Annals of Oncology Advance Access originally published online on March 17, 2009
Annals of Oncology 2009 20(9):1505-1510; doi:10.1093/annonc/mdp037
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breast cancer |
Early detection of second breast cancers improves prognosis in breast cancer survivors
1 Istituto per lo Studio e la Prevenzione Oncologica, Istituto Scientifico della Regione Toscana, Florence, Italy
2 Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia
3 Cancer Research UK, Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, London, UK
* Correspondence to: Assoc. Prof. N. Houssami, Screening and Test Evaluation Program, School of Public Health, Edward Ford Building (A27), University of Sydney, Sydney NSW 2006, Australia. Tel: +61-02-419-273510; Fax: +61-02-93517420; E-mail: nehmath{at}med.usyd.edu.au
Background: The impact of early detection of second breast cancers in women who have survived a primary breast cancer is unknown. We examined the prognostic effect of detection of ipsilateral breast relapse (IBR) or contralateral breast cancer (CBC) in the asymptomatic relative to symptomatic phase.
Patients and methods: Subjects were women with histology-verified second (invasive or in situ) breast cancer (N = 1044) in a breast centre in Florence (1980–2005). Symptom status, test, tumour stage, and outcomes data were obtained from clinical records and linkage with mortality registry. Disease-specific survival was measured from first cancer diagnosis to avoid lead-time bias. Sensitivity analysis was used to allow for length-time bias.
Results: Second cancers (IBR = 455; CBC = 589; median age 60 years) were diagnosed in 699 asymptomatic and 345 symptomatic women (67% versus 3%, P < 0.0001). Mammography was more sensitive than clinical examination (86% versus 57%, P < 0.0001); however, 13.8% of cases were only identified clinically. Asymptomatic cancers were smaller than symptomatic for both IBR (P < 0.001) and CBC (P < 0.001). Early-stage tumours were more frequent in asymptomatic (58.1%) than symptomatic (22.6%) women (P < 0.0001). Fewer women with asymptomatic than symptomatic CBC had node metastases (P = 0.0001). Hazard ratio (HR) for asymptomatic (relative to symptomatic) detection was 0.51 (0.32–0.80) for IBR, 0.53 (0.36–0.78) for CBC, and 0.53 (0.40–0.72) in all subjects (P < 0.0001). Length bias-adjusted HRs ranged from 0.53 to 0.73.
Conclusion: Detection of second breast cancers in the asymptomatic phase leads to detection of early-stage cancer and improves relative survival by between 27% and 47%.
Key words: contralateral cancer, disease-specific survival, early detection, ipsilateral breast relapse, lead-time bias, second breast cancer
These authors have equally contributed to the development and reporting of this work. Received for publication November 26, 2008. Accepted for publication January 27, 2009.
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