Breast Cancer Facts & Figures 2017-2018

Breast Cancer

Facts & Figures 2017-2018

Contents

Breast Cancer Basic Facts 1

Table 1. Estimated New Female Breast Cancer Cases

and Deaths by Age, US, 2017 1

Figure 1. Age-specific Female Breast Cancer Incidence Rates

by Race/Ethnicity, 2010-2014, US 2

Breast Cancer Occurrence 3

Table 2. Age-specific Probability of Developing Invasive

Breast Cancer for US Women 4

Figure 2. Female Breast Cancer Incidence (2010-2014)

and Mortality (2011-2015) Rates by Race/Ethnicity, US 4

Figure 3. Female Breast Cancer Incidence Rates

by Subtype and Race/Ethnicity, 2010-2014, US 5

Table 3. Female Breast Cancer Incidence (2010-2014) and

Mortality (2011-2015) Rates by Race/Ethnicity and State 6

Figure 4. Geographic Variation in Female Breast Cancer

Death Rates by Race, 2011-2015 7

Figure 5. Trends in Incidence Rates of Invasive and In Situ

Female Breast Cancer by Age, 1975-2014, US 8

Figure 6a. Trends in Female Breast Cancer Incidence

Rates by Race/Ethnicity, 1975-2014, US 9

Figure 6b. Trends in Female Breast Cancer Death

Rates by Race/Ethnicity, 1975-2015, US 9

Figure 7. Trends in Female Breast Cancer Incidence

Rates by Tumor Size, 1992-2014, US 9

Figure 8. Trends in Female Breast Cancer Incidence

Rates by Stage and Race/Ethnicity, 1992-2014, US 10

Figure 9. Female Breast Cancer-specific Survival and

Stage Distribution by Race/Ethnicity, 2007-2013, US 11

Figure 10. Trends in Female Breast Cancer 5-year

Relative Survival Rates by Race, 1975-2013, US 11

Breast Cancer Risk Factors 12

Table 4. Factors That Increase the Relative Risk for Breast Cancer in

Women 13

Breast Cancer Screening 19

Table 5. Prevalence of Mammography (%), Women

40 and Older, US, 2015 21

Table 6. Prevalence of Mammography* (%) by State,

Women 40 and Older, 2014 23

Breast Cancer Treatment 24

Figure 11. Female Breast Cancer Treatment Patterns (%),

by Stage, 2013, US 25

What Is the American Cancer Society

Doing About Breast Cancer? 28

Sources of Statistics 32

References 33

Global Headquarters: American Cancer Society Inc.

250 Williams Street, NW, Atlanta, GA 30303-1002

404-320-3333

including the right to reproduce this publication

or portions thereof in any form.

For written permission, address the Legal department of

the American Cancer Society, 250 Williams Street, NW,

Atlanta, GA 30303-1002.

This publication attempts to summarize current scientific information

about breast cancer. Except when specified, it does not represent

the official policy of the American Cancer Society.

Suggested citation: American Cancer Society. Breast Cancer Facts &

Figures 2017-2018. Atlanta: American Cancer Society, Inc. 2017.

Breast Cancer Facts & Figures 2017-2018 1

Breast Cancer Basic Facts

What is breast cancer?

Cancer is a group of diseases that cause cells in the body

to change and spread out of control. Most types of cancer

cells eventually form a lump or mass called a tumor, and

are named after the part of the body where the tumor

originates. Most breast cancers begin either in the breast

tissue made up of glands for milk production, called

lobules, or in the ducts that connect the lobules to the

nipple. The remainder of the breast is made up of fatty,

connective, and lymphatic tissues.

What are the signs and symptoms

of breast cancer?

Breast cancer typically produces no symptoms when the

tumor is small and most easily treated, which is why

screening is important for early detection. The most

common physical sign is a painless lump. Sometimes

breast cancer spreads to underarm lymph nodes and

causes a lump or swelling, even before the original breast

tumor is large enough to be felt. Less common signs and

symptoms include breast pain or heaviness; persistent

changes, such as swelling, thickening, or redness of the

skin; and nipple abnormalities such as spontaneous

discharge (especially if bloody), erosion, or retraction.

Any persistent change in the breast should be evaluated

by a physician as soon as possible.

How is breast cancer diagnosed?

Breast cancer is typically detected either during a

screening examination, before symptoms have developed,

or after a woman notices a lump. Most masses seen on a

mammogram and most breast lumps turn out to be

benign (not cancerous), do not grow uncontrollably or

spread, and are not life-threatening. When cancer is

suspected, microscopic analysis of breast tissue is

necessary for a diagnosis and to determine the extent of

spread (stage) and characterize the type of the disease.

The tissue for microscopic analysis can be obtained from

a needle biopsy (fine-needle or wider core needle) or

surgical incision. Selection of the type of biopsy is based

on multiple factors, including the size and location of the

mass, as well as patient factors and preferences and

resources.

How is breast cancer staged?

The prognosis of invasive breast cancer is strongly

influenced by the stage of the disease – that is, the extent

or spread of the cancer when it is first diagnosed. There

are two main staging systems for cancer. The TNM

classification of tumors uses information on tumor size

and how far it has spread within the breast and to adjacent

tissues (T), the extent of spread to the nearby lymph nodes

(N), and the presence or absence of distant metastases

(spread to distant organs) (M).

Once the T, N, and M are

determined, a stage of 0, I, II, III, or IV is assigned, with

stage 0 being in situ (abnormal cells have not penetrated

the ducts or glands from which they originated), stage I

being early-stage invasive cancer, and stage IV being the

most advanced disease. The TNM staging system is

commonly used in clinical settings. The latest revision

(8th edition) to the TNM stage for breast cancer also

incorporates biologic factors in order to further refine the

breast cancer staging system and will be implemented by

oncology programs in 2018.

Table 1. Estimated New Female Breast Cancer Cases

and Deaths by Age, US, 2017

In Situ Cases Invasive Cases Deaths

Age Number % Number % Number %

<40 1,610 3% 11,16 0 4% 990 2%

40-49 12,4 40 20% 36,920 15% 3,480 9%

50-59 17, 68 0 28% 58,620 23% 7,590 19%

60-69 17,550 28% 68,070 27% 9,420 23%

70-79 10,370 16% 47,860 19% 8,220 20%

80+ 3,760 6% 30,080 12% 10,910 27%

All ages 63,410 252,710 40,610

Estimates are rounded to the nearest 10. Percentages may not sum to 100

due to rounding.

2 Breast Cancer Facts & Figures 2017-2018

The Surveillance, Epidemiology, and End Results (SEER)

Summary Stage system is more simplified and is

commonly used in reporting cancer registry data and for

public health research and planning.

According to the SEER Summary Stage system:

• In situ stage refers to the presence of abnormal cells

that have not invaded nearby tissues (corresponding

to stage 0 in the TNM staging system).

• Local stage refers to cancers that are confined to the

breast (corresponding to stage I and some stage II

cancers).

• Regional stage refers to tumors that have spread to

surrounding tissue or nearby lymph nodes (generally

corresponding to stage II or III cancers, depending

on size and lymph node involvement).

• Distant stage refers to cancers that have

metastasized (spread) to distant organs or lymph

nodes above the collarbone (corresponding to some

stage IIIc and all stage IV cancers).

What are the types of breast cancer?

In Situ

There are two main types of in situ breast cancer: ductal

carcinoma in situ (DCIS) and lobular carcinoma in situ

(LCIS), also known as lobular neoplasia. Other in situ

breast cancers have characteristics of both ductal and

lobular carcinomas or have unknown origins.

• Ductal carcinoma in situ. DCIS (83% of in situ cases

diagnosed during 2010-2014) refers to a condition in

which abnormal cells replace the normal epithelial

cells that line the breast ducts and may greatly

expand the ducts and lobules. DCIS may or may not

progress to invasive cancer; in fact, sometimes DCIS

grows so slowly that even without treatment it would

not affect a woman’s health. Long-term studies of

women whose DCIS was untreated because it was

originally misclassified as benign found that 20%-

53% were diagnosed with an invasive breast cancer

over the course of 10 or more years.

3-7

• Lobular carcinoma in situ. LCIS (13% of in situ

cases) refers to abnormal cells growing within and

expanding some of the lobules of the breast. LCIS is

generally not thought to be a precursor of invasive

cancer, but is a strong risk factor for developing

invasive cancer.

See pages 13 and 24 for additional information on

DCIS and LCIS. More information can also be found in

the Cancer Facts & Figures 2015, Special Section: Breast

Carcinoma In Situ.

Invasive

Most (80%) breast cancers are invasive, or infiltrating,

which means they have broken through the walls of the

glands or ducts where they originated and grown into

surrounding breast tissue. Although breast cancer

generally has been referred to as a single disease, there

are up to 21 distinct histological subtypes and at least

four different molecular subtypes that differ in terms of

risk factors, presentation, response to treatment, and

outcomes.

8-10

Gene expression profiling techniques have

allowed better understanding of the molecular subtypes of

breast cancers; however, this is a costly and complicated

Figure 1. Age-specific Female Breast Cancer Incidence

Rates by Race/Ethnicity, 2010-2014, US

Rate per 100,000

Age

Note: Rates are per 100,000 and age adjusted to the 2000 US standard

population.

Sources: Incidence: North American Association of Central Cancer Registries

(NAACCR), 2017. Mortality: National Center for Health Statistics, Centers for

Disease Control and Prevention, 2017.

American Cancer Society, Inc., Surveillance Research, 2017

Non-Hispanic White

Non-Hispanic Black

Hispanic

Asian/Pacific Islander

100

200

300

400

500

85+80-8475-7970-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-24

Breast Cancer Facts & Figures 2017-2018 3

process and is not currently standard practice.

Approximations of molecular subtypes have been

identified using routinely evaluated biological markers,

including the presence or absence of hormone (estrogen

or progesterone) receptors (HR+/HR-) and excess levels of

human epidermal growth factor receptor 2 (HER2, a

growth-promoting protein) and/or extra copies of the

HER2 gene (HER2+/HER2-).

The four main molecular

subtypes and their distribution are described here.

• Luminal A (HR+/HER2-) (71%). These cancers tend

to be slow-growing and less aggressive than other

subtypes. Luminal A tumors are associated with the

most favorable prognosis, particularly in the short

term, in part because they are more responsive to

anti-hormone therapy (see page 27).

12, 13

• Triple negative (HR-/HER2-) (12%). So called

because they are estrogen receptor (ER)-,

progesterone receptor (PR)-, and HER2-, these

cancers are twice as common in black women as

white women in the US, and are also more common

in premenopausal women and those with a BRCA1

gene mutation.

The majority (about 75%) of triple

negative breast cancers fall in to the basal-like

subtype defined by gene expression profiling. Triple

negative breast cancers have a poorer short-term

prognosis than other subtypes, in part because there

are currently no targeted therapies for these tumors.

• Luminal B (HR+/HER2+) (12%). Like luminal A

cancers, luminal B cancers are ER+ and/or PR+ and

are further defined by being highly positive for Ki67

(indicator of a large proportion of actively dividing

cells) or HER2. Luminal B breast cancers tend to be

higher grade and are associated with poorer survival

than luminal A cancers.

• HER2-enriched (HR-/HER2+) (5%). HER2-enriched

cancers tend to grow and spread more aggressively

than other subtypes and are associated with poorer

short-term prognosis compared to HR+ breast

cancers.

However, the recent widespread use of

targeted therapies for HER2+ cancers has improved

outcomes for these patients. For more information

about the treatment of HER2+ breast cancers, see the

section on targeted therapy on page 28.

Breast Cancer Occurrence

How many cases and deaths are

estimated to occur in 2017?

In 2017, an estimated 252,710 new cases of invasive breast

cancer will be diagnosed among women (Table 1, page 1)

and 2,470 cases will be diagnosed in men. In addition,

63,410 cases of in situ breast carcinoma will be diagnosed

among women. Approximately 40,610 women and 460

men are expected to die from breast cancer in 2017.

How many women alive today have

ever had breast cancer?

More than 3.5 million US women with a history of breast

cancer were alive on January 1, 2016.

Some of these

women were cancer-free, while others still had evidence

of cancer and may have been undergoing treatment.

Who gets breast cancer?

Age

• Breast cancer incidence and death rates generally

increase with age (Figure 1). The decrease in

incidence rates that occurs in women 80 years of age

and older may reflect lower rates of screening, the

detection of cancers by mammography before 80

years of age, and/or incomplete detection.

• During 2010-2014, the median age at the time of

breast cancer diagnosis was 62.

This means that

half of women who developed breast cancer were 62

years of age or younger at the time of diagnosis. The

median age of diagnosis is younger for black women

(59) than white women (63).

4 Breast Cancer Facts & Figures 2017-2018

• A woman living in the US has a 12.4%, or a 1-in-8,

lifetime risk of being diagnosed with breast cancer

(Table 2). Conversely, 7 out of 8 women born today will

not be diagnosed with breast cancer in their lifetimes.

In the 1970s, the lifetime risk of being diagnosed with

breast cancer was 1 in 11. This increase in risk over

the past four decades is due to longer life expectancy,

as well as increases in breast cancer incidence due in

part to changes in reproductive patterns, menopausal

hormone use, the rising prevalence of obesity, and

increased detection through screening. Lifetime risk

reflects an average woman’s risk over an entire

lifetime, including the possibility that she may die

from another cause before she would have been

diagnosed with breast cancer and does not apply only

to women who live to a very old age.

Race/Ethnicity

• Figure 2 shows breast cancer incidence and death

rates by race and ethnicity during the most recent

time period. Incidence and death rates for breast

cancer are higher among non-Hispanic white (NHW)

and non-Hispanic black (NHB) women than other

racial and ethnic groups. Asian/Pacific Islander (API)

women have the lowest incidence and death rates.

