in Combination (ATAC) trial, which compared anastrozole and tamoxifen in women over 65 years of age, with a small proportion of patients who were over 70 years, just 27% were included, revealed a benefit in favor of anastrozole by reducing recurrence at 9.7% in anastrazole arms vs 12.5% in tamoxifen arms at 5 years, but no effect of overall survival (OS) was noted. In the subgroup analysis, the advantage of anastrozole was mainly observed in patients who had not received any adjuvant chemotherapy and in those who had lymph node involvement, whereas in the BIG 1-98 trial, letrozole was more beneficial in patients having received chemotherapy and in those with lymph node metastasis. 43
the results of PRIME 2 trial on the treatment guidelines. Resistance to RT omission persists even in selected cases  due to the risk of local recurrence and the availability of alternative forms of RT (e.g. hypofractionated or intraoperative RT) . While some guidelines [24, 25] do not recommend RT omission after BCS, recent survey of treatment recommendations in olderwomen with BC found that 26% of clinicians choose to omit RT on the basis of chronological age . There is no international consensus on how small a difference in 5-year local recurrence rates for RT+ and RT- patients would have to be for RT to be omitted. If the RT effects are extrapolated from the EBCTCG overview of the breast conserving therapy, the current estimated 5-year rate in the absence of RT is 3% . While clinicians still have concerns for local recurrence even in low risk patients , the impact can be minimized with the possibility of further salvage BCS.
Although there is no single definition of readmission , most studies on readmissions among women with breastcancer have analyzed factors related to those occur- ring 30 days [15–17] or 1 year after surgical treatment . Our study is consistent with prior series in showing an association between surgical complications (mainly wound complications and surgical-site infections) and early readmissions [14, 16]. An analysis of risk factors re- lated to readmission after immediate breast reconstruction surgery found that patients with surgical complications had a 4-fold increased risk of early readmission . An- other study found that most early readmissions after mast- ectomy were related to postoperative complications, rather than exacerbations of comorbidities . Other studies have shown that additional risk factors for early re- admission were length of stay, payer type, physician vol- ume, and active smoking [17, 18].
One third of new breastcancer diagnoses occur in women aged over 70 years in the UK .. Increasing age results in rising rates of comorbidity and frailty  so tolerance to some standard breastcancer therapies may decrease  and older patients may prioritise quality of life over quantity . Consequently, older patients with operable breastcancer may be offered alternative treatment modalities, such as primary endocrine therapy (PET) [5,6], where oestrogen receptor (ER) positive disease is treated with endocrine therapy alone. A meta-analysis comparing PET with surgery found no difference in survival, although rates of local control were inferior with PET , which may necessitate a change in management [8,9]. Case series indicate that older frailer women tend to be treated with PET and have inferior overall survival rates as would be expected due to higher other-cause mortality .
Death rates for breastcancer have steadily decreased in women due to earlier detection, such as mammography, and improved treatments (4-9). Mammography is the single most effective method of early detection for breastcancer. It can identify the cancer at an early stage, when treatment is more effective (1). The American Cancer Society screening guidelines recommend that average-risk women aged 40 and older receive mammography screening on an annual basis (1). About 38%-54% of women do not maintain annual adherence to screening mammograms (10, 11), and only 49% having received screening when using a biennial schedule (11). Annual mammography with adequate follow-up is estimated to result in reductions in mortality ranging from 25% to 44% (6, 7, 12-15). Mammography is a highly accurate screening tool, but like most medical tests, it does not have perfect sensitivity and specificity. Generally, reported positive predictive values ranges from 78% to 90% (1, 16, 17). One drawback of mammography is the false positive results. One large study found that over a 10-year period of annual mammogram screenings, the chance of having a false positive result was close to 50% (18).
Mammography remains the most important breast imaging technique. It is the method of choice for breastcancer population screening in asymptomatic women and is the first imaging technique indicated to evaluate most clinical breast alterations (FLETCHER, 2003). Mammography also allows biopsies of suspected lesions to be performed before they manifest clinically. There is broad agreement that mammographic screening reduces breastcancer mortality by 30 to 40% among regularly screened asymptomatic women (KADAOUI, 2012). Other benefits of early detection include the possibility of more conservative breast-preserving surgeries, increased overall survival and disease-free time (FITZGERALD, 2012). The National Cancer Institute (INCA, in portuguese) recommends that women between 50 and 69 years old have a mammogram every two years. This is also the routine adopted in most countries that implemented breastcancerscreening and had an impact on reducing mortality frombreastcancer. The benefits of screening mammography include the possibility of finding cancer at an early stage and having a more conservative and therefore less aggressive treatment, as well as a lower chance of death due to the disease due to timely treatment (INCA, 2016). Breastcancerscreening programs have significantly reduced mortality due to early diagnosis in a large number of cases; however, it has been observed that screening mammograms have been followed up with a large number of cases. number of unnecessary biopsies. In Brazil, in the quest for standardization of mammographic reports, the Breast Imaging Reporting and Data System (BI- RADS™) model adopted by the American College of Radiology was adopted as a consensus. It comprises not only a classification of results, but also a set of results. actions that, when applied, allow greater efficiency of earlybreastcancer detection programs (ROVEDA JUNIOR, 2017). Therefore, this study aims to evaluate the promotion of early diagnosis of breastcancer by performing screening mammography in women aged 50 to 69 years.
