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BACKGROUND: We aimed to identify a five-fraction schedule of adjuvant radiotherapy (radiation therapy) delivered in 1 week that is non-inferior in terms of local cancer control and is as safe as an international standard 15-fraction regimen after primary surgery for early breast cancer. Here, we present 5-year results of the FAST-Forward trial.METHODS: FAST-Forward is a multicentre, phase 3, randomised, non-inferiority trial done at 97 hospitals (47 radiotherapy centres and 50 referring hospitals) in the UK. Patients aged at least 18 years with invasive carcinoma of the breast (pT1-3, pN0-1, M0) after breast conservation surgery or mastectomy were eligible. We randomly allocated patients to either 40 Gy in 15 fractions (over 3 weeks), 27 Gy in five fractions (over 1 week), or 26 Gy in five fractions (over 1 week) to the whole breast or chest wall. Allocation was not masked because of the nature of the intervention. The primary endpoint was ipsilateral breast tumour relapse; assuming a 2% 5-year incidence for 40 Gy, non-inferiority was predefined as ≤1·6% excess for five-fraction schedules (critical hazard ratio [HR] of 1·81). Normal tissue effects were assessed by clinicians, patients, and from photographs. This trial is registered at isrctn.com, ISRCTN19906132.FINDINGS: Between Nov 24, 2011, and June 19, 2014, we recruited and obtained consent from 4096 patients from 97 UK centres, of whom 1361 were assigned to the 40 Gy schedule, 1367 to the 27 Gy schedule, and 1368 to the 26 Gy schedule. At a median follow-up of 71·5 months (IQR 71·3 to 71·7), the primary endpoint event occurred in 79 patients (31 in the 40 Gy group, 27 in the 27 Gy group, and 21 in the 26 Gy group); HRs versus 40 Gy in 15 fractions were 0·86 (95% CI 0·51 to 1·44) for 27 Gy in five fractions and 0·67 (0·38 to 1·16) for 26 Gy in five fractions. 5-year incidence of ipsilateral breast tumour relapse after 40 Gy was 2·1% (1·4 to 3·1); estimated absolute differences versus 40 Gy in 15 fractions were -0·3% (-1·0 to 0·9) for 27 Gy in five fractions (probability of incorrectly accepting an inferior five-fraction schedule: p=0·0022 vs 40 Gy in 15 fractions) and -0·7% (-1·3 to 0·3) for 26 Gy in five fractions (p=0·00019 vs 40 Gy in 15 fractions). At 5 years, any moderate or marked clinician-assessed normal tissue effects in the breast or chest wall was reported for 98 of 986 (9·9%) 40 Gy patients, 155 (15·4%) of 1005 27 Gy patients, and 121 of 1020 (11·9%) 26 Gy patients. Across all clinician assessments from 1-5 years, odds ratios versus 40 Gy in 15 fractions were 1·55 (95% CI 1·32 to 1·83, pINTERPRETATION: 26 Gy in five fractions over 1 week is non-inferior to the standard of 40 Gy in 15 fractions over 3 weeks for local tumour control, and is as safe in terms of normal tissue effects up to 5 years for patients prescribed adjuvant local radiotherapy after primary surgery for early-stage breast cancer.FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Breast cancer is the first cause of cancer-related death in Portuguese women. This study aimed to characterize female breast cancer mortality in Portugal in the period between 2002 and 2013, with a special focus on spatiotemporal patterns.The breast cancer mortality rate was studied using descriptive analysis (unadjusted and age-adjusted), and spatiotemporal clustering analyses.In 2002 - 2013 the breast cancer mortality rate was 28.47/100 000 inhabitants and the age-adjusted mortality rate was 19.46/100 000 inhabitants. In this period the Lisbon region (urban), Alentejo and Algarve (rural) presented higher breast cancer mortality rate, but Madeira (urban), Lisbon and Algarve had higher age-adjusted mortality rate. In the spatiotemporal analysis, the overall mortality rate showed an increasing trend of 1.218%/year, without spatial variations. Also, different patterns were detected in the50, 50 - 64 and ≥ 65 age-groups (+ 0.725%, - 1.781% and + 0.896%, respectively). One temporal (2004 - 2006) and one spatiotemporal cluster (North coast) presented significantly lower mortality rate than expected for the period and/or area (26.2 and 16.1/100 000 inhabitants, respectively). Conversely, two spatiotemporal clusters, located in the city of Lisbon (2002 - 2007) and in the Centre region (2008 - 2013), presented significantly higher breast cancer mortality rate than expected (48.6 and 34.9/100 000 inhabitants, relative risk: 1.74 and 1.26, respectively).The annual female crude and adjusted breast cancer mortality rate matched previous publications. However the annual increase detected in the unadjusted rate clashes with the published literature. Overall, the presence of spatiotemporal clusters supports the uneven distribution of the breast cancer mortality reported previously in the different Portuguese regions.This study identified areas and trends of the female breast cancer mortality rate, showing high spatiotemporal variations that must support further detailed studies/interventions.Introdução: O cancro da mama é a primeira causa de morte relacionada com cancro em mulheres portuguesas. Este estudo pretende caracterizar a mortalidade feminina por cancro da mama em Portugal no período de 2002 a 2013, com enfoque nos padrões espácio-temporais. Material e Métodos: A taxa de mortalidade por cancro da mama foi estudada com recurso a análise descritiva (bruta e ajustada para a idade), e análise de clustering espácio-temporal. Resultados: Em 2002 – 2013 a taxa de mortalidade por cancro da mama foi 28,47/100 000 habitantes e a taxa de mortalidade ajustada pela idade foi de 19,46/100 000 habitantes. Neste período a região de Lisboa (urbana), Alentejo e Algarve (rural) apresentaram taxas de mortalidade mais elevadas, mas após ajustamento pela idade a Madeira (urbana), Lisboa e Algarve demonstraram taxas de mortalidade superiores. Na análise espácio-temporal, a taxa de mortalidade geral apresentou um crescimento de 1,218%/ano, sem variações espaciais. Adicionalmente, padrões diferentes foram detetados nos grupos de mulheres com50, 50 - 64 e ≥ 65 anos (+ 0,725%, - 1,781% e + 0,896%, respetivamente). Um cluster temporal (2004 – 2006) e um espácio-temporal (costa Norte) apresentaram taxa de mortalidade significativamente mais baixas que o esperado para o período e/ou área (26,2 e16,1/100 000 habitantes, respetivamente). Por outro lado, dois clusters espácio-temporais, localizados na cidade de Lisboa (2002 – 2007) e na zona Centro (2008 – 2013), apresentaram taxas de mortalidade por cancro da mama superiores às expectáveis (48,6 e 34,9/100 000 habitantes, risco relativo: 1,74 e 1,26, respetivamente). Discussão: A taxa anual bruta e ajustada para a idade de mortalidade por cancro da mama aproximam-se das anteriormente publicadas. No entanto, o aumento anual nas taxas brutas contrasta com a literatura neste tópico. A presença de clusters espácio-temporais suporta a distribuição variável da taxa de mortalidade por cancro da mama nas diferentes regiões do país. Conclusão: Este estudo identificou áreas e tendências na taxa de mortalidade feminina por cancro da mama, demonstrando variações espácio-temporais nesta taxa que suportam estudos e intervenções mais detalhadas nesta área.

