Long-term inequalities in breast cancer survival--a ten year follow-up study of patients managed within a National Health Care System (Sweden)

Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District

Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.

Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women

Question

Does breast conservation offer a survival benefit compared with mastectomy when results are adjusted for main confounders such as comorbidity and socioeconomic status?

Findings

In this large cohort study based on prospectively collected national data from 48 986 patients with breast cancer, overall and breast cancer–specific survival were significantly better after breast-conserving surgery followed by radiotherapy than after mastectomy with or without radiotherapy despite stepwise adjustment for tumor characteristics, treatment, demographics, comorbidity, and socioeconomic background.

Meaning

Breast conservation seems to offer a survival benefit independent of measured confounders and should be given priority if both breast conservation and mastectomy are valid options.

Importance

Cohort studies show better survival after breast-conserving surgery (BCS) with postoperative radiotherapy (RT) than after mastectomy (Mx) without RT. It remains unclear whether this is an independent effect or a consequence of selection bias.

Objective

To determine whether the reported survival benefit of breast conservation is eliminated by adjustment for 2 pivotal confounders, comorbidity and socioeconomic status.

Design, Setting, and Participants

Cohort study using prospectively collected national data. Swedish public health care; nationwide clinical data from the National Breast Cancer Quality Register, comorbidity data from Patient Registers at the National Board of Health and Welfare, and individual-level education and income data from Statistics Sweden. The cohort included all women diagnosed as having primary invasive T1-2 N0-2 breast cancer and undergoing breast surgery in Sweden from 2008 to 2017. Data were analyzed between August 19, 2020, and November 12, 2020.

Exposures

Locoregional treatment comparing 3 groups: breast-conserving surgery with radiotherapy (BCS+RT), mastectomy without radiotherapy (Mx-RT), and mastectomy with radiotherapy (Mx+RT).

Main Outcomes and Measures

Overall survival (OS) and breast cancer–specific survival (BCSS). Main outcomes were determined before initiation of data retrieval.

Results

Among 48 986 women, 29 367 (59.9%) had BCS+RT, 12413 (25.3%) had Mx-RT, and 7206 (14.7%) had Mx+RT. Median follow-up was 6.28 years (range, 0.01-11.70). All-cause death occurred in 6573 cases, with death caused by breast cancer in 2313 cases; 5-year OS was 91.1% (95% CI, 90.8-91.3) and BCSS was 96.3% (95% CI, 96.1-96.4). Apart from expected differences in clinical parameters, women receiving Mx-RT were older, had a lower level of education, and lower income. Both Mx groups had a higher comorbidity burden irrespective of RT. After stepwise adjustment for all covariates, OS and BCSS were significantly worse after Mx-RT (hazard ratio [HR], 1.79; 95% CI, 1.66-1.92 and HR, 1.66; 95% CI, 1.45-1.90, respectively) and Mx+RT (HR, 1.24; 95% CI, 1.13-1.37 and HR, 1.26; 95% CI, 1.08-1.46, respectively) than after BCS+RT.

Conclusions and Relevance

Despite adjustment for previously unmeasured confounders, BCS+RT yielded better survival than Mx irrespective of RT. If both interventions are valid options, mastectomy should not be regarded as equal to breast conservation.

Population-based mammography screening attendance in Sweden 2017-2018: A cross-sectional register study to assess the impact of sociodemographic factors

Sweden has a population-based mammography screening programme for women aged 40–74. The objective of this study was to examine the association between mammography screening attendance and sociodemographic factors in 15 of Sweden's 21 health care regions. Register-based information was collected on all mammography screening invitations and attendance during 2017 and 2018, and linked to individual-level sociodemographic data from Statistics Sweden. Odds ratios (ORs) and 95% confidence intervals (CIs) for attendance were computed by sociodemographic factor. The study sample included 1.5 million women, aged 40–75, with an overall screening attendance of 81.3%. The lowest odds of attending were found for women living without a partner (OR = 0.52, 95% CI: 0.52–0.53), low-income women (OR = 0.57, 95% CI: 0.56–0.57), and non-Nordic women born in Europe (OR = 0.60, 95% CI: 0.59–0.61). Other groups with lower odds of attending were women whose main source of income was social assistance or benefits (OR = 0.62, 95% CI: 0.62–0.63), those not owning their home (OR = 0.66, 95% CI: 0.66–0.67), and those with low level of education (OR = 0.72, 95% CI: 0.71–0.73). Having multiple of these sociodemographic characteristics further lowered the odds of attending. Although overall mammography screening attendance in Sweden is high, sociodemographic inequalities exist, and efforts should be made to address these. Particular attention should be given to low-income women who live without a partner.

•

Mammography screening attendance in Sweden was 81% in 2017–2018.

•

Sociodemographic inequalities were found for screening attendance.

•

Having multiple low attendance risk factors further decreased the odds of attending.

•

Lowest attendance among low-income women who live without a partner.

Early detection of breast cancer rectifies inequality of breast cancer outcomes

Objectives

To explain apparent differences among mammography screening services in Sweden using individual data on participation in screening and with breast cancer–specific survival as an outcome.

