Introduction
Methods
Data source, study design, and patient selection
Study variables
Main exposure
Outcomes
Survival months
Tumor characteristics and adjuvant treatment
Sociodemographic characteristics
Statistical analysis
Results
Sociodemographic characteristics
Variable | Number of patients (n = 277,127) | Non-Hispanic White (n = 191,777) | Non-Hispanic Black (n = 28,250) | Hispanic (All races) (n = 30,813) | Other (n = 26,287) | Pearson Chi-square |
---|---|---|---|---|---|---|
Surgery | 86.4692*** | |||||
Patients with surgery recommended but not performed, patients refused | 1,486 | 938 (0.49) | 257 (0.91) | 140 (0.45) | 151 (0.57) | |
Patients who received surgery | 275,641 | 190,839 (99.51) | 27,993 (99.09) | 30,673 (99.55) | 26,136 (99.43) | |
Subtypes | 4.6exp(3)*** | |||||
Luminal A | 209,996 | 149,932 (78.18) | 17,973 (63.62) | 22,437 (72.82) | 19,654 (74.77) | |
Luminal B | 27,478 | 17,776 (9.27) | 3,064 (10.85) | 3,585 (11.63) | 3,053 (11.61) | |
HER2 enriched | 10,838 | 6,530 (3.40) | 1,456 (5.15) | 1,438 (4.67) | 1,414 (5.38) | |
Triple negative | 28,815 | 17,539 (9.15) | 5,757 (20.38) | 3,353 (10.88) | 2,166 (8.24) | |
Age at diagnosis | 5.7exp(3)*** | |||||
40–49 | 48,079 | 28,312 (14.76) | 5,566 (19.70) | 7,963 (25.84) | 6,238 (23.73) | |
50–59 | 72,810 | 47,643 (24.84) | 8,443 (29.89) | 9,225 (29.94) | 7,499 (28.53) | |
60–69 | 81,609 | 58,454 (30.48) | 8,031 (28.43) | 7,819 (25.38) | 7,305 (27.79) | |
70–79 | 51,583 | 39,045 (20.36) | 4,509 (15.96) | 4,225 (13.71) | 3,804 (14.47) | |
80+ | 23,046 | 18,323 (9.55) | 1,701 (6.02) | 1,581 (5.13) | 1,441 (5.48) | |
Tumor grade | 4.2exp(3)*** | |||||
Grade I; well differentiated | 69,674 | 52,293 (27.27) | 4,722 (16.72) | 6,675 (21.66) | 5,984 (22.76) | |
Grade II; moderately differentiated | 125,240 | 88,117 (45.95) | 11,160 (39.50) | 13,796 (44.77) | 12,167 (46.29) | |
Grade III; poorly differentiated | 82,213 | 51,367 (26.78) | 12,368 (43.78) | 10,342 (33.56) | 8,136 (30.95) | |
Tumor site | 367.0890*** | |||||
Nipple | 1,008 | 647 (0.34) | 101 (0.36) | 142 (0.46) | 118 (0.45) | |
Central portion of the breast | 14,156 | 9,912 (5.17) | 1,234 (4.37) | 1,516 (4.92) | 1,494 (5.68) | |
Upper-inner quadrant of the breast | 40,050 | 27,181 (14.17) | 4,102 (14.52) | 4,486 (14.56) | 4,281 (16.29) | |
Lower-inner quadrant of the breast | 17,578 | 12,006 (6.26) | 2,098 (7.43) | 1,875 (6.09) | 1,599 (6.08) | |
Upper-outer quadrant of the breast | 108,230 | 75,762 (39.51) | 11,157 (39.49) | 11,808 (38.32) | 9,503 (36.15) | |
Lower-outer quadrant of the breast | 23,767 | 16,572 (8.64) | 2,442 (8.64) | 2,580 (8.37) | 2,173 (8.27) | |
