Degree of urbanization and mammographic density in Dutch breast cancer screening participants: results from the EPIC-NL cohort

It has been observed that women living in urban areas have a higher mammographic density (MD) compared to women living in rural areas. This association might be explained by regional differences in reproductive and lifestyle factors or perhaps by variation in exposure to ambient air pollution as air pollution particles have been described to show estrogenic activity. We investigated the association between degree of urbanization and MD, and aimed to unravel the underlying etiology. 2,543 EPIC-NL participants were studied, and general linear models were used. Urbanization was categorized into five categories according to the number of addresses/km². Information on reproductive and lifestyle factors was obtained from the recruitment questionnaire. Air pollution exposure was estimated using land-use regression models. MD was expressed as percent density (PD) and dense area (DA), and was quantified using Cumulus. Women living in extremely urbanized areas had a higher PD (21.4 %, 95 % confidence interval (CI) 20.5–22.3 %) compared to women living in not urbanized areas (16.1, 95 % CI 14.5–17.8 %, P _trend < 0.01).The association persisted after adjustment for reproductive and lifestyle factors as well as for individual exposure to air pollution (adjusted PD_{extremely_urbanized} = 22.1 %, 95 % CI 18.0–26.5 % versus adjusted PD_{not_urbanized} = 16.9 %, 95 % CI 13.0–21.2, P _trend < 0.01).The results for DA showed close similarity to the results for PD. We found evidence that degree of urbanization is associated with MD. The association could not be explained by differences in reproductive and lifestyle factors or by variation in air pollution exposure.