Acta Biomed 2020; Vol. 91, N.

2: 332-341 DOI: 10.23750/abm.v91i2.8399 © Mattioli 1885

Original article

Breast cancer in women: a descriptive analysis of the

national cancer database
Andrea Sisti1, Maria T. Huayllani1, Daniel Boczar1, David J. Restrepo1, Aaron C. Spaulding2,
Gabriel Emmanuel3, Sanjay P. Bagaria3, Sarah A. McLaughlin3, Alexander S. Parker4,
Antonio J. Forte1
1
Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic,
Jacksonville, Florida, USA; 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA; 3 Department
of Surgery, Mayo Clinic, Jacksonville, Florida, USA; 4 Office of Research Affairs, University of Florida, College of Medicine,
Jacksonville, FL, USA

Summary. Background and aim of the work: Breast cancer is the most common cancer in women in the United
States. National Cancer Database (NCDB) is one of the largest tumor databases of the United States. This
study aimed to evaluate the features of breast cancer in women from a large updated database. Methods: We
describe and analyze the frequencies and percentages of the clinical and pathological features of women di-
agnosed with breast cancer registered in NCDB, in a period from 2004 to 2015. Results: A total of 2,423,875
women were diagnosed with breast cancer between 2004 and 2015. The nationally representative analysis dem-
onstrated that the incidence of breast cancer among women increased over the years. Upper-outer quadrant
was the most frequent primary tumor site, and the intraductal carcinoma was the most frequent histology. The
prevalence of breast cancer increased with age. The most frequent grade at diagnosis was grade II. Broadly, in-
vasive characteristics were noted more frequently in younger patients. Left and right breast were affected with
almost the same frequency, with a slight predominance of the left breast. The most frequent surgical treatment
was a partial mastectomy. Reconstruction with implant was the most frequent choice. Post-mastectomy radia-
tion therapy was administered in the majority of patients. Conclusions: To the authors’ knowledge, the current
study is the largest descriptive analysis to date on the clinical and pathological features of breast cancer in a
population-based database. The increase in incidence over the years indicates an important need for etiologic
research and innovative approaches to improve breast cancer prevention. (www.actabiomedica.it)

Key words: breast, cancer, breast neoplasms, epidemiology, NCDB, women

Introduction tabase (NCDB) every year (3). The NCDB - jointly

sponsored by the American College of Surgeons and
Breast cancer in the United States is the most the American Cancer Society, is a clinical oncology
common cancer in women after skin cancer, regardless database sourced from hospital registry data that are
of race or ethnicity (1). The incidence rate for female collected in more than 1500 Commission on Cancer
breast cancer in the United States from 2010 to 2014 (CoC)-accredited facilities. NCDB data are used to
was 123.6 per 100000 population, and an estimated of analyze and track patients with malignant neoplastic
40920 American females will die from breast cancer diseases, their treatments, and outcomes. As a result,
in 2018 (2). the data represent more than 70 percent of newly diag-
Data concerning this type of cancer is submit- nosed cancer cases nationwide and more than 34 mil-
ted to the nationally recognized National Cancer Da- lion historical records (3). The purpose of this work
Breast cancer in women 333

