Age-adjusted Breast Cancer Mortality Research Articles

Analysis of Breast Cancer Mortality in the US—1975 to 2019

Breast cancer mortality in the US declined between 1975 and 2019. The association of changes in metastatic breast cancer treatment with improved breast cancer mortality is unclear. To simulate the relative associations of breast cancer screening, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer with improved breast cancer mortality. Using aggregated observational and clinical trial data on the dissemination and effects of screening and treatment, 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models simulated US breast cancer mortality rates. Death due to breast cancer, overall and by estrogen receptor and ERBB2 (formerly HER2) status, among women aged 30 to 79 years in the US from 1975 to 2019 was simulated. Screening mammography, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer. Model-estimated age-adjusted breast cancer mortality rate associated with screening, stage I to III treatment, and metastatic treatment relative to the absence of these exposures was assessed, as was model-estimated median survival after breast cancer metastatic recurrence. The breast cancer mortality rate in the US (age adjusted) was 48/100 000 women in 1975 and 27/100 000 women in 2019. In 2019, the combination of screening, stage I to III treatment, and metastatic treatment was associated with a 58% reduction (model range, 55%-61%) in breast cancer mortality. Of this reduction, 29% (model range, 19%-33%) was associated with treatment of metastatic breast cancer, 47% (model range, 35%-60%) with treatment of stage I to III breast cancer, and 25% (model range, 21%-33%) with mammography screening. Based on simulations, the greatest change in survival after metastatic recurrence occurred between 2000 and 2019, from 1.9 years (model range, 1.0-2.7 years) to 3.2 years (model range, 2.0-4.9 years). Median survival for estrogen receptor (ER)-positive/ERBB2-positive breast cancer improved by 2.5 years (model range, 2.0-3.4 years), whereas median survival for ER-/ERBB2- breast cancer improved by 0.5 years (model range, 0.3-0.8 years). According to 4 simulation models, breast cancer screening and treatment in 2019 were associated with a 58% reduction in US breast cancer mortality compared with interventions in 1975. Simulations suggested that treatment for stage I to III breast cancer was associated with approximately 47% of the mortality reduction, whereas treatment for metastatic breast cancer was associated with 29% of the reduction and screening with 25% of the reduction.

County Mammogram Uptake can be Predicted from Social Determinants of Health, but Patterns Do Not Hold for Individual Patients.

The objective of this study is to describe patterns in barriers to breast cancer screening uptake with the end goal of improving screening adherence and decreasing the burden of mortality due to breast cancer. This study looks at social determinants of health and their association to screening and mortality. It also investigates the extent that models trained on county data are generalizable to individuals. County level screening uptake and age adjusted mortality due to breast cancer are combined with the Centers for Disease Controls Social Vulnerability Index (SVI) to train a model predicting screening uptake rates. Patterns learned are then applied to de-identified electronic medical records from individual patients to make predictions on mammogram screening follow through. Accurate predictions can be made about a county's breast cancer screening uptake with the SVI. However, the association between increased screening, and decreased age adjusted mortality, doesn't hold in areas with a high proportion of minority residents. It is also shown that patterns learned from county SVI data have little discriminative power at the patient level. This study demonstrates that social determinants in the SVI can explain much of the variance in county breast cancer screening rates. However, these same patterns fail to discriminate which patients will have timely follow through of a mammogram screening test. This study also concludes that the core association between increased screening and decreased age adjusted mortality does not hold in high proportion minority areas. The objective of this study is to describe patterns in social determinants of health and their association with female breast cancer screening uptake, age adjusted breast cancer mortality rate and the extent that models trained on county data are generalizable to individuals.

Abstract C008: Associations of county-level structural racism indices with cancer mortality disparities in Florida

