Hysterectomy-corrected rates of endometrial cancer among women younger than age 50 in the United States

Purpose

This analysis describes the impact of hysterectomy on incidence rates and trends in endometrioid endometrial cancer in the United States among women of reproductive age.

Methods

Hysterectomy prevalence for states containing Surveillance, Epidemiology, and End Results (SEER) registry was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) between 1992 and 2010. The population was adjusted for age, race, and calendar year strata. Age-adjusted incidence rates and trends of endometrial cancer among women age 20–49 corrected for hysterectomy were estimated.

Results

Hysterectomy prevalence varied by age, race, and ethnicity. Increasing incidence trends were observed, and were attenuated after correcting for hysterectomy. Among all women, the incidence was increasing 1.6% annually (95% CI 0.9, 2.3) and this increase was no longer significant after correction for hysterectomy (+?0.7; 95% CI ??0.1, 1.5). Stage at diagnosis was similar with and without correction for hysterectomy. The largest increase in incidence over time was among Hispanic women; even after correction for hysterectomy, incidence was increasing (1.8%; 95% CI 0.2, 3.4) annually.

Conclusion

Overall, endometrioid endometrial cancer incidence rates in the US remain stable among women of reproductive age. Routine reporting of endometrial cancer incidence does not accurately measure incidence among racial and ethnic minorities.

     

History of uterine leiomyoma and risk of endometrial cancer in black women

Background

Previous studies have found an association between uterine leiomyomata (UL) and uterine malignancies. This relation has not been studied in black women, who are disproportionately affected by UL.

Methods

We investigated prospectively the association between self-reported physician-diagnosed UL and endometrial cancer in the Black Women’s Health Study. During 1995–2013, 47,267 participants with intact uteri completed biennial health questionnaires. Reports of endometrial cancer were confirmed by pathology data from medical records and cancer registries. Cox regression was used to derive incidence rate ratios (IRR) and 95 % confidence intervals (CI).

Results

There were 300 incident endometrial cancer cases during 689,546 person-years of follow-up. In multivariable models, UL history was associated with a 42 % greater incidence of endometrial cancer compared with no such history (95 % CI 1.12–1.80). IRRs for cancer diagnosed 0–2, 3–9, and ≥10 years after UL diagnosis were 3.20 (95 % CI 2.06–4.98), 0.95 (95 % CI 0.60–1.52), and 1.35 (95 % CI 1.03–1.77), respectively. Stronger overall associations between UL history and endometrial cancer were observed for later stages at cancer diagnosis (IRR = 2.25, 95 % CI 1.09–4.63) and type II/III cancers (IRR = 3.13, 95 % CI 1.64–5.99).

Conclusions

In this large cohort of black women, a history of UL was positively associated with endometrial cancer, particularly type II/III tumors. The strongest association was observed for cancer diagnosed within 2 years of UL diagnosis, a finding that might be explained by greater surveillance of women with UL or misdiagnosis of cancer as UL. However, an association was also observed for cancer reported ≥10 years after UL diagnosis.

     

Body size over the life-course and the risk of endometrial cancer: the California Teachers Study

Purpose

Obesity is a public health epidemic and a major risk factor for endometrial cancer. Here, we identify key aspects of body size which jointly, over the life-course (since adolescence), are associated with endometrial cancer risk.

Methods

Among 88,142 participants in the California Teachers Study, 887 were diagnosed with invasive type 1 endometrial cancer between 1997–1998 and 2012. Multivariable Cox proportional hazards models provided estimates of hazard rate ratios (HR) and 95% confidence intervals (CI) for endometrial cancer associated with life-course body size phenotypes, which incorporated validated measures.

Results

Among women currently using hormone therapy, endometrial cancer risk was only associated with height (HR 1.78, 95% CI 1.32–2.40 for ≥67 vs. <67 inches). Among women not using hormone therapy, tall women who were overweight/obese in adolescence (HR 4.33, 95% CI 2.51–7.46) or who became overweight/obese as adults (HR 4.74, 95% CI 2.70–8.32) were at greatest risk.

