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Breast Cancer in the U.S.


Introduction

Since the 1950s, the overall trend of breast cancer incidence in the U.S. has been gradually upward, with recent declines beginning circa 2000. Mortality rates have also been declining over recent years, with larger decreases observed for women younger than 50. However, both incidence and mortality differ substantially among women from different racial and ethnic groups. Additionally, studies show that socioeconomic factors contribute to disparities in breast cancer care. The reduction of these disparities is a primary and ongoing objective of leading public and private health organizations. At the same time, current medical research continues to build upon significant scientific advances toward the collective vision of reducing the burden of breast cancer and improving outcomes for all.

Breast Cancer Trends

Pedestrians. Source: Linda Bartlett (photographer). Adapted from NCI Visuals Online. AV-8000-0304.

Breast cancer is the most common non-skin cancer among U.S. women. During 2011, an estimated 280,130 new cases were diagnosed: 230,480 invasive breast cancers and 57,650 cases of in situ carcinoma. Of these, an approximate 83% were ductal carcinoma in situ.1 If the current incidence rate stays the same, women born today have about a 1 in 8 chance of developing breast cancer at some point during their lives.2 Presently, there are over 2.5 million women living in the U.S. who have been diagnosed and treated for breast cancer.3

Gender is the most important risk factor for breast cancer. While in any given year the disease will be diagnosed in a small number of men (2,140 new cases estimated for 2011), the number of women diagnosed with breast cancer will be about 100 times greater.4 Age is the second most important risk factor; the majority of advanced breast cancer cases are diagnosed in women over 50. Other factors are also known to increase a woman's risk for the disease.5 However, most breast cancers occur in women with no apparent risk factors other than gender and age.

U.S. Breast Cancer Incidence 1988-2008
Source: NCI. A Snapshot of Breast Cancer (updated, Oct. 2011) Retrieved Jan. 3, 2012 at: http://www.cancer.gov/aboutnci/
servingpeople/snapshots/breast.pdf

The overall trend of U.S. breast cancer incidence has been gradually upward. From 1950 to 1975, the rate of new breast cancer cases had risen by less than 1%.6 Through most of the 1980s, incidence rates rose sharply, as measured by an average annual increase of 4.0%. From 1987 to 1994, rates stabilized, followed by a slower increase of 1.7% per year. More recently, data suggest that incidence has slightly declined.3

Many experts attribute the overall rise in incidence to a combination of influences that include changes in women's reproductive patterns (i.e., delayed childbearing and having fewer children), improvements in imaging technology, and an increased use of screening mammography, which can detect breast cancer before it causes symptoms. From the early 1970s through the late 1990s the incidence of ductal carcinoma in situ (DCIS), one of the most common types of early stage breast cancers, increased more than sevenfold.7

U.S. Breast Cancer Mortality
Source: NCI. A Snapshot of Breast Cancer (updated, Oct. 2011) Retrieved Jan. 3, 2012 at: http://www.cancer.gov/aboutnci/
servingpeople/snapshots/breast.pdf

As breast cancer incidence rates have risen, mortality rates from breast cancer have declined. Between 1990 and 2008, the mortality rate for women of all races combined declined by 2.2% annually,3 with larger decreases in women younger than 50.1 These decreases are largely attributed to earlier detection through screening and increased awareness, as well as improved treatment.8

Still, breast cancer remains the second leading cause of cancer death in U.S women, after lung cancer.8 According to the American Cancer Society, an estimated 39,520 U.S. women lost their lives to this disease in 2011.1 Based on the most recent data, 11% of women diagnosed with breast cancer die from the disease within five years. At 10 years, the rate is 18%, and at 15 years, the mortality rate for women diagnosed with breast cancer is roughly 23%. The key to surviving the disease is early detection. If detected and treated early, the 5 year relative survival rate for localized breast cancer is 99%.1

Information for Every Woman Counts (EWC) Providers

The California Cancer Registry (CCR) collects information on almost all cancers diagnosed among Californians. Since 1988, the California Cancer Registry (CCR) has collected detailed information on over 3.4 million cancer cases, including breast cancer. Data are used to design best strategies and policies for improving cancer prevention, treatment, and control throughout the state. The system is considered one of the leading cancer registries in the world.

