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Breast density and mode of detection in relation to breast cancer specific survival: a cohort study
© Olsson et al.; licensee BioMed Central Ltd. 2014
Received: 12 June 2013
Accepted: 10 March 2014
Published: 28 March 2014
The aim of this study was to examine breast density in relation to breast cancer specific survival and to assess if this potential association was modified by mode of detection. An additional aim was to study whether the established association between mode of detection and survival is modified by breast density.
The study included 619 cases from a prospective cohort, The Malmö Diet and Cancer Study. Breast density estimated qualitatively, was analyzed in relation to breast cancer death, in non-symptomatic and symptomatic women, using Cox regression calculating hazard ratios (HR) with 95% confidence intervals. Adjustments were made in several steps for; diagnostic age, tumour size, axillary lymph node involvement, grade, hormone receptor status, body mass index (baseline), diagnostic period, use of hormone replacement therapy at diagnosis and mode of detection. Detection mode in relation to survival was analyzed stratified for breast density. Differences in HR following different adjustments were analyzed by Freedmans%.
After adjustment for age and other prognostic factors, women with dense, as compared to fatty breasts, had an increased risk of breast cancer death, HR 2.56:1.07-6.11, with a statistically significant trend over density categories, p = 0.04. In the stratified analysis, the effect was less pronounced in non-symptomatic women, HR 2.04:0.49-8.49 as compared to symptomatic, HR 3.40:1.06-10.90. In the unadjusted model, symptomatic women had a higher risk of breast cancer death, regardless of breast density. Analyzed by Freedmans%, age, tumour size, lymph nodes, grade, diagnostic period, ER and PgR explained 55.5% of the observed differences in mortality between non-symptomatic and symptomatic cases. Additional adjustment for breast density caused only a minor change.
High breast density at diagnosis may be associated with decreased breast cancer survival. This association appears to be stronger in women with symptomatic cancers but breast density could not explain differences in survival according to detection mode.
High breast density is an independent risk factor for breast cancer [1] but also decreases the sensitivity [2–4] for tumour detection by mammography [2–5].
The concept of breast density is based on the radiological appearance of the breast parenchyma and denser breasts have a higher proportion of epithelial and connective tissue in relation to fat, while non-dense breasts are richer in fat [6, 7]. Breast density decreases after menopause [8] and with increasing body mass index (BMI) [9–11]. It has also been related to hormonal factors such as menopausal status and use of hormone replacement therapy (HRT) [8, 11, 12], but the biological mechanism connecting breast density to breast cancer risk is not clearly understood.
In order to increase sensitivity, shorter screening intervals have been suggested for younger women and/or women with denser breasts [13]. However, the effect of such interventions regarding mortality, or the potential effect of breast density on survival per se, is not known.
Six studies, have reported on breast density in relation to breast cancer specific survival. Two of the studies found that women with dense breasts had a slightly impaired survival [5, 14], one found a statistically significant better survival in women with dense breasts [4], and two studies found no association at all [15, 16]. In one study, breast density was associated with poorer survival only in women not receiving radiotherapy [17]. Women with screening detected breast tumours have a better prognosis compared to women with clinically diagnosed breast cancer, despite adjustment for stage at diagnosis and other tumour characteristics [18–21]. The prognostic advantage associated with mammography screening could be less evident in women with denser breasts, given the lower mammographic sensitivity. If breast density has an independent effect on survival, breast density would affect outcome regardless of detection mode, and might explain part of the survival difference between women with non-symptomatic vs. symptomatic tumours.
The aim of this study was to examine breast density in relation to survival following breast cancer diagnosis, using breast cancer specific death as the endpoint and to assess if this potential association was modified by mode of detection. An additional aim was to examine whether the established association between mode of detection and survival is modified by breast density.
The Malmö Diet and Cancer Study
The Malmö Diet and Cancer Study (MDCS) is a population based, prospective cohort study inviting residents in Malmö, Sweden, born between 1923 and 1950. Between 1991–1996, 17 035 women were enrolled, corresponding to a participation rate of approximately 40%. The study includes questionnaires and interviews on diet, medications, socio-economy and life-style factors [22, 23]. Blood samples and information on weight and height were collected at baseline, and BMI was calculated as kg/m2[22, 23].
Identification of breast cancer patients
Data on cancer events in the MDCS-population has been retrieved from the Swedish Cancer Registry and The Regional Tumour Registry for Southern Sweden. Until 31 Dec. 2007, 826 incident breast cancer cases were diagnosed. Women with prevalent breast cancer at baseline (n = 576) were excluded. Participants in the Malmö Diet and Cancer Study have all given written informed consent at baseline. Through subsequent advertisements, included women have been informed about planned additional analyses and about the possibilities of withdrawal. No new contacts have been taken with included women or their relatives for this particular study. The present study was approved by The Ethical Committee at Lund University (Dnr 652/2005 and Dnr 166/2007).
Screening status
This study included women from the MDCS cohort, potentially exposed to mammography screening. The general screening service started in Malmö in 1990 and was, during the study period, inviting women 50–69 years of age but with an extension of the upper age-limit to 74 years during the last decade. Women were invited at 18 or 24 months intervals depending on parenchymal pattern, (the shorter interval for women with denser breasts) [24]. Since there was no information on the presence of breast implants, or the use of opportunistic screening among participants in the general screening program, we refer to this group as non-symptomatic cancers. Mammography, and opportunistic screening, has to some extent been available outside the general screening program. Out of the final study population (n = 619, see below), 30 women were considered as diagnosed by screening outside general screening and they were classified as non-symptomatic if clearly stated in the clinical notes that they were asymptomatic at the time of the diagnostic mammogram. No information on screening intervals was available for this group. The diagnostic ages in women with non-symptomatic cancers ranged from 48 to 81 years, which were the limits used to define the present study population. An interval cancer was defined as a symptomatic breast cancer, diagnosed clinically within 18 or 24 months, (depending on the planned screening interval), from a previously normal screening mammogram.
Study population
Out of 826 incident breast cancer cases, 79 cases with cancer in situ were excluded as the primary objective of the present study was to investigate survival. Fifteen cases with bilateral tumours were excluded due to the difficulty to retrospectively evaluate the stage of these tumours. Women with unknown screening status (n = 19) and unknown breast density (n = 36) were also excluded. Finally, 65 women were excluded due to insufficient amounts of tumour tissue. A single woman could be excluded for several reasons. Adding the age criteria 48–81 years for non-symptomatic cancers, the final study population included 619 cases. Out of these 619 women, 350 were non-symptomatic, 177 were symptomatic and 87 were interval cancers. In another five symptomatic women diagnosed clinically, it was not possible to exclude the possibility of an interval cancer. These women were included as "symptomatic" in analyses using two categories of detection mode (non-symptomatic/symptomatic) and as "unknown" in analyses using three categories (non-symptomatic/interval/symptomatic). The eighteen year period of inclusion was divided into three six-year categories to define diagnostic period.
Information on cause of death and vital status was retrieved from the Swedish Causes of Death Registry, with last follow up 31 Dec. 2010 [25]. At the end of follow up, 76 women had died from breast cancer as underlying or contributing cause of death (mean age at death: 70.1 years; standard deviation (SD): 8.6). Forty-seven women had died from other causes (mean age at death: 73.9 years; SD: 6.6). Median follow-up from diagnosis to death, end of follow-up or emigration (2 women) was 7.8 years (range 0.5-19.1).
Tumour and patient characteristics
Information on tumour size, axillary lymph node involvement (ALNI), type of surgery, planned adjuvant therapy, menopausal status and use of HRT at diagnosis was collected from medical journals, including pathology reports. Fifty-eight women had not been operated in the axilla and thus had missing information on ALNI. In most of these cases, an axillary dissection had been considered unnecessary at the pre-operative evaluation and they were classified as ALNI negative. All these women had a tumour size less than or equal to 20 mm, and were free from distant metastases at diagnosis. One woman with distant metastases at diagnosis, but registered as having negative lymph nodes was classified as "unknown" for ALNI. The study population included four women with distant metastases at diagnosis, one diagnosed with an interval cancer and the other three had symptomatic tumours. Three of these women had died from breast cancer at end of follow-up. Cases diagnosed from study start in 1991 and until 31 Dec 2004, were re-evaluated regarding tumour type according to the World Health Organization-classification [26], and assessed for tumour grade according to Elston and Ellis [27] by one senior pathologist [28]. For cases diagnosed 1 Jan 2005 to 31 Dec 2007, information on tumour grade was collected from the pathology reports.
