetS during follow-up. Participants who consumed nuts ≥2 servings/week presented a 32 % lower risk of developing MetS than those who never/almost never consumed (adjusted OR = 0·68, 95 % CI 0·50, 0·92). The inverse association was stronger among participants who were health professionals.ConclusionsNut consumption was significantly associated with lower risk of developing MetS after a 6-year follow-up period in a cohort of Spanish graduates.

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The association of dietary antioxidants intake with the risk of cardiovascular disease: Tehran Lipid and Glucose Study

10.21203/rs.2.18583/v1 ◽

2019 ◽

Author(s):

Parvin Mirmiran ◽

Zohreh Esfandiar ◽

Firoozeh Hosseini-Esfahani ◽

somayeh Hosseinpour-Niazi ◽

Fereidoun Azizi

Keyword(s):

Cardiovascular Disease ◽

Vitamin E ◽

Fruits And Vegetables ◽

Protective Role ◽

Inverse Association ◽

Dietary Intakes ◽

Daily Consumption ◽

Cox Proportional Hazard ◽

Cox Proportional Hazard Regression

Abstract Aim: This study investigated the association between daily consumption of dietary vitamins A, E, C and zinc and the incidence of cardiovascular disease (CVD). Methods: Eligible adults (n=5102) were selected from among participants of the Tehran Lipid and Glucose Study with an average follow-up of 5.3 years. Dietary intakes were assessed using a valid and reliable semi-quantitative food frequency questionnaire. Anthropometrics and biochemical variables were evaluated at baseline and follow-up examinations. Multivariate Cox proportional hazard regression models were used to estimate the development of CVD in relation to total intakes of vitamins A, E, C and zinc. Results: This study was conducted on 2253 men and 2849 women, aged 47.0±11.6 and 45.6±10.5 years, respectively. Main source of dietary vitamins A, E, C and zinc was fruits, vegetables and legumes in our study. Risk of CVD decreased from quartiles 1 to 4 for vitamin E intake (HR (95% CI): 1.00, 0.91, 0.77, 0.57, P trend =0.03). The association between risk of CVD and the quartiles of vitamin A, vitamin C and zinc intake was not significant. Conclusion : Our study suggests an inverse association between vitamin E intake and the risk of CVD, results emphasizing the potential protective role of fruits and vegetables in the prevention of CVD.

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Aspirin use and mortality in women with stage I-III breast cancer: A population-based study.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.521 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 521-521

Author(s):

Thomas Ian Barron ◽

Linda Sharp ◽

Kathleen Bennett ◽

Kala Visvanathan

Keyword(s):

Breast Cancer ◽

Exposure Duration ◽

Proportional Hazards ◽

Early Stage ◽

Cox Proportional Hazards ◽

Stage I ◽

Response Analysis ◽

Limited Information ◽

Specific Mortality

521 Background: Recent observational studies have associated aspirin (ASP) use with large reductions in breast cancer (BC) mortality. However, these studies have provided limited information on dose or duration of ASP use, key issues relevant to translation of the results into clinical practice. Methods: Linked National Cancer Registry Ireland and prescription refill data (General Medical Services Ireland, GMS) were used to identify women aged 50-80 with incident stage I-III BC (2001-2006). ASP use was defined as high or low by the median number of ASP days’ supply (85 days) in the 90 days pre-diagnosis. Full capture of ASP use is expected as the GMS provides all medications, including ASP, without charge. Hazard ratios (HR) with 95% confidence intervals (CI) for ASP use and (i) all-cause and (ii) BC-specific mortality were estimated using Cox proportional hazards models adjusted for age, stage, grade, ER, PR, HER-2 status, comorbidity and other drug exposures. Analyses were stratified by tumor stage and nodal status. Results: 2714 women with stage I-III BC were identified (median follow-up = 3.3 years), of whom 642 (23.7%) used ASP in the 90 days pre diagnosis. High and low ASP exposure groups were strongly predictive of post-diagnosis ASP exposure levels (High: mean post diagnosis exposure duration – 83% of follow-up; dose – 75mg/day in 91% of women. Low: mean post-diagnosis exposure duration – 58% of follow-up; dose – 75mg/day in 80% of women). Women with any ASP use had a non-significant reduction in all-cause (HR 0.85 95%CI 0.68, 1.06) and BC-specific (HR 0.86 95%CI 0.65, 1.15) mortality, compared to ASP unexposed women. However, in the dose response analysis high ASP exposure was associated with a significant reduction in all-cause (HR 0.70 95% CI 0.51, 0.95) and BC-specific (HR 0.63 95% CI 0.42, 0.96) mortality. No reduction was observed for low ASP exposure. The benefits of ASP exposure were greater in early stage, node negative disease. Conclusions: Only high ASP exposure was associated with a significant reduction in all cause and BC-specific mortality. These findings may explain inconsistent results from previous studies. Our findings can inform future clinical trials.

