Journal of the National Cancer Institute Advance Access published online on July 24, 2007
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djm059
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© The Author 2007. Published by Oxford University Press.
ARTICLES |
Breast Cancer Incidence, 1980–2006: Combined Roles of Menopausal Hormone Therapy, Screening Mammography, and Estrogen Receptor Status
Affiliations of authors: Oncology Research, Center for Health Research, Kaiser Permanente Northwest, Portland, OR (AGG); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD (JVL, JDC, RNH)
Correspondence to: Andrew G. Glass, MD, Oncology Research, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Ave, Portland, OR 97227 (e-mail: andrew.glass{at}kpchr.org).
Background: Breast cancer incidence has been rising since at least 1935–1939, but recent US data reveal a statistically significant decline in breast cancer incidence in 2003 that persisted through 2004. Identifying the specific contributions of the potential causes of this long-term increase and the recent decrease in incidence has been challenging. Marked changes in rates of mammography screening and use of menopausal hormone therapy since 1980 have added further complexity. We examined the potential association between menopausal hormone therapy use and recent changes in breast cancer incidence.
Methods: Using tumor registry, clinical, pathology, and pharmacy data from Kaiser Permanente Northwest, a large prepaid US health plan, we compared age-specific and age-adjusted breast cancer incidence rates (2-year moving averages) with use of screening mammography and dispensed menopausal hormone therapy prescriptions between 1980 and 2006. Temporal changes in incidence rates were assessed via joinpoint regression.
Results: A total of 7386 incident invasive breast cancers were diagnosed in plan members from 1980 through 2006. Overall age-adjusted breast cancer incidence rates per 100000 women rose 25% from the early 1980s (105.6) to 1992–1993 (131.7) and an additional 15% through 2000–2001 (151.3), then dropped by 18% to 2003–2004 (123.6) and edged up slightly in 2005–2006 (126.2). These patterns were largely restricted to women aged 45 years or older and to estrogen receptor–positive (ER+) breast cancers. Incidence rates of ER-negative tumors experienced neither of the rises seen for ER+ tumors but also fell precipitously from 2003 through 2006. Rates of mammography screening sharply increased from 1980 to 1993 but then leveled off, and 75%–79% of women aged 45 years or older received a mammogram at least once every 2 years from 1993 through 2006. Menopausal hormone therapy dispensings, particularly of estrogen-plus-progestin formulations, increased from 1988 to 2002 but then dropped by approximately 75% after 2002.
Conclusions: From 1980 through 2006, quantitative and qualitative trends in breast cancer incidence rates, particularly for ER+ tumors, parallel major changes in patterns of mammography screening and use of menopausal hormone therapy.
| CONTEXT AND CAVEATS Prior knowledge The incidence of breast cancer in the United States has risen steadily in recent decades through 2003, when incidence began to decline. Rates of menopausal hormone therapy use and screening mammography have also changed over time, and the relative contributions of these factors to the incidence of breast cancer is unclear. Study design Analysis of time trends in breast cancer incidence, dispensed menopausal hormone therapy prescriptions, and screening mammography use among women enrolled in a large health plan from 1980 through 2006. Contribution In women aged 45 years and older, age-adjusted incidence of breast cancer (mainly estrogen receptor–positive) rose from the early 1980s through 2001, then dropped by 18% from 2003 through 2006. Menopausal hormone therapy dispensings increased from 1988 to 2002 and then dropped by 75%. Rates of mammography screening increased from 1980 through 1993 and then remained largely stable through 2006. Implications The rise in breast cancer incidence rates through the late 1990s is consistent with the effects of mammography screening and increasing use of menopausal hormone therapy, and the recent decline in incidence is consistent with the drop in hormone use. Limitations This descriptive, population-level study examined aggregate data, so changes in other unmeasured risk factors could theoretically explain the observed incidence patterns.
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Manuscript received September 11, 2006; revised May 11, 2007; accepted June 11, 2007.
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