Conclusions

Considering absolute body mass, changes in adiposity over time, and body fat distribution together, instead of each measure alone, we identified lifetime obesity phenotypes associated with endometrial cancer risk. These results more clearly define specific risk groups, and may explain inconsistent findings across studies, improve risk prediction models, and aid in developing targeted interventions for endometrial cancer.

     

Association between lifestyle,menstrual/reproductive history,and histological factors and risk of breast cancer in women biopsied for benign breast disease

Purpose

Women with benign breast disease (BBD) have an increased risk of subsequent breast cancer. However, whether conventional breast cancer risk factors influence risk of breast cancer among women with BBD is unclear. In this study, we investigated the associations of lifestyle, menstrual/reproductive, and histological factors with risk of breast cancer among women biopsied for BBD.

Methods

We conducted a case–control study, nested within a cohort of 15,395 women biopsied for BBD at Kaiser Permanente Northwest between 1971 and 2006. Cases were women who developed a subsequent invasive breast cancer during follow-up; controls were individually matched to cases on age at BBD diagnosis. A total of 526 case–control pairs were included in the study. We calculated crude and multivariable OR and 95% CI for the associations between lifestyle, menstrual/reproductive, and histological factors and breast cancer risk using conditional logistic regression.

Results

Compared to premenopausal women, postmenopausal women had reduced risk of subsequent breast cancer (OR 0.60; 95% CI 0.39–0.94), whereas women who ever used hormone replacement therapy (HRT) had increased risk (OR 3.61; 95% CI 1.68–7.75), as did women whose BBD lesion showed atypical hyperplasia (OR 5.56; 95% CI 2.05–15.06). Smoking, BMI, early menarche, multiparity (≥4), history of oophorectomy, and extent of lobular involution were not associated with risk of breast cancer.

Conclusion

This study suggests that use of HRT and having atypical hyperplasia are associated with increased risk of breast cancer among women with BBD, while postmenopausal women with BBD have a reduced risk.

     

Population mixing and incidence of cancers in adolescents and young adults between 1990 and 2013 in Yorkshire,UK

Purpose

Epidemiological evidence suggests a role for an infectious etiology for cancers in teenagers and young adults (TYAs). We investigated this by describing associations between infection transmission using the population mixing (PM) proxy and incidence of cancers in TYAs in Yorkshire, UK.

Methods

We extracted cancer cases from the Yorkshire Specialist Register of Cancer in Children and Young People from 1990 to 2013 (n = 1929). Using multivariable Poisson regression models (adjusting for effects of deprivation and population density), we investigated whether PM was associated with cancer incidence. We included population mixing–population density interaction terms to examine for differences in effects of PM in urban and rural populations.

Results

Nonsignificant IRRs were observed for leukemias (IRR 1.20, 95% CI 0.91–1.59), lymphomas (IRR 1.09, 95% CI 0.90–1.32), central nervous system tumors (IRR 1.06, 95% CI 0.80–1.40) and germ cell tumors (IRR 1.14, 95% CI 0.92–1.41). The association between PM and cancer incidence did not vary in urban and rural areas.

Conclusions

Study results suggest PM is not associated with incidence of cancers among TYAs. This effect does not differ between rural and urban settings.

     

A healthy lifestyle index and its association with risk of breast,endometrial, and ovarian cancer among Canadian women

Purpose

Several modifiable risk factors have been associated with risk of female cancers, but there is limited data regarding their combined effect on risk among Canadian women. Therefore, we assessed the joint association of modifiable risk factors, using a healthy lifestyle index (HLI) score, with risk of specific reproductive cancers.

Method

This study included a subcohort of 3,185 of the 39,618 women, who participated in the Canadian Study of Diet, Lifestyle, and Health, and in whom 410, 177, and 100 postmenopausal breast, endometrial, and ovarian cancers, respectively, were ascertained. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazards regression models modified for the case-cohort design.

