Lack of survival gain for elderly women with breast cancer

Background.

The number of elderly women with breast cancer is increasing and will become a major health concern. However, little is known about the optimal treatment for this age group. The aim of this study was to describe time trends for the overall Dutch breast cancer cohort with an emphasis on differences between young and elderly patients.

Methods.

All adult female patients diagnosed in 1995–2005 were selected from the Netherlands Cancer Registry. Relative excess risks for death (adjusted for stage, histology, treatment, and grade) were estimated using a multivariate generalized linear model with a Poisson distribution, based on collapsed relative survival data, using exact survival times.

Results.

Overall, 127,805 patients were included. Treatment of patients aged ≥75 years changed significantly over time: they received less surgery, more adjuvant hormonal treatment and chemotherapy, and more hormonal treatment without surgery. In contrast to younger patients, the relative survival did not improve significantly over time for elderly patients. With increasing age, the observed–expected death ratio decreased to almost 1.0.

Conclusion.

Survival for elderly patients with breast cancer did not improve significantly. Observed–expected death ratios in the elderly are close to 1, indicating that excess mortality is low. Elderly patients with breast cancer have a higher risk for overtreatment and undertreatment, with a delicate therapeutic balance between breast cancer survival gain and potential toxicities. To improve breast cancer survival in the elderly, a critical reappraisal is needed of costs and benefits of hormonal as well as other treatments, and better selection of patients who can benefit from available therapies is warranted.     

174例乳腺癌生存因素分析

目的 分析影响乳腺癌生存率的相关因素。方法 收集174例乳腺癌病人的完整临床资料与病理,随访5年以上,观察其生存时间,制作Kaplan-Meier评价生存曲线,并做比较分析。结果 乳腺癌高发年龄在40~49岁;Ⅰ期、Ⅱ期与Ⅲ期乳腺癌患者总体生存曲线不同;乳腺癌的肿块大小与腋窝淋巴结转移成正相关;绝经后患者5年生存率低于未绝经患者;ER(-)病例平均无病存活时间小于ER(+)病例。结论 必须重视乳腺癌的早期检查、早期诊断和早期系统治疗;全社会应普及乳腺癌的筛查工作。     

Association between reproductive factors and breast cancer survival in younger women

This analysis investigated whether reproductive factors such as age at menarche, parity, and timing and outcomes of pregnancies were associated with survival among women with breast cancer younger than 55 years. Female residents of Atlanta, Georgia, and central New Jersey who were diagnosed with a primary, incident invasive breast cancer between 1990 and 1992 and enrolled in a population-based study (n = 1,264) were followed for 8–10 years. Detailed exposure and covariate information was collected via in-person interviews administered shortly after diagnosis. Vital status as of January 1, 2000 was ascertained through the National Death Index via the state cancer registries (n = 292 deaths). Cox regression methods were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusted for confounders. Parity of 4 or more births, as compared with nulliparity, was positively associated with all-cause mortality, [HR (95% CI) = 1.71 (1.09–2.67)]. Increased mortality was associated with having given birth within 5 years prior to diagnosis (≤5 vs. >5 years) [1.78 (1.28–2.47)], and was more pronounced among women with a pre-diagnostic body mass index of <25 kg/m² [2.54 (1.61–4.00)]. Early age at menarche and early age at first birth also modestly increased mortality; history of miscarriage, induced abortion, and ever breastfeeding were not related to survival. These results may help elucidate breast cancer progression mechanisms and enable a better understanding of how reproductive characteristics influence breast cancer survival. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Physical activity and survival in breast cancer