Tissue micro arrays for immunohistochemical analyses were constructed as described previously in order to define hormone receptor status; oestrogen receptor α (ER) and progesterone receptor (PgR) [28]. In this study, ≤10% or >10% of positive nuclei defined negative and positive hormone receptor status, in accordance with clinically used limits [29].
Breast density
Breast density was estimated qualitatively and reported by experienced breast radiologists at the initial evaluation of the diagnostic mammogram. In the assessment of women recalled from screening with suspicion of breast cancer, the screening mammogram (craniocaudal and mediolateral oblique views) was completed with as many views as needed, corresponding to a diagnostic mammography examination with at least three views. Thus, the assessment of breast density was done at the time of the diagnostic work-up and not at the screening readings. Breast density was measured using both breasts and all views, although when there was an apparent effect of the tumor on the surrounding tissue in terms of higher breast density, the contralateral view was used. When breast density differed between breasts, not related to the tumour, the breast with the highest breast density was used for final decision. Information on breast density was missing in about one third of cases, and these mammograms were retrospectively revised by one breast radiologist (SZ) and a trained, supervised resident in radiology (HS). In 36 women, no mammograms were possible to find for revision. At end of follow-up, 11out of these 36 women had died from breast cancer and they were excluded from the study. The mammograms at the institution were analogue up until 2003 and digital from 2004 and onwards. Routinely, during the last 30 years, a three category classification of breast density has been used: "fatty", "moderate" or "dense". This classification is a modification of the Breast Imaging Reporting and Data System (BI-RADS) where "fatty" corresponds to BI-RADS 1 (almost entirely fat), "moderate" to BI-RADS 2 + 3 (scattered fibroglandular densities; and heterogeneously dense) and "dense" to BI-RADS 4 (extremely dense) [30].
For the descriptive analysis of the study-population, the three density categories described above were used. In some stratified analyses, fatty breasts and moderately dense breast were combined and compared to dense breasts.
Factors related to the ability to diagnose a tumour; age, use of HRT, menopausal status and breast density at diagnosis, BMI at baseline, diagnostic period and mode of detection were compared according to outcome, defined as alive at end of follow-up, dead from breast cancer (as cause of death or contributing cause of death), or dead from other causes. Vital status and cause of death were further investigated in relation to known prognostic factors and treatment; diagnostic age, tumour size, ALNI, tumour grade, ER, PgR, type of surgery, type of lymph node examination and planned adjuvant treatment.
Factors related to the ability to diagnose a tumour were also investigated in relation to breast density. Differences were tested with ANOVA for continuous variables, and the Chi-2 test for categorical variables. All tests were two-sided and a p-value <0.05 was considered significant.
Breast density was analysed in relation to subsequent breast cancer death using Cox proportional hazards analysis calculating hazard ratios (HR) with 95% confidence intervals (CI). Adjustments were first made for prognostic factors; age, diagnostic period, tumour size, ALNI, grade, ER and PgR (HR2). Additional adjustments included BMI and HRT (HR3). The correlation between diagnostic age and menopausal status was tested using tau-b, analysing diagnostic age as a categorical variable (ten-year categories) and showed a statistically significant correlation, 0.405, p = <0.001, which is why the adjustments did not include menopausal status. All analyses were performed separately in non-symptomatic and symptomatic cases. In a final model, analysing all subjects, adjustments were also made for detection mode (HR4), and interactions between detection mode and breast density were tested using an interaction term. Linear trends over density categories were calculated yielding two-sided p-values. The association between detection mode and breast cancer death was analysed by the same model, first adjusting for prognostic factors as above (HR2 and HR3), and finally, in the analysis of all subjects, also for breast density (fatty/moderate/dense). Interactions between detection mode and breast density were tested using an interaction term. Freedmans% [31] was used to determine the contribution of these adjustments to the survival difference between non-symptomatic and symptomatic cases. Freedmans% was defined as: 100(1- a/b); where b is the logarithm of the unadjusted HR, and a, the logarithm of the adjusted HR.
The proportional hazard assumption was tested using a log minus log curve, and for all analyses on survival, the assumption was met. Missing values were included as separate categories in all multivariate analyses, thus, the adjustments made did not affect the number of included cases. All analyses were repeated excluding the four women with distant metastasis at diagnosis and all analyses were also repeated using death from causes other than breast cancer as the event and adjusted separately for age, BMI, HRT and diagnostic period as these factors are likely to affect overall mortality. A sensitivity analysis was made to the un-stratified Cox analyses, by adding adjustment for one modality of adjuvant therapy at the time (planned radio-therapy yes/no, planned chemo-therapy yes/no, planned antihormonal treatment yes/no). SPSS 20.0 was used for all calculations.
Vital status and factors potentially related to breast density and tumour detection
Alive (n = 496)
Dead breast cancer (n = 76)
Dead other cause (n = 47)
All (n = 619)
Number (column percent)Mean, SD in italics
Age at baseline
56.0 (6.6)
58.2 (7.8)
61.6 (6.9)
56.7 (7.0)
Age at diagnosis
64.0 (7.3)
64.5 (8.7)
67.8 (7.6)
64.4 (7.5)
HRT at diagnosis
169 (34.1)
17 (22.4)
11 (23.4)
197 (31.8)
168 (33.9)
21 (27.6)
11 (23.4)
200 (32.3)
159 (32.0)
38 (50.0)
25 (53.2)
222 (35.9)
Menopausal status at diagnosis
40 (8.1)
11 (14.5)
2 (4.3)
53 (8.6)
446 (89.9)
65 (85.5)
42 (89.4)
553 (89.3)
10 (2.0)
0 (0.0)
3 (6.4)
13 (2.1)
BMI at baseline
21 (4.2)
4 (5.3)
2 (4.3)
27 (4.4)
20- < 25
242 (48.8)
33 (43.4)
18 (38.3)
293 (47.3)
25- < 30
159 (32.1)
30 (39.5)
14 (29.8)
203 (32.8)
74 (14.9)
9 (11.8)
13 (27.7)
96 (15.5)
Detection mode (three categories)
301 (60.7)
27 (35.5)
22 (46.8)
350 (56.5)
68 (13.7)
13 (17.1)
6 (12.8)
87 (14.1)
122 (24.6)
36 (47.4)
19 (40.4)
177 (28.6)
5 (1.0)
0 (0.0)
0 (0.0)
5 (0.8)
Detection mode (symptomatic including interval cancer)
301 (60.7)
27 (35.5)
22 (46.8)
350 (56.5)
195 (39.3)
49 (64.5)
25 (53.2)
269 (43.5)
Breast density
73 (14.7)
7 (9.2)
13 (27.7)
93 (15.0)
254 (51.2)
37 (48.7)
21 (44.7)
312 (50.4)
169 (34.1)
32 (42.1)
13 (27.7)
214 (34.6)
Diagnostic period
62 (12.5)
21 (27.6)
94 (15.2)
173 (34.9)
28 (36.8)
19 (40.4)
220 (35.6)
261 (52.6)
27 (35.5)
17 (36.2)
305 (49.3)
Vital status, prognostic factors and treatment
Alive (n = 496)
Dead breast cancer (n = 76)
Dead other cause (n = 47)
All (n = 619)
Number (column percent)
Tumour size (mm)
160 (32.3)
1 (1.3)
13 (27.7)
174 (28.1)
>10- ≤20
225 (45.4)
31 (40.8)
17 (36.2)
273 (44.1)
109 (22.0)
44 (57.9)
17 (36.2)
170 (27.5)
2 (0.4)
0 (0.0)
0 (0.0)
2 (0.3)
Axillary lymph node status (ALNI)
371 (74.8)
28 (36.8)
37 (78.7)
436 (70.4)
124 (25.0)
48 (63.2)
10 (21.3)
