Georgia epidemiology report [Vol. 25, no. 9 (Sept. 2009)]

September 2009

volume 25 number 09

Breast Cancer in Georgia

Overview Breast cancer is a malignant tumor that starts in the cells of the breast. There are several types of breast cancer, which may involve the lobules (the glands that produce milk), the ducts (which carry milk to the nipple), and/or the fatty tissue, the lymph nodes, and blood vessels. Breast cancer can be considered "in-situ", meaning the cancer cells have not spread beyond the site of the original tumor; or "invasive", meaning the cancer has spread to other parts of the breast or the body. While breast cancer is most commonly diagnosed in women, men can also get breast cancer. In Georgia between 2002 and 2006, over 99% of all diagnosed cases were in women and fewer than 1% were in men.

are more likely to die from the disease (Figure 1). Georgia's incidence and mortality rates for breast cancer were lower than the US average for the years 2002-2006: Georgia's breast cancer incidence rate was 119 per 100,000 and the mortality rate was 24 per 100,000. For the same time period, the US breast cancer incidence rate was 122 per 100,000 and the mortality rate was 25 per 100,000.
Table 1. Top Five Cancer Types and Cancer Deaths in GA Females (2002-2006)

Methods The number of cancer cases and incidence rates for the state of Georgia were obtained from the Georgia Comprehensive Cancer Registry (GCCR). The GCCR is a population-based cancer registry that includes all cancer cases diagnosed in Georgia residents since January 1, 1995. GCCR collects, analyzes, utilizes and dis-

Cases
Breast Lung & Bronchus Colon & Rectum Uterine Corpus Melanoma

Deaths
Lung & Bronchus Breast Colon & Rectum Pancreas Ovary

seminates cancer incidence data. This information is used to assist

state agencies, health care providers,

and Georgia citizens to monitor

cancer incidence trends; plan and implement cancer control and prevention activities; develop public and

Figure 1. Georgia Breast Cancer Incidence and Mortality Rates by Race
Figure 1. Breast Cancer Incidence and Mortality Rates by Race

professional education programs; and stimulate scientific cancer research.

United States Georgia

The number of cancer deaths and mortality rates for the state of Georgia were obtained from the Georgia Division of Public Health, Vital Records

140 120 115 115

127 122

Branch.

100

Rate per 100,000 Population

Incidence and Mortality of Breast Cancer Breast cancer is the leading cause of cancer diagnosed in Georgia women, and the second leading cause of cancer death in Georgia women (Table 1).
By Race White women are more likely to be diagnosed with breast cancer than black women; however black women

80 60 40 20
0 Black

White

33 31

24 22

Black

White

The Georgia Epidemiology Report via e-mail , see last page for details. Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER.

By Age Although breast cancer can occur in women younger than 40, it is far less common. Breast cancer incidence and mortality sharply increase at age group 40-49. In Georgia, breast cancer rates are highest among women over 60 years of age, and mortality is highest among women over 80 years of age (Figure 2).
By Stage at Diagnosis In Georgia women, the majority of breast cancer diagnoses occur in the in-situ and localized stages (68%). Only 3% of diagnoses in white women and 6% in black women occurred at a distant stage in 2002-2006, however there are still disparities between the groups, with black women generally being diagnosed at later stages than white women (Figure 3).
By Geography Women living in urban counties in Georgia have higher rates of breast cancer than those living in rural counties. Incidence rates for white women are higher than for black women in both rural and urban counties. Mortality rates for black women are higher than for white women despite urban status (Figure 4 and Map 1).
Stage at diagnosis is very similar for women in both urban and rural counties. Women living in urban counties were more likely to be diagnosed at an in-situ stage, and were slightly less likely to be diagnosed at a regional stage, or to have their stage unknown. Easier access to screening services, as well as a higher number of services in urban counties may account for diagnosing women at an earlier stage (Figure 5).
Survival Survival from breast cancer depends on how early the tumor is found, and how aggressive it is. For tumors found early (at the localized stage), five-year survival rates are 94% among US black women and 99% among US white women. If the cancer is diagnosed at the distant stage, the survival rates drop to 16% and 25%, respectively (Figure 6).
Risk Factors Breast cancer has many recognized risk factors, some of which are controllable, and some are not (Table 2). However, the presence of one or more risk factors does not confirm that breast cancer will occur in a woman.