is to update the demographic and clinical data about 8541 and 8543 into ‘Breast Paget’ type; 9020 code into
breast cancer in women, meaningful to the surgeons ‘phylloides’ type; other codes were grouped as ‘others’.
and the scientific community. The behavior of the breast cancer was reported as
benign, borderline, in situ/carcinoma in situ and in-
vasive. The grade was reported as follows: grade I, II,
Methods III and IV, where well differentiated (grade I) was the
most like normal tissue, and undifferentiated (grade
We aimed to analyze data from the NCDB to IV) was the least like normal tissue, as stated in di-
assess the demographic and clinical characteristics of agnosis.
female breast cancer patients between 2004 and 2015 The stage was assigned depending on the path-
(3). Demographics and cancer-specific characteristics ologic stage group, when it was not reported it was
were calculated using IBM SPSS Statistics for Win- assigned depending on the clinical stage group. The
dows, Version 22.0 software (IBM Corp., Armonk, stage was divided into 0, I, II, III and IV, according
NY ) and reported as frequencies and percentages. We to American Joint Committee on Cancer (AJCC) 7th
included all female patients with breast cancer report- edition traditional stage classification. We did not con-
ed in the database. sider patients with not applicable or unknown stage.
Age of female patients was divided into three The records of the surgical procedure performed
groups, as follows: ≤40 years, 40 to 60 years and >60 in the primary site were divided into no surgery, par-
years. The race was classified into White, Black, Asian, tial mastectomy, complete mastectomy, and unknown;
Native American and other races. The mean of the other kinds of procedures were excluded. The complete
number of days between the date of diagnosis and the mastectomy group included total mastectomy, subcuta-
most definitive surgical procedure on the primary site neous mastectomy, modified radical mastectomy, radi-
was calculated. Tumor size was divided into the fol- cal mastectomy, extended radical mastectomy, bilateral
lowing groups: <2 cm, 2-4.9 cm, and ≥5cm. The tumor mastectomy for a single tumor involving both breasts
location was classified according to the International and mastectomy NOS (not otherwise specified). Types
Classification of Diseases for Oncology, Third Edition of reconstruction after complete mastectomy were di-
which includes: breast upper-outer quadrant (UOQ), vided into reconstruction with autologous tissue, with
breast upper-inner quadrant (UIQ), breast lower- implant and combined (with tissue and implant). We
outer quadrant (LOQ), breast lower-inner quadrant included only the patients that had a reported a type
(LIQ), breast central portion, breast axillary tail, breast of reconstruction.
overlapping lesion, and nipple (4). Laterality identified Radiation therapy was reported as follows: none
the side of the breast on which the reportable primary (radiation not administered); beam radiation (x-ray,
tumor originated. cobalt, linear accelerator, neutron beam, betatron,
Histology results were named according to the spray radiation, intraoperative radiation and stereotac-
third edition of International Classification of Diseas- tic radiosurgery as gamma knife and
es for Oncology codes (ICD-O-3), reported by regis- Proton beam); radioactive implants (brachythera-
tries for cases diagnosed in 2001 and subsequently (4). py, interstitial implants, molds, seeds, needles, or intra-
We regrouped the histology types into the most mean- cavitary applicators of radioactive materials as cesium,
ingful types that have a higher percentage of occur- radium, radon, and radioactive gold); radioisotopes
rence in the database, as follows: 8343 code into ‘papil- internal use of radioactive isotopes (iodine131, phos-
lary’ type; 8070, 8071, 8072, 8074, 8075, 8076, 8052 phorus32, strontium 89 and 90) administered orally,
codes into ‘squamous’ type; 8453, 8500, 8503, 8507, intracavitary, or by intravenous injection; combination
8514, 8521 codes into ‘intraductal’ type; 8140, 8147, of beam radiation with radioactive implants or radio-
8190 codes into ‘adenocarcinoma’ type; 8520 code into isotopes.
‘lobular’ type; 8522, 8523, 8524, 8560, 8940 codes into
‘mixed’ type; 8530 code into ‘inflammatory’ type; 8540,
334 A. Sisti, M.T. Huayllani, D. Boczar, et al.

Results Table 1. Demographic data

Characteristic n %
A total of 2423875 women were diagnosed with Total females with breast cancer 2423875 100
breast cancer between 2004 and 2015 (Table 1). The Age
incidence of this disease among women increased over
<=40 years old 136525 5.60%
the years (Figure 1). Mean age was 60.91±13.36 (18-
40-60 years old 1065754 44.00%
90 years old). 136525 female patients (5.6%) were ≤40
years old, 1065754 (44%) patients were between 40 and >60 years old 1221596 50.40%
60 years old, and 1221596 (50.4%) patients were >60 Race*
years old (Figure 2). The predominant race was white White 2022918 84.39%
(2022918 patients, 84.3%), followed by black (271401 Black 271401 11.32%
patients, 11.3%), Asian (6138 patients, 0.2%), Native Asian 6138 0.26%
American (78535 patients, 3.2%) and other (18256 pa- Native American 78535 3.28%
tients, 0.7%). The average number of days between the Other 18256 0.76%
date of diagnosis and the date on which the most defin- Period of diagnosis
itive surgical procedure was performed on the primary
2004-2006 513042 21.17%
site was 51. Concerning the size of the tumor, 31574
2007-2009 588678 24.29%
(1.30%) patients had a <2 cm tumor, 148008 (6.11%)
2010-2012 631994 26.07%
patients had a tumor between 2-4.9 cm, and 2244293
2013-2015 690161 28.47%
(92.59%) patients had a tumor >=5cm (Table 2).
Within this cohort, the location of the breast can- *patients with unknown race were excluded
cer (Figure 3) was UOQ for 807728 patients (39.50%),
UIQ for 255431 patients (12.49%), LOQ for 170278 (6.09%), the nipple for 14392 patients (0.7%), axillary
patients (8.33%), LIQ for 136025 patients (6.65%), tail of breast for 9972 patients (0.49%) and overlap-
the central portion of the breast for 124531 patients ping lesion of breast for 526593 patients (25.75%). The