182 (29.4)
1 (0.2)
0 (0.0)
0 (0.0)
1 (0.2)
Nottingham grade
152 (30.6)
7 (9.2)
14 (29.8)
173 (27.9)
249 (50.2)
27 (35.5)
20 (42.6)
296 (47.8)
91 (18.3)
42 (55.3)
12 (25.5)
145 (23.4)
4 (0.8)
0 (0.0)
1 (2.1)
5 (0.8)
Estrogen receptor status (ER)
47 (9.5)
19 (25.0)
5 (10.6)
71 (11.5)
394 (79.4)
53 (69.7)
40 (85.1)
487 (78.7)
55 (11.1)
4 (5.3)
2 (4.3)
61 (9.9)
Progesterone receptor status (PgR)
182 (36.7)
44 (57.9)
26 (55.3)
252 (40.7)
201 (40.5)
22 (28.9)
14 (29.8)
237 (38.3)
113 (22.8)
10 (13.2)
7 (14.9)
130 (21.0)
Type of surgery
182 (36.7)
48 (63.2)
19 (40.4)
249 (40.2)
311 (62.7)
28 (36.8)
28 (59.6)
367 (59.3)
3 (0.6)
0 (0.0)
0 (0.0)
3 (0.5)
Axillary dissection
48 (9.7)
1 (1.3)
7 (14.9)
56 (9.0)
280 (56.5)
63 (82.9)
33 (70.2)
376 (60.7)
Single node
2 (0.4)
0 (0.0)
0 (0.0)
2 (0.3)
Sentinel node
162 (32.7)
11 (14.5)
6 (12.8)
179 (28.9)
4 (0.8)
1 (1.3)
1 (2.1)
6 (1.0)
Antihormonal treatment
245 (49.4)
33 (43.4)
28 (59.6)
306 (49.4)
242 (48.8)
42 (55.3)
19 (40.4)
303 (48.9)
9 (1.8)
1 (1.3)
0 (0.0)
10 (1.6)
380 (76.6)
51 (67.1)
42 (89.4)
473 (76.4)
57 (11.5)
23 (30.3)
3 (6.4)
83 (13.4)
59 (11.9)
2 (2.6)
2 (4.3)
63 (10.2)
172 (34.7)
27 (35.5)
23 (48.9)
222 (35.9)
269 (54.2)
47 (61.8)
22 (46.8)
338 (54.6)
55 (11.1)
2 (2.6)
2 (4.3)
59 (9.5)
Potential determinants for breast density and tumour detection
Breast density
Fatty (n = 93)
Moderate (n = 312)
Dense (n = 214)
Number (column percent)Mean, SD in italics
Age at baseline
60.1 (7.1)
56.8 (6.8)
55.1 (6.7)
Age at diagnosis
67.4 (7.3)
65.2 (7.1)
62.0 (7.6)
< 0.0001
HRT at diagnosis
25 (26.9)
126 (40.4)
46 (21.5)
10 (10.8)
84 (26.9)
106 (49.5)
58 (62.4)
102 (32.6)
62 (29.0)
Menopausal status at diagnosis
3 (3.2)
18 (5.8)
32 (15.0)
89 (95.7)
287 (92.0)
177 (82.7)
1 (1.1)
7 (2.2)
5 (2.3)
BMI at baseline
0 (0.0)
10 (3.2)
17 (7.9)
20- < 25
29 (31.2)
135 (43.3)
129 (60.3)
25- < 30
27 (29.0)
123 (39.4)
53 (24.8)
37 (39.8)
44 (14.1)
15 (7.0)
Detection mode (three categories)
50 (53.8)
183 (58.7)
117 (54.7)
10 (10.8)
43 (13.8)
34 (15.9)
31 (33.3)
83 (26.6)
63 (29.4)
2 (2.2)
3 (1.0)
0 (0.0)
Detection mode (symptomatic including interval cancers)
50 (53.8)
183 (58.7)
117 (54.7)
43 (46.2)
129 (41.3)
97 (45.3)
Breast density and subsequent breast cancer mortality in relation to mode of detection
Rate of breast cancer deaths
7 of 93
37 of 312
1.82 (0.81-4.08)
1.80 (0.79-4.10)
2.02 (0.87-4.67)
2.09 (0.90-4.85)
32 of 214
1.92 (0.85-4.35)
2.24 (0.97-5.13)
2.56 (1.07-6.11)
2.63 (1.10-6.30)
p-value for trend
3 of 50
13 of 183
1.37 (0.39-4.81)
1.30 (0.36-4.76)
1.40 (0.38-5.17)
11 of 117
1.47 (0.41-5.27)
1.66 (0.43-6.41)
2.04 (0.49-8.49)
p-value for trend
4 of 43
24 of 129
2.43 (0.84-7.02)
2.20 (0.74-6.51)
2.62 (0.86-7.98)
21 of 97
2.33 (0.80-6.80)
2.71 (0.91-8.06)
3.40 (1.06-10.90)
p-value for trend
Mode of detection and subsequent breast cancer mortality in relation to breast density
Rate of breast cancer deaths
27 of 350
49 of 269
2.68 (1.67-4.28)
1.55 (0.95-2.53)
1.52 (0.92-2.50)
1.56 (0.94-2.58)
16 of 233
28 of 172
2.63 (1.42-4.87)
1.48 (0.76-2.88)
1.54 (0.79-3.02)
11 of 117
21 of 97
2.63 (1.26-5.47)
1.71 (0.75-3.90)
1.63 (0.68-3.91)
In the unadjusted model, symptomatic cases had a higher risk of breast cancer death as compared to non-symptomatic regardless of breast density, Table 5. The HRs were attenuated in the adjusted models, and did not reach statistical significance. Estimated by Freedmans%, diagnostic age, tumour size, ALNI, grade, ER and PgR explained 55.6% of the observed differences in mortality between non-symptomatic and symptomatic cases. Additional adjustment for breast density caused only a minor change in Freedmans%, +0.6 per cent units.
All results remained similar excluding women with distant metastases at diagnosis (data not shown). Women with dense, as compared to fatty breasts, had a decreased risk of death from causes other than breast cancer in the crude model including all subjects, HR: 0.42:0.20-0.91, p-value for trend 0.03. The HR was 0.68(0.31-1.49) adjusted for age at diagnosis and diagnostic period, and 0.74(0.31-1.73) adjusted for age, BMI, HRT and diagnostic period (Additional file 1: Table S1 and Table S2). Results were similar after adjustment for planned chemotherapy and planned anti-hormonal therapy. Adjustment for radio-therapy caused only minor changes in the results but diminished the hazard ratios slightly. In the fully adjusted models in Table 4, HR3 changed from 2.59:1.08-6.20 to 2.51:1.04-6.02 and HR4 changed from 2.66:1.11-6.38 to 2.59:1.08-6.23 for women with dense breasts. In the fully adjusted models in Table 5 HR3 changed from 1.55:0.95-2.52 to 1.44:0.87-2.38 and HR4 from 1.54:0.94-2.52 to 1.45:0.88-2.40 for women with symptomatic tumours.
In the present study high breast density was positively associated with death from breast cancer, in a dose–response pattern. Moreover, this association was most pronounced among symptomatic women. Breast density did not substantially contribute to the difference in survival between women with non-symptomatic vs. symptomatic cancers.
Some methodological issues have to be considered. All Swedish residents are given a unique civil registration number at birth which facilitates record-linkage. The Swedish Cause of Death Registry offers complete data with a coverage of 97.3% in 2008 [32] and the cause of death for malignant tumours has been shown to be correct in 90% of cases [33]. Hence, information on cause of death in the present study is expected to have a high completeness and correctness.
Breast density in this study was estimated qualitatively by several radiologists. Both qualitative and quantitative methods of measuring mammographic density have shown an association between density and breast cancer risk [1]. Quantitative measurements are thought to be more exact and reliable [34]. However, there is no consensus which quantitative measure of breast density to use [35], which is why we consider it relevant to use a readily available qualitative mode of assessment such as a modified BI-RADS. Known determinants for breast density (BMI, HRT, age and menopausal status) were distributed as expected in relation to different categories of density in this study, indicating a valid measurement of breast density. No formal assessment of inter-observer variability was performed at the initial estimation of breast density in this study, which is a limitation. However, in a not yet published study, 1200 recent screening mammograms were prospectively double-read by the same observers as in the present investigation. When applying the BIRADS classification with the modification described above, a kappa coefficient of 0.60 (0.55-0.65, 95% confidence interval) and a quadratic weighted kappa of 0.66 (0.62-0.70, 95% confidence interval) were found. This provides support of a substantial inter-observer agreement between the radiologists.
There was a change from analogue to digital mammography at our institution in 2004. Difference in acquisition method has been reported not to be of great importance when using a qualitative density measure such as BI-RADS [35].
BMI was used for adjustment as a potential confounder of the possibility to detect a tumour clinically or at screening mammography. It would have been more accurate to adjust for BMI at diagnosis but this information was not available. Weight changes over time cannot be excluded, which could have resulted in residual confounding. Weight gain and a consequent rise in BMI is probably the most likely change to occur with increasing age [36, 37]. We believe this non-differential misclassification could have attenuated the effect seen among women with fatty breasts.
