result is corroborated by studiesperformed in other countries, whichhave shown that even with nationalhealth care coverage, disparities incancer survival persist among thepoor. For example, in Canada, overallsurvival of women with cancer wasfound to be poorer among women oflow socioeconomic status than amongthose of high socioeconomic status,although insurance coverage isuniversal.1 According to Coleman andcolleagues,2 in Great Britain,inequalities in survival persistedbetween patients living in affluentareas and those living in poor areasfor 44 of 47 adult cancers examined.The authors concluded that there was‘‘strong evidence of systematicdisadvantage in outcome’’ among thepoorer patients in England, despitehaving insurance coverage.2 There isevidence of ‘‘systematic disadvan-tage’’ among low-income patients inthe United States as well.

What is this systematic disadvan-tage? Individuals who qualify forMedicaid, in addition to meeting low-income standards, are more likely tohave less education, are less likely tohave a stable medical home, are morelikely to be recent immigrants, and are

320 Breast Diseases: A Year Book� Quar

Vol 21 No 4 2011

more likely to be unemployed or havea job with few benefits (such as paidsick leave). These individuals havemultiple disadvantages in society.

In our experience, many low-income patients face significantorganizational barriers to accessingDM services. Although obtaininga DM appointment at our facility istimely (the current wait time isapproximately 48 hours for a dia-gnostic imaging appointment), manyof our Medicaid and uninsuredpatients must overcome significantbarriers prior to calling for anappointment. For example, many low-income women obtain their primarycare at local community healthcenters and clinics. As a result, thesewomen can face significant delays indiagnosis due to the bureaucracyinvolved. For instance, a woman witha breast symptom typically firstcontacts her primary care provider fora clinical evaluation. After this initialappointment, the primary careprovider must then obtain a voucher,which allows the woman to seeka diagnostic workup at a specificbreast imaging facility. The timeneeded to obtain a voucher canfurther contribute to delays in

terly

diagnosis. In addition, in ourexperience, Medicaid and uninsuredpatients often have difficulty gettingtime off of work to obtain diagnosticmedical care, especially if more than 1outpatient visit is required.

Hopefully, the results of this studyby Schuur and colleagues will stim-ulate further research to identifystrategies to reduce some of theorganizational barriers to thediagnosis and treatment of breastcancer in the United States.

D. M. Farria, MD, MPH

References1. Booth CM, Li G, Zhang-Salomons J,

Mackillop WJ. The impact ofsocioeconomic status on stage ofcancer at diagnosis and survival:a population-based study in Ontario,Canada. Cancer. 2010;116:4160-4167.

2. Coleman MP, Babb P, Slogett A,Quinn M, De Stavola B.Socioeconomic inequalities in cancersurvival in England and Wales.Cancer. 2001;91:208-216.

Breast Cancer Recurrence inOlder Women Five to Ten Yearsafter Diagnosis

Bosco JLF, for the BOW Investigators(Boston Univ School of Medicine, MA;et al)

Cancer Epidemiol Biomarkers Prev 18:2979-2983, 2009

Little is known about the risk ofrecurrence >5 years after diagnosisamong older breast cancer survivors.

A community-based population ofwomen $65 years diagnosed withearly-stage breast cancer who surviveddisease free for 5 years was followedfor 5 additional years or until a diag-nosis of breast cancer recurrence,second primary, death, or loss tofollow-up. These 5-year disease-freesurvivors (N¼ 1,277) had primarybreast cancers that were node negative(77%) and estrogen receptor positive orunknown (86%). Five percent (n¼ 61)developed a recurrence between 5 and

10 years after diagnosis: 25% local,9.8% regional, and 66% distant.Women who were node positive[hazard ratio (HR), 3.9; 95% confi-dence interval (95% CI), 1.5-10], hadpoorly differentiated tumors (HR, 2.5;95% CI, 0.9-6.6), or who receivedbreast conserving surgery withoutradiation therapy (HR, 2.4; 95% CI,1.0-5.8) had higher recurrence ratescompared with node negative, well dif-ferentiated, and receipt of mastectomy,respectively. Not receiving adjuvant

tamoxifen, compared with receivingadjuvant tamoxifen, was also positivelyassociated with late recurrence amongwomen with estrogen receptor–posi-tive/unknown tumors. Although rela-tively few women experience a laterecurrence, most recurrences presentas advanced disease, which is difficultto treat in older women. This study oflate recurrence emphasizes that therisk, although small, is not negligibleeven in this group at high risk ofdeath due to competing causes.

The estimated 5-year survivalrates for women with early-stage breastcancer are 83.5% for regional-stagetumors and 98% for local-stagetumors. While such survival rates areencouraging, breast cancer recurrenceafter primary therapy remainsa problem. Most recurrences occurwithin the first 5 years followingdiagnosis,1 with some studies reportinga peak hazard of over 13% forrecurrence between the first and secondyears following diagnosis.2 Recentstudies have demonstrated that thispeak in recurrence is not limited to year2 but also includes another peakaround year 5 following diagnosis ofearly-stage breast cancers.2,3 There islimited information on the patient-related and clinical characteristics thatpredict recurrences more than 5 yearsafter diagnosis.

In this study, Bosco andcolleagues examined the risk ofrecurrence beyond 5 years afterdiagnosis in a cohort of 1277 womenage 65 and older diagnosed withearly-stage disease between 1990 and1994 in 6 different regional US healthcare systems. While their data suggestan overall low rate of late recurrence(5% for all stages of disease), it isimportant to note that the majority ofthe study cohort had node-negativedisease. Indeed, women with node-positive disease had 4 times the risk oflate recurrence than women withnode-negative disease. Bosco andcolleagues also found a trend towardan increased risk of late recurrenceamong women who underwent breast-conserving surgery without radiationand with a shorter duration oftamoxifen therapy. Prior studies haveshown that older women are less likelyto receive guideline-recommendedmanagement of breast cancer, and thisarticle highlights the potential impactof such undertreatment on the risk oflate recurrence. Caution should betaken when extrapolating this study’sfindings to older patients treated withmore recently developed adjuvantregimens, such as aromataseinhibitors and trastuzumab therapy.

Several patient-related issues stillneed to be addressed to improve ourability to identify patients at high risk

Breast D

for late recurrence. For example, arethere modifiable epidemiologicalfactors at the time of diagnosis, suchas body mass index, alcohol intake, orsmoking status, that can predict laterecurrences? If such patient-relatedfactors can be identified, targetedinterventions can be investigated inthe posttreatment setting to reduce theburden of late recurrences.

A. M. Brewster, MD, MHSR. McGaha, MPH

References1. Early Breast Cancer Trialists’

Collaborative Group (EBCTCG).Effects of chemotherapy andhormonal therapy for early breastcancer on recurrence and 15-yearsurvival: an overview of therandomised trials. Lancet. 2005;365:1687-1717.

2. Demicheli R, Biganzoli E,Boracchi P, Greco M, Retsky MW.Recurrence dynamics does notdepend on the recurrence site. BreastCancer Res. 2008;10:R83.

3. Jatoi I, Tsimelzon A, Weiss H,Clark GM, Hilsenbeck SG. Hazardrates of recurrence followingdiagnosis of primary breast cancer.Breast Cancer Res Treat. 2005;89:173-178.

iseases: A Year Book� Quarterly 321Vol 21 No 4 2011