Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance, Epidemiology, and End Results and institutional analysis: 1990 to 2011 390 Cancer January 15, 2020...

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Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance, Epidemiology, and End Results and institutional analysis: 1990 to 2011 390 Cancer January 15, 2020 Original Article Metastatic Breast Cancer Survival Improvement Restricted by Regional Disparity: Surveillance, Epidemiology, and End Results and Institutional Analysis: 1990 to 2011 Judith A. Malmgren, PhD 1,2; Gregory S. Calip, PharmD, MPH, PhD 3; Mary K. Atwood, CTR4; Musa Mayer, MS, MFA5; and Henry G. Kaplan, MD4 BACKGROUND: The extent of breast cancer outcome disparity can be measured by comparing Surveillance, Epidemiology, and End Results (SEER) breast cancer-specific survival (BCSS) by region and with institutional cohort (IC) rates. METHODS: Patients who were diagnosed with a first primary, de novo, stage IV breast cancer at ages 25 to 84 years from 1990 to 2011 were studied. The change in 5-year BCSS over time from 1990 to 2011 was compared using the SEER 9 registries (SEER 9) without the Seattle-Puget Sound (S-PS) region (n = 12,121), the S-PS region alone (n = 1931), and the S-PS region IC (n = 261). The IC BCSS endpoint was breast cancer death con- firmed from chart and/or death certificate and cause-specific survival for SEER registries. BCSS was estimated using the Kaplan-Meier method. Hazard ratios (HzR) were calculated using Cox proportional-hazards models. RESULTS: For SEER 9 without the S-PS region, 5-year BCSS improved 7% (from 19% to 26%) over time, it improved 14% for the S-PS region (21% to 35%), and it improved 27% for the S-PS IC (29% to 56%). In the IC Cox proportional-hazards model, recent diagnosis year, chemotherapy, surgery, and age <70 years were="" associated="" with="" better="" survival.="" for="" seer="" 9,="" additional="" significant="" factors="" were="" white="" race="" and="" positive="" hormone="" receptor="" status="" and="" s-ps="" region="" was="" associated="" with="" better="" survival="" (hzr,="" 0.87;="" 95%="" ci,="" 0.84-0.90).="" in="" an="" adjusted="" model,="" hazard="" of="" bc="" death="" decreased="" in="" the="" most="" recent="" time="" period="" (2005-2011)="" by="" 28%="" in="" seer="" 9="" without="" s-ps,="" 43%="" in="" the="" s-ps="" region="" and="" 45%="" in="" the="" ic="" (hzr,="" 0.72="" [95%="" ci,="" 0.67-0.76],="" 0.57="" [95%="" ci,="" 0.49-0.66],="" and="" 0.55="" [95%="" ci,="" 0.39-0.78],="" respectively).="" conclusions:="" over="" 2="" decades,="" the="" survival="" of="" patients="" with="" metastatic="" breast="" cancer="" improved="" nationally,="" but="" with="" regional="" survival="" disparity="" and="" differential="" improvement.="" to="" achieve="" equitable="" outcomes,="" access="" and="" treatment="" approaches="" will="" need="" to="" be="" identified="" and="" adopted.="" cancer="" 2020;126:390-399.="" ©="" 2019="" the="" authors.="" cancer="" published="" by="" wiley="" periodicals,="" inc.="" on="" behalf="" of="" american="" cancer="" society.="" this="" is="" an="" open="" access="" article="" under="" the="" terms="" of="" the="" creative="" commons="" attribution-noncommercial-noderivs="" license,="" which="" permits="" use="" and="" distribution="" in="" any="" medium,="" provided="" the="" original="" work="" is="" properly="" cited,="" the="" use="" is="" non-commercial="" and="" no="" modifications="" or="" adaptations="" are="" made.="" keywords:="" differential="" survival,="" disease-specific="" survival="" (dss),="" metastatic="" breast="" cancer,="" regional="" disparity.