Women with dense breasts, participating in the general screening program in Malmö, were invited at 18 instead of 24 months intervals. This may explain why the interval cancers were only slightly more common among women with dense breasts, which would otherwise have been expected according to data from previous studies [38, 39]. This weak association between interval cancers and high breast density could also have attenuated a potential adverse effect of density on survival in women with non-symptomatic cancers. Indeed, the strongest effect of density was seen in symptomatic cases. Interval cancers, which might have been missed at screening due to a masking effect at mammography, were included in this group, although the results may also indicate an independent effect of density on survival. There is however a problem with small numbers of breast cancer deaths in the stratified analyses, resulting in wide confidence intervals and consequently poor precision, why the results must be interpreted with caution. However, our main result is not a difference between symptomatic and non-symptomatic women but instead an over-all association between breast density and survival.
The increased mortality seen among women with dense breasts could be explained by competing mortality from other causes than breast cancer in women with fatty breasts. This seems unlikely however, as fewer women died from other causes than from breast cancer, and women who died from other causes died at a higher age. Moreover, although fatty breasts were associated with an increased risk of death from other causes, after adjustments for age, BMI, HRT and diagnostic period, these results were considerably attenuated and not statistically significant. It is also necessary to consider potential effects of lead time but to completely adjust for lead time bias is a challenging task. We adjusted our results for age, tumour size, axillary lymph node involvement, grade, hormone-receptor status, use of HRT and BMI. All this factors are likely to be associated with lead time and we believe these adjustments would have diminished potential effects of lead time bias. We are however aware that there could be residual confounding regarding lead time, which may have influenced our results through earlier tumour detected in women with fatty breasts. If so, this would then have led to a spuriously better survival in women with fatty breasts.
It is well known that younger women with breast cancer tend to have more aggressive tumours and younger women tend to have denser breasts. However, the proportion of younger women in this cohort is relatively low; mean age at diagnosis was 64.4 years (SD 7.5). All analysis were adjusted for age, tumour size, axillary lymph node involvement, grade and hormone-receptor status, which we believe would have diminished potential confounding by more aggressive tumours in younger women.
Results from previous studies on breast density and breast cancer specific survival are difficult to compare due to differences in methodology. The present and three previous studies [4, 5, 14] used different qualitative classifications of breast density. Two studies used quantitative estimation of density by a computer-assisted method but one of these studies included only 27 breast cancer deaths [17]. In a recent study from Sweden, evaluating breast density quantitatively, comparing 1115 screening-detected breast cancers and 285 interval cancers in postmenopausal women, women with interval cancers had generally more aggressive tumour characteristics and worse 5 year survival, although these differences were most pronounced among women with non-dense breasts [40]. There are however several differences between their and our study. Firstly, the study by Eriksson and al. used quantitative, computer assisted measures of breast density while we estimated breast density qualitatively. Secondly, symptomatic women not diagnosed as interval cancers were excluded from the study by Eriksson et al. It was not possible to study interval cancer separately in our analysis due to small numbers, which would indeed have been interesting. Thirdly, the end point in the study by Eriksson et al. was 5 year breast cancer specific survival, while most women in our study had a considerably longer follow-up, median 7.8 years (0.5-19.1). The limited number of events in our study must also be considered although the number of events was not given in the study by Eriksson et al.
Two investigations both used the BI-RADS classification of breast density in four categories [15, 16] but differed in size and design. Moreover, Chui et al. [5] estimated breast density at baseline in a screening program instead of at diagnosis, which may to some extent have attenuated their findings given potential changes in breast density over time. The results by Chiu et al., also based on a Swedish population, were similar to ours with an increased risk of breast cancer death in relation to density and with an even more increased risk in adjusted analyses. A problem in the majority of previous, and the present study, was the low number of included events, ranging from 26 [14] to 127 [5]. Despite a mean follow-up time of 7.8 years, the present study only included 76 events in the main analysis. On the other hand, the study by Gierach et al., based on data from the US Breast Cancer Surveillance Consortium, included 9232 women out of whom 889 died from breast cancer [16]. Their results showed no association between breast density and death from breast cancer. In that study nearly fifteen percent of women were treated with breast conserving surgery and not treated with radiotherapy, which most women in Sweden would have been. Women with BI-RADS category 1 were also to a lesser extent treated with chemotherapy than women in BI-RADS category 4, despite women with fatty breasts having more adverse tumour characteristics. Their results were indeed stratified for stage and adjusted for therapy but it could be that other population related differences, e.g. lack of population based mammography screening in the United States and differences regarding health care financing make results difficult to compare.
The mechanism underlying the association between breast density and breast cancer is not clear. Several studies have addressed the issue of an association between breast density and prognostic tumour characteristics but in most of these studies, no association or conflicting results have been seen between density and tumour size, ALNI or hormone receptor status [41]. Genetic factors could be of importance and there is evidence of common genetic polymorphisms related to both breast density and breast cancer development [42]. Apart from underlying genetics, breast density could biologically reflect hormonal factors [12, 43, 44], and factors related to oxidative stress [45, 46], which could affect epithelial and/or stroma related processes [45–49]. It is possible to hypothesise that such factors could also influence breast cancer risk and/or outcome.
In conclusion, in this study, high breast density at diagnosis may be associated with a decreased breast cancer specific survival. This association appears to be stronger in women with symptomatic cancers.
Hormone replacement therapy
Body mass index
Malmö diet and cancer study
Standard deviation
Axillary lymph node involvement
Estrogene receptor
- PgR:
Progesterone receptor
Breast imaging reporting and data system
Analysis of variance
Hazard ratio.
The study was conducted within the Breast Cancer network at Lund University (BCLU) and was supported by grants from The Ernhold Lundström Foundation, The Einar and Inga Nilsson Foundation, The Malmö University Hospital Foundation for Cancer Research, The Anna Lisa and Sven-Eric Lundgrens Foundation, The Crafoord Foundation, The Malmö University Hospital Founds and Donations and The Mossfelt Foundation. None of the foundations influenced the design, interpretation of data or the content of the manuscript. We also express our gratitude to Professor Göran Landberg for contributing data.
Authors' Affiliations
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Pre-publication history
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An exciting expansion of the Vilna Gaon's powerful ideas on the purpose of Creation, the Jewish People and its history and destiny, and the coming of Mashiach.
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Ryan Bader vs. Vladimir Matyushenko
Our first trip to the light heavyweight ranks is next, as Ryan Bader (14-3) faces off with Vladimir Matyushenko (26-6). Both men are coming off losses to top contenders, as Bader was defeated by Lyoto Machida and Matyushenko was bested by Alexander Gustafsson. The third man inside the Octagon will be John McCarthy.
Round 1: Matyushenko is the second-oldest active fighter in the UFC at 42 years old. Bader lands a huge left coming in that floors Matyushenko, and Bader pounces, grabbing the head and cranking a choke from the bottom position. Bader is able to lock up a leg in half-guard and tightens the grip, forcing Matyushenko to tap quickly.
Ryan Bader def. Vladimir Matyushenko via submission (guillotine choke) at :50 of Round 1


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Tournament Details
The University of Alabama at Birmingham's Master of Science in Health Administration Program, in conjunction with the Alumni Association of the Graduate Programs in Health Administration, is hosting its 11th annual MSHA Golf Classic on Thursday, April 21, 2016, at Ballantrae Golf Club in Pelham, Alabama.
Tournament Prices:
Individual Price: $150
Team of 4 Price: $600
Tournament Format:
4-person Scramble
1st Place: Team trip to Pinehurst Resort in North Carolina
2nd Place: Golf bag; $100 credit to Ballantrae Pro Shop
3rd Place: Free round of golf at Ballantrae; $50 credit to Ballantrae Pro Shop
Additional Prizes:
Hole in One: Acura Vehicle
Hole in One: $1000 shopping spree to PGA Store
Longest Drive: Weekend stay in Panama City, FL
Closest to the Pin: Weekend stay in San Destin, FL
Please visit our registration page for further information on how to register for the event.
Proper golf attire should be worn in accordance with Ballantrae Golf Club's Rules and Regulations. You may want to bring rain gear, too.
Event Sponsorships:
We encourage you to look at our sponsorship packages. There are opportunities for every budget and good intention! Please click here to see more details.
There is ample parking at the event location:
Ballantrae Golf Club
1300 Ballantrae Club Drive
Pelham, AL 35124


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A spotted hyena pulls on a carcass.
