Review Reports - Understanding Susceptibility to Breast Cancer: From Risk Factors to Prevention Strategies

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The review covers a broad range of risk factors, mechanisms, and chemoprevention strategies for breast cancer development. This article has been written smoothly in English. However, this manuscript is not recommended for publication due to the following shortcomings.

The Author affiliations are suggested to be written in English.
The Abstract is illogically organized and should be rewritten.
References are missing in Lines 35-40, 70, and 101. There are many repetitions of content in the text. For examples, the content of lines 25-47 is repetitive with that of ‘Breast cancer risk factors’part; The titles of parts 2.1.2, 2.1.3, and 2.2.2 are redundant with their subtitles; Risk factors and chemoprevention strategies are redundant with following text.
Although early mechanisms of breast cancer are described, the rationale of Non-modifiable breast cancer risk factors contributing to breast cancer development should be explained in related text. To this end, parts 2 and 3 are suggestive to reorganized logically. What’s more, biomarkers that predict individual responses to chemopreventive agents are not discussed.
Is pos-pregnancyin line 275 actually post-pregnance due to spelling error?
Many terminologies, which appear only once in the text, do not need to be abbreviated. Please check these terms.

Author Response

Comment: The review covers a broad range of risk factors, mechanisms, and chemoprevention strategies for breast cancer development. This article has been written smoothly in English. However, this manuscript is not recommended for publication due to the following shortcomings.

Response: We sincerely appreciate the reviewer’s insightful comments and suggestions, which have greatly contributed to improving the clarity and quality of our manuscript. Thank you for your valuable feedback.

Comment: The Author affiliations are suggested to be written in English.

Response: We appreciate the reviewer’s suggestion regarding the author affiliations. We have revised them to be written entirely in English, ensuring consistency with the journal's formatting guidelines.

We have included the following affiliations in the revised version of the manuscript.

-Institute of Molecular and Cellular Biology of Cancer (IBMCC-CIC), University of Salamanca/CSIC, 37007 Salamanca, Spain.

-Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain.

Comment: The Abstract is illogically organized and should be rewritten.

Response: Thank you very much for your appreciation. We have revised the abstract to enhance its organization and clarity.

“Breast cancer is the most common malignancy among women globally, with incidence rates continuing to rise. A comprehensive understanding of its risk factors and the underlying biological mechanisms that drive tumor initiation is essential for developing effective prevention strategies. This review examines key non-modifiable risk factors, such as genetic predisposition, demographic characteristics, family history, mammographic density, and reproductive milestones, as well as modifiable risk factors like exogenous hormone exposure, obesity, diet, and physical inactivity. Importantly, reproductive history plays a dual role, providing long-term protection while temporarily increasing breast cancer risk shortly after pregnancy. Current chemoprevention strategies primarily depend on selective estrogen receptor modulators (SERMs), including tamoxifen and raloxifene, which have demonstrated efficacy in reducing the incidence of estrogen receptor-positive breast cancer but remain underutilized due to adverse effects. Emerging approaches such as aromatase inhibitors, RANKL inhibitors, progesterone antagonists, PI3K inhibitors, and immunoprevention strategies show promise for expanding preventive options. Understanding the interactions between risk factors, hormonal influences, and tumorigenesis is critical for optimizing breast cancer prevention and advancing safer, more targeted chemopreventive interventions.”

Comment: References are missing in Lines 35-40, 70, and 101.

Response: Thank you. We appreciate the reviewer’s observation regarding missing references. We have carefully reviewed the manuscript and added appropriate citations in lines 35-40, 70, and 101 to support the statements made in these sections.

…There are many repetitions of content in the text. For examples, the content of lines 25-47 is repetitive with that of ‘Breast cancer risk factors’part;

Response: We appreciate the reviewer’s insightful comment regarding content repetition. Upon reviewing the manuscript, we agree that some information in lines 25-47 overlaps with the ‘Breast Cancer Risk Factors’ section. To improve clarity and avoid redundancy, we have revised the introduction to provide a concise overview of the relevance of breast cancer risk factors without preempting detailed explanations. We have also ensured a smoother transition to the subsequent sections and have clarified the increasing incidence of breast cancer due to demographic and lifestyle factors, integrating references accordingly. The revised introduction now maintains a logical flow while avoiding repetition.

We have included the following paragraph in the revised manuscript (lines X-Y).

“Introduction

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related mortality in women worldwide. In 2022, over 2.3 million new cases were reported, accounting for 11.6% of all cancer diagnoses, with incidence rates expected to surpass 3 million annually by 2040 (1,2). While advances in early detection and treatment have improved survival, prevention remains a major challenge. The rising incidence of breast cancer is driven by demographic shifts, reproductive trends, and lifestyle changes, including increasing life expectancy, delayed childbearing, and the adoption of Westernized habits such as reduced physical activity and higher obesity rates (5–7).

Understanding breast cancer risk factors is crucial for developing effective prevention strategies. These risk factors include genetic predisposition, reproductive history, lifestyle behaviors, and hormonal influences, all of which shape an individual’s susceptibility to the disease (3,4) (Figure 1). This review summarizes key risk factors for breast cancer and discusses current and emerging chemopreventive strategies aimed at reducing its incidence.”

Comment: The titles of parts 2.1.2, 2.1.3, and 2.2.2 are redundant with their subtitles. Risk factors and chemoprevention strategies are redundant with following text.

Response: We appreciate the reviewer’s feedback regarding redundancies in the titles of sections 2.1.1, 2.1.2, and 2.1.3. To improve clarity and conciseness, we have revised these titles to avoid unnecessary repetition while maintaining their informative value. The updated titles now ensure a clearer structure and better readability.

We have changed these subtitles as follows:

2.1.1. Germline Mutations and Single Nucleotide Variants

2.1.2. Demographic risk factors

2.1.3. Familial and personal history risk factors

Comment: Although early mechanisms of breast cancer are described, the rationale of Non-modifiable breast cancer risk factors contributing to breast cancer development should be explained in related text. To this end, parts 2 and 3 are suggestive to reorganized logically.

Response: We appreciate the reviewer’s insightful comments regarding the rationale behind non-modifiable risk factors contributing to breast cancer development and the need to discuss predictive biomarkers for chemoprevention. To address these points, we have revised Section 2 to explicitly describe how each non-modifiable risk factor influences early breast carcinogenesis through genomic instability, hormonal alterations, and inflammatory microenvironments.

We have included the following in the revised version of the manuscript.