Abstract Existing multidimensional measures of structural racism are largely measured on the state level, which may mask underlying heterogeneity on smaller levels of geography. This study pilots an empirical approach to operationalizing structural racism in cancer equity research by introducing an association-sensitive inequality index developed to capture county-level structural racism, utilizing the state of Florida as an empirical case study. Three structural racism indices per county were constructed, incorporating comparisons between (a) non-Hispanic/Latinx Blacks and non-Hispanic/Latinx whites, (b) Hispanics/Latinx and non-Hispanic/Latinx whites, and (c) non-Hispanic/Latinx Blacks and Hispanics/Latinx. Unadjusted and adjusted regression models were fit to assess the ecological association between the structural racism indices and race/ethnicity-specific measures of (1) age-adjusted all-cause mortality, (2) age-adjusted overall cancer mortality, (3) age-adjusted lung cancer mortality, (4) age-adjusted breast cancer mortality, and (5) prevalence of late stage cancer diagnosis. Unadjusted and adjusted Poisson regression models were fit to assess the ecological association between the structural racism indices and race/ethnicity-specific measures of (1) age-adjusted all-cause mortality, (2) age-adjusted overall cancer mortality, (3) age-adjusted lung cancer mortality, (4) age-adjusted breast cancer mortality, and (5) prevalence of late stage cancer diagnosis. In fully adjusted models, county-level Black-white structural racism was associated with higher levels of all-cause, overall cancer, lung cancer, and breast cancer mortality rates among Black residents (p<0·0001), higher levels of all-cause mortality in white residents (p<0·0001). County- level Latinx-white structural racism was associated with lower levels of all-cause and overall cancer mortality and slightly higher lung cancer mortality among Hispanic/Latinx residents, and higher levels of all-cause mortality and lower levels of overall cancer mortality among white residents. This study provides evidence of structural racism impacts among cancer disparities within Black and Hispanic/Latinx communities, an understudied population in empirical structural racism literature. Study findings demonstrate that the relationship between the Black-white structural racism index and the health outcomes of interest correspond best with a “universal harm” relationship, whereby both Black and white Floridians experienced increased negative health outcomes associated with increasing levels of structural racism. Citation Format: Zinzi D. Bailey, Marlene Camacho-Rivera, Kasim Ortiz. Associations of county-level structural racism indices with cancer mortality disparities in Florida [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C008.

Geographical Variation in Social Determinants of Female Breast Cancer Mortality Across US Counties

Breast cancer mortality is complex and traditional approaches that seek to identify determinants of mortality assume that their effects on mortality are stationary across geographic space and scales. To identify geographic variation in the associations of population demographics, environmental, lifestyle, and health care access with breast cancer mortality at the US county-level. This geospatial cross-sectional study used data from the Surveillance, Epidemiology, and End Results (SEER) database on adult female patients with breast cancer. Statistical and spatial analysis was completed using adjusted mortality rates from 2015 to 2019 for 2176 counties in the US. Data were analyzed July 2022. County-level population demographics, environmental, lifestyle, and health care access variables were obtained from open data sources. Model coefficients describing the association between 18 variables and age-adjusted breast cancer mortality rate. Compared with a multivariable linear regression (OLS), multiscale geographically weighted regression (MGWR) relaxed the assumption of spatial stationarity and allowed for the magnitude, direction, and significance of coefficients to change across geographic space. Both OLS and MGWR models agreed that county-level age-adjusted breast cancer mortality rates were significantly positively associated with obesity (OLS: β, 1.21; 95% CI, 0.88 to 1.54; mean [SD] MGWR: β, 0.72 [0.02]) and negatively associated with proportion of adults screened via mammograms (OLS: β, -1.27; 95% CI, -1.70 to -0.84; mean [SD] MGWR: β, -1.07 [0.16]). Furthermore, the MGWR model revealed that these 2 determinants were associated with a stationary effect on mortality across the US. However, the MGWR model provided important insights on other county-level factors differentially associated with breast cancer mortality across the US. Both models agreed that smoking (OLS: β, -0.65; 95% CI, -0.98 to -0.32; mean [SD] MGWR: β, -0.75 [0.92]), food environment index (OLS: β, -1.35; 95% CI, -1.72 to -0.98; mean [SD] MGWR: β, -1.69 [0.70]), exercise opportunities (OLS: β, -0.56; 95% CI, -0.91 to -0.21; mean [SD] MGWR: β, -0.59 [0.81]), racial segregation (OLS: β, -0.60; 95% CI, -0.89 to -0.31; mean [SD] MGWR: β, -0.47 [0.41]), mental health care physician ratio (OLS: β, -0.93; 95% CI, -1.44 to -0.42; mean [SD] MGWR: β, -0.48 [0.92]), and primary care physician ratio (OLS: β, -1.46; 95% CI, -2.13 to -0.79; mean [SD] MGWR: β, -1.06 [0.57]) were negatively associated with breast cancer mortality, and that light pollution was positively associated (OLS: β, 0.48; 95% CI, 0.24 to 0.72; mean [SD] MGWR: β, 0.27 [0.04]). But in the MGWR model, the magnitude of effect sizes and significance varied across geographical regions. Inversely, the OLS model found that disability was not a significant variable for breast cancer mortality, yet the MGWR model found that it was significantly positively associated in some geographical locations. This cross-sectional study found that not all social determinants associated with breast cancer mortality are spatially stationary and provides spatially explicit insights for public health practitioners to guide geographically targeted interventions.

