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As much as COVID-19 is a health and economic crisis, at its core, it is also a governance crisis.

NDI President Derek Mitchell and new Director of Democratic Governance Kristen Sample delve into ways governments and the international community have risen (or not) to meet the challenges of the COVID-19 pandemic.

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Derek Mitchell: As we all continue to shelter in place and respond to the colossal health and economic crisis that is COVID-19, we must not forget that at its core, pandemics are as much a result of governance failure as any failure of healthcare or health system.
Since working to support democratic processes, institutions and governance around the world is what NDI does for a living, we thought it useful to delve into the role governance has played in the COVID-19 pandemic with NDI's experience in more than 50 countries around the world serving as a guide. Welcome to DemWorks. My name is Derek Mitchell, president of the National Democratic Institute.
To discuss all this with me in this podcast, I'm joined by NDI's new director of democratic governance, Kristen Sample.
Kristen Sample: Thank you so much Derek.
DM: Kristen just joined us on March 1. She brings more than 20 years of democratic governance experience with her to NBI having advised and evaluated programs at UN Women, UN Democracy Fund, the Open Society Foundation, Global Partners, Governance and International IDEA. Kristen is an expert on countering corruption, legislative strengthening in the nexus of gender and politics and she has led projects focused on the impact of democratic reform on economic development and citizen security. At a moment when the global crisis in governance is at the center of international conversation, at least before the pandemic push pause, we are thrilled to have Kristen aboard to look at that issue with fresh creativity here at NBI. So welcome Kristen to your very first DemWorks podcast.
KS: I'm really pleased to have the opportunity to speak with you today on such important issues.
DM: So we'll speak about the crisis of governance but also the pandemic factor as well. But I do want to start with this global governance crisis that has sort of preceded this. This is a broader overhang. We've seen all over the world popular demonstrations over the past year and more and everywhere from Moscow to Managua, to Hong Kong, to Khartoum, to Algeria, to Istanbul, to Paris. You can go on and on. And what it represents is a frustration with the quality of governance. Democracy somehow is not delivering for people. And I want to hear your thoughts on that. It's a moment of turmoil certainly. People will look at this and say, "Well, democracy is failing," but it's more than democracy that this is happening. It's a general quality of governance question that I think actually provides an opportunity. So let me just ask your thoughts on that first off, Kristen.
KS: Yeah. Thanks so much for that question, Derek. I think that NDI, since we have officers or programs spanning every region of the world basically in more than 50 countries, we're in a very good position to be able to take the pulse of what's happening in the different countries. In fact, we have been conducting surveys every two weeks of our country programs to get a sense of what's happening on the ground and we've received some very interesting signals that I'm really happy to be able to share with you today.
On the one side, we are saying that in many countries governments are responding very seriously, in very concerted ways to the health crisis. I mean in more than two thirds of the countries. The governments in the countries where we work are closing nonessential businesses in over 60%, they are communicating in ways, having very intensive communication campaigns that really are reaching all citizens. But when it comes to the democracy side, when it comes to implementing that response and pursuing a response that's consistent with democratic principles and norms and values and institutions, we are seeing some troubling developments at the same time.
For instance, the number of governments by our account, over 40% of the governments in the countries where we work are declaring emergency powers and it's clear that this is an extraordinary situation that requires extraordinary measures, but in many cases these emergency powers are inconsistent with democratic principles. They are not linked to the crisis. There is no provision for legislative oversight or in many cases, these have no sunset class, so there's no time limit and these are simply open-ended.
And link to that and linked in many cases to these emergency powers, emergency decrees, we're seeing an uptick also in threats to fundamental freedoms. For instance, nearly half of our countries are reporting that there are measures in place where governments are repressing non-state media who are critical of the government's response to the pandemic and that in some cases, again, almost 50% of our countries, there are measures in place where governments are limiting space for civil society to engage in political actions.
Another factor that I'd like to highlight too is while we're all distracted by the pandemic and while people are at home and perhaps with less access to information and less direct contact with government, there are also signals that many governments are using this as an opportunity to diminish anti-corruption controls. So that means that in some cases economic response packages or healthcare delivery is taking place with less transparency and less openness, which as you can imagine is a risk in terms of making sure that those resources are actually getting where they need to be.
And all of this, all of the stresses, the frustration and these concerns of course also have impacts when it comes to citizen trust, interpersonal trust citizen trust of the government and also we're seeing greater potential for civic unrest and a deteriorating security environment.
So all together, I hate to start with such a pessimistic view, but I think it is important again, through the networks that we have, the relationships that we have with political and civic actors on the ground, to convey the seriousness of the situation and to make sure that we're always communicating that well, this response requires really drastic measures. These measures need to be consonant of course, with the principles of democratic governance.
DM: Right. It fits into this broader competition of narratives that occurred even before the pandemic began, where China or Russia saying, "Look, authoritarian governments are more efficient in providing services. We do this stuff better. Democracy is messy." And they're able, as you say, to take advantage of this moment when people are looking for strong central control to make that case and to both do that rhetorically but also through provision of services.
And then it's not just those major countries. You'll have folks whether it's Hungary or Poland or you just go around the world, they're postponing elections. They are shutting down civil society, they're settling scores with adversaries. They're constraining public debate, saying that those things are luxuries during a time of crisis and that gives them an opportunity then as you said, for not just power grabs, but resource grabs and money grabs and they say, "Look, these are extraordinary times. They require extraordinary measures." And the concern is that these extraordinary measures will be permanent, that they'll say you need us to be surveilling people.
So this is a challenge for certainly those who do democracy work and for folks inside these countries. But I think the broader question of security, we'll talk about that maybe a little bit later, but it's interesting what we're seeing on the ground as you say.
You do a lot of work in the legislative sphere, you have a lot of background on that. How legislatures are particularly important. Civil society is too, but just focusing on legislature's role as a check and balance against executive overreach, can you talk about from the NDI experience or your other observation, how legislatures are being challenged, how they're dealing with this moment, how they're adapting to deal with the COVID-19 moment.
KS: Yeah, absolutely. So I'm so glad you brought this point up. The first challenge that I'd highlight is this risk that the legislative branch is getting sidelined. In a crisis like this, the executive branch is generally front and center. Their role is clearly understood by citizens. Head of state might be the one out there doing daily press briefings or a health minister communicating medical reports. And there's this sense of emergency that as I sort of alluding to before, it seems to empower the executive branch. And unfortunately that seems to be, in many cases, at the expense of the legislative power.
And additionally, another challenge and another reason that legislatures are perhaps getting crowded out or sidelined is simply that, the coronavirus, by it's dynamic, it's not socially compatible. And since parliaments are these multi-member bodies that have more diffuse operations, more diffuse leadership and that involve hundreds of different people, it's simply just a challenge to assemble a large group of people together, bring them together and keep them front and center in this crisis.
So if that first challenge is making sure that people just keep in mind that legislatures matter and the legislatures are able to exert their rights and their authority, I'd say that the second challenge of course is just how do parliaments, legislatures operate in a virtual world. Politicians are by nature, they like to shake hands, they like to get out on the street, they need to be in touch with their constituents. And there are so many challenge involved in this current world that we have where we should all be social distancing.
So looking across the world where we work, their parliaments are adopting different measures. Some of them are using social distancing restrictions like reducing the number of MPs in sessions. Others are moving to remote voting, remote deliberations. And then others are not meeting at all, which of course is quite terrible. And in those cases where legislatures have been dissolved or have been suspended for long periods of time.
We are working too, as you were saying, as NDI closely with parliaments in a number of countries to try to do those adaptations to the rules of procedures so that they're able to continue meeting in session and continue deliberating and continuing exercising oversight. For instance, we have connected parliamentarians in Colombia with parliamentarians in Ecuador. We have virtual sessions to learn from Ecuador's experience in adopting a regulation for the implementation of virtual session and teleworking.
So we are trying to connect parliamentarians across countries to understand how some parliaments have been moving forward in terms of remote procedures and how that's going for them. And two more challenges. One I'd highlight is that oversight role that we've been talking about. And from the same survey that we conducted with our country programs, we found that in 59% of the countries, checks and balances have been weakened, have deteriorated under the pandemic.
And this is happening at such an unfortunate time when there's so many policy measures that need to be approved and put in place. If we just take the issue of debt policy for instance, I saw a statistic from the Westminster Foundation that more than 80 countries have already requested emergency aid from the IMF. I mean these countries are struggling of course to meet different types of fiscal obligations and they are desperate for cash in order to ramp up health services and put in place economic measures.
And so these governments are taking on debt obligations, debt burns that are going to have far reaching impacts and long lasting impacts that should really be approved by the legislative branch and include monitoring and reporting. And that's not always the case in most of these instances.
DM: So you just say it's a very dangerous time and folks are adapting procedurally, but there are really implications to this longterm, including for security. And I think we'll get to that after the break.
For more than 35 years, NDI has been honored to work with courageous and committed pro-democracy activists and leaders around the world to help countries develop the institutions, practices and skills necessary for democracy's success.
KS: Welcome back. Derek, I've heard you speak to the issue of authoritarian systems and how they're operating in this crisis and that the authoritarian nature in itself makes health crises more likely. And you've also said in some of your speeches and some of the conversations we've had that it's not a coincidence that the pandemic started in China and I'd really like to hear from your expertise, your deep background on China specifically. Can you explain to listeners why that is? Why there is that connection?
DM: Well, as I said at the top, this is not just a health crisis, it's a governance crisis. It's a factor of governance both in the prevention of the pandemic and the response to it. We talked so far mostly about the response, how we're responding to the pandemic, but the core of the pandemic is a failure of governance. The difference between a local health crisis that is contained and a pandemic lies in the ability of a political system to respond to that early challenge quickly and effectively. And that requires both government and civic action. And if you're going to deal with this crisis early, it requires both. To do that, you have to act swiftly. You have to have widespread testing and contact tracing. You need critical support from citizens. In order to do all that and to ensure that that happens, you have to have basic civic trust.
Closed societies routinely fail that test of having that civic trust and that rapid action for some very practical reasons. When a government suppresses a free flow of information, when it fails to empower independent civic institutions, when it's too insecure to convey bad news candidly, doesn't feel that it has a political legitimacy, therefore, it's insecure to convey bad news. When its data can't be trusted because it's opaque, when its officials are afraid to speak truth to power or communicate inconvenient truths to their superiors or act decisively, absent waiting for some strict orders from the very center and they can't move quickly, the result can be deadly.
It turns what is a local health issue into a pandemic so it crosses borders. It becomes not just a problem for one country but for all others. So democratic governance is very, very practical and once again in this regard, transparent, accountable, inclusive, responsive, open governments is essential to crisis response but it's also essential to prevent the crisis from emerging to begin with.
And it is a matter of national security. This highlights frankly what many of us have known all along, that this is not just nice but has very practical national security effects. And as we just talked earlier, the irony is that just as the world needs more open democratic societies to prevent future crises and deal with the current one, there are opportunistic politicians who are closing political and civic space. That I think is a very practical reason why that closed societies cause these pandemics.
KS: I think that all of those points that you've been raising in terms of the threats and the vulnerabilities are so important for us to keep front and center. At the same time, here in NDI, as you know, is we're very keen to make sure that there are also opportunities to elevate the many examples around the world where governments are acting democratically and effectively in response to the crisis and they're framing and working with citizens in ways that are absolutely consistent with democratic values and principles. And so I do want to showcase some of those.
I think it's received a lot of press around the world how New Zealand, for instance has reacted, and I read this week that New Zealand is perhaps one of the very first countries to have been able to successfully eliminate COVID. They have no new COVID cases. And it's a case that really stands out for the way that the prime minister has been able to deliver information in a very clear, compassionate, inclusive way, a way that's very grounded in science of course, and transparent.
And at the same time where the legislature has had an important role developing a parliamentary select committee that's providing scrutiny of the government's response. The government has also been very affirmative there I think, in terms of issues of freedom of information and media freedom and has said that they would not slow down, for instance, their commitment to responding to requests for information during the crisis. So there's certainly the case of New Zealand, which is so interesting and it's shown such early success, but there are other places around the world too where specific measures taken by the government I think have been so positive and far reaching.
Uruguay comes to mind for instance. We see so many cases where authoritarian leaders are using this crisis to be able to settle scores as you were saying, or to act in a very partisan fashion. But in Uruguay, the president convened all of the former presidential candidates to give a joint press conference to send a powerful message of unity and to show that across the party divide, they were working together to develop responses.
Taiwan also really stands out for its cross party coordination, the transparent communications they've had, the very creative efforts that the government has put in place there, I think they've called it humor, not rumor. A campaign to share facts in real time to counter disinformation, to manage fear. So there aren't many cases out there as I was saying, of governments that are responding effectively and in ways that are building that citizen trust that you were mentioning.
DM: Yes. And then a further one, another democracy that's a leading democracy, probably the first out of the gate is South Korea. They did exactly what was necessary. People are looking at that example, a democratic example. They didn't sacrifice rights at all. They obviously had very strong controls at times of the society, but it took very swift action. They did widespread testing, contact tracing and they worked with civil society and is shown over and over that civil society is probably one of the most important factors. It's not simply a government driven thing that makes a response success. Civil society serves as a very efficient force multiplier for government. We saw that in Katrina, hurricane Katrina. We see it's proved over and over that it really is effective in getting the word out and messaging.
Ensuring is like in Taiwan through their civic tech community, they're sort of hackers. They're young citizens, who themselves in a voluntary fashion, formed a community. They were viewed as allies and partners not alienated from the government. And that partnership has been a success in Taiwan, has been a success in South Korea and is essential for a success. And that means that governments need to be open, need to be transparent, they need to see society as partners. So this is absolutely critical.
KS: Yeah. And I just want to add on the South Korea example. I'm so glad you brought that up because South Korea held elections during the pandemic on April 15, they had national assembly lessons and they were actually able to organize those elections in a way that was seen as very transparent, that was very consistent with electoral integrity and they had higher levels of turnout than in previous elections, which is pretty amazing. And there's so many countries around the world that are facing elections in 2020. I think the way that South Korea was able to do it with a very intensive communication campaign as you were speaking again to their transparency of communication, they had expanded early voting measures in place. They had home voting, they had very comprehensive safeguards for people to be able to vote in person. So even organizing an election in a time that seems so difficult and so challenging, I think that as you were saying, democracies like South Korea are showing that there is a way forward.
DM: Right. And I think we can learn some lessons from that as well. There are groups, including NDI has been at the center of this, of putting together documents that say here are the election integrity guidelines for this moment, that democracy should not be sacrificed at the alter of crisis response, that elections need to move forward if they can be done in the right way and if they need to be postponed, it's postponed within a certain timeframe and only during a period of high crisis. So there are principles here where democracy can continue to move forward. It makes the society stronger, it builds that civic trust that's important for crisis response. But we need to... You can walk and chew gum at the same time at this moment. So I'm glad we were able to talk about some of these democratic examples.
KS: Absolutely. And I will be right back after this quick message.
You can hear more from other democracy heroes by listening to our DemWorks podcast available on iTunes and SoundCloud.
DM: Welcome back with Kristen Sample. Of course you're new to NDI, but you know NDI very well and it's a fundamental principle everywhere that nations will only succeed when societies are fully inclusive, where they don't leave anybody behind. They enable all to contribute equally. That means women, that means young people, that means traditionally marginalized groups, LGBT communities, et cetera. It's just plain logic that if you leave anybody behind, that you're not going to get the most out of your citizen when you're going to hold your country back, and yet we are witnessing negative impacts toward these populations during this COVID-19 moment. Kristen, can you speak to this, explain what's going on here and why it matters?
KS: Sure, absolutely. I mean obviously this crisis isn't occurring in a vacuum. It's occurring in a context where across the world, across all countries, there are already this array of existing intersecting inequalities where some people were coming into this crisis already in a disadvantaged place. And then the pandemic itself has differentiated impacts that affect women and other marginalized groups disproportionately. I'll just give a few examples.
I mean lockdown for women who are living in relationships of power imbalance and of abuse perhaps, lockdown for them means locked in, with an abusive partner. And for instance our survey of country offices that I was referring to previously, in 66% of our countries, there seems to be an increase in sexual and gender based violence since the pandemic. In 15% of those countries, it's a significant increase. Of course these women might be locked in in vulnerable situations and then at the same time have less access to government resources, government support. So that's one example.
Others, people with disabilities for instance, who have always struggled to access health services, transportation in an equitable fashion, you can imagine that that lack of access and the differentiated impact of the pandemic on them is life threatening in some cases.
There are digital divide concerns, people in rural areas or women, other marginalized groups who may have less access to information, to resources. There are real concerns also and cases around the world where this pandemic is being exploited by anti migrant hate groups for instance, who try to link movement and migration to the origin of the virus. Or in some cases, for instance in Africa and some of the countries where we work, media outlets are perpetuating stereotypes against people with albinism for instance, and placing the blame for the virus on them.
So there are so many challenges around making sure that people have access to resources, people are safe and that we are able to convey and support a message of social cohesion and solidarity instead of the divisions that we're seeing pop up around the world. I think that in our case, for instance in Indiana, what we're trying to do is reinforce the need for inclusive decision-making, making sure for instance, that women are involved in decision making and other marginalized groups are involved in decision making and representation and in these deliberation bodies, making sure that the policymaking is taking into account these vulnerabilities and these different differentiated needs. And also the government messaging is inclusive, getting to everybody and it's supporting the social cohesion messaging and solidarity messages.
DM: And again, this is critical for the crisis response, pandemic response. I mean COVID-19 doesn't discriminate. Whoever has it, whoever is vulnerable or subject will get it and it will spread to the society writ large. So if you're not inclusive, if you're excluding folks, if politicians then see that there is an opportunity here as some politicians will to divide and conquer, to play on fear. Or spoilers from the outside may see that there are opportunities if they're divided societies, to create tensions that then require or enable them to negotiate the deal that you want to make or promote corruption within the society.
There are all kinds of ways this makes societies less stable, less secure, and affects the development and certainly the response to crises. So this is not just a nice thing, it's not just a human rights thing. This is fundamentally important to national security, international security and to everything that we're seeking to achieve through democracy.
KS: Absolutely. And I think along the things I'd really like to hear from you too, Derek, in terms of how you see along the lines of this being an international crisis that includes the whole world, that joins us all although we are in very different places. How you see role NDI's role in supporting that cross border cooperation and solidarity and having the international community come together?
DM: Given that authoritarians are claiming their model is unique for this moment, we have to be out there making our case. But in terms of our specific adaptations that we are doing, we are working in places like Ethiopia to ensure that the public opinion surveys are necessary invents of their postponed elections or continue forward, but can be done virtually. That we can adapt legislative rules of procedure in places that need it to allow for remote voting and continue the legislative process to ensure that election integrity is maintained.
As I mentioned earlier, there are certain principles and established accepted international principles for when and how to postpone elections, how to hold them during moments of crisis. And we put together crisis response kits that can be used. It's called the practical toolkit for politicians during a pandemic that can help political parties figure out how to do crisis management or help the government put together crisis communication.
So a lot of things that can be done internally and done across different countries that ensure the solidarity is still there, the momentum for democracy is still there. The expectation that democratic norms are sustained in this moment so that the headlines are not simply roll back authoritarian opportunism, that massive surveillance, all the things that people may succumb to because of fear during crisis, that there is an alternative voice and it says it doesn't have to be like that. Or if it does have to be like that now, it doesn't have to continue to be like that indefinitely and that there are some standards by which these things are being imposed.
So that international norm setting at this moment, it's probably more important than ever to do and we are trying to do at national level. We're trying to do it across different countries to ensure that there is not a vacuum to which the authoritarian voice moves and has free open season for its own values. It goes across, I think, a lot of different countries. And Kristen, I'd be interested in your thoughts from your perspective of governance, how that's working.
KS: I think that there's a real role for the international community to play. And I wanted to highlight that too in what you're saying because these challenges are so vast that clearly we have to work together on people to people exchanges and supporting lesson sharing. And so I do think that there's an absolute role for the international community playing in terms of getting out the messages of that democracy is not a luxury, it's not something that could be put into a coma or put on hold while we're all sheltering, that it's something that has to be reaffirmed on a daily basis.
And so I do think that countries also have to, in addition to standing firm, standing on their own ground on democratic principles, they also have to be willing to promote and expand those democratic principles across borders, especially to counter those liberal influences that you were referring to earlier, that in some cases are, really transmitted and increased through disinformation campaigns or phony PR campaigns that need to be called out of course by all actors.
DM: Thanks again, Kristen for joining me in conversation about how democracies can best meet the challenges of COVID and how NDI with its global partners are meeting the moment.
KS: Thank you, Derek.
DM: I'd also like to say thank you to our listeners. To learn more about NDI or to listen to other DemWorks podcasts, please visit our website at www.ndi.org. Thanks very much.


