Racial and age differences in multiple primary cancers after breast cancer: a population-based analysis

Risks of second non-breast primaries following breast cancer in women: a systematic review and meta-analysis

BACKGROUND

Second primary cancer incidence is rising among breast cancer survivors. We examined the risks of non-breast second primaries, in combination and at specific cancer sites, through a systematic review and meta-analysis.

METHODS

We conducted a systematic search of PubMed, Embase, and Web of Science, seeking studies published by March 2022. We included studies that reported standardized incidence ratios (SIRs), with associated standard errors, assessing the combined risk of second non-breast primaries following breast cancer. We performed meta-analyses of combined second primary risks, stratifying by age, follow-up duration, and geographic region. We also assessed second primary risks at several specific sites, stratifying by age. The inverse variance method with DerSimonian-Laird estimators was used in all meta-analyses, assuming a random-effects model. Associated biases and study quality were evaluated using the Newcastle-Ottawa scale.

RESULTS

One prospective and twenty-seven retrospective cohort studies were identified. SIRs for second non-breast primaries combined ranged from 0.84 to 1.84. The summary SIR estimate was 1.24 (95% CI 1.14-1.36, I2: 99%). This varied by age: the estimate was 1.59 (95% CI 1.36-1.85) when breast cancer was diagnosed before age 50, which was significantly higher than in women first diagnosed at 50 or over (SIR: 1.13, 95% CI 1.01-1.36, p for difference: < 0.001). SPC risks were also significantly higher when based on Asian, rather than European, registries (Asia-SIR: 1.47, 95% CI 1.29-1.67. Europe-SIR: 1.16, 95% CI 1.04-1.28). There were significantly increased risks of second thyroid (SIR: 1.89, 95% CI 1.49-2.38), corpus uteri (SIR: 1.84, 95% CI 1.53-2.23), ovary (SIR: 1.53, 95% CI 1.35-1.73), kidney (SIR: 1.43, 95% CI 1.17-1.73), oesophagus (SIR: 1.39, 95% CI 1.26-1.55), skin (melanoma) (SIR: 1.34, 95% CI 1.18-1.52), blood (leukaemia) (SIR: 1.30, 95% CI 1.17-1.45), lung (SIR: 1.25, 95% CI 1.03-1.51), stomach (SIR: 1.23, 95% CI 1.12-1.36) and bladder (SIR: 1.15, 95% CI 1.05-1.26) primaries.

CONCLUSIONS

Breast cancer survivors are at significantly increased risk of second primaries at many sites. Risks are higher for those diagnosed with breast cancer before age 50 and in Asian breast cancer survivors compared to European breast cancer survivors. This study is limited by a lack of data on potentially confounding variables. The conclusions may inform clinical management decisions following breast cancer, although specific clinical recommendations lie outside the scope of this review.

Risk of second primary cancer among breast cancer patients: A systematic review and meta-analysis

Objectives

The aim of this study was to estimate the extra risk of second primary cancer among breast cancer patients.

Methods and materials

This is a systematic review. A comprehensive search of literature was performed in PubMed, Web of Science, Cochrane library, and Scopus. The search included all published studies up to October 2022. This systematic review included studies published in the English language that reported the risk of second primary non-breast cancer [i.e., standardized incidence ratio (SIR)] among breast cancer patients older than 15 years. After evaluating the methodological quality of the selected studies, SIRs were pooled with consideration of heterogeneity among studies. The estimates were pooled by age and time since the diagnosis of primary breast cancer for both sexes (male and female). Age was categorized based on before 50 years and after 50 years, and time was categorized as duration of less than and more than 10 years, respectively.

Results

From 2,484 articles, 30 articles were eligible for inclusion in the systematic review and meta-analysis. The studies varied in terms of population, number of cases, study design, setting, and year of implementation of the research. The estimated SIR for men and women was 1.28 (95% CI: 1.18, 1.38) and 1.27 (95% CI: 1.15, 1.39), respectively. Women diagnosed with breast cancer before menopause [SIR: 1.52 (95% CI: 1.34, 1.71) vs. 1.21 (95% CI: 1.08, 1.34)] as well as women after 10 years since their breast cancer diagnosis [1.33 (95% CI: 1.22, 1.431) vs. 1.24 (95% CI: 1.10, 1.37)] were at a higher risk of developing second primary cancer. Among men, while there were no differences in risk based on age, with the increase of time, the risk of second primary cancer was reduced [SIR: 1.22 (95% CI: 1.12, 1.33) vs. 1.00 (95% CI: 0.79, 1.22)].

Conclusion

There is an extra risk of second primary cancer among breast cancer patients. The extra risk should be considered for further screening and preventive measures among this population.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=336062, identifier (CRD42022336062).

Association between breast cancer and the risk of colorectal cancer

BACKGROUND

The literature to date has suggested a potential increase in colorectal cancer (CRC) among patients with breast cancer.

METHODS

We performed a systematic review of the literature and included 37 retrospective cohort studies and 8 case-control studies. The primary aim was to determine the prevalence of CRC. Secondary aims included analysis of adenomatous polyps and analysis of CRC prevalence by age. We calculated pooled prevalence rates and odds ratios (ORs) using random effects models with 95% confidence intervals (CI).