According to the CCR, breast cancer incidence in California has remained relatively stable since 1988, while mortality has declined by as much as 30%. As with national trends, improved treatment and earlier diagnosis are key factors. Over the last two decades, the percentage of California women of screening age who report having mammograms has risen from 39% to 61%. As a result, more cancers are being diagnosed at an early stage while late-stage disease has declined. Compared to the nation, the rate of invasive breast cancers from 2004-2008 was the same among California's Asian American/Pacific Islanders, 5% higher among African Americans, 10% lower among Hispanics, and 8% higher among White (non-Hispanic) women.9 For more information, please visit the California Cancer Registry website.

Screening Guidelines

Guidelines for breast cancer screening are revised regularly to take into account new research findings and developments. Currently, there is a lack of consensus among guidelines with regard to optimal ages for beginning and ending screening and how frequently to screen. Guidelines also differ in their recommendations for the use of clinical breast examination and breast self-examination. Screening guidelines by American Cancer Society (ACS), the U.S. Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG) are highlighted below. For the most recent recommendations of other major guidelines (e.g., American College of Physicians (ACP)), please refer to the website of the National Guideline Clearinghouse.

The 2015 ACS guidelines recommend that women of average risk undergo annual screening mammography between the ages of 45-54 and transition to biennial screening at the age of 55 with the option of continuing to screen annually.  In addition, the guidelines suggest that women should be offered the option of beginning annual screening at the age of 40 and that screening should continue as long as women are in good health with a life expectancy of at least 10 years.The ACS does not recommend clinical breast exam (CBE) for breast cancer screening for women of any age.  For certain women at high risk for breast cancer, ACS recommends screening with magnetic resonance imaging (MRI) as an adjunct to mammography.10

In 2009, the U.S. Preventive Services Task Force (USPSTF) recommended that biennial screening mammography begin at age 50 for women with average risk. The Task Force states that the decision to start mammography screening before the age of 50 should be an individual one and take into account the patient's situation, including her values regarding the benefits and harms of screening. For older women, the USPSTF maintains that the current evidence is insufficient for assessing the additional benefits of screening mammography in women past age 74. Similarly, with regard to clinical breast examination, the Task Force believes that there is insufficient evidence for assessing the additional benefits of clinical breast examination beyond screening mammography in women 40 years or older. With regard to breast self-examination, the USPSTF recommends against clinicians teaching women how to perform breast self-examination (BSE), stating that evidence suggests that teaching BSE does not reduce breast cancer mortality.11

The American College of Obstetricians and Gynecologists (ACOG) guidelines from 2011 recommend annual screening mammography for women 40 years and older; beginning at age 75, women  should consult with their physicians to decide whether or not to continue with mammographic screening and should consider medical comorbidities and life expectancy. ACOG supports the use of clinical breast exam as a screening tool and recommends that women 40 and older have annual CBE, while women ages 20-39 have a CBE every one to three years. ACOG is in favor of considering teaching high-risk women breast self-examination and recommends that all women be taught about breast self-awareness.12

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Racial and Ethnic Patterns

Incidence by Race/Ethnicity
(per 100,000 women)

White (non-Hispanic) 125.4
African American 116.1
Hispanic/Latina* 91.0
American Indian/Alaskan Native 89.2
Asian American/Pacific Islander 84.9

*Hispanic/Latina may be any race.

