Bao Ning Zhang

A Nation-Wide multicenter 10-year (1999-2008) retrospective clinical epidemiological study of female breast cancer in china

BackgroundAccording to the very limited cancer registry, incidence and mortality rates for female breast cancer in China are regarded to be increasing especially in the metropolitan areas. Representative data on the breast cancer profile of Chinese women and its time trend over years are relatively rare. The aims of the current study are to illustrate the breast cancer profile of Chinese women in time span and to explore the current treatment approaches to female breast cancer.MethodsThis was a hospital-based nation-wide and multi-center retrospective study of female primary breast cancer cases. China was divided into 7 regions according to the geographic distribution; from each region, one tertiary hospital was selected. With the exception of January and February, one month was randomly selected to represent each year from year 1999 to 2008 at every hospital. All inpatient cases within the selected month were reviewed and related information was collected based on the designed case report form (CRF). The Cancer Hospital/Institute, Chinese Academy of Medical Sciences (CICAMS) was the leading hospital in this study.ResultsFour-thousand two-hundred and eleven cases were randomly selected from the total pool of 45,200 patients and were included in the analysis. The mean age at diagnosis was 48.7 years (s.d. = 10.5 yrs) and breast cancer peaked in age group 40-49 yrs (38.6%). The most common subtype was infiltrating ductal carcinoma (86.5%). Clinical stage I & II accounted for 60.6% of 4,211 patients. Three-thousand five-hundred and thirty-four cases had estrogen receptor (ER) and progestin receptor (PR) tests, among them, 47.9% were positive for both. Two-thousand eight-hundred and forty-nine cases had human epidermal growth factor receptor 2(HER-2) tests, 25.8% of them were HER-2 positive. Among all treatment options, surgery (96.9% (4,078/4,211)) was predominant, followed by chemotherapy (81.4% (3,428/4,211). Much less patients underwent radiotherapy (22.6% (952/4,211)) and endocrine therapy (38.0% (1,599/4,211)).ConclusionsThe younger age of breast cancer onset among Chinese women and more advanced tumor stages pose a great challenge. Adjuvant therapy, especially radiotherapy and endocrine therapy are of great unmet needs.

Risk Factors for Breast Cancer Among Chinese Women: A 10-Year Nationwide Multicenter Cross-Sectional Study

Background The characteristics of established risk factors for breast cancer may vary among countries. A better understanding of local characteristics of risk factors may help in devising effective prevention strategies for breast cancer. Methods Information on exposures to risk factors was collected from the medical charts of 4211 women with breast cancer diagnosed during 1999–2008. The distributions of these exposures among regions, and by menopausal status and birth period, were compared with the χ2 test. Crude associations between the selected factors and breast cancer were estimated using the cases in the present study and a representative control population, which was selected from qualified published studies. Results As compared with cases from less developed regions, those from more developed regions were significantly more likely to be nulliparous, had fewer childbirths (P < 0.05), and were less likely to have breastfed (P = 0.08). As compared with premenopausal cases, postmenopausal cases were more likely to be overweight and to have breastfed and had more childbirths (P < 0.05). The number of live births and rate of breastfeeding decreased in relation to birth period (P for trends <0.001). Overweight, late menopause, and family history of breast cancer were significantly associated with breast cancer among Chinese women. Conclusions Breast cancer incidence was associated with nulliparity and history of breastfeeding. Population attributable risks should be assessed, especially for more developed areas and young women. The effects of body mass index, age at menopause, and family history of breast cancer should be given priority during assessment of breast cancer risk among Chinese women.

Age of Diagnosis of Breast Cancer in China: Almost 10 Years Earlier than in the United States and the European Union

BACKGROUND The study aimed to describe the age distribution of breast cancer diagnosis among Chinese females for comparison with the United States and the European Union, and provide evidence for the screening target population in China. MATERIALS AND METHODS Median age was estimated from hospital databases from 7 tertiary hospitals in China. Population-based data in China, United States and European Union was extracted from the National Central Cancer Registry, SEER program and GLOBOCAN 2008, respectively. Age-standardized distribution of breast cancer at diagnosis in the 3 areas was estimated based on the World Standard Population 2000. RESULTS The median age of breast cancer at diagnosis was around 50 in China, nearly 10 years earlier than United States and European Union. The diagnosis age in China did not vary between subgroups of calendar year, region and pathological characteristics. With adjustment for population structure, median age of breast cancer at diagnosis was 50~54 in China, but 55~59 in United States and European Union. CONCLUSIONS The median diagnosis age of female breast cancer is much earlier in China than in the United States and the European Union pointing to racial differences in genetics and lifestyle. Screening programs should start at an earlier age for Chinese women and age disparities between Chinese and Western women warrant further studies.

