Affiliations of authors: Department of Epidemiology and Biostatistics, The George Washington University School of Public Health and Health Services, Washington, DC (KWH, HAY, PHL); Cancer Prevention Fellowship Program, Division of Cancer Prevention (KWH), Division of Cancer Epidemiology and Genetics (WFA, SSD), National Cancer Institute, National Institutes of Health, Bethesda, MD; The George Washington University Cancer Institute, Washington, DC (PHL)
Correspondence to: Kenneth W. Hance, PhD, MPH, Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, 6120 Executive Blvd., Suite T41, Bethesda, MD 20892 (e-mail: hancek{at}mail.nih.gov).
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ABSTRACT |
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INTRODUCTION |
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Possibly because of varying case definitions, population-based estimates for IBC incidence range widely, from <1% to 10%. For example, using codes from the Surveillance, Epidemiology, and End Results (SEER) Program, Levine et al. (6) noted IBC incidence rates of 6% and 10% among white and black women, respectively; however, the codes may have included LABC cases, inflating the IBC incidence estimates. Using a more conservative definition for IBC in SEER, the International Classification of Diseases for Oncology (ICD-O-2) morphology code 8530/3, Chang et al. (9) reported much lower incidence rates of 0.5% and 0.7% in white and black women, respectively. More recent population-based studies using clinical and pathologic (4) or pathologic only (10,11) case definitions suggest that 1.0%1.3% of all incident breast carcinomas in women are IBC.
In a previous study, we evaluated age-specific incidence rate patterns and survival outcome in both IBC and LABC patients; however, temporal trends were not examined and a less comprehensive SEER-based definition for IBC was employed (4). We recently reported comparisons of age-specific incidence rate patterns for seven different histopathologic types of breast carcinoma including IBC; however, survival outcomes and temporal trends were not reported, and a conservative case definition for IBC (ICD-O-2 8530/3) was used for the purposes of comparison (10). Thus, the primary purpose of this study was to determine the true population-based incidence of IBC. An additional goal was to evaluate changes in IBC incidence and survival over time, particularly by race. To examine these questions, we used a comprehensive definition designed to capture all of the clinically and/or pathologically defined IBC cases diagnosed in the National Cancer Institute's SEER Program.
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SUBJECTS AND METHODS |
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We examined the publicly available records of the nine population-based registries in the SEER 9 Registries database (November 2002 submission) (12). The registries are located in San Francisco-Oakland, Metropolitan Detroit, Seattle (Puget Sound), Metropolitan Atlanta, Connecticut, Hawaii, Iowa, New Mexico, and Utah. Through these nine registries, SEER provides information on patient demographics and tumor characteristics of newly diagnosed malignancies for approximately 10% of the U.S. population.
SEER Case Definition and Selection
The SEER database provides modified AJCC staging information for breast cancer cases, which does not include tumor designations that distinguish between IBC and LABC cases. However, SEER's "Extent of DiseaseExtent" (EOD-E) codes do provide tumor definitions similar to those of the AJCC (13) that can be used to uniquely define LABC and IBC cases (Table 1).
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Study Variables
The primary endpoints of this study were incidence rates and survival stratified by patient demographic characteristics and incident tumor characteristics. Patient demographics included age at diagnosis (<50, 5059, 6069, 7079, or 80+ years), race (whites, blacks, or other), and a surrogate endpoint for menopausal status of 50 years of age. Morabia and Flandre (15) reported that 50 years of age is an appropriate surrogate for menopausal status when information about menstrual history is not available. Moreover, recent population-based studies of age-specific incidence rate patterns for IBC and other histopathologic subtypes of breast cancer used 50 years of age as a surrogate for menopausal status (4,10).
Tumor characteristics included tumor size (2 cm versus >2 cm), axillary lymph node status (lymph node positive versus negative), estrogen receptor (ER) and progesterone receptor (PgR) expression (positive versus negative), and tumor grade. The variable for tumor size was dichotomized to approximate the AJCC criteria for T1 tumors (
2 cm) (5). Grade was defined according to ICD-O-2 coding conventions (14); histologic nuclear grades 1 (well-differentiated) and 2 (moderately differentiated) were defined as low-grade tumors, and histologic nuclear grades 3 (poorly differentiated) and 4 (undifferentiated) were defined as high-grade tumors. Data for patient demographics and/or tumor characteristics that were missing or coded as "other or unknown" were not included in this analysis.