Source: American Cancer Society. Breast cancer facts & figures 2011-2012. Retrieved Jan. 3, 2012
at: http://www.cancer.org
/Research/CancerFactsFigures
/BreastCancerFactsFigures/breast-cancer-
facts-and-figures-2011-2012


Mortality by Race/Ethnicity
(per 100,000 women)

African American 32.4
White (non-Hispanic) 23.9
Hispanic/Latina* 15.3
American Indian/Alaskan Native 17.6
Asian American/Pacific Islander 12.1

*Hispanic/Latina may be any race.

Source: American Cancer Society. Breast cancer facts & figures 2011-2012. Retrieved Jan. 3, 2012 at: http://www.cancer.org
/Research/CancerFactsFigures
/BreastCancerFactsFigures/breast-cancer-
facts-and-figures-2011-2012

In the United States, breast cancer incidence rates differ substantially among women from different racial and ethnic groups.

Incidence is highest for non-Hispanic white women, followed by African American, Hispanic/Latina, American Indian/Alaskan Native, and lastly, Asian American/Pacific Islander.1 The incidence rate for the highest group (non-Hispanic white) is 50% greater in comparison with lowest group (Asian American/Pacific Islander). While reasons for these differences are not fully understood, potential explanations include differences in risk factor exposure, differences in genetics and biology, and differences in socioeconomic conditions.

Mortality rates among racial/ethnic groups have a different pattern of disparity than that observed for incidence.

Although incidence is highest for non-Hispanic white women, African American women have the highest mortality rate, followed by Hispanic/Latina, American/Pacific Islander, and American Indian/Alaskan Native women. Additionally, the five-year survival rate for African Americans is just 77%, compared to a 90% five-year survival rate for whites.1 Moreover, between 1990 and 2002, as the mortality rate for women of all race/ethnicities combined declined by 2.3% annually, it declined by 2.4% annually in white women and just 1.0% annually for African American women.13

In a report on trends in U.S. mortality rates for four major cancers, including breast cancer, the Centers for Disease Control and Prevention (CDC) states that differences among racial/ethnic groups "result from a combination of factors such as behaviors (e.g. smoking and nutrition); access to preventive, diagnostic, therapeutic, and screening services; and aggressiveness of treatment.14 The CDC, which funds screening to underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), believes that modifying these factors could prevent more than half of the cancer deaths and eliminate most racial/ethnic disparities in cancer death rates.

Research Lab. Source: Bill Branson (photographer). Adapted from NCI Visuals Online. AV-8000-0403.

Additionally, some researchers have highlighted differences in biology, especially in African American women, whose breast tumors often exhibit more aggressive characteristics. The prevalence of triple negative breast tumors among African American women, for instance, may be more than twice that of white women.15 Characterized by three biological components (i.e., negative for estrogen receptor, progesterone receptor, and HER2), these triple negative tumors are unresponsive to the most common and effective breast cancer treatments and are more likely to have poor prognosis.16 In addition, relative to other racial/ethnic groups, pre-menopausal African American women may have a higher prevalence of basal-like breast tumors - one of the more aggressive breast cancer subtypes for which there are currently no targeted treatments.17

While these and other biological differences have been observed, it is important to note that they do not preclude the influence of social factors. As one health disparities researcher explains, biology is adaptive; it changes with changing environmental conditions.18 As such, the finding of biological differences among groups living in different social conditions would not be unexpected.

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Socioeconomic Factors

Among the U.S. population, over 25%
of African Americans and Hispanics/Latinos currently live in poverty, compared with
10% of non-Hispanic whites.

According to 2010 U.S. Census data, over 25% of African Americans and Hispanics/Latinos currently live in poverty, compared with 10% of non-Hispanic whites. Moreover, 20% of African Americans and 33% of Hispanics lack health insurance, while only 10% of whites are uninsured.19 According to the American Cancer Society, people living in poverty and those who lack health insurance are more likely to be diagnosed with advanced stage disease, more likely to receive substandard medical care, and more likely to die from cancer.20

Woman and Child. Source: Linda Bartlett (photographer). Adapted from NCI Visuals Online. AV-8000-3673.