Figure 2. Georgia Breast Cancer Incidence and Mortality Rates by AgFeigGurreou2.pGeorgia Breast Cancer Incidence and Mortality by
Age Group
2002-2006 Incidence 2002-2006 Mortality

Rate per 100,000 population

450 400 350 300 250 200 150 100
50 14 2 0 0-39

396

343

356

252

146

150

21

45

67

89

40-49 50-59 60-69 70-79

80+

Age Group

Figure 3. Stage at Diagnosis

Stage at Diagnosis - GA White Unknow n 2002-2006
2%

Distant 3%
Regional 25%

In-Situ 19%

In-Situ Localized Regional

Localized 51%

Distant Unknow n

Stage at Diagnosis - GA Black 2002-2006
Unknow n
2%

Distant 6%
Regional 31%

In-Situ 19%
Localized 42%

In-Situ Localized Regional Distant Unknow n

Figure 4F.igGureeo4r.gGiaeoBrrgeiaasBtreCaasnt CcearncInercIindceidnecnecaenadndMMoorrttaalliittyy Rates

by Geography

Rates by Geography

Rate per 100,000 Population

2002-2006 Incidence 2002-2006 Mortality

140

119 120

117

104

119

115

100

80

60

40

24

31

31

23

22

20

0

State of Urban Black Rural Black Urban Rural White

Georgia

White

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Table 2. Risk Factors for Breast Cancer

Controllable

Uncontrollable

Not having children

Sex (Female)

Taking birth control pills

Older age

Hormone replacement

Genetic risk factors

therapy

Family or personal history

Not breastfeeding

Race

Alcohol use

Exposure to chest radiation

Obesity

Early menstuation/late

Lack of exercise

menopause

Treatment with

diethylstilbestrol

Figure 5. Stage at Diagnosis

Stage at Diagnosis - GA Urban Unknow n 2002-2006
2%

Distant 4%
Regional 26%

In-Situ 20%

Localized 48%

In-Situ Localized Regional Distant Unknow n

Stage at Diagnosis - GA Rural Unknow n 2002-2006
3%

Distant 4%
Regional 27%

In-Situ 16%
Localized 50%

In-Situ Localized Regional Distant Unknow n

Figure 6. Percent of U.S. Women Surviving Five Years after
DiagnoFsiigsuwrei6t.hPBerrceeantstofCUaSnWcoemr ebnySSutrvaigviengofFDiveisYeeaasres aafntedr Race, 1999- D2i0ag0n5osis with Breast Cancer, by Stage of Disease and Race,
1999-2005

100

90

80

78

Black
94 99

White
85 72

Percent of Women Surviving 5 Years

60

40

25

20

16

0 All Stages

Localized

Regional

Distant

Symptoms of Breast Cancer

The most common symptom of breast cancer is a new lump or

mass; however, not all lumps are cancerous. It is important to

have any new lumps inspected by a physician. Other symptoms

of breast cancer include:

-

Swelling in part of the breast

-

Skin irritation or dimpling

-

Nipple pain or nipple inversion

-

Redness or scaliness on the nipple or breast skin

-

Nipple discharge (not breast milk)

-

A lump in the underarm area

Detection and Screening The earlier breast cancer is found, the better the chances for treatment to be effective and thus, a better chance for survival. There are two primary methods of screening that are recommended to women: a mammogram and a clinical breast exam (CBE). Mammograms use X-ray technology to obtain an image
of the breast to inspect for tumors or other abnormalities. Women aged 40 and older are advised to have a mammogram every year. A CBE is a physical breast examination by a health care professional to feel for any lumps. Women in their 20s and 30s should have a CBE every three years, and every year after age 40.

