Trends in breast cancer survival in Germany from 1976 to 2008—A period analysis by age and stage

Time-trends and age and stage differences in 5-year relative survival for common cancer types by sex in the canton of Zurich, Switzerland

BACKGROUND

Survival trends help to evaluate the progress made to reduce the burden of cancer. The aim was to estimate the trends in 5-year relative survival of patients diagnosed with breast, prostate, lung, colorectal cancer and skin melanoma in the time periods 1980-1989, 1990-1999, 2000-2009 and 2010-2015 in the Canton of Zurich, Switzerland. Furthermore, we investigated relative survival differences by TNM stage and age group.

METHODS

Data from the Cancer Registry of Zurich was used from 1980 to and including 2015, including incident cases of breast (N = 26,060), prostate (N= 23,858), colorectal (N= 19,305), lung cancer (N= 16,858) and skin melanoma (N= 9780) with follow-up until 31 December 2020. The cohort approach was used to estimate 5-year relative survival.

RESULTS

The 5-year relative survival increased significantly between 1980 and 1989, and 2010 and2015: from 0.70 to 0.89 for breast, from 0.60 to 0.92 for prostate, from 0.09 to 0.23 (men) and from 0.10 to 0.27 (women) for lung, from 0.46 to 0.66 (men) and from 0.48 to 0.68 (women) for colorectal cancer, and from 0.74 to 0.94 (men) and from 0.86 to 0.96 (women) for skin melanoma. Survival for stage IV tumors was considerably lower compared to lower-staged tumors for all cancer types. Furthermore, relative survival was similar for the age groups <80 years but lower for patients aged 80 years and older.

CONCLUSION

The observed increasing trends in survival are encouraging and likely reflect raised awareness around cancer, improved diagnostic methods, and improved treatments. The fact that stage I tumor patients have generally high relative survival reflects the efforts made regarding early detection.

Therapy-related myeloid neoplasm in early breast cancer patients treated with adjuvant chemotherapy

BACKGROUND

Long-term complications are becoming more important as the survival rate of breast cancer improves. Treatment-related myeloid neoplasm is an important long-term complication in breast cancer survivors as it has a poor prognosis.

OBJECTIVE

We evaluated the incidence and risk factors for the development of treatment-related acute myeloid leukaemia (AML)/myelodysplastic syndrome (MDS) in patients treated with early breast cancer.

METHODS

We accessed the national Korean database to identify 153,565 patients diagnosed with breast cancer between January 2007 and October 2016 who underwent surgery for breast cancer. We estimated the cumulative incidence of AML/MDS and analysed the risk factors for developing AML/MDS.

RESULTS

Of 153,575 patients, 79,321 received anthracycline-based adjuvant therapy, 14,317 received adjuvant therapy without anthracyclines and 46,657 did not receive adjuvant chemotherapy. Overall, 120 developed AML (105 in the anthracycline group, 9 in the non-anthracycline group and 6 in the control group), and 128 developed MDS (96, 9 and 23 in each group). The 10-year cumulative incidence of AML/MDS was the highest in the anthracycline group (0.221% and 0.199%), followed by the non-anthracycline group (0.122% and 0.163%) and the control group (0.024% and 0.089%). The risk of developing AML/MDS was significantly higher in patients treated with anthracyclines (hazard ratio [HR] 9.531; p < 0.0001 for AML and HR 2.559; p < 0.0001 for MDS) compared to patients in the control group.

CONCLUSION

This study found that anthracycline-based adjuvant therapy significantly increased the risk of AML/MDS in Korean breast cancer patients, with the risk persisting for at least 10 years. While the cumulative incidence was low, the long-term risks of AML/MDS should be taken into account considering the poor outcomes associated with these neoplasms.

Fifteen-year survival and conditional survival of women with breast cancer in Osaka, Japan: A population-based study

BACKGROUND

In recent years, the survival of patients with breast cancer has improved. However, few published studies have a longer than 10-year follow-up. Conditional relative survival (CRS), which is relative survival (RS) of patients who have survived beyond a certain period after diagnosis, is useful for assessing excess mortality among long-term survivors compared with the general population.

METHODS

This was a retrospective observational cohort study. Population-based cancer registry data in Osaka, Japan were used to determine 15-year RS and 5-year CRS of women with breast cancer diagnosed between 2001 and 2002 and followed up for at least 15 years. Fifteen-year RS and age-standardized RS (ASR) were calculated by Ederer II and cohort methods. Five-year CRS according to age group and extent of disease (localized, regional, and distant) was estimated for every year from diagnosis to 10 years.

RESULTS

In the cohort of 4006 patients, the ASR declined progressively, the 5-year ASR being 85.8%, 10-year ASR 77.3%, and 15-year ASR 71.6%. The overall 5-year CRS exceeded 90% at 5 years after diagnosis, reflecting a small excess mortality compared with the general population. The 5-year CRS of patients with regional and distant disease did not reach 90% within 10 years of follow-up (89.4% for regional and 72.9% for distant disease 10 years after diagnosis), indicating that these patients had substantial excess mortality.