="" introduction="" variation="" in="" breast="" cancer="" recurrence="" and="" survival="" may="" be="" influenced="" by="" age,="" race,="" access="" to="" care,="" insurance="" coverage,="" socioeconomic="" status,="" geographic="" area="" of="" residence="" (urban/rural="" or="" metropolitan/nonmetropolitan),="" and="" timely="" diagnosis="" and="" treatment.1-4="" from="" national="" statistics,="" factors="" contributing="" to="" state="" variations="" in="" cancer="" incidence="" rates="" include="" risk="" factor="" prevalence,="" access="" to="" and="" utilization="" of="" early="" detection="" services,="" and="" completeness="" of="" reporting.5="" despite="" survival="" improvements="" across="" poverty="" levels="" for="" all="" stages="" of="" disease,="" relative="" survival="" remains="" lower="" among="" women="" residing="" in="" poor="" areas="" compared="" with="" affluent="" women.6="" some="" evidence="" links="" guideline="" compliance="" to="" improved="" and="" optimal="" outcomes,="" but="" a="" lack="" of="" ability="" to="" compare="" guideline="" adherence="" in="" national="" databases="" inhibits="" the="" ability="" to="" evaluate="" widespread="" adherence="" or="" efficacy.7,8="" we="" previously="" observed="" significant="" improvement="" in="" 5-year="" disease-specific="" survival="" of="" patients="" with="" de="" novo="" stage="" iv="" metastatic="" breast="" cancer="" (mbc)="" over="" time="" from="" 1990="" to="" 2010="" without="" a="" concurrent="" improvement="" in="" the="" survival="" of="" pa-="" tients="" with="" recurrent="" mbc="" from="" our="" study="" of="" an="" institutional="" cohort="" of="" breast="" cancer="" registry="" patients.9="" the="" 5-year="" breast="" cancer-specific="" survival="" (bcss)="" rates="" in="" our="" institutional="" cohort="" of="" patients="" with="" stage="" iv="" breast="" cancer="" were="" significantly="" higher="" than="" the="" rates="" previously="" reported="" for="" stage="" iv="" breast="" cancer="" from="" surveillance,="" epidemiology,="" and="" end="" results="" (seer)="" registry="" data.10="" regional="" disparity="" in="" breast="" cancer="" outcomes="" can="" be="" measured="" by="" comparing="" bcss="" rates="" from="" seer="" across="" geo-="" graphic="" regions="" and="" with="" the="" rates="" from="" a="" seer-embedded="" institutional="" cohort.="" we="" compared="" seer="" aggregate="" data="" to="" corresponding="" author:="" judith="" a.="" malmgren,="" phd,="" 12025="" ninth="" avenue="" nw,="" seattle,="" wa="" 98177;="" [email protected]="" 1="" healthstat="" consulting,="" inc.,="" seattle,="" washington;="" 2="" department="" of="" epidemiology, university="" of="" washington,="" seattle,="" washington;="" 3="" center="" for="" pharmacoepidemiology="" and="" pharmacoeconomic="" research, university="" of="" illinois="" at="" chicago,="" chicago,="" illinois;="" 4="" swedish="" cancer="" institute,="" seattle,="" washington;="" 5="" metastatic="" breast="" cancer="" alliance,="" new="" york,="" new="" york="" we="" acknowledge="" and="" sincerely="" thank="" dr.="" marc="" hurlbert="" for="" his="" invaluable="" assistance.