Prognostic Tools for Older Women with Breast Cancer: A Systematic Review

Background: Breast cancer is the most common cancer in women, and older patients comprise an increasing proportion of patients with this disease. The older breast cancer population is heterogenous with unique factors affecting clinical decision making. While many models have been developed and tested for breast cancer patients of all ages, tools specifically developed for older patients with breast cancer have not been recently reviewed. We systematically reviewed prognostic models developed and/or validated for older patients with breast cancer. Methods: We conducted a systematic search in 3 electronic databases. We identified original studies that were published prior to 8 November 2022 and presented the development and/or validation of models based mainly on clinico-pathological factors to predict response to treatment, recurrence, and/or mortality in older patients with breast cancer. The PROBAST was used to assess the ROB and applicability of each included tool. Results: We screened titles and abstracts of 7316 records. This generated 126 studies for a full text review. We identified 17 eligible articles, all of which presented tool development. The models were developed between 1996 and 2022, mostly using national registry data. The prognostic models were mainly developed in the United States (n = 7; 41%). For the derivation cohorts, the median sample size was 213 (interquartile range, 81-845). For the 17 included modes, the median number of predictive factors was 7 (4.5-10). Conclusions: There have been several studies focused on developing prognostic tools specifically for older patients with breast cancer, and the predictions made by these tools vary widely to include response to treatment, recurrence, and mortality. While external validation was rare, we found that it was typically concordant with interval validation results. Studies that were not validated or only internally validated still require external validation. However, most of the models presented in this review represent promising tools for clinical application in the care of older patients with breast cancer.

Relationship between age and drinking patterns and drinking problems among Japanese, Japanese-Americans, and Caucasians

Comparing alcohol consumption patterns by age and gender among Japanese in Japan and Japanese-Americans and Caucasians in the United States, this study examined the associations between age and both heavy drinking and social problems using logistic regression for each ethnic group of male current drinkers. As reported in previous studies of Caucasians, men drink more alcohol than women, older respondents are more likely than younger ones to be abstainers, and the percentages of heavier drinkers and problem drinkers are higher among the young than among older people. Although Japanese-Americans reported consuming less alcohol than Caucasians, their drinking patterns by age were similar: among both United States populations, younger respondents are at higher risk for drinking problems than older respondents, even when alcohol consumption and sociodemographic variables are controlled by logistic regression. However, this association of age and drinking patterns and drinking problems is not universal. Japanese men consumed more alcohol and had a higher proportion of heavier drinkers in the middle age groups; the association between age and drinking problems also varied in this group. In addition to aging, sociocultural factors such as drinking norms probably account for the differences in drinking behavior among different age groups. This study may stimulate further cross-cultural comparison of drinking patterns and problems.

Effect of changes in maternal age, parity, and birth weight distribution on primary cesarean delivery rates

OBJECTIVE

To examine the effect of maternal age on cesarean delivery risk and to quantify the impact of demographic changes since 1970 on primary cesarean delivery rates.

DESIGN

A cohort study.

SETTING

Nonfederal short-stay hospitals in Washington State.

PARTICIPANTS

All women who delivered live singletons with linked birth certificate and hospital discharge data from 1987 through 1990.

MAIN OUTCOME MEASURES

Maternal age-, birth weight-, and parity-specific primary cesarean delivery rates, Mantel-Haenszel relative risk estimates for primary cesarean delivery by 5-year age category stratified by parity, and direct standardization of 1987 through 1990 primary cesarean rates to 1970 Washington State maternal age, birth weight, and parity distribution.

RESULTS

Primary cesarean rates ranged from 3.2% for multiparous teenage women who delivered infants weighing 3500 g through 3999 g to 58.9% for primiparous women 40 years of age or older who delivered infants weighing 4000 g or more. After adjustment, the risk of cesarean delivery increased with each 5-year age increment among women 20 years of age or older. We estimated that if the maternal age, parity, and birth weight distribution from 1987 through 1990 were identical to what existed in 1970, Washington State's primary cesarean rate from 1987 through 1990 would have been 12.2%, compared with the observed rate of 14.8%.

CONCLUSION

The lower adjusted primary cesarean rate reflects the demographic changes in the childbearing population, which may be responsible for 18% of the 1987 through 1990 cesarean delivery rates. These findings suggest the importance of using maternal age-, birth weight-, and parity-specific primary cesarean delivery rates to compare populations and study temporal trends.