Axillary tail of the breast | 1,305 | 885 (0.46) | 197 (0.70) | 135 (0.44) | 88 (0.33) | |
Overlapping lesion of the breast | 71,033 | 48,812 (25.45) | 6,919 (24.49) | 8,271 (26.84) | 7,031 (26.75) | |
Tumor stage | 1.3exp(3)*** | |||||
Localized only | 197,500 | 139,928 (72.96) | 18,501 (65.49) | 20,277 (65.81) | 18,794 (71.50) | |
Regional, direct extension only | 3,423 | 2,437 (1.27) | 368 (1.30) | 332 (1.08) | 286 (1.09) | |
Regional, lymph nodes only | 68,290 | 44,318 (23.11) | 8,323 (29.46) | 9,169 (29.76) | 6,480 (24.65) | |
Regional, both direct extension and lymph nodes | 7,914 | 5,094 (2.66) | 1,058 (3.75) | 1,035 (3.36) | 727 (2.77) | |
Marital status | 1.1exp(4)*** | |||||
Married/Domestic Partner | 165,394 | 118,800 (61.99) | 10,678 (37.80) | 17,991 (58.39) | 17,845 (67.89) | |
Divorced | 32,038 | 22,181 (11.57) | 4,457 (15.78) | 3,456 (11.22) | 1,944 (7.40) | |
Widowed | 37,364 | 27,269 (14.22) | 4,096 (14.50) | 3,142 (10.20) | 2,857 (10.87) | |
Separated | 3,073 | 1,407 (0.73) | 681 (2.41) | 724 (2.35) | 261 (0.99) | |
Never married | 39,258 | 22,040 (11.49) | 8,338 (29.52) | 5,500 (17.85) | 3,380 (12.86) | |
Year of diagnosis | 348.4360*** | |||||
2010 | 30,717 | 22,092 (11.52) | 2,999 (10.62) | 2,953 (9.58) | 2,673 (10.17) | |
2011 | 31,810 | 22,487 (11.73) | 3,110 (11.01) | 3,375 (10.95) | 2,838 (10.80) | |
2012 | 33,035 | 23,131 (12.06) | 3,415 (12.09) | 3,521 (11.43) | 2,968 (11.29) | |
2013 | 34,302 | 23,840 (12.43) | 3,480 (12.32) | 3,753 (12.18) | 3,229 (12.28) | |
2014 | 34,957 | 24,208 (12.62) | 3,629 (12.85) | 3,838 (12.46) | 3,282 (12.49) | |
2015 | 36,769 | 25,244 (13.16) | 3,716 (13.15) | 4,210 (13.66) | 3,599 (13.69) | |
2016 | 37,470 | 25,276 (13.18) | 3,899 (13.80) | 4,559 (14.80) | 3,736 (14.21) | |
2017 | 38,067 | 25,499 (13.30) | 4,002 (14.17) | 4,604 (14.94) | 3,962 (15.07) | |
Median income | 1.8exp(4)*** | |||||
< $35,000 | 3,797 | 2,946 (1.54) | 645 (2.28) | 135 (0.44) | 71 (0.27) | |
$35,000–$44,999 | 19,617 | 13,749 (7.17) | 4,795 (16.97) | 840 (2.73) | 233 (0.89) | |
$45,000–$54,999 | 40,359 | 29,846 (15.56) | 5,508 (19.50) | 3,940 (12.79) | 1,065 (4.05) | |
$55,000–$64,999 | 66,982 | 43,241 (22.55) | 7,620 (26.97) | 10,239 (33.23) | 5,882 (22.38) | |
$65,000–$74,999 | 58,796 | 42,341 (22.08) | 4,776 (16.91) | 7,209 (23.40) | 4,470 (17.00) | |
> $75,000 | 87,576 | 59,654 (31.11) | 4,906 (17.37) | 8,450 (27.42) | 14,566 (55.41) | |
Urban–Rural | 6.7exp(3)*** | |||||
Counties in metropolitan areas greater than 1 million | 172,590 | 112,780 (58.81) | 19,349 (68.49) | 21,765 (70.64) | 18,696 (71.12) | |