Methods

We analysed breast cancer survival data from the Swedish Cancer Register on breast cancer cases from nine Swedish counties diagnosed in women eligible for screening. Data were available on 38,278 breast cancers diagnosed and 4312 breast cancer deaths. Survival to death from breast cancer was estimated using the Kaplan–Meier estimate, for all cases in each county, and separately for cases of women participating and not participating in their last invitation to screening. Formal statistical comparisons of survival were made using proportional hazards regression.

Results

All counties showed a reduction in the hazard of breast cancer death with participation in screening, but the reductions for individual counties varied substantially, ranging from 51% (95% confidence interval 46–55%) to 81% (95% confidence interval 74–85%). Survival rates in nonparticipating women ranged from 53% (95% confidence interval 40–65%) to 74% (95% confidence interval 72–77%), while the corresponding survival in women participating in screening varied from 80% (95% confidence interval 77–84%) to 86% (95% confidence interval 83–88%), a considerably narrower range.

Conclusions

Differences among counties in the effect of screening on breast cancer outcomes were mainly due to variation in survival in women not participating in screening. Screening conferred similarly high survival rates in all counties. This indicates that the performance of screening services was similar across counties and that detection and treatment of breast cancer in early-stage reduces inequalities in breast cancer outcome.

Breast Cancer Survival Defined by Biological Receptor and Menopausal Status in Vietnamese Women

Little is known about breast cancer in Vietnamese women. Previous studies have reported the frequencies of prognostic factors of breast cancer in this population. The aim of this study was to examine the prognostic factors associated with the survival rates of patients with breast cancer treated at the National Cancer Hospital, Hanoi, Vietnam. We recruited 248 women with operable breast cancer treated with surgery and adjuvant therapy. Tumor tissue samples were stained by many immunohistochemical approaches and analyzed for estrogen receptor, progesterone receptor, and HER2 gene amplification status. A Cox model was used to determine the relationship between survival and the prognostic factors. The disease-free survival rate, overall survival rate, and cancer-specific survival rate were 75.8%, 80.6%, and 86.4%, respectively, at 5 years and 62.3%, 68.1%, and 78.9%, respectively, at 10 years. The lung was the most common metastatic site. Women with factors associated with a poor prognosis (eg, advanced clinical stage, high tumor grade, progesterone receptor [PR] negativity, HER2 amplification) had significantly lower survival rates. Patients with PR-negative breast cancer had significantly worse survival rates compared to those who were PR positive, according to multivariate analysis (hazard ratio = 1.77, 95% confidence interval: 1.01-3.11, P = .045); however, there was only a statistically significant difference in postmenopausal patients. The PR was a prognostic factor in postmenopausal women with breast cancer, but not in premenopausal women.

Geographical and socioeconomic differences in uptake of Pap test and mammography in Italy: results from the National Health Interview Survey

OBJECTIVE

The Italian National Health Service instituted cervical and breast cancer screening programmes in 1999; the local health authorities have a mandate to implement these screening programmes by inviting all women aged 25-64 years for a Pap test every 3 years (or for an Human Papilloma Virus (HPV) test every 5 years) and women aged 50-69 years for a mammography every 2 years. However, the implementation of screening programmes throughout the country is still incomplete. This study aims to: (1) describe cervical and breast cancer screening uptake and (2) evaluate geographical and individual socioeconomic difference in screening uptake.

METHODS

Data both from the Italian National Health Interview Survey (NHIS) conducted by the National Institute of Statistics in 2012-2013 and from the Italian National Centre for Screening Monitoring (INCSM) were used. The NHIS interviewed a national representative random sample of 32 831 women aged 25-64 years and of 16 459 women aged 50-69 years. Logistic multilevel models were used to estimate the effect of socioeconomic variables and behavioural factors (level 1) on screening uptake. Data on screening invitation coverage at the regional level, taken from INCSM, were used as ecological (level 2) covariates.

RESULTS

Total 3-year Pap test and 2-year mammography uptake were 62.1% and 56.4%, respectively; screening programmes accounted for 1/3 and 1/2 of total test uptake, respectively. Strong geographical differences were observed. Uptake was associated with high educational levels, healthy behaviours, being a former smoker and being Italian versus foreign national. Differences in uptake between Italian regions were mostly explained by the invitation coverage to screening programmes.

CONCLUSIONS

The uptake of both screening programmes in Italy is still under acceptable levels. Screening programme implementation has the potential to reduce the health inequalities gap between regions but only if uptake increases.