Introduction: Information on breast cancer mortality can be useful for planning public policies. Objective: Analyze the trend of mortality from breast cancer in women in the state of Ceará. Method: Exploratory descriptive study whose variables were: year and place of death, sex, basic cause of death, and age in an age range. The statistical analysis of the data was performed in the Gretl program by means of linear regression where the breast cancer mortality rates were considered dependent variables and the years of the study period, the independent variables. The regression coefficients, their 95% confidence intervals and the respective p-values of the tests of statistical significance were presented. Results: 141,168 deaths from breast cancer were reported across Brazil. The state of Ceará represents 3.73% of this total and had a growth of 92.7% in the number of deaths from breast cancer. There was an increase in specific mortality rates from the age of 40 onwards, increasing until the last age group surveyed. Conclusion: The analysis carried out in this study showed a progressive trend in the number of deaths in Ceará, in the Northeast and in Brazil. It is essential to develop strategies that prioritize actions to shorten the delay in the management of breast cancer cases in health services so that early detection reduces the number of deaths. Introducción: la información sobre mortalidad por cáncer de mama puede ser útil para planificar políticas públicas. Objetivo: Analizar la tendencia de mortalidad por cáncer de seno en mujeres en el Estado de Ceará. Método: Estudio exploratorio descriptivo cuyas variables utilizadas fueron: año y lugar de muerte, sexo, causa básica de muerte y edad en un rango de edad. El análisis estadístico de los datos se realizó en el programa Gretl mediante regresión lineal donde las tasas de mortalidad por cáncer de mama se consideraron variables dependientes y los años del período estudiado fueron variables independientes. Se presentaron los coeficientes de regresión, sus intervalos de confianza del 95% y los respectivos valores p de las pruebas de significación estadística. Resultados: Se notificaron 141.168 muertes por cáncer de mama en todo Brasil. El Estado de Ceará representa el 3,73% de este total e mostró un aumento del 92,7% en el número de muertes por cáncer de seno. Hubo un aumento en las tasas de mortalidad específicas a partir de los 40 años, aumentando hasta el último grupo de edad encuestado. Conclusión: El análisis realizado en este estudio mostró una tendencia progresiva en el número de muertes en Ceará, en el noreste y en Brasil. Es esencial desarrollar estrategias que prioricen las acciones para reducir la demora en el manejo de casos de cáncer de seno en los servicios de salud para que la detección temprana, reduciendo así el número de muertes. Introdução: Informações sobre mortalidade por câncer de mama podem ser úteis para o planejamento de políticas públicas. Objetivo: Analisar a tendência da mortalidade por câncer de mama em mulheres no Estado do Ceará. Método: Estudo descritivo exploratório cujas variáveis utilizadas foram: ano e local da ocorrência do óbito, sexo, causa básica de morte e a idade em faixa etária. A análise estatística dos dados foi realizada no programa Gretl, por meio de regressão linear, no qual as taxas de mortalidade por câncer de mama foram consideradas variáveis dependentes e os anos do período estudado, variáveis independentes. Foram apresentados os coeficientes de regressão, seus intervalos de confiança de 95% e os respectivos valores-p dos testes de significância estatística. Resultados: Foram notificados 141.168 óbitos por câncer de mama em todo o Brasil. O Estado Ceará representa 3,73% desse total e apresentou um aumento de 92,7% no número de óbitos por câncer de mama. Observou-se um aumento das taxas específicas de mortalidade a partir dos 40 anos de idade se mantendo crescente até a última faixa etária pesquisada. Conclusão: A análise realizada neste estudo evidenciou uma tendência progressiva no número de óbitos no Ceará, no Nordeste e no Brasil. É imprescindível a elaboração de estratégias que priorizem ações, a fim reduzir o atraso na condução dos casos de câncer de mama nos serviços de saúde para que a detecção precoce reduza o número de óbitos.