Counties in metropolitan areas of 250 k to 1 million | 58,086 | 40,567 (21.15) | 4,942 (17.49) | 6,737 (21.86) | 5,840 (22.22) | |
Counties in metropolitan areas less than 250 k | 19,049 | 14,817 (7.73) | 1,950 (6.90) | 1,440 (4.67) | 842 (3.20) | |
Non-metropolitan counties adjacent to a metropolitan area | 15,984 | 13,759 (7.17) | 1,505 (5.33) | 499 (1.62) | 221 (0.84) | |
Non-metropolitan counties non-adjacent to a metropolitan area | 11,418 | 9,854 (5.14) | 504 (1.78) | 372 (1.21) | 688 (2.62) | |
Radiation therapy | 983.2506*** | |||||
No | 106,188 | 71,589 (37.33) | 10,494 (37.15) | 12,957 (42.05) | 11,148 (42.41) | |
Yes | 161,811 | 114,632 (59.77) | 16,559 (58.62) | 16,347 (53.05) | 14,273 (54.30) | |
Missing | 9,128 | 5,556 (2.90) | 1,197 (4.24) | 1,509 (4.90) | 866 (3.29) | |
Chemotherapy | 3.0exp(3)*** | |||||
No | 171,081 | 124,213 (64.77) | 14,039 (49.70) | 17,061 (55.37) | 15,768 (59.98) | |
Yes | 106,046 | 67,564 (35.23) | 14,211 (50.30) | 13,752 (44.63) | 10,519 (40.02) | |
Pathological inflammatory breast cancer | 0.074 | |||||
No | 276,913 | 191,635 (99.93) | 28,223 (99.90) | 30,781 (99.90) | 26,274 (99.95) | |
Yes | 214 | 142 (0.07) | 27 (0.10) | 32 (0.10) | 13 (0.05) |
Variable | Number of patients (n = 277,127) | Patients who received surgery (n = 275,641) | Patients with surgery recommended but not performed (n = 1486) | Pearson Chi-square |
---|---|---|---|---|
Race and ethnicity | 86.4692*** | |||
Non-Hispanic White | 191,777 | 190,839 (99.51) | 938 (0.49) | |
Non-Hispanic Black | 28,250 | 27,993 (99.09) | 257 (0.91) | |
Hispanic (All races) | 30,813 | 30,673 (99.55) | 140 (0.45) | |
Other | 26,287 | 26,136 (99.43) | 151 (0.57) | |
Subtypes | 10.2803* | |||
Luminal A | 209,996 | 208,897 (99.48) | 1,099 (0.52) | |
Luminal B | 27,478 | 27,296 (99.34) | 182 (0.66) | |
HER2 enriched | 10,838 | 10,775 (99.42) | 63 (0.58) | |
Triple negative | 28,815 | 28,673 (99.51) | 142 (0.49) | |
Age at diagnosis | 2.3exp(3)*** | |||
40–49 | 48,079 | 47,940 (99.71) | 139 (0.29) | |
50–59 | 72,810 | 72,571 (99.67) | 239 (0.33) | |
60–69 | 81,609 | 81,362 (99.70) | 247 (0.30) | |
70–79 | 51,583 | 51,355 (99.56) | 228 (0.44) | |
80+ | 23,046 | 22,413 (97.25) | 633 (2.75) | |
Tumor grade | 26.4617*** | |||
Grade I; well differentiated | 69,674 | 69,362 (99.55) | 312 (0.45) | |
Grade II; moderately differentiated | 125,240 | 124,473 (99.39) | 767 (0.61) | |
Grade III; poorly differentiated | 82,213 | 81,806 (99.50) | 407 (0.50) | |
Tumor site | 49.6519*** | |||
Nipple | 1,008 | 1,000 (99.21) | 8 (0.79) | |
Central portion of the breast | 14,156 | 14,030 (99.11) | 126 (0.89) | |
Upper-inner quadrant of the breast | 40,050 | 39,842 (99.48) | 208 (0.52) | |
