The prevalence of hepatic steatosis and MAFLD based on the liver ultrasound elastography in Chinese breast cancer women

The prevalence of hepatic steatosis and MAFLD based on the liver ultrasound elastography in Chinese breast cancer women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The prevalence of hepatic steatosis and MAFLD based on the liver ultrasound elastography in Chinese breast cancer women Zhou Xu, Shen Tian, Ren-hua Li, Juan Tang, Xin-yu Liang, Jun Xiao, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4332680/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Breast cancer is the most common malignancy in women and also shares similar risk factors with fatty liver, especially metabolic associated fatty liver disease (MAFLD). Chemotherapy can lead to hepatic impairment and hepatic steatosis (HS), which seriously affects the treatment and quality of life of breast cancer women (BCW). Therefore, this study aims to investigate the incidences of HS and MAFLD based on liver ultrasound elastography (USE), liver function abnormalities, and metabolic syndrome in Chinese BCW in the initially diagnosed, during chemotherapy and follow-up stages. Methods A total of 767 BCW treated at Chongqing Breast Cancer Centre were finally enrolled and classified into initially diagnosed group, chemotherapy group, and the follow-up group. The related conditions of HS and MAFLD as well as liver function abnormalities and metabolic syndrome were assessed by liver conventional ultrasound (US) or USE in all groups. Results Compare to US-diagnosed HS (21.7%, 36.7%, 38%), higher incidence of HS (60.4%, 78.6%, 68.0%) were detected by USE in the initially diagnosed, chemotherapy and follow-up groups. 50–70% of US-negative patients were detected by USE as having a fatty liver, which was predominantly mild to moderate. Based on the USE diagnosis, there was a higher prevalence of MAFLD in the initially diagnosed group (49.8%), which increased to 68.1% in the chemotherapy group and decreased in the follow-up group (59.1%), with a predominantly decrease of mild-to-moderate cases. BMI and age subgroups showed a higher incidence of MAFLD in patients with BMI ≥ 23 kg/m 2 or age ≥ 60 years old. In addition, BCW combined with MAFLD had a higher incidence of liver function abnormalities and metabolic syndrome. Conclusion Patients treated with chemotherapy for breast cancer have a higher incidence of HS and MAFLD, especially overweight or obese and menopausal patients. Breast cancer patients with combined MAFLD have higher rates of liver function abnormalities and metabolic syndrome. USE has a higher sensitivity than US and can detect more patients with mild to moderate fatty liver disease, enabling early intervention. breast cancer hepatic steatosis metabolic associated fatty liver disease ultrasonography ultrasound elastography Introduction Hepatic steatosis (HS) is a chronic liver disorder characterized by excessive fat accumulation in hepatocytes. Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide which is thought to be still on the rise.[ 1 , 2 ] NFALD is characterized by the presence of at least 5% HS, in the absence of any other underlying liver diseases such as chronic viral hepatitis, the use of certain medications that induce steatosis like tamoxifen, and other chronic liver diseases, such as autoimmune hepatitis, or excessive alcohol consumption.[ 3 ] NAFLD was initially thought to be a benign, reversible disease with a favorable prognosis, but recent studies have shown that NAFLD is more than just a liver disorder.[ 1 – 3 ] A subset of these patients has the potential to develop nonalcoholic steatohepatitis (NASH), which represents a more advanced and increasingly deteriorating form of liver disease. NAFLD has been associated with various extrahepatic diseases.[ 4 – 7 ] Apart from hepatocellular carcinoma, NAFLD has also been correlated with the development of breast, colorectal and other types of cancer.[ 5 , 8 – 10 ] Recognizing the metabolic dysfunction underlying the fatty liver disease, an international consensus panel consisting of representatives from 22 countries has proposed a new term, metabolic-associated fatty liver disease (MAFLD), to replace NAFLD.[ 11 ] The criteria for MAFLD include the presence of HS, along with at least one of the following: type 2 diabetes mellitus, overweight/obesity, or metabolic dysregulation. Fatty liver and metabolic dysfunction play crucial roles in the determination of MAFLD and are also observed in breast cancer women (BCW), leading to adverse consequences.[ 12 ] Breast cancer is the most common cancer in women, constituting over 10% of new cancer diagnoses annually. Globally, it ranks as the second leading cause of cancer-related deaths among women.[ 13 ] Recent studies have identified metabolic syndrome (MetS) and obesity as risk factors for breast cancer.[ 14 , 15 ] Risk factors for HS include obesity, hormonal status, diabetes, and MetS.[ 16 , 17 ] Additionally, chemotherapy and endocrine medications like tamoxifen have been found to increase the risk of HS in some BCW.[ 18 , 19 ] Due to the shared risk factors between HS and breast cancer, their relationship has been investigated, and several studies have shown a close association.[ 5 , 10 , 20 – 22 ] A Korea cohort study included 25,947 subjects and revealed that NAFLD, in addition to hepatocellular carcinoma, was also involved in the development of breast cancer in females and colorectal cancer in males.[ 5 ] Another case-control study reported a strong link between NAFLD and breast cancer independent of traditional risk factors, particularly in the non-obese population.[ 10 ] However, a small study using liver MRI to measure hepatic fat accumulation found a similar prevalence of NAFLD in BCW compared to the general population.[ 21 ] Importantly, one of our recent studies discovered MAFLD increased the risk of breast lesions and BI-RADS ≥ 4 categories breast lesions in postmenopausal women.[ 23 ] Another matched cohort study revealed a higher prevalence of MAFLD in breast cancer survivors compared to the general population when screened with USE (63.2% vs. 21.6%).[ 24 ] Traditionally, conventional ultrasonography (US) has been the primary method for diagnosing HS in BCW. However, liver ultrasound elastography (USE) is increasingly being employed for this purpose.[ 25 ] USE assesses the extent of ultrasonic attenuation caused by hepatic fat using vibration-controlled elastography, which is particularly effective in detecting mild steatosis.[ 26 , 27 ] Limited studies have investigated the prevalence of MAFLD in BCW, specifically utilizing USE, especially during chemotherapy. Therefore, the objective of this study is to examine the prevalence of HS and MAFLD using either US or USE, as well as liver function abnormalities and MetS in Chinese BCW in the initially diagnosed, during chemotherapy and follow-up stages. Patients and methods Study population A cross-sectional survey was carried out among breast cancer survivors between November 2019 and April 2021 at the Department of Endocrine and Breast Surgery of The First Affiliated Hospital of Chongqing Medical University, which serves as the Breast Cancer Center in Chongqing, China. The breast cancer diagnosis were confirmed through biopsy procedures conducted by experienced pathologists at the Clinical Pathological Diagnosis Center of Chongqing Medical University. HS was assessed by experienced ultrasound diagnostic technicians using US and USE. USE was equipped with a newly developed technology called Vibration Controlled Transient Elastography (VCTE), specifically utilizing a controlled attenuation parameter (CAP) measurement. It was determined that the use of VCTE with CAP measurement was more sensitive in diagnosing HS compared to traditional ultrasonography.[ 28 , 29 ] The study involved a total of 767 subjects who were at their initial diagnosis or after chemotherapy or during follow-up period. Initially diagnosed group were those who had been diagnosed with breast cancer for the first time without any treatment. Chemotherapy group included those who had received neoadjuvant or adjuvant chemotherapy and the follow-up group were those who have undergone chemotherapy. Exclusion criteria encompassed missing anthropological data and laboratory test results, patients below 18 years of age, and patients with recurrent or metastatic breast cancer. The study was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University and was conducted following the principles outlined in the Helsinki Declaration. Informed consent was waived as the information obtained was retrospective and anonymous. Clinical assessment Information pertaining to patient age, medical background, and anthropometric measurements, which encompassed height, body weight, waist circumference, and blood pressure, were extracted from the healthcare records system. Body mass index (BMI) was computed using the following formula: BMI = weight (in kilograms) divided by the square of height (in meters). Blood samples were procured following a minimum fasting period of 8 hours and subjected to analysis utilizing standard laboratory protocols. The determination of MAFLD involved the identification of HS based on US or USE in conjunction with any of the following three symptoms: overweight/obesity, diabetes mellitus (DM), or metabolic dysregulation.[ 11 ] Metabolic dysregulation was characterized by the presence of at least two of the following conditions: 1) Blood pressure equal to or greater than 130/85 mm Hg or history of hypertension treatment; 2) Prediabetes, indicated by fasting glucose levels ranging from 5.6 to 6.9 mmol/L, 2-hour post-load glucose levels between 7.8 and 11.0 mmol/L, or HbA1c levels from 5.7–6.4%; 3) Abdominal obesity: waist circumference (WC) equal to or greater than 80 cm; 4) Triglycerides (TG) exceeding 1.7 mmol/L; 5) Low levels of high-density lipoprotein cholesterol (HDL) below 1.3 mmol/L; 6) C-reactive protein (CRP) levels surpassing 2 mg/L; 7) Homeostasis model assessment-insulin resistance (HOMA-IR) score equal to or greater than 2.5. The ultrasonography procedure was performed and evaluated by experienced clinical radiologists using an ultrasound scanner (Aplio500, Toshiba Medical Systems, Japan or HD11XE, Philips Medical Systems, U.S.A) or ultrasound elastography (FibroTouch, Wuxi Hisky Medical Technologies Co., Ltd., China). Indications of hepatic steatosis on ultrasound included liver parenchymal brightness, deep attenuation in liver parenchyma, vascular blurring and evident liver-to-kidney contrast.[ 30 ] The ultrasound attenuation parameter (UAP), which measured the extent of ultrasound signal attenuation in the liver, was utilized to quantify liver steatosis for USE. A successful test was defined as having at least ten valid measurements with an interquartile range/median of UAP equal to or less than 30%. The cut-offs for UAP used for the diagnosis of normal, mild, moderate and severe grade steatosis were 240 dB/m, 265 dB/m and 295 dB/m, respectively. Liver function abnormalities were defined as follows: alkaline phosphatase (ALP) greater than 135 U/L, aspartate aminotransferase (AST) greater than 40 U/L, alanine aminotransferase (ALT) greater than 40 U/L, gamma-glutamyl transferase (GGT) greater than 49 U/L, and total bilirubin (TBIL) greater than 17.1 µmol/L.