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Surgery for Stage IV Breast Cancer: Domestic and International Disparities

Surgery for Stage IV Breast Cancer: Domestic and International Disparities Advances in systemic therapy have improved survival of women with metastatic breast cancer. The Thomas et al1 analysis of Surveillance, Epidemiology, and End Results (SEER) data supports the concept that surgery may contribute to an outcome advantage by reducing the total body burden of disease. While this study’s overarching focus is indeed meaningful, it is also informative to place results from this report in the context of conversations regarding breast cancer disparities associated with racial/ethnic identity, young age, and country of origin. First, lifetime incidence of breast cancer is lower for African American compared with white American women; therefore, African American women account for a smaller proportion of breast cancer cases compared with their general population distribution. Thomas and colleagues1 found a disproportionately high prevalence of African American women among their stage IV study population, and African American women were also 30% less likely to undergo surgery. This treatment imbalance raises questions regarding selection of patients that are triaged toward more aggressive care. Interestingly, Park et al2 published a different analysis of SEER data, demonstrating that treatment variables are likely just as important as disease stage and tumor biology in explaining breast cancer survival improvements observed over the past several decades. Unfortunately, one can infer from these 2 SEER-based studies that inequities in the treatment offered to African American women may contribute to their disproportionately high breast cancer mortality risk. Second, breast cancer incidence increases with age; however, the breast cancer burden of young/premenopausal women generates substantial attention because of the associated impact on a population subset that assumes much of the nation’s family and general workforce responsibilities. Furthermore, while the population-based incidence rates of breast cancer in women younger than 45 years have been stable over the past several decades, we are indeed seeing a larger number of young patients with breast cancer because census data confirm that this demographic has grown by nearly 10 million since 1980.3 Unfortunately, the population-based incidence of stage IV breast cancer has doubled among young American women4 but happily, Thomas et al1 found that younger women were more likely to undergo surgery, and age younger than 45 years was an independent predictor of prolonged survival. Finally, regarding international populations, 2 phase 3 trials comparing surgery vs no surgery in metastatic breast cancer were presented at the 2013 San Antonio Breast Cancer Symposium, with neither demonstrating a survival advantage associated with surgery.5 Unfortunately, both of the these studies are subject to questions regarding their relevance in a more affluent country such as the United States, where patients have improved access to advanced diagnostic and treatment options. For example, the trial conducted in India did not include anti-HER2/neu therapy and the Turkish trial did not mandate biopsy of the metastatic focus. Both of these strategies are standard in the United States and influence survival. It is difficult (if not impossible) to identify any breast cancer study that does not provide an opportunity to investigate disparities in disease burden and outcome. Back to top Article Information Corresponding Author: Lisa A. Newman, MD, MPH, University of Michigan, Comprehensive Cancer Center, 1500 E Medical Center Dr, Ann Arbor, MI 48167 (lanewman@umich.edu). Published Online: December 2, 2015. doi:10.1001/jamasurg.2015.4507. Conflict of Interest Disclosures: None reported. References 1. Thomas A, Khan SA, Chrischilles EA, Schroeder MC. Initial surgery and survival in stage IV breast cancer in the United States, 1988-2011 [published online December 2, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.4539.Google Scholar 2. Park JH, Anderson WF, Gail MH. Improvements in US breast cancer survival and proportion explained by tumor size and estrogen-receptor status. J Clin Oncol. 2015;33(26):2870-2876.PubMedGoogle ScholarCrossref 3. Rosenberg SM, Newman LA, Partridge AH. Breast cancer in young women: rare disease or public health problem? JAMA Oncol. 2015;1(7):877-878.PubMedGoogle ScholarCrossref 4. Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA. 2013;309(8):800-805.PubMedGoogle ScholarCrossref 5. Hartmann S, Reimer T, Gerber B, Stachs A. Primary metastatic breast cancer: the impact of locoregional therapy. Breast Care (Basel). 2014;9(1):23-28.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Surgery for Stage IV Breast Cancer: Domestic and International Disparities

JAMA Surgery , Volume 151 (5) – May 1, 2016

Surgery for Stage IV Breast Cancer: Domestic and International Disparities

Abstract

Advances in systemic therapy have improved survival of women with metastatic breast cancer. The Thomas et al1 analysis of Surveillance, Epidemiology, and End Results (SEER) data supports the concept that surgery may contribute to an outcome advantage by reducing the total body burden of disease. While this study’s overarching focus is indeed meaningful, it is also informative to place results from this report in the context of conversations regarding breast cancer disparities associated...
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.4507
Publisher site
See Article on Publisher Site