World map of Coronavirus (Covid-19)



19. Governance is Key During COVID-19? (w/ Kristen Sample) Posted 6 days ago

Democracy (General), COVID-19 Podcast NDI Listen democracy

El lunes 21 de julio de 2009 fui invitado a exponer en la Jornada "Violencia en el deporte: prevención o represión", organizada por el Club Nacional de Football bajo los auspicios de la Universidad Católica del Uruguay, El Derecho Digital, El Observatorio del Deporte, el Ministerio del Interior y el Ministerio de Turismo y Deporte.No fue mi condición de simpatizante tricolor, ni la de profesor de Universidad ORT en materias como "Ética y libertad de expresión" o "Cultura y sociedad contemporánea" lo que me animó a cumplir con mi compromiso y concurrir en medio de una tarde peculiarmente fría y bajo una lluvia torrencial.Ocurre que el encuentro me resultaba sumamente atractivo. Y no solo por la calidad de los expositores, provenientes de todos los ámbitos de la realidad nacional, o por la presencia de altas jerarquías de gobierno y personalidades de distintas empresas y organizaciones, sino por el tema de fondo y en esencia, por la estrategia elegida para abordarlo.Menciono apenas los títulos de los distintos paneles para que el lector comprenda a qué me refiero: "Violencia en el deporte: un enfoque multidimensional", "Causas de la violencia: mitos y realidades", "Violencia en el fútbol: responsabilidades compartidas" y por último, la mesa que tuve el honor de integrar, "Periodismo ante la violencia: los poderes del lenguaje".En una oportunidad próxima y espero que cercana, ofreceré aquí lo dicho aquella tarde, donde entre otras cosas rechacé cualquier sugerencia de controlar la prensa cualquiera fuese la excusa, declaré que la prevención y la represión legal son caras de una misma moneda, invité al autocontrol verbal por parte de los periodistas y analicé –muy respetuosamente, aclaro –, dos casos de desborde del lenguaje periodístico, uno algo remoto y otro reciente: el de Martín Reyes, cuando elogió y comparó el cabezazo del argelino Zidane en el pecho de un adversario comparándolo con la rebeldía y la dignidad de un Albert Camus, y el de Sánchez Padilla, cuando en su programa Estadio Uno –ante el asesinato de dos jóvenes hinchas–, declaró que en el Uruguay se precisaba una cárcel como la de Guantánamo.A cuenta de esas reflexiones hechas aquel martes con la gabardina empapada, por ahora reproduzco aquí una versión condensada de un artículo con similar talante sobre el mismo tema, que publiqué hace casi una década en el último número histórico de la revista "Cuadernos de Marcha", con el título de "Reflexiones sobre la violencia".Lenguaje y proximidadVoy a comenzar un poco al azar, recordando que en tiempos de paz –póngale comillas si lo desea– los mandatos culturales y ciertas preprogramaciones biológicas obran en el sentido del respeto del semejante. Para poder remontarlos y librar el camino para el uso de la fuerza física –sea para someter, neutralizar o suprimir un semejante–, es preciso un preámbulo de segregación que procure legitimar la acción violenta.Dice, por ejemplo, Ana María Fernández, en un texto titulado "Las violencias cotidianas también son violencia política" (Instituciones estalladas): "Solo se victimiza a aquel que es percibido como inferior; de este modo se legitiman todo los actos de discriminación". La autora recogió el testimonio de una mujer golpeada que decía: "nadie te da un sopapo sin decirte ¡idiota! y sin hacerte sentir tonta".Por su parte, en El capitán por su boca muere. Ensayo sobre la mentalidad de un torturador, el psicoanalista Daniel Gil examina las manifestaciones de un militar uruguayo que reconoció y justificó públicamente los métodos degradantes que fueron utilizados durante la dictadura. En particular, es inquietante recordar determinado momento de esta obra¸ cuando el autor encuentra ciertos rasgos comunes entre las declaraciones del Capitán Tróccoli y las realizadas por algunos nazis después de la Segunda Guerra Mundial y los soldados norteamericanos después la guerra de Vietnam.En una conferencia en el Instituto Goethe, titulada "Diferenciación, violencia física y éticas incluyentes" - ciclo Los diferentes. La discriminación en la construcción del 'nosotros y ellos' –(y del yo y el tú), organizado por la revista Relaciones -, me permití utilizar esa línea de argumentación para fundamentar filosóficamente la interrupción excepcional del embarazo sobre nuevas bases, distintas a las utilizadas por los defensores tradicionales del aborto. Sostuve entonces que el embrión es un diferente, pero cuanto más diferente querramos verlo más legitimada -en apariencia- quedará nuestra decisión de suprimirlo. El enfoque correcto, a mi juicio, reside en elegir, entre dos males, el menor, a pesar de que se pierda algo valioso, en los excepcionales casos en que la razón y la conciencia dicten practicar un aborto. Además, dije que la prohibición es contraproducente, que no es el Estado el que debe decidir (como en China comunista), ni la madre o su compañero (como en algunos países de Occidente), sino que el eje de la decisión debe desplazarse hacia unos "mediadores en salud reproductiva".Pero impidamos que el árbol oculte el bosque, y no nos tentemos por algunos de sus senderos.Hay dos aspectos que quiero retener del libro de Daniel Gil. Uno refiere al uso del lenguaje. El preámbulo de diferenciación, que legitimará las acciones violentas posteriores, ya comienza con el lenguaje. Dice Daniel Gil que en todos los casos se produce "una modificación del lenguaje para referirse a los prisioneros. En él desaparece la condición humana: [y se habla] de 'pichis', 'paquetes'. o se habla de las víctimas como números. Ya en el lenguaje comienza el proceso de diferenciación. Este fenómeno yo lo generalizaría para muchas escaladas de violencia, cualquiera sea su signo ideológico. Por ejemplo, los seguidores de Fidel Castro tildaban de "gusanos" -algunos tildan todavía, en presente-, a todos los que se oponían a la revolución.El otro aspecto interesantísimo es el que refiere a las experiencias de Stanley Milgram sobre obediencia a la autoridad. Una variante en ellas, muy particular, es la "proximidad". Al parecer, cuando se hace necesario el contacto físico, o la cercanía visual o auditiva de la posible "víctima", se hace más difícil provocar un daño a otro ser humano. Desde luego, en las situaciones de guerra, algunos individuos logran desaprender esta característica. Pero para vencer el efecto inhibitorio de la "proximidad" tanto más necesario se hacen los preámbulos de diferenciación.De cara al encuentro de políticas que busquen atenuar o extinguir los fenómenos violentos, es fundamental retener estos dos aspectos: el del cambio en el lenguaje para convertir al otro en un "otro", precisamente, y el del efecto de la proximidad física, sea mediante un contacto visual, táctil o auditivo. Porque provisoriamente, a partir de esos elementos, podríamos adoptar dos recomendaciones para prevenir, contener o amortiguar los conflictos.En primer lugar, los partidarios no ingenuos de la paz deberían cuidar el lenguaje para referirse a un "adversario", o procurar que los demás así lo hagan. Numerosos especialistas coinciden en este punto. En segundo lugar, deberían promover las reuniones de carácter informal, o entrevistas distendidas –sin agenda rígida–, entre potenciales bandos en pugna. Por lo menos eso es lo que sugiere Rolf Denker, en un libro breve pero abarcador titulado Elucidaciones sobre la agresión.Por cierto que las sociedades contemporáneas plantean problemas de escala para la realización de medidas preventivas como ésas. Basta pensar en el lenguaje que utilizan algunos medios de prensa o algunos periodistas para hablar de instituciones, políticos o empresas, o en el hecho de que la TV, a distancia del telespectador, sin proximidad física alguna, convierte en persona no grata a cualquiera respecto del cual se pueda hablar con o sin fundamento, y el lector podrá extraer por sí mismo las consecuencias. En otras palabras, las medidas preventivas inspiradas en los conocimientos acumulados hasta ahora sobre la violencia, encuentran desde el pique muchas dificultades -sean las dos mencionadas hasta ahora, o cualquiera de las restantes que vamos a comentar-.Un prisma que giraAhora bien, después de todo, ¿cuál es el alcance de aquéllas recomendaciones? ¿Valen para el hogar y los parientes enemistados lo mismo que para los liceos con jóvenes conflictivos? ¿Valen para el trato entre diferentes sectores sociales? ¿Tendrán alguna aplicación en los conflictos entre naciones o entre bloques de naciones?Lamento desilusionar al lector, pero no me propongo desglosar mi tema en tantos capítulos. Y no es porque yo crea que los distintos tipos y dimensiones de la violencia posean todos la misma causa o sean susceptibles del mismo tratamiento: no es lo mismo el psicokiller con una posible falla en su neuroquímica que dos comunidades enfrentadas por un trozo de tierra. Ocurre que prefiero una aproximación al tanteo, ensayística, para que quede a su cargo el "gestaltizar" en alguna figura los puntos que algo caprichosamente voy marcando en el papel. Igual que en los entretenimientos de las revistas y los diarios, usted tiene que trazar la línea punteada para ver el dibujo, o buscar las semejanzas y las diferencias. No pretenda que yo lo haga todo -no soy su papá, ni me financia el BID-.¿Qué otros datos y qué otras interpretaciones puedo arrimar al lector?Recuerdo algunas tesis sobre la violencia -para preparar lo que vendrá después-, incluidas en un libro del psicoanalista Friedrich Hacker, latoso pero sugerente:"Los problemas que sólo pueden resolverse con violencia deben ser planteados de nuevo"."La violencia, prohibida como delito, es preceptuada, rebautizada y justificada como sanción"."La legitimación de la violencia se sirve de la trampa de las denominaciones: la propia violencia se describe y se siente como derecho natural, deber, defensa propia y servicio a objetivos superiores".Por último, esta tesis es la que me gusta más de todas: "La violencia es simple; las alternativas a la violencia son complejas".Friedrich Hacker -no confundirlo con el economista Hayek ni con los hackers informáticos- realiza sobre el final de su obra una afirmación también muy compartible: "Tengo la opinión de que la tolerancia para la complejidad y la facultad de soportar las tensiones de problemas no resueltos -en lugar de caer en la tentación de dar soluciones precipitadas y casi siempre violentas- demuestran madurez, tanto individual como colectiva".Esas tesis de Hacker sugieren que estamos ante un fenómeno complejo, por cierto, que desafía nuestra capacidad de ampliar el "foco" de nuestra atención. Para tener una somera idea de la existencia de los múltiples factores que inciden en el problema, podríamos pensar en interrogar a los sociólogos. Con toda seguridad, ellos acudirán a ciertas estadísticas. Por ejemplo, aquellas que señalan la correlación entre un alto porcentaje de jóvenes entre 15 y 29 años y la existencia de conflictos armados. Esto ocurre en Camboya, Somalia, Uganda, Iraq, Ruanda, Congo, Gaza, Argelia y Colombia, pero no en países como Canadá y Suecia. Si a una población más joven se le añade una alta tasa de desempleo, puede esperarse alguna forma de estallido social.Pero esos elementos no actúan con carácter lineal, y los propios sociólogos advierten que no se trata de los únicos factores. Y todo eso sin olvidar el espinoso asunto de definir adecuadamente los términos -¿qué es violencia? ¿qué es agresión? ¿qué es paz y qué es guerra? ¿qué niveles, qué dimensiones importa distinguir?-, o todas las dificultades inherentes que involucra la investigación, o las que implica la adopción de políticas preventivas - sobre la base de una información incompleta siempre-.Si faltaban manos en el plato para hacer mucho garabato, basta recurrir a la genética. ¿La violencia no estará en nosotros? ¿La violencia no estará en nuestros genes? ¿Qué dice al respecto el genoma humano, cuyas líneas generales han sido recientemente desentrañadas?El genoma humano está diciendo muchas cosas a los investigadores, quizá demasiadas. Y puede que no sea prudente reflexionar o actuar sobre bases algo inciertas, pero tampoco lo sería ignorarlas. Por ejemplo, en un libro reciente de Matt Ridley se afirma: "Las personas con niveles de serotonina anormalmente bajos en el cerebro tienden a ser impulsivas. Las que cometen crímenes violentos, o se suicidan, son a menudo las que tienen menos serotonina". Al parecer, las características genéticas de ciertas personas tienen como consecuencia, que "tales personas tienen más transportador de serotonina, lo que significa que circula más serotonina. Es mucho menos probable que estas personas sean neuróticas y algo más probable que sean más amables que la media, cualquiera sea su sexo, raza, educación o renta".En resumen, las cuestiones que suscita nuestro objeto temático –la violencia–, recuerdan las molestas características de un problema filosófico. Un problema filosófico es un prisma que gira ante nuestros ojos. Y no alcanza con reconocer las múltiples dimensiones y admitir retóricamente que es un problema "muy complejo", porque a veces eso es sinónimo de claudicación. Eso a veces es una forma elegante de desertar a la tarea de profundizar una cuestión, para terminar aceptando tales o cuales mitos o lugares comunes sobre la misma.Educar para la sensibilidadAsí que voy a seguir haciendo girar el prisma. Y ahora voy a señalar otra faceta diferente de la cuestión. La frase evangélica "Perdónalos Señor. No saben lo que hacen" puede tener también mucha aplicación aquí. Es el conocimiento -entendido en sentido muy amplio, como lo que las personas creen de la realidad, sin excluir lo que sienten o son incapaces de sentir acerca de ella-, y el aprendizaje de ciertas cosas, lo que puede ser definitorio. En cierta ocasión le pregunté al Dr. Ricardo Bernardi, en un marco no filosófico especulativo sino pragmático político, acerca de los resortes íntimos de los asesinos. Mi inquietud era elemental: ¿por qué algunas personas matan o injurian a otras?Su comienzo de respuesta me condujo a un sugerente trabajo, titulado Reflective-Functioning Manual. For Application To Adult Attachment Interviews de Peter Fonagy, Mary Target, Howard Steele y Miriam Steele. Después de una lectura rápida de ese texto, uno puede sospechar que la tendencia de ciertas personas a adoptar conductas criminales se vincula de algún modo con algo que se denomina "función reflectiva", la construcción del otro como un semejante, que tiene sentimientos como nosotros.Hace algunos años, en medio de noticias sobre menores que habían sido victimarios en episodios violentos, y en la misma pista de las investigaciones sobre la "función reflectiva", un funcionario del INAME me sugirió muy sutilmente la necesidad de ser cautelosos al interpretar ese tipo de casos. Palabras más o menos, me manifestó: "Muchos de esos niños no saben todavía qué significa la muerte de otra persona. Yo mismo lo entendí recién a los 13 años, cuando se me murió un abuelo muy querido. Antes no había sentido nada, o por lo menos, no había sentido nada semejante, con la desaparición física de otras personas conocidas, vecinos o familiares lejanos".Educar para la prevención, educar para la paz, supone educar para que "sepan lo que hacen", es decir, educar para un conocimiento moral que no sea exclusivamente racional, y no consista en un mero conocimiento de reglas de juego, o de normas de convivencia, sino en algo que involucre la experiencia, los sentimientos, las emociones, la sensibilidad humana.La conclusión provisoria sobre estos enfoques apuntan a la educación y a la sensibilización con el prójimo. En particular, todo parece conducir a la planificación del estímulo y el desarrollo de habilidades específicas en los niños y adolescentes, habilidades concernientes a la empatía, a la ejercitación de procesos psicológicos identificatorios, a la ejercitación de las "capacidades lectoras" de las intenciones de los otros. Y dicho sea de paso, también a reclamar a los planificadores educativos y a los profesores de arte, literatura y filosofía, un desempeño menos unilateral y más enérgico de sus vocaciones respectivas, habida cuenta de las imprevisibles consecuencias que podría tener priorizar las matemáticas, el lenguaje y la informática, en desmedro de todo lo que la moda hoy denomina la "inteligencia emocional".En esa misma dirección concurrían las insuficientemente atendidas sugerencias de Rodolfo Tálice -quién supo nutrirse largamente de las investigaciones de Konrad Lorenz, Niko Tinbergen y Karl von Frisch-, en su estupendo trabajo sobre El hombre: agresión y vinculación. Según Tálice, la clase política debería recordar que los ciudadanos que procura gobernar son mamíferos humanos que arrastran más de 80 millones de años de herencia biológica. Y que por lo tanto, "sus medidas y resoluciones puramente culturales (sociales, técnicas, administrativas, económicas) han de ser completadas con las biológicas o etológicas". Resumo aquí algunas de ellas:- Dosificar la masificación urbana.- Evitar los hormigueros habitacionales que conspiran contra el instinto espacial individual.- Fomentar los deportes competitivos, frenadores o derivativos del comportamiento agresivo, pero no para aumentar la cantidad de espectadores sino la de participantes activos.- Reducir mediante ordenanzas los estímulos agresógenos, especialmente el ruido en las grandes ciudades.- Favorecer los comportamientos lúdicos, derivativos y sustitutos del comportamiento agresivo.- Estimular el temprano comportamiento vinculatorio madre-hijo.- Educar para desestimular la agresión natural, recompensando el buen comportamiento espontáneo (aprendizaje "operante") y rehuir los castigos (inoperantes).- Facilitar el intercambio internacional suprimiendo trabas para la circulación de personas, documentos, obras etcétera.- Promover los encuentros deportivos internacionales.El "tercer lado" por la pazLíneas arriba dijimos que nuestras reflexiones en torno de la violencia enfrentaban una cuestión que posee un inocultable parecido con cualquier problema filosófico tradicional y lo comparamos con un prisma que gira ante nuestros ojos. Esto pone en evidencia la necesidad de discernir aspectos. Distinguir niveles, o planos, parece ineludible en este caso. En palabras de Hacker, es menester alcanzar "la tolerancia para la complejidad y la facultad de soportar las tensiones de problemas no resueltos".Por ello hemos alejado hasta este momento esos planteos peligrosos, por lo polisémicos, que denuncian "la violencia del sistema". Expresiones como ésa, o similares, poseen una generalidad que las vincula al lenguaje poético y literario. Son propias de personas que están peleadas con la vida, o que están en pose histriónica de denuncia, o bien buscan un efecto catártico en su público. En ciertas ocasiones, afirmar que "la violencia está en el sistema" es condenarse a perder la propia condición de agentes de cambio. Si en realidad el "sistema" lo abarca todo, nuestros brazos agitados, nuestras propuestas, o nuestras protestas, también serán reabsorbidas por el sistema, y no habrá nada para hacer.Eso suena tan absurdo como decir "el planeta llueve", en vez de hablar con mayor precisión y referirnos a tales o cuales zonas donde se producen determinadas condiciones meteorológicas. Por motivos análogos, a un cirujano no le alcanza con que se le diga que el paciente está enfermo, porque esa obviedad nada aporta y deberá circunscribirse con precisión y exactitud mucho mayores dónde está localizado el problema. Dejando las metáforas y volviendo a nuestros términos, digamos que, ya se trate de la defensa de los derechos de la mujer, de la promoción de minorías sexuales, o de la protección del ambiente, todos los movimientos por los derechos civiles se comportan de una manera mucho más práctica, ignorando de hecho las declaraciones del tipo "la violencia está en el sistema", a pesar de que en algunos casos formen parte de sus discursos proselitistas.Esos movimientos han logrado en muchos casos mejoras drásticas en las condiciones de vida de muchas personas, o en la protección del ambiente, porque se han concentrado en un determinado corte o segmento - o subsistema-, y sobre él han trabajado. Saben que "aunque lo deseable y definitivo sería cambiar el sistema" -así parecen razonar-, de todos modos también creen en que los cambios graduales pueden ser, y suelen ser sustanciales para la vida de muchas personas concretas.Apenas hemos señalado las principales dificultades que poseen ese tipo de expresiones generales y confusas, como las del ataq ue al "sistema". Muchas otras podrían señalarse. Un ejemplo es el de las personas que sin ninguna alternativa visible atacan modos de producción, o modelos sociales, como si tuvieran a disposición una solución diferente real, no ideal, y como si fuera fácil conducir a la humanidad entera hacia otros caminos -habida cuenta de las experiencias trágicas del llamado socialismo real y las de la Alemania nazi-. Por otra parte, muchas de las denuncias contra "el sistema" ilustran el error de antropomorfizar entidades colectivas. Quienes las formulan, sugiriendo que se refieren a algo más ominoso y todopoderoso que nos sobrevuela a todos, olvidan que su utilidad reside en que constituyen vigorosas formas retóricas, pero que pueden alejarnos de un enfoque más operativo y transformador de la realidad. El denominador común de esas actitudes consiste en perder el tiempo en insultar la tormenta, en vez de conducirse hacia un refugio y proteger a aquellos que estén a su alcance.Para finalizar, diré que hemos recorrido muchos senderos para abordar la violencia desde "la complejidad" -en el sentido de Friedrich Hacker y también, por cierto, en el de Edgar Morin-. Pero no ha sido en vano. Claro que omitimos muchas nombres que se suelen incluir en este tipo de aproximaciones, como el de Mahatma Gandhi o el de Martin Luther King. Pero no hemos caminado en círculo, compañero lector. Porque compartimos muchos elementos, ausentes con excesiva frecuencia de las mesas de trabajo de los responsables en estos temas, que podrían convertir los análisis sobre la violencia en algo diferente de un mero lamento, o de una expresión de nobles deseos. Por ello reflexionamos sobre la importancia del lenguaje y la proximidad física. Por ello nos referimos a la "función reflectiva" y a la educación para la paz, como educación para la empatía. Y por ello mencionamos posibles factores genéticos, atendimos las recomendaciones surgidas de la etología, y descartamos las "explicaciones" generales en exceso, como las socorridas apelaciones al "sistema".Ahora me gustaría culminar, con un autor que se ha ocupado pragmáticamente de la cultura de la paz. Me refiero a William Ury, autor de obras como Alcanzar la paz, y copartícipe en la creación de la metodología de Harvard para la resolución de conflictos. Las afirmaciones de Ury son harto provocativas, pero sólidamente fundadas en experiencias de la asistencia social, las mediaciones en conflictos internacionales y los hallazgos recientes de la antropología. Según el autor, los 5.000 años de guerras y violencias de todo tipo que hemos conocido hasta el presente, representan apenas el uno por ciento de toda la historia de la humanidad.Según el autor, el homo sapiens no es una especie "asesina por naturaleza", porque sus miembros otrora han sabido coexistir con sabiduría. En sus libros, Ury ha denunciado con extraordinario detalle y solvencia profesional los errores técnicos cometidos al evaluar restos humanos, por parte de antropólogos y arqueólogos demasiado apresurados en demostrar que la violencia está en nuestra historia como especie. La posibilidad de responder a determinados estímulos con una conducta violenta posee una base antropológica, y puede que en cierto sentido llevemos eso en nuestros genes. Pero eso es tan cierto como el otro hecho complementario: también posee base biológica la potencialidad de desplegar conductas cooperativas –a la larga más adaptativas que las violentas-.No es un pacifismo ingenuo el del autor. Muy por el contrario, William Ury cree que ciertos conflictos son inevitables y además que hay derechos que no se conquistan sin lucha. Sin embargo, para el autor los conflictos guardan ciertas similitudes con el agua –o la lluvia-. Si se mantienen dentro de ciertos límites y se contienen, puede ser benéficos. Pero si se deja llegar el momento en que los ríos –o los conflictos- se desbordan, sin haber tomado ninguna precaución, ya nada habrá para hacer. Sobre la base de sus investigaciones de campo como antropólogo, Ury ha encontrado que la prevención y la resolución eficiente de conflictos, ya se trate de pequeñas comunidades, organizaciones empresariales, familias o naciones enteras, reside en la fortificación del "tercer lado".El "tercer lado" es un concepto que refiere a las actitudes de los terceros que contemplan un conflicto entre personas o grupos. Es todo lo contrario de la pasividad. En ocasiones, puede aludir a una autoridad que interviene, pero en otras puede designar la presencia de mediadores voluntarios, honestos y competentes. El "tercer lado" puede adoptar un carácter de negociación formal, o puede ser la reacción espontánea de las personas que contemplan una discusión para impedir que llegue a mayores.Las reflexiones de Umberto Eco sobre la guerra son completamente funcionales al paradigma del "tercer lado": la guerra algún día se convertirá en tabú, igual que el incesto, una vez que se adviertan sus efectos devastadores; en un planeta globalizado, los dos bandos pierden; es como jugar un ajedrez de un solo color, y donde no importa qué pieza de qué lado se suprima; la humanidad demoró en relacionar el coito con la procreación, y luego demoró en vincular la endogamia con la muerte o las enfermedades de los descendientes, pero al cabo la humanidad aprendió. Ahora bastan dos semanas para que la opinión pública advierta que un conflicto en cualquier parte pueda llevar a la bancarrota de una compañía aérea.En sus palabras: "Sin duda, un tabú no se proclama: se autoproclama. Pero hay aceleraciones de los tiempos de crecimiento. Para darse cuenta de que al unirse a la madre o a la hermana se bloqueaba el intercambio entre los grupos, se necesitaron decenas de millares de años, tal y como parece que se necesitó mucho tiempo antes de que la humanidad determinara una relación de causa y efecto entre acto sexual y embarazo. Pero para darse cuenta de que con una guerra las compañías aéreas cierran han sido suficientes dos semanas. Es compatible, pues, con el deber intelectual y con el sentido común anunciar la necesidad de un tabú, que, aun así, nadie tiene la autoridad de proclamar, fijando sus tiempos de maduración. Es deber intelectual proclamar la imposibilidad de la guerra. Aunque no hubiera solución posible".Luego agrega de modo muy sugerente: "A lo sumo, recordar que nuestro siglo ha conocido una excelente alternativa a la guerra, es decir, la guerra «fría». Ocasión de horrores, injusticias, intolerancias, conflictos locales, terror difuso, la historia al final deberá admitir que ha sido una solución muy humana y porcentualmente blanda, que ha visto incluso vencedores y vencidos. Pero no es competencia de la función intelectual declarar guerras frías. (.) En términos de derechos de la especie, [la guerra] es peor que un delito: es un despilfarro inútil".Regresemos a William Ury para culminar este breve viaje sobre la violencia, donde hemos procurado mostrar otros elementos y otras aproximaciones. Hemos procurado construir un enfoque no más optimista, sino más realista, precisamente: "Es posible que el conflicto sea inevitable, pero no lo son la pelea, la violencia y la guerra. Podemos escoger entre manejar nuestros conflictos de manera destructiva o constructiva (.) Se necesita paciencia para escuchar y buscar un acuerdo. Intervenir en los conflictos de otras personas puede ser igualmente difícil. A nadie le gusta ser acusado de 'entrometido'. Nadie quiere correr el riesgo de tensar las relaciones con sus amigos, parientes y aliados. Da miedo quedar involucrado en una situación cargada de violencia, o abiertamente violenta. Asumir el tercer lado no es una tarea fácil. (.) La paz es más difícil de alcanzar que la guerra. La paz a la que podemos aspirar no es entonces la paz armoniosa de los cementerios, no es la paz sumisa del esclavo, sino la paz construida por los valientes".FUENTESCourtoisie, Agustín, Una propuesta sobre el aborto. Mediadores en salud reproductiva, Cuadernos de Marcha, Tercera Epoca, Año XIII, N° 145, noviembre de 1998, pág. 11-15.Denker, Rolf, Elucidaciones sobre la agresión, Amorrortu, orig. 1971, B.Aires, 1973, trad. Ana Ma. S. de Peisker y revisión de Ricardo MontiEco, Umberto, "Pensar la guerra", en Cinco escritos morales. Bompiani Ed., versión castellana Ed. Lúmen, traducción Helena Lozano Miralles, 1997.Eibl-Eibesfeldt, Irenäus, El hombre preprogramado, Alianza Universidad, trad. Pedro Gálvez, pub. orig.1973, ed. castellana Madrid, 1987.Fonagy, Peter, et al., Reflective-Functioning Manual. Version 5. For Application To Adult Attachment Interviews, Psychoanalysis Unit, Sub-Department of Clinical Health Psychology, University College London (material circulado vía Internet).Gil, Daniel, El capitán por su boca muere o la piedad de Eros. Ensayo sobre la mentalidad de un torturador, ed. Trilce, Montevideo, 1999.Hacker, Friedrich, Agresión, ed. Grijalbo, Barcelona, 1973.Hasler, Alfred, El odio en el mundo actual, Alianza Ed., trad. Federico Latorre, orig. 1969, ed. Castellana, Madrid 1973.Ridley, Matt, Genoma. La autobiografía de una especie en 23 capítulos, Taurus, Madrid, 2001.Tálice, Rodolfo, El hombre: agresión y vinculación, Librerías Papacito, Editores, 1976.Ury, William, Alcanzar la Paz. Diez caminos para resolver conflictos, Editorial Paidós, Buenos Aires, 2000. * Profesor de Cultura y Sociedad Contemporánea en la Licenciatura de estudios Internacionales, FACS, Universidad ORT Uruguay.

