Decrease In Breast Cancer Mortality Research Articles

German Mammography Screening Program

How come I’ve got a tumor? I was only just screened.” Probably every woman has heard something like this from a friend or a neighbor, and in some cases it may make the difference between going for screening mammography or not. The aim of the German mammography screening program is to achieve a lasting decrease in breast cancer mortality. The program’s success, however, can be accurately evaluated only after at least 10 years have elapsed. Therefore other criteria, the so-called surrogate parameters defined in the European guidelines (1) and adapted for use in the German program, are employed to assess the quality and efficacy of screening at an early point in time. The Mammography Cooperative (Kooperationsgemeinschaft Mammographie) evaluates the relevant data according to section 23 paragraph 1 of the cancer screening guideline and publishes the findings in regular reports (2).

Breast cancer mortality in Norway after the introduction of mammography screening

An organized mammography screening program was gradually implemented in Norway during the period 1996-2004. Norwegian authorities have initiated an evaluation of the program. Our study focused on breast cancer mortality. Using Poisson regression, we compared the change in breast cancer mortality from before to during screening in four counties starting the program early controlling for change in breast cancer mortality during the same time in counties starting the program late. A follow-up model included death in all breast cancers diagnosed during the follow-up period. An evaluation model included only breast cancers diagnosed in ages where screening was offered. The study group had been invited for screening one to three times and followed for on average of 5.9 years. In the follow-up model, 314 breast cancer deaths were observed in the study group, and 523, 404 and 638, respectively, in the four control groups. The ratio between the changes in breast cancer mortality between early and late starting counties was 0.93 (95% confidence interval [CI] 0.77-1.12). In the evaluation model, this ratio was 0.89 (95% CI: 0.71-1.12). In Norway, where 40% of women used regular mammography prior to the program, the implementation of the organized mammography screening program was associated with a statistically nonsignificant decrease in breast cancer mortality of around 11%.

The Role of Capecitabine in Early Stage Breast Cancer

Adjuvant systemic therapy is partly responsible for the decrease in breast cancer mortality we have seen over the past two decades. Hormonal therapy and combination chemotherapy based on anthracyclines and taxanes represent the best current approach for early breast cancer patients. Primary as well as secondary development of resistance represents the major challenges to improve our results. Major benefits have been achieved as we recognized populations with particular molecular abnormalities (HER2 positive) and applied specific targeted agents (trastuzumab). However, the addition of other traditional chemotherapy agents has remained a challenge. With consistent data both as a single agent and as part of combinations in the treatment of advanced disease, capecitabine is being explored in over 20,000 early breast cancer patients currently participating in clinical trials. In this review, we discuss the available evidence for the incorporation of capecitabine in the (neo)-adjuvant treatment of patients with breast cancer.

Contribution of Early Detection and Adjuvant Treatments to Breast Cancer Mortality Reduction in Catalonia, Spain

BackgroundReductions in breast cancer (BC) mortality in Western countries have been attributed to the use of screening mammography and adjuvant treatments. The goal of this work was to analyze the contributions of both interventions to the decrease in BC mortality between 1975 and 2008 in Catalonia.Methodology/Principal FindingsA stochastic model was used to quantify the contribution of each intervention. Age standardized BC mortality rates for calendar years 1975–2008 were estimated in four hypothetical scenarios: 1) Only screening, 2) Only adjuvant treatment, 3) Both interventions, and 4) No intervention. For the 30–69 age group, observed Catalan BC mortality rates per 100,000 women-year rose from 29.4 in 1975 to 38.3 in 1993, and afterwards continuously decreased to 23.2 in 2008. If neither of the two interventions had been used, in 2008 the estimated BC mortality would have been 43.5, which, compared to the observed BC mortality rate, indicates a 46.7% reduction. In 2008 the reduction attributable to screening was 20.4%, to adjuvant treatments was 15.8% and to both interventions 34.1%.Conclusions/SignificanceScreening and adjuvant treatments similarly contributed to reducing BC mortality in Catalonia. Mathematical models have been useful to assess the impact of interventions addressed to reduce BC mortality that occurred over nearly the same periods.