RESULTS

We identified 1,055,917 individuals with breast cancer among whom 9097 cases of CRC were detected. The pooled event rate for CRC was 0.7% (95% CI, 0.6%-0.9%; I²=97%). Four case-control studies reported prevalence of CRC (N=17,873 patients with breast cancer and 70,366 controls), including 46 cases of CRC in the patients with breast cancer, and 272 CRC in the controls (OR, 1.2; 95% CI, 0.4%-3.7%; P = .7). Six studies reported prevalence of advanced adenomas in patients with breast cancer (N=1087) compared with controls (N=1356) with 62 cases of advanced adenomas in patients compared with 47 in the controls (OR, 1.5; 95% CI, 0.97-2.2; P = .07). In patients with breast cancer <50 years old (4 studies, N=64,706), the pooled OR was increased (OR, 2.5; 95% CI, 1.7-3.5; P =.001). In 3 studies of women <45 years old (N=92,594), the risk was increased (OR, 2.3; 95% CI, 1.7-2.6; P < .001).

CONCLUSIONS

Patients with breast cancer should not undergo CRC screening at intervals different from the general population. In patients with breast cancer <50 years old, CRC screening should be considered at age 45 years.

The association between breast cancer and thyroid cancer: a meta-analysis

Previous studies have suggested an association between breast cancer and thyroid cancer; however, there has not been a formal meta-analysis which collates the existing evidence supporting the hypothesis that breast cancer or thyroid cancer predisposes an individual to developing the other. A systematic search was carried out using PubMed and Medline. We searched for articles containing epidemiological evidence of breast cancer following thyroid cancer and vice versa. Additionally, we searched for articles that included epidemiological data involving the incidence of all second primary malignancies (SPMs) following both breast cancer and thyroid cancer, and compared the datasets. The meta-analysis performed in a total of 18 studies showed that there is a significantly increased risk of developing thyroid cancer as a second primary malignancy of breast cancer (SIR = 1.59, 95 % confidence interval (CI) 1.28-1.99). Additionally, there was marginally increased risk of developing breast cancer as a second primary malignancy of thyroid cancer (SIR = 1.24, 95 % CI 1.16-1.33), compared to the general risk of developing a second primary malignancy following thyroid cancer. The findings suggest that the risk of developing thyroid cancer as a second primary malignancy of breast cancer and vice versa is increased compared to the background risk of developing other SPMs. The risk of developing thyroid cancer after a primary breast cancer was higher than the risk of developing breast cancer as a second primary malignancy of thyroid cancer. This suggests that the effects of treatment-related factors and specific pathological processes of each cancer may contribute to the increased risk rather than common risk factors including genetic factors. Elucidation of the common mechanisms between breast cancer and thyroid cancer will have important implications in both diagnostic and therapeutic management of these cancers. Benefit of thyroid ultrasound screening after breast cancer surgery needs to be assessed.

Estimation of the risk of secondary cancer in the thyroid gland and the breast outside the treated volume in patients undergoing brain, mediastinum and breast radiotherapy

The purpose of this study was to measure the peripheral dose which is the absorbed dose in organs located outside the treatment volume such as the thyroid gland and the breast in patients undergoing radiotherapy, utilising the MOSFET dosemeters, as well as to estimate the probability of secondary cancer. The thyroid gland doses, expressed as a percentage of the prescribed dose (%TD), were measured to be 2.0±0.3 %, in whole brain irradiation, 10.0±8.0 % in mediastinum treatment and 8.0±2.0 and 2.0±0.8 % in breast treatment, with and without the supraclavicular irradiation, respectively, with a corresponding risk of 0.2, 2.0, 1.0 and 0.3 %. The dose to the breast was 7.0±2.0 %, in the mediastinum treatment, and 4.0±1.0 and 2.0±0.8 %, in the breast treatment, with and without supraclavicular irradiation, respectively, with a corresponding risk of 4.0, 2.0 and 1.0 %. Although the results indicate that the risk is not negligible, its significance should be considered in conjunction with the existing pathology and age of the patients.

Relation of risk of contralateral breast cancer to the interval since the first primary tumour

BACKGROUND

There is no consensus on how to separate contralateral breast cancer (CBC) occurring as distant spread of the primary breast cancer (BC) from an independent CBC.

METHODS

We used standardised incidence ratios (SIRs) to analyse the variations in the risk of CBC over time among 6629 women with BC diagnosed between 1954 and 1983. To explore the most appropriate cutoff to separate the two types of CBC, we analysed the deviance between models including different cutoff points as compared with the basal model with no cutoff date. We also performed a prognostic study through a Cox model.

RESULTS

The SIR was much higher during the first 2 years of follow-up than afterwards. The best cutoff appeared to be 2 years. The risk of early CBC was linked to tumour spread and the risk of late CBC was linked to age and to the size of the tumour. Radiotherapy was not selected by the model either for early or late CBC risk.

CONCLUSION

A clearer pattern of CBC risk might appear if studies used a similar cutoff time after the initial BC.