• Between the ages of 65 and 84, NHW women have

markedly higher breast cancer incidence rates than

NHB women (Figure 1, page 2). However, NHB

women have higher incidence rates before age 40 and

are more likely to die from breast cancer at every age.

• Racial/ethnic variation in incidence rates for specific

breast cancer subtypes are shown in Figure 3. NHW

women have the highest rates of HR+/HER2- breast

cancers, whereas NHB women have the highest rates

of triple negative breast cancers.

Are there geographic differences in

breast cancer rates?

Table 3, page 6 shows the variation in state-level

breast cancer incidence and death rates per 100,000

women by race/ethnicity. Although the overall incidence

rate for breast cancer in the US remains slightly higher in

NHW women compared to NHB women, in 9 of 43 states

with data for both groups, rates are higher among NHB

women. Data for AI/AN women are too sparse to provide

by state; however, a recent study found that rates were

more than 2-fold higher among women in Alaska (141.3

per 100,000) than those living in the Southwest US (59.6

per 100,000) during 1999-2009.

Table 2. Age-specific Probability of Developing Invasive

Breast Cancer for US Women

Current age 10-year probability: or 1 in:

20 0.1% 1,567

30 0.5% 220

40 1.5% 68

50 2.3% 43

60 3.4% 29

70 3.9% 25

Lifetime risk 12.4% 8

Note: Probability is among those free of cancer at beginning of age interval.

Based on cases diagnosed 2012-2014. Percentages and “1 in” numbers may

not be numerically equivalent due to rounding.

*Statsitics based on data from Contract Health Service Delivery Area (CHSDA)

counties. Note: Rates are age adjusted to the 2000 US standard population.

Sources: Incidence – NAACCR, 2017. Mortality – National Center for Health

Statistics, Centers for Disease Control and Prevention, 2017.

Rate per 100,000

Incidence Mortality

120

150

Asian/

Pacific Islander

Hispanic/

Latina

American Indian/

Alaska Native*

Non-Hispanic

Black

Non-Hispanic

White

20.8

29.5

14.3

14.2

11.3

128.7

125.5

100.7

91.9

90.7

Figure 2. Female Breast Cancer Incidence (2010-2014)

and Mortality (2011-2015) Rates by Race/Ethnicity, US

Breast Cancer Facts & Figures 2017-2018 5

In contrast to incidence, breast cancer death rates are

higher among NHB women than NHW women in every

state, with rates in some states (e.g., Louisiana and

Mississippi) as much as 60% higher. Death rates reflect

both cancer incidence and survival. Breast cancer

mortality rates among white women tend to be highest in

the North Central, Mid-Atlantic, and Western regions of

the US. Among black women, the highest death rates are

found in some of the South Central and Mid-Atlantic

states, as well as California (Figure 4, page 7). Factors

that contribute to geographic disparities include

variations in risk factors and access to screening and

treatment, which are influenced by socioeconomic

factors, legislative policies, and proximity to medical

services.

How has the occurrence of breast

cancer changed over time?

Incidence trends

Figure 5, page 8 presents trends for in situ and

invasive breast cancer incidence rates since 1975, when

population-based cancer registration began in the 9

oldest Surveillance, Epidemiology and End Results

(SEER) registries.

Incidence rates of in situ and invasive breast cancer rose

rapidly during the 1980s and 1990s (Figure 5a, page

8), largely because of increases in mammography

screening. The widespread uptake of mammography

screening inflated the incidence rate because cancers

were being diagnosed 1 to 3 years earlier than they would

have been in the absence of screening, and may also have

led to the detection of indolent (very slow-growing)

tumors. In addition, some of the historic increase in

breast cancer incidence reflects changes in reproductive

patterns, such as delayed childbearing and having fewer

children, which are known risk factors for breast cancer.

The increase in incidence was greater in women 50 years

of age and older than in those younger than 50.

Invasive breast cancer rates stabilized between 1987 and

1994 (Figure 5b, page 8). Incidence rates increased

again in the latter half of the 1990s, which may reflect

further increases in the prevalence of mammography

screening, as well as rising rates of obesity and the use of

menopausal hormones, both of which increase breast

cancer risk. Between 2002 and 2003, invasive breast

cancer rates dropped sharply (nearly 7%), likely due to

the decreased use of menopausal hormones following the

2002 publication of clinical trial results that found higher

risk of breast cancer and heart disease among users.

19, 20

The decline in incidence occurred primarily in white

women, in those 50 years of age and older, and for ER+

disease.

19, 21

From 2005 to 2014, the overall invasive breast

cancer incidence rate was stable, but the trends vary by

race and age.

Incidence rates of in situ breast cancer have been stable

since 2000 among women 50 and older and since 2007

among younger women.

HR = hormone receptor, HER2 = human epidermal growth factor receptor 2.

Note: Rates are age adjusted to the 2000 US standard population.

Source: NAACCR, 2017.

Rate per 100,000

Non-Hispanic White

Non-Hispanic Black

American Indian/Alaska Native

Hispanic/Latina

Asian/Paciﬁc Islander

14 14

1212

Figure 3. Female Breast Cancer Incidence Rates by

Subtype and Race/Ethnicity, 2010-2014, US

100

Triple negativeHR-/HER2+HR+/HER2+HR+/HER2-

6 Breast Cancer Facts & Figures 2017-2018

Table 3. Female Breast Cancer Incidence (2010-2014) and Mortality (2011-2015) Rates by Race/Ethnicity and State

Incidence Mortality

State

Non-

Hispanic

White

Non-

Hispanic

Black

Hispanic/

Latina

Asian/

Pacific

Islander

Non-

Hispanic

White

Non-

Hispanic

Black

Hispanic/

Latina

Asian/

Pacific

Islander

Alabama 118.2 124.9 64.3 87.4 20.0 28.5 * *

Alaska 125.9 133.7 80.4 92.3 20.0 * * *

Arizona 120.5 107. 8 88.9 75.6 20.3 26.2 15.0 12.0

Arkansas 110.5 114. 2 148.1 126.9 20.5 30.3 15.3 *

California 139.0 129.0 89.2 95.7 23.1 31.9 14.5 12.6

Colorado 127.1 119.1 104.2 76.1 19.3 25.5 17.2 7.7

Connecticut 143.3 122.9 127.5 89.2 18.9 20.8 10.3 9.0

Delaware 135.8 130.6 100.0 85.9 21.2 26.0 * *

District of Columbia 157.6 141.6 70.8 90.4 22.6 34.4 * *

Florida 121.3 108.3 98 .1 70.1 20.1 25.8 15.3 9.8

Georgia 125.2 126.3 93.2 74.4 20.1 29.2 10.9 8.8

Hawaii 143.3 120.5 151.6 132.1 21.4 * * 14.4

Idaho 121.9 * 89.1 76.0 21.3 * * *

Illinois 135.7 131.8 89.5 92.7 22.5 31.2 10.9 11.7

Indiana 120.9 130.6 83.7 66.1 21.0 29.6 14.9 *

Iowa 124.7 105.1 6 7.1 68.2 19.3 21.4 * *

Kansas 124.4 126.2 84.2 63.2 19.9 30.1 11.6 *

Kentucky 124.3 127.0 54.2 64.4 21.4 28.5 * *

Louisiana 121.8 132.5 91.5 62.6 20.2 33.6 9.6 *

Maine 126.5 * * 76.3 18.0 * * *

Maryland 135.2 132.4 91.8 84.3 21.2 28.1 10.9 9.2

Massachusetts 141.8 114.7 87. 2 87.7 19.1 20.6 10.9 7.2

Michigan 122.0 127.1 80.0 85.3 21.0 29.8 16.2 9.2

Minnesota

†

131.5 103.1 103.1 68.9 18.8 23.0 11. 4 7.3

Mississippi 113.4 121.0 41.4 60.6 19.5 31.5 * *

Missouri 126.0 133.4 78.9 88.2 21.3 32.6 10.5 14.4

Montana 122.6 * 134.3 112.5 20.4 * * *

Nebraska 123.7 127.8 93.4 65.6 20.3 27.8 * *

Nevada

†

121.3 108.1 75.5 78.5 24.5 29.4 11. 2 14.4

New Hampshire 142.3 * 92.2 72.1 20.2 * * *

New Jersey 142.3 125.9 98.7 92.2 23.0 32.3 13.2 11. 2

New Mexico

†

123.2 98.8 103.2 65.6 21.2 32.4 16.8 *

New York 139.6 119.5 101.3 92.2 20.2 26.8 14.7 9.6

North Carolina 130.3 134.1 82.5 77.7 19.7 29.1 10.1 12.1

North Dakota 122.2 * * * 17.5 * * *

Ohio 123.7 123.8 64.3 79.8 22.2 31.0 9.9 10.9

Oklahoma 114. 8 122.9 96.9 80.5 23.0 33.6 13.1 *

Oregon 128.5 127.1 97.0 76.9 20.8 30.0 12.1 9.9

Pennsylvania 131.8 130.8 86.5 73.8 21.2 31.7 12.2 11.2

Rhode Island 135.6 113. 4 85.2 68.9 18.8 26.9 * *

South Carolina 128.8 125.7 89.6 76.3 20.5 29.0 9.4 *

South Dakota 132.1 * * * 20.2 * * *

Tennessee 121.8 126.3 66.5 70.2 20.7 31.5 11.5 11.6

Texas 122.5 120.3 88.0 65.0 20.6 30.4 15.5 9.9

Utah 116. 8 90.3 101.8 91.2 20.9 * 11.8 19.2

Vermont 130.5 * * * 19.0 * * *

Virginia 130.0 134.3 80.6 79.0 21.0 29.5 11.7 9.8

Washington 139.3 125.7 93.6 98.3 20.9 25.6 9.7 11.1

West Virginia 115.1 120.1 * 77. 8 22.2 30.5 * *

Wisconsin 129.1 133.5 90.2 74.2 19.8 31.6 7.7 *

Wyoming 116.1 * 85.5 * 19.4 * * *

United States 128.7 125.5 91.9 90.7 20.8 29.5 14.2 11.3

Note: Rates are per 100,000 and age adjusted to 2000 US standard population. *Statistic not displayed due to fewer than 25 cases or deaths. †This state’s registry did

not achieve high-quality data standards for one or more years during 2010-2014, according to NAACCR data quality indicators and are not included in the overall US

incidence rate.

Sources: Incidence: NAACCR, 2017. Mortality: National Center for Health Statistics, Centers for Disease Control and Prevention, 2017.

Breast Cancer Facts & Figures 2017-2018 7

Note: Rates are per 100,000 and age adjusted to the 2000 US standard population. Statistic not displayed for states with fewer than 25 deaths during 2011-2015.

Source: National Center for Health Statistics, Centers for Disease Control and Prevention, 2017.

Deaths per 100,000

17.5 - 19.4

19.5 - 20.2

20.3 - 20.9

21.0 - 21.4

21.5 - 24.5

Deaths per 100,000

20.6 - 23.0

23.1 - 28.1

28.2 - 29.8

29.9 - 31.5

31.6 - 34.4

Data not shown

Non-Hispanic Blacks

Non-Hispanic Whites

Figure 4. Geographic Variation in Female Breast Cancer Death Rates by Race, 2011-2015

8 Breast Cancer Facts & Figures 2017-2018

Race/Ethnicity: Figure 6a presents trends in invasive

female breast cancer incidence rates by race and

ethnicity. Incidence data are available for white and black

women since 1975 and for women of other races and

ethnicities since 1992. During 2005-2014, overall breast

cancer incidence rates increased among API (1.7% per

year), NHB (0.4% per year), and Hispanic (0.3% per year)

women, but were stable among NHW and AI/AN women.

Age: Trends for invasive breast cancer by age at diagnosis

are shown in Figure 5b. Although long-term data (shown)

suggest breast cancer incidence rates have increased

slightly among women over the age of 50 during the

most recent period (2005-2014), data with broader

coverage indicate that rates are relatively stable in this

age group.

In contrast, among women under age 50,

incidence rates have slowly increased (0.2% per year)

since the mid-1990s.

Tumor size: Incidence rates during 2005-2014 were stable

for smaller (≤ 2.0 cm) tumors and increased by 1.3%

annually for 2.1-5.0 cm tumors and 1.9% annually for

tumors larger than 5.0 cm (Figure 7).

Stage: Incidence rates during 2005-2014 increased for

localized breast cancer among NHW (0.7% per year),

NHB (1.5%), API (2.1%), and Hispanic (0.6%) women;

decreased (NHWs, 1.4% per year) or remained stable for

regional stage tumors; and increased for distant stage

tumors for all groups (NHWs: 2.0% per year; API: 1.7%;

Hispanics: 0.7%) except NHBs (Figure 8, page 10).

Incidence rates for breast cancer with unknown stage

decreased in all groups. The decline for regional stage

disease in NHWs may reflect a shift toward earlier stage

at diagnosis. The increase in distant-stage disease

coupled with the decrease in unknown stage may be due

to more complete staging of advanced tumors.

Mortality trends

Overall breast cancer death rates increased by 0.4% per

year from 1975 to 1989, but since have decreased rapidly,

for a total decline of 39% through 2015. As a result,

322,600 breast cancer deaths have been averted in US

women through 2015. The decrease occurred in both

younger and older women, but has slowed among women

younger than 50 since 2007. From 2006 through 2015,

breast cancer death rates declined annually by 2.6% in

Figure 5. Trends in Incidence Rates of Invasive and In Situ Female Breast Cancer by Age, 1975-2014, US

a. In Situ

Year

Rate per 100,000

b. Invasive

Year

Rate per 100,000

Note: Rates are age adjusted to the 2000 US standard population. Invasive breast cancer rates are adjusted for reporting delay.

