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Original Article Apolipoprotein E (APOE) Polymorphisms and Susceptibility to Breast Cancer: A Meta-Analysis
Mostafa Saadat, PhD
Cancer Research and Treatment : Official Journal of Korean Cancer Association 2012;44(2):121-126.
DOI: https://doi.org/10.4143/crt.2012.44.2.121
Published online: June 30, 2012

Department of Biology, Shiraz University College of Sciences, Shiraz, Iran.

Correspondence: Mostafa Saadat, PhD. Department of Biology, Shiraz University College of Sciences, Shiraz 71454, Iran.
Tel: 98-711-6137432, Fax: 98-711-6286421, msaadat41@yahoo.com
• Received: March 1, 2012   • Accepted: April 30, 2012

Copyright © 2012 by the Korean Cancer Association

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    Apolipoprotein E (APOE, MIM: 107741) has three functionally distinct isoforms of the protein (E2, E3, and E4), encoded by corresponding alleles ε2, ε3, and ε4, which have been well described. Findings from previous studies investigating association between APOE polymorphisms and breast cancer risk have been inconsistent. The present meta-analysis was conducted in order to investigate association of APOE polymorphisms with risk of breast cancer.
  • Materials and Methods
    Several electronic databases were used for identification of studies containing information on APOE polymorphisms and breast cancer risk published up to January 2012. We identified 10 eligible studies, including 3,835 subjects (2008 patients, and 1,827 healthy controls), that reported on polymorphisms of APOE and risk of breast cancer. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were obtained using a fixed and random-effects models.
  • Results
    Among studies reported from Asia, an association of the ε4 allele with increased risk of breast cancer, in comparison with the ε3 allele, was observed (OR, 1.56; 95% CI, 1.19 to 2.04; p=0.001). It should be noted that allele ε2 showed no association with breast cancer risk. Among Caucasians, neither the ε4 (OR, 0.99; 95% CI, 0.83 to 1.17; p=0.917) nor the ε2 (OR, 0.92; 95% CI, 0.72 to 1.17; p=0.514) allele showed an association with susceptibility to breast cancer, when compared with the ε3 allele. Carriers of the ε4 allele (E4E4, E4E3, and E4E2 genotypes), in comparison with the E3E3 genotype, showed an association with elevated risk of breast cancer only among Asians (OR, 1.75; 95% CI, 1.23 to 2.47; p=0.002). No publication bias was detected.
  • Conclusion
    This meta-analysis suggest that the APOEε4 allele is a low-penetrant risk factor for development of breast cancer.
  • Key words: Apolipoproteins E, Breast neoplasms, Meta-analysis, Disease susceptibility
Apolipoprotein E (APOE, MIM: 107741) is involved in cholesterol transport, lipid metabolism, and protein synthesis through mediation of binding of the low-density lipoprotein receptor and the APOE receptor of lipid particles to specific lipoprotein receptors. It is also involved in numerous other functions, including tissue repair, immune response and regulation, and cell growth and differentiation. The APOE gene is located on human chromosome 19q13.2; three functionally distinct isoforms of the protein (E2, E3, and E4), encoded by corresponding alleles ε2, ε3, and ε4, have been described. These isoforms, originally identified by isoelectric focusing, are defined by amino acid changes at positions 112 (rs. 429358) and 158 (rs. 7412): alleles ε2, ε3, and ε4 are defined, respectively, by cysteine/cysteine, cysteine/arginine, and arginine/arginine at these two sites. The most common isoform is ε3, with a frequency of approximately 70-80% [1,2].
Individual case-control association studies are usually small and underpowered and, thus, are unable to provide a definitive answer, even in cases involving existence of a true association. Thus, meta-analysis can effectively combine data from several studies, resulting in increased statistical power (lower type II error rate). Findings from previous studies investigating the association between APOE polymorphisms and breast cancer risk have been inconsistent [3-10]. Some studies have reported an association of E4, compared with the E3E3 genotype, with increased risk of breast cancer [7,9], while other reported findings have indicated no association between APOE polymorphism and risk of breast cancer. To the best of our knowledge this is the first meta-analysis to investigate the association of APOE polymorphisms with risk of breast cancer.
1. Search strategy
Electronic databases, including MEDLINE (National Library of Medicine, Washington, DC), Scopus, EBSCOhost Research Databases, ProQuest, Scirus, Directory of Open Access Journals (DOAJ), Indian Science Abstract, Google Scholar, SAGE, Open J-Gate, High-Wire, J-STAGE, KoreaMed, and Scientific Information Database (SID) were searched for identification of studies on APOE polymorphisms and breast cancer published up to January 2012. Search terms included "breast cancer", polymorphisms, "apolipoprotein E" or "apoE" or "APOE" or "Apo E." In addition, references cited in the retrieved articles were screened in an effort to trace additional relevant studies.
2. Inclusion criteria
The meta-analysis was limited to articles published in the English language. Articles describing case-control design studies and their primary references, which showed no obvious overlap of cases with other studies were selected for analysis. A report by Menzel et al. [6] included two case-control groups; therefore it was included as two studies in the meta-analysis. Also, a report by Niemi et al. [4], who investigated risk associated with either breast cancer or benign breast cancer with APOE polymorphism, was included as two case control studies. Articles selected for meta-analysis had no overlap of subjects with other studies.
3. Data extraction
All studies were reviewed twice and a standardized form was used for data extraction. Data were collected on the authors, year of publication, country of origin, study design, source of control group (hospital based, population based), ethnicity, and numbers of APOE genotypes and/or APOE alleles among cases and controls. A database was established according to information extracted from each article. It should be noted that in the report by Menzel et al. [6], numbers of participants for each genotype of APOE were not reported, as with other papers as well. Also, the numbers of participants for each polymorphism of APOE were not equal. Therefore, the prevalence of the alleles was estimated from the row data. Table 1 lists the number of cases and control groups for each allele of the APOE polymorphism.
4. Statistical analysis