Tumor marker phenotype concordance in second primary breast cancer, California, 1999-2004

Breast cancer is the most common cancer among women. It is estimated that 7% of women who have breast cancer will develop a subsequent second independent breast tumor within 10 years of the first. The status of estrogen (ER), progesterone (PR) and human growth hormone (HER2) receptors, individually and as phenotypic combinations, impacts the clinical course of breast cancer and may impact the course of subsequent primary tumors and patient survival. Our aims were to determine tumor marker phenotype concordance between first and second primary breast cancers (FPBC and SPBC), describe demographic and clinical characteristics, and examine first tumor treatments associated with phenotype concordance. A total of 76,209 cases of female invasive breast cancer were identified in the California Cancer Registry from 1999 to 2004. Of those, 1,407 women who had not undergone a prophylactic mastectomy, had information on the status of three tumor markers, and were diagnosed with an SPBC during the study period were selected. SPBCs were significantly smaller, diagnosed at a higher stage and were node positive. Patients whose FPBC was ER(+)/-/PR(+)/-/HER2- and triple negative (TN) (ER-/PR-/HER2-), often had concordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2+ and HER2-positive (ER-/PR-/HER2+) FPBCs, often had discordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2- SPBCs often lacked HER2 expression and were ER and/or PR positive. Tumor laterality and synchronicity significantly predicted concordance as did having a FPBC whose phenotypes were ER(+)/-/PR(+)/-/HER2+, HER2-positive and TN, while first primary tumor treatment with chemotherapy predicted discordance. The relationship between multiple primary breast cancer phenotype concordance and patient prognosis has yet to be determined. Our results indicate that SPBC surveillance strategies include consideration of FPBC phenotype. Although our results are provocative, they may have been influenced by current criteria used to determine tumor independence.

BRCA1, BRCA2, TP53, and CDKN2A germline mutations in patients with breast cancer and cutaneous melanoma

PURPOSE

From epidemiological studies it appears that breast cancer (BC) and cutaneous melanoma (CMM) in the same individual occur at a higher frequency than expected by chance. Genetic factors common to both cancers can be suspected. Our goal was to estimate the involvement of "high risk" genes in patients presenting these two neoplasia, selected irrespectively from family history and age at diagnosis.

EXPERIMENTAL DESIGN

Eighty two patients with BC and CMM were screened for BRCA1, BRCA2, TP53, CDKN2A and CDK4 (exon 2) germline mutations.

RESULTS

Deleterious mutations were identified in 6 patients: two carriers of a BRCA1 germline mutation, two carriers of TP53 germline mutations (one of which also harbored a BRCA2 deleterious mutation, the other one a BRCA2 unclassified variant), and two carriers of a CDKN2A germline mutation. In addition, 6 variants of unknown signification were identified in BRCA1 or BRCA2 genes. Regarding family history, 3/13 (23%) patients with a positive family history of BC or CMM were carriers of a germline mutation, whereas only 3/69 (4%) patients without family history were carriers of a germline mutation.

CONCLUSION

Our findings show that few patients with BC and CMM who lacked family histories of these cancers are carriers of deleterious germline mutations in four of the five genes we examined. We describe for the first time, two simultaneous BRCA2 and TP53 mutations, suggesting that analysis in more than one gene could be performed if a patient's personal or familial history does not match a single syndrome.

Women with multiple primary breast cancers diagnosed within a five year period, 1994-1998

INTRODUCTION

Women diagnosed with a primary breast cancer are at higher risk for a second primary. Few studies have focused on a comparison of women with single breast primary cancers and women with multiple primary breast cancers. The 1994-1998 NAACCR dataset aggregated from high quality registries representing more than one-third of the US population provides a unique opportunity to examine the incidence of multiple primary breast cancers in a large population.

MATERIALS AND METHODS

Using this multi-registry dataset, we describe the incidence pattern of malignant synchronous (within 2 months) and short-term metachronous (from 3 to 60 months) multiple primaries and single primary breast cancers by demographic and tumor characteristics.

RESULTS

Synchronous multiple primary tumors were more similar in age, stage, and tumor grade to single breast tumors than they were to short-term metachronous tumors. The short-term metachronous tumors did not resemble either the synchronous tumors or the single primaries.

DISCUSSION

These findings may indicate that while synchronous multiple primaries may have treatment implications different from single primaries, their etiology may be similar to single breast primaries. Further, they may actually be multi-centric single primaries. The two-month interval between multiple primaries is arbitrary and may not distinguish between the synchronous tumors and those occurring within 12 months of the index tumor. The rules for defining and counting breast primaries have implications for interpretation of incidence rates and temporal trends. These data also suggest the need for standard definitions for multiple primary breast tumors among clinicians, pathologists, and surveillance epidemiologists.

