Cortesi et al. BMC Cancer 2010, 10:90 http://www.biomedcentral.com/1471-2407/10/90 involved in trying to improve the outcomes of breast cancer. The results of a recent study in an Ashkenazi Jewish population suggested that among the subgroup of patients with BC carrying a BRCA1 mutation, those who received chemotherapy had a better survival rate compared with those who did not [8]. The primary aim of our study was to calculate disease free survival (DFS) and overall survival (OS) of BC patients at high risk (H) or intermediate slightly (IS) increased risk based on family history and those without a family history of breast cancer using the population registered with the Breast Cancer Registry in Modena. Previous studies were aimed at evaluating the outcome in BRCA-positive and BRCA-negativepatients, but none showed a significant survival difference between differ- ent risk categories. In case of statistically significant dif- ferences in OS between the three groups, a secondary aim was to determine whether patients with a better prognosis were BRCA1 mutation carriers, showing that the outcome could be considered an indicator of BRCA1 inheritance. Additionally, we evaluated whether che- motherapy could play a role in the prognosis of BRCA1 carriers, providing more benefit in this patient popula- tion than in patients with sporadic breast cancer. Methods Patients Patients included in our analysis were diagnosed between 1988 and 2006 at the Department of Oncology and Haematology in Modena. All newly-diagnosed, biopsy-proven primary breast cancer patients were eval- uated. The family history was collected and classified according to the Modena criteria (without family his- tory, IS increased risk, or H risk)[14] and a blood sam- ple, preserved with EDTA, was obtained with informed consent and frozen at -80°C for biological studies. On the basis of the Modena criteria for familial risk, patients who did not have any family history were con- sidered to have sporadic breast cancer, patients with one or two breast cancers at ≥ 40 years, without a first- degree relationship, were considered at IS increased risk, and patients with breast cancer at ≤ 35 years, three or more breast cancers with a first-degree relationship, and at least one case at ≤ 40 years or bilateral breast cancer had a H risk of being hereditary. All research regarding the identification, counselling, genetic testing, and clinical data regarding individuals at risk of developing breast cancer were ethically approved by the Ethics Commitee of Modena (reference number 45/00). Mutational analysis In 1995, DNA started to be extracted from frozen whole blood using the Invisorb Blood Universal kit (Invitek, Page 2 of 9 Berlin, Germany), amplified by PCR using primers speci- fic for the coding sequence and exon-intron boundaries of BRCA1, and analyzed by Direct Automated Sequen- cing using an ABI Prism 3100 (Applied Biosystems, Fos- ter City, CA). Subsequently, patients with breast cancer provided consent for genetic testing that was completed for each case. Samples negative for BRCA1 mutations were tested for BRCA1 rearrangements using the multiplex ligation- dependent probe amplification assay (MRC Holland, Amsterdam, The Netherlands) following the manufac- turer’s protocol. Statistical analysis The c2 test was used to determine differences in clinico- pathological features between groups. Survival curves were estimated using the Kaplan-Meier method includ- ing the log-rank test group comparison. Patients who were BRCA1 carriers were matched with patients with sporadic breast cancer from the Modena cancer registry. This registry, initiated in 1988, covers an area with approximately 650,000 inhabitants in Northern Italy. A database with a total of 3858 cases of sporadic breast cancer was used to find four matched controls for each case and a randomized matches were assigned between BRCA1 and patients with sporadic BC of the same age at diagnosis (range, between 26 and 76 ± 4 years), tumour grade (I, II, and III), and stage (I, II, and III). Multivariate analyses of DFS and OS were conducted using a proportional hazards Cox regression model. All statistical analyses were done with SPSS, version 12.0 (SPSS Inc, Chicago, IL). Results Patient Characteristics From January 1988 and December 2006, 5923 patients were diagnosed with breast cancer. According to their family history, 4912 were considered sporadic breast cancers, 691 were at IS increased risk, and 320 were considered H risk. The patients’ characteristics are detailed in Table 1. The H risk group presented with a medullary carcinoma histotype more frequently than the other two groups (p < .0001). The H risk group was more likely to have stage II disease than the sporadic and IS increased risk groups (p < .0001), and to have a significantly lower estrogen receptor (ER) and progester- one receptor (PgR) expression levels (p < .0001) as mea- sured by immunohistochemical analysis (clone 6F11, Ventana, for ER; and clone 1E2, Ventana, for PgR) and stained by Ventana Benchmark autostainer. The ER and PgR receptor status was tested by evaluating the percen- tage of nuclear immunoreactivity with respect to all the nuclei in the neoplastic cells, independently of the stain- ing intensity. No differences were seen in the Ki67 level