Lower-inner quadrant of the breast | 17,578 | 17,496 (99.53) | 82 (0.47) | |
Upper-outer quadrant of the breast | 108,230 | 107,710 (99.52) | 520 (0.48) | |
Lower-outer quadrant of the breast | 23,767 | 23,656 (99.53) | 111 (0.47) | |
Axillary tail of the breast | 1,305 | 1,298 (99.46) | 7 (0.54) | |
Overlapping lesion of the breast | 71,033 | 70,609 (99.40) | 424 (0.60) | |
Tumor stage | 615.9641*** | |||
Localized only | 197,500 | 196,538 (99.51) | 962 (0.49) | |
Regional, direct extension only | 3,423 | 3,311 (96.73) | 112 (3.27) | |
Regional, lymph nodes only | 68,290 | 67,990 (99.56) | 300 (0.44) | |
Regional, both direct extension and lymph nodes | 7,914 | 7,802 (98.58) | 112 (1.42) | |
Marital status | 759.8123*** | |||
Married | 164,397 | 163,925 (99.71) | 472 (0.29) | |
Unmarried/Domestic partner | 997 | 996 (99.90) | 1 (0.10) | |
Divorced | 32,038 | 31,855 (99.43) | 183 (0.57) | |
Widowed | 37,364 | 36,837 (98.59) | 527 (1.41) | |
Separated | 3,073 | 3,044 (99.06) | 29 (0.94) | |
Never married | 39,258 | 38,984 (99.30) | 274 (0.70) | |
Year of diagnosis | 72.0314*** | |||
2010 | 30,717 | 30,611 (99.65) | 106 (0.35) | |
2011 | 31,810 | 31,678 (99.59) | 132 (0.41) | |
2012 | 33,035 | 32,871 (99.50) | 164 (0.50) | |
2013 | 34,302 | 34,142 (99.53) | 160 (0.47) | |
2014 | 34,957 | 34,783 (99.50) | 174 (0.50) | |
2015 | 36,769 | 36,532 (99.36) | 237 (0.64) | |
2016 | 37,470 | 37,219 (99.33) | 251 (0.67) | |
2017 | 38,067 | 37,805 (99.31) | 262 (0.69) | |
Median income | 15.7957** | |||
< $35,000 | 3,797 | 3,780 (99.55) | 17 (0.45) | |
$35,000–$44,999 | 19,617 | 19,525 (99.53) | 92 (0.47) | |
$45,000–$54,999 | 40,359 | 40,130 (99.43) | 229 (0.57) | |
$55,000–$64,999 | 66,982 | 66,674 (99.54) | 308 (0.46) | |
$65,000–$74,999 | 58,796 | 58,476 (99.46) | 320 (0.54) | |
> $75,000 | 87,576 | 87,056 (99.41) | 520 (0.59) | |
Urban–Rural | 6.8024 ns | |||
Counties in metropolitan areas greater than 1 million | 172,590 | 171,648 (99.45) | 942 (0.55) | |
Counties in metropolitan areas of 250 k to 1 million | 58,086 | 57,756 (99.43) | 330 (0.57) | |
Counties in metropolitan areas less than 250 k | 19,049 | 18,963 (99.55) | 86 (0.45) | |
Non-metropolitan counties adjacent to a metropolitan area | 15,984 | 15,913 (99.56) | 71 (0.44) | |
Non-metropolitan counties non-adjacent to a metropolitan area | 11,418 | 11,361 (99.50) | 57 (0.50) | |
Radiation therapy | 2.2exp(3)*** | |||
No | 106,188 | 104,747 (98.64) | 1,441 (1.36) | |
Yes | 161,811 | 161,787 (99.99) | 24 (0.01) | |
Missing | 9,128 | 9,107 (99.77) | 21 (0.23) | |
Chemotherapy | 579.0282*** | |||
