Breast Cancer Statistics, 2013

Transcription

1 Brest Cncer Sttistics, 2013 Crol DeSntis, MPH 1 *; Jiemin M, PhD 1 ; Leh Bryn, MPH 1 ; Ahmedin Jeml, DVM, PhD 2 In this rticle, the Americn Cncer Society provides n overview of femle brest cncer sttistics in the United Sttes, including dt on incidence, mortlity, survivl, nd screening. Approximtely 232,340 new cses of invsive brest cncer nd 39,620 brest cncer deths re expected to occur mong US women in One in 8 women in the United Sttes will develop brest cncer in her lifetime. Brest cncer incidence rtes incresed slightly mong Africn Americn women; decresed mong Hispnic women; nd were stble mong whites, Asin Americns/Pcific Islnders, nd Americn Indins/ Alsk Ntives from 2006 to Historiclly, white women hve hd the highest brest cncer incidence rtes mong women ged 40 yers nd older; however, incidence rtes re converging mong white nd Africn Americn women, prticulrly mong women ged 50 yers to 59 yers. Incidence rtes incresed for estrogen receptor-positive brest cncers in the youngest white women, Hispnic women ged 60 yers to 69 yers, nd ll but the oldest Africn Americn women. In contrst, estrogen receptor-negtive brest cncers declined mong most ge nd rcil/ethnic groups. These divergent trends my reflect etiologic heterogeneity nd the differing effects of some fctors, such s obesity nd prity, on risk by tumor subtype. Since 1990, brest cncer deth rtes hve dropped by 34 nd this decrese ws evident in ll rcil/ethnic groups except Americn Indins/Alsk Ntives. Nevertheless, survivl disprities persist by rce/ethnicity, with Africn Americn women hving the poorest brest cncer survivl of ny rcil/ethnic group. Continued progress in the control of brest cncer will require sustined nd incresed efforts to provide high-qulity screening, dignosis, nd tretment to ll segments of the popultion. CA Cncer J Clin 2013;000: VC 2013 Americn Cncer Society, Inc. Keywords: brest neoplsms, epidemiology, helth disprities, screening nd erly detection Introduction Excluding skin cncers, brest cncer is the most common cncer dignosed mong women in the United Sttes, ccounting for nerly 1 in 3 cncers. It is lso the second leding cuse of cncer deth mong women fter lung cncer. In this rticle, we describe trends in brest cncer incidence, mortlity, nd survivl rtes by rce/ethnicity in the United Sttes, s well s stte vritions in these mesures. We further exmine recent incidence trends by estrogen receptor (ER) sttus nd ge t dignosis. Additionl dt re vilble from the biennil publiction of Brest Cncer Fcts & Figures (vilble t cncer. org/sttisticscncer.org/sttistics). Mterils nd Methods Dt Sources Dt regrding incidence, probbilities for developing cncer, nd cuse-specific survivl were obtined from the Surveillnce, Epidemiology, nd End Results (SEER) progrm of the Ntionl Cncer Institute. 1-4 The SEER progrm hs been collecting clinicl, pthologicl, nd demogrphic informtion on cncer ptients since Dt re vilble for whites, Africn Americns, nd ll rces combined since 1973 nd for Americn Indins/Alsk Ntives, Asin Americns/Pcific Islnders, nd Hispnics/Ltins since The SEER progrm begn collecting informtion on ER sttus in Over time, dt concerning ER sttus hve become more complete, with missing informtion rnging from 23 in 2000 to 4 in To ccount for the improvement in completeness when nlyzing trends, we llocted ER sttus for those with missing informtion ccording to 1 Epidemiologist, Surveillnce nd Helth Services Reserch, Americn Cncer Society, Atlnt, GA; 2 Vice President, Surveillnce nd Helth Services Reserch, Americn Cncer Society, Atlnt, GA Corresponding uthor: Crol DeSntis, MPH, Surveillnce nd Helth Services Reserch, Americn Cncer Society, 250 Willims St NW, Atlnt, GA 30303; crol.desntis@cncer.org DISCLOSURES: The uthors report no conflicts of interest. VC 2013 Americn Cncer Society, Inc. doi: /cc Avilble online t ccncerjournl.com VOLUME 00 _ NUMBER 00 _ AUGUST

