Trends in axillary surgery and clinical outcomes among breast cancer patients with sentinel node metastasis

BackgroundThere is a lack of studies examining the long-term trend and survival of axillary surgery for breast cancer patients with sentinel node metastasis, especially for the patients with 3–5 node metastases.MethodsBreast cancer patients with 1–5 sentinel node metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016. Our study presented the trend of axillary surgery and assessed the long-term survival of sentinel lymph node biopsy (SLNB) alone vs axillary lymph node dissection (ALND) for those patients.ResultsOf the 41,996 patients diagnosed with T_1-2 breast cancer after lumpectomy and radiation included, 34,940 had 1-2 sentinel node metastases and 7056 had 3-5 sentinel node metastases. The percentage of patients undergoing SLNB alone increased from 22.4% in 2000 to 81.0% in 2016 for patients with 1–2 sentinel node metastases, and quadrupled from 5.2% in 2009 to 20.6% in 2016 for those with 3–5 sentinel node metastases. Completion of ALND did not benefit the long-term survival of 1–2 sentinel node metastasis patients (hazard ratio [HR] = 1.02, P = 0.539), but improved the long-term survival of 3–5 node metastasis patients (HR = 0.73, P < 0.001). Subgroup analysis demonstrated the inferiority of SLNB to ALND in all subgroups of 3–5 sentinel node metastases.ConclusionFor patients with T_1-2 breast cancer after lumpectomy and radiation, SLNB alone was an efficient and safe surgical choice for 1–2 sentinel node metastases but not for 3–5 sentinel node metastases. It is worth noting that for patients with 3–5 node metastasis, the proportion of omitted ALND quadrupled after 2009.     

Predicting the status of axillary lymph nodes in breast cancer: A multiparameter approach including axillary ultrasound scanning

In a prospective study, we attempted to predict axillary metastases in 135 breast cancer patients by a preoperative multiparameter evaluation including axillary ultrasound scanning (US). After surgery, factors associated with lymph node metastases by univariate analysis were included in a multivariate model. By multivariate analysis, the stronger independent predictors of lymph node metastases were suspicious axillary US (p < 0.001), tumor location in the outer quadrants (p = 0.001) and high Ki-67 index (>10%) (p = 0.002). A predictive model based on these variables, identified a high-risk group (20.0%) represented by women with suspicious axillary US, tumor in the outer quadrants and high Ki-67 index, with axillary metastases in 100%, whereas all patients with opposite features (8.1%) had uninvolved axillary lymph nodes. This multiparameter evaluation including axillary US may be used to optimize the selection of breast cancer patients candidate to sentinel lymph node biopsy or axillary lymph node dissection. The accuracy of this predictive model still requires prospective validation in a larger sample of women.     

Are males with early breast cancer treated differently from females with early breast cancer in Australia and New Zealand?

Breast cancer in males is much rare than in females so in practice, male breast cancer treatment is likely to follow the guidelines developed for female breast cancer patients. The objective of this study is to compare the characteristics and treatment pattern of male breast cancer patients with comparable subgroups of female breast cancer patients using data submitted to the National Breast Cancer Audit.This is a retrospective analysis of 151 male breast cancers diagnosed and treated between 2000 and 2008. Most of the male early breast cancer cases in this group were symptomatic ones in men aged > 50 years with one invasive tumour. There was a similar proportion of lymph node positive cancer among males and females, although male breast cancer was more likely to be unifocal (P = 0.007) and oestrogen receptor positive (P = 0.001). Male breast cancer patients almost always underwent mastectomy and a significant proportion of them (11%) received no surgical treatment. There were no differences in axillary surgery although males were more likely to undergo a level 2 axillary surgery and less likely to have sentinel node biopsy. Male patients were significantly less likely to undergo radiotherapy, chemotherapy or hormonal therapy for oestrogen receptor positive tumours.Conclusion: While the female oriented treatment guidelines are available, male patients with early breast cancer received different surgical and adjuvant treatment from comparable females.     