PurposeKnowledge about lifestyle factors possibly influencing survival after breast cancer (BC) is paramount. We examined associations between two types of postdiagnosis physical activity (PA) and overall survival after BC.Patients and methodsWe used prospective data on 959 BC survivors from the Diet, Cancer, and Health cohort, all enrolled before diagnosis. Self-reported PA was measured as time per activity, and estimated metabolic equivalent task (MET)–hours per week were summed for each activity. We constructed measures for household, exercise, and total PA. The association between postdiagnosis PA and all-cause mortality was estimated as hazard ratio (HRs) based on Cox proportional hazards model, with time since diagnosis as the underlying time scale. Prediagnosis PA, body mass index (BMI), and receptor status were examined as potential effect modifiers.ResultsWe identified 144 deaths from all causes during the study period. In adjusted analyses, exercise PA above eight MET h/week compared to lower levels of activity was significantly associated with improved overall survival (HR, 0.68; confidence interval [CI]: 0.47–0.99). When comparing participation in exercise to non-participation, we found a 44% risk reduction in overall survival (HR, 0.56; CI: 0.33–0.95). Neither between household nor total PA and overall survival did, we find significant associations. Prediagnosis PA, BMI, and receptor status did not modify the effect significantly.ConclusionExercise PA corresponding to 2.5 h or more of brisk weekly walking after BC diagnosis may reduce mortality by up to 32% compared to low-level exercise. Participation in exercise PA may reduce mortality by 44% compared to non-participation.     

An overview of prognostic factors for long-term survivors of breast cancer

Background Numerous studies have examined prognostic factors for survival of breast cancer patients, but relatively few have dealt specifically with 10+-year survivors. Methods A review of the PubMed database from 1995 to 2006 was undertaken with the following inclusion criteria: median/mean follow-up time at least 10 years; overall survival and/or disease-specific survival known; and relative risk and statistical probability values reported. In addition, we used data from the long-standing Eindhoven Cancer Registry to illustrate survival probability as indicated by various prognostic factors. Results 10-year breast cancer survivors showed 90% 5-year relative survival. Tumor size, nodal status and grade remained the most important prognostic factors for long-term survival, although their role decreased over time. Most studies agreed on the long-term prognostic values of MI (mitotic index), LVI (lymphovascular invasion), Her2-positivity, gene profiling and comorbidity for either all or a subgroup of breast cancer patients (node-positive or negative). The roles of age, socioeconomic status, histological type, BRCA and p53 mutation were mixed, often decreasing after correction for stronger prognosticators, thus limiting their clinical value. Local and regional recurrence, metastases and second cancer may substantially impair long-term survival. Healthy lifestyle was consistently related to lower overall mortality. Conclusions Effects of traditional prognostic factors persist in the long term and more recent factors need further follow-up. The prognosis for breast cancer patients who have survived at least 10 years is favourable and increases over time. Improved long-term survival can be achieved by earlier detection, more effective modern therapy and healthier lifestyle.     

上海人群结直肠癌生存率分析

背景与目的：中国结直肠癌的发病率和死亡率逐年上升,该研究分析了结直肠癌生存率资料,以促进结直肠癌的防治。方法：根据上海市肿瘤登记处收集的2002—2006年结直肠癌登记和生存随访报告资料,采用寿命表法和Ederer Ⅱ法对结直肠癌患者的观察生存率(observed survival,OS)和相对生存率(relative survival,RS)及其相关人口学和疾病状况特征资料进行分析,以反映上海地区人群结直肠癌的生存现况。结果：纳入分析的上海市2002—2006年诊断的结肠癌和直肠癌病例分别为16682例和11906例,5年OS分别为48.84%和51.65%,5年RS分别为70.50%和71.31%。各种不同诊断时期别间的生存率差异有统计学意义(P<0.05)。Ⅰ期患者的生存率明显高于Ⅲ期和Ⅳ期。不同性别、年龄、肿瘤组织学类型和居住区域的结直肠癌患者生存情况差异有统计学意义(P<0.05)。女性生存率较男性高,>44~54岁年龄段患者生存率高于其他年龄组,上皮型肿瘤的结肠癌患者生存率高于其他组织学类型的结肠癌患者,非上皮型肿瘤的直肠癌患者生存率高于其他组织学类型的直肠癌患者。过去30年来,上海地区结直肠癌的5年OS和RS都有明显改善。结论：上海市结直肠癌患者的生存水平较高,接近发达国家水平。不同特征人群结直肠癌生存的差异为进一步改善早期筛查和临床诊治提供了发展方向。     