Results

Each unit increase in the HLI score was associated with 3% and 5% reductions in risk of postmenopausal breast cancer and endometrial cancer, respectively (HR 0.97; 95% CI 0.94–0.99 and HR 0.95; 95% CI 0.90–0.99, respectively). Compared to those with HLI score in the lowest category, those in the highest category had 30% and 46% reductions in risk of these cancers, respectively. The HLI score was not associated with altered risk of ovarian cancer.

Conclusion

Our findings suggest that promoting a healthy lifestyle may aid in the primary prevention of postmenopausal breast and endometrial cancers.

     

Risk of skin cancer following tamoxifen treatment in more than 16,000 breast cancer patients: a cohort study

Background

Women with breast cancer are at increased risk of developing skin cancer. Little is known about how tamoxifen affects this risk. We aimed to investigate whether tamoxifen treatment following breast cancer is associated with skin cancer.

Methods

A cohort consisting of 44,589 women diagnosed with breast cancer during 1977–2007 from the nationwide clinical database of the Danish Breast Cancer Cooperative Group, was followed for a primary skin cancer [basal cell carcinoma (BCC), squamous cell carcinoma (SCC) or melanoma] in the Danish Cancer Registry supplemented by data on BCC and SCC from the Danish Pathology Register. We investigated incidence of skin cancer among 16,214 women treated with tamoxifen compared to 28,375 women not treated with tamoxifen by calculating incidence rate ratios (IRRs) in Cox regression models.

Results

Tamoxifen users were followed for a median of 2.9 years. The median duration of tamoxifen treatment increased from around 1 year among women diagnosed before 1999 to nearly 2.5 years among women diagnosed in 1999 or later. Women treated with tamoxifen had an IRR 1.06 (95 % CI 0.72–1.55) for SCC and an IRR 1.40 (95 % CI 0.95–2.08) for melanoma when compared to non-users. The observed number of these types of cancer (37 SCCs and 38 melanomas among users) did not allow stratification on calendar-period. The overall IRR for BCC was 0.96 (95 % CI 0.84–1.09), but the IRR differed by menopausal status and calendar-period at diagnosis of breast cancer.

Conclusions

Our overall results indicate that tamoxifen is not associated with skin cancer. However, the inconsistency of results from stratifications prevents a firm conclusion.

     

Endometriosis and risk of ovarian and endometrial cancers in a large prospective cohort of U.S. nurses

Purpose

Endometriosis is associated with ovarian cancer, but the relation with endometrial cancer is unclear. Prior studies generally were retrospective and had potential limitations, including use of self-reported endometriosis, failure to account for delays between symptom onset and endometriosis diagnosis, and changes in risk factors post-endometriosis diagnosis. We evaluated whether these limitations obscured a weak association with endometrial cancer and the extent to which these limitations impacted associations with ovarian cancer.

Methods

Cox proportional hazards regression models were used to assess associations between endometriosis and cancer risk, evaluating the impacts of self-reported vs. laparoscopically confirmed endometriosis, delayed diagnosis, and post-endometriosis diagnosis changes in risk factor exposures on relative risk estimates.

Results

Over 18 years of follow-up, we identified 228 ovarian and 166 endometrial cancers among 102,025 and 97,109 eligible women, respectively. Self-reported endometriosis was associated with ovarian cancer [relative risk (RR): 1.81; 95% confidence interval (CI): 1.26–2.58]; this association was stronger for laparoscopically confirmed endometriosis (HR: 2.14; 95% CI 1.45–3.15). No association was observed with endometrial cancer (self-report RR: 0.78; 95% CI 0.42–1.44; laparoscopic-confirmation RR: 0.76; 95% CI 0.35–1.64). Accounting for diagnosis delays or post-endometriosis diagnosis changes in risk factors had a little impact.

Conclusions

This study adds to the evidence that endometriosis is not strongly linked to endometrial cancer risk and that the association with ovarian cancer is robust to misclassification, diagnostic delay, and changes in exposures post-endometriosis diagnosis. Our analysis suggests that confounding and misclassification do not obscure a weak association for endometrial cancer risk, although our results should be replicated.

