Variation In Breast Cancer Survival Research Articles

Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study

Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps. The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors. Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48-53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44-47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes). Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention. Susan G Komen and the International Agency for Research on Cancer.

Breast Cancer Survival and Survival Gap Apportionment in Sub-Saharan Africa: African Breast Cancer – Disparities in Outcomes ABC-DO Cohort

Background: Breast cancer is the second leading cause of cancer death in women in sub-Saharan Africa, yet there are few large-scale survival studies with rich clinical and epidemiologic data and few losses to follow-up to inform intervention strategies needed to avert premature deaths. Methods: In the hospital-based African Breast Cancer – Disparities in Outcomes (ABC-DO) cohort, characterized by rich sociodemographic, clinical and treatment data, 2214 women newly diagnosed with breast cancer across five Sub-Saharan African countries were prospectively followed using a trimonthly mobile phone contact protocol. Flexible proportional mortality models were used to estimate observed survival, hazard ratios and predict survival under scenarios of modifying risk factors. Findings: Among 2156 women followed up to three years, 879 (41%) died, 1118 (52%) were alive and 159 (7%) were censored early. Three-year survival was 50% overall, but varied between races in Namibia (90% white, 69% mixed-race and 56% in black women) and South Africa (76% mixed-race, 59% black) and between countries: 44 to 47% in Uganda and Zambia and 36% in Nigeria. Ten percent of all women died within 6 months of diagnosis, but three-year survival remained low (58%) conditional on surviving to this time-point. Among survival determinants, improvements in early diagnosis and treatment were predicted to result in the largest survival gains of up to a combined 22% absolute increase, compared to the contributions of social inequalities (up to 5%), non-receptor positive tumours (up to 4%) and young age or HIV (<2% each). Interpretation: Large variations in breast cancer survival in sub-Saharan African countries demonstrate that improvements are possible. At least one-third of the projected 416000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable down-staging and treatment improvements. Improving survival in socially disadvantaged women warrants special attention. Funding Statement: Susan G Komen Foundation and International Agency for Research on Cancer Declaration of Interests: The authors confirm no competing interests. Ethics Approval Statement: ABC-DO was approved by all institutional ethics committees and each woman provided informed consent.

Highlights of This Issue

Mapping breast cancer survival can help cancer-control programs prioritize efforts with limited resources. Wiese and colleagues used Bayesian spatial models to assess whether geographic variation in breast cancer survival among patients in New Jersey persists after adjusting for key individual and neighborhood measures of poverty and economic inequality. The results support a growing understanding of the independent association between neighborhood socioeconomic measures and breast cancer survival. More effective health interventions could be developed if geographic variations were examined more routinely in the context of neighborhood socioeconomic inequalities in addition to individual characteristics.The impact of processed meat intake on the risk of bladder cancer is not clear. In this study, Xu evaluated the association of processed meat intake with bladder cancer using data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) cohort. As a result, intake of processed red meat was significantly associated with the incidence of bladder cancer after multivariate adjustment. By contrast, there was only a suggestive but not significant association between total processed meat intake and bladder cancer risk. The study suggests that bladder cancer risk is increased with cumulative intake of processed red meat.Infection with Helicobacter pylori can lead to chronic atrophic gastritis, a gastric cancer precursor. Autoimmune gastritis is an alternative form of gastritis that may be marked by autoantibodies against parietal cells (APCA). Wang and colleagues measured seropositivity to APCA in a nested case–control study of upper gastrointestinal cancers in a rural Chinese cohort. The authors found that APCA positivity was associated with lower risk of gastric cancer that was strongest in the gastric cardia. APCA negativity when assessed along with a serologic marker for atrophic gastritis revealed complex and strong associations with gastric cancer that may be useful in risk stratification.Multiple myeloma (MM) is a common hematologic malignancy preceded by monoclonal gammopathy of undetermined significance (MGUS). Chang and colleagues aimed to identify a new clinical predictor to guide MGUS management. Multivariable analyses were performed using data from the U.S. Veterans Health Administration. The rate of rise in serum monoclonal protein concentration of &gt;0.1 g/dL in the year following MGUS diagnosis was positively associated with progression of MGUS to MM. These findings enhance the current risk stratification. The identified clinical predictor is a dynamic measure for disease progression with prognostic value. It has the potential to inform MGUS management and MM prevention.