="" doi:="" 10.1002/cncr.32531,="" received:="" may="" 10,="" 2019;="" revised:="" august="" 25,="" 2019;="" accepted:="" august="" 30,="" 2019,="" published="" online="" october="" 22,="" 2019="" in="" wiley="" online="" library="" (wileyonlinelibrary.com)="" mailto:="" https://orcid.org/0000-0001-6939-8828="" https://orcid.org/0000-0002-7744-3518="" http://creativecommons.org/licenses/by-nc-nd/4.0/="" mailto:[email protected]="" metastatic="" breast="" cancer="" survival="" disparity/malmgren="" et="" al="" 391cancer="" january="" 15,="" 2020="" the="" regional="" subset="" from="" the="" seattle-puget="" sound="" (s-ps)="" area="" registry="" and="" to="" an="" institutional="" cohort="" (ic)="" located="" in="" the="" s-ps="" registry="" area="" whose="" cases="" are="" included="" in="" the="" s-ps="" cancer="" surveillance="" system="" (seer="" 9="" without="" s-ps,="" n="12,121;" s-ps,="" n="1931;" and="" seattle="" ic,="" n="261)." our="" objectives="" were="" to="" compare="" survival="" rates="" to="" evaluate="" regional="" disparity="" in="" de="" novo="" mbc="" survival,="" to="" compare="" survival="" rate="" improvement="" over="" time="" by="" region="" and="" insti-="" tution,="" and="" to="" assess="" the="" impact="" of="" temporal="" advances="" in="" systemic="" therapies="" on="" trends="" in="" de="" novo="" stage="" iv="" mbc="" survival="" rates.="" in="" particular,="" our="" focus="" was="" on="" regional="" survival="" differences="" and="" the="" potential="" for="" survival="" rate="" improvement="" over="" time="" as="" patients="" with="" metastatic="" disease="" have="" a="" poor="" prognosis="" and="" are="" often="" treated="" with="" palliative="" rather="" than="" with="" stabilizing="" or="" curative="" intent.="" materials="" and="" methods="" the="" analysis="" included="" patients="" aged="" 25="" to="" 84="" years="" with="" first="" primary="" breast="" cancer="" who="" were="" diagnosed="" with="" de="" novo="" stage="" iv="" breast="" cancer="" from="" 1990="" to="" 2011="" in="" the="" seer="" 9="" registries="" and="" an="" institutional="" cohort="" (ic)="" located="" in="" the="" seer="" 9="" s-ps="" region="" (vital="" status="" through="" 2016).="" we="" calculated="" 5="" -year="" breast="" cancer-specific="" sur-="" vival="" (bcss)="" for="" 3="" time="" periods="" (1990-1998,="" 1999-2004,="" and="" 2005-2011),="" during="" which="" adjuvant="" chemotherapy="" treatments="" changed="" significantly="" and="" was="" available="" for="" the="" ic="" patients="" (table="" 1).11="" for="" the="" ic,="" the="" bcss="" end-="" point="" was="" breast="" cancer="" death="" confirmed="" from="" chart="" and/="" or="" death="" certificate.="" for="" seer,="" seer*stat-documented="" cause-specific="" survival="" was="" used.12="" the="" seer="" s-ps="" region="" was="" used="" separately="" for="" comparison="" with="" seer="" 9="" without="" s-ps="" and="" the="" ic.="" five-year="" bcss="" and="" 95%="" cis="" and="" cox="" proportional="" hazard="" models="" were="" calculated="" using="" spss="" 25.0="" (ibm="" corporation)="" for="" the="" institutional="" cohort="" and="" stata="" (statacorp="" llc)="" for="" seer="" 9.13,14="" bcss="" was="" estimated="" as="" the="" net="" measure="" representing="" survival="" from="" death="" caused="" by="" the="" primary="" diagnosed="" breast="" cancer="" in="" the="" absence="" of="" other="" causes="" of="" death.="" patients="" who="" died="" of="" causes="" other="" than="" those="" specified="" were="" considered="" to="" be="" censored.15="" cox="" proportional="" hazards="" modelling="" was="" used="" to="" es-="" timate="" adjusted="" hazard="" ratios="" (hzr)="" with="" corresponding="" 95%="" cis,="" with="" death="" from="" disease="" as="" the="" endpoint.="" the="" ic="" was="" used="" to="" build="" an="" a="" priori="" model="" informed="" by="" a="" chi-square="" analysis="" and="" tested="" by="" stepwise="" entry="" into="" the="" model="" with="" a="" subsequent="" forced-entry="" model="" to="" include="" all="" variables="" of="" interest="" in="" the="" seer="" 9="" population.