2 Brest Cncer Sttistics, 2013 observed proportions of ER-positive (ER1) nd ER-negtive (ER-) brest cncer cses by ge nd yer of dignosis using the method previously described by Anderson et l. 5 Trends by ER sttus were lso djusted for reporting dely using dely djustment rtios from the Ntionl Cncer Institute through the Cncer Query Systems (CnQues) dtbse. 6 Dely djustment ccounts for nticipted future corrections to reported cncer cse counts nd primrily ffects the most recent yers of incidence dt. Dely djustment rtios re not vilble for the SEER 13 nd SEER 18 registries, nd therefore SEER 9 dely fctors were used to djust these dt. Furthermore, rtios re not vilble by Hispnic ethnicity nd therefore rtios for whites nd Africn Americns were used to djust rtes for non-hispnic whites nd non-hispnic Africn Americns, respectively, nd white rtios were used for Hispnics. Incidence rtes by rce/ethnicity for 2006 through 2010, stte-specific incidence rtes, nd the proportion of brest cncers dignosed t in situ nd regionl/distnt stges were obtined using dt from the North Americn Assocition of Centrl Cncer Registries bsed on incidence dt from SEER nd the Ntionl Progrm of Cncer Registries. 7,8 Mortlity dt were obtined from the SEER progrm s SEER*Stt dtbse s provided by the Ntionl Center for Helth Sttistics. 4,9,10 Beginning in 1969, dt re vilble for whites nd Africn Americns. Since 1990, dt re vilble for the 5 mjor rcil nd ethnic groups: non-hispnic whites, Africn Americns, Asin Americns/Pcific Islnders, Americn Indins/Alsk Ntives, nd Hispnics. Popultion dt were obtined from the US Census Bureu. Prevlence dt regrding mmmogrphy by ge nd stte were obtined from the 2010 nd 2012 Behviorl Risk Fctor Surveillnce System, n ongoing system of surveys conducted by the individul stte helth deprtments in coopertion with the Centers for Disese Control nd Prevention. For describing the current screening prevlence by stte, we used 2012 dt; however, we used dt from 2010 for exmining the ssocition with currently vilble incidence dt from 2006 through Sttisticl Anlyses Estimtes of the totl number of invsive nd in situ brest cncer cses nd brest cncer deths for 2013 were published previously. 11 We clculted the estimted number of brest cncer cses by ge t dignosis by pplying the proportion of cses dignosed in ech ge group during 2006 through 2010 from the North Americn Assocition of Centrl Cncer Registries nlytic file to the totl number of estimted cses of invsive nd in situ brest cncer. Similrly, we clculted the estimted number of brest cncer deths by ge t deth by pplying the proportion of deths tht occurred in ech ge group during 2006 through 2010 to the totl estimted brest cncer deths in We exmined incidence trends by rce/ethnicity, ge, nd ER sttus nd mortlity trends by stte using the Joinpoint regression progrm to clculte the verge nnul percent chnge. 12 The reltionship between stte-level mmmogrphy screening rtes in 2010 nd the percentge of brest cncer cses dignosed t in situ nd lte stges between 2006 nd 2010 ws exmined by the Person correltion coefficient. Probbilities of developing brest cncer were clculted using DevCn (Probbility of Developing Cncer Softwre), which ws developed by the Ntionl Cncer Institute. 13 Selected Findings Expected Numbers of New Cses nd Deths Tble 1 shows the estimted number of femle brest cncer cses nd deths tht re expected to occur in the United Sttes in 2013 by ge. Approximtely 232,340 new cses of invsive brest cncer nd 39,620 deths re expected mong US women in Approximtely 79 of new cses nd 88 of brest cncer deths in 2013 will occur mong women ged 50 yers nd older. In ddition to invsive brest cncers, bout 64,640 new dignoses of in situ brest cncer re expected mong US women in Probbility of Developing Invsive Femle Brest Cncer A womn living in the United Sttes hs 12.3, or 1-in- 8, lifetime risk of being dignosed with brest cncer (Tble 2). In the 1970s, the lifetime risk of being dignosed with brest cncer ws 1 in 11. This increse in risk is due to longer life expectncy, s well s increses in brest TABLE 1. Estimted New Femle Brest Cncer Cses nd Deths by Age, United Sttes, 2013 AGE IN SITU CASES INVASIVE CASES DEATHS <40 1,900 10,980 1,020 <50 15,650 48,910 4, ,770 84,210 11, ,220 99,220 22,870 All ges 64, ,340 39,620 Rounded to the nerest 10. Source: Totl estimted cses re bsed on 1995 to 2009 incidence rtes from 49 sttes s reported by the North Americn Assocition for Centrl Cncer Registries. Totl estimted deths re bsed on dt from US Mortlity Dt, 1995 to 2009, Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention. 2 CA: A Cncer Journl for Clinicins