2.1 Non-Modifiable Breast Cancer Risk Factors and Their Contribution to Carcinogenesis

2.1.1. Germline Mutations and Single Nucleotide Variants

Line 111-113: Germline mutations in BRCA1 and BRCA2, which account for roughly 15% of hereditary breast cancer cases, compromise DNA repair mechanisms, leading to genomic in-stability and increased tumorigenesis

2.1.2. Demographic risk factors

Line 172-173: Breast cancer predominantly affects women due to hormonal influences on mammary gland development and function.

Line 182-183: After female sex, age is the most significant risk factor for breast cancer, due to the accumulation of genetic mutations, epigenetic alteration and cellular senescence along life increase susceptibility to tumorigenesis (Qing et al, 2020; Hendrick et al., 2021).

-Hendrick RE, Monticciolo DL, Biggs KW, Malak SF. Age distributions of breast cancer

diagnosis and mortality by race and ethnicity in US women. Cancer. 2021 Dec 1;127(23):4384-

doi: 10.1002/cncr.33846. Epub 2021 Aug 24. PMID: 34427920.

-Qing T, Mohsen H, Marczyk M, Ye Y, O'Meara T, Zhao H, Townsend JP, Gerstein M, Hatzis C, Kluger Y, Pusztai L. Germline variant burden in cancer genes correlates with age at diagnosis

and somatic mutation burden. Nat Commun. 2020 May 15;11(1):2438. doi: 10.1038/s41467-

020-16293-7. PMID: 32415133; PMCID: PMC7228928.

2.1.3. Familial and personal history risk factors

Line 222-224: A positive family history suggests the presence of inherited genetic mutations or shared environmental exposures that predispose individuals to breast cancer.

Line 243-245: High mammographic density, characterized by increased fibroglandular tissue, is associated with greater susceptibility to malignant transformation due to enhanced epithelial-stromal interactions and hormonal influences (Moran et al.,2019; Mai et al., 2022)

-Moran O, Eisen A, Demsky R, Blackmore K, Knight JA, Panchal S, Ginsburg O, Zbuk K, Yaffe M, Metcalfe KA, Narod SA, Kotsopoulos J. Predictors of mammographic density among women with a strong family history of breast cancer. BMC Cancer. 2019 Jun 26;19(1):631. doi: 10.1186/s12885-019-5855-2. PMID: 31242899; PMCID: PMC6595553.

-Mai Tran TX, Kim S, Song H, Park B. Family history of breast cancer, mammographic breast density and breast cancer risk: Findings from a cohort study of Korean women. Breast. 2022 Oct;65:180-186. doi: 10.1016/j.breast.2022.08.008. Epub 2022 Aug 23. PMID: 36049384; PMCID: PMC9441334

Line 268-270: A personal history of benign breast diseases or prior breast cancer increases the likelihood of developing subsequent malignancies due to persistent genomic alterations and residual tumor cells (Zeng et al., 2020; Bazire et al., 2017).

-Zeng Z, Vo A, Li X, Shidfar A, Saldana P, Blanco L, Xuei X, Luo Y, Khan SA, Clare SE. Somatic genetic aberrations in benign breast disease and the risk of subsequent breast cancer. NPJ Breast Cancer. 2020 Jun 12;6:24. doi: 10.1038/s41523-020-0165-z. PMID: 32566745; PMCID: PMC7293275.

- Bazire L, De Rycke Y, Asselain B, Fourquet A, Kirova YM. Risks of second malignancies after breast cancer treatment: Long-term results. Cancer Radiother. 2017 Feb;21(1):10-15. doi: 10.1016/j.canrad.2016.07.101. Epub 2016 Dec 26. PMID: 28034681.

2.1.4. Hormonal risk factors: age at menopause and menarche

Line 272-280: Early menarche and late menopause are associated with an increased risk of breast cancer, due to they extend the lifetime exposure of the breast tissue to endogenous estrogens. Prolonged estrogen stimulation enhances the proliferation of mammary epithelial cells, thereby increasing the likelihood of replication errors and accumulation of somatic mutations. In addition, sustained estrogen exposure can alter the local microenvironment by upregulating growth factors and inflammatory mediators, which further promotes genomic instability and facilitates malignant transformation. Conversely, a shorter reproductive span reduces the cumulative hormonal load and may confer a protective effect against tumorigenesis (Key et al.,2002; Collaborative Group on Hormonal Factors in Breast Cancer, 2012 .)

-Key T, Appleby P, Barnes I, Reeves G; Endogenous Hormones and Breast Cancer Collaborative Group. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst. 2002 Apr 17;94(8):606-16. doi: 10.1093/jnci/94.8.606. PMID: 11959894.

-Collaborative Group on Hormonal Factors in Breast Cancer. Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. Lancet Oncol. 2012 Nov;13(11):1141-51. doi: 10.1016/S1470-2045(12)70425-4. Epub 2012 Oct 17. PMID: 23084519; PMCID: PMC3488186.

Comment: What’s more, biomarkers that predict individual responses to chemopreventive agents are not discussed.

Response: We have not added this section because there are not many studies evaluating biomarkers of chemoprevention. We have added a sentence in conclusions to clarify this issue.

Line 898-899: Future research should focus on identifying biomarkers that predict individual responses to chemopreventive agents, which is crucial for optimizing their clinical use.

Comment: Is pos-pregnancyin line 275 actually post-pregnance due to spelling error?

Response: We appreciate the reviewer’s attention to detail. The term 'pos-pregnancy' in previous line 275 was indeed a typographical error. We have corrected it to 'post-pregnancy' in the revised manuscript.

Comment: Many terminologies, which appear only once in the text, do not need to be abbreviated. Please check these terms.

Response: We appreciate the reviewer’s comment on the use of abbreviations. We have carefully reviewed the manuscript and removed abbreviations that appeared only once, replacing them with their full terms for clarity. The revised version ensures that abbreviations are only retained when they are used multiple times or are widely recognized in the field.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript titled “Understanding Susceptibility to Breast Cancer: From Risk Factors to Prevention Strategies” presents a comprehensive review of breast cancer risk factors and prevention strategies, highlighting the importance of understanding the underlying biological mechanisms of the disease. While the manuscript effectively summarises studies on breast cancer, it lacks recent references, and certain key aspects related to risk factors and prevention strategies warrant further exploration. The following points outline the areas requiring revision:

The manuscript includes 269 references, yet only 10 are from the years 2022–2025. To enhance the relevance and timeliness of the review, it is recommended that more recent studies be incorporated.
Section 4. Prevention Strategies for Breast Cancer would benefit from a discussion on natural product-derived drugs, particularly resveratrol. While not currently approved for clinical use in breast cancer treatment, resveratrol has provided valuable insights into novel chemotherapeutic targets (Lieb et al., 2025; 10.3390/biology14020194). Additionally, presenting a summary table of treatment and prevention strategies would improve clarity and facilitate comprehension.
In subsection 2.2.2. Lifestyle Risk Factors: Alcohol, Overweight, and Physical Activity, the role of diet and nutrition in breast cancer incidence should be further explored. Beyond alcohol consumption, smoking, and obesity, excessive intake of specific micronutrients—including magnesium, iron, zinc, and phosphorus—has been implicated in promoting excessive cell proliferation or facilitating DNA damage (Brown et al., 2018; 10.1016/j.bbcan.2018.04.007). Furthermore, recent findings indicate that high dietary phosphorus intake is associated with an increased risk of breast cancer (Brown et al., 2023; 10.3390/nu15173735).

