Progress in Chronic Disease Prevention Chronic Disease Reports: Deaths from Breast Cancer among Women -- United States, 1986

In 1986, breast cancer (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 174) was the underlying cause of death for 40,534 women in the United States. Breast cancer accounted for 32% of diagnosed cancers and 20% of cancer deaths among women (1).* Breast cancer incidence and mortality in the United States and worldwide have increased in cohorts of women born since 1900, for reasons not well understood (3,4).

Breast cancer mortality increases with age; 54% of deaths from breast cancer in the United States in 1986 occurred in women greater than or equal to 65 years of age (2). Age-adjusted rates of breast cancer mortality were 12% higher in black women than in white women (5).

When age-adjusted to the 1986 U.S. population, breast cancer mortality rates in 1986 were generally lower in southern states and higher in northern states (Table 1, Figure 1). Age-adjusted mortality rates were lowest in Hawaii (23.0 per 100,000 females) and highest in Delaware (40.6 per 100,000).

According to the National Cancer Institute, overall 5-year survival with breast cancer is now 75%; 5-year survival in women diagnosed with localized breast cancer is 90%; and survival in women diagnosed with "regional" or "distant" breast cancer is substantially lower. Survival is lower in black women than in white women at all stages of diagnosis (1). Reported by: Div of Surveillance and Epidemiologic Studies, Epidemiology Program Office; Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Risk factors for breast cancer among women include exposure to radiation, a history of breast cancer in close female relatives, early menarche and late menopause, nulliparity, and childbearing at older ages (6). Other possible risk factors remain controversial; the consumption of animal fat and protein (7) and alcohol (8), nonbreastfeeding (9), and use of oral contraceptives (10) and estrogen replacement therapy (11) have all been suggested. Bilateral oophorectomy, sometimes performed concurrently with hysterectomy (12), lowers the risk of breast cancer (6).

Although several risk factors have been identified, approaches to primary prevention are limited. The two principal modes established for secondary prevention are clinical breast examination and mammography (13).

To assess the efficacy of combined mammography and physical breast examination in reducing breast cancer mortality, a large randomized clinical trial was conducted at the Health Insurance Plan in New York City in the mid-1960s (14). Based on this study, at least 19% of breast cancer deaths among women in the United States can be estimated to be attributable to nonuse of mammography (Table 2). Other studies indicate similar results (15,16).

Mammographic techniques have improved markedly during the last 25 years. The dose of radiation used has decreased 100-fold (17), and the sensitivity of mammographic screening has increased (18). However, greater than 60% of U.S. women greater than or equal to 40 years of age report never having had a mammogram (19), and many of the women who have had mammograms have not fully complied with recommended screening intervals. Nonuse increases with age and is thus inversely associated with risk of breast cancer mortality. The challenge remains to increase use of effective technology.

References

1. National Cancer Institute. Annual cancer statistics review, 1987.

Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1988; NIH publication no. 88-2789.

2. NCHS. Vital statistics of the United States, 1986. Vol II--Mortality, pt A. Hyattsville, Mary land: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (PHS)88-1122.

3. Stevens RG, Moolgavkar SH, Lee JAH. Temporal trends in breast cancer. Am J Epidemiol 1982;115:759-77.

4. Hahn RA, Moolgavkar SH. Nulliparity, decade of first birth, and breast cancer in Connecticut cohorts, 1855 to 1945: an ecological study. Am J Public Health (in press).

5. CDC. Health, United States, 1988. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (PHS)89-1232.

6. Thomas DB. Epidemiologic and related studies of breast cancer etiology. Rev Can Epidemiol 1980;1:153-217.

7. Toniolo P, Riboli E, Protta F, Charrel M, Cappa APM. Calorie-providing nutrients and risk of breast cancer. JNCI 1989;81:278-86.

8. Longnecker MP, Berlin JA, Orza MS, Chalmers TC. A meta-analysis of alcohol consumption in relation to risk of breast cancer. JAMA 1988;260:652-6.

9. McTiernan A, Thomas DB. Evidence for a protective effect of lactation on risk of breast cancer in young women: results from a case-control study. Am J Epidemiol 1986;124:353-8. 10. Rosenberg L, Miller DR, Kaufman DW, et al. Breast cancer and oral contraceptive use. Am J Epidemiol 1984;119:167-76. 11. Bergkvist L, Adami H-O, Persson I, Hoover R, Schairer C. The risk of breast cancer after estrogen and estrogen-progestin replacement. N Engl J Med 1989;321:293-7. 12. Howe HL. Age-specific hysterectomy and oophorectomy prevalence rates and the risks for cancer of the reproductive system. Am J Public Health 1984;74:560-3. 13. American Cancer Society. Summary of current guidelines for the cancer-related checkup: recommendations. Atlanta: American Cancer Society, 1988; ACS publication no. 3347.01-PE. 14. Shapiro S, Venet W, Strax P, Venet L. Periodic screening for breast cancer: the Health Insurance Plan Project and its sequelae, 1963-1986. Baltimore: Johns Hopkins University Press, 1988. 15. Tabar L, Dean PB. The control of breast cancer through mammography screening: what is the evidence? Radiol Clin North Am 1987;25:993-1005. 16. Seidman H, Gelb SK, Silverberg E, LaVerda N, Lubera JA. Survival experience in the Breast Cancer Detection Demonstration Project. CA 1987;37:258-91. 17. Paulus DD. Imaging in breast cancer. CA 1987;37:133-50. 18. Day NE, Walter SD, Tabar L, Fagerberg CJG, Collette HJA. The sensitivity and lead time of breast cancer screening: a comparison of the results of different studies. In: Day NE, Miller AB, eds. Screening for breast cancer. Lewiston, New York: Hans Huber Publishers, 1988. 19. CDC. Provisional estimates from the National Health Interview Survey supplement on cancer control--United States, January-March 1987. MMWR 1988;37:417-20,425. *Men also die from breast cancer (ICD-9-CM 175), but at less than 1/100th the rate among women (2).

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