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Treatment and Prognosis There are several forms of treatment of breast cancer, and all have related benefits and side effects. Localized cancers (those that have not spread beyond the site of origin) are most easily and usually most successfully treated, hence the importance of regular screening. The most common forms of treatment are: Surgery: This option can range from a simple lumpec-
tomy to remove a breast mass to a radical mastectomy that removes the entire breast and lymph nodes. The type of surgery required depends on the severity of the cancer. Chemotherapy: This involves the use of strong drugs to kill the cancer cells. Chemotherapy is often administered after surgery to prevent cancer from returning; however it may also be given before surgery to reduce the size of the tumor. Radiation therapy: This uses high-energy radiation to kill cancer cells. Hormone therapy: Drugs may be given to block the effects of estrogen, which may contribute to the growth of cancer in some women. Immunotherapy: For some women with tumors that have too much of a growth protein called HER2/neu, the use of Herceptin can stop the protein from causing breast cancer cell growth.
Services in Georgia National Breast and Cervical Cancer Early Detection Program This program was created by the Centers for Disease Control and Prevention (CDC) after Congress passed the Breast and Cervical Cancer Mortality Prevention Act in 1990. The program aims to provide access to breast and cervical cancer screening to low-income, uninsured, and underinsured women. The program is funded in all 50 states.
In Georgia the program is called the Breast and Cervical Cancer Program (also: Cancer Screening Program), and helps to provide mammograms and CBEs to women in need. It was launched in 1994 and is primarily funded by the CDC and the state; additional funding sources include Susan G. Komen for the Cure.
In order to be eligible for the program, a woman must have a household income equal to or less than 200% of the federal poverty level, be uninsured or underinsured (and not eligible for Medicaid or Medicare), and it must have been at least one year since her last mammogram or pap test, or else she must have suspicious symptoms suggestive of cancer. Women generally must be age 40 or older to receive screening services, although sometimes younger women with abnormal symptoms may be referred for diagnostic services.
This article was written by Alissa Berzen, MPH, Breast and Cervical Cancer Screening Epidemiologist and Rana Bayakly, MPH, GA Comprehensive Cancer Registry

Women's Health Medicaid Program The Women's Health Medicaid Program is administered in Georgia through the Georgia Department of Community Health, and was established in 2001 following the passage of the National Breast and Cervical Cancer Prevention and Treatment Act of 2000.
Low-income women who have been diagnosed with breast cancer and need to access treatment can apply to the program. To be considered eligible, a woman must meet the financial requirement for the Breast and Cervical Cancer Program, be under 65 years of age, be a US citizen and Georgia resident, and must not have health coverage (and not be eligible for Medicare or Medicaid).
Definitions: Age-adjusted rate: A rate calculated in a manner that allows for the comparison of rates derived from populations with different age structures.
Cancer incidence rate: The number of new cancer cases occurring in a population during a specified period of time. Often expressed per 100,000 population.
Cancer mortality rate: The number of cancer deaths occurring in a population during a specified period of time. Often expressed per 100,000 populations.
Risk factor: A behavior, characteristic, or finding on clinical examination that is consistently associated with increased probability of a disease or complications from the disease.
Cancer Stages: Local: an invasive malignant cancer confined entirely to
the organ of origin. Regional: A malignant cancer that
o has extended beyond the limits of the organ of origin directly into surrounding organs or tissue; and
o involves regional lymph nodes by way of lymphatic system; and
o has both regional extension and involvement of region al lymph nodes. Distant: A malignant cancer that has spread to parts of the
body remote from the primary tumor either by direct ex tension or by discontinuous metastasis to distant organs, tissues or via the lymphatic system to distant lymph nodes.
Rural-Urban Classification: The rural urban classification of Georgia counties was based on the 2003 Rural-Urban Continuum Codes from the United States Department of Agriculture, Economic Research Service. Information about the Rural-Urban Continuum Codes can be retrieved from http://www.ers.usda.gov/Data/RuralUrbanContinuumCodes/.