[ 31 ] MetS was defined according to the criteria proposed by the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III.[ 32 ] Diagnosis of MetS required the presence of at least three out of the following five components: a waist circumference equal to or greater than 80 cm for women; blood pressure equal to or greater than 130/85 mm Hg or current use of antihypertensive medications; triglyceride (TG) levels equal to or greater than 150 mg/dL (1.7 mmol/L); high-density lipoprotein-cholesterol (HDL) levels below 50 mg/dL for women (1.3 mmol/L); and fasting blood glucose levels equal to or greater than 100 mg/dL (5.6 mmol/L) or current use of medications for hyperglycemia. Statistical analysis The statistical analysis was conducted utilizing SPSS software (version 20.0). Continuous variables were assessed for normality and presented as either mean ± standard deviation or medians with interquartile range, depending on their distribution. Categorical variables were compared using the chi-square test, while continuous variables were compared between subjects using either the Student's t-test or Mann-Whitney U test, depending on the appropriateness of the test. A p-value of less than 0.05 in a two-tailed test was considered statistically significant. Results This study included a total of 767 BCW with complete data. Among them, there were 217 patients in the initially diagnosed group, 184 patients in the chemotherapy group, and 366 patients in the follow-up group, with an average follow-up time of 30 months. The anthropometric measurements, laboratory test results and other baseline characteristics of initially diagnosed group and chemotherapy group were presented in Table 1 . There was no significant difference in the age and BMI of initially diagnosed group and chemotherapy group (50.9 ± 11.3 vs. 50.2 ± 9.6 vs. 51.33 ± 10.4 years, 23.5 ± 3.1 vs. 24.0 ± 3.0 vs. 23.5 ± 2.9 kg/m 2 ). Compared to initially diagnosed group, liver enzymes (ALT, AST, GGT), total cholesterol and fasting glucose level significantly elevated in chemotherapy group, which remained high in follow-up group. Especially, the average CAP value indicating steatosis was higher in chemotherapy group (258.4 ± 27.7) and follow-up group (254.0 ± 31.7) compare to initially diagnosed group (247.3 ± 31.1, P < 0.05). A total of 513 breast cancer patients (irrespective of treatment stage) with complete data on their age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, HDL-C, fasting glucose, hs-CRP were screened for multivariate analysis (Supplement Table 1 ). Compared to non-HS subjects, patients with HS had higher age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, fasting glucose, hs-CRP and lower HDL-C level (P < 0.05). The variables used for analysis included age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, HDL-C, fasting glucose, hs-CRP. Total cholesterol and HDL-C were removed from the model after being tested for multicollinearity. The logistic model obtained was of statistical significance (χ 2 = 255.551, p < 0.001) and percentage accuracy in classification (PAC) was 81.7%. By contrast, the logistic model for US-diagnosed HS had lower PAC (75.6%). After adjusting for age, BMI and other factors, binary logistic regression analysis determined that the independent influencing factors of HS based on USE were gender, BMI, GGT and Triglycerides (P < 0.05). For every 1-unit increase in BMI, GGT, and Triglycerides, the risk of HS increases by 66.3%, 2.4%, and 147.4%, respectively. Table 1 Baseline characteristics of Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages Variable Initially diagnosed group (n = 217) Chemotherapy group (n = 184) Follow-up group (n = 366) P value Age, years 50.9 ± 11.3 50.2 ± 9.6 51.33 ± 10.4 0.09 BMI, kg/m 2 23.5 ± 3.1 24.0 ± 3.0 23.5 ± 2.9 0.159 Waist circumference, cm 85.0 ± 10.0 85.2 ± 8.4 81.8 ± 8.3 < 0.0001 Alb, g/L 42.2 ± 3.2 40.1 ± 4.8 48.1 ± 3.3 < 0.0001 ALT, U/L 13.0 (8.0) 27.0 (20.0) 18.0 (12.0) < 0.0001 AST, U/L 16.0 (6.0) 23.0 (12.0) 21.0 (8.0) < 0.0001 GGT, U/L 15.0 (13.0) 22.0 (21.0) 21.0 (20.0) 0.001 ALP, U/L 63.2 ± 21.4 66.5 ± 21.1 75.0 ± 26.1 < 0.0001 Total cholesterol, mmol/L 4.4 ± 0.9 5.0 ± 1.1 4.7 ± 1.0 < 0.0001 Triglycerides, mmol/L 1.0 (0.7) 1.0 (1.0) 1.4 (1.0) < 0.0001 LDL-C, mmol/L 2.87 ± 0.8 3.2 ± 1.0 2.8 ± 1.0 < 0.0001 HDL-C, mmol/L 1.3 ± 0.3 1.3 ± 0.4 1.4 ± 0.4 < 0.0001 Fasting glucose, mmol/L 5.2 ± 1.0 6.6 ± 2.6 5.9 ± 1.1 < 0.0001 HbA1c, % 5.6 ± 0.9 5.8 ± 1.0 5.8 ± 0.9 0.447 hs-CRP, mg/L 0.7 (1.2) 1.0 (1.8) 0.6 (0.9) 0.001 LSM 6.3 ± 1.8 6.7 ± 2.1 6.6 ± 2.4 0.284 CAP 247.3 ± 31.1 258.4 ± 27.7 254.0 ± 31.7 0.001 Data are mean ± SD or median (IQR). P values were derived from Student t-test, the Mann-Whitney U test or chi-square test. BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; Alb, plasma albumin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; ALP, alkaline phosphatase; HDL, high-density lipoprotein-cholesterol; LDL, low-density lipoprotein-cholesterol; HbA1c, hemoglobin A1c; hs-CRP, plasma high-sensitivity C-reactive protein; LSM, liver stiffness measurement; CAP, controlled attenuation parameter. The prevalence of HS detected by US was significantly higher in the chemotherapy group than in the primary diagnosis group (36.7% versus 21.7%, P < 0.05), and increased to 38.0% in the follow-up patients (Table 2 ). USE had a higher rate of HS detection compared to US. USE-diagnosed HS increased to 78.6% in the chemotherapy group compared to the first-diagnosed group (60.4%, p < 0.05), and decreased in the follow-up group (68%), mainly in mild-to-moderate HS. After grading by UAP measurement, moderate to severe HS cases accounted for 29.5%, 42.8% and 39.2%, respectively in initially diagnosed, chemotherapy and follow-up groups. BMI subgroups showed that BMI ≥ 23 had a higher HS prevalence, 86.7%, 91.8% and 86.5% in the three groups (Table 3 ). HS prevalence was significantly higher in the chemotherapy group of patients with normal or low BMI than in the first diagnosis group (58.3% vs. 31.7%, p 0.05). Age stratification showed that menopausal patients ≥ 60 years of age had a higher prevalence of HS, 82.6%, 83.3% and 77.9% in the three groups, respectively (Table 3 ). The prevalence of HS was significantly higher in the chemotherapy group than in the first diagnosis group in patients younger than 60 years of age (77.8% vs. 54.7%, p < 0.05), with a significant decrease in the follow-up group (65.3%, p < 0.05). Table 2 Prevalence of hepatic steatosis (HS) based on US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages US-diagnosed HS USE-diagnosed HS Grading Mild moderate severe Initially diagnosed group 43/198 (21.7%) 131/217 (60.4%) 67 (30.9%) 48 (22.1%) 16 (7.4%) Chemotherapy group 61/166 (36.7%) * 143/182 (78.6%) * 65 (35.7%) 63 (34.6%) * 15 (8.2%) Follow-up group 139/366 (38.0%) † 246/362 (68.0%) § 104 (28.7%) 105 (29.0%) 37 (10.2%) HS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). Table 3 Age and BMI stratification of hepatic steatosis (HS) diagnosed by USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages Stratification Initially diagnosed group Chemotherapy group Follow-up group BMI, kg/m 2 < 23 33/104 (31.7%) 42/72 (58.3%) * 73/162 (45.1%) ≥ 23 98/113 (86.7%) 101/110 (91.8%) 173/200 (86.5%) Age, years < 60 93/170 (54.7%) 123/158 (77.8%) * 186/285 (65.3%) § ≥ 60 38/46 (82.6%) 20/24 (83.3%) 60/77 (77.9%) HS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). In the initially diagnosed group, 155 BCW were US negative patients, whereas 51% were further diagnosed with HS by USE (Table 4 ). Most of these are mild (70.0%) and moderate (26.6%) cases. Similarly, 70% and 51.3% BCW were US-negative but USE-positive in chemotherapy group, of which mild to moderate cases accounted for 94.6% and 91.3% respectively. Table 4 Comparison of diagnosis of hepatic steatosis (HS) by US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages US USE Grading Negative Positive Mild moderate severe Initially diagnosed group Negative (155) 76 (49.0%) 79 (51.0%) 55 (35.5%) 21 (13.5%) 3 (1.9%) Positive (43) 1 (2.3%) 42 (97.7%) 9 (20.9%) 21 (48.8%) 12 (27.9%) Chemotherapy group Negative (105) 31 (29.5%) 74 (70.5%) 48 (45.7%) 22 (21.0%) 4 (3.8%) Positive (59) 2 (3.4%) 57 (96.6%) 12 (20.3%) 36 (61.0%) 9 (15.3%) Follow-up group Negative (224) 109 (48.7%) 115 (51.3%) 178 (36.8%) 80 (16.5%) 10 (2.1%) Positive (59) 7 (5.1%) 131 (94.9%) 50 (20.8%) 125 (52.1%) 55 (22.9%) HS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. The prevalence of MAFLD based on US in chemotherapy group was significantly higher than in the initially diagnosed group (33.1% vs. 20.4%, P < 0.05), and the proportion increased to 34.7% in follow-up group (Table 5 ). With the implementation of USE, MAFLD prevalence increased to 68.1% in the chemotherapy group compared to the initially diagnosed group (49.8%, p < 0.05), but decreased in the follow-up group to 59.1%. Moderate to severe HS cases accounted for 28.6%, 41.2%, and 37.1% in the initially diagnosed, chemotherapy, and follow-up groups, respectively. The different BMI categories revealed that overweight or obese patients had a greater occurrence of MAFLD, reaching as high as 91.8% in the chemotherapy group (Table 6 ). Comparatively, the chemotherapy group had a significantly higher prevalence of MAFLD than the initially diagnosed group among patients with normal or low BMI (31.9% vs. 9.6%, p < 0.05), and this occurrence decreased in the follow-up group (25.9%) but remained higher than in the first-diagnosis group (p < 0.05). When considering age, menopausal patients aged 60 years or older exhibited a higher prevalence of MAFLD. In patients younger than 60 years of age, the chemotherapy group had a significantly higher prevalence of MAFLD compared to the initially diagnosed group (67.1% vs. 42.9%, p < 0.05), which decreased significantly in the follow-up group (55.4%, p < 0.05), but still remained higher than in the first-diagnosis group (p < 0.05). Table 5 Prevalence of MAFLD based on US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages US-diagnosed MAFLD USE-diagnosed MAFLD USE-grading Mild moderate severe Initially diagnosed group 42/206 (20.4%) 108/217 (49.8%) 46 (21.2%) 46 (21.2%) 16 (7.4%) Chemotherapy group 57/172 (33.1%) * 124/182 (68.1%) * 49 (26.9%) 60 (33.0%) * 15 (8.2%) Follow-up group 127/366 (34.7%) † 215/364 (59.1%) 80 (22.0%) 98 (26.9%) 37 (10.2%) MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). Table 6 Age and BMI stratification of MAFLD diagnosed by USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages Stratification Initially diagnosed group Chemotherapy group Follow-up group BMI, kg/m 2 < 23 10/104 (9.6%) 23/72 (31.9%) * 42/162 (25.9%) † ≥ 23 98/113 (86.7%) 101/110 (91.8%) 173/200 (86.5%) Age, years < 60 73/170 (42.9%) 106/158 (67.1%) * 158/285 (55.4%) †§ ≥ 60 35/46 (76.1%) 18/24 (75.0%) 57/77 (74.0%) MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). The prevalence of liver function abnormalities in chemotherapy group was higher