Breast cancer (BC) risk for BRCA1 and BRCA2 mutation carriers varies by genetic and familial factors. About 50 common variants have been shown to modify BC risk for mutation carriers. All but three, were identified in general population studies. Other mutation carrier-specific susceptibility variants may exist but studies of mutation carriers have so far been underpowered. We conduct a novel case-only genome-wide association study comparing genotype frequencies between 60,212 general population BC cases and 13,007 cases with BRCA1 or BRCA2 mutations. We identify robust novel associations for 2 variants with BC for BRCA1 and 3 for BRCA2 mutation carriers, P < 10-8, at 5 loci, which are not associated with risk in the general population. They include rs60882887 at 11p11.2 where MADD, SP11 and EIF1, genes previously implicated in BC biology, are predicted as potential targets. These findings will contribute towards customising BC polygenic risk scores for BRCA1 and BRCA2 mutation carriers. ; BCAC acknowledgements. We thank all the individuals who took part in these studies and all the researchers, clinicians, technicians and administrative staff who have enabled this work to be carried out. ABCFS thank Maggie Angelakos, Judi Maskiell, Gillian Dite. ABCS thanks the Blood bank Sanquin, The Netherlands. ABCTB Investigators: Christine Clarke, Deborah Marsh, Rodney Scott, Robert Baxter, Desmond Yip, Jane Carpenter, Alison Davis, Nirmala Pathmanathan, Peter Simpson, J. Dinny Graham, Mythily Sachchithananthan. Samples are made available to researchers on a non-exclusive basis. BBCS thanks Eileen Williams, Elaine Ryder-Mills, Kara Sargus. BCEES thanks Allyson Thomson, Christobel Saunders, Terry Slevin, BreastScreen Western Australia, Elizabeth Wylie, Rachel Lloyd. The BCINIS study would not have been possible without the contributions of Dr. K. Landsman, Dr. N. Gronich, Dr. A. Flugelman, Dr. W. Saliba, Dr. E. Liani, Dr. I. Cohen, Dr. S. Kalet, Dr. V. Friedman, Dr. O. Barnet of the NICCC in Haifa, and all the contributing family medicine, surgery, pathology and oncology teams in all medical institutes in Northern Israel. The BREOGAN study would not have been possible without the contributions of the following: Manuela Gago-Dominguez, Jose Esteban Castelao, Angel Carracedo, Victor Munoz Garzon, Alejandro Novo Dominguez, Maria Elena Martinez, Sara Miranda Ponte, Carmen Redondo Marey, Maite Pena Fernandez, Manuel Enguix Castelo, Maria Torres, Manuel Calaza (BREOGAN), Jose Antunez, Maximo Fraga and the staff of the Department of Pathology and Biobank of the University Hospital Complex of Santiago-CHUS, Instituto de Investigacion Sanitaria de Santiago, IDIS, Xerencia de Xestion Integrada de Santiago-SERGAS; Joaquin Gonzalez-Carrero and the staff of the Department of Pathology and Biobank of University Hospital Complex of Vigo, Instituto de Investigacion Biomedica Galicia Sur, SERGAS, Vigo, Spain. BSUCH thanks Peter Bugert, Medical Faculty Mannheim. CBCS thanks study participants, co-investigators, collaborators and staff of the Canadian Breast Cancer Study, and project coordinators Agnes Lai and Celine Morissette. CCGP thanks Styliani Apostolaki, Anna Margiolaki, Georgios Nintos, Maria Perraki, Georgia Saloustrou, Georgia Sevastaki, Konstantinos Pompodakis. CGPS thanks staff and participants of the Copenhagen General Population Study. For the excellent technical assistance: Dorthe Uldall Andersen, Maria Birna Arnadottir, Anne Bank, Dorthe Kjeldgard Hansen. The Danish Cancer Biobank is acknowledged for providing infrastructure for the collection of blood samples for the cases. CNIO-BCS thanks Guillermo Pita, Charo Alonso, Nuria alvarez, Pilar Zamora, Primitiva Menendez, the Human Genotyping-CEGEN Unit (CNIO). The CTS Steering Committee includes Leslie Bernstein, Susan Neuhausen, James Lacey, Sophia Wang, Huiyan Ma, and Jessica Clague DeHart at the Beckman Research Institute of City of Hope, Dennis Deapen, Rich Pinder, and Eunjung Lee at the University of Southern California, Pam Horn-Ross, Peggy Reynolds, Christina Clarke Dur and David Nelson at the Cancer Prevention Institute of California, Hoda Anton-Culver, Argyrios Ziogas, and Hannah Park at the University of California Irvine, and Fred Schumacher at Case Western University. DIETCOMPLYF thanks the patients, nurses and clinical staff involved in the study. The DietCompLyf study was funded by the charity Against Breast Cancer (Registered Charity Number 1121258) and the NCRN. We thank the participants and the investigators of EPIC (European Prospective Investigation into Cancer and Nutrition). ESTHER thanks Hartwig Ziegler, Sonja Wolf, Volker Hermann, Christa Stegmaier, Katja Butterbach. GC-HBOC thanks Stefanie Engert, Heide Hellebrand, Sandra Krober and LIFE - Leipzig Research Centre for Civilization Diseases (Markus Loeffler, Joachim Thiery, Matthias Nuchter, Ronny Baber). The GENICA Network: Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tubingen, Germany [HB, Wing-Yee Lo], German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tubingen [[HB], gefordert durch die Deutsche Forschungsgemeinschaft (DFG) im Rahmen der Exzellenzstrategie des Bundes und der Lander - EXC 2180 - 390900677 [HB], Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany [YDK, Christian Baisch], Institute of Pathology, University of Bonn, Germany [Hans-Peter Fischer], Molecular Genetics of Breast Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany [Ute Hamann], Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, Germany [Thomas Bruning, Beate Pesch, Sylvia Rabstein, Anne Lotz]; and Institute of Occupational Medicine and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Germany [Volker Harth]. HABCS thanks Michael Bremer. HEBCS thanks Kirsimari Aaltonen, Irja Erkkila. HUBCS thanks Shamil Gantsev. KARMA and SASBAC thank the Swedish Medical Research Counsel. KBCP thanks Eija Myohanen, Helena Kemilainen. kConFab/AOCS wish to thank Heather Thorne, Eveline Niedermayr, all the kConFab research nurses and staff, the heads and staff of the Family Cancer Clinics, and the Clinical Follow-Up Study (which has received funding from the NHMRC, the National Breast Cancer Foundation, Cancer Australia, and the National Institute of Health (USA)) for their contributions to this resource, and the many families who contribute to kConFab. LMBC thanks Gilian Peuteman, Thomas Van Brussel, EvyVanderheyden and Kathleen Corthouts. MARIE thanks Petra Seibold, Dieter Flesch-Janys, Judith Heinz, Nadia Obi, Alina Vrieling, Sabine Behrens, Ursula Eilber, Muhabbet Celik, Til Olchers and Stefan Nickels. MBCSG (Milan Breast Cancer Study Group): Mariarosaria Calvello, Davide Bondavalli, Aliana Guerrieri Gonzaga, Monica Marabelli, Irene Feroce, and the personnel of the Cogentech Cancer Genetic Test Laboratory. The MCCS was made possible by the contribution of many people, including the original investigators, the teams that recruited the participants and continue working on follow-up, and the many thousands of Melbourne residents who continue to participate in the study. We thank the coordinators, the research staff and especially the MMHS participants for their continued collaboration on research studies in breast cancer. MSKCC thanks Marina Corines, Lauren Jacobs. MTLGEBCS would like to thank Martine Tranchant (CHU de Quebec - Universite Laval Research Center), Marie-France Valois, Annie Turgeon and Lea Heguy (McGill University Health Center, Royal Victoria Hospital; McGill University) for DNA extraction, sample management and skilful technical assistance. J.S. is Chair holder of the Canada Research Chair in Oncogenetics. NBHS and SBCGS thank study participants and research staff for their contributions and commitment to the studies. For NHS and NHS2 the study protocol was approved by the institutional review boards of the Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, and those of participating registries as required. We would like to thank the participants and staff of the NHS and NHS2 for their valuable contributions as well as the following state cancer registries for their help: A.L., A.Z., A.R., C.A., C.O., C.T., D.E., F.L., G.A., I.D., I.L., I.N., I.A., K.Y., L.A., M.E., M.D., M.A., M.I., N.E., N.H., N.J., N.Y., N.C., N.D., O.H., O.K., O.R., P.A., R.I., S.C., T.N., T.X., V.A., W.A., and W.Y. The authors assume full responsibility for analyses and interpretation of these data. OFBCR thanks Teresa Selander, Nayana Weerasooriya. ORIGO thanks E. Krol-Warmerdam, and J. Blom for patient accrual, administering questionnaires, and managing clinical information. PBCS thanks Louise Brinton, Mark Sherman, Neonila Szeszenia-Dabrowska, Beata Peplonska, Witold Zatonski, Pei Chao, Michael Stagner. The ethical approval for the POSH study is MREC /00/6/69, UKCRN ID: 1137. We thank staff in the Experimental Cancer Medicine Centre (ECMC) supported Faculty of Medicine Tissue Bank and the Faculty of Medicine DNA Banking resource. RBCS thanks Jannet Blom, Saskia Pelders, Annette Heemskerk and the Erasmus MC Family Cancer Clinic. We thank the SEARCH and EPIC teams. SKKDKFZS thanks all study participants, clinicians, family doctors, researchers and technicians for their contributions and commitment to this study. SZBCS thanks Ewa Putresza. UCIBCS thanks Irene Masunaka. UKBGS thanks Breast Cancer Now and the Institute of Cancer Research for support and funding of the Breakthrough Generations Study, and the study participants, study staff, and the doctors, nurses and other health care providers and health information sources who have contributed to the study. We acknowledge NHS funding to the Royal Marsden/ICR NIHR Biomedical Research Centre. We acknowledge funding to the Manchester NIHR Biomedical Research Centre (IS-BRC-1215-20007). The authors thank the WHI investigators and staff for their dedication and the study participants for making the program possible. CIMBA acknowledgments. All the families and clinicians who contribute to the studies; Catherine M. Phelan for her contribution to CIMBA until she passed away on 22 September 2017; Sue Healey, in particular taking on the task of mutation classification with the late Olga Sinilnikova; Maggie Angelakos, Judi Maskiell, Gillian Dite, Helen Tsimiklis; members and participants in the New York site of the Breast Cancer Family Registry; members and participants in the Ontario Familial Breast Cancer Registry; Vilius Rudaitis and Laimonas Grikeviius; Drs Janis Eglitis, Anna Krilova and Aivars Stengrevics; Yuan Chun Ding and Linda Steele for their work in participant enrollment and biospecimen and data management; Bent Ejlertsen and Anne-Marie Gerdes for the recruitment and genetic counseling of participants; Alicia Barroso, Rosario Alonso and Guillermo Pita; all the individuals and the researchers who took part in CONSIT TEAM (Consorzio Italiano Tumori Ereditari Alla Mammella), in particular: Bernard Peissel, Dario Zimbalatti, Daniela Zaffaroni, Alessandra Viel, Giuseppe Giannini Liliana Varesco, Viviana Gismondi, Maria Grazia Tibiletti, Daniela Furlan, Antonella Savarese, Aline Martayan, Stefania Tommasi, Brunella Pilato and the personnel of the Cogentech Cancer Genetic Test Laboratory, Milan, Italy. Ms. JoEllen Weaver and Dr. Betsy Bove; FPGMX: members of the Cancer Genetics group (IDIS): Marta Santamarina, Miguel Aguado and Olivia Rios; IFE - Leipzig Research Centre for Civilization Diseases (Markus Loeffler, Joachim Thiery, Matthias Nuchter, Ronny Baber); We thank all participants, clinicians, family doctors, researchers, and technicians for their contributions and commitment to the DKFZ study and the collaborating groups in Lahore, Pakistan (Noor Muhammad, Sidra Gull, Seerat Bajwa, Faiz Ali Khan, Humaira Naeemi, Saima Faisal, Asif Loya, Mohammed Aasim Yusuf) and Bogota, Colombia (Ignacio Briceno, Fabian Gil). Genetic Modifiers of Cancer Risk in BRCA1/2 Mutation Carriers (GEMO) study is a study from the National Cancer Genetics Network UNICANCER Genetic Group, France. We wish to pay a tribute to Olga M. Sinilnikova, who with Dominique Stoppa-Lyonnet initiated and coordinated GEMO until she sadly passed away on the 30th June 2014. The team in Lyon (Olga Sinilnikova, Melanie Leone, Laure Barjhoux, Carole Verny-Pierre, Sylvie Mazoyer, Francesca Damiola, Valerie Sornin) managed the GEMO samples until the biological resource centre was transferred to Paris in December 2015 (Noura Mebirouk, Fabienne Lesueur, Dominique Stoppa-Lyonnet). We want to thank all the GEMO collaborating groups for their contribution to this study: Coordinating Centre, Service de Genetique, Institut Curie, Paris, France: Muriel Belotti, Ophelie Bertrand, Anne-Marie Birot, Bruno Buecher, Sandrine Caputo, Anais Dupre, Emmanuelle Fourme, Marion Gauthier-Villars, Lisa Golmard, Claude Houdayer, Marine Le Mentec, Virginie Moncoutier, Antoine de Pauw, Claire Saule, Dominique Stoppa-Lyonnet, and Inserm U900, Institut Curie, Paris, France: Fabienne Lesueur, Noura Mebirouk. Contributing Centres: Unite Mixte de Genetique Constitutionnelle des Cancers Frequents, Hospices Civils de Lyon - Centre Leon Berard, Lyon, France: Nadia Boutry-Kryza, Alain Calender, Sophie Giraud, Melanie Leone. Institut Gustave Roussy, Villejuif, France: Brigitte Bressac-de-Paillerets, Olivier Caron, Marine Guillaud-Bataille. Centre Jean Perrin, Clermont-Ferrand, France: Yves-Jean Bignon, Nancy Uhrhammer. Centre Leon Berard, Lyon, France: Valerie Bonadona, Christine Lasset. Centre Francois Baclesse, Caen, France: Pascaline Berthet, Laurent Castera, Dominique Vaur. Institut Paoli Calmettes, Marseille, France: Violaine Bourdon, Catherine Nogues, Tetsuro Noguchi, Cornel Popovici, Audrey Remenieras, Hagay Sobol. CHU Arnaud-de-Villeneuve, Montpellier, France: Isabelle Coupier, Pascal Pujol. Centre Oscar Lambret, Lille, France: Claude Adenis, Aurelie Dumont, Francoise Revillion. Centre Paul Strauss, Strasbourg, France: Daniele Muller. Institut Bergonie, Bordeaux, France: Emmanuelle Barouk-Simonet, Francoise Bonnet, Virginie Bubien, Michel Longy, Nicolas Sevenet, Institut Claudius Regaud, Toulouse, France: Laurence Gladieff, Rosine Guimbaud, Viviane Feillel, Christine Toulas. CHU Grenoble, France: Helene Dreyfus, Christine Dominique Leroux, Magalie Peysselon, Rebischung. CHU Dijon, France: Amandine Baurand, Geoffrey Bertolone, Fanny Coron, Laurence Faivre, Caroline Jacquot, Sarab Lizard. CHU St-Etienne, France: Caroline Kientz, Marine Lebrun, Fabienne Prieur. Hotel Dieu Centre Hospitalier, Chambery, France: Sandra Fert Ferrer. Centre Antoine Lacassagne, Nice, France: Veronique Mari. CHU Limoges, France: Laurence Venat-Bouvet. CHU Nantes, France: Stephane Bezieau, Capucine Delnatte. CHU Bretonneau, Tours and Centre Hospitalier de Bourges France: Isabelle Mortemousque. Groupe Hospitalier Pitie-Salpetriere, Paris, France: Chrystelle Colas, Florence Coulet, Florent Soubrier, Mathilde Warcoin. CHU Vandoeuvre-les-Nancy, France: Myriam Bronner, Johanna Sokolowska. CHU Besancon, France: Marie-Agnes Collonge-Rame, Alexandre Damette. CHU Poitiers, Centre Hospitalier d'Angouleme and Centre Hospitalier de Niort, France: Paul Gesta. Centre Hospitalier de La Rochelle: Hakima Lallaoui. CHU Nimes Caremeau, France: Jean Chiesa. CHI Poissy, France: Denise Molina-Gomes. CHU Angers, France: Olivier Ingster; Ilse Coene en Brecht Crombez; Ilse Coene and Brecht Crombez; Alicia Tosar and Paula Diaque; Drs.Sofia Khan, Taru A. Muranen, Carl Blomqvist, Irja Erkkila and Virpi Palola; The Hereditary Breast and Ovarian Cancer Research Group Netherlands (HEBON) consists of the following Collaborating Centers: Coordinating center: Netherlands Cancer Institute, Amsterdam, NL: M.A. Rookus, F.B.L. Hogervorst, F.E. van Leeuwen, S. Verhoef, M.K. Schmidt, N.S. Russell, D.J. Jenner; Erasmus Medical Center, Rotterdam, NL: J.M. Collee, A.M.W. van den Ouweland, M.J. Hooning, C. Seynaeve, C.H.M. van Deurzen, I.M. Obdeijn; Leiden University Medical Center, NL: C.J. van Asperen, J.T. Wijnen, R.A.E.M. Tollenaar, P. Devilee, T.C.T.E.F. van Cronenburg; Radboud University Nijmegen Medical Center, NL: C.M. Kets, A.R. Mensenkamp; University Medical Center Utrecht, NL: M.G.E.M. Ausems, R.B. van der Luijt, C.C. van der Pol; Amsterdam Medical Center, NL: C.M. Aalfs, T.A.M. van Os; VU University Medical Center, Amsterdam, NL: J.J.P. Gille, Q. Waisfisz, H.E.J. Meijers-Heijboer; University Hospital Maastricht, NL: E.B. Gomez-Garcia, M.J. Blok; University Medical Center Groningen, NL: J.C. Oosterwijk, A.H. van der Hout, M.J. Mourits, G.H. de Bock; The Netherlands Foundation for the detection of hereditary tumours, Leiden, NL: H.F. Vasen; The Netherlands Comprehensive Cancer Organization (IKNL): S. Siesling, J.Verloop; the ICO Hereditary Cancer Program team led by Dr. Gabriel Capella; the ICO Hereditary Cancer Program team led by Dr. Gabriel Capella; Dr Martine Dumont for sample management and skillful assistance; Ana Peixoto, Catarina Santos and Pedro Pinto; members of the Center of Molecular Diagnosis, Oncogenetics Department and Molecular Oncology Research Center of Barretos Cancer Hospital; Heather Thorne, Eveline Niedermayr, all the kConFab research nurses and staff, the heads and staff of the Family Cancer Clinics, and the Clinical Follow-Up Study (which has received funding from the NHMRC, the National Breast Cancer Foundation, Cancer Australia, and the National Institute of Health (USA)) for their contributions to this resource, and the many families who contribute to kConFab; the investigators of the Australia New Zealand NRG Oncology group; members and participants in the Ontario Cancer Genetics Network; Leigha Senter, Kevin Sweet, Caroline Craven, Julia Cooper, Amber Aielts, and Michelle O'Conor; HVH: acknowledgments to the Cellex Foundation for providing research facilities and equipment. Dr Juliette Coignard was supported by a fellowship of INCa Institut National du Cancer N degrees 2015-181, la Ligue Nationale contre le Cancer IP/SC-15229 and Olga Sinilnikova's fellowship (2016). BCAC Funding. BCAC is funded by Cancer Research UK [C1287/A16563, C1287/A10118], the European Union's Horizon 2020 Research and Innovation Programme (grant numbers 634935 and 633784 for BRIDGES and B-CAST respectively), and by the European Communitys Seventh Framework Programme under grant agreement number 223175 (grant number HEALTH-F2-2009-223175) (COGS). The EU Horizon 2020 Research and Innovation Programme funding source had no role in study design, data collection, data analysis, data interpretation or writing of the report. Genotyping of the OncoArray was funded by the NIH Grant U19 CA148065, and Cancer UK Grant C1287/A16563 and the PERSPECTIVE project supported by the Government of Canada through Genome Canada and the Canadian Institutes of Health Research (grant GPH-129344) and, the Ministere de l'Economie, Science et Innovation du Quebec through Genome Quebec and the PSRSIIRI-701 grant, and the Quebec Breast Cancer Foundation. The Australian Breast Cancer Family Study (ABCFS) was supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The ABCFS was also supported by the National Health and Medical Research Council of Australia, the New South Wales Cancer Council, the Victorian Health Promotion Foundation (Australia) and the Victorian Breast Cancer Research Consortium. J.L.H. is a National Health and Medical Research Council (NHMRC) Senior Principal Research Fellow. M.C.S. is a NHMRC Senior Research Fellow. The ABCS study was supported by the Dutch Cancer Society [grants NKI 2007-3839; 2009 4363]. The Australian Breast Cancer Tissue Bank (ABCTB) was supported by the National Health and Medical Research Council of Australia, The Cancer Institute NSW and the National Breast Cancer Foundation. The work of the BBCC was partly funded by ELAN-Fond of the University Hospital of Erlangen. The BBCS is funded by Cancer Research UK and Breast Cancer Now and acknowledges NHS funding to the NIHR Biomedical Research Centre, and the National Cancer Research Network (NCRN). The BCEES was funded by the National Health and Medical Research Council, Australia and the Cancer Council Western Australia and acknowledges funding from the National Breast Cancer Foundation (JS). For the BCFR-NY, BCFR-PA, BCFR-UT this work was supported by grant UM1 CA164920 from the National Cancer Institute. The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the BCFR. The BREast Oncology GAlician Network (BREOGAN) is funded by Accion Estrategica de Salud del Instituto de Salud Carlos III FIS PI12/02125/Cofinanciado FEDER; Accion Estrategica de Salud del Instituto de Salud Carlos III FIS Intrasalud (PI13/01136); Programa Grupos Emergentes, Cancer Genetics Unit, Instituto de Investigacion Biomedica Galicia Sur. Xerencia de Xestion Integrada de Vigo-SERGAS, Instituto de Salud Carlos III, Spain; Grant 10CSA012E, Conselleria de Industria Programa Sectorial de Investigacion Aplicada, PEME I + D e I + D Suma del Plan Gallego de Investigacion, Desarrollo e Innovacion Tecnologica de la Conselleria de Industria de la Xunta de Galicia, Spain; Grant EC11-192. Fomento de la Investigacion Clinica Independiente, Ministerio de Sanidad, Servicios Sociales e Igualdad, Spain; and Grant FEDER-Innterconecta. Ministerio de Economia y Competitividad, Xunta de Galicia, Spain. The BSUCH study was supported by the Dietmar-Hopp Foundation, the Helmholtz Society and the German Cancer Research Center (DKFZ). CBCS is funded by the Canadian Cancer Society (grant # 313404) and the Canadian Institutes of Health Research. CCGP is supported by funding from the University of Crete. The CECILE study was supported by Fondation de France, Institut National du Cancer (INCa), Ligue Nationale contre le Cancer, Agence Nationale de Securite Sanitaire, de l'Alimentation, de l'Environnement et du Travail (ANSES), Agence Nationale de la Recherche (ANR). The CGPS was supported by the Chief Physician Johan Boserup and Lise Boserup Fund, the Danish Medical Research Council, and Herlev and Gentofte Hospital. The CNIO-BCS was supported by the Instituto de Salud Carlos III, the Red Tematica de Investigacion Cooperativa en Cancer and grants from the Asociacion Espanola Contra el Cancer and the Fondo de Investigacion Sanitario (PI11/00923 and PI12/00070). The CTS was initially supported by the California Breast Cancer Act of 1993 and the California Breast Cancer Research Fund (contract 97-10500) and is currently funded through the National Institutes of Health (R01 CA77398, UM1 CA164917, and U01 CA199277). Collection of cancer incidence data was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885. The University of Westminster curates the DietCompLyf database funded by Against Breast Cancer Registered Charity No. 1121258 and the NCRN. The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by: Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Generale de l'Education Nationale, Institut National de la Sante et de la Recherche Medicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ), Federal Ministry of Education and Research (BMBF) (Germany); the Hellenic Health Foundation, the Stavros Niarchos Foundation (Greece); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), Statistics Netherlands (The Netherlands); Health Research Fund (FIS), PI13/00061 to Granada, PI13/01162 to EPIC-Murcia, Regional Governments of Andalucia, Asturias, Basque Country, Murcia and Navarra, ISCIII RETIC (RD06/0020) (Spain); Cancer Research UK (14136 to EPIC-Norfolk; C570/A16491 and C8221/A19170 to EPIC-Oxford), Medical Research Council (1000143 to EPIC-Norfolk, MR/M012190/1 to EPIC-Oxford) (United Kingdom). The ESTHER study was supported by a grant from the Baden Wurttemberg Ministry of Science, Research and Arts. Additional cases were recruited in the context of the VERDI study, which was supported by a grant from the German Cancer Aid (Deutsche Krebshilfe). The GC-HBOC (German Consortium of Hereditary Breast and Ovarian Cancer) is supported by the German Cancer Aid (grant no 110837, coordinator: Rita K. Schmutzler, Cologne). This work was also funded by the European Regional Development Fund and Free State of Saxony, Germany (LIFE - Leipzig Research Centre for Civilization Diseases, project numbers 713-241202, 713-241202, 14505/2470, 14575/2470). The GENICA was funded by the Federal Ministry of Education and Research (BMBF) Germany grants 01KW9975/5, 01KW9976/8, 01KW9977/0 and 01KW0114, the Robert Bosch Foundation, Stuttgart, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, the Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, as well as the Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany. The GESBC was supported by the Deutsche Krebshilfe e. V. [70492] and the German Cancer Research Center (DKFZ). The HABCS study was supported by the Claudia von Schilling Foundation for Breast Cancer Research, by the Lower Saxonian Cancer Society, and by the Rudolf Bartling Foundation. The HEBCS was financially supported by the Helsinki UniversityHospital Research Fund, the Finnish Cancer Society, and the Sigrid Juselius Foundation. The HUBCS was supported by a grant from the German Federal Ministry of Research and Education (RUS08/017), and by the Russian Foundation for Basic Research and the Federal Agency for Scientific Organizations for support the Bioresource collections and RFBR grants 14-04-97088, 17-29-06014 and 17-44-020498. Financial support for KARBAC was provided through the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet, the Swedish Cancer Society, The Gustav V Jubilee foundation and Bert von Kantzows foundation. The KARMA study was supported by Marit and Hans Rausings Initiative Against Breast Cancer. The KBCP was financially supported by the special Government Funding (EVO) of Kuopio University Hospital grants, Cancer Fund of North Savo, the Finnish Cancer Organizations, and by the strategic funding of the University of Eastern Finland. kConFab is supported by a grant from the National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia. Financial support for the AOCS was provided by the United States Army Medical Research and Materiel Command [DAMD17-01-1-0729], Cancer Council Victoria, Queensland Cancer Fund, Cancer Council New South Wales, Cancer Council South Australia, The Cancer Foundation of Western Australia, Cancer Council Tasmania and the National Health and Medical Research Council of Australia (NHMRC; 400413, 400281, 199600). G.C.T. and P.W. are supported by the NHMRC. RB was a Cancer Institute NSW Clinical Research Fellow. LMBC is supported by the 'Stichting tegen Kanker'. The MARIE study was supported by the Deutsche Krebshilfe e.V. [70-2892-BR I, 106332, 108253, 108419, 110826, 110828], the Hamburg Cancer Society, the German Cancer Research Center (DKFZ) and the Federal Ministry of Education and Research (BMBF) Germany [01KH0402]. MBCSG is supported by grants from the Italian Association for Cancer Research (AIRC; IG2014 no.15547) to P. Radice. The MCBCS was supported by the NIH grants CA192393, CA116167, CA176785 an NIH Specialized Program of Research Excellence (SPORE) in Breast Cancer [CA116201], and the Breast Cancer Research Foundation and a generous gift from the David F. and Margaret T. Grohne Family Foundation. The Melbourne Collaborative Cohort Study (MCCS) cohort recruitment was funded by VicHealth and Cancer Council Victoria. The MCCS was further augmented by Australian National Health and Medical Research Council grants 209057, 396414 and 1074383 and by infrastructure provided by Cancer Council Victoria. Cases and their vital status were ascertained through the Victorian Cancer Registry and the Australian Institute of Health and Welfare, including the National Death Index and the Australian Cancer Database. The MEC was support by NIH grants CA63464, CA54281, CA098758, CA132839 and CA164973. The MISS study is supported by funding from ERC-2011-294576 Advanced grant, Swedish Cancer Society, Swedish Research Council, Local hospital funds, Berta Kamprad Foundation, Gunnar Nilsson. The MMHS study was supported by NIH grants CA97396, CA128931, CA116201, CA140286 and CA177150. MSKCC is supported by grants from the Breast Cancer Research Foundation and Robert and Kate Niehaus Clinical Cancer Genetics Initiative. The work of MTLGEBCS was supported by the Quebec Breast Cancer Foundation, the Canadian Institutes of Health Research for the CIHR Team in Familial Risks of Breast Cancer program - grant # CRN-87521 and the Ministry of Economic Development, Innovation and Export Trade - grant # PSR-SIIRI-701. The NBHS was supported by NIH grant R01CA100374. Biological sample preparation was conducted the Survey and Biospecimen Shared Resource, which is supported by P30 CA68485. The Northern California Breast Cancer Family Registry (NC-BCFR) and Ontario Familial Breast Cancer Registry (OFBCR) were supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The Carolina Breast Cancer Study was funded by Komen Foundation, the National Cancer Institute (P50 CA058223, U54 CA156733, U01 CA179715), and the North Carolina University Cancer Research Fund. The NHS was supported by NIH grants P01 CA87969, UM1 CA186107, and U19 CA148065. The NHS2 was supported by NIH grants UM1 CA176726 and U19 CA148065. The ORIGO study was supported by the Dutch Cancer Society (RUL 1997-1505) and the Biobanking and Biomolecular Resources Research Infrastructure (BBMRI-NL CP16). The PBCS was funded by Intramural Research Funds of the National Cancer Institute, Department of Health and Human Services, USA. Genotyping for PLCO was supported by the Intramural Research Program of the National Institutes of Health, NCI, Division of Cancer Epidemiology and Genetics. The PLCO is supported by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics and supported by contracts from the Division of Cancer Prevention, National Cancer Institute, National Institutes of Health. The POSH study is funded by Cancer Research UK (grants C1275/A11699, C1275/C22524, C1275/A19187, C1275/A15956 and Breast Cancer Campaign 2010PR62, 2013PR044. The RBCS was funded by the Dutch Cancer Society (DDHK 2004-3124, DDHK 2009-4318. SEARCH is funded by Cancer Research UK [C490/A10124, C490/A16561] and supported by the UK National Institute for Health Research Biomedical Research Centre at the University of Cambridge. The University of Cambridge has received salary support for PDPP from the NHS in the East of England through the Clinical Academic Reserve. The Sister Study (SISTER) is supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences (Z01-ES044005 and Z01-ES049033). The Two Sister Study (2SISTER) was supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences (Z01-ES044005 and Z01-ES102245), and, also by a grant from Susan G. Komen for the Cure, grant FAS0703856. SKKDKFZS is supported by the DKFZ. The SMC is funded by the Swedish Cancer Foundation and the Swedish Research Council (VR 2017-00644) grant for the Swedish Infrastructure for Medical Population-based Life-course Environmental Research (SIMPLER). The SZBCS and IHCC were supported by Grant PBZ_KBN_122/P05/2004 and the program of the Minister of Science and Higher Education under the name Regional Initiative of Excellence in 2019-2022 project number 002/RID/2018/19 amount of financing 12 000 000 PLN. The TNBCC was supported by: a Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a grant from the Breast Cancer Research Foundation, a generous gift from the David F. and Margaret T. Grohne Family Foundation. The UCIBCS component of this research was supported by the NIH [CA58860, CA92044] and the Lon V Smith Foundation [LVS39420]. The UKBGS is funded by Breast Cancer Now and the Institute of Cancer Research (ICR), London. The UKOPS study was funded by The Eve Appeal (The Oak Foundation) and supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. CIMBA Funding. CIMBA: The CIMBA data management and data analysis were supported by Cancer Research - UK grants C12292/A20861, C12292/A11174. GCT and ABS are NHMRC Research Fellows. iCOGS: the European Community's Seventh Framework Programme under grant agreement no 223175 (HEALTH-F2-2009-223175) (COGS), Cancer Research UK (C1287/A10118, C1287/A 10710, C12292/A11174, C1281/A12014, C5047/A8384, C5047/A15007, C5047/A10692, C8197/A16565), the National Institutes of Health (CA128978) and Post-Cancer GWAS initiative (1U19 CA148537, 1U19 CA148065 and 1U19 CA148112 - the GAME-ON initiative), the Department of Defence (W81XWH-10-1-0341), the Canadian Institutes of Health Research (CIHR) for the CIHR Team in Familial Risks of Breast Cancer (CRN-87521), and the Ministry of Economic Development, Innovation and Export Trade (PSR-SIIRI-701), Komen Foundation for the Cure, the Breast Cancer Research Foundation, and the Ovarian Cancer Research Fund. The PERSPECTIVE project was supported by the Government of Canada through Genome Canada and the Canadian Institutes of Health Research, the Ministry of Economy, Science and Innovation through Genome Quebec, and The Quebec Breast Cancer Foundation. BCFR: UM1 CA164920 from the National Cancer Institute. The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the BCFR. BIDMC: Breast Cancer Research Foundation. CNIO: Spanish Ministry of Health PI16/00440 supported by FEDER funds, the Spanish Ministry of Economy