Quantitative exploration of possible reasons for the recent improvement in breast cancer survival

Objective Breast cancer mortality has been declining in many countries including Canada because of improvements in survival. This study attempts to explain observed trends in breast cancer survival with special attention given to the role of improvements in early detection and treatment. Methods This study is based on 4,312 women diagnosed with primary invasive breast carcinoma treated in a Canadian breast center between 1976 and 2000 and followed to the end of 2001. Observed and relative survival rates were calculated. Multivariate relative survival regression models were used to assess trends in breast cancer survival over the study period. Results The proportion of women with small tumors (≤10 mm) was higher in late 1990s, while that of women with regional involvement was lower compared to earlier periods. Adjuvant chemotherapy or endocrine therapy use increased steadily from 6.6% to 84.0% during the study period. Five-year relative survival rates ranged between 82.1% and 83.7% between 1976 and 1990, and increased thereafter to reach 87.6% in 1991–95, and 92.1% in 1996–2000. During the first five years after diagnosis, women diagnosed in 1991–95 and 1996–2000 experienced a reduction in breast cancer mortality of 28% (Relative Risk (RR)= 0.72; 95% CI: 0.59–0.89) and 49% (RR = 0.51; 95% CI: 0.39–0.68) respectively compared to women diagnosed in 1976–90. Improvement in breast cancer survival in 1990’s could not be explained by characteristics of women, biology of the tumor, advancements in early detection and type of initial treatments. Conclusion A substantial increase in breast cancer survival was observed in the 1990s but the reasons for this improvement remain elusive. Better knowledge of these reasons could help not only to further reduce the burden related to breast cancer but also the burden related to other major cancer sites.     

Population-based study of breast cancer survival in Cote d'Or (France): prognostic factors and relative survival.

BACKGROUND: Few population-based studies have reported jointly analyses of relative survival according to the following prognostic factors: tumour-node-metastasis (TNM) stage, age, number of examined and positive nodes, hormonal status, histological Scarff, Bloom and Richardson (SBR) grade, tumour extension, hormone receptor status and tumour multifocal status. PATIENTS AND METHODS: Data on female invasive breast cancer were provided by the Cote d'Or breast cancer registry. The Kaplan-Meier method and log-rank test were used to estimate and compare the survival probability at 1, 5, 10 and 15 years. The effect of prognostic factors on survival was assessed with crude and relative multivariate survival analyses. RESULTS: Crude survival seemed to be worse in patients aged >60 years compared with those aged 45-60 (P > 0.0001), whereas relative survival did not differ. TNM stage, histological SBR grade, progesterone receptor status, tumour multifocal status, locoregional extension and the period of diagnosis were independent prognostic factors of crude and relative survival. CONCLUSION: Breast cancer is influenced by many factors. Despite the absence of any association between the number of examined nodes and overall survival in this study, the number of nodes removed, in conjunction with other prognostic factors, may be useful in selecting node-negative patients for systemic therapy.     

乳腺癌骨转移患者生存分析

目的 提高对乳腺癌骨转移患者预后影-向因素的进一步认识，指导临床个体化治疗。方法 回顾分析有完整病例资料的乳腺癌骨转移患者68例。结果 68例患者的中位生存期20个月，乳腺癌骨转移合并肝脏和/或肺转移同时存在时，患者的中位生存期13．5个月；乳腺癌骨转移不合并肝脏和/或肺转移患者的中位生存期为26个月；仅有骨转移而不合并其他脏器转移的患者的平均生存时间为44.2个月。结论 乳腺癌转移患者中肝脏和/或肺转移是预后不良指标。骨转移而不合并其他转移的患者生存期较长，其次是骨转移合并肺转移者、合并淋巴结转移、骨转移合并多个脏器转移者及合并肝脏转移者。     

Parity in relation to survival following breast cancer

Aim

The present study examines the association between parity and survival following breast cancer diagnosis.

