Black Forest Cake

My husband's birthday was in the recent past. I try to make birthdays special by making a cake from scratch for each of my family member. Even though we are not much of sweet eaters, my husband would be appreciative of a nicely made cake. I decided to make a Black Forest Cake as it is moist and delicious! Most importantly it is easy to make. This also happens to be one of the first cakes that I attempted 4-5 years ago when I first started baking. I must admit that it has been a learning curve and that I have learnt much since then about baking cakes.

So I made a 4-layer Black Forest cake with fresh cherries in between the layers and whipped cream frosting. I used the maraschino cherries in syrup for the garnish on top. I had only two 6 inch pans so I baked in them and sliced each cake into 2 layers. This batter would easily fill three 6 inch pans. If you do that you don't have to cut the cake into layers.  This batter would also be enough for two 8-inch pans, in which case you will have to slice the cake into 2 and then layer. I wanted something small and tall so I went with 6 inch pan. 

Without sounding boastful, I must admit that my family loved the cake! My kids called it the "best cake ever!" My husband ate 2 pieces and even the neighbor's kids who are picky enjoyed it! I am convinced that the cake was good! 

So without further ado, here is the recipe. The recipe has been adapted from this recipe here. 

Servings: 8-10 

Prep time: 45-60 mins Cook time: 30- 40 mins Total time: 75-100 mins 

Ingredients: 

For the cake: 

Flour: 2 cups 

Cocoa powder: 3/4 cup 

Instant coffee: 1 & 1/2 tbsp

Powdered sugar: 1 & 1/2 cups 

Baking soda: 1 & 1/2 tsp

Baking powder: 1 tsp

Salt: 1/4 tsp

Cooking oil: 1 cup

Vanilla essence: 1 tsp 

Milk: 1 cup

Hot water: 1 cup

Eggs: 2 large 

For the frosting: 

Whipping cream: 2 cups

Confectioners sugar: 2 cups 

Vanilla essence: 1 tsp 

For layering and garnishing:

Cherries: 1 cup

Sugar syrup: 1/2-1 cup 

Chocolate curls: 1/4 cup 

Method: 

Preheat the oven to 350 degrees. 

Place the bowl and beaters for the cream in the freezer to chill. 

Grease and line three 6 inch or two 8 inch trays with parchment paper and keep ready.

Dissolve the instant coffee in the hot water and keep ready.

Seive all the dry ingredients into a bowl. Mix well. 

In another bowl, beat the eggs well. To this add oil, vanilla essence, milk and mix. 

Now slowly add the wet ingredients to the dry ingredients.  Add in the instant coffee and mix.Do not overmix.

Pour the mixture into the prepared pans until 3/4 th full. 

Tap the pans against the kitchen counter before placing it on the middle rack in the oven. Bake at 350 degF. for 30-40 mins or until a toothpick when inserted comes out clean. 

Take the pans out and let them cool on the kitchen counter for atleast 30 mins.

While the cakes are cooling, prepare the whipped cream. 

To make the whipping cream, take the chilled bowl and beaters out. To this add the whipping cream. Whip on medium until soft peaks emerge, around 3-4 minutes. 

Now add in the vanilla essence and the confectioners sugar little at a time. Whip for another 2-3 minutes.

Keep the cream back in the fridge until ready to frost the cake.

Assembling the cake:

Once the cakes are cooled, level each of the cakes. 

If you are using 2 pans, you will have to slice each cake into 2 layers. Keep the layers aside. 

Sprinkle sugar syrup on all the layers. This keeps the cake moist.

Take a cake circle ( the cardboard on which you intend to assemble the cake). Place some frosting on the middle of the cake circle. Place the first layer of cake. Place a large dollop of whipped cream on top of it. Using an angled spatula, spread the cream evenly. Now evenly distribute pieces of cherry on top of the cream. 

Place the next layer of cake and repeat the above process. Do this to all available layers until you have placed the last layer on top. 

Once the last layer is placed, frost the cake evenly in all directions. 

You can pipe peaks of whipped cream on top and make borders at the bottom. I used Wilton tip no: . Place cherries on top of the peaks.

Decorate the middle with chocolate shavings. If you wish you can decorate the sides of the cake with chocolate shavings too!! 

Refrigerate the cake until ready to eat. 

Enjoy!! 

