Time trends and regional differences in registration, stage distribution, surgical management and survival of breast cancer in Denmark

Design and Development of an Intelligent Clinical Decision Support System Applied to the Evaluation of Breast Cancer Risk

Breast cancer is currently one of the main causes of death and tumoral diseases in women. Even if early diagnosis processes have evolved in the last years thanks to the popularization of mammogram tests, nowadays, it is still a challenge to have available reliable diagnosis systems that are exempt of variability in their interpretation. To this end, in this work, the design and development of an intelligent clinical decision support system to be used in the preventive diagnosis of breast cancer is presented, aiming both to improve the accuracy in the evaluation and to reduce its uncertainty. Through the integration of expert systems (based on Mamdani-type fuzzy-logic inference engines) deployed in cascade, exploratory factorial analysis, data augmentation approaches, and classification algorithms such as k-neighbors and bagged trees, the system is able to learn and to interpret the patient’s medical-healthcare data, generating an alert level associated to the danger she has of suffering from cancer. For the system’s initial performance tests, a software implementation of it has been built that was used in the diagnosis of a series of patients contained into a 130-cases database provided by the School of Medicine and Public Health of the University of Wisconsin-Madison, which has been also used to create the knowledge base. The obtained results, characterized as areas under the ROC curves of 0.95–0.97 and high success rates, highlight the huge diagnosis and preventive potential of the developed system, and they allow forecasting, even when a detailed and contrasted validation is still pending, its relevance and applicability within the clinical field.

Surgical and radiotherapy patterns of care in the management of breast cancer in NSW and ACT Australia

INTRODUCTION

This study aims to report on the surgical and radiotherapy patterns of breast cancer care in New South Wales (NSW) and Australian Capital Territory (ACT) in Australia, to identify factors that impact on utilisation of evidence-based treatment and to report on the overall survival (OS) rate and the influencing factors on OS.

METHODS

Cancer registry data linked to hospital records for all patients with breast cancer diagnosis in NSW and ACT between 2009 and 2014 were used to calculate rates of breast conserving surgery (BCS), mastectomy, sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND) and radiotherapy. Multivariate analysis used to identify factors that led to variations in care. 5-year OS was calculated and cox regression model assessed factors that influenced survival.

RESULTS

Data for 30,337 patients were analysed. BCS and mastectomy rates were 64% and 36%, respectively. The SLNB, ALND and ALND after SLNB rates were 61.5%, 32.1% and 6.4%, respectively. Radiotherapy was utilised in 63%. Younger age, socio-economic disadvantage, longer distance to a radiotherapy facility and overseas place of birth were factors that predicted for increased rates of mastectomy and ALND. Radiotherapy was more likely to be utilised in later years of diagnosis, patients between 40-69 years old, and those who lived in major cities and closer to a radiotherapy facility. 5-year OS was 80.5%. Older patients, the socioeconomically disadvantaged and those advanced tumours had worse survival.

CONCLUSION

Variations in breast cancer care continue to exist in certain patient groups that we identified. Targeted strategic planning and further research to identify other drivers of existing disparities remain a priority.

The Global and Regional Survival Rate of Women With Breast Cancer: A Systematic Review and Meta-analysis

Breast cancer is the most common cancer among women in the world. The aim of this study was to measure the global and regional survival rates of women with breast cancer. We searched Medline/PubMed, Web of Science, Scopus, and Google Scholar to identify cohort studies on the survival rate of women with primary invasive breast cancer until the end of June 2017. We used random effect models to estimate the pooled 1-, 3-, 5-, and 10-year survival rates. Subgroup analysis and meta-regression models were used to investigate the potential sources of heterogeneity. One hundred twenty-six studies were included in the meta-analysis. Between-study heterogeneities in the 1-, 3-, 5-, and 10-year survival rates were significantly high (all I²s > 50%; P = .001). The global 1-, 3-, 5-, and 10-year pooled survival rates in women with breast cancer were 0.92 (95% confidence interval [CI], 0.90-0.94), 0.75 (95% CI, 0.71-0.79), 0.73 (95% CI, 0.71-0.75), and 0.61% (95% CI, 0.54-0.67), respectively. Subgroup analysis revealed that survival rates varied in different World Health Organization regions, age and stage at diagnosis, year of the studies, and degree of development of countries. Meta-regression indicated that year of the study (β = 0.07; P = .002) and development of country (β = -0.1; P = .0001) were potential sources of heterogeneity. The survival rate was improved in recent decades; however, it is lower in developing regions than developed ones.