Comprehensive cancer control-research & development: knowing what we do and doing what we know

Comprehensive cancer control is defined as an integrated and coordinated approach to reducing cancer incidence, morbidity, and mortality across the cancer control continuum from primary prevention to end-of-life care. This approach assumes that when the public sector, non-governmental organizations, academia, and the private sector share with each other their skills, knowledge, and resources, a country can take advantage of all its talents and resources to more quickly reduce the burden of cancer for all its population. One critical issue for comprehensive cancer control is the extent to which the private sector can contribute to cancer prevention and control programs and policies that have historically been lead by the public health sector, and similarly how can the public sector increase its investment and involvement in clinical research and practice issues that are largely driven by the private sector worldwide? In addition, building capacity to integrate research that is appropriate to the culture and context of the population will be important in different settings, in particular research related to cancer control interventions that have the capacity to influence outcomes. To whatever extent cancer control research is ultimately funded through the private and public sectors, if investments in research discoveries are ultimately to benefit the populations that bear the greatest burden of disease, then new approaches to integrating the lessons learned from science with the lessons learned from service (public health, clinical, and public policy) must be found to close the gap between what we know and what we do. Communities of practice for international cancer control, like the ones fostered by the first three International Cancer Control Congresses, represent an important forum for knowledge exchange opportunities to accelerate the translation of new knowledge into action to reduce the burden of cancer worldwide.

Body Mass Index and Breast Cancer Defined by Biological Receptor Status in Pre-Menopausal and Post-Menopausal Women: A Multicenter Study in China

Background Few studies have investigated the association between body mass index (BMI) and breast cancer with consideration to estrogen/progesterone/human epidermal growth factor type 2 receptor status (ER/PR/HER2) in the breast tissue among Chinese pre- and post-menopausal women. Methods Four thousand two hundred and eleven breast cancer patients were selected randomly from seven geographic regions of China from 1999 to 2008. Demographic data, risk factors, pathologic features, and biological receptor status of cases were collected from the medical charts. Chi-square test, fisher exact test, rank-correlation analysis, and multivariate logistic regression model were adopted to explore whether BMI differed according to biological receptor status in pre- and post-menopausal women. Results Three thousand two hundred and eighty one eligible cases with BMI data were included. No statistically significant differences in demographic characteristics were found between the cases with BMI data and those without. In the rank-correlation analysis, the rates of PR+ and HER2+ were positively correlated with increasing BMI among post-menopausal women (rs BMI, PR+ = 0.867, P = 0.001; rs BMI, HER2+ = 0.636, P = 0.048), but the ER+ rates did not vary by increasing BMI. Controlling for confounding factors, multivariate logistic regression models with BMI<24 kg/m2 as the reference group were performed and found that BMI≥24 kg/m2 was only positively correlated with PR+ status among post-menopausal breast cancer cases (adjusted OR = 1.420, 95% CI: 1.116–1.808, Wald = 8.116, P = 0.004). Conclusions Post-menopausal women with high BMI (≥24 kg/m2) have a higher proportion of PR+ breast cancer. In addition to effects mediated via the estrogen metabolism pathway, high BMI might increase the risk of breast cancer by other routes, which should be examined further in future etiological mechanism studies.

[10-year changes and development of surgical treatment for breast cancer in China].