Indeed, factors associated with lower socioeconomic status (SES) may explain many of the differences observed in breast cancer incidence and mortality among racial and ethnic groups. In the case of screening, for example, data from 2003 show that white, African American, and Hispanic women aged 40 and older were mammographically screened at similar rates (55.5%, 54.2% and 52.6%, respectively). Women with and without health insurance, however, were screened at remarkably different rates (58% vs. 28.9%).13 Other research studies have linked lower levels of education to later stage diagnosis21 and have shown that low income, independent of race, is associated with inferior treatment (e.g., no surgery, or no radiation therapy after breast-conserving surgery).22 As the National Cancer Institute explains, "[S]tudies have found that SES, more than race, predicts the likelihood of a group’s access to education, certain occupations, and health insurance, as well as income level and living conditions -- all of which are associated with someone’s chance of developing and surviving cancer.23

Socioeconomic factors can have an unwanted effect on provider/patient interactions.

Additionally, socioeconomic factors can have an unwanted effect on provider/patient interactions. According to health researchers, some providers may withhold information if they think the patient won't understand. Likewise, physicians may not recommend a treatment to a patient that they think cannot afford it.21 The message to healthcare providers is to be aware of these potential biases when interacting with patients and to treat all patients equally. The National Cancer Institute is clear on this issue: "equal care for cancer results in equal outcomes and equal survival rates...Conversely, unequal outcomes strongly suggest unequal care."24

As the principal agency for cancer research in the U.S., the National Cancer Institute (NCI) supports scientific studies on socioeconomic factors and their relationship to cancer incidence, survival, and mortality. NCI also supports numerous intervention efforts, recognizing that the burden of cancer is too often greater for the poor, the uninsured, and for ethnic minorities. Indeed, the Center to Reduce Cancer Health Disparities (CRCHD) established in 2001, was created by NCI "to reduce the unequal burden of cancer in our society and train the next generation of competitive researchers in cancer and cancer health disparities research." 25

In addressing disparity issues, the CRCHD considers the influence of financial and physical barriers, as well as barriers related to information and education, and those related to cultural differences and biases in cancer care.24 An example comes from the CRCHD's Patient Navigator Program (PNP) which trains and assigns healthcare workers from local communities to help underserved patients overcome health system barriers to obtaining quality cancer care. For more information on the Patient Navigator Program, or for additional information about CRCHD's mission, strategies and objectives, visit the CRCHD website.

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Patient Rights

Women in Waiting Room. Source: Bill Branson (photographer). Adapted from NCI Visuals Online. AV-9011-4016.

Consumer Bill of Rights and Responsibilities (1998)

In the U.S., patients have certain rights and protections. This section summarizes key provisions of the Consumer Bill of Rights and Responsibilities, issued in 1998, and the more recent Patient's Bill of Rights, created along with the Affordable Care Act in 2010. While all patients benefit from both these bills, women with breast cancer are especially helped by the new protections that apply to health coverage (see Patient's Bill of Rights (2010) below). Providers are encouraged to communicate with their patients about these recent changes. They were made to ensure that all Americans get the care they need.

In 1998, the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry issued the Consumer Bill of Rights and Responsibilities as part of its final report entitled Quality First: Better Health Care for All Americans. The Consumer Bill of Rights proposed eight principles which have been adopted by many U.S. health plans, including those sponsored by the federal government. Following is a summary of these principles:26

  1. Information Disclosure. Consumers have the right to receive accurate, easily understood information, and some consumers require assistance in making informed health care decisions about their health plans, professionals and facilities.
  2. Choice of Providers and Plans. Consumers have the right to a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care.
  3. Access to Emergency Services. Consumers have the right to access emergency health care services when and where the need arises.
  4. Participation in Treatment Decisions. Consumers have the right and responsibility to fully participate in all decisions related to their health care. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators.
  5. Respect and Nondiscrimination. Consumers have the right to considerate, respectful care from all members of the health care industry at all times and under all circumstances.
  6. Confidentiality of Health Information. Consumers have the right to communicate with health care providers in confidence and to have the confidentiality of their individually identifiable health care information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records.
  7. Complaints and Appeals. Consumers have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review.
  8. Consumer Responsibilities. In a health care system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume reasonable responsibilities. Greater individual involvement by consumers in their care increases the likelihood of achieving the best outcomes and helps support a quality improvement, cost-conscious environment.