     

Dietary total antioxidant capacity in relation to endometrial cancer risk: a case–control study in Italy

Purpose

To investigate the role of the overall antioxidant activity of diet, we estimated the relation between three dietary indices of total antioxidant capacity (TAC) and endometrial cancer risk

Methods

We analyzed data from an Italian case–control study including 454 women with incident, histologically confirmed endometrial cancer, and 908 frequency-matched controls admitted to the same hospitals as cases for acute non-neoplastic conditions. A reproducible and valid food frequency questionnaire was used to assess subjects’ habitual diet. TAC was measured using Italian food composition tables in terms of Ferric-reducing antioxidant power (FRAP), Trolox equivalent antioxidant capacity (TEAC), and total radical-trapping antioxidant parameter (TRAP). We computed odds ratios (OR) and corresponding 95 % confidence intervals (CIs) using conditional multiple logistic regression models, including terms for recognized endometrial cancer risk factors and total energy intake.

Results

TAC was inversely related to endometrial cancer risk with ORs for the highest versus the lowest quartile of 0.69 (95 % CI 0.47–1.00) for FRAP, 0.68 (95 % CI 0.46–0.99) for TEAC, and 0.68 (95 % CI 0.47–0.98) for TRAP. The relations appeared consistent in strata of selected risk factors and decreased when considering TAC without the contribution of coffee.

Conclusions

Our findings suggest a favorable role of a diet high in TAC on endometrial cancer risk, which can be partially driven by coffee consumption.

     

Safety of fertility preservation in breast cancer patients in a register-based matched cohort study

Purpose

To determine if women with breast cancer that undergo fertility preservation (FP), with or without hormonal stimulation, present with an increased risk of breast cancer recurrence.

Methods

A matched cohort study on women with breast cancer attempting to ensure FP in Stockholm from 1999 to 2013 [exposed women (n = 188), age-matched unexposed controls (n = 378)] was designed using the Stockholm regional data from the Swedish National Breast Cancer Quality Register. Breast cancer relapse rates [incidence rate ratio (IRR)] and 95% confidence interval (CI) were estimated using Cox regression and adjusted for potential confounding factors. Completeness of the registry at the time of the study was close to 99%.

Results

Most women attempted FP by hormonal stimulation treatment (n = 148, 79%) with the objective of freezing their eggs or embryos. A smaller group elected FP methods without hormone stimulation (n = 40, 21%). Women who received hormone stimulation did not present with a higher relapse rate than unexposed control women in a model adjusted for age and calendar period of diagnosis (IRR 0.59, 95% CI 0.34–1.04). The results remained virtually unchanged after adjustment for tumor size, estrogen receptor status, affected lymph nodes, and chemotherapy treatment (IRR 0.66, 95% CI 0.37–1.17).

Conclusion

Evidence was not found that fertility preservation, with or without hormonal stimulation, was associated with an increased risk of breast cancer recurrence. The high coverage rate of this population-based study supports the safe practice of fertility preservation in young women with breast cancer.

     

Jim Crow and estrogen-receptor-negative breast cancer: US-born black and white non-Hispanic women, 1992–2012

Purpose

It is unknown whether Jim Crow—i.e., legal racial discrimination practiced by 21 US states and the District of Columbia and outlawed by the US Civil Rights Act in 1964—affects US cancer outcomes. We hypothesized that Jim Crow birthplace would be associated with higher risk of estrogen-receptor-negative (ER?) breast tumors among US black, but not white, women and also a higher black versus white risk for ER? tumors.

Methods

We analyzed data from the SEER 13 registry group (excluding Alaska) for 47,157 US-born black non-Hispanic and 348,514 US-born white non-Hispanic women, aged 25–84 inclusive, diagnosed with primary invasive breast cancer between 1 January 1992 and 31 December 2012.