Hyenas tear into a carcass as scavengering birds wait their turn. Hyenas eat almost everything on a carcass, including the bones.
A spotted hyena wearing a radio collar stands at alert over a carcass.
Spotted hyenas are known for their "laughs," but research shows the hyena giggles are anything but light-hearted. The animals usually make the noise during social conflicts.
Hyenas are aggressive, but they know how to cooperate. According to a 2009 study published in the journal Animal Behavior, hyenas are quicker learners than non-human primates when it comes to figuring out how to do a task to get food.
A spotted hyena enjoys a meal. Hyena females outrank males and get to eat first.


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Category Archives: mobile payment
Carrier Billing – Got to catch them all!
The urgency to get direct carrier billing deployed and active, to avoid long term loss of access to high spending users has been brought into sharp focus over the last few weeks by the big surge in revenues coming in to app stores from … Continue reading
MWC 2016 roundup: Payment will be everything – everything must be able to pay
The Mobile World Congress 2016 catchphrase, 'mobile is everything' could equally have been, 'everything is mobile'. Although the big Android handset manufacturers, including HTC, LG, Sony and our close partner Samsung, all launched new handsets as usual, it was the … Continue reading
Bango expands app store carrier billing across Middle East region
Kuwait is the latest market to launch Google Play through the Bango Payment Platform, confirming the region's importance for app stores It comes as a surprise to many mobile payments watchers that carrier-billed payments have proved such a big hit with … Continue reading
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Bango have a great story to tell this year; the first launch of Direct Carrier Billing in Africa of Google Play, with Telkom South Africa. Trevor Goldberg, VP Business Development MNOs went to AfricaCom to spread the word and enable more African … Continue reading
To break into the mainstream sometimes it's best to go underground
Amazon Underground, the new app for Android smartphones, offers a selection of apps, games and in-app content, all for free. It is designed to break Amazon into the mainstream on Android smartphones by increasing store distribution and customer acquisition. Consequently … Continue reading
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Mobile payment is increasingly in the headlines as major brands all develop their strategies and look to gain market share, which has resulted in a wide array of new payment innovations being announced. When looking at Bango Payment, Apple Pay, … Continue reading
Samsung gains the most accepted mobile wallet on the planet
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Elliott Lives
Well, Elliott Smith's not with us in the physical world any longer, but, especially for those of us who got to know him at least briefly, he's still living in his beautiful songs, a double-CD of which is being released in a few weeks on May 8 (which I dig, because that makes a great birthday gift for me). His friends and fans still mourn his apparent suicide (though the coroner's office never offically named a cause of death and the investigation by the L.A.P.D. remains open). Still, we've still got his mind-blowing catalogue of music, which is expanding soon.
I'm listening to the new double album, New Moon, right now, though I don't have a promo copy of it as yet (Kill Rock Stars, which is releasing New Moon, is streaming it on a password-protected site for journalists to preview). It's classic Elliott, from the years when I personally was most impressed with his songwriting (darker, more drug and drink obsessed), and also about the same time period when I knew Elliott and would sit with him on my porch listening to him play acoustic songs by himself, Neil Young, and Hank Williams. The songs span 1994 - 1997, when he released his first self-titled album and the seminal Either/Or. I'm pretty averse to songs making me tear up, but these are starting to have that effect. As soon as I figure out a way to post a couple songs up here or get a promo CD, I'll share a couple with you; until then, you've got something to look for. Here's hoping your resting in peace, my friend.
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Lot 65: THUNDERBIRDS: A rare Thunderbi
Games, Trains & Automobiles TOY SALE - Worldwide Postage Available On All Items
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October 22, 2016
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Description: THUNDERBIRDS: A rare Thunderbirds Porcelain Doll Collection collectors edition ' Parker ' doll. 'Signed & Authorised by Sylvia Anderson'. Made by English Classic Porcelains. Mint, within the original box. Complete with certificate (signed by Sylvia Anderson). Licensed by Carlton. 41cm tall. Within the original tube box.
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The National Association of Marriage Enhancement (N.A.M.E.), IMC 20 host, is dedicated to counseling couples and providing the local church with marriage ministry resources. NAME's mission is two fold: to see marriages saved and strengthened.Learn More
We regret to announce that our second IMC of 2016, IMC Indiana, scheduled for November 4-5, 2016 has been CANCELED. Due to an unfortunate venue cancellation beyond our control, we must reschedule. Please stay tuned for updates!Learn More
Starting 2016, the annual International Marriage Conference (IMC) is moving regional! Thank you to all who attended our first ever regional conference on April 15-16, 2016 in Victorville, CA. Lives were changed and marriages were saved!Learn More


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More Videos...
1970 Ford Maverick 557 Cubic Inches
Not my car, but the engine was just finished and I was helping a little as he broke in the engine for the first time. Beautiful car.
557 bbf stroker 460 dyno 700HP 700LB
Scott Johnston RHP built 557, SVO A block, forged rotating assembly, Kaase P-51 heads, 10.2:1 XR298R, built for broad torque & street use. We saw 697HP at 5900rpm.
572 CID Big Block Ford Kaase P51 Head 900 HP @ 7000 rpm all motor
A460 block @ 4.500 bore, eagle 4340 4.500 stroke crank, eagle H-beam rods with ARP L19 rod bolts, Kaase P51 cylinder heads (stock--unported) comp cams solid roller, Diamond 16 to 1 pistons, Danny Bee belt drive, T&D rockers, TFS intake, Carb Shop 1050 dominator, MSD crank trigger ignition. Engine built by Vrbancic Bros Racing, Ontario CA
Starting up a 460
Starting up the ford 460 that wad built in my shop at my tech school. Theres flames coming out of the awesome headers.


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|"Dawid Weiss (Commented) (JIRA)" <j...@apache.org>
|[jira] [Commented] (LUCENE-3877) Lucene should not call System.out.println
|Wed, 21 Mar 2012 19:09:41 GMT
[ https://issues.apache.org/jira/browse/LUCENE-3877?page=com.atlassian.jira.plugin.system.issuetabpanels:comment-tabpanel&focusedCommentId=13234881#comment-13234881 ] Dawid Weiss commented on LUCENE-3877: ------------------------------------- You can just as well substitute your own implementation of PrintStream using System.setOut/setErr and check stacks on printlns... But I agree with Benson that a static analysis approach is much cleaner. Don't know if there's anything out of the box in findbugs/ pmd, but even if not then this can be done as a 10-liner by applying an aspect to classes via aspectj and parsing the output logs detecting if an aspect has been applied (it shouldn't match anywhere). > Lucene should not call System.out.println > ----------------------------------------- > > Key: LUCENE-3877 > URL: https://issues.apache.org/jira/browse/LUCENE-3877 > Project: Lucene - Java > Issue Type: Bug > Reporter: Michael McCandless > Fix For: 3.6, 4.0 > > Attachments: IllegalSystemTest.java, IllegalSystemTest.java > > > We seem to have accumulated a few random sops... > Eg, PairOutputs.java (oal.util.fst) and MultiDocValues.java, at least. > Can we somehow detect (eg, have a test failure) if we accidentally leave errant System.out.println's (leftover from debugging)...? -- This message is automatically generated by JIRA. If you think it was sent incorrectly, please contact your JIRA administrators: https://issues.apache.org/jira/secure/ContactAdministrators!default.jspa For more information on JIRA, see: http://www.atlassian.com/software/jira --------------------------------------------------------------------- To unsubscribe, e-mail: firstname.lastname@example.com For additional commands, e-mail: email@example.com
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Arts, Culture and the State
Theorising Cultural Policy
By (author) Joseph Mahon
Format: Hardback
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Arts, Culture and the State by Joseph Mahon
Book Description
The title of this book is Arts, Culture and the State and is written by author Joseph Mahon. The book Arts, Culture and the State is published by Palgrave MacMillan. The ISBN of this book is 9780230547131 and the format is Hardback. The publisher has not provided a book description for Arts, Culture and the State by Joseph Mahon.
Book DetailsISBN: 9780230547131
(235mm x 156mm x 28mm)
Imprint: Palgrave MacMillan
Publisher: Palgrave MacMillan
Publish Date: 1-Sep-2009
Country of Publication: United States
Other Editions...