Predicting toxicity from chemotherapy in the elderly is also of great importance, and several groups have used vari- ous measures to predict toxicity and prognosis (Extermann et al., 2004; Extermann et al., 2012; Hurria et al., 2011). Hurria et al. (2011) were able to predict risk of chemotherapy toxic- ity in a heterogeneous elderly cancer population, using a comprehensive screening tool that included GA factors. The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score developed by Extermann and colleagues (2012) was able to distinguish risk levels for severe toxicity in a mixed elderly cohort. Despite having an important prognostic value in oncology, a CGA is time consuming, poorly financially com- pensated in most health care systems, and not required for every patient (Extermann et al., 2004). For these reasons, there is increasing interest in the use of simpler geriatric screening tools. These tools are short and easy to administer (Deschodt et al., 2011) and avoid the efforts of doing GA in fit older patients who do not require extensive assessment. Several screening tools are used in oncology, such as the G8 (Bellera et al., 2012; Soubeyran et al., 2008), the Flemish version of the Triage Risk Screening Tool (fTRST) (Braes et al., 2009; Kenis et al., 2006; Meldon et al., 2003; Moons et al., 2007), the Groningen Frailty
Breastcancer mortality rates have decreased substantially over the past 25 years thanks to improvements in treatment and screening programs, but much remains to be done. We must pay more attention to women 50 years of age and younger and women 70 years of age and older in good health, because breastcancer in these populations represents a substantial burden and concrete solutions are available to physicians. For young women who are at risk, we must provide instruction in BSE, perform CBE, prescribe screening mammography, and, where appropriate, refer for genetic counseling. For olderwomen in good health, CBE and prescribing mammography are appropriate. To improve these practices, we must act upon physicians’ attitudes and skills and issue clearer recommendations.
The Best Chance Network (BCN), one of the first funded programs through NBCCEDP, was established in SC in 1991. The program provides health resources and services to all 46 counties in SC. Screening services offered through the BCN include mammograms, clinical breast exams, pap tests, pelvic exams, and human papillomavirus tests. Other services include diagnostic testing for women with abnormal screening results, support services with patient navigation, referral for treatment, and community education on breast and cervical cancer. Since the BCN’s inception, the program has provided breast and cervical cancer screenings to more than 11,755 women and 178,162 mammograms (South Carolina Department of Health and Environmental Control, 2016). In addition, the BCN program has diagnosed more than 1,800 breast cancers and 3,400 cervical cancers since 1991 (South Carolina Department of Health and Environmental Control, 2017). The appropriation of additional funding from the SC State Legislature in years 2015 and 2016 has enabled BCN to increase services and expand eligibility criteria, which allows more women to be screened (South Carolina Department of Health and Environmental Control, 2017). Best Chance is a resonant resource that moderates the financial barrier to early detection and partners with organizations to extend assistance to address low-income populations.
Abstract Though incidence rates of female breastcancer has declined since 1975 to 2014, in women of ages 20-59 years old, breastcancer is the leading cause of cancer-related deaths in the United States. Early detection of breastcancer via screening mammography has been shown to improve options for treatment, outcomes, and survival. Despite the success of screening mammography, screening adherence remains critical for clinical outcomes. This study explored the effect of a reminder system with educational materials on breastcancer knowledge and screening practices among primarily African-American women in North Florida. The participants were divided into two groups: the experimental group, which received this reminder system, and a control group, which did not. Both groups were surveyed using a questionnaire that included nine true or false questions regarding breastcancer facts, statistics, and screening guidelines. The experimental group scored significantly higher [t (138) = 2.60, p < .010] than the control group regarding breastcancer knowledge. Based on this study, a reminder system can be recommended as an effective intervention for increasing breastcancer knowledge.