CONCLUSION

Long-term survival data can help cancer survivors plan their lives and receive better medical care and support.

Subtyping of metastatic breast cancer based on plasma circulating tumor DNA alterations: An observational, multicentre platform study

BACKGROUND

After multiple lines of therapies, no guideline or consensus is currently available for the treatment of patients with metastatic breast cancer. This study aims to evaluate the efficacy of a novel re-subtyping and treatment strategy based on ctDNA alterations.

METHODS

This observational, multicentre study recruited 223 patients with metastatic breast cancer intending to receive late-line therapy from Dec 1, 2016, to June 31, 2019. This study took place in Hunan Cancer Hospital, the Forth Hospital of Changsha and Zhuzhou Central Hospital in China. ctDNA alterations were assessed by next-generation sequencing (NGS). Patients with druggable ctDNA alterations were treated with corresponding targeted drugs which are clinically available. Other patients received physician-chosen treatment. This study was registered with ClinicalTrials.gov, NCT05079074.

FINDINGS

The progression-free survival (hazard ratio: 0.45, 95% Confidence Interval (CI): 0.33-0.62, P < 0.0001) and disease control rate (89.4% vs. 65.9%, P < 0.0001) were significantly improved in patients who received druggable ctDNA alteration-guided therapy compared with those of patients who received physician-chosen treatment. ctDNA alterations with top rank and high clustering scores were classified into four subtypes based on their functions as follows: 1) extracellular function (ECF), 2) cell proliferation (CP), 3) nuclear function (NF), and 4) cascade signaling pathway (CSP). A significant benefit from ctDNA alteration-guided treatment was observed in patients with NF and CSP ctDNA alterations, with hazard ratios of 0.39 (95% CI: 0.24-0.65, P = 0.0003) and 0.14 (95% CI: 0.04-0.46, P < 0.0001), respectively.

INTERPRETATION

After multiline traditional pathological HR/HER2 subtype-guided therapies, ctDNA testing could identify druggable ctDNA alterations to guide late-line therapy for patients with metastatic breast cancer.

FUNDING

This work was supported by Key Grants of Research and Development in Hunan Province (2018SK2124, 2018SK2120), Natural Science Foundation of Hunan (2019JJ50360), Hunan Provincial Health Commission Project (B2019085, B2019089 and C2019070), and Changsha Science and Technology Project (kq2004125 and kq2004137).

Adherence to the Dutch Breast Cancer Guidelines for Surveillance in Breast Cancer Survivors: Real-World Data from a Pooled Multicenter Analysis

Background

Regular follow-up after treatment for breast cancer is crucial to detect potential recurrences and second contralateral breast cancer in an early stage. However, information about follow-up patterns in the Netherlands is scarce.

Patients and Methods

Details concerning diagnostic procedures and policlinic visits in the first 5 years following a breast cancer diagnosis were gathered between 2009 and 2019 for 9916 patients from 4 large Dutch hospitals. This information was used to analyze the adherence of breast cancer surveillance to guidelines in the Netherlands. Multivariable logistic regression was used to relate the average number of a patient’s imaging procedures to their demographics, tumor–treatment characteristics, and individual locoregional recurrence risk (LRR), estimated by a risk-prediction tool, called INFLUENCE.

Results

The average number of policlinic contacts per patient decreased from 4.4 in the first to 2.0 in the fifth follow-up year. In each of the 5 follow-up years, the share of patients without imaging procedures was relatively high, ranging between 31.4% and 33.6%. Observed guidelines deviations were highly significant (P < .001). A higher age, lower UICC stage, and having undergone radio- or chemotherapy were significantly associated with a higher chance of receiving an imaging procedure. The estimated average LRR-risk was 3.5% in patients without any follow-up imaging compared with 2.3% in patients with the recommended number of 5 imagings.

Conclusion

Compared to guidelines, more policlinic visits were made, although at inadequate intervals, and fewer imaging procedures were performed. The frequency of imaging procedures did not correlate with the patients’ individual risk profiles for LRR.

Improved risk estimation of locoregional recurrence, secondary contralateral tumors and distant metastases in early breast cancer: the INFLUENCE 2.0 model

PURPOSE

To extend the functionality of the existing INFLUENCE nomogram for locoregional recurrence (LRR) of breast cancer toward the prediction of secondary primary tumors (SP) and distant metastases (DM) using updated follow-up data and the best suitable statistical approaches.

METHODS

Data on women diagnosed with non-metastatic invasive breast cancer were derived from the Netherlands Cancer Registry (n = 13,494). To provide flexible time-dependent individual risk predictions for LRR, SP, and DM, three statistical approaches were assessed; a Cox proportional hazard approach (COX), a parametric spline approach (PAR), and a random survival forest (RSF). These approaches were evaluated on their discrimination using the Area Under the Curve (AUC) statistic and on calibration using the Integrated Calibration Index (ICI). To correct for optimism, the performance measures were assessed by drawing 200 bootstrap samples.