than in the initially diagnosed group (28.3% vs. 7.5%, P < 0.05), which was more evident in the US-diagnosed HS patients (38.6% vs. 16.3%, P < 0.05). (Table 7 ) By contrast, the proportion decreased in USE-diagnosed HS patients (29.6% vs. 11.5%, P < 0.05). In the chemotherapy group, about half of severe HS patients (57.1%) were diagnosed with liver function abnormalities, compared to 25% in the initially diagnosed group, which remained high in follow-up group (50%). It was also shown that the prevalence of liver function abnormalities in the chemotherapy group with MAFLD based on the US was higher than in the initial diagnosis group (41.5% vs. 16.7%, P < 0.05), and declined to 31.5% in follow-up group. The results were similar in USE-diagnosed MAFLD patients (12.1%, 32.5% vs. 23.7%, P < 0.05) in initially diagnosed, chemotherapy and follow-up groups. Table 7 Prevalence of liver function abnormalities (LA) among Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages LA LA in US-diagnosed HS LA in USE-diagnosed HS Grading LA in US-diagnosed MAFLD LA in USE-diagnosed MAFLD Mild moderate severe Initially diagnosed group 16/213 (7.5%) 7/43 (16.3%) 15/130 (11.5%) 5/67 (7.5%) 6/47 (12.8%) 4/16 (25.0%) 7/42 (16.7%) 13/107 (12.1%) Chemotherapy group 49/173 (28.3%) * 22/57 (38.6%) * 40/135 (29.6%) * 13/63 (20.6%) 19/58 (32.8%) 8/14 (57.1%) 22/53 (41.5%) * 38/117 (32.5%) * Follow-up group 70/353 (19.8%) † 42/135 (31.1%) 55/242 (22.7%) † 11/103 (10.7%) 26/103 (25.2%) 18/36 (50.0%) 39/124 (31.5%) † 50/211 (23.7%) † LA, liver function abnormalities; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). The prevalence of MetS were similar in three BCW groups (26.7% vs. 28.3% vs. 31.4%, Table 8 ). However, 76.7% patients were diagnosed with MetS in US-diagnosed HS patients within initially diagnosed group, this number declined to 42.6% and 54% in chemotherapy and follow-up groups. The percentage of MetS in BCW with severe HS accounted for 75.0%, 66.7% and 59.5% respectively in initially diagnosed group, chemotherapy group and follow-up group. The MetS prevalence was higher in patients with US-diagnosed MAFLD in three groups (78.6% vs. 45.6% vs. 59.1%). Table 8 Prevalence of metabolic syndrome (MetS) among Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages MetS MetS in US-diagnosed HS MetS in USE-diagnosed HS Grading MetS in US-diagnosed MAFLD MetS in USE-diagnosed MAFLD Mild moderate severe Initially diagnosed group 58/217 (26.7%) 33/43 (76.7%) 53/131 (40.5%) 16/67 (23.9%) 25/48 (52.1%) 12/16 (75.0%) 33/42 (78.6%) 53/108 (49.1%) Chemotherapy group 54/184 (28.3%) 26/61 (42.6%) * 48/143 (33.6%) 16/65 (24.6%) 22/63 (34.9%) 10/15 (66.7%) 26/57 (45.6%) * 48/124 (38.7%) Follow-up group 115/366 (31.4%) 75/139 (54.0%) † 105/246 (42.7%) 26/104 (25.0%) 57/105 (54.3%) § 22/37 (59.5%) 75/127 (59.1%) 105/215 (48.8%) MetS, metabolic syndrome; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; *: significant statistic difference between initially diagnosed group and chemotherapy group (P value < 0.05); †: significant statistic difference between initially diagnosed group and follow-up group (P < 0.05); §: statistic difference between chemotherapy group and follow-up group (P value < 0.05). Discussion In this study, we explored the prevalence of HS, MAFLD, liver function abnormalities and MetS in different breast cancer survivor groups (initially diagnosed, chemotherapy, follow-up groups). The elevated occurrence of HS in individuals with breast cancer may be attributed to the combination of shared risk factors. It is crucial to assess HS when managing BCW. A nationwide Sweden study[ 33 ] indicated that steatosis resulted in a 10.7% higher absolute excess risk of mortality over a twenty-year period. In an observational clinical study[ 34 ], 107 individuals with metastatic breast cancer underwent abdominal CT scans. The study found that patients with HS, particularly premenopausal patients, had a higher prevalence of hepatic metastases both at the time of diagnosis and during follow-up. However, the study did not observe a significant difference in survival between the two groups. Our previous investigation[ 24 ] demonstrated that HS prevalence was 22.7% in the general population, 37.4% in breast cancer survivals and increased to 68.3% when HS was screened using USE. In the present study, 21.7% of BCW were diagnosed with HS by US in the initially diagnosed group, which increased to 36.7% and 38.0% in the chemotherapy and follow-up groups. The occurrence of HS diagnosed by USE in chemotherapy group (78.6%) was high, similar to the previous study[ 24 ], whereas decreased to 68.0% in follow-up group. One possible reason for this could be that US mainly detected moderate to severe cases, which were less likely to recover or even continue to deteriorate during the follow-up period. USE, on the other hand, found more mild and moderate cases, which were more likely to recover during follow-up. A high proportion of US-negative HS (51% − 70%) was further discovered by USE in the initially diagnosed group and chemotherapy group, predominantly with mild to moderate cases (49% − 66%). USE is considered a more sensitive diagnostic method for detecting HS compared to traditional ultrasound[ 25 ]. In our study, we utilized FibroTouch, a newer type of transient elastography, to identify mild and moderate cases of HS that might be missed by regular ultrasound. A Chinese study[ 27 ] evaluated the diagnostic performance of UAP and LSM by FibroTouch for diagnosis of HS and hepatic fibrosis in patients with NAFLD and revealed that diagnostic performance of UAP for steatosis was significantly superior to that of the hepatic steatosis index. USE can be considered as a screening tool for high-risk populations with a greater likelihood of HS. NFALD is closely associated with metabolic disorders such as obesity, insulin resistance, and dyslipidemia. The rise in the prevalence of NFALD in recent decades has become a significant concern in the field of hepatology and public health.[ 35 , 36 ] A Chinese cohort[ 37 ] consisted of 217 patients with newly diagnosed BCW reported higher prevalence of NAFLD in BCW compared with health examinees (45.2% vs. 20.3%). The new concept of MAFLD, based on metabolic disorders, is more closely correlated with breast cancer. In this study, approximately 50–70% of individuals with breast cancer were diagnosed with MAFLD when USE was employed. In contrast, when using traditional ultrasound, only 20–30% of cases could be detected. In addition, MAFLD was more than 86% in the overweight or obese BCW and up to 91.8% in the chemotherapy group. BMI, one of the diagnostic criteria of MAFLD, is also risk factor for breast cancer. A meta-analysis[ 38 ] consisting of 12 prospective studies found that for every 5 kg/m 2 increase in BMI, there was a two percent higher risk of developing breast cancer in women. Another Chinese research demonstrated that the molecule released by adipocytes in breast tissue stimulated the growth and multiplication of specific breast cancer cells.[ 39 ] 70–80% of menopausal BCW were diagnosed with MAFLD. The decline in estrogen is strongly associated with fatty liver and metabolic disorders.[ 40 , 41 ] In the chemotherapy group, there was a significant increase observed in liver function abnormalities, which remained high in follow-up group. Chemotherapy was found to have negative impacts on quality of life and lipid levels, as reported in previous studies.[ 42 – 45 ] A study [ 46 ] indicated that chemotherapy caused notable changes in plasma lipid and lipoprotein levels in individuals with breast cancer, potentially through gene modulation. Intriguingly, the prevalence of liver function abnormalities was higher in US-diagnosed HS patients, compare to USE-diagnosed HS cases. Same situation was also observed for MetS. One possible reason was that HS detected by US were mostly severe cases which were undoubtedly more likely to develop liver and metabolic disorders. However mild to moderate degrees also required early detection and intervention to avoid further deterioration in the future. To the best of our knowledge, this study represents the first investigation into the presence of HS and MAFLD using USE in various stages of breast cancer patients. However, it is important to acknowledge that this study has a number of limitations. Firstly, due to reasons such as a relatively small sample size and incomplete data, further classification analysis based on molecular subtypes or treatment methods (endocrine therapy, radiation therapy, etc.) could not be conducted. However, the current results emphasize the high prevalence of HS and MAFLD in chemotherapy patients and those under follow-up, drawing public attention. According to the analysis of existing data, in the follow-up group, the prevalence of HS (60–70%) and MAFLD (50–65%) were similar in BCW, regardless of whether they received chemotherapy alone or endocrine therapy alone or a combination. Excluding patients with missing anthropologic and laboratory test results may also contribute to selection bias. However, this group of people is a minority. In the future, the sample size will be expanded, and relevant stratified analysis will be conducted. Additionally, it's important to note that the present study was not a self-controlled research which could provide a better understanding of the effects of chemotherapy. Although it cannot establish a causal relationship, the current findings suggest a high prevalence of MAFLD across all groups, with an increasing risk of MAFLD after undergoing chemotherapy. In summary, this study revealed that breast cancer survivors have a higher prevalence of HS and MAFLD, and liver function abnormalities, particularly in the chemotherapy group. These conditions persisted at a high percentage during the follow-up period. After chemotherapy, MAFLD patients are more likely to experience concurrent liver function abnormalities, especially in cases with moderate to severe conditions. More attention should be given to overweight or postmenopausal breast cancer survivors. The use of USE can aid in the early detection of mild to moderate HS cases. Managing MAFLD through strategies such as calorie reduction, exercise, and healthy eating habits may benefit breast cancer survivors. Further studies are needed to investigate the potential causal mechanisms underlying these associations. Abbreviations BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; Alb, plasma albumin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; ALP, alkaline phosphatase; HDL, high-density lipoprotein-cholesterol; LDL, low-density lipoprotein-cholesterol; HbA1c, hemoglobin A1c; hs-CRP, plasma high-sensitivity C-reactive protein; LSM, liver stiffness measurement; CAP, controlled attenuation parameter; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women; LA, liver function abnormalities; MetS, metabolic syndrome; Declarations Ethics approval and consent to participate All procedures in studies involving human participants were performed according to the ethical standards of the institutional research committee (the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University, approval number: 2020-100) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was waived on account of the study’s retrospective design. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors have no conflicts of interest to declare. Funding Not applicable. Authors' contributions ZX and LQK, conceptualization; ST, RHL, JT and XYL, investigation; ZX, JX, JW, YLC, JYS, data acquisition; ZX, RLS, CYM and JHF, data analysis; ZX, ST, RHL, JT, XYL, JX, writing original draft; JW, YLC, JYS, RLS, CYM, drafting of tables; LQK and KNW, writing - review & editing. All authors read and approved the final manuscript. Acknowledgments The authors thank professor Hong-yuan Li for his guidance in the study design. 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(2018) Status of lipid and lipoprotein in female breast cancer patients at initial diagnosis and during chemotherapy. Lipids Health Dis 17:91. https://doi.org/10.1186/s12944-018-0745-1 Jesus M de, Mohammed T, Singh M et al. (2022) Etiology and Management of Dyslipidemia in Patients With Cancer. Front Cardiovasc Med 9:892335. https://doi.org/10.3389/fcvm.2022.892335 Sharma M, Tuaine J, McLaren B et al. (2016) Chemotherapy Agents Alter Plasma Lipids in Breast Cancer Patients and Show Differential Effects on Lipid Metabolism Genes in Liver Cells. PLoS One 11:e0148049. https://doi.org/10.1371/journal.pone.0148049 Additional Declarations No competing interests reported. Supplementary Files SupplementTable1and2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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05:01:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1176809,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4332680/v1/9cd6b80d-6f1a-4713-b779-2c992fb09b74.pdf"},{"id":55990005,"identity":"486aa152-d50a-40f3-b2ab-17f852582ef9","added_by":"auto","created_at":"2024-05-07 09:01:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":48590,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTable1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4332680/v1/a01b277ae1d046132061dc87.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The prevalence of hepatic steatosis and MAFLD based on the liver ultrasound elastography in Chinese breast cancer women","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatic steatosis (HS) is a chronic liver disorder characterized by excessive fat accumulation in hepatocytes. Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide which is thought to be still on the rise.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] NFALD is characterized by the presence of at least 5% HS, in the absence of any other underlying liver diseases such as chronic viral hepatitis, the use of certain medications that induce steatosis like tamoxifen, and other chronic liver diseases, such as autoimmune hepatitis, or excessive alcohol consumption.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] NAFLD was initially thought to be a benign, reversible disease with a favorable prognosis, but recent studies have shown that NAFLD is more than just a liver disorder.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] A subset of these patients has the potential to develop nonalcoholic steatohepatitis (NASH), which represents a more advanced and increasingly deteriorating form of liver disease. NAFLD has been associated with various extrahepatic diseases.[\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Apart from hepatocellular carcinoma, NAFLD has also been correlated with the development of breast, colorectal and other types of cancer.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Recognizing the metabolic dysfunction underlying the fatty liver disease, an international consensus panel consisting of representatives from 22 countries has proposed a new term, metabolic-associated fatty liver disease (MAFLD), to replace NAFLD.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The criteria for MAFLD include the presence of HS, along with at least one of the following: type 2 diabetes mellitus, overweight/obesity, or metabolic dysregulation. Fatty liver and metabolic dysfunction play crucial roles in the determination of MAFLD and are also observed in breast cancer women (BCW), leading to adverse consequences.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBreast cancer is the most common cancer in women, constituting over 10% of new cancer diagnoses annually. Globally, it ranks as the second leading cause of cancer-related deaths among women.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Recent studies have identified metabolic syndrome (MetS) and obesity as risk factors for breast cancer.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Risk factors for HS include obesity, hormonal status, diabetes, and MetS.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Additionally, chemotherapy and endocrine medications like tamoxifen have been found to increase the risk of HS in some BCW.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Due to the shared risk factors between HS and breast cancer, their relationship has been investigated, and several studies have shown a close association.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] A Korea cohort study included 25,947 subjects and revealed that NAFLD, in addition to hepatocellular carcinoma, was also involved in the development of breast cancer in females and colorectal cancer in males.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Another case-control study reported a strong link between NAFLD and breast cancer independent of traditional risk factors, particularly in the non-obese population.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] However, a small study using liver MRI to measure hepatic fat accumulation found a similar prevalence of NAFLD in BCW compared to the general population.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Importantly, one of our recent studies discovered MAFLD increased the risk of breast lesions and BI-RADS\u0026thinsp;\u0026ge;\u0026thinsp;4 categories breast lesions in postmenopausal women.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Another matched cohort study revealed a higher prevalence of MAFLD in breast cancer survivors compared to the general population when screened with USE (63.2% vs. 21.6%).[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTraditionally, conventional ultrasonography (US) has been the primary method for diagnosing HS in BCW. However, liver ultrasound elastography (USE) is increasingly being employed for this purpose.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] USE assesses the extent of ultrasonic attenuation caused by hepatic fat using vibration-controlled elastography, which is particularly effective in detecting mild steatosis.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Limited studies have investigated the prevalence of MAFLD in BCW, specifically utilizing USE, especially during chemotherapy. Therefore, the objective of this study is to examine the prevalence of HS and MAFLD using either US or USE, as well as liver function abnormalities and MetS in Chinese BCW in the initially diagnosed, during chemotherapy and follow-up stages.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was carried out among breast cancer survivors between November 2019 and April 2021 at the Department of Endocrine and Breast Surgery of The First Affiliated Hospital of Chongqing Medical University, which serves as the Breast Cancer Center in Chongqing, China. The breast cancer diagnosis were confirmed through biopsy procedures conducted by experienced pathologists at the Clinical Pathological Diagnosis Center of Chongqing Medical University. HS was assessed by experienced ultrasound diagnostic technicians using US and USE. USE was equipped with a newly developed technology called Vibration Controlled Transient Elastography (VCTE), specifically utilizing a controlled attenuation parameter (CAP) measurement. It was determined that the use of VCTE with CAP measurement was more sensitive in diagnosing HS compared to traditional ultrasonography.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] The study involved a total of 767 subjects who were at their initial diagnosis or after chemotherapy or during follow-up period. Initially diagnosed group were those who had been diagnosed with breast cancer for the first time without any treatment. Chemotherapy group included those who had received neoadjuvant or adjuvant chemotherapy and the follow-up group were those who have undergone chemotherapy. Exclusion criteria encompassed missing anthropological data and laboratory test results, patients below 18 years of age, and patients with recurrent or metastatic breast cancer. The study was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University and was conducted following the principles outlined in the Helsinki Declaration. Informed consent was waived as the information obtained was retrospective and anonymous.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical assessment\u003c/h2\u003e \u003cp\u003eInformation pertaining to patient age, medical background, and anthropometric measurements, which encompassed height, body weight, waist circumference, and blood pressure, were extracted from the healthcare records system. Body mass index (BMI) was computed using the following formula: BMI\u0026thinsp;=\u0026thinsp;weight (in kilograms) divided by the square of height (in meters). Blood samples were procured following a minimum fasting period of 8 hours and subjected to analysis utilizing standard laboratory protocols.\u003c/p\u003e \u003cp\u003eThe determination of MAFLD involved the identification of HS based on US or USE in conjunction with any of the following three symptoms: overweight/obesity, diabetes mellitus (DM), or metabolic dysregulation.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Metabolic dysregulation was characterized by the presence of at least two of the following conditions: 1) Blood pressure equal to or greater than 130/85 mm Hg or history of hypertension treatment; 2) Prediabetes, indicated by fasting glucose levels ranging from 5.6 to 6.9 mmol/L, 2-hour post-load glucose levels between 7.8 and 11.0 mmol/L, or HbA1c levels from 5.7\u0026ndash;6.4%; 3) Abdominal obesity: waist circumference (WC) equal to or greater than 80 cm; 4) Triglycerides (TG) exceeding 1.7 mmol/L; 5) Low levels of high-density lipoprotein cholesterol (HDL) below 1.3 mmol/L; 6) C-reactive protein (CRP) levels surpassing 2 mg/L; 7) Homeostasis model assessment-insulin resistance (HOMA-IR) score equal to or greater than 2.5. The ultrasonography procedure was performed and evaluated by experienced clinical radiologists using an ultrasound scanner (Aplio500, Toshiba Medical Systems, Japan or HD11XE, Philips Medical Systems, U.S.A) or ultrasound elastography (FibroTouch, Wuxi Hisky Medical Technologies Co., Ltd., China). Indications of hepatic steatosis on ultrasound included liver parenchymal brightness, deep attenuation in liver parenchyma, vascular blurring and evident liver-to-kidney contrast.