Adjusting Expected Mortality Rates Using Information From a Control Population: An Example Using Socioeconomic Status

Expected or reference mortality rates are commonly used in the calculation of measures such as relative survival in population-based cancer survival studies and standardized mortality ratios. These expected rates are usually presented according to age, sex, and calendar year. In certain situations, stratification of expected rates by other factors is required to avoid potential bias if interest lies in quantifying measures according to such factors as, for example, socioeconomic status. If data are not available on a population level, information from a control population could be used to adjust expected rates. We have presented two approaches for adjusting expected mortality rates using information from a control population: a Poisson generalized linear model and a flexible parametric survival model. We used a control group from BCBaSe-a register-based, matched breast cancer cohort in Sweden with diagnoses between 1992 and 2012-to illustrate the two methods using socioeconomic status as a risk factor of interest. Results showed that Poisson and flexible parametric survival approaches estimate similar adjusted mortality rates according to socioeconomic status. Additional uncertainty involved in the methods to estimate stratified, expected mortality rates described in this study can be accounted for using a parametric bootstrap, but this might make little difference if using a large control population.

Absence of socioeconomic inequalities in access to good-quality breast cancer treatment within a population-wide screening programme in Turin (Italy)

Several studies suggest that population-based breast cancer screening programmes might help reduce social inequalities in breast cancer survival both by increasing early diagnosis and by improving access to effective treatments. To start disentangling the two effects, we evaluated social inequalities in quality of treatment of screen-detected breast cancer in the city of Turin (Italy). Combining data from the Audit System on Quality of Breast Cancer Treatment and the Turin Longitudinal Study, we analysed 2700 cases in the screening target age class 50-69 diagnosed in the period 1995-2008. We selected 10 indicators of the pathway of care, relative to timeliness and appropriateness of diagnosis and treatment, and three indicators of socioeconomic position: education, occupational status and housing characteristics. For each indicator of care, relative risks of failure were estimated by robust Poisson regression models, controlling for calendar period of diagnosis, size of tumour and activity volume of the surgery units. The principal predictor of failure of the good care indicators was the calendar period of diagnosis, with a general improvement with time in the quality of diagnosis and treatment, followed by size of the tumour and volume of activity. Socioeconomic indicators show only a marginal independent effect on timeliness indicators. The observed associations of quality indicators with socioeconomic characteristics are lower than expected, suggesting a possible role of the screening programme in reducing disparities in the access to good-quality treatments thanks to its capability to enter screen-detected women into a protected pathway of care.

The impacts of public mammography screening on the relationship between socioeconomic status and cancer stage

This study aimed to investigate the relationship between socioeconomic inequality and mortality following the introduction of a public mammography screening program in Norway by exploring the role of change in stage distribution as the mechanism for differences before and after the introduction of the screening program. Attained education level was used as a measure of socioeconomic status in this population-based study. All women aged 50–69 years diagnosed with breast cancer from 1999–2008 and with follow-up data until the end of 2009 were included. The primary endpoint was all-cause mortality. The results of a mediation analysis indicated that the introduction of screening led to stage distribution related reductions of −5.6 (95% confidence interval = −6.7 to −4.5), −2.5 (−3.0 to −2.1), and −1.4 (−1.9 to −0.9) fewer deaths per 1000 women for with a primary school education, secondary school education, and university education, respectively. The study showed that stage distribution explained −5 (−5.9 to −4.1) fewer deaths among women with a university education and −2.4 (−2.9 to −2.0) fewer deaths among women with a secondary school education before program implementation when compared to the group with a primary school education. There were significant reductions in mortality due to stage distribution after program implementation with differences relative to women with primary school of −1.8 (−2.2 to −1.4) and −0.7 (−0.9 to −0.5) fewer deaths in favor of women with university education and secondary school, respectively. The results indicate reduced importance of cancer stage as a reason for differences in mortality by socioeconomic status after the introduction of a public mammography program.

•

The effects of breast cancer screening on socioeconomic inequality in survival are unknown.

•

Stage and socioeconomic status in relation to the introduction of a screening program was examined.

•

Mortality differences due to stage distribution were reduced after program implementation.

•

Socioeconomic status by stage may be less important after screening introduction.

RELATIVE EFFECTIVENESS IN BREAST CANCER TREATMENT: A HEALTH PRODUCTION APPROACH

Background: Pharmaceuticals’ relative effectiveness has come to the fore in the policy arena, reflecting the need to understand how relative efficacy (what can work) translates into added benefit in routine clinical use (what does work). European payers and licensing authorities assess value for money and post-launch benefit–risk profiles, and efforts to standardize assessments of relative effectiveness across the European Union (EU) are under way. However, the ways that relative effectiveness differs across EU healthcare settings are poorly understood.

Methods: To understand which factors influence differences in relative effectiveness, we developed an analytical framework that treats the healthcare system as a health production function. Using evidence on breast cancer from England, Spain, and Sweden as a case study, we investigated the reasons why the relative effectiveness of a new drug might vary across healthcare systems. Evidence was identified from a literature review and national clinical guidance.

Results: The review included thirteen international studies and thirty country-specific studies. Cross-country differences in population age structure, deprivation, and educational attainment were consistently associated with variation in outcomes. Screening intensity appeared to drive differences in survival, although the impact on mortality was unclear.

Conclusions: The way efficacy translates into relative effectiveness across health systems is likely to be influenced by a range of complex and interrelated factors. These factors could inform government and payer policy decisions on ways to optimize relative effectiveness, and help increase understanding of the potential transferability of data on relative effectiveness from one health system to another.

