1838
The American College of
Surgeons Commission on
Cancer and the American
Cancer Society
Address for reprints: Herman R. Menck, M.B.A.,
American College of Surgeons, 55 East Erie
Street, Chicago, IL 6061 1.
Received April 29, 1996; revision received July
18, 1996; accepted July 23, 1996.
0 1996 American Cancer Society
The National Cancer Data Base
Report on Breast Carcinoma
Characteristics and Outcome in
Relation to Age
David P. Winchester, M.D.
Robert T. Osteen, M.D?
Herman R. Menck, M.B.A?
Department of Surgery, Northwestern University Medical School, Chicago; Illinois;
Department of Surgery, Evanston Hospital, Evanston, Illinois; Cancer Department, American
College of Surgeons, Chicago, Illinois.
Department of Surgery, Brigham and Womens Hospital, Boston, Massachusetts
Clinical Information, Commission on Cancer at The American College of Surgeons,
Chicago, Illinois.
BACKGROUND. Previous data from the National Cancer Data Base have examined
time trends in stage of disease, treatment patterns, and survival for selected can-
cers. The most current (1993) data for breast carcinoma are described here.
METHODS. Five Calls for Data have yielded a total of 508,724 breast cancer cases
diagnosed from 1985 to 1993, from hospital cancer registries throughout the U.S.
RESULTS. Women younger than age 35 had a lower rate of ductal carcinoma in
situ, higher grade primary tumors, more advanced American Joint Committee on
Cancer stage disease, and poorer 5-year relative survival than older premenopausal
women. African American women were more likely to have advanced disease than
non-Hispanic whites in all three age groups analyzed. Improved time trends of
early detection of breast carcinoma and use of breast conservation treatment are
reported. The overall prognosis for breast carcinoma remains relatively good for
all age groups when compared with other cancers.
CONCLUSIONS. These data are consistent with the hypothesis that younger women
are at increased risk for biologically more aggressive breast carcinoma. Cancer 1996;
78:1838-43.0 1996 American Cancer Society.
KEYWORDS: breast carcinoma, age, national survey, treatment, survival, National
Cancer Data Base.
I t has been previously reported that frequency of use of breast con-
servation surgery has been increasing over time, but that not all
population groups have participated equally in this treatment change
pattern.-3 The breast carcinoma surgery decision is understood to
include many factors and to be influenced both by patient preference
and physician recommendation.
It has also been hypothesized that breast carcinoma may be a
more aggressive disease in young women, and more indolent in older
patients, particularly the very elderly. In the latter group, comorbid