Observational studies are at risk of confounding between treatment allocation and outcomes, which leads to bias in estimates of treatment effects. The statistical techniques used in our study mitigate against confounding that is due to factors observed in the dataset. However, these techniques will not fully account for the effects of confounders which are not observed in our dataset, especially if there are confounders which are uncorrelated to observed covariates. With respect to BCSS, it was hypothesized a priori that disease characteristics and age were primary confounders between the outcome and treatment choice. On the other hand, unobserved characteristics such as frailty, which is not routinely collected by the registry may be accounted for in part due to its correlation with age and comorbidity and so are partially adjusted for in the various models. As a result, the key finding in the present study are unlikely to be explained as being primarily due to confounding. By contrast, it is clear that these (health) factors could have a strong confounding effect with respect to death from non-breastcancer causes, and so overall survival was not considered.
Global policies and guidelines suggest prevention as the important priority and the cost-effective approach to curb the world’s burden of BC; especially, in LMICs where inadequate trained oncology health personnel, poor infra- structure, and economical and geographical barriers to BC treatment exist [4, 6–9]. World Health Organization  recommends screening and early detection as the two main components of cancer prevention/control for coun- tries with high prevalence and mortality rates of cancer as well as late presentation of most curable cancers . The use of active interventions such as breastcancer education (BCE), breast self-examination (BSE), and clinical breast examination (CBE) has shown to decrease the incidence, late presentation, and death rates of BC among women [11, 12]. Hence, BCE, BSE, and CBE seem the effective prevention/control and early detection measures for BC in limited resource countries [6, 12–14].
effectiveness of monthly BSE is unclear. As a significant numbers of women detect masses when they are bathing or dressing; monthly BSE can help women become more aware of their health status [10-13]. Although, there are some emphases on performing BSE, evidences show that less than 20% of Iranian women conducting regular BSE . Based on the results of researches which have done in Iran, The researchers concluded that Iranian women did not know how to perform BSE . The economic dependency coupled with illiteracy and ignorance particularly in rural women increases their risk of breastcancer. Researches show that rural residence itself, particularly residence in an isolated rural location, is a risk factor for not having received a screening CBE and mammogram, which lends credence to arguments for improving access to mammography in rural settings, particularly remote ones [16-18]. So, it seems that rural women have low awareness. Actually lack of knowledge about the benefit of earlybreastcancerscreening is a significant barrier for some women to seek mammography . On the other hand, on the basis of health behaviors distribution models in human society, many epidemiologists believe that the increase of knowledge and improvement of attitudes and beliefs concerning promotion of breastcancerscreening programs among rural female populations [20, 21]. Several studies have shown that the knowledge and perception of rural women directly influence their attendance and accepting or screening behavior [22-25]. Although in Asia and Middle East, especially in Iran the incidence of breastcancer is rapidly increasing, but just a few studies have examined the knowledge, attitude and practice of women toward breastcancer and prevention programs in Iran. These studies are often of small sample size and targeted women in especial profession [1, 23]. In Iran, however, there are no regular population-based screening programs, and no prevention programs for controlling cancers, suggesting that knowledge about risk factors, symptoms, the benefits of earlycancer-screening guidelines and the use of health care clinics for cancertreatment, especially breastcancer, may be low in the Iranian population [23-28]. In this study, we reported data derived from an investigation of the knowledge, attitudes, and practices regarding breastcancer and prevention programs, especially BSE, among Iranian rural female population.
Abstract: Background: Radiotherapy plays an important role in the management and survival of patients with breastcancer. The aim of this study was to examine the association between age, comorbidities and use of radiotherapy in this population. Methods: Patients diagnosed with breastcancerfrom 2004–2013 were identified from the American College of Surgeons National Cancer Database (NCDB). Follow-up time was measured from the date of diagnosis (baseline) to the date of death or censoring. Adjusted hazard ratios (aHR) and 95% confidence intervals (95%CI) were used as the measure of association. Results: Independently of comorbidities and other important outcome-related factors, patients >65 years of age who received radiotherapy survived significantly longer than those who did not receive radiotherapy (aHR = 0.53, 95%CI = 0.52–0.54). However, as women aged, those with comorbidities were less likely to receive RT (adjusted P-trend by age <0.0001). Conclusions: The development of decision-making tools to assist clinicians, and olderwomen with breastcancer and comorbidities, are needed to facilitate personalized treatment plans regarding RT. This is particularly relevant as the population ages and the number of women with breastcancer is expected to increase in the near future.