Impact of seasonal and geographical differences on breast cancer survival

Purpose: Seasonal and geographic variations in ultraviolet B intensities (UVB) impact the vitamin D status, and these differences might significantly affect cancer prognosis. This study evaluates the association between seasonal and geographic differences in UVB exposure and breast cancer survival. Methods: We divided Korea into two regions according to erythemally weighted annual UVB exposure as follows: Seoul and the southern region. Recurrence and death were also grouped into two seasons: spring/summer and autumn/winter. Results: The survival and relapse rates, when stratified by season of diagnosis, demonstrated no significant differences between spring/summer and autumn/winter. Among the 1,488 breast cancer patients in our cohort who demonstrated recurrence, 775 cases (52.1%) relapsed during the spring/summer and 594 patients (52.6%) died during the autumn/winter. In total, 6,178 patients (89.1%) and 3,909 patients (91.3%) in Seoul and the southern region survived (P=0.005). The relapse rate in the Seoul group (13.7%) was higher than the southern group (11.9%). By Kaplan-Meier analysis, there were no statistical differences between the Seoul and southern groups in terms of disease-free (P=0.43) and cancer-specific survival (P=0.18). In the Cox analysis, after the adjustment of all the other factors, season of diagnosis and residential area have no statistical significance. Conclusion: We conclude from our findings that death from breast cancer occurs more frequently in the autumn/winter, and that patients in the southern area of Korea demonstrate better survival. However, we find no significant relationship between geographic and seasonal variations in breast cancer survival.

Does breast cancer screening level health inequalities out? A population-based study in an Italian region

Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. A cohort study was performed, including all women <70 years and residing in Emilia-Romagna who had infiltrating breast cancer registered in 1997-2000 (transitional screening period) or 2001-03 (consolidation screening period). Cancer cases were retrieved from the regional Breast Cancer Registry and followed up for 5 years. Educational level was determined from census data and allocated to cancer cases by individual record linkage. Age at diagnosis was classified into two groups (30-49, 50-69: screening target population). A total of 9639 cases were analyzed. In the 1997-2000 period, low-educated women had significantly lower survival compared with high-educated women, both in the younger and in the older age-groups. After the full implementation of the screening programme, these differences decreased in both age-groups, until disappearing completely among women in the age-group invited to screening. Our findings suggest that a fee-free population-based organized mammography screening programme with active invitation of the whole target population could be effective in reducing differences in survival in the population targeted by the screening.

Brystkreftkirurgi i Norge 1986 – 2009

Studies have revealed variations in breast cancer survival between different counties in Norway. This study describes trends in surgical treatment of ductal carcinoma in situ (DCIS) and breast cancer in Norway, over time and by county. Information about surgical treatment, age and county for 3,915 women with DCIS and for 54,732 women with breast cancer, diagnosed in the periods 1995-2009 and 1986-2009 respectively, was provided from the incidence database at the Cancer Registry of Norway. In the period 1995-97, 3.0 in 100,000 women with DCIS had breast conserving treatment (BCT), while 5.0 in 100,000 had mastectomy. In 2004-06 the rates were 8.6 and 4.2, respectively. In 1995-97, 18.7 in 100,000 women with breast cancer had BCT, while 77.3 in 100,000 had mastectomy. In 2004-06 the rates were 57.9 and 50.8, respectively. The percentage of women with DCIS or breast cancer who were treated with BCT was lower in 2007-09 in all counties than in 2004-06. For 2007-09 the percentage of women with DCIS who were treated with BCT varied by county from 39% to 75%. For breast cancer the percentage varied from 33% to 67%. The number and percentage of women with DCIS or breast cancer who were treated with BCT increased until 2005, then it fell, and the percentage varied between counties. The reasons for this need to be identified and followed up with regard to the recommendations from the Norwegian Breast Cancer Group.