Introduction: Breast cancer is the neoplasm that causes more deaths in the female population worldwide and in Brazil. Objective: To analyze the epidemiological profile, trend and spatial distribution of female breast cancer mortality in Alagoas from 2001 to 2016. Method: Mixed ecological study, including female deaths from breast cancer recorded in Alagoas in the period. Sociodemographic variables (age, color/race, marital status, education and place of occurrence) and the specific mortality rate by age group and municipality were used. Data were obtained from the Mortality Information System and population data from the Brazilian Institute of Geography and Statistics (IBGE). The trend analysis used the Joinpoint regression model and Moran statistics for the spatial distribution. Results: 1,816 deaths in the period, 25.3% between 50-59 years, 46.3%, brown race, 36.1%, married, 35.5%, with less than 8 years of education and 67.2% of deaths within the hospital environment. The age groups of 40 years or older showed a growing trend and the highest growth, for 80 years old or more (average annual percent variation: 9.2; p

Introduction: Breast cancer is disease of relatively good prognostics if diagnosed and treated precociously, an average of 80% of the patients survive after five years of the diagnoses, however what we observe is that it is the second neoplasm in the world. Objective: To analyze the growth of breast cancer mortality rate and the conditions of human development in Brazil. Method: It is a descriptive study of temporary series along the two terms from 1998 to 2002 and 2008 to 2012. Results: When we analyze the mortality rates and the Human Development Index, comparing the first five years (from 1998 to 2002) with the second term of five years (2008 to 2012), we observed a growth in the mortality rate in the majority of the capitals, except from Maceió, Porto Alegre, Florianópolis and Palmas. There was a growth in the HDI in all capitals of the country. There was a growth in the Human Development Index in all capitals of the country. Conclusion: There was a general growth in the breast cancer rates in Brasil, although the conditions of Human Development nation wide. Introducción: El cáncer de mama es considerado de relativo buen pronóstico si se diagnostica y tratado precozmente con sobrevida media del 80% después de cinco años del diagnóstico, pero lo que se observa es que se trata de la segunda neoplasia más incidente en todo el mundo. Objetivo: Analizar el crecimiento de la tasa de mortalidad por cáncer de mama y las condiciones de desarrollo humano en Brasil. Método: Se trata de un estudio descriptivo de series temporales en los dos períodos comprendidos entre 1998 a 2002 y 2008 a 2012. Resultados: Ao se analizaren las tasas de mortalidad y los IDH comparando el primer quinquenio (período 1998-2002) con el segundo, (Período 2008-2012), se observó un aumento en la tasa de mortalidad de la mayoría de las capitales con excepción de Maceió, Porto Alegre, Florianópolis y Palmas. Y hubo un aumento del IDH en todas las capitales del país. Conclusión: Se ha producido un crecimiento del cáncer de mama en Brasil de forma general, incluso habiendo también una mejora de las condiciones de desarrollo humano en todo el país. Introdução: O câncer de mama é considerado de relativo bom prognóstico se diagnosticado e tratado precocemente com sobrevida média de 80% após cinco anos do diagnóstico, porém o que se observa é que se trata da segunda neoplasia mais incidente em todo o mundo. Objetivo: Analisar o crescimento da taxa de mortalidade por câncer de mama e as condições de desenvolvimento humano no Brasil. Método: Trata-se de um estudo descritivo de séries temporais nos dois períodos compreendidos entre 1998 a 2002 e 2008 a 2012. Resultados: Ao se analisarem as taxas de mortalidade e os índices de Desenvolvimento Humano (IDH), comparando o primeiro quinquênio (período de 1998-2002) com o segundo (período de 2008-2012), foi observado um aumento na taxa de mortalidade da maioria das capitais, com exceção de Maceió, Porto Alegre, Florianópolis e Palmas. Ocorreu um aumento do IDH em todas as capitais do país. Conclusão: Houve crescimento nos índices de câncer de mama no Brasil de forma geral mesmo havendo também uma melhoria das condições de desenvolvimento humano em todo o país.