and Competitiveness (MINECO) SAF2014-57680-R and the Spanish Research Network on Rare diseases (CIBERER). COH-CCGCRN: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under grant number R25CA112486, and RC4CA153828 (PI: J. Weitzel) from the National Cancer Institute and the Office of the Director, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. CONSIT TEAM: Funds from Italian citizens who allocated the 5x1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects '5x1000') to S. Manoukian. Associazione Italiana Ricerca sul Cancro (AIRC; IG2015 no.16732) to P. Peterlongo. DEMOKRITOS: European Union (European Social Fund - ESF) and Greek national funds through the Operational Program Education and Lifelong Learning of the National Strategic Reference Framework (NSRF) - Research Funding Program of the General Secretariat for Research & Technology: SYN11_10_19 NBCA. Investing in knowledge society through the European Social Fund. DKFZ: German Cancer Research Center. EMBRACE: Cancer Research UK Grants C1287/A10118 and C1287/A11990. D. Gareth Evans and Fiona Lalloo are supported by an NIHR grant to the Biomedical Research Centre, Manchester. The Investigators at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust are supported by an NIHR grant to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. Ros Eeles and Elizabeth Bancroft are supported by Cancer Research UK Grant C5047/A8385. Ros Eeles is also supported by NIHR support to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. FCCC: A.K.G. was in part funded by the NCI (R01 CA214545), The University of Kansas Cancer Center Support Grant (P30 CA168524), The Kansas Institute for Precision Medicine (P20 GM130423), and the Kansas Bioscience Authority Eminent Scholar Program. A.K.G. is the Chancellors Distinguished Chair in Biomedical Sciences Professorship. A.Vega is supported by the Spanish Health Research Foundation, Instituto de Salud Carlos III (ISCIII), partially supported by FEDER funds through Research Activity Intensification Program (contract grant numbers: INT15/00070, INT16/00154, INT17/00133), and through Centro de Investigacion Biomedica en Red de Enferemdades Raras CIBERER (ACCI 2016: ER17P1AC7112/2018); Autonomous Government of Galicia (Consolidation and structuring program: IN607B), and by the Fundacion Mutua Madrilena (call 2018). GC-HBOC: German Cancer Aid (grant no 110837, Rita K. Schmutzler) and the European Regional Development Fund and Free State of Saxony, Germany (LIFE - Leipzig Research Centre for Civilization Diseases, project numbers 713-241202, 713-241202, 14505/2470, 14575/2470). GEMO: Ligue Nationale Contre le Cancer; the Association Le cancer du sein, parlons-en! Award, the Canadian Institutes of Health Research for the CIHR Team in Familial Risks of Breast Cancer program and the French National Institute of Cancer (INCa grants 2013-1-BCB-01-ICH-1 and SHS-E-SP 18-015). GEORGETOWN: the Non-Therapeutic Subject Registry Shared Resource at Georgetown University (NIH/NCI grant P30-CA051008), the Fisher Center for Hereditary Cancer and Clinical Genomics Research, and Swing Fore the Cure. G-FAST: Bruce Poppe is a senior clinical investigator of FWO. Mattias Van Heetvelde obtained funding from IWT. HCSC: Spanish Ministry of Health PI15/00059, PI16/01292, and CB-161200301 CIBERONC from ISCIII (Spain), partially supported by European Regional Development FEDER funds. HEBCS: Helsinki University Hospital Research Fund, the Finnish Cancer Society and the Sigrid Juselius Foundation. HEBON: the Dutch Cancer Society grants NKI1998-1854, NKI2004-3088, NKI2007-3756, the Netherlands Organization of Scientific Research grant NWO 91109024, the Pink Ribbon grants 110005 and 2014-187.WO76, the BBMRI grant NWO 184.021.007/CP46 and the Transcan grant JTC 2012 Cancer 12-054. HEBON thanks the registration teams of Dutch Cancer Registry (IKNL; S. Siesling, J. Verloop) and the Dutch Pathology database (PALGA; L. Overbeek) for part of the data collection. ICO: The authors would like to particularly acknowledge the support of the Asociacion Espanola Contra el Cancer (AECC), the Instituto de Salud Carlos III (organismo adscrito al Ministerio de Economia y Competitividad) and Fondo Europeo de Desarrollo Regional (FEDER), una manera de hacer Europa (PI10/01422, PI13/00285, PIE13/00022, PI15/00854, PI16/00563 and CIBERONC) and the Institut Catala de la Salut and Autonomous Government of Catalonia (2009SGR290, 2014SGR338 and PERIS Project MedPerCan). INHERIT: Canadian Institutes of Health Research for the CIHR Team in Familial Risks of Breast Cancer program - grant # CRN-87521 and the Ministry of Economic Development, Innovation and Export Trade - grant # PSR-SIIRI-701. IOVHBOCS: Ministero della Salute and 5x1000 Istituto Oncologico Veneto grant. kConFab: The National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia. MAYO: NIH grants CA116167, CA192393 and CA176785, an NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201),and a grant from the Breast Cancer Research Foundation. MCGILL: Jewish General Hospital Weekend to End Breast Cancer, Quebec Ministry of Economic Development, Innovation and Export Trade. Marc Tischkowitz is supported by the funded by the European Union Seventh Framework Program (2007Y2013)/European Research Council (Grant No. 310018). MSKCC: the Breast Cancer Research Foundation, the Robert and Kate Niehaus Clinical Cancer Genetics Initiative, the Andrew Sabin Research Fund and a Cancer Center Support Grant/Core Grant (P30 CA008748). NCI: the Intramural Research Program of the US National Cancer Institute, NIH, and by support services contracts NO2-CP-11019-50, N02-CP-21013-63 and N02-CP-65504 with Westat, Inc, Rockville, MD. NNPIO: the Russian Foundation for Basic Research (grants 17-00-00171, 18-515-45012 and 19-515-25001). NRG Oncology: U10 CA180868, NRG SDMC grant U10 CA180822, NRG Administrative Office and the NRG Tissue Bank (CA 27469), the NRG Statistical and Data Center (CA 37517) and the Intramural Research Program, NCI. OSUCCG: Ohio State University Comprehensive Cancer Center. PBCS: Italian Association of Cancer Research (AIRC) [IG 2013 N.14477] and Tuscany Institute for Tumours (ITT) grant 2014-2015-2016. SMC: the Israeli Cancer Association. SWE-BRCA: the Swedish Cancer Society. UCHICAGO: NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA125183), R01 CA142996, 1U01CA161032 and by the Ralph and Marion Falk Medical Research Trust, the Entertainment Industry Fund National Women's Cancer Research Alliance and the Breast Cancer research Foundation. UCSF: UCSF Cancer Risk Program and Helen Diller Family Comprehensive Cancer Center. UPENN: Breast Cancer Research Foundation; Susan G. Komen Foundation for the cure, Basser Research Center for BRCA. UPITT/MWH: Hackers for Hope Pittsburgh. VFCTG: Victorian Cancer Agency, Cancer Australia, National Breast Cancer Foundation. WCP: Dr Karlan is funded by the American Cancer Society Early Detection Professorship (SIOP-06-258-01-COUN) and the National Center for Advancing Translational Sciences (NCATS), Grant UL1TR000124. HVH: Supported by the Carlos III National Health Institute funded by FEDER funds - a way to build Europe - PI16/11363. MT Parsons is supported by a grant from Newcastle University. Kelly-Anne Phillips is an Australian National Breast Cancer Foundation Fellow. ; Sí

Publisher's version (útgefin grein) ; Breast cancer is a common disease partially caused by genetic risk factors. Germline pathogenic variants in DNA repair genes BRCA1, BRCA2, PALB2, ATM, and CHEK2 are associated with breast cancer risk. FANCM, which encodes for a DNA translocase, has been proposed as a breast cancer predisposition gene, with greater effects for the ER-negative and triple-negative breast cancer (TNBC) subtypes. We tested the three recurrent protein-truncating variants FANCM:p.Arg658*, p.Gln1701*, and p.Arg1931* for association with breast cancer risk in 67,112 cases, 53,766 controls, and 26,662 carriers of pathogenic variants of BRCA1 or BRCA2. These three variants were also studied functionally by measuring survival and chromosome fragility in FANCM−/− patient-derived immortalized fibroblasts treated with diepoxybutane or olaparib. We observed that FANCM:p.Arg658* was associated with increased risk of ER-negative disease and TNBC (OR = 2.44, P = 0.034 and OR = 3.79; P = 0.009, respectively). In a country-restricted analysis, we confirmed the associations detected for FANCM:p.Arg658* and found that also FANCM:p.Arg1931* was associated with ER-negative breast cancer risk (OR = 1.96; P = 0.006). The functional results indicated that all three variants were deleterious affecting cell survival and chromosome stability with FANCM:p.Arg658* causing more severe phenotypes. In conclusion, we confirmed that the two rare FANCM deleterious variants p.Arg658* and p.Arg1931* are risk factors for ER-negative and TNBC subtypes. Overall our data suggest that the effect of truncating variants on breast cancer risk may depend on their position in the gene. Cell sensitivity to olaparib exposure, identifies a possible therapeutic option to treat FANCM-associated tumors. ; Peterlongo laboratory is supported by Associazione Italiana Ricerca sul Cancro (AIRC; IG2015 no.16732) to P. Peterlongo and by a fellowship from Fondazione Umberto Veronesi to G. Figlioli. Surrallés laboratory is supported by the ICREA-Academia program, the Spanish Ministry of Health (projects FANCOSTEM and FANCOLEN), the Spanish Ministry of Economy and Competiveness (projects CB06/07/0023 and RTI2018-098419-B-I00), the European Commission (EUROFANCOLEN project HEALTH-F5-2012-305421 and P-SPHERE COFUND project), the Fanconi Anemia Research Fund Inc, and the "Fondo Europeo de Desarrollo Regional, una manera de hacer Europa" (FEDER). CIBERER is an initiative of the Instituto de Salud Carlos III, Spain. BCAC: we thank all the individuals who took part in these studies and all the researchers, clinicians, technicians and administrative staff who have enabled this work to be carried out. ABCFS thank Maggie Angelakos, Judi Maskiell, Tu Nguyen-Dumont is a National Breast Cancer Foundation (Australia) Career Development Fellow. ABCS thanks the Blood bank Sanquin, The Netherlands. Samples are made available to researchers on a non-exclusive basis. BCEES thanks Allyson Thomson, Christobel Saunders, Terry Slevin, BreastScreen Western Australia, Elizabeth Wylie, Rachel Lloyd. The BCINIS study would not have been possible without the contributions of Dr. Hedy Rennert, Dr. K. Landsman, Dr. N. Gronich, Dr. A. Flugelman, Dr. W. Saliba, Dr. E. Liani, Dr. I. Cohen, Dr. S. Kalet, Dr. V. Friedman, Dr. O. Barnet of the NICCC in Haifa, and all the contributing family medicine, surgery, pathology and oncology teams in all medical institutes in Northern Israel. The BREOGAN study would not have been possible without the contributions of the following: Manuela Gago-Dominguez, Jose Esteban Castelao, Angel Carracedo, Victor Muñoz Garzón, Alejandro Novo Domínguez, Maria Elena Martinez, Sara Miranda Ponte, Carmen Redondo Marey, Maite Peña Fernández, Manuel Enguix Castelo, Maria Torres, Manuel Calaza (BREOGAN), José Antúnez, Máximo Fraga and the staff of the Department of Pathology and Biobank of the University Hospital Complex of Santiago-CHUS, Instituto de Investigación Sanitaria de Santiago, IDIS, Xerencia de Xestion Integrada de Santiago-SERGAS; Joaquín González-Carreró and the staff of the Department of Pathology and Biobank of University Hospital Complex of Vigo, Instituto de Investigacion Biomedica Galicia Sur, SERGAS, Vigo, Spain. BSUCH thanks Peter Bugert, Medical Faculty Mannheim. CBCS thanks study participants, co-investigators, collaborators and staff of the Canadian Breast Cancer Study, and project coordinators Agnes Lai and Celine Morissette. CCGP thanks Styliani Apostolaki, Anna Margiolaki, Georgios Nintos, Maria Perraki, Georgia Saloustrou, Georgia Sevastaki, Konstantinos Pompodakis. CGPS thanks staff and participants of the Copenhagen General Population Study. For the excellent technical assistance: Dorthe Uldall Andersen, Maria Birna Arnadottir, Anne Bank, Dorthe Kjeldgård Hansen. The Danish Cancer Biobank is acknowledged for providing infrastructure for the collection of blood samples for the cases. Investigators from the CPS-II cohort thank the participants and Study Management Group for their invaluable contributions to this research. They also acknowledge the contribution to this study from central cancer registries supported through the Centers for Disease Control and Prevention National Program of Cancer Registries, as well as cancer registries supported by the National Cancer Institute Surveillance Epidemiology and End Results program. The CTS Steering Committee includes Leslie Bernstein, Susan Neuhausen, James Lacey, Sophia Wang, Huiyan Ma, and Jessica Clague DeHart at the Beckman Research Institute of City of Hope, Dennis Deapen, Rich Pinder, and Eunjung Lee at the University of Southern California, Pam Horn-Ross, Peggy Reynolds, Christina Clarke Dur and David Nelson at the Cancer Prevention Institute of California, Hoda Anton-Culver, Argyrios Ziogas, and Hannah Park at the University of California Irvine, and Fred Schumacher at Case Western University. DIETCOMPLYF thanks the patients, nurses and clinical staff involved in the study. The DietCompLyf study was funded by the charity Against Breast Cancer (Registered Charity Number 1121258) and the NCRN. We thank the participants and the investigators of EPIC (European Prospective Investigation into Cancer and Nutrition). ESTHER thanks Hartwig Ziegler, Sonja Wolf, Volker Hermann, Christa Stegmaier, Katja Butterbach. FHRISK thanks NIHR for funding. GC-HBOC thanks Stefanie Engert, Heide Hellebrand, Sandra Kröber and LIFE - Leipzig Research Centre for Civilization Diseases (Markus Loeffler, Joachim Thiery, Matthias Nüchter, Ronny Baber). The GENICA Network: Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tübingen, Germany [HB, Wing-Yee Lo], German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) [HB], Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany's Excellence Strategy - EXC 2180 - 390900677 [HB], Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany [Yon-Dschun Ko, Christian Baisch], Institute of Pathology, University of Bonn, Germany [Hans-Peter Fischer], Molecular Genetics of Breast Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany [Ute Hamann], Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, Germany [TB, Beate Pesch, Sylvia Rabstein, Anne Lotz]; and Institute of Occupational Medicine and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Germany [Volker Harth]. HABCS thanks Michael Bremer. HEBCS thanks Heidi Toiminen, Kristiina Aittomäki, Irja Erkkilä and Outi Malkavaara. HMBCS thanks Peter Hillemanns, Hans Christiansen and Johann H. Karstens. HUBCS thanks Shamil Gantsev. KARMA thanks the Swedish Medical Research Counsel. KBCP thanks Eija Myöhänen, Helena Kemiläinen. LMBC thanks Gilian Peuteman, Thomas Van Brussel, EvyVanderheyden and Kathleen Corthouts. MABCS thanks Milena Jakimovska (RCGEB "Georgi D. Efremov), Katerina Kubelka, Mitko Karadjozov (Adzibadem-Sistina" Hospital), Andrej Arsovski and Liljana Stojanovska (Re-Medika" Hospital) for their contributions and commitment to this study. MARIE thanks Petra Seibold, Dieter Flesch-Janys, Judith Heinz, Nadia Obi, Alina Vrieling, Sabine Behrens, Ursula Eilber, Muhabbet Celik, Til Olchers and Stefan Nickels. MBCSG (Milan Breast Cancer Study Group) thanks Daniela Zaffaroni, Irene Feroce, and the personnel of the Cogentech Cancer Genetic Test Laboratory. We thank the coordinators, the research staff and especially the MMHS participants for their continued collaboration on research studies in breast cancer. MSKCC thanks Marina Corines and Lauren Jacobs. MTLGEBCS would like to thank Martine Tranchant (CHU de Québec Research Center), Marie-France Valois, Annie Turgeon and Lea Heguy (McGill University Health Center, Royal Victoria Hospital; McGill University) for DNA extraction, sample management and skillful technical assistance. J.S. is Chairholder of the Canada Research Chair in Oncogenetics. NBHS thanks study participants and research staff for their contributions and commitment to the studies. We would like to thank the participants and staff of the Nurses' Health Study and Nurses' Health Study II for their valuable contributions as well as the following state cancer registries for their help: AL, AZ, AR, CA, CO, CT, DE, FL, GA, ID, IL, IN, IA, KY, LA, ME, MD, MA, MI, NE, NH, NJ, NY, NC, ND, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WY. The study protocol was approved by the institutional review boards of the Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, and those of participating registries as required. The authors assume full responsibility for analyses and interpretation of these data. OFBCR thanks Teresa Selander and Nayana Weerasooriya. ORIGO thanks E. Krol-Warmerdam, and J. Blom for patient accrual, administering questionnaires, and managing clinical information. PBCS thanks Louise Brinton, Mark Sherman, Neonila Szeszenia-Dabrowska, Beata Peplonska, Witold Zatonski, Pei Chao and Michael Stagner. The ethical approval for the POSH study is MREC /00/6/69, UKCRN ID: 1137. We thank staff in the Experimental Cancer Medicine Centre (ECMC) supported Faculty of Medicine Tissue Bank and the Faculty of Medicine DNA Banking resource. PREFACE thanks Sonja Oeser and Silke Landrith. PROCAS thanks NIHR for funding. RBCS thanks Petra Bos, Jannet Blom, Ellen Crepin, Elisabeth Huijskens, Anja Kromwijk-Nieuwlaat, Annette Heemskerk, the Erasmus MC Family Cancer Clinic. We thank the SEARCH and EPIC teams. SKKDKFZS thanks all study participants, clinicians, family doctors, researchers and technicians for their contributions and commitment to this study. We thank the SUCCESS Study teams in Munich, Duessldorf, Erlangen and Ulm. SZBCS thanks Ewa Putresza. UCIBCS thanks Irene Masunaka. UKBGS thanks Breast Cancer Now and the Institute of Cancer Research for support and funding of the Breakthrough Generations Study, and the study participants, study staff, and the doctors, nurses and other health care providers and health information sources who have contributed to the study. We acknowledge NHS funding to the Royal Marsden/ICR NIHR Biomedical Research Centre. CIMBA: we are grateful to all the families and clinicians who contribute to the studies; Sue Healey, in particular taking on the task of mutation classification with the late Olga Sinilnikova; Maggie Angelakos, Judi Maskiell, Helen Tsimiklis; members and participants in the New York site of the Breast Cancer Family Registry; members and participants in the Ontario Familial Breast Cancer Registry; Vilius Rudaitis and Laimonas Griškevičius; Yuan Chun Ding and Linda Steele for their work in participant enrollment and biospecimen and data management; Bent Ejlertsen and Anne-Marie Gerdes for the recruitment and genetic counseling of participants; Alicia Barroso, Rosario Alonso and Guillermo Pita; all the individuals and the researchers who took part in CONSIT TEAM (Consorzio Italiano Tumori Ereditari Alla Mammella), thanks in particular: Giulia Cagnoli, Roberta Villa, Irene Feroce, Mariarosaria Calvello, Riccardo Dolcetti, Giuseppe Giannini, Laura Papi, Gabriele Lorenzo Capone, Liliana Varesco, Viviana Gismondi, Maria Grazia Tibiletti, Daniela Furlan, Antonella Savarese, Aline Martayan, Stefania Tommasi, Brunella Pilato, Isabella Marchi, Elena Bandieri, Antonio Russo, Daniele Calistri and the personnel of the Cogentech Cancer Genetic Test Laboratory, Milan, Italy. FPGMX: members of the Cancer Genetics group (IDIS): Ana Blanco, Miguel Aguado, Uxía Esperón and Belinda Rodríguez. We thank all participants, clinicians, family doctors, researchers, and technicians for their contributions and commitment to the DKFZ study and the collaborating groups in Lahore, Pakistan (Noor Muhammad, Sidra Gull, Seerat Bajwa, Faiz Ali Khan, Humaira Naeemi, Saima Faisal, Asif Loya, Mohammed Aasim Yusuf) and Bogota, Colombia (Diana Torres, Ignacio Briceno, Fabian Gil). Genetic Modifiers of Cancer Risk in BRCA1/2 Mutation Carriers (GEMO) study is a study from the National Cancer Genetics Network UNICANCER Genetic Group, France. We wish to pay a tribute to Olga M. Sinilnikova, who with Dominique Stoppa-Lyonnet initiated and coordinated GEMO until she sadly passed away on the 30th June 2014. The team in Lyon (Olga Sinilnikova, Mélanie Léoné, Laure Barjhoux, Carole Verny-Pierre, Sylvie Mazoyer, Francesca Damiola, Valérie Sornin) managed the GEMO samples until the biological resource centre was transferred to Paris in December 2015 (Noura Mebirouk, Fabienne Lesueur, Dominique Stoppa-Lyonnet). We want to thank all the GEMO collaborating groups for their contribution to this study. Drs.Sofia Khan, Irja Erkkilä and Virpi Palola; The Hereditary Breast and Ovarian Cancer Research Group Netherlands (HEBON) consists of the following Collaborating Centers: Netherlands Cancer Institute (coordinating center), Amsterdam, NL: M.A. Rookus, F.B.L. Hogervorst, F.E. van Leeuwen, M.A. Adank, M.K. Schmidt, N.S. Russell, D.J. Jenner; Erasmus Medical Center, Rotterdam, NL: J.M. Collée, A.M.W. van den Ouweland, M.J. Hooning, C.M. Seynaeve, C.H.M. van Deurzen, I.M. Obdeijn; Leiden University Medical Center, NL: C.J. van Asperen, P. Devilee, T.C.T.E.F. van Cronenburg; Radboud University Nijmegen Medical Center, NL: C.M. Kets, A.R. Mensenkamp; University Medical Center Utrecht, NL: M.G.E.M. Ausems, M.J. Koudijs; Amsterdam Medical Center, NL: C.M. Aalfs, H.E.J. Meijers-Heijboer; VU University Medical Center, Amsterdam, NL: K. van Engelen, J.J.P. Gille; Maastricht University Medical Center, NL: E.B. Gómez-Garcia, M.J. Blok; University of Groningen, NL: J.C. Oosterwijk, A.H. van der Hout, M.J. Mourits, G.H. de Bock; The Netherlands Comprehensive Cancer Organisation (IKNL): S. Siesling, J.Verloop; The nationwide network and registry of histo- and cytopathology in The Netherlands (PALGA): A.W. van den Belt-Dusebout. HEBON thanks the study participants and the registration teams of IKNL and PALGA for part of the data collection. Overbeek; the Hungarian Breast and Ovarian Cancer Study Group members (Janos Papp, Aniko Bozsik, Zoltan Matrai, Miklos Kasler, Judit Franko, Maria Balogh, Gabriella Domokos, Judit Ferenczi, Department of Molecular Genetics, National Institute of Oncology, Budapest, Hungary) and the clinicians and patients for their contributions to this study; HVH (University Hospital Vall d'Hebron) the authors acknowledge the Oncogenetics Group (VHIO) and the High Risk and Cancer Prevention Unit of the University Hospital Vall d'Hebron, Miguel Servet Progam (CP10/00617), and the Cellex Foundation for providing research facilities and equipment; the ICO Hereditary Cancer Program team led by Dr. Gabriel Capella; the ICO Hereditary Cancer Program team led by Dr. Gabriel Capella; Dr Martine Dumont for sample management and skillful assistance; Catarina Santos and Pedro Pinto; members of the Center of Molecular Diagnosis, Oncogenetics Department and Molecular Oncology Research Center of Barretos Cancer Hospital; Heather Thorne, Eveline Niedermayr, all the kConFab investigators, research nurses and staff, the heads and staff of the Family Cancer Clinics, and the Clinical Follow Up Study (which has received funding from the NHMRC, the National Breast Cancer Foundation, Cancer Australia, and the National Institute of Health (USA)) for their contributions to this resource, and the many families who contribute to kConFab; the investigators of the Australia New Zealand NRG Oncology group; members and participants in the Ontario Cancer Genetics Network; Kevin Sweet, Caroline Craven, Julia Cooper, Amber Aielts, and Michelle O'Conor; Christina Selkirk; Helena Jernström, Karin Henriksson, Katja Harbst, Maria Soller, Ulf Kristoffersson; from Gothenburg Sahlgrenska University Hospital: Anna Öfverholm, Margareta Nordling, Per Karlsson, Zakaria Einbeigi; from Stockholm and Karolinska University Hospital: Anna von Wachenfeldt, Annelie Liljegren, Annika Lindblom, Brita Arver, Gisela Barbany Bustinza; from Umeå University Hospital: Beatrice Melin, Christina Edwinsdotter Ardnor, Monica Emanuelsson; from Uppsala University: Hans Ehrencrona, Maritta Hellström Pigg, Richard Rosenquist; from Linköping University Hospital: Marie Stenmark-Askmalm, Sigrun Liedgren; Cecilia Zvocec, Qun Niu; Joyce Seldon and Lorna Kwan; Dr. Robert Nussbaum, Beth Crawford, Kate Loranger, Julie Mak, Nicola Stewart, Robin Lee, Amie Blanco and Peggy Conrad and Salina Chan; Carole Pye, Patricia Harrington and Eva Wozniak. OSUCCG thanks Kevin Sweet, Caroline Craven, Julia Cooper, Michelle O'Conor and Amber Aeilts. BCAC is funded by Cancer Research UK [C1287/A16563, C1287/A10118], the European Union's Horizon 2020 Research and Innovation Programme (grant numbers 634935 and 633784 for BRIDGES and B-CAST respectively), and by the European Community´s Seventh Framework Programme under grant agreement number 223175 (grant number HEALTH-F2-2009-223175) (COGS). The EU Horizon 2020 Research and Innovation Programme funding source had no role in study design, data collection, data analysis, data interpretation or writing of the report. Genotyping of the OncoArray was funded by the NIH Grant U19 CA148065, and Cancer UK Grant C1287/A16563 and the PERSPECTIVE project supported by the Government of Canada through Genome Canada and the Canadian Institutes of Health Research (grant GPH-129344) and, the Ministère de l'Économie, Science et Innovation du Québec through Genome Québec and the PSRSIIRI-701 grant, and the Quebec Breast Cancer Foundation. The Australian Breast Cancer Family Study (ABCFS) was supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The ABCFS was also supported by the National Health and Medical Research Council of Australia, the New South Wales Cancer Council, the Victorian Health Promotion Foundation (Australia) and the Victorian Breast Cancer Research Consortium. J.L.H. is a National Health and Medical Research Council (NHMRC) Senior Principal Research Fellow. M.C.S. is a NHMRC Senior Research Fellow. The ABCS study was supported by the Dutch Cancer Society [grants NKI 2007-3839; 2009 4363]. The Australian Breast Cancer Tissue Bank (ABCTB) was supported by the National Health and Medical Research Council of Australia, The Cancer Institute NSW and the National Breast Cancer Foundation. The AHS study is supported by the intramural research program of the National Institutes of Health, the National Cancer Institute (grant number Z01-CP010119), and the National Institute of Environmental Health Sciences (grant number Z01-ES049030). The work of the BBCC was partly funded by ELAN-Fond of the University Hospital of Erlangen. The BBCS is funded by Cancer Research UK and Breast Cancer Now and acknowledges NHS funding to the NIHR Biomedical Research Centre, and the National Cancer Research Network (NCRN). The BCEES was funded by the National Health and Medical Research Council, Australia and the Cancer Council Western Australia. For the BCFR-NY, BCFR-PA, BCFR-UT this work was supported by grant UM1 CA164920 from the National Cancer Institute. The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the BCFR. BCINIS study was funded by the BCRF (The Breast Cancer Research Foundation, USA). The BREast Oncology GAlician Network (BREOGAN) is funded by Acción Estratégica de Salud del Instituto de Salud Carlos III FIS PI12/02125/Cofinanciado FEDER; Acción Estratégica de Salud del Instituto de Salud Carlos III FIS Intrasalud (PI13/01136); Programa Grupos Emergentes, Cancer Genetics Unit, Instituto de Investigacion Biomedica Galicia Sur. Xerencia de Xestion Integrada de Vigo-SERGAS, Instituto de Salud Carlos III, Spain; Grant 10CSA012E, Consellería de Industria Programa Sectorial de Investigación Aplicada, PEME I + D e I + D Suma del Plan Gallego de Investigación, Desarrollo e Innovación Tecnológica de la Consellería de Industria de la Xunta de Galicia, Spain; Grant EC11-192. Fomento de la Investigación Clínica Independiente, Ministerio de Sanidad, Servicios Sociales e Igualdad, Spain; and Grant FEDER-Innterconecta. Ministerio de Economia y Competitividad, Xunta de Galicia, Spain. The BSUCH study was supported by the Dietmar-Hopp Foundation, the Helmholtz Society and the German Cancer Research Center (DKFZ). Sample collection and processing was funded in part by grants from the National Cancer Institute (NCI R01CA120120 and K24CA169004). CBCS is funded by the Canadian Cancer Society (grant # 313404) and the Canadian Institutes of Health Research. CCGP is supported by funding from the University of Crete. The CECILE study was supported by Fondation de France, Institut National du Cancer (INCa), Ligue Nationale contre le Cancer, Agence Nationale de Sécurité Sanitaire, de l'Alimentation, de l'Environnement et du Travail (ANSES), Agence Nationale de la Recherche (ANR). The CGPS was supported by the Chief Physician Johan Boserup and Lise Boserup Fund, the Danish Medical Research Council, and Herlev and Gentofte Hospital. The American Cancer Society funds the creation, maintenance, and updating of the CPS-II cohort. The CTS was initially supported by the California Breast Cancer Act of 1993 and the California Breast Cancer Research Fund (contract 97-10500) and is currently funded through the National Institutes of Health (R01 CA77398, K05 CA136967, UM1 CA164917, and U01 CA199277). Collection of cancer incidence data was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885. The University of Westminster curates the DietCompLyf database funded by Against Breast Cancer Registered Charity No. 1121258 and the NCRN. The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by: Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l'Education Nationale, Institut National de la Santé et de la Recherche Médicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ), Federal Ministry of Education and Research (BMBF) (Germany); the Hellenic Health Foundation, the Stavros Niarchos Foundation (Greece); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), Statistics Netherlands (The Netherlands); Health Research Fund (FIS), PI13/00061 to Granada, PI13/01162 to EPIC-Murcia, Regional Governments of Andalucía, Asturias, Basque Country, Murcia and Navarra, ISCIII RETIC (RD06/0020) (Spain); Cancer Research UK (14136 to EPIC-Norfolk; C570/A16491 and C8221/A19170 to EPIC-Oxford), Medical Research Council (1000143 to EPIC-Norfolk, MR/M012190/1 to EPIC-Oxford) (United Kingdom). The ESTHER study was supported by a grant from the Baden Württemberg Ministry of Science, Research and Arts. Additional cases were recruited in the context of the VERDI study, which was supported by a grant from the German Cancer Aid (Deutsche Krebshilfe). FHRISK is funded from NIHR grant PGfAR 0707-10031. The GC-HBOC (German Consortium of Hereditary Breast and Ovarian Cancer) is supported by the German Cancer Aid (grant no 110837, coordinator: Rita K. Schmutzler, Cologne). This work was also funded by the European Regional Development Fund and Free State of Saxony, Germany (LIFE - Leipzig Research Centre for Civilization Diseases, project numbers 713-241202, 713-241202, 14505/2470, 14575/2470). The GENICA was funded by the Federal Ministry of Education and Research (BMBF) Germany grants 01KW9975/5, 01KW9976/8, 01KW9977/0 and 01KW0114, the Robert Bosch Foundation, Stuttgart, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, the Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, as well as the Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany. The GEPARSIXTO study was conducted by the German Breast Group GmbH. The GESBC was supported by the Deutsche Krebshilfe e. V. [70492] and the German Cancer Research Center (DKFZ). The HABCS study was supported by the Claudia von Schilling Foundation for Breast Cancer Research, by the Lower Saxonian Cancer Society, and by the Rudolf Bartling Foundation. The HEBCS was financially supported by the Helsinki University Central Hospital Research Fund, Academy of Finland (266528), the Finnish Cancer Society, and the Sigrid Juselius Foundation. The HMBCS was supported by a grant from the German Research Foundation (Do 761/10-1). The HUBCS was supported by a grant from the German Federal Ministry of Research and Education (RUS08/017), and by the Russian Foundation for Basic Research and the Federal Agency for Scientific Organizations for support the Bioresource collections and RFBR grants 14-04-97088, 17-29-06014 and 17-44-020498. E.K was supported by the program for support the bioresource collections №007-030164/2 and study was performed as part of the assignment of the Ministry of Science and Higher Education of Russian Federation (№АААА-А16-116020350032-1). Financial support for KARBAC was provided through the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet, the Swedish Cancer Society, The Gustav V Jubilee foundation and Bert von Kantzows foundation. The KARMA study was supported by Märit and Hans Rausings Initiative Against Breast Cancer. The KBCP was financially supported by the special Government Funding (EVO) of Kuopio University Hospital grants, Cancer Fund of