3 TABLE 2. IF CURRENT AGE IS: Age-Specific Probbilities of Developing Invsive Femle Brest Cncer THE PROBABILITY OF DEVELOPING BREAST CANCER IN THE NEXT 10 YEARS IS: OR 1 IN: , Lifetime risk Among those free of cncer t the beginning of the ge intervl. Bsed on cses dignosed between 2008 nd Percentges nd "1 in" numbers my not be numericlly equivlent due to rounding. Probbilities derived using the Ntionl Cncer Institute DevCn Softwre (version 6.7.0). cncer incidence. Lifetime risk reflects n verge womn s risk over n entire lifetime, including the possibility tht she my die of nother cuse before she would hve been dignosed with brest cncer. Age-specific probbilities for developing brest cncer over 10-yer period re lso provided in Tble 2. For exmple, the risk for womn ged 50 yers without cncer of being dignosed with brest cncer over the next 10 yers is 2.3 (or 1 in 43 women who re ged 50 yers will be dignosed with brest cncer by ge 60 yers). Long-Term Incidence Trends Dely-djusted incidence rtes for in situ nd invsive femle brest cncer for women ged younger thn 50 yers nd those ged 50 yers nd older re presented in Figure 1. Much of the historic increse in brest cncer incidence reflects chnges in reproductive ptterns, such s delyed childbering nd hving fewer children, which re recognized risk fctors for brest cncer. However, brest cncer incidence rtes incresed rpidly in the 1980s due lrgely to the greter use of mmmogrphy screening. The widespred uptke of mmmogrphy screening inflted the incidence rte becuse cncers were being dignosed 1 to 3 yers erlier thn they otherwise would hve in the bsence of screening nd my lso hve led to the detection of indolent cses. Overll rtes stbilized in the erly 1990s, followed by slower increse during the ltter hlf of the decde. This trend my reflect further increses in the prevlence of mmmogrphy screening s well s rising rtes of obesity nd the use of menopusl hormones, both of which increse brest cncer risk. Between 2002 nd 2003, brest cncer rtes dropped shrply (nerly 7), most likely due to the decresed use of menopusl hormones fter the 2002 publiction of the results of the Women s Helth Inititive rndomized tril The decline occurred primrily in white women, in women ged 50 yers nd older, nd in women with ER1 disese. 15,17 This trend my lso, in prt, reflect declines in mmmogrphy screening. The percentge of women ged 40 yers nd older who reported hving mmmogrm within the pst 2 yers peked in 2000, declined slightly, nd hs since stbilized. 18 Similr reversls in brest cncer trends hve been observed interntionlly s well Brest cncer incidence rtes hve been reltively stble mong women ged younger thn 50 yers since 1985 nd since 2004 mong women ged 50 yers nd older. 4 Incidence rtes of in situ brest cncer rose rpidly in the 1980s nd 1990s (Fig. 1), lrgely becuse of incresed FIGURE 1. Incidence nd Mortlity Rtes* of Femle Brest Cncer by Age, United Sttes, 1975 to *Rtes re ge djusted to the 2000 US stndrd popultion within ech ge group. Sources: Incidence: Surveillnce, Epidemiology, nd End Results (SEER) Progrm, SEER 9 registries, Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences; 2013; dt were djusted for reporting dely. Mortlity: Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention, s provided by the SEER progrm. VOLUME 00 _ NUMBER 00 _ AUGUST

4 Brest Cncer Sttistics, 2013 TABLE 3. Rtes nd Trends in Incidence nd Mortlity nd Cuse-Specific Survivl for Femle Brest Cncer by Rce/Ethnicity INCIDENCE MORTALITY 5-YEAR CAUSE-SPECIFIC SURVIVAL RACE/ETHNICITY AAPC AAPC Non-Hispnic White b c 88.6 Africn Americn c c 78.9 Asin Americn/Pcific Islnder c 91.1 Americn Indin/Alsk Ntive Hispnic/Ltin c c 87.0 AAPC indictes verge nnul percent chnge. b AAPC is for white women nd is not exclusive of Hispnic ethnicity. c AAPC is significntly different from zero (P <.05). Sources: Incidence rtes: Copelnd et l. 8 AAPCs, mortlity rtes, nd survivl: Howlder et l. 4 dignosis s result of increses in mmmogrphy screening. The increse ws observed in women ged both older nd younger thn 50 yers, lthough it ws lrger in the older ge group. Since 1999, incidence rtes of in situ brest cncer hve stbilized in women ged 50 yers nd older, but continue to increse in younger women (1.9 per yer from 1998 to 2010). The stbiliztion in incidence mong older women likely reflects trends in mmmogrphy screening rtes, which peked in 2000 nd then stbilized t slightly lower rte. 18 It my lso reflect reduced pool of prevlent cses s result of widespred screening. Incidence Trends by Rce/Ethnicity Brest cncer incidence rtes nd short-term () trends by rce/ethnicity re described in Tble 3. 