Breast cancer screening in developing countries

Diagnosing breast cancer early and efficiently is a critical component of any strategy aimed at decreasing breast cancer mortality in developing countries. In this chapter, I evaluate the evidence behind screening strategies and its controversies. The effect of breast-cancer screening has never been formally evaluated in developing countries, and data from the major screening trials need to be viewed in this context. Screening asymptomatic women by means of breast self-examination, clinical examination or mammography can play a significant role in decreasing breast-cancer mortality in developing countries. Major programmes should not be implemented, however, until adequate diagnostic and therapeutic facilities are in place. The most fundamental interventions in early detection, diagnosis, surgery, radiation therapy, and drug therapy must be integrated, organised and resourced appropriately within existing healthcare structures.

Sociodemographic Determinants of Nonattendance in a Population-Based Mammography Screening Program in the City of Manisa, Turkey

Objectives. Community based breast cancer screening has decreased breast cancer mortality in women. This study examined the predictors of nonattendence for invitational breast cancer screening in relation to socioeconomic status in the city of Manisa, in western Turkey. Study Design. For the evaluation of the reasons for refusing to participate in the study, two districts were selected. 446 women aged between 50 and 69 years were selected from the program database by systematic random sampling. Methods. The questionnaire consisted of sociodemographic variables and the adapted version of Champion's Health Belief Model Scale. Univariete and multivariete logistic regression analysis were performed throughout the data analysis. Results. Being from an urban district and being from the western region were the risk factors for not participating in the screening program (P = 0.014, P = 0.023). A statistical significance was found between mammography-benefit, mammography-barrier and program participation (P = 0.044, P = 0.006). Although there were many more barriers for not participating in the screening program for the women of the slum district, the attendence rate of the slum district was higher than that of the urban district. Conclusions. Increased attendance may be achieved through enhancement of breast cancer awareness and by reducing some of the modifiable barriers.

Risk Factors of Developing Long-Lasting Breast Pain After Breast Cancer Radiotherapy

Postoperative radiotherapy decreases breast cancer mortality. However, studies have revealed a long-lasting breast pain among some women after radiotherapy. The purpose of this study was to identify risk factors that contribute to breast pain after breast cancer radiotherapy. We identified 1,027 recurrence-free women in two cohorts of Swedish women treated for breast cancer. The women had breast-conserving surgery and postoperative radiotherapy, the breast was treated to 48 Gy in 2.4-Gy fractions or to 50 Gy in 2.0-Gy fractions. Young women received a boost of up to 16 Gy. Women with more than three lymph node metastases had locoregional radiotherapy. Systemic treatments were given according to health-care guidelines. Three to 17 years after radiotherapy, we collected data using a study-specific questionnaire. We investigated the relation between breast pain and potential risk modifiers: age at treatment, time since treatment, chemotherapy, photon energy, fractionation size, boost, loco-regional radiotherapy, axillary surgery, overweight, and smoking. Eight hundred seventy-seven women (85%) returned the questionnaires. Among women up to 39 years of age at treatment, 23.1% had breast pain, compared with 8.7% among women older than 60 years (RR 2.66; 95% CI 1.33-5.36). Higher age at treatment (RR 0.96; 95% CI 0.94-0.98, annual decrease) and longer time since treatment (RR 0.93; 95% CI 0.88-0.98, annual decrease) were related to a lower occurrence of breast pain. Chemotherapy increased the occurrence of breast pain (RR 1.72; 95% CI 1.19-2.47). In the multivariable model only age and time since treatment were statistically significantly related to the occurrence of breast pain. We found no statistically significant relation between breast pain and the other potential risk modifiers. Younger women having undergone breast-conserving surgery with postoperative radiotherapy report a higher occurrence of long-lasting breast pain compared to older women. Time since treatment may decrease the occurrence of pain.