Books By Author Joseph Mahon
Simone De Beauvoir and Her Catholicism, Paperback (January 2007)View all books by Joseph Mahon
Simone de Beauvoir, raised in a traditional Catholic family, De Beauvoir rejected religious and social values of her family on and advanced a radical political and philosophical debate that was in direct opposition to the Catholic Church. This book examines that she had a tenacious grasp of the rudiments and refinements of Catholicism.
» Have you read this book? We'd like to know what you think about it - write a review about Arts, Culture and the State book by Joseph Mahon and you'll earn 50c in Boomerang Bucks loyalty dollars (you must be a member - it's free to sign up!)
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Food Additives China Manufacturer - Chinaprice: contact company for price
a big exporter in China.
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- Address: coastal industrial park,jiaonan,qingdao,china, qingdao, China
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- Website: http://www.jiali-bio.com
Published date: September 7, 2012 -
- Business Description: We,JiaLi Bio Group,a well established food additives manufacturer,also a big exporter in china
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Your Tween's very own chair! Perfect size and look for today's Tween girl! Fashion forward skull fabric and accent pillows completes the cool design that your Tween will love. Strong hard wood frame is covered in poly urathane foam. The cozy soft minky fabric is soft soft to the touch and very easy to clean with mild soap and water. This item is proudly made in the USA!
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Hola! I do not speak Spanish! I do, however, have an entire Impact report just for you! Some pre-show notes before we start:
– There are 15 days left in the Meet Me There IndieGoGo drive. For those of you who aren't aware, my very dearest friend/ our favourite With Leather Editor has written a movie, and it's really, really good. It also stars Goldust, and hey, he's a guy a lot of people like. If you've got a few dollars to spare, toss it their way and help it be the best movie it can be.
– Speaking of cool stuff for you cool cats to do, check out The Mandible Claw! We have fun stuff happening, amazing contributors, and a podcast. This week we were on vacation, but now is the best time to familiarize yourself before we return next week relaxed, rejuvenated, and funky fresh.
– Social Media is all the rage these days. Should you like to find out what I'm up to, send any questions, or even better, send gifs of cats on treadmills, I can be found on Twitter here. You can also follow With Leather (do it!), and UPROXX (also do that!). Sharing is caring, so be sure to like and share this on Facebook, Tumblr, Reddit, billboards, the sides of bridges, abandoned mine shafts, bathroom stalls, and wherever else you can think of.
This week on Impact: Corpus Christi proves why they shouldn't be allowed to have nice things, Taryn Terrell reminds us that we can't have nice things, and Joseph Park shows up so I can say at least some nice things. COSAS BONITAS!
Best: WrestleCon makes dreams come true
Last week's hiatus was due mostly in part to the fact that my boyfriend and I were on our way to New York/New Jersey for Chikara and various rassles-filled situations. These included watching the lovely and handsome Dan Barry pretend to be Sabu, Athena and Ayako Hamada tear the house down (WITHOUT EVEN ASKING PERMISSION FIRST, I MIGHT ADD), my heart exploding with joy in a million different ways at Chikara, and something or other that happened on Sunday.
WrestleCon on Saturday was basically a hug-filled parade of joy and hugs, and were it physically possible I would have exploded in a shower of rainbows and sparkly unicorn stickers by lunchtime. It's a good thing I didn't, because one of my birthday presents from Brandon ended up being this:
That's right! That's Mike Knox! You know, from WWE and also hugging me at WrestleCon? In short, he remembers making the video for me in Texas, now understands that I couldn't come see The Eights because Canada, and hugged me so hard that he almost broke my glasses. Ilu, TNA bit player who just shows up and smiles and punches people. Ilu so much.
Worst: CHAVANDEZ, NOT MY CAMPEONES
It's always incredibly frustrating when the outcome of a match is telegraphed right off the bat. Oh, this is Chavandez's home state? Oh, they're coming out with some guy waving a Texas flag? Oh, there's a stipulation that if they lose, they'll never be able to tag together again? Well…fudge.
This is a prime example of one of the drawbacks of Impact always being on the road. Storytelling and continuity can very easily get lost in trying to please an unpredictable live crowd. The argument that we're living in a post-kayfabe era is never more valid than when a title is won or lost on a wrestler's home turf. As easy as it is for me to believe that there are anthropomorphic time-traveling ants from the future, or that Wes Brisco is mentally competent enough to ride a motorcycle, it's situations like this that make it blatantly clear that this is a real-life business with monetary goals to be met and a few thousand in-person fans to be made happy in the short-term whilst the rest of us at home are miserable in the long-term.
The match itself isn't even anything particularly special. The first two falls of the mandated best of three come all too quickly, so we're basically left with a two-segment match we've seen before, and will probably see again given that there are really only three teams in the tag division, and one is busy participating in the AJ Styles after-school special. I can't even really give Mecha Shiva a best, because everyone is just going through the motions, and it's as bad as Sarah Michelle Gellar's singing voice.
Best: Aces & Eights ARE SO EXCITED
I struggled a lot with bests this week, I'm not going to lie. I always feel like the biggest a-hole wrestling fan after going to a really fantastic independent show, because coming back to a major promotion is always so disappointing. You'll never see me happier than when I'm at a Chikara show, and you'll never see me more miserable than during the first WWE or TNA show afterwards. I had a blast at Raw this week (for the most part), but WrestleMania continually felt like a waste of my time and the $200 we spent per ticket. As such, I always look for touchstones during a show – reminders of why I continually watch and pay money into a company who doesn't give me the same experiences I treasure from independent wrestling. A reminder of why I don't just give up major televised wrestling shows and spend all of my time and money on old AWA episodes, JWP DVDs, and traveling to wherever I can see Jessicka Havok kick the bejeepers out of anyone and everyone.
As much as I criticize what has happened in the past, and the stalling efforts of a storyline that shows glimmers of brilliance, it's almost comforting to see a few seconds of "the Eights" yelling and revving their engines and getting hyped up for Bully Ray's match against Alphonse Elric or whatever. It's short and it's dumb, but it's so painfully TNA that it becomes endearing. And hey, there's WWE's Mike Knox, smiling and standing on his hind legs like a little Rory Calhoun. I hugged that guy once and it was glorious.
Worst: Corpus Christi, you awful mother-effers
I'm sorry, are you BOOING Joseph Park? Joseph Park, brother of, you know, Abyss? Joseph Park, attorney at law, trained Impact Wrestler and Impact Star? Joseph Park, future recipient of the biggest, most loving hug I can muster? I don't know how I can give you a bigger Worst, but when I find out, you better believe you're getting it.


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Arguably the worst review ever.
Album Rating: 2.5review is lol
Album Rating: 1.0Anyone else digging the Avenged Sevenfold cover on Track 6?
Album Rating: 2.0rip skele
he showd up a coupla days ago
Album Rating: 2.0ya but its not the same
ye miss those rant videos
Album Rating: 2.0i thought this was a 4.5 for you snide. or is that wretched and divine?
yeah, the album cover is PRETTY BAD...
Album Rating: 2.0dam
I don't know if other BVB fans are going to come out of the closet or something, but shit like that would be hilarious
Album Rating: 2.0as far as i know snide and skele are the only two bvb fans with the balls to represent
he actually wrote two reviews for this lol
Bands: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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Lots of American seniors on Medicare Parts A and B are are now seeing that with the perfect Medicare Supplement Insurance Insurance Policy they are able to:
Research a Medicare Supplement Insurance Plan today with the protection you require at a rate that suits your budget.
Secure your physical health and preserve your personal wealth with a Medicare Supplemental Insurance Plan
Like hundreds of thousands of patients that our company have aided down through the years, you assuredly found that attempting to make up your mind on the right Medicare Supplement Insurance Plan is trying at times. Morever, trying to find a Medigap Insurance Provider to coordinate with when examining costs is trying as well.
Fortunately, this isn't always the case. Locating a Medicare Supplement Broker that can take the pain out comparison shopping is simple when you realize that:
Get a Medicare Supplemental Insurance Policy with our company and be happy about both your lower cost costs and the comprehensive policies.
However that's not all our company is willing and capable of doing. Have you ever had a go to take out an insurance plan like a Medigap Insurance? Thousands and thousands of American senior citizens are unfortunately denied a plan or gotten restrictions on their policy that they were blindsided by once they had paid the initial premium payment. There is often colossal hassles involved in receiving that payment returned or attaining different acceptable Medicare Supplemental Plan or other coverage.
