American Journal of Epidemiology

The Author 2013. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of
Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Vol. 177, No. 7

DOI: 10.1093/aje/kws291
Advance Access publication:
February 25, 2013

Original Contribution
Association of Leukocyte Telomere Length With Breast Cancer Risk: Nested
Case-Control Findings From the Shanghai Womens Health Study

Shimian Qu, Wanqing Wen, Xiao-Ou Shu, Wong-Ho Chow, Yong-Bing Xiang, Jie Wu, Bu-Tian Ji,
Nathaniel Rothman, Gong Yang, Qiuyin Cai, Yu-Tang Gao, and Wei Zheng*
* Correspondence to Dr. Wei Zheng, Vanderbilt Epidemiology Center and Vanderbilt-Ingram Cancer Center, Vanderbilt University School
of Medicine, 2525 West End Avenue, 8th Floor, Nashville, TN 37203-1738 (e-mail: wei.zheng@vanderbilt.edu).

Telomeres are specialized chromatin structures essential for the maintenance of chromosomal integrity and
stability. Telomere shortening has been linked to multiple aging-related diseases, including cancer. Evidence
associating telomere length with breast cancer riskmost of which has been from retrospective case-control
studiesis conflicting. We conducted a nested case-control study based on the Shanghai Womens Health
Study (19972009) in which we evaluated the association of telomere length and breast cancer risk using peripheral blood samples collected before cancer diagnosis (601 cases and 695 controls). We used monochrome
multiplex quantitative polymerase chain reaction to measure relative telomere length. Multiple logistic regressions were used to derive adjusted odds ratios with 95% confidence intervals as the measure of association.
Telomere length was inversely correlated with age (r = 0.22). Women with moderately long telomeres (those in
the fourth quintile) had the lowest breast cancer risk. Risk increased in a dose-response manner with decreasing
quintile of telomere length; odds ratios were 1.39 (95% confidence interval (CI): 0.95, 2.04), 1.79 (95% CI: 1.17,
2.75), and 2.39 (95% CI: 1.45, 3.92), respectively, for the third, second, and first quintiles compared with the
fourth quintile. A slightly elevated risk of breast cancer (odds ratio = 1.35, 95% CI: 0.90, 2.04), although one that
was not statistically significant, was found in the top quintile (longest telomeres). Our results support the hypothesis that telomere shortening is associated with increased risk of breast cancer and suggest a possible elevated
risk associated with long telomeres.
breast cancer; biomarkers; epidemiology; genetic factors; telomere

Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio.

Telomeres, located at the ends of eukaryotic chromosomes, are specialized chromatin structures composed of
highly conserved tandem hexameric nucleotide repeats,
TTAGGG (1). Telomeres are essential for preserving chromosomal integrity and stability through prohibiting karyotypic aberrations, such as chromosome ends fusion, nucleolytic
decay, and aberrant recombination (2). Telomere length is
maintained by telomerase, a multisubunit ribonucleoprotein
polymerase that normally is not expressed in somatic tissue
but is elevated in germ cells and neoplastic tissues (1, 3).
Telomeres undergo progressive shortening with each cell division, partly because of the incomplete replication at 3

end of chromosomes during DNA replication. When the critical telomere length is reached, the signal for replicative senescence is activated, and the cell enters cell-cycle arrest or
undergoes apoptosis (4). Short telomeres can lead to chromosomal instability, which can increase the rates of genetic
mutations and chromosome abnormalities (4). It has been
shown that cigarette smoking, oxidative stress, and chronic
inammation might cause telomere shortening (58). Telomere shortening has been shown to be associated with multiple aging-related diseases, such as cancer (1). In humans, the
best example of a short telomere phenotype is dyskeratosis
congenita. Patients with this disease carry mutations in the

617

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Initially submitted March 13, 2012; accepted for publication June 14, 2012.