Abstract PO-043: Perceived everyday discrimination, socioeconomic status, and mammography screening behavior

Abstract Black women (BW) experience age-adjusted breast cancer mortality rates that are 40-70% higher than White women. Although BW are more likely to report having had a mammogram compared to other racial/ethnic minority groups, differences in mammography utilization exist among women with lower socioeconomic status (SES). Moreover, perceived everyday discrimination (PED) has been shown to have an inverse relationship on health screening behavior among BW. However, mammography screening behaviors of BW with low SES, who also report higher levels of PED, is not well known. This study aims to explore the relationship between perceived discrimination, SES (income, education, health insurance), and mammography screening behavior. Methods: Participants completed a 40-item survey and were recruited between 2020-2021 through a community-based participatory research initiative—Bench to Community. Logistic regression was used to test the associations of mammography utilization with PED—short version of Everyday Discrimination Scale, SES, and race/ethnicity. Results: Most participants (n=159) identified as BW (55%)—African American, African, and Caribbean, followed by White (34%), and other groups (9.3%). Twenty-five percent had some high school (HS) or a HS diploma, 25% had some college education with 15% reporting an income below $25,000. Many respondents had health insurance (96%), and 74% reported having had a mammogram. Discrimination alone significantly impacted whether an individual had a mammogram, such that those who reported higher levels of PED were 38% less likely to have a mammogram, χ2(12) = 36.924, p<.001. Additionally, while education significantly contributed to the model, income demonstrated a trending influence overall, with less than $25,000 income reaching significance (B=-3.331, SE=1.210, Wald = 7.576, p=.006). As race and insurance did not significantly contribute to the overall model, subsequent model fitting excluded these variables. In a model that included only discrimination, education, and income, all three predictors significantly contributed to the model χ2(9)= 33.571, p<.001. Discrimination (B= -.536, SE=.178, Wald = 9.106, p=.003), education overall (B=-1.177, SE=.604, Wald = 3.797, p=.051), and income (B=-2.674, SE=.956, Wald = 7.815, p=.005) were significant predictors. More specifically, those with some college education or less were 3.245 times less likely to have a mammogram. In this final model, those who reported making less than $25,000 household income were .069 times less likely to have a mammogram. Lastly, race alone was significantly (p=.006) predictive of mammogram screening behavior. Discussion/Conclusion: PED, education, and income were associated with mammography screening behavior. The excess mortality faced by BW, is a probable reflection of their position within our hierarchal society. Addressing these social determinants of health factors may improve our understanding of ways discrimination leaves BW vulnerable to disparate health outcomes, including breast cancer. Citation Format: Jessica Vinegar, Marissa Ericson, Kommah McDowell, Tonya Fairley, Rick Kittles, Lindsey Treviño, Dede Teteh. Perceived everyday discrimination, socioeconomic status, and mammography screening behavior [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-043.

Recent Changes in the Patterns of Breast Cancer as a Proportion of All Deaths According to Race and Ethnicity.

Recent reports suggest that racial differences in breast cancer incidence rates have decreased. We examined whether these findings apply to breast cancer mortality while considering age, period, and cohort influences on both absolute and relative measures of breast cancer mortality. Using publicly available datasets (CDC WONDER, Human Mortality Database), we developed an age-period-cohort model of breast cancer mortality and breast cancer deaths as a proportion of all deaths during 1968-2019 among all women and by 5 race/ethnicity groups with sufficient numbers for estimation: Hispanic (all races), American Indian/Alaska Native and Asian/Pacific Islanders (regardless of ethnicity), non-Hispanic Black, and non-Hispanic White. Initially increasing after 1968, age-adjusted breast cancer mortality rates have decreased among all racial/ethnic groups since 1988. The age-adjusted percent of all deaths due to breast cancer also has been declining for non-Hispanic White women since about 1990 while increasing or holding steady for other race/ethnic groups. In 2019, the age-adjusted percent of deaths due to breast cancer for women was highest for Asian/Pacific Islanders (5.6%) followed by non-Hispanic Black (4.5%), Hispanic (4.4%), non-Hispanic White (4.1%), and American Indian/Alaska Native women (2.6%). Breast cancer mortality disparities are now greater on both relative and absolute scales for non-Hispanic Black women, and using the relative scale for Asian/Pacific Islander and Hispanic women, compared with non-Hispanic White women for the first time in 50 years.

Abstract 1183: Race, copy number variation, and local hog concentration in breast cancer mortality