conditions often exist. In addition to a possible comor-
bid effect for the elderly, it can be speculated that
younger women may be more concerned with breast
image and appearance in relation to their lifestyle and
longer life expectancy. These various considerations
led us to seek to better understand the relationship
between breast carcinoma biology and age, whether
breast carcinoma management patterns were related
to age, and whether outcome differed by age.
Extensive information in the National Cancer Data
Base (NCDB) can be stratified by age and allow one
to examine variables of interest. This report analyzes
the patient and tumor characteristics, treatment, and
outcome in breast carcinoma patients stratified as
young, premenopausal (younger than 35 years), older
premenopausal (35-49 years), and postmenopausal
(50 years and older).
METHODS
The methods of the NCDB and the Commission on
Cancer (COC) have been previously d e ~ c r i b e d These
.~,~
data from NCDB participating hospitals comprise a
convenience (nonrandom) sample voluntarily submit-
ted by hospital cancer registries. Approximately 91%
of the cases come from facilities who are members of
the Approvals Program of the COC.
Participating hospitals submitted data on their
breast carcinoma patients from 1985 through 1993.
Over this 8-year period, there were 13,733 women
younger than age 35, 109,880 between the ages of 35-
49, and 385,111 age 50 or older, totalling 508,724cases.
Anatomic site and histology were coded using the
International Classification of Diseases for Oncology
2 manual.fi Histology was further subcategorized as
noninvasive and invasive ductal and lobular carci-
noma, a combination of ductal and lobular histology
and other or unknown histology. The data base con-
tains information on grade of tumor from 1-4. For
purposes of this study, Grades 1 and 2 were combined
and designated low grade whereas Grade 3 and 4 rep-
resented high grade.
Staging was done according to the American Joint
Committee on Cancer (AJCC).To maximize the num-
ber of patients for whom stage was reported, the term
Combined AJCC Stage Group was used, which in-
cludes the pathologic (pAJCC)stage group when docu-
mented, augmented by the clinical (cAJCC) stage
group when pathologic stage is not recorded. The ratio
of early to late stage disease was defined as Stages 0
and I to Stages 11, 111, and IV.
Surgical procedures were coded following the
Data Acquisition Manual (DAM). Breast-conserving
surgery was compared with modified radical mastec-
Breast Carcinoma and AgeMlinchester et al. 1839
tomy across the three age groups and in relation to
ethnicity or race.
Survival rates were computed for cases diagnosed
in 1985- 1988 following traditional procedures for rela-
tive ~urvival.~ Survival analysis included outcome by
age and ethnicity.
The purpose of this analysis was to describe group
trends across the years of this study and to formulate
hypotheses from associations indicated in the descrip-
tive analyses. The aggregate NCDB data are presented
in several summary tables and figures. Ethnicity analy-
sis was limited to non-Hispanic whites and African
Americans because of their larger sampling size in the
young premenopausal category.
In NCDB publications the data are generally pre-
sented in stratified form (cross-tabulations) so that
possible associations can be directly assessed, without
regression techniques. Significance tests (chi-square)
are unfortunately a measure of two things: significance
and sample size. We consider them misleading when
used with this type of data for several reasons. First,
these are descriptive national survey data and were
not collected to evaluate a priori hypotheses, so the
problem of multiple significance tests is present. Sec-
ond, the numbers of cases under analysis are so large
that the statistical assumptions of significance testing
are not met. Repeated chi-square testing of these data
at the P < 0.001 significance level suggest that mark-
edly more comparisons have significance than the
data reasonably support. Third, the cancer population
under study represents nearly half of the universe of
which they are a subset, further clouding possible in-
terpretation. Thus, we recommend a straightforward,
stratified, and conservative assessment of the data pat-
terns presented. Inferences should be based on bio-
logic reasonableness and clinical judgement in the ab-
sence of individual hypothesis/significance test re-
view.
RESULTS
The proportion of African Americans and non-His-
panic whites varied by age group. In 1993, African
American women constituted 16.4% of patients diag-
nosed younger than age 35, 10.1% for those between
35-49 years of age, and 6.7% for postmenopausal pa-
tients. There was a corresponding increase in non-
Hispanic whites including 74.4%of patients diagnosed
younger than age 35, 82.5% for those between 35-49
years of age, and 88.8% for postmenopausal patients.
There were some differences in histology as a
function of age. Ductal carcinoma in situ (DCIS) was
observed in only 3.8% of women younger than the age
of 35,8% in the older premenopausal group, and 7.1%
in the postmenopausal age group. Invasive lobular his-
1840 CANCER October 15,1996 I Volume 78 I Number 8