Contralateral Breast Cancer: Factors Associated with Stage and Size at Presentation

Few reports have evaluated factors associated with the stage at presentation of contralateral breast cancer and whether contralateral cancer presentation has changed in recent years, during which increased screening and enhanced adjuvant therapy of the initial tumor has been introduced. Patients with initial cancers staged 0-IIIB diagnosed between 1980 and 1999 who subsequently developed contralateral breast cancer were evaluated for stage, primary tumor size and histologic features, patient age and year of diagnosis, synchronous or metachronous presentation, and time from initial tumor to diagnosis of contralateral breast cancer. Tumor presentation was compared with contemporaneously diagnosed unilateral breast cancer patients. A total of 171 patients were diagnosed with contralateral breast cancer; 161 cases if lobular carcinoma in situ for either the initial or the contralateral tumor were excluded. Contralateral tumors were of significantly smaller size and of earlier stage than initial tumors. Contralateral cancers demonstrated earlier stage distributions with more recent year of diagnosis; initial tumors in contralateral patients did not. Earlier stage at presentation of contralateral tumors was associated in a multivariate model with more recent year of contralateral tumor diagnosis and earlier stage at presentation of the initial tumor; contralateral tumor size was associated with the size of the initial tumor. More recently diagnosed contralateral breast cancers are presenting with earlier stages of disease. The stages of initial tumors in these patients have not undergone such an improvement. Initial tumor size and stage is strongly associated with contralateral breast cancer size and stage; this association is independent of the year of diagnosis. Increased compliance with screening might be expected to improve both initial tumor stage and tumor size presentations in contralateral tumor patients, as well as the presentation of contralateral cancers.

Obesity, tamoxifen use, and outcomes in women with estrogen receptor-positive early-stage breast cancer

BACKGROUND

Obesity is associated with both increased breast cancer risk and poorer prognosis after disease onset. However, little is known about the effect of obesity on treatment efficacy. We evaluated the association of obesity with outcomes and with tamoxifen efficacy in women with early-stage, hormone-responsive breast cancer participating in a multicenter cancer cooperative group clinical trial.

METHODS

The cohort consisted of 3385 women enrolled in National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol B-14, a randomized, placebo-controlled trial evaluating tamoxifen for lymph node-negative, estrogen receptor (ER)-positive breast cancer. Hazards of breast cancer recurrence, contralateral breast tumors, other new primary cancers, and several mortality endpoints were evaluated in relation to body mass index (BMI), using statistical modeling to adjust for other prognostic factors. Median follow-up time was 166 months. All statistical tests were two-sided.

RESULTS

The hazard of breast cancer recurrence was the same among obese (BMI > or =30.0 kg/m2) women as compared with underweight and normal-weight women (BMI <25.0; hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.80 to 1.18). Contralateral breast cancer hazard was higher in obese women than in underweight/normal-weight women (HR = 1.58, 95% CI = 1.10 to 2.25), as was the risk of other primary cancers (HR = 1.62, 95% CI = 1.16 to 2.24). Compared with normal-weight women, obese women had greater all-cause mortality (HR = 1.31, 95% CI = 1.12 to 1.54) and greater risk of deaths due to causes unrelated to breast cancer (HR = 1.49, 95% CI = 1.15 to 1.92). Breast cancer mortality was not statistically significantly increased for obese women (HR = 1.20, 95% CI = 0.97 to 1.49). Tamoxifen reduced breast cancer recurrence and mortality, regardless of BMI.

CONCLUSIONS

For women with lymph node-negative, ER-positive breast cancer, obesity was not associated with a material increase in recurrence risk or a change in tamoxifen efficacy. However, because obesity was associated with increased risks of contralateral breast cancer, of other primary cancers, and of overall mortality, it may influence long-term outcomes for breast cancer survivors.

The Descriptive Epidemiology of Second Primary Breast Cancer

BACKGROUND

It is well established that the incidence rates of first primary breast cancer have been increasing over time. In contrast, the incidence rates of second primary breast cancer are largely undocumented. This study describes the epidemiology of second primary breast cancer among a population-based cohort of 305,533 U.S. women diagnosed with breast cancer between 1973 and 1998.

METHODS

We compared age-specific incidence rates for overall and second primary breast cancer according to year of diagnosis and demographic and tumor characteristics.

RESULTS

Overall, age-specific rates of breast cancer increased with increasing age and year of diagnosis, whereas incidence of second primary breast cancer peaked among young women and declined after 1988. Consistent with what is known about genetic susceptibility to breast cancer, at every age the rate of second primaries was greater than the overall rate; among women age 20 to 29 years the rate of second primary was more than 100 times greater. Although overall age-specific rates of breast cancer for African-American women were lower than for whites, rates of second primaries were higher. Women with a first primary that was either lobular or medullary had a greater likelihood of developing a second primary, although, there were relatively few with these histologic types.

CONCLUSIONS

The pattern of incidence rates for first and second primary breast cancer differ markedly over time and by age.

Risk factors for colorectal cancer following breast cancer

OBJECTIVE

To investigate risk factors for colorectal cancer following breast cancer.

METHODS

In this nested case-control study, all women (n = 14,900) with a first primary breast cancer (1978-1992) were identified from the western Washington population-based Surveillance, Epidemiology, and End Results Cancer Registry. Cases (n = 160) developed a second primary colorectal cancer before 1995, at least 6 months after the first cancer diagnosis. Controls (n = 310, matched to the cases on calendar year, age and breast cancer stage) were randomly selected from those who did not develop a second primary cancer and who survived to the case's colorectal cancer diagnosis date. Characteristics of the cases and controls at initial diagnosis were compared using conditional logistic regression.

