Breast Cancer in South-Central West Virginia.
Subject: Breast cancer (Risk factors)
Breast cancer (Diagnosis)
Breast cancer (Care and treatment)
Breast cancer (Patient outcomes)
Breast cancer (Demographic aspects)
Cancer (Diagnosis)
Cancer (Usage)
Cancer (Care and treatment)
Cancer (Methods)
Cancer (Health aspects)
Author: Kusminsky, Roberto E.
Pub Date: 10/01/2009
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: Oct, 2009 Source Volume: 105 Source Issue: S1
Product: Product Code: 8000432 Cancer Therapy NAICS Code: 621 Ambulatory Health Care Services
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 218949140
Full Text: Objectives

This paper should give the reader an opportunity to appraise the current status of breast cancer in a rural state, and provide an overview of a highly prevalent disease. Furthermore, after examining the information contained herein, the reader will gain insights regarding some of the national trends this disease appears to follow.

Introduction

It is estimated that 185,000 new cases of female breast cancer will be diagnosed this year in the US, with approximately 2,000 additional cases appearing in males. Breast cancer is the leading type of female cancer and the second cause of cancer-related deaths in women. The burden of this disease requires constant efforts to improve its outcomes, and the information derived from cancer registries provides valuable evidence to measure the quality of cancer care and often highlights opportunities for progress. Advances in diagnostic and therapeutic modalities are eventually reflected in the data carefully recorded over time. Charleston Area Medical Center (CAMC), a 900-bed tertiary care facility with a broad range of services, has a dynamic and engaged cancer registry, and its recorded data projects a reasonable cross-sectional image of the status and outcomes of specific cancer types. At CAMC, breast cancer is diagnosed and treated approximately 240 times a year. From 1998 to 2007, 2401 cases were recorded in the institution's registry and were available for analysis. This review of ten years of available information creates a credible blueprint of the position of this disease in South-Central West Virginia.

Incidence

The rate of breast cancer diagnosis in the US has increased since the early 1990s, but fortunately the overall breast cancer death rate has decreased steadily. While rates of certain types of cancer can vary widely among states, the fluctuation of female breast cancer incidence is fairly narrow. However, a variation in incidence rates has been seen in the past decade that is open to interpretation. For instance, there has been a decline in the incidence of breast cancer between 1999 and 2003, associated with a corresponding decrease in the incidence of invasive cancer during the same period, the largest being observed in 2002-2003 (1). This kind of information must be interpreted with caution, particularly when attempts are made to compare, for example, rates between states or counties. This is due to a multiplicity of factors playing a role in the observed events and contributing to differences among groups over time, such as rates of breast cancer detection, populations represented in the data, reporting delays, variations in health care and behaviors, and others. For instance, the number of WV women over 50 years old reporting no mammogram has not decreased but remained stable at 22-23% between the years 20002006, while nationwide the trend appears similarly stable at 20%.(2)

As of 2005, West Virginia ranked 48th in the country for invasive breast cancer incidence, at 114.4/ 100,000 persons, while the US rate was 117.7/100,000 (3). For WV, this translates into approximately 1150 new cases of breast cancer a year. From 2001 to 2004, centrally located Kanawha County, which reports the largest number of yearly new cases in the state, exhibited an annual invasive breast cancer incidence of 122.6-128.4 per 100,000 (4).

Age distribution

The age distribution of 2401 cases is shown in Fig. 1, and Table 1 shows the remarkable similarity in age allocation with the rest of the country. The highest prevalence was seen among women in the 50-69 age groups (50% of all recorded cases). In the US, the median age of breast cancer diagnosis was 61 years during the 2001-2005 period (5). A small number of patients under 30 years of age were diagnosed intermittently during five of the ten years covered in this analysis.