The effect of 14-3-3ζ expression on tamoxifen resistance and breast cancer recurrence: a Danish population-based study

PURPOSE

Overexpression of 14-3-3ζ has been linked to breast cancer recurrence in several studies, including studies assessing its effect on tamoxifen resistance. The study was performed to estimate the effect of 14-3-3ζ and differentiate potential prognostic or predictive utility.

METHODS

A case-control study, nested in a population of 11,251 females residing on the Jutland Peninsula of Denmark, was performed. Participants were aged 35-69, diagnosed with stage I, II, or III breast cancer between 1985 and 2001, and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent breast cancer cases with estrogen receptor-positive disease treated with tamoxifen for at least 1 year (ER+/TAM+) and 300 cases with estrogen receptor-negative disease never treated with tamoxifen (ER-/TAM-). We matched cases to controls on ER/TAM status, date of surgery, menopausal status, stage, and county. 14-3-3ζ expression was assessed using immunohistochemistry on tissue microarrays. We computed the odds ratio (OR) associating 14-3-3ζ expression with breast cancer recurrence adjusting for confounding using logistic regression. A quantitative bias analysis was performed to account for bias due to expression assay methods.

RESULTS

Associations for cytoplasmic and nuclear 14-3-3ζ staining above the 50th percentile were near null in both ER+/TAM+ and ER-/TAM- patients. When examining combined 14-3-3ζ staining, the association increased in the ER+/TAM+ group (adjusted OR 1.44, 95% confidence interval (CI) 1.05, 1.99). A nearly twofold increase in odds of recurrence was observed in above the 75th percentile staining of combined 14-3-3ζ, both for ER+/TAM+ patients (adjusted OR 1.93, 95% CI 1.15, 3.24) and ER-/TAM- patients (adjusted OR 1.93, 95% CI 1.03, 3.62), indicating potential prognostic utility.

CONCLUSION

Evidence is lacking to conclude that 14-3-3ζ is a useful marker of tamoxifen resistance; however, 14-3-3ζ expression is a potentially useful prognostic marker of breast cancer recurrence. Independent utility beyond established prognostic markers needs to be determined.

Apolipoprotein D expression does not predict breast cancer recurrence among tamoxifen-treated patients

BACKGROUND

Apolipoprotein D (ApoD) has been proposed as a predictor of breast cancer recurrence among estrogen receptor-positive (ER+), tamoxifen-treated patients.

METHODS

We conducted a population-based case-control study nested in a population of 11,251 women aged 35-69 years at diagnosis with Stage I-III breast cancer between 1985 and 2001 on Denmark's Jutland Peninsula and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent or contralateral breast cancers cases among women with ER+ disease treated with tamoxifen for at least 1 year and 300 cases in women with ER- disease never treated with tamoxifen. We matched one control subject per case and assessed ApoD expression in the tumor cell nucleus and cytoplasm using tissue microarray immunohistochemistry. We computed the odds ratio (OR) associating ApoD expression with recurrence and adjusted for potential confounding using logistic regression.

RESULTS

Cytoplasmic ApoD expression was seen in 68% of ER+ tumors, in 66% of ER- tumors, and in 66% of controls across both groups. In women with ER+ tumors, the associations of cytoplasmic ApoD expression with recurrence (OR = 1.0; 95% CI = 0.7 to 1.4) and increasing cytoplasmic expression with recurrence (OR = 1.0; 95% CI = 0.996 to 1.003) were null, as were those for women with ER- tumors. Associations for nuclear ApoD expression and combined nuclear and cytoplasmic expression were similarly near-null.