Increased alcohol-related oesophageal cancer mortality rates in Japanese men

Age-adjusted oesophageal cancer mortality rates for Japanese women declined by 58% between 1960 and 1989, whereas corresponding rates for Japanese men have shown no decline. We speculate that alcohol-related oesophageal cancer mortality rates have been increasing in Japanese men replacing non-alcohol related oesophageal cancer deaths. Specifically, male birth cohorts, which experienced increased alcohol-related cirrhosis mortality rates, would also experience a rise in oesophageal cancer mortality rates. To test this hypothesis, we compared male to female ratios of oesophageal cancer mortality rates by birth cohort with those of liver cirrhosis mortality rates. We calculated the attributable risk of alcohol consumption and smoking to oesophageal cancer in Japanese men using oesophageal cancer mortality rates in Japanese women as a baseline, i.e. non-alcohol and non-smoking related oesophageal cancer deaths. We applied this method to head and neck cancer deaths to test its feasibility. Male birth cohorts born after 1926, which experienced male to female cirrhosis mortality ratios, also experienced increased oesophageal cancer mortality ratios. Overall, drinking and smoking accounted for 86% of all oesophageal cancer deaths and 85% of head and neck cancer deaths among Japanese men.

Variations in the accuracy of obstetric procedures and diagnoses on birth records in Washington State, 1989

The authors abstracted a sample of 7,536 hospital medical records to validate the accuracy of the coding of obstetric information on 1) birth certificates, 2) a statewide computerized hospital discharge abstract data system, and 3) a linked file merging birth certificates and the hospital abstract data for Washington State deliveries occurring in 1989. Measures of accuracy of coding of delivery method and obstetric procedures varied greatly among the 23 hospitals that participated in the study. Computerized hospital discharge data were generally more complete and accurate than were birth certificate data. The linked file was more likely to identify obstetric procedures than was either source alone. For example, only 84.1% of cesarean deliveries noted in the hospital charts were identified on birth certificates (range among hospitals, 37-100%). Using the linked file, the authors identified 99.8% of cesarean deliveries (range, 97-100%). Linked birth certificate-hospital abstract files may become an excellent source of data for epidemiologic and health care studies; however, further training of medical record personnel and standardization of coding are needed to improve the quality of computerized data on obstetric events.

Average daily alcohol consumption during adult life among decedents with and without cirrhosis: the 1986 National Mortality Followback Survey

The relationship of alcohol consumption and cirrhosis mortality was examined by sampling 1% of deaths in the U.S. using the 1986 National Mortality Followback Survey. Quantity and frequency of decedent's alcohol consumption was obtained from next of kin through mailed questionnaire. The percentage of decedents with cirrhosis increased sharply with the increasing number of drinks per day. Three drinks per day was associated with a significantly higher percentage of cirrhosis deaths compared with lifetime abstainers for both whites and blacks. Although blacks had a significantly higher percentage of abstainers than whites, of those persons who were reported to drink every day, blacks were more likely to be heavier drinkers (5 or more drinks per day). Blacks did not have a higher risk of cirrhosis mortality than whites for each drinking category. Although Native Americans were oversampled, the number of deaths was too small for statistical comparisons.

Alcohol-related problems encountered by Japanese, Caucasians, and Japanese-Americans

Using population-based survey data, personal-problematic and socioproblematic factors were examined among Japanese in Japan, Japanese-Americans in Hawaii, and Japanese-Americans; Caucasians in California were analyzed as a control group. Caucasian males were more likely to exhibit drinking-related social problems, whereas Japanese males showed more personal-problematic symptoms. Japanese-American men, both in Hawaii and California, were least likely among the three ethnic groups to have personal-problematic symptoms and were more likely to have socioproblematic symptoms than Japanese men. These differences might be explained by differences in the perception of social problems.

The relationship between three subtypes of the flushing response and DSM-III alcohol abuse in Japanese

This study examined the relationship between the flushing response and drinking patterns and DSM-III alcohol abuse among Japanese using data collected in the joint U.S.-Japan collaborative study. The flushing response was classified into the following three subtypes: typical flushing (always flushed in the face after drinking), atypical flushing (sometimes) and nonflushing (never). This study of male current drinkers showed that typical flushers drank less alcohol than did atypical and nonflushers, but there was no observed difference between the drinking patterns of atypical flushers and nonflushers. Although the relationship was less pronounced, a similar association was found for female current drinkers. The 12-month prevalence of DSM-III alcohol abuse was estimated to be highest among atypical flushers and lowest among typical flushers, with nonflushers in between for both genders. When daily alcohol consumption and other pertinent sociodemographic variables were controlled, logistic regression analyses revealed that the risk for alcohol abuse by men was approximately 3.0 times higher among atypical flushers and 1.7 times higher among nonflushers than among typical flushers. The corresponding risks for abuse by women were 7.8 (atypical flushers) and 2.8 (nonflushers) times higher. Possible explanations for these differences in drinking patterns and the risk for alcohol abuse among the three flushing subtypes and between genders are discussed.