I am bringing this to Angie's Fiesta Friday #198. Her co-hosts this week are two accomplished bloggers and my favorite people, Judi @ cookingwithauntjuju.com and Liz @ Spades, Spatulas and Spoons.

Cooking made easy: 

While baking it is good practice to make sure all the ingredients are at room temperature unless the recipes calls for a specific temperature. This includes the eggs too. 

Tip for healthy living: 

It is better to use as much natural ingredients as possible while cooking. This makes the food much healthier and nutritious. 

Food for thought: 

Silent gratitude isn't much to anyone. Gertrude Stein 

Please do share your thoughts. Your opinion matters!

Let us stay connected on Facebook | Pinterest | Twitter | Instagram | Google+

Veestro: Organic, plant-based meals , a Review

Ready to cook meal services are nothing new to me. There are several vendors out there who send 1-2 meal recipes with the exact ingredients prepackaged, to your doorstep. I have tried meals  from Blue Apron and Hello Fresh. It is definitely convenient as you don't have to go grocery shopping, you know what you are going to cook on a given day as you place your order atleast a week ahead of time. The ingredients are purported to be fresh and from the best sources and they are literally delivered to your doorstep. The flip side is that this service does tend to be a bit pricey and you still have to make time to cook the meals. I also feel bad that there is so much packaging that is required. 

When Veestro reached out to bloggers via Meatless Monday, to try their plant-based vegetarian food service, I was intrigued to say the least. I cook and eat vegetarian meals most of the time. I do not eat meat. I truly believe  that eating vegetarian food is a healthier way to live. Those who are used to eating meat in all their meals often find it hard to go vegetarian. I usually recommend beginning by switching to one vegetarian meal a day and then going to one vegetarian day a week. Meatless Mondays is a great way to do this. I was very happy when I was one of the bloggers selected to try their meals. 

A week later a big box was delivered to my doorstep with contents packed in a nice freezer pack. I was pleasantly surprised when I saw that the meals were already cooked. All I had to do was heat them up as per package instruction and serve it. My expectation was to see ingredients, not prepared meals!! 

In the package that I was sent I had 4 meals and one drink. They were as follows: 

Tuscan Calzone
Veggie Lasagna 
Southwest BBQ chick'n
Golden Chickpea Stew

Hand Grenade

Tuscan Calzone

The Tuscan Calzone was a decent sized one. All I had to do was stick it in the oven for 18-20 mins and Voila!! It was nice and crusty with filling of vegan cheese, tofu and squash. 

Veggie Lasagna 

The veggie lasagna was made from Rice noodles, vegan cheese and  zucchini. It was truly delicious! I don't think that I could have made that at home!! My husband and I enjoyed it.

Southwest BBQ chick'n

The Southwest BBQ Chick'n meal came with a slice  of vegan chick'n breast , a side of fries and a side of saut�ed vegetables ( squash and corn). It is a great vegan alternative to the regular BBQ chicken. 

Golden Chickpea Stew

The golden Chickpea Stew was made from chickpeas, quinoa and vegetables such as squash, potatoes and tomatoes. It was more like a curry which was right down my alley. I eat all these ingredients regularly but not cooked together. I make quinoa salad, quinoa dosa and quinoa pilaf but never tried it in a stew! 

Hand Grenade

I simply loved the hand grenade!!! The taste was refreshing with no added sugar. It was made up of apples, celery, kale, broccoli, kiwi and maqui Berry. 

All portions were decent sized and filling. The cooking instructions were simple and easy to follow. The ingredients were clearly listed at the back with the nutrition information. There was no ingredient that I did not know or couldn't pronounce. The meals tasted fresh and  were delicious. 

Veestro would be the place to go for Vegans. Each item listed above costs roughly around $10.00. You get everything that they promised and the convenience makes it worth it especially if you are only now going vegetarian/vegan and are at a loss as to how to substitute for meat! This might give you some ideas for vegetarian/vegan cooking too!!

Happy eating!!

I am sharing  this at Angie's Fiesta Friday #198. Her co-hosts this week are two accomplished bloggers and my favorite people, Judi @ cookingwithauntjuju.com and Liz @ Spades, Spatulas and Spoons.

Please do share your thoughts. Your opinion matters!

Let us stay connected on Facebook | Pinterest | Twitter | Instagram | Google+

CHRONIC PPI USE INCREASE GASTRIC CANCER RISK

Use of a proton-pump inhibitor (PPI) after Helicobacter pylori eradication more than doubles the risk for gastric cancer, according to a population-based study from Hong Kong.