BACKGROUND: The 70-gene signature test (MammaPrint) has been shown to improve prediction of clinical outcome in women with early-stage breast cancer. We sought to provide prospective evidence of the clinical utility of the addition of the 70-gene signature to standard clinical-pathological criteria in selecting patients for adjuvant chemotherapy. METHODS: In this randomized, phase 3 study, we enrolled 6693 women with early-stage breast cancer and determined their genomic risk (using the 70-gene signature) and their clinical risk (using a modified version of Adjuvant! Online). Women at low clinical and genomic risk did not receive chemotherapy, whereas those at high clinical and genomic risk did receive such therapy. In patients with discordant risk results, either the genomic risk or the clinical risk was used to determine the use of chemotherapy. The primary goal was to assess whether, among patients with high-risk clinical features and a low-risk gene-expression profile who did not receive chemotherapy, the lower boundary of the 95% confidence interval for the rate of 5-year survival without distant metastasis would be 92% (i.e., the noninferiority boundary) or higher. RESULTS: A total of 1550 patients (23.2%) were deemed to be at high clinical risk and low genomic risk. At 5 years, the rate of survival without distant metastasis in this group was 94.7% (95% confidence interval, 92.5 to 96.2) among those not receiving chemotherapy. The absolute difference in this survival rate between these patients and those who received chemotherapy was 1.5 percentage points, with the rate being lower without chemotherapy. Similar rates of survival without distant metastasis were reported in the subgroup of patients who had estrogen-receptor-positive, human epidermal growth factor receptor 2-negative, and either node-negative or node-positive disease. CONCLUSIONS: Among women with early-stage breast cancer who were at high clinical risk and low genomic risk for recurrence, the receipt of no chemotherapy on the basis of the 70-gene signature led to a 5-year rate of survival without distant metastasis that was 1.5 percentage points lower than the rate with chemotherapy. Given these findings, approximately 46% of women with breast cancer who are at high clinical risk might not require chemotherapy. (Funded by the European Commission Sixth Framework Program and others; ClinicalTrials.gov number, NCT00433589; EudraCT number, 2005-002625-31.).

Objective To determine whether there is an association between dietary patterns/indices and foods from the main food groups (highest vs lowest intakes) prior to or after cancer diagnosis and mortality and cancer recurrence in cancer survivors. Participants Survivors of common cancers with a 10-year survival rate of >= 50%: bladder, bowel, breast, cervical, kidney, laryngeal, prostate, testicular, uterine cancer, malignant melanoma and (non-) Hodgkin's lymphoma. Outcome measures Mortality (overall, cancer-specific, from other causes) and cancer recurrence. Information sources PubMed, Embase and the Cochrane Library were searched from inception to April 2017. Additional studies were identified by searching reference lists. Two authors independently screened titles and abstracts, assessed study quality and extracted the data. Results A total of 38 studies were included. The risk of bias was rated low for the included randomised controlled trials (RCTs) and moderate for the cohort studies. The quality of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach and was rated moderate (RCTs), and (very) low (cohort studies). Reducing the amount of fat after diagnosis appears to decrease the risk of breast cancer recurrence. Adherence to a high-quality diet and prudent diet after diagnosis appears to decrease the risk of death from other causes (and overall mortality for high-quality diet) in breast cancer survivors. Adherence to a Western diet, before and after diagnosis, appears to increase the risk of overall mortality and death from other causes among breast cancer survivors. Evidence from studies among other cancer survivors was too limited or could not be identified. Conclusion For many cancer survivors, there is little evidence to date to indicate that particular dietary behaviours influence outcomes with regard to recurrence and mortality. Notwithstanding, limited evidence suggests that a low-fat diet, a high-quality diet and a prudent diet are beneficial for breast cancer survivors, while a Western diet is detrimental for breast cancer survivors.

The prognosis of the association between Breast Cancer (BC) and Meningioma (M) is unknown. To evaluate the survival impact of tumor exposure sequence in patients with both tumors. Patients were divided in groups according to the tumors sequence: BC before M (group 1), synchronous BC + M (group 2) and BC after M (group 3). The SEER database was used. Demographics, meningioma and breast cancer variables were analyzed. The primary outcome was oncological survival. A total of 1715 patients were included (median follow-up:84 months). Group 2 had the shortest survival (median:32 months) and group 1 the longest (median:110 months). On the unadjusted analysis, group 2 had the shortest survival (HR:3.13, 95% CI 1.62-6.04) and adjusted analysis confirmed this finding (HR 3.11, 95% CI 1.58-6.19), with no statistical difference between the metachronous tumors groups. Increasing age (HR:1.13, 95% CI 1.11-1.15, p 0.05). The association between surgery and radiotherapy in BC treatment improved the outcome (HR 0.37, 95% CI 0.23-0.93, p 0.05) on stratified analysis. Synchronous tumors were associated with lower survival. Increasing age had a negative influence on patient survival. Although surgery and radiotherapy for breast cancer had a positive influence in the outcome, meningioma treatment was not related with survival. Grade III meningioma and hormonal receptor status only influenced synchronous tumors patient survival. info:eu-repo/semantics/publishedVersion

