Deaths from Breast Cancer -- United States, 1991

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States (1). For 1990, the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) reported that the incidence of breast cancer was approximately 109 per 100,000 women (2). The annual incidence of breast cancer among women increased approximately 52% during 1950-1990, while the death rate increased 4% during the same period (2). This report summarizes epidemiologic information about deaths from breast cancer in 1991 and describes mortality trends during 1980-1991.

Decedents for whom the underlying cause of death was breast cancer (International Classification of Diseases, Adapted, Ninth Revision, codes 174.0-174.9) were identified from public-use mortality data tapes (3). Denominators for rate calculations were derived from U.S. census population estimates (4,5). Rates were directly standardized to the age distribution of the 1970 U.S. population and were analyzed by state, age group, year, and race. To increase the precision of the rates presented, race was characterized only as "white," "black," and "other."

In 1991, 43,583 women died from breast cancer; the overall death rate was 27.0 per 100,000 women (Table_1) page 279. The death rate for black women (31.9) was 19% higher than for white women (26.8). Rates for black women and white women were 2.6 times and 2.2 times higher, respectively, than that for women of other races (12.4). Since 1981, this rank order of death rates by race has been consistent.

During 1980-1991, race-specific death rates for breast cancer among white women remained constant, increasing less than 1%. In comparison, from 1980 to 1991, rates for black women increased 21%, from 26.4 to 31.9 per 100,000 women, and rates for women of other races increased 29%, from 9.6 to 12.4.

In 1991, death rates for breast cancer were 15-fold higher for women aged greater than or equal to 50 years (91.8) than for women aged less than 50 years (6.0) (Table_1) page 279. In both age categories, death rates were higher for black women than for white women and women of other races.

Death rates varied from 17.6 in Hawaii to 35.9 in the District of Columbia (Table_2). Based on regional analysis, rates were highest in the Northeast. For white women, death rates ranged from 20.4 in Hawaii to 32.9 in New Jersey and for women of races other than white*, from 14.5 in Washington to 39.6 in the District of Columbia. For women aged less than 50 years, rates ranged from 2.8 in Alaska to 10.7 in the District of Columbia, and for women aged greater than or equal to 50 years, from 58.5 in Hawaii to 113.1 in New Jersey.

Reported by: Cancer Surveillance Section, Epidemiology and Statistics Br, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, in 1991, death rates for breast cancer varied substantially by race. These variations may reflect race-specific differences in stage of disease at diagnosis, survival rates, and prevalence of risk factors for breast cancer. For example, a SEER report for 1990 ** (the most recent year for which data are available) indicated substantial differences in the 5-year relative survival rate for white women (80.5%) compared with black women (64.1%). In addition, stage-specific data from SEER *** indicated survival among white women exceeded that for black women at all stages, and among white women breast cancer was more likely to be diagnosed at an earlier stage (2).

Differences in state-specific death rates for breast cancer in 1991 may reflect factors that include racial composition, socioeconomic status, and access to and use of breast cancer screening and treatment. For example, for races other than white, the rate was highest in the District of Columbia, where 97% of the female residents in this combined category were black, and lowest in Washington, where 30% of the female residents in this category were black.

Established risk factors for breast cancer include family history of breast cancer, history of benign breast disease, prior history of breast cancer, exposure to ionizing radiation, early age at menarche, late age at menopause, late age at first live birth, nulliparity, white race, and high socioeconomic status (1,6). Because many of these established risk factors are not alterable, secondary prevention is the current strategy for reducing mortality associated with breast cancer.

Programs to reduce breast cancer mortality should emphasize the role of routine mammography screening to detect breast cancer at earlier, more treatable stages. The importance of this approach is underscored by findings from SEER indicating a 5-year relative survival rate of 93.2% for women with local disease compared with 18.2% for women with distant disease (2). Randomized clinical trials of breast cancer screening demonstrate an approximately 30% reduction in mortality for women aged 50-69 years; however, there has been no statistically significant decrease among women aged 40- 49 years (7). For women aged greater than or equal to 50 years, routine screening with mammography and clinical breast examination has been recommended every 1-2 years (1,8).