The "clear dose-response and time-response" trend in PPI use and gastric cancer risk observed suggests the need for "caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori," write Wai Keung Leung, MBChB, MD, from Queen Mary Hospital, Hong Kong, and colleagues.

The study was published online October 31 in Gut.

The researchers point out, however, that this was an observational study, which can't prove cause and effect.

The new results also conflict with a recently published, US Food and Drug Administration�mandated follow-up study conducted with pantoprazole, said David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School in Norfolk (Aliment Pharmacol Ther. 2016;43:73-82).

"No increased risk [for gastric cancer] was observed with prolonged PPI exposure," he said.

Dr Johnson, who was asked for comment, also stated that the study has a "geographic bias" because it is from Hong Kong and "specific risks for gastric cancer are well recognized in Asian patients."

In the new study, Dr Leung and colleagues partly focused on H pylori infection and its relationship with gastric cancer.

H pylori eradication has been shown to reduce the risk for gastric cancer by 33% to 47%, but many patients develop gastric cancer even after eradication of H pylori. PPI therapy, "although generally considered safe," is associated with worsening gastric atrophy, particularly in H pylori�infected patients, the researchers point out. A recent meta-analysis found a 43% increased risk for gastric cancer among long-term PPI users, but it is was unable to adjust for H pylori, the major confounding factor.

Using a territory-wide health database in Hong Kong, Dr Leung and colleagues compared the risk for gastric cancer in PPI users and histamine-2 receptor antagonist (H2RA) users among 63,397 adults successfully treated with a 7-day course of triple therapy to eradicate H pylori between 2003 and 2012. 

"PPIs are much more potent than H2RA in terms of gastric acid suppression, and previous studies did not reveal any association between gastric cancer development and H2RA. Hence, H2RA was selected as a negative control exposure in our study," the researchers explain.

During a median follow-up of 7.6 years, 153 (0.24%) people developed gastric cancer after H pylori eradication therapy, mostly in noncardia regions (62%). None of the patients with gastric cancer tested positive for H pylori at diagnosis, but all had long-standing gastritis. The median age at cancer diagnosis was 71.4 years, and the median time from H pylori eradication to gastric cancer was 4.9 years.

After propensity score adjustment, people taking PPIs at least weekly had a greater than twofold increased risk for gastric cancer development (hazard ratio [HR], 2.44; 95% confidence interval [CI], 1.42 - 4.20). The propensity score�adjusted absolute risk difference between PPI use and non-PPI use was 4.29 excess gastric cancer cases per 10,000 person-years.

H2RA users had no increased risk (HR, 0.72; 95% CI, 0.48 - 1.07), which "further supports the specific role of PPIs on gastric cancer development," the researchers say.

After stratification by tumor site, PPI use was only significantly associated with an increased risk for noncardia gastric cancer (HR, 2.59; 95% CI, 1.42 - 4.72) but not cardia cancer (HR, 1.97; 95% CI, 0.57 - 6.82); "although this result should be interpreted with caution as this subgroup analysis has a relatively small number of cardia cancers," the researchers say.

Gastric cancer risk increased with longer duration of PPI use. The HR was 5.04 (95% CI, 1.23 - 20.61) for 1 year of use or longer, 6.65 (95% CI, 1.62 - 27.26) for 2 years of use or longer, and 8.34 (95% CI, 2.02 - 34.41) for 3 years use or longer.

More frequent use was also associated with greater risk. When compared with the reference group (less than weekly use), gastric cancer risk progressively increased with more frequent PPI use. The HR was 2.43 (95% CI, 1.37 - 4.31) for weekly to less than daily use, increasing to 4.55 (95% CI, 1.12 - 18.52) for daily PPI use.

The results remained significant by various sensitivity analyses.

A strength of the study is its use of data from a large population-based database with complete information on subsequent diagnoses and drug prescriptions, which minimizes selection, information, and recall biases, the researchers say. Use of strict exclusion criteria as well as propensity score adjustment to control for potential confounders and restricting the sample to patients with successful H pylorieradication are other strengths.

In terms of study weaknesses, the researchers  lacked information on some risk factors, such as diet, family history, and socioeconomic status.  And despite the large sample of more than 63,000 H pylori�infected patients, the small number of gastric cancer cases did not allow for any "meaningful evaluation of the dosage effect and role of different PPIs," the researchers say. 