TABLE 1 41.4% in those older than age 50. Women in the oldest
Frequency of Breast Cancers, and the Ratio of Early Stage to age group were less likely to have axillary dissection as
Advanced Stage Disease,aby Age Group and Diagnosis Year part of breast-conserving surgery (18.3% with axillary
dissection, 12.7% without) compared with those aged
35-49 (24.4% with axillary dissection, 10.8% without)
Younger than 35 35-49 50 and older and younger than 35 (24.2% with axillary dissection.
9.1% without).
DiagnosislYear Ratio No. Ratio No. Ratio No.
For all three age groups, African American women
1985 0.5 1637) 0.7 (4395) 0.8 (16358) received less breast-conserving surgery than non-His-
1986 0.6 (708) 0.9 (4556) 0.9 117444) panic whites (Table 3). In 1993, for those younger than
1987 0.5 (1125) 0.8 (8125) 1 i30973) 35, 36% of African American women had breast-con-
1988 0.5 (15451 0.9 (11504) 1 143656) serving surgery, compared with 42.3% in non-Hispanic
I990 0.5 (1473) 0.9 (11537) 1.1 140023)
1991 0.5 (1739) 0.9 (15249) 1.2 i52050)
whites (for those aged 35-49, 38.1% vs. 45.4%; and for
1992 0.5 (2083) 0.9 (18400) 1.3 (60707) those aged 50 and older, 33.1% vs. 42.2%).
1993 0.6 (2136) 0.9 (19338) 1.4 (63546) Table 4 summarizes 5-year relative survival rates
Average 0.5 (11446) 0.9 (93104) 1.1 (324757) of patients of all ethnicities combined for the 3 age
groups. The patient cohorts in the young premeno-
"Patients with unknown sIaae have been omitted
pausal group (70%) and post menopausal group (73%)
had similar, but poorer survival rates relative to the
older premenopausal patients (80%).
tology was also less common in the youngest age Survival data were analyzed for AJCC Stage I,
group, 3.1% in relation to older premenopausal lymph node negative, and Stage I1 patients in relation
women (5.9%)and postmenopausal women (8.3%). to age (Table 5). For non-Hispanic whites, a similar
High grade tumors were observed in 67.1% of stage-survival relationship was reported with the best
young premenopausal patients, 52% of older pre- survival in those aged 35-49 years for both Stage I
menopausal patients, and 39.9% of women age 50 and (92%) and Stage I1 (81%) patients. The youngest Afri-
older. can American women had similar relative survival
The ratio of early stage disease to advanced stage rates (Stage I, 90%; Stage II,68%) as their non-Hispanic
disease (Stage 0 and I/ Stage 11,111, and IV), based on white counterparts (Stage I, 88%; Stage 11, 71%). How-
AJCC staging, was analyzed for the 3 age categories ever, older premenopausal (Stage I, 86%; Stage II,70%)
annually for 8 years (Table 1). For all diagnosis years, and postmenopausal African American women (Stage
the younger age groups were reported with more ad- I, 78%; Stage 11, 68%) had poorer relative survival rates
vanced disease, with ratios of 0.5% for those younger than premenopausal (Stage I, 92%; Stage 11, 81%) and
35,O.g for those aged 35-49, and 1.1 for those age 50 postmenopausal (Stage I, 84%; Stage 11, 74%) non-His-
and older. The stage of disease was stable over the 8- panic whites.
year period for young and older premenopausal pa-
tients, but showed a n increasing trend in women older
than age 50. Thus, later stage disease was the hallmark DISCUSSION
of young premenopausal patients in relation to their Studies involving the biologic aggressiveness of breast
older counterparts. carcinoma in relation to age have produced conflicting
In 1993, African American women had a particu- results for several reasons. Breast carcinoma is a bio-
larly unfavorable stage distribution ranging (from logically heterogenous disease across all age groups.
youngest to oldest) from 0.3 to 0.6 to 0.8, whereas the The disease is relatively uncommon in the very young,
corresponding ratio for non-Hispanic whites was 0.6, limiting the ability to study this population, and treat-
1, and 1.4, respectively. ment is probably influenced by the age of the patient.
The data relating the type of surgical treatment to In addition, there has been no clear consensus as to
age, by year of diagnosis 1985-1993, illustrates a what constitutes old and young.
steady increase in the utilization of breast-conserving Through the cooperation of participating hospi-
therapy for all age groups (Table 2). Despite their less tals in the NCDB, it was possible, over an 8-year pe-
favorable distribution of stage at first diagnosis, in re- riod, to accession 13,742 women with breast carci-
cent years younger women were similarly likely to have noma who were younger than age of 35, but this repre-
had breast-conserving surgery. In 1993, 41.3% of fe- sented a small number when considering the fact that
male breast carcinoma patients had a partial mastec- there were 109,930 women between the ages of 35-
tomy, compared with 44.4% in those aged 35-49, and 49 and 385,369 aged 50 or older. Nonetheless, it was
 Breast Carcinoma and AgeMlinchester et al. 1841