618 Qu et al.

MATERIALS AND METHODS

Study population

Subjects of the present study were participants in the

Shanghai Womens Health Study, a population-based cohort
study. Detailed methodology for the Shanghai Womens
Health Study has been published elsewhere (22). The study
was approved by the relevant institutional review boards for
human research. Briey, from 1997 to 2000, a total of 74,942
Chinese women between the ages of 40 and 70 years who
resided in 7 urban communities of Shanghai were recruited
into the cohort study, with a response rate of 92.7%. Inperson interviews were conducted to collect information regarding demographic characteristics, anthropometrics, usual
dietary habits, physical activities, and other lifestyle factors.
Of the study participants, 56,831 (75.8%) provided a blood
sample at baseline recruitment (Appendix Table 1). Buffy
coat samples were stored at 80C until DNA isolation.
The cohort has been followed using a combination of biennial home visits, record linkage to cancer incidence and
mortality data collected by the Shanghai Cancer Registry,
and death certicate data collected by the Shanghai Vital
Statistics Unit. For cohort members who were diagnosed
with cancer, medical charts were reviewed to verify the diagnosis, and detailed information regarding pathologic
characteristics of the cancer was obtained.
Included in the current nested case-control study were 601
incident breast cancer cases identied during follow-up of the
cohort to December 2009, as well as their matched controls.
Incidence-density sampling method was used to select

controls from the same risk set as the index case. Cases and
controls were individually matched on age (difference 730
days), date (difference 30 days), and time (morning or afternoon) of sample collection, time interval since last meal (difference 2 hours), antibiotic use in the past week (yes vs.
no), and menopausal status at time of sample collection. Typically, one control was selected for each case. Because some
cases from our substudy could be matched with the controls
for cases with other types of cancers, there were second controls for 91 cases and third controls for 3 cases.
Laboratory methods

Genomic DNA was extracted from buffy coats using a

QIAamp DNA kit (Qiagen, Valencia, California) following
the manufacturers protocol. Relative telomere length was
measured using a monochrome multiplex quantitative polymerase chain reaction method described recently by
Cawthon (23), with minor modications. Briey, telomere
length assay was carried out in a 15-L polymerase chain
reaction consisting of 1x QuantiFast SYBR Green PCR
Master Mix (Qiagen), 700-nM telomere primers telg and
telc, 200-nM albumin primers albugcr1 and albdgcr1, and
5-ng DNA. A multistep thermal cycling procedure was
performed on a Bio-Rad (Hercules, California) CFX384
Real-Time System. After amplication, a dissociation curve
was performed to conrm the specicity of the reaction. For
each standard curve, 2-fold serial dilutions of a reference
DNA sample were used to produce a standard curve. Additionally, a calibrator DNA (same as the reference DNA), 2
negative controls, and 2 quality-control DNA samples with a
long and short telomere length (Telo TAGGG Telomere
Length Assay kit; Roche, Indianapolis, Indiana) were included in each of the 384-well assay plates. Bio-Rad CFX
manager version 1.6 software was used to determine the relative telomere length through a 2-step relative quantication.
In the rst step, the ratio of the telomere repeat copy number
to the single-copy gene (albumin) copy number, as a
measure of relative telomere length, was determined for each
sample based on the standard curve. In the second step, the
ratio for each sample was normalized to the calibrator DNA
to standardize sample values across all reaction plates.
Samples from each matched case-control set were assayed
on the same plate. Laboratory personnel were blinded to
each subjects case-control status. Coefcients of variation
for the interplate ratio of telomere repeat copy number to the
single-copy gene (albumin) copy number were 15.6% and
16.2% for the long and short telomere quality-control
samples, respectively. Inter- and intraplate coefcients of
variation of calibrator DNA samples were 12.2% and 5.3%,
respectively. The mean ratio of long to short telomere
quality-control samples in our assays was 2.9, very close to
the mean ratio of 2.7 determined by southern blot method
(Telo TAGGG Telomere Length Assay kit; Roche), indicating that our protocol to estimate telomere lengths was valid.
Statistical methods