Stage

The stage distribution is depicted in Fig. 2. Of the total cases, 1956 had pathological information, whereas 445 (18.5%) were unstaged. The stage distribution comparisons can be seen in Table 2. When the first and second five-year periods are examined separately, the number of unstaged patients, although still high, decreases to 14.9% in the most recent years. More notable was a statistically significant change in the percentages of Stages 0, I and IV seen in both periods, with a p value = 0.001 for Stage 0 and IV, and 0.043 for Stage I (Fig. 3). Although this trend toward an increase in earlier detection is real, Stage 0 cases in the population reported here are not approaching the dramatic increase in incidence seen in the US over the last fifteen years, where it now stands at 20% of incident breast cancers (6). However, the statistics cited in this narrative are skewed by the relatively large number of cases without pathological staging.

Histology

The most common histologic types reported during the 10-year period are shown in Fig. 4. As expected, invasive ductal carcinoma was the most frequent histologic diagnosis (61%), followed by ductal carcinoma in situ (DCIS). The incidence of DCIS increased from 7.4% in the first five years to 11.9% in the second five-year period, and this change was highly statistically significant, with a p value < 0.0001. This trend coincides with the observed increase in incidence of Stage 0 cases. Other types appearing infrequently during the 10-year period included inflammatory cancer (7 cases), cystosarcoma phylloides (9 cases), sarcoma (4 cases), metaplastic (4 cases), and Paget's disease of the breast (3 cases). Lymphoma was reported in 6 cases during the period of interest, but no information is available to determine whether they were primary or secondary.

Hormone receptors

Estrogen (ER) and progesterone receptor (PR) positive and negative status was recorded in 1646 cases. Of these, 27.2% were reported as ER and PR negative. This percentage of negative receptor expression coincides with the general profile of breast cancers: about 65% are ER/PR positive, 25% are ER/PR negative, 10% are ER positive and PR negative, and 5% are ER negative and PR positive (7), with slight variations reported in the literature (8). The percentage of hormone-receptor negative tumors is significant, because the possibility of administering endocrine therapy to those patients is decreased, and triple-negative tumors (those which do not express human epidermal growth factor receptor type 2 or HER2, in addition to lacking estrogen and progesterone receptors) are a challenging problem given that treatment is restricted by the absence of a clear target (9).

Treatment

Approximately 98% of 2401 cases were available to review treatment information and its delivery by age group, as shown in Tables 3 and 4. Hormonal and radiation therapy were utilized more often than chemotherapy overall: in fact, chemotherapy was not recommended 62% of the time (Table 3). However, chemotherapy was the most common treatment modality used for the 40-59 age group (Table 4), suggesting perhaps a more aggressive approach for younger patients.

Although menopausal status could not be ascertained, it is of interest to note that 52.5% of 1073 patients who received hormonal therapy were in the 30-59 age group (Fig. 5), even though the percentage of patients with ER/PR positive grouping was, as expected, higher in the older population (Fig. 6). A small percentage of patients did not receive the intended therapy or refused it (Table 3).

Surgical treatment was recorded in 1748 patients, or 72.8% of the 2401 cases registered. Table 5 illustrates the distribution of breast conserving therapy (BCT) by age group for the entire 10-year period. These results project the image of a reasonable 53% overall rate of breast conservation procedures, and suggests that the patients in the 70-90 age group still undergo a larger number of mastectomies as opposed to breast conservation, in contrast with patients in the remaining age-groups. In fact, when the first five years are compared with the second five-year period, a different conclusion emerges: the overall rate of breast conserving surgery is lower (47.1%) than the rate of mastectomies (52.8%), mostly on account of the 70-89 group and the 40-49 year-old patients as well (Table 6). These rates are practically reversed when the same analysis is performed in the second five-year period, demonstrating a 58% rate of breast conservation and a 42% rate of mastectomies for the entire cohort. (Table 7).