Socioeconomic disparities in breast cancer incidence and survival among parous women: findings from a population-based cohort, 1964-2008

Background

Socioeconomic position (SEP) has been associated with breast cancer incidence and survival. We examined the associations between two socioeconomic indicators and long-term breast cancer incidence and survival in a population-based cohort of parous women.

Methods

Residents of Jerusalem who gave birth between 1964–1976 (n = 40,586) were linked to the Israel Cancer Registry and Israel Population Registry to determine breast cancer incidence and vital status through mid-2008. SEP was assessed by husband’s occupation and the woman’s education. We used log ranks tests to compare incidence and survival curves by SEP, and Cox proportional hazard models to adjust for demographic, reproductive and diagnostic factors and assess effect modification by ethnic origin.

Results

In multivariable models, women of high SEP had a greater risk of breast cancer compared to women of low SEP (Occupation: HR 1.18, 95 % CI 1.03-1.35; Education: HR 1.39, 95 % CI 1.21-1.60) and women of low SEP had a greater risk of mortality after a breast cancer diagnosis (Occupation: HR 1.33, 95 % CI 1.04-1.70; Education: HR 1.37, 95 % CI 1.06-1.76). The association between education and survival was modified by ethnic origin, with a gradient effect observed only among women of European origin. Women of Asian, North African and Israeli origin showed no such trend.

Conclusions

SEP was associated with long-term breast cancer incidence and survival among Israeli Jews. Education had a stronger effect on breast cancer outcomes than occupation, suggesting that a behavioral mechanism may underlie disparities. More research is needed to explain the difference in the effect of education on survival among European women compared to women of other ethnicities.

Association of Parity and Time since Last Birth with Breast Cancer Prognosis by Intrinsic Subtype

BACKGROUND

Parity and time since last birth influence breast cancer risk and vary by intrinsic tumor subtype, but the independent effects of these factors on prognosis have received limited attention.

METHODS

Study participants were 1,140 invasive breast cancer patients from phases I and II of the population-based Carolina Breast Cancer Study, with tissue blocks available for subtyping using immunohistochemical markers. Breast cancer risk factors, including pregnancy history, were collected via in-person interviews administered shortly after diagnosis. Vital status was determined using the National Death Index. The association of parity and birth recency with breast cancer-specific and overall survival was assessed using Cox proportional hazards models.

RESULTS

During follow-up (median = 13.5 years), 450 patients died, 61% due to breast cancer (n = 276). High parity (3+ births) and recent birth (<5 years before diagnosis) were positively associated with breast cancer-specific mortality, independent of age, race, and selected socioeconomic factors [parity, reference = nulliparous, adjusted HR = 1.76; 95% confidence interval (CI) = 1.13-2.73; birth recency, reference = 10+ years, adjusted HR = 1.29; 95% CI, 0.79-2.11]. The associations were stronger among patients with luminal tumors and those surviving longer than 5 years.

CONCLUSIONS

Parity and recent birth are associated with worse survival among breast cancer patients, particularly among luminal breast cancers and long-term survivors.

IMPACT

The biologic effects of parity and birth recency may extend from etiology to tumor promotion and progression.

The impact of age at diagnosis on socioeconomic inequalities in adult cancer survival in England

BACKGROUND

Understanding the age at which persistent socioeconomic inequalities in cancer survival become apparent may help motivate and support targeting of cancer site-specific interventions, and tailoring guidelines to patients at higher risk.

PATIENTS AND METHODS

We analysed data on more than 40,000 patients diagnosed in England with one of three common cancers in men and women, breast, colon and lung, 2001-2005 with follow-up to the end of 2011. We estimated net survival for each of the five deprivation categories (affluent, 2, 3, 4, deprived), cancer site, sex and age group (15-44, 45-54, 55-64, and 65-74 and 75-99 years).

RESULTS

The magnitude and pattern of the age specific socioeconomic inequalities in survival was different for breast, colon and lung. For breast cancer the deprivation gap in 1-year survival widened with increasing age at diagnosis, whereas the opposite was true for lung cancer, with colon cancer having an intermediate pattern. The 'deprivation gap' in 1-year breast cancer survival widened steadily from -0.8% for women diagnosed at 15-44 years to -4.8% for women diagnosed at 75-99 years, and was the widest for women diagnosed at 65-74 years for 5- and 10-year survival. For colon cancer in men, the gap was widest in patients diagnosed aged 55-64 for 1-, 5- and 10-year survival. For lung cancer, the 'deprivation gap' in survival in patients diagnoses aged 15-44 years was more than 10% for 1-year survival in men and for 1- and 5-year survival in women.

CONCLUSION

Our findings suggest that reduction of socioeconomic inequalities in survival will require updating of current guidelines to ensure the availability of optimal treatment and appropriate management of lung cancer patients in all age groups and older patients in deprived groups with breast or colon cancer.