Means and percentages of selected baseline characteristics for cases and controls were calculated and compared
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components of telomerase complex, which results in short

telomeres, leading to bone marrow failure and an elevated
risk of cancer (9).
Studies using clinical samples obtained from patients
with cancerincluding cancers of the breast, lung, and
colon/rectumhave shown that, in general, telomere length
is shorter in cancer tissues than in adjacent tissues (10).
Recently, several epidemiologic studies have evaluated the
association of germline telomere length, measured using
DNA from peripheral blood cells or buccal cells, with
cancer risk and prognosis (11, 12). Regarding breast
cancer, results from previous studies have been conicting.
Of the 8 retrospective case-control studies reported to date,
2 showed short telomere length to be associated with increased risk (13, 14), whereas 2 other studies found an elevated risk among women with longer telomeres (15, 16).
Four studies showed no signicant association (1720). To
our knowledge, only 2 prospective studies have been conducted, and both studies failed to identify any statistically
signicant associations (14, 21). Reasons for the apparently
contradictory results remain unknown. Differences in study
designs, sample sizes, analytic approaches, laboratory assay
protocols, and background exposures could have contributed to the inconsistent ndings. To clarify the association
between telomere length and breast cancer risk, we conducted a large case-control study nested within the Shanghai Womens Health Study using blood samples collected
before cancer diagnosis.

Telomere Length and Breast Cancer 619

Table 1. Comparison of Demographic Characteristics and Known Breast Cancer Risk Factors in Cases and Their
Matched Controls, Shanghai Womens Health Study, 19972000
Variable

Cases (n = 601)
%

Mean (SD)

Controls (n = 695)
%

Mean (SD)

P Valuea

Demographic characteristic
Age at blood collection, years

52.7 (8.8)

53.4 (9.0)

0.163

High school education or above

50.6

38.4

<0.001

Family income >30,000 yuan

18.6

17.0

0.4362

Postmenopausal

48.3

50.4

0.449

Known risk factors

0.134

Age at menopause, yearsb

49.3 (4.6)

48.8 (3.8)

0.009

Age at menarche, years

14.7 (1.8)

15.0 (1.8)

<0.001

Age at first live birth, years

26.4 (4.1)

25.5 (4.2)

0.004

1.6 (1.1)

1.8 (1.2)

0.971

24.4 (3.5)

24.3 (3.5)

0.513

Number of live births

Body mass indexc
34.9

36.7

0.747

Ever used hormone replacement

3.0

3.3

0.002

Family history of breast cancer

4.0

1.3

0.163

Abbreviation: SD, standard deviation.

P values were derived from t tests for continuous variables or 2 tests for categorical variables.
b
Among postmenopausal women.
c
Weight (kg)/height (m)2.
a

using t tests for continuous variables and 2 tests for categorical variables. Data on relative telomere length were
log-transformed so that these data were approximately normally distributed.
We compared the case-control difference of the geometric
means of the log-transformed telomere length using a 2-way
(case-control status and matched sets) analysis of variance
with adjustment for age at blood collection. Because DNA
samples for cases and controls in the same matched sets were
assayed on the same plates, interplate differences for the
matched sets were accounted for automatically. To evaluate
the association between breast cancer risk and telomere
length, the ratio for telomere length was categorized into
quintiles based on distribution among controls. Odds ratios
and 95% condence intervals were estimated using conditional logistic regression models to account for the matched
sets, with additional adjustment for age at blood collection.
Further adjustment for other demographic characteristics and
known breast cancer risk factors did not materially alter the
association between telomere length and breast cancer risk.
Tests for linear trend were estimated using the median value
for each telomere length quintile. A restricted cubic spline
function was used in the conditional logistic regression
model to evaluate the shape of the association (24). The
model with 4 knots was used in the analysis because this
model had the best t of data as demonstrated by its having
the lowest Akaike information criterion value. Likelihood
ratio tests were used to evaluate linear effect, nonlinear effect,
and overall effect of telomere length on breast cancer risk.
Stratied analyses were performed to evaluate potential interactions. All statistical tests were based on 2-sided probability.
Am J Epidemiol. 2013;177(7):617624