CONCLUSION

ApoD expression is likely not a predictor of recurrence in tamoxifen-treated patients.

IMPACT

This study eliminates the previously suggested marker ApoD as a predictor of recurrence among tamoxifen-treated women.

Pak1, adjuvant tamoxifen therapy, and breast cancer recurrence risk in a Danish population-based study

Background Adjuvant tamoxifen therapy approximately halves the risk of estrogen receptor-positive (ER+) breast cancer recurrence, but many women do not respond to therapy. Observational studies nested in clinical trial populations suggest that overexpression or nuclear localization of p21-activated kinase 1 (Pak1) in primary tumors predicts tamoxifen failure. Material and methods We measured the association between Pak1 expression and breast cancer recurrence in a Danish population-based case-control study. Pak1 cytoplasmic expression level and nuclear positivity were determined by immunohistochemical staining of primary breast tumors from recurrence cases and matched controls from two breast cancer populations; women diagnosed with ER-positive tumors who received at least one year of tamoxifen therapy (ER+/TAM+), and women diagnosed with ER-negative tumors who survived for at least one year (ER-/TAM-). Pak1 staining was assessed by a single, blinded pathologist, and associations were estimated with conditional logistic regression models. Results We included 541 recurrence cases and 1:1 matched controls from the ER+/TAM + group and 300 recurrence cases and 1:1 matched controls from the ER-/TAM - group. Pak1 cytoplasmic intensity was not associated with breast cancer recurrence in either group (ER+/TAM + ORadj for strong vs. no cytoplasmic staining = 0.91, 95% CI 0.57, 1.5; ER-/TAM - ORadj for strong vs. no cytoplasmic staining = 0.74, 95% CI 0.39, 1.4). Associations between Pak1 nuclear positivity and breast cancer recurrence were similarly near null in both groups. Conclusion Pak1 positivity in primary breast tumors was neither predictive nor prognostic in this prospective, population-based study.

Breast cancer screening controversies: who, when, why, and how?

Mammographic screening is effective in reducing mortality from breast cancer. The issue is not whether mammography is effective, but whether the false positive rate and false negative rates can be reduced. This review will discuss controversies including the reduction in breast cancer mortality, overdiagnosis, the ideal screening candidate, and the optimal imaging modality for breast cancer screening. The article will compare and contrast screening mammography, tomosynthesis, whole-breast screening ultrasound, magnetic resonance imaging, and molecular breast imaging. Though supplemental imaging modalities are being utilized to improve breast cancer diagnosis, mammography still remains the gold standard for breast cancer screening.

Glucocorticoid prescriptions and breast cancer recurrence: a Danish nationwide prospective cohort study

BACKGROUND

Treatment with synthetic glucocorticoids (GCs) depresses the immune response and may therefore modify cancer outcomes. We investigated the association between GC use and breast cancer recurrence.

MATERIALS AND METHODS

We conducted a population-based cohort study to examine the risk of breast cancer recurrence associated with GC use among incident stage I-III female breast cancer patients aged >18 years diagnosed 1996-2003 in Denmark. Data on patients, clinical and treatment factors, recurrence, and comorbidities as well as data on GC prescriptions and potential confounders were obtained from Danish population-based medical registries. GCs were categorized according to administrative route: systemic, inhaled, or intestinal. Women were followed for up to 10 years or until 31 December 2008. We used Cox proportional hazards regression models to compute hazard ratios (HRs) and associated 95% confidence intervals (95% CIs) to evaluate the association between GC use and recurrence. Time-varying drug exposures were lagged by 1 year.