Trends in endocrine therapy prescription and survival in patients with non-metastatic hormone receptor positive breast cancer treated with endocrine therapy: A population based-study

PurposeTo identify prognostic factors of invasive–disease free survival (iDFS) in women with non-metastatic hormone receptor positive (HR+) breast cancer (BC) in daily routine practice.MethodsWe performed a retrospective study using data from the Côte d’Or breast and gynecological cancer registry in France. All women diagnosed with primary invasive non-metastatic HR + BC from 1998 to 2015 and treated by endocrine therapy (ET) were included. Women with bilateral tumors or who received ET for either metastasis or relapse were excluded. We performed adjusted survival analysis and Cox regression to identify prognostic factors of iDFS.ResultsA total of 3976 women were included. Age at diagnosis, ET class, SBR grade, treatment, stage and comorbidity were independently associated with iDFS. Women who had neither surgery nor radiotherapy had the highest risk of recurrence (HR = 3.75, 95%CI [2.65–5.32], p < 0.0001). Receiving aromatase inhibitors (AI) was associated with a lower risk of recurrence (HR = 0.70, 95%CI [0.54–0.90], p = 0.055) compared to tamoxifen. Compared to women with no comorbidities, women with 1 or 2 comorbidities were more likely to receive AI (OR = 1.63, 95%CI [1.22–2.17], p = 0.0009).ConclusionsComorbidities, age at diagnosis and previous treatment were associated with iDFS in non-metastatic HR + BC patients. This study also showed that women who received tamoxifen for their cancer experienced worse iDFS compared to women treated with AI.     

Surgery for breast cancer in the elderly--how relevant?

Studies suggest that elderly women receive less aggressive treatment, experience higher disease progression and mortality from breast cancer. We report on an experience of 256 consecutive cases of symptomatic breast cancer in a population of over 75 years of age. 142/256 patients underwent surgical intervention in the form of breast conserving surgery or mastectomy, 114/256 did not. Mean follow up was 6.4 years. Our results show a statistically significant association between surgery and survival (p = 0.05, CI 0.00046-0.19641) and a strong statistically significant association between surgery and disease progression/recurrence (p = 0.001, CI 0.08713-0.03145). Women treated conservatively are significantly less fit hence suffering high cancer unrelated mortality; as a consequence they suffer higher disease related progression and mortality. In our study surgical treatment with adjuvant endocrine and/or radiotherapy was associated with a statistically significant advantage in terms of disease related mortality and local disease control.     

Meta-analysis of breast cancer outcome and toxicity in adjuvant trials of aromatase inhibitors in postmenopausal women

The present meta-analysis examines randomized trials of third-generation aromatase inhibitors (AIs) as alternatives to tamoxifen in three treatment settings: monotherapy, sequenced therapy and extended therapy. Eleven randomized controlled trials (RCTs) were chosen based on their similarity in terms of study design and included 34,070 post-menopausal women who had undergone surgery for estrogen-sensitive early breast cancer. DFS was significantly improved by AI monotherapy (Hazard Ratio (HR): 0.89, p = 0.001), sequenced therapy (HR: 0.7, p < 0.00001) and extended therapy (HR: 0.62, p < 0.00001). All of the patients benefited significantly from sequenced therapy (HR: 0.81, p = 0.003), and hormone receptor-positive patients benefited from AI monotherapy (HR = 0.92, p = 0.046) with respect to OS. AI monotherapy conferred significantly lower risks for thromboembolic events (OR = 0.61; p < 0.001) and endometrial cancer (OR = 0.26; p < 0.001) compared with tamoxifen monotherapy; however, there was a greater risk of cardiovascular events (OR = 1.20; p = 0.030). Sequenced therapy was also superior in terms of endometrial cancer but was inferior with respect to fractures, thromboembolic and cardiovascular events.     

Smoking and survival of breast cancer patients: A meta-analysis of cohort studies