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Breast Cancer Systemic Treatments and Upper Limb Lymphedema: A Risk-Assessment Platform Encompassing Tumor-Specific Pathological Features Reveals the Potential Role of Trastuzumab

Journal of Clinical Medicine ◽

10.3390/jcm8020138 ◽

2019 ◽

Vol 8 (2) ◽

pp. 138 ◽

Cited By ~ 7

Author(s):

Marco Invernizzi ◽

Anna Michelotti ◽

Marianna Noale ◽

Gianluca Lopez ◽

Letterio Runza ◽

...

Keyword(s):

Breast Cancer ◽

Risk Assessment ◽

Proportional Hazards ◽

Growth Factor Receptor ◽

Cox Proportional Hazards ◽

Breast Cancers ◽

Pathological Features ◽

Systemic Treatments

Breast cancer related lymphedema (BCRL) is frequent but strategies for an individualized risk assessment are lacking. We aimed to define whether tumor-specific pathological features, coupled with clinical and therapeutic data, could help identify patients at risk. Data from 368 patients with node-positive breast cancers were retrospectively collected, including 75 patients with BCRL (0.4–25.6 years follow-up). BCRL was assessed during the standard follow-up oncology visits using the circumferential measurement. Clinicopathologic and therapeutic factors associated with BCRL were integrated into a Cox proportional hazards regression model. Lymphovascular invasion (LVI) was more common in BCRL patients (n = 33, 44% vs. n = 85, 29%, p = 0.01), akin extra nodal extension (ENE) of the metastasis (n = 57, 76% vs. n = 180, 61%, p = 0.02). Sentinel lymph node excision without axillary dissection and extra-axillary radiotherapy were BCRL-unrelated. A higher number of BCRL-positive patients were treated with taxane-based chemotherapy with or without trastuzumab, compared to BCRL-negative patients (p < 0.01). Treatment with trastuzumab and/or taxanes, adjusted for systemic infections, laterality, therapy, and pathological features (i.e., LVI and ENE), had a significant impact in BCRL-free survival (p < 0.01). This work offers new insights on BCRL risk stratification, where the integration of clinical, therapeutic, and tumor-specific pathological data suggests a possible role of anti-human epidermal growth factor receptor 2 (HER2) therapy in BCRL pathogenesis.

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CYP27A1 expression is associated with risk of late lethal estrogen receptor-positive breast cancer in postmenopausal patients

Breast Cancer Research ◽

10.1186/s13058-020-01347-x ◽

2020 ◽

Vol 22 (1) ◽

Author(s):

Siker Kimbung ◽

Maria Inasu ◽

Tor Stålhammar ◽

Björn Nodin ◽

Karin Elebro ◽

...

Keyword(s):