The team also notes that PPIs users may have a higher chance of undergoing endoscopy than non-PPI users, leading to discovery of more gastric cancers due to surveillance bias.

Dr Johnson said there was another study weakness: "Important" demographic variables that are risk factors for gastric cancer � such as  smoking, alcohol use, obesity, diet, and family history � are not accounted for.  

He also made a general observation about PPI-related research: "Most studies showed that any potential effects of PPIs tend to disappear with time and that the most likely explanation for the effects is confounding by indication rather than causality."

Despite these limitations, Dr Leung and colleagues write that, to their knowledge, "this is the first study to demonstrate that long-term PPIs use, even after H. pylori eradication therapy, is still associated with an increased risk of gastric cancer. This is likely related to the profound acid suppression of PPIs that worsens atrophic gastritis, particularly in those patients with established gastric atrophy as a result of chronic H. pylori-induced inflammation."

EDITOR'S NOTE: The story has been updated to included comments from an expert not involved with the study.

The study had no specific funding. Dr Leung has received honorarium for attending advisory board meetings of Takeda and Abbott Laboratories. Dr Johnson has or has had financial ties to Pfizer Inc, which makes a PPI; Epigenomics; WebMD; CRH Medical; and Medtronic.

STATIN USE INCREASE DIABETES RISK

Long-term statin use is associated with an increased risk of type 2 diabetes of approximately 30% in individuals at high risk of the disease, even after taking into account known risk factors and potential confounders, say US researchers.

They looked at the development of diabetes among statin users in the Diabetes Prevention Program (DPP), which included more than 3200 participants.

Over 10 years, statin use was linked to a 36% increased risk of being diagnosed with type 2 diabetes, falling to 27% after taking into account baseline risk factors and clinical criteria used to determine the need for statins.

The findings are consistent with previous studies suggesting that statin use substantially increases the risk of type 2 diabetes.

The new study was published online October 23 in BMJ Open Diabetes Research & Care by lead author Jill P Crandall, MD, department of medicine and diabetes research center, Albert Einstein College of Medicine, New York, New York, and colleagues.

As previously reported by Medscape Medical News, a study of more than 8700 Finnish men aged 45 to 73 years showed that over 6 years of statins therapy were linked to a 46% increased risk of type 2 diabetes � more than double prior estimates.

This was followed by recent data from the Australian Longitudinal Study on Women's Health, which indicated that, among almost 8400 women aged 76 to 82 years, the risk of new-onset diabetes ranged from 17% with the lowest statin doses to 51% with the highest doses.

Despite accumulating evidence, the current researchers still maintain that the overall healthcare advice remains unchanged � the benefits of statins outweigh the risks.

"For individual patients, a potential modest increase in diabetes risk clearly needs to be balanced against the consistent and highly significant reductions in myocardial infarction, stroke, and cardiovascular death associated with statin treatment," they state.

They add: "Nonetheless, glucose status should be monitored and healthy lifestyle behaviors reinforced in high-risk patients who are prescribed statins for cardiovascular disease prophylaxis."

First Look at Diabetes Risk From Statins in High-Risk Patients

The researchers point out that the diabetogenic effect of statins has previously been studied in individuals typically at relatively low risk of diabetes and that the incidence of disease was based on self-report, rather than being the primary outcome.

They therefore set out to examine the issue in DPP participants, which included 3234 US adults randomized to intensive lifestyle intervention, metformin, or placebo.

After a mean follow-up of 3.2 years, participants were invited to take part in the DPP outcomes study, which included quarterly lifestyle sessions alongside open-label metformin for those originally randomized to the drug and two additional lifestyle programs per year for those originally randomized to the lifestyle intervention.

Approximately 50% of DPP participants were from ethnic groups and 20% were aged = 60 years. To be included, they had to be aged = 25 years and have a body mass index = 24 kg/m². They also had to have a fasting plasma glucose (FPG) of 95�125 mg/dL and impaired glucose tolerance, placing them at high risk of type 2 diabetes.

The primary end point was diabetes diagnosis using an annual 75-g oral glucose tolerance test or semiannual FPG level with repeat confirmation testing. Lipids and blood pressure were assessed annually and statin use was based on self-report.