ObjectivesPublished articles reported controversial results about the association of breast cancer survival with smoking. Hence, a meta-analysis was performed to investigate this association.MethodsA comprehensive search was performed to identify relevant cohort studies (up to May 31st, 2016). In the current smoking and former smoking v. never smoking analyses, the fixed- or random-effect model was selected based on the heterogeneity test among studies. And the heterogeneity was measured using Q test and I² statistic. Publication bias was estimated using Egger's regression asymmetry test.ResultsThirteen articles with 44 studies were included. Compared with never smokers, current smokers have a higher breast cancer-specific mortality and all-cause mortality, with pooled hazard ratio (HR) (HR = 1.30 95%CI: 1.16–1.45; I² = 52.4%) and (HR = 1.59, 95%CI: 1.41–1.78; I² = 87.1%), respectively. While former smokers tend to have a moderately increased all-cause mortality (HR = 1.10, 95%CI: 1.07–1.12; I² = 0.0%), but there was no significant association between former smoking and breast cancer-specific mortality (HR = 0.95, 95%CI: 0.90–1.02; I² = 0.0%).ConclusionThe present evidence indicates that current smoking leads to higher breast cancer-specific mortality and all-cause mortality than never smoking in breast cancer patients. However former smoking just causes a mild increase in all-cause morality, but not breast cancer-specific mortality.     

Predicting the survival benefit of local surgery in patients aged 70 years or older with stage IV breast cancer: A population-based analysis

PurposeThe aim of this study was to establish individualized nomograms to predict survival outcomes in older female patients with stage IV breast cancer who did or did not undergo local surgery, and to determine which patients could benefit from surgery.MethodsA total of 3,129 female patients with stage IV breast cancer aged ≥70 years between 2010 and 2015 were included in the Surveillance, Epidemiology, and End Results program. Multivariate Cox regression analysis was used to identify risk factors for overall survival (OS) and breast cancer-specific survival (BCSS). Survival analysis was performed using the Kaplan–Meier plot and log-rank test. Nomograms and risk stratification models were constructed.ResultsPatients who underwent surgery had better OS (HR = 0.751, 95% CI [0.668–0.843], P < 0.001) and BCSS (HR = 0.713, 95% CI [0.627–0.810], P < 0.001) than patients who did not undergo surgery. Patients with human epidermal growth factor receptor 2-positive, lung or liver metastases may not benefit from surgery. In the stratification model, low-risk patients benefited from surgery (OS, HR = 0.688, 95% CI [0.568–0.833], P < 0.001; BCSS, HR = 0.632, 95% CI [0.509–0.784], P < 0.001), while patients in the high-risk group had similar outcomes (OS, HR = 0.920, 95% CI [0.709–1.193], P = 0.509; BCSS, HR = 0.953, 95% CI [0.713–1.275], P = 0.737).ConclusionOlder female patients with stage IV breast cancer who underwent surgery had better OS and BCSS than those who did not in each specific subgroup. Patients in low- or intermediate-risk group benefit from surgery while those in the high-risk group do not.     

Time to Begin Adjuvant Chemotherapy and Survival in Breast Cancer Patients: A Retrospective Observational Study Using Latent Class Analysis

The analysis of time to treatment data and the evaluation of subsequent effects on health outcomes can be complex due to the nature of the data and the relationships amongst the variables. This study proposes an alternative method of analyzing such data using latent class analysis (LCA). The association between time to begin adjuvant chemotherapy after breast cancer surgery and survival was investigated using both “traditional” regression analysis and LCA. Women with breast cancer undergoing surgery and subsequent adjuvant chemotherapy in two English regions between January 01, 1998 and December 31, 2004 were identified from a linked cancer registry‐Hospital Episode Statistics dataset (n = 10,366). Patient, tumor, and treatment information were extracted. A Cox proportional hazards model was used to analyze 5‐year survival using regression analysis and LCA. Using “traditional” regression analysis, women beginning chemotherapy >10 weeks after surgery had worse survival in region 1 (HR = 1.49, 95% CI 1.13–1.95 compared to <3 weeks) but not region 2. LCA split the women into three groups representing short, medium, and long waits. The median time to begin chemotherapy in the “long” wait group was 70 (region 1) and 57 (region 2) days. In this group, increased time to begin chemotherapy was associated with worse survival (region 1 HR = 1.15, 95% CI 1.11–1.18; region 2 HR = 1.08, 95% CI 1.03–1.13 per week increase). LCA identified a group of 13–15% of women for whom a longer time to begin chemotherapy had an adverse effect on survival. This methodology provides an excellent framework in which to examine complex associations between the delivery of patient care and patient outcomes.     

Extensive pure ductal carcinoma in situ of the breast: Identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery

AimTo identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS).Patients and methodsBetween January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded.ResultsRespectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement.ConclusionSkin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.     