North Savo, the Finnish Cancer Organizations, and by the strategic funding of the University of Eastern Finland. LMBC is supported by the 'Stichting tegen Kanker'. DL is supported by the FWO. The MABCS study is funded by the Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov" and supported by the German Academic Exchange Program, DAAD. The MARIE study was supported by the Deutsche Krebshilfe e.V. [70-2892-BR I, 106332, 108253, 108419, 110826, 110828], the Hamburg Cancer Society, the German Cancer Research Center (DKFZ) and the Federal Ministry of Education and Research (BMBF) Germany [01KH0402]. MBCSG is supported by grants from the Italian Association for Cancer Research (AIRC) and by funds from the Italian citizens who allocated the 5/1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects "5 × 1000"). The MCBCS was supported by the NIH grants CA192393, CA116167, CA176785 an NIH Specialized Program of Research Excellence (SPORE) in Breast Cancer [CA116201], and the Breast Cancer Research Foundation and a generous gift from the David F. and Margaret T. Grohne Family Foundation. MCCS cohort recruitment was funded by VicHealth and Cancer Council Victoria. The MCCS was further supported by Australian NHMRC grants 209057 and 396414, and by infrastructure provided by Cancer Council Victoria. Cases and their vital status were ascertained through the Victorian Cancer Registry (VCR) and the Australian Institute of Health and Welfare (AIHW), including the National Death Index and the Australian Cancer Database. The MEC was support by NIH grants CA63464, CA54281, CA098758, CA132839 and CA164973. The MISS study is supported by funding from ERC-2011-294576 Advanced grant, Swedish Cancer Society, Swedish Research Council, Local hospital funds, Berta Kamprad Foundation, Gunnar Nilsson. The MMHS study was supported by NIH grants CA97396, CA128931, CA116201, CA140286 and CA177150. MSKCC is supported by grants from the Breast Cancer Research Foundation and Robert and Kate Niehaus Clinical Cancer Genetics Initiative. The work of MTLGEBCS was supported by the Quebec Breast Cancer Foundation, the Canadian Institutes of Health Research for the "CIHR Team in Familial Risks of Breast Cancer" program – grant # CRN-87521 and the Ministry of Economic Development, Innovation and Export Trade – grant # PSR-SIIRI-701. The NBHS was supported by NIH grant R01CA100374. Biological sample preparation was conducted the Survey and Biospecimen Shared Resource, which is supported by P30 CA68485. The Northern California Breast Cancer Family Registry (NC-BCFR) and Ontario Familial Breast Cancer Registry (OFBCR) were supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The Carolina Breast Cancer Study was funded by Komen Foundation, the National Cancer Institute (P50 CA058223, U54 CA156733, U01 CA179715), and the North Carolina University Cancer Research Fund. The NHS was supported by NIH grants P01 CA87969, UM1 CA186107, and U19 CA148065. The NHS2 was supported by NIH grants UM1 CA176726 and U19 CA148065. The ORIGO study was supported by the Dutch Cancer Society (RUL 1997-1505) and the Biobanking and Biomolecular Resources Research Infrastructure (BBMRI-NL CP16). The PBCS was funded by Intramural Research Funds of the National Cancer Institute, Department of Health and Human Services, USA. Genotyping for PLCO was supported by the Intramural Research Program of the National Institutes of Health, NCI, Division of Cancer Epidemiology and Genetics. The PLCO is supported by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics and supported by contracts from the Division of Cancer Prevention, National Cancer Institute, National Institutes of Health. The POSH study is funded by Cancer Research UK (grants C1275/A11699, C1275/C22524, C1275/A19187, C1275/A15956 and Breast Cancer Campaign 2010PR62, 2013PR044. PROCAS is funded from NIHR grant PGfAR 0707-10031. The RBCS was funded by the Dutch Cancer Society (DDHK 2004-3124, DDHK 2009-4318). SEARCH is funded by Cancer Research UK [C490/A10124, C490/A16561] and supported by the UK National Institute for Health Research Biomedical Research Centre at the University of Cambridge. The University of Cambridge has received salary support for PDPP from the NHS in the East of England through the Clinical Academic Reserve. The Sister Study (SISTER) is supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences (Z01-ES044005 and Z01-ES049033). The Two Sister Study (2SISTER) was supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences (Z01-ES044005 and Z01-ES102245), and, also by a grant from Susan G. Komen for the Cure, grant FAS0703856. SKKDKFZS is supported by the DKFZ. The SMC is funded by the Swedish Cancer Foundation and the Swedish Research Council [grant 2017-00644 for the Swedish Infrastructure for Medical Population-based Life-course Environmental Research (SIMPLER)]. The SZBCS is financially supported under the program of Minister of Science and Higher Education "Regional Initiative of Excellence" in years 2019-2022, Grant No 002/RID/2018/19. The TNBCC was supported by: a Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a grant from the Breast Cancer Research Foundation, a generous gift from the David F. and Margaret T. Grohne Family Foundation. The UCIBCS component of this research was supported by the NIH [CA58860, CA92044] and the Lon V Smith Foundation [LVS39420]. The UKBGS is funded by Breast Cancer Now and the Institute of Cancer Research (ICR), London. ICR acknowledges NHS funding to the NIHR Biomedical Research Centre. The UKOPS study was funded by The Eve Appeal (The Oak Foundation) and supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. The USRT Study was funded by Intramural Research Funds of the National Cancer Institute, Department of Health and Human Services, USA. CIMBA CIMBA: The CIMBA data management and data analysis were supported by Cancer Research – UK grants C12292/A20861, C12292/A11174. ACA is a Cancer Research -UK Senior Cancer Research Fellow. GCT and ABS are NHMRC Research Fellows. The PERSPECTIVE project was supported by the Government of Canada through Genome Canada and the Canadian Institutes of Health Research, the Ministry of Economy, Science and Innovation through Genome Québec, and The Quebec Breast Cancer Foundation. BCFR: UM1 CA164920 from the National Cancer Institute. The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centers in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the BCFR. BFBOCC: Lithuania (BFBOCC-LT): Research Council of Lithuania grant SEN-18/2015 and Nr. P-MIP-19-164. BIDMC: Breast Cancer Research Foundation. BMBSA: Cancer Association of South Africa (PI Elizabeth J. van Rensburg). CNIO: Spanish Ministry of Health PI16/00440 supported by FEDER funds, the Spanish Ministry of Economy and Competitiveness (MINECO) SAF2014-57680-R and the Spanish Research Network on Rare diseases (CIBERER). COH-CCGCRN: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under grant number R25CA112486, and RC4CA153828 (PI: J. Weitzel) from the National Cancer Institute and the Office of the Director, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. CONSIT TEAM: Associazione Italiana Ricerca sul Cancro (AIRC; IG2014 no.15547) to P. Radice. Funds from Italian citizens who allocated the 5 × 1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects '5 × 1000') to S. Manoukian. UNIROMA1: Italian Association for Cancer Research (AIRC; grant no. 21389) to L. Ottini. DFKZ: German Cancer Research Center. EMBRACE: Cancer Research UK Grants C1287/A10118 and C1287/A11990. D. Gareth Evans and Fiona Lalloo are supported by an NIHR grant to the Biomedical Research Centre, Manchester (IS-BRC-1215-20007). The Investigators at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust are supported by an NIHR grant to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. Ros Eeles and Elizabeth Bancroft are supported by Cancer Research UK Grant C5047/A8385. Ros Eeles is also supported by NIHR support to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. FCCC: NIH/NCI grant P30-CA006927. The University of Kansas Cancer Center (P30 CA168524) and the Kansas Bioscience Authority Eminent Scholar Program. A.K.G. was funded by R0 1CA140323, R01 CA214545, and by the Chancellors Distinguished Chair in Biomedical Sciences Professorship. Ana Vega is supported by the Spanish Health Research Foundation, Instituto de Salud Carlos III (ISCIII), partially supported by FEDER funds through Research Activity Intensification Program (contract grant numbers: INT15/00070, INT16/00154, INT17/00133), and through Centro de Investigación Biomédica en Red de Enferemdades Raras CIBERER (ACCI 2016: ER17P1AC7112/2018); Autonomous Government of Galicia (Consolidation and structuring program: IN607B), and by the Fundación Mutua Madrileña (call 2018). GC-HBOC: German Cancer Aid (grant no 110837, Rita K. Schmutzler) and the European Regional Development Fund and Free State of Saxony, Germany (LIFE - Leipzig Research Centre for Civilization Diseases, project numbers 713-241202, 713-241202, 14505/2470, 14575/2470). GEMO: Ligue Nationale Contre le Cancer; the Association "Le cancer du sein, parlons-en!" Award, the Canadian Institutes of Health Research for the "CIHR Team in Familial Risks of Breast Cancer" program, the French National Institute of Cancer (INCa) (grants AOR 01 082, 2013-1-BCB-01-ICH-1 and SHS-E-SP 18-015) and the Fondation ARC pour la recherche sur le cancer (grant PJA 20151203365). GEORGETOWN: the Survey, Recruitment and Biospecimen Shared Resource at Georgetown University (NIH/NCI grant P30-CA051008) and the Fisher Center for Hereditary Cancer and Clinical Genomics Research. HCSC: Spanish Ministry of Health PI15/00059, PI16/01292, and CB-161200301 CIBERONC from ISCIII (Spain), partially supported by European Regional Development FEDER funds. HEBCS: Helsinki University Hospital Research Fund, Academy of Finland (266528), the Finnish Cancer Society and the Sigrid Juselius Foundation. HEBON: the Dutch Cancer Society grants NKI1998-1854, NKI2004-3088, NKI2007-3756, the Netherlands Organization of Scientific Research grant NWO 91109024, the Pink Ribbon grants 110005 and 2014-187.WO76, the BBMRI grant NWO 184.021.007/CP46 and the Transcan grant JTC 2012 Cancer 12-054. HUNBOCS: Hungarian Research Grants KTIA-OTKA CK-80745 and NKFI_OTKA K-112228. HVH (University Hospital Vall d'Hebron) This work was supported by Spanish Instituto de Salud Carlos III (ISCIII) funding, an initiative of the Spanish Ministry of Economy and Innovation partially supported by European Regional Development FEDER Funds: FIS PI12/02585 and PI15/00355. ICO: The authors would like to particularly acknowledge the support of the Asociación Española Contra el Cáncer (AECC), the Instituto de Salud Carlos III (organismo adscrito al Ministerio de Economía y Competitividad) and "Fondo Europeo de Desarrollo Regional (FEDER), una manera de hacer Europa" (PI10/01422, PI13/00285, PIE13/00022, PI15/00854, PI16/00563, P18/01029, and CIBERONC) and the Institut Català de la Salut and Autonomous Government of Catalonia (2009SGR290, 2014SGR338, 2017SGR449, and PERIS Project MedPerCan), and CERCA program. IHCC: PBZ_KBN_122/P05/2004. ILUH: Icelandic Association "Walking for Breast Cancer Research" and by the Landspitali University Hospital Research Fund. INHERIT: Canadian Institutes of Health Research for the "CIHR Team in Familial Risks of Breast Cancer" program – grant # CRN-87521 and the Ministry of Economic Development, Innovation and Export Trade – grant # PSR-SIIRI-701. IOVHBOCS: Ministero della Salute and "5 × 1000" Istituto Oncologico Veneto grant. IPOBCS: Liga Portuguesa Contra o Cancro. kConFab: The National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia. MAYO: NIH grants CA116167, CA192393 and CA176785, an NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), and a grant from the Breast Cancer Research Foundation. MCGILL: Jewish General Hospital Weekend to End Breast Cancer, Quebec Ministry of Economic Development, Innovation and Export Trade. Marc Tischkowitz is supported by the funded by the European Union Seventh Framework Program (2007Y2013)/European Research Council (Grant No. 310018). MSKCC: the Breast Cancer Research Foundation, the Robert and Kate Niehaus Clinical Cancer Genetics Initiative, the Andrew Sabin Research Fund and a Cancer Center Support Grant/Core Grant (P30 CA008748). NCI: the Intramural Research Program of the US National Cancer Institute, NIH, and by support services contracts NO2-CP-11019-50, N02-CP-21013-63 and N02-CP-65504 with Westat, Inc, Rockville, MD. NNPIO: the Russian Foundation for Basic Research (grants 17-54-12007, 17-00-00171 and 18-515-45012). NRG Oncology: U10 CA180868, NRG SDMC grant U10 CA180822, NRG Administrative Office and the NRG Tissue Bank (CA 27469), the NRG Statistical and Data Center (CA 37517) and the Intramural Research Program, NCI. OSUCCG: was funded by the Ohio State University Comprehensive Cancer Center. PBCS: Italian Association of Cancer Research (AIRC) [IG 2013 N.14477] and Tuscany Institute for Tumors (ITT) grant 2014-2015-2016. SMC: the Israeli Cancer Association. SWE-BRCA: the Swedish Cancer Society. UCHICAGO: NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA125183), R01 CA142996, 1U01CA161032 and by the Ralph and Marion Falk Medical Research Trust, the Entertainment Industry Fund National Women's Cancer Research Alliance and the Breast Cancer research Foundation. UCSF: UCSF Cancer Risk Program and Helen Diller Family Comprehensive Cancer Center. UKFOCR: Cancer Researc h UK. UPENN: National Institutes of Health (NIH) (R01-CA102776 and R01-CA083855; Breast Cancer Research Foundation; Susan G. Komen Foundation for the cure, Basser Research Center for BRCA. UPITT/MWH: Hackers for Hope Pittsburgh. VFCTG: Victorian Cancer Agency, Cancer Australia, National Breast Cancer Foundation. WCP: Dr Karlan is funded by the American Cancer Society Early Detection Professorship (SIOP-06-258-01-COUN) and the National Center for Advancing Translational Sciences (NCATS), Grant UL1TR000124. ; Peer Reviewed

In the 15-years I have served in the United States Army, the focal point of my tactical and academic study has been almost entirely centered on the Middle East and its unique cultural complexities. As an Infantryman, I was embroiled in the early efforts to prevent a Sunni-Shia civil war in post-invasion Iraq, while also hunting down al-Qaeda operatives under the leadership of Abu Musab al-Zarqawi. A year later, during General Patraeus's troop surge, I was in the urban sprawl of Northwest Baghdad fighting not only a Sunni insurgency, but also the Iranian-backed Jaysh al-Mahdi, comprised of local Shia militia groups. In 2010, I led a battalion reconnaissance team in the Arghandab River Valley of Afghanistan against the Taliban near the very birthplace of their Salafi-jihadist movement. In subsequent years, following my graduation from the Special Forces Qualification Course, I served in the 5th Special Forces Group (SFG) on a variety of missions in support of Operation Inherent Resolve in Turkey and Syria. As a fluent Arabic speaker, I was heavily involved in early efforts to train and equip the Free Syrian Army for its fight against the Islamic State. Following this deployment, I served as a liaison officer to the United States Embassy and Turkish General Staff in Ankara, having daily interaction with foreign dignitaries, defense attachés, and military officials in strategic level planning and coordination efforts. I culminated my time with 5th SFG as the assistant operations sergeant of a detachment fighting the Islamic State in Syria. My understanding of the culture of jihad, the various jihadist groups operating throughout the Central Command (CENTCOM) area of responsibility, and the intricacy of Middle Eastern problem sets as a whole, has come from years of dedicated cultural analysis, in-depth study of Sunni and Shia Islam, and field experience from the strategic to the tactical level. It is because of this experience that I am compelled to discuss the culture of jihad in the 21st Century. ; Winner of the 2020 Friends of the Kreitzberg Library Award for Outstanding Research in the College of Graduate and Continuing Studies Degree Completion category. ; 1 The Culture of Jihad in the 21st Century Michael J. Bearden Norwich University SOCI401: Cultural and Anthropology Studies Dr. Timothy Maynard April 30, 2020 2 The Culture of Jihad in the 21st Century In the 15-years I have served in the United States Army, the focal point of my tactical and academic study has been almost entirely centered on the Middle East and its unique cultural complexities. As an Infantryman, I was embroiled in the early efforts to prevent a Sunni-Shia civil war in post-invasion Iraq, while also hunting down al-Qaeda operatives under the leadership of Abu Musab al-Zarqawi. A year later, during General Patraeus's troop surge, I was in the urban sprawl of Northwest Baghdad fighting not only a Sunni insurgency, but also the Iranian-backed Jaysh al-Mahdi, comprised of local Shia militia groups. In 2010, I led a battalion reconnaissance team in the Arghandab River Valley of Afghanistan against the Taliban near the very birthplace of their Salafi-jihadist movement. In subsequent years, following my graduation from the Special Forces Qualification Course, I served in the 5th Special Forces Group (SFG) on a variety of missions in support of Operation Inherent Resolve in Turkey and Syria. As a fluent Arabic speaker, I was heavily involved in early efforts to train and equip the Free Syrian Army for its fight against the Islamic State. Following this deployment, I served as a liaison officer to the United States Embassy and Turkish General Staff in Ankara, having daily interaction with foreign dignitaries, defense attachés, and military officials in strategic level planning and coordination efforts. I culminated my time with 5th SFG as the assistant operations sergeant of a detachment fighting the Islamic State in Syria. My understanding of the culture of jihad, the various jihadist groups operating throughout the Central Command (CENTCOM) area of responsibility, and the intricacy of Middle Eastern problem sets as a whole, has come from years of dedicated cultural analysis, in-depth study of Sunni and Shia Islam, and field experience from the strategic to the tactical level. It is because of this experience that I am compelled to discuss the culture of jihad in the 21st Century. 3 Since its beginning in circa 610 CE, when the prophet Muhammad ibn Abdullah was visited by the angel Gabriel in a cave near Mecca, Islam has shaken the foundations of the Middle East and remained in a state of near-perpetual conflict with the Western world. Islam is an Arabic term most closely relating to the English words submission or surrender. Mujahedeen, or holy warriors, spread this new religion by the sword throughout Asia, forcing the "submission" of thousands, and have hardly been at peace with their neighbors since. Centuries later, in the two decades following the attacks on the World Trade Center and Pentagon in the United States, radical Islam's stance against the West has altered the diplomatic landscape between the world's great powers, fundamentally changed the United States' national strategic direction, and caused youth from all walks of life to sacrifice the best years of their lives in holy war to protect the supra-national community of Islam. From the invasion of Afghanistan to the subsequent invasions of Iraq and Syria to the ongoing peace talks with the Taliban, diplomatic and military efforts to eradicate jihadists from the Middle East have to-date been nearly ineffectual. Not only have these efforts failed to contain or defeat jihad, but at times have served to strengthen Islamic extremists' resolve in their call to arms against the West. Because jihad is such a fundamental part of the Islamic faith, it can never be "defeated" in the sense of traditional military eradication of an enemy force, but it can be confronted, contained, or refocused, as this paper will address. I argue that enabling local solutions and promoting education, alongside tailored surgical strike and security cooperation operations where necessary, are the keys to confronting, containing, and countering jihad. 4 Background Defining Jihad and Salafism Jihad is a transliterated form of the Arabic word meaning to struggle or to strive. In the traditional teachings of the Islamic faith, jihad is broken into two distinct categories: Greater jihad and lesser jihad. Greater jihad includes the personal struggle against selfish desires, emphasizing discipline and morality, as well as the struggle against Satan and the forces of evil. It includes jihad of the heart, jihad of the mind, and jihad of the tongue, involving praise for those who follow the will of Allah and correction for those who have gone astray (Gorka, 2016). The second category, lesser jihad, is viewed as the struggle against the enemies of Islam and the defense of its people. Lesser jihad is commonly referred to as Jihad of the Sword. Gorka (p. 60) reveals that, over time, this category of jihad has been used as justification for at least seven different subsets of holy war: 1. Using holy war to build an empire 2. Going after apostate regimes or individuals 3. Revolting against non-pious Muslim leaders 4. Fighting against the forces of imperialism in Muslim lands 5. Countering the West's pagan influence 6. Guerrilla warfare against a foreign invader 7. Using jihad as justification for terrorist attacks against civilian targets In a broad sense, lesser jihad can be viewed as offensive or defensive martial action. On the offensive side, jihadists use religion to justify building an empire, such as the Islamic State, attack apostate regimes, like those of the Taliban against Afghan government forces, and use terrorism against civilians, like the attacks on the World Trade Center. This offensive action 5 often takes jihadists beyond the borders of the ummah, or the people of Islam, striking fear into hearts of unbelievers around the globe. The defensive variety, especially in recent history, has most often correlated directly with the use of guerrilla warfare against foreign invaders, such as al-Qaeda's attacks on the international military coalitions that invaded Afghanistan and Iraq. This radical view of Islam is mostly practiced by those who follow the way of the Salafi, or the pious predecessors from the time of Muhammad, who experienced Islam in its purest form. It is believed that the first three generations who practiced the teachings of the prophet Muhammad are the ones who all Muslims thereafter should try to emulate. Themes of Salafism focus on complete adherence to sharia law, the fight against apostate Muslim regimes, and the spread and protection of Islam and its followers. At its core, Salafism is a very traditionalist view of Islam and has been practiced by multiple 21st Century terrorist organizations. The terms jihad and Salafi have shared such a close relationship in the last few decades that they have become nearly synonymous, at times described as Salafi-Jihadism or Jihadi-Salafism (Gorka, 2016; Nilsson, 2019) What Cultural Influences Lead One to the Path of Jihad? Before the attacks on 9/11, the largest call to jihad answered by the international Muslim community was in response to the Soviet invasion of Afghanistan in 1979. Stopping the spread of communism and defending the ummah against the atrocities of Russian ground forces was seen as a noble and just cause for young Muslim men, and not just among Muslims (Gorka, 2016; Nilsson, 2019). Many nations, including the United States, funded, equipped, and trained the Afghan mujahedeen (those who conduct jihad) for the fight against the Soviet empire. Jihad in the 21st Century has been viewed in a much different light, as it is most closely associated with acts of extreme violence against Western nations. While the piles of rubble that used to be the 6 World Trade Center smoldered, and a gaping hole scarred the wall of the Pentagon, people of the world were forced to ask themselves, "How could a person do this? Why would someone take their own lives and thousands of others in the name of Allah?" Religious Justification for Jihad. Though jihad has become almost entirely associated with Islamic holy war, the term itself is still simply the Arabic word for striving. Struggling against one's selfish desires, striving to maintain traditional values, and defending a community against a common enemy are not just Islamic concepts, they are universal to most tightly-knit cultures. Similarly, Christians and Jews are taught self-discipline, adherence to moral codes, and defending their belief against enemies of their faith. So, why has the Islamic flavor of this common cultural theme become so violent, causing deep unrest around the world in our modern era? Verses from the Qur'an can begin to unpack why horrific public executions, suicide bombings, and advocating for generalized violence against non-Muslims may be justifiable in jihadist culture. The Qur'an (2015) lays out the following decree in chapter 9, verse 29: Fight those from among the People of the Book who believe not in Allah, nor in the Last Day, nor hold as unlawful what Allah and His Messenger have declared to be unlawful, nor follow the true religion, until they pay the tax with their own hand and acknowledge their subjection (p. 208). My personal study of Islam and conversations with Muslims in the field revealed that this bit of prose has been used as motivation and justification for jihad by groups like al-Qaeda, the Taliban, the Islamic State, and Hay'at Tahrir al-Sham of our modern age. Some of the following themes are evident in the translation: 7 • Jews and Christians are recognized as People of the Book, but are required to accept the following—Allah as the one true god, sharia as the acceptable law, and Islam as the one true religion. • If Jews and Christians refuse to accept these statutes, they must pay a tax called the jizyah to show their subjugation. • If they refuse to do either of these, they are to be put to the sword (p. 208). Salafi-jihadist groups such as the Taliban and Islamic State have tried to revive the jizyah tax in areas under their control. Likewise, hundreds of Christians, Jews, and even Muslims who refuse to adhere to strict sharia law have been publicly executed. This vehement enforcement of arcane Islamic law is seen as a return to the purest form of Islam, as pious as the first few generations who followed the Prophet Muhammad. Another common religious cultural theme that ties these jihadist organizations together is a message of religious oppression. They preach to young Muslims that the Islamic world is under siege by the West and that their god, their value systems, and their way of life are being threatened by the evils of capitalism and democracy (Venhaus, 2010). In joining organizations like al-Qaeda or the Islamic State, young men from across the globe find a sense of purpose and direction in their cause to protect the ummah. This theme is manifested in the teachings of Anwar al-Awlaki, the spiritual leader of al-Qaeda and the father of home-grown terrorism in the United States. He calls on Muslims living among those in the West: How can your conscience allow you to live in peaceful coexistence with a nation that is responsible for the tyranny and crimes committed against your own brothers and sisters? How can you have your loyalty to a government that is leading the war against Islam and Muslims? Hence, my advice to you is this, you have two choices: either hijra [migration 8 to an Islamic land] or jihad. You either leave or you fight. You leave and live among Muslims or you stay behind and fight with your hand, your wealth, and your word. I specifically invite the youth to either fight in the West or join their brothers on the fronts of jihad: Afghanistan, Iraq, and Somalia (as cited in Gorka, 2016). This way of thinking is also captured in chapter 9, verse 5 of the Qur'an (2015): Kill the idolaters wherever you find them and take them prisoners, and beleaguer them, and lie in wait for them at every place of ambush. But if they repent and observe Prayer and pay the Zakat, then leave their way free (p. 204). When taken literally, as they are by followers of Salafi-jihad, scriptures such as these leave no choice. To these men who have committed themselves fully to the ways of the pious ones, they are compelled to become shahid, or martyrs in the protection of the ummah. The Qur'an promises paradise for those who do: Surely, Allah has purchased of the believers their persons and their property in return for the Garden they shall have; they fight in the cause of Allah, and they slay and are slain—a promise the He has made incumbent on Himself in the Torah, and the Gospel, and the Qur'an. And who is more faithful to his promise than Allah? Rejoice, then, in your bargain which you have made with Him; and that it is which is the supreme triumph (p. 222). The concept of becoming a martyr in the struggle for Islam is romanticized by jihadist groups, like al-Qaeda and the Islamic State, and even state governments in local programming. In Lebanon, Mothers of Martyrs are interviewed to share the stories of their sons' glorious end while fighting abroad against the infidels (Venhaus, 2010). The Qur'an itself calls this sacrifice the supreme triumph for a jihadist, striving for the glory of Allah. 