The full report to the President on the Consumer Bill of Rights and Responsibilities is available on the website of The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.

Patient's Bill of Rights (2010)

On June 22, 2010, the Departments of Health and Human Services, Labor, and Treasury issued regulations to implement a new Patient’s Bill of Rights under the Affordable Care Act. The Patient's Bill of Rights includes a set of protections that apply to health coverage starting on or after September 23, 2010, as outlined below.27

  1. Provides Coverage to Americans with Pre-existing Conditions. Beginning July 1, 2010, Americans who were unable to obtain health insurance because of a pre-existing condition were able to enroll in the Pre-existing Condition Insurance Plan (PCIP). PCIP ends in 2014, when the ban on insurers refusing to cover adults with pre-existing conditions goes into full effect and individuals will have affordable choices through Exchanges.
  2. Protects Choice of Doctors. Health plan members are free to designate any available participating primary care provider as their provider. Insurers and employer plans are prohibited from requiring a referral for obstetrical or gynecological care.
  3. Keeps Young Adults Covered. Children under the age of 26 are able to stay on their parent’s family policy, or be added to it.
  4. Ends Lifetime Limits on Coverage. Prohibits the use of lifetime limits in all health plans and insurance policies issued or renewed on or after September 23, 2010.
  5. Ends Pre-Existing Condition Exclusions for Children. Prohibits insurance plans from denying coverage to children based on a pre-existing condition(s). This ban includes both benefit limitations and coverage denials. (Applies to all types of insurance except for individual policies that are grandfathered, and will be extended to Americans of all ages starting in 2014.)
  6. Ends Arbitrary Withdrawals of Insurance Coverage. Prohibits insurers and plans from rescinding coverage except in cases involving fraud or an intentional misrepresentation of material facts. Insurers and plans seeking to rescind coverage must provide at least 30 days advance notice to give people time to appeal.
  7. Reviews Premium Increases. Requires more transparency of insurance companies’ requests to raise rates. Improves oversight.
  8. Gets the Most from Premium Dollars. Requires individual and small group insurers to spend at least 80%, and large group insurers to spend at least 85% of premium dollars on direct medical care, and efforts to improve the quality of care. Requires new transparency into how premium dollars are spent. Requires public disclosure of rates at www.HealthCare.gov
  9. Restricts Annual Dollar Limits on Coverage. Phases out the use of annual dollar limits until 2014 when the Affordable Care Act bans them for most plans.
  10. Removes Insurance Company Barriers to Emergency Services. Prohibits higher cost-sharing for emergency services that are obtained out of a plan's network. Sets requirements on how health plans should reimburse out-of-network providers. (Applies to all individual markets and group health plans except those that are grandfathered.)

Since the Patient’s Bill of Rights was enacted, the Affordable Care Act has provided the following additional rights and protections.

  1. Preventive Care at No Cost. Beginning August 1, 2012, preventive health care services are covered with no cost sharing for new health plans. Examples include mammograms; screenings for cervical cancer; FDA-approved contraceptive methods, education and counseling; HIV screening and counseling; and other services. (For complete list of services, please see Preventive Services Covered Under the Affordable Care Act on the HealthCare.gov website.
  2. Guarantees Right of Appeal. Ensures a patient's right to appeal health insurance plan decisions to deny payment for services or treatments. Spells out how a plan must handle an appeal and, if needed, permits an independent review organization to decide whether to uphold or overturn the plan’s decision.