4,8 Longterm trends in incidence rtes by rce/ethnicity re lso shown in Figure 2. Femle brest cncer incidence rtes vry substntilly by rce/ethnicity. From 2006 to 2010, the verge nnul femle brest cncer incidence rte ws highest in non-hispnic white women (127.3 cses per 100,000 femles) nd lowest for Asin Americns/Pcific Islnders (84.7 cses per 100,000 femles). During 2006 through 2010 (the most recent 5 yers of dt vilble), overll brest cncer incidence rtes incresed slightly (0.2 per yer) mong Africn Americn women; decresed by 0.6 per yer in Hispnic women; nd did not chnge significntly mong non-hispnic whites, Asin Americns/ Pcific Islnders, or Americn Indins/Alsk Ntives. Notbly, brest cncer incidence rtes for white nd Africn Americn women re converging. Rtes for white nd Africn Americn women were djusted for delys in cse reporting; dely-djusted rtes re not vilble for other rces/ethnicities, resulting in slightly underestimted rtes for the most recent dt yers. In ddition, rtes for Americn Indins/Alsk Ntives re less stble thn for other rcil nd ethnic groups becuse high-qulity dt for this group re only vilble from limited geogrphic res. Incidence Trends by Age nd ER Sttus Brest cncer incidence trends by ge for the 3 lrgest rcil/ ethnic groups re presented in Figure 3. Although non- Hispnic white women hve the highest overll brest cncer incidence rtes in most ge groups, Africn Americn women hve higher rtes mong women ged younger thn 40 yers. 4 In this figure, incidence rtes re similr for white nd Africn Americn women ged 30 yers to 49 yers. FIGURE 2. Trends in Femle Brest Cncer Incidence Rtes* by Rce nd Ethnicity, 1975 to *Rtes re ge djusted to the 2000 US stndrd popultion. Rtes for Asin Americns/Pcific Islnders, Hispnics/Ltins, nd Americn Indins/Alsk Ntives re 2-yer moving verges. Source: Surveillnce, Epidemiology, nd End Results (SEER) Progrm, Ntionl Cncer Institute. Dt for whites nd Africn Americns re from the SEER 9 registries nd were djusted for reporting delys. Dt for other rces/ethnicities re from the SEER 13 registries. For Hispnics, incidence dt do not include cses from the Alsk Ntive Registry. Incidence dt for Americn Indins/Alsk Ntives re bsed on Contrct Helth Service Delivery Are (CHSDA) counties. 4 CA: A Cncer Journl for Clinicins

5 FIGURE 3. Trends in Femle Brest Cncer Incidence Rtes* by Age, Rce/Ethnicity, nd Estrogen Receptor Sttus, 2000 to *Rtes re per 100,000 ge djusted to the 2000 US stndrd popultion. Note: A smller scle ws used to plot estrogen receptor-negtive incidence rtes to fcilitte visuliztion of the trends. ER sttus ws imputed for those with missing informtion. Source: Incidence: Surveillnce, Epidemiology, nd End Results (SEER) Progrm, SEER 18 registries, Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences; Dt were djusted for reporting dely. Notbly, in the women ged 50 yers to 59 yers, brest cncer incidence rtes hve recently converged mong non- Hispnic white nd Africn Americn women. Overll brest cncer incidence rtes incresed during the most recent time period () mong non-hispnic white women ged 30 yers to 49 yers nd Africn Americn women ged 60 yers to 69 yers, wheres rtes decresed for Hispnic women ged 30 yers to 49 yers nd 50 yers to 59 yers. If incidence rtes continue to increse mong Africn Americn women ged 60 yers to 69 yers, rtes for Africn Americn nd white women my lso converge in this ge group. We further exmined the ge-specific nd rce-specific incidence trends by ER sttus. In every ge group, white women hve the highest rtes of ER1 brest cncer nd Africn Americn women hve the highest rtes of ER- brest cncer. These differences my reflect rcil vritions in the prevlence of risk fctors tht differ by VOLUME 00 _ NUMBER 00 _ AUGUST

6 Brest Cncer Sttistics, 2013 ER sttus. For exmple, reproductive history nd obesity pper to be more strongly ssocited with ER1 brest cncer, wheres lower socioeconomic sttus is ssocited with n incresed risk of ER- brest cncer. 24,25 Studies tht include blck women with brest cncer in Afric hve suggested tht genetic differences my lso ply role. 26,27 Recent incidence trends vry substntilly by ER sttus. During 2006 through 2010, the incidence rtes of ER1 brest cncer incresed in every ge group mong Africn Americn women except for the oldest (those ged 70 yers nd older), with fster increses mong younger ge groups. Rtes of ER1 brest cncers lso incresed mong younger (ged 30 yers to 49 yers) white women nd Hispnic women ged 60 yers to 69 yers, wheres slight decrese ws observed for older (those ged 70 yers nd older) Hispnic women. Significnt decreses were lso observed for ER- brest cncer in most ge/rcil/ethnic groups. ERbrest cncer declined shrply (more thn 3 per yer) mong ll women ged younger thn 60 yers. Among women ged 60 yers to 69 yers, the decrese in ERbrest cncers ws observed only mong white women. In the oldest ge group (those ged 70 yers nd older), ERbrest cncers decresed mong both non-hispnic white nd Hispnic women. Previous studies hve lso noted incresing trends for ER1 brest cncer nd decresing trends for ER- brest cncer in the United Sttes nd Denmrk. 