Abstract ED06-02: Breast cancer screening in low- and middle-income countries

Abstract Breast cancer is the commonest cancer in the majority of low and middle income countries (LMIC's). Survival from breast cancer depends on two main factors – early detection and treatment. In LMICs, delayed presentation of breast cancer is a common occurrence. Barriers to early presentation are lack of access to optimal treatment, lack of financial resources, ignorance and psychosocial issues which include fatalism, fear of death, fear of mastectomy, and lack of autonomy on the part of the woman. Downsizing symptomatic disease as well as screening for asymptomatic disease can reduce mortality from breast cancer. Public education and awareness is a key first step as any early detection program is unlikely to succeed unless the public is aware of the potential benefits. The effectiveness and efficiency of screening modalities including screening mammography, clinical breast examination (CBE) and breast self-examination (BSE) are reviewed in the context of resource availability and population-based need. While mammographic screening is the gold standard for early detection of breast cancer, considerations regarding cost-effectiveness and quality assurance of such a program in LMICs is a concern. The identification of a target group for mammography screening in LMICs should be based on the burden of disease in the population, the potential to benefit from screening, and available resources. Although there may be exceptions, in the absence of such information, the preponderance of the evidence suggests that in most countries it would be reasonable to begin a breast cancer screening program by offering mammography every 2 years to women between the ages of 50 and 65. Although two observational studies on BSE provide evidence that this screening modality reduces breast cancer mortality, this has not been confirmed in two randomized trials. Currently, the evidence is not sufficiently conclusive to justify the recommendation for routine CBE in population-based screening programs, because CBE has not been shown to independently decrease breast cancer mortality, although there are current trials to evaluate this modality. It is also important that any screening program be accompanied by the development of resources required for diagnosis and treatment. The success of any early detection program can be measured by cancer stage at diagnosis, and eventually improvement in survival. Citation Information: Cancer Prev Res 2011;4(10 Suppl):ED06-02.

Mammography activity in Norway 1983 to 2008

Background. In Norway, an organized screening mammography program, the Norwegian Breast Cancer Screening Program (NBCSP) started in four counties in 1996 and became nationwide in 2004. We collected data on pre-program screening activity, and in view of this activity we evaluated the potential impact of the program on breast cancer mortality in Norway. Methods. We searched data sources on mammography activity in Norway. Three data sources reported on examination activity, and two on self-reported examinations. We aimed at calculating annual number of women examined by mammography from 1983 to 2008, and coverage rate in program and non-program Norwegian counties. Results. The annual number of women examined increased from 5000 in 1983 to 110 000 in 1993 to reach its maximum of 131 000 in 2002, excluding program examinations. The annual number of women examined in the organized program increased from 1996 to a steady state about 190 000 in 2004. Prior to start of the organized program, 40% of women in target age groups reported to have had mammography examination. During the years 1996–2002, 64% of first participants in the organized program reported to have been examined previously. Assuming that the Norwegian program would in absence of prior screening have decreased breast cancer mortality by 25%, and that the activity in- and outside the organized program were equally effective, the measured effect of the organized program would under actual circumstances be a reduction of 11%. Conclusion. The example of Norway illustrates that although monitoring of screening outcome is highly warranted, this may be seriously jeopardized if use of mammography examinations was widespread prior to implementation of an organized program.

Adjuvant chemotherapy and radiotherapy in triple-negative breast carcinoma: A prospective randomized controlled multi-center trial

Background and purpose: Triple-negative breast cancer (TNBC) presents a high risk breast cancer that lacks the benefit from hormone treatment, chemotherapy is the main strategy even though it exists in poor prognosis. Use of adjuvant radiation therapy, which significantly decreases breast cancer mortality, has not been well described among poor TNBC women. The aim of this study was to evaluate whether the combination of chemotherapy and radiotherapy could significantly increase survival outcomes in TNBC women after mastectomy. Patients and methods: A prospective randomized controlled multi-center study was performed between February 2001 and February 2006 and comprised 681 women with triple-negative stage I–II breast cancer received mastectomy, of them, 315 cases received systemic chemotherapy alone, 366 patients received radiation after the course of chemotherapy. Recurrence-free survival (RFS) and overall survival (OS) were estimated. Simultaneously local and systemic toxicity were observed. Results: After a median follow-up of 86.5months, five-year RFS rates were 88.3% and 74.6% for adjuvant chemotherapy plus radiation and adjuvant chemotherapy alone, respectively, with significant difference between the two groups (HR 0.77 [95% CI 0.72, 0.98]; P=0.02). Five-year OS significantly improved in adjuvant chemotherapy plus radiation group compared with chemotherapy alone (90.4% and 78.7%) (HR 0.79 [95% CI 0.74, 0.97]; P=0.03). No severe toxicity was reported. Conclusions: Patients received standard adjuvant chemotherapy plus radiation therapy was more effective than chemotherapy alone in women with triple-negative early-stage breast cancer after mastectomy.