RESULTS

Age, tumor grade, pT, pN, multifocality, type of surgery, hormonal receptor status, HER2-status, and adjuvant therapy were included as predictors. While all three approaches showed adequate calibration, the RSF approach offers the best optimism-corrected 5-year AUC for LRR (0.75, 95%CI: 0.74-0.76) and SP (0.67, 95%CI: 0.65-0.68). For the prediction of DM, all three approaches showed equivalent discrimination (5-year AUC: 0.77-0.78), while COX seems to have an advantage concerning calibration (ICI < 0.01). Finally, an online calculator of INFLUENCE 2.0 was created.

CONCLUSIONS

INFLUENCE 2.0 is a flexible model to predict time-dependent individual risks of LRR, SP and DM at a 5-year scale; it can support clinical decision-making regarding personalized follow-up strategies for curatively treated non-metastatic breast cancer patients.

Predicting the risk of locoregional recurrence after early breast cancer: an external validation of the Dutch INFLUENCE-nomogram with clinical cancer registry data from Germany

Purpose

Follow-up after breast cancer treatment aims for an early detection of locoregional breast cancer recurrences (LRR) to improve the patients’ outcome. By estimating individual’s 5-year recurrence-risks, the Dutch INFLUENCE-nomogram can assist health professionals and patients in developing personalized risk-based follow-up pathways. The objective of this study is to validate the prediction tool on non-Dutch patients.

Material and methods

Data for this external validation derive from a large clinical cancer registry in southern Germany, covering a population of 1.1 million. Patients with curative resection of early-stage breast cancer, diagnosed between 2000 and 2012, were included in the analysis (n = 6520). For each of them, an individual LRR-risk was estimated by the INFLUENCE-nomogram. Its predictive ability was tested by comparing estimated and observed LRR-probabilities using the Hosmer–Lemeshow goodness-of-fit test and C-statistics.

Results

In the German validation-cohort, 2.8% of the patients developed an LRR within 5 years after primary surgery (n = 184). While the INFLUENCE-nomogram generally underestimates the actual LRR-risk of the German patients (p < 0.001), its discriminative ability is comparable to the one observed in the original Dutch modeling-cohort (C-statistic German validation-cohort: 0.73, CI 0.69–0.77 vs. C-statistic Dutch modeling-cohort: 0.71, CI 0.69–0.73). Similar results were obtained in most of the subgroup analyses stratified by age, type of surgery and intrinsic biological subtypes.

Conclusion

The outcomes of this external validation underline the generalizability of the INFLUENCE-nomogram beyond the Dutch population. The model performance could be enhanced in future by incorporating additional risk factors for LRR.

Change in Survival in Metastatic Breast Cancer with Treatment Advances: Meta-Analysis and Systematic Review

Background

Metastatic breast cancer (MBC) treatment has changed substantially over time, but we do not know whether survival post-metastasis has improved at the population level.

Methods

We searched for studies of MBC patients that reported survival after metastasis in at least two time periods between 1970 and the present. We used meta-regression models to test for survival improvement over time in four disease groups: recurrent, recurrent estrogen (ER)-positive, recurrent ER-negative, and de novo stage IV. We performed sensitivity analyses based on bias in some studies that could lead earlier cohorts to include more aggressive cancers.

Results

There were 15 studies of recurrent MBC (N = 18 678 patients; 3073 ER-positive and 1239 ER-negative); meta-regression showed no survival improvement among patients recurring between 1980 and 1990, but median survival increased from 21 (95% confidence interval [CI] = 18 to 25) months to 38 (95% CI = 31 to 47) months from 1990 to 2010. For ER-positive MBC patients, median survival increased during 1990–2010 from 32 (95% CI = 23 to 43) to 57 (95% CI = 37 to 87) months, and for ER-negative MBC patients from 14 (95% CI = 11 to 19) to 33 (95% CI = 21 to 51) months. Among eight studies (N = 35 831) of de novo stage IV MBC, median survival increased during 1990–2010 from 20 (95% CI = 16 to 24) to 31 (95% CI = 24 to 39) months. Results did not change in sensitivity analyses.

Conclusion

By bridging studies over time, we demonstrated improvements in survival for recurrent and de novo stage IV MBC overall and across ER-defined subtypes since 1990. These results can inform patient-doctor discussions about MBC prognosis and therapy.

Increasing trends in in situ breast cancer incidence in a region with no population-based mammographic screening program: results from Zurich, Switzerland 2003-2014

PURPOSE

Increase in in situ breast cancer (BCIS) incidence has been reported across Europe and the USA. However, little is known about the trends in BCIS incidence in regions without population-based mammographic screening programs. We set out to investigate these trends in Zurich, Switzerland, where only opportunistic mammographic screening exists.