Predictive role of the overexpression for CXCR4, C-Met,and VEGF-C among breast cancer patients: A meta-analysis

BackgroundThe overexpression of CXCR4, C-Met and VEGF-C present widely in breast tumors, they may be markers of resistance to treatment. However, the studies are still controversial. Thus, this meta-analysis aims to research the relationship between the overexpression of CXCR4, C-Met, VEGF-C and clinical prognosis among breast cancer patients.MethodsPubMed and EMBASE databases were searched for eligible literature. The outcomes of interest were progression-free survival (PFS), relapse-free survival (RFS) and overall survival (OS). All tests of statistical significance were two sided.ResultsA total of 7830 patients from 28 eligible studies were assessed. The overexpression of the CXCR4 and C-Met both implied significantly worse PFS compared with normal expression [HR = 2.56, 95% CI = 1.34–4.91, P = 0.005; and HR = 1.63 95% CI = 1.20–2.22, P = 0.002]. Meanwhile, if patients had high expression of CXCR4, they would have worse OS [HR = 2.56 95% CI = 1.52–4.31, P = 0.000]. However, the overexpression of C-Met did not relate to OS for breast cancer patients [HR = 1.16, 95% CI = 0.69–1.95, P = 0.570]. Meanwhile, no statistically significant different was observed with respect to PFS and OS between VEGF-C overexpression and normal expression [HR = 0.99, 95% CI = 0.64–1.52, P = 0.968; and HR = 0.76, 95% CI = 0.43–1.33, P = 0.333].ConclusionsOur meta-analysis showed that CXCR4 and C-Met were efficient prognostic factors for breast cancer. Nevertheless, highly expressing VEGF-C was not related to progression-free survival and overall survival. Due to the small samples and insufficient date, further studies should be conducted to clarify the association between the overexpression of CXCR4 or C-Met or VEGF-C and the prognosis about breast cancer patients.     

Prognostic impact of HER2-low expression in hormone receptor positive early breast cancer

BackgroundRecent data suggest that human epidermal growth factor receptor 2 (HER2)-low breast cancer may represent a distinct entity. We aimed to compare disease characteristics and outcomes between HER2-low and HER2-0 in estrogen receptor (ER) positive, early-stage breast cancer.MethodsA single center retrospective study comprising all women with ER positive, HER2 negative early breast cancer, for whom an Oncotype DX test was performed between 2005 and 2012. Women were grouped to HER2-low (immunohistochemistry +1 or +2 and in situ hybridization not amplified) or HER2-0. Clinico-pathological features and Oncotype recurrence score (RS) were collected. Data on overall-survival (OS), disease-free survival (DFS) and distant disease-free survival (DDFS) were evaluated according to HER2 expression status.Results608 women were included, of which 304 women had HER2-0 and 304 had HER2-low disease. Lobular subtype was significantly more common in HER-0 compared to HER2-low disease (17% vs. 8%, p = 0.005). The prevalence of other clinic-pathological characteristics and long-term prognosis were comparable between both groups. For women with high genomic risk (RS > 25), HER2-low expression was associated with significantly favorable OS (HR = 0.31, 95% CI 0.11–0.78, p = 0.01), DFS (HR = 0.40, 95% CI 0.20–0.82, p = 0.01) and DDFS (HR = 0.26, 95% CI 0.11–0.63, P = 0.002) compared to women with HER2-0. For women with low genomic risk (RS ≤ 25), long-term prognosis was unrelated to HER2 expression.ConclusionThe prognostic impact of HER2-low expression in early-stage luminal disease varies across the genomic risk, with significant favorable outcomes of HER2-low expression compared to HER2-0 in women with high genomic risk.     