Source: Surveillance, Epidemiology, and End Results (SEER) Program, SEER 9 Registries, National Cancer Institute, 2017.

American Cancer Society, Inc., Surveillance Research, 2017

100

150

200

250

300

350

400

201420102005200019951990198519801975

100

120

201420102005200019951990198519801975

Ages 20+

Ages 20-49

Ages 50+

Breast Cancer Facts & Figures 2017-2018 9

AI/ANs, 1.8% in NHWs, 1.5% in NHBs, 1.4% in Hispanics,

and 0.9% in APIs.

Notably, the decline among AI/AN

women began in 2005, more than a decade later than

other racial and ethnic groups.

The decline in breast cancer mortality has been

attributed to both improvements in treatment and early

detection.

However, not all women have benefited

equally, as indicated by the striking divergence in

mortality trends between black and white women

beginning in the early 1980s (Figure 6b). This disparity

likely reflects a combination of factors, including

differences in stage at diagnosis, obesity and comorbidities,

and tumor characteristics, as well as access, adherence,

and response to treatment.

24-27

It may also reflect

differences in mammography screening. Although

findings from national surveys indicate current

screening rates are similar between black and white

women, these estimates likely overestimate

mammography rates, especially for blacks.

28-30

treatment for breast cancers has improved, the racial

disparity widened; in 2015, breast cancer death rates

were 39% higher in black than white women.

Figure 6a. Trends in Female Breast Cancer Incidence

Rates by Race/Ethnicity, 1975-2014, US

Rate per 100,000

Year

Figure 6b. Trends in Female Breast Cancer Death Rates

by Race/Ethnicity, 1975-2015, US

Rate per 100,000

Year

Black

White

Hispanic/

Latina

Asian/Pacific Islander

White

Black

Asian/Pacific Islander

Hispanic/Latina

100

120

140

160

201420102005200019951990198519801975

201520102005200019951990198519801975

Note: Rates are age adjusted to the 2000 US standard population and adjusted

for reporting delays.

Source: SEER Program, National Cancer Institute, 2017. Data for whites and

blacks are from the 9 SEER registries and data for other races/ethnicities are

3-year moving averages from the 13 SEER registries. For Hispanics, incidence

data do not include cases from the Alaska Native Registry. Data for AI/AN not

shown due to small counts and unstable rates.

Note: Rates are age adjusted to the 2000 US standard population.

Source: National Center for Health Statistics, Centers for Disease Control and

Prevention, 2017. Rates for Hispanics exclude deaths from Louisiana, New

Hampshire, and Oklahoma. Data for AI/AN not shown due to small counts and

unstable rates.

American Cancer Society, Inc., Surveillance Research, 2017

Figure 7. Trends in Female Breast Cancer Incidence

Rates by Tumor Size, 1992-2014, US

Rate per 100,000

<2.0 cm

2.0-4.9 cm

5+ cm

unknown

Year

Note: Rates are age adjusted to the 2000 US standard population and adjusted

for reporting delays.

Source: 13 SEER Registries, National Cancer Institute, 2017.

American Cancer Society, Inc., Surveillance Research, 2017

201420122010200820062004200220001998199619941992

10 Breast Cancer Facts & Figures 2017-2018

Breast cancer survival

Relative survival rates are an estimate of the percentage

of patients who will survive for a given period of time

after a cancer diagnosis, accounting for normal life

expectancy. Survival among cancer patients is compared

to survival among people of the same age and race who

have not been diagnosed with cancer.

Based on the most recent data, relative survival rates for

women diagnosed with breast cancer are:

• 91% at 5 years after diagnosis

• 86% after 10 years

• 80% after 15 years

Relative survival rates should be interpreted with

caution. First, they are based on the average experience

of all women and do not predict individual prognosis

because many patient and tumor characteristics that

influence breast cancer survival are not taken into

account. Second, long-term survival rates are based on

the experience of women diagnosed and treated many

years ago and do not reflect the most recent

improvements in early detection and treatment.

Stage at diagnosis

Breast cancer survival varies by stage at diagnosis

(Figure 9a). The overall 5-year relative survival rate is

99% for localized disease, 85% for regional disease, and

27% for distant-stage disease.

Survival within each

stage varies by tumor size. For example, among women

with regional disease, the 5-year relative survival is 95%

for tumors less than or equal to 2.0 cm, 85% for tumors

2.1-5.0 cm, and 72% for tumors greater than 5.0 cm.

Race/ethnicity and socioeconomic factors

Since 1975, the breast cancer 5-year relative survival rate

has increased significantly for both black and white

women (Figure 10). While there remains a substantial

gap, especially for late-stage diagnoses, the racial

disparity seems to be narrowing. In the most recent

period, the 5-year relative survival rate was 83% for black

women and 92% for white women. The racial disparity in

survival reflects later stage at diagnosis and poorer

stage-specific survival in black women as well as higher

rates of more aggressive, triple negative breast cancer.

Cause-specific survival instead of relative survival is

used to describe the cancer experience of racial and

ethnic minorities because reliable life expectancy is not

available for some groups. Cause-specific survival is the

probability of not dying of breast cancer within five years

of diagnosis. For every stage of disease, API women have

the highest survival and NHB women have the lowest

survival (Figure 9). Poverty, less education, and a lack of

health insurance are associated with lower breast cancer

survival.

32-36

Figure 8. Trends in Female Breast Cancer Incidence

Rates by Stage and Race/Ethnicity, 1992-2014, US

Rate per 100,000

Non-Hispanic White Non-Hispanic Black

Rate per 100,000

Asian/Paciﬁc Islander Hispanic

Note: Rates are two year moving averages, age adjusted to the 2000 US

standard population, and adjusted for reporting delay.

Source: 13 SEER Registries, National Cancer Institute, 2017.

American Cancer Society, Inc., Surveillance Research, 2017

100

20132008200319981993

100

20132008200319981993

100

20132008200319981993

100

20132008200319981993

Localized

Regional Distant Unknown

Breast Cancer Facts & Figures 2017-2018 11

Male breast cancer

Breast cancer in men is rare, accounting for less than 1%

of breast cancer cases in the US. However, since 1975, the

incidence rate has increased slightly, from 1.0 case per

100,000 men during 1975-1979 to 1.3 cases per 100,000

men during 2010-2014. Men are more likely than women

to be diagnosed with advanced-stage breast cancer,

which likely reflects decreased awareness and delayed

detection because screening mammography is not

recommended for men due to the rarity of the disease.

Similar to female breast cancer, the incidence of male

breast cancer increases with age. The death rate for male

breast cancer has decreased slightly from 0.4 (per

100,000) during 1975-1979 to 0.3 (per 100,000) during

2011-2015 due to improvements in treatment.

Due to the infrequency of male breast cancer, much less

is known about the disease than female breast cancer.

Risk factors include radiation exposure, BRCA 1/2 gene

mutations, Klinefelter syndrome, testicular disorders,

family history of breast or ovarian cancer, diabetes,

gynecomastia (enlarged breasts), and obesity.

38, 39

Figure 10. Trends in Female Breast Cancer 5-year

Relative Survival Rates by Race, 1975-2013, US

Percent

100

2007-

2013

2003-

2006

1999-

2001

1996-

1998

1993-

1995

1990-

1992

1987-

1989

1984-

1986

1981-

1983

1978-

1980

1975-

1977

Year

Survival rates are based on follow-up of patients through 2014.

Source: Howlader et al.

American Cancer Society, Inc., Surveillance Research, 2017

White Black

Figure 9. Female Breast Cancer-specific Survival and Stage Distribution by Race/Ethnicity, 2007-2013, US

a. Five-year Breast Cancer-speciﬁc Survival Rates (%) b. Stage Distribution (%)

0 25 50 75 100

Unstaged

Distant

Regional

Localized

0 25 50 75 100

Unstaged

Distant

Regional

Localized

Survival rates are based on patients diagnosed during 2007-2013 and followed through 2014. Stage distribution percentages may not sum to 100 due to rounding.

Sources: Survival – SEER Program, 18 SEER registries, National Cancer Institute, 2016. Stage distribution – NAACCR, 2017.

American Cancer Society, Inc., Surveillance Research, 2017

Non-Hispanic White

Non-Hispanic Black

American Indian/Alsaka Native

Hispanic

Asian/Pacific Islander

12 Breast Cancer Facts & Figures 2017-2018

Breast Cancer Risk Factors

About one-third of postmenopausal breast cancers are

thought to be caused by behavioral factors that are

modifiable, such as postmenopausal obesity, physical

inactivity, use of combined estrogen and progestin

menopausal hormones, alcohol consumption, and not

breastfeeding.

Many risk factors affect lifetime

exposure of breast tissue to hormones (early menarche,

late menopause, obesity, and hormone use). Hormones

are thought to influence breast cancer risk by increasing

cell proliferation, thereby increasing the likelihood of

DNA damage, as well as promoting cancer growth.

Although exposures that influence risk accumulate

throughout a woman’s life, research suggests that the

time between menarche and first pregnancy may be

particularly critical.

41, 42

Many established risk factors for

breast cancer are specifically associated with HR+/

luminal breast cancer; less is known about risk factors

for HR-, HER2+ or basal-like breast cancers.

Factors

associated with an increased or decreased risk of breast

cancer are discussed below.

Family history and personal

characteristics

Family history

Women and men with a family history of breast cancer,

especially in a first-degree relative (parent, child, or

sibling), are at increased risk for the disease. Compared

to women without a family history, risk of breast cancer

is about 2 times higher for women with one affected

first-degree female relative and 3-4 times higher for

women with more than one first-degree relative.

Risk is further increased when the affected relative was

diagnosed at a young age or if the cancer was diagnosed

in both breasts. It is important to note that the majority

of women with one or more affected first-degree relatives

will never develop breast cancer and that most women

who develop breast cancer do not have a family history

of the disease.

A family history of ovarian cancer is also associated with

increased breast cancer risk in both men and women.

Women with a family history of breast or ovarian cancer

should discuss this with their physician or a genetic

counselor because it may signal the presence of a genetic

predisposition to cancer.

Genetic predisposition

Inherited mutations (genetic alterations) in BRCA1 and

BRCA2, the most well-studied breast cancer susceptibility

genes, account for 5%-10% of all female breast cancers,

5%-20% of male breast cancer, and 15%-20% of all familial

breast cancers.

45, 46

These mutations are rare (much less

than 1%) in the general population, but occur slightly

more often in certain ethnic or geographically isolated

groups, such as those of Ashkenazi (Eastern European)

Jewish descent (about 2%).

Compared to women in the

general population who have a 10% risk of developing

breast cancer by 80 years of age, the corresponding risks

for BRCA1 and BRCA2 mutation carriers are estimated to

be as much as 70%.

Mutations in PALB2, a different gene

that works with BRCA2, appear to confer risk that may be

as high as BRCA2 mutations.

Other inherited conditions associated with a smaller

increase in breast cancer risk include the Li-Fraumeni

and Cowden syndromes.

In addition, more than 150 less

rare genetic variants are associated with slightly elevated

risk.

Scientists now believe that much of the occurrence

of breast cancer clustered in families results from the

interaction between lifestyle factors and these low-risk

variations.

The US Preventive Services Task Force recommends

primary care providers routinely collect and update

family medical history and screen women with a family

history of breast, ovarian, tubal, or peritoneal cancer

with one of several brief questionnaires to determine if

there is a need for in-depth genetic counseling to consider

BRCA testing.

Those who consider testing are strongly

encouraged to talk with a genetic counselor before

making a decision so that the benefits and potential

consequences can be understood and carefully considered.

Breast Cancer Facts & Figures 2017-2018 13

Personal history of breast cancer

Women diagnosed with breast cancer have a small

increased risk of developing a new cancer in the opposite

breast; however, rates of second breast cancers have

declined steadily since 1985.

The decrease has

predominantly been among ER+ breast cancer patients

and may reflect the effect of hormone therapy

(e.g., tamoxifen and aromatase inhibitors) or other

adjuvant treatments.

DCIS and LCIS

DCIS is considered a potential precursor to invasive

cancer, and is also associated with an increased risk for

developing a new invasive breast cancer. Women with a

history of DCIS are about 10 times more likely to be

diagnosed with an invasive breast cancer than women

without DCIS.

Although LCIS seldom becomes invasive cancer, it is a

strong indicator of increased risk. Women with LCIS are 7

to 12 times more likely to develop invasive cancer in either

breast than women without LCIS.

Women with LCIS

have been estimated to have a 2% annual risk of being

diagnosed with invasive breast cancer.

Benign breast disease

Doctors often categorize benign breast conditions into 3

general groups reflecting the associated degree of cancer

risk: nonproliferative lesions, proliferative lesions without

atypia (abnormal cells or patterns of cells), and

proliferative lesions with atypia.

• Nonproliferative lesions are not associated with

overgrowth of breast tissue and include fibrosis

and simple cysts (also known as fibrocystic changes)

and mild hyperplasia. Nonproliferative conditions

are associated with little to no increased breast

cancer risk.

• Proliferative lesions without atypia are associated

with a small increase in the risk of breast cancer (1.5

to 2 times the risk of those who do not have one of

these lesions) and include usual ductal hyperplasia

(without atypia) and fibroadenoma.

• Proliferative lesions with atypia are associated with

about 4 times higher than average risk. These include

atypical ductal hyperplasia and atypical lobular

hyperplasia.

Benign breast conditions are most strongly associated

with risk for HR+ breast cancers. Women should keep

detailed records of any benign breast biopsy results,

as they are valuable for risk assessment, screening,

and counseling for chemoprevention and other risk-

reduction strategies.