Figure 1. Number of female breast cancer cases in the United States from 2004 to 2015
Breast cancer in women 335

Table 2. Breast cancer characteristics

Characteristics of tumor n %
Tumor size
<2 cm 31574 1.30%
2-4.9 cm 148008 6.11%
>=5 cm 2244293 92.59%
Primary tumor site
Left breast 1225286 50.60%
Right breast 1188795 49.00%
Location*
Nipple 14392 0.70%
Central portion of the breast 124531 6.09%
Upper-inner quadrant 255431 12.49%
Lower-inner quadrant 136025 6.65%
Figure 2. Age at diagnosis
Upper-outer quadrant 807728 39.50%
Lower-outer quadrant 170278 8.33%
primary tumor site was left breast in 50.6% of patients Axillary tail of breast 9972 0.49%
and the right breast in 49% of patients. Overlapping lesion of breast 526593 25.7%
Histology results were reported (Table 2 and 3, Histology types
Figure 4) as follows: 1629174 (67.21%) patients had Papillary carcinoma 8831 0.36%
intraductal carcinoma, 235379 (9.71%) patients had Squamous carcinoma 937 0.04%
lobular carcinoma, 15073 (0.62%) patients had adeno- Intraductal carcinoma 1629174 67.21%
carcinoma,8831 (0.36%) patients had papillary carci- Adenocarcinoma 15073 0.62%
noma, 8277 (0.34%) patients had inflammatory car- Lobular carcinoma 235379 9.71%
cinoma, 7087 (0.29%) patients had mammary Paget, Mixed types 293746 12.12%
Inflammatory carcinoma 8277 0.34%
3227 (0.13%) patients had phylloides, 937 (0.04%) pa-
Mammary Paget 7087 0.29%
tients had squamous carcinoma, 293746 (12.12%) pa-
Phylloides 3227 0.13%
tients had a mixed histology between these types, and
Others 222144 9.16%
222144 (9.16%) patients had another types of tumor
Behavior
on histology. In situ 491187 20.30%
The behavior of the breast cancers was invasive invasive 1932688 79.70%
for 1932688 patients (79.7%) followed by in situ/car- Grade **
cinoma in situ for 491187 (20.3%) patients; there was I 461096 21.70%
not any benign or borderline tumor included in the II 920687 43.40%
database. The grade as stated in the final pathologic III 719178 33.90%
diagnosis (Table 2, Figure 5) was I for 461096 patients IV 20216 0.95%
(19%), II for 920687 patients (38%), III for 719178 Stage ***
patients (29.7%), IV for 20216 patients (0.8%), not Stage 0 486856 20.88%
determined for 302698 patients (12.5%). With respect Stage I 961981 41.27%
to stage, 486856 (20.88%) patients corresponded to Stage II 587352 25.20%
Stage 0, 961981 (41.27%) patients to Stage I, 587352 Stage III 203159 8.71%
(25.20%) patients to Stage II, 203159 (8.71%) patients Stage IV 91864 3.94%
to Stage III, 91864 (3.94%) patients to Stage IV. * 378925 patients with not otherwise specified location of the
Overall, 1320210 (54.57%) patients underwent tumor were excluded
** 302698 patients who did not have information on grade were
partial mastectomy, whereas 922391 (38.13%) patients excluded
underwent complete mastectomy (Table 4, Figure 6). ** 92663 patients with unknown stage were excluded
336 A. Sisti, M.T. Huayllani, D. Boczar, et al.

(3.03%) radioactive implants, 625 patients (0.03%)

radioisotopes and 2462 patients (0.10%) combination
of beam radiation with radioactive implants or radio-
isotopes (Table 3).
Radiation therapy before surgery was adminis-
tered in 7967 patients (0.33%) and after surgery in
1214097 patients (50.77%). Overall thirty-day mor-
tality was 0.1% (2200 patients), whereas overall nine-
ty-day mortality was 0.3% (7635 patients).