RESULTS

Table 1 presents the distributions of selected baseline demographic characteristics and major risk factors for breast
cancer cases and matched controls. Cases and controls were
comparable in age at blood collection, age at menopause,
body mass index (BMI; weight (kg)/height (m)2), and participation in leisure-time physical activity. There were
signicant case-control differences in the distributions of education, age at menarche, age at rst live birth, and family
history of breast cancer. Very few women in this cohort regularly smoked cigarettes (2.9%), drank alcoholic beverages
(2.7%), or took hormone replacement therapy (3.3%).
Telomere length was inversely correlated with age
(r = 0.22; P < 0.0001). The geometric means of telomere
length were approximately 6.6% (cases) and 4.2% (controls) shorter in women who were 5059 years of age and
10.9% (cases) and 9.4% (controls) shorter in those who
were 60 years of age or older compared with women who
were younger than 50 years (data not shown). With the exception of BMI, no apparent association of telomere length
was seen for other major breast cancer risk factors listed in
Table 1. Both underweight (BMI <18.5) and obesity (BMI
30) were associated with reduced telomere length (data
not shown).
Overall, no signicant difference was observed in geometric means of telomere length between cases and controls (Table 2). Among postmenopausal women, however,
telomere length was signicantly shorter in cases than in
controls (P = 0.0485). No difference was observed among
premenopausal women.

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Ever exercised regularly

620 Qu et al.

Table 2. Case-Control Differences in Relative Telomere Length, Shanghai Womens Health Study, 19972009
Subject Category

No. of Subjects

P Value

95% CIa

Log Telomere Length

All women
Cases

601

0.040

0.054, 0.027

Controls

695

0.027

0.039, 0.014

Cases

311

0.002

0.016, 0.020

Controls

345

0.004

0.013, 0.021

Cases

290

0.084

0.103, 0.064

Controls

350

0.058

0.076, 0.041

0.1337

Premenopausal women
0.8634

Postmenopausal women
0.0485

Abbreviation: CI, confidence interval.

a
Adjusted for age.

Table 3. Adjusted Odds Ratios for the Association Between Telomere Length and Breast Cancer Risk by
Menopausal Status, Shanghai Womens Health Study, 19972009
Quintile of Telomere Length
by Participant Category

No. of Cases

No. of Controls

Longest Telomere
Group

Second-Longest
Telomere Group

ORa,b

95% CIa,b

ORa,c

95% CIa,c

0.90, 2.04

All women

601

695

5 (long)

117

139

1.00

Referent

1.35

88

139

0.74

0.49, 1.12

1.00

Referent

119

139

1.03

0.66, 1.61

1.39

0.95, 2.04

129

139

1.32

0.81, 2.16

1.79

1.17, 2.75

1 (short)

148

139

1.77

1.02, 3.06

2.39

1.45, 3.92

Premenopausal women

311

345

5 (long)

70

68

1.00

Referent

1.69

0.98, 2.91

46

75

0.59

0.34, 1.02

1.00

Referent

75

72

1.05

0.60, 1.83

1.77

1.06, 2.97

60

71

0.99

0.51, 1.92

1.67

0.90, 3.11

1 (short)

60

59

1.33

0.63, 2.80

2.25

1.11, 4.58

290

350

5 (long)

47

71

1.00

Referent

1.03

0.54, 1.96

42

64

0.98

0.51, 1.87

1.00

Referent

44

67

0.99

0.46, 2.11

1.01

0.56, 1.83

69

68

1.74

0.82, 3.70

1.78

0.97, 3.26

1 (short)

88

80

2.32

0.99, 5.43

2.38

1.18, 4.80

Postmenopausal women

Abbreviations: CI, confidence interval; OR, odds ratio.

a
Adjusted for age at blood collection.
b
Using subjects in the longest telomere group, the fifth quintile was the reference group.
c
Using subjects in the second-longest telomere group, the fourth quintile was the reference group.

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condence interval (CI): 1.02, 3.06) (Table 3). This association was stronger in postmenopausal women (for quintile
1 vs. quintile 5, OR = 2.32, 95% CI: 0.99, 5.43) than
in premenopausal women (for quintile 1 vs. quintile 5,
OR = 1.33, 95% CI: 0.63, 2. 80), although the interaction
test was not statistically signicant. Women in the secondlongest telomere group (fourth quintile) had the lowest risk

To estimate odds ratios for the association between

breast cancer risk and telomere length, subjects were categorized into 5 groups based on quintile distribution among
controls (Table 3). Compared with women in the longest
telomere group (top 20%), those in the shortest telomere
group (bottom 20%) had a statistically signicant increase
in the risk of breast cancer (odds ratio (OR) = 1.77, 95%

