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only eight women in the higher stratification and a linear trend analysis was not significant (Freedman et al., 2007). A nested case–control study using data from the Nurses’ Health Study (NHS) (Bertone-Johnson et al., 2005) found no significant relationship between higher plasma 25OHD concentrations and decreased risk for breast cancer overall, except when the population was restricted to women over 60 years of age. Another nested case–control cohort study of postmenopausal women participating in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial also found no evidence supporting the hypothesis that higher plasma 25OHD concentrations were associated with reduced risk of breast cancer in this cohort (Freedman et al., 2008).

Analysis of the results of RCTs reviewed in AHRQ-Tufts found no significant effect of supplementation with both vitamin D and calcium on breast cancer incidence and no association between the intervention and risk for death from breast cancer. Subjects with lower baseline 25OHD levels were found to be at increased risk for breast cancer; however, the association was not significant after adjusting for body mass index and physical activity (Chlebowski et al., 2008).

A meta-analysis of evidence from observational studies carried out by IARC (2008) evaluated associations between serum vitamin D levels and cancer. The analyses for breast cancer risk indicated no significant or consistent associations. A literature review and all-inclusive meta-analysis of published studies of heterogeneous quality individually examined the impact of estimated vitamin D intake, circulating 25OHD levels, and calcium intake on breast cancer risk (Chen et al., 2010). Their analysis suggests an inverse relationship between risk and level of vitamin D intake, serum 25OHD3 level, and calcium intake.

Additional evidence from randomized controlled trials WHI was used as a data source in an 8-year follow-up study for risk of benign proliferative breast disease, a putative premalignant condition associated with increased risk of subsequent cancer (Rohan et al., 2009). This study identified an association between risk for breast cancer and baseline age but found no effect of supplemental calcium and vitamin D intervention on reducing risk for breast cancer.

Observational studies Several case–control and cohort studies conducted subsequent to the systematic reviews were identified that examined associations between dietary and supplemental intake of vitamin D and calcium and risk for breast cancer, and these have shown mixed results. Rossi et al. (2009), a large case–control study in Italy, found an inverse association between vitamin D intake and risk for breast cancer at intakes of 188 IU/day or greater, suggesting a threshold effect; however, when risk was cal-

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