Author Response

The manuscript titled “Understanding Susceptibility to Breast Cancer: From Risk Factors to Prevention Strategies” presents a comprehensive review of breast cancer risk factors and prevention strategies, highlighting the importance of understanding the underlying biological mechanisms of the disease. While the manuscript effectively summarises studies on breast cancer, it lacks recent references, and certain key aspects related to risk factors and prevention strategies warrant further exploration. The following points outline the areas requiring revision:

Response: We sincerely appreciate the reviewer’s insightful comments, which have been crucial in enhancing the manuscript. We have thoroughly addressed each of the suggested revisions, ensuring that our review remains comprehensive, current, and scientifically rigorous.

The manuscript includes 269 references, yet only 10 are from the years 2022–2025. To enhance the relevance and timeliness of the review, it is recommended that more recent studies be incorporated.

Response: We appreciate the reviewer’s suggestion to include more recent references. To ensure our discussion reflects the latest advancements, we have incorporated studies published between 2022 and 2025 that cover key aspects, including epidemiology, molecular mechanisms, early detection, targeted therapies, chemoprevention, and quality-of-life interventions. At the same time, we have retained foundational references that remain widely cited or provide essential background, ensuring a comprehensive and scientifically rigorous review. We thank the reviewer for this valuable suggestion, which has helped us enhance the manuscript. Below, we highlight the references recently incorporated in each section.

We have added the following new references in the revised version of the manuscript.

-Ferraresi A, Thongchot S, Isidoro C. Resveratrol Promotes Self-digestion to Put Cancer to Sleep. J Cancer Prev. 2024 Mar 30;29(1):1-5. doi: 10.15430/JCP.24.001. Epub 2024 Mar 29. PMID: 38567110; PMCID: PMC10982519.

-Burke A, O'Driscoll J, Abubakar M, Bennett KE, Carmody E, Flanagan F, Gierach GL, Mullooly M. A systematic review of determinants of breast cancer risk among women with benign breast disease. NPJ Breast Cancer. 2025 Feb 15;11(1):16. doi: 10.1038/s41523-024-00703-w. PMID: 39955290; PMCID: PMC11829998.

-Hoang T, Lee J, Jung SY, Kim J. Determining risk-adapted starting age and interval for breast cancer screening based on reproductive and hormonal factors. Int J Cancer. 2025 May 1;156(9):1692-1702. doi: 10.1002/ijc.35265. PMID: 39600253.

- Lam A, Hao Z, Yiu K, Chan S, Chan F, Sung J, Tsoi K. Long-term use of low-dose aspirin for cancer prevention: A 20-year longitudinal cohort study of 1,506,525 Hong Kong residents. Int J Cancer. 2025 Jan 18. doi: 10.1002/ijc.35331. PMID: 39825684.

-Lynch BM, Bassett JK, Milne RL, Patel AV, Rees-Punia E, Lee IM, Moore SC, Matthews CE. Estimating cancer incidence attributable to physical inactivity in the United States. Cancer. 2025 Feb 15;131(4):e35725. doi: 10.1002/cncr.35725. PMID: 39937584; PMCID: PMC11818651.

-Massey ZB, Anbari AB, Wang N, Adediran A, Lawrie LL, Martinez P, McCarthy D. Developing and testing health warnings about alcohol and risk for breast cancer: Results from a national experiment with young adult women in the United States. Alcohol Clin Exp Res. 2025 Feb 22. doi: 10.1111/acer.70003. PMID: 39985486.

-Okyere J, Ayebeng C, Adjedu SA, Dickson KS. Age at first menstruation and clinical breast cancer screening utilization: insights from the 2021 Côte d'Ivoire demographic and health survey. Reprod Health. 2024 Nov 28;21(1):176. doi: 10.1186/s12978-024-01915-w. PMID: 39605012; PMCID: PMC11603926.

-Patel R, Jin C, Jaber D, Casasanta N, Jain M, Fu W, Wu C, Moshier E, Tiersten A. Low Dose Tamoxifen for Breast Cancer Prevention: A Real-World Experience. Clin Breast Cancer. 2024 Dec 31:S1526-8209(24)00370-7. doi: 10.1016/j.clbc.2024.12.020. PMID: 39837695.

- Brown RB, Bigelow P, Dubin JA, Mielke JG. High Dietary Phosphorus Is Associated with Increased Breast Cancer Risk in a U.S. Cohort of Middle-Aged Women. Nutrients. 2023 Aug 25;15(17):3735. doi: 10.3390/nu15173735. PMID: 37686766; PMCID: PMC10490459.

Section 4. Prevention Strategies for Breast Cancer would benefit from a discussion on natural product-derived drugs, particularly resveratrol. While not currently approved for clinical use in breast cancer treatment, resveratrol has provided valuable insights into novel chemotherapeutic targets (Lieb et al., 2025; 10.3390/biology14020194).

Response: We sincerely thank the reviewer for underscoring the importance of natural product-derived compounds, particularly resveratrol, in breast cancer prevention. In accordance with your suggestion, we have now included a concise discussion on these agents in Section 4 of the manuscript. While resveratrol is not yet approved for clinical use against breast cancer, emerging preclinical evidence indicates its ability to modulate oncogenic pathways and influence chemopreventive targets (Berman et al. 2017; Zhang et al. 2021). We believe this addition strengthens our discussion by highlighting the potential impact of flavonoids and other bioactive compounds in novel preventive strategies.

We have included the following new paragraph in the revised section of the manuscript.