The effect of acculturation on drinking attitudes among Japanese in Japan and Japanese Americans in Hawaii and California

Data from a joint Japan-U.S. collaborative study were examined to determine the relationship of acculturation to drinking attitudes among Japanese in Japan and Japanese Americans in Hawaii and California. Drinking attitudes (i.e., self-reported acceptable or appropriate levels of drinking) among ethnic groups differed significantly for the nine situations studied: (1) at a bar with friends, (2) at a party at someone else's house, (3) as a parent, spending time with small children, (4) during working hours, (5) visiting in-laws, (6) with friends at home, (7) with friends after work, (8) with people at sports events and (9) before driving a car. Factor analysis was used to determine the differences in drinking attitudes among these ethnic groups. Japanese and Japanese Americans differentiated drinking situations into different categories. The major difference between the two groups was that the Japanese associated spending time with small children with a situation appropriate for drinking, such as being with friends at home, whereas Japanese Americans associated spending time with small children with a situation inappropriate for drinking, such as before driving.

The association of drinking levels and drinking attitudes among Japanese in Japan and Japanese-Americans in Hawaii and California

This study examined cross-cultural differences in drinking attitudes and drinking levels and their correlation among Japanese in Japan and Japanese-Americans in Hawaii or California. In most situations, an increase in drinking levels was associated with more tolerant drinking attitudes in all three groups. Abstainers were less likely to say that getting drunk is sometimes all right, whereas the reverse was true for heavier drinkers. Drinking levels among Japanese, especially among Japanese women, were not highly associated with how much drinking was perceived as acceptable in each situation, whereas among Japanese-Americans, drinking levels were highly associated with drinking attitudes. Although the Japanese had generally tolerant attitudes toward drinking, they indicated higher abstention rates before driving than Japanese-Americans regardless of their drinking levels. This may reflect the impact of public education on drunken driving in Japan.

A method for estimating alcohol-related liver cirrhosis mortality in Japan

In Japan, per capita alcohol consumption increased sharply during the post World War II period followed by an increase in cirrhosis mortality. The prevalence of alcoholic cirrhosis among hospitalized patients also increased, from 11% in 1969 to 18% in 1985. Despite an increase in the percentage of drinkers among young women, over 80% of women in Japan are still abstainers or light drinkers. Thus, female cirrhosis mortality rates can be used as a proxy measure of non-alcohol-related cirrhosis mortality rates to estimate alcohol-related cirrhosis deaths among Japanese men. Employing this method, we conclude that two-thirds of cirrhosis deaths among men between 24 and 85 years of age and half of all cirrhosis deaths were attributable to alcohol. Two factors are probably responsible for the differences in proportional morbidity and proportional mortality of alcohol-related cirrhosis: differences in survival rates between alcoholic and non-alcoholic cirrhosis patients and detection bias toward post-hepatic cirrhosis. The synergistic effect of alcohol on viral hepatitis may in part explain excess cirrhosis deaths among Japanese men.

Alcohol consumption and the risk of developing liver cirrhosis: implications for future research

Studies of the association of alcohol consumption and liver cirrhosis were reviewed, focusing on possible biases of study design. Daily alcohol consumption (as opposed to intermittent binge drinking), amount of alcohol consumed, longer duration of alcohol abuse, and being female were associated with the increased risk of cirrhosis. Follow-up studies reviewed failed to take full advantage of the study design and added little information to existing literature. Retrospective studies were relatively free of bias and are valuable tools in estimating the risk of cirrhosis. Future research needs to take the following variables into consideration: better ascertainment of alcohol consumption, consumption patterns, changes in alcohol consumption, gender, and body weight.

Genetic or cultural determinants of drinking: a study of embarrassment at facial flushing among Japanese and Japanese-Americans

Facial flushing after the ingestion of alcohol is common among Asians. Flushers are genetically less able to tolerate alcohol than nonflushers and are less likely to become alcoholics. This study examined whether lower consumption of alcohol among flushers was correlated with cultural factors such as embarrassment over flushing as well as with biological factors among Japanese in Japan and Japanese-Americans using data from a joint Japan-U.S. collaborative survey. Eight hundred forty-six Japanese and 737 Japanese-American current drinkers with known flushing status were studied. The mean alcohol intake differed significantly between groups: (1) habitat--Japanese versus Japanese-Americans, (2) flushing status--flushers versus nonflushers, and (3) embarrassment about flushing. Among men, ethnicity was the major determinant of alcohol consumption, followed by flushing status and embarrassment about flushing. Among women, differences were not significant. Lower alcohol consumption by flushers than by nonflushers has been attributed to differences in physiological reactions to alcohol. However, this study demonstrated that cultural factors such as embarrassment also contribute to lower alcohol consumption by flushers. The lack of interaction between habitat and flushing status and between habitat and embarrassment status suggests that flushing status and embarrassment status associated with drinking levels are independent of habitat.