Table 4. Factors That Increase the Relative Risk for

Breast Cancer in Women

Relative

Risk Factor

>4.0 Age (65+ versus <65 years, although risk increases across

all ages until age 80)

Biopsy-confirmed atypical hyperplasia

Certain inherited genetic mutations for breast cancer

(BRC A1 and/or BRCA2)

Ductal carcinoma in situ

Lobular carcinoma in situ

Mammographically dense breasts (compared to least

dense)

Personal history of early-onset (<40 years) breast cancer

Two or more first-degree relatives with breast cancer

diagnosed at an early age

2.1- 4.0 Personal history of breast cancer (40+ years)

High endogenous estrogen or testosterone levels

(postmenopausal)

High-dose radiation to chest

One first-degree relative with breast cancer

1.1-2.0 Alcohol consumption

Ashkenazi Jewish heritage

Diethylstilbestrol exposure

Early menarche (<12 years)

Height (tall)

High socioeconomic status

Late age at first full-term pregnancy (>30 years)

Late menopause (>55 years)

Never breastfed a child

No full-term pregnancies

Obesity (postmenopausal)/adult weight gain

Personal history of endometrium or ovarian cancer

Proliferative breast disease without atypia (usual ductal

hyperplasia and fibroadenoma)

Recent and long-term use of menopausal hormone therapy

containing estrogen and progestin

Recent oral contraceptive use

14 Breast Cancer Facts & Figures 2017-2018

Breast density

Breast tissue density is a mammographic indicator of the

amount of glandular and connective tissue relative to

fatty tissue. Compared to women with 11%-25% breast

density, those with 26%-50% or 50% or greater breast

density have about a 1.6 or 2.3 times, respectively, higher

risk of breast cancer.

About 43% of US women ages 40-74

have heterogeneously dense or extremely dense breasts

(BI-RADS C or D).

Breast density is influenced by

genetics, but generally decreases with age, pregnancy,

menopause, and higher body weight.

61, 62

Some drugs also

affect breast density, including tamoxifen (decreases

density) and combined menopausal hormone therapy

(increases density).

63, 64

Mammographic detection of breast cancer is impaired in

areas of dense breast tissue.

More than half of US states

now have laws requiring that mammography reports

include information about breast density.

Many states

with these laws also require that women with dense

breasts be told that they may benefit from supplemental

imaging tests, such as ultrasound or MRI. Digital breast

tomosynthesis is also useful in evaluating dense breasts.

However, there is currently no expert consensus about

what other tests, if any, should be done in addition to

mammograms to screen for breast cancer in women with

dense breasts.

67, 68

Height

Many studies have found that taller women have a higher

risk of breast cancer than shorter women.

69, 70

A recent study

from Europe found that an increase of 2 inches in height was

associated with about a 10% higher risk of breast cancer

diagnosis and death.

Height is also associated with a

number of other cancers, and although the reasons are

not fully understood, it may reflect differences in early

growth as well as hormonal or genetic factors.

Menstrual cycles

Breast cancer risk increases slightly for each year earlier

menstruation begins (by about 5%) and for each year

later menopause begins (by about 3%).

For example,

breast cancer risk is about 20% higher among girls who

begin menstruating before age 11 compared to those who

begin at age 13.

Likewise, women who experience

menopause at age 55 or older have about a 12% higher

risk compared to those who do so between ages 50-54.

The increased risk may be due to longer lifetime exposure

to reproductive hormones and has been more strongly

linked to HR+ breast cancer than other subtypes.

Bone mineral density

High bone mineral density in postmenopausal women

has been associated with a 60% to 80% increased risk for

breast cancer compared to low bone density; risk appears

to be most strongly related to HR+ disease.

74, 75

Bone

density is not thought to be an independent risk factor for

breast cancer, but a marker of cumulative estrogen

exposure.

However, because bone density is routinely

measured to identify women at increased risk for

osteoporosis (high bone density indicates absence of

osteoporosis), it also may be helpful for identifying

women at increased risk for breast cancer.

Endogenous hormone levels

Postmenopausal women with naturally high levels of

certain endogenous sex hormones have about twice the

risk of developing breast cancer compared to women with

the lowest levels, with the strongest relationships found for

HR+ tumors.

77, 78

High circulating hormone levels are

associated with, and may reflect, the effects of other breast

cancer risk factors, such as postmenopausal obesity and

alcohol use.

Although it is challenging to study the

relationship of hormones in premenopausal women

because levels vary across the menstrual cycle, a recent

large review found that high levels of circulating estrogens

and androgens are associated with a small increased risk

of breast cancer in premenopausal women.

Reproductive factors

Pregnancy

Having a first child before age 35 and having a greater

number of children is associated with decreased risk of

HR+ breast cancer.

In contrast, there appears to be a

transient increase in HR- breast cancer risk (lasting about

10 years) following a full-term pregnancy, particularly

among women who are older at first birth.

81, 82

Breast Cancer Facts & Figures 2017-2018 15

Fertility drugs

More research is needed on the relationship between

breast cancer risk and the long-term effects of ovulation-

stimulating drugs.

A long-term follow-up study of

women seen at 5 US fertility clinics found no association

with ever use of clomiphene or gonadotropins; however,

risk of invasive breast cancer was increased among

women who underwent more than 12 clomiphene

treatment cycles compared to women who had never

used fertility drugs.

Recently published results of a

long-term follow-up study of Dutch women who used

fertility drugs for in vitro fertilization (IVF), found no

overall association of breast cancer risk with IVF and a

significantly reduced risk of breast cancer among women

who had undergone seven or more IVF cycles.

Breastfeeding

Most studies suggest that breastfeeding for a year or more

slightly reduces a woman’s overall risk of breast cancer,

with longer duration associated with greater risk

reduction.

In a review of 47 studies in 30 countries, the

risk of breast cancer was reduced by 4% for every 12

months of breastfeeding.

One possible explanation for

this effect may be that breastfeeding inhibits

menstruation, thus reducing the lifetime number of

menstrual cycles.

Another possible explanation relates

to structural changes that occur in the breast following

lactation and weaning.

The protective effect may be

stronger for or even limited to triple negative cancers.

86, 89-90

Hormonal birth control

Studies suggest that recent use of oral contraceptives

(combined estrogen and progesterone) is associated with

a small increase in breast cancer risk, particularly among

women who begin use before 20 years of age or before

first pregnancy.

Risk appears to diminish when women

stop use, and after about 10 years, is similar to those who

have never taken oral contraceptives. Most of this

research considered high-dose estrogen formulations,

which were more common in the past. It is unclear if

newer, low-dose estrogen formulations increase breast

cancer risk.

Some, but not all, studies have found recent use of the

injectable progestin-only contraceptive depot-

medroxyprogesterone acetate (Depo-Provera) to be

associated with increased risk of breast cancer; however,

no association has been found with prior use (5 or more

years ago).

92-94

Studies of the levonorgestrel-releasing

intrauterine device (Mirena) have also produced

conflicting results.

95-98

Depo-Provera and Mirena have only

been in use since the 1990s, thus studies with additional

years of follow-up data are needed. Importantly, overall

breast cancer risk is low in young women, and most

studies suggest that any elevation in risk is temporary.

Postmenopausal hormones

Recent use of menopausal hormones (also referred to as

hormone therapy or hormone replacement therapy) with

combined estrogen and progestin increases the risk of

breast cancer, with higher risk associated with longer

use.

99, 100

Risk is also greater for women who start hormone

therapy soon after the onset of menopause compared to

those who begin later.

99, 101

Although discontinuation of

hormone use diminishes breast cancer risk, some increase

in risk seems to persist.

102

The increased risk associated

with estrogen and progestin therapy may be largely due

to increased mammographic density.

Postmenopausal estrogen-only therapy has been

associated with uterine problems (including endometrial

cancer), and is therefore only given to women who have

previously undergone hysterectomy. The effects of

estrogen-only therapy on breast cancer risk is less clear.

The US Preventive Services Task Force has concluded that

the use of estrogen alone is associated with reduced risk of

breast cancer based on results from the Women’s Health

Initiative randomized trial, which found that women who

used estrogen-only therapy for an average of 6 years had a

23% lower risk of developing breast cancer.

104

It should be

noted, however, that some observational studies have

found a slight increase in breast cancer risk among

estrogen therapy users, particularly among lean women

and those who begin therapy soon after menopause.

101, 105, 106

Conflicting results may reflect higher rates of screening

in menopausal hormone users, which were not controlled

for in the observational studies.

107

16 Breast Cancer Facts & Figures 2017-2018

Obesity, physical activity, and diet

Obesity and weight gain

Postmenopausal breast cancer risk is about 1.5 times

higher in overweight women and about 2 times higher in

obese women than in lean women.

108

This is likely due, in

part, to higher estrogen levels because fat tissue is the

largest source of estrogen in postmenopausal women, but

may also be related to other mechanisms, including the

higher levels of insulin among obese women.

109, 110

Obesity

is a risk factor for type II diabetes, which has also been

linked to increased risk for postmenopausal breast

cancer.

111, 112

A review of 40 studies concluded that breast

cancer risk was 16% higher in women with type II

diabetes independent of obesity.

113

Weight gain also increases risk of postmenopausal breast

cancer. A large meta-analysis recently concluded that each

5 kg (about 11 pounds) gained during adulthood increases

risk of postmenopausal breast cancer by 11%.

114

Notably,

the increased risk was only observed among women who

did not use menopausal hormones. Although some

studies have found weight loss to be associated with

reduced risk, results are inconsistent.

115-117

It is more

difficult to examine the effect of weight loss because it is

often not sustained.

In contrast, studies have found that obesity protects

against premenopausal breast cancer. A large meta-

analysis found that among women between 40 and 49

years of age, the risk for developing breast cancer was

about 14% lower in overweight women and 26% lower in

obese women compared to women who were normal

weight.

118

The underlying mechanisms for this inverse

relationship are not well understood, but the protective

effect may be limited to HR+/luminal A breast cancers.

Physical activity

Women who get regular physical activity have a 10%-20%

lower risk of breast cancer compared to women who are

inactive.

119

The protective effect is independent of BMI

and may be limited to women who have never used

menopausal hormone therapy.

119

A greater reduction in

risk is associated with increasing amounts of exercise and

more vigorous activity; however, even smaller amounts of

exercise, including walking, appear beneficial.

120

American Cancer Society study that included more than

73,000 postmenopausal women found that breast cancer

risk was 14% lower among women who reported walking 7

or more hours per week compared to women who walked

3 or less hours per week.

120

The benefit may be due to the

effects of physical activity on systemic inflammation,

hormones, and energy balance.

119, 121

What is the difference between absolute,

lifetime, and relative risks?

Absolute risk: Absolute risk is the likelihood of being

diagnosed with cancer over a certain period of time.

For example, 22 out of 10,000 women ages 50-54 will

be diagnosed with breast cancer in the next year.

Lifetime risk: Lifetime risk is the absolute risk of being

diagnosed with cancer over the course of a lifetime

from birth to death. Lifetime risk of breast cancer

reflects the average probability of a female being

diagnosed with breast cancer in the US. A woman

living in the US has a 12% chance of being diagnosed

with breast cancer in her lifetime (Table 2, page 4).

Another way to say this is that 1 out of every 8 women

will be diagnosed with breast cancer in her lifetime.

Relative risk: Relative risk compares the absolute risk

of disease among people with a particular risk factor

to the risk among people without that risk factor. If

the relative risk is above 1.0, then risk is higher among

those with the risk factor than among those without

the factor. Relative risks below 1.0 reflect an inverse

association between the exposure and the disease,

or a protective effect. For example, one study found

women ages 50-59 who were current users of combined

estrogen and progestin menopausal hormones had

a relative risk of developing breast cancer of 1.21, or

a 21% increased risk compared to women who have

not used hormone therapy.

100

While relative risks are

useful for comparisons, they do not provide information

about the absolute risk of the exposed group. In this

example, 33 breast cancers per year would be expected

to be diagnosed among 10,000 women ages 50-59

who use estrogen and progestin (that is the absolute

risk among this group). Among 10,000 women of the

same ages who never used menopausal hormones, 27

cases per year would be expected. Therefore, the 21%

increased relative risk results in a total of 6 additional

breast cancers diagnosed per 10,000 women per year.

Breast Cancer Facts & Figures 2017-2018 17

Diet

Numerous studies have examined the relationship

between food consumption (including fat, fiber, soy,

dairy, meat, and fruits and vegetables) and breast cancer

with mixed results. Although early diet and breast cancer

studies focused on fat intake, a recent meta-analysis

concluded there was no association.

122

It has been

suggested that soy consumption may reduce breast cancer

risk, in part because of historically low breast cancer rates

among Asian women. A meta-analysis showed that soy

intake was inversely associated with breast cancer risk in

Asian but not Western populations, perhaps because

Asian women generally consume more soy products

beginning at an earlier age than Western women.

123

There is growing evidence that high levels of fruit and/or

vegetable consumption may reduce the risk of HR- breast

cancer.

124-126

These findings are supported by studies

linking lower breast cancer risk to higher blood levels

of carotenoids (micronutrients found in fruit and

vegetables).

127-129

The effect of diet on breast cancer risk

remains an active area of research, with studies

particularly focused on timing of exposure, specific

dietary components, and risk differences by tumor

hormone receptor status.

Alcohol

Numerous studies have confirmed that alcohol

consumption increases the risk of breast cancer in

women by about 7%-10% for each 10g (roughly one drink)

of alcohol consumed per day on average.