5,17,28-30 The resons for the diverging trends re not cler. We previously suggested tht they my reflect the estblishment of newer lower cutoff for ER positivity (1 of tumor nuclei positive by immunohistochemistry), which hd been s high s ,31 However, recent study suggests this my not be much of contributing fctor becuse similr recent trends were observed in Denmrk, where ER mesurement hs been consistent. 28 There is growing body of evidence tht brest cncer risk fctors for ER1 nd ER- brest cncers re distinct. 24,32 It hs recently been hypothesized tht the divergent trends by ER sttus my be reflective of incresing trends in obesity nd chnges in reproductive ptterns, fctors tht studies suggest my be differentilly ssocited with ER1 nd ER- brest cncers. 24,32 Other fctors, such s high levels of fruit nd vegetble consumption nd physicl ctivity, hve lso been linked to lower risk of ER- brest cncers. 33,34 Long-Term Mortlity Trends Figure 1 lso shows trends in deth rtes for brest cncer by ge t deth. After slowly incresing for mny yers (0.4 nnully from ), brest cncer deth rtes decresed by 34 from 1990 to The decline ws lrger mong women ged younger thn 50 yers (3.1 per yer) thn mong those ged 50 yers nd older (1.9 per yer). 4 Declines in brest cncer mortlity hve been ttributed to both improvements in tretment nd erly detection. 35 Mortlity Trends by Rce/Ethnicity Similr to incidence rtes, mortlity rtes vry by rce nd ethnicity. During 2006 through 2010, the verge nnul femle brest cncer deth rte ws highest in Africn Americns (30.8 deths per 100,000 femles) nd lowest mong Asin Americns/Pcific Islnders (11.5 deths per 100,000 femles) (Tble 3). 4 The higher deth rte mong Africn Americns, despite their hving lower incidence rte thn non-hispnic whites, is due to both lter stge of disese t dignosis nd poorer stge-specific survivl. For exmple, the 5-yer reltive survivl for regionl stge brest cncer is 74 in Africn Americn women compred with 86 in white women. 4 Reserch suggests tht rcil disprities in cncer mortlity re driven in lrge prt by differences in socioeconomic sttus. 36 Long-term trends in brest cncer mortlity rtes by rce/ethnicity re shown in Figure 4. From 2001 through 2010, brest cncer deth rtes declined nnully by 1.8 in non-hispnic whites, 1.7 in Hispnics/Ltins, 1.6 in Africn Americns, nd 1.0 in Asin Americns/ Pcific Islnders, but remined unchnged mong Americn Indins/Alsk Ntives. A striking divergence in long-term brest cncer mortlity trends between Africn Americn nd white women begn in the erly 1980s. This mortlity difference most likely reflects combintion of fctors, including differences in stge t dignosis, obesity nd other comorbidities, nd tumor chrcteristics, s well s ccess to, complince with, nd response to tretment. 37,38 By 2010, deth rtes were 41 higher in Africn Americn compred with white women. Survivl The 5-yer cuse-specific survivl rtes by rce/ethnicity re provided in Tble 3. 4 Cuse-specific survivl rtes re used insted of reltive survivl to describe survivl in rcil nd ethnic minorities becuse estimtes of norml life expectncy re not vilble for ll rcil/ethnic groups. Cusespecific survivl is the probbility of not dying of brest cncer within specified number of yers fter dignosis. Africn Americn women hve the lowest 5-yer survivl rte (78.9) of ny rcil or ethnic group. Asin Americn/ Pcific Islnder women hve the highest 5-yer brest cncer survivl rte (91.1). Poverty, less eduction, nd lck of helth insurnce re lso ssocited with lower brest cncer survivl Ptients with brest cncer who reside in lower-income 6 CA: A Cncer Journl for Clinicins

7 FIGURE 4. Trends in Femle Brest Cncer Deth Rtes* by Rce nd Ethnicity, 1975 to *Rtes re ge djusted to the 2000 US stndrd popultion. Note: For Hispnics, informtion is included for ll sttes except Connecticut, Mine, Mrylnd, Minnesot, New Hmpshire, New York, North Dkot, Oklhom, Vermont, nd the District of Columbi. For Americn Indins/Alsk Ntives, dt re from Contrct Helth Service Delivery Are (CHSDA) counties. Source: Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention, s provided by the Surveillnce, Epidemiology, nd End Results Progrm, Ntionl Cncer Institute. res hve lower 5-yer survivl rtes thn those in higherincome res t every stge of dignosis. 