Identification of intermediate risk breast cancer patients with1–3 positive lymph nodes and excellent survival after tamoxifen as only systemic adjuvant therapy by use of markers of proliferation and apoptosis

BackgroundAccording to current guidelines, patients with primary breast cancer and 1–3 lymph node metastases will in general be offered adjuvant chemotherapy.AimOur objective was to investigate the relationship between markers of proliferation and apoptosis with survival for patients subjected to adjuvant tamoxifen solely.Material and methodsTumour cytosol samples from 409 consecutive patients with operable oestrogen receptor positive BC, stage I–III and treated with tamoxifen for 2 or 5 years were assessed for levels of caspase-cleaved cytokeratin-18 (ccCK18), an indicator of apoptosis, by use of an ELISA assay. Data on S-phase fraction (SPF) were available for 370 patients. Survival analyses were performed according to levels of ccCK18 and SPF separately, as well as combined.ResultsA wide range of ccCK18 protein levels was found, median 9.97, range 0.0–87.3 pg/μgDNA. Increasing SPFs were significantly associated with a lower distant recurrence-free survival (DRFS) (p = 0.025) and breast cancer survival (BCS) (p = 0.046). In the group with low SPF (below mean), low amounts of ccCK/18 correlated with a shorter DRFS (p = 0.0028) and BCS (p = 0.0027). A Proliferation Index (PI); a quotient of ccCK18/SPF was constructed. Low PI (high ccCK18/SPF ratios) were significantly correlated with an improved survival both when analysed as continuous variables; DRFS (p = 0.021), BCS (p = 0.038) and when divided into quartiles; DRFS (p < 0.001) and BCS (p = 0.0012). A similar correlation was found in patients with 1–3 lymph node metastases; DRFS (p = 0.089) and BCS (p = 0.019). A Cox's proportional hazard model including age, tumour size, lymph node status, PgR and ccCK18/SPF was used for multivariate analysis. High ccCK18/SPF ratios correlated with improved survival; DRFS (HR = 0.47 (0.22–0.98), p = 0.043), and BCS (HR = 0.39 (0.16–1.00), p = 0.049), respectively.ConclusionBy use of a proliferation index based on markers of proliferation and apoptosis, a group of patients with 1–3 lymph node metastases with good outcome following adjuvant tamoxifen was identified; this group could possibly be spared adjuvant chemotherapy.     

Fracture risk increases after diagnosis of breast or other cancers in postmenopausal women: results from the Women’s Health Initiative

Summary  Risk for falls and fractures increases after breast cancer or other cancer diagnosis in postmenopausal women. Factors other than falls may be the major causes for the increased fracture risk. Introduction  Cancer treatment and prognosis may have detrimental effects on bone health. However, there is a lack of prospective investigations on fracture risk among incident cancer cases. Methods  In this study, postmenopausal women (N = 146,959) from the Women’s Health Initiative prospective cohort, who had no cancer history at baseline, were followed for up to 9 years and classified into no cancer, incident breast cancer (BC) and incident other cancer (OC) groups. The main outcomes measured were incident fractures and falls before and after cancer diagnosis. Hazards ratios (HR) and 95% confidence intervals (CI) were computed from Cox proportional hazards model. Results  While hip fracture risk before a cancer diagnosis was similar between the no cancer and cancer groups, hip fracture risk was significantly higher after BC diagnosis (HR = 1.55, CI = 1.13–2.11) and the elevated risk was even more notable after OC diagnosis (HR = 2.09, CI = 1.65–2.65). Risk of falls also increased after BC (HR = 1.15, CI = 1.06–1.25) or OC diagnosis (HR = 1.27, CI = 1.18–1.36), but could not fully explain the elevated hip fracture risk. Incident clinical vertebral and total fractures were also significantly increased after OC diagnosis (p < 0.05). Conclusions  Postmenopausal women have significantly elevated risks for falls and fractures after a cancer diagnosis. The causes for this increased risk remained to be investigated.     

Effect of the American College of Surgeons Oncology Group Z0011 trial on axillary management in breast cancer patients in the Australian setting