Background Cancer mortality peaked in the European Union (EU) in the late 1980s and declined thereafter. Materials and methods We analyzed EU cancer mortality data provided by the World Health Organization in 1970–2003, using joinpoint analysis. Results Overall, cancer mortality levelled off in men since 1988 and declined in 1993–2003 (annual percent change, APC = -1.3%). In women, a steady decline has been observed since the early 1970s. The decline in male cancer mortality has been driven by lung cancer, which levelled off since the late 1980s and declined thereafter (APC = 2.7% in 1997–2003). Recent decreases were also observed for other tobacco-related cancers, as oral cavity/pharynx, esophagus, larynx and bladder, as well as for colorectal (APC = -0.9% in 1992–2003) and prostate cancers (APC = -1.0% in 1994–2003). In women, breast cancer mortality levelled off since the early 1990s and declined thereafter (APC = -1.0% in 1998–2003). Female mortality declined through the period 1970–2003 for colorectal and uterine cancer, while it increased over the last three decades for lung cancer (APC = 4.6% in 2001–2003). In both sexes, mortality declined in 1970–2003 for stomach cancer and for a few cancers amenable to treatment. Conclusion This update analysis of the mortality from cancer in the EU shows favorable patterns over recent years in both sexes.

Purpose The aim of this nationwide, register-based cohort study was to determine whether women treated for depression before primary early-stage breast cancer are at increased risk for receiving treatment that is not in accordance with national guidelines and for poorer survival. Material and Methods We identified 45,325 women with early breast cancer diagnosed in Denmark from 1998 to 2011. Of these, 744 women (2%) had had a previous hospital contact (as an inpatient or outpatient) for depression and another 6,068 (13%) had been treated with antidepressants. Associations between previous treatment of depression and risk of receiving nonguideline treatment of breast cancer were assessed in multivariable logistic regression analyses. We compared the overall survival, breast cancer–specific survival, and risk of death by suicide of women who were and were not treated for depression before breast cancer in multivariable Cox regression analyses. Results Tumor stage did not indicate a delay in diagnosis of breast cancer in women previously treated for depression; however, those given antidepressants before breast cancer had a significantly increased risk of receiving nonguideline treatment (odds ratio, 1.14; 95% CI, 1.03 to 1.27) and significantly worse overall survival (hazard ratio, 1.21; 95% CI, 1.14 to 1.28) and breast cancer–specific survival (hazard ratio, 1.11; 95% CI, 1.03 to 1.20). Increased but nonsignificant estimated risks were also found for women with previous hospital contacts for depression. In subgroup analyses, the association of depression with poor survival was particularly strong among women who did not receive the indicated adjuvant systemic therapy. Conclusion Women previously treated for depression constitute a large subgroup of patients with breast cancer who are at risk for receiving nonguideline breast cancer treatment, which probably contributes to poorer overall and breast cancer–specific survival.

Background: While comorbidity indices are useful for describing trends in survival, information on specific comorbidities is needed for the clinician advising the individual breast cancer patient on her treatment. Here we present an analysis of overall survival, breast cancer-specific mortality, and effect of medical adjuvant treatment among breast cancer patients suffering from 12 major comorbidities compared with breast cancer patients without comorbidities. Material and methods: The study population was identified from the Danish Breast Cancer Cooperative Group and included 59,673 women without prior cancer diagnosed with early-stage breast cancer in Denmark from 1990 to 2008 with an estimated median potential follow-up of 14 years and 10 months. Information on comorbidity and causes of death was derived from population-based registries. Multivariable proportional hazards regression models were used to assess the effect of comorbidities on mortality, all-cause and breast cancer specific, using patients without comorbidity as reference. Results: At breast cancer diagnosis, 16% of patients had comorbidities and 84% did not. Compared with the latter, the risk of dying from all causes was significantly increased for all types of comorbidity, but the risk of dying from breast cancer was significantly increased only for peripheral vascular disease, dementia, chronic pulmonary disease, liver, and renal diseases. Comorbidities diagnosed within 5 years of breast cancer diagnosis correlated with a greater risk of dying than comorbidities diagnosed more than 5 years before breast cancer diagnosis. With a few exceptions, the effect of adjuvant treatment on breast cancer mortality was similar among patients with and without comorbidity. Conclusion: Breast cancer mortality was not significantly elevated for patients with prior myocardial infarction, congestive heart failure, cerebrovascular disease, connective tissue disease, ulcer disease, and diabetes. The similar effect of adjuvant treatment in patients with and without comorbidity underlines the importance of adhering to guideline therapy.

