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1.  Predictors of early death in female patients with breast cancer in the UK: a cohort study 
BMJ Open  2011;1(2):e000247.
Objective
To identify factors predicting early death in women with breast cancer.
Design
Cohort study.
Setting
29 trusts across seven cancer networks in the North Thames area.
Participants
15 037 women with primary breast cancer diagnosed between January 1996 and December 2005.
Methods
Logistic regression analyses to determine predictors of early death and factors associated with lack of surgical treatment.
Main exposures
Age at diagnosis, mode of presentation, ethnicity, disease severity, comorbidities, treatment and period of diagnosis in relation to the Cancer Plan (the NHS's strategy in 2000 for investment in and reform of cancer services).
Main outcome measures
Death from any cause within 1 year of diagnosis, and receipt of surgical treatment.
Results
By 31 December 2006, 4765 women had died, 980 in the year after diagnosis. Older age and disease severity independently predicted early death. Women over 80 were more likely to die early than women under 50 (OR 8.05, 95% CI 5.96 to 10.88). Presence of distant metastases on diagnosis increased the odds of early death more than eightfold (OR 8.41, 95% CI 6.49 to 10.89). Two or more recorded comorbidities were associated with a nearly fourfold increase. There was a significant decrease in odds associated with surgery (OR 0.29, 95% CI 0.24 to 0.35). Independently of disease severity and comorbidities, women over 70 were less likely than those under 50 to be treated surgically and this was even more pronounced in those aged over 80 (OR 0.09, 95% CI 0.07 to 0.10). Other factors independently associated with a reduced likelihood of surgery included a non-screening presentation, non-white ethnicity and additional comorbidities.
Conclusions
These findings may partially explain the survival discrepancies between the UK and other European countries in female patients with breast cancer. The study identifies a group of women with a particularly poor prognosis for whom interventions aiming at early detection may be targeted.
Article summary
Article focus
Several studies have shown that the UK has lower survival for breast cancer than some other European countries with a similar expenditure on healthcare.
Differences have been shown to occur mainly in older patients and in the first year after diagnosis.
Several reasons/explanations have been proposed.
Key messages
This study shows that patients with breast cancer dying in the first year after diagnosis are more likely to be older and have more advanced disease and existing comorbidities.
Surgical treatment and (to a lesser extent) radiotherapy and tamoxifen usage were associated with a reduced risk of early death.
The likelihood of receiving surgery was inversely related to age, independently of comorbidity and disease severity.
These findings suggest that early detection, management of comorbidities and optimisation of treatment of older patients are important target areas to improve outcomes.
Strengths and limitations of this study
This is a large cohort of women with a diagnosis of breast cancer, and the results may be generalisable to women treated for breast cancer in the UK during the same time period.
Many variables that may be related to both risk factors and outcomes have not been assessed in this study. However, their correlation with death within a year would have to be very strong to explain the strong associations seen in our data.
doi:10.1136/bmjopen-2011-000247
PMCID: PMC3227804  PMID: 22123920

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