RESULTS

The incidence of colorectal cancer was associated with a family history of breast cancer (v.s. no family history, matched odds ratio (mOR) = 2.1, 95% confidence interval (CI): 1.1-4.1), high body mass index (> or = 30kg/m2 v.s. < 30kg/m2, mOR = 2.2, CI: 1.2-3.9), and lobular breast cancer histology (v.s. ductal, mOR = 2.0, CI: 0.9-4.4). Risk was unrelated to menopausal status, prior hormone replacement therapy and estrogen/progesterone receptor status of the breast tumors.

CONCLUSIONS

The risk of developing a second primary colorectal cancer may be elevated among certain subsets of breast cancer patients.

Cancer-specific survival of patients with multiple cancers: an application to patients with multiple breast cancers

In the analysis of cause-specific survival, the causes of death must be known. For single-cancer patients with a known cause of death, the estimation of the cause-specific survival rate is straightforward. For multiple-cancer patients with two primary cancers, however, the analysis of cause-specific survival rates is more complex, particularly if the cancers are of the same primary site. In these situations, a concept of cancer-specific survival may also be distinguished from cause-specific survival. Cancer-specific survival rates are studied here by introducing two models, the primary one where the death from cancer is attributed to one of the cancers, and an alternative where such an attribution is not necessary. The models are illustrated using data on patients with multiple breast cancers. The model-based survival rates are compared with each other and with the corresponding relative survival rates based on analogous modelling of relative survival. The results show that for the subsequent breast cancer, the cancer-specific survival rates based on the alternative, where the distinction between the cancers as a cause of death was not necessary, tended to be higher than those based on that distinction. It is thus possible that the subsequent cancer was too often coded as a cause of death, particularly when being localized at diagnosis.

Radiation dose, chemotherapy and risk of lung cancer after breast cancer treatment

It is of particular concern to evaluate the risk of lung cancer occurrence after breast cancer treatment as women with breast cancer quite often undergo radiation therapy as part of their initial treatment and their life expectancy remains long. From a roster of 7711 women initially treated for breast cancer between 1954 and 1984, a cohort-study was performed among 4171 1-year survivors followed during the period 1975-1995. The relationship between the radiation dose received by the lung and the risk of lung cancer was then evaluated in a nested case-control study of 11 breast-cancer patients who developed lung cancer and 22 controls matched for age at diagnosis of breast cancer, period of initial treatment and length of follow-up. Among the 4171 women, six developed lung cancer during the entire follow-up as compared to 5.4 cases expected (SIR = 1.1, 95% CI: 0.4-2.3). When considering only the women initially treated by radiotherapy with or without adjunction of chemotherapy and excluding the 10 first years of follow-up, the SIR was significantly increased (SIR = 3.2, 95%CI: 1.0-7.4). In the case-control study, nine of the 11 lung cancers occurred in the ipsilateral lung and two in the trachea. The overall odds ratio (OR) of lung cancer associated with initial radiotherapy was 1.4 (95% CI: 0.2-11.1) and an excess in the OR of 7% (90% CI: ? to 41%, p = 0.10) per gray delivered to the site of lung cancer was evidenced. Our results agree with previous studies in favor of an increased risk of lung cancer after radiation therapy for breast cancer.

Efficacy of Breast Conservation Therapy in Early Stage Bilateral Breast Cancer

The purpose of this study was to evaluate the outcome of patients with bilateral breast cancer as compared to unilateral breast cancer treated with breast conservation therapy. Sixty patients with bilateral breast cancer (BBC) and 1,080 unilateral breast cancer (UBC) patients treated with breast conservation therapy from 1977 to 1994 were analyzed for outcome. Of the 60 bilateral patients, 44 were metachronous bilateral breast cancer patients (MBBC) and 16 were synchronous bilateral breast cancer patients (SBBC). The majority of patients received lumpectomy, axillary node dissection, and localized radiation therapy. Median tumor size was 1.4 cm for BBC and 1.5 cm for UBC patients. Median total dose to the tumor bed was 60 Gy for both unilateral and bilateral patients. Of the 44 MBBC patients, 14 received breast conservation for both the first and second lesions, while 30 received breast conservation for only the second metachronous lesion. Thus 58 lesions in 44 patients were treated with breast conservation therapy. Of the SBBC patients, 13 of 16 patients received breast-conserving therapy for both breasts, while 3 received a mastectomy for the second synchronous primary. Median follow-up was 50 months for SBBC patients, 45 months for MBBC patients, and 52 months for UBC patients. Local control and survival were analyzed in patients with SBBC, MBBC, and UBC. The interval to development of local recurrence and survival were calculated from the time of development of the second breast lesion in patients with MBBC. No differences were found for survival and failure-free survival in patients with SBBC, MBBC, or UBC. Five-year overall survival by lifetable analysis was 76% for SBBC, 78% for MBBC, and 87% for UBC patients (p = 0.32 by log-rank analysis). The 5-year failure-free survival was 79% for SBBC, 73% for MBBC, and 85% for UBC patients (p = 0.28 by log-rank analysis). No significant differences were seen for median age, tumor size, pathologic node status, tamoxifen use, chemotherapy use, or median total radiation dose for SBBC, MBBC, or UBC patients. A significant difference was found in the incidence of family history of breast cancer in patients with unilateral versus bilateral breast cancer (p = 0.028 by chi-square analysis). However, there was no difference in outcome of patients by family history of breast cancer. The local control was identical in both BBC and UBC patients, with a local failure rate of 3%. Therefore, breast conservation therapy in local-regional, early stage breast cancer is a rational and efficacious treatment modality for patients with SBBC, MBBC, and UBC.