Women who

have 2-3 alcoholic drinks per day have a 20% higher risk

of breast cancer compared to non-drinkers. There is also

evidence that alcohol consumption before first pregnancy

may particularly affect risk.

41, 130

One of the mechanisms

by which alcohol increases risk is by increasing estrogen

and androgen levels.

131

Alcohol use appears more strongly

associated with increased risk for HR+ than HR- breast

cancers.

132

Tobacco

Accumulating research indicates that smoking may

slightly increase breast cancer risk, particularly long-

term, heavy smoking and among women who start

smoking before their first pregnancy.

133-136

The 2014 US

Surgeon General’s report on smoking concluded that

there is “suggestive but not sufficient” evidence that

smoking increases the risk of breast cancer.

137

A review by

American Cancer Society researchers found that women

who initiated smoking before the birth of their first child

had a 21% higher risk of breast cancer than women who

never smoked.

135

Some studies suggest secondhand

smoke may increase risk, particularly for premenopausal

breast cancer.

133, 134

Environmental and other risk factors

Radiation

Radiation exposure has been shown to increase breast

cancer risk in studies of atomic bomb survivors and

females treated with high-dose radiation therapy to the

chest between 10 and 30 years of age, such as for Hodgkin

lymphoma.

138, 139

This may be because breast tissue is

most susceptible to carcinogens before it is fully

differentiated, which occurs with first childbirth.

140

Breast cancer risk starts to rise about 8 years after

radiation treatment and continues to be elevated for

more than 35 years.

139, 141

Although radiation treatments

have evolved to include lower doses given over smaller

areas, recent studies suggest that the elevated breast

cancer risk persists.

141, 142

Diethylstilbestrol exposure

From the 1940s through the 1960s, some pregnant

women were given the drug diethylstilbestrol (DES)

because it was thought to lower the risk of miscarriage.

These women have an increased risk (about 30%) of

developing breast cancer compared to women who have

not taken DES.

143

Some studies also suggest that women

whose mothers took DES during pregnancy also have a

slightly higher risk of breast cancer.

144

Environmental pollutants

In general, epidemiological studies have not found clear

relationships between environmental pollutants, such as

organochlorine pesticides, and breast cancer. Studies to

date have found no association between increased

concentrations of organochlorines (e.g., dichlorodiphenyl-

18 Breast Cancer Facts & Figures 2017-2018

trichloroethane or DDT) in blood and fat tissue and

breast cancer risk,

145-148

although a recent study found in

utero exposure to DDT was linked to breast cancer risk

later in life.

149

Animal studies have demonstrated that

prolonged, high-dose exposure to many industrial

chemicals can increase mammary tumor development,

but it is unknown whether the much lower dose

exposures that occur in the general environment in air,

drinking water, and consumer products increase human

breast cancer risk.

150

Night shift work

Most studies of nurses who work night shifts and flight

attendants who experience circadian rhythm disruption

caused by crossing multiple time zones have found

increased risks of breast cancer associated with long-

term employment.

151, 152

Elevated risk appears to be most

strongly associated with shift working during early

adulthood.

153

Exposure to light at night disrupts the

production of melatonin, a hormone that regulates sleep.

Experimental evidence suggests that melatonin may also

inhibit the growth of small, established tumors and

prevent new tumors from developing.

154

Based on the

results of studies in humans and animals, the

International Agency for Research on Cancer concluded

in 2007 that shift work, particularly at night, was

probably carcinogenic to humans.

155

Shift work at night is

a common exposure, involving about 15% to 20% of

workers in the US and Europe, and much of the

population in industrialized countries is exposed to

artificial light at night.

Factors that are not associated

with breast cancer risk

Abortion

There are persistent claims that women who have had an

abortion are at increased risk for developing breast cancer

based on early studies that have since been deemed

methodologically flawed by the American College of

Obstetricians and Gynecology.

156

Indeed, a large body of

solid scientific evidence, including a review by a panel of

experts convened by the National Cancer Institute in

2003, confirms that there is no link between breast

cancer and abortion (either spontaneous or induced).

157

Bras

Although internet rumors have suggested that bras cause

breast cancer by obstructing lymph flow, there is no

scientific basis or evidence to support this claim. A recent

population-based study of more than 1,500 women found

no association between wearing a bra and breast cancer.

158

Breast implants

No association has been found between breast implants

and risk of breast cancer; however, there is evidence that

women with implants are at increased risk of a rare type of

lymphoma.

159

Breast implants can also obstruct the view of

breast tissue during mammography. A woman with breast

implants should inform the mammography facility about

the implants during scheduling so that additional x-ray

pictures (called implant displacement views) may be used

to allow for more complete breast imaging.

Hair dyes, relaxers, and antiperspirants

Although one recent study suggested that selected hair

products may be associated with breast cancer, most

studies have failed to reveal any correlation.

160

combined analysis of 14 studies found no association

between the use of permanent hair dyes and breast

cancer.

161

A study of more than 48,000 black women found

no link to breast cancer with use of hair relaxers.

162

Although antiperspirant use has been less well-studied,

there is presently no convincing scientific evidence of an

association with breast cancer.

163, 164

Chemoprevention and

prophylactic surgery

Chemoprevention

The use of drugs to reduce the risk of disease is called

chemoprevention. Currently, the US Food and Drug

Administration (FDA) has approved two drugs for the

prevention of breast cancer in high-risk women:

tamoxifen and raloxifene (postmenopausal women only).

These drugs are classified as selective estrogen receptor

modulators (or SERMs) because they block estrogen in

some tissues of the body, but act like estrogen in others.

A recent meta-analysis, including more than 83,000

high-risk women, found that SERMs reduced breast

Breast Cancer Facts & Figures 2017-2018 19

cancer risk by 38% over 10 years.

165

Although the benefit

is limited to ER+ disease, these drugs lower the risk of

both invasive cancer and ductal carcinoma in situ.

However, SERMs are associated with some side effects,

including hot flashes, nausea, and fatigue. Premenopausal

women taking tamoxifen can also experience menstrual

changes. More serious side effects are rare, but include

blood clots and endometrial cancer.

165

Clinical trials are examining another class of drugs –

aromatase inhibitors – to see if they may also be effective

for reducing breast cancer risk among postmenopausal

women. Currently, these drugs are only approved to

prevent breast cancer recurrence. Aromatase inhibitors

target the enzyme responsible for producing estrogen in

fat tissue, and thus are only effective in women without

functioning ovaries (e.g., postmenopausal women),

because ovaries are the primary source of estrogen before

menopause. Early clinical trial results are promising:

breast cancer risk was reduced by more than half in

high-risk women taking anastrozole or exemestane

compared to placebo.

166, 167

Women taking aromatase

inhibitors must be monitored for osteoporosis, as these

medications can decrease bone density.

Prophylactic surgery

Women at very high risk of breast cancer (such as those

with BRCA gene mutations) may elect prophylactic

(preventive) mastectomy. This operation removes one or

both breasts. Removing both breasts before cancer is

diagnosed reduces the risk of breast cancer by 90% or

more.

168

Prophylactic salpingo-oophorectomy (surgical

removal of the fallopian tubes and ovaries) has also been

shown to reduce the risk of both breast and ovarian

cancers,

169, 170

but a recent study found that the breast

cancer benefit may be limited to women who carry

BRCA2 mutations.

171

Importantly, however, not all women

who elect to have these surgeries would have developed

cancer. A woman considering prophylactic surgery

should discuss the benefits and limitations with her

doctor and a second opinion is strongly recommended.

See page 25 for further discussion of contralateral

prophylactic mastectomy.

Breast Cancer Screening

American Cancer Society recommendations for the early

detection of breast cancer vary depending on a woman’s

age and include mammography, as well as magnetic

resonance imaging (MRI) for women at high risk. In 2015,

the American Cancer Society updated its breast cancer

screening guideline for average-risk women.

172

Mammography

Mammography is a low-dose x-ray procedure that allows

visualization of the internal structure of the breast. There

are three main types of mammography: screen-film,

digital, and digital breast tomosynthesis. Screen-film

mammography uses x-ray equipment to record images.

Digital mammography, which uses more specialized

computerized equipment to capture a digital image of the

breast and delivers lower doses of radiation, has largely

replaced film mammography. Studies have shown that

digital mammograms are more accurate for women under

the age of 50 and those with dense breast tissue.

173-175

In 2011, the FDA approved the use of digital breast

tomosynthesis or 3-dimensional (3-D) mammography,

which constructs a 3-D image of the breast with multiple

high-resolution x-rays, to be used in combination with a

2-D digital mammography image. The benefits and

limitations of tomosynthesis in community practice are

still being assessed. Recent studies suggest that the

addition of breast tomosynthesis to digital mammography

may reduce false positives and slightly improve cancer

detection compared to digital mammography alone.

176-178

However, when the 2-D images are produced separately

from the tomographic images, women receive about twice

the radiation dose. Recently, the FDA approved the use of

tomographic images to produce synthetic, conventional

2-D images, thus reducing the radiation dose to that

similar to conventional digital mammography. This

20 Breast Cancer Facts & Figures 2017-2018

newer type of mammographic screening is not yet

available in all communities and may not be fully covered

by health insurance.

For women at average-risk of breast cancer, the American

Cancer Society recommends that those 40 to 44 years of

age have the option to begin annual mammography; those

45 to 54 years should undergo annual mammography;

and those 55 years of age or older may transition to

biennial mammography or continue with annual

mammograms. Women should continue screening as

long as their overall health is good and they have a life

expectancy of 10 years or more.

It is especially important that women are regularly

screened to increase the chance that a breast cancer is

detected early before it has spread. Recommended

screening intervals are based on the duration of time a

breast cancer is detectable before symptoms develop.

Combined results from randomized controlled screening

trials suggest that mammography reduces the risk of

dying from breast cancer by about 20%, whereas studies

of modern mammography screening programs in Europe

and Canada found that the risk of breast cancer death

among women exposed to screening was reduced by

more than 40%.

179-181

Early detection of breast cancer by

mammography also leads to a greater range of treatment

options, including less-extensive surgery (e.g., breast-

conserving surgery like lumpectomy versus mastectomy)

and the use of chemotherapy with fewer serious side effects,

or sometimes, the option to forgo chemotherapy.

However, mammography screening does have limitations

or potential harms, which are described below.

The Affordable Care Act requires that Medicare and all

new health insurance plans fully cover screening

mammograms without any out-of-pocket expense for

patients. For help locating a free or low-cost screening

mammogram in your area, contact the American Cancer

Society at 1-800-227-2345.

False-positive results

Mammography sometimes leads to follow-up

examinations, including biopsies, when there is no

cancer, referred to as false-positive test results. A false

positive is most likely following a woman’s initial

screening mammogram.

182

Other factors that increase

the likelihood of a false positive include the use of

postmenopausal hormone therapy and having more

American Cancer Society Guideline for

Breast Cancer Screening, 2015

172

These recommendations represent guidance

from the American Cancer Society for women at

average risk of breast cancer, i.e., women without

a personal history of breast cancer, a suspected

or confirmed genetic mutation known to increase

risk of breast cancer (e.g., BRCA), or a history of

previous radiotherapy to the chest at a young age.

We recommend that all women should become

familiar with the potential benefits, limitations, and

harms associated with breast cancer screening.

Recommendations*:

1. Women with an average risk of breast cancer

should undergo regular screening mammography

starting at age 45 years (strong recommendation).

• Women should have the opportunity to

begin annual screening between the ages of

40 and 44 (qualified recommendation).

• Women who are age 45 to 54 should be screened

annually (qualified recommendation).

• Women who are age 55 and older should transition to

biennial screening or have the opportunity to continue

screening annually (qualified recommendation).

2. Women should continue screening

mammography as long as their overall health

is good and they have a life expectancy of 10

years or more (qualified recommendation).

3. The American Cancer Society does not

recommend clinical breast examination for breast

cancer screening among average-risk women

at any age (qualified recommendation).

*A strong recommendation conveys the consensus that the benefits of

adherence to that intervention outweigh the undesirable effects that may

result from screening. Qualified recommendations indicate there is clear

evidence of the benefit of screening but less certainty about either the balance

of benefits and harms, or about patients’ values and preferences, which

could lead to different decisions about screening.

Breast Cancer Facts & Figures 2017-2018 21

mammographically dense breast tissue.

182, 183

On average,

1 in 9 women are recalled from each screening

examination for further testing (most often additional

mammographic views), but most (95%) do not have

cancer.

184

According to one US study, over the course

of 10 screening examinations, about one-half of women

experience a false positive, and about 19% undergo biopsy

but do not have cancer.

185

Overdiagnosis

Mammography likely results in some overdiagnosis; that

is, the diagnosis of cancer that would not cause a woman

any harm in her lifetime and that would not have

progressed or otherwise been detected in the absence of

screening. There are two circumstances that can lead to

overdiagnosis. The first is a breast cancer is diagnosed by

screening in a woman who dies shortly afterward from a

cause other than breast cancer. National guidelines

recommend against screening in women who are very ill

or have limited life expectancy. The second, which is

more difficult to measure, is the detection of a truly

non-progressive in situ or invasive cancer. Estimates of

the prevalence of overdiagnosis are highly variable,

ranging from <5% to more than 30%.

186-191

Radiation exposure

The dose of radiation during a mammogram is very small

and the risk of harm is minimal.

192, 193

Limitations of mammography

Not all breast cancer will be detected early by a

mammogram, and some cancers that are screen-detected

still have poor prognosis. Most women will never be

diagnosed with breast cancer, but will undergo regular

screening and may experience one or more “false alarms.”

In an effort to maximize the benefits and minimize the

harms of screening, some scientists are attempting to

determine which factors could be used to individualize

screening recommendations (e.g., which women could

start screening at older ages and/or be screened less

often).