9 Though enforcing the jizyah, publicly executing those who do not follow sharia law, and seeking opportunities to kill infidels through suicide attacks represent a very small, extremist cultural sect of Islam, each of these practices is still justifiable if one looks to the Qur'an. This could be viewed as no different than a rural Pentecostal church in the Deep South who maintains strict standards for how women must dress and act: it all comes down to interpretation and a community's willingness to subjugate themselves to these standards. Spiritual leaders of jihadist groups in the 21st Century have used the Qur'an as continued justification for a variety of cruel, inhumane, and brutal actions that served to shock the West. The holy book of Islam acts as the essential glue, binding together all facets of Arab and Islamic culture. Artistic Inspiration for Jihad. A far cry from the harsh proclamations of the Qur'an, Arabic poetry predates Islam by centuries and serves as a bedrock of Arabic culture across the Middle East. Early desert nomads composed poems mostly in mono-rhyme and in one of sixteen standard canonical measures, which made them easy to commit to memory (Creswell & Haykel, 2015). Naturally, this beautiful form of cultural expression has found a home in the modern jihadist movement, where it has become an inspiration for new recruits to join the cause and crucial in the sustainment of those already fighting infidels abroad. Creswell and Haykel assert that although analysts have generally ignored this facet of jihadist culture, it is woven deeply into the fabric of modern Islamic extremism. Osama bin Laden, most recognized as the former head of al-Qaeda, was also a highly-celebrated jihadist poet. Without question, his lyrical genius inspired young Arabs with stories of a return to the heroic and chivalrous past of Islam. One of his most famous works celebrates the martyrdom of the 9/11 hijackers. This is a theme among modern jihadist poetry, which preserves the tales of suicide bombers, the conquered apostate regimes of Iraq and Syria, and the glories of jihadist heroes (Creswell & Haykel). Likewise, in a 10 group of individuals who have each traveled far from home to defend Islam against the kuffar, these poems help to establish a sense of cultural identity, strengthening their wartime bond and solidifying their resolve. In seeing the videos of the Islamic State as they carved a path of destruction across large swathes of Iraq in early 2014, it may be difficult for one to believe that its members were motivated by the rhythmic lines of jihadist poetry. It is hard to accept that the same young fighter who is willing to behead an infidel for all the free world to see, could also be found passionately reciting lines celebrating the glorious return of an Islamic caliphate. During its rise, the Islamic State capitalized on the lyrical talent of a Damascus-born woman named Ahlam al-Nasr. In her first broadcast, called the Blaze of Truth, she sang each one of her 107 works a cappella, in accordance with the Islamic State's ban on musical instruments. The video was uploaded to Youtube, receiving thousands of views and further shares on multiple social media platforms (Creswell & Haykel, 2015). In the early days of the group's brutal campaign in Iraq, al-Nasr celebrated victory in Mosul as a new dawn for the country: "Ask Mosul, city of Islam, about the lions— how their fierce struggle brought liberation. The land of glory has shed its humiliation and defeat and put on the raiment of splendor" (as cited in Creswell & Haykel, 2015). Her choice of words helps one sense her deep passion for jihad, hidden within the lines. Mujahedeen are called lions and liberators. Mosul is called both a city of Islam and a land of 11 glory that, because of its liberation, has been released from the chains of shame and can now live in the splendor and pride of its former renown. Poetry has succored those serving in times of war for hundreds, even thousands of years. In the same manner, this key element of artistic cultural expression has helped bind together the modern jihadi movement, capturing the heroic deeds of martyrs who would otherwise remain nameless and unrecognized by the outside world. Serving in lands far away from home, young jihadists find inspiration, strength, and a renewed sense of identity in these haunting bits of rhyme. Social Pressure to Join Jihad. Abdullah Anas was an Algerian who served as one of the mujahedeen in Afghanistan in the 1980s and spent several years studying under Abdullah Azzam, the Palestinian "Father of Resistance to the Soviets" (Gall, 2020). Working to help Algerians achieve nonviolent change in their government, Anas, now in his 60s, has spent a life living and working among jihadists. To Anas, jihad is a fundamental principle of Muslim culture through which mujahedeen receive rewards in heaven: "I will never denounce jihad. As a Muslim, I know this to be a noble deed—where man can be the most beastly" (Gall). In a study of three Swedish jihadists, with experiences ranging from 1980s Afghanistan to the modern fight in Syria, Nilsson (2019) suggests that one of the fundamental social justifications for joining jihad is the sense that Islam and Muslims are collectively under attack. This, again, is a theme that applies to more than just the modern jihadist movement: Americans lined up in droves outside recruiting stations following the attacks on Pearl Harbor and decades later after September 11, 2001. Following the invasion of Afghanistan and Iraq, many Muslims from around the world began to see this not as just the West going after the 9/11 conspirators, but as a global attack on Islam. Each day, fresh news stories of coalition soldiers' crimes against 12 Muslim civilians and pictures of burning villages continued to motivate men to join the fight to protect the ummah from the foreign invaders. Nilsson contends that since most jihadists are very young, in their teens and early twenties, they are very susceptible to the influences of close friends and social groups. Safet, a young Muslim living in Sweden, was pressured by a friend to join the Islamic State in Syria, saying that he became convinced by his friend Ahmed that the group was fighting to protect Muslims (Nilsson). However, after realizing that the Islamic State was actually killing other Muslims in a practice called takfir, or excommunication, Safet became disillusioned and returned to Sweden (Nilsson). From the fight against the foreign invaders in the early 2000s in Afghanistan and Iraq, to the struggle for the establishment of an Islamic caliphate in 2015, it seems jihadists have most often been motivated by the need to protect the international Muslim community. Aside from the social responsibility of defending their faith and people, the need for adventure also seems to permeate the ideations of young men seeking to join a jihadist group. One of Nilsson's (2019) most interesting theories is that jihad is not the radicalization of Islam, but rather the Islamization of radicalism. Individuals who are already naturally predisposed to such adventurous or nihilistic behavior get caught up in the social dynamics of their time, ending up in a jihadist movement. Venhaus (2010) explains that in interviews with over 2,000 al-Qaeda prisoners from Iraq to Guantanamo Bay, he found that young Muslim men sought the cause of jihad for a number of normal social pressures felt by normal teens worldwide: "Revenge seekers need an outlet for their frustration, status seekers need recognition, identity seekers need a group to join, and thrill seekers need adventure" (Venhaus). The Effects of Social Media and Technology on Jihad. In the modern era, news is no longer bound by the time it takes for an article to be published, printed, and distributed across 13 great distance in a community. Social media platforms like Facebook, Youtube, Twitter, and Instagram have made sharing news instantaneous. Additionally, the advent of the smartphone, which acts simultaneously as a hand-held computer, high definition camera, and telephone with nearly world-wide coverage has forever changed the media landscape. In the era of modern jihad, one can post a single video that moves the minds of thousands in a matter of seconds. Following the 2003 invasion of Iraq to topple Saddam Hussein's regime, news stories of atrocity among the efforts of coalition troops over the next decade served to further the cause of local and foreign jihadists to protect the ummah from these invaders. Accidental bombing of civilians, mistreatment of the prisoners at Abu Ghraib, and a general ignorance toward Muslim culture were fueled by social media and smartphone technology. Venhaus (2010) claims that throughout this early phase of the war in Iraq, al-Qaeda very rarely had to actively recruit, their global brand was aggressively promoted through satellite television, internet chat rooms, and social media platforms; willing candidates sought them out. This use of media continued to be perfected by jihadist organizations like the Islamic State, who published a digital magazine called Dabiq, named for the ideological capital of the proposed caliphate, which rallied Muslims to jihad through stories of glory and heroism in the cause for Islam. The Islamic State also posted grisly execution videos, with stunning music and production value, including super high-definition shots of their brutality. Publications and videos such as these could be copied, saved, shared, and re-shared before any sort of government intervention could stop them. Creswell and Haykel (2015) reveal that jihadists were running a massive, secret network of social media websites and fake accounts that could be rapidly assembled and dissembled by hackers. The effects of social media and technology on modern jihadist culture are easy to understand, but challenging to measure in scope and reach. Just as easily as videos of Islamic 14 State propaganda or poetry can be shared, so too can stories of coalition force atrocities in Afghanistan and Iraq. This has put strategists in a unique position, where it is nearly impossible to control the narrative. Unfortunately, the story that breaks first is still the one that is liked and shared the most, even if the truth comes out after. Effects of Western Culture on Jihad. Rapid globalization, including the widespread diffusion of the internet and technology into the Middle East in the last two decades has continued to foment jihadist hatred for the West. Personal conversations with multiple Muslims in Iraq and Afghanistan revealed that the decadence, lavish richness, and sinful lifestyles portrayed by Western movies and media served to fuel the fires of disdain among the pious Salafi-jihadists. Additionally, Muslim men living in Western nations following the attacks on the World Trade Center were ostracized and feared by society, often leading them to an eventual radicalization process. Being denied a peaceful coexistence because of continued Western misperception, caused many young Muslims to become angry and seek community and brotherhood among other Muslims experiencing the same problems. Venhaus (2010) notes that out of the over 2,000 captured jihadists interviewed, more than 30 per cent of them sought al-Qaeda because they were angry. Under the tutelage of local al-Qaeda mentors, the frustrations of these young men were then turned upon their neighbors through careful instruction and manipulation. They were taught to see the West as the enemy of Islam, with hundreds of the ummah being harmed by their military coalitions in Afghanistan and Iraq each day. They were instructed in the ways of the pious ones who came before them, inspiring them to turn from the sinfulness of their Western neighbors and take pride in their newfound self-discipline and righteousness in the eyes of Allah. Eventually, many of these young men would travel to their 15 ancestral homelands to join the struggle, or conduct terrorist attacks on their own Western communities. Analysis A Unique Challenge Given the litany of reasons one might join jihad, the incredibly complex cultural and social environment, and the fluidity of the modern jihadist movement, how can the United States begin to contain this problem? The reasons one individual might join a jihadist cause are as various and sundry as why one might choose to join any movement or profession over another. As Nilsson (2019) and Venhaus (2010) have detailed, there appears to be no singular marker: one could be an extremely religious or a passive Muslim, rich or poor, single or married with a family, have a completely stable social life or be isolated with no friends. Jihadists can be from any country, any walk of life, and usually do not widely broadcast their intentions prior to taking part in acts of violence for the cause of Islam. It is because of the near-impossibility of clearly identifying a pattern of distinguishable cultural markers that make it such a challenge for the United States government and its allies to address the threat of jihad. Targeting an individual before they become a jihadist or before they commit a terrorist act has been one of the most formidable challenges of our time for military and law enforcement professionals alike. Usually, the much simpler job is finding a jihadist who has allowed their communications discipline to slip before an act, or catching them in a pitched battle on foreign soil. In order to protect citizens of the West and East alike against jihadists' aims, the United States Government must be prepared to confront, contain, and counter the jihadist narrative "left of bang," before an attack occurs. 16 The Global War on Terrorism: Taking the Fight to the Jihadists. In the months that followed September 11, 2001, President George W. Bush deployed Central Intelligence Agency (CIA) paramilitary officers and US Special Operations Forces (SOF) to find, fix, and finish pockets of al-Qaeda militants being harbored by the Taliban in Afghanistan. A fierce campaign of relentless aerial bombardment and mounted assaults by the forces of the Afghan Northern Alliance led to a swift and decisive defeat of al-Qaeda and the Taliban. With Kabul and Kandahar in allied hands, and an interim government established under the leadership of the Pashtun Hamid Karzai, the future of a free and prosperous Afghanistan seemed assured, but what came to be known as The Long War had only just begun. Trillions of dollars, thousands of lives, and 19 years later, the United States and its allies have been forced to the negotiating table with the Salafi-jihadist Taliban. Likewise, after Saddam Hussein's continued disregard for international law, threats against the United States, and open violence against his own people, the administration of President Bush decided again to pursue a military option. Much like Afghanistan, the coalition was led by CIA operatives and SOF operators, coordinating airstrikes on key positions in a tactical display of American firepower affectionately titled Shock and Awe. However, unlike Afghanistan, a massive conventional invasion followed the bombing campaign, bent on toppling the Baathist regime and finding Saddam's chemical weapons stockpiles. What followed was a series of policy failures, leading to a steady influx of jihadists partnering with local insurgents seeking to oust the foreign invaders and protect the ummah from the atrocities of the kuffar. In my professional opinion, Iraq is still recovering from the decade-long military occupation, cleaning up the destruction left by the Islamic State, and on the brink of civil war due to concerns about being an Iranian puppet state. 17 Ineffective Military Methods to Combat Jihad Operation Iraqi Freedom. During my first combat rotation as an Infantryman in the Triangle of Death in southern Iraq in 2005-2006, I experienced the initial rumblings of a civil war between the Sunni and Shia Muslims in Iraq, each wrestling for power in a post-Saddam world. I was also witness to the inundation of foreign jihadists, joining the ranks of al-Qaeda in Iraq under the leadership of Abu Musab al-Zarqawi, who at times headquartered in my area of operations. As I analyze our highly-kinetic and aggressive initial campaigns years later, I can see that the coalition's fight, first against Saddam, then against al-Qaeda, only bolstered jihadist motivation. In being a foreign invader, we inadvertently created a jihadist resistance movement, bent on the removal of their occupiers. Kilcullen (2010) explains this dilemma by explaining that focusing on the wrong metrics in a fight against insurgents can be deceptive: If you kill 20 insurgents, they may have 40 relatives who are now in a blood feud with your unit and are compelled to take revenge. Again in 2007-2008, I was deployed to Iraq as an Infantry squad leader to the sacred city of Khadimiyah in Northwest Baghadad. This was during the famous troop surge, meant to fix the ongoing problems with stability throughout the country. Being in the home of the beautiful Shrine of the Seventh Imam, it was a predominantly Shia area. Over the course of 15 months, my unit fought several engagements against Iranian-backed Shia militias and worked on project after project to strengthen local civil infrastructure, all while maintaining the utmost discretion against damaging homes or creating civilian casualties. Yet again, although we had conducted a nearly perfect counterinsurgency fight, it seemed that Kilcullen's insurgent math still applied: Fighting the jihadists only served to create more unrest within the population, no matter if we were restoring essential services and reducing damage to homes or not. 18 Operation Enduring Freedom. Nearly a decade after the fall of al-Qaeda and its Taliban hosts, I was deployed to the mountains of Afghanistan from 2010-2011. Stationed along the Arghandab River, just north of Kandahar, we were in the heart of the Pashtun Taliban. Again, the same story remained true: We fought the Taliban jihadists almost daily, but could not seem to win over the true key terrain in a counterinsurgency fight: The hearts and minds of the people. The Taliban would harass our unit's base of operations with a few pop shots as we called them, which would unleash a massive response in firepower and resources. Thousands of rounds of machine gun ammunition would be fired into the farm fields surrounding our Combat Out Post (COP), squads would be sent in pursuit of the attackers, and helicopters would spend hours scouring the terrain in an attempt to heap justice on the insurgents. This massive effort against so few served to erode the unit's motivation, exhaust our supplies, and alienate the civilian population whose homes and fields had been damaged in the process. Reflections on Personal Combat Experience. After years of combat experience and deeply studying Muslim culture, I can now see how the mistakes the coalitions made early-on in both operations only fueled the fires of insurgency, resistance to foreign occupiers, and generalized hatred for the West. Porch (2013) argues brilliantly that US counterinsurgency doctrine made the same mistake as its imperialistic predecessors of centuries before: Believing that military action was a proper vehicle for providing Middle Easterners with Western values, as well as a foundation for governance, social programs, and economic transformation in a region. This became evident in my own experience, realizing that no matter what sort of social, infrastructure, or economic programs ran alongside our military efforts, the people of both Afghanistan and Iraq felt the enormous social weight of being occupied by a foreign power, rendering these efforts nearly ineffectual. On the contrary, local and foreign jihadist movements 19 capitalized on each and every mistake of coalition forces, increasing their recruitment and resolve against the West. Though our military may have been winning every major battle against the jihadists, our policy makers and field commanders made the fundamental mistake of believing that these non-Western nations lived in some sort of time-warp, in which the adoption of Western democracy, rule of law, and capitalism would allow them to thrive as a nation (Porch). Effective Military Methods to Combat Jihad Surgical Strike and Precision Targeting. A unique feature of the Global War on Terrorism was the US military's continued perfection of covert strike operations with surgical precision deep into enemy safe havens. This was put on display in the rout of al-Qaeda by CIA and SOF in Afghanistan, in the kill/capture missions against the Baathists in the deck of cards in Iraq, and later in the killing of Osama bin Laden in Pakistan and Sheik Abu Bakr al-Baghdadi in Iraq. Having the ability to appear out of nowhere in the middle of the night, kill or capture an intended target with zero damage to infrastructure or civilian casualties, and leave within minutes of arrival struck fear into the hearts and minds of jihadists across the globe. The success and efficacy of this type of operation was acknowledged in the 2015 National Military Strategy, which stated: "The best way to counter VEOs [violent extremist organizations] is by way of.military strengths such as ISR, precision strike [emphasis added], training, and logistical support" (p.11). Likewise, President Obama's massive expansion of the use of drones, which could watch individuals for days and execute a precise strike that only touched the intended target, has continued to sow fear and deny jihadists' freedom of maneuver on a global scale. The US military and its allies have only continued to master these types of operations throughout the 20 fights in Afghanistan, Iraq, Syria, and other locations. The jihadists know this, and realize that one wrong move at any time could mean disaster. Security Cooperation. An additional theme that has spelled the end for jihadists throughout the globe has been the training, advising, and equipping of security forces and partners within Afghanistan, Iraq, Syria, and other nations. Enabling the host-nation military to handle jihadist movements on their own helps the United States military work itself out of a job. US Army Special Forces are uniquely suited to accomplish this mission: With specialized training, language capability, and cultural understanding, they are able to train foreign security forces through a variety of Principle Tasks. These tasks include Foreign Internal Defense, which focuses on a holistic approach to internal security and protection of citizens against lawlessness and insurgency, and Security Force Assistance, which can be focused internally or externally against threats to a nation's stability and security. The success of these mission sets was evident in 2014, during my own experience with the Afghan Commando Kandaks' continued fight against the Taliban and in closely following the Iraqi Counterterrorism Service's efforts against the Islamic State. Both of these forces, built from the ground-up by US Army Special Forces have continually fortified weak conventional military force operations against jihadist groups in their respective nations. Muslim Youth Efforts Against Jihad Globalization, though it has been proven to bolster the jihadists' narrative against the West, has also been beneficial to the movement against jihad itself. Because youth of the world have access to technology that allows them to see the atrocities and lies associated with global jihadist organizations, they are beginning to turn the tide. During the Islamic State's rise to power in Iraq and Syria, Muslim youth from across Europe travelled to join the jihadists in their 21 fight against the West. However, groups of Muslim youth also spoke up to counter this narrative. In 2015 the Muslim Youth League, an anti-Islamic State cultural movement, declared a holy war against all extremist organizations (Dearden, 2015). The group called on all Muslims to stand united against those who have hijacked Islam and misrepresented the faith. Through engagement work in schools and communities, as well as a robust online campaign, the Muslim Youth League is fighting back against jihadist propaganda that bids young Muslims join the Islamic State and other extremist groups (Dearden). Since the time of this publication, the Muslim Youth League has spread to several countries throughout the Middle East, Asia, and Europe, each with their own social media presence, outreach programs, community events, and websites. Local Government Efforts Against Jihad In the years following the Islamic State's spread across Iraq and Syria, the United Kingdom has developed a robust strategy to help at-risk Muslims avoid the radicalization process. The program itself is called Contest, and includes four distinct categories: Prevent, Prepare, Protect, and Pursue (British Broadcasting Corporation [BBC], 2017). Police departments and social organizations have built relationships with doctors, faith leaders, teachers and others, who are required to report suspicious persons to the proper authorities. In response to these reporting requirements and recommendations, over 7,500 reports were filed between 2015-2016, with one in 10 being actionable intelligence for government and police forces (BBC). In 2015 alone, over 150 people, including 50 children, were kept from traveling to conflict zones in Iraq and Syria (BBC). The strategy has of course drawn criticism, for fear that it will further alienate Muslims from their local communities, but it presents as an excellent plan of action for identifying individuals who are at risk beyond just using traditional signals intelligence and 22 surveillance techniques. It does more than just target the individual, it also seeks to reform them through education, outreach, and community programs. Counterarguments You Can Kill an Idea. I have heard the opinion throughout my time in the military that jihad and the idea of Islamic supremacy can be completely eradicated. The example most often given is that Nazism, including the idea that the Aryan race was superior to all others, was effectively destroyed by a global military campaign. This argument is weak. The Nazis represented a very small portion of German culture, including among those serving in the military, so it was relatively easy to contain once there was an overwhelming military victory by the Allies. However, although the German Army of the 1940s was defeated militarily, the idea of white supremacy lives on in small social groups throughout the world to this day. The Ongoing Taliban Peace Talks. I have colleagues throughout the military who are convinced that the current negotiations with the Taliban are a key indicator of success in our two decades at war against the Salafi-jihadist group. The issue with this is that temporary cease fires have already been violated several times, leading one to believe that the strategic level leadership's messages are simply not reaching their subordinates or that local factions are not adhering to the agreement. Trusting that radical Muslim extremists will not allow Afghanistan to become a future safe haven for other jihadists, as it has in the past, is simply unrealistic. Believing some sort of quasi peace deal is going to miraculously pacify an organization that hates everything the West stands for is misguided. My own experiences throughout the Middle East have proven that the spirit of jihad and hatred will live on in Afghanistan. The Islamic State is Nearly Defeated. Multiple global media outlets continue to run stories about the dismantling of the Islamic State, as though the battle is won. Though Sheik Abu 23 Bakr al-Baghdadi has been killed, and the proposed Islamic caliphate was never fully realized, it would be naïve to think that the Islamic State's jihad is over. The movement will metastasize and take on new forms in other parts of the globe: It is already happening. Jihadists are continually leaving the battlefields of Iraq and Syria, headed back to their former homes in mainland Europe. As these individuals reenter the diaspora, the concern is that they will radicalize other individuals and conduct terrorist attacks within the continent. Conclusion The reasons an individual seeks to join a jihadist movement are deeply rooted in personal social dynamics, the security situation of their country, and a multitude of other religious, cultural, and economic factors. I agree with Venhaus (2010) and Gorka (2016) who assert that there is no singular military operation or strategy that can bring about a decisive victory against something so intangible as why one might join the modern jihadist movement. Use of the US military as a vehicle for the establishment of Western democracy and nation-building efforts in tribal nations like Afghanistan and Iraq only served to invigorate the jihadists' call to arms. Jihad is not something that can be eradicated completely by military force. Jihad must be confronted, contained, and countered through a comprehensive approach that empowers state and non-state actors to develop local solutions and directs expeditious military applications only where completely necessary. Recommendations Promote and Protect the Muslim Youth Leagues In order to truly create a cultural paradigm shift in Muslim youth at risk of radicalization, groups like the Muslim Youth League (BBC, 2017) should be promoted by governments worldwide as a bastion of true and peaceful Islam. While they should no doubt be supported, 24 governments must also protect these organizations from becoming targets for violent acts of terrorism or influence operations by jihadists. Through a combination of deep cultural understanding and positive messaging, the Muslim Youth League has already shown its effectiveness in the United Kingdom and beyond. Because the youth of each nation understand the social pressures and cultural influences that may lead one to seek jihad, they can effectively develop tailored, local solutions to persuade at-risk individuals. The Muslim Youth Leagues are on the front lines of countering the jihadist worldview, taking a stand and declaring war on jihad and its misrepresentations of Islam. Enable Local Solutions for Local Problems This should be accomplished through unified government action that involves all the United States' instruments of national power including diplomacy, information sharing, military action where necessary, and economic stimulus as needed. The specific issue with efforts like these, is that they cannot be accomplished during what is perceived by locals as a military occupation. This was proven true in Afghanistan and later in Iraq. Despite massive efforts to rebuild infrastructure, aid in agricultural processes, build schools, and organize community projects, the United States and its allies were still viewed as pushing Western values and democracy on nations through military occupation. As much as possible, we must limit our military presence in areas that are ripe for developing a jihadist movement, or in ones that are recovering. I have seen firsthand that government efforts against jihadist organizations or at-risk communities have often been fragmented, poorly staffed, and uncoordinated. Venhaus (2010) suggests the creation of an agency that is staffed, trained, funded, enabled, and equipped for strategic communications, calling it the United States Strategic Communications Agency. An 25 agency like this could ensure that a comprehensive national communications strategy is developed and achieved, with a focus on enabling local community efforts to counter the jihadist narrative. By promoting social outreach, religious education, and community programs, this agency could bolster the efforts of community leaders and stifle jihadist aims in their areas. Support Religious Education and Reintegration Reintegration programs in Saudi Arabia, Indonesia, Singapore and elsewhere have successfully rehabilitated former jihadists through religious education (Venhaus, 2010). Countering the apocalyptic world view of jihadist groups like al-Qaeda and the Islamic State requires local religious leaders who understand their community's issues to band together and refute the extremist narrative. Through careful, patient, and individually-tailored instruction, Muslim religious leaders can invalidate each and every one of the extremists' claims. Individuals who turn to jihad are often seeking this type of direction, they just find it in the wrong places. Counter Threats with Tailored Military Force Packages Continued themes among the military failures in counterinsurgency and counterterrorism operations during the early years of the Global War on Terrorism are indiscriminate use of force, lack of cultural understanding, and hyper-focus on tactical gains while failing at the strategic level. US government nation-building efforts on the backs of the military cost our country trillions of dollars, thousands of lives, and years of frustration, bogged-down in an endless quagmire of misunderstanding. US Army Special Forces are selected, trained, equipped, and enabled to clandestinely handle complex problem sets in denied or politically-sensitive environments. Each Special Forces Group is regionally-aligned, with Operational Detachments developing deep cultural understanding through Area Studies and continuous relationship-building with regional state and 26 non-state actors. Special Forces operators understand the complex cultural and security situations in their areas of responsibility and have the language capability and strategic understanding to operate with complete independence of outside support. Frankly, if given the authority and autonomy to do their jobs, Special Forces can coerce, disrupt, or overthrow jihadist organizations unilaterally, or train, advise, and equip foreign security forces to accomplish this task on their own. This can all be done independent of a large, slow, and expensive conventional military occupation. Organizations like al-Qaeda must be kept in a state of constant fear and uncertainty. US Special Operations Forces are uniquely suited to this task. Through structured, rapid application of military force, SOF can find, fix, and finish intended targets with surgical precision. This has proven true in the capture of Saddam Hussein and the elimination of Osama bin Laden and Abu Bakr al-Baghdadi, among numerous other targets throughout the Global War on Terrorism. Continuing to deny safe havens through short, precise applications of combat power is crucial and does not rely on a conventional military occupation of the target area. Operations such as these, characterized by discriminate use of force and strategic impact, should be the main avenue for denying the relative safety, security, and freedom of maneuver of jihadist organizations. 27 References British Broadcasting Corporation (2017, June 4). Reality check: What is the prevent strategy? Reality Check. https://www.bbc.com/news/election-2017-40151991. Creswell, R., & Haykel, B. (2015, June 1). Battle lines: Want to understand the jihadis? Read their poetry. The New Yorker. https://www.newyorker.com/magazine/2015/06/08/battle-lines-jihad-creswell-and-haykel. Dearden, L. (2015, March 21). Young British Muslims declare own jihad against ISIS and other terrorists who 'hijack' Islam. Independent. https://www.independent.co.uk/news/uk/home-news/young-british-muslims-declare-own-jihad-against-isis-and-other-terrorists-who-hijack-islam-10146534.html. Dempsey, M. (2015). The national military strategy of the United States of America 2015: The United States military's contribution to national security. The Joint Staff. https://www.jcs.mil/Portals/36/Documents/Publications/UNCLASS_2018_National_Military_Strategy_Description.pdf. Gall, C. (2020, January 31). From armed struggle to peaceful protest, a road still to travel: A veteran of the Afghan jihad working for nonviolent change in Algeria. The New York Times. https://www.nytimes.com/2020/01/31/world/middleeast/from-armed-struggle-to-peaceful-protest-a-road-still-to-travel.html. Gorka, S. L. (2016). Defeating jihad: The winnable war. Regnery Publishing. Kilcullen, D. J. (2010). Counterinsurgency. Oxford University Press. Nilsson, M. (2019, 18 June) Motivations for jihad and cognitive dissonance: A qualitative analysis of former Swedish jihadists. Studies in Conflict and Terrorism. https://doi.org/10.1080/1057610X.2019.1626091. 28 Porch, D. (2013). Counterinsurgency: Exposing the myths of the new way of war. Cambridge University Press. Qur'an (M. Ali, Trans.; 7th ed.) (2015). Islam International Publications. (Original work published ca. 1537). Venhaus, J. (2010). Why youth join al-Qaeda. Special Report, 236(1), 1-12. https://www.usip. org/sites/default/files/SR236Venhaus.pdf.