Division of Public Health http://health.state.ga.us
Please send comments to: gaepinfo@dhr.state.ga.us

Rhonda M. Medows, M.D., F.A.A.F.P. Acting Director, State Health Officer
Cherie Drenzek, D.V.M., M.S. Director, Acute Disease Epi Section

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.P.H., Ph.D. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer

Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 | Fax: (404) 657-7517

The Georgia Epidemiology Report Epidemiology Section Two Peachtree St., NW Atlanta, GA 30303-3186
Providers can contact Public Health IMMEDIATELY 24 hours a day, 7 days a week, by calling: 1-866-PUB-HLTH (1-866-782-4584) to report immediately notifiable diseases and public health emergencies
September 2009

Due to the rising costs of printing and mailing the GER to over 30,000 subscribers, we are switching to an electronic version of the GER. The electronic version will be available as a portable document format (pdf ) file on the Division of Public Health web site, http://www.health.state.ga.us/epi/manuals/ger.asp. We will send an e-mail notification to all subscribers when the monthly GER has been posted to the web site. This will enable us to continue distributing the GER to all of our subscribers.
We have also created an electronic database where GER subscribers may log on to request an electronic subscription to the GER, enter their current e-mail address for the GER electronic notification, update their contact information, or cancel their electronic subscription. To access this database, please visit this website, https:// sendss.state.ga.us/ger, and follow the instructions when prompted.
We look forward to continuing to provide you with important public health information in Georgia.
Volume25Number09

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for June 2009

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for June 2009
2009 94 3276 41 2 63 1088 14 7 8 5 9 3 0 8 0 254 74 17 73 54 67 1 42

Previous 3 Months Total Ending in June

2007

2008

2009

195

204

225

10867

11304

10176

42

53

101

4

17

5

146

143

177

4570

3988

3411

34

30

36

25

10

12

37

43

24

11

8

14

4

16

18

4

7

11

0

2

0

5

4

47

0

0

0

362

549

543

628

401

199

26

43

46

133

175

213

109

144

173

315

384

201

3

6

3

139

145

112

Previous 12 Months Total Ending in June

2007

2008

2009

626

700

739

41794

42967

42506

264

267

331

33

58

34

700

707

818

19490

16982

15489

128

141

150

76

49

51

176

168

165

48

40

50

8

23

42

19

26

26

0

2

1

28

15

83

0

0

0

1931

2147

2335

1790

1487

728

104

128

180

535

708

818

419

508

653

1101

1359

1089

10

15

10

520

481

425

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period
Latest 12 Months

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

HIV, non-AIDS 10

2,896

2,906

Percent Female MSM

25

32

Risk Group Distribution %

IDU

MSM&IDU HS

Unknown Perinatal White

2

1

4

61

<1

25

Race Distribution %

Black

Hispanic Other

69

4

<1

8/08-07/09 AIDS

0

1,692

1,692

21

34

2

1

6

56

<1

25

67

6

<1

Five Years Ago:**

HIV, non-AIDS 25

2,116

2,141

32

30

9

4

12

44

<1

20

75

3

<1

08/04-07/05 AIDS

5

1,524

1,529

26

33

7

3

13

45

<1

19

75

4

<1

Cumulative: HIV, non-AIDS 226

13,796

13,908

31

30

5

2

10

53

<1

22

73

4

1

08/81-07/09 AIDS

240

34,304

34,544

20

43

14

5

14

24

<1

30

66

3

<1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period

***HIV, non-AIDS was not collected until 12/31/2003

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