The American College of Surgeons Oncology Group Z0011 Trial demonstrated that early breast cancer patients with positive axillary sentinel lymph nodes treated with breast‐conserving surgery and breast radiotherapy had no additional oncologic benefit of proceeding to an axillary lymph node dissection (ALND). The extent to which practice has changed in Australia remains unclear. The aim of this study was to investigate the effect of the Z0011 trial on the management of positive axillary sentinel nodes at an Australian institutional level. We reviewed all breast cancer cases treated at the Sydney Adventist Hospital over a 10‐year period from 1 January 2008 to 31 December 2017. Patients who fulfilled the Z0011 trial criteria were selected. These patients were divided into two groups according to the year of surgery, before and after 1 January 2011 when the Z0011 study was published. Clinicopathologic data and axillary surgical management were compared. Of the 237 patients fulfilling the Z0011 trial criteria, there were 73 patients before and 158 patients after 1 January 2011. In the earlier group the rate of proceeding to an ALND following a positive sentinel node was 78.1% compared to 43.7% in the latter group (P < 0.0001). There was a significant decline in the rate of ALND over this 10‐year period (r = ?0.79, P = 0.006). The Z0011 trial has influenced the surgical management of the axilla leading to a significant reduction in the rate of an ALND in patients fulfilling the Z0011 trial criteria at our institution.     

Management of breast cancer: basic principles

Breast cancer is the commonest cancer in the United Kingdom. Its incidence is increasing and although mortality from the disease is decreasing it still accounts for over 10,000 deaths a year. All women referred with breast symptoms should undergo triple assessment with clinical examination, radiological imaging and a biopsy of any abnormality found. The treatment of patients with breast cancer should be multidisciplinary and all patients should be discussed and treatment plans formulated at regular multidisciplinary meetings. Patients with breast cancer are usually treated surgically and may have a range of surgical options open to them, although for the majority this will involve breast-conserving surgery or mastectomy. A lymph node staging procedure is also performed for invasive cancers to guide the use of adjuvant therapy and achieve loco-regional disease control. Unless there is preoperative evidence of involved axillary lymph nodes this should take the form of a sentinel lymph node biopsy. Throughout the course of treatment, patients should have access to dedicated breast care nurses to help explain treatment options further, answer questions, and allay any fears they may have.     

Positive versus negative sentinel nodes in early breast cancer patients: Axillary or loco-regional relapse and survival. A study spanning 2000–2012

Sentinel Node Biopsy (SNB) is a minimally invasive alternative to elective axillary lymph node dissection (ALND) for nodal staging in early breast cancer. The present study was conducted to evaluate prognostic implications of a negative sentinel node (SN) versus a positive SN (followed by completion ALND) in a closely followed-up sample of early breast cancer patients.We studied 889 consecutive breast cancer patients operated for 908 primaries. Patients received adjuvant therapy with chemotherapy, hormone therapy and eventually trastuzumab. Radiation therapy was based on tangential radiation fields that usually included axillary level I.Median follow-up was 47 months. Axillary recurrence was seen in 1.2% (2/162) of positive SN patients, and 0.8% (5/625) of negative SN patients (p = n.s.). There was an overall 3.2% loco-regional failure rate (29/908). Incidence of distant recurrence was 3.3% (23/693) for negative SN patients, and 4.6% (9/196) for positive SN patients (p = n.s.). Overall mortality rate was 4% (8/198) for positive SN patients, while the corresponding specific mortality rate was 2.5% (5/198). For patients with negative SNs, overall mortality was 4.9% (34/693), and the specific mortality was 1.4% (19/693) (p = n.s.).We did not find significant differences in axillary/loco-regional relapse, distant metastases, disease-free interval or mortality between SN negative and SN positive patients, with a follow-up over 4 years.     

Disparities in female breast cancer mortality rates between urban centers and rural areas of Brazil: Ecological time-series study

ObjectivesTo evaluate trends in breast cancer mortality in urban centers and rural areas of Brazil.MethodsEcological time-series study using data on breast cancer deaths and census. Mortality trends were analyzed using change-point regression: 1980–2010.ResultsA declining trend was found in five urban centers: São Paulo (APC = −1.7%), Porto Alegre (APC = −1.6%), Belo Horizonte (APC = −1.2%), Rio de Janeiro and Recife (APC = −0.9%). An increasing was found in: Porto Velho (APC = 9.0%), Teresina (APC = 4.6%), João Pessoa (APC = 1.6%), Belém (APC = 0.8%) and Fortaleza (APC = 0.5%). In the majority of rural areas, mortality continues to rise, with the exception of some areas in the southern.ConclusionDisparities in breast cancer mortality were found across the country, with increasing trends occurring predominantly in the north and northeastern regions. One of the reasons for this disparity may be that access to treatment is more difficult for patients living in rural areas and in the north of Brazil.