Results

Jim Crow birthplace was associated with increased odds of ER? breast cancer only among the black, not white women, with the effect strongest for women born before 1965. Among black women, the odds ratio (OR) for an ER? tumor, comparing women born in a Jim Crow versus not Jim Crow state, equaled 1.09 (95% confidence interval [CI] 1.06, 1.13), on par with the OR comparing women in the worst versus best census tract socioeconomic quintiles (1.15; 95% CI 1.07, 1.23). The black versus white OR for ER? was higher among women born in Jim Crow versus non-Jim Crow states (1.41 [95% CI 1.13, 1.46] vs. 1.27 [95% CI 1.24, 1.31]).

Conclusions

The unique Jim Crow effect for US black women for breast cancer ER status underscores why analysis of racial/ethnic inequities must be historically contextualized.

     

Socio-demographic and reproductive determinants of cervical neoplasia in seven sub-Sahara African countries

Background

Since most human papilloma virus (HPV) infections regress without any intervention, HPV is a necessary but may not be a solely sufficient cause of cervical intraepithelial neoplasia (CIN) and cervical cancer. Hence, the influence of cofactors on progression from cervical HPV infection to high-grade CIN and invasive cervical cancer has been a subject of intensive research.

Objective

We assessed the effect of socio-demographic and sexual reproductive factors on the prevalence of invasive cervical cancer and CIN diagnosed in cross-sectional cervical cancer screening projects carried out in seven sites of different sub-Saharan countries.

Methods

Between January 2000 and August 2007, healthy women aged 25–59 who participated in the screening projects were interviewed for socio-demographic, reproductive, and behavioral characteristics, investigated for disease confirmation with colposcopy, and had biopsies directed from colposcopically abnormal areas by trained local physicians. Odds ratios (ORs) and their 95% confidence intervals (CIs) from logistic regression analyses were used to assess the effect of women characteristics on CIN 1, CIN 2–3, CIN 3, and invasive cancer outcome measures.

Results

Among 47,361 women screened and investigated for disease confirmation, CIN 1 was diagnosed in 1,069 (2.3%), CIN 2 in 517 (1.1%), CIN 3 in 175 (0.5%), and invasive cancer in 485 (1.0%). The site-specific prevalence of CIN 2–3 lesions ranged from 0.3 to 5.1% and from 0.2 to 1.9% for invasive cancers. Risk factors for CIN 2–3 were being widowed or separated versus currently married (OR 1.3, 95% CI 1.0–1.7 a); and having had at least four pregnancies versus zero or one pregnancy (OR at least 1.4-fold, 95% CI 1.1–1.8). Risk factors for invasive cancer were being widowed or separated versus currently married (OR 2.0, 95% CI 1.3–3.1); and having had at least three pregnancies versus zero or one pregnancy (OR at least 3.0-fold, 95% CI 2.1–4.2). Additionally, cervical cancer risk increased with increasing age, age at menarche, and age at marriage, while the risk decreased with increasing level of education and in those with some form of employment compared to housewives.

Conclusion

The exposure of the exocervix and/or the increased levels of estrogen and progesterone for more prolonged periods during pregnancy in multiparous women and the vulnerability of widowed/separated women in society might result in increased risk of cervical neoplasia more so among women exposed to HPV infection. High parity probably explains the persistently high rates of cervical cancer in sub-Saharan Africa.

     

Predictors of vasomotor symptoms among breast cancer survivors

Purpose

Vasomotor symptoms (VMS) are a common side effect of breast cancer treatment, yet modifiable factors that may predict VMS among breast cancer survivors are unknown.

Methods

We estimated multivariable-adjusted odds ratios and 95% confidence intervals (aOR, 95% CI) for predictors of VMS among 3595 breast cancer survivors enrolled in the Life and Longevity after Cancer (LILAC) study, an ancillary study of the Women’s Health Initiative (WHI).