RESULTS

We included 18 251 breast cancer patients. Median recurrence follow-up was 6.9 years; 3408 women developed recurrence during follow-up. Four thousand six hundred two women filled at least one GC prescription after diagnosis. In unadjusted models, no association was observed among users of systemic, inhaled, and intestinal GCs (HRsystemic = 1.1, 95% CI 0.9-1.3; HRinhaled = 0.9, 95% CI 0.7-1.0; and HRintestinal = 1.0, 95% CI 0.9-1.2) versus nonusers. In adjusted models, the results were also near null (HRsystemic = 1.1, 95% CI 0.9-1.2; HRinhaled = 0.8, 95% CI 0.7-1.0; and HRintestinal = 1.0, 95% CI 0.8-1.2).

CONCLUSION

We found no evidence of an effect of GC use on breast cancer recurrence.

Comparative analysis of breast cancer mortality following mammography screening in Denmark and Norway

BACKGROUND

Denmark and Norway are the best countries to study effects of mammography screening, because they are the only countries with stepwise introduction of nationwide mammography screening, enabling comparative effectiveness studies of high quality. Although Denmark and Norway are countries with similar populations and health care systems, reported reductions in breast cancer mortality (incidence-based) caused by screening differed vastly; 25% in Denmark versus 10% in Norway. This study explores reasons for this difference.

PATIENTS AND METHODS

We compared two published studies from the Danish and Norwegian screening programs (Olsen et al., 2005; Kalager et al., 2010) investigating biennial mammography screening for women age 50-69 years. Four comparison groups of women were constructed ('current' and 'historical screening groups'; 'current' and 'historical nonscreening groups') based on county of residence. We calculated incidence-based breast cancer mortality in the current versus the historical period for screening and nonscreening groups, using mortality rate ratios (MRR) in the two countries, accounting for concomitant changes in breast cancer mortality.

RESULTS

In the screening groups, similar reductions in breast cancer mortality were found when periods preceding and following start of screening were compared, in Denmark [25%; MRR 0.75; 95% confidence interval (CI) 0.64% to 0.88%] and in Norway (28%; MRR 0.72; 95% CI 0.63% to 0.81%). However, mortality increased in Denmark in the current nonscreening group compared with the historical nonscreening group; for women >59 years, breast cancer mortality increased by 14% (MRR 1.14, 95% CI 1.07-1.22), whereas in Norway a 19% reduction was seen (MRR 0.81, 95% CI 0.72-0.92). This increase accounts for the different relative effect of screening in Denmark and Norway; 25% breast cancer mortality reduction in Denmark, 10% in Norway.

CONCLUSIONS

The seemingly larger effect of screening in Denmark may not be solely attributable to screening itself, but to increased breast cancer mortality in women older than 59 years not invited to screening.

Real and artificial controversies in breast cancer screening

SUMMARY We review the apparent disparities between different reviews of the effects of mammographic screening on mortality from breast cancer and overdiagnosis. When results of each review are expressed with respect to a common population and a common baseline, all find a substantial mortality benefit and variation among estimates is minor. There are genuine disagreements about overdiagnosis, but methods that take account of lead time and underlying incidence trends yield estimates of overdiagnosis that are modest and are outweighed by the mortality benefit. There is potential for individualized screening regimens, particularly with respect to breast density.

Breast cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK, 2000-2007: a population-based study

BACKGROUND

We investigate whether differences in breast cancer survival in six high-income countries can be explained by differences in stage at diagnosis using routine data from population-based cancer registries.

METHODS

We analysed the data on 257,362 women diagnosed with breast cancer during 2000-7 and registered in 13 population-based cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Flexible parametric hazard models were used to estimate net survival and the excess hazard of dying from breast cancer up to 3 years after diagnosis.

RESULTS

Age-standardised 3-year net survival was 87-89% in the UK and Denmark, and 91-94% in the other four countries. Stage at diagnosis was relatively advanced in Denmark: only 30% of women had Tumour, Nodes, Metastasis (TNM) stage I disease, compared with 42-45% elsewhere. Women in the UK had low survival for TNM stage III-IV disease compared with other countries.