Smoking studies produce new findings regarding breast and lung cancer link

Three recent studies explored how smoking is related to certain breast and lung cancer risks. In the first study, postmenopausal women who were current or former smokers were found to have a 16% higher risk of developing breast cancer than never-smokers.1 The study also found that women who had extensive exposure to passive smoking, either as children or adults, had an excess risk of developing breast cancer. Although previous studies have indicated a link between smoking and breast cancer, passive smoking risk remains controversial. Researchers, led byJuhua Luo, MD, of West Virginia University in Morgantown, and Karen Margolis, MD, of Health-Partners Research Foundation in Minneapolis, Minnesota, used data from the 1993-1998 Women's Health Initiative Observational Study to determine links between smoking, passive smoking, and breast cancer They analyzed data from nearly 80,000 women between the ages of 50 and 79 years across 40 clinical centers nationwide, identifying a total of 3250 cases of invasive breast cancer diagnosed over 10 years. Participants were asked a variety of questions, including whether they had ever smoked, at what age they began smoking, how many cigarettes they smoked each day, and at what age they quit smoking. They also were asked if they had lived in smoking households as children or adults and whether they had worked in smoking environments. Researchers found that smokers had a 16% increased risk of developing breast cancer after menopause; former smokers had a 9% increased risk. Those women who had smoked for 50 years or more had the highest risk compared with lifetime nonsmokers. Women who started smoking as teenagers also had a particularly high risk. The increased risk continued for 20 years after a person had stopped smoking. Nonsmoking women who had been exposed to extensive passive smoking had a 32% excess risk of breast cancer “Extensive” was defined as more than 10 years' exposure in childhood, more than 20 years' exposure as an adult at home, and more than 10 years' exposure as an adult at work. However, because their analysis of secondhand smoke was limited to the most extensive passive smoking category, the authors say more research is needed to confirm these findings. In another study by Kenneth Piazza, MD, MPH, and Andrew Hyland, PhD, at Roswell Park Cancer Institute in Buffalo, New York, smoke free homes and workplaces were linked to reductions in breast cancer incidence and mortality rates.2 The study found a statistically significant decrease in breast cancer mortality, particularly among younger premenopausal women, as the number of smoke- free homes and workplaces increased. An estimated 20% of the change in breast cancer mortality rates was due to changes in smoke-free home and workplace policies. Similar to the first group of researchers, Drs. Piazza and Hyland cited the lack of definitive evidence regarding passive smoke and risk of breast cancer However, the study also found that states with higher percentages of women working and living in smoke-free environments had lower breast cancer rates. In a third study, researchers found that many longtime smokers quit spontaneously shortly before their lung cancer was diagnosed.3 As a result, they speculate that sudden smoking cessation may be a symptom of lung cancer The study found that most patients who quit did so before noticing any cancer symptoms. They also often quit with no difficulty, despite having tried to quit unsuccessfully in the past, notes lead author Barbara Campling, MD, a medical oncologist at Thomas Jefferson University in Philadelphia, Pennsylvania. Researchers interviewed 115 lung cancer patients from the Philadelphia Veterans Affairs Medical Center, all of whom had been smokers. Of these, 55 patients (48%) had quit smoking before diagnosis and only 6 (11%) of these patients had experienced symptoms before they quit. The patients who quit were as dependent on nicotine as those who continued to smoke, yet 31% said they quit without difficulty. Investigators compared these results with those found in patients with prostate cancer and heart attack survivors. In the patients with lung cancer, the median time elapsed between quitting smoking and lung cancer diagnosis was 2.7 years. The interval between quitting and the event was 24.3 years for patients with prostate cancer and 10 years for heart attack survivors. Dr. Campling and colleagues speculated that smoking cessation may be caused by tumor secretion of a substance that interferes with nicotine addiction. She cautions that these results should not be misinterpreted to suggest that heavy smokers should continue smoking; they still should be strongly encouraged to quit.