Impact of breast carcinoma on African-American women: the Detroit experience

BACKGROUND

National and regional population-based data have demonstrated substantially worse outcome in African-American patients with breast carcinoma when compared with white patients, as well as a younger age distribution among African-American patients with breast carcinoma. The extent to which various socioeconomic, environmental, lifestyle, and genetic factors interact to account for this ethnicity-related disparity in survival is poorly understood. Greater than one-half of the inner-city population of Detroit, Michigan is African American, and greater metropolitan Detroit has been one of the contributing registries for the Surveillance, Epidemiology, and End Results (SEER) program since its inception in 1973. The impact of breast carcinoma on African Americans in the Detroit area is therefore well documented and provides significant insight into the history, epidemiology, and biology of this major public health care problem.

METHODS

A review of the medical literature published over the past 20 years regarding African-American patients with breast carcinoma was performed. The pertinent findings were summarized in the context of advances made in breast carcinoma screening, treatment, and risk reduction during that period.

RESULTS

The large African-American population of Detroit is a major factor contributing to the excessive breast carcinoma mortality rate reported for this city, which is one of the highest in the United States. Improvements in early detection of breast carcinoma by using screening mammography have been apparent in the earlier stage distributions of breast carcinoma observed in both white and African-American patients; however, progress has lagged substantially for the latter group. Detroit SEER registry data also have shown a younger age distribution of African-American patients with breast carcinoma and higher rates of estrogen receptor negative tumors. Finally, preliminary data from health maintenance organizations have suggested improved breast carcinoma outcome for African Americans who possess greater socioeconomic benefits, but disparities in disease stage at presentation persist.

CONCLUSIONS

The diverse Detroit community is ideally suited for breast carcinoma screening programs and clinical investigations that seek to address and overcome ethnicity-related survival disparities and barriers to health care. Findings from these studies can be correlated with results from similar projects in other geographic areas.

Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer

PURPOSE

Clinical practice guidelines of many professional societies call for routine staging chest x-rays (SCXR) for all patients with invasive cancer. Given the estimated 157,000 patients annually for whom this recommendation pertains, this screening examination represents a considerable health care expenditure. If it were shown that SCXR rarely changed the management of low-risk subsets of this population, it might be possible to selectively omit this practice from the care of these patients with substantial resultant cost savings.

PATIENTS AND METHODS

All patients with clinical stage I and II breast cancer presenting to the Baystate Medical Center from 1989 through 1997 were identified through the Tumor Registry. Their hospital records were reviewed for clinical presentation and documentation of SCXR.

RESULTS

One thousand four hundred ninety-four patients were identified with clinical stage I and II disease. SCXR were available for review on 1,003 patients. Only one asymptomatic patient was upstaged to stage IV based on a SCXR. Two patients with primary lung tumors were also identified. These data demonstrate an asymptomatic pulmonary metastasis detection rate of 0. 099% (95% confidence interval, 0.0% to 0.6%). The total charges of SCXR for this group approached $180,000.

CONCLUSION

These data demonstrate the low diagnostic yield and high cost of routine SCXR in the management of asymptomatic patients with clinical stage I and stage II breast cancer. Because other studies have shown that SCXR changes neither quality of life nor overall survival, SCXR should be limited to symptomatic patients in whom metastatic disease is suspected.

Surveillance for uterine abnormalities in tamoxifen-treated breast carcinoma survivors: a community based study

BACKGROUND

Tamoxifen-treated breast carcinoma survivors are at elevated risk of endometrial carcinoma. Whether to recommend annual surveillance for uterine abnormalities in this population is currently under debate.

METHODS

This study was a cross-sectional, community-based investigation of tamoxifen use and the frequency of surveillance for endometrial carcinomas in 541 women with breast carcinoma. Study participants whose breast carcinoma was diagnosed in 1994 were interviewed in 1998. Data were collected from a telephone interview and from a cancer registry record. Tests for uterine abnormalities, based on participant reports of endometrial biopsy and transvaginal ultrasound, were categorized according to frequency. Testing for uterine abnormalities was defined as irregular if women reported tests once every 3 years, on average, and as regular, if they reported annual tests.

RESULTS

Forty-nine percent of respondents were current tamoxifen users, 12% were former tamoxifen users, and 39% reported never taking tamoxifen. Of respondents with a uterus (n = 385), 19% reported irregular and 30% regular testing for uterine abnormalities after their breast carcinoma diagnosis. Respondents more frequently reported transvaginal ultrasound (37%) than endometrial biopsy (29%). Women 65 years of age and older were significantly less likely to report regular surveillance for uterine abnormalities (16%) than those younger than 65 years (35%). Current tamoxifen users more frequently reported regular surveillance (43%) than either former (35%) or never tamoxifen users (15%). Multivariable analyses showed tamoxifen users were more likely to have regular (odds ratio [OR], 9.8; 95% confidence interval [CI], 4.4-21.8) or to have irregular testing for uterine abnormalities (OR, 3.9; 95% CI, 1.9-8.1) compared with women who never used tamoxifen, after adjustment for age, number of recent gynecologic visits, and gynecologic symptoms.