Current UK guidelines  state that primary endocrine therapy (PET) should only be offered if “significant comorbidity precludes surgery” and that age alone should not affect the decision . However, PET continues to be widely used in the UK as an alternative to surgery with PET used in up to 40% of women over 70, compared with less than 6% in women under 70 . Increasing age, being deemed too frail or unfit for surgery are cited as reasons for olderwomen receiving non-standard treatment such as PET [3, 4]. Patient choice is also identified as a factor in women receiving PET instead of standard surgical treatment. Oncologic outcomes with PET are acceptable, but rates of local control are inferior to surgery and there may be a small reduction in breastcancer specific survival [7, 8]. This needs to be balanced against short term morbidity associated with surgery. Weighing such ‘trade offs’ is complex, requiring adequate information about each option and its consequences .
A UK-based audit of management protocols in olderwomen with early operable primary breastcancer reported that 40% of them were treated by non-operative therapy. This fact has impacted on how ER-negative primary breastcancer in olderwomen could be studied. Most of the available studies only include patients treated by surgery (often using surgical spec- imens for studying biological features), introducing a potential bias towards a comparatively fitter older population. If we were to encompass all olderwomen with ER-negative tumours regardless of primary treatment, we have to study their biological features using tumour tissue obtained from diagnostic needle core biopsies. The limitations of such approach include the small quantity and quality of the specimen, and method used to process the tissue (eg fresh fro- zen or formalin fixed paraffin embedded tissues).
13.6% in Malaysia by Parsa (18) , and very low in Brazil by Bimer (23) . We found mammography to be significantly related to only history of breast disease. Despite the fact that mammography constitutes an efficient method for early diagnosis of breastcancer in women aged above 40 years and those at risk, the rate of mammography in our study did not change with increasing age (24) . As using screening modalities contributes to early diagnosis of breastcancer and efficacious treatment in early stages reduces mortality (25) , our findings do not indicate an acceptable behavior by our participants regarding earlybreastcancer diagnosis, including self-examination, clinical examination, and mammography. Therefore, planning and designing educational intervention proper for the cultural and social features of the community and using health education models may improve these behaviors in women age above 20 years.
Breastcancer has been reported to be one of the leading causes of mortality among women worldwide; 508,000 women died as a result of breastcancer in 2011 1 . Coleman et al. 2 and Fregene and Newman 3 reported that the incidence of breastcancer amongst women in Western countries (including the United States of America, the United Kingdom, Canada and Australia) was significantly greater than that for women in African countries; the proportion of women that died as a result of the disease was higher amongst women in the African countries. This difference in mortality could be as a result of poor awareness of women about breastcancer, poor diagnostic facilities, poor treatment facilities, and high cost of the disease management 3 . WHO suggests that there will be a 70% increase in the incidence of breastcancer by 2030 in developing countries such as Nigeria 4 . Consequently, appropriate measures should be put in place to improve breastcancer detection and treatment.
Patients who were alive were censored at the end of the study period. Patients who died from other causes than breastcancer were censored at the time of death. For early stage operable breastcancer, the standard treatment at the time of the study period included modified radical mastectomy or wide local excision and axillary clearance. Chemotherapy was not indicated as adjuvant treatment as a routine practice in this group of patients. However, patients having high risk of recurrence were treated with adjuvant chemotherapy if they have no significant comorbidity and good performance status. Indications for adjuvant radiotherapy included patients who underwent breast conserving surgery (BCS) and high risk post-mastectomy patients with tumor size 5 cm or more with 4 or more metastatic lymph nodes or positive surgical margins.
This study is subject to several limitations. Misclassification error is possible when relying on procedure and diagnosis coding from health care claims in the absence of patient charts or provider attestations, where the extent of data entry error, undercoding, or overcoding is unknown. Patients’ medical history was limited to health care claims during the reporting years in this study, such that comorbidities or other sociodemographic factors outside of this data were unknown. Coding of diagnostic radiologic procedures may be subject to data coding limitations as well as coding changes and revised code definitions that occurred during the time of the study. BI-RADS information is lacking in the MarketScan administrative claims data. Similarly, clinicians’ rationales for use of various diagnostic procedures and evidence of whether patients were symptomatic or asymptomatic are not found in claims data. The distinction between screening and diagnostic ultrasound procedures and criteria for dense breast tissue in distinguishing screening versus diagnostic ultrasounds are not available using standard reimbursement codes, and our ability to make this distinction using sequencing of events or other algorithms is limited. Unmeasurable characteristics of patients with different diagnostic pathways or progressions, such as the patient’s income level, proximity and availability of diagnostic services or specialists, family situation (e.g., support network, spouse, dependents), and other sociode- mographic factors, may account for the differences found in health care costs and utilization. Controlling for specific Table 6 Mean (SD) and median paid amounts for breast