TABLE 2
Frequency and Percentage of Patients by Surgical Procedure, by Age Group, and Year of Diagnosis
~~ ~~ ~ ~~ ~

Age groups Ow)

Younger than 35 35-49 50 and older

Partial Partial Partial

mastectomy mastectomy mastectomy
Lymph node Lymph node Lymph node
removal removal removal
Modified Modified Modified
DiagnosisRear Without With radical No. Without With radical No. Without With radical No.

1985 10.5 19.4 48.2 (936) 9.3 17.6 52.1 (6152) 10.8 11.5 55.8 (23043)
1986 7 20.5 49.2 (1062) 7.8 16 52.1 (6858) 9.1 12 54.3 (26428)
1987 6.9 19.4 56 (1483) 7.5 18.9 56.7 (10707) 9 13.2 60.3 (40818)
1988 6.5 19.3 57.5 (1921) 7.9 18 57.4 (14252) 9.3 12.6 61.2 (53298)
1990 12.9 22.3 50.3 (1733) 14.9 22.8 49.5 (13581) 16 17 53.2 (46973)
1991 10.2 24.9 52.3 (1918) 12.1 25 49.8 (16861) 14.3 19.4 52.4 (57104)
1992 9 27.8 51.3 (2388) 11.3 28.5 47.9 (20812) 13.8 22.4 50.3 (69402)
1993 9.4 31.9 49.3 12292) 11.9 32.5 45.5 (20657) 14.9 26.5 47.6 (68045)
Average 9.1 24.2 52 (137331 10.8 24.4 50.5 (109880) 12.7 18.3 53.6 (385111)

TABLE 3 TABLE 4
Frequency and Percentage of Patients Who Received Breast. Five-year Relative Survival (Percent)for Breast Carcinoma by Age
Conserving Surgery by Age Group and Ethnicity, 1993 Group, AU Stages, All Ethnicities, 1985-88

Age ~ O U (yrsl
P sunival No.

Younger Younger than 35 years 70 (5806)

than 35 35-49 50 and older 35-49 80 (40860)
50 years or older 73 (152170)
% No. % NO. % No.

Non-Hispanic white 42.3 (721) 45.4 (7733) 42.2 (25504)

African American 36 (135) 38.1 (795) 33.1 (1504) TABLE 5
Five-year Relative Survival (Percent) for Breast Carcinoma by Age
Group, by Ethnicity, 1985-88