Abstract B59: Patterns of breast cancer mortality over 10 years by tumor phenotype and Hispanic versus non-Hispanic white ethnicity

Abstract Introduction: Breast cancer tumor phenotypes, defined by expression of hormone receptor status, have been found to be biologically distinct and to influence treatment and survival. Tumor phenotypes are relevant to therapeutic response and length of survival and could explain ethnic-related variation in breast cancer survival. Some studies have reported that Hispanic (H) women are more likely to have ER- and triple negative (ER-, PR-, HER2-) tumors than non-Hispanic white (NHW), and have poorer survival. The purpose of this study was to determine if tumor phenotype influences the difference in survival between H and NHW women with breast cancer. Study Population and Methods: Data from the New Mexico site of a collaborative, population-based cohort, the ‘Health, Eating, Activity, Lifestyle’ (HEAL) Study, were analyzed to compare Hispanic to non-Hispanic white women for patterns of early and late mortality over approximately 10 years of follow-up, and to assess the influence of tumor phenotype as defined by ER, PR, and HER2 hormone receptor status (+/-). The analysis included 533 women (126 H, 407 NHW) diagnosed with their first primary of breast cancer between 1996 and 1999. Hormone receptor status was determined by immunohistochemistry. Other prognostic tumor characteristics were abstracted from medical records by the SEER New Mexico Tumor Registry. Results: The risk of breast cancer mortality was higher in H than NHW women, adjusting for significant covariates, including tumor phenotype, age at baseline interview and SEER summary stage during the first four to six years after baseline interview (HR4yrs=2.33 (95%CI 1.27–4.26); HR6yrs=2.07 (95%CI 1.24–3.45), but was attenuated at 10 years; HR10yrs=1.51 (1.00–2.28). This time-dependent pattern of mortality was also found for ER-compared to ER+ tumors (HR4yrs=2.14 (95%CI 1.12–4.10); HR6yrs=1.89 (95%CI 1.08–3.32); HR10yrs=1.39 (95%CI 0.87–2.23), adjusting for age at baseline interview, stage and ethnicity. The pattern was similar for the triple negative phenotype, but the HR estimates were more unstable, due to the smaller sample sizes across phenotype categories. Adjustment for tumor phenotype had little impact on the estimates for ethnicity (&amp;lt;10% change), after adjustment for age and stage. Similarly, adjustment for ethnicity had little impact on the estimates for tumor phenotypes. Conclusion: Ethnicity and tumor phenotype appear to have independent effects on breast cancer mortality in this population-based cohort of women with breast cancer. The effects of both ethnicity and tumor phenotype are greater for early mortality and diminish with time, and are independent of age and stage of disease. This time-dependent effect has not been previously reported for H compared to NHW women. These results suggest the need to explore factors other than tumor phenotype that may explain the difference between H and NHW women for breast cancer survival. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B59.

Relapse in breast cancer: How much mode of breast cancer detection matters? Results from an Italian national cancer institute.

e12012 Background: The reasons for variation in breast cancer survival are multifactorial. In patients diagnosed with early breast cancer, evidence has emerged relatively to more favorable outcomes...

Breast cancer survival: The association of age within stage of disease.

1547 Background: Breast cancer survival varies with age, race/ethnicity, and ER/PR/HER2 subtypes. Older, white women tend to have a more favorable form of breast cancer. We have previously shown that there is variation of breast cancer subtypes with age and race/ethnicity. The purpose of this investigation is to determine how survival differs by age among the AJCC pathologic stages. Methods: Using the California Cancer Registry 2001-2008, we examined 92,231 cases of Stages I-III first primary female invasive breast cancers. Five-year relative survival was computed for women younger than 40 years of age, 40-69 years of age, and 70 years and older within each stage. The Log-Rank test was used to compare survival between women ages 40-69 (the largest group) versus older and younger women. Results: There were 63,436 (68.8%) women ages 40-69; 23,120 (25.1%) ages 70 and older; and 5,675 (6.2%) younger than age 40. For Stage I, women ages 40-69 had 99% survival, statistically significantly better (P< 0.0001) than younger and older women. Younger women had the worst survival (95%). For Stage II, women ages 40-69 had the best survival (92%), significantly higher than both younger and older women, who had identical survival at 88%. (P< 0.0001) Survival for women with Stage III cancer was almost identical for women ages 40-69 (75%) and women younger than age 40 (74%) (P > 0.05). Women 70 and older had the poorest survival (66%), significantly worse than the younger age groups (P<0.0001). Conclusions: Women younger than 40 years of age have worse survival than older women in Stages 1 and 2. However, in Stage III, younger women have better survival than women 70 and older. While it is conceded that older women generally have a more favorable form of breast cancer, the gap in survival between older and younger women widens with increasing stage of disease. Caution is advised when making sweeping generalizations regarding breast cancer survival. Variation in breast cancer survival depends on a variety of factors including stage, age, race/ethnicity, and ER/PR/HER2 subtypes.