Natural product-derived compounds, notably flavonoids and resveratrol, have received substantial attention for their potential role in reducing breast cancer risk. Flavonoids, a group of polyphenolic compounds found abundantly in fruits, vegetables, teas, and wines, exhibit anti-carcinogenic properties (Bosetti et al. 2005). Epidemiological studies suggest that dietary intake of flavonoids may lower tumor risk across various organs, including the breast (Bosetti et al. 2005; Romagnolo and Selmin, 2012). Mechanistically, these compounds exert anti-proliferative effects by inhibiting signaling pathways crucial for cancer cell growth and survival (Romagnolo et al. 2012).

Resveratrol, a natural polyphenol present in grapes, red wine, berries, and peanuts, has demonstrated potential anti-cancer activity. Preclinical work indicates that resveratrol may reduce breast cancer cell proliferation by promoting apoptosis and regulating key cell signaling cascades (Berman et al. 2017). Furthermore, recent studies show that resveratrol can induce autophagy-dependent tumor dormancy, highlighting possible applications in both prevention and therapy (Ferraresi et al. 2024). However, as most findings to date derive from preclinical models, additional clinical research is warranted to confirm both the efficacy and safety of flavonoids and resveratrol as chemopreventive agents in breast cancer.

References

-Bosetti C, Spertini L, Parpinel M, Gnagnarella P, Lagiou P, Negri E, Franceschi S, Montella M, Peterson J, Dwyer J, Giacosa A, La Vecchia C. Flavonoids and breast cancer risk in Italy. Cancer Epidemiol Biomarkers Prev. 2005 Apr;14(4):805-8. doi: 10.1158/1055-9965.EPI-04-0838. PMID: 15824147.

-Romagnolo DF, Selmin OI. Flavonoids and cancer prevention: a review of the evidence. J Nutr Gerontol Geriatr. 2012;31(3):206-38. doi: 10.1080/21551197.2012.702534. PMID: 22888839.

-Berman AY, Motechin RA, Wiesenfeld MY, Holz MK. The therapeutic potential of resveratrol: a review of clinical trials. NPJ Precis Oncol. 2017;1:35. doi: 10.1038/s41698-017-0038-6. Epub 2017 Sep 25. PMID: 28989978; PMCID: PMC5630227.

-Ferraresi A, Thongchot S, Isidoro C. Resveratrol Promotes Self-digestion to Put Cancer to Sleep. J Cancer Prev. 2024 Mar 30;29(1):1-5. doi: 10.15430/JCP.24.001. Epub 2024 Mar 29. PMID: 38567110; PMCID: PMC10982519.

Additionally, presenting a summary table of treatment and prevention strategies would improve clarity and facilitate comprehension.

Response: We sincerely appreciate the reviewer’s suggestion to provide a summary table for improved clarity. Since this review focuses specifically on breast cancer prevention rather than treatment, we have created a concise table of relevant strategies highlighted in the manuscript. We believe this addition will enhance readability and help readers compare various preventive approaches at a glance.

Table 1. Summary of Breast Cancer Prevention Strategies

Prevention Strategy	Mechanism of Action	Key Findings	References
Bilateral Prophylactic Mastectomy	Surgical removal of breast tissue in high-risk women	Reduces breast cancer risk by up to 95% in BRCA1/2 mutation carriers and by up to 90% in women with a strong family history	[234–238]
Selective Estrogen Receptor Modulators (SERMs)	Blocks estrogen receptor signaling in breast tissue	Tamoxifen reduces invasive breast cancer incidence by 49% and ER+ breast cancer by 69%; raloxifene reduces breast cancer incidence by 72% in postmenopausal women	[239-246]
Aromatase Inhibitors (AIs)	Lowers estrogen production by inhibiting aromatase enzyme	Exemestane reduces breast cancer risk by 65%; anastrozole reduces risk by 49%	[247-249]
Metformin	AMPK activation and IGF-1 regulation reduce tumor cell proliferation	Observational studies suggest reduced breast cancer incidence in diabetic patients on long-term therapy; clinical trials ongoing	[251-253]
RANK/RANKL Inhibition (Denosumab)	Blocks RANKL signaling, reducing proliferation of BRCA1-mutant cells	Preclinical models show inhibition of preneoplastic lesion formation and tumor progression; clinical trials evaluating chemopreventive effects in BRCA1 carriers	[254]
Progesterone Antagonists (Mifepristone, Ulipristal Acetate)	Blocks progesterone-driven proliferation in mammary epithelial cells	Preclinical studies suggest inhibition of BRCA1-related tumorigenesis; clinical trials evaluating feasibility	[255]
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)	COX-2 inhibition reduces prostaglandin-mediated tumor growth	Aspirin use for ≥10 years associated with 26% reduced breast cancer risk; celecoxib shows promise in high-risk women	[256–259, 288]
PI3K Inhibitors (Alpelisib)	Inhibits PI3K pathway involved in early tumor development	Preclinical models show reduced progression of atypical hyperplasia; clinical trials needed	[260]
Somatostatin Analogs (Octreotide, Pasireotide)	Reduces IGF-1 signaling associated with mammary proliferation	Preclinical models indicate suppression of epithelial proliferation and delayed tumor initiation	[261–264]
Low-Dose Tamoxifen	Maintains chemopreventive effects while reducing side effects	5 mg/day significantly lowers biomarkers associated with breast cancer risk; trials ongoing	[265–266, 290]
Natural Product-Derived Compounds (Flavonoids, Resveratrol)	Antioxidant and anti-inflammatory properties modulate tumorigenic pathways	Epidemiological studies suggest flavonoids may reduce breast cancer risk; resveratrol shows apoptosis-inducing effects in preclinical models	[280-283]
MUC1 Vaccines	Induces immune response against tumor-associated MUC1 epitopes	Phase II trial in colorectal adenoma shows 38% reduction in recurrence; ongoing trial in DCIS	[267-268]
DNA Vaccines	Stimulates targeted immune response against breast cancer antigens	Ongoing trials in BRCA mutation carriers; prior HER2-targeted vaccine showed long-term efficacy	[269]

Note: Reference numbers correspond to those cited in the main text.

In subsection 2.2.2. Lifestyle Risk Factors: Alcohol, Overweight, and Physical Activity, the role of diet and nutrition in breast cancer incidence should be further explored. Beyond alcohol consumption, smoking, and obesity, excessive intake of specific micronutrients—including magnesium, iron, zinc, and phosphorus—has been implicated in promoting excessive cell proliferation or facilitating DNA damage (Brown et al., 2018; 10.1016/j.bbcan.2018.04.007). Furthermore, recent findings indicate that high dietary phosphorus intake is associated with an increased risk of breast cancer (Brown et al., 2023; 10.3390/nu15173735).