Results

VMS post-diagnosis were reported by 790 (22.0%) participants. Risk of VMS after diagnosis was positively associated with prior chemotherapy (aOR 1.80, 95% CI 1.21–2.68) and adjuvant hormone therapy (aOR 2.73, 95% CI 2.08–3.58), postmenopausal hormone therapy use (aOR 1.67, 95% CI 1.30–2.13), prior VMS (aOR 2.20, 95% CI 1.73–2.80), bilateral oophorectomy (aOR 1.77, 95% CI 1.37–2.27), and baseline antidepressant use (aOR 1.49, 1.06–2.09). VMS post-diagnosis were less likely among younger women (aOR 0.94, 95% CI 0.93–0.96), women younger at menopause (aOR 0.98, 95% CI 0.97–1.00), women with more time since diagnosis (aOR 0.92, 95% CI 0.90–0.94), and diabetics (aOR 0.45, 95% CI 0.21–0.95). Metabolic syndrome was not associated with post-diagnosis VMS (aOR 0.76, 95% CI 0.45–1.28).

Conclusions

VMS following breast cancer diagnosis was related to a number of modifiable factors, but was unrelated to metabolic syndrome.

Implications for Cancer Survivors

Identification of factors that predispose women to VMS following a breast cancer diagnosis may allow clinicians to recognize and address VMS in the subset of women who are most likely to experience such symptoms.

     

Active smoking and risk of Luminal and Basal-like breast cancer subtypes in the Carolina Breast Cancer Study

Purpose

Growing evidence suggests an association between active cigarette smoking and increased breast cancer risk. However, the weak magnitude of association and conflicting results have yielded uncertainty and it is unknown whether associations differ by breast cancer subtype.

Methods

Using population-based case–control data from phases I and II of the Carolina Breast Cancer Study, we examined associations between self-reported measures of smoking and risk of Luminal and Basal-like breast cancers. We used logistic regression models to estimate case–control odds ratios (OR) and 95 % confidence intervals (CI).

Results

Ever smoking (current and former) was associated with a weakly increased risk of Luminal breast cancer (OR 1.12, 95 % CI 0.92–1.36) and was not associated with risk of Basal-like breast cancer (OR 0.96, 95 % CI 0.69–1.32). Similarly, smoking duration of more than 20 years was associated with increased risk of Luminal (OR 1.51, 95 % CI 1.19–1.93), but not Basal-like breast cancer (OR 0.90, 95 % CI 0.57–1.43). When stratified by race, elevated odds ratios between smoking and Luminal breast cancer risk were found among black women across multiple exposure measures (ever smoking, duration, and dose); conversely, among white women odds ratios were attenuated or null.

Conclusions

Results from our study demonstrate a positive association between smoking and Luminal breast cancer risk, particularly among black women and women with long smoking histories. Addressing breast cancer heterogeneity in studies of smoking and breast cancer risk may elucidate associations masked in prior studies.

     

A population-based audit of ethnicity and breast cancer risk in one general practice catchment area in North London,UK: implications for practice

Objectives

To conduct a pilot population-based study within a general practice catchment area to determine whether the incidence of breast cancer was increased in the Ashkenazi population.

Design

Population-based cohort study.

Setting

A single general practice catchment area in North London.

Participants

1947 women over the age of 16 who responded to a questionnaire about ethnicity and breast cancer.

Main outcome measures

Incidence of breast cancer, ethnicity.

Results

This study showed a 1.5-fold (95% CI 0.93–2.39) increase in breast cancer risk in the Ashkenazim compared with the non-Ashkenazi white population. The increased incidence was for both premenopausal and postmenopausal breast cancer (expected incidence pre:post is 1:4 whereas in the Ashkenazim it was 1:1; 51 and 52% of cases respectively). This increase was not shown in the Sephardim. Asians had a reduction in incidence (OR = 0.44; 95% CI 0.10–1.89). Results were adjusted for other risk factors for breast cancer.

Conclusion

This study showed a 1.5-fold increase in breast cancer rates in Ashkenazim compared with the non-Jewish white population when adjusted for age (i.e. corrections were made to allow comparison of age groups) and this is not observed in the Sephardic population. The proportion of premenopausal breast cancer was just over double that of the general population. This is the first general practice population-based study in the UK to address this issue and has implications for general practitioners who care for patients from the Ashkenazi community.