Abstract Purpose of study: Female breast cancer is the second leading cause of cancer death in U.S. women, and the incidence of new breast cancer cases continues to increase. Despite slightly lower breast cancer incidence rates among African American (AA) compared to European American (EA) women in the U.S., AA women experience significantly higher breast cancer mortality. To better understand the extent to which environmental and genetic factors might help explain higher mortality rates among AA women, we examined the association between a measure of exposure to chemical pollutants and genomic profiling with breast cancer mortality among women with breast cancer in North Carolina. Procedures: Using a molecular epidemiologic approach, we examined the association of county hog concentration (a marker of environmental exposure to chemical pollutants) and genomic variations identified via targeted exome sequencing with age-adjusted breast cancer mortality rates among 146 women in North Carolina, stratified by race (AA vs. EA). The odds of breast cancer-specific mortality were estimated as a function of county hog concentration quintiles. Results: Overall, breast cancer mortality among AA women was higher than among EA women (OR=1.4, p<0.0001). Although there was no effect of hog concentration on breast cancer mortality of EA women, there was an increase in deaths from breast cancer in African American women in the highest quintile of hog concentration (OR=1.18, p=0.03), compared to the lower quintiles. In the lowest quintile of hog concentration, breast cancer mortality remained higher among AA versus EA women (OR=1.38, p=0.0002). This suggests that along with environmental factors, biological factors also contribute to disparities. Next, we performed targeted exome sequencing of breast cancer samples collected from a cohort in eastern North Carolina. AA breast cancer samples showed a high frequency of CNVs (copy number variations) of COL11A2, COL12A1, CYP21A2, LYRM2, COL9A1, DNAH11, and DST. EA breast cancer samples showed a high frequency of CNVs of PRG4, PLB1, CHRM5, OCA2, HMCN1, and MUC5B. Among these, HMCN1, MUC5B (among EA), and COL12A1, DNAH11, DST (among AA) were genes with significantly high CNVs identified from The Cancer Genome Atlas. Conclusions: Our findings suggest that living in a county with a high concentration of hogs may increase breast cancer mortality risk among AA women, and the high frequency of CNVs varies by race; both CNV and county hog concentration may contribute to racial disparities in breast cancer mortality among AA and EA women in North Carolina. Citation Format: Jung S. Byun, Sean Lee, Sijung Yun, Eliseo J. Perez-Stable, Anna M. Napoles, Paul Strickland, Kevin L. Gardner. Race, copy number variation, and local hog concentration in breast cancer mortality [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1183.

Impact of air pollution on breast cancer incidence and mortality: a nationwide analysis in South Korea

Breast cancer is one of the major female health problems worldwide. Although there is growing evidence indicating that air pollution increases the risk of breast cancer, there is still inconsistency among previous studies. Unlike the previous studies those had case-control or cohort study designs, we performed a nationwide, whole-population census study. In all 252 administrative districts in South Korea, the associations between ambient NO2 and particulate matter 10 (PM10) concentration, and age-adjusted breast cancer mortality rate in females (from 2005 to 2016, Nmortality = 23,565), and incidence rate (from 2004 to 2013, Nincidence = 133,373) were investigated via multivariable beta regression. Population density, altitude, rate of higher education, smoking rate, obesity rate, parity, unemployment rate, breastfeeding rate, oral contraceptive usage rate, and Gross Regional Domestic Product per capita were considered as potential confounders. Ambient air pollutant concentrations were positively and significantly associated with the breast cancer incidence rate: per 100 ppb CO increase, Odds Ratio OR = 1.08 (95% Confidence Interval CI = 1.06–1.10), per 10 ppb NO2, OR = 1.14 (95% CI = 1.12–1.16), per 1 ppb SO2, OR = 1.04 (95% CI = 1.02–1.05), per 10 µg/m3 PM10, OR = 1.13 (95% CI = 1.09–1.17). However, no significant association between the air pollutants and the breast cancer mortality rate was observed except for PM10: per 10 µg/m3 PM10, OR = 1.05 (95% CI = 1.01–1.09).

Trends in incidence, mortality and survival in women with breast cancer from 1985 to 2012 in Granada, Spain: a population-based study

BackgroundThe incidence of breast cancer has increased since the 1970s. Despite favorable trends in prognosis, the role of changes in clinical practice and the introduction of screening remain controversial. We examined breast cancer trends to shed light on their determinants.MethodsData were obtained for 8502 new cases of breast cancer in women between 1985 and 2012 from a population-based cancer registry in Granada (southern Spain), and for 2470 breast cancer deaths registered by the Andalusian Institute of Statistics. Joinpoint regression analyses of incidence and mortality rates were obtained. Observed and net survival rates were calculated for 1, 3 and 5 years. The results are reported here for overall survival and survival stratified by age group and tumor stage.ResultsOverall, age-adjusted (European Standard Population) incidence rates increased from 48.0 cases × 100,000 women in 1985–1989 to 83.4 in 2008–2012, with an annual percentage change (APC) of 2.5% (95%CI, 2.1–2.9) for 1985–2012. The greatest increase was in women younger than 40 years (APC 3.5, 95%CI, 2.4–4.8). For 2000–2012 the incidence trend increased only for stage I tumors (APC 3.8, 95%CI, 1.9–5.8). Overall age-adjusted breast cancer mortality decreased (APC − 1, 95%CI, − 1.4 – − 0.5), as did mortality in the 50–69 year age group (APC − 1.3, 95%CI, − 2.2 – − 0.4). Age-standardized net survival increased from 67.5% at 5 years in 1985–1989 to 83.7% in 2010–2012. All age groups younger than 70 years showed a similar evolution. Five-year net survival rates were 96.6% for patients with tumors diagnosed in stage I, 88.2% for stage II, 62.5% for stage III and 23.3% for stage IV.ConclusionsBreast cancer incidence is increasing – a reflection of the evolution of risk factors and increasing diagnostic pressure. After screening was introduced, the incidence of stage I tumors increased, with no decrease in the incidence of more advanced stages. Reductions were seen for overall mortality and mortality in the 50–69 year age group, but no changes were found after screening implementation. Survival trends have evolved favorably except for the 70–84 year age group and for metastatic tumors.