Odds ratio (OR) and their corresponding 95% confidence intervals (CI) of breast cancer associated with the genetic polymorphism of APOE were calculated for each comparison. First, I estimated the risk of the ε2 and ε4 alleles, compared with the wild-type ε3 allele. In the second step, I estimated the association between APOE genotypes and susceptibility to breast cancer. In this step, risks of the ε2 carriers (E2E2 and E2E3 genotypes) and ε4 carriers (E4E4, E4E3, and E4E2 genotypes) were compared with those of the E3E3 genotype.
In order to account for the possibility of heterogeneity across studies, a statistical test for heterogeneity was performed based on the Q statistic test, in which a p-value less than 0.10 suggested significant heterogeneity between studies [11]. Association was measured using random-effect or fixed-effect models according to the heterogeneity of the study. The fixed-effects method assumes no significant heterogeneity between results of the individual studies being pooled, whereas, the random-effects method allows for such heterogeneity. The fixed-effects method was used by Mantel and Haenszel [11] and the random-effects method was used by DerSimonian and Laird [12]. Visual inspection of Begg's funnel plots was performed for assessment of publication bias. An asymmetric plot suggested possible bias, in which case Egger's test [13] was used.
We identified 10 eligible studies, including 3,835 subjects (2008 patients, and 1,827 healthy controls), that reported on polymorphisms of APOE and risk of breast cancer, which are summarized in Table 1 [3-10]. The forest plot of the meta-analysis of the APOE alleles is shown in Fig. 1. Comparison of prevalence of the ε4 vs. ε3 alleles among cases and controls showed statistically significant heterogeneity between studies (Q=36.2, df=9, p<0.001). In order to find the source of heterogeneity, we stratified the studies based on the ethnicity of participants. As a result, heterogeneity showed a dramatic decrease among studies reported from Asia (Q=2.31, df=2, p=0.315), and a significant association was revealed. Presence of the ε4 allele indicated increased risk of breast cancer, in comparison with the ε3 allele (OR, 1.56; 95% CI, 1.19 to 2.04; p=0.001). It should be noted that no association of the ε2 allele with breast cancer risk was observed (Table 2).
Among other studies, heterogeneity was still observed. Excluding studies reported by Yaylim et al. [5] (due to a very small sample size) and Menzel et al. [6] (because there was not an equal number of the polymorphism at positions 112 and 158), heterogeneity showed a decrease (p>0.381) (Table 2). When compared with the ε3 allele, no association of either the ε4 (OR, 0.99; 95% CI, 0.83 to 1.17; p=0.917) or the ε2 (OR, 0.92; 95% CI, 0.72 to 1.17; p=0.514) allele with susceptibility to breast cancer was observed.
From 10 studies [3-10], only five studies [3,5,7,9,10] reported frequencies of APOE genotypes; these are summarized in Table 3. The forest plot of the meta-analysis of the APOE genotypes is shown in Fig. 2. As shown in Table 4, carriers of the ε4 allele (E4E4, E4E3, and E4E2 genotypes), in comparison with the E3E3 genotype, showed an association with elevated risk of breast cancer only among Asians (OR, 1.75; 95% CI, 1.23 to 2.47; p=0.002).
In order to assess publication bias for reported comparisons of the alleles and genotypes of APOE polymorphism and breast cancer risk, Begg's funnel plots were prepared and Egger's test was performed on the set of 10 studies [3-10]. The funnel plots (Fig. 3) appeared to be symmetrical in shape, and results of statistical analysis showed no significant publication bias.
The main finding of the present study was that carriers of the ε4 allele (E4E4, E4E3, and E4E2 genotypes), in comparison with the E3E3 genotype, showed an association with elevated risk of breast cancer only among Asians. In conclusion, findings of this meta-analysis suggest that the APOE ε4 allele is a low-penetrant risk factor for development of breast cancer. The APOE ε4 allele has been associated with increased risk of several multifactorial diseases, including hypertension [14] and coronary heart disease [15].
Based on findings from animal studies, ecologic studies, and studies of migrants from areas with low fat intake to those with high fat intake, an association of dietary fat intake with breast cancer risk has been hypothesized [16]. Previous studies have reported increased risk of breast cancer in association with elevated triglyceride (TG) levels [17]. Association of increased TG concentrations with decreased levels of sex hormone binding globulin, resulting in elevated levels of free estardiol and subsequently increased risk of breast cancer, has been reported [18]. Association of elevated TG levels with breast cancer risk among women with the APOE E4 genotype has been reported. The APOE E4 genotype has been reported to reduce TG clearance from plasma, resulting in persistently elevated TG concentrations, which could result in decreased levels of sex hormone binding globulin and elevated levels of free estradiol [3,19].
Possible association of some genetic polymorphisms with altered risk of some types of cancers only in some ethnic groups has been previously reported [20-23]. For example, increased risk of gastric cancer in association with the GSTT1 polymorphism has been reported only among Caucasians [21]. In relation to the XRCC1 polymorphism, association of Arg399Gln with lung and breast cancers among Asians, but not among Western countries, has been reported [20,23]. Similarly, findings from the present study indicated the APOE ε4 allele as a risk factor for development of breast cancer in Asia.
The gene encoding APOE was mapped on human chromosome 19q13.2. Of particular interest, based on published meta-analysis, single nucleotide polymorphisms of several genes, including XPD, ERCC2, XRCC1, and TGFB1, located on human chromosome 19q13, have been associated with breast cancer risk [23-25]. Therefore, it is quite probable that our present finding indicates a true association. We know that the major limitation of this study is the small number of articles available for meta-analysis, as well as its geographical distribution; for example, there are no reports from China, Western Europe, etc. Future well-designed large epidemiological studies are warranted in order to provide validation for the present findings.
The present meta-analysis suggest that the APOE ε4 allele is a low-penetrant risk factor for development of breast cancer.
Acknowledgements
The author is indebted to Dr. Maryam Ansari-Lari for critical reading of the manuscript and for her contribution in the discussion. This study was supported by Shiraz University.