The 40-49 year-old group of patients had a 43.7% rate of BCT during the first five-year period (153 total cases in that age group) and this incidence climbed to 60.4% during the second five years of this analysis (182 cases). The current overall rate of 58% for breast conserving therapies compares well with the national rates: as of 2006, BCT was performed in 57% of 56,000 patients treated at 250 hospitals across the country, as reported by the National Cancer Data Base from the American College of Surgeons. This is almost double the 33-37% rate of BCT for the years 1994-1995, as reported for this region of WV by Jubelirer et al. (10).

Survival

Survival and mortality rates should be viewed with circumspection because a variety of factors affect their precise interpretation, just as is the case with incidence rates. Furthermore, survival information does not include the experience of women receiving current therapies or exposure to recent therapeutic advances.

Mortality rates for female breast cancer have been declining consistently, but the trend in rates varies over time. From 1990 to 2005, the average annual percent decline has been approximately 2.2% (11). During 2005, the US mortality rate for female breast cancer was 25.0 per 100,000 per year, compared with WV 25.1/100,000 annual death rate. The same year Kanawha County reported a mortality rate of 23.4/100,000, with a trend in mortality interpreted as stable and similar to the US rate, while the trend for the state was falling and analogous to the US (12). The five-year survival rate for 1092 cases recorded at CAMC (all-cause mortality) is shown in Fig. 7, with a somewhat unanticipated 70.6% 5-year survival rate for patients with stage III breast cancer, although this was in synchrony with the rate reported for the institution by the National Cancer Database of the American College of Surgeons for stage III cases diagnosed during 1998-2001. These survival rates improved when the analysis focused on breast cancer specific mortality of the same 1092 cases, as seen in Fig. 8. Finally, the survival rates for breast cancer-specific and all-cause mortality for unstaged cases is shown in Fig. 9.

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Discussion

The findings in this report confirm an increase in the incidence of stage 0 and I cases and a decrease in the numbers of patients with stage IV over the period of interest. These outcomes suggest that programs of prevention and early detection perhaps play a role in the presentation of patients with breast cancer in this area of the state. Interestingly, the decrease in incidence of breast cancer seen during 2002-2003 was not exclusively attributed to a decrease in the use of hormonal replacement therapy (13), but it was also credited to a decrease in mammography screening rates (14). Therefore, the information derived from cancer registries should be used to promote the proven mechanisms of prevention and early detection, particularly in light of reports underscoring the elevated mortality currently seen in younger women (15) and the rising incidence of breast cancer among female cancer survivors (16). Mammographic screening is not only effective in detecting breast cancer early, but it does reduce the mortality of the disease. Magnetic resonance imaging is finding its place within the detection armamentarium, and the indications for its use are maturing rapidly. Thirty-five years ago approximately 75% of women diagnosed with breast cancer survived their disease 5 years, whereas today nearly 90% of them do. Treatment modalities continue to evolve, and the processes of care are also changing: breast centers are now providing comprehensive and multidisciplinary care for patients with breast disease, and careful recording of accurate data will continue to assist and motivate health care providers to improve the quality of care given to patients with breast disease.

Acknowledgements: The author wishes to thank the invaluable assistance rendered during the preparation of the manuscript by Ms. Kathi McCormick, BA, CCS, CTR, Clinical Data Coordinator; and L. Scott Dean, Ph.D., MBA, Senior Biostatistician for the CAMC Health Education and Research Institute.

CME Post-Test

24. T or F The rate of breast cancer diagnosis has decreased since the 1990s, while the overall mortality rate has remained stable.

25. T or F The incidence of invasive breast cancer in WV is lower than the US rate.

26. In the US, the median age of breast cancer diagnosis is:

a. 51

b. 54

c. 61

d. 64

27. T or F The incidence of early stage breast cancer is increasing, while the incidence of stage IV is decreasing

References

(1.) Stewart SL, Sabatino SA, Foster SL, et al. Decline in Breast Cancer Incidence--United States, 1999--2003. MMWR 2007; 56 (22): 549-553.