For additional information, please visit HealthCare.gov, the official U.S. government site with ongoing news and information about the Affordable Care Act.

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Current Research

In 1997, NCI assembled a multidisciplinary working group of scientists, clinicians, and advocates to help define a national research agenda for breast cancer.

Since the passage of the National Cancer Act in 1971,28 the National Cancer Institute (NCI) has led the nation's effort in supporting a wide range of scientific studies whose collective and ultimate mission is saving lives. In 1997, NCI assembled a multidisciplinary working group of scientists, clinicians, and advocates to help define a national research agenda for breast cancer. Seven years later, a separate NCI Breast Cancer Working Group was convened to assess the nation's progress. At the time of the 2004 assessment, the following initiatives were either in clinical trials or had been developed and approved:29

  • tamoxifen for the prevention of breast cancer in high-risk women
  • aromatase inhibitors for treatment of estrogen receptor-positive breast cancer
  • monoclonal antibodies for treatment of tumors that express HER2/ErbB2
  • sentinel node biopsy for less-invasive surgical diagnosis and prognosis
  • lumpectomy with radiation as an equivalent alternative to mastectomy for certain stages of disease
  • preoperative therapy to reduce the size of large tumors, thereby allowing more women to undergo breast-conserving surgery
Research Lab. Source: Bill Branson (photographer). Adapted from NCI Visuals Online.

Since 1998, NCI's breast cancer research investment has increased from $348.6 million29 to $631.2 million in 2010.30 In FY 2010, the total dollars were distributed among seven scientific areas of interest as follows: biology (22%); etiology (14%); prevention (5%); early detection, diagnosis and prognosis (16%); treatment (24%); cancer control, survivorship, and outcomes research (16%); and lastly, scientific model systems (3%).30 These seven areas, also called the Common Scientific Outline (CSO), continue to guide all NCI research today. Moreover, the CSO serves to facilitate coordination and comparison among public, private, national, and international cancer research organizations. For listings of current breast cancer research projects, funding opportunities, and resources, refer to NCI's Cancer Research Portfolio website.

In addition to government organizations, private organizations provide significant levels of support for breast cancer research in the U.S. The largest among these is the American Cancer Society (ACS), which has awarded approximately $450.7 million in breast cancer research grants since 1971. ACS currently funds over 200 grants, totaling $114 million in breast cancer research. ACS also sponsors grants in support of training for health professionals seeking to develop their clinical expertise and/or their ability to conduct independent research. Select areas of breast cancer research currently being investigated by ACS grantees are listed as follows:31

  • examining reasons for treatment differences between African American and white patients with breast cancer.
  • investigating how health system and contextual factors contribute to racial disparities in breast cancer mortality
  • exploring new therapies for the treatment of breast cancer that target cells of the immune system and evaluating whether the immune system plays a role in inflammatory responses that promote cancer progression
  • identifying and cataloging ribonucleic acids (RNAs) that are characteristic of normal and breast cancer tissues, with the goal of generating an “RNA fingerprint” of breast cancer
  • identifying genes that may determine susceptibility to lymphedema
  • developing a tool to aid women in understanding their personal breast cancer risk and identifying women with high risk who may benefit from preventive therapies and tailored screening recommendations
  • evaluating factors that influence mammography interpretation by radiologists, developing a test set that identifies radiologists who could benefit from additional training, and creating a continuing medical education course that reduces recall rates while maintaining or improving cancer detection

In addition to these, ACS notes a number of specific recent advances in breast cancer research that have led to improved methods across broad areas, including hormone therapy for prevention in high-risk women; magnetic resonance imaging (MRI) for use in breast biopsy procedures (allowing for many samples with one small incision); microvascular surgery and skin-sparing mastectomy (facilitating a more natural-looking breast in breast reconstruction); and in breast cancer treatment, the use of monoclonal antibodies (trastuzumab); more effective dosing methods with chemotherapy, and progress with antiangiogenesis therapy.32 Additionally, recent advances in the delivery of radiation therapy have made this method more precise, resulting in fewer side effects.