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] The ultrasound attenuation parameter (UAP), which measured the extent of ultrasound signal attenuation in the liver, was utilized to quantify liver steatosis for USE. A successful test was defined as having at least ten valid measurements with an interquartile range/median of UAP equal to or less than 30%. The cut-offs for UAP used for the diagnosis of normal, mild, moderate and severe grade steatosis were 240 dB/m, 265 dB/m and 295 dB/m, respectively. Liver function abnormalities were defined as follows: alkaline phosphatase (ALP) greater than 135 U/L, aspartate aminotransferase (AST) greater than 40 U/L, alanine aminotransferase (ALT) greater than 40 U/L, gamma-glutamyl transferase (GGT) greater than 49 U/L, and total bilirubin (TBIL) greater than 17.1 \u0026micro;mol/L.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] MetS was defined according to the criteria proposed by the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Diagnosis of MetS required the presence of at least three out of the following five components: a waist circumference equal to or greater than 80 cm for women; blood pressure equal to or greater than 130/85 mm Hg or current use of antihypertensive medications; triglyceride (TG) levels equal to or greater than 150 mg/dL (1.7 mmol/L); high-density lipoprotein-cholesterol (HDL) levels below 50 mg/dL for women (1.3 mmol/L); and fasting blood glucose levels equal to or greater than 100 mg/dL (5.6 mmol/L) or current use of medications for hyperglycemia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe statistical analysis was conducted utilizing SPSS software (version 20.0). Continuous variables were assessed for normality and presented as either mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or medians with interquartile range, depending on their distribution. Categorical variables were compared using the chi-square test, while continuous variables were compared between subjects using either the Student's t-test or Mann-Whitney U test, depending on the appropriateness of the test. A p-value of less than 0.05 in a two-tailed test was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study included a total of 767 BCW with complete data. Among them, there were 217 patients in the initially diagnosed group, 184 patients in the chemotherapy group, and 366 patients in the follow-up group, with an average follow-up time of 30 months. The anthropometric measurements, laboratory test results and other baseline characteristics of initially diagnosed group and chemotherapy group were presented in Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e. There was no significant difference in the age and BMI of initially diagnosed group and chemotherapy group (50.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 vs. 50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 vs. 51.33\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 years, 23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 vs. 24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 vs. 23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 kg/m\u003csup\u003e2\u003c/sup\u003e). Compared to initially diagnosed group, liver enzymes (ALT, AST, GGT), total cholesterol and fasting glucose level significantly elevated in chemotherapy group, which remained high in follow-up group. Especially, the average CAP value indicating steatosis was higher in chemotherapy group (258.4\u0026thinsp;\u0026plusmn;\u0026thinsp;27.7) and follow-up group (254.0\u0026thinsp;\u0026plusmn;\u0026thinsp;31.7) compare to initially diagnosed group (247.3\u0026thinsp;\u0026plusmn;\u0026thinsp;31.1, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A total of 513 breast cancer patients (irrespective of treatment stage) with complete data on their age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, HDL-C, fasting glucose, hs-CRP were screened for multivariate analysis (Supplement Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e). Compared to non-HS subjects, patients with HS had higher age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, fasting glucose, hs-CRP and lower HDL-C level (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The variables used for analysis included age, BMI, waist circumference, ALT, AST, GGT, ALP, total cholesterol, triglycerides, LDL-C, HDL-C, fasting glucose, hs-CRP. Total cholesterol and HDL-C were removed from the model after being tested for multicollinearity. The logistic model obtained was of statistical significance (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;255.551, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and percentage accuracy in classification (PAC) was 81.7%. By contrast, the logistic model for US-diagnosed HS had lower PAC (75.6%). After adjusting for age, BMI and other factors, binary logistic regression analysis determined that the independent influencing factors of HS based on USE were gender, BMI, GGT and Triglycerides (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For every 1-unit increase in BMI, GGT, and Triglycerides, the risk of HS increases by 66.3%, 2.4%, and 147.4%, respectively.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline characteristics of Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInitially diagnosed group (n\u0026thinsp;=\u0026thinsp;217)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChemotherapy group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;184)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;366)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.33\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWaist circumference, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlb, g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALT, U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.0 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAST, U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.0 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGGT, U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.0 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0 (21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALP, U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.0\u0026thinsp;\u0026plusmn;\u0026thinsp;26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal cholesterol, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTriglycerides, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLDL-C, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHDL-C, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFasting glucose, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHbA1c, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehs-CRP, mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e247.3\u0026thinsp;\u0026plusmn;\u0026thinsp;31.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e258.4\u0026thinsp;\u0026plusmn;\u0026thinsp;27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e254.0\u0026thinsp;\u0026plusmn;\u0026thinsp;31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (IQR). P values were derived from Student t-test, the Mann-Whitney U test or chi-square test.\u003c/p\u003e\n \u003cp\u003eBMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; Alb, plasma albumin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; ALP, alkaline phosphatase; HDL, high-density lipoprotein-cholesterol; LDL, low-density lipoprotein-cholesterol; HbA1c, hemoglobin A1c; hs-CRP, plasma high-sensitivity C-reactive protein; LSM, liver stiffness measurement; CAP, controlled attenuation parameter.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe prevalence of HS detected by US was significantly higher in the chemotherapy group than in the primary diagnosis group (36.7% versus 21.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and increased to 38.0% in the follow-up patients (Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). USE had a higher rate of HS detection compared to US. USE-diagnosed HS increased to 78.6% in the chemotherapy group compared to the first-diagnosed group (60.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and decreased in the follow-up group (68%), mainly in mild-to-moderate HS. After grading by UAP measurement, moderate to severe HS cases accounted for 29.5%, 42.8% and 39.2%, respectively in initially diagnosed, chemotherapy and follow-up groups. BMI subgroups showed that BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 had a higher HS prevalence, 86.7%, 91.8% and 86.5% in the three groups (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e). HS prevalence was significantly higher in the chemotherapy group of patients with normal or low BMI than in the first diagnosis group (58.3% vs. 31.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and decreased in the follow-up group (45.1%, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Age stratification showed that menopausal patients\u0026thinsp;\u0026ge;\u0026thinsp;60 years of age had a higher prevalence of HS, 82.6%, 83.3% and 77.9% in the three groups, respectively (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e). The prevalence of HS was significantly higher in the chemotherapy group than in the first diagnosis group in patients younger than 60 years of age (77.8% vs. 54.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with a significant decrease in the follow-up group (65.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of hepatic steatosis (HS) based on US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUS-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUSE-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGrading\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitially diagnosed group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43/198\u003c/p\u003e\n \u003cp\u003e(21.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131/217\u003c/p\u003e\n \u003cp\u003e(60.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003cp\u003e(30.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e(22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e(7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61/166\u003c/p\u003e\n \u003cp\u003e(36.7%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143/182\u003c/p\u003e\n \u003cp\u003e(78.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003cp\u003e(35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003cp\u003e(34.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e(8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139/366\u003c/p\u003e\n \u003cp\u003e(38.0%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e246/362\u003c/p\u003e\n \u003cp\u003e(68.0%)\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003cp\u003e(28.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003cp\u003e(29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e(10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eHS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAge and BMI stratification of hepatic steatosis (HS) diagnosed by USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStratification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInitially diagnosed group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChemotherapy group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up group\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33/104\u003c/p\u003e\n \u003cp\u003e(31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42/72\u003c/p\u003e\n \u003cp\u003e(58.3%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73/162\u003c/p\u003e\n \u003cp\u003e(45.