Variations in care for operable breast cancer and outcomes between rural and metropolitan centers in Australia

e11517 Background: The causes of variation in breast cancer survival remain uncertain. Care provided to women with breast cancer may vary in relation to both the care setting and characteristics of the clinicians. Methods: To compare the outcomes of management of breast cancer treated in rural and metropolitan centers, a prospective audit of breast cancer in a region of Australia was undertaken. Over a nine-year observation period 2102 women with invasive breast cancer underwent potentially curative surgery. Treatments received, including systemic adjuvant therapy, were compared to contemporary guideline-based indicators. Breast cancer specific mortality was analyzed using Cox proportional hazards models. Results: Overall agreement of received treatment with the indicators was high. Women treated within rural centers were, however, much less likely to receive post operative radiotherapy after breast conserving surgery (86.4% vs. 97.0%; p&lt;0.001). The overall recurrence rate, including distant metastases, for all women was 11.6%. Local or regional recurrence was more frequent in rural centers compared with metropolitan centers (4.1% versus 2.1%; p=0.05). Breast cancer mortality was increased in women with large tumors, high grade disease, and positive axillary lymph nodes. Non-compliance with treatment guidelines was associated with a trend towards increased breast cancer mortality (HR=1.55; p=0.056). After adjustment for these factors and patient age, undergoing surgery in rural centers was associated with increased breast cancer mortality (HR=1.84; p&lt;0.001). Although women treated in rural centers were older, their cancer stage and tumour characteristics were similar to those of women treated in metropolitan centers. Non-cancer related mortality was elevated in women treated in rural centers compared with women travelling to a city for surgery (HR=2.08; p=0.005). Conclusions: Increased non-cancer related mortality in rural treated women suggests increased medical co-morbidity in this group, which may have influenced treatment choices and outcomes. Low rates of adjuvant radiotherapy were noted for women treated in rural centers. In addition, clinically significant differences in outcome, including breast cancer mortality, were observed. No significant financial relationships to disclose.

The role of poverty rate and racial distribution in the geographic clustering of breast cancer survival among older women: a geographic and multilevel analysis.

The authors examined disparities in survival among women aged 66 years or older in association with census-tract-level poverty rate, racial distribution, and individual-level factors, including patient-, treatment-, and tumor-related factors, utilization of medical care, and mammography use. They used linked data from the 1992-1999 Surveillance, Epidemiology, and End Results (SEER) programs, 1991-1999 Medicare claims, and the 1990 US Census. A geographic information system and advanced statistics identified areas of increased or reduced breast cancer survival and possible reasons for geographic variation in survival in 2 of the 5 SEER areas studied. In the Detroit, Michigan, area, one geographic cluster of shorter-than-expected breast cancer survival was identified (hazard ratio (HR) = 1.60). An additional area where survival was longer than expected approached statistical significance (HR = 0.4; P = 0.056). In the Atlanta, Georgia, area, one cluster of shorter- (HR = 1.81) and one cluster of longer-than-expected (HR = 0.72) breast cancer survival were identified. Stage at diagnosis and census-tract poverty (and patient's race in Atlanta) explained the geographic variation in breast cancer survival. No geographic clusters were identified in the 3 other SEER programs. Interventions to reduce late-stage breast cancer, focusing on areas of high poverty and targeting African Americans, may reduce disparities in breast cancer survival in the Detroit and Atlanta areas.

Geographic variations in breast cancer survival among older women: implications for quality of breast cancer care.

