Causes of death in women with breast cancer: a risks and rates study on a population-based cohort

Abstract

Introduction: The increasing survival of patients with breast cancer has prompted the assessment of mortality due to all causes of death in these patients. We estimated the absolute risks of death from different causes, useful for health-care planning and clinical prediction, as well as cause-specific hazards, useful for hypothesis generation on etiology and risk factors.

Materials and methods: Using data from population-based cancer registries we performed a retrospective study on a cohort of women diagnosed with primary breast cancer. We carried out a competing-cause analysis computing cumulative incidence functions (CIFs) and cause-specific hazards (CSHs) in the whole cohort, separately by age, stage and registry area.

Results: The study cohort comprised 12,742 women followed up for six years. Breast cancer showed the highest CIF, 13.71%, and cardiovascular disease was the second leading cause of death with a CIF of 3.60%. The contribution of breast cancer deaths to the CIF for all causes varied widely by age class: 89.25% in women diagnosed at age <50 years, 72.94% in women diagnosed at age 50-69 and 48.25% in women diagnosed at age ≥70. Greater CIF variations were observed according to stage: the contribution of causes other than breast cancer to CIF for all causes was 73.4% in women with stage I disease, 42.9% in stage II-III and only 13.2% in stage IV. CSH computation revealed temporal variations: in women diagnosed at age ≥70 the CSH for breast cancer was equaled by that for cardiovascular disease and "other diseases" in the sixth year following diagnosis, and an early peak for breast cancer was identified in the first year following diagnosis. Among women aged 50-69 we identified an early peak for breast cancer followed by a further peak near the second year of follow-up. Comparison by geographic area highlighted conspicuous variations: the highest CIF for cardiovascular disease was more than 70% higher than the lowest, while for breast cancer the highest CIF doubled the lowest.

Conclusion: The integrated interpretation of absolute risks and hazards suggests the need for multidisciplinary surveillance and prevention using community-based, holistic and well-coordinated survivorship care models.

Keywords: breast cancer; cardio-oncology; cardiovascular disease; cause-specific death; competing-risk model; geographic variation; population-based cancer registries; respiratory disease.

Figure 1

Cumulative incidence of mortality by different causes-of-death groups.

Figure 2

Cumulative incidence of mortality by different causes-of-death groups. (A) Age <50 years. (B) Age 50−69 years. (C) Age ≥70 years. (D) Women with stage I breast cancer. (E) Women with stage II−III breast cancer. (F) Women with stage IV breast cancer.

Figure 3

Cause-specific hazards by different causes-of-death groups. (A) Age <50 years. (B) Age 50−69 years. (C) Age ≥70 years. (D) Women with stage I breast cancer. (E) Women with stage II−III breast cancer. (F) Women with stage IV breast cancer. (G) CVD divided into cerebrovascular and other CVDs in women diagnosed at age 50–69. (H) CVD divided into cerebrovascular and other CVDs in women diagnosed at age ≥70. py, person years.