Effectiveness of population-based service screening with mammography for women ages 40 to 49 years with a high or low risk of breast cancer: socioeconomic status, parity, and age at birth of first child

BACKGROUND

Invitation to mammography screening of women aged 40 to 49 years is a matter of debate in many countries and a cost-effective alternative in countries without screening among women aged 40 to 49 years could be inviting those at higher risk. The relative effectiveness of mammography screening was estimated for subgroups based on the breast cancer risk factors parity, age at time of birth of first child, and socioeconomic status (SES).

METHODS

The SCReening of Young Women (SCRY) database consists of all women aged 40 to 49 years in Sweden between 1986 and 2005 and was split into a study and control group. The study group consisted of women residing in areas in which women aged 40 to 49 years were invited to screening and the control group of women in areas in which women aged 40 to 49 years were not invited to screening. Rate ratio (RR) estimates were calculated for 2 exposures: invitation and attendance.

RESULTS

There were striking similarities noted in the RR pattern for women invited to and attending screening and no statistically significant difference or trend in the RR was noted by risk group. The RR estimates increased by increasing parity for parity of 0 to 2 and ranged from 0.55 (95% confidence interval [95% CI], 0.38-0.79) to 0.79 (95% CI, 0.65-0.95) for attending women. The RR for women with high SES was lower than that for women with low SES (RR, 0.72 [95% CI, 0.60-0.86] and RR, 0.79 [95% CI, 0.63-0.99], respectively). For women aged 20 to 24 years at the time of the birth of their first child, the RR was 0.73 (95% CI, 0.58-0.91) and estimates for other ages were similar.

CONCLUSIONS

There was no statistically significant difference noted in the relative effectiveness of mammography screening by parity, age at the time of birth of the first child, or SES.

Socioeconomic status and epithelial ovarian cancer survival in Sweden

PURPOSE

To investigate socioeconomic disparities in epithelial ovarian cancer (EOC) survival in Sweden.

METHODS

A cohort of 635 women with invasive EOC who participated in a nationwide population-based case-control study was included in the present population-based prospective study. Women were diagnosed with EOC between 1993 and 1995. Mortality until 31 December 2007 was determined through linkage with the Swedish Cause of Death Registry. Clinical data (tumor stage and tumor differentiation) and indicators of socioeconomic status (SES, education level, and annual individual disposable income) were retrieved from medical records and a nationwide database, respectively. The Cox proportional hazards regression model and the Laplace regression model were used to estimate the effect of clinical factors and SES on EOC survival.

RESULTS

The main factors associated with EOC survival were tumor stage and tumor differentiation: women with stage II, III, and IV tumors had a greater mortality risk than those with stage I tumors [hazard ratio (HR) 2.65, 95 % confidence interval (CI) 1.73-4.07; HR 6.69, 95 % CI 4.85-9.22; HR 12.84, 95 % CI 8.90-18.66, respectively]. After adjustment for these tumor characteristics, no clear association remained between our indicators of SES and EOC survival, but better survival was observed among women with stage IV tumors and a higher income level, and among women with poorly differentiated tumors and a higher education level. Nevertheless, there was no evidence of extended survival among women with higher compared to lower SES.

CONCLUSIONS

Our study provides no convincing evidence of an association between SES and EOC survival in Sweden.

Pre- and postoperative alcohol consumption in breast cancer patients: impact on early events

Purpose

To investigate the association between pre- and postoperative alcohol consumption and risk for early breast cancer events, since the association between alcohol consumption and prognosis in breast cancer patients is unclear.

Methods

Alcohol consumption was recorded for 934 primary breast cancer patients who underwent breast cancer surgery in Lund, Sweden, between 2002 and 2011 and were followed until December 31^st 2012. Clinical data were obtained from medical records and population registries. Pre- and postoperative alcohol consumption was analyzed in relation to risk for early events.

Results

Median follow-up time was 3.03 years and 100 breast cancer events, 65 distant metastases, and 76 deaths occurred. Compared to no consumption, any preoperative alcohol consumption was weakly associated with lower risk for early events, adjusted HR 0.69 (0.45-1.04), distant metastases, 0.60 (0.36-1.00) and death, 0.62 (0.38-1.01). In the 572 patients without axillary lymph node involvement, any alcohol consumption was not associated with risk for early events. However, in the 360 patients with axillary lymph node involvement, preoperative alcohol consumption was associated with lower risk for early events (adjusted HR 0.43 0.24-0.77; P_interaction = 0.01).

Conclusion

Pre- and postoperative alcohol consumption was weakly associated with lower risk for early breast cancer events. The data does not support recommending that all breast cancer patients abstain from low to moderate alcohol consumption.