Telomere Length and Breast Cancer 621

of breast cancer, and a reverse J-shaped association was observed using restricted cubic spline function (Figure 1; test
for nonlinearity P = 0.0127 in all women combined). When
women in the fourth quintile were used as the reference
group for risk estimate, odds ratios for multiple groups with
a short telomere were statistically signicant (Table 3; odds
ratios are shown in the right panel). A similar pattern of
association was found after excluding cases diagnosed
within the rst year after blood collection.
Both BMI and physical activity level have been reported
to be related to telomere length. Therefore, we investigated
potential interactions of telomere lengths with these 2 variables, as well as with years of menstruation (as a measure
of cumulative endogenous estrogen exposure), in relation to
breast cancer risk (Table 4). A short telomere was associated with elevated breast cancer risk in all groups dened by
BMI, physical activity level, and years of menstruation, although not all odds ratios were statistically signicant. A
4-fold elevated risk of breast cancer was observed among
overweight postmenopausal women (BMI 25) who also
had a short telomere length (lowest quintile). The test for
multiplicative interaction between BMI and telomere length
was marginally signicant (P = 0.078) (Table 4).
DISCUSSION

In the present large case-control study in which we used

genomic DNA from peripheral blood cells collected before
cancer diagnosis, we observed a reverse J-shaped association between telomere length and breast cancer risk. Compared with the group of women whose telomeres were in
the 60th to 79th percentiles of length (fourth quintile), the
risk of breast cancer was increased in a dose-response
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Figure 1. Association between baseline leukocyte telomere length

and subsequent risk of breast cancer, Shanghai Womens Health
Study, 19972009. OR, odds ratio.

manner with a decreasing quintile of telomeres to a more

than 2-fold elevated risk in women with the shortest telomeres (bottom quintile). Women in the top quintile, whose
telomere length measured in the top 20%, also had an elevated risk, although the risk estimate was not statistically
signicant. In general, our study supports the hypothesis
that telomere shortening is associated with an elevated risk
of breast cancer.
It has been well documented that short telomeres are associated with multiple premature aging syndromes, including ataxia telangiectasia, ataxia-telangiectasialike disorder,
aplastic anemia, Bloom syndrome, Fanconi anemia, Nijmegen breakage syndrome, and dyskeratosis congenita (1, 9).
Patients with these syndromes have an elevated risk of
cancer. Mouse models also support the notion that telomerase deciency and short telomere-length increase the risk
of a tumor (1). Epidemiologic studies have linked short
telomeres in peripheral blood leukocytes to elevated risks
of several human cancers, including cancers of the bladder,
esophagus, stomach, head and neck, ovary, and kidneys
(11, 12, 25). Breast cancer has been investigated in multiple
previous studies. However, 8 of 10 previous studies were
retrospective case-control studies that used blood samples
collected after cancer diagnosis or even cancer treatment to
assess telomere length (1320). Results from these studies
have been inconsistent, perhaps because of the inuence of
cancer diagnosis and treatment on telomeres (26). Indeed, a
recent study in which investigators used blood samples collected after cancer diagnosis showed a striking inverse association between telomere length and the risks of cancers
of the breast and colon/rectum (14). The association,
however, was substantially attenuated when using samples
collected before cancer diagnosis (14). Four of the 8 retrospective case-control studies showed no signicant association (1720), and 2 other studies found an elevated risk
among women with longer telomeres (15, 16). Only 2
nested case-control studies of breast cancer have examined
the association with telomere length (14, 21). Using data
and prospectively collected samples from the Nurses
Health Study, De Vivo et al. (21) reported that having a
short telomere length was related to a slightly elevated, although not statistically signicantly so, risk of breast cancer
in postmenopausal women (bottom quartile versus top,
OR = 1.25, 95% CI: 0.93, 1.88). Intriguingly, the risk of
breast cancer was lowest in the third quartile, similar to
what was found in our study. The other published prospective study, which was nested within the European Prospective Investigation Into Cancer and Nutrition-Norfolk
cohort, showed that short telomeres were associated with a
nonsignicantly elevated breast cancer risk (quintile 4 vs.
quintile 1, OR = 1.58, 95% CI: 0.75, 3.31) (14). The sample
size for that study, however, was relatively small (199 cases
and 420 controls). Although neither of those studies reported statistically signicant associations, the direction of association identied in both studies was consistent with the
direction found in our study.
The observation of a suggestive elevated risk of breast
cancer among women in the longest telomere group is unexpected, although biologically plausible. Long telomeres
could be a result of telomerase reactivation, which may