METHODS

Data from 989 women diagnosed with a primary BCIS between 2003 and 2014 were used in our analyses. Age-standardized incidence rates per 100,000 person-years (ASR) were computed per year. Additional analyses by BCIS subtype, by age group at diagnosis and by incidence period were conducted. Incidence trends over time were assessed using joinpoint regression analysis.

RESULTS

The overall BCIS ASR was 10.7 cases per 100,000 person-years with an increasing trend over the study period. A similar trend was observed for the ductal carcinoma in situ (DCIS) ASR, while the lobular carcinoma in situ (LCIS) ASR decreased. Age-specific analyses revealed that the 50-59 year age group had the highest BCIS ASR. The highest increase in BCIS ASR, even though not statistically significant, was observed for the < 40 year age group.

CONCLUSIONS

BCIS ASR increased linearly over a 12-year period. The increase was reflected by an increase in DCIS ASR, whereas LCIS ASR decreased over time. The highest increase in BCIS ASR over the study period was observed for the < 40 year age group, even though not statistically significant. Patient and tumor characteristics of this group that may be associated with BCIS development warrant further investigation.

Breast cancer mortality in Saudi Arabia: Modelling observed and unobserved factors

Background

Breast cancer is one of the most dangerous and frequently occurring cancers among women, and it also affects men. We aimed to determine the prevalence and factors associated with mortality among patients with breast cancer in Saudi Arabia.

Method

Data for this analysis of breast cancer mortality among Saudi Arabians were obtained from the Saudi Arabian Cancer Registry at the King Faisal Hospital and Research Centre. Both descriptive and inferential statistical analyses were conducted using proportions, chi-squared tests, and the Cox regression model. Frequentist and Bayesian inferential statistics were used to estimate the risk ratios. A frailty term was specified to control for suspected heterogeneity across regions. Bayesian and deviance information criteria were used to discriminate between the frequentist and Bayesian frailty models, respectively.

Results

Out of 5,411 patients, 708 (13.08%) deaths occurred that were attributable to breast cancer. Of those, 12 (1.69%) were men. Among patients who died of breast cancer, 353 (49.86%) had tumours that originated on the left side and 338 (47.74%) on the right side. In terms of the stage or extent of breast cancer, 318 (44.92%) deaths occurred among patients who had distant metastases, followed by 304 (42.94%) who had regional metastases and 86 (12.15%) with localized cancers. Men were 72% more likely than women to die from breast cancer. Divorcees were twice as likely to die, compared to their married counterparts. Patients whose tumours were classified as Grade IV had the highest mortality rate, which was 5.0 times higher than patients with Grade I tumours (credible interval (CrI); 1.577, 14.085) and 3.7 times higher than patients with Grade II tumours (CrI; 1.205, 9.434).

Conclusion

There is a high prevalence of breast cancer mortality among Saudi Arabian women, with the highest prevalence among divorced women. Though the prevalence of breast cancer mortality among men is lower than that of women, men had a higher risk of death. We therefore recommend an intensive health education programme for both men and women. These programmes should discuss the consequences of divorce, the prevalence of breast cancer among men, and early diagnoses and treatments for breast cancer.

Development of a Quality of Sexual Life Questionnaire for Breast Cancer Survivors in Mainland China

BACKGROUND There is a great need for a quality of sexual life questionnaire (QVS) in breast cancer survivors (BCSs) based on the Chinese social culture since the imported tools lack localization verification. To develop a QVS in BCSs and determine its validity and reliability. MATERIAL AND METHODS In the qualitative study, a total of 21 BCSs were interviewed by purposive sampling and snowball sampling; and in the quantitative study, a total of 249 BCSs, who were admitted and received outpatient follow-up, were investigated. Regarding construct validity, factor analysis was performed. The female sexual function index (FSFI), self-rating depression scale (SDS), and Locke-Wallace marital adjustment test (LWMAT) were used to evaluate criterion validity. Cronbach's alpha coefficient was used as an index of internal consistency. To evaluate test-retest reliability, 50 patients were re-evaluated after 1 week. RESULTS We put 28 items in the factor analysis model: (1) 5 factors were extracted by exploratory factor analysis (EFA), with a cumulative contribution of 60.37%; (2) the confirmatory factor analysis (CFA) showed that the path coefficients among the factors were all above 0.5, and the standardized load coefficients of the most items were above 0.5; (3) the Cronbach's alpha coefficient was 0.929 for the overall questionnaire, and ranged from 0.571 to 0.869 for the 5 factors; (4) the correlation coefficients between the overall questionnaire and the FSFI, SDS, and LWMAT were 0.582, -0.456 and 0.515, respectively (P<0.01); and (5) the test-retest correlation coefficient was 0.816, and the split-half-reliability coefficient was 0.899. CONCLUSIONS The QVS in BCSs has good reliability and validity, and can be used to assess the quality of sexual life among BCSs in Mainland China.