Conflict of interest relevant to this article was not reported.

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Fig. 1
Forest plot of the meta-analysis of associations between alleles of apolipoprotein E (APOE) polymorphism and breast cancer risk. CI, confidence interval.
crt-44-121-g001.jpg
Fig. 2
Forest plot of the meta-analysis of associations between genotypes of apolipoprotein E (APOE) polymorphism and breast cancer risk. CI, confidence interval.
crt-44-121-g002.jpg
Fig. 3
Funnel plots of the meta-analysis of associations between alleles and/or genotypes of apolipoprotein E (APOE) polymorphisms and breast cancer risk (p-values of Egger's test were 0.556, 0.297, 0.923, and 0.488, for ε2 vs. ε3, ε4 vs. ε3, E2 carriers vs. E3E3, and E4 carriers vs. E3E3 comparisons, respectively).
crt-44-121-g003.jpg
Table 1
Prevalence of APOE alleles in studies used in the meta-analysis
Study Ethnicity Source
of controls		 Place Controls Cases
ε2 ε3 ε4 Total ε2 ε3 ε4 Total
Moysich et al., 2000 [3] Caucasians Hospital USA 43 533 88 664 34 424 62 520
Niemi et al., 2000 [4] Caucasians Population Finland 29 408 97 534 17 331 74 422
Niemi et al., 2000 [4] Caucasians Population Finland 29 408 97 534 22 467 109 589
Yaylim et al., 2003 [5] Caucasians ND Turkey 0 40 0 40 2 61 1 64
Menzel et al., 2004 [6] Caucasians Population Czech Rep. 27 237 36 300 15 156 17 188
Menzel et al., 2004 [6] Caucasians Hospital Austria 53 449 176 678 31 337 64 432
Chang et al., 2005 [7] Asians Hospital Taiwan 45 349 70 464 56 410 114 580
Chang et al., 2006 [8] Asians ND Taiwan 24 256 16 296 34 496 52 582
Surekha et al., 2008 [9] Caucasoid Hospital India 11 201 8 220 6 193 21 220
Porrata-Doria et al., 2010 [10] Caucasians Hospital Puerto-Rico 61 350 47 458 59 299 52 410