622 Qu et al.
Table 4. Odds Ratiosa for Breast Cancer by Joint Distributions of Telomere Length and Body Mass Index,b Physical Activity Level, and Years
of Menstruation, Shanghai Womens Health Study, 19972009
Quartile of Telomere Length
First
OR

Second
95% CI

OR

Third

95% CI

OR

All Women

Fourth
95% CI

OR

95% CI

Body mass index

<25

1.66

1.00, 2.77

1.27

0.82, 1.96

1.00

Referent

1.12

0.72, 1.75

25

2.02

1.19, 3.42

1.24

0.75, 2.03

1.33

0.81, 2.19

1.18

0.67, 2.07

P for interaction

0.786

Exercise
Yes

1.58

0.92, 2.70

0.89

0.54, 1.47

1.06

0.65, 1.72

0.96

0.55, 1.69

No

1.68

1.01, 2.77

1.32

0.86, 2.04

1.00

Referent

1.04

1.67, 1.61

P for interaction

0.612

Years of menstruation
1.56

0.87, 2.79

0.96

0.57, 1.60

1.00

Referent

1.05

0.64, 1.73

32 years

2.46

1.36, 4.45

1.76

1.04, 2.97

1.38

0.81, 2.35

1.37

0.77, 2.47

P for interaction

0.793
Postmenopausal Women d

Body mass index

<25

3.01

1.33, 6.81

2.56

1.24, 5.27

1.00

Referent

2.04

0.85, 4.87

25

4.23

1.90, 9.41

2.22

1.02, 4.82

2.74

1.25, 6.02

1.70

0.64, 4.55

P for interaction

0.078

Exercise
Yes

1.95

0.93, 4.06

1.46

0.71, 2.97

0.96

0.48, 1.91

0.97

0.40, 2.31

No

2.19

1.02, 4.71

1.33

0.67, 2.61

1.00

Referent

1.07

0.49, 2.31

1.00

Referent

1.09

0.37, 3.23

1.47

0.61, 3.57

1.68

0.63, 4.46

P for interaction

0.967

Years of menstruation
<32 years

2.35

0.87, 6.39

0.79

0.29, 2.19

32 years

3.49

1.37, 8.84

2.67

1.14, 6.30

P for interaction

0.383

Abbreviations: CI, confidence interval; OR, odds ratio.

a
Adjusted for age at blood collection.
b
Weight (kg)/height (m)2.
c
There were 601 cases and 695 controls.
d
There were 290 postmenopausal cases and 350 controls.

predispose cells to delayed senescence and increase the

chance of acquiring genetic abnormalities. It has been
shown that a long telomere may be associated with an increased risk of some cancers (12), including lung cancer
(27) and non-Hodgkins lymphoma (28). Specically for
breast cancer, a previous study also found an elevated risk
of cancer related to long telomeres (15). However, blood
samples for that study were collected after patients were diagnosed with cancer.
The major strengths of our study include the large sample
size and the use of blood samples collected before diagnosis. Very few women smoked cigarettes regularly (2.4%)
(22), and thus potential confounding effects due to cigarette
smoking should be minimal. Similar to other studies, however, the precision of relative telomere measurement was

not optimal, and a relatively large coefcient of variation

was observed. However, this measurement error should be
random, which tends to attenuate the association between
telomeres and breast cancer risk. By analyzing samples
from the same case-control set in the same plate and using
the monochrome multiplex quantitative polymerase chain
reaction method, we should have minimized the impact of
interplate variation and detection bias on study results. Extensive data were collected in our study, which allowed us
to carefully evaluate the potential inuence of confounders
on our results. No major confounder, however, was identied in the study. Nevertheless, we cannot completely rule
out the possibility of unmeasured or residual confounding
effects on our results. The potential for selection bias
should be small in this study because of the very high
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<32 years