Statistical Analysis
The SEER 9 Registries database was accessed in ASCII format and analyzed with the SAS statistical software package (SAS for Windows Version 8.2, SAS Institute Inc., Cary, NC). The National Cancer Institute's SEER*Stat software package version 5.0.20 was used to calculate incidence rates, 95% confidence intervals (CIs) estimated by the gamma method, cumulative relative survival, and median survival time. Incidence rates were expressed per 100 000 woman-years and were age-adjusted by the direct method to the 2000 U.S. standard population (16). Rate ratios (RRs) were calculated by dividing the age-adjusted breast cancer incidence rate in women with a high-risk prognostic factor by the incidence rate in women with the corresponding low-risk prognostic factor. Low-risk prognostic factors were assigned a rate ratio of 1.0 and served as the reference group. Differences in the rate ratios for patient demographics and tumor characteristics were evaluated using 95% confidence limits that were calculated as previously described (17,18).
To characterize the age distribution of cases in each breast cancer subtype, continuous 1-year age frequency distributions were constructed using density plots as previously described (19,20). Briefly, age frequency distributions were constructed using a smoothing function with a filter width of 20; the vertical axis of each density plot represented the smoothed estimates of the proportion or density (where density x 100 = percent) of patients who developed breast cancer at the corresponding age at diagnosis on the horizontal axis. The area under the curve of each age density histogram included 100% of all breast cancer cases. KolmogorovSmirnov (KS) statistics define the maximum difference in the cumulative proportions of two nonparametric distributions (19). In this study, KS statistics were used to test for statistically significant differences in the age frequency distributions of IBC patients stratified by race and ER receptor status (21).
Differences in the mean age at diagnosis by breast cancer subtype were evaluated using one-way analysis of variance and the Student's t test (22). The MantelHaenszel chi-square test of trend statistic (16) was used to evaluate temporal trends in the age-adjusted incidence rates of each breast cancer subtype across 3-year intervals from 1988 through 1999. Age density histograms, age-specific incidence rate curves, and cumulative survival data were plotted using the S-Plus 6.0 software package (Insightful Corporation, Seattle, WA).
Cumulative relative survival was defined as breast cancerspecific survival corrected for corresponding national mortality rates (23). KaplanMeier product-limit curves (24) and log-rank tests (25) were used to evaluate differences in overall and breast cancerspecific survival by breast cancer subtype. In all statistical tests, P<.05 was considered to be statistically significant. All statistical tests were two-sided.
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RESULTS |
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Differences in tumor characteristics by breast cancer subtype were also evaluated (Table 2). Women diagnosed with LABC (RR = 5.4, 95% CI = 4.9 to 6.0) or IBC (RR = 5.1, 95% CI = 4.2 to 6.4) were more likely to present with larger tumors (>2.0 cm) at diagnosis than with smaller tumors (2.0 cm). In contrast, women diagnosed with non-T4 breast cancer were more likely to present with smaller tumors than with larger tumors (RR = 0.45, 95% CI = 0.44 to 0.46). High nuclear grade tumors were also more commonly observed than low nuclear grade tumors in women with LABC (RR = 1.6, 95% CI = 1.5 to 1.8) or IBC (RR = 3.1, 95% CI = 2.8 to 3.4), but not in women with non-T4 breast cancer (RR = 0.66, 95% CI = 0.65 to 0.67). Moreover, positive lymph node involvement was more common in LABC (RR = 2.5, 95% CI = 2.3 to 2.7) and IBC (RR = 4.7, 95% CI = 4.2 to 5.3) cases but was less common in non-T4 breast cancer cases (RR = 0.399, 95% CI = 0.396 to 0.404). In Table 3, the same patient and tumor characteristics were evaluated by IBC subtypes (ClinPath, PathOnly, and ClinOnly IBC). The patterns of association within each of these IBC subtypes were similar to those observed with total IBC.