APOE, apolipoprotein E; ND, not described.

Table 2
Summary of meta-analysis of case-control studies examining alleles of APOE polymorphism and breast cancer risk
Studies No. of studies ε2 vs. ε3 ε4 vs. ε3
Q OR 95% CI p-value Q OR 95% CI p-value
All studies 10 6.88 0.88 0.74-1.05 0.179 36.62a) 0.96 0.84-1.09 0.539
All studies excluding studies 4-6 7 5.05 0.90 0.74-1.09 0.318 12.03 1.13 0.98-1.31 0.085
Asians 3 1.93 0.88 0.64-1.20 0.429 2.31 1.56 1.19-2.04 0.001
Caucasians excluding studies 4-6 3 3.07 0.92 0.72-1.17 0.514 2.03 0.99 0.83-1.17 0.917

a)There is significant (p<0.001) heterogeneity between studies. APOE, apolipoprotein E; Q, Q-statistic; OR, odds ratio; CI, confidence interval.

Table 3
Prevalence of apolipoprotein E (APOE) genotypes in studies used in the meta-analysis
Study Controls Cases
E2E2 E3E2 E3E3 E4E2 E4E3 E4E4 Total E2E2 E3E2 E3E3 E4E2 E4E3 E4E4 Total
Moysich et al., 2000 [3] 1 34 216 7 67 7 332 2 26 173 4 52 3 260
Yaylim et al., 2003 [5] 0 0 20 0 0 0 20 0 2 29 0 1 0 32
Chang et al., 2005 [7] 14 4 145 13 66 1 232 11 24 145 10 96 4 290
Surekha et al., 2008 [9] 0 9 93 2 6 0 110 0 6 84 0 19 1 110
Porrata-Doria et al., 2010 [10] 0 19 165 42 1 2 229 0 13 143 46 0 3 205
Table 4
Summary of meta-analysis of case-control studies examining genotypes of APOE polymorphism and breast cancer risk
Studies No. of studies E2 carriers vs. E3E3 E2 carriers vs. E3E3
Q OR 95% CI p-value Q OR 95% CI p-value
All studies 5 5.96 1.14 0.81-1.59 0.379 7.87 1.29 1.03-1.62 0.024
Asians 2 2.42 1.53 0.91-2.58 0.108 1.31 1.75 1.23-2.47 0.002
Caucasians excluding studies 4-6 3 1.68 0.95 0.62-1.47 0.842 1.74 1.05 0.78-1.41 0.750

There is significant (p<0.001) heterogeneity between studies. There is no significant heterogeneity between studies. E2 carriers indicates E2E2+E2E3 genotypes and E4 carriers indicates E4E4+E4E3+E4E2 genotypes. APOE, apolipoprotein E; Q, Q-statistic; OR, odds ratio; CI, confidence interval.

Figure & Data

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      Apolipoprotein E (APOE) Polymorphisms and Susceptibility to Breast Cancer: A Meta-Analysis
      Cancer Res Treat. 2012;44(2):121-126.   Published online June 30, 2012
      DOI: https://doi.org/10.4143/crt.2012.44.2.121
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    Apolipoprotein E (APOE) Polymorphisms and Susceptibility to Breast Cancer: A Meta-Analysis
    Image Image Image
    Fig. 1 Forest plot of the meta-analysis of associations between alleles of apolipoprotein E (APOE) polymorphism and breast cancer risk. CI, confidence interval.
    Fig. 2 Forest plot of the meta-analysis of associations between genotypes of apolipoprotein E (APOE) polymorphism and breast cancer risk. CI, confidence interval.
    Fig. 3 Funnel plots of the meta-analysis of associations between alleles and/or genotypes of apolipoprotein E (APOE) polymorphisms and breast cancer risk (p-values of Egger's test were 0.556, 0.297, 0.923, and 0.488, for ε2 vs. ε3, ε4 vs. ε3, E2 carriers vs. E3E3, and E4 carriers vs. E3E3 comparisons, respectively).