Excessive milk production during breast-feeding prior to breast cancer diagnosis is associated with increased risk for early events

Breast-feeding is a known protective factor against breast cancer. Breast-feeding duration is influenced by hormone levels, milk production, and lifestyle factors. The aims were to investigate how breast-feeding duration and milk production affected tumor characteristics and risk for early breast cancer events in primary breast cancer patients. Between 2002 and 2008, 634 breast cancer patients in Lund, Sweden, took part in an ongoing prospective cohort study. Data were extracted from questionnaires, pathology reports, and patients’ charts from 592 patients without preoperative treatment. Breast-feeding duration ≤12 months of the first child was associated with higher frequency of ER+/PgR+ tumors (P=0.02). Median follow-up time was 4.9 years. Higher risk for early events was observed for breast-feeding duration of first child >12 months (LogRank P=0.001), total breast-feeding duration >12 months (LogRank P=0.008), as well as ‘excessive milk production’ during breast-feeding of the first child (LogRank P=0.001). Patients with ‘almost no milk production’ had no events. In a multivariable model including both ‘excessive milk production’ and breast-feeding duration of the first child >12 months, both were associated with a two-fold risk for early events, adjusted HRs 2.33 (95% CI: 1.25-4.36) and 2.39 (0.97-5.85), respectively, while total breast-feeding duration was not. ‘Excessive milk production’ was associated with a two-fold risk of early distant metastases, adjusted HR 2.59 (1.13-5.94), but not duration. In conclusion, ‘excessive milk production’ during breast-feeding was associated with higher risk for early events independent of tumor characteristics, stressing the need to consider host factors in the evaluation of prognostic markers.

Socio-economic status and survival from breast cancer for young, Australian, urban women

OBJECTIVE

To estimate the association between measures of socio-economic status (SES) and breast cancer (BC) survival for young, urban Australian women.

METHODS

We used a population-based sample of 1,029 women followed prospectively for a median of 7.9 years. SES was defined by education and area of residence. Hazard ratios (HRs) associated with SES measures were estimated for (i) distant recurrence (DR) and (ii) all-cause mortality as end-points.

RESULTS

HRs for area of residence were not significantly different from unity, with or without adjustment for age at diagnosis and education level. The univariable HR estimate of DR for women with university education compared with women with incomplete high school education was 1.51 (95% CI = 1.08 - 2.13, p = 0.02), which reduced to 1.20 (95% CI = 0.85 - 1.72, p = 0.3) after adjusting for age at diagnosis and area of residence. Adjusting for prognostic factors differentially distributed across SES groups did not substantially alter the association between survival and SES.

CONCLUSIONS

Among young, urban Australian women there is no association between SES and BC survival.

IMPLICATIONS

This lack of estimates of association may be partly attributed to universal access to adequate breast cancer care in urban areas.

Lower treatment intensity and poorer survival in metastatic colorectal cancer patients who live alone

Background:

Socioeconomic status (SES) and social support influences cancer survival. If SES and social support affects cancer treatment has not been thoroughly explored.

Methods:

A cohort consisting of all patients who were initially diagnosed with or who developed metastatic colorectal cancer (mCRC, n=781) in three Scandinavian university hospitals from October 2003 to August 2006 was set up. Clinical and socioeconomic data were registered prospectively.

Results:

Patients living alone more often had synchronous metastases at presentation and were less often treated with combination chemotherapy than those cohabitating (HR 0.19, 95% CI 0.04–0.85, P=0.03). Surgical removal of metastases was less common in patients living alone (HR 0.29, 95% CI 0.10–0.86, P=0.02) but more common among university-educated patients (HR 2.22, 95% CI 1.10–4.49, P=0.02). Smoking, being married and having children did not influence treatment or survival. Median survival was 7.7 months in patients living alone and 11.7 months in patients living with someone (P<0.001). Living alone remained a prognostic factor for survival after correction for age and comorbidity.

Conclusion:

Patients living alone received less combination chemotherapy and less secondary surgery. Living alone is a strong independent risk factor for poor survival in mCRC.

Racial disparities in physical and functional domains in women with breast cancer

INTRODUCTION

African-American women are more likely than white women to have functional impairments after breast cancer (BC) surgery; however, no differences were found in self-reported health status surveys at 12+ months postsurgery.

PURPOSE

This analysis compared white and African-American BC survivors' (BCS) health status, health-related quality of life, and the occurrence of physical impairments after BC treatment.

METHODS

One hundred sixty-six women (130 white, 28 African-American, 8 other) were assessed for impairments preoperatively and at 1, 3, 6, 9, and 12+ months postsurgery. Health status was assessed at 12+ months using the Short Form Health Survey (SF36v2™). Analysis of variance estimated differences between groups for health status and impairment occurrence.

RESULTS

No differences were found between groups for BC type, stage, grade, or tumor size; surgery type; or number of lymph nodes sampled. African-American BCS had more estrogen/progesterone receptor-negative tumors (p < 0.001; p = 0.036) and received radiation more frequently (p = 0.03). More African-American BCS were employed (p = 0.022) and reported higher rates of social activities (p = 0.011) but less recreational activities (p = 0.020) than white BCS. African-American BCS had higher rates of cording (p = 0.013) and lymphedema (p = 0.011) postoperatively. No differences were found in self-reported health status.

CONCLUSION

In a military healthcare system, where access to care is ubiquitous, there were no significant differences in many BC characteristics commonly attributed to race. African-American women had more ER/PR-negative tumors; however, no other BC characteristics differed between racial groups. African-American women exhibited more physical impairments, although their BC treatment only differed regarding radiation therapy. This suggests that African-American BCS may be at higher risk for physical impairments and should be monitored prospectively for early identification and treatment.

Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world

CONTEXT

Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important.

OBJECTIVES

To evaluate the literature in the developed world for barriers to access for low SE groups.

METHODS

Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access.

RESULTS

A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access.

CONCLUSION

Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.

African ancestry and higher prevalence of triple-negative breast cancer: findings from an international study

BACKGROUND

The study of breast cancer in women with African ancestry offers the promise of identifying markers for risk assessment and treatment of triple-negative disease.

METHODS

African American and white American women with invasive cancer diagnosed at the Henry Ford Health System comprised the primary study population, and Ghanaian patients diagnosed and/or treated at the Komfo Anokye Teaching Hospital in Kumasi, Ghana constituted the comparison group. Formalin-fixed, paraffin-embedded specimens were transported to the University of Michigan for histopathology confirmation, and assessment of estrogen and progesterone receptors and HER-2/neu expression.

RESULTS

The study population included 1008 white Americans, 581 African Americans, and 75 Ghanaians. Mean age at diagnosis was 48.0 years for Ghanaian, 60.8 years for African American, and 62.4 for white American cases (P=.002). Proportions of Ghanaian, African American, and white American cases with estrogen receptor-negative tumors were 76%, 36%, and 22%, respectively (P<.001), and proportions with triple-negative disease were 82%, 26%, and 16%, respectively (P<.001). All Ghanaian cases were palpable, locally advanced cancers; 57 (76%) were grade 3. A total of 147 American women were diagnosed as stage III or IV; of these, 67.5% (n=46) of African Americans and 44.6% (n=29) of white Americans were grade 3. Among palpable, grade 3 cancers, Ghanaians had the highest prevalence of triple-negative tumors (82.2%), followed by African Americans (32.8%) and white Americans (10.2%).

CONCLUSIONS

Our study demonstrates progressively increasing frequency of estrogen receptor-negative and triple-negative tumors among breast cancer patients with white American, African American, and Ghanaian/African backgrounds. This pattern indicates a need for additional investigations correlating the extent of African ancestry and high-risk breast cancer subtypes.

Is breast cancer the same disease in Asian and Western countries?

A mini-symposium was held in Montreal, Canada, at the International Surgical Week for the Breast Surgical International in 2007 addressing the question whether breast cancer is the same disease in Asian and Western countries. Numerous investigators from Asian and Western countries presented the epidemiologic and clinical outcome data of women with breast cancer. Although there are significant similarities, the striking difference is that the peak age for breast cancer is between 40 and 50 years in the Asian countries, whereas the peak age in the Western countries is between 60 and 70 years. Also, the incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is increasing, the mortality rate is definitely decreasing. Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries.

BACKGROUND

Whether breast cancer is the same disease in Asian and Western countries was the topic of a 2007 Breast Surgery International symposium at International Surgical Week.

METHODS

Participating investigators from China, Taiwan, India, Japan, South Korea, Sweden, Canada, and the United States were asked beforehand to provide data on the epidemiology and treatment outcome of women in their countries.

RESULTS

Comparisons of the epidemiologic and clinical outcome data of women with breast cancer showed significant similarities, but the striking difference is that the peak age is between 40 and 50 years in Asian countries, but is between 60 and 70 years in Western countries. The incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is also increasing, the mortality rate is definitely decreasing.

DISCUSSION

Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries.

Surgical mammography reporting in a limited resource environment

BACKGROUND

Lack of resources and dedicated breast radiology has forced professionals other than radiologists to read mammography. We report a series of surgeon-read mammography in a developing country.

METHODS

Data were collected prospectively form January 2003 to June 2008 for all mammography performed at a tertiary hospital. The data acquired were demographics, previous treatment for breast pathology, and indication for and outcome of mammography, including diagnostic procedures and their results. The results were benchmarked against standard performance indicators.

RESULTS

Of 8,743 mammograms performed, 1,468 were for palpable lumps; the cancer diagnosis rate was 640 per 1,000 investigations (for 885 of these reported as compatible with malignancy, the cancer diagnosis rate was 95%; for 183 reported as indeterminate 60%, for 400 reported as benign/no abnormality 4%). Of 4,998 cancer follow-up mammograms, the cancer diagnosis rate was 15 per 1,000. For 76 of these reported as compatible with malignancy, the cancer diagnosis rate was 67%, for 161 reported as indeterminate, the biopsy rate was 36%, and cancer diagnosis rates of biopsy was 41%. Of 75 cancers diagnosed, 26 were locally recurrent after breast conservation and 49 new contralateral primaries, 84% of these were stage 0-I. Of 2,001 mammograms performed for screening, the biopsy rate was 4.5% and the cancer diagnosis rate of biopsy was 27%; the overall cancer diagnosis rate was 11 per 1,000 examinations; 96% of these were stage 0-1.

CONCLUSIONS

Dedicated breast surgeons are equally proficient at mammography interpretation as radiologists. In resource-restricted environments, nonavailability of dedicated breast radiologists should not preclude development of breast units.