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98/113\u003c/p\u003e\n \u003cp\u003e(86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101/110\u003c/p\u003e\n \u003cp\u003e(91.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e173/200\u003c/p\u003e\n \u003cp\u003e(86.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93/170\u003c/p\u003e\n \u003cp\u003e(54.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123/158\u003c/p\u003e\n \u003cp\u003e(77.8%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e186/285\u003c/p\u003e\n \u003cp\u003e(65.3%)\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38/46\u003c/p\u003e\n \u003cp\u003e(82.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20/24\u003c/p\u003e\n \u003cp\u003e(83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60/77\u003c/p\u003e\n \u003cp\u003e(77.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eHS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the initially diagnosed group, 155 BCW were US negative patients, whereas 51% were further diagnosed with HS by USE (Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e). Most of these are mild (70.0%) and moderate (26.6%) cases. Similarly, 70% and 51.3% BCW were US-negative but USE-positive in chemotherapy group, of which mild to moderate cases accounted for 94.6% and 91.3% respectively.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eComparison of diagnosis of hepatic steatosis (HS) by US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUSE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGrading\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitially diagnosed group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative (155)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003cp\u003e(49.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003cp\u003e(51.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e(35.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e(13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePositive (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e(97.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e(20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e(48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative (105)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003cp\u003e(29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003cp\u003e(70.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e(45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e(21.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePositive (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e(96.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003cp\u003e(61.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e(15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative (224)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003cp\u003e(48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003cp\u003e(51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003cp\u003e(36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003cp\u003e(16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePositive (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003cp\u003e(94.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003cp\u003e(20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003cp\u003e(52.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e(22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eHS, hepatic steatosis; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe prevalence of MAFLD based on US in chemotherapy group was significantly higher than in the initially diagnosed group (33.1% vs. 20.4%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the proportion increased to 34.7% in follow-up group (Table\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e). With the implementation of USE, MAFLD prevalence increased to 68.1% in the chemotherapy group compared to the initially diagnosed group (49.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but decreased in the follow-up group to 59.1%. Moderate to severe HS cases accounted for 28.6%, 41.2%, and 37.1% in the initially diagnosed, chemotherapy, and follow-up groups, respectively. The different BMI categories revealed that overweight or obese patients had a greater occurrence of MAFLD, reaching as high as 91.8% in the chemotherapy group (Table\u0026nbsp;\u003cspan\u003e6\u003c/span\u003e). Comparatively, the chemotherapy group had a significantly higher prevalence of MAFLD than the initially diagnosed group among patients with normal or low BMI (31.9% vs. 9.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and this occurrence decreased in the follow-up group (25.9%) but remained higher than in the first-diagnosis group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). When considering age, menopausal patients aged 60 years or older exhibited a higher prevalence of MAFLD. In patients younger than 60 years of age, the chemotherapy group had a significantly higher prevalence of MAFLD compared to the initially diagnosed group (67.1% vs. 42.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which decreased significantly in the follow-up group (55.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but still remained higher than in the first-diagnosis group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of MAFLD based on US and USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUS-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUSE-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUSE-grading\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitially diagnosed group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42/206\u003c/p\u003e\n \u003cp\u003e(20.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108/217\u003c/p\u003e\n \u003cp\u003e(49.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e(21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e(21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e(7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57/172\u003c/p\u003e\n \u003cp\u003e(33.1%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124/182\u003c/p\u003e\n \u003cp\u003e(68.1%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003cp\u003e(26.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003cp\u003e(33.0%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e(8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e127/366\u003c/p\u003e\n \u003cp\u003e(34.7%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e215/364\u003c/p\u003e\n \u003cp\u003e(59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003cp\u003e(22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003cp\u003e(26.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e(10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003eMAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAge and BMI stratification of MAFLD diagnosed by USE in Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStratification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInitially diagnosed group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChemotherapy group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up group\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10/104\u003c/p\u003e\n \u003cp\u003e(9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23/72\u003c/p\u003e\n \u003cp\u003e(31.9%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42/162\u003c/p\u003e\n \u003cp\u003e(25.9%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98/113\u003c/p\u003e\n \u003cp\u003e(86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101/110\u003c/p\u003e\n \u003cp\u003e(91.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e173/200\u003c/p\u003e\n \u003cp\u003e(86.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73/170\u003c/p\u003e\n \u003cp\u003e(42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106/158\u003c/p\u003e\n \u003cp\u003e(67.1%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158/285\u003c/p\u003e\n \u003cp\u003e(55.4%)\u003csup\u003e\u0026dagger;\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35/46\u003c/p\u003e\n \u003cp\u003e(76.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18/24\u003c/p\u003e\n \u003cp\u003e(75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57/77\u003c/p\u003e\n \u003cp\u003e(74.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eMAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women. *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe prevalence of liver function abnormalities in chemotherapy group was higher than in the initially diagnosed group (28.3% vs. 7.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which was more evident in the US-diagnosed HS patients (38.6% vs. 16.3%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). (Table\u0026nbsp;\u003cspan\u003e7\u003c/span\u003e) By contrast, the proportion decreased in USE-diagnosed HS patients (29.6% vs. 11.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In the chemotherapy group, about half of severe HS patients (57.1%) were diagnosed with liver function abnormalities, compared to 25% in the initially diagnosed group, which remained high in follow-up group (50%). It was also shown that the prevalence of liver function abnormalities in the chemotherapy group with MAFLD based on the US was higher than in the initial diagnosis group (41.5% vs. 16.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and declined to 31.5% in follow-up group. The results were similar in USE-diagnosed MAFLD patients (12.1%, 32.5% vs. 23.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in initially diagnosed, chemotherapy and follow-up groups.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 7\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of liver function abnormalities (LA) among Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA in US-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA in USE-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGrading\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA in US-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA in USE-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitially diagnosed group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16/213\u003c/p\u003e\n \u003cp\u003e(7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/43\u003c/p\u003e\n \u003cp\u003e(16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15/130\u003c/p\u003e\n \u003cp\u003e(11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5/67\u003c/p\u003e\n \u003cp\u003e(7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6/47\u003c/p\u003e\n \u003cp\u003e(12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/16\u003c/p\u003e\n \u003cp\u003e(25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/42\u003c/p\u003e\n \u003cp\u003e(16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13/107\u003c/p\u003e\n \u003cp\u003e(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49/173\u003c/p\u003e\n \u003cp\u003e(28.3%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22/57\u003c/p\u003e\n \u003cp\u003e(38.