Methods

Medical records of 4453 women diagnosed with breast cancer in Malmö, Sweden, between 1961 and 1991 were analysed. All women were followed until 31 December 2003, using the Swedish Cause-of-Death Registry. Breast cancer specific mortality rate was calculated in different levels of parity. Corresponding relative risks, with 95% confidence intervals (CI), were obtained using Cox's proportional hazards analysis. All analyses were adjusted for potential prognostic factors and stratified for age, menopausal status and diagnostic period.

Results

As compared to women with one child, nulliparity (RR 1.27: 95% CI 1.09–1.47), and high parity (four or more children) (1.49: 1.20–1.85) were positively associated with a high mortality from breast cancer. When adjusted for potential confounders, the association was only statistically significant for high parity (1.33: 1.07–1.66). In the analyses stratified on age and menopausal status, there was a similar positive association between high parity and breast cancer death in all strata, although only statistically significant among women older than 45 years of age or postmenopausal. Nulliparity was associated with breast cancer death in women that were younger than 45 years of age (1.28: 0.79–2.09) or premenopausal (1.30: 0.95–1.80), but these associations did not reach statistical significance. There was no association between nulliparity and breast cancer death in women older than 45 years of age or postmenopausal. All associations were similar in analyses stratified for diagnostic period.

Conclusion

Women with four or more children have a poor breast cancer survival as compared to women with one child.     

Completeness of case ascertainment and survival time error in English cancer registries: impact on 1-year survival estimates

Background:

It has been suggested that cancer registries in England are too dependent on processing of information from death certificates, and consequently that cancer survival statistics reported for England are systematically biased and too low.

Methods:

We have linked routine cancer registration records for colorectal, lung, and breast cancer patients with information from the Hospital Episode Statistics (HES) database for the period 2001–2007. Based on record linkage with the HES database, records missing in the cancer register were identified, and dates of diagnosis were revised. The effects of those revisions on the estimated survival time and proportion of patients surviving for 1 year or more were studied. Cases that were absent in the cancer register and present in the HES data with a relevant diagnosis code and a relevant surgery code were used to estimate (a) the completeness of the cancer register. Differences in survival times calculated from the two data sources were used to estimate (b) the possible extent of error in the recorded survival time in the cancer register. Finally, we combined (a) and (b) to estimate (c) the resulting differences in 1-year cumulative survival estimates.

Results:

Completeness of case ascertainment in English cancer registries is high, around 98–99%. Using HES data added 1.9%, 0.4% and 2.0% to the number of colorectal, lung, and breast cancer registrations, respectively. Around 5–6% of rapidly fatal cancer registrations had survival time extended by more than a month, and almost 3% of rapidly fatal breast cancer records were extended by more than a year. The resulting impact on estimates of 1-year survival was small, amounting to 1.0, 0.8, and 0.4 percentage points for colorectal, lung, and breast cancer, respectively.

Interpretation:

English cancer registration data cannot be dismissed as unfit for the purpose of cancer survival analysis. However, investigators should retain a critical attitude to data quality and sources of error in international cancer survival studies.     

Breast cancer subtypes and survival in Chinese women with operable primary breast cancer

Objective: To investigate the associations between the different breast cancer subtypes and survival in Chinese women with operable primary breast cancer. Methods: A total of 1538 Chinese women with operable primary breast cancer were analyzed in this study, the median follow-up was 77 months. Estrogen receptor (ER), progesterone receptor (PR), and HER2 status were available for these patients. Results: Luminal A (ER+ and/or PR+, HER2-) had a favorable disease-free survival (DFS) and overall survival (OS) c...     