A locus at 19p13 is associated with breast cancer (BC) and ovarian cancer (OC) risk. Here we analyse 438 SNPs in this region in 46,451 BC and 15,438 OC cases, 15,252 BRCA1 mutation carriers and 73,444 controls and identify 13 candidate causal SNPs associated with serous OC (P=9.2 × 10(-20)), ER-negative BC (P=1.1 × 10(-13)), BRCA1-associated BC (P=7.7 × 10(-16)) and triple negative BC (P-diff=2 × 10(-5)). Genotype-gene expression associations are identified for candidate target genes ANKLE1 (P=2 × 10(-3)) and ABHD8 (P<2 × 10(-3)). Chromosome conformation capture identifies interactions between four candidate SNPs and ABHD8, and luciferase assays indicate six risk alleles increased transactivation of the ADHD8 promoter. Targeted deletion of a region containing risk SNP rs56069439 in a putative enhancer induces ANKLE1 downregulation; and mRNA stability assays indicate functional effects for an ANKLE1 3'-UTR SNP. Altogether, these data suggest that multiple SNPs at 19p13 regulate ABHD8 and perhaps ANKLE1 expression, and indicate common mechanisms underlying breast and ovarian cancer risk. ; We thank all the individuals who took part in these studies and all the researchers, clin- icians, technicians and administrative staff who have enabled this work to be carried out, in particular those involved in the COGS project: Rosalind A. Eeles, Ali Amin Al Olama, Zsofia Kote-Jarai, Sara Benlloch (PRACTICAL), Andrew Lee, and Ed Dicks, Craig Luccarini and the staff of the Centre for Genetic Epidemiology Laboratory, the staff of the CNIO genotyping unit, Daniel C. Tessier, Francois Bacot, Daniel Vincent, Sylvie LaBoissie ` re and Frederic Robidoux and the staff of the McGill University and Ge ́ nome Que ́ bec Innovation Centre, Sune F. Nielsen, Borge G. Nordestgaard, and the staff of the Copenhagen DNA laboratory, and Julie M. Cunningham, Sharon A. Windebank, Christopher A. Hilker, Jeffrey Meyer and the staff of Mayo Clinic Genotyping Core Facility. BCAC (acknowledgements by study) (ABCFS) : Maggie Angelakos, Judi Maskiell, Gillian Dite. (ABCS) C Ellen van der Schoot, Sanquin Amsterdam. (ACP) The ACP study wishes to thank the participants in the Thai Breast Cancer study. Special Thanks also go to the Thai Ministry of Public Health (MOPH), doctors and nurses who helped with the data collection process. Finally, the study would like to thank Dr Prat Boonyawongviroj, the former Permanent Secretary of MOPH and Dr Pornthep Siriwanarungsan, the Department Director-Generalof Disease Control who have supported the study throughout. (BBCS) Eileen Williams, Elaine Ryder-Mills, Kara Sargus (BIGGS) Niall McInerney, Gabrielle Colleran, Andrew Rowan, Angela Jones. (BSUCH) Peter Bugert, Medical Faculty Mannheim (CGPS) Staff and participants of the Copenhagen General Population Study. For the excellent technical assistance: Dorthe Uldall Andersen, Maria Birna Arnadottir, Anne Bank, Dorthe Kjeldgård Hansen (CNIO-BCS) Guillermo Pita, Charo Alonso, Daniel Herrero, Nuria A ́ lvarez, Pilar Zamora, Primitiva Menendez, the Human Genotyping-CEGEN Unit (CNIO)(CTS). The CTS Steering Committee includes Leslie Bernstein, Susan Neuhausen, James Lacey, Sophia Wang, Huiyan Ma, Yani Lu, and Jessica Clague DeHart at the Beckman Research Institute of City of Hope, Dennis Deapen, Rich Pinder, Eunjung Lee, and Fred Schumacher at the University of Southern California, Pam Horn-Ross, Peggy Reynolds, Christina Clarke Dur and David Nelson at the Cancer Prevention Institute of California, and Hoda Anton-Culver, Argyrios Ziogas, and Hannah Park at the University of California Irvine. (ESTHER) Hartwig Ziegler, Sonja Wolf, Volker Hermann. (GC-HBOC) Heide Hellebrand, Stefanie Engert and GC-HBOC (Supported by Deutsche Krebshilfe). (GENICA) The GENICA Network: Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tu ̈bingen, Germany [HB, Wing-Yee Lo, Christina Justenhoven], German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) [HB], Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany [Yon-Dschun Ko, Christian Baisch], Institute of Pathology, University of Bonn, Germany [Hans-Peter Fischer], Molecular Genetics of Breast Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany [UH], Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, Germany [Thomas Bru ̈ning, Beate Pesch, Sylvia Rabstein, Anne Lotz]; and Institute of Occupational Medicine and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Germany [Volker Harth] (HEBCS) Kirsimari Aaltonen, Karl von Smitten, Sofia Khan, Tuomas Heikkinen, Irja Erkkila ̈ . (HMBCS) Natalia Antonenkova, Peter Hillemanns, Hans Christiansen and Johann H. Karstens (KBCP) Eija Myo ̈ ha ̈ nen, Helena Kemila ̈ inen. (kConFab/AOCS) We wish to thank Heather Thorne, Eveline Niedermayr, all the kConFab research nurses and staff, the heads and staff of the Family Cancer Clinics, and the Clinical Follow Up Study (which has received funding from the NHMRC, the National Breast Cancer Foundation, Cancer Australia, and the National Institute of Health (USA)) for their contributions to this resource, and the many families who contribute to kConFab. (LAABC) We thank all the study participants and the entire data collection team, especially Annie Fung and June Yashiki. (LMBC) Gilian Peuteman, Dominiek Smeets, Thomas Van Brussel and Kathleen Corthouts. (MARIE) Petra Seibold, Judith Heinz, Nadia Obi, Alina Vrieling, Sabine Behrens, Ursula Eilber, Muhabbet Celik, Til Olchers and Stefan Nickels. (MCCS) MCCS cohort recruitment was funded by VicHealth and Cancer Council Victoria. The MCCS was further supported by Australian NHMRC grants 209057, 251553 and 504711 and by infrastructure provided by Cancer Council Victoria. Cases and their vital status were ascertained through the Victorian Cancer Registry (VCR) and the Australian Institute of Health and Welfare (AIHW), including the National Death Index. (MBCSG) Bernard Peissel and Daniela Zaffaroni and Giulietta Scuvera of the Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Milan, Italy; Monica Barile and Irene Feroce of the Istituto Europeo di Oncologia (IEO), Milan, Italy; and the personnel of the Cogentech Cancer Genetic Test Laboratory. (MTLGEBCS) We would like to thank Martine Tranchant (CHU de Que ́ bec Research Center), Marie-France Valois, Annie Turgeon and Lea Heguy (McGill University Health Center, Royal Victoria Hospital; McGill Uni- versity) for DNA extraction, sample management and skilful technical assistance. J.S. is Chairholder of the Canada Research Chair in Oncogenetics. (MYBRCA) Phuah Sze Yee, Peter Kang, Kang In Nee, Kavitta Sivanandan, Shivaani Mariapun, Yoon Sook-Yee, Daphne Lee, Teh Yew Ching and Nur Aishah Mohd Taib for DNA Extraction and patient recruitment. (NBHS) We thank study partcipants and research staff for their contributions and commitment to this study. (OBCS) Meeri Otsukka, Kari Mono- nen(OFBCR) Teresa Selander, Nayana Weerasooriya(ORIGO) We thank E. Krol-War- merdam, and J. Blom for patient accrual, administering questionnaires, and managing clinical information. The LUMC survival data were retrieved from the Leiden hospital- based cancer registry system (ONCDOC) with the help of Dr J. Molenaar. (PBCS) Louise Brinton, Mark Sherman, Neonila Szeszenia-Dabrowska, Beata Peplonska, Witold Zatonski, Pei Chao, Michael Stagner(pKARMA) The Swedish Medical Research Counsel. (RBCS) Petra Bos, Jannet Blom, Ellen Crepin, Elisabeth Huijskens, Annette Heemskerk, the Erasmus MC Family Cancer Clinic. (SASBAC) The Swedish Medical Research Counsel. (SBCGS) We thank study partcipants and research staff for their contributions and commitment to this study. (SBCS) Sue Higham, Helen Cramp, Ian Brock, Malcolm W. R. Reed, Sabapathy Balasubramanian and Dan Connley. (SEARCH) The SEARCH and EPIC teams. (SGBCC) We thank the participants and research coordinator Kimberley Chua. (SKKDKFZS) We thank all study participants, clinicians, family doctors, researchers and technicians for their contributions and commitment to this study. (TNBCC) Robert Pilarski and Charles Shapiro were instrumental in the formation of the OSU Breast Cancer Tissue Bank. We thank the Human Genetics Sample Bank for processing of samples and providing OSU Columbus area control samples. (UKBGS) We thank Breakthrough Breast Cancer and the Institute of Cancer Research for support and funding of the Breakthrough Generations Study, and the study participants, study staff, and the doctors, nurses and other health care providers and health information sources who have contributed to the study. We acknowledge NHS funding to the Royal Marsden/ ICR NIHR Biomedical Research Centre. OCAC (acknowledgements by study) : This study would not have been possible without the contributions of the following: J Dennis, P. Hall (COGS); D. C. Tessier, F. Bacot, D. Vincent, S. LaBoissie ` re and F. Robidoux and the staff of the genotyping unit, (Genome Quebec); D. C. Whiteman, P. M. Webb, A. C. Green, N. K. Hayward, P. G. Parsons, D. M. Purdie, B. M. Smithers, D. Gotley, A. Clouston, I. Brown, S. Moore. K. Harrap, T. Sadkowski, S. O'Brien, E. Minehan, D. Roffe, S. O'Keefe, S. Lipshut, G. Connor . Berry, F. Walker, T. Barnes, J. Thomas, L. Terry, M. Connard, L. Bowes, M-R. Malt, J. White, C. Mosse, N. Tait, C. Bambach, A. Biankan, R. Brancatisano, M. Coleman, M. Cox, S. Deane, G. L. Falk, J. Gallagher, M. Hollands, T. Hugh, D. Hunt, J. Jorgensen, C. Martin, M. Richardson, G. Smith, R. Smith, D. Storey, J. Avramovic, J. Croese, J. D'Arcy, S. Fairley, J. Hansen, J. Masson, L. Nathanson, B. O'Loughlin, L. Rutherford, R. Turner, M. Windsor, J. Bessell, P. Devitt, G. Jamieson, D. Watson, S. Blamey, A. Boussioutas, R. Cade, G. Crosthwaite, I. Faragher, J. Gribbin, G. Hebbard, G. Kiroff, B. Mann, R. Millar, P. O'Brien, R. Thomas, S. Wood, S. Archer, K. Faulkner, J. Hamdorf (ACS); R. Stuart-Harris, F. Kirsten, J. Rutovitz, P. Clingan, A.Glasgow, A. Proietto, S. Braye, G. Otton, J. Shannon, T. Bonaventura, J. Stewart, S. Begbie, M. Friedlander, D. Bell, S. Baron-Hay, G. Gard, D. Nevell, N. Pavlakis, S. Valmadre, B. Young, C Camaris, R. Crouch, L. Edwards, N. Hacker, D. Marsden, G. Robertson, P. Beale, J. Beith, J. Carter, C. Dalrymple, R. Houghton, P. Russell, L. Anderson, M. Links, J. Grygiel, J. Hill, A. Brand, K. Byth, R. Jaworski, P. Harnett, R. Sharma,.G Wain, D. Purdie, D. Whiteman, B. Ward, D. Papadimos, A. Crandon, M. Cummings, K. Horwood. A. Obermair, L. Perrin, D. Wyld, J. Nicklin, M. Davy, M. K. Oehler, C. Hall, T. Dodd, T. Healy, K. Pittman, D. Henderson, J. Miller, J. Pierdes, A. Achan, P. Blomfield, D. Challis, R. McIntosh, A. Parker, B. Brown, R. Rome, D. Allen, P. Grant, S. Hyde, R. Laurie, M. Robbie, D. Healy, T. Jobling, T. Manolitsas, J. McNealage, P Rogers, B. Susil, E. Sumithran, I. Simpson, I. Haviv, K. Phillips, D. Rischin, S. Fox, D. Johnson, S. Lade, P. Waring, M. Loughrey, N.O'Callaghan, B. Murray, L. Mileshkin, P. Allan; V. Billson, J. Pyman, D. Neesham, M. Quinn, A. Hamilton, C. Underhill, R. Bell, L. F Ng, R. Blum, V.Ganju, I. Hammond, C. Stewart, Y. Leung, M. Buck, N. Zeps (ACS); G. Peuteman, T. Van Brussel and D. Smeets (BEL); U. Eilber and T. Koehler (GER); L. Gacucova (HMO); P. Schu ̈rmann, F. Kramer, W. Zheng, T.-W. Park-Simon, K. Beer-Grondke and D. Schmidt (HJO); G.S. Keeney, S. Windebank, C. Hilker and J. Vollenweider (MAY); the state cancer registries of AL, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KY, LA, ME, MD, MA, MI, NE, NH, NJ, NY, NC, ND, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, and WYL (NHS); L. Paddock, M. King, U. Chandran, A. Samoila, and Y. Bensman (NJO); L. Brinton, M. Sherman, A. Hutchinson, N. Szeszenia- Dabrowska, B. Peplonska, W. Zatonski, A. Soni, P. Chao and M. Stagner (POL); ); C. Luccarini, P. Harrington the SEARCH team and ECRIC (SEA); the Scottish Gynaecological Clinical Trails group and SCOTROC1 investigators (SRO); W-H. Chow, Y-T. Gao (SWH); Information about TCGA and the investigators and institutions who constitute the TCGA research network can be found at http://cancergenome.nih.gov/ (TCGA); I. Jacobs, M. Widschwendter, E. Wozniak, N. Balogun, A. Ryan and J. Ford (UKO); Carole Pye (UKR); a full list of the investigators who contributed to the generation of the WTCCC data is available from http://www.wtccc.org.uk/ (WTCCC). CIMBA (acknowledgements by study) : (BCFR-AU) Maggie Angelakos, Judi Maskiell, Gillian Dite, Helen Tsimiklis. (BCFR-NY) We wish to thank members and participants in the New York site of the Breast Cancer Family Registry for their contributions to the study. (BCFR-ON) We wish to thank members and participants in the Ontario Familial Breast Cancer Registry for their contributions to the study. (BFBOCC-LT) We acknowledge Vilius Rudaitis, Laimonas Gris ˇ kevic ˇ ius, Ramu ̄ nas Janavic ˇ ius (if not in the authorship). BFBOCC-LV acknowledge Drs Janis Eglitis, Anna Krilova and Aivars Stengrevics. (BMBSA) We wish to thank the families who contribute to the BMBSA study. (BRICOH) We wish to thank Yuan Chun Ding and Linda Steele for their work in participant enrolment and biospecimen and data management.(CNIO) We thank Alicia Barroso, Rosario Alonso and Guillermo Pita for their assistance. (CONSIT TEAM) Alessandra Viel and Riccardo Dolcetti of the CRO Aviano National Cancer Institute, Aviano (PN), Italy; Laura Ottini of the 'Sapienza' University, Rome, Italy; Liliana Varesco of the IRCCS AOU San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy; Laura Papi and Gabriele Capone of the University of Florence, Florence, Italy; Antonella Savarese and Aline Martayan of the Istituto Nazionale Tumori Regina Elena, Rome, Italy; Stefania Tommasi and Brunella Pilato of the Istituto Nazionale Tumori 'Giovanni Paolo II', Bari, Italy. (CORE) The CIMBA data management and analysis is funded through Cancer Research- UK grant C12292/A11174. ACA is a Senior Cancer Research - UK Research Fellow. (EMBRACE) RE is supported by NIHR support to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. (FCCC) We thank Ms. JoEllen Weaver and Dr Betsy Bove for their technical support. (GEMO) Genetic Modifiers of Cancer Risk in BRCA1/2 Mutation Carriers (GEMO) study: National Cancer Genetics Network ) UNICANCER Genetic Group * , France. We wish to thank all the GEMO collaborating groups for their contribution to this study. GEMO Collaborating Centres are: Coordinating Centres, Unite ́ Mixte de Ge ́ ne ́ tique Constitutionnelle des Cancers Fre ́ quents, Hospices Civils de Lyon - Centre Le ́ on Be ́ rard, and Equipe ) Ge ́ ne ́ tique du cancer du sein * , Centre de Recherche en Cance ́ rologie de Lyon: Olga Sinilnikova w , Sylvie Mazoyer, Francesca Damiola, Laure Barjhoux, Carole Verny-Pierre, Me ́ lanie Le ́ one, Nadia Boutry-Kryza, Alain Calender, Sophie Giraud; and Service de Ge ́ ne ́ tique Oncologique, Institut Curie, Paris: Dominique Stoppa-Lyonnet, Marion Gauthier-Villars, Bruno Buecher, Claude Houdayer, Etienne Rouleau, Lisa Golmard, Agne ` s Collet, Virginie Moncoutier, Ce ́ drick Lefol, Muriel Belotti, Antoine de Pauw, Camille Elan, Catherine Nogues, Emmanuelle Fourme, Anne-Marie Birot. Institut Gustave Roussy, Villejuif: Brigitte Bressac-de-Pail- lerets, Olivier Caron, Marine Guillaud-Bataille. Centre Jean Perrin, Clermont–Ferrand: Yves-Jean Bignon, Nancy Uhrhammer. Centre Le ́ on Be ́ rard, Lyon: Christine Lasset, Vale ́ rie Bonadona, Sandrine Handallou. Centre Franc ̧ ois Baclesse, Caen: Agne ` s Hardouin, Pascaline Berthet, Dominique Vaur, Laurent Castera. Institut Paoli Calmettes, Marseille: Hagay Sobol, Violaine Bourdon, Tetsuro Noguchi, Audrey Remenieras, Franc ̧ ois Eisinger. CHU Arnaud-de-Villeneuve, Montpellier: Isabelle Coupier, Pascal Pujol. Centre Oscar Lambret, Lille: Jean-Philippe Peyrat, Joe ̈ lle Fournier, Franc ̧ oise Re ́ villion, Philippe Vennin w , Claude Adenis. Centre Paul Strauss, Strasbourg: Danie ` le Muller, Jean-Pierre Fricker. Institut Bergonie ́ , Bordeaux: Emmanuelle Barouk-Simonet, Franc ̧ oise Bonnet, Virginie Bubien, Nicolas Sevenet, Michel Longy. Institut Claudius Regaud, Toulouse: Christine Toulas, Rosine Guimbaud, Laurence Gladieff, Viviane Feillel. CHU Grenoble: Dominique Leroux, He ́ le ` ne Dreyfus, Christine Rebischung, Magalie Peysselon. CHU Dijon: Fanny Coron, Laurence Faivre. CHU St-Etienne: Fabienne Prieur, Marine Lebrun, Caroline Kientz. Ho ˆ tel Dieu Centre Hospitalier, Chambe ́ ry: Sandra Fert Ferrer. Centre Antoine Lacassagne, Nice: Marc Fre ́ nay. CHU Limoges: Laurence Ve ́ nat-Bouvet. CHU Nantes: Capucine Delnatte. CHU Bretonneau, Tours: Isabelle Mortemousque. Groupe Hospitalier Pitie ́ -Salpe ́ trie ` re, Paris: Florence Coulet, Chrystelle Colas, Florent Soubrier, Mathilde Warcoin. CHU Vandoeuvre-les- Nancy: Johanna Sokolowska, Myriam Bronner. CHU Besanc ̧ on: Marie-Agne ` s Collonge- Rame, Alexandre Damette. Creighton University, Omaha, USA: Henry T. Lynch, Carrie L. Snyder. (G-FAST) We wish to thank the technical support of Ilse Coene en Brecht Crombez. (HCSC) We acknowledge Alicia Tosar for her technical assistance(HEBCS) HEBCS would like to thank Dr Kristiina Aittoma ̈ ki, Taru A. Muranen, Drs Carl Blomqvist and Kirsimari Aaltonen and RNs Irja Erkkila ̈ and Virpi Palola for their help with the HEBCS data and samples. (HEBON) The Hereditary Breast and Ovarian Cancer Research Group Netherlands (HEBON) consists of the following Collaborating Centres: Coordinating center: Netherlands Cancer Institute, Amsterdam, NL: M.A. Rookus, F.B.L. Hogervorst, F.E. van Leeuwen, S. Verhoef, M.K. Schmidt, N.S. Russell, J.L. de Lange, R. Wijnands; Erasmus Medical Center, Rotterdam, NL: J.M. Colle ́ e, A.M.W. van den Ouweland, M.J. Hooning, C. Seynaeve, C.H.M. van Deurzen, I.M. Obdeijn; Leiden University Medical Center, NL: C.J. van Asperen, J.T. Wijnen, R.A.E.M. Tollenaar, P. Devilee, T.C.T.E.F. van Cronenburg; Radboud University Nijmegen Medical Center, NL: C.M. Kets, A.R. Mensenkamp; University Medical Center Utrecht, NL: M.G.E.M. Ausems, R.B. van der Luijt, C.C. van der Pol; Amsterdam Medical Center, NL: C.M. Aalfs, T.A.M. van Os; VU University Medical Center, Amsterdam, NL: J.J.P. Gille, Q. Waisfisz, H.E.J. Meijers-Heijboer; University Hospital Maastricht, NL: E.B. Go ́ mez- Garcia, M.J. Blok; University Medical Center Groningen, NL: J.C. Oosterwijk, A.H. van der Hout, M.J. Mourits, G.H. de Bock; The Netherlands Foundation for the detection of hereditary tumours, Leiden, NL: H.F. Vasen; The Netherlands Comprehensive Cancer Organization (IKNL): S. Siesling, J.Verloop; The Dutch Pathology Registry (PALGA): L.I.H. Overbeek. The HEBON study is supported by the Dutch Cancer Society grants NKI1998-1854, NKI2004-3088, NKI2007-3756, the Netherlands Organization of Scien- tific Research grant NWO 91109024, the Pink Ribbon grants 110005 and 2014- 187.WO76, the BBMRI grant NWO 184.021.007/CP46 and the Transcan grant JTC 2012 Cancer 12-054. HEBON thanks the registration teams of IKNL and PALGA for part of the data collection. (HRBCP) We wish to thank Hong Kong Sanatoriuma and Hospital for their continual support. (HUNBOCS) We wish to thank the Hungarian Breast and Ovarian Cancer Study Group members (Janos Papp, Tibor Vaszko, Aniko Bozsik, Timea Pocza, Judit Franko, Maria Balogh, Gabriella Domokos, Judit Ferenczi, Department of Molecular Genetics, National Institute of Oncology, Budapest, Hungary) and the clin- icians and patients for their contributions to this study.(HVH) We wish to thank the Oncogenetics Group (VHIO), and the High Risk and Cancer Prevention Unit of the University Hospital Vall d'Hebron.(ICO) We wish to thank the ICO Hereditary Cancer Program team led by Dr Gabriel Capella. (INHERIT) We would like to thank Dr Martine Dumont, Martine Tranchant for sample management and skilful technical assistance. J.S. is Chairholder of the Canada Research Chair in Oncogenetics. J.S. and P.S. were part of the QC and Genotyping coordinating group of iCOGS (BCAC and CIMBA). (IPOBCS) We wish to thank Drs Ana Peixoto, Catarina Santos, Patrı ́ cia Rocha and Pedro Pinto for their skilful contribution to the study. (KCONFAB) We wish to thank Heather Thorne, Eveline Niedermayr, all the kConFab research nurses and staff, the heads and staff of the Family Cancer Clinics, and the Clinical Follow Up Study (which has received funding from the NHMRC, the National Breast Cancer Foundation, Cancer Australia, and the National Institute of Health (USA)) for their contributions to this resource, and the many families who contribute to kConFab. (MODSQUAD) Modifier Study of Quantitative Effects on Disease (MODSQUAD): we acknowledge ModSQuaD members Csilla Szabo (National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA); Lenka Foretova and Eva Machackova (Department of Cancer Epidemiology and Genetics, Masaryk Memorial Cancer Institute and MF MU, Brno, Czech Republic); and Michal Zikan, Petr Pohlreich and Zdenek Kleibl (Oncogynecologic Center and Department of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic). (MSKCC) Anne Lincoln, Lauren Jacobs. (NICCC) We wish to thank the NICCC National Familial Cancer Consultation Service team led by Sara Dishon, the lab team led by Dr Flavio Lejbkowicz, and the research field operations team led by Dr Mila Pinchev. (NRG Oncology) We thank the investigators of the Australia New Zealand NRG Oncology group. (OCGN) We wish to thank members and participants in the Ontario Cancer Genetics Network for their contributions to the study. (OSU CCG) Leigha Senter, Kevin Sweet, Caroline Craven, and Michelle O'Conor were instrumental in accrual of study participants, ascertainment of medical records and database management. Samples were processed by the OSU Human Genetics Sample Bank. (SEABASS) We would like to thank Yip Cheng Har, Nur Aishah Mohd Taib, Phuah Sze Yee, Norhashimah Hassan and all the research nurses, research assistants and doctors involved in the MyBrCa Study for assistance in patient recruitment, data collection and sample preparation. In addition, we thank Philip Iau, Sng Jen-Hwei and Sharifah Nor Akmal for contributing samples from the Singapore Breast Cancer Study nd the HUKM-HKL Study respectively. The Malaysian Breast Cancer Genetic Study is funded by research grants from the Malaysian Ministry of Science, Technology and Innovation, Ministry of Higher Education (UM.C/HIR/MOHE/06) and charitable funding from Cancer Research Initiatives Foundation. (SMC) SMC team wishes to acknowledge the assistance of the Meirav Comprehensice breast cancer center team at the Sheba Medical Center for assistance in this study. (SWE-BRCA) Swedish scientists participating as SWE-BRCA collaborators are: from Lund University and University Hospital: Åke Borg, Håkan Olsson, Helena Jernstro ̈ m, Karin Henriksson, Katja Harbst, Maria Soller, Ulf Kristoffersson; from Gothenburg Sahlgrenska University Hospital: Anna O ̈ fverholm, Margareta Nordling, Per Karlsson, Zakaria Einbeigi; from Stockholm and Karolinska University Hospital: Anna von Wachenfeldt, Annelie Liljegren, Annika Lindblom, Brita Arver, Gisela Barbany Bustinza, Johanna Rantala; from Umeå University Hospital: Beatrice Melin, Christina Edwinsdotter Ardnor, Monica Emanuelsson; from Uppsala University: Hans Ehrencrona, Maritta Hellstro ̈ m Pigg, Richard Rosenquist; from Linko ̈ ping University Hospital: Marie Stenmark-Askmalm, Sigrun Lied- gren(UCHICAGO) We wish to thank Cecilia Zvocec, Qun Niu, physicians, genetic counsellors, research nurses and staff of the Cancer Risk Clinic for their contributions to this resource, and the many families who contribute to our programme. (UCLA) We thank Joyce Seldon MSGC and Lorna Kwan, MPH for assembling the data for this study. (UCSF) We would like to thank Dr Robert Nussbaum and the following genetic coun- sellors for participant recruitment: Beth Crawford, Kate Loranger, Julie Mak, Nicola Stewart, Robin Lee, Amie Blanco and Peggy Conrad. And thanks to Ms. Salina Chan for her data management. (UKFOCR) We thank Carole Pye, Patricia Harrington and Eva Wozniak for their contributions towards the UKFOCR. (VFCTG) Geoffrey Lindeman, Marion Harris, Martin Delatycki of the Victorian Familial Cancer Trials Group. We thank Sarah Sawyer and Rebecca Driessen for assembling this data and Ella Thompson for performing all DNA amplification. Grant Support : The COGS project is funded through a European Commission's Seventh Framework Programme grant (agreement number 223175—HEALTH-F2-2009- 223175). BCAC is funded by Cancer Research UK [C1287/A10118, C1287/A12014] and by the European Community ́ s Seventh Framework Programme under grant agreement number 223175 (grant number HEALTH-F2-2009-223175) (COGS). The CIMBA data management and analytical work is funded by Cancer Research UK (C12292/A11174, C12292/A20861). Funding for the iCOGS infrastructure came from: the European Community's Seventh Framework Programme under grant agreement n ° 223175 (HEALTH-F2-2009-223175) (COGS), Cancer Research UK (C1287/A10118, C1287/A 10710, C12292/A11174, C1281/A12014, C5047/A8384, C5047/A15007, C5047/A10692, C8197/A16565), the National Institutes of Health (CA128978) and Post-Cancer GWAS initiative (1U19 CA148537, 1U19 CA148065 and 1U19 CA148112 - the GAME-ON initiative), the Department of Defence (W81XWH-10-1-0341), the Canadian Institutes of Health Research (CIHR) for the CIHR Team in Familial Risks of Breast Cancer, Komen Foundation for the Cure, the Breast Cancer Research Foundation, and the Ovarian Cancer Research Fund. The Ovarian Cancer Association Consortium is supported by a grant from the Ovarian Cancer Research Fund thanks to donations by the family and friends of Kathryn Sladek Smith (PPD/RPCI.07). The scientific development and funding for this project were in part supported by the US National Cancer Institute GAME-ON Post-GWAS Initiative (U19-CA148112). This study made use of data generated by the Wellcome Trust Case Control consortium. Funding for the project was provided by the Wellcome Trust under award 076113. The results published here are in part based on data generated by The Cancer Genome Atlas Project established by the National Cancer Institute and National Human Genome Research Institute. Personal support: K.L. is supported by a K99/R00 grant from the National Cancer Institute (Grant number 1K99CA184415-01). This project was supported in part by a Program Project Development Grant from the Ovarian Cancer Research Fund (S.A.G and A.M). The in vitro aspects of this project were performed within the Norris Cancer Centre at USC, which is supported in part by award number P30CA014089 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health. D.F.E. is a Principal Research Fellow of Cancer Research UK. A.C.A. is a Cancer Research—UK Senior Cancer Research Fellow. G.C.