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40/135\u003c/p\u003e\n \u003cp\u003e(29.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13/63\u003c/p\u003e\n \u003cp\u003e(20.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19/58\u003c/p\u003e\n \u003cp\u003e(32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/14\u003c/p\u003e\n \u003cp\u003e(57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22/53\u003c/p\u003e\n \u003cp\u003e(41.5%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38/117\u003c/p\u003e\n \u003cp\u003e(32.5%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70/353\u003c/p\u003e\n \u003cp\u003e(19.8%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42/135\u003c/p\u003e\n \u003cp\u003e(31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55/242\u003c/p\u003e\n \u003cp\u003e(22.7%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11/103\u003c/p\u003e\n \u003cp\u003e(10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26/103\u003c/p\u003e\n \u003cp\u003e(25.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18/36\u003c/p\u003e\n \u003cp\u003e(50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39/124\u003c/p\u003e\n \u003cp\u003e(31.5%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50/211\u003c/p\u003e\n \u003cp\u003e(23.7%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003eLA, liver function abnormalities; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe prevalence of MetS were similar in three BCW groups (26.7% vs. 28.3% vs. 31.4%, Table\u0026nbsp;\u003cspan\u003e8\u003c/span\u003e). However, 76.7% patients were diagnosed with MetS in US-diagnosed HS patients within initially diagnosed group, this number declined to 42.6% and 54% in chemotherapy and follow-up groups. The percentage of MetS in BCW with severe HS accounted for 75.0%, 66.7% and 59.5% respectively in initially diagnosed group, chemotherapy group and follow-up group. The MetS prevalence was higher in patients with US-diagnosed MAFLD in three groups (78.6% vs. 45.6% vs. 59.1%).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab8\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 8\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of metabolic syndrome (MetS) among Chinese breast cancer woman in the initially diagnosed, during chemotherapy and follow-up stages\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMetS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMetS in US-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMetS in USE-diagnosed HS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGrading\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMetS in US-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMetS in USE-diagnosed MAFLD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitially diagnosed group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58/217\u003c/p\u003e\n \u003cp\u003e(26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33/43\u003c/p\u003e\n \u003cp\u003e(76.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53/131\u003c/p\u003e\n \u003cp\u003e(40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16/67\u003c/p\u003e\n \u003cp\u003e(23.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25/48\u003c/p\u003e\n \u003cp\u003e(52.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003cp\u003e(75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33/42\u003c/p\u003e\n \u003cp\u003e(78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53/108\u003c/p\u003e\n \u003cp\u003e(49.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54/184\u003c/p\u003e\n \u003cp\u003e(28.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26/61\u003c/p\u003e\n \u003cp\u003e(42.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48/143\u003c/p\u003e\n \u003cp\u003e(33.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16/65\u003c/p\u003e\n \u003cp\u003e(24.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22/63\u003c/p\u003e\n \u003cp\u003e(34.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10/15\u003c/p\u003e\n \u003cp\u003e(66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26/57\u003c/p\u003e\n \u003cp\u003e(45.6%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48/124\u003c/p\u003e\n \u003cp\u003e(38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115/366\u003c/p\u003e\n \u003cp\u003e(31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75/139\u003c/p\u003e\n \u003cp\u003e(54.0%)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105/246\u003c/p\u003e\n \u003cp\u003e(42.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26/104\u003c/p\u003e\n \u003cp\u003e(25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57/105\u003c/p\u003e\n \u003cp\u003e(54.3%)\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22/37\u003c/p\u003e\n \u003cp\u003e(59.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75/127\u003c/p\u003e\n \u003cp\u003e(59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105/215\u003c/p\u003e\n \u003cp\u003e(48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003eMetS, metabolic syndrome; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; *: significant statistic difference between initially diagnosed group and chemotherapy group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026dagger;: significant statistic difference between initially diagnosed group and follow-up group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); \u0026sect;: statistic difference between chemotherapy group and follow-up group (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we explored the prevalence of HS, MAFLD, liver function abnormalities and MetS in different breast cancer survivor groups (initially diagnosed, chemotherapy, follow-up groups). The elevated occurrence of HS in individuals with breast cancer may be attributed to the combination of shared risk factors. It is crucial to assess HS when managing BCW. A nationwide Sweden study[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] indicated that steatosis resulted in a 10.7% higher absolute excess risk of mortality over a twenty-year period. In an observational clinical study[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], 107 individuals with metastatic breast cancer underwent abdominal CT scans. The study found that patients with HS, particularly premenopausal patients, had a higher prevalence of hepatic metastases both at the time of diagnosis and during follow-up. However, the study did not observe a significant difference in survival between the two groups. Our previous investigation[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] demonstrated that HS prevalence was 22.7% in the general population, 37.4% in breast cancer survivals and increased to 68.3% when HS was screened using USE. In the present study, 21.7% of BCW were diagnosed with HS by US in the initially diagnosed group, which increased to 36.7% and 38.0% in the chemotherapy and follow-up groups. The occurrence of HS diagnosed by USE in chemotherapy group (78.6%) was high, similar to the previous study[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], whereas decreased to 68.0% in follow-up group. One possible reason for this could be that US mainly detected moderate to severe cases, which were less likely to recover or even continue to deteriorate during the follow-up period. USE, on the other hand, found more mild and moderate cases, which were more likely to recover during follow-up. A high proportion of US-negative HS (51% \u0026minus;\u0026thinsp;70%) was further discovered by USE in the initially diagnosed group and chemotherapy group, predominantly with mild to moderate cases (49% \u0026minus;\u0026thinsp;66%). USE is considered a more sensitive diagnostic method for detecting HS compared to traditional ultrasound[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study, we utilized FibroTouch, a newer type of transient elastography, to identify mild and moderate cases of HS that might be missed by regular ultrasound. A Chinese study[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] evaluated the diagnostic performance of UAP and LSM by FibroTouch for diagnosis of HS and hepatic fibrosis in patients with NAFLD and revealed that diagnostic performance of UAP for steatosis was significantly superior to that of the hepatic steatosis index. USE can be considered as a screening tool for high-risk populations with a greater likelihood of HS.\u003c/p\u003e \u003cp\u003eNFALD is closely associated with metabolic disorders such as obesity, insulin resistance, and dyslipidemia. The rise in the prevalence of NFALD in recent decades has become a significant concern in the field of hepatology and public health.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] A Chinese cohort[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] consisted of 217 patients with newly diagnosed BCW reported higher prevalence of NAFLD in BCW compared with health examinees (45.2% vs. 20.3%). The new concept of MAFLD, based on metabolic disorders, is more closely correlated with breast cancer. In this study, approximately 50\u0026ndash;70% of individuals with breast cancer were diagnosed with MAFLD when USE was employed. In contrast, when using traditional ultrasound, only 20\u0026ndash;30% of cases could be detected. In addition, MAFLD was more than 86% in the overweight or obese BCW and up to 91.8% in the chemotherapy group. BMI, one of the diagnostic criteria of MAFLD, is also risk factor for breast cancer. A meta-analysis[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] consisting of 12 prospective studies found that for every 5 kg/m\u003csup\u003e2\u003c/sup\u003e increase in BMI, there was a two percent higher risk of developing breast cancer in women. Another Chinese research demonstrated that the molecule released by adipocytes in breast tissue stimulated the growth and multiplication of specific breast cancer cells.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] 70\u0026ndash;80% of menopausal BCW were diagnosed with MAFLD. The decline in estrogen is strongly associated with fatty liver and metabolic disorders.[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn the chemotherapy group, there was a significant increase observed in liver function abnormalities, which remained high in follow-up group. Chemotherapy was found to have negative impacts on quality of life and lipid levels, as reported in previous studies.[\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] A study [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] indicated that chemotherapy caused notable changes in plasma lipid and lipoprotein levels in individuals with breast cancer, potentially through gene modulation. Intriguingly, the prevalence of liver function abnormalities was higher in US-diagnosed HS patients, compare to USE-diagnosed HS cases. Same situation was also observed for MetS. One possible reason was that HS detected by US were mostly severe cases which were undoubtedly more likely to develop liver and metabolic disorders. However mild to moderate degrees also required early detection and intervention to avoid further deterioration in the future.