CONCLUSION

International differences in breast cancer survival are partly explained by differences in stage at diagnosis, and partly by differences in stage-specific survival. Low overall survival arises if the stage distribution is adverse (e.g. Denmark) but stage-specific survival is normal; or if the stage distribution is typical but stage-specific survival is low (e.g. UK). International differences in staging diagnostics and stage-specific cancer therapies should be investigated.

Statin prescriptions and breast cancer recurrence risk: a Danish nationwide prospective cohort study

BACKGROUND

Accumulating evidence suggests that statins affect diseases other than cardiovascular disease, including cancer, and that these effects may depend on the lipid solubility of specific statins. Though many studies have reported an association between statin use and breast cancer incidence, the relationship between statin use and breast cancer recurrence has not been well studied.

METHODS

We conducted a nationwide, population-based prospective cohort study of all female residents in Denmark diagnosed with stage I-III invasive breast carcinoma who were reported to the Danish Breast Cancer Cooperative Group registry between 1996 and 2003 (n = 18,769). Women were followed for a median of 6.8 years after diagnosis. Prescriptions for lipophilic and hydrophilic statins were ascertained from the national electronic pharmacy database. Associations between statin prescriptions and breast cancer recurrence were estimated with generalized linear models and Cox proportional hazards regression with adjustment for age and menopausal status at diagnosis; histological grade; estrogen receptor status; receipt of adjuvant therapy; type of primary surgery received; pre-diagnosis hormone replacement therapy; and co-prescriptions of aspirin, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, or anticoagulants. All statistical tests were two-sided.

RESULTS

Most prescriptions for lipophilic statins in the study population were for simvastatin. Exclusive simvastatin users experienced approximately 10 fewer breast cancer recurrences per 100 women after 10 years of follow-up (adjusted 10-year risk difference = -0.10, 95% confidence interval = -0.11 to -0.08), compared with women who were not prescribed a statin. Exclusive hydrophilic statin users had approximately the same risk of breast cancer recurrence as women not prescribed a statin over follow-up (adjusted 10-year risk difference = 0.05, 95% confidence interval = -0.01 to 0.11).

CONCLUSIONS

Simvastatin, a highly lipophilic statin, was associated with a reduced risk of breast cancer recurrence among Danish women diagnosed with stage I-III breast carcinoma, whereas no association between hydrophilic statin use and breast cancer recurrence was observed.

CYP2D6 inhibition and breast cancer recurrence in a population-based study in Denmark

BACKGROUND

Cytochrome P450 2D6 (CYP2D6) inhibition reduces the concentration of 4-hydroxylated tamoxifen metabolites, but the clinical relevance remains uncertain.

METHODS

We conducted a large case-control study nested in the population of 11 251 women aged 35-69 years at diagnosis of stage I-III breast cancer between 1985 and 2001 on Denmark's Jutland Peninsula and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent or contralateral breast cancers among women with estrogen receptor-positive (ER+) disease treated with tamoxifen for at least 1 year and 300 cancers in women with ER-negative (ER-) disease never treated with tamoxifen. We matched one control subject per case patient on ER status, menopausal status, stage, calendar time, and county, genotyped the CYP2D6*4 allele to assess genetic inhibition, and ascertained prescription history to assess drug-drug inhibition. We estimated the odds ratio (OR), associating CYP2D6 inhibition with breast cancer recurrence and adjusted for potential confounding with logistic regression. To address bias from incomplete information on CYP2D6 function, we used Monte Carlo simulation to complete a record-level probabilistic bias analysis. All statistical tests were two-sided.