-T. and P.M.W. are supported by the National Health and Medical Research Council. (WCP) B.Y.K is funded by the American Cancer Society Early Detection Professorship (SIOP- 06-258-01-COUN) and the National Center for Advancing Translational Sciences (NCATS), Grant UL1TR000124. L.E.K. is supported by a Canadian Institutes of Health Research Investigator award (MSH-87734). S.P.K. is supported by a Gates Cambridge Scholarship. J.S. is Chairholder of the Canada Research Chair in Oncogenetics. RB was a Cancer Institute NSW Clinical Research Fellow. M.C.S. is a NHMRC Senior Research Fellow. A.K.G. was funded by 5U01CA113916, R01CA140323, and by the Chancellors Distinguished Chair in Biomedical Sciences Professorship. J.L.H. is a National Health and Medical Research Council (NHMRC) Senior Principal Research Fellow. S.L.E. and J.D.F. are supported by Fellowships from the National Breast Cancer Foundation (NBCF) Australia and NHMRC project grant (1058415). Funding : BCAC: The Australian Breast Cancer Family Study (ABCFS) was supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centres in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The ABCFS was also supported by the National Health and Medical Research Council of Australia, the New South Wales Cancer Council, the Victorian Health Promotion Foundation (Australia) and the Victorian Breast Cancer Research Consortium. The ABCS study was supported by the Dutch Cancer Society [grants NKI 2007-3839; 2009 4363]. The ACP study is funded by the Breast Cancer Research Trust, UK. The BBCS is funded by Cancer Research UK and Breakthrough Breast Cancer and acknowledges NHS funding to the NIHR Biomedical Research Centre, and the National Cancer Research Network (NCRN).ES is supported by NIHR Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust in partnership with King's College London, United Kingdom. IT is supported by the Oxford Biomedical Research Centre.The BSUCH study was supported by the Dietmar-Hopp Foundation, the Helmholtz Society and the German Cancer Research Center (DKFZ). The CGPS was supported by the Chief Physician Johan Boserup and Lise Boserup Fund, the Danish Medical Research Council and Herlev HospitalThe CNIO-BCS was supported by the Instituto de Salud Carlos III, the Red Tema ́ tica de Investigacio ́ n Cooperativa en Ca ́ ncer and grants from the Asociacio ́ n Espan ̃ ola Contra el Ca ́ ncer and the Fondo de Investigacio ́ n Sanitario (PI11/00923 and PI12/00070). The CTS was initially supported by the California Breast Cancer Act of 1993 and the California Breast Cancer Research Fund (contract 97-10500) and is cur- rently funded through the National Institutes of Health (R01 CA77398). Collection of cancer incidence data was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885. HAC receives support from the Lon V Smith Foundation (LVS39420). The ESTHER study was supported by a grant from the Baden Wu ̈rttemberg Ministry of Science, Research and Arts. Additional cases were recruited in the context of the VERDI study, which was supported by a grant from the German Cancer Aid (Deutsche Krebshilfe). The GC-HBOC was supported by Deutsche Krebshilfe (107 352). The GENICA was funded by the Federal Ministry of Education and Research (BMBF) Germany grants 01KW9975/5, 01KW9976/8, 01KW9977/0 and 01KW0114, the Robert Bosch Foundation, Stuttgart, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, the Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, as well as the Department of Internal Medicine, Evangelische Kliniken Bonn gGmbH, Johanniter Krankenhaus, Bonn, Germany. The HEBCS was financially supported by the Helsinki University Central Hospital Research Fund, Academy of Finland (266528), the Finnish Cancer Society, The Nordic Cancer Union and the Sigrid Juselius Foundation. The HMBCS was supported by a grant from the Friends of Hannover Medical School and by the Rudolf Bartling Foundation. The KBCP was financially supported by the special Government Funding (EVO) of Kuopio University Hospital grants, Cancer Fund of North Savo, the Finnish Cancer Organizations, and by the strategic funding of the University of Eastern Finland. kConFab is supported by a grant from the National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia. Financial support for the AOCS was provided by the United States Army Medical Research and Materiel Command [DAMD17-01-1-0729], Cancer Council Victoria, Queensland Cancer Fund, Cancer Council New South Wales, Cancer Council South Australia, The Cancer Foundation of Western Australia, Cancer Council Tasmania and the National Health and Medical Research Council of Australia (NHMRC; 400413, 400281, 199600). LAABC is supported by grants (1RB-0287, 3PB-0102, 5PB-0018, 10PB-0098) from the California Breast Cancer Research Program. Incident breast cancer cases were collected by the USC Cancer Surveillance Program (CSP), which is supported under subcontract by the California Department of Health. The CSP is also part of the National Cancer Institute's Division of Cancer Prevention and Control Surveillance, Epidemiology, and End Results Program, under contract number N01CN25403. LMBC is supported by the 'Stichting tegen Kanker' (232-2008 and 196-2010). Diether Lambrechts is supported by the FWO and the KULPFV/10/016-SymBioSysII.The MARIE study was supported by the Deutsche Krebshilfe e.V. [70-2892-BR I, 106332, 108253, 108419], the Hamburg Cancer Society, the German Cancer Research Center (DKFZ) and the Federal Ministry of Education and Research (BMBF) Germany [01KH0402]. (MBCSG) is supported by grants from the Italian Association for Cancer Research (AIRC) and by funds from the Italian citizens who allocated the 5/1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects '5x1000'). The work of MTLGEBCS was supported by the Quebec Breast Cancer Foundation, the Canadian Institutes of Health Research for the 'CIHR Team in Familial Risks of Breast Cancer' program – grant # CRN-87521 and the Ministry of Economic Development, Innovation and Export Trade – grant # PSR-SIIRI-701.MYBRCA is funded by research grants from the Malaysian Ministry of Science, Technology and Innovation (MOSTI), Malaysian Ministry of Higher Education (UM.C/HlR/MOHE/06) and Cancer Research Initiatives Foundation (CARIF). Additional controls were recruited by the Singapore Eye Research Institute, which was supported by a grant from the Biomedical Research Council (BMRC08/1/35/19/550), Singapore and the National medical Research Council, Singa- pore (NMRC/CG/SERI/2010). The NBHS was supported by NIH grant R01CA100374. Biological sample preparation was conducted the Survey and Biospecimen Shared Resource, which is supported by P30 CA68485. The OBCS was supported by research grants from the Finnish Cancer Foundation, the Academy of Finland (grant number 250083, 122715 and Center of Excellence grant number 251314), the Finnish Cancer Foundation, the Sigrid Juselius Foundation, the University of Oulu, the University of Oulu Support Foundation and the special Governmental EVO funds for Oulu University Hospital-based research activities. The Ontario Familial Breast Cancer Registry (OFBCR) was supported by grant UM1 CA164920 from the National Cancer Institute (USA). The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centres in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the USA Government or the BCFR. The ORIGO study was supported by the Dutch Cancer Society (RUL 1997-1505) and the Biobanking and Biomolecular Resources Research Infrastructure (BBMRI-NL CP16). The PBCS was funded by Intramural Research Funds of the National Cancer Institute, Department of Health and Human Services, USA. The pKARMA study was supported by Ma ̈ rit and Hans Rausings Initiative Against Breast CancerThe RBCS was funded by the Dutch Cancer Society (DDHK 2004-3124, DDHK 2009-4318). The SASBAC study was sup- ported by funding from the Agency for Science, Technology and Research of Singapore (A*STAR), the US National Institute of Health (NIH) and the Susan G. Komen Breast Cancer Foundation. The SBCGS was supported primarily by NIH grants R01CA64277, R01CA148667, and R37CA70867. Biological sample preparation was conducted the Survey and Biospecimen Shared Resource, which is supported by P30 CA68485. The scientific development and funding of this project were, in part, supported by the Genetic Associations and Mechanisms in Oncology (GAME-ON) Network U19 CA148065.The SBCS was supported by Yorkshire Cancer Research S295, S299, S305PA and Sheffield Experimental Cancer Medicine Centre.SEARCH is funded by a programme grant from Cancer Research UK [C490/A10124] and supported by the UK National Institute for Health Research Biomedical Research Centre at the University of Cambridge.SGBCC is funded by the NUS start-up Grant, National University Cancer Institute Singapore (NCIS) Centre Grant and the NMRC Clinician Scientist Award. Additional controls were recruited by the Singapore Consortium of Cohort Studies-Multi-ethnic cohort (SCCS-MEC), which was funded by the Biomedical Research Council, grant number: 05/ 1/21/19/425.SKKDKFZS is supported by the DKFZ. The TNBCC was supported by: a Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a grant from the Breast Cancer Research Foundation, a generous gift from the David F. and Margaret T. Grohne Family Foundation, the Hellenic Cooperative Oncology Group research grant (HR R_BG/04) and the Greek General Secretary for Research and Technology (GSRT) Program, Research Excellence II, the European Union (European Social Fund – ESF), and Greek national funds through the Operational Program 'Education and Lifelong Learning' of the National Strategic Reference Framework (NSRF) - ARISTEIA. The UKBGS is funded by Breakthrough Breast Cancer and the Institute of Cancer Research (ICR), London. ICR acknowledges NHS funding to the NIHR Biomedical Research Centre. Funding : OCAC : Funding of the constituent studies was provided by the American Cancer Society (CRTG-00-196-01-CCE); the California Cancer Research Program (00-01389 V-20170, N01-CN25403, 2II0200); the Canadian Institutes for Health Research (MOP-86727); Cancer Council Victoria; Cancer Council Queensland; Cancer Council New South Wales; Cancer Council South Australia; Cancer Council Tasmania; Cancer Foundation of Western Australia; the Cancer Institute of New Jersey; Cancer Research UK (C490/A6187, C490/A10119, C490/A10124, C536/A13086, C536/A6689); the Celma Mastry Ovarian Cancer Foundation; the Danish Cancer Society (94-222-52); the ELAN Program of the University of Erlangen-Nuremberg; the Eve Appeal; the Helsinki University Central Hospital Research Fund; Helse Vest; Imperial Experimental Cancer Research Centre (C1312/A15589); the Norwegian Cancer Society; the Norwegian Research Council; the Ovarian Cancer Research Fund; Nationaal Kankerplan of Belgium; Grant-in-Aid for the Third Term Comprehensive 10-Year Strategy for Cancer Control from the Ministry of Health Labour and Welfare of Japan; the L and S Milken Foun- dation; the Polish Ministry of Science and Higher Education (4 PO5C 028 14, 2 PO5A 068 27); Malaysian Ministry of Higher Education (UM.C/HlR/MOHE/06) and Cancer Research Initiatives Foundation; the Roswell Park Cancer Institute Alliance Foundation; the US National Cancer Institute (K07-CA095666, K07-CA143047, K22-CA138563, N01-CN55424, N01-PC067010, N01-PC035137, P01-CA017054, P01-CA087696, P30-CA15083, P50-CA105009, P50- CA136393, R01-CA014089, R01-CA016056, R01-CA017054, R01-CA049449, R01-CA050385, R01-CA054419, R01- CA058598, R01-CA058860, R01-CA061107, R01-CA061132, R01-CA063682, R01-CA064277, R01-CA067262, R01- CA071766, R01-CA074850, R01-CA076016, R01-CA080742, R01-CA080978, R01-CA083918, R01-CA087538, R01- CA092044, R01-095023, R01-CA106414, R01-CA122443, R01-CA112523, R01-CA114343, R01-CA126841, R01- CA136924, R01-CA149429, R03-CA113148, R03-CA115195, R37-CA070867, R37-CA70867, U01-CA069417, U01- CA071966, R01-CA063678 and Intramural research funds); the US Army Medical Research and Material Command (DAMD17-98-1- 8659, DAMD17-01-1-0729, DAMD17-02-1-0666, DAMD17-02-1- 0669, W81XWH-10-1-0280); the National Health and Medical Research Council of Australia (199600 and 400281); the German Federal Ministry of Education and Research of Germany Programme of Clinical Biomedical Research (01 GB 9401); the state of Baden-Wu ̈rttemberg through Medical Faculty of the University of Ulm (P.685); the Minnesota Ovarian Cancer Alliance; the Mayo Foundation; the Fred C. and Katherine B. Andersen Foundation; the Lon V. Smith Foundation (LVS-39420); the Oak Foundation; the OHSU Foundation; the Mermaid I project; the Rudolf-Bartling Foundation; the UK National Institute for Health Research Biomedical Research Centres at the University of Cambridge, Imperial College London, University College Hospital 'Womens Health Theme' and the Royal Marsden Hospital; WorkSafeBC. Funding : CIMBA (BCFR—all) : This work was supported by grant UM1 CA164920 from the National Cancer Institute. The content of this manuscript does not necessarily reflect the views or policies of the National Cancer Institute or any of the collaborating centres in the Breast Cancer Family Registry (BCFR), nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government or the BCFR. (BFBOCC-LT) BFBOCC is partly supported by: Lithuania (BFBOCC-LT): Research Council of Lithuania grant LIG-07/2012; (BIDMC) BIDMC is supported by the Breast Cancer Research Foundation. (BMBSA) BRCA-gene mutations and breast cancer in South African women (BMBSA) was supported by grants from the Cancer Association of South Africa (CANSA) to Elizabeth J. van Rensburg. (BRICOH) SLN was partially supported by the Morris and Horowitz Familes Endowed Professorship. (CBCS) This work was supported by the NEYE Foundation. (CNIO) This work was partially supported by Spanish Association against Cancer (AECC08), RTICC 06/0020/1060, FISPI08/1120, Mutua Madrilen ̃ a Foundation (FMMA) and SAF2010-20493 (COH-CCGCRN) City of Hope Clinical Cancer Genetics Community Network and the Hereditary Cancer Research Registry, supported in part by Award Number RC4CA153828 (PI: J. Weitzel) from the National Cancer Institute and the Office of the Director, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. (CONSIT TEAM) Funds from Italian citizens who allocated the 5x1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects '5x1000') to Siranoush Manoukian. (CORE) The CIMBA data management and data analysis were supported by Cancer Research – UK grants C12292/A11174 and C1287/A10118.SH is supported by an NHMRC Program Grant to GCT. ACA is a Cancer Research -UK Senior Cancer Research Fellow. (DEMOKRITOS) This research has been co-financed by the European Union (European Social Fund – ESF) and Greek national funds through the Operational Program 'Education and Lifelong Learning' of the National Strategic Reference Frame- work (NSRF) - Research Funding Program of the General Secretariat for Research and Technology: ARISTEIA. Investing in knowledge society through the European Social Fund.(DKFZ) The DKFZ study was supported by the DKFZ. (EMBRACE) EMBRACE is supported by Cancer Research UK Grants C1287/A10118 and C1287/A11990. D. Gareth Evans and Fiona Lalloo are supported by an NIHR grant to the Biomedical Research Centre, Manchester. The Investigators at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust are supported by an NIHR grant to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. (FCCC) The authors acknowledge support from The University of Kansas Cancer Center (P30 CA168524) and the Kansas Bioscience Authority Eminent Scholar Program. (GC-HBOC) The German Consortium of Hereditary Breast and Ovarian Cancer (GC-HBOC) is supported by the German Cancer Aid (grant no 109076, Rita K. Schmutzler) and by the Center for Molecular Medicine Cologne (CMMC). (GEMO) The study was supported by the Ligue Nationale Contre le Cancer; the Association 'Le cancer du sein, parlons-en!' Award; the Canadian Institutes of Health Research for the 'CIHR Team in Familial Risks of Breast Cancer' program and the French National Institute of Cancer (INCa). (GEORGETOWN) CI received support from the Non-Therapeutic Subject Registry Shared Resource at Georgetown University (NIH/NCI grant P30-CA051008), the Fisher Center for Familial Cancer Research, and Swing Fore the Cure. (G-FAST) Kim De Leeneer is supported by GOA grant BOF10/ GOA/019 (Ghent University) and spearhead financing of Ghent University Hospital. (HCSC) HCSC supported by a grant RD12/0036/0006 and 12/00539 from ISCIII (Spain), partially supported by European Regional Development FEDER funds. (HEBCS) The HEBCS was financially supported by the Helsinki University Hospital Research Fund, Academy of Finland (266528), the Finnish Cancer Society and the Sigrid Juselius Foundation. (HEBON) The HEBON study is supported by the Dutch Cancer Society grants NKI1998-1854, NKI2004-3088, NKI2007-3756, the Netherlands Organization of Scientific Research grant NWO 91109024, the Pink Ribbon grant 110005 and the BBMRI grant NWO 184.021.007/CP46. HEBON thanks the registration teams of the Comprehensive Cancer Centre Netherlands and Comprehensive Centre South (together the Netherlands Cancer Registry) and PALGA (Dutch Pathology Registry) for part of the data collection. (HRBCP) HRBCP is supported by The Hong Kong Hereditary Breast Cancer Family Registry and the Dr Ellen Li Charitable Foundation, Hong Kong (HUNBOCS) Hungarian Breast and Ovarian Cancer Study was supported by Hungarian Research Grants KTIA-OTKA CK-80745, OTKA K-112228 and the Norwegian EEA Financial Mechanism Hu0115/NA/2008-3/OP-9. (ICO) Contract grant sponsor: Asociacio ́ n Espan ̃ ola Contra el Ca ́ ncer, Spanish Health Research Fund; Carlos III Health Institute; Catalan Health Institute and Autonomous Government of Catalonia. Contract grant numbers: ISCIIIRETIC RD06/0020/1051, RD12/0036/008, PI10/01422, PI10/ 00748, PI13/00285, PIE13/00022, 2009SGR290 and 2014SGR364. (IHCC) The IHCC was supported by Grant PBZ_KBN_122/P05/2004(ILUH) The ILUH group was supported by the Icelandic Association 'Walking for Breast Cancer Research' and by the Landspitali University Hospital Research Fund. (INHERIT) This work was supported by the Canadian Institutes of Health Research for the 'CIHR Team in Familial Risks of Breast Cancer' program, the Canadian Breast Cancer Research Alliance-grant #019511 and the Ministry of Economic Development, Innovation and Export Trade – grant # PSR-SIIRI- 701. (IOVHBOCS) IOVHBOCS is supported by Ministero della Salute and '5 1,000' Istituto Oncologico Veneto grant. (IPOBCS) This study was in part supported by Liga Portuguesa Contra o Cancro.(KCONFAB) kConFab is supported by a grant from the National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia; (KOHBRA) KOHBRA is supported by a grant from the National R&D Program for Cancer Control, Ministry for Health, Welfare and Family Affairs,Republic of Korea (1020350). (MAYO) MAYO is supported by NIH grants CA116167, CA128978 and CA176785, an NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a U.S. Department of Defence Ovarian Cancer Idea award (W81XWH-10-1-0341), a grant from the Breast Cancer Research Foundation, a generous gift from the David F. and Margaret T. Grohne Family Foundation and the Ting Tsung and Wei Fong Chao Foundation. (MCGILL) Jewish General Hospital Weekend to End Breast Cancer, Quebec Ministry of Economic Development, Innovation and Export Trade (MODSQUAD) MODSQUAD was supported by MH CZ - DRO (MMCI, 00209805) and by the European Regional Development Fund and the State Budget of the Czech Republic (RECAMO, CZ.1.05/2.1.00/03.0101) to LF, and by Charles University in Prague project UNCE204024 (MZ). (MSKCC) MSKCC is supported by grants from the Breast Cancer Research Foundation, the Robert and Kate Niehaus Clinical Cancer Genetics Initiative, and the Andrew Sabin Research Fund. (NAROD) 1R01 CA149429- 01. (NCI) The research of Drs MH Greene, JT Loud and PL Mai was supported by the Intramural Research Program of the US National Cancer Institute, NIH, and by support services contracts NO2-CP-11019-50 and N02-CP-65504 with Westat, Inc, Rockville, MD. (NICCC) NICCC is supported by Clalit Health Services in Israel. Some of it's activities are supported by the Israel Cancer Association and the Breast Cancer Research Foundation (BCRF), NY. (NNPIO) This work has been supported by the Russian Federation for Basic Research (grants 13-04-92613, 14-04-93959 and 15-04-01744). (NRG Oncology) This study was supported by National Cancer Institute grants to the NRG Oncology Administrative Office and Tissue Bank (CA 27469), the NRG Oncology Statistical and Data Center (CA 37517), and NRG Oncology's Cancer Prevention and Control Committee (CA 101165). (OSU CCG) OSUCCG is supported by the Ohio State University Comprehensive Cancer Center. (PBCS) This work was supported by the ITT (Istituto Toscano Tumori) grants 2011-2013. (SEABASS) Ministry of Science, Technol- ogy and Innovation, Ministry of Higher Education (UM.C/HlR/MOHE/06) and Cancer Research Initiatives Foundation. (SMC) This project was partially funded through a grant by the Isreal cancer association and the funding for the Israeli Inherited breast cancer consortium (SWE-BRCA) SWE-BRCA collaborators are supported by the Swedish Cancer Society. (UCHICAGO) UCHICAGO is supported by NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA125183), R01 CA142996, 1U01CA161032 and by the Ralph and Marion Falk Medical Research Trust, the Entertainment Industry Fund National Women's Cancer Research Alliance and the Breast Cancer research Foundation. OIO is an ACS Clinical Research Professor.(UCLA) Jonsson Comprehensive Cancer Center Foundation; Breast Cancer Research Foundation. (UCSF) UCSF Cancer Risk Program and Helen Diller Family Comprehensive Cancer Center. (UKFOCR) UKFOCR was supported by a project grant from CRUK to Paul Pharoah. (UPENN) National Institutes of Health (NIH) (R01-CA102776 and R01- CA083855; Breast Cancer Research Foundation; Susan G. Komen Foundation for the cure, Basser Research Center for BRCA. (UPITT/MWH) Frieda G. and Saul F. Shapira BRCA-Associated Cancer Research Program;Hackers for Hope Pittsburgh. (VFCTG) Victorian Cancer Agency, Cancer Australia, National Breast Cancer Foundation unding for the iCOGS infrastructure came from: the European Community's Seventh Framework Programme under grant agreement n ° 223175 (HEALTH-F2-2009-223175) (COGS), Cancer Research UK (C1287/A10118, C1287/A 10710, C12292/A11174, C1281/ A12014, C5047/A8384, C5047/A15007, C5047/A10692, C8197/A16565), the National Institutes of Health (CA128978) and Post-Cancer GWAS initiative (1U19 CA148537, 1U19 CA148065 and 1U19 CA148112 - the GAME-ON initiative), the Department of Defence (W81XWH-10-1-0341), the Canadian Institutes of Health Research (CIHR) for the CIHR Team in Familial Risks of Breast Cancer, Komen Foundation for the Cure, the Breast Cancer Research Foundation, and the Ovarian Cancer Research Fund and grants R01-CA122443 and P50-CA136393. ; Sí