194

Despite these limitations, mammography is the single

most effective method of early breast cancer detection

since it can often identify cancer several years before

physical symptoms develop. It is the position of the

American Cancer Society that the balance of benefits to

possible harms strongly supports the value of regular

breast cancer screening in women for whom it is

recommended.

Table 5. Prevalence of Mammography (%), Women

40 and Older, US, 2015

Characteristic

Within

the past

year

Within

the past

two years

Overall 50 64

Age (years)

40-44 38 49

45-54 54 69

55+ 53 68

Race/Ethnicity

Non-Hispanic White 50 65

Non-Hispanic Black 55 69

Asian American 47 59

American Indian and Alaska Native 46 60

Hispanic/Latina 46 61

Education

Some high school or less 39 51

High school diploma or GED 45 58

Some college/Assoc. degree 51 66

College graduate 58 73

Sexual orientation

Gay/Lesbian 62 78

Straight 50 64

Bisexual * *

Health insurance status (ages 40-64)

Uninsured 21 31

Insured 53 68

Immigration

Born in US 51 66

Born in US territory 47 59

In US fewer than 10 years 33 46

In US 10 or more years 47 60

Region

Northeast 54 67

Midwest 51 63

South 50 65

West 47 63

GED = General Educational Development high school equivalency. *Estimate

not provided due to instability. Note: Estimates are age adjusted to the 2000 US

standard population. Mammography prevalence estimates do not distinguish

between examinations for screening and diagnosis.

Source: National Health Interview Survey, 2015.

American Cancer Society, Surveillance Research, 2017

22 Breast Cancer Facts & Figures 2017-2018

Prevalence of mammography

According to the 2015 National Health Interview Survey,

50% of women 40 years of age and older reported having

had a mammogram within the past year and 64%

reported having a mammogram in the past 2 years

(Table 5, page 21).

195

Among women 40 years of age and

older, mammography prevalence increased from 29% in

1987 to 70% in 2000, and has since gradually declined.

Women who have less than a high school education, who

have no health insurance coverage, or who are recent

immigrants to the US are least likely to have had a recent

mammogram. Efforts to increase screening should

specifically target socioeconomically disadvantaged

women and recent immigrants.

Table 6 shows the percentage of US women 40 years of

age and older who have had a recent mammogram by

state, based on data from the 2014 Behavioral Risk Factor

Surveillance System.

196

Among women of all races

combined 40 years of age and older, reported rates of

mammograms in the past 2 years range from 62% in

Idaho to 82% in Massachusetts.

The Centers for Disease Control and Prevention’s

National Breast and Cervical Cancer Early Detection

Program (NBCCEDP) was established in 1990 to improve

access to breast cancer screening and diagnostic services

for low-income women and was recently shown to help

save lives from breast cancer.

197

However, the CDC

estimates that the program is currently only reaching

about 11% of eligible women due in part to funding

shortages.

198

Magnetic resonance imaging (MRI)

An expert panel convened by the American Cancer

Society published recommendations for the use of MRI

for screening women at increased risk for breast cancer in

2007.

199

The panel recommended annual MRI screening

in addition to mammography for women at high lifetime

risk (~20%-25% or greater) beginning at 30 years of age.

Women at moderately increased risk (15%-20% lifetime

risk) should talk with their doctors about the benefits

and limitations of adding MRI screening to their yearly

mammogram. MRI screening is not recommended for

women whose lifetime risk of breast cancer is less than

15%. Studies indicates that although MRI is underutilized

among high-risk women, it is often used in women who

are not at high risk for breast cancer.

200

MRI uses magnetic fields instead of x-rays to produce

very detailed, cross-sectional images of the body. A

contrast material (usually gadolinium) is injected into a

vein to improve the ability to capture detailed images of

breast tissue. It is important that screening MRIs are

done at facilities that can perform an MRI-guided breast

biopsy if abnormalities are found. Otherwise, the scan

must be repeated at another facility if a biopsy is

necessary. Although MRI is more expensive than

mammography, most major insurance companies will

cover some portion of the costs if a woman can be shown

to be at high risk. MRIs should supplement, but not

replace, mammography screening.

Breast ultrasound

Breast ultrasound is sometimes used to evaluate abnormal

findings from a mammogram or physical exam. Studies

have shown that ultrasound detects more cancer than

mammography alone when screening women with

mammographically dense breast tissue; however, it also

increases the likelihood of false-positive results.

67, 201

The

use of ultrasound instead of mammograms for breast

cancer screening is not recommended.

Clinical breast examination (CBE)

The American Cancer Society no longer recommends

CBE for average-risk asymptomatic women based on lack

of clear benefits for CBE alone or in conjunction with

mammography. Compared to mammography alone, CBE

plus mammography has been shown to detect only a

small additional proportion of breast cancer tumors and

increases the probability of false positives.

202, 203

Breast self-awareness

Although the American Cancer Society no longer

recommends that all women perform monthly breast

self-exams (BSE), all women should become familiar with

both the appearance and feel of their breasts and report

Breast Cancer Facts & Figures 2017-2018 23

Table 6. Prevalence of Mammography* (%) by State, Women 40 and Older, 2014

Within the past year Within the past two years

All NH White NH Black

Uninsured

(Ages

40-64) All NH White NH Black

Uninsured

(Ages

40-64)

United States (median)* 56 56 60 27 73 72 77 43

Range 45-68 45-68 40-71 16-46 62-82 62-83 55-89 29-68

Alabama 57 55 65 27 73 71 80 39

Alaska 45 45 * 25 63 62 * 40

Arizona 54 54 55 38 71 72 74 51

Arkansas 49 49 53 21 65 65 66 29

California 60 59 71 44 77 77 89 56

Colorado 51 52 58 28 69 69 86 44

Connecticut 64 64 65 34 80 80 82 54

Delaware 63 64 63 37 79 80 78 68

District of Columbia 53 52 56 * 75 72 79 *

Florida 58 58 62 27 74 74 79 46

Georgia 60 57 67 35 75 73 81 52

Hawaii 65 62 * 34 79 76 * 52

Idaho 47 47 * 19 62 63 * 34

Illinois 55 55 56 17 74 72 79 46

Indiana 52 52 58 22 67 67 74 35

Iowa 62 62 * 28 76 76 * 37

Kansas 56 57 57 26 71 72 75 39

Kentucky 61 60 64 27 75 74 78 37

Louisiana 58 56 61 36 75 74 77 53

Maine 63 63 * 28 78 79 * 43

Maryland 63 62 70 41 79 78 84 60

Massachusetts 68 68 64 46 82 83 75 59

Michigan 58 58 59 26 76 76 80 44

Minnesota 61 61 63 39 77 77 75 56

Mississippi 53 53 58 29 68 67 71 42

Missouri 55 54 64 25 68 67 77 34

Montana 50 51 * 23 69 69 * 41

Nebraska 53 54 56 16 70 71 69 30

Nevada 52 51 40 22 70 69 54 44

New Hampshire 62 62 * 35 79 79 * 51

New Jersey 59 57 64 33 74 74 75 51

New Mexico 49 50 * 24 66 67 * 38

New York 60 59 63 40 75 74 78 53

North Carolina 63 63 65 28 77 77 78 46

North Dakota 56 57 * 33 72 73 * 43

Ohio 56 55 65 25 72 71 82 35

Oklahoma 51 52 51 23 66 66 67 37

Oregon 54 54 * 26 70 71 * 36

Pennsylvania 57 57 60 19 73 73 77 37

Rhode Island 65 66 54 34 81 81 78 47

South Carolina 54 53 59 22 72 71 77 36

South Dakota 61 61 * 27 75 75 * 48

Tennessee 56 55 61 22 73 72 78 37

Texas 54 55 58 35 71 71 76 51

Utah 49 50 * 19 66 67 * 33

Vermont 56 57 * 25 74 75 * 37

Virginia 60 58 69 31 75 74 84 51

Washington 53 54 54 20 71 72 72 32

West Virginia 56 56 50 20 72 72 71 31

Wisconsin 59 60 57 * 74 75 67 32

Wyoming 47 47 * 21 65 66 * 40

NH: non-Hispanic. *Estimate not provided due to instability.

Source: Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, public use data file, 2014.

24 Breast Cancer Facts & Figures 2017-2018

any changes promptly to their physician. Experts have

concluded that self-awareness seems to be at least as

effective for detecting breast cancer as structured BSE.

204-206

If symptoms develop, women should contact a doctor

immediately, even after a recent normal mammogram.

However, most lumps are not abnormal, and for women

who are still menstruating, they can appear and

disappear with the menstrual cycle. Most breast lumps

are not cancerous.

Breast Cancer Treatment

Treatment decisions are made jointly by the patient and

the physician after consideration of the stage and

biological characteristics of the cancer, the patient’s age,

menopausal status, and preferences, and the risks and

benefits associated with each option.

In Situ

Since there is no certain way to determine the progressive

potential of a DCIS lesion, surgery and sometimes

radiation and/or hormone therapy is the usual course of

action following a diagnosis of DCIS. However, there may

be a group of patients that could safely forgo surgical

treatment for DCIS. Several clinical trials are underway

that are comparing standard treatment to active

monitoring in women with low-risk DCIS.

207-209

Research

is also ongoing to identify molecular markers of DCIS

that could predict recurrence or progression to invasive

cancer.

210

Classic LCIS does not require surgical treatment, but

there is no consensus about optimal treatment for more

aggressive (pleomorphic) LCIS.

56, 211

Invasive

Figure 11 shows treatment patterns among US women

with invasive breast cancer in 2013. Most women with

early-stage breast cancer will have some type of surgery,

which is often combined with other treatments to reduce

the risk of recurrence, such as radiation therapy,

chemotherapy, hormone therapy, and/or targeted

therapy. Patients with metastatic disease are primarily

treated with systemic therapies, which can include

chemotherapy, targeted therapy, and hormonal therapy.

Surgery

The primary goals of breast cancer surgery are to remove

the cancer and determine its stage. Surgical treatment

involves breast-conserving surgery (BCS) or mastectomy.

With BCS (also known as partial mastectomy or

lumpectomy), only cancerous tissue, plus a rim of normal

tissue (tumor margin), is removed. BCS is generally not

an option in those with a high tumor-to-breast ratio,

those with multicentric cancers, or those with

inflammatory or locally advanced cancers. In most cases,

BCS needs to be followed by radiation to the breast, and

thus patients who are not candidates for breast

radiotherapy, such as those who had previous breast

radiation, are also not candidates for BCS. Simple or total

mastectomy includes removal of the entire breast.

Modified radical mastectomy includes removal of the

entire breast, plus a full axillary lymph node dissection

(see below for discussion of lymph node procedures).

Radical mastectomy is rarely performed anymore

because removal of the underlying chest muscles is not

necessary to remove all of the cancer in most patients.

Long-term results of multiple international, randomized

clinical trials have found equivalent survival for the

majority of patients with stage I or II breast cancer who

have BCS followed by radiation or mastectomy.

212, 213

Some more recent, observational studies even suggest

possible improved survival and reduced recurrence rates

with BCS.

214-217

In addition, risk of complications is nearly

twice as high for women who undergo mastectomy with

reconstruction compared to BCS plus radiation.

218

Nevertheless, many BCS-eligible women continue to

undergo mastectomy.

219, 220

Reasons include reluctance to

undergo radiation therapy after BCS and fear of

recurrence.

221

Younger women (those under 40 years of

Breast Cancer Facts & Figures 2017-2018 25

age), patients with larger and/or more aggressive tumors,

and those who live farther from their treatment facility

are also more likely to undergo mastectomy.

219, 221-223

Some women who are diagnosed with breast cancer in

one breast choose to have the unaffected breast removed

as well. This is known as contralateral prophylactic

mastectomy (CPM) or bilateral mastectomy. Recent

studies have shown marked increases in the rate of CPM

for women diagnosed with invasive breast cancer, as well

as DCIS.

220, 224-226

Although CPM greatly reduces the risk of

developing a new breast cancer, it does not improve

long-term breast cancer survival for the vast majority of

women and doubles the risk of surgical complications.

227, 228

Both BCS and mastectomy are usually accompanied by

removal of one or more regional lymph nodes from the

axilla to determine if the disease has spread beyond the

breast and help stage the cancer. The presence of cancer

cells in the lymph nodes increases the risk of recurrence,

and so can help determine the need for further

treatment. Sentinel lymph node biopsy (SLNB) involves

removing and testing selected lymph nodes before any

others are excised. Although cancer in sentinel lymph

nodes was traditionally an indication for additional

axillary lymph node surgery, studies have shown that it

may not be necessary when cancer cells are found only in

1 or 2 sentinel lymph nodes in patients undergoing BCS

with whole breast radiation.

229, 230

A full axillary lymph

node dissection (ALND) is often indicated for patients

with one or more axillary lymph nodes found to contain

cancer prior to surgery. Ongoing clinical trials are

investigating the safety of avoiding ALND in patients who

were initially diagnosed with lymph node-positive breast

cancer, but have small tumors or in whom neoadjuvant

chemotherapy appears to have eliminated cancer in the

lymph nodes. Patients should talk with their doctors to

determine what lymph node procedure is planned for

their surgery.

Surgery (and/or radiation therapy) involving the axillary

lymph nodes can lead to lymphedema, a serious swelling

of the arm caused by retention of lymph fluid. It affects

about 20% of women who undergo ALND and 6% of

patients who receive SLNB.

231

There are several effective

therapies for lymphedema, and some evidence suggests

that upper-body exercise and physical therapy may reduce

the risk and lessen the severity of this condition.