Discussion

The current study is the largest descriptive analy-

sis to date on the clinical and pathological features of
breast cancer in a population-based database. Breast
Figure 3. Location of the primary tumor
cancer occurs more frequently in the UOQ, and we
observed an overall prevalence of 39.50% in this
study. Previous studies on smaller cohorts of patients
According to the type of reconstruction after observed a prevalence of UOQ tumor location rang-
complete mastectomy, 93405 (40.02%) patients un- ing from 36.1% to 62% (Table 7) (5-8, 10-12). The
derwent reconstruction with autologous tissue, 106130 higher frequency of occurrence of breast cancer in the
(45.47%) patients underwent reconstruction with im- UOQ is generally attributed to the higher amount of
plants, and 33861 (14.51%) patients underwent com- tissue in that breast quadrant (13). Nevertheless, the
bined reconstruction with tissue and implant (Table 3). larger amount of breast tissue alone in UOQ cannot
Radiation therapy was not administered in completely explain the disproportional occurrence of
1140676 patients (47.63%). 1165746 patients breast cancer in each quadrant (14). Ellsworth et al.
(48.67%) underwent beam radiation, 72500 patients observed a greater genomic instability in outer breast

Table 3. Age distribution depending on histology

Histology Mean age (years) Std. Deviation Number of patients

Papillary 68.11 12.757 8831
Squamous 64.51 14.469 937
Intraductal 60.53 13.448 1629174
Adenocarcinoma 63.44 14.064 15073
Lobular 61.92 12.867 235379
Mixed 61.13 12.931 293746
Inflammatory 57.84 13.929 8277
Angyomyosarcoma 69.38 7.999 8
Paget 63.62 14.949 7087
Phylloides 52.35 14.548 3227
Others 62.04 13.436 222136
Total 60.91 13.366 2423875
Breast cancer in women 337

Figure 4. Histology

execption of a sharp reduction in 2010 (Figure 1). Hou

et al. already showed a significant increase in the in-
cidence rates of all breast cancer from 2000 to 2009
(17). We confirmed the same upgoing trend from 2010
to 2015 as well. Furthermore, the prevalence of breast
cancer increased with age, which Stapleton et al. also
observed while studying the Surveillance, Epidemiol-
ogy, and End Results (SEER) Program database (18).
From our NCDB analysis, 94.4% of patients were
diagnosed with breast cancer after 40 years old (44%
between 40 and 60 years old and 50.4% after 60 years
old). As such, annual mammography is strongly sug-
Figure 5. Grade at diagnosis gested after the age 40, as it is demonstrated to de-
creases mortality (19).
quadrants compared with the inner quadrants (15). The most frequent histology type in our study was
Darbre observed that the higher occurrence of breast an intraductal carcinoma, followed by lobular carci-
cancer in UOQ could be related to the use of cosmet- noma, in accordance with the literature data (Table 4)
ics applied to the adjacent underarm and upper breast (20, 21). Broadly, invasive characteristics were noted
area, that may contain both DNA-damaging chemi- more frequently in younger patients, in accordance
cals and chemicals which in turn could mimic estrogen with the findings by Escarela et al. from a SEER analy-
action (16). sis (21). Presence of tumor cells in lymphatic channels
Our descriptive analysis of breast cancer in the (not lymph nodes) or blood vessels within the primary
United States showed that the incidence of this dis- tumor was noted more frequently in younger patients,
ease among women has increased over the years, with as well as a higher grade at diagnosis (Table 5 and 6).
338 A. Sisti, M.T. Huayllani, D. Boczar, et al.

Table 4. Management. NOS: Not otherwise specified

Treatment n %
Type of surgery *
None 171966 7.11%
Local tumor destruction, NOS 352 0.01%
Partial mastectomy 1320210 54.57%
Subcutaneous mastectomy 18218 23.79%
Total (simple) mastectomy 575422 0.75%
Modified radical mastectomy 306483 12.67%
Radical mastectomy 11128 0.46%
Extended radical mastectomy 427 0.02%
Bilateral mastectomy for a single tumor involving both breasts, as for bilateral 288 0.01%
inflammatory carcinoma
Mastectomy, NOS 11140 0.46%
Surgery, NOS 3481 0.14%
Type of reconstruction
Autologous tissue 93405 40.02%
Implant 106130 45.47%
Combined (tissue and implant) 33861 14.51%
Type of radiation **
None (Radiation not administered) 1140676 47.63%
Beam radiation 1165746 48.67%
Radioactive implants 72500 3.03%
Radioisotopes 625 0.03%
Combination of beam radiation with radioactive implants or radioisotopes 2462 0.10%
Radiation therapy NOS 13012 0.54%
Radiation sequence with surgery ***
No radiation therapy and/or surgical procedures 1162082 48.59%
Radiation before surgery 7967 0.33%
Radiation after surgery 1214097 50.77%
Radiation before and after surgery 1009 0.04%
Intraoperative radiation 5017 0.21%