(2.) CDC, Behavioral Risk Factor Surveillance System: www.cdc.gov/BRFSS/ (accessed 4/6/2009).

(3.) US Cancer Statistics working group. United States Cancer Statistics: 1999-2005 Incidence and Mortality Web-based Report. Atlanta: US Department of Health and Human Services, CDC and National Cancer Institute; 2009. Available at: www. cdc.gov/uscs (accessed 3/28/09).

(4.) CDC's National Program of Cancer Registries Cancer Surveillance System (NPCR-CSS). January 2007 data

submission and SEER November 2006 submission as published in United States Cancer Statistics 2004.

(5.) Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 19752005, National Cancer Institute.

(6.) Jemal A, Murray T, Ward E, et al: Cancer statistics, 2008. CA Cancer J Clin 58:7196, 2008.

(7.) http://www.breastcancer.org/treatment/ hormonal/what_is_it/hormone_role.jsp (accessed 4/1 /09)

(8.) A Rhodes, B Jasani, A J Balaton, et al. Frequency of oestrogen and progesterone receptor positivity by immunohistochemical analysis in 7016 breast carcinomas: correlation with patient age, assay sensitivity, threshold value, and mammographic screening. J. Clin. Pathol. 2000; 53:688-696.

(9.) Tan AR, Swain SM. Therapeutic strategies for triple-negative breast cancer. Cancer J, 2008; 14: 343-351.

(10.) Jubelirer SJ, Harpold R, Miller S,. et al. 1WMJ2001; 97: 144-7.

(11.) Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 19752005, National Cancer Institute.

(12.) U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992005 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2009. Available at: www. cdc.gov/uscs.

(13.) Ravdin M, Cronin KA, Howlander N, etal. The decrease in breast cancer incidence in 2003 in the United States. NEJM 2007; 356: 1670-74.

(14.) CDC. Use of mammograms among women aged > 40 years. United States, 20002005. MMWR 2007; 56: 49-51.

(15.) Gnerlich JL, Deshpande AD, Jeffe DB, et al. Elevated breast cancer mortality in women younger than age 40 years compared with older women is attributed to poorer survival in early stage disease. ACS 2009; 208:341 -347.

(16.) Soerjomataram I, Louwman WJ, Duijm LEM et al. Rising incidence of breast cancer among female cancer survivors: implications for surveillance. BJC 2009; 100: 77-81.

Roberto E. Kusminsky, MD, MPH, FACS Professor of Surgery, West Virginia University Charleston, West Virginia
Table 1. Age distribution

            CAMC   US *
Age         (%)    (%)

Under 29    0.25   0.39
  30-39     4.0    4.4
    40-49   19.0   18.4
    50-59   27.0   25.3
    60-69   23.0   22.1
    70-79   18.0   18.6
    80-89   7.0    9.7
      90+   0.76   0.9

* NCDB, Commission on Cancer, ACoS. Benchmark
Reports, v.9.0 (yrs 2000-06, all states, N = 1,218,232)

Table 2. Stage distribution

           CAMC~   WV *   US *
Stage      (%)     (%)    (%)

0          10.1    17.7   18.4
I          34.8    38.7   37.9
II         26.6    27.6   27.3
III        7.0     8.4    8.0
IV         2.8     4.3    3.3
Unknown    18.5    3.0    4.8

* NCDB, Commission on Cancer, ACoS. Benchmark
Reports, v.9.0 (yrs 2000-06, all states, N = 1,218,232)

~ CAMC registry, yrs 1998-07, N = 2401.

Table 3. Treatment modalities

                     Hormonal    ChemoRx     RadioRx
                     (%/cases)   (%/cases)   (%/cases)

Received             45.6/1073   33.4/791    44.3/1048
Not recommended      54.3/1260   61.9/1466   53.1/1255
Refused              0.6/17      2.9/69      0.9/22
Not given            --          1.6/40      1.6/38
Total *              97.8/2350   98.5/2366   98.4/2363

* Percentages of 2401 cases available for review 1998-2007.