Response: We appreciate the reviewer’s insightful recommendation to expand our discussion on diet and nutrition concerning breast cancer incidence. We have revised Subsection 2.2.2 to address the roles of specific micronutrients, such as magnesium, iron, zinc, and phosphorus, and incorporated recent findings on high dietary phosphorus intake (Brown et al., 2023). Additionally, we modified Figure 1 to illustrate diet as a modifiable risk factor. These additions enhance our exploration of how specific dietary components and overall dietary patterns may impact breast cancer risk.

We have included the following test, updates Subsection 2.2.2

Diet and Nutrition

Recent evidence suggests that dietary intake of specific micronutrients may influence the risk of developing breast cancer, while other dietary components, such as fiber, have been studied for their potential protective effects against various cancer types. In the case of phosphorus, a cohort study in middle-aged U.S. women found that a daily intake exceeding 1800 mg was associated with an approximately 2.3-fold increased risk of breast cancer (Brown et al., 2023). Although the results did not reach statistical significance due to the limited sample size (RR: 2.30; 95% CI: 0.94–5.61; p = 0.07), the study's clinically relevant effect size, dose-response relationship, and biological plausibility support further investigation (Brown et al., 2023).

A Mendelian randomization study also identified a potential role for magnesium and phosphorus in breast cancer risk. A one-standard deviation (0.08 mmol/L) higher genetically predicted circulating magnesium concentration was associated with a 17% increased overall breast cancer risk and a 20% increased risk for estrogen receptor-positive (ER+) breast cancer (Papadimitriou et al., 2021). Conversely, higher genetically predicted phosphorus levels were inversely associated with estrogen receptor-negative (ER−) breast cancer (OR: 0.84, 95% CI: 0.72–0.98, p = 0.03), suggesting a potential protective effect that warrants further study (Papadimitriou et al., 2021).

Regarding dietary fiber, findings from the European Prospective Investigation into Cancer and Nutrition (EPIC) study demonstrated that doubling total fiber intake from food could reduce colorectal cancer risk by approximately 40% (Bingham et al., 2003). Although fiber's protective role has been more extensively studied in colorectal cancer, other studies have suggested that fruit and vegetable consumption may also reduce the risk of various cancers, including breast cancer (Riboli et al., 2003). However, the evidence for breast cancer remains inconsistent, with case-control studies showing stronger associations than prospective cohort studies (Riboli et al., 2003).

For iron intake, a large Canadian cohort study of 49,654 women found no significant association between total dietary iron or heme iron intake and breast cancer risk, even among women with high alcohol consumption or those using hormone replacement therapy (Kabat et al., 2007). However, a separate study measuring elemental levels in benign breast tissue suggested a modest positive association between zinc (OR = 1.37, p-trend = 0.04), iron (OR = 1.58, p-trend = 0.07), and calcium (OR = 1.46, p-trend = 0.14) and subsequent breast cancer risk (Cui et al., 2007). Notably, the positive association between iron levels and breast cancer risk was more pronounced in postmenopausal women (OR = 2.77; 95% CI: 1.25–6.13, p-trend = 0.008), suggesting a potential hormonal influence on iron metabolism and carcinogenesis (Cui et al., 2007).

Collectively, these findings underscore the importance of further research into the role of diet and micronutrient intake—particularly phosphorus, magnesium, zinc, iron, and calcium—in breast cancer susceptibility. Large-scale prospective studies incorporating both dietary intake assessments and biological measurements of these nutrients are needed to clarify their relevance in breast cancer etiology and prevention.

References

-Papadimitriou N, Dimou N, Gill D, Tzoulaki I, Murphy N, Riboli E, Lewis SJ, Martin RM, Gunter MJ, Tsilidis KK. Genetically predicted circulating concentrations of micronutrients and risk of breast cancer: A Mendelian randomization study. Int J Cancer. 2021 Feb 1;148(3):646-653. doi: 10.1002/ijc.33246. Epub 2020 Aug 25. PMID: 32761610; PMCID: PMC8268064.

- Bingham SA, Day NE, Luben R, Ferrari P, Slimani N, Norat T, Clavel-Chapelon F, Kesse E, Nieters A, Boeing H, Tjønneland A, Overvad K, Martinez C, Dorronsoro M, Gonzalez CA, Key TJ, Trichopoulou A, Naska A, Vineis P, Tumino R, Krogh V, Bueno-de-Mesquita HB, Peeters PH, Berglund G, Hallmans G, Lund E, Skeie G, Kaaks R, Riboli E; European Prospective Investigation into Cancer and Nutrition. Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. Lancet. 2003 May 3;361(9368):1496-501. doi: 10.1016/s0140-6736(03)13174-1.

-Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. Am J Clin Nutr. 2003 Sep;78(3 Suppl):559S-569S. doi: 10.1093/ajcn/78.3.559S. PMID: 12936950.

-Kabat GC, Miller AB, Jain M, Rohan TE. Dietary iron and heme iron intake and risk of breast cancer: a prospective cohort study. Cancer Epidemiol Biomarkers Prev. 2007 Jun;16(6):1306-8. doi: 10.1158/1055-9965.EPI-07-0086. PMID: 17548704.

-Cui Y, Vogt S, Olson N, Glass AG, Rohan TE. Levels of zinc, selenium, calcium, and iron in benign breast tissue and risk of subsequent breast cancer. Cancer Epidemiol Biomarkers Prev. 2007 Aug;16(8):1682-5. doi: 10.1158/1055-9965.EPI-07-0187. Erratum in: Cancer Epidemiol Biomarkers Prev. 2007 Oct;16(10):2173. PMID: 17684146.

Reviewer 3 Report

Comments and Suggestions for Authors

This review is an attempt to understand the underlying causes and susceptibility to breast cancer, genetics, sex, age, ethnicity, family history, mammography density, benign breast disease, prior breast cancer and age of menarche and menopause as well as modifiable factors such as lifestyle and reproductive history. This is a very broad topic and the different subjects are discussed more or less detailed. The topic on genetics is described in less detail and not always correct. Overall, the paper could be of interest for most with interest in breast cancer.

Comments:

All genes should be written in italic, now only a few are - here and there as if not written by the same author, eg. genes on row 391, 392?

In the figure 1, risk factors, the color of the circles are not clear - they look very much like and none is really brown?

About the genetic proportion in breast cancer is only said that 5-10% is hereditary. I think it could be of value to state that around one third of all cases has a family history and a smaller (5-10) har a know genetic contribution. As whole the breast cancer genes are briefly described compared to the much more detailed information in the following subject.