BACKGROUND The Norwegian Breast Cancer Screening Program started in 1996. To the authors' knowledge, this is the first report using individual-based data on invitation and participation to analyze breast cancer mortality among screened and nonscreened women in the program. METHODS Information on dates of invitation, attendance, breast cancer diagnosis, emigration, death, and cause of death was linked by using unique 11-digit personal identification numbers assigned all inhabitants of Norway at birth or immigration. In total, 699,628 women ages 50 to 69 years without prior a diagnosis of breast cancer were invited to the program from 1996 to 2009 and were followed for breast cancer through 2009 and death through 2010. Incidence-based breast cancer mortality rate ratios (MRRs) were compared between the screened and nonscreened cohorts using a Poisson regression model. The MRRs were adjusted for calendar period, attained age, years since inclusion in the cohorts, and self-selection bias. RESULTS The crude breast cancer mortality rate was 20.7 per 100,000 women-years for the screened cohort compared with 39.7 per 100,000 women-years for the nonscreened cohort, resulting in an MRR of 0.52 (95% confidence interval, 0.47-0.59). The mortality reduction associated with attendance in the program was 43% (MRR, 0.57; 95% confidence interval, 0.51-0.64) after adjusting for calendar period, attained age, years after inclusion in the cohort, and self-selection bias. CONCLUSIONS After 15 years of follow-up, a 43% reduction in mortality was observed among women who attended the national mammographic screening program in Norway.

Purpose It is unknown whether irradiation of the internal mammary lymph nodes improves survival in patients with early-stage breast cancer. A possible survival benefit might be offset by radiation-induced heart disease. We assessed the effect of internal mammary node irradiation (IMNI) in patients with early-stage node-positive breast cancer. Patients and Methods In this nationwide, prospective population-based cohort study, we included patients who underwent operation for unilateral early-stage node-positive breast cancer. Patients with right-sided disease were allocated to IMNI, whereas patients with left-sided disease were allocated to no IMNI because of the risk of radiation-induced heart disease. The primary end point was overall survival. Secondary end points were breast cancer mortality and distant recurrence. Analyses were by intention to treat. Results A total of 3,089 patients were included. Of these, 1,492 patients were allocated to IMNI, whereas 1,597 patients were allocated to no IMNI. With a median of 8.9 years of follow-up time, the 8-year overall survival rates were 75.9% with IMNI versus 72.2% without IMNI. The adjusted hazard ratio (HR) for death was 0.82 (95% CI, 0.72 to 0.94; P = .005). Breast cancer mortality was 20.9% with IMNI versus 23.4% without IMNI (adjusted HR, 0.85; 95% CI, 0.73 to 0.98; P = .03). The risk of distant recurrence at 8 years was 27.4% with IMNI versus 29.7% without IMNI (adjusted HR, 0.89; 95% CI, 0.78 to 1.01; P = .07). The effect of IMNI was more pronounced in patients at high risk of internal mammary node metastasis. Equal numbers in each group died of ischemic heart disease. Conclusion In this naturally allocated, population-based cohort study, IMNI increased overall survival in patients with early-stage node-positive breast cancer.

This study re-examined the differential effect of socioeconomic status on the survival of women with breast cancer in Canada and the United States. Ontario and California cancer registries provided 1,913 cases from urban and rural places. Stage-adjusted cohorts (1998–2000) were followed until 2006. Socioeconomic data were taken from population censuses. SES-survival associations were observed in California, but not in Ontario, and Canadian survival advantages in low-income areas were replicated. A better controlled and updated comparison reaffirmed the equity advantage of Canadian health care.

OBJETIVO: Descrever a mortalidade por câncer de mama feminino no Brasil segundo a cor, nos anos de 2000 e 2010.MÉTODOS: Estudo descritivo, no qual os dados populacionais foram obtidos do Instituto Brasileiro de Geografia e Estatística (IBGE). As informações de óbitos por câncer de mama foram coletadas do Ministério da Saúde, através do Sistema de Informações sobre Mortalidade (SIM). Foram calculadas as taxas de mortalidade bruta por câncer de mama feminino de acordo com a cor e o grupo etário, até 49 anos ou ≥ 50 anos. Os resultados foram também avaliados pelas cinco macrorregiões do país (Norte, Nordeste, Centro-Oeste, Sul e Sudeste).RESULTADOS: No Brasil, em mulheres com 50 anos ou mais, as maiores taxas brutas de mortalidade por câncer de mama em 2000 foram de 62,6/100.000, 46,0/100.000 e 29,7/100.000, entre amarelas, brancas e pretas, respectivamente. Nas mulheres com menos de 50 anos, em 2000, a mortalidade bruta variou de 2,0/100.000 entre as indígenas a 6,8/100.000 entre as mulheres brancas. Após dez anos, em mulheres com idade superior a 50 anos, a taxa bruta de mortalidade entre amarelas, brancas e pretas foi de 21,5, 53,2 e 40,4 por 100.000, respectivamente. Nas macrorregiões do país, as maiores taxas de mortalidade por câncer de mama foram observadas nas mulheres brancas e pretas das regiões Sul e Sudeste. No Nordeste, as taxas de mortalidade em mulheres pretas e pardas dobraram em 2010.CONCLUSÃO: As taxas de mortalidade por câncer de mama apresentam variações étnicas e geográficas. Entretanto, não se pode excluir a possibilidade de que grandes variações tenham ocorrido em decorrência de melhoria na qualidade da informação sobre a mortalidade no país. PURPOSE: To describe the mortality of female breast cancer in Brazil according to color, in the years 2000 and 2010.METHODS: A descriptive study in which demographic data were obtained from the Brazilian Institute of Geography and Statistics (IBGE). The breast cancer death information in Brazil was collected from the Ministry of Health through the Mortality Information System (SIM). The crude mortality rates for female breast cancer were calculated according to color and age group, up to 49 years and ≥50 years. The results obtained were distributed into five geographical regions of the country (North, Northeast, Midwest, South and Southeast).RESULTS: In Brazil, in women aged 50 or more, the highest crude mortality rates of breast cancer in 2000 were 62.6/100,000, 46.0/100,000 and 29.7/100,000 among yellow, white and black women, respectively. In women under 50 years in 2000, the crude mortality ranged from 2.0/100,000 among indigenous women to 6.8/100,000 among white women. After ten years, in women over 50 years, the crude mortality rate among yellow, white and black women was 21.5, 53.2 and 40.4 per 100,000, respectively. In the country's regions, the highest mortality rates of breast cancer were observed in white and black women from the South and Southeast. In the Northeast, mortality rates in black and brown women doubled in 2010.CONCLUSION: Breast cancer mortality rates show ethnic and geographical variations. However, it is not possible to exclude the possibility that large variations have occurred as a result of improvement in the quality of information on mortality in the country.