Abstract

Advances in systemic therapy have improved survival of women with metastatic breast cancer. The Thomas et al1 analysis of Surveillance, Epidemiology, and End Results (SEER) data supports the concept that surgery may contribute to an outcome advantage by reducing the total body burden of disease. While this study’s overarching focus is indeed meaningful, it is also informative to place results from this report in the context of conversations regarding breast cancer disparities associated with racial/ethnic identity, young age, and country of origin. First, lifetime incidence of breast cancer is lower for African American compared with white American women; therefore, African American women account for a smaller proportion of breast cancer cases compared with their general population distribution. Thomas and colleagues1 found a disproportionately high prevalence of African American women among their stage IV study population, and African American women were also 30% less likely to undergo surgery. This treatment imbalance raises questions regarding selection of patients that are triaged toward more aggressive care. Interestingly, Park et al2 published a different analysis of SEER data, demonstrating that treatment variables are likely just as important as disease stage and tumor biology in explaining breast cancer survival improvements observed over the past several decades. Unfortunately, one can infer from these 2 SEER-based studies that inequities in the treatment offered to African American women may contribute to their disproportionately high breast cancer mortality risk. Second, breast cancer incidence increases with age; however, the breast cancer burden of young/premenopausal women generates substantial attention because of the associated impact on a population subset that assumes much of the nation’s family and general workforce responsibilities. Furthermore, while the population-based incidence rates of breast cancer in women younger than 45 years have been stable over the past several decades, we are indeed seeing a larger number of young patients with breast cancer because census data confirm that this demographic has grown by nearly 10 million since 1980.3 Unfortunately, the population-based incidence of stage IV breast cancer has doubled among young American women4 but happily, Thomas et al1 found that younger women were more likely to undergo surgery, and age younger than 45 years was an independent predictor of prolonged survival. Finally, regarding international populations, 2 phase 3 trials comparing surgery vs no surgery in metastatic breast cancer were presented at the 2013 San Antonio Breast Cancer Symposium, with neither demonstrating a survival advantage associated with surgery.5 Unfortunately, both of the these studies are subject to questions regarding their relevance in a more affluent country such as the United States, where patients have improved access to advanced diagnostic and treatment options. For example, the trial conducted in India did not include anti-HER2/neu therapy and the Turkish trial did not mandate biopsy of the metastatic focus. Both of these strategies are standard in the United States and influence survival. It is difficult (if not impossible) to identify any breast cancer study that does not provide an opportunity to investigate disparities in disease burden and outcome. Back to top Article Information Corresponding Author: Lisa A. Newman, MD, MPH, University of Michigan, Comprehensive Cancer Center, 1500 E Medical Center Dr, Ann Arbor, MI 48167 (lanewman@umich.edu). Published Online: December 2, 2015. doi:10.1001/jamasurg.2015.4507. Conflict of Interest Disclosures: None reported. References 1. Thomas A, Khan SA, Chrischilles EA, Schroeder MC. Initial surgery and survival in stage IV breast cancer in the United States, 1988-2011 [published online December 2, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.4539.Google Scholar 2. Park JH, Anderson WF, Gail MH. Improvements in US breast cancer survival and proportion explained by tumor size and estrogen-receptor status. J Clin Oncol. 2015;33(26):2870-2876.PubMedGoogle ScholarCrossref 3. Rosenberg SM, Newman LA, Partridge AH. Breast cancer in young women: rare disease or public health problem? JAMA Oncol. 2015;1(7):877-878.PubMedGoogle ScholarCrossref 4. Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA. 2013;309(8):800-805.PubMedGoogle ScholarCrossref 5. Hartmann S, Reimer T, Gerber B, Stachs A. Primary metastatic breast cancer: the impact of locoregional therapy. Breast Care (Basel). 2014;9(1):23-28.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: May 1, 2016

Keywords: survival analysis,breast cancer metastatic,age factors,india,seer program,surgical procedures, operative,united states,women's health,world health,surgery specialty,country of turkey,operative management of breast cancer,african american,young adult,health disparity,health care disparities,cancer surgery,breast cancer prognostic factor

References