OBJECTIVE To investigate the changes and development of surgical treatment for breast cancer from 1999 to 2008 in China, and compare the differences between the surgical methods used in high-resource and low-resource areas. METHODS Clinicopathological data of surgical treatment for female primary breast cancer was collected via medical chart review at hospitals in seven geographic areas in China. Chi-square test and chisqure test for linear trends were used to analyze the changes and development of the surgical methods used for breast cancer in the 10 years. RESULTS A total of 4211 primary breast cancer patients were selected from the 10-year database, including 4078 women (97.5%) treated by surgical operation. Among 3271 women (80.21%) treated with modified radical mastectomy, the surgical rate was rising from 68.89% in 1999 to 80.17% in 2008, ascending by 11.28% (χ(2) = 31.143, P < 0.001). In high-resource areas, the surgical rate of modified radical mastectomy was rising from 45.64% in 1999 to 76.13% in 2008, ascending by 30.49% (χ(2) = 89.393, P < 0.001), while in low-resource areas it kept a steady rate at 80% in the ten years (χ(2) = 2.113,P = 0.146). Among 231 women (5.66%) treated with breast-conserving surgery, the surgical rate was rising from 1.29% in 1999 to 11.57% in 2008, ascending by 10.28% (χ(2) = 102.835, P < 0.001). In high-resource areas, the surgical rate of breast-conserving surgery was rising from 2.68% in 1999 to 16.87% in 2008, ascending by 14.19% (χ(2) = 69.544, P < 0.001), while in low-resource areas it was rising from 0.42% in 1999 to 6.22% in 2008, ascending by 5.80% (χ(2) = 30.003, P < 0.001). Among 469 women (11.50%) treated with Halsted radical mastectomy, the surgical rate was declining from 28.28% in 1999 to 4.96% in 2008, descending by 23.32% (χ(2) = 206.202, P < 0.001). In high-resource areas, the surgical rate of Halsted radical mastectomy was declining from 50.34% in 1999 to 3.29% in 2008, descending by 47.05% (χ(2) = 274.830, P < 0.001), while in low-resource areas it was declining from 14.58% in 1999 to 6.64% in 2008, descending by 7.94% (χ(2) = 8.166, P = 0.004). Among 3786 women treated with breast mastectomy (including modified radical mastectomy and Halsted radical mastectomy), the surgical rate was declining from 98.46% in 1999 to 86.36% in 2008, descending by 12.10% (χ(2) = 95.744, P < 0.001). In high-resource areas, the surgical rate of breast mastectomy was declining from 96.64% in 1999 to 80.66% in 2008, descending by 15.98% (χ(2) = 53.446, P < 0.001), while in low-resource areas it was declining from 99.58% in 1999 to 92.12% in 2008, descending by 7.46% (χ(2) = 36.758,P < 0.001). CONCLUSIONS The main primary surgical treatment for breast cancer is modified radical mastectomy during the period 1999 - 2008. Halsted radical mastectomy is gradually replaced by modified radical mastectomy and breast-conserving surgery. The rate of changes for breast-conserving surgery and mastectomy is higher in high-resource areas than that in low-resource areas. Breast-conserving surgery will become the main treatment for early-stage breast cancer.

Epidemiologic study of radiotherapy use in China in patients with breast cancer between 1999 and 2008.

BACKGROUND To investigate the use of radiotherapy (RT) in China in patients with breast cancer over a 10-year period. A hospital-based, nationwide, multicenter, retrospective epidemiologic study of women with primary breast cancer was conducted. PATIENTS AND METHODS Patients were selected randomly in 7 hospitals from 1999 to 2008. Data on overall RT, postmastectomy RT (PMRT), RT after conservative breast surgery (PBRT) and palliative RT (PRT) were recorded. RT use was analyzed, and differences were compared by using the Cochran-Armitage trend test and the χ(2) test. A total of 3732 patients were included: 1009 (27%) received RT, including 688 (18.4%) PMRT, 170 (4.6%) PBRT, 86 (2.3%) PRT, 47 (1.3%) both PMRT and PRT, and 18 (0.5%) other RT. RESULTS Overall use of RT increased significantly from 1999 to 2008 (2P < .001). There was a slight but significant increase in PMRT (2P = .012) and a 10-fold increase in PBRT (2P < .001); use of PRT was relatively constant (2P = .777). There was a significant difference among regions in the use of RT, PMRT, PBRT, and PRT (2P < .01). Of patients with stage III disease, 51.6% and of those with node-positive stage II disease treated by radical mastectomy, 21% had received PMRT. In patients treated by using breast conservative surgery, 83.7% received PBRT, which was not affected by stage. CONCLUSION In summary, in China, the overall use of RT in patients with breast cancer was quite low, but there was an increasing trend in those treated between 1999 and 2008.