胰腺癌治疗方式评价及预后分析

背景与目的:胰腺癌缺乏有效治疗手段,预后较差,预后因素不明确.本研究分析胰腺癌患者的临床特征、治疗方式与生存期关系,探讨胰腺癌的预后因素及最佳治疗方式.方法:收集病理诊断明确的胰腺癌患者临床特征、治疗方式,电话随访生存期,评价其对预后价值.结果:302例胰腺癌患者中位生存期为6.1个月,1、2和3年生存率分别为30.1%、10.6%和2.6%.Cox单因素分析显示肿瘤部位、分期、治疗方式影响胰腺癌生存期(P≤0.01),未治疗或仅行支持治疗患者中位生存期为1.3个月,手术、化疗、胆汁引流、经动脉介入化疗及多种方法综合治疗后患者中位生存期分别为11.0、7.3、3.5、9.0和11.0个月,死亡风险显著降低(P<0.05);Cox多因素分析显示肿瘤分期、治疗方式是胰腺癌预后因素(P<0.01).结论:肿瘤分期、治疗是胰腺癌独立预后因素.肿瘤部位位于胰头颈部、分期早,手术、经动脉介入化疗、化疗、胆汁引流及多种方法综合治疗患者生存期显著延长.     

Prognostic and predictive factors for breast cancer

Prognostic factors can be useful for making decisions about which patients should receive adjuvant therapy, and predictive factors can be used to predict response or lack of response to a particular therapy. We review the standard factors that are available today for primary breast cancer, and we describe some of the new, potential prognostic and predictive factors that are currently under investigation. Supported in part by grants CA30195, CA58183, CA54174 from the National Cancer Institute.     

Comparison of cancer survival in UK and Australia: rates are higher in Australia for three major sites

Relative survival of patients diagnosed with cancers of the colorectum, lung and female breast from Yorkshire, UK and New South Wales (NSW), Australia in 1992-2000 were compared using multiple regression models to adjust for various factors. Statistically significant differences were observed for all sites, Yorkshire patients having a 47-58% higher risk of excess death than those of NSW.     

Comparison of cancer registry and clinical data as predictors for breast cancer survival

Background  In spite of the increasing amount of clinically relevant information for survival from breast cancer, the amount of data recorded in a population-based cancer registry is limited and the registry-based survival predictions are routinely made without clinical details. Objective  To find out how important is the role of screening and clinical tumor characteristics in addition to cancer registry information in describing the breast cancer survival. Methods  A representative clinical database on 483 breast cancer patients diagnosed during 1996–1997 in Tampere University Hospital Area was linked with Finnish Cancer Registry data and a survival model including the available registry variables was compared to models including screen-detection information and clinical tumor characteristics also. Results and conclusion  Estimates of registry stage and age act as surrogates for clinical variables and mammography-detection. The surrogacy was found to be almost complete indicating that clinical variables are not necessarily needed when making breast cancer mortality predictions based on a population-based cancer registry. In cases with dissimilar staging cancer registry stage gave a better picture of the breast cancer survival than the clinical stage. This work was performed in Finnish Cancer Registry, Helsinki, Finland.     

Up‐to‐date cancer survival: Period analysis and beyond

Since its introduction in 1996, period analysis has been shown to be useful for deriving more up‐to‐date cancer survival estimates, and the method is now increasingly used for that purpose in national and international cancer survival studies. However, period analysis, like other commonly employed methods, is just a special case from a broad class of design options in the analysis of cancer survival data. Here, we explore a broader range of design options, including 2 model‐based approaches, for deriving up‐to‐date estimates of 5‐ and 10‐year relative survival for patients diagnosed in the most recent 5‐year interval for which data are available. The performance of the various designs is evaluated empirically for 20 common forms of cancer using more than 50‐year long time series of data from the Finnish Cancer Registry. Period analysis as well as the 2 model‐based approaches, one using a “cohort‐type model” and another using a “period‐type model”, all performed better than traditional cohort or complete analysis. Compared with “standard period analysis”, the cohort‐type model further increased up‐to‐dateness of survival estimates, whereas the period‐type model increased their precision. While our analysis confirms advantages of period analysis over traditional methods in terms of up‐to‐dateness of cancer survival data, further improvements are possible by flexible use of model‐based approaches. © 2008 Wiley‐Liss, Inc.     