Table 4. Treatment modalities received by age-group

              Hormonal     ChemoRx     RadioRx
Age           (% */cases)  (%/cases)   (%/cases)

< 30          0.18/2       0.3/3       0.3/4
30-39         3.6/39       7.5/60      4.6/49
40-49         18.8/202     29.9/237    21.7/228
50-59         30.1/324     36.1/286    28.2/296
60-69         22.2/239     18.8/149    22.9/241
70-79         18.7/201     6.3/50      16.6/174
80-89         5.8/63       0.7/6       5.2/55
90 +          0.2/3        0/0         0.09/1
Total Cases   1073         791         1048

* Percentages of the cases receiving the therapy of interest.

Table 5. Breast Conserving Surgery by
Age-Group: (1998-2007: 1748 Cases)

           BCT         Mastectomy
Age        (cases/%)   (cases/%)

< 30       6/0.3       1/0.05
30-39      36/2.0      37/2.1
40-49      177/10.1    158/9.0
50-59      268/15.3    195/11.1
60-69      225/12.8    183/10.4
70-79      146/8.3     166/9.4
80-89      59/3.3      74/4.2
90+        11/0.6      6/0.3
Total      928/53.0    820/47.0

Table 6. Breast Conserving Therapy
(1998-2002: 781 Cases)

Age        BCT         Mastectomy
           (Cases/%)   (Cases/%)

< 30       4/0.5       0
30-39      21/2.6      18/2.3
40-49      67/8.5      86/11.1
50-59      107/13.7    101/12.9
60-69      90/11.5     83/10.6
70-79      57/7.2      88/11.2
80-89      19/2.4      34/4.3
90 +       3/0.3       3/0.3
Total      368/47.1    413/52.8

Table 7. Breast Conserving Therapy
(2003-2007: 967 Cases)

Age        BCT         Mastectomy
           (Cases/%)   (Cases/%)

< 30       2/0.2       1/0.1
30-39      15/1.5      19/1.9
40-49      110/11.3    72/7.4
50-59      161/16.6    94/9.7
60-69      135/13.9    100/10.3
70-79      89/9.2      78/8.0
80-89      40/4.1      40/4.1
90 +       8/0.8       3/0.3
Total      560/57.9    407/42.8

Figure 1. Age distribution for 2401 Cases

1998-2007

29 Under     0.3%
30-39        4.0%
40-49       19.0%
50-59       27.0%
60-69       23.0%
70-79       18.0%
80-89        7.0%
90 Over    0.296%

Figure 2. Stage distribution for 2401 Cases

1998-2007

Stage 0      0.1%
Stage I     34.8%
Stage II    26.6%
Stage III    7.0%
Stage IV     2.8%
Unstaged    18.5%

Figure 3. Changes in Stages 0, I and IV Cases

           1998-02   2003-07

Stage 0     7.80%     12.4%
Stage I     32.7%     36.7%
Stage IV     3.9%      1.7%

Note: Table made from bar graph.

Figure 4. Most Common Histologic Types

1998-2007

Inv Duct    61.0%
Inv Lob      9.5%
Duct/Lob     4.0%
Medullary    0.4%
Tubular      1.7%
DCIS        19.3%

Note: Table made from bar graph.

Figure 5. Endocrine Therapy (1073 cases)

Age Groups

<30        8%
30-39    3.65
40-49   18.9%
50-59   30.13%
60-69   22.4%
70-79   18.8%
80-89    5.25%
90+     27.0%

Note: Table made from bar graph.

Figure 6. Percentage of ER/PR Positive Patients by Age-Group
(1198 Cases)

1998-2007

<30     14.2%
30-39   37.8%
40-49   47.1%
50-59   51.1%
60-69   46.3%
70-79   55.1%
80-89   57.5%
90+     43.4%

Note: Table made from bar graph.
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