41 Vrition by Stte Stte vritions in mmmogrphy screening prevlence, brest cncer incidence, nd mortlity rtes nd the proportion of brest cncers dignosed t in situ nd regionl/distnt stges re presented in Tble 4. In 2012, the prevlence of recent mmmogrphy screening within the pst yer mong non-hispnic white women ged 40 yers nd older rnged from 48 in Wyoming to 72 in Msschusetts. Thirty-two sttes hd smple sizes lrge enough to estimte the prevlence of mmmogrphy screening within the pst yer in Africn Americn women ged 40 yers nd older, which rnged from 49 in Arknss to 73 in Delwre. Brest cncer incidence rtes rnged from cses per 100,000 femles in Arknss to cses per 100,000 femles in the District of Columbi mong non- Hispnic white women nd from 83.4 cses per 100,000 femles in New Mexico to cses per 100,000 femles in Alsk mong Africn Americn women. When compring incidence rtes mong sttes, it is importnt to consider tht incidence rtes reflect the intensity of screening s well s disese occurrence. The percentge of in situ brest cncers, n indictor of mmmogrphy use, vried from 15.6 in New Mexico to 25.2 in Msschusetts mong non-hispnic white women nd from 15.6 in Mississippi to 27.7 in Msschusetts mong Africn Americn women. The proportion of regionl/distnt stge cncers rnged from 29.0 in Vermont to 38.4 in Uth mong non-hispnic white women nd from 36.9 in Delwre to 53.2 in Arknss mong Africn Americn women. We ssessed the reltionship between mmmogrphy screening rtes in 2010 nd brest cncer stge t dignosis during 2006 through Stte-level mmmogrphy screening prevlence ws positively correlted with the percentge of brest cncers dignosed t in situ stge (correltion coefficient [r] ; P <.001) nd negtively correlted with the percentge of brest cncers dignosed t lte stges (r ; P <.001) mong non-hispnic white women. Among Africn Americn women, sttelevel mmmogrphy screening prevlence ws lso correlted with in situ dignoses (r ; P 5.006), but not with lte-stge dignoses. Despite similr screening rtes, Africn Americn women hve remined more likely to be dignosed with regionl nd distnt stge brest cncers compred with white women, which my reflect differences in the qulity of mmmogrphy screening nd delyed follow-up for bnorml mmmogrphy findings. 42,43 Brest cncer deth rtes mong non-hispnic white women rnged from 19.9 in Hwii to 26.2 in New Jersey. In contrst, brest cncer deth rtes mong Africn Americn women rnged from 19.7 in Rhode Islnd to 35.4 in Tennessee. We lso exmined trends in brest cncer mortlity rtes from 2001 through 2010 by stte for women of ll rces combined (dt not shown). Deth rtes significntly declined in 36 sttes during the lst 10 yers; however, they remined reltively unchnged in the remining 14 sttes (Alsk, Arknss, Delwre, Hwii, Idho, Mine, Montn, Nebrsk, Nevd, New Mexico, South Dkot, Uth, West Virgini, nd Wyoming) s well s the District of Columbi. The lck of decline in these sttes is likely relted to vritions in the prevlence nd qulity of mmmogrphy screening, s well s stte differences in rcil nd socioeconomic composition. Conclusions Overll brest cncer incidence rtes re converging mong white nd Africn Americn women becuse of increses in Africn Americn women coupled with stble rtes in white women. Incidence rtes decresed for ERtumors nd incresed for ER1 tumors. The decrese in ER- brest cncers my hve contributed to the declines in brest cncer mortlity rtes becuse these cncers often hve poorer prognosis thn ER1 brest cncers. VOLUME 00 _ NUMBER 00 _ AUGUST

8 Brest Cncer Sttistics, 2013 TABLE 4. Stte Vrition in Femle Brest Cncer Incidence nd Mortlity Rtes b nd Mmmogrphy Usge by Rce NON-HISPANIC WHITE AFRICAN AMERICAN RECENT MAMMOGRAM c 2012 INCIDENCE MORTALITY RECENT MAMMOGRAM c 2012 INCIDENCE MORTALITY AGE 401, IN SITU d REGIONAL/ DISTANT d INVASIVE AGE 401, IN SITU d REGIONAL/ DISTANT d INVASIVE Stte Albm Alsk Arizon Arknss Cliforni Colordo Connecticut Delwre District of Columbi e Florid Georgi Hwii Idho Illinois Indin Iow Knss Kentucky Louisin Mine Mrylnd Msschusetts f Michign Minnesot Mississippi Missouri Montn Nebrsk Nevd New Hmpshire New Jersey New Mexico New York North Crolin North Dkot e Ohio Oklhom Oregon CA: A Cncer Journl for Clinicins

9 TABLE 4. Continued NON-HISPANIC WHITE AFRICAN AMERICAN RECENT MAMMOGRAM c 2012 INCIDENCE MORTALITY RECENT MAMMOGRAM c 2012 INCIDENCE MORTALITY AGE 401, IN SITU d REGIONAL/ DISTANT d INVASIVE AGE 401, IN SITU d REGIONAL/ DISTANT d INVASIVE Pennsylvni Rhode Islnd South Crolin e South Dkot Tennessee Texs Uth Vermont Virgini Wshington West Virgini Wisconsin Wyoming United Sttes Rnge Sttistics were not shown for mmmogrphy if estimtes were bsed on fewer thn 50 respondents nd for incidence nd mortlity rtes bsed on 25 or fewer cses or deths. b All rtes re per 100,000 femles nd ge-djusted to 2000 US stndrd popultion. c Recent mmmogrm is defined s hving hd mmmogrm within the pst yer. d The denomintors for percent in