    Fig. 1

    Fig. 2

    Fig. 3

    Apolipoprotein E (APOE) Polymorphisms and Susceptibility to Breast Cancer: A Meta-Analysis
    Study Ethnicity Source
    of controls    		 Place Controls Cases
    ε2 ε3 ε4 Total ε2 ε3 ε4 Total
    Moysich et al., 2000 [3] Caucasians Hospital USA 43 533 88 664 34 424 62 520
    Niemi et al., 2000 [4] Caucasians Population Finland 29 408 97 534 17 331 74 422
    Niemi et al., 2000 [4] Caucasians Population Finland 29 408 97 534 22 467 109 589
    Yaylim et al., 2003 [5] Caucasians ND Turkey 0 40 0 40 2 61 1 64
    Menzel et al., 2004 [6] Caucasians Population Czech Rep. 27 237 36 300 15 156 17 188
    Menzel et al., 2004 [6] Caucasians Hospital Austria 53 449 176 678 31 337 64 432
    Chang et al., 2005 [7] Asians Hospital Taiwan 45 349 70 464 56 410 114 580
    Chang et al., 2006 [8] Asians ND Taiwan 24 256 16 296 34 496 52 582
    Surekha et al., 2008 [9] Caucasoid Hospital India 11 201 8 220 6 193 21 220
    Porrata-Doria et al., 2010 [10] Caucasians Hospital Puerto-Rico 61 350 47 458 59 299 52 410
    Studies No. of studies ε2 vs. ε3 ε4 vs. ε3
    Q OR 95% CI p-value Q OR 95% CI p-value
    All studies 10 6.88 0.88 0.74-1.05 0.179 36.62a) 0.96 0.84-1.09 0.539
    All studies excluding studies 4-6 7 5.05 0.90 0.74-1.09 0.318 12.03 1.13 0.98-1.31 0.085
    Asians 3 1.93 0.88 0.64-1.20 0.429 2.31 1.56 1.19-2.04 0.001
    Caucasians excluding studies 4-6 3 3.07 0.92 0.72-1.17 0.514 2.03 0.99 0.83-1.17 0.917
    Study Controls Cases
    E2E2 E3E2 E3E3 E4E2 E4E3 E4E4 Total E2E2 E3E2 E3E3 E4E2 E4E3 E4E4 Total
    Moysich et al., 2000 [3] 1 34 216 7 67 7 332 2 26 173 4 52 3 260
    Yaylim et al., 2003 [5] 0 0 20 0 0 0 20 0 2 29 0 1 0 32
    Chang et al., 2005 [7] 14 4 145 13 66 1 232 11 24 145 10 96 4 290
    Surekha et al., 2008 [9] 0 9 93 2 6 0 110 0 6 84 0 19 1 110
    Porrata-Doria et al., 2010 [10] 0 19 165 42 1 2 229 0 13 143 46 0 3 205
    Studies No. of studies E2 carriers vs. E3E3 E2 carriers vs. E3E3
    Q OR 95% CI p-value Q OR 95% CI p-value
    All studies 5 5.96 1.14 0.81-1.59 0.379 7.87 1.29 1.03-1.62 0.024
    Asians 2 2.42 1.53 0.91-2.58 0.108 1.31 1.75 1.23-2.47 0.002
    Caucasians excluding studies 4-6 3 1.68 0.95 0.62-1.47 0.842 1.74 1.05 0.78-1.41 0.750
    Table 1 Prevalence of APOE alleles in studies used in the meta-analysis

    APOE, apolipoprotein E; ND, not described.

    Table 2 Summary of meta-analysis of case-control studies examining alleles of APOE polymorphism and breast cancer risk

    a)There is significant (p<0.001) heterogeneity between studies. APOE, apolipoprotein E; Q, Q-statistic; OR, odds ratio; CI, confidence interval.

    Table 3 Prevalence of apolipoprotein E (APOE) genotypes in studies used in the meta-analysis

    Table 4 Summary of meta-analysis of case-control studies examining genotypes of APOE polymorphism and breast cancer risk

    There is significant (p<0.001) heterogeneity between studies. There is no significant heterogeneity between studies. E2 carriers indicates E2E2+E2E3 genotypes and E4 carriers indicates E4E4+E4E3+E4E2 genotypes. APOE, apolipoprotein E; Q, Q-statistic; OR, odds ratio; CI, confidence interval.

    Table 1

    Table 2

    Table 3

    Table 4

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