232, 233

Women who undergo mastectomy may have breast

reconstruction, either with a saline or silicone implant,

tissue from another part of the body, or a combination of

the two. Breast reconstruction among US women

undergoing mastectomy has increased from 12% in 1998

Figure 11. Female Breast Cancer Treatment Patterns (%), by Stage, 2013, US

BCS = breast-conserving surgery; RT = radiation therapy; chemo = chemotherapy and includes targeted therapy and immunotherapy drugs.

Source: National Cancer Data Base, 2013.

American Cancer Society, Inc., Surveillance Research, 2017

Stage IVStage IIIStages I and II

Percent

1717

1 1 1 1

3 3

7 7

4 4

2 2 2 2 2 2 2 2

BCS alone

BCS + RT

BCS + RT + chemo

BCS + chemo

Mastectomy alone

Mastectomy + RT

Mastectomy + chemo

Mastectomy + RT + chemo

RT and/or chemo

No surgery, RT, or chemo

26 Breast Cancer Facts & Figures 2017-2018

to 36% in 2011.

220

A woman considering breast

reconstruction should discuss this option with her breast

surgeon prior to the mastectomy in order to coordinate

the treatment plan with a plastic surgeon. Some types of

reconstruction can begin during the mastectomy itself,

and reconstruction influences the time spent in the

hospital after a procedure, as well as the recovery time.

The cosmetic appearance of immediate reconstruction

can be negatively affected by subsequent radiotherapy.

Women who do not choose reconstruction prior to

surgery can opt to undergo reconstruction later. Since

1998, the Women’s Health and Cancer Rights Act has

required group health plans, insurance companies, and

health maintenance organizations that offer mastectomy

coverage to also pay for reconstructive surgery.

Reconstruction is also covered by Medicare and

Medicaid, though Medicaid benefits vary by state.

Radiation therapy

Radiation therapy is the use of high-energy beams or

particles to kill cancer cells and is often used after surgery

to destroy cancer cells remaining in the breast, chest

wall, or underarm area. BCS is almost always followed by

radiation therapy to the breast because it has been shown

to reduce the risk of cancer recurrence by about 50% at 10

years and the risk of breast cancer death by almost 20% at

15 years.

213

However, radiation is not necessary in women

70 years of age and older with small, lymph node-negative,

HR+ cancers, because it hasn’t been shown to improve

survival in patients who take hormonal therapy for at

least five years.

234

Some mastectomy-treated patients also

benefit from radiation if their tumor is larger than 5 cm,

growing in to nearby tissues, or if cancer is found in the

lymph nodes. Radiation can also be used to treat the

symptoms of advanced breast cancer, especially when it

has spread to the central nervous system or bones.

Radiation therapy may be administered as external beam

radiation, brachytherapy, or a combination of both. The

method depends on the type, stage, and location of the

tumor, as well as patient characteristics, and doctor and

patient preference. External beam radiation is the

standard type of radiation, whereby radiation from a

machine outside the body is focused on the area affected

by cancer. Traditionally, external beam radiation therapy

is administered 5 days per week over 5 to 7 weeks, but in

select patients a 3-week course appears to be as

effective.

235, 236

Brachytherapy uses a radioactive source

placed in catheters or other devices that are put into the

cavity left after BCS and is sometimes an option for

patients with early-stage breast cancers. Intracavitary

brachytherapy is typically given daily for 5 days.

Accumulating evidence suggests intracavity brachytherapy

may be as effective as whole breast radiation for selected

patients, but deliverable in less time and with fewer side

effects.

237-240

However, most studies of intracavitary

brachytherapy have not followed patients for more than 5

years, so its long-term efficacy as compared to whole

breast radiation has not been established.

For intraoperative radiation therapy, a single dose of

radiation is administered to the tumor bed during

breast-conserving surgery. It can be used instead of

intracavitary brachytherapy but is only available at

limited centers.

241

Systemic therapy

Systemic therapy is treatment that travels through the

bloodstream and affects and treats almost all parts of the

body. Systemic therapy includes chemotherapy, hormone

therapy, and targeted therapy, all of which work through

different mechanisms. For example, chemotherapy drugs

generally work by attacking cells that grow quickly, such

as cancer cells. Hormone therapy works by either blocking

the body’s natural hormones or lowering the levels of

those hormones, which can act to promote the growth of

some cancers. Targeted drugs work by attacking specific

molecules in or on cells that may be more common or

active in cancer cells.

When systemic treatment is given to patients before

surgery, it is called neoadjuvant or preoperative therapy.

For larger breast tumors, it is often used to shrink the

tumor enough to make surgical removal easier and less

extensive (such as BCS in women who would otherwise

have required mastectomy). Neoadjuvant systemic

therapy has been found to be as effective as the same

therapy given after surgery in terms of survival and distant

recurrence.

242

Systemic treatment given to patients after

surgery is called adjuvant therapy. It is used to kill any

Breast Cancer Facts & Figures 2017-2018 27

undetected tumor cells (micrometastases) that may have

migrated to other parts of the body. Systemic therapy is

the main treatment option for women with metastatic

breast cancer.

Chemotherapy

The benefit of chemotherapy is dependent on multiple

factors, including the size of the tumor, the number of

lymph nodes involved, the presence of estrogen or

progesterone receptors, and the presence of HER2

overexpression on the cancer cells. Triple negative and

HER2+ breast cancers tend to be more sensitive to

chemotherapy than HR+ tumors.

243

There are also gene

expression panels (such as Oncotype DX, PAM 50, and

MammaPrint) that can help assess the risk of distant

recurrence in women with early-stage, HR+, HER2- breast

cancers, and potentially identify those who would more

likely benefit from chemotherapy, as well as those who

could safely avoid it. The Oncotype Dx 21-Gene

Recurrence Score is used most widely in the United

States; a high score identifies women who would more

likely benefit from adjuvant chemotherapy (in addition to

hormone therapy) whereas a low score identifies women

who could safely avoid it.

244

These scores are independent

of patient age and tumor size. Clinical trials are currently

underway to further evaluate the predictive value of

some of these tests in women with intermediate risk

scores and those with node positive disease.

Research has established that combinations of drugs are

more effective than one drug alone for treatment of

early-stage breast cancer, and several options exist when

selecting a chemotherapy regimen. Depending on the

combination of drugs used, adjuvant and neoadjuvant

chemotherapy is usually given for 3 to 6 months. This

treatment is most effective when the full dose and cycle

of drugs are completed in a timely manner, without

significant delays or interruption.

Hormone (anti-estrogen) therapy

Estrogen, a hormone produced by the ovaries in addition

to other tissues, promotes the growth of HR+ breast

cancers. Patients with these tumors can be given

hormone therapy to lower estrogen levels or block the

effects of estrogen on the growth of breast cancer cells.

These drugs are different than menopausal hormone

therapies, which actually increase hormone levels.

Hormone therapy for breast cancer can be different in

premenopausal and postmenopausal women.

Tamoxifen is a treatment that blocks the effects of

estrogen in breast tissue but has estrogenic effects in

other tissues, such as the liver, uterus, and bones.

Tamoxifen can be used to treat both early- and

advanced-HR+ breast cancer in both pre- and

postmenopausal women. Adjuvant treatment of early-

stage HR+ breast cancer with tamoxifen for at least 5

years has been shown to reduce the rate of recurrence by

approximately 40%-50% throughout the first decade, and

reduces breast cancer mortality by about one-third

throughout the first 15 years.

245

More recently, studies

have shown that extended use of adjuvant tamoxifen (10

years versus 5 years) further reduces the risk of breast

cancer recurrence and mortality, so clinical practice

guidelines now recommend consideration of adjuvant

tamoxifen therapy for 10 years.

247

Aromatase inhibitors (AIs), such as letrozole, anastrozole,

and exemestane, are another class of drugs used to treat

both early- and advanced-HR+ breast cancer. Clinical trials

in postmenopausal women have demonstrated a small

advantage to including an AI initially or over the course

of treatment rather than 5 years of tamoxifen alone.

248

Treatment guidelines recommend AIs should usually be

included in the treatment of postmenopausal women with

HR+ breast cancer.

247

Although AIs have fewer serious

side effects than tamoxifen, they can cause osteoporosis

(with resulting bone fractures), joint pain, and other

musculoskeletal symptoms because they completely

deplete postmenopausal women of estrogen. Clinical

trials continue to assess the optimal timing and duration

of these treatments.

The mainstay of treatment for most premenopausal

women with HR+ tumors is tamoxifen. Some women may

also benefit from surgical removal (oophorectomy) or

chemical suppression of the ovaries, which are the main

source of estrogen prior to menopause. Potentially

reversible ovarian suppression can be achieved with a

class of drugs called luteinizing hormone-releasing

hormone (LHRH) analogs. Ovarian suppression can also

28 Breast Cancer Facts & Figures 2017-2018

allow the use of AIs in premenopausal women. Initial

results from two ongoing clinical trials comparing

premenopausal early-stage breast cancer patients treated

with ovarian suppression, plus either an AI or tamoxifen,

found greater reduction in risk of recurrence with AIs.

249

Adding ovarian suppression to tamoxifen or aromatase

inhibitors has been shown to improve survival in

premenopausal women with advanced (metastatic) HR+

breast cancer.

250

Fulvestrant is another treatment used to

treat metastatic breast cancer. It is an anti-estrogen drug

given by intramuscular injection that reduces the number

of estrogen receptors and blocks estrogen binding.

Targeted therapy

About 17% of breast cancers overproduce the growth-

promoting protein HER2/neu, and multiple medications

are now approved for the treatment of this subtype.

Trastuzumab, the first approved drug, is a monoclonal

antibody that directly targets the HER2 protein. The

combined results of two large trials indicate that adding

trastuzumab to standard chemotherapy for early-stage

HER2+ breast cancer reduces the risk of recurrence and

death by 52% and 33%, respectively, compared to

chemotherapy alone.

251

This drug is also a standard part

of the treatment for advanced HER2+ breast cancer.

Several newer drugs have been developed that target the

HER2 protein that can be used in combination with

trastuzumab or if trastuzumab is no longer working. All

invasive breast cancers should be tested for the HER2

gene amplification or protein overexpression to identify

women who would benefit from this therapy.

Other types of targeted therapies can be used along with

aromatase inhibitors in women with HR+ breast cancer,

where they have been shown to make these hormone

therapies more effective.

What Is the American Cancer Society

Doing About Breast Cancer?

As an organization of nearly 2 million strong, the American

Cancer Society is committed to a world free from the

pain and suffering of breast cancer – and all cancers.

Prevention, Early Detection,

and Treatment

The American Cancer Society is doing everything in our

power to help prevent breast cancer – and all cancers. We

promote healthy lifestyles by issuing cancer guidelines

for prevention and early detection, helping people avoid

tobacco, and reducing barriers to healthy eating and

exercise. For those who are diagnosed, we’re there every

minute of every day.

Information, 24 hours a day, seven days a week

The American Cancer Society is available 24 hours a day,

seven days a week online at

cancer.org

and by calling us at

1-800-227-2345. Callers are connected with caring,

trained American Cancer Society staff who can help

them locate a hospital, understand breast cancer and

treatment options, learn what to expect and how to plan,

address insurance concerns, find financial resources,

find a local support group, and more. We can also help

people who speak languages other than English or

Spanish find the assistance they need, offering services in

more than 200 languages.

People can visit

cancer.org/breastcancer

to find information

on every aspect of the breast cancer experience, from

prevention to survivorship. We also publish a wide variety

of pamphlets and books that cover a multitude of topics,

from patient education, quality-of-life and caregiving

issues to healthy living. Visit

cancer.org/bookstore

for a

complete list of books that are available for order.

Breast Cancer Facts & Figures 2017-2018 29

Help navigating the health care system

Learning how to navigate the cancer journey and the

health care system can be overwhelming for anyone, but

it is particularly difficult for those who are medically

underserved, those who experience language or health

literacy barriers, and those with limited resources. The

American Cancer Society Patient Navigator Program

reaches those most in need. The largest oncology-focused

patient navigator program in the country, it has specially

trained patient navigators at more than 120 sites across

the nation. Patient navigators can help: find rides to and

from cancer-related appointments; assist with medical

financial issues, including insurance navigation; identify

community resources; and provide information on a

patient’s cancer diagnosis and treatment process. We

collaborate with a variety of organizations, including the

National Cancer Institute’s Center to Reduce Cancer

Health Disparities, the Center for Medicare and Medicaid

Services, and numerous cancer treatment centers to

implement and evaluate this program.

Breast cancer support

Through the American Cancer Society Reach To

Recovery® program, breast cancer patients are paired

with trained volunteers who have had similar diagnoses

and treatment plans to provide more personal, one-on-

one support.

Finding hope and inspiration

Women with breast cancer and their loved ones do not

have to face their experience alone. The American Cancer

Society Cancer Survivors Network® provides a safe online

connection where cancer patients can find others with

similar experiences and interests. At

csn.cancer.org

members can join chat rooms and build their own

support network from among the members.

Transportation to treatment

The American Cancer Society Road To Recovery®

program offers cancer patients free transportation to and

from their cancer-related treatment. For those who

cannot drive themselves or have no other means of

getting to treatment, trained volunteers donate their

spare time and the use of their personal vehicle to give

cancer patients in their community a much-needed ride.

Other transportation programs are also available in

certain areas. Call us at 1-800-227-2345 for more

information.

Lodging during treatment

The American Cancer Society Hope Lodge® program

provides a free home away from home for cancer patients

and their caregivers. More than just a roof over their

heads, it is a nurturing community where patients can

share stories and offer each other emotional support.

Through our Hotel Partners Program, we also partner

with local hotels across the country to provide free or

discounted lodging to patients and their caregivers in

communities without a Hope Lodge facility.