OBJECTIVES: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii. METHODS: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses. RESULTS: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women. CONCLUSIONS: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

Effects of socioeconomic status on the long-term survival of 808 women with node-negative breast cancer in Canada and the United States were observed. Ontario and California samples diagnosed between 1988 and 1990 were followed until 2006. Socioeconomic data were taken from population censuses. Compared with their California counterparts, residents of low-income urban areas in Ontario experienced a significant 15-year survival advantage (RR = 1.66 [95% CI: 1.00, 2.76]). In these and other vulnerable, lower-middle- to working-class neighborhoods, significantly more Ontario residents gained access to adjuvant radiation therapy (RR = 1.75 [1.21, 2.53]) which seemed associated with better long-term survival (RR = 1.36 [0.99, 1.86]). This stage-adjusted, historical cohort analysis suggests much greater cancer care equity in Canada than in the United States.

Background: This study tested the hypothesis that physician supply thresholds are associated with breast cancer survival in Ontario. Methods: The 5-year survival of 17,820 female breast cancer patients diagnosed between 1995 and 1997 was surveilled until 2003 for all-cause mortality. Physician supply densities in 1991 and 2001 were computed for 49 Ontario regions. Results: There were independent threshold effects for general practitioners (GP; 7.25 per 10,000) and obstetrician/gynecologists (OB/GYN; 6 per 100,000) at or above which women with breast cancer were more likely to survive for 5 years. The respective risk of living in areas undersupplied with OB/ GYN and GP increased 30% to nearly 5-fold during the 1990s. Five-year survival tended to be lower in provincial areas outside of Toronto, which experienced GP (odds ratio, 0.83; 90% CI, 0.70–0.99) and OB/GYN (odds ratio, 0.76; 95% CI, 0.61–0.96) supply decreases. Conclusion: As they do in America, primary care physician supplies in Canada seem to matter in the effective provision of cancer care. Community resources such as health care service endowments, including physician supplies, may be particularly critical to the performance of health care systems such as Canada’s, which aim to provide medically necessary care for all. (J Am Board Fam Med 2010;23:104–108.)

Research into Canada’s physician supply problem, whether it is real or merely perceived, has been nearly exclusively descriptive, with opinionated and often self-interested advocates typically debating the possible effects of various identified supply shortages. However, what are the actual sentinel, population-level health effects of any such developing shortages? Clearly, the rational development of evidence-based physician supply policies will require not only knowledge regarding prevalent changes in primary care and specialist physician supplies and practice patterns but also knowledge concerning the effects that any such changes may have on key population health indicators. Essentially, an answer still is needed to this field’s “so what?” question. Much already is known regarding physician supply trends in Canada, but very little is known regarding important physician supply/population health relations. The objective of this study was to begin to fill this critical policy-relevant knowledge gap. Primary care physician supplies have been associated consistently and significantly with improved health outcomes (all-cause, cancer, heart disease, stroke, and infant mortality) over the past generation in the United States.1 Several US studies focused on a sentinel health indicator of great public health significance—breast cancer—and observed that community, typically county-level, primary care physician supplies were associated significantly with more prevalent screening mammography, more localized disease at diagnosis, and longer breast cancer survival.2–5 These advantages appeared to be fairly specific to primary care, and overall physician supplies generally were not predictive. We are not aware of any such Canadian physician supply/cancer care knowledge. It certainly appears plausible that, in a single-payer, universally accessible healthcare system such as that in Canada, community healthcare service endowments, a key element of which is physician supply, would be critical. In fact, having consistently observed that personal economic resources explain very little of the regional or temporal variability in Canadian cancer care, although they are highly predictive in the United States,6–11 our research group theorized that key community-level resources, such as physician supplies and other healthcare resources, would be even more predictive in Canada. Others have theorized that good primary care predicts not only more effective prevention but also more effective referral and continuity of care.12–14 We therefore hypothesized the following: 1) Primary care physician supplies in Canada are associated significantly with localized breast cancer at the time of diagnosis and with more prevalent 5-year breast cancer survival (Hypothesis 1). 2) Regions in which primary care physician supplies had decreased significantly during the 1990s were significantly disadvantaged on both breast cancer stage at diagnosis and survival (Hypothesis 2).