A mixed linear model controlling for case underascertainment across multiple cancer registries estimated time trends in survival

OBJECTIVES

Large temporal and geographical variation in survival rates estimated from epidemiological cancer registries coupled with heterogeneity in death certificate only (DCO) notifications makes it difficult to interpret trends in survival. The aim of our study is to introduce a method for estimating such trends while accounting for heterogeneity in DCO notifications in a cancer site-specific manner.

STUDY DESIGN AND SETTING

We used the data of 4.0 million cancer cases notified in 14 German epidemiological cancer registries. Annual 5-year relative survival rates from 2002 through 2013 were estimated, and proportions of DCO notifications were recorded. "DCO-excluded" survival rates were regressed on DCO proportions and calendar years using a mixed linear model with cancer registry as a random effect. Based on this model, trends in survival rates were estimated for Germany at 0% DCO.

RESULTS

For most cancer sites and age groups, we estimated significant positive trends in survival. Age-standardized survival for all cancers combined increased by 7.1% units for women and 10.8% units for men.

CONCLUSION

The described method could be used to estimate trends in cancer survival based on the data from epidemiological cancer registries with differing DCO proportions and with changing DCO proportions over time.

Recent Improvement in the Long-term Survival of Breast Cancer Patients by Age and Stage in Japan

Background

Recent improvements in 5-year survival of breast cancer have been reported in Japan and other countries. Though the number of long-term breast cancer survivors has been increasing, recent improvements in 10-year survival have not been reported. Moreover, the degree of improvement according to age and disease stage remains unclear.

Methods

We calculated long-term survival using data on breast cancer diagnosed from 1993 through 2006 from six prefectural population-based cancer registries in Japan. The recent increase in 10-year relative survival was assessed by comparing the results of period analysis in 2002–2006 with the results of cohort analysis in 1993–1997. We also conducted stratified analyses by age group (15–34, 35–49, 50–69, and 70–99 years) and disease stage (localized, regional, and distant).

Results

A total of 63,348 patients were analysed. Ten-year relative survival improved by 2.4% (76.9% vs 79.3%) from 1993 through 2006. By age and stage, 10-year relative survival clearly improved in the age 35–49 years (+2.9%; 78.1% vs 81.0%), 50–69 years (+2.8%; 75.2% vs 78.0%) and regional disease (+3.4%; 64.9% vs 68.3%). In contrast, the degree of improvement was small in the age 15–34 years (+0.1%; 68.2% vs 68.3%), 70–99 years (+1.0%; 87.6% vs 88.6%), localized disease (+1.1%; 92.6% vs 93.7%) and distant metastasis (+0.9%; 13.8% vs 14.7%).

Conclusions

These population-based cancer registry data show that 10-year relative survival improved 2.4% over this period in Japan. By age and stage, improvement in the age 15–34 years and distant metastasis was very small, which suggests the need for new therapeutic strategies in these patients.

Adjuvant chemotherapeutic treatment of 1650 patients with early breast cancer in routine care in Germany: data from the prospective TMK cohort study

BACKGROUND

Several regimens for which efficacy was established in randomized controlled trials are recommended in current treatment guidelines for early breast cancer. However, knowledge on use and effectiveness of commonly administered chemotherapeutic agents in real-life care and across all breast cancer subtypes is limited.

METHODS

The prospective, multicentre German TMK cohort study (Tumour Registry Breast Cancer) recruited patients in 148 oncology outpatient-centres. Data from 1650 patients who completed adjuvant chemotherapy were analysed regarding treatment regimens and taxane use from 2007 to 2014. The association of patient characteristics with application of taxane-free regimens was examined with a multivariate regression model.

RESULTS

The preferred adjuvant treatment shifted from fluorouracil, anthracycline and cyclophosphamide containing regimens to anthracycline/taxane combinations. Taxane use increased for all subtypes, and the greatest rise was among node-negative patients. Older age, node-negativity, lower grading, HR-positive/HER2-negative subtype and earlier start year of therapy were significantly associated with taxane-free therapy.

CONCLUSIONS

Treatment with anthracycline/taxane-based chemotherapy in Germany has been rising for every subtype. The increased taxane use reflects updated guideline recommendations over the past decade. Cohort studies like the TMK provide insight into real-life treatment of patients outside of clinical trials.

Candidate miRNAs in human breast cancer biomarkers: a systematic review

BACKGROUND

Breast cancer (BC) is the most prevalent cancer and the main cause of cancer deaths among females around the world. For early diagnosis of BC, there would be an immediate and essential requirement to search for sensitive biomarkers.

METHODS

To identify candidate miRNA biomarkers for BC, we performed a general systematic review regarding the published miRNA profiling researches comparing miRNA expression level between BC and normal tissues. A miRNA ranking system was selected, which considered frequency of comparisons in direction and agreement of differential expression.

RESULTS

We determined that two miRNAs (mir-21 and miR-210) were upregulated consistently and six miRNAs (miR-145, miR-139-5p, miR-195, miR-99a, miR-497 and miR-205) were downregulated consistently in at least three studies. MiR-21 as the most consistently reported miRNA was upregulated in six profiling studies.