Paths to health equity: Local area variation in progress toward eliminating breast cancer mortality disparities, 1990-2009.

US breast cancer deaths have been declining since 1989, but African American women are still more likely than white women to die of breast cancer. Black/white disparities in breast cancer mortality rate ratios have actually been increasing. Across 762 US counties with enough deaths to generate reliable rates, county-level, age-adjusted breast cancer mortality rates were examined for women who were 35 to 74 years old during the period of 1989-2010. Twenty-two years of mortality data generated twenty 3-year rolling average data points, each centered on a specific year from 1990 to 2009. Mixed linear models were used to group each county into 1 of 4 mutually exclusive trend patterns. The most recent 3-year average black breast cancer mortality rate for each county was also categorized as being worse or not worse than the breast cancer mortality rate for the total US population. More than half of the counties (54%) showed persistent, unchanging disparities. Roughly 1 in 4 (24%) had a divergent pattern of worsening black/white disparities. However, 10.5% of the counties sustained racial equality over the 20-year period, and 11.7% of the counties actually showed a converging pattern from high disparities to greater equality. Twenty-three counties had 2008-2010 black mortality rates better than the US average mortality rate. Disparities are not inevitable. Four US counties have sustained both optimal and equitable black outcomes as measured by both absolute (better than the US average) and relative benchmarks (equality in the local black/white rate ratio) for decades, and 6 counties have shown a path from disparities to health equity.

Abstract B33: Female breast cancer in New England: Incidence, mortality, and prevention trends with attention to potential cancer racial/ethnic differences

Abstract Introduction: Breast cancer is estimated to be the first leading cancer type in incidence and the second leading cancer type in mortality in women in 2011 in the United States (US). In addition to the clinical breast exam, an annual mammogram is recommended as a breast cancer screening test. Cancer racial/ethnic disparities are defined as differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific racial/ethnic population groups in the US. The objectives of this study are: 1) to describe female breast cancer incidence, mortality, and mammogram use annual trends in New England; and 2) to evaluate potential female breast cancer racial/ethnic disparities in New England. Methods: Age-adjusted invasive breast cancer incidence rates in women were collected for 2004-2008 from the North American Association of Cancer Registries. Age-adjusted breast cancer mortality rates in women were collected for 2002-2006 from the Centers for Disease Control and Prevention (CDC). Mammogram use within the past 2 years, by women age 40+ or 50+, data were collected for 2000-2010 from the CDC. Results: Invasive female breast cancer shows an increasing incidence trend in Massachusetts (MA) and Rhode Island (RI), decreasing incidence trend in Maine, and stable incidence trend in Connecticut (CT), New Hampshire (NH), and Vermont. Nationwide, New England states rank among the top 10 US states in invasive female breast cancer incidence rate. In terms of race/ethnicity, non-Hispanic Blacks from RI show an increasing incidence trend of invasive female breast cancer, compared with non-Hispanic Blacks from CT, MA, and US. In addition, there is a decreasing female breast cancer mortality trend in non-Hispanic Whites from NH. The mammogram use analysis shows that VT has the lowest percentage of women having it within the past 2 years in New England and the percentage of women who have had it within the same time period is decreasing in RI. In general, 50+ women have had a mammogram within the past 2 years at a higher percentage than 40+ women. Conclusions: MA, CT, RI, and NH lead the US states in invasive female breast cancer incidence. These results suggest state or regional-specific conditions that need to be addressed. Further studies of female breast cancer racial/ethnic disparities in New England are needed. Finally, mammogram use increases with age. However, its use should be further encouraged among women in New England. Funding: National Institutes of Health, National Cancer Institute Research Supplement to Promote Diversity in Health-related Research (PI Brian C. Lewis, PhD, University of Massachusetts Medical School, Worcester, MA). Citation Format: Wilfredo Eugenio De Jesus-Monge, Vivianna Margarita De Jesus-Monge. Female breast cancer in New England: Incidence, mortality, and prevention trends with attention to potential cancer racial/ethnic differences. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B33. doi:10.1158/1538-7755.DISP13-B33

Health and economic impact of breast cancer mortality in young women, 1970-2008.