A nomogram to predict the probability of axillary lymph node metastasis in female patients with breast cancer in China: A nationwide, multicenter, 10-year epidemiological study

Axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB) alone may lead to postoperative complications. Among patients with positive ALN in the preoperative examination, approximately 40% patients do not have SLN metastasis. Herein, we aimed to develop a model to predict the probability of ALN metastasis as a preoperative tool to support clinical decision-making. We retrospectively analyzed the clinicopathological features of 4211 female patients with breast cancer who were diagnosed in seven breast cancer centers representing entire China, over 10 years (1999-2008). The patients were randomly categorized into a training cohort or validation cohort (3:1 ratio). Multivariate logistic regression analysis was performed for 1869 patients with complete information on the study variables. Age at diagnosis, tumor size, tumor quadrant, clinical nodal status, local invasion status, pathological type, and molecular subtypes were the independent predictors of ALN metastasis. The nomogram was then developed using the seven variables. Further, it was subsequently validated in 642 patients with complete data on variables in the validation cohort. Coefficient of determination (R2) and the area under the receiver-operating characteristic (ROC) curve (AUC) were calculated to be 0.979 and 0.7007, showing good calibration and discrimination of the model, respectively. The false-negative rates of the nomogram were 0 and 6.9% for the predicted risk cut-off values of 14.03% and 20%, respectively. Therefore, when the predicted risk is less than 20%, SLNB may be avoided. After further validation in various patient populations, this model may support increasingly limited axillary surgery in breast cancer.

Application of intraoperative frozen section examination in the management of female breast cancer in China: a nationwide, multicenter 10-year epidemiological study

BackgroundIntraoperative frozen section examination (IFSE) during breast cancer surgery can partly reflect the status of surgical treatment since the surgical method used directly determines the purpose of IFSE use in disease management. This study aims to investigate the application of, changing trends in, and factors influencing IFSE in the management of female breast cancer in China.MethodsWe collected the sociodemographic and clinical data of 4,211 breast cancer patients between 1999 and 2008 and statistically analyzed these data using χ2 or Fisher’s exact tests.ResultsA total of 2,283 (54.22%) patients with breast cancer underwent IFSE. During the 10-year study period, IFSE use was associated with an increase in the number of sentinel lymph node biopsies (SLNB) and breast-conserving surgeries (BS) performed, with significant regional differences noted in this trend (P <0.05). Patients’ education, occupation, age, tumor size estimated by preoperative palpation, and the use of imaging examinations affected the purpose of IFSE use (P <0.05).ConclusionsOur results show that the purpose of IFSE in the surgical treatment of breast cancer in China is gradually approaching that in developed countries. We believe that policymakers must address the differences in breast cancer treatment based on the socioeconomic status of patients. Lastly, the use of IFSE for determining tumor characteristics should be avoided as far as possible, and patient education and breast cancer screening programs tailored to the Chinese population should be established. Our findings may guide the formulation of breast cancer control strategies in China and other low-income countries.

Epidemiologic study of compliance to postmastectomy radiation therapy guidelines in breast cancer patients in China between 1999 and 2008

PURPOSE To evaluate compliance with postmastectomy radiation therapy (PMRT) guidelines in breast cancer patients in China over a 10-year period. METHODS AND MATERIALS A hospital-based, nationwide, multicenter retrospective epidemiologic study of primary breast cancer in women was conducted. Seven first-class, upper-level hospitals from different geographic regions of China were selected. One month was randomly selected to represent each year from 1999-2008 in every hospital. All inpatient cases within the selected months were reviewed and demographic, clinical, and pathologic characteristics and treatment patterns were collected. Patients enrolled in this study had to meet the following inclusion criteria: (1) treated with mastectomy and axillary dissection; (2) information regarding whether or not they received postmastectomy radiation therapy was available; and (3) information about staging was available. Patients were divided into 3 groups based on National Comprehensive Cancer Network guidelines. Utilization of PMRT in each group was analyzed and compared between different years and different hospitals. RESULTS A total of 2310 patients were analyzed. There were 643 (27.8%) patients in the PMRT recommended group, 557 (24.1%) patients in the controversial group, and 1110 (48.1%) patients in the nonrecommended group. PMRT was used in 48.8% of patients in the recommended group, 15.6% in the controversial group, and 5.7% in the nonrecommended group. There was a trend toward increasing use of radiation therapy in the recommended and controversial groups from 1999-2008. The use of PMRT in the nonrecommended group remained relatively stable from 1999-2008. Fewer positive nodes and nonreceipt of chemotherapy or hormone therapy were associated with underuse of PMRT in the recommended group. In the controversial group, a higher ratio of positive nodes was associated with use of PMRT. CONCLUSIONS There is an apparent underuse of PMRT in the PMRT recommended group. Efforts should be made to improve the compliance to PMRT guidelines.