From a baseline of approximately 4%, statin use progressively increased at the 10-year follow-up to reach 35% in the placebo group, 37% in the metformin group, and 33% in the lifestyle intervention group (P = .36 between groups).

Simvastatin was the most commonly used statin, taken by 40% of participants, followed by atorvastatin by 37% and, much less frequently, lovastatin and pravastatin, by 9% and 8%, respectively.

Statins users were typically older and more likely to be men than nonusers but did not differ by ethnicity. Compared with nonusers, they also had modestly higher baseline FPG and HbA_1c, higher baseline low-density lipoprotein (LDL) cholesterol and triglycerides, and were more likely to have a history of cardiovascular disease and hypertension.

Taking into account age, sex, and ethnicity, researchers found that statin use was associated with a significantly increased risk of developing diabetes, at a hazard ratio (HR) of 1.36 for all three groups combined.

Further adjustment for baseline diabetes risk factors, including family history of diabetes and FPG, reduced the HR to 1.35, and additional adjustment for statin treatment confounders, such as blood pressure, cholesterol levels, baseline cardiovascular risk factors, and socioeconomic status, lowered the HR to 1.27.

Diabetes risk did not differ depending on statin potency or magnitude of LDL-cholesterol reduction, although longer statin use was significantly associated with greater diabetes risk (HR per visit with statin use, 1.06; P=.007).

Mechanisms Underlying Effect "Poorly Understood"

Discussing the findings, the researchers say that "it has been suggested that statins may 'uncover' diabetes in individuals at high risk, which on a population basis, could result in modest increase in diabetes risk."

They point out, however, that "variation in baseline diabetes risk factors failed to explain the further risk associated with statin therapy in our cohort, and the HR estimate was greatest among our lifestyle participants, who experienced the largest study-related reductions in diabetes risk."

The mechanisms underlying any diabetogenic effect of statins are "poorly understood," they add.

Although several studies have looked at changes in insulin sensitivity during statin use, "we saw no evidence of an effect of statins to modify insulin resistance, assessed as fasting insulin concentrations," they write.

And although statins have been reported to reduce pancreatic beta-cell insulin secretion in vitro, "the relevance to insulin secretion in vivo is not known," they state.

Taken together, evidence from studies published so far points to "an acceleration of typical glycemic deterioration, rather than a unique or statin-specific mechanism," they conclude.

LONG TERM RISK OF BREAST CANCER RECURRENCE

LONG TERM RISK OF BREAST CANCER RECURRENCE

The risk of breast cancer returning continues long after the initial treatment has been completed. A new analysis shows that in the 20 years after initial diagnosis, there is an ongoing, steady risk of the cancer recurring in the form of deadly metastatic disease.

The absolute, cumulative risk for metastatic or distant recurrence among women with estrogen receptor�positive (ER+) breast cancer ranged from 10% to 41% over that time span, depending on various disease characteristics.

The findings about women with ER+ disease, which is the most common form of breast cancer, were published online November 8 in the New England Journal of Medicine.

The data come from a meta-analysis that included 88 clinical trials involving 62,923 women who were disease free after 5 years of scheduled endocrine therapy with tamoxifen or aromatase inhibitors.

Thus, all of the recurrences happened after that initial 5 years.

The women all had stage T1 (=2 cm) or T2 (>2 cm to 5 cm) breast cancers (of varying grades) with fewer than 10 positive lymph nodes and no distant metastases. The patients were followed for up to 15 years after the 5-year treatment period, which generated 20-year data.

What is "surprising" about the findings is the "unrelenting risk over 20 years" and that metastases occur even among patients with the best prognoses, senior author Daniel Hayes, MD, of the University of Michigan Cancer Center in Ann Arbor, told Medscape Medical News.

The main aim of the study was to identify subgroups of patients for whom endocrine therapy could be stopped (thereby avoiding the side effects) after 5 years because their risk for long-term distant recurrence was "so small," say Dr Hayes and his international team of coauthors.

But they found that even among women with the least-threatening profile of small tumors (T1) who had no lymph node involvement (N0), there was a cumulative recurrence risk of 13% over a 20-year period. (The risk was 10% for the less aggressive, low-grade cancers; 13% for moderate-grade cancers; and 17% for high-grade.)

Notably, the annual rate of distant recurrence for these patients was about 1% for a period of 5 to 20 years (ie, after treatment ended), resulting in the 13% cumulative risk.