Age adjustment of cancer survival rates: methods, point estimates and standard errors

We empirically evaluated the performance of a new method for age adjustment of cancer survival compared to traditional age adjustment using data from the Finnish Cancer Registry. We find that both methods provide almost identical results for absolute survival but the new method generally provides more meaningful estimates of relative survival with often a smaller standard error.     

New prognostic factors associated with long-term survival in node-negative breast cancer patients

Background  This study was undertaken to determine the absolute and relative value of angiogenesis, proliferating cell nuclear antigen (PCNA) and conventional prognostic factors in predicting relapse-free survival (RFS) and overall survival (OS) rates associated with long-term survival in Japanese patients with node-negative breast cancer. Patients and Methods  Two hundred patients with histological node-negative breast cancer were studied. We investigated nine clinicopathological factors, including angiogenesis, PCNA using permanent-section immunohistochemistry, clinical tumor size, histological grade (HG), tumor necrosis, lymphatic vessel invasion (LVI), histological extension, histological classification, and infiltrating growth (INF), followed for a median of 10 years (range, 1 to 20). Results  Twenty-one patients (10.5%) had recurrence and 15 patients (7.5%) died of breast cancer. Univariate analysis showed that PCNA, clinical tumor size, HG, angiogenesis, and LVI were significantly predictive of 20-year RFS or OS. Tumor necrosis was significantly predictive of OS, not of RFS. Multivariate analysis showed that clinical tumor size (P=0.0003), angiogenesis (P=0.0003), PCNA (P= 0.0064), and HG (P=0.0401) were significant independent prognostic factors for RFS. PCNA (P< 0.0001) and clinical tumor size (P=0.0112) were significant independent prognostic factors for OS, while angiogenesis was a borderline significant factor. Conclusion  PCNA and angiogenesis were important new prognostic factors in node-negative breast cancer patients.     

Trends in breast cancer treatment in Korea and impact of compliance with consensus recommendations on survival

Although some studies suggest that conformity with consensus recommendations for breast cancer therapy is associated with increased survival, the data are not clear. We identified patients in four hospital-based breast cancer registries in Korea who had undergone primary curative surgery (stage 0–III) from 1993 through 2002 (n = 8,407). We collected demographic and clinical characteristics such as age, stage, treatment, and hormone receptor status. We gathered 1993–2004 mortality data by linkage to the National Statistical Office. During the follow-up period of 43,145 person–years (mean, 5.13 years), we identified 899 deceased cases. We used the standard Poisson regression model to estimate the hazard ratio (HR) for survival in relation to conformity with guidelines for chemo-, hormone, and locoregional therapy. Guideline compliance for systemic therapy increased from 24.0% in 1993 to 83.8% in 2002. Among mastectomy patients with <4 positive lymph nodes and tumors <5 cm, post-mastectomy radiotherapy was associated with poor survival (HR 2.07; 95% CI: 1.53–2.81). Tamoxifen use was associated with better survival among patients with hormone receptor-positive tumors (HR 0.57; 95% CI: 0.45–0.73) and with poorer survival among hormone receptor-negative patients who had affected nodes (HR 1.58; 95% CI: 1.01–2.44). Relative to conformity, non-conformity with both chemo- and hormone therapy guidelines was associated with a 76% higher risk of death. Compliance with consensus recommendations for chemo- and hormone therapy is significantly associated with better survival. Overuse of post-mastectomy radiotherapy and tamoxifen beyond the consensus recommendations may be harmful. Young Ho Yun and Sang Min Park contributed equally to this work as first authors.