Breast Cancer ◽

Estrogen Receptor ◽

Proportional Hazards ◽

Tumor Biology ◽

Cox Proportional Hazards ◽

Receptor Expression ◽

Cancer Specific Survival ◽

Swedish Population ◽

Estrogen Receptor Positive

Abstract Background 27-Hydroxycholesterol (27HC) stimulates estrogen receptor-positive (ER+) breast cancer (BC) progression. Inhibiting the sterol 27-hydroxylase (CYP27A1) abrogates these growth-promoting effects of 27HC in mice. However, the significance of CYP27A1 expression on BC biology and prognosis is unclear. Methods Intratumoral CYP27A1 expression in invasive BC was measured by immunohistochemistry in two Swedish population-based cohorts (n = 645 and n = 813, respectively). Cox proportional hazards models were used to evaluate the association between CYP27A1 expression and prognosis. Results CYP27A1 was highly expressed in less than 1/3 of the tumors. High CYP27A1 expression was more frequent among high-grade tumors lacking hormone receptor expression and with larger tumor sizes. Over a median of 12.2 years follow-up in cohort 1, high CYP27A1 expression was associated with impaired survival, specifically after 5 years from diagnosis among all patients [overall survival (OS), HRadjusted = 1.93, 95%CI = 1.26–2.97, P = 0.003; breast cancer-specific survival (BCSS), HRadjusted = 2.33, 95%CI = 1.28–4.23, P = 0.006] and among patients ≥ 55 years presenting with ER+ tumors [OS, HRadjusted = 1.99, 95%CI = 1.24–3.21, P = 0.004; BCSS, HRadjusted = 2.78, 95%CI = 1.41–5.51, P = 0.003]. Among all patients in cohort 2 (median follow-up of 7.0 years), CYP27A1 expression was significantly associated with shorter OS and RFS in univariable analyses across the full follow-up period. However after adjusting for tumor characteristics and treatments, the association with survival after 5 years from diagnosis was non-significant among all patients [OS, HRadjusted = 1.08, 95%CI = 0.05–2.35, P = 0.83 and RFS, HRadjusted = 1.22, 95%CI = 0.68–2.18, P = 0.50] as well as among patients ≥ 55 years presenting with ER+ tumors [OS, HRadjusted = 0.46 95% CI = 0.11–1.98, P = 0.30 and RFS, HRadjusted = 0.97 95% CI = 0.44–2.10, P = 0.93]. Conclusion CYP27A1 demonstrated great potentials as a biomarker of aggressive tumor biology and late lethal disease in postmenopausal patients with ER+ BC. Future studies should investigate if the benefits of prolonged endocrine therapy and cholesterol-lowering medication in BC are modified by CYP27A1 expression.

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Fish consumption and the risk of myocardial infarction and stroke in the German arm of the European Prospective Investigation into Cancer and Nutrition (EPIC-Germany)

British Journal Of Nutrition ◽

10.1017/s0007114513000202 ◽

2013 ◽

Vol 110 (6) ◽

pp. 1118-1125 ◽

Cited By ~ 13

Author(s):

Tilman Kühn ◽

Birgit Teucher ◽

Rudolf Kaaks ◽

Heiner Boeing ◽

Cornelia Weikert ◽

...

Keyword(s):

Myocardial Infarction ◽

Ischaemic Stroke ◽

Fish Consumption ◽

Proportional Hazards ◽

Haemorrhagic Stroke ◽

Cox Proportional Hazards ◽

Inverse Association ◽

Meta Analyses ◽

Prospective Investigation

Recent meta-analyses have confirmed that fish consumption is related to decreased risks of ischaemic stroke and fatal CHD, while there seem to be no clear associations between fish consumption and the risks of haemorrhagic stroke and non-fatal CHD. As no studies in German populations have been reported to date, we assessed whether fish consumption as recorded by FFQ between 1994 and 1998 was related to incident myocardial infarction (MI) and stroke within the German arm of the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Cox proportional hazards regression analyses were conducted based on the data of 48 315 participants aged 35–65 years at baseline. The median fish intake was 16·4 g/d (25th–75th percentile 8·2–28·8 g/d). During a mean follow-up of 8·1 years, 605 incident MI and 525 incident strokes have been documented. After multiple adjustment, fish consumption was not related to incident MI (hazard ratio (HR) 0·84, 95 % CI 0·66, 1·08, Ptrend= 0·21) or stroke (HR 0·96, 95 % CI 0·73, 1·26, Ptrend= 0·67). Separate analyses for fatal MI, ischaemic stroke and haemorrhagic stroke did not show significant associations, either. With regard to non-fatal MI, there was a non-significant trend for an inverse association (HR 0·78, 95 % CI 0·59, 1·03, Ptrend= 0·07). Overall, fish consumption was not related to the risks of MI and stroke in the EPIC-Germany study.

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