     

Regret around fertility choices is decreased with pre-treatment counseling in gynecologic cancer patients

Purpose

Data have demonstrated an association between regret and lack of fertility counseling among patients undergoing treatment for non-gynecologic cancers. We sought to determine if fertility-related regret is reduced with pre-treatment counseling or fertility-sparing surgery (FSS) in patients with gynecologic cancers.

Methods

A cross-sectional survey was administered to 593 reproductive-age survivors (18–40 years old at diagnosis) of localized cervix, ovarian, or endometrial cancers that were eligible for FSS. A validated decision regret score was used to evaluate regret in patients.

Results

Four hundred seventy women completed the survey. Forty-six percent received pre-treatment counseling about treatment’s effects on fertility. Having received counseling (adjusted ß-coefficient of ?1.24, 95 % CI?=??2.29 to ?0.18, p?=?0.02), satisfactory counseling (adjusted ß-coefficient of ?2.71, 95 % CI?=??3.86 to ?1.57, p?<?0.001), and FSS (adjusted ß-coefficient of ?1.26, 95 % CI?=??2.39 to ?0.14, p?=?0.03) were associated with lower regret post-treatment, after adjusting for age. Time since diagnosis, prior parity, socioeconomic status and cancer type were not associated with regret (p?>?0.05). While 50 % of women reported desiring more children after diagnosis, desire for children after treatment was associated with increased regret (adjusted ß-coefficient of 3.97, 95 % CI?=?2.92–5.02, p?<?0.001).

Conclusions

Though less than half of study participants received counseling about the effect of cancer treatment on future fertility, both fertility counseling and FSS were associated with decreased regret in reproductive-aged women with gynecologic cancers. The desire for more children after treatment was associated with increased regret.

Implications for cancer survivors

Inquiring about fertility desires and providing counseling regarding reproductive outcomes following cancer treatment should be implemented as part of the treatment process.

     

Economic and disease burden of breast cancer associated with suboptimal breastfeeding practices in Mexico

Purpose

Exclusive breastfeeding and longer breastfeeding reduce women’s breast cancer risk but Mexico has one of the lowest breastfeeding rates worldwide. We estimated the lifetime economic and disease burden of breast cancer in Mexico if 95% of parous women breastfeed each child exclusively for 6 months and continue breastfeeding for over a year.

Methods

We used a static microsimulation model with a cost-of-illness approach to simulate a cohort of Mexican women. We estimated breast cancer incidence, premature mortality, disability-adjusted life years (DALYs), medical costs, and income losses due to breast cancer and extrapolated the results to 1.116 million Mexican women of age 15 in 2012. Costs were expressed in 2015 US dollars and discounted at a 3% annual rate.

Results

We estimated that 2,186 premature deaths (95% CI 2,123–2,248), 9,936 breast cancer cases (95% CI 9,651–10,220), 45,109 DALYs (95% CI 43,000–47,217), and $245 million USD (95% CI 234–256) in medical costs and income losses owing to breast cancer could be saved over a cohort’s lifetime. Medical costs account for 80% of the economic burden; income losses and opportunity costs for caregivers account for 15 and 5%, respectively.

Conclusions

In Mexico, the burden of breast cancer due to suboptimal breastfeeding in women is high in terms of morbidity, premature mortality, and the economic costs for the health sector and society.

     

The continuum of breast cancer care and outcomes in the U.S. Military Health System: an analysis by benefit type and care source

Purpose

This study investigates transition rates between breast cancer diagnosis, recurrence, and death by insurance benefit type and care source in U.S. Military Health System (MHS).

Methods

The MHS data repository and central cancer registry linked data were used to identify women aged 40–64 with histologically confirmed breast cancer between 2003 and 2007. Three-state continuous time Markov models were used to estimate transition rates and transition rate ratios (TRRs) by TRICARE benefit type (Prime or non-Prime) and care source (direct, purchased, or both), adjusted for demographic, tumor, and treatment variables.