CONCLUSIONS

Although these miRNAs require being validated and further investigated, they could be potential candidates for BC miRNA biomarkers and used for early prognosis or diagnosis.

New approaches for improving outcomes in breast cancer in Europe

Considerable progress has been made in breast cancer treatment in Europe over the past three decades, yet survival rates for metastatic disease remain poor, underlining the need for further advances. While the use of predictive biomarkers for response to systemic therapy could improve drug development efficiency, progress in identifying such markers has been slow. The currently inadequate classification of breast cancer subtypes is a further challenge. Improved understanding of the molecular pathology of the disease has led to the identification of new targets for drug treatment, and evolving classifications should reflect these developments. Further ongoing challenges include difficulties in finding optimal combinations and sequences of systemic therapies, circumventing multidrug resistance and intra-tumor heterogeneity, problems associated with fragmentation in clinical trials and translational research efforts. Adoption of some of the strategies identified in this article may lead to further improvements in outcomes for patients with the disease.

Provision of breast cancer care and survival in Germany - results from a population-based high resolution study from Saarland

BACKGROUND

Studies on the implementation of Clinical Practice Guidelines (CPG) and particularly its effect on breast cancer (BRC) survival on a population-level are scant. This population-based high resolution study from Germany aims at providing data on the usage of BRC treatment, the extent of adherence to CPG and, as a novelty, survival of BRC patients according to major recommended treatment options.

METHODS

Data from the Saarland Cancer Registry including women diagnosed with invasive BRC without distant metastasis and followed up between 2000 and 2009 were used. Provision of cancer care according to major treatment options is presented by age, clinical subtypes of BRC, and over time. Conventional and modeled period analysis was used to derive estimates of most up-to-date 5-year relative survival (RS) and the effect of non-adherence to CPG on relative excess risk of death (RER).

RESULTS

The study revealed increasing guideline adherence, with high levels already seen for local treatment (e.g. 67% of the BRC patients in 2008/09 received breast conserving surgery), and substantial progress since the millennium change with regard to sentinel node dissection (SND) and adjuvant systemic treatments (e.g. SND and chemotherapy provided to 62% of all patients and 79% of the patients with nodal positive or hormone receptor negative BRC in 2008/09, respectively). It further demonstrated increased cancer related mortality among patients without guideline compliant cancer treatment (e.g. patients with nodal positive and hormone receptor negative BRC who were not treated with chemotherapy had a 5-year RS of 29% (RER: 2.89, 95% CI: 1.46-5.71) compared to 54% for patients obtaining chemotherapy).

CONCLUSIONS

This study provides data on the implementation of CPG in a highly developed European country and extends available population-based survival data of BRC patients and may provide evidence of increased cancer related excess mortality, if BRC patients do not receive guideline compatible treatment.

Metastatic breast cancer: prolongation of survival in routine care is restricted to hormone-receptor- and Her2-positive tumors

18,000 women die due to metastatic breast cancer in Germany per year. Median survival is 20–28 months after diagnosis. The question we wanted to answer was whether survival has improved in routine care? For this purpose we conducted a retrospective analysis of all patients with metastatic breast cancer who were treated between 06/1995-06/2013 in a community-based oncology group practice in Germany. 716 patients were analyzed with a median age of 61 (31–93). Localizations of metastases were distributed as follows: 47% visceral, 36% bone, 9% lymphatic, 4% CNS, 4% others. 79% were hormone-receptor-positive, 20% Her2-positive, 9% triple-negative. Median overall survival was 34 months (95% Confidence Interval: 31–37), median disease-specific survival 36.8 months and disease-specific survival after 5 years 34%. Survival was significantly correlated with localizations of metastases, number of metastasized organs, disease free survival since initial diagnosis, hormone-receptor status and age. Patients with hormone-receptor-positive tumors had a median overall survival of 37 months, Her2-positive patients of 34 months and triple-negative patients of 13 months. 86% of hormone-receptor-positive patients received antihormonal therapy. 81% of Her2-positive patients received anti-Her2 therapy. In summary, longer survival is strongly restricted to hormone receptor- and Her2-positive tumors most likely due to targeted therapies directed against the estrogen-receptor and Her2.

Treatment of primary breast cancer at the surgical unit of the Charité 1984-1998

BACKGROUND

We have analyzed the patient population of one clinic (Charité) over a period of 15 years. Besides the changes in the technical facilities and therapeutical guidelines during these years, this period also reflects the changes in the health system attributable to the reunification of East and West Germany. Until now only few analyses for breast cancer patients from the German speaking area have been reported.

PATIENTS AND METHODS

All 2,062 patients undergoing surgical treatment for breast cancer between 1984 and 1998 were documented and followed up until 2007. The analysis included 1,560 patients with a primary breast cancer who fulfilled certain inclusion criteria. The treatment strategies applied to this population are presented in 3 time periods (1984-1990, 1991-1993, and 1994-1998). The effects of prognostic factors on overall survival were investigated using univariate analyses.