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Of all microscopically confirmed malignancies of the breast diagnosed in the SEER 9 Registries database between 1988 and 2000, IBC comprised 7.0% (1936 of 27 747) of all breast cancerspecific mortality. KaplanMeier plots (Fig. 5) show that breast cancerspecific survival was statistically significantly poorer in patients with IBC than in patients with LABC or non-T4 breast cancer (log-rank test, P<.001). The median survival times of women with non-T4 breast cancer (greater than 10 years), LABC (6.4 years), and IBC (2.9 years) were also statistically significantly different (P<.0001) (Fig. 5, A). When actuarial breast cancerspecific survival among the IBC subtypes was compared (Fig. 5, B), patients with pathologically defined IBC (PathOnly IBC) had statistically significantly shorter survival than patients with IBC defined by clinical features only (ClinOnly IBC) or by both clinical and pathologic features (ClinPath IBC) (log-rank test, P<.001). However, the median survival time of patients with PathOnly IBC (2.3 years) was not statistically different from that of patients with ClinOnly IBC (3.0 years) or ClinPath IBC (2.9 years) (P = .058).
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When IBC patients were stratified by ER status for analysis of breast cancerspecific survival, IBC patients with ER-negative tumors had poorer survival than those with ER-positive tumors (log-rank test, P<.001). ER-negative patients had a median survival of 2.0 years, compared with 4.0 years for ER-positive patients (P<.0001).
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DISCUSSION |
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The age distribution of IBC patients (rates and frequency) revealed a pattern of early age at diagnosis that was consistent with what has been seen in previous studies (4,7,9,26,27). In a recent study, the age-specific incidence rate pattern for IBC was similar to that for medullary breast carcinoma but different than that for other histopathologic subtypes (10). Further research is required to determine whether genetic predisposition and/or early life exposures account for this peculiar age distribution. Our findings also showed an earlier age at IBC diagnosis in black women, suggesting that substantial racial disparities exist in IBC patients relative to non-T4 breast cancer patients.
Total IBC comprised 2.0% of all incident breast cancer cases, similar to the lower end of earlier estimates (13,6,26,28,29) but higher than recent population-based studies of IBC (4,911). A large number of cases were defined by clinical features of IBC without pathologic confirmation of dermal lymphatic invasion (ClinOnly IBC; n = 1910), suggesting that studies lacking a clinically defined IBC case definition may underestimate the true incidence of this disease.
In the 3-year intervals between 1988 and 1990 and 1997 and 1999, the age-adjusted incidence rate of IBC rose by 25%. This increase in IBC incidence was statistically significant only in white women, and the results suggest that IBC incidence rates in white women may be catching up to those in black women. By contrast, Chang et al. (9) reported that the incidence of IBC doubled in both blacks and whites between 1975 and 1977 and 1990 and 1992, with the rates of IBC in white patients lagging behind those in black patients.
Possible explanations for the increase in IBC incidence that we observed may be heightened clinical awareness and earlier detection with screening mammography. The period of our study indeed coincides with a rise in mammography use (30,31). However, earlier detection over time with screening mammography is generally associated with a fall in the rate of late-stage disease (32), as seen for LABC but not IBC in this study. IBC may be difficult to detect by mammography for several reasons. First, studies examining the mammographic patterns of inflammatory changes associated with IBC commonly show skin thickening, stromal coarsening, and diffusely increased breast density, whereas an associated mass and/or malignant-type calcification, although common in patients with IBC, may be absent on mammography owing to diffusely increased breast density (3336). Second, IBC by its clinicopathologic definition is a diffuse tumor (3,5). Thus, the utility of mammographic screening in the early detection and diagnosis of IBC may be limited because of the combination of a diffuse tumor obscured by increased breast density brought on by inflammation.
Another possible explanation for the increased incidence of IBC is changing patterns of risk factor exposure. There is some evidence that reproductive hormone exposure plays a role in the etiology of IBC (37,38). Although the differences did not reach statistical significance, Chang et al. (38) reported that IBC patients were younger at menarche and at the time of their first live birth and that a higher proportion of IBC patients were premenopausal than their non-IBC counterparts. In a subsequent study by Chang et al. (39), premenopausal IBC patients were shown to have statistically significantly worse survival than postmenopausal IBC patients. In our study, we found, as have others (3,10), that the age-specific incidence rates of IBC rose rapidly until 50 years of age and then stabilized. We observed this pattern for IBC incidence irrespective of race or ER status. These data support the findings of Chang et al. (38,39), suggesting that premenopausal events such as the premenopausal hormonal milieu may be important factors in the initiation and progression of IBC.