Antiestrogens and Their Therapeutic Applications in Breast Cancer and Other Diseases

The identification of the link between breast cancer and estrogens has led to the development of antiestrogens, in particular tamoxifen, to inhibit the activities of estrogen receptors (ERs) in breast cancer cells. The clinical use of tamoxifen has played a major part in decreasing breast cancer mortality over the past 30 years. Though antiestrogenic in the breast, some antiestrogens have estrogen-like actions in other tissues, acting to promote bone density and protect against cardiovascular disease, thus raising the possibility of their use in counteracting the effects of estrogen loss following menopause. Moreover, antiestrogens show efficacy as chemopreventive agents in women at high risk of developing breast cancer. Thus, antiestrogens define an important and well-understood class of cancer drug, which continue to be a mainstay in breast cancer treatment.

On the Frontline of Screening for Breast Cancer

The mainstay of screening for breast cancer is the mammogram. There are several randomized control trials that demonstrate a significant decrease in breast cancer mortality when compared to women without screening mammography included in their care. Digital mammography has improved detection in the dense breast. With the introduction of digital mammography, other novel techniques such as stereo digital mammography (SDM) and tomosynthesis can reduce recall significantly without a negative effect on cancer detection. Magnetic resonance imaging (MRI) and ultrasound added to mammography can improve cancer detection for high-risk women but can have false positive consequences.

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

Breast Cancer Screening: What are the Last Changes?

Mammography, clinical breast-examination (CBE) and breast self-examination (BSE) are the mainly recommended screening methods for early diagnosis of breast cancer. In recent years, guidelines concerning screening methods were revised. To date, CBE and BSE are not routinely recommended for early diagnosis of breast cancer in western countries. Due to important value in decreasing breast cancer mortality rate, mammography, is the recommended breast cancer screening method; but the changes related with the time of mammography screening is rised to notice. In 2010, the US Preventive Services Task Force (USPSTF) which is one of the important health authority, guidelines concerning screening mammography were revised. Accordingly, while the mammography that is recommended for women starting aged 40 years by many health authorities, the USPSTF no longer advises routine screening mammography for women aged 40–49 and for those aged ≥75.; and biennial screening is advised for those aged 50–74. It is necessary for health professionals working in breast health area to learn the last changes concerning about breast cancer screening methods. Together with CBE and BSE, it is also important to encourage women to participate mammography screening with an understanding of its benefits and risks. In this article, it is aimed to critique new guidelines about breast cancer screening methods. It is also critiqued the potential benefits and risks of mammography that is currently considered the ‘‘gold standard’’ for breast cancer screening for women.

Evolución de la mortalidad por cáncer de mama y diseminación de la mamografía de cribado en Cataluña: un análisis por regiones sanitarias

The decrease of breast cancer (BC) mortality rates has been attributed to early detection programs and therapeutic advances. The objective is to compare BC mortality trend in health regions of Catalonia during the period 1993-2007. In parallel, dissemination of periodic mammography in the health regions has been analyzed. Mortality and health surveys data were used. Poisson and «joinpoint» regression analyses were used to compare regional BC mortality rates and quantify their temporal evolution. Mixed effects models were used to compare the rates and their evolution by region. The BC mortality rate decreased 3% annually in Cataluña. Between 1993 and 2007, the standard mortality rate changed from 34.8 to 23.3 per 100,000 women. Barcelona ciutat showed higher mortality rates than the Centre (rate ratio (RR)=0.873), Costa de Ponent (RR=0.885), Tarragona (RR=0.9) and Lleida regions (RR=0.915), but these differences tend to disappear over time. There were no observed trend changes in the evolution of the regional mortality rates, except in the Centre region. The use of periodic mammography was similar across health regions. During the 90s, Barcelona ciutat had a 36.1% utilization of periodic mammography in women aged 40-74, in the 1994 survey, the Centre 23.7 and Costa de Ponent 25.2%. The progressive increase in the use of periodic mammography and the decrease of BC mortality were similar in the eight health regions of Catalonia.

Perspektiven der digitalen Mammographieplattform

In Europe one out of every nine women suffers from breast cancer during her lifetime. Since the introduction of mammography screening programs more breast cancers are being diagnosed when they are still small and early stage cancers with a favourable prognosis. The introduction of digital mammography systems has led to a continuous reduction of breast cancer mortality especially in specific patient subgroups. Furthermore, the digital mammography platform enables the development of new, innovative breast imaging methods to increase sensitivity and decrease breast cancer mortality. This digital mammography platform includes digital breast tomosynthesis, digital contrast medium mammography and digital contrast medium breast tomosynthesis as well as fused data sets from digital mammography with ultrasound or MRI. The following article summarizes these new applications, describes the strengths of the digital platform and illustrates the potential advantages of an improved breast cancer diagnosis by digital mammography.