CONCLUSIONS

The results of the current study indicate that half of the breast carcinoma survivors in this population were tested for uterine abnormalities. Although at increased risk, 38% of tamoxifen users never had a test. Clear guidelines need to be established for the type and frequency of testing for uterine abnormalities among tamoxifen-treated breast carcinoma patients.

Increased risk of second cancers following breast cancer: role of the initial treatment

OBJECTIVES AND METHODS

The risk of second primary malignancies (SMN) was studied in a cohort of 4,416 one-year survivors of a breast cancer. The role of the menopausal status and of the initial treatment modalities (surgery, radiotherapy, and chemotherapy) was investigated.

RESULTS

Excluding second primary breast cancer and non-melanoma skin cancer, a total of 193 (4.4%) patients developed a SMN between 1973 and 1992, compared with 136 expected (Standardised Incidence Ratio, SIR = 1.4, 95% CI (1.2-1.6)). No trend towards either an increase or a decrease was noted in the SIR with time after treatment (p = 0.2). The greatest increase in the relative risk concerned soft tissue cancers (SIR = 13.0, 95% CI: 6.8-22.3), followed by leukaemia (SIR = 3.1, 95% CI: 1.7-5.0), melanoma (SIR = 2.7, 95% CI: 1.4-4.8), kidney (SIR = 2.5, 95% CI: 1.2-4.5), ovary (SIR = 2.0, 95% CI: 1.2-3.1) and uterine tumours (SIR = 1.9, 95% CI: 1.4-2.5). The SIR was 3.0 (95% CI 1.8-4.7) in women under 40 at the time of the breast cancer, 1.9 (95% CI: 1.4-2.4) in those aged 40-49 and 1.2 (95% CI 1.0-1.4) in those aged 50 or more. In the 2,514 women who had received radiotherapy as initial treatment without chemotherapy, the SIR for all SMN was 1.6 (95% CI: 1.1-2.3) fold higher than in those who had not received radiotherapy as initial treatment.

CONCLUSION

In conclusion, this study confirms the increased risk of second malignancies in women treated for a breast cancer, and particularly in those who were younger at the time of treatment for breast cancer. Our results also suggest that radiotherapy may play a role in the onset of these second lesions.

Incidence and Detection of Contralateral Breast Cancer

In this study we estimated the efficacy of contralateral breast biopsy as a subsidiary method of early detection of bilateral breast cancer. We performed blind biopsies in the upper outer quadrant of the opposite breast in 195 patients undergoing surgical treatment for primary breast cancer. The histologic examination of the biopsy specimens showed 12 malignant lesions, which accounts for an incidence of 6.1%. In detail, we had two infiltrating ductal cancers, two infiltrating lobular cancers, three ductal in situ cancers, and five lobular in situ cancers. The overall incidence of invasive disease was 2.05%. We concluded that contralateral breast biopsy should be reconsidered as a method for enhancing early detection of contralateral breast cancer in high-risk groups, especially when it meets the emotional needs of patients. Permission given, it is included in the main surgical treatment of patients, avoiding the cost and complications of anesthesia, and it is cosmetically acceptable, without being an emotional burden for the woman.

Prognosis among African-American women and white women with lymph node negative breast carcinoma: findings from two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP)

BACKGROUND

A disparity in breast carcinoma survival between African-American and white women has been noted over the past several decades. A major factor implicated in this disparity is stage of disease at diagnosis. In this study, survival and related endpoints were examined among African-American women and white women with lymph node negative breast carcinoma who participated in two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP).

METHODS

Patients from two studies, one conducted among patients with estrogen receptor (ER) negative tumors and the other among patients with ER positive tumors, were included. Study goals were to determine whether African-Americans and whites had comparable outcomes, accounting for ER status and differences in patient characteristics at diagnosis, and to determine whether treatment response was similar for African-Americans and whites.

RESULTS

Five-year survival rates were 83% for African-Americans and 85% for whites among ER negative patients, and 93% for African-Americans and 92% for whites among ER positive patients. Rates of disease free survival (DFS) (i.e., time to disease recurrence, second primary cancer, or death) were 71% for African-Americans and 74% for whites at 5 years among ER negative patients, and 81% for African-Americans and 80% for whites among ER positive patients. African-Americans tended to have less favorable baseline prognostic characteristics. Adjusted relative risk (RR) estimates indicated similar prognosis for African-Americans compared with whites for mortality (African-American/white RR = 1.02 with 95% confidence interval [CI], 0.66-1.56 among ER negative patients; RR = 1.14 with 95% CI, 0.84-1.54 among ER positive patients) and DFS (RR = 0.98 with 95% CI, 0.70-1.37 for ER negative patients; RR = 0.96 with 95% CI, 0.75-1.22 for ER positive patients). Estimated percent reductions in DFS events for patients receiving adjuvant therapy were 32% for ER negative African-Americans, 36% for ER negative whites, 20% for ER positive African-Americans, and 39% for ER positive whites.

CONCLUSIONS

African-American and white patients with localized breast carcinoma had similar outcomes and benefited equally from systemic therapy. These results suggest that early detection and appropriate therapy among African-American patients could result in a reduction in the current disparity in breast carcinoma mortality between African-Americans and whites.