Things like this don't happen to our customers. Our Medigap Agents in-house are also skillful "field underwriters.†So we shall not only aid you in finding the least expensive for Medigap Quotes, but we shall make certain you will meet the requirements for the that insurance plan before we ask you to apply. With a couple of quick quick questions about your health and medical history, you could immediatley enrolled for Medicare Supplement Insurance Coverage that will approve you on the spot, without hassles or anxieties about the possibility revoking policies.
Our agents don't recommend a certain policy plan unless we know you will qualify for approval by the Medicare Supplemental carrier Additionally , our Lowest Rate Guarantee insures that you never ever need to write a check for our services and are always making payments the inexpensive available cost on the suggested insurance plan you qualify to receive.
What's more, for your convenience, we have made deals with with all of our Medicare Supplemental Insurance Companies to allow you apply for their plans right over the phone in just minutes. You will get the least expensive Medicare Supplemental Bills available, coverage for the rest of your days and, if you select Medicare Supplemental Plan F, you'll never need to write another check in the future for Medicare covered medical necessities like exams, therapy, x-rays, prescription medication, etc..
A Bit About Medicare Supplement Plan F
Medigap, as it ls often called, is the name applied to health care plans usually called Medicare Supplemental Insurance. Medigap Plans supplement the gaps in Medicare health coverage that are not covered by Medicare Part A and Medicare Part B and are made to fit with Medicare like a key fits into a lock.
A Medigap Plan is not an substitute for Original Medicare like Medicare Advantage Policy, instead it works in conjunction with Original Medicare. Also, Medigap Plans differ from Medicare Advantage because they have no deductibles, no co-pays and no network restrictions that could impede you healing when you can't see the right doctor.
When you enroll in the best Medigap Medigap Policy for example, a Medicare Supplement Plan F you will never, ever need to spend a single dollar when you receive treatment in a physician's office, hospital or specialty treatment center that accepts Original Medicare.
So this means that you choose Medicare Supplement Plan F, whether your health care bills are astronomical , you will will not ever have to pay any extra bills for health care bills just as long as Medicare greenlights the charges.
Medigap Policies : Everything you need to know
When you want medical care with a specialty treatment center, doctor or hospital, just whip out your your Medicare Supplemental Insurance card to the hospital, doctor, or specialty treatment center. Then, almost magically, everything will be taken care of for you.
Consider that, after your claim is filed with Medicare for Medicare Part B charges, Medicare usually convey your claim directly to your Medicare Supplement Company without you having to do anything. After this hand off, your Medicare Supplemental Provider will process the claim, in most instances without ever needing human assistance
With a quick comparison of Medicare Supplemental Insurance Policies, you can discover the one that's right for your budget and your health and then everything will be taken care of for you. And again, if you decide on a Medicare Supplement Insurance Plan F from us, you won't ever get leftover medical debt to pay for.
Our company believes that doctors ought to be able to prescribe what the best medical attention is for you while your Medigap Policies guarantees you are not burdened with medical bills. Additionally, when you enroll a Medicare Supplement Insurance Policies like the recommended Medicare Supplemental Plan F it's YOURS FOR YOUR ENTIRE LIFE. Unlike Medicare Advantage Plans, if you continue to pay the monthly premiums, the Medicare Supplement Carrier won't ever take your plan away from you… EVER!
Just like the hundreds of thousands of elderly people our company have assisted for nearly three decades, you have figured out that trying figure out the decision on the correct Medicare Supplement Insurance Plans is irritiating right?. Furthermore, trying to acquire a Medicare Supplement Insurance Company that will help out when assessing Medicare Supplement Quotes is difficult as well.
Good thing though, not every brokerage is like this. Locating a Medigap Policy Broker you can trust is simple because:
Our services are completely free.
Medicare Insurance Policies: Why shop with our company?
If you are on Medicare, you're doubtlessly dealing with painful final decisions on selecting the perfect Medicare Supplement Insurance Plan and you're doubtlessly duped by Medicare Advantage salespeople.
Medicare Supplemental Policy Companies are federally mandated to offer the exact same coverage options. So see, it is so crucial to shop Medigap Plan Premiums from the best providers with a partner you can trust.
We are not like others, seeing as we work on your behalf, not just one Medicare Insurance Policy Provider. Our industry professionals examine all of the Medigap Providers selling Medicare Supplement Insurance Plans and seek out the good ones that have a long-standing reputation and also they can honor their promises into the foreseable future. Basically, our industry analysts excludes the insignificant Medigap Companies and the unreliable and shady.
When our team has located the right Medicare Supplement Insurance Policy Carriers that are up to our uncompromising standards, we then use our state of the art and our proprietary software technology carry out Medigap Rate online comparisons. By shopping around for you, our agents obtain the best value for your particular situation based on your specific needs, not what the Medicare Supplement Insurance Policy Providers want to sell to you.
Furthermore that is not the full measure our agents are capable of for you. Have you ever tried apply for an insurance plan like a Medicare Supplement Insurance Policy? A lot of Medicare patients, are often denied coverage or received restrictions on their policy after they had paid the first bill. Most often there will be enormous problems getting a refund or locating replacement Medicare Supplemental Policy or other coverage.
We won't let this happen to you.
All the Medicare Supplemental Insurance Policy Agents on our team also are Medicare Supplemental Insurance Policy field underwriters.†This means we will not only assist to buy the most affordable Medicare Supplemental Rates, but we will make sure that you will be qualified for the plan before we go through the approval process. By answering fast questions in regards to your medical history, you could easily be instantly approved for a Medicare Supplemental Insurance Policy that will accept you the first time, with no hassles or fears about of being denied coverage.
We won't advise you to sign up for a Medicare Supplemental Insurance Policy to you unless we are certain you will qualify be approved by the Medicare Supplemental Insurance Policy carrier. Furthermore, our Most Affordable Rate Guarantee ensures you won't ever pay a penny for our professional and that you pay the lowest available rate for the plan you are qualified for.
For your convenience , we made deals with all our Medigap Policy Providers to allow you to enroll in their policies right over your phone in a matter of minutes. You will receive the least expensive Medicare Supplement available to you, a policy for life and, when you select a Medicare Supplement Plan F, you will never pay a penny again for Medicare-eligible Medicare covered.


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Although we might think that our bodies simply shut down and completely relax during sleep, in fact many parts of the body remain surprisingly active.
This is especially true of the brain which sends out se constant stream of signals controlling what is known as our sleep cycle. There are five stages to a normal sleep cycle and, on-line caso good night's sleep, you will experience all five of them several times in succession. The five stages of sleep are broadly divided in two groups. The first group, which comprises the first four stages, is known as non-rapid eye movement or NREM sleep, while the second group, which contains just e single stage, is referred to as rapid eye movement or REM sleep.
The main difference between NREM and REM sleep is seen in terms of the brains activity. In addition, REM sleep is also characterized by irregular but rapid breathing Lunar Sleep and heartbeat, em rise in blood pressure and almost em o muscle activity. Throughout a normal night's sleep you pass through the various stages of sleep several times, but tend to spend about the first third of sleep in the NREM stages and the final third of sleep in na direção de REM stage.
Stage 1 is the stage during which you fall asleep and sees you feeling drowsy and drifting in and out of sleep. Eye movements begin to slow during stage 1 and you start to lose control over your muscles. It is also quite common during this stage to experience sudden contraction and jerking of the muscles.
About half of all sleep is stage 2 sleep during which your brain activity and heart rate slows, your temperature drops and eye movement is reduced to virtually none at all, although there can be occasional short bursts of eye movement.
Both stages 3 and 4 are very similar and, together, are referred to as deep sleep. Brain waves during these two stages are very slow and there is dentro de movement in either the eyes or the muscles. REM sleep is interspersed throughout the other stages of sleep, which do not necessarily follow lá strict numerical sequence, and, in totalidade, represents about caso quarter of the time spent in sleep. The first period of REM sleep for example follows stage 1 and lasts for only about ten minutes, while the final period of REM sleep, from which you normally awaken, lasts about an hour.
This repetition of the sleep stages gives rise to the sleep cycles and lá normal night's sleep consists of several sleep cycles. As these cycles continue throughout sleep, REM sleep is also seen to increase. Although it is difficult to control our sleep cycles, there is na direção de great deal that we can do to prevent these cycles from becoming disrupted and thus to ensure sound sleep and, where necessary, to help to cure insomnia.
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Gite La Cinquieme Saison
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TripAdvisor Reviews Gite La Cinquieme Saison Montreal
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Racoon county
... see you could literally walk for hours and still not reach the end.think our favourite was the Chinese garden. We caught the metro to the Latin quarter where we got a meal for just �2.50 each, we even got the most amazing dinner entertainment as we arrived in the middle of a circus festival so there was loads of street performers.
