B Rachet

DM Parkin

E Mitry

H Brenner

LM Woods

M J Quinn

M P Coleman

MJ Quinn

MP Coleman

N Cooper

RG Blanks

V Beral

English

PubMed

Crossref

Survival from cancer of the breast in women in England and Wales up to 2001

Quinn, MJ

Cooper, N

Rachet, B

Mitry, E

Coleman, MP

LSHTM Research Online

Quinn, MJ; Cooper, N; Rachet, B; Mitry, E; Coleman, MP (2008)Survival from cancer of the breast in women in England and Walesup to 2001. British journal of cancer, 99 Suppl 1. pp. 53-55. ISSN0007-0920Downloaded from: http://researchonline.lshtm.ac.uk/6958/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/Survival AnalysisSurvival from cancer of the breast in women in Englandand Wales up to 2001MJ Quinn1, N Cooper1, B Rachet2, E Mitry3 and MP Coleman*,21Social and Health Analysis and Reporting Division, Off ice for National Statistics (Room FG/114), 1 Myddelton Street, London EC1R 1UW, UK; 2CancerResearch UK Cancer Survival Group, Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Population Health, London Schoolof Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; 3De´partement d’He´patogastroente´rologie et Oncologie Digestive, CentreHospitalo-Universitaire Ambroise-Pare´, 9 avenue Charles de Gaulle, F-92100 Boulogne, FranceBritish Journal of Cancer (2008) 99, S53 – S55. doi:10.1038/sj.bjc.6604587 www.bjcancer.comPublished online 23 September 2008& 2008 Cancer Research UKBreast cancer is the most common cancer in womenworldwide (Parkin, 2001). In England and Wales at the end ofthe 1990s, approximately 36 000 new cases were diagnosed eachyear, representing 30% of the annual total of 120 000 cases. Thenumber of cases exceeds the combined total for the second andthird most common cancers in women, those of the large bowel(14 700 cases, 12%) and lung (12 600 cases, 10%). Breast cancer inmen is comparatively uncommon, and is not consideredfurther here.During the 1970s and 1980s, age-standardised incidenceincreased on average by approximately 2% each year (Quinnet al, 2001). The NHS breast-screening programme began in 1988,covering women aged 50 –64 years and using single mediolateraloblique view mammography and a 3-year interval between screens.During the prolonged prevalence round, overall breast cancerincidence increased by approximately 20%; it subsequentlydeclined, but then rose again, and by the late 1990s, incidencewas some 7% higher than at the peak in the early 1990s (Office forNational Statistics, 2003). Part of the increase, possibly as much as20% in post-menopausal women, may have resulted from theincreasing use of hormone replacement therapy (HRT) in the1990s (Beral et al, 1997).After the exclusion of in situ tumours, we analysed the data for382 277 women diagnosed with a first, primary, malignantneoplasm of the breast in England and Wales during the 14-yearperiod 1986–1999 and followed up to 31 December 2001, some89% of those eligible for analysis. Approximately 6.1% of womenwho were otherwise eligible were excluded with zero recordedsurvival (date of diagnosis same as date of death): most of thesewomen will have been registered from a death certificate only(DCO), and their duration of survival is unknown, but they couldnot be reliably distinguished in these data from women with truezero survival. The proportion of women excluded from analysis asDCO records was very similar in all socioeconomic groups. Afurther 2.4% of women were excluded because it was not their firstprimary cancer: for one-third of these women, the previous cancerwas also a breast cancer, diagnosed before 1986.Major shifts in the morphological distribution of breastcancers have occurred over the last 30 years. The proportiondescribed as an adenocarcinoma has been falling steadily,from 36% in the early 1970s (Coleman et al, 1999) to 6% in thesedata by the late 1990s. In the early 1970s, ductal, lobular