RESULTS

The percentage of pT1 tumors changed from 50.7% in the first period to 63.1% in the third period. The percentage of node-negative patients hardly changed with time (on average 61.6%). However, the percentage of patients with less than 10 assessed nodes decreased from 48.4% to 6.7% and 2.5% for the 3 periods, respectively. Therapeutic strategies changed drastically. Survival rate increased substantially, most likely due to improved therapeutic strategies, but also for other reasons not considered in the analysis.

Breast cancer survival in Germany: a population-based high resolution study from Saarland

Population-based survival studies of breast cancer patients are commonly restricted to age- and stage-specific analyses. This study from Germany aimed at extending available population-based survival data on further prognostic cancer characteristics such as tumor grade, hormone receptor status and human epidermal growth factor receptor type 2 (HER2/neu) expression. Data from the population-based Saarland Cancer Registry including female patients diagnosed with invasive breast cancer between 2000 and 2009 were included. Period analysis methodology and regression modelling were used to obtain estimates of 5-year relative survival and tumor related excess risks in 2005-2009. Overall age standardized 5-year relative survival was 83%. In addition to age and stage, tumor grade and hormone receptor status were independent predictors of 5-year relative survival. Detailed analyses by age, stage, morphology, tumor grade, hormone receptor status and HER2/neu expression consistently revealed lower survival of patients with high grade, hormone receptor negative or HER2/neu positive cancers and patients aged 70 years or older. This high resolution study extends available population-based survival data of breast cancer patients. Particular efforts should be made to overcome the persisting large survival deficits, which were observed for elderly patients in all clinical subgroups.

Women's knowledge, attitudes and practice about breast cancer screening in the region of Monastir (Tunisia)

Breast cancer remains a worldwide public health problem. In Tunisia, it is considered to be the primary women's cancer and causes high morbidity and mortality. This study aimed to investigate female knowledge, attitudes and practice of breast cancer screening in the region of Monastir (Tunisia). We conducted a descriptive cross-sectional design exploring knowledge, attitudes and practices of women in the region of Monastir on breast cancer screening. The study was conducted in health centres of this region from 1 March 2009 to 30 June 2009. Data were collected via a structured questionnaire containing 15 items on demographic status, knowledge of risk factors and screening methods and attitudes towards the relevance and effectiveness of breast cancer screening. A scoring scheme was used to score women's responses. A total of 900 women agreed to take part in the study. Their mean age was 41.6±12.4 years and 64% did not exceed the primary level of education. According to the constructed scores, 92% of participants had poor knowledge of the specific risk factors for breast cancer and 63.2% had poor knowledge of the screening methods. Proper practice of breast cancer screening was observed in 14.3% of cases. Multiple logistic regression analysis showed that good knowledge of risk factors and screening methods, higher level of education and positive family history of breast cancer were independently correlated with breast cancer screening practice. This study revealed poor knowledge of breast cancer and the screening methods as well as low levels of practice of breast cancer screening among women in the region of Monastir. Results justify educational programs to raise women's adherence to breast cancer screening programs in Tunisia.

Model based period analysis of absolute and relative survival with R: data preparation, model fitting and derivation of survival estimates

Period analysis is increasingly employed in analyses of long-term survival of patients with chronic diseases such as cancer, as it derives more up-to-date survival estimates than traditional cohort based approaches. It has recently been extended with regression modelling using generalized linear models, which increases the precision of the survival estimates and enables to assess and account for effects of additional covariates. This paper provides a detailed presentation how model based period analysis may be used to derive population-based absolute and relative survival estimates using the freely available R language and statistical environment and already available R programs for period analysis. After an introduction of the underlying regression model and a description of the software tools we provide a step-by-step implementation of two regression models in R and illustrate how estimates and a test for trend over time in relative survival may be derived using data from a population based cancer registry.

Genome-wide methylation screen in low-grade breast cancer identifies novel epigenetically altered genes as potential biomarkers for tumor diagnosis

Aberrant DNA methylation constitutes a well-established epigenetic marker for breast cancer. Changes in methylation early in cancer development may be clinically relevant for cancer detection and prognosis-based therapeutic decisions. In the present study, a combination of methyl-CpG immunoprecipitation (MCIp) and human CpG island (CGI) arrays was applied to compare genome-wide DNA methylation profiles in 10 low-grade in situ and invasive breast cancers against 10 normal breast samples. In total, 214 CGIs were found to be hypermethylated in ≥6 of 10 tumors. Functional term enrichment analyses revealed an overrepresentation of homeobox genes and genes involved in transcription and regulation of transcription. Significant hypermethylation of 11 selected genes in tumor vs. normal tissue was validated in two independent sample sets (45 tumors and 11 controls, 43 tumors and 8 controls) using quantitative EpiTyper technology. In tumors, median methylation levels of BCAN, HOXD1, KCTD8, KLF11, NXPH1, POU4F1, SIM1, and TCF7L1 were ≥30% higher than in normal samples, representing potential biomarkers for tumor diagnosis. Using the 90th percentile of methylation levels in normal tissue as cutoff value, 62-92% of in situ samples (n=13), 72-97% of invasive samples from the first validation set (n=32), and 86-100% of invasive samples from the second validation set (n=43) were classified as hypermethylated. Hypermethylation of KLF11 and SIM1 might also be associated with increased risk of developing metastases. In summary, early methylation changes are frequent in the low-grade pathway of breast cancer and may be useful in the development of differential diagnostic and possibly also prognostic markers.