It is said that BRCA1-2 carriers have an increased risk of also prostate and pancreatic cancer , and the risks of other cancer in BRCA1 and -2 should be more detailed and correct - it is not the same for those two genes which are the most well known BC genes today.

Perhaps it would be a good idea to describe what genes are being counselled today in clinical genetics about the moderate risk genes. I am not sure about those mentioned here.

I think it is more than 70 loci described in breast cancer - perhaps a later paper from BCAC will give the most appropriate number.

This genetic section ends with the conclusion that 90% of breast cancer cases are sporadic and that is not correct since approx 30% are familial and a smaller proportion have high-risk genes.

BRCA2 increases the risk of male BC but I don't think male breast cancer is strongly associated, most male breast cancer cases do not relate do BRCA2 - perhaps rephrase?

row 419-421 italic?

Author Response

Response: Thank you for your insightful comments and for acknowledging the importance of our review. We have updated the genetics section to enhance accuracy and offer a more thorough discussion.

Comments:

1-All genes should be written in italic, now only a few are - here and there as if not written by the same author, eg. genes on row 391, 392?

Response: We sincerely appreciate the reviewer’s careful attention to detail. We have thoroughly revised the manuscript to ensure that all gene names are consistently italicized throughout the text, correcting any inconsistencies that were previously present.

2-In the figure 1, risk factors, the color of the circles are not clear - they look very much like and none is really brown?

Response: We appreciate the reviewer’s observation. The description of the colors in Figure 1 was incorrect, and we have now revised the text to accurately reflect the color scheme: non-modifiable risk factors are highlighted in purple, modifiable risk factors in green, and reproductive history factors in blue. The figure was created using BioRender, ensuring clarity and consistency in its visual representation.

3-About the genetic proportion in breast cancer is only said that 5-10% is hereditary. I think it could be of value to state that around one third of all cases has a family history and a smaller (5-10) har a know genetic contribution. As whole the breast cancer genes are briefly described compared to the much more detailed information in the following subject.

Response: Thank you for emphasizing the importance of clarifying that approximately one-third of breast cancer cases show a familial pattern, while only 5–10% are attributed to known high-penetrance genetic mutations (Momenimovahed and Salehiniya, 2019). We have revised the text to highlight both the broader familial influence and the smaller portion of cases linked to specific hereditary genes. Furthermore, we have enhanced the genetic overview to better align with the detailed information that follows.

We have included a clearer distinction between broadly familial breast cancer and strictly hereditary cases at the end of the "Genetic risk factors" subsection (Section 2.1.1) and added the following test:

“While one-third of breast cancer cases show familial clustering, only 5–10% are due to high-penetrance mutations in genes such as BRCA1 and BRCA2 (Momenimovahed and Salehiniya, 2019). This highlights the heterogeneous genetic landscape, where moderate-risk variants, polygenic factors, and shared environmental influences may play a role. (Shiovitz and Korde, 2015).”

References

-Momenimovahed Z, Salehiniya H. Epidemiological characteristics of and risk factors for breast cancer in the world. Breast Cancer (Dove Med Press). 2019 Apr 10;11:151-164. doi: 10.2147/BCTT.S176070. PMID: 31040712; PMCID: PMC6462164.

-Shiovitz S, Korde LA. Genetics of breast cancer: a topic in evolution. Ann Oncol. 2015. Jul;26(7):1291-9. doi: 10.1093/annonc/mdv022. Epub 2015 Jan 20. PMID: 25605744; PMCID: PMC4478970.

4-It is said that BRCA1-2 carriers have an increased risk of also prostate and pancreatic cancer , and the risks of other cancer in BRCA1 and -2 should be more detailed and correct - it is not the same for those two genes which are the most well known BC genes today.

Response: Thank you for your comment about the distinct cancer risks linked to BRCA1 versus BRCA2. We agree that their associated malignancies vary, particularly beyond breast and ovarian cancer. Women with BRCA1 mutations have a higher lifetime risk of triple-negative breast cancers and generally show an increased tendency for ovarian cancer, while BRCA2 carriers exhibit a broader tumor spectrum, including male breast cancer, prostate cancer, and a slightly elevated risk of pancreatic cancer (Kuchenbaecker 2017; Mersch 2015). We have revised the text to clarify these distinctions and offer more precise risk estimates.

We have included an additional paragraph that could appear at the end of the “High-penetrance genes” subsection (Section 2.1.1) to clarify the differences in extra-mammary cancer risks for BRCA1 and BRCA2. By adding this paragraph, we provide clearer distinctions in the spectrum of extra-mammary cancers associated with BRCA1 compared to BRCA2, thereby enhancing clinical relevance and accuracy in the manuscript.

“Although both genes markedly increase breast and ovarian cancer risk, their associated malignancy profiles differ. BRCA1 carriers more frequently develop triple-negative breast cancers, while BRCA2 mutation carriers exhibit a broader tumor spectrum, including increased risks of prostate, male breast, and pancreatic cancer (Kuchenbaecker 2017; Mersch 2015). This highlights the importance of multigene panels and personalized risk assessments in clinical practice.”

References

- Kuchenbaecker KB, Hopper JL, Barnes DR, Phillips KA, Mooij TM, Roos-Blom MJ, Jervis S, van Leeuwen FE, Milne RL, Andrieu N, Goldgar DE, Terry MB, Rookus MA, Easton DF, Antoniou AC; BRCA1 and BRCA2 Cohort Consortium; McGuffog L, Evans DG, Barrowdale D, Frost D, Adlard J, Ong KR, Izatt L, Tischkowitz M, Eeles R, Davidson R, Hodgson S, Ellis S, Nogues C, Lasset C, Stoppa-Lyonnet D, Fricker JP, Faivre L, Berthet P, Hooning MJ, van der Kolk LE, Kets CM, Adank MA, John EM, Chung WK, Andrulis IL, Southey M, Daly MB, Buys SS, Osorio A, Engel C, Kast K, Schmutzler RK, Caldes T, Jakubowska A, Simard J, Friedlander ML, McLachlan SA, Machackova E, Foretova L, Tan YY, Singer CF, Olah E, Gerdes AM, Arver B, Olsson H. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA. 2017 Jun 20;317(23):2402-2416. doi: 10.1001/jama.2017.7112. PMID: 28632866.

- Mersch J, Jackson MA, Park M, Nebgen D, Peterson SK, Singletary C, Arun BK, Litton JK. Cancers associated with BRCA1 and BRCA2 mutations other than breast and ovarian. Cancer. 2015 Jan 15;121(2):269-75. doi: 10.1002/cncr.29041. Epub 2014 Sep 15. Erratum in: Cancer. 2015 Jul 15;121(14):2474-5. doi: 10.1002/cncr.29357. PMID: 25224030; PMCID: PMC4293332.