andmedullary tumours comprised less than 10% of all breast cancers,but by the late 1990s this figure had reached 75%, ductalcarcinomas alone comprising 60% of all breast cancers. Theproportion of tumours with unspecified morphology has con-tinued to fall, from 47% in 1971–1975 to 30% in 1986–1990 andless than 5% in 1996–1999. Even this massive improvement in dataquality cannot account for the overall increase in ductal, lobularand medullary tumours.SURVIVAL TRENDSFor women diagnosed in the late 1990s, relative survival 1 yearafter diagnosis had reached 94%, a deprivation-adjusted averageincrease of 2.0% every 5 years since 1986–1990 (Table 1, Figure 1).Five-year survival had reached 80%, an average increase of 6.2%every 5 years over the same period. Ten-year survival rose evenmore markedly, by almost 10%, from 58% for women diagnosedduring 1986–1990 to 67% for women diagnosed during 1991–1995,just 5 years later.This trend is confirmed by hybrid analysis of the survivalprobabilities observed during 2000– 2001 (Brenner and Rachet,2004), with a predicted 10-year survival of 73% for womendiagnosed at about that time.DEPRIVATIONThe deprivation gap in 5-year and 10-year survival forwomen diagnosed during 1986–1990 was close to 6% (Table 2).The gap in 1-year survival was smaller, at approximately 3%.Survival has increased in all groups of the population, butthe difference between rich and poor has not changed at all(Figure 2).Short-term predictions of survival by socioeconomic group,again using hybrid analysis of the probabilities of survival*Correspondence: Professor MP Coleman;E-mail: michel.coleman@lshtm.ac.ukBritish Journal of Cancer (2008) 99, S53 – S55& 2008 Cancer Research UK All rights reserved 0007 – 0920/08 $32.00www.bjcancer.comobserved during 2000–2001, do not suggest any imminent changein the significant deprivation gap in survival between affluent anddeprived women.COMMENTBreast cancer survival rose rapidly and significantly during the1990s, and although the difference in survival between affluent anddeprived women did not improve, at least it did not widen, incontrast to the widening deprivation gap in survival seen for mostother malignancies (Coleman et al, 2004).The trends in breast cancer survival among women diagnosedup to 1999 extend the continuing increase seen since the 1970s and1980s, when 1-year survival rose from 84 to 90% and 5-yearsurvival from 54 to 68% (Coleman et al, 1999). Women aged 50– 64years were invited for mammographic screening from 1988, and5-year survival for women in the age range 50–69 years rose byTable 1 Trends in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, adults (15–99 years) diagnosedduring 1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisSurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CI1 year Women 90.2 (90.0, 90.4) 92.5 (92.3, 92.6) 94.4 (94.2, 94.5) 2.0** (1.7, 2.3) 94.9 (94.7, 95.1)5 years Women 68.3 (68.0, 68.6) 75.2 (74.9, 75.4) 79.8 (79.5, 80.1) 6.1** (5.5, 6.7) 80.9 (80.5, 81.3)10 years Women 57.5 (57.1, 57.8) 67.0 (66.7, 67.4) 9.6** (8.4, 10.9) 72.5 (72.1, 73.0)CI¼ confidence interval. aSurvival estimated with cohort or complete approach (see Rachet et al, 2008). bMean absolute change (%) in survival every 5 years, adjusted fordeprivation (see Rachet et al, 2008). cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.020406080100Relative survival (%)0 2 4 6 8 10Years since diagnosis2000–20011996–19991991–19951986–1990WomenFigure 1 Relative survival (%) up to 10 years after diagnosis by calendarperiod of diagnosis: England and Wales, adults (15–99 years) diagnosedduring 1986–1999 and followed up to 2001. Survival estimated with cohortor complete approach (1986–1990, 1991–1995, 1996–1999) or hybridapproach (2000–2001) (see Rachet et al, 2008).607080901005-year relative survival (%)Affluent 2 3 4 DeprivedDeprivation