* 4760 patients who did not have information about surgery were excluded
** 28854 patients who did not have information on radiation were excluded
*** 32429 patients who did not have information on radiation sequence were excluded

The post-mastectomy reconstruction with im- could bring to prefer the reconstruction with implants,
plant was the most used reconstructive modality, including longer anesthesia, more blood loss, a longer
whereas the reconstruction with autologous tissue and hospitalization, risk of necrosis of the flap, and possible
combined were less frequently performed, probably issues at the donor site (scars, and abdominal hernias)
due to the cost and the necessity of suitable instru- (23). The risk of complications after breast reconstruc-
ments such as the microscope (22). Moreover, disad- tion with autologous flap increases with age and BMI
vantages of autogenous tissue-based reconstruction (body mass index), in smokers and diabetic patients
Breast cancer in women 339

Figure 6. Type of surgery

Table 5. Age distribution depending on Grade

Grade Mean age (years) Std. Deviation Number of patients

Grade I 63.29 12.589 461096

Grade II 61.80 13.238 920687
Grade III 58.53 13.632 719178
Grade IV 58.90 13.226 20216
Cell type not determined, not stated, not applicable 60.38 13.333 302698
Total 60.91 13.366 2423875

Table 6. Presence or absence of tumor cells in lymphatic channels (not lymph nodes) or blood vessels within the primary tumor as
noted microscopically by the pathologist. 1101720 patients with missing data were not included

Lymph-vascular invasion Mean age (years) Std. Deviation Number of patients

Lymphvascular invasion is not present 61.60 12.792 858226

Lymphvascular invasion is present 59.24 13.947 168431
Not applicable 61.57 12.898 6272
Unknown 61.25 13.588 289226
Total 60.91 13.366 2423875
340 A. Sisti, M.T. Huayllani, D. Boczar, et al.

Table 7. Percentage of primary breast tumor location in UOQ (upper-outer quadrant) as reported in other studies and in this study

Author, year Location of Total Number of Database analyzed Years UOQ

the study patients included tumor
location
(%)
Hazrah P (5) India 187 Department Of Surgery All India 1994-2005 62
Institute of Medical Sciences

Rummel S (6) USA 980 Clinical Breast Care Project 2001-2013 51.5
Wu S (7) China 1044 Sun Yat-Sen Cancer Center 1999-2007 50.2
Sarp S (8) Switzerland 1522 Geneva Cancer Registry 1984 - 2002 39

Nunes RD (9) Brazil 2582 Population-Based Cancer Registry of 1989-2003 53.7

Goiânia (RCBPGO)
Siotos C (10) USA 5295 Johns Hopkins Sidney Kimmel 2003-2015 36.2
Comprehensive
Cancer Center
Sohn VY (11) USA 26,121 The Department of Defense tumor 1990-2005 57
registry encompasses
all military facilities from the United
States Army, Air Force, and Navy
Eisemann N (12) Germany Not specified Epidemiological cancer register of 1999-2009 36.1
Schleswig-Holstein
Sisti A (this study) USA 2423875 National Cancer Database (NCDB) 2004-15 39.50

(23). Post-mastectomy radiation therapy (PMRT) is Ethical approval: This article does not contain any studies with
human participants or animals performed by any of the authors.
generally recommended for patients with advanced
disease (24). It has been shown to improve control of Funding: This study was supported in part by the Mayo Clinic
local disease and overall survival. There is also a reduc- Robert D. and Patricia E. Kern Center for the Science of Health
tion in relapse rates for patients with more than three Care Delivery.
positive lymph nodes. In our cohort, PMRT was ad- Conflict of interest: Each author declares that he or she has no
ministered to 1214097 patients (50.77%). commercial associations (e.g. consultancies, stock ownership, equity
interest, patent/licensing arrangement etc.) that might pose a con-
flict of interest in connection with the submitted article

Conclusion

This nationally representative analysis of the years References

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