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this study represents the first investigation into the presence of HS and MAFLD using USE in various stages of breast cancer patients. However, it is important to acknowledge that this study has a number of limitations. Firstly, due to reasons such as a relatively small sample size and incomplete data, further classification analysis based on molecular subtypes or treatment methods (endocrine therapy, radiation therapy, etc.) could not be conducted. However, the current results emphasize the high prevalence of HS and MAFLD in chemotherapy patients and those under follow-up, drawing public attention. According to the analysis of existing data, in the follow-up group, the prevalence of HS (60\u0026ndash;70%) and MAFLD (50\u0026ndash;65%) were similar in BCW, regardless of whether they received chemotherapy alone or endocrine therapy alone or a combination. Excluding patients with missing anthropologic and laboratory test results may also contribute to selection bias. However, this group of people is a minority. In the future, the sample size will be expanded, and relevant stratified analysis will be conducted. Additionally, it's important to note that the present study was not a self-controlled research which could provide a better understanding of the effects of chemotherapy. Although it cannot establish a causal relationship, the current findings suggest a high prevalence of MAFLD across all groups, with an increasing risk of MAFLD after undergoing chemotherapy.\u003c/p\u003e \u003cp\u003eIn summary, this study revealed that breast cancer survivors have a higher prevalence of HS and MAFLD, and liver function abnormalities, particularly in the chemotherapy group. These conditions persisted at a high percentage during the follow-up period. After chemotherapy, MAFLD patients are more likely to experience concurrent liver function abnormalities, especially in cases with moderate to severe conditions. More attention should be given to overweight or postmenopausal breast cancer survivors. The use of USE can aid in the early detection of mild to moderate HS cases. Managing MAFLD through strategies such as calorie reduction, exercise, and healthy eating habits may benefit breast cancer survivors. Further studies are needed to investigate the potential causal mechanisms underlying these associations.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eBMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; Alb, plasma albumin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; ALP, alkaline phosphatase; HDL, high-density lipoprotein-cholesterol; LDL, low-density lipoprotein-cholesterol; HbA1c, hemoglobin A1c; hs-CRP, plasma high-sensitivity C-reactive protein; LSM, liver stiffness measurement; CAP, controlled attenuation parameter; HS, hepatic steatosis; MAFLD, metabolic associated fatty liver disease; US, ultrasound; USE, ultrasound elastography; BCW, breast cancer women; LA, liver function abnormalities; MetS, metabolic syndrome;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures in studies involving human participants were performed according to the ethical standards of the institutional research committee (the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University, approval number: 2020-100) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u0026nbsp;Written informed consent was waived on account of the study\u0026rsquo;s retrospective design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZX and LQK, conceptualization; ST, RHL, JT and XYL, investigation; ZX, JX, JW, YLC, JYS, data acquisition; ZX, RLS, CYM and JHF, data analysis; ZX, ST, RHL, JT, XYL, JX, writing original draft; JW, YLC, JYS, RLS, CYM, drafting of tables; LQK and KNW, writing - review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank professor Hong-yuan Li for his guidance in the study design.\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVernon G, Baranova A, Younossi ZM (2011) Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Alimentary pharmacology \u0026amp; therapeutics 34:274\u0026ndash;285. https://doi.org/10.1111/j.1365-2036.2011.04724.x\u003c/li\u003e\n\u003cli\u003eYounossi ZM, Koenig AB, Abdelatif D et al. (2016) Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. 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Hepatology International 14:889\u0026ndash;919. https://doi.org/10.1007/s12072-020-10094-2\u003c/li\u003e\n\u003cli\u003eNeedleman L, Kurtz AB, Rifkin MD et al. (1986) Sonography of diffuse benign liver disease: accuracy of pattern recognition and grading. AJR American journal of roentgenology 146:1011\u0026ndash;1015. https://doi.org/10.2214/ajr.146.5.1011\u003c/li\u003e\n\u003cli\u003eCai Q, Huang D, Yu H et al. (2020) COVID-19: Abnormal liver function tests. J Hepatol 73:566\u0026ndash;574. https://doi.org/10.1016/j.jhep.2020.04.006\u003c/li\u003e\n\u003cli\u003eThird Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 106:3143\u0026ndash;3421\u003c/li\u003e\n\u003cli\u003eSimon TG, Roelstraete B, Khalili H et al. (2021) Mortality in biopsy-confirmed nonalcoholic fatty liver disease: results from a nationwide cohort. Gut 70:1375\u0026ndash;1382. https://doi.org/10.1136/gutjnl-2020-322786\u003c/li\u003e\n\u003cli\u003eOcak Duran A, Yildirim A, Inanc M et al. (2015) Hepatic steatosis is associated with higher incidence of liver metastasis in patients with metastatic breast cancer; an observational clinical study. Journal of B.U.ON. 20:963\u0026ndash;969\u003c/li\u003e\n\u003cli\u003eKim NH, Kim JH, Kim YJ et al. (2014) Clinical and metabolic factors associated with development and regression of nonalcoholic fatty liver disease in nonobese subjects. Liver international : official journal of the International Association for the Study of the Liver 34:604\u0026ndash;611. https://doi.org/10.1111/liv.12454\u003c/li\u003e\n\u003cli\u003eXu C, Yu C, Ma H et al. (2013) Prevalence and risk factors for the development of nonalcoholic fatty liver disease in a nonobese Chinese population: the Zhejiang Zhenhai Study. 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World Journal of Gastroenterology 21:7613\u0026ndash;7620. https://doi.org/10.3748/wjg.v21.i25.7613\u003c/li\u003e\n\u003cli\u003eKo S-H, Kim H-S (2020) Menopause-Associated Lipid Metabolic Disorders and Foods Beneficial for Postmenopausal Women. Nutrients 12. https://doi.org/10.3390/nu12010202\u003c/li\u003e\n\u003cli\u003eHoofnagle JH, Bj\u0026ouml;rnsson ES (2019) Drug-Induced Liver Injury - Types and Phenotypes. N Engl J Med 381:264\u0026ndash;273. https://doi.org/10.1056/NEJMra1816149\u003c/li\u003e\n\u003cli\u003eMudd TW, Guddati AK (2021) Management of hepatotoxicity of chemotherapy and targeted agents. Am J Cancer Res 11:3461\u0026ndash;3474\u003c/li\u003e\n\u003cli\u003eLi X, Liu Z-L, Wu Y-T et al. (2018) Status of lipid and lipoprotein in female breast cancer patients at initial diagnosis and during chemotherapy. Lipids Health Dis 17:91. https://doi.org/10.1186/s12944-018-0745-1\u003c/li\u003e\n\u003cli\u003eJesus M de, Mohammed T, Singh M et al. (2022) Etiology and Management of Dyslipidemia in Patients With Cancer. Front Cardiovasc Med 9:892335. https://doi.org/10.3389/fcvm.2022.892335\u003c/li\u003e\n\u003cli\u003eSharma M, Tuaine J, McLaren B et al. (2016) Chemotherapy Agents Alter Plasma Lipids in Breast Cancer Patients and Show Differential Effects on Lipid Metabolism Genes in Liver Cells. PLoS One 11:e0148049. https://doi.org/10.1371/journal.pone.0148049\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"breast cancer, hepatic steatosis, metabolic associated fatty liver disease, ultrasonography, ultrasound elastography","lastPublishedDoi":"10.21203/rs.3.rs-4332680/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4332680/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBreast cancer is the most common malignancy in women and also shares similar risk factors with fatty liver, especially metabolic associated fatty liver disease (MAFLD). Chemotherapy can lead to hepatic impairment and hepatic steatosis (HS), which seriously affects the treatment and quality of life of breast cancer women (BCW). Therefore, this study aims to investigate the incidences of HS and MAFLD based on liver ultrasound elastography (USE), liver function abnormalities, and metabolic syndrome in Chinese BCW in the initially diagnosed, during chemotherapy and follow-up stages.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 767 BCW treated at Chongqing Breast Cancer Centre were finally enrolled and classified into initially diagnosed group, chemotherapy group, and the follow-up group. The related conditions of HS and MAFLD as well as liver function abnormalities and metabolic syndrome were assessed by liver conventional ultrasound (US) or USE in all groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompare to US-diagnosed HS (21.7%, 36.7%, 38%), higher incidence of HS (60.4%, 78.6%, 68.0%) were detected by USE in the initially diagnosed, chemotherapy and follow-up groups. 50\u0026ndash;70% of US-negative patients were detected by USE as having a fatty liver, which was predominantly mild to moderate. Based on the USE diagnosis, there was a higher prevalence of MAFLD in the initially diagnosed group (49.8%), which increased to 68.1% in the chemotherapy group and decreased in the follow-up group (59.1%), with a predominantly decrease of mild-to-moderate cases. BMI and age subgroups showed a higher incidence of MAFLD in patients with BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e or age\u0026thinsp;\u0026ge;\u0026thinsp;60 years old. In addition, BCW combined with MAFLD had a higher incidence of liver function abnormalities and metabolic syndrome.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients treated with chemotherapy for breast cancer have a higher incidence of HS and MAFLD, especially overweight or obese and menopausal patients. Breast cancer patients with combined MAFLD have higher rates of liver function abnormalities and metabolic syndrome. USE has a higher sensitivity than US and can detect more patients with mild to moderate fatty liver disease, enabling early intervention.\u003c/p\u003e","manuscriptTitle":"The prevalence of hepatic steatosis and MAFLD based on the liver ultrasound elastography in Chinese breast cancer women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-07 09:01:04","doi":"10.21203/rs.3.rs-4332680/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4a36897-9255-4f67-b901-308267ef613e","owner":[],"postedDate":"May 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-21T04:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-07 09:01:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4332680","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4332680","identity":"rs-4332680","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}