Prognostic factors for metachronous contralateral breast cancer: a comparison of the linear Cox regression model and its artificial neural network extension

The purpose of the present study was to assess prognostic factor for metachronous contralateral recurrence of breast cancer (CBC). Two factors were of particular interest, namely estrogen (ER) and progesterone (PgR) receptors assayed with the biochemical method in primary tumor tissue. Information was obtained from a prospective clinical database for 1763 axillary node-negative women who had received curative surgery, mostly of the conservative type, and followed-up for a median of 82 months. The analysis was performed based on both a standard (linear) Cox model and an artificial neural network (ANN) extension of this model proposed by Faraggi and Simon. Furthermore, to assess the prognostic importance of the factors considered, model predictive ability was computed. In agreement with already published studies, the results of our analysis confirmed the prognostic role of age at surgery, histology, and primary tumor site, in that young patients (< or = 45 years) with tumors of lobular histology or located at inner/central mammary quadrants were at greater risk of developing CBC. ER and PgR were also shown to have a prognostic role. Their effect, however, was not simple in relation to the presence of interactions between ER and age, and between PgR and histology. In fact, ER appeared to play a protective role in young patients, whereas the opposite was true in older women. Higher levels of PgR implied a greater hazard of CBC occurrence in infiltrating duct carcinoma or tumors with an associated extensive intraductal component, and a lower hazard in infiltrating lobular carcinoma or other histotypes. In spite of the above findings, the predictive value of both the standard and ANN Cox models was relatively low, thus suggesting an intrinsic limitation of the prognostic variables considered, rather than their suboptimal modeling. Research for better prognostic variables should therefore continue.

Clinical epidemiology of bilateral breast cancer

BACKGROUND

The clinical epidemiology of bilateral breast cancer was assessed in a population-based study from Saarland, Germany.

METHODS

Clinical aspects of breast cancer, including age and tumor spread at diagnosis and survival, were compared between 251 patients with bilateral breast cancer and all 9585 patients with a first diagnosis of breast cancer registered with the population-based cancer registry of Saarland, Germany, between 1968 to 1987.

RESULTS

The patients with bilateral breast cancer were on average considerably younger at the time of diagnosis of the first breast cancer than the total group of patients with breast cancer (mean age, 55.7 years versus 60.5 years). Overall, the distribution of tumor spread at diagnosis of the second breast cancers was similar to the corresponding distribution of first breast cancers, but a much less favorable distribution was observed among second breast cancers that developed in women younger than 50 years of age. The survival rates after diagnosis of a second breast cancer were much worse than the survival rates after a first breast cancer diagnosis. These differences persisted after control for important covariates such as age and tumor spread and were more pronounced if the first tumor was diagnosed in an advanced stage and if the time interval between diagnosis of the first and second cancers was short. Nevertheless, tumor spread at diagnosis of the second cancer was by far the most important predictor of survival among patients with bilateral breast cancer.

CONCLUSIONS

The differences in clinical aspects of first and second breast cancers should be considered in clinical management of patients with breast cancer. Further research is required to explain these differences.

Cervical intraepithelial neoplasia in patients with breast cancer: a cytological and colposcopic study

Twenty-six patients with treated breast cancer who had been randomised previously to receive combination chemotherapy including alkylating agents (n = 14) or to undergo oophorectomy (n = 12) following surgery underwent cytological and colposcopic screening of the uterine cervix. Colposcopically directed cervical punch biopsies were taken from all patients in whom a colposcopic abnormality was detected. Breast cancer patients were compared with 79 controls with normal cervical cytology and no known breast malignancy. Colposcopically directed punch biopsies were taken from the cervical transformation zone of all controls. Significantly more breast cancer patients who had received chemotherapy (43%) than controls (10%) had CIN (P < 0.01) and significantly more patients who had received chemotherapy (14%) than controls (3%) had CIN 2 or 3 (P < 0.05). The proportion of breast cancer patients in the oophorectomy group with CIN (17%) did not differ significantly from the control group. No case of CIN was detected by cervical cytology. This study suggests that breast cancer patients receiving combination chemotherapy including alkylating agents are at increased risk of CIN, and that cervical cytology alone may be an inadequate form of screening for these patients.

Second primary neoplasms following breast cancer in Saarland, Germany, 1968-1987

A statewide cohort study on the occurrence of second primary neoplasms was conducted among 9678 women first diagnosed with breast cancer in Saarland, Germany between 1968 and 1987. A total number of 409 second primary neoplasms was observed compared to 328 cases that would have been expected based on the incidence rates of the general population (standardised incidence ratio, SIR = 1.25). This elevation in incidence of second neoplasms was primarily due to increased occurrence of cancer of the opposite breast (SIR = 2.48), which was most pronounced for patients below the age of 50 (SIR = 4.20) and within the first 5 years after diagnosis (SIR = 2.91). There was a moderate elevation in incidence of malignant tumours of the ovaries (SIR = 1.46), while the incidence of most other malignancies was lower than in the general population. Our results, which are in agreement with previous findings from Northern Europe, the U.S.A. and Japan provide valuable background information for aetiological research, as well as for surveillance of breast cancer patients.