category2000–20011996–19991991–19951986–1990WomenFigure 2 Trends in the deprivation gap in 5-year relative survival (%) bycalendar period of diagnosis: England and Wales, adults (15–99 years)diagnosed during 1986–1999 and followed up to 2001.Table 2 Trends in the deprivation gap in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, adults(15–99 years) diagnosed during 1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CI1 year Women 3.1** (3.6, 2.5) 2.9** (3.4, 2.5) 2.6** (3.1, 2.2) 0.2 (0.1, 0.6) 2.7** (3.2, 2.1)5 years Women 5.6** (6.5, 4.7) 5.6** (6.4, 4.9) 5.8** (6.7, 4.8) 0.1 (0.8, 0.6) 5.2** (6.3, 4.1)10 years Women 5.6** (6.6, 4.6) 5.9** (6.9, 4.9) 0.3 (1.7, 1.2) 6.1** (7.5, 4.8)CI¼ confidence interval. aSurvival estimated with cohort or complete approach (see Rachet et al, 2008). bMean absolute change (%) in the deprivation gap in survival every5 years, adjusted for the underlying trend in survival (see Rachet et al, 2008). cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.Survival from cancer of the breast in womenMJ Quinn et alS54British Journal of Cancer (2008) 99(S1), S53 – S55 & 2008 Cancer Research UK7–10% between 1986 and 1993, much more than for either olderwomen (less than 2%) or younger women (less than 4%) (Colemanet al, 2000a, b). By the late 1990s, however, this difference in age-specific trends had vanished (Rachet et al, 2005). Earlier diagnosisfollowing mammography will increase survival time even if deathis not delayed by treatment (lead-time bias), but the age-specificsurvival trends suggest that lead-time bias is unlikely to be the soleexplanation for the overall increase in survival.Further analysis of our data shows that the incidence of breastcancer rose more rapidly among affluent women than amongdeprived women between 1986 and 1999 (Figure 3). If the moremarked increase in incidence among affluent women were solelyattributable to higher compliance with screening, and if we acceptthe impact of screening on survival, then the deprivation gap inrelative survival would also have been expected to increase, and itdid not (Figure 2). The incidence trends may therefore also reflectdeprivation-specific trends in risk factors, including reproductivehistory and the use of HRT.Despite the increase in breast cancer incidence during the 1990s,mortality has fallen in all age groups (Quinn et al, 2001). The largerfalls in mortality in the screened age groups indicate that by thelate 1990s, approximately one-third of the 20% overall reduction inbreast cancer mortality was directly attributable to screening,although most of the fall in mortality was attributable to acombination of earlier diagnosis outside the screening programme,increasingly widespread use of tamoxifen since the 1980s andother, more recent improvements in chemotherapy, andmore indirect effects of the screening programme, such asimprovement in the organisation and delivery of services tosymptomatically detected cases as well as screen-detected cases(Blanks et al, 2000).We have recently predicted that long-term survival up to 20years after diagnosis is likely to continue improving. The largestpredicted increase also affects women aged 50–69 years atdiagnosis (Woods et al, 2007).For more than 30 years, breast cancer survival in England andWales has been consistently lower in women from deprived areas,even after adjustment for higher background mortality in the moredeprived areas. In the 1970s and early 1980s, the deprivation gap in5-year survival was approximately 10%. The gap fell to 6% forwomen diagnosed during 1986–1990, but it has not changed anyfurther since that time. This is remarkable because, for mostcancers for which 5-year survival has improved as rapidly as it hasdone for breast cancer (approximately 6% every 5 years), thedeprivation gap in survival has also widened considerably (Cole-man et al, 2004). The