="" the="" proportional="" hazards="" assumption="" was="" evaluated="" graph-="" ically="" using="" the="" log(-log[survival])="" versus="" log="" of="" survival="" time.="" we="" found="" no="" evidence="" suggesting="" violation="" of="" the="" proportionality="" assumption.="" all="" p="" values="" were="" 2-sided="" using="" a="" .05="" level="" of="" significance.="" data="" from="" the="" seer="" 9="" population-based="" cancer="" registries="" (connecticut,="" detroit,="" atlanta,="" san="" francisco-="" oakland,="" hawaii,="" iowa,="" new="" mexico,="" seattle-puget="" sound,="" and="" utah)="" were="" included="" in="" our="" analysis.16="" the="" seer="" pro-="" gram="" is="" funded="" by="" the="" national="" institutes="" of="" health="" and="" the="" national="" cancer="" institute="" and="" represents="" cancer="" incidence="" data="" for="" approximately="" 28%="" of="" the="" us="" population.="" the="" institutional="" cohort="" (ic)="" breast="" cancer="" registry="" database,="" which="" was="" created="" in="" 1990,="" contains="" detailed="" information="" on="" diagnosis,="" pathology,="" staging,="" surgery,="" chemotherapy,="" radiation="" therapy,="" tumor="" markers,="" and="" vital="" status="" at="" follow-up,="" including="" cause-specific="" death.="" incident="" breast="" cancer="" cases="" are="" entered="" at="" the="" time="" of="" diag-="" nosis="" in="" a="" health="" insurance="" portability="" and="" accountability="" act="" of="" 1996="" (hipaa)-compliant="" and="" institutional="" review="" board="" (irb)-approved="" research="" registry.="" this="" project="" was="" hipaa="" compliant="" and="" irb="" approved.="" patient="" vital="" and="" disease="" status,="" including="" date,="" site="" and="" type="" of="" recurrence,="" and="" date="" and="" cause="" of="" death,="" is="" collected="" prospectively="" through="" annual="" updates="" by="" a="" certified="" cancer="" registrar.="" follow-up="" is="" obtained="" from:="" 1)="" electronic="" chart="" review;="" 2)="" an="" irb-approved,="" physician-directed="" follow-up="" letter;="" 3)="" an="" institutional="" cancer="" registry;="" and="" 4)="" the="" seer="" s-ps="" registry.17="" table="" 1.="" change="" in="" systemic="" therapy="" from="" 1990="" to="" 2011:="" stage="" iv="" breast="" cancer,="" ic="" patients="" only, n =" 261" systemic="" therapy="" no.="" of="" patients="" (%)="" p1990-1998="" 1999-2004="" 2005-2011="" initial="" chemotherapy,="" n =" 175" 51="" (64)="" 40="" (66)="" 84="" (70)="" .629="" taxane="" therapy,="" n =" 99" 11="" (21)="" 24="" (60)="" 64="" (76)=""><.001 anthracycline="" therapy,="" n =" 114" 43="" (83)="" 28="" (70)="" 43="" (51)="" .001="" trastuzumab="" therapy:="" her-2–positive="" patients,="" n =" 45" 0="" (0)="" 8="" (68)="" 25="" (100)=""><.001 neoadjuvant therapy, n = 64 18 (23) 7 (12) 39 (33) .007 hormone therapy: hr-positive patients, n = 193 48 (86) 41 (89) 83 (91) .583 abbreviation: hr, hormone receptor. original article 392 cancer january 15, 2020 results the seer 9 without s-ps population and the seer s-ps region population were both older than the ic patients (mean age, 61 vs 55 years). more ic and s-ps patients identified as white race (ic, 81%; s-ps, 89%) than seer 9 without s-ps patients (75%) (table 2). of all invasive breast cancers in the populations, 5% of those in seer 9 without s-ps, 4% of those in the s-ps region, and 3% of those in the ic were de novo stage iv. patients in the s-ps region and in the ic were more often hormone recep- tor (hr)-positive (66% and 74%, respectively, vs 56% in seer 9 without s-ps). stage iv surgical treatment was received by ≥50% of patients in all 3 groups (seer 9 without s-ps, 58%; s-ps, 56%; ic, 50%). patients in the neoadjuvant="" therapy,="" n =" 64" 18="" (23)="" 7="" (12)="" 39="" (33)="" .007="" hormone="" therapy:="" hr-positive="" patients,="" n =" 193" 48="" (86)="" 41="" (89)="" 83="" (91)="" .583="" abbreviation:="" hr,="" hormone="" receptor.