RESULTS

The frequency of the CYP2D6*4 minor allele was 24% in case patients with ER+ tumors, 23% in case patients with ER- tumors, and 22% each in control subjects with ER+ and ER- tumors. In women with ER+ tumors, the associations of one functional allele with recurrence (OR = 0.99; 95% confidence interval = 0.76 to 1.3) and no functional allele with recurrence (OR = 1.4; 95% confidence interval = 0.84 to 2.3) were near null, as were those for women with ER- tumors. The near-null associations persisted when evaluated by intake of medications, by combining genotype with medication history, in the probabilistic bias analysis, or by restricting the analysis to women with ER expression confirmed by re-assay.

CONCLUSION

The association between CYP2D6 inhibition and recurrence in tamoxifen-treated patients is likely null or small.

Why did the breast cancer lymph node status distribution improve in Denmark in the pre-mammography screening period of 1978-1994?

BACKGROUND

Danish breast cancer patients diagnosed in 1978-1994 experienced a trend over time towards a more favourable distribution of lymph node status at time of diagnosis, which was not due to mammography screening. We investigated how this trend could be explained by patient characteristics at diagnosis: age (biological processes), calendar period (e.g. environmental changes), birth cohort (living conditions over a life time), post-menopausal status (a predictor of less favourable nodal status), and tumour diameter (a marker of detection time).

MATERIAL AND METHODS

The data set consisted of 22 955 patients aged 30-69 years at time of diagnosis with known lymph node status, known tumour diameter, known menopausal status, and clinically detected tumours, available from the Danish Breast Cancer Cooperative Group (DBCG). Age, period, cohort, menopausal status, and tumour diameter were used as predictors in generalised linear models with either node-positive status (at least one of the excised lymph nodes being tumour-positive) or severely node-positive status (at least half of the excised lymph nodes being tumour-positive) as outcomes. Lymph node status was assessed both empirically and estimated using an EM algorithm in order to reduce misclassification.

RESULTS AND DISCUSSION

We found that the improved lymph node status distribution was most likely a period effect due to a combination of earlier detection of clinical tumours, explaining most of the trend in node-positive breast cancer and half of the trend in severely node-positive breast cancer, and some unknown factor affecting lymph node status but not necessarily other tumour characteristics.

Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: An audit

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994-2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.

Tamoxifen's protection against breast cancer recurrence is not reduced by concurrent use of the SSRI citalopram

Tamoxifen remains an important adjuvant therapy to reduce the rate of breast cancer recurrence among patients with oestrogen-receptor-positive tumours. Cytochrome P-450 2D6 metabolises tamoxifen to metabolites that more readily bind the oestrogen receptor. This enzyme also metabolises selective serotonin reuptake inhibitors (SSRI), so these widely used drugs – when taken concurrently – may reduce tamoxifen's prevention of breast cancer recurrence. We studied citalopram use in 184 cases of breast cancer recurrence and 184 matched controls without recurrence after equivalent follow-up. Cases and controls were nested in a population of female residents of Northern Denmark with stages I–III oestrogen-receptor-positive breast cancer 1985–2001 and who took tamoxifen for 1, 2, or most often for 5 years. We ascertained prescription histories by linking participants' central personal registry numbers to prescription databases from the National Health Service. Seventeen cases (9%) and 21 controls (11%) received at least one prescription for the SSRI citalopram while taking tamoxifen (adjusted conditional odds ratio=0.85, 95% confidence interval=0.42, 1.7). We also observed no reduction of tamoxifen effectiveness among regular citalopram users (⩾30% overlap with tamoxifen use). These results suggest that concurrent use of citalopram does not reduce tamoxifen's prevention of breast cancer recurrence.

Trends in breast cancer during three decades in Denmark: stage at diagnosis, surgical management and survival

BACKGROUND

Diagnostic and treatment of breast cancer has steadily improved in the last decades; mammography-screening, more aggressive axillary surgery and finally sentinel lymph node biopsies. This study analyses the impact of time trends in diagnostic and surgical procedures on stage at diagnosis and survival in three Danish counties in three decades.