deprivation gap in relative survival isadjusted for the wide socioeconomic differences in backgroundmortality, and for changes over time in those differentials.Differences in crude survival (unadjusted for background mortal-ity; data not shown) are actually wider than those for relativesurvival. The lack of improvement in the deprivation gap inrelative survival is therefore not an artefact of failure to adjust forchanges in background mortality among women with breastcancer.REFERENCESBeral V, Banks E, Reeves GK, Wallis M (1997) Hormone replacementtherapy and high incidence of breast cancer between mammographicscreens. Lancet 349: 1103 – 1104Blanks RG, Moss SM, McGahan CE, Quinn MJ, Babb P (2000) Effect of NHSBreast Screening Programme on mortality from breast cancer in Englandand Wales, 1990 – 1998: comparison of observed with predictedmortality. Br Med J 321: 665 – 669Brenner H, Rachet B (2004) Hybrid analysis for up-to-date long-termsurvival rates in cancer registries with delayed recording of incidentcases. Eur J Cancer 40: 2494 – 2501Coleman MP, Babb P, Damiecki P, Grosclaude PC, Honjo S, Jones J,Knerer G, Pitard A, Quinn MJ, Sloggett A, De Stavola BL (1999) CancerSurvival Trends in England and Wales 1971 – 1995: Deprivation and NHSRegion. Studies on Medical and Population Subjects No. 61. TheStationery Office: LondonColeman MP, Babb P, Harris S, Quinn MJ, Sloggett A, De Stavola BL (2000a)Cancer survival in England and Wales, 1991–1998. Health Stat Q 6: 71 – 80Coleman MP, Babb P, Stockton DL, Møller H, Forman D (2000b) Breastcancer incidence, survival and mortality trends in England and Wales[Erratum in Lancet 2000; 356: 774]. Lancet 356: 590 – 591Coleman MP, Rachet B, Woods LM, Mitry E, Riga M, Cooper N, Quinn MJ,Brenner H, Este`ve J (2004) Trends and socio-economic inequalities incancer survival in England and Wales up to 2001. Br J Cancer 90:1367 – 1373Office for National Statistics (2003) Cancer statistics: registrations of cancerdiagnosed in 2000, England. Series MB1 no. 31. The Stationery Office:LondonParkin DM (2001) Global cancer statistics in the year 2000. Lancet Oncol 2:533 – 543Quinn MJ, Babb P, Brock A, Kirby L, Jones J (2001) CancerTrends in England and Wales 1950 – 1999. Studies onMedical and Population Subjects No. 66. Office for National Statistics:LondonRachet B, Coleman MP, Cooper N, Quinn MJ (2005) Cancer survival:England and Wales, 1991 – 2001, twenty major cancers by age group.Office for National Statistics. http://www.statistics.gov.uk/statbase/ssdataset.asp?vlnk¼ 7899Rachet B, Woods LM, Mitry E, Riga M, Cooper N, Quinn MJ, Steward J,Brenner H, Este`ve J, Sullivan R, Coleman MP (2008) Cancer survivalin England and Wales at the end of the 20th century. Br J Cancer99(Suppl 1): S2 – S10Woods LM, Rachet B, Cooper N, Coleman MP (2007) Predicted trends inlong-term breast cancer survival in England and Wales. Br J Cancer 96:1135 – 11386080100120140Incidence rate per 100 0001986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999Year of diagnosisAffluent234DeprivedFigure 3 Trends in the age-standardised incidence of breast cancerin women aged 15–99 years, by deprivation group: England andWales, 1986–1999.Survival from cancer of the breast in womenMJ Quinn et alS55British Journal of Cancer (2008) 99(S1), S53 – S55& 2008 Cancer Research UK

Hormone replacement therapy and high incidence of breast cancer between mammographic screens.

Office for National Statistics. http://www.statistics.gov.uk/statbase/ ssdataset.asp?vlnk7899 R a c h e tB ,W o o d sL M ,M i t r yE ,R i g aM ,C o o p e rN ,Q u i n nM J ,S t e w a r dJ

Survival from cancer of the breast in women in England and Wales up to 2001.

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Survival from cancer of the breast in women in England and Wales up to 2001

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