5-Perhaps it would be a good idea to describe what genes are being counselled today in clinical genetics about the moderate risk genes. I am not sure about those mentioned here.

Response: Thank you for your suggestion to clarify which moderate-risk genes are currently included in clinical genetic counseling for breast cancer. In addition to the established high-penetrance BRCA1 and BRCA2, clinical practice now routinely includes moderate-risk genes such as ATM, CHEK2, and PALB2 (Dorling 2021; Buys 2017). Other genes, including BARD1, BRIP1, RAD51C, and RAD51D, are also evaluated in some expanded panels due to evidence showing that they confer a two- to four-fold increase in breast cancer risk (Dorling 2021; Shiovitz 2015). These findings often lead to adjusted screening protocols (e.g., annual MRI) and, in certain cases, to prophylactic interventions. We have updated the text accordingly to better reflect current clinical practice and the available scientific evidence.

We have added the following text to the genetic risk factors section:

“Beyond high-penetrance mutations in BRCA1, BRCA2, TP53, and PTEN, current clinical practice increasingly includes testing of moderate-risk genes such as ATM, CHEK2, and PALB2 (Dorling 2021; Buys 2017). Some expanded panels also evaluate BARD1, BRIP1, RAD51C, and RAD51D, among others, as they can confer a risk approximately two- to four-fold above that of the general population (Dorling 2021; Shiovitz and Korde, 2015). Identifying pathogenic variants in these genes guides intensive surveillance (e.g., annual MRI) and prophylactic decision-making, emphasizing the evolving role of personalized risk assessment in breast cancer prevention (McGuire, 2020).”

References

- Dorling L, Carvalho S, Allen J, et al., Breast Cancer Risk Genes – Association Analysis in More than 113,000 Women. N Engl J Med. 2021 Feb 4;384(5):428-439. doi: 10.1056/NEJMoa1913948. Epub 2021 Jan 20. PMID: 33471991; PMCID: PMC7611105.

- Buys SS, Sandbach JF, Gammon A, Patel G, Kidd J, Brown K, Kloza K, Strom S, Dejournett J, Sargen M, Vincent L, Hill B, Wenstrup RJ. A study of over 35,000 women with breast cancer tested with a 25-gene panel of hereditary cancer genes. Cancer. 2017 May 15;123(10):1721-1730. doi: 10.1002/cncr.30498. Epub 2017 Jan 13. PMID: 28085182.

- McGuire KP, Mamounas EP. Management of Hereditary Breast Cancer: ASCO, ASTRO, and SSO Guideline. Ann Surg Oncol. 2020 Jun;27(6):1721-1723. doi: 10.1245/s10434-020-08396-8. Epub 2020 Apr 3. PMID: 32246307.

- Shiovitz S, Korde LA. Genetics of breast cancer: a topic in evolution. Ann Oncol. 2015. Jul;26(7):1291-9. doi: 10.1093/annonc/mdv022. Epub 2015 Jan 20. PMID: 25605744; PMCID: PMC4478970.

6-I think it is more than 70 loci described in breast cancer - perhaps a later paper from BCAC will give the most appropriate number.

Response: Thank you for your comment. Indeed, subsequent and more recent large-scale GWAS from the Breast Cancer Association Consortium (BCAC) and other groups have identified many novel susceptibility loci, bringing the total well beyond the 70 initially described in earlier studies. For instance, Zhang et al. (2020) reported 32 new loci, and when combined with previous findings, this raised the cumulative number of known breast cancer risk regions to over 170. Other BCAC meta-analyses, such as Mavaddat et al. (2019), also support the current estimate exceeding 170 low-penetrance loci.

To address this more accurately in the manuscript, we have replaced the earlier statement of “over 70 loci” with a more up-to-date figure and added the following paragraph in the “Genetic risk factors” subsection:

We have added this paragraph in the “Genetic risk factors” subsection to introduce SNPs, replacing the earlier mention of “over 70 loci” with more recent estimates.

“Subsequent large-scale genome-wide association studies (GWAS), including those led by the Breast Cancer Association Consortium (BCAC), have significantly expanded the catalog of common susceptibility loci, now surpassing 170 regions associated with increased breast cancer risk (Mavaddat 2019; Zhang 2020). The cumulative effect of these multiple low-penetrance variants can substantially modify individual risk, highlighting the polygenic nature of breast cancer predisposition (Michailidou 2017).

References

- Mavaddat N, Michailidou K, Dennis J, Lush M, Fachal L, Lee A, Tyrer JP, Chen TH, Wang Q, Bolla MK, Yang XR, et al. Polygenic Risk Scores for Prediction of Breast Cancer and Breast Cancer Subtypes. Am J Hum Genet. 2019 Jan 3;104(1):21-34. doi: 10.1016/j.ajhg.2018.11.002. Epub 2018 Dec 13. PMID: 30554720; PMCID: PMC6323553.

- Zhang H-Q, Darst BF, Song L, Wan P, Kallianpur A, Hu Y, Dai J, Sheng X, Hou L, Cheng C, Li J, Wen W, Long J, Easton DF, Zheng W, Shu XO, Li C. Genome-wide association study identifies 32 novel breast cancer susceptibility loci from overall and subtype analyses. Nat Genet. 2020 Jun;52(6):572-581. doi: 10.1038/s41588-020-0609-2. Epub 2020 May 18. PMID: 32424353; PMCID: PMC7808397.

- Michailidou K, Lindström S, Dennis J, Beesley J, Hui S, Kar S, Lemaçon A, Soucy P, Glubb D, Rostamianfar A, Bolla MK, Wang Q, Dicks E, Lee A, Wang Z, Allen J, Keeman R, Underwood M, Flores ER, Ghoussaini M, Karlins E, Desai KV, Guzman A, … Easton DF.Association analysis identifies 65 new breast cancer risk loci. Nature. 2017 Nov 2;551(7678):92-94. doi:10.1038/nature24284. Epub 2017 Oct 23. PMID: 29059683; PMCID: PMC5798588.

7-This genetic section ends with the conclusion that 90% of breast cancer cases are sporadic and that is not correct since approx 30% are familial and a smaller proportion have high-risk genes.

Response: Thank you for emphasizing this point. We agree that a larger percentage of breast cancer cases is familial than the original text indicated. While 5–10% of breast cancers can be attributed to high-penetrance single-gene mutations (such as BRCA1, BRCA2, TP53, etc.), an additional subset—often estimated at 15–20%—shows familial clustering without a single identified high-risk gene (Shiovitz and Korde, 2015). Therefore, roughly 25–30% of breast cancers can be regarded as familial or hereditary in a broader sense, and we have adjusted the wording in the revised manuscript to reflect this distinction.