A national health objective for the year 2000 is to reduce breast cancer deaths to no more than 25.2 per 100,000 (baseline: 27.2 in 1987) (objective 16.3); specific age, racial/ethnic, and socioeconomic groups have been targeted for increases in screening (objective 16.11) (9). Recent results of the Behavioral Risk Factor Surveillance System indicate that in 1992, a median of 56% of women aged greater than or equal to 50 years reported having had a mammogram and clinical breast examination within the preceding 2 years (10). Based on the rapid increases in screening during the 1980s, breast cancer death rates could be reduced by the mid-1990s (2).

References

1. American Cancer Society. Cancer facts and figures, 1994. Atlanta: American Cancer Society, 1994; publication no. 5008.94.

2. Hankey BF, Brinton LA, Kessler LG, Abrams J. Section IV: breast. In: Miller BA, Reis LAG, Hankey BF, et al, eds. SEER cancer statistics review, 1973-90. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1991:IV.1-IV.24; DHHS publication no. (NIH)93-2789.

3. NCHS. Vital statistics mortality data, underlying cause of death, 1980-1991 {Machine-readable public-use data tapes}. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1980-1991.

4. Bureau of the Census. 1980-89 Intercensal population estimates by race, sex, and age {Machine-readable data files}. Washington, DC: US Department of Commerce, Bureau of the Census, nd.

5. Irwin R. 1990-92 Postcensal population estimates by race, sex, and age {Machine-readable data files}. Alexandra, Virginia: Demo-Detail, 1993.

6. Kelsey JL. Breast cancer epidemiology: summary and future directions. Epidemiol Rev 1993;15:256-63.

7. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst 1993;85:1644-56.

8. Volkers N. NCI replaces guidelines with statement of evidence. J Natl Cancer Inst 1994;86:14-5.

9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50213.

10. CDC. 1992 BRFSS summary prevalence report. Atlanta: US Department of Health and Human Services, Public Health Service, 1993.

* Because of the small number of breast cancer deaths among women in other racial/ethnic groups and small populations of these groups in some states, the categories "black" and "other races" were combined for this state-specific analysis. 

** For women with breast cancer diagnosed during 1983-1989. 

*** For women with breast cancer diagnosed during 1983-1987.

TABLE 1. Number of breast cancer deaths * and age-adjusted death rates +, by race &
and age group -- United States, 1991
========================================================================================================
                                    Rate
                         --------------------------
                                    Age group (yrs)
                No.                 ---------------
Race          deaths     Total       <50>=50
---------------------------------------------------
White         38,250      26.8       5.7      92.0
Black          4,809      31.9       9.1     102.1
Other            519      12.4       3.7      39.0

Total         43,583 @    27.0       6.0      91.8
---------------------------------------------------
* International Classification of Diseases, Adapted, Ninth Revision, codes 174.0-174.9.
+ Per 100,000 women, adjusted to the 1970 U.S. population.
& To increase the precision of the rates presented, race was categorized only as "white," "black," and
  "other."
@ Five deaths occurred among persons of unknown race.
========================================================================================================