Lastly, NCI reminds that the "successful application of evidence-based interventions for preempting cancer through prevention, detection, diagnosis, and treatment depends on our ability to move effective interventions into practice." 33 Collaborative, multidisciplinary partnerships across public and private sectors help ensure that the beneficial results of breast cancer research are widely adopted by public health programs and clinical practices throughout the U.S., reaching as many people as possible.

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Notes

1American Cancer Society. (2012). Breast cancer facts & figures 2011-2012. Retrieved from: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf

2National Cancer Institute. Probability of breast cancer in American women. (2010, September 17). Retrieved from: http://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer

3Surveillance Epidemiology and End Results (SEER). (2011, November 10). SEER stat fact sheets: breast cancer. Retrieved from: http://seer.cancer.gov/statfacts/html/breast.html?statfacts_ page= breast.html&x=14&y=17

4American Cancer Society. (2011, November 18). What are the key statistics about breast cancer in men? Retrieved from: http://www.cancer.org/Cancer/BreastCancerinMen/DetailedGuide/breast-cancer-in-men-key-statistics

5In addition to gender and age, other risk factors for breast cancer include family history and genetic factors; clinical factors (high breast density, personal history of breast cancer, certain benign changes, and high-dose radiation therapy to the chest); reproductive factors (early onset of menses and late menopause, nulliparity or first full-term pregnancy after age 30, current or recent use of combined hormone replacement therapy (HRT) for greater than 2 to 5 years); daily alcohol consumption; and obesity, especially after menopause.

6Boffey, P. (1988, February 2). Breast cancer continues gradual rise. The New York Times. Retrieved from: www.nytimes.com

7Allegra, C. J., Aberle, D. R., Ganschow, P., Hahn, S. M., Lee, C. N., Millon-Underwood, S,...Zon, R. (2010). National Institutes of Health state-of-the-science conference statement: diagnosis and management of ductal carcinoma in situ September 22–24, 2009. Journal of the National Cancer Institute, 102(3), 161-169. doi:10.1093/jcni/djp485

8American Cancer Society.(2011, December 9). What are the key statistics for breast cancer? Retrieved from: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics

9American Cancer Society, & California Department of Public Health, California Cancer Registry. (2011, September). California Cancer Facts and Figures 2012. Retrieved from the California Cancer Registry website: http://www.ccrcal.org/pdf/Reports/ACS_2012.pdf

10Oeffinger, K. C., Fontham, E.  T. H., Etzioni, R., Herzig, A., Michaelson, J. S., Ya-Chen, T. S.,…Wender, R. (2015). Breast cancer screening update for women at average risk. 2015 guideline update from the American Cancer Society. JAMA, 314(15): 1599-614.doi: 10.1001/jama.2015.12783

11U.S. Preventive Services Task Force (USPSTF).(2009). Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 151 (10), 716-726. doi: 10.7326/0003-4819-151-10-200911170-00008

12The American College of Obstetricians and Gynecologists. (2011, August). Practice bulletin no. 122: breast cancer screening. Obstetrics & Gynecology, 118 (2 Pt 1): 372-82. doi: 10.1097/AOG.0b013e31822c98e5

13American Cancer Society. (2006). Breast cancer facts & figures 2005-2006. Retrieved from: http://www.cancer.org/Research/CancerFactsFigures/BreastCancerFactsFigures/breast-cancer-facts--figures-2005-2006

14Centers for Disease Control and Prevention. (2002, January 25). Recent trends in mortality rates for four major cancers, by sex and race/ethnicity --- United States, 1990-1998. MMWR Weekly, 51 (03), 49-53. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5103a1.htm