Day 2
We headed to parc Jean drapeau which was like a zombie invasion happened and we were ...
The Old, and Cold, Montreal
... being spoken and dissemenated outside of Europe. It's not hard to imagine that if the British hadn't conceded the language to Quebec that they would have joined the Revolution and that the United States today could include Quebec and other parts of modern-day Canada.
In the aftermath of the American Revolution, the loyalists to King George emigrated to Canada. Jeremy has an ancester on his mother's mother's side who was a loyalist ...
A City under a City.
... to serve as a court eunuch. He managed to work his way up to lead the Chinese Navy. He led fleets of up to 63 ships on 7 voyages to the Western Sea and finally the Indian Ocean with up to 28,000 people. These voyages occurred 87 years earlier than Christopher Columbus voyages.
We we celebrated our last night in Montreal with a beautiful roast chicken and vegetables and a very special chocolate dessert. Perfect!
Onward Ho, Eh!
... so we had a quick skip to the front entrance.
We took the standard #selfie in front of the Basilique, which is tall and symmetrical and stunning, and then tiptoed inside. Fodor's description of the Basilique nailed it spot on, "everything about this place ... seems designed to make you gasp ... The whole place is so overwhelming it's easy to miss such lesser features." Of note, were the thousands of gold-plated stars that adorned ...
... get to know each other when you are stuck in a car for 8 hours and when your car breaks down in a snowstorm). Montreal is a wonderful city and very different from the ones I have seen so far. It seems to be more European, with less skyscrapers and billboards than New York and Boston and more cosy bars that reminded me of Quartier Latin. We explored nightlife as well as day life and even though it was a short visit, we experienced quite a few adventures and made great memories! ...


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Tropical Fish Keeping - Aquarium fish care and resources (http://www.tropicalfishkeeping.com/forum.php)
- Freshwater Aquarium Equipment (http://www.tropicalfishkeeping.com/freshwater-aquarium-equipment/)
- - Im new at this, and have some tank questions.... (http://www.tropicalfishkeeping.com/freshwater-aquarium-equipment/im-new-have-some-tank-questions-11994/)
Im new at this, and have some tank questions....
I bought a used 29 gallon tank setup that at one time came as a kit from wal-mart. Will the heater and filter that came with it be good enough or should I upgrade? Also im buying a 75 gallon tank by itself brand new. I need to know whats some good HOB filters and a good heater to buy? If it helps they are going to be freshwater community tanks, or maybe put some discus in the 29 gallon? Im new at this so please bare with me...
Re: Im new at this, and have some tank questions....
For the 29, if it is an aquaview filter IMHO, they suck big time. The heater should be fine but could be better.
Visotherm heaters are some of the better ones in medium price range. Aqua clear HOB are what I use. For the 29 I would get a 50 gallon rated one, I think that is the AC30, and for the 75 I would get one rated for 100 gallons, I think the AC50. Just so many more ways to customize them. If you have the money, I would go with a canister for the 75. I have never used them myself but Hagen is often recommended.
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Tropical Fish Keeping - Aquarium fish care and resources (http://www.tropicalfishkeeping.com/forum.php)
- Cichlids (http://www.tropicalfishkeeping.com/cichlids/)
- - Blue....Black Striped (http://www.tropicalfishkeeping.com/cichlids/blue-black-striped-9673/)
Blue....Black Striped
Hey, iv previously had account on this site and cant remmeebr any of it....long time ago.....anyways......i have a 10 gallon tank with just 4 blue cichlids that have black stripes.......just curious to know why 2 of them are kinda yellow now......and how big do they grow?......it doesnt look like they are growing......3 are about 1-1 1/2 inches the big one is like 2inches
Re: Blue....Black Striped
Do you have pictures of these fish?
Re: Blue....Black Striped
no sorry i dont have any pics.....they are just yellow now dont know why.....they were blue before lol but they act normal.....can you look into it for me and let me know thatnks.
Re: Blue....Black Striped
yes i do here is the pic of the 2 that are yellow lupin......i just put them up in my tank profileshttp://fishforum.com/userpix/4096_DSCN0360_1.jpg
i was just surfing the net to find out why they are yellow and i came across this forum and she was saying that the males turn yellow when they mature. Ture or False? and why?
Re: Blue Kenya Cichlids
by Pam Chin on Mon Oct 15, 2007 8:07 pm
Hi Bellingham,
The scientific name for this fish is Metriaclima lombardoi, the common name is Kenyi. They fry, juveniles and females are a beautiful blue fish with black bars. When the males mature they turn yellow with black bars. They are going to be too aggressvie for your tank, and they also will require different water conditions and diet. Sorry!
Cichlid Power!
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Mario Balotelli net worth and salary: Mario Balotelli is an Italian professional soccer player who has a net worth of $60 million. As a 22 year old he signed a $36 million contract with Manchester City. Born in Palermo, Italy, Mario Balotelli, also known as Mario Barwuah Balotelli, grew up in the Brescia region with a foster family, after complications with his health and his family's less than ideal living conditions necessitated that he be raised by someone else. The Barwuahs, his biological family, did not seek to regain custody of their son, though he was never formally adopted by the Balotelli family who took him in, until he had achieved national attention as a football player, which created some controversy. Though he has played incredibly well for all of the teams with whom he has worked, he is known for disciplinary issues and for a lack of commitment to training and practice. He has also been the subject of widespread racial taunts that grew to be so ugly, that some football teams, such as Juventus, were forced to ban home fans from games and cancel part of their home season. Fans have also physically attacked him after games for what they felt was "un-sportsmanlike" conduct during the game. Though he has played well for Manchester City since 2010, his disagreements with the team's manager have led to speculation that he will be let go at the end of the 2012 season.
Mario Balotelli Net Worth
Mario Balotelli
Football player
Date of Birth
Aug 12, 1990 (26 years old)
6 ft 2 in (1.88 m)
176 lbs (80 kg)
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Top Definition
When a large black man jizzes in a milk carton and a girl drinks it
Yo man jamall gave shanequa a Low Fat Chocolate Milk and she spilled it on the floor so he hit her
by Huge Black Nigger August 13, 2011
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September events at GEORGIA AU
Our Georgia AU chapter took part in the September 11 East Cobber Parade. The annual parade was particularly eventful this year, falling on the anniversary of the September 11 tragedy
Chapter members helped educate their community on the importance and value of church-state separation. If you would like to be involved in future Georgia AU events check the chapter's meet up web site at http://www.meetup.com/americansunited-georgia/ .


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Reqirement of Sr Accountant ( 3 yrs)
Purvanchal Business Solution
RS 1,75,000 To 4,00,000 Aligarh, Bijnor, Gonda, Kanpur, Lucknow, Moradabad, Muzaffarnagar, Nagina, Varanasi, Dehradun, Haridwar
Sr Accountant and a Junior Accountant and Store Executive as Well as Business Development Officer Required in Sidcul Haridwar
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Marketing Executive ( 1 - 2 yrs)
ARGShreeradhe Services
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Space Pharmaceuticals Pvt. Ltd.
Hyderabad, Patna, Chandigarh, South Delhi, Ahmedabad, Ghaziabad, Greater Noida, Jalalabad-Bijnor, Kanpur, Lucknow, Muzaffarnagar
-> arranging appointments with doctors, pharmacists and hospital medical teams, which may include pre-arranged appointments or regular 'cold' calling; -> making presentations to doctors, practice staff and nurses in GP surgeries, hospital do...
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Sales & Marketing Executive, Team Leader ( 0 - 5 yrs)
RS 90,000 To 4,00,000 Chandigarh, Muzaffarnagar, Saharanpur, Dehradun, Haridwar, Roorkee
Sales & Marketing Executive for Web & Software Development Company
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sales, marketing executive, team laeder, sales executive ( 0 - 1 yrs)
V Five Pvt. Ltd.
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sales, marketing executive, team laeder, sales executive
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India Infotech is looking for Freshers (20+ Openings): SEO SMO SEM (PPC) Content Writing Business Development Requirements: Education - We donot care Young and Energetic Good Communications Skills is a must Quick Learner Adaptive Smart, I...
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Experience in Working with Applicators (painting Contractors) and Influences (architects/int. Designers). from Floor Tiles, Kitchen Fittings, Sanitary Fittings, Lighting's & Electrical Fittings, Paints Any other Industry Where Interaction with A...
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