TABLE 2. Number of breast cancer deaths * and age-adjusted death rates +, by state,
race, and age group -- United States, 1991
==================================================================================================
                                                            Rate
                                    ---------------------------------------------------
                                            Race
                                    ---------------------    Age group (yrs)
                            No.                 Other      -------------------
State                     deaths    White    than white &    <50>=50    Total
---------------------------------------------------------------------------------------
Alabama                      691     24.1       31.7         6.6          85.0     25.8
Alaska                        33     24.0         @          2.8            @      20.2
Arizona                      551     24.7       17.1         6.6          78.7     24.3
Arkansas                     398     21.6       32.9         6.2          75.0     23.1
California                 4,303     26.6       20.3         5.6          87.7     25.7
Colorado                     505     27.3       21.0         5.9          92.5     27.1
Connecticut                  615     27.4       22.4         5.8          93.0     27.2
Delaware                     125     28.8         @          4.2            @      29.0
District of Columbia         144       @        39.6        10.7            @      35.9
Florida                    2,629     24.9       25.1         6.2          83.2     25.1
Georgia                      932     24.6       26.2         7.1          80.5     25.0
Hawaii                       111     20.4       16.5         4.3          58.5     17.6
Idaho                        150     25.5         @          5.1          87.3     25.2
Illinois                   2,270     30.2       31.1         6.5         104.7     30.5
Indiana                      964     25.6       27.1         5.6          88.0     25.7
Iowa                         554     26.4         @          6.1          88.7     26.3
Kansas                       422     24.7       18.9         5.6          82.8     24.5
Kentucky                     577     24.0       30.2         5.8          81.7     24.4
Louisiana                    683     24.9       32.7         7.8          86.4     27.1
Maine                        220     26.2         @          5.8          88.5     26.1
Maryland                     834     27.5       32.3         6.8          96.4     28.7
Massachusetts              1,323     31.1       30.1         6.1         108.7     31.2
Michigan                   1,634     27.7       32.2         5.9          97.7     28.4
Minnesota                    787     27.4       33.8         5.7          95.6     27.7
Mississippi                  408     22.4       30.8         5.5          85.0     25.0
Missouri                     984     26.5       34.5         5.4          94.4     27.2
Montana                      120     22.0         @          3.9          79.7     22.4
Nebraska                     276     25.0         @          5.2          86.2     25.0
Nevada                       165     25.0         @          2.9          88.1     23.8
New Hampshire                203     29.7         @          6.1         102.3     29.6
New Jersey                 1,778     32.9       32.2         6.9         113.1     32.9
New Mexico                   195     23.4         @          6.1          74.4     22.8
New York                   3,646     30.2       26.3         5.9         103.2     29.7
North Carolina             1,132     26.3       27.0         6.6          87.9     26.5
North Dakota                 122     28.5         @          7.1            @      29.1
Ohio                       2,023     27.3       26.7         5.6          94.0     27.3
Oklahoma                     496     25.1       17.9         5.6          81.6     24.2
Oregon                       487     25.3         @          5.3          85.2     24.8
Pennsylvania               2,633     28.5       36.1         6.3          99.8     29.2
Rhode Island                 237     31.4         &          8.2         103.8     31.6
South Carolina               595     25.9       33.8         7.2          92.3     28.0
South Dakota                 113     20.7         @          4.3          71.5     20.8
Tennessee                    827     23.8       37.1         6.5          84.4     25.6
Texas                      2,250     23.1       30.6         5.7          80.5     24.0
Utah                         197     25.4         @          4.6          87.4     24.9
Vermont                       98     27.3         @          6.1            @      27.2
Virginia                   1,050     27.8       30.1         6.7          94.8     28.2
Washington                   777     26.4       14.5         5.9          86.7     25.6
West Virgina                 330     25.1         @          6.6          81.9     25.1
Wisconsin                    918     27.8       20.4         5.2          96.4     27.5
Wyoming                       68     26.4         @          8.7            @      26.0

Total                     43,583     26.8       27.6         6.0          91.8     27.0
---------------------------------------------------------------------------------------
* International Classification of Diseases, Adapted, Ninth Revision, codes 174.0-174.9.
+ Per 100,000 women, adjusted to the 1970 U.S. population.
& Because of the small number of breast cancer deaths among women in other racial/ethnic groups
  and small populations of these groups in some states, the categories "black" and "other races"
  were combined for this state-specific analysis.
@ Less than 100,000 in denominator or less than five cases.
==================================================================================================

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