METHODS

We compare extent of disease and outcome in three complete population-based patient cohorts with primary invasive breast cancer, diagnosed in 1986, 1996-1997 and 2002-2003; 3 385 patients, thereby comparing populations with and without centralised breast cancer management, mammography-screening, sentinel lymph node biopsies and the effect of time-period.

RESULTS

The 5-year over-all survival increased significantly (p <0.001) from 74% (70-78) in 1986 to 84% (82-86) in 2002-2003 with a corresponding increase in 10-year relative survival from 63% (58-68) in 1986 to 74% (71-77) in 1996-1997. In 1986 patients from Funen had median 10 lymph-nodes removed vs. median 5 and 7 in the other counties (p <0.001), and significantly more patients had positive lymph-nodes. In 1996-1997 the number of lymph-nodes removed increased significantly in all counties (median 12,13,14). In Funen, mammography-screening was implemented and patients had more favourable stage distribution (p <0.001). This was associated with significantly better over-all survival in univariate- but not in multivariate analysis. In 2002-2003 we found smaller tumors and more favourable stage-distribution in patients from Funen (p <0.001), and the 5-year relative survival increased to 90% (86-93). With increasing attention to the axilla more patients were found with positive nodal status, least in Funen (45% vs. 51% and 53%) (p <0.001). We found no significant differences in over-all survival according to county.

CONCLUSION

During these three decades over-all survival of breast cancer improved. In the earlier periods we found survival differences according to residence, but in the late cohort there were no difference despite better stage distribution in the county with mammography-screening.

Does place matter for cancer survival in Norway? A multilevel analysis of the importance of hospital affiliation and municipality socio-economic resources

Multilevel discrete-time hazard models for cancer mortality in cancer patients were estimated from register and census data to find out whether hospital affiliation and municipality socio-economic resources had an impact on cancer survival in Norway in the 1990s. Affiliation to a small local hospital was a disadvantage in only one health region. There were also other differences between health regions. Most notably, those who lived in Oslo and Southern Norway had a relatively poor survival, given the size of the nearest hospital. In addition to confirming the better prognosis for patients who themselves had high education, it was found that survival improved with increasing average education. This was primarily a result of earlier diagnosis. The impact of the economic situation was less clear. While a high average income was unrelated to mortality, as opposed to the beneficial impact of high individual income, a high unemployment rate, picking up also effects of individual unemployment, had an adverse effect.

Surgical management of invasive breast cancer: a 5-year prospective study of treatment in the Australian Capital Territory and South-Eastern New South Wales

BACKGROUND

Breast cancer is a major health problem in Australia. The aim of the present report is to evaluate the surgical management of invasive breast cancers in our region.

METHODOLOGY

As part of a multidisciplinary quality assurance project, data were collected for the majority of breast cancers treated in our region between July 1997 and June 2002. Participants included surgeons, medical and radiation oncologists, pathologists and general practitioners.

RESULTS

Over the 5-year period, 1069 invasive breast cancers were treated. Mastectomy (52%) was more common than breast conservation. For cancers less than 2 cm in diameter (61%), breast conservation was achieved in 62%. High nuclear grade cancers (27%) resulted in mastectomy in 60%. This treatment pattern was the same for patients living in urban and rural areas and in all age groups. Those patients requiring two or more operations (30%) to achieve surgical clearance still had a 33% rate of breast conservation. Over the last 5 years there has been an increase in sentinel node biopsies (16 sentinel node biopsies during 1998-1999; 64 during 2001-2002) and axillary dissections started to decrease. A small group has had no axillary node biopsy or dissection, mainly patients over 70 years of age. Multimodality treatments increased over the 5-year period of our study with the use of postoperative radiotherapy increasing from 60% to 65% and chemotherapy from 36% to 55%.

CONCLUSIONS

The project has mapped treatment trends for breast cancer in our region and documented the implementation of new treatment methods as well as the increasing use of multidisciplinary management, multimodality treatment and the implementation of best practice guidelines.