Breast cancer is the second-leading cause of cancer-related deaths among women aged <50 years. Studies on the effects of breast cancer mortality among young women are limited. To assess trends in breast cancer mortality rates among women aged 20-49 years, estimate years of potential life lost (YPLL), and the value of productivity losses due to premature mortality. Age-adjusted rates and rate ratios (RRs) were calculated using 1970-2008 U.S. mortality data. Breast cancer mortality rates over time were assessed using Joinpoint regression modeling. YPLL was calculated using number of cancer deaths and the remaining life expectancy at the age of death. Value of productivity losses was estimated using the number of deaths and the present value of future lifetime earnings. From 1970 to 2008, the age-adjusted breast cancer mortality rate among young women was 12.02/100,000. Rates were higher in the Northeast (RR=1.03, 95% CI, 1.02-1.04). The annual decline in breast cancer mortality rates among blacks was smaller (-0.68%) compared with whites (-2.02%). The total number of deaths associated with breast cancer was 225,866, which accounted for an estimated 7.98 million YPLL. The estimated total productivity loss in 2008 was $5.49 billion and individual lifetime lost earnings were $1.10 million. Considering the effect of breast cancer on women of working age and the disproportionate impact on black women, more age-appropriate interventions with multiple strategies are needed to help reduce these substantial health and economic burdens, improve survival, and in turn reduce productivity costs associated with premature death.

Trends in Breast Cancer Stage and Mortality in Michigan (1992–2009) by Race, Socioeconomic Status, and Area Healthcare Resources

The long-term effect of socioeconomic status (SES) and healthcare resources availability (HCA) on breast cancer stage of presentation and mortality rates among patients in Michigan is unclear. Using data from the Michigan Department of Community Health (MDCH) between 1992 and 2009, we calculated annual proportions of late-stage diagnosis and age-adjusted breast cancer mortality rates by race and zip code in Michigan. SES and HCA were defined at the zip-code level. Joinpoint regression was used to compare the Average Annual Percent Change (AAPC) in the median zip-code level percent late stage diagnosis and mortality rate for blacks and whites and for each level of SES and HCA. Between 1992 and 2009, the proportion of late stage diagnosis increased among white women [AAPC = 1.0 (0.4, 1.6)], but was statistically unchanged among black women [AAPC = −0.5 (−1.9, 0.8)]. The breast cancer mortality rate declined among whites [AAPC = −1.3% (−1.8,−0.8)], but remained statistically unchanged among blacks [AAPC = −0.3% (−0.3, 1.0)]. In all SES and HCA area types, disparities in percent late stage between blacks and whites appeared to narrow over time, while the differences in breast cancer mortality rates between blacks and whites appeared to increase over time.

Insufficient sleep associated with increased breast cancer mortality

To the Editor: Restless legs syndrome (RLS) is a neurological condition that ocTo the Editor Sleep disturbance increases the risk for breast cancer. For example, Kazizaki et al. [1] reported that women with short sleep duration had a higher risk of breast cancer, compared to women who slept 7 hours per day. However , little is known about sleep disturbance and breast cancer mortality. In our analysis, we assessed the risk of breast cancer death associated with insufficient sleep. Age adjusted data on sleep disturbance in the 50 states in the United States as well as the District of Columbia are from perceived insufficient rest or sleep among adults – United States, 2008 [2]. Age adjusted breast cancer mortality is from American Cancer Society Cancer Facts and Figures [3]. Data on race by state are from the 2010 US census. There was a significant correlation between percentage of persons who reported insufficient sleep everyday in the preceding 30 days versus breast cancer mortality in the 50 states in the United States as well as the District of Columbia (p = 0.013). Because breast cancer survival is higher in white women than black women [4], multiple linear regression was performed . The association of insufficient sleep everyday in the preceding 30 days with breast cancer mortality was significant (p = 0.01) and unrelated to the percentage in the white population (p = 0.114). Studies suggest that melatonin is involved in the relationship of sleep and breast cancer, and melatonin exerts an antiproliferativ e effect on breast cancer cells [5]. Moreover, breast cancer has become more prevalent for reasons that are poorly understood. Likewise, prevalen ce of sleeping difficulties and sleepiness has increased; whereas, sleep duration per night has decrease d. These sleep aberrations may be putting more women at risk for death from breast cancer.