OBJECTIVES: This study examined whether place and socio-economic status had differential effects on the survival of women diagnosed with breast cancer in Ontario during the 1980s and the 1990s. METHODS: The Ontario Cancer Registry provided 29,934 primary malignant breast cancer cases. Successive historical cohorts (1986-1988 and 1995-1997) were, respectively, followed until 1994 and 2003. Diverse places were compared: the greater metropolitan Toronto area, other cities, ranging in size from 50,000 to a million people, smaller towns and villages, and rural and remote areas. Socio-economic data for each woman's residence at the time of diagnosis were taken from population censuses. RESULTS: Very small cities (6%) with populations between 50,000 and 100,000 were the only places where breast cancer survival had advanced less compared to the province as a whole. Income gradients began to appear, however, in larger cities. Urban residents in the lowest income areas were significantly disadvantaged compared to the highest income areas during the 1990s, but not during the 1980s. CONCLUSION: This historical analysis of breast cancer survival evidenced remarkably equitable advances across nearly all of Ontario's diverse places. The most likely explanation for such substantial equity seems to be Canada's universally accessible, single-payer, health care system.

The treatment of loco-regional recurrence (LRR) after breast cancer is based on the achievement of loco-regional control by radical surgery and adjuvant postoperative radiotherapy. Antiestrogens used as treatment in patients with steroid receptor positive LRR can increase disease free survival. Adjuvant chemotherapy is not applied to patients with LRR who have had radical loco-regional salvage treatment. Further studies are needed to elucidate this issue.

PURPOSE: Extending previous Canadian-United States cancer survival comparisons in large metropolitan areas, this study compares breast cancer survival in smaller metropolitan areas: Winnipeg, Manitoba and Des Moines, Iowa. METHODS: Manitoba and Iowa cancer registries, respectively, provided a total of 2,383 and 1,545 women with breast cancer (1984 to 1992, followed until December 31, 1997). Socioeconomic data for each person's residence at the time of diagnosis was taken from population censuses. RESULTS: Socioeconomic status and breast cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Des Moines, residents of the lowest fifth of income areas in Winnipeg experienced a significant 5-year survival advantage (survival rate ratio [SRR] = 1.14). In these lowest income areas, the Canadian survival advantage was larger among women aged 25 to 64 years (SRR = 1.23), and this was observed in the middle fifth of income areas among this younger cohort (SRR = 1.11). The Canadian survival advantage even seemed apparent in the poorest neighborhoods with relatively high representations of Aboriginal people (SRR = 1.16). CONCLUSION: This study replicated the finding of advantaged Canadian cancer survival in smaller metropolitan areas that had been consistently observed in larger metropolitan areas. Canada's single payer health care system seems to offer similar advantages across a number of diverse urban contexts.

Early detection and proper care of breast cancer are currently the best available approaches to the treatment of patients with the disease. In countries with a breast cancer screening programme, there has been a demonstrated reduction in breast cancer-related mortality. Such reduction has also been observed in Switzerland, a country in which no national programme of screening is available. Although there is no doubt that early diagnosis might have had a major role in reducing breast cancer mortality the magnitude of this effect is unknown. Research with tailored approaches on alternative imaging for early detection of breast cancer in high-risk women and on treatments offered according to proper criteria of responsiveness to therapies is warranted.

Background. The Edinburgh randomised trial of breast- cancer screening recruited women aged 45-64 years from 1978 to 1981 (cohort 1), and those aged 45-49 years during 1982-85 (cohorts 2 and 3). Results based on 14 years of follow-up and 270000 woman-years of observation are reported.Methods Breast-cancer mortality rates in the intervention group (28628 women offered screening) were compared with those in the control group (26026) with adjustment for socioeconomic status (SES) of general medical practices. Rate ratios were derived by means of logistic regression for the total trial population and for women first offered screening while younger than 50 years. Analyses were by intention to treat.Findings Initial unadjusted results showed a difference of just 13% in breast-cancer mortality rates between the intervention and control groups (156 deaths [5.18 per 10000] vs 167 [6.04 per 10000]; rate ratio 0.87 [95% CI 0.70-1.06]), but the results were influenced by differences in SES by trial group. After adjustment for SES, the rate ratio was 0.79 (95% CI 0.60-1.02). When deaths after diagnosis more than 3 years after the end of the study were censored the rate ratio became 0.71 (0.53-0.95). There was no evidence of heterogeneity by age at entry and no evidence that younger entrants had smaller or delayed benefit (rate ratio 0.70 [0.41-1.20]). No breast-cancer mortality benefit was observed for women whose breast cancers were diagnosed when they were younger than 50 years. Other-cause mortality rates did not differ by trial group when adjusted for SES.Interpretation. Our findings confirm results from randomised trials in Sweden and the USA that screening for breast cancer lowers breast-cancer mortality. Similar results are reported by the UK geographical comparison, UK Trial of Early Detection of Breast Cancer. The results for younger women suggest benefit from introduction of screening before 50 years of age.