="" original="" article="" 392="" cancer="" january="" 15,="" 2020="" results="" the="" seer="" 9="" without="" s-ps="" population="" and="" the="" seer="" s-ps="" region="" population="" were="" both="" older="" than="" the="" ic="" patients="" (mean="" age,="" 61="" vs="" 55="" years).="" more="" ic="" and="" s-ps="" patients="" identified="" as="" white="" race="" (ic,="" 81%;="" s-ps,="" 89%)="" than="" seer="" 9="" without="" s-ps="" patients="" (75%)="" (table="" 2).="" of="" all="" invasive="" breast="" cancers="" in="" the="" populations,="" 5%="" of="" those="" in="" seer="" 9="" without="" s-ps,="" 4%="" of="" those="" in="" the="" s-ps="" region,="" and="" 3%="" of="" those="" in="" the="" ic="" were="" de="" novo="" stage="" iv.="" patients="" in="" the="" s-ps="" region="" and="" in="" the="" ic="" were="" more="" often="" hormone="" recep-="" tor="" (hr)-positive="" (66%="" and="" 74%,="" respectively,="" vs="" 56%="" in="" seer="" 9="" without="" s-ps).="" stage="" iv="" surgical="" treatment="" was="" received="" by="" ≥50%="" of="" patients="" in="" all="" 3="" groups="" (seer="" 9="" without="" s-ps,="" 58%;="" s-ps,="" 56%;="" ic,="" 50%).="" patients="" in="">
Answered 13 days AfterJun 07, 2021

Answer To: Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance,...

Vijayalakshmi answered on Jun 20 2021
137 Votes
1) the statement "... a possible statistical cure, in that patients may be able to live long enough .with disease to die of other causes" - This concept is sometimes described as a competing risk - meaning that in a Survival analysis model we are interested in looking for a particular event (i.e. death by breast cancer) but a different event (i.e. death by heart disease) may occur first. Discuss what implications this type of situation may have on being able to perform a survival analysis and being able to interpret the results.
SURVIVAL ANALYSIS MODEL:
Survival analysis is a branch of statistics for analyzing the expected duration of time until one event occurs, such as death in biological organisms and failure in mechanical systems. Here, in the above situation we want to analyse the expected duration between the event occur due to metastatic breast cancer and due to heart disease.
Survival analysis performed to investigate the factors that contribute to an outcome over a time. It can answer questions like, what proportion samples can survive over a period of time? What treatment is more effective in prolonging the lifespan and reducing the duration of symptoms?
Some of the terminologies commonly used in survival analysis model are, the following terms are commonly used in survival analyses:
· Event: disease occurrence, recurrence or recovery, death or any other experience of interest. Here in this discussion event is death due to breast cancer.
· Time: time is the duration between the beginning to end of the observation of the study. In this study time is between treatment of breast cancer either surgery or chemotherapy to the occurrence of the event.
· Censoring: it occurs when a subject is left before the occurrence of event of interest due to many reasons like no contact, left treatment in between, death due to some other reason than the event of interest. Due to this reason after the censor no information is known about the sample. A censored...
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