We have included this statement at the end of the “Genetic risk factors” subsection (Section 2.1.1), replacing the previous sentence that mentioned 90% of breast cancers are sporadic.

“Although 5–10% of breast cancers are attributable to high-penetrance germline mutations—most notably in BRCA1, BRCA2, TP53, and PTEN—an additional 15–20% exhibit familial aggregation without a single identified high-risk gene (Shiovitz and korde, 2015). Consequently, approximately 25–30% of breast cancers show some familial component, while the remaining cases are considered sporadic (Momenimovahed and Alehiniya, 2019). Recognizing this broader spectrum of familial risk underscores the importance of multigene panels and personalized risk assessments in clinical practice.”

References

- Shiovitz S, Korde LA. Genetics of breast cancer: a topic in evolution. Ann Oncol. 2015. Jul;26(7):1291-9. doi: 10.1093/annonc/mdv022. Epub 2015 Jan 20. PMID: 25605744; PMCID: PMC4478970.

- Momenimovahed Z, Salehiniya H. Epidemiological characteristics of and risk factors for breast cancer in the world. Breast Cancer (Dove Med Press). 2019 Apr 10;11:151-164. doi: 10.2147/BCTT.S176070. PMID: 31040712; PMCID: PMC6462164.

This revised paragraph clarifies the difference between high-penetrance hereditary cases and those with a familial predisposition, ensuring accuracy and consistency with current literature.

8-BRCA2 increases the risk of male BC but I don't think male breast cancer is strongly

Response: Thank you for your insightful comment. We have revised the manuscript to clarify that, while BRCA2 mutations significantly increase the risk of male breast cancer, they are found in about 12% of cases, indicating that most occurrences happen without this genetic link. This revision is supported by current literature.

We have added this clarified statement on the Section 2.1.2., replacing the previous sentence about 90% of breast cancers being sporadic.

Men carrying BRCA2 mutations have a significantly increased risk of developing breast cancer compared to the general male population. However, it is estimated that only about 10–15% of male breast cancer cases are associated with BRCA2 mutations, indicating that the majority of these tumors occur without this genetic alteration (Mersch 2015; Kuchenbaecker 2017). Therefore, while BRCA2 is a key predisposing factor in men, other genetic or environmental factors contribute to the development of male breast cancer in most cases.

References

-row 419-421 italic?

Response: Thank you for your comment. We have removed the italicized rows where they are not applicable.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The revised version of this manuscript has improved greatly and given a comprehensive overview of breast cancer by supplementing the parts of Diet and nutrition, natural products-derived drugs, and etc. The reviewer recommend the article to be published in the IJMS journal after revision again.

Minor concerns

1.Passive voice should be applied for the sentence ‘Figure created with Biorender’ in Figure 1

Adjust the citation format of the literature[297] [89]and [240][241] among others.

3.Delete the abbreviations of professional terms that only appear once.

4.Check Latin words in vitro, in vivo, etc. in italic font throughout text.

5.Although the authors have discussed the disadvantage of chemoprevention of breast cancer, the advantages of natural medicines and their future application in breast cancer are lacking.

Author Response

Comment: The revised version of this manuscript has improved greatly and given a comprehensive overview of breast cancer by supplementing the parts of Diet and nutrition, natural products-derived drugs, and etc. The reviewer recommend the article to be published in the IJMS journal after revision again.

Response: Thank you very much for your comments, which have been of great help in improving the manuscript.

Minor concerns

1.Passive voice should be applied for the sentence ‘Figure created with Biorender’ in Figure 1

Response: We have changed the caption by adding the following information: Created in BioRender. García, N. (2025) https://BioRender.com/t06q492, since this is the correct way to cite the figure according to BioRender.

2. Adjust the citation format of the literature[297] [89]and [240][241] among others.

Response: The format of the citations will be adjusted once the review is finished, with the help of the IJMS team for the final format of the paper.

3.Delete the abbreviations of professional terms that only appear once.

Response: Thank you so much. We have eliminate some of the abbreviations that only appear once.

4.Check Latin words in vitro, in vivo, etc. in italic font throughout text.

Response: Thank you so much. We have change this Latin words to italic fount.

5.Although the authors have discussed the disadvantage of chemoprevention of breast cancer, the advantages of natural medicines and their future application in breast cancer are lacking.

Response: Thank you so much for this comment. We have added this paragraph in lines 882-885: Natural compounds such as flavonoids and resveratrol show potential for breast cancer prevention by modulating pathways like PI3K/AKT and NFκB. Their low toxicity and good tolerability make them attractive alternatives or complements to conventional agents, especially in women at intermediate risk [298, 299].

298. González-Bosch C, Zunszain PA, Mann GE. Control of Redox Homeostasis by Short-Chain Fatty Acids: Implications for the Prevention and Treatment of Breast Cancer. Pathogens. 2023 Mar 19;12(3):486. doi: 10.3390/pathogens12030486. PMID: 36986408; PMCID: PMC10058806.

299. Ávila-Gálvez MÁ, Giménez-Bastida JA, Espín JC, González-Sarrías A. Dietary Phenolics against Breast Cancer. A Critical Evidence-Based Review and Future Perspectives. Int J Mol Sci. 2020 Aug 10;21(16):5718. doi: 10.3390/ijms21165718. PMID: 32784973; PMCID: PMC7461055.

Moreover, we have added the next sentence in the discussion part: "Moreover, natural products can target multiple pathways, have fewer side effects, and may enhance the effectiveness of conventional therapies, making them promising for breast cancer chemoprevention." (lines 956-958)

Reviewer 2 Report

Comments and Suggestions for Authors

I have reviewed the revised manuscript, and I confirm that it is now accepted for publication.

Author Response

Thank you very much for your comments, which have greatly improved the quality of the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

The only comment I had on the ms as it reads now what that I though there was a sign as % missing after the figure 15 given at (I think) row. 350 or 351.

Author Response

Thank you very much for your comments, which have greatly improved the quality of the manuscript. In row 350, we refer to the fact that physical inactivity has been associated with the development of 15 types of malignancies.
We have modified the text to better express it:

"Physical activity has long been tied to reduced incidence of colon, endometrial, and premenopausal and postmenopausal breast cancer; and newly updated epidemiologic evidence now identifies inactivity as a potential contributor to as many as 15 types of malignancies."