Non-Hispanic white African American

possible to make useful comparisons among the three
groups. Age AOUP (yrsl SuMval No. SuMval No.
Some differences were observed in relating histol- Stage I
ogy to age. Invasive lobular histology was observed Younger than 35
less commonly in the youngest age group, an observa- years 88 (959) 90 (128)
tion also made by Marcus et al., and DCIS was ob- 35-49 92 (8384) 86 (592)
50 years or older 84 (41371) 78 (1666)
served less frequently in the young age group, contrary
Stage II
to the result in the series by Marcus et al. These latter Younger than 35
inconsistencies may be related to inconsistent age cat- years 71 (1486) 68 1247)
egories and classification of pure DCIS or invasive his- 35-49 81 (9745) 70 (1142)
tology with concomitant DCIS. 50 wars or older 74 135849) 68 (2222)
There was a strikingly higher percentage of high
grade tumors in young, premenopausal patients
(66.1%)versus postmenopausal women (39.9%). This with early stage disease being defined as in situ and Stage
result was consistent with the analysis done by Marcus I, lymph node negative breast carcinoma and late stage
et al. as AJCC Stages 11,111, and IV.Women younger than age
We found it useful in our analysis to express AJCC 35 had a consistently low ratio over the 8-year period.
stage distribution in terms of ratio of early to late disease, Thus, the youngest group experienced more advanced
1842 CANCER October 15,1996 I Volume 78 / Number 8
disease than older premenopausal patients who
were observed to have a stable ratio over the same
time period and the oldest postmenopausal patients
who had the most favorable stage of disease, which
was increasing over the 8-year study period. These
results are consistent with several studies demon-
strating an increased incidence in young women of
histologically positive lymph
African American women were more likely to have
advanced disease than non-Hispanic whites in all
three age groups. Osteen et al. also reported that the
percentage of African Americans with Stage 0 or I dis-
ease was 37.5% compared with 54.5% for non-His-
panic whites.I4 Like non-Hispanic whites, African
Americans had a more favorable pathologic stage with
advancing age.
According to Krieger, the relative risk for devel-
oping breast carcinoma in young women is elevated
in the African American population based on a study
linking census-derived data to population-based regis-
try r e c o r d ~ . In
' ~ our data base, the proportion of
women developing breast carcinoma who were Afri-
can American was highest in those younger than 35
and diminished in a linear fashion with age. This may
reflect trends in the comparative size of ethnic popula-
tions-at-risk.
The utilization of breast-conserving surgery stead-
ily increased across all age groups from 1985 to 1993,
with the change being of similar magnitude in each
age group. The observation that the oldest women in
our study were less likely to have axillary dissection
than younger women may reflect a less aggressive sur-
gical approach due to comorbid diseases. Another ex-
planation might be the surgical practice of avoiding
axillary dissection in older postmenopausal, receptor
positive, clinical No patients because adjuvant tamoxi-
fen therapy would be recommended irrespective of
lymph node status.
When the data were analyzed in relation to eth-
nicity, significantly less breast-conserving surgery was
utilized across all age groups for African American
women in relation to non-Hispanic white women.
These differences were also reported in the annual
review of patient care from the NCDB for the years
1994 and 1995.'s'6
The most definitive assessment of the biologic ag-
gressiveness of breast carcinoma is survival rate. The
analysis of survival rate in relation to age has produced
conflicting results. Albain et al. conducted a compre-
hensive review of population-based breast carcinoma
outcome literature, synthesized published results from
cooperative groups, examined univariate and multi-
variate single institution studies, and described the
results from a new San Antonio data base in at-
tempting to answer this question." Lymph node posi-
tive women younger than age 30-35 had a poorer
prognosis than their older counterparts, but the data
for lymph node negative women were less consistent.
Our results confirmed a poorer prognosis in women
younger than age 35 with AJCC Stage I1 disease, but
demonstrated a similarly decreased relative 5-year sur-
vival rate in women 50 and older relative to women
in the 35-49 age group. Because our results are ex-
pressed in terms of relative survival rate, there were
competing causes for death in the older age group.
There was little difference in survival between the
older and younger groups after correcting for these
deaths. Differences were less apparent among all three
age groups for AJCC Stage I lymph node negative
women, although they were slightly lower in the age
50 and older group.
When analyzing relative survival rates in the three
age groups in relation to ethnicity, African American
and non-Hispanic white women did equally well when
younger than age 35, but African Americans experi-
enced a poorer survival rate relative to non-Hispanic
whites in the other 2 age groups for both Stage I and
Stage I1 disease. A report from the NCDB in 1994 re-
vealed a relative 5-year survival rate of 60% for African
Americans versus 73% for non-Hispanic whites for all
age and stages combined.' Similarly diminished rela-
tive 5-year survival rates in the oldest group are likely
related to competing causes of mortality.
In summary, women younger than age 35 had
higher grade primary tumors, more advanced AJCC
stage, and poorer relative 5-year survival rate in Stage
I1 disease than older premenopausal women. These
data are consistent with the hypothesis that younger
women are at increased risk to a more biologically
aggressive form of breast carcinoma.
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