Telomere Length and Breast Cancer 623

response rate (92.7%) at the baseline survey and the very

low rate of loss to follow-up (<1%).
In conclusion, our study, a large case-control study using
prediagnostic samples, revealed a reverse J-shaped association between telomere length and breast cancer risk. In
general, these ndings support the hypothesis that telomere
shortening is associated with an elevated risk of breast
cancer, but they also suggest a possible adverse effect of
long telomeres. Additional research is needed to further
evaluate the association of telomere length and breast
cancer risk.

ACKNOWLEDGMENTS

REFERENCES
1. Blasco MA. Telomeres and human disease: ageing, cancer
and beyond. Nat Rev Genet. 2005;6(8):611622.
2. Stewart SA, Weinberg RA. Telomeres: cancer to human
aging. Annu Rev Cell Dev Biol. 2006;22:531557.
3. Greider CW. Telomerase activity, cell proliferation, and
cancer. Proc Natl Acad Sci U S A. 1998;95(1):9092.
4. Mathon NF, Lloyd AC. Cell senescence and cancer. Nat Rev
Cancer. 2001;1(3):203213.
5. Epel ES, Blackburn EH, Lin J, et al. Accelerated telomere
shortening in response to life stress. Proc Natl Acad Sci
U S A. 2004;101(49):1731217315.
6. Oikawa S, Tada-Oikawa S, Kawanishi S. Site-specic DNA
damage at the GGG sequence by UVA involves acceleration
of telomere shortening. Biochemistry. 2001;40(15):
47634768.
7. Valdes AM, Andrew T, Gardner JP, et al. Obesity, cigarette
smoking, and telomere length in women. Lancet. 2005;
366(9486):662664.
8. von Zglinicki T . Oxidative stress shortens telomeres. Trends
Biochem Sci. 2002;27(7):339344.
9. Alter BP, Giri N, Savage SA, et al. Cancer in dyskeratosis
congenita. Blood. 2009;113(26):65496557.
Am J Epidemiol. 2013;177(7):617624

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Author afliations: Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center
and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee (Shimian Qu, Wanqing Wen, Xiao-Ou Shu, Jie Wu,
Gong Yang, Qiuyin Cai, Wei Zheng); Occupational Epidemiology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Wong-Ho Chow,
Bu-Tian Ji, Nathaniel Rothman); and Department of Epidemiology, Shanghai Cancer Institute, Shanghai, Peoples
Republic of China (Yong-Bing Xiang, Yu-Tang Gao).
Funding for this work was provided by the National Institutes of Health (grant R37 CA 070867). Sample preparations and telomere length assays were performed at the
Survey and Biospecimen Shared Resource, which is supported in part by the Vanderbilt-Ingram Cancer Center
(P30 CA68485).
We wish to thank Regina Courtney for her excellent laboratory assistance in sample handling and preparation.
Conict of interest: none declared.