Help with appearance-related side effects

of treatment

The Look Good Feel Better® program teaches women how

to cope with appearance-related side effects of cancer

treatment. Group workshops are free and led by licensed

volunteer beauty professionals (cosmetologists,

estheticians, and nail technicians). Skin care, makeup,

and hair loss solution techniques and tips are provided in

a supportive environment. Information and materials are

also available for men and teens. This program is a

collaboration of the American Cancer Society, the Look

Good Feel Better Foundation, and the Professional

Beauty Association. To learn more, visit the Look Good

Feel Better website at

lookgoodfeelbetter.org

or call 1-800-

395-LOOK (1-800-395-5665).

Hair-loss and mastectomy products

Some women wear wigs, hats, breast forms, and special

bras to help cope with the effects of a mastectomy and

hair loss. The American Cancer Society “tlc” Tender

Loving Care® publication offers affordable hair loss and

mastectomy products, as well as advice on how to use

those products. The “tlc”

products and catalogs may be

ordered online at

tlcdirect.org

or by calling 1-800-850-

9445. All proceeds from product sales go back into our

survivorship programs and services.

30 Breast Cancer Facts & Figures 2017-2018

Support after treatment

The end of breast cancer treatment does not mean the

end of a cancer journey. Cancer survivors may experience

long-term or late effects resulting from the disease or its

treatment. The Life After Treatment: The Next Chapter in

Your Survivorship Journey guide may help cancer

survivors as they begin the next phase of their journey.

Visit

cancer.org/survivorshipguide

to download a free copy

of the guide.

The American Cancer Society has also recently published

a follow-up care guideline for breast cancer survivors

that builds upon available evidence, surveillance

guidelines, and standard clinical practice and is designed

to facilitate the provision of high-quality, standardized,

clinical care by primary care providers.

252

The breast

cancer guideline addresses the assessment and

management of potential long-term and late effects, as

well as recommendations for health promotion,

surveillance for recurrence, screening for second primary

cancers, and the coordination of care between specialists

and primary care clinicians.

Research

The American Cancer Society invests more in breast

cancer research than any other cancer type. Our funded

research has led to the development of potentially

lifesaving breast cancer drugs such as tamoxifen and

Herceptin, as well as improved understanding of genes

linked to breast cancer. We are currently funding more

than $59 million in breast cancer research through 159

research and training grants. These grants are awarded

in multiple areas relevant to the disease, including

genetics, etiology, diagnostics (imaging and biomarkers),

drug development; and preclinical, clinical, and

epidemiological studies in prevention, diagnosis,

treatment, and quality of life.

Specific examples of ongoing breast cancer research

being conducted by American Cancer Society grantees

include:

• Researching new ways of treating HER2+ breast

cancer patients who do not respond to or become

resistant to existing targeted therapies

• Evaluating psychosocial interventions aimed at

supporting Latinas with breast cancer and their

family partners to reduce distress and improve

quality of life

• Exploring how a gene called amphiregulin may cause

a woman with ER+ breast cancer to become resistant

to hormonal therapies

• Investigating ways to prevent breast cancer patients

from developing brain metastases by studying

proteins that may be involved in the spread of breast

cancer to the brain

• Evaluating whether a non-invasive and inexpensive

technique called auricular point acupressure can

help women with breast cancer manage their pain

at home

Internally, the American Cancer Society also conducts

epidemiologic studies of breast cancer and performs

surveillance research to monitor racial and

socioeconomic disparities in breast cancer screening,

incidence, survival, and mortality. Using information

collected from more than 600,000 women in Cancer

Prevention Study-II (CPS-II), American Cancer Society

epidemiologists study the influence of many risk factors,

including alcohol consumption, diethylstilbestrol (DES),

estrogen hormone use, family history of cancer, obesity,

smoking, and spontaneous abortion on the risk of death

from breast cancer. In order to continue to explore the

effects of changing exposures and to provide greater

opportunity to integrate biological and genetic factors

into studies of other risk factors, more than 304,000 men

and women were enrolled in the American Cancer

Society Cancer Prevention Study-3 (CPS-3), and nearly all

provided a blood sample at the time of enrollment. The

blood specimens and questionnaire data collected from

CPS-3 participants will provide unique opportunities for

research in the US.

Advocacy

The American Cancer Society’s nonprofit, nonpartisan

advocacy affiliate, the American Cancer Society Cancer

Action Network

(ACS CAN), advocates at the federal,

state, and local levels to increase access to quality breast

Breast Cancer Facts & Figures 2017-2018 31

cancer screenings, diagnostic and treatment services, and

care for all women; increase government funding for breast

cancer research; and provide a voice for the concerns of

breast cancer patients and survivors. Following are some

of the efforts that ACS CAN has been involved with in the

past few years to fight breast cancer – and all cancers:

• Improving Access to Affordable Care through

Health Care Reform: The Affordable Care Act (ACA)

was signed into law on March 23, 2010, giving cancer

patients access to quality, affordable health care. All

new health insurance plans, including those offered

through state health insurance exchanges, are

required to cover preventive services rated “A” or “B”

by the US Preventive Services Task Force, including

mammography screening, at no cost to patients.

Additionally, the ACA removed cost sharing for any

preventive services covered by Medicare. ACS CAN

advocates for clear, comprehensive coverage of these

preventive services, including breast cancer

screening, and encourages states to broaden access

to health care coverage for all low-income Americans

through state Medicaid programs.

• The National Breast and Cervical Cancer Early

Detection Program (NBCCEDP): Protecting and

increasing funding for the NBCCEDP is a high priority

for ACS CAN at both the state and federal levels.

Administered by the Centers for Disease Control

and Prevention, this successful program provides

community-based breast and cervical cancer

screenings to low-income, uninsured, and underinsured

women. More than 50% of the women screened are from

racial/ethnic minority groups. Currently, only one in

10 eligible women can be served by the program due

to federal funding cuts. ACS CAN is asking Congress

to increase funding to ensure that more women have

access to cancer screening.

• Protecting the Breast and Cervical Cancer

Prevention and Treatment Act (BCCPTA): In 2000,

Congress passed the BCCPTA, ensuring that low-

income women diagnosed with cancer through the

NBCCEDP were provided a pathway to treatment

services through their state Medicaid program.

In recent years, a number of states have considered

proposals to eliminate the treatment program due to

misconceptions around coverage needs following

implementation of the ACA.

• The Breast Density and Mammography Reporting

Act: Mammography sensitivity is lower for women

with mammographically dense breasts because dense

breast tissue makes it harder for doctors to see cancer

on mammograms. The federal Breast Density and

Mammography Reporting Act directs an evidence-

based process to inform women about breast density

and risk. Additionally, this legislation encourages

new research to support the creation of clinical

guidelines and best practices for screening of and

reports to women with mammographically dense

breasts.

• Patient Navigation: Patient navigation can improve

quality of cancer care, particularly in vulnerable

populations. ACS CAN supports the federal Patient

Navigation Assistance Act, which would create a

coverage solution that incentivizes providers to

use patient navigators in order to improve care

coordination for patients. The organization also is

working with Congress and federal agencies to help

increase funding for patient navigation programs.

• Funding for Cancer Research: ACS CAN continues

to work to increase government funding for cancer

research at the National Institutes of Health, including

the National Cancer Institute and the National

Center on Minority Health and Health Disparities.

It is important to note that the preceding references to

ACA provisions and other federal laws and guidance

reflect current law as of July 18, 2017, and do not take into

account potential changes to the ACA or other federal

laws and guidance subsequently considered by Congress

and the administration.

32 Breast Cancer Facts & Figures 2017-2018

Sources of Statistics

General information. Unless otherwise stated, the

statistics and statements in this booklet refer to invasive

(not in situ) female breast cancer.

Estimated new breast cancer cases. The overall

estimated number of new in situ and invasive breast

cancer cases diagnosed in the US in 2017 was projected

using a spatiotemporal model based on incidence data

from 49 states and the District of Columbia for the years

1995-2013 that met the North American Association of

Central Cancer Registries’ (NAACCR) high-quality data

standard for incidence. This method considers

geographic variations in sociodemographic and lifestyle

factors, medical settings, and cancer screening behaviors

as predictors of incidence, and also accounts for expected

delays in case reporting. Estimates for specific age groups

are based on the proportions of cases diagnosed in each

age group in the NAACCR data during 2010-2014 applied

to the overall 2017 estimate.

Incidence rates. Incidence rates are defined as the

number of people per 100,000 who develop a disease

during a given time period. All incidence rates in this

publication are age adjusted to the 2000 US standard

population to allow comparisons across populations with

different age distributions. Breast cancer incidence rates

for the US in the most recent time period were calculated

using data on cancer cases collected by NAACCR and

population data collected by the US Census Bureau.

When referenced as such, NAACCR incidence data were

made available on the NAACCR website (

naaccr.org

) and

within the Cancer in North America publications.

253, 254

Long-term incidence trends are based on American

Cancer Society analysis of the SEER 9 Registries Public

Use Dataset using SEER*Stat 8.3.4, a statistical software

package from the National Cancer Institute.

255, 256

Short-

term trends by race/ethnicity, age, tumor size, and stage

at diagnosis are based on delay-adjusted incidence rates

from the SEER 13 registries.

When referenced as such,

US SEER incidence rates and trends were previously

made available on SEER’s website (seer.cancer. gov) and

within the SEER Cancer Statistics Review 1975-2014.

Note that because of delays in reporting newly diagnosed

cancer cases to the cancer registries, cancer incidence rates

for the most recent diagnosis years may be underestimated.

Incidence rates adjusted for delays in reporting are used

when available and are referenced as such.

Estimated breast cancer deaths. The overall estimated

number of breast cancer deaths in the US is calculated by

fitting the number of breast cancer deaths for 1997-2014

to a statistical model that forecasts the number of deaths

expected to occur in 2017. Data on the number of deaths

are obtained from the National Center for Health

Statistics (NCHS) at the Centers for Disease Control and

Prevention. Age-specific estimates were calculated using

the proportions of deaths that occurred in each age group

during 2011-2015 applied to the overall 2017 estimate.

Mortality rates. Similar to incidence rates, mortality

rates are defined as the number of people per 100,000

who die from a disease during a given time period. Death

rates used in this publication were previously made

available by SEER on their website (

seer.cancer.gov

) and

within the SEER Cancer Statistics Review 1975-2014.

Death rates were calculated using data on cancer deaths

compiled by NCHS and population data collected by the

US Census Bureau. All death rates in this publication

were age adjusted to the 2000 US standard population.

Survival. Five-year survival statistics are based on

cancer patients diagnosed during 2007-2013; 10-year

survival rates are based on diagnoses during 2001-2013;

and 15-year survival rates are based on diagnoses during

1996-2013. All patients were followed through 2014.

Relative survival rates are used to adjust for normal life

expectancy (and events such as death from heart disease,

accidents, and diseases of old age). Relative survival is

calculated by dividing the percentage of observed 5-year

survival for cancer patients by the 5-year survival

expected for people in the general population who are

similar to the patient group with respect to age, sex, race,

and calendar year of observation. Cause-specific survival

rates are the probability of not dying of breast cancer

Breast Cancer Facts & Figures 2017-2018 33

within 5 years after diagnosis. When referenced as such,

5-year survival statistics were originally published in

SEER Cancer Statistics Review, 1975-2014.

Probability of developing cancer. Probabilities of

developing breast cancer were calculated using DevCan

6.7.5 (Probability of Developing Cancer Software),

developed by the National Cancer Institute.

257

These

probabilities reflect the average experience of women in

the US and do not take into account individual behaviors

and risk factors (e.g., utilization of mammography

screening and family history of breast cancer).

Screening. Prevalence estimates of mammography by

age and state were obtained through analysis of data

from the Behavioral Risk Factor Surveillance System

(BRFSS).

196

The BRFSS is an ongoing system of surveys

conducted by the state health departments in

cooperation with the Centers for Disease Control and

Prevention. Prevalence estimates of mammography by

race/ethnicity, poverty, and other demographic factors

are from the National Health Interview Survey.

195

Important note about estimated cases and deaths. The

estimated numbers of new breast cancer cases and

deaths in 2017 should be interpreted with caution. The

projection method is model-based, so the estimated

numbers may vary from previous years for reasons other

than changes in cancer occurrence. Therefore, while

3-year-ahead projections provide a reasonably accurate

estimate of the cancer burden in 2017, we strongly

discourage the use of our estimates to track changes in

cancer occurrence. Age-adjusted incidence and mortality

rates reported by the SEER program and the NCHS,

respectively, are the preferred statistics to track cancer

trends in the US. Rates from state cancer registries are

useful for tracking local trends.

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Acknowledgments

The production of this report would not have been possible without the efforts of:

Rick Alteri, MD; Ted Gansler, MD, MPH; Mia M Gaudet, PhD; Gretchen Gierach, PhD, MPH; Mamta Kalidas, MD; Joan

Kramer, MD; Katie McMahon, MPH; Kimberly Miller, MPH; Lisa A Newman, MD, MPH; Anthony Piercy; Cheri Richards, MS;

Ann Goding Sauer, MSPH; Scott Simpson; Robert Smith, PhD; Lindsey Torre, MSPH; Dana Wagner; and Jiaquan Xu, MD.

Breast Cancer Facts & Figures is a biennial publication of the American Cancer Society, Atlanta, Georgia.

For more information, contact:

Carol DeSantis, MPH; Rebecca Siegel, MPH; Ahmedin Jemal, DVM, PhD

Surveillance and Health Services Research Program

No. 861017

Models used for illustrative purposes only.

The American Cancer Society’s mission

is to save lives, celebrate lives,

and lead the fight for a world without cancer.