Open Access Research article

Assessing risk of breast cancer in an ethnically South-East Asia population (results of a multiple ethnic groups study)

Fei Gao123*, David Machin5, Khuan-Yew Chow6, Yu-Fan Sim1, Stephen W Duffy7, David B Matchar34, Chien-Hui Goh1 and Kee-Seng Chia8

Author Affiliations

1 Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre Singapore, 11 Hospital Drive, Singapore 169610

2 National Heart Centre Singapore, 17 Third Hospital Drive Avenue, Singapore 168752

3 Health Services & Systems Research, Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857

4 Department of Medicine, Duke University Medical Center, 2400 Pratt Street, Durham, NC, 27705, USA

5 Medical Statistics Unit, School of Health and Related Research, University of Sheffield, Regents Court, 30 Regent Street, Sheffield, S1 4DA, UK

6 National Registry of Diseases Office, Health Promotion Board, Ministry of Health, Singapore, 168937

7 Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK

8 Centre for Molecular Epidemiology, National University of Singapore, Singapore, 138671

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BMC Cancer 2012, 12:529  doi:10.1186/1471-2407-12-529

Published: 19 November 2012



Gail and others developed a model (GAIL) using age-at-menarche, age-at-birth of first live child, number of previous benign breast biopsy examinations, and number of first-degree-relatives with breast cancer as well as baseline age-specific breast cancer risks for predicting the 5-year risk of invasive breast cancer for Caucasian women. However, the validity of the model for projecting risk in South-East Asian women is uncertain. We evaluated GAIL and attempted to improve its performance for Singapore women of Chinese, Malay and Indian origins.


Data from the Singapore Breast Screening Programme (SBSP) are used. Motivated by lower breast cancer incidence in many Asian countries, we utilised race-specific invasive breast cancer and other cause mortality rates for Singapore women to produce GAIL-SBSP. By using risk factor information from a nested case-control study within SBSP, alternative models incorporating fewer then additional risk factors were determined. Their accuracy was assessed by comparing the expected cases (E) with the observed (O) by the ratio (E/O) and 95% confidence interval (CI) and the respective concordance statistics estimated.


From 28,883 women, GAIL-SBSP predicted 241.83 cases during the 5-year follow-up while 241 were reported (E/O=1.00, CI=0.88 to 1.14). Except for women who had two or more first-degree-relatives with breast cancer, satisfactory prediction was present in almost all risk categories. This agreement was reflected in Chinese and Malay, but not in Indian women. We also found that a simplified model (S-GAIL-SBSP) including only age-at-menarche, age-at-birth of first live child and number of first-degree-relatives performed similarly with associated concordance statistics of 0.5997. Taking account of body mass index and parity did not improve the calibration of S-GAIL-SBSP.


GAIL can be refined by using national race-specific invasive breast cancer rates and mortality rates for causes other than breast cancer. A revised model containing only three variables (S-GAIL-SBSP) provides a simpler approach for projecting absolute risk of invasive breast cancer in South-East Asia women. Nevertheless its role in counseling the individual women regarding their risk of breast cancer remains problematical and needs to be validated in independent data.