Trends in the survival of patients diagnosed with breast cancer in the Nordic countries 1964-2003 followed up to the end of 2006

BACKGROUND

Breast cancer is the leading cancer among women worldwide in terms of both incidence and mortality. European patients have generally high 5-year relative survival ratios, and the Nordic countries, except for Denmark, have ratios among the highest.

MATERIAL AND METHODS

Based on the NORDCAN database we present trends in age-standardised incidence and mortality rates of invasive breast cancer in the Nordic countries, alongside 5- and 10-year relative survival for the period of diagnosis 1964-2003 followed up to the end of 2006. Excess mortality rates are also provided for varying follow-up intervals after diagnosis. The analysis is confined to invasive breast cancer in Nordic women.

RESULTS

Incidence increased rapidly in all five countries, whereas mortality remained almost unchanged. Both incidence and mortality rates were highest in Denmark. Between 1964 and 2003 both 5- and 10-year relative survival increased by 20-30 percentage points in all countries, and 10-year survival remained around 10 percentage points lower than 5-year survival. Relative survival was lowest in Denmark throughout the period, with a 5-year survival of 79% for years 1999-2003, but 83-87% in the other countries. From 1964 the youngest women had the highest survival ratios up until the introduction of screening, when a shift occurred towards higher survival among age groups 50-59 and 60-69 in each country, except for Denmark. Excess death rates during the first months after diagnosis were highest in Denmark.

CONCLUSION

Breast cancer survival is high and rising in the Nordic countries, and probably relates to the early implementation of organised mammography screening in each country except Denmark and a high and relatively uniform standard of living, diagnosis and treatment. Denmark stands out with higher mortality and poorer survival. The major determinants may include a failure to instigate national breast screening and a greater co-morbidity resulting from a higher prevalence of both tobacco smoking and alcohol consumption.

Sobrevida de mulheres tratadas por câncer de mama no estado do Rio de Janeiro

OBJETIVO: Avaliar a associação entre sobrevida de mulheres com câncer de mama e estrutura e práticas observadas nos estabelecimentos de assistência oncológica. MÉTODOS: Estudo longitudinal retrospectivo, baseado em informações do Sistema de Autorização de Procedimentos de Alta Complexidade do Sistema Único de Saúde e em amostra aleatória de 310 prontuários de mulheres prevalentes atendidas em 15 unidades hospitalares e ambulatoriais oncológicas com quimioterapia entre 1999 e 2002, no estado do Rio de Janeiro. Foram consideradas como variáveis independentes características da estrutura das unidades oncológicas e as suas intervenções praticadas, controlando o efeito com variáveis sociodemográficas e clínicas das pacientes. Para análise dos dados, foram utilizados a técnica de Kaplan-Meier e o modelo de risco de Cox (pseudo-verossimilhança). RESULTADOS: As análises de Kaplan-Meier apontaram associações significativas entre sobrevida e tempo entre diagnóstico e início do tratamento, realização de cirurgia, utilização de hormonioterapia, tipo de hormonioterapia, combinações terapêuticas, tipo de unidade e plano de saúde, volume de atendimento em câncer de mama do estabelecimento e natureza jurídica da unidade. Estimativas obtidas pelo modelo de Cox indicaram associações positivas entre o hazard de morte e tempo entre diagnóstico e início do tratamento, volume de atendimento de câncer de mama do estabelecimento e tipo de unidade combinado ao uso de plano de saúde; e negativas entre sobrevida e cirurgia de mama e tipo de hormonioterapia. CONCLUSÕES: Os resultados mostram associação entre sobrevida de câncer de mama e o cuidado de saúde prestado pelos serviços credenciados, com implicações práticas para pautar novas propostas para o controle do câncer no Brasil.

Social differences in breast cancer survival in relation to patient management within a National Health Care System (Sweden)

Epidemiologic studies have shown that cancer survival is poorer in low compared with high socioeconomic groups. We investigated whether these differences were associated with disparities in tumour characteristics and management. This cohort study was based on 9,908 women aged 20-79 years at diagnosis with primary breast cancer identified in a Swedish population-based clinical register. Information on socioeconomic standing was obtained from a social database. The 5-year cause-specific survival (CSS) and mortality hazard ratios (HR) were estimated by Cox proportional hazard models to assess differences in survival between socioeconomic groups while adjusting for diagnostic intensity, tumour characteristics and treatment. Following adjustment for age, year and stage at diagnosis, the risk of dying of breast cancer was 35% lower among women with high education compared with that of low education (HR = 0.65, 95% CI 0.53-0.80). When compared with women with high education, a lower percentage of women with low education had been investigated for proliferation (84 vs. 76%) or hormone receptor status (89 vs. 81%), had tumours <or=20 mm (68 vs. 64%), were treated at a main hospital (75 vs. 68%) and had received radiation treatment (80 vs. 67%) or chemotherapy (31 vs. 18%). However, these proportional differences could not explain the observed social gradient in survival. To minimize social differences in breast cancer survival, further research should address not only factors leading to inequities in management but also focus on patient factors such as health awareness, comorbidity burden and compliance to adjuvant treatment.