Digital slide images for primary diagnostics in breast pathology: a feasibility study

Digital slide images have been used in many areas of pathology such as teaching, research, digital archiving, teleconsultation, and quality assurance testing. However, they have not much been used as yet for upfront diagnostics. The aim of this study was therefore to test the feasibility of digital slide image-based diagnosis of breast specimens. Sections of 100 breast specimens previously diagnosed conventionally were scanned and rediagnosed on digital slide images by the same pathologists who performed the initial light microscopy-based diagnosis. The digital slide image diagnoses were compared with the light microscopy diagnoses and classified as concordant, slightly discrepant (without clinical or prognostic consequences), or discrepant. The original light microscopy- and digital slide image-based diagnoses were concordant in 93% and slightly discrepant in 6% of cases. There was only 1 discrepant case with clinical or prognostic implication to the patient. However, for this case, no final agreement could be achieved. For 4 of the 6 slightly discrepant cases, digital slide image diagnosis was considered the better one, whereas the original diagnosis was preferred in only 1 case. In addition, for 1 case categorized as slightly discrepant, both the digital slide image and conventional diagnosis were imperfect according to 2 reviewing breast pathologists. This study demonstrates that upfront histopathologic diagnosis of breast biopsies and resections can reliably be done on digital slide image.

Trends of population-based breast cancer survival in Germany and the US: decreasing discrepancies, but persistent survival gap of elderly patients in Germany

Background

Studies have revealed both higher cancer survival in the US than in Germany and substantial improvement of cancer survival in the past in these countries. This population-based study aims at comparing most recent 5-year relative survival of breast cancer patients and preceding trends in both countries.

Methods

Women with a first invasive breast cancer diagnosed and followed up between 1988 and 2008 from Germany and the US (utilizing data from the Saarland Cancer Registry and the Surveillance, Epidemiology, and End Results Program, respectively) were included. Period analysis was used to derive most up-to-date 5-year relative survival and preceding survival trends according to age and stage.

Results

Since 1993, age standardized relative survival has steadily improved in Germany and the US to 83% and 88%, respectively. In the period 2005–08, relative survival of localized cancer was above 97% in both countries, and 79% and 83% for locally/regionally spread breast cancer, respectively. Prognosis of metastasized disease has remained very poor overall, with improvement essentially being restricted to younger patients. The proportion of patients diagnosed with localized breast cancer was consistently higher in the US. If adjusted for stage, the differences in relative survival between both countries diminished over time and eventually disappeared.

Conclusions

Similar survival is now observed in both countries for patients below the age of 70 years, but in Germany survival is still much lower for elderly patients. The observed trends point to treatment advances as a major cause for improved survival. However, substantial differences in mammography usage existed between both countries and might probably also account for the observed differences (to a lesser extent, also differences in health care systems, and delivery of cancer care). Encouraging, survival of breast cancer patients has improved in Germany to a much greater extent than in the US, albeit the persisting survival gap for elderly patients in Germany requires particular attention by researchers, public health authorities, and clinicians.

The descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality

BACKGROUND

This paper presents the latest international descriptive epidemiological data for invasive breast cancer amongst women, including incidence, survival and mortality, as well as information on mammographic screening programmes.

RESULTS

Almost 1.4 million women were diagnosed with breast cancer worldwide in 2008 and approximately 459,000 deaths were recorded. Incidence rates were much higher in more developed countries compared to less developed countries (71.7/100,000 and 29.3/100,000 respectively, adjusted to the World 2000 Standard Population) whereas the corresponding mortality rates were 17.1/100,000 and 11.8/100,000. Five-year relative survival estimates range from 12% in parts of Africa to almost 90% in the United States, Australia and Canada, with the differential linked to a combination of early detection, access to treatment services and cultural barriers. Observed improvements in breast cancer survival in more developed parts of the world over recent decades have been attributed to the introduction of population-based screening using mammography and the systemic use of adjuvant therapies.

CONCLUSION

The future worldwide breast cancer burden will be strongly influenced by large predicted rises in incidence throughout parts of Asia due to an increasingly "westernised" lifestyle. Efforts are underway to reduce the global disparities in survival for women with breast cancer using cost-effective interventions.