situ include ll brest cncers. The denomintors for percent regionl/distnt include only invsive brest cncers. e Mortlity dt for white women in these sttes re not exclusive of Hispnic ethnicity. f The incidence rte for white women in Msschusetts is not exclusive of Hispnic ethnicity. Sources: Mmmogrphy: Behviorl Risk Fctor Surveillnce System 2012, Centers for Disese Control nd Prevention. Incidence: Surveillnce, Epidemiology, nd End Results nd Ntionl Progrm of Cncer Registries res reported by the North Americn Assocition of Centrl Cncer Registries (NAACCR) for 2006 through Incidence dt re not vilble for Minnesot. Overll US incidence dt do not include dt from Arknss, Minnesot, Nevd, Ohio, nd Virgini. Mortlity: Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention. Although brest cncer deth rtes hve dropped 34 since 1990, not ll segments of the popultion hve benefited from this decrese. TABLE 5. Age 40 nd over l Annul mmmogrm Americn Cncer Society Guidelines for the Erly Detection of Brest Cncer in Averge- Risk, Asymptomtic Women l Annul clinicl brest exmintion (preferbly prior to mmmogrm) l Brest self-exmintion (optionl) Ages l Clinicl brest exmintion t lest every 3 y l Brest self-exmintion (optionl) Clinicins should follow recommended screening guidelines (Tble 5) nd encourge their ptients ged 40 yers nd older to hve nnul mmmogrphy. Consistent follow-up of bnorml results, prompt dignosis, nd the delivery of high-qulity tretment is criticl to further improve brest cncer outcomes. It is lso importnt tht ptients t high risk of brest cncer re identified nd offered pproprite screening nd follow-up. Strtegies tht my help reduce the risk of brest cncer include voiding weight gin nd obesity, engging in regulr physicl ctivity, nd minimizing lcohol intke. 44 The incresed risk of brest cncer ssocited with the use of combined estrogen nd progestin therpy should be considered when evluting tretment options for ptients with menopusl symptoms. 45 Clinicins re dvised to VOLUME 00 _ NUMBER 00 _ AUGUST

10 Brest Cncer Sttistics, 2013 discuss the use of tmoxifen nd rloxifene for chemoprevention with women t n incresed risk of brest cncer Dt from the 2010 Ntionl Helth Interview Survey suggest tht the use of brest cncer chemoprevention drugs remins remrkbly low (well under 1), with little increse in use observed since 2000, nd note slight shift towrd rloxifene since its pprovl in Although exemestne is currently pproved by the US Food nd Drug Administrtion to prevent brest cncer recurrence, promising results from clinicl trils led the Americn Society of Clinicl Oncology to include exemestne in their guidelines s third option for chemoprevention. 48 Continued progress in the control of brest cncer will require sustined nd incresed efforts to provide high-qulity screening, dignosis, nd tretment to ll segments of the popultion. References 1. Surveillnce, Epidemiology, nd End Results (SEER) Progrm. SEER*Stt Dtbse: Incidence-SEER 9 Regs Reserch Dt, Nov Sub ( ) <Ktrin/Rit Popultion Adjustment>- Linked To County Attributes-Totl US, Counties. Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences, Surveillnce Reserch Progrm, Surveillnce Systems Brnch; Relesed April 2013 bsed on the November 2012 submission. 2. Surveillnce, Epidemiology, nd End Results (SEER) Progrm. SEER*Stt Dtbse: Incidence-SEER 13 Regs Reserch Dt, Nov Sub ( ) <Ktrin/Rit Popultion Adjustment>- Linked To County Attributes-Totl US, Counties. Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences, Surveillnce Reserch Progrm, Surveillnce Systems Brnch; Relesed April 2013 bsed on the November 2012 submission. 3. Surveillnce, Epidemiology, nd End Results (SEER) Progrm. SEER*Stt Dtbse: Incidence-SEER 18 Regs Reserch Dt1Hurricne Ktrin Impcted Louisin Cses, Nov Sub ( ) <Ktrin/Rit Popultion Adjustment>- Linked To County Attributes-Totl US, Counties. Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences, Surveillnce Reserch Progrm, Surveillnce Systems Brnch; Relesed April 2013 bsed on the November 2012 submission. 4. Howlder N, Noone AM, Krpcho M, et l, eds. SEER Cncer Sttistics Review, Bethesd, MD: Ntionl Cncer Institute; Anderson WF, Ktki HA, Rosenberg PS. Incidence of brest cncer in the United Sttes: current nd future trends. J Ntl Cncer Inst. 2011;103: Ntionl Cncer Institute. Cncer Query Systems: Dely-Adjusted SEER Incidence Rtes. surveillnce.cncer.gov/dely/cnques. html/. Accessed June 3, Surveillnce, Epidemiology nd End Results (SEER) Progrm. SEER*Stt Dtbse: NAACCR Incidence-CiNA Anlytic File, , for NHIAv2 Origin, Custom File With County, ACS Fcts nd Figures Projection Project, North Americn Assocition of Centrl Cncer Registries. Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences, Surveillnce Reserch Progrm, Surveillnce Systems Brnch; Copelnd G, Lke A, Firth R, et l, eds. Combined Cncer Incidence for the United Sttes, Cnd nd North Americ. Vol 1. Cncer In North Americ:. Springfield, IL: North Americn Assocition of Centrl Cncer Registries Inc; Surveillnce, Epidemiology, nd End Results (SEER) Progrm. SEER*Stt Dtbse: Mortlity-All COD, Aggregted With Stte, Totl US ( ) <Ktrin/Rit Popultion Adjustment>. Bethesd, MD: Ntionl Cncer Institute, Division of Cncer Control nd Popultion Sciences, Surveillnce Reserch Progrm, Surveillnce Systems Brnch; Relesed April 2013; underlying mortlity dt provided by Ntionl Center for Helth Sttistics (cdc.gov/nchs). 10. Surveillnce, Epidemiology, nd End Results (SEER) Progrm. SEER*Stt Dtbse: Mortlity-All COD, Aggregted With County, Totl US ( ) <Ktrin/ Rit Popultion Adjustment>-Linked To County Attributes-Totl US, Counties. 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11 therpy, screening mmmogrphy, nd estrogen receptor sttus. J Ntl Cncer Inst. 2007;99: Hmmond ME, Hyes DF, Dowsett M, et l; Americn Society of Clinicl Oncology; College of Americn Pthologists. Americn Society of Clinicl Oncology/College of Americn Pthologists guideline recommendtions for immunohistochemicl testing of estrogen nd progesterone receptors in brest cncer (unbridged version). Arch Pthol Lb Med. 2010;134: e48-e Colditz GA, Rosner BA, Chen WY, Holmes MD, Hnkinson SE. Risk fctors for brest cncer ccording to estrogen nd progesterone receptor sttus. J Ntl Cncer Inst. 2004;96: Zhng X, Spiegelmn D, Bglietto L, et l. Crotenoid intkes nd risk of brest cncer defined by estrogen receptor nd progesterone receptor sttus: pooled nlysis of 18 prospective cohort studies. Am J Clin Nutr. 2012;95: Wu Y, Zhng D, Kng S. Physicl ctivity nd risk of brest cncer: met-nlysis of prospective studies. Brest Cncer Res Tret. 2013;137: Berry DA, Cronin KA, Plevritis SK, et l. Effect of screening nd djuvnt therpy on mortlity from brest cncer. N Engl J Med. 2005;353: Siegel R, Wrd E, Brwley O, Jeml A. Cncer sttistics, 2011: the impct of eliminting socioeconomic nd rcil disprities on premture cncer deths. CA Cncer J Clin. 2011;61: Ooi SL, Mrtinez ME, Li CI. Disprities in brest cncer chrcteristics nd outcomes by rce/ethnicity. Brest Cncer Res Tret. 2011;127: Curtis E, Qule C, Hggstrom D, Smith- Bindmn R. Rcil nd ethnic differences in brest cncer survivl: how much is explined by screening, tumor severity, biology, tretment, comorbidities, nd demogrphics? Cncer. 2008;112: Sprgue BL, Trenthm-Dietz A, Gngnon RE, et l. Socioeconomic sttus nd survivl fter n invsive brest cncer dignosis. Cncer. 2011;117: Hlpern MT, Bin J, Wrd EM, Schrg NM, Chen AY. Insurnce sttus nd stge of cncer t dignosis mong women with brest cncer. Cncer. 2007;110: Hrper S, Lynch J, Meersmn SC, Breen N, Dvis WW, Reichmn MC. Trends in resocioeconomic nd rce-ethnic disprities in brest cncer incidence, stge t dignosis, screening, mortlity, nd survivl mong women ges 50 yers nd over ( ). Cncer Epidemiol Biomrkers Prev. 2009;18: Goldmn LE, Wlker R, Miglioretti DL, Smith-Bindmn R, Kerlikowske K; Ntionl Cncer Institute Brest Cncer Surveillnce Consortium. Accurcy of dignostic mmmogrphy t fcilities serving vulnerble women. Med Cre. 2011;49: Gorin SS, Heck JE, Cheng B, Smith SJ. Delys in brest cncer dignosis nd tretment by rcil/ethnic group. Arch Intern Med. 2006;166: Kushi LH, Doyle C, McCullough M, et l; Americn Cncer Society 2010 Nutrition nd Physicl Activity Guidelines Advisory Committee. Americn Cncer Society Guidelines on nutrition nd physicl ctivity for cncer prevention: reducing the risk of cncer with helthy food choices nd physicl ctivity. CA Cncer J Clin. 2012;62: Chlebowski RT, Anderson GL. Chnging concepts: menopusl hormone therpy nd brest cncer. J Ntl Cncer Inst. 2012; 104: Nelson HD, Smith ME, Griffin JC, Fu R. Use of medictions to reduce risk for primry brest cncer: systemtic review for the U.S. Preventive Services Tsk Force. Ann Intern Med. 2013;158: Bevers TB, Armstrong DK, Arun B, et l. Brest cncer risk reduction. J Ntl Compr Cnc Netw. 2010;8: Visvnthn K, Hurley P, Bntug E, et l. Use of phrmcologic interventions for brest cncer risk reduction: Americn Society of Clinicl Oncology clinicl prctice guideline. JClinOncol. 2013;31: Wters EA, McNeel TS, Stevens WM, Freedmn AN. Use of tmoxifen nd rloxifene for brest cncer chemoprevention in Brest Cncer Res Tret. 2012;134: VOLUME 00 _ NUMBER 00 _ AUGUST