15The Mid-Atlantic Breast Cancer Information Exchange (MABCIE). (2006, April 10). Behind the Cancer Headlines. Racial differences in triple negative breast tumors among women in Atlanta. Retrieved from: http://www.mabcie.com/April_10,_2006_breast_cancer.html

16Steelquist, C.(2005, May 5). Ethnic differences in breast-cancer. Retrieved from the Fred Hutchinson Cancer Research Center website at: http://www.fhcrc.org

17The Mid-Atlantic Breast Cancer Information Exchange (MABCIE). (2006, June 12). Behind the Cancer Headlines. Pre-menopausal African-American women more likely to have certain type of breast cancer. Retrieved from: http://www.mabcie.com/June_12,_2006_breast_cancer.html

18The Mid-Antlantic Breast Cancer Information Exchange (MABCIE). (2005, Feburary 18). Behind the Cancer Headlines. Overcoming racial and ethnic disparities in healthcare. Retrieved from: http://www.mabcie.com/February_28,_2005_breast_cancer.html

19American Cancer Society. Cancer facts & figures 2012. Retrieved from: http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2012

20American Cancer Society.Cancer facts & figures 2006. Retrieved from: http://www.cancer.org/Research/CancerFactsFigures/cancer-facts-figures-2006

21American Cancer Society. (2002, February 20). Lower education, income linked to late cancer diagnosis. Retrieved from: http://www.cancer.org

22American Cancer Society.(2004, April 3). Treatment for breast cancer linked to socioeconomic status. Retrieved from: http://www.cancer.org

23National Cancer Institute.(2005, November 30). Cancer health disparities: a fact sheet. Benchmarks. Retrieved from: http://benchmarks.cancer.gov/2005/11/cancer-health-disparities-a-fact-sheet/

24National Cancer Institute. (2005, August 25). Health Information tip sheet for writers: cancer health disparities. Benchmarks. Retrieved from: http://www.cancer.gov/newscenter

25Center to Reduce Cancer Health Disparities (n.d.). Mission statement. Retrieved from: http://crchd.cancer.gov

26Advisory Commission on Consumer Protection and Quality in the Health Care Industry. (1998, July 18). Consumer bill of rights and responsibilities - summary of the document. Retrieved from: http://archive.ahrq.gov/hcqual/press/cbor.html#head1

27HealthCare.gov. (2010, July 1). Patient's bill of rights. Retrieved from: http://www.healthcare.gov

28For information on The National Cancer Act of 1971, see: http://legislative.cancer.gov/history/phsa/1971

29National Cancer Institute. (2004, October). Breast cancer progress report. Retrieved from: http://planning.cancer.gov/library/2004breastProgRpt.pdf

30National Cancer Institute. (2011, October). A snapshot of breast cancer. Retrieved from: http://www.cancer.gov

31American Cancer Society. (2012). Breast cancer facts and figures 2011-2012. Retrieved from: http://www.cancer.org/Research/CancerFactsFigures/BreastCancerFactsFigures/breast-cancer-facts-and-figures-2011-2012

32American Cancer Society. (2005, September 16). What's new in breast cancer research? Retrieved from: http://www.cancer.org

33National Cancer Institute. (2006, January). The NCI strategic plan for leading the nation. Retrieved from: http://cancer.gov


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Last updated: November 4, 2015

The Breast Cancer Review is sponsored by the Department of Health Care Services (DHCS), Every Woman Counts (EWC) program, with the goal of providing healthcare professionals a general reference for breast cancer screening, diagnosis, and treatment. The Breast Cancer Review is not an expression of medical opinion, diagnosis, prognosis or treatment recommendation for any particular patient. It should be used for informational purposes only. EWC does not dispense clinical advice or patient care consultation. Links to other web resources are offered as a courtesy; no endorsement is made or implied.  While every care has been taken in their selection, EWC makes no claims as to the validity, quality, or viability of their content.

 

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