The new study "quantifies the 20-year risk more reliably than previous studies," owing to size, length of follow-up, and the quality of clinical trial-only evidence, say the authors.

The data "can help women and their health care professionals decide whether to extend therapy beyond 5 years and whether to persist if adverse events occur," they conclude.

An expert not involved with the study welcomed it but called attention to the concept of data reliability.

It is likely that the risk estimates presented in the paper do not completely apply to contemporary patients. Dr Lajos Pusztai

In short, some of the risks reported in the new study are probably higher than those seen currently, he suggested.

Nevertheless, Dr Pusztai agreed with the study authors that the major predictor of distant recurrence risk was status of the tumor stage and lymph node involvement at diagnosis.

Table 1. Distant Recurrence Risk to 20 Years

Stage at Diagnosis	Nodes Involved	Cumulative Risk
T1	0	13%
	1 - 3	20%
	4 - 9	34%
T2	0	19%
	1 - 3	26%
	4 - 9	41%

The main massage for me is that clinical stage matters. Dr Lajos Pusztai

The study authors state, "The risk of distant recurrence was strongly correlated with the original TN status." They also report that tumor grade and Ki-67 status were of only moderate independent predictive value for recurrence and that HER2 status was not predictive (however, only 2% of the women received trastuzumab).

Talking With Patients

Dr Pusztai said that the new data raise "a pressing clinical question: who are the patients who really need 10 years of endocrine treatment and who are cured with 5 years?"

He explained that several randomized clinical trials have demonstrated that 10 years of adjuvant antiestrogen therapy is more efficacious than 5 years of therapy. However, "the improvement is small, with 2% to 3% fewer distant recurrences, and the costs and potential side effects of taking a pill for 10 years are not negligible," he observed.

Useful" molecular diagnostic tests, including the Breast Cancer Index and the Prosigna assay, can now help identify patients who are both at risk for recurrence and remain endocrine sensitive and therefore benefit from extended endocrine therapy, he added.

Another expert who was approached for comment, Virginia Kaklamani, MD, of the Unitersity of Texas Health Science Center, San Antonio, said the new study "changes the conversation with patients.

"Extended endocrine therapy becomes an important part of the discussion, given the fact that [distant] recurrence after 5 years is higher than recurrence during the first 5 years," she told Medscape Medical News.

Extended endocrine therapy becomes an important part of the discussion. Dr Virginia Kaklamani

This is a reference to the fact that the study analyzed recurrence and disease-specific mortality risks in 5-year increments. And for each subgroup analysis, the same pattern was seen: a steady increase of associated risk over time, up to 20 years.

Steven Vogl, MD, a private practitioner in New York City, said the study was "good to have" and that he would look at it "again and again" with patients.

"What's nice about this paper is that they give you what you need to know ? the risk of distant metastases and death from breast cancer," he told Medscape Medical News.

He explained that breast cancer is only deadly once it spreads to distant vital organs.

Overall, the risk for breast cancer mortality "looks identical to distant recurrence except with lower percentages at each time point," summarized Dr Hayes.

Table 2. Cancer Mortality Risk to 20 Years

Stage at Diagnosis	Nodes Involved	Cumulative Risk
T1	0	7%
	1 - 3	13%
	4 - 9	22%
T2	0	13%
	1 - 3	20%
	4 - 9	29%

The new meta-analysis has several limitations, including that it involved women who were scheduled to receive 5 years of endocrine therapy ? not who completed it. In six of the trials that investigated only tamoxifen, a "substantial minority" (11% to 31%) of women did not complete treatment.

That fact may lead to higher rates of recurrence risk in the study, just as 100% completion would lead to lower risk.

However, the authors also suspect that the rate of distant recurrence would have been 5% to 10% higher had the data not been tamped down by unreported breast-cancer events.

The team also could not "reliably assess" the relevance of chemotherapy to prognosis after the treatment period ended at 20 years. They acknowledged that the risk for recurrence after 5 years may be lower for women who receive contemporary chemotherapy compared to the risk for women in the study, echoing Dr Pusztai's comments.

The study was funded by Cancer Research UK, the British Heart Foundation, and the Medical Research Council at the University of Oxford. Dr Pusztai has worked with Biotheranostic to assess use of their Breast Cancer Index. Dr Hayes, and Dr Kaklamani, and Dr Vogl have disclosed no relevant financial relationships.