The decline in breast cancer mortality in Europe: An update (to 2009)

We updated trends in breast cancer mortality in Europe up to the late 2000’s. In the EU, age-adjusted (world standard population) breast cancer mortality rates declined by 6.9% between 2002 and 2006, from 17.9 to 16.7/100,000. The largest falls were in northern European countries, but more recent declines were also observed in central and eastern Europe. In 2007, all major European countries had overall breast cancer rates between 15 and 19/100,000. In relative terms, the declines in mortality were larger at younger age (−11.6% at age 20–49 years between 2002 and 2007 in the EU), and became smaller with advancing age (−6.6% at age 50–69, −5.0% at age 70–79 years). The present report confirms and further quantifies the persisting steady fall in breast cancer mortality in Europe over the last 25–30 years, which is mainly due to advancements in the therapy.

The Impact of Detection and Treatment of Carcinoma In Situ on Breast Cancer Mortality

Abstract Purpose: Ductal carcinoma in situ (DCIS), a nonobligate precursor to invasive breast cancer, makes up 20% of new breast cancer diagnoses. DCIS is primarily detected by mammography and has excellent prognosis regardless of therapy choice. We aim to quantify the impact of detection and treatment of DCIS on breast cancer mortality using computer modeling. Methods: We used a validated microsimulation model to replicate U.S. trends in breast cancer incidence and mortality from 1975 to 2000. All breast cancer tumors began in the in situ stage and progressed through more advanced stages with increasing tumor size and lymph node involvement, with a fraction of tumors assumed as nonlethal. Age-adjusted breast cancer mortality was examined under historical U.S. screening and treatment patterns and three alternative scenarios: (1) only women 50 years and older received screening and all breast cancer cases received treatment according to historical patterns, (2) all women received screening according to historical patterns but DCIS was untreated unless later detected at an invasive stage, and (3) historical screening was used but DCIS was never treated. Results: The model predicts breast cancer mortality rates declined during the 1990s to a low of 39.9 per 100,000 in 2000, which is consistent with observed mortality based on the SEER program (38.0 per 100,000 in 2000). Delaying mammography until age 50 or postponing treatment until DCIS progressed to invasive cancer increased mortality to 42.4 and 43.2 per 100,000, respectively, by 2000. If DCIS patients did not receive any treatment, mortality remained steady (∼51.2 per 100,000) through 2000. Conclusions: Our model results suggested detection and treatment of DCIS in the U.S. reduced breast cancer deaths in the year 2000 by about 28%. Most of this benefit (92%–94%) could also be achieved if instead mammography began at age 50 or treatment was reserved for invasive breast cancers only.

The “Tipping Point” for Breast Cancer Mortality Decline Has Resulted from Size Reductions Due to Mammographic Screening

Considering the declining breast cancer mortality in the United States, it is apparent that a ‘‘tipping point’’ was reached between 1986 and 1991, most apparent after 1990. For the first time since 1930, the previously unyielding ageadjusted breast cancer mortality rate began a continuous decline, starting about 5 years after the upsurge in use of mammographic screening in the 1980s (Fig. 1). This mortality decline had reached 30% in the entire United States by 2007 (Fig. 2; http://www.seer.cancer.gov) and had reached as much as 48% in Delaware, 41% in Rhode Island, and 40% in Massachusetts (http://statecancerprofiles.cancer.gov), the three highest states in mammography use recorded by the 2006 Behavioral Risk Factor Surveillance System (BRFSS) telephone surveys (http://cdc.gov/brfss/). The BRFSS estimates mammography use at least every 2 years by women over the age of 40. In contrast, mortality decline has been only 11% in Utah, 12% in Mississippi, and 14% in Oklahoma, three of the four lowest states in BRFSS reports of screening incidence (Fig. 3; http://statecancerprofiles. cancer.gov). Although the BRFSS rates may be somewhat exaggerated because they are based on women’s recall, the resultant relative ranking is undoubtedly correct because survey techniques are similar across the country. States with the greatest decline in mortality are also states with high initial incidence and mortality from breast cancer due to well-established demographic features such as older age, higher socioeconomic status, and higher education level. Because mammographic screening reduces mortality by earlier detection of a cancer with a biologically progressive disease course in most situations, a reduced rate of advanced breast cancers in a population is a surrogate for the success of screening. Here, we analyze the role of the steady change in tumor size as a result of breast cancer screening and attempt to demonstrate a temporal and possible causal relationship between changes in tumor size and the beginning of the decrease in breast cancer mortality (that is, the tipping point). The mean maximum diameter of all breast cancers was about 3.5 cm before 1950, about 3.0 cm in 1968 (just before the introduction of mammography), reached about 2.5 cm by 1987, and had a progressive further decline to less than 2.0 cm by 2006. The median maximum diameter of breast cancer, a better description of the usual presentation because it eliminates the bias of the extended ‘‘tail’’ of very large cancers, was 2.5 cm in 1968, 2.0 cm by 1987, and 1.5 cm after 2002. Accompanying this overall size decrease, the axillary lymph node metastatic rate, which was over 60% in the 1950s, usually with multiple node metastases, decreased to about 50% by 1968, and thereafter progressively declined to less than 30% by 2006. Equally important was the progressive decline in the number of lymph node metastases involved in women with invasive breast cancer through the years, so that now only one node metastasis is found in about 50% of patients who have regional nodal metastases, and all nodal metastases are limited to the excised sentinel nodes in up to two-thirds of patients. With the adoption of limited axillary node sampling by sentinel node biopsy, smaller volumes of nodal involvement have been recorded as pathologists more rigorously section and examine the few sentinel nodes submitted (median # 2), which in turn technically increases the rate of nodal metastases by up to 20%, a good example of the Society of Surgical Oncology 2011