Results

Analyses included 2668 women with transitions from diagnosis to recurrence (n?=?832), recurrence to death (n?=?79), and diagnosis to death without recurrence (n?=?91). Compared to women with Prime within each care source, women with non-Prime using both care sources had higher transition rates (TRR 1.47, 95% CI 1.03, 2.10). Compared to those using direct care within each benefit type, women utilizing both care sources with non-Prime had higher transition rates (TRR 1.86, 95% CI 1.11, 3.13), while women with Prime utilizing purchased care had lower transition rates (TRR 0.82, 95% CI 0.68, 0.98).

Conclusions

In the MHS, women with non-Prime benefit plans compared to Prime had higher transition rates along the breast cancer continuum among both care source users. Purchased care users had lower transition rates than direct care users among Prime beneficiaries.

Implications for Cancer Survivors

Benefit plan and care source may be associated with breast cancer progression. Further research is needed to demonstrate differences in survivorship.

     

Alcohol intake and invasive breast cancer risk by molecular subtype and race in the Carolina Breast Cancer Study

Purpose

Alcohol is an established breast cancer risk factor, but there is little evidence on whether the association differs between African Americans and whites.

Methods

Invasive breast cancers (n = 1,795; 1,014 white, 781 African American) and age- and race-matched controls (n = 1,558; 844 white, 714 African American) from the Carolina Breast Cancer Study (Phases I–II) were used to estimate odds ratios (ORs) and 95 % confidence interval (CI) for pre-diagnosis drinks per week and breast cancer risk.

Results

African American controls reported lower alcohol intake than white controls across all age groups. Light drinking (0 to ≤2 per week) was more prevalent among African American controls. Moderate-to-heavy drinking was more prevalent in white controls. African Americans who reported drinking >7 drinks per week had an elevated risk compared to light drinkers [adjusted OR, 95% CI 1.62 (1.03–2.54)]. A weaker association was observed among whites [adjusted OR, 95% CI 1.20 (0.87–1.67)]. The association of >7 drinks per week with estrogen receptor-negative [adjusted OR, 95% CI 2.17 (1.25–3.75)] and triple-negative [adjusted OR, 95% CI 2.12 (1.12–4.04)] breast cancers was significant for African American, but not white women. We observed significantly elevated ORs for heavy intake at ages <25 and >50 years of age for African American women only. We found no evidence of statistical interaction between alcohol intake and oral contraceptive use or smoking.

Conclusions

Drinking more than seven alcoholic beverages per week increased invasive breast cancer risk among white and African American women, with significant increases only among African American women. Genetic or environmental factors that differ by race may mediate the alcohol–breast cancer risk association.

     

Swedish prospective multicenter trial evaluating sentinel lymph node biopsy after neoadjuvant systemic therapy in clinically node-positive breast cancer

Purpose

The clinical significance of nodal micrometastasis is debated. Our primary objective was to determine whether, among women with early-stage breast cancer, regional lymph node micrometastasis is an independent risk factor for mortality. The secondary objective was to identify subgroups of women who have the highest risk of death from early-stage breast cancer with micrometastases.

Methods

206,625 women diagnosed with early-stage breast cancer (IA, IB, and IIA) from 2004 to 2012 were identified in the Surveillance, epidemiology, and end results database. Nodal status was classified as node-negative, isolated-tumor cells, micrometastases, and macrometastases. Women were classified into eight ethnic groups. Logistic regression was performed to estimate the odds ratio of being diagnosed with micrometastases. The Cox proportional hazard model was used to estimate the hazard ratio (HR) of breast cancer-specific death associated with micrometastases for each ethnic group.

Results

The 8-year breast cancer-specific survival was 96.6 % for women with node-negative breast cancers and was 94.6 % for women with micrometastases (adjusted HR 1.49; 95 % CI 1.31–1.69; P < .001). Among women with micrometastases, the 8-year breast cancer-specific survival was 95.1 % for white women and was 90.6 % for black women (HR 1.80; 95 % CI 1.29–2.52; P = .0006).

Conclusion(s)

Nodal micrometastasis is an independent risk factor for breast cancer mortality among women with early-stage breast cancer. Black women are more likely to die from breast cancer with micrometastases than white women.