Breast cancer care, such as utilization of screening procedures and types of treatment received, varies substantially by geographic region of the United States. However, little is known about variations in survival with breast cancer. We examined breast cancer incidence, survival, and mortality in the 66 health service areas covered by the Surveillance, Epidemiology, and End Results (SEER) program for women aged 65 and older at diagnosis. Incidence and survival data were derived from SEER, while breast cancer mortality data were from Vital Statistics data. There was considerable variation in breast cancer survival among the 66 health service areas (chi2 = 202.7, p <.0001). There was also significant variation in incidence and mortality from breast cancer. In a partial correlation weighted for the size of the health service area, both incidence (r =.812) and percent 5-year survival (r = -.587) correlate with mortality. In a Poisson regression analysis, the combination of variation in incidence and variation in survival explains 90.9% of the variation in mortality. There is considerable geographic variation in survival from breast cancer among older women, and this contributes to variation in breast cancer mortality. Geographic variations in breast cancer mortality should diminish as the quality of breast cancer care becomes more standardized.

Efficacy of systemic adjuvant therapy for breast cancer in African-American and Caucasian women.

Observed variations in breast cancer survival by racial/ethnic background have been attributed to many factors, including differences in clinical and pathologic disease features at diagnosis and economic resource inequities that may affect treatment access and quality. In this report, we examine outcomes for African-American and Caucasian breast cancer patients participating in selected randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP) to determine whether prognosis or efficacy of systemic adjuvant therapy differed between these groups. Randomized clinical trials offer the advantages of a similar disease stage and a uniform treatment plan for all participants. Patients from four NSABP trials enrolling patients from 1982 through 1994 with axillary lymph node-negative disease (543 African-American and 7582 Caucasian) and three trials enrolling patients from 1984 through 1991 with axillary lymph node-positive disease (548 African-American and 4986 Caucasian) were included. Disease-free survival (DFS), which was defined as time on study free of breast cancer recurrence, second primary cancer, or death preceding these events, and survival risk ratios (RRs) with two-sided 95% confidence intervals (CIs) for African-Americans versus Caucasians were computed from Cox proportional hazards models that included relevant prognostic covariates. Treatment benefits for the therapies evaluated in these trials were estimated separately for African-Americans and for Caucasians. Among patients with lymph node-negative disease, African-Americans had similar DFS rates to Caucasians (African-American/Caucasian RR = 1.06, 95% CI = 0.92 to 1.23) but had modestly greater mortality rates (RR = 1.21, 95% CI = 1.01 to 1.46). Among lymph node-positive patients, DFS was similar (RR = 1.04, 95% CI = 0.93 to 1.17) and survival was again less favorable for African-Americans (RR = 1.18 95% CI = 1.03 to 1.34). Survival excluding deaths most likely attributable to causes other than cancer was similar between African-Americans and Caucasians (RR = 1.08 [95% CI = 0.88 to 1.33] for lymph node-negative patients and RR = 1.09 [95% CI = 0.96 to 1.25] for lymph node-positive patients). Among lymph node-negative and lymph node-positive patients, African-Americans and Caucasians realized comparable benefit from either the addition of chemotherapy or tamoxifen to surgery alone or the addition of chemotherapy to tamoxifen. In summary, African-American women and Caucasian women who were diagnosed at a comparable disease stage and were similarly treated tended to experience similar breast cancer prognosis. However, a mortality deficit persisted for African-American women relative to Caucasian women, which may be in part due to greater mortality from noncancer causes among African-Americans. Benefit from systemic adjuvant therapy for recurrence and mortality reduction was comparable between African-Americans and Caucasians. This study and investigations in other health-care settings suggest that African-American women and Caucasian women with breast cancer derive a similar benefit from systemic adjuvant therapy when it is administered in accordance with their clinical and pathologic disease presentation.

Ethnic variation in breast cancer survival: A review

Intercountry, as well as intracountry, survival comparisons have revealed some differences in breast cancer survival among various ethnic populations. Most of these differences are probably explained by factors related to socioeconomic status. However, the well documented survival advantage of Japanese patients compared to Caucasian patients remains unexplained. Some recent studies suggest an adverse prognostic effect for obesity. Although still inconclusive, these findings raise the possibility that the better survival of Japanese patients may be in part related to their lower mean body weight. An effect of the lower fat intake of the Japanese in explaining their breast cancer survival advantage has little support at present, but, like the obesity hypothesis, deserves further study.