10. Bisof M, Heaphy CM, Grifth JK. Telomeres: prognostic

markers for solid tumors. Int J Cancer. 2006;119(10):
22552260.
11. Ma H, Zhou Z, Wei S, et al. Shortened telomere length is
associated with increased risk of cancer: a meta-analysis.
PLoS One. 2011;6:e20466.
12. Wentzensen IM, Mirabello L, Pfeiffer RM, et al. The
association of telomere length and cancer: a metaanalysis. Cancer Epidemiol Biomarkers Prev. 2011;20(6):
12381250.
13. Levy T, Agoulnik I, Atkinson EN, et al. Telomere length in
human white blood cells remains constant with age and is
shorter in breast cancer patients. Anticancer Res. 1998;
18(3A):13451349.
14. Pooley KA, Sandhu MS, Tyrer J, et al. Telomere length in
prospective and retrospective cancer case-control studies.
Cancer Res. 2010;70(8):31703176.
15. Svenson U, Nordfjall K, Stegmayr B, et al. Breast cancer
survival is associated with telomere length in peripheral blood
cells. Cancer Res. 2008;68(10):36183623.
16. Gramatges MM, Telli ML, Balise R, et al. Longer relative
telomere length in blood from women with sporadic and
familial breast cancer compared with healthy controls. Cancer
Epidemiol Biomarkers Prev. 2010;19(2):605613.
17. Zheng YL, Ambrosone C, Byrne C, et al. Telomere length in
blood cells and breast cancer risk: investigations in two casecontrol studies. Breast Cancer Res Treat. 2010;120(3):
769775.
18. Shen J, Terry MB, Gurvich I, et al. Short telomere length and
breast cancer risk: a study in sister sets. Cancer Res. 2007;
67(11):55385544.
19. Shen J, Gammon MD, Terry MB, et al. Telomere length,
oxidative damage, antioxidants and breast cancer risk. Int
J Cancer. 2009;124(7):16371643.
20. Barwell J, Pangon L, Georgiou A, et al. Is telomere length in
peripheral blood lymphocytes correlated with cancer
susceptibility or radiosensitivity? Br J Cancer. 2007;97(12):
16961700.
21. De Vivo I, Prescott J, Wong JY, et al. A prospective study of
relative telomere length and postmenopausal breast cancer
risk. Cancer Epidemiol Biomarkers Prev. 2009;18(4):
11521156.
22. Zheng W, Chow WH, Yang G, et al. The Shanghai Womens
Health Study: rationale, study design, and baseline
characteristics. Am J Epidemiol. 2005;162(11):11231131.
23. Cawthon RM. Telomere length measurement by a novel
monochrome multiplex quantitative PCR method. Nucleic
Acids Res. 2009;37(3):e21.
24. Harrell F. Regression Modeling Strategies. New York, NY:
Springer; 2001.
25. Prescott J, Wentzensen IM, Savage SA, et al. Epidemiologic
evidence for a role of telomere dysfunction in cancer
etiology. Mutat Res. 2011;730(1-2):7584.
26. Schroder CP, Wisman GB, de JS, et al. Telomere length in
breast cancer patients before and after chemotherapy with or
without stem cell transplantation. Br J Cancer. 2001;84(10):
13481353.
27. Shen M, Cawthon R, Rothman N, et al. A prospective study
of telomere length measured by monochrome multiplex
quantitative PCR and risk of lung cancer. Lung Cancer.
2011;73(2):133137.
28. Lan Q, Cawthon R, Shen M, et al. A prospective study of
telomere length measured by monochrome multiplex
quantitative PCR and risk of non-Hodgkin lymphoma. Clin
Cancer Res. 2009;15(23):74297433.

624 Qu et al.

Appendix Table 1. Comparison of Demographic Characteristics and Known Breast Cancer Risk Factors in
Subjects With and Without Blood Samples, Shanghai Womens Health Study, 19972009
Provided a Blood Sample at Baseline
No (n = 18,111)

Variable
%

Mean
(SD)

Yes (n = 56,831)
%

Mean
(SD)

P Valuea

Demographic characteristic
Age at blood collection, years

52.0 (9.1)

52.2 (9.1)

0.0604

High school education or above

51.7

38.2

<0.001

Family income >30,000 yuan

20.9

16.4

<0.0001

Postmenopausal

48.9

49.8

0.0353

Known risk factors

48.8 (4.1)

48.6 (4.4)

<0.0001

Age at menarche, years

14.9 (1.7)

14.9 (1.7)

0.0135

Age at first live birth, years

25.5 (4.2)

25.5 (4.1)

0.2047

1.7 (1.2)

1.8 (1.2)

<0.0001

23.7 (3.5)

24.1 (3.4)

<0.0001

Number of live births

Body mass indexc
33.2

36.2

<0.0001

Ever used hormone replacement

Ever exercised regularly

3.6

3.5

0.3128

Family history of breast cancer

1.8

1.9

0.1143

Abbreviation: SD, standard deviation.

P values were derived from t tests for continuous variables or 2 tests for categorical variables.
b
Among postmenopausal women.
c
Weight (kg)/height (m)2.
a

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Age at menopause, yearsb