The Racial Disparity in Breast Cancer Mortality

Black women die of breast cancer at a much higher rate than white women. Recent studies have suggested that this racial disparity might be even greater in Chicago than the country as a whole. When data describing this racial disparity are presented they are sometimes attributed in part to racial differences in tumor biology. Vital records data were employed to calculate age-adjusted breast cancer mortality rates for women in Chicago, New York City and the United States from 1980-2005. Race-specific rate ratios were used to measure the disparity in breast cancer mortality. Breast cancer mortality rates by race are the main outcome. In all three geographies the rate ratios were approximately equal in 1980 and stayed that way until the early 1990s, when the white rates started to decline while the black rates remained rather constant. By 2005 the black:white rate ratio was 1.36 in NYC, 1.38 in the US, and 1.98 in Chicago. In any number of ways these data are inconsistent with the notion that the disparity in black:white breast cancer mortality rates is a function of differential biology. Three societal hypotheses are posited that may explain this disparity. All three are actionable, beginning today.

A prospective study of cardiorespiratory fitness and breast cancer mortality.

Physical activity may protect against breast cancer. Few prospective studies have evaluated breast cancer mortality in relation to cardiorespiratory fitness (CRF), an objective marker of physiologic response to physical activity habits. We examined the association between CRF and risk of death from breast cancer in the Aerobics Center Longitudinal Study. Women (N = 14,811), aged 20 to 83 yr with no prior breast cancer history, received a preventive medical examination at the Cooper Clinic in Dallas, Texas, between 1970 and 2001. Mortality surveillance was completed through December 31, 2003. CRF was quantified as maximal treadmill exercise test duration and was categorized for analysis as low (lowest 20% of exercise duration), moderate (middle 40%), and high (upper 40%). At baseline, all participants were able to complete the exercise test to at least 85% of their age-predicted maximal heart rate. A total of 68 breast cancer deaths occurred during follow-up (mean = 16 yr). Age-adjusted breast cancer mortality rates per 10,000 woman-years were 4.4, 3.2, and 1.8 for low, moderate, and high CRF groups, respectively (trend P = 0.008). After further controlling for body mass index, smoking, drinking, chronic conditions, abnormal exercise ECG responses, family history of breast cancer, oral contraceptive use, and estrogen use, hazard ratios (95% CI) for breast cancer mortality across incremental CRF categories were 1.00 (referent), 0.67 (0.35-1.26), and 0.45 (0.22-0.95) (trend P = 0.04). These results indicate that CRF is associated with a reduced risk of dying from breast cancer in women.

Racial disparities in breast cancer outcome

Since the 1970s, overall age-adjusted breast cancer mortality rates in the U.S. have been higher among African American (AA) women than among Caucasian American (CA) women. The racial disparity is not fully explainable based on socioeconomic factors. Suspected biologic factors underlying this trend may be interpreted by both epidemiologic and clinical perspectives. Descriptive epidemiologic studies suggest that breast cancer may be a mixture of at least 2 main diseases and/or causal pathways. The first breast cancer is early-onset, with peak incidence near age 50 years and generally more aggressive outcome. The second breast cancer is late-onset, with peak incidence near age 70 years and more indolent course. The early-onset type of breast cancer is overrepresented among AA women compared with CA women. Clinical studies suggest that the course of breast cancer may be characterized by a common pathway through sequential dormant and active states eventually resulting in clustered appearance of clinical metastases. A balance between tumor and host traits influences the pace of the common pathway. Therefore, the recurrence risk profile of a single patient is seemingly determined by a specific mix of hierarchical prognostic factors, resulting from the unique genetic, environmental, or behavioral traits of that individual, which may be affected by race-related factors. We suggest that the components of the AA versus CA disparity not attributable to socioeconomic factors are a particular case of the more general issue of host-tumor interaction and that epidemiologic and clinical views are complementary; each is observing biologic parameters, which are not completely captured by the other. A 'unifying hypothesis' incorporating findings from genetics, epidemiology, and clinical studies should be aggressively pursued.