Abstract
BackgroundAssociations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES. MethodsAll women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality – accounting for competing risks – were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included. ResultsWe included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found. ConclusionsHigh SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.
Highlights
Women diagnosed with early stage breast cancer have a higher mortality risk as compared to the general population, even years after their initial breast cancer diagnosis [1,2]
As breast cancer survival is largely determined by distant metastases (DM) [13] (which in turn are influ enced by the occurrence of local (LR) or regional recurrences (RR) [14]), the relation between socioeconomic status (SES), the entire recurrent event process and mortality has to be adequately assessed
Using data on all consecu tive recurrences, and by using a joint modelling framework including the correlation with excess mortality, we provide a unique insight in the prognosis of young breast cancer patients according to SES
Summary
Women diagnosed with early stage breast cancer have a higher mortality risk as compared to the general population, even years after their initial breast cancer diagnosis [1,2] This is mainly caused by the occurrence of (late) recurrences (local, regional and distant), second primary cancers and late side effects of treatment [2]. Comorbidity is unlikely to play a large role in young women, and access to treatment is expected to be equal in these coun tries To further explore these mortality differences, it is important to take into account recurrent events. As breast cancer survival is largely determined by distant metastases (DM) [13] (which in turn are influ enced by the occurrence of local (LR) or regional recurrences (RR) [14]), the relation between SES, the entire recurrent event process (including all subsequent events) and mortality has to be adequately assessed. Adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association
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