We observed a modest trend for improvement in IBC survival in this study; however, the median survival time of IBC patients improved by only 8.4 months between 1988 and 1990 and 1997 and 1999. A statistically significant improvement in IBC survival after the 19881990 interval coincided with the more common use of anthracycline-based neoadjuvant therapy and the introduction of paclitaxel-based regimens in the clinical management of IBC in the 1990s (40). Although we were unable to directly examine how changes in therapy for IBC affected survival, distinct tumor features, unique age distributions, and different survival outcomes for IBC and LABC suggest that future clinical trials should use a case definition for IBC that more effectively excludes LABC. Moreover, our survival analysis supports the conclusions of Somlo et al. (41), who argued for the need to develop standard staging criterion for treatment planning in which individuals at higher risk of developing more aggressive IBC subtypes receive more aggressive neoadjuvant and adjuvant chemotherapy.
Studies of breast cancer survival outcomes in equal-access health care systems demonstrate that African-American race/ethnicity is an independent predictor of elevated risk for breast cancer mortality (42,43). These findings are consistent with our finding that among black women breast cancer mortality was higher in IBC patients than in patients with either LABC or non-T4 disease. It is interesting to note that the 5-year relative risk of death in black women diagnosed with breast cancer and treated in the U.S. Department of Defense health care system was 25%, whereas that for black women diagnosed in the SEER Registries database was 34% (42). These findings suggest that equal access to health care such as that provided in the U.S. Department of Defense health care system improves breast cancer mortality among black women but does not fully account for racial disparities in survival outcome between black and white women.
Race and socioeconomic status have been reported to be independent predictors of advanced stage at diagnosis in breast cancer (44,45). Race is also a statistically significant predictor of tumor aggressiveness as measured by histologic grade within each stage of breast cancer (46). Although black and white women have equivalent response rates to local and systemic breast cancer therapy, higher rates of locoregional recurrence in black patients suggest the presence of a biologic determinant for more aggressive breast cancer (43). The early age at diagnosis, age-specific incidence rate patterns, and poor survival outcomes described for IBC patients in this study are consistent with the effects of both race/ethnicity and biologic determinants of aggressive breast cancer.
The strength of this study is its large-scale population-based design. The potential limitations of this study include 1) a lack of histopathologic slide review, 2) missing or incomplete data, 3) nonstandardized measurement of hormone receptor expression, and 4) lack of data for menstrual status, reproductive risk factors, method of detection, and treatment. Although SEER does not provide information about reproductive risk factors, it does provide information on the most important risk factor for female breast cancer, which is age at diagnosis. Therefore, we used 50 years of age as a surrogate for menopausal status (15). Without information about the method of detection, it is not possible for us to distinguish between the impact of heightened clinical awareness and screening mammography on the temporal trends in IBC incidence. Treatment records were unavailable; however, the standard tumor characteristics described in this study are beneficial in predicting prognosis irrespective of treatment (47).
Biomarkers for early detection and targeted therapies based on an understanding of the molecular determinants of IBC might improve the clinical management of this disease and improve survival among patients. The understanding of the molecular determinants of IBC is poised for advancement, with the efforts of several laboratories to develop microarray-based genomic profiles to define the molecular signature of IBC (48,49). A gene expression profile that is characteristic of IBC may help resolve the debate over how to appropriately define IBC (7,8,50). Comparing the gene expression profiles of IBC patients stratified by menopausal status, race, and hormone receptor status should facilitate our understanding of the etiology of this disease and may help to identify IBC subtypes that may possess common therapeutic responses and clinical outcomes. With further characterization of the molecular profile and etiology of IBC, we may eventually determine why IBC incidence continues to rise and why the IBC phenotype is so aggressive and resistant to current treatment modalities.
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Manuscript received June 9, 2004; revised April 26, 2005; accepted May 26, 2005.
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