Imaging for the Diagnosis and Management of Ductal Carcinoma In Situ

Diagnosis of ductal carcinoma in situ (DCIS) has increased dramatically in parallel with the increased use of screening mammography. There are specific mammographic findings, most associated with shapes (amorphous, fine and coarse pleomorphic, and fine linear) and distributions (linear and segmental) of calcifications that permit a reasonable sensitivity for detection of DCIS without an unreasonable decrease in specificity, especially in view of the dramatic decrease in breast cancer mortality associated with early detection. While some DCIS may never progress to invasive disease, at this time, we cannot make that separation. This should be an active area for research.

Recurrent Early-Stage Triple-Negative Breast Cancer

Background and purpose: Triple-negative breast cancer (TNBC) presents a high risk breast cancer that lacks the benefit from hormone treatment, chemotherapy is the main strategy even though it exists in poor prognosis. Use of adjuvant radiation therapy, which significantly decreases breast cancer mortality, has not been well described among poor TNBC women. The aim of this study was to evaluate whether the combination of chemotherapy and radiotherapy could significantly increase survival outcomes in TNBC women after mastectomy. Patients and methods: A prospective randomized controlled multi-center study was performed between February 2001 and February 2006 and comprised 681 women with triple-negative stage I–II breast cancer received mastectomy, of them, 315 cases received systemic chemotherapy alone, 366 patients received radiation after the course of chemotherapy. Recurrence-free survival (RFS) and overall survival (OS) were estimated. Simultaneously local and systemic toxicity were observed. Results: After a median follow-up of 86.5 months, five-year RFS rates were 88.3% and 74.6% for adjuvant chemotherapy plus radiation and adjuvant chemotherapy alone, respectively, with significant difference between the two groups (HR 0.77 [95% CI 0.72, 0.98]; P = 0.02). Five-year OS significantly improved in adjuvant chemotherapy plus radiation group compared with chemotherapy alone (90.4% and 78.7%) (HR 0.79 [95% CI 0.74, 0.97]; P = 0.03). No severe toxicity was reported. Conclusions: Patients received standard adjuvant chemotherapy plus radiation therapy was more effective than chemotherapy alone in women with triple-negative early-stage breast cancer after mastectomy.

System Barriers to Treatment in Women with Locally

Background: Breast cancer in the United States will affect approximately one in eight women. Despite a decrease in breast cancer mortality due to increased awareness and more effective screening, many patients still present for treatment after extended delays in diagnosis, resulting in large tumor size, locally advanced disease, inflammatory features, and greater likelihood of regional and distant metastasis. Purpose: The purpose of this study is to identify reasons why patients may encounter delays in obtaining a diagnosis, seeking medical care, and initiating treatment once symptoms appear. Methodology: A 39-item Likert-scale questionnaire was administered to 34 consecutive patients with histologically-verified stage III breast cancer and who had experienced a 3-month or greater delay in diagnosis or initiation of treatment from the time of onset of symptoms. Findings: Physician barriers: Roughly one-fourth of women reported that their physician did not believe that their breast lump/symptom was related to cancer (235%) and 177% of physicians did not think that a biopsy was necessary. System barriers: Among systems barriers, “delay in scheduling diagnostic tests” remained the most prevalent barrier to breast cancer treatment (382%). Delays due to obtaining insurance authorization for tests, treatment or doctor visits, accounted for 265% of the barriers. Other barriers, such as delays in referral to an oncologist, negative mammogram, and negative biopsy, continued to be present, but were not as frequently reported (less than 25%). Summary Concluding Statement: We observed substantial delays between symptom presentation and diagnosis in a proportion of patients who came to seek therapy at City Of Hope National Medical Center. We identified system and physician barriers contributing to this delay. These barriers could serve as the basis for future intervention studies to decrease the delay from time of presentation of breast signs/symptoms to diagnosis and treatment of breast cancer.