No | 171,081 | 169,714 (99.20) | 1,367 (0.80) | |
Yes | 106,046 | 105,927 (99.89) | 119 (0.11) |
Trend of surgery refusal over time
Primary outcome on surgery refusal
Variable | Crude Odds Ratio of refusing the recommended surgery (95% Confidence Interval) | Adjusted Odds Ratio of refusing the recommended surgery (95% Confidence Interval) |
---|---|---|
Race and ethnicity | ||
Non-Hispanic White | 1.00 (reference) | 1.00 (reference) |
Non-Hispanic Black | 1.87 (1.63–2.15)*** | 2.12 (1.82–2.47)*** |
Hispanic (All races) | 0.93 (0.78–1.11)ns | 0.97 (0.81–1.17)ns |
Other | 1.18 (0.99–1.397)ns | 1.18 (0.99–1.42)ns |
Subtypes | ||
Luminal A | 1.00 (reference) | 1.00 (reference) |
Luminal B | 1.27 (1.08–1.48)** | 1.93 (1.62–2.28)*** |
HER2 enriched | 1.11 (0.86–1.43)ns | 1.64 (1.25–2.16)*** |
Triple negative | 0.94 0(.79–1.12)ns | 1.36 (1.12–1.66)** |
Age at diagnosis | ||
40–49 | 1.00 (reference) | 1.00 (reference) |
50–59 | 1.14 (0.92–1.4)ns | 1.15 (0.93–1.43)ns |
60–69 | 1.05 (0.85–1.29)ns | 1.04 (0.84–1.29)ns |
70–79 | 1.53 (1.24–1.89)*** | 0.97 (.77–1.21)ns |
80+ | 9.74 (8.10–11.71)*** | 3.06 (2.48–3.78)*** |
Tumor grade | ||
Grade I; well differentiated | 1.00 (reference) | 1.00 (reference) |
Grade II; moderately differentiated | 1.37 (1.20–1.56)*** | 1.31 (1.14–1.49)*** |
Grade III; poorly differentiated | 1.11 (0.954–1.282)ns | 1.11 (0.94–1.32)ns |
Tumor site | ||
Nipple | 1.00 (reference) | 1.00 (reference) |
Central portion of the breast | 1.12 (0.55–2.30)ns | 1.73 (0.83–3.60)ns |
Upper-inner quadrant of the breast | 0.65 (0.32–1.33)ns | 1.85 (0.89–3.84)ns |
Lower-inner quadrant of the breast | 0.59 (0.28–1.21)ns | 1.54 (0.73–3.25)ns |
Upper-outer quadrant of the breast | 0.60 (0.30–1.22)ns | 1.78 (0.87–3.66)ns |
Lower-outer quadrant of the breast | 0.59 (0.9–1.21)ns | 1.57 (0.75–3.28)ns |
Axillary tail of the breast | 0.67 (0.24–1.86)ns | 1.75 (0.62–4.99)ns |
Overlapping lesion of the breast | 0.75 (0.37–1.52)ns | 1.92 (0.93–3.96)ns |
Tumor stage | ||
Localized only | 1.00 (reference) | 1.00 (reference) |
Regional, direct extension only | 6.91 (5.67–8.43)*** | 4.2 (3.39–5.21)*** |
Regional, lymph nodes only | 0.90 (0.79–1.03)ns | 1.57 (1.37–1.81)*** |
Regional, both direct extension and lymph nodes | 2.93 (2.41–3.57)*** | 4.02 (3.23–4.98)*** |
Marital status | ||
Married | 1.00 (reference) | 1.00 (reference) |
Unmarried/Domestic partner | 0.35 (0.05–2.48)ns | 0.4 (0.05–2.84)ns |
Divorced | 2.00 (1.68–2.37)*** | 1.69 (1.42–2.02)*** |
Widowed | 4.97 (4.39–5.63)*** | 1.66 (1.43–1.93)*** |
Separated | 3.31 (2.27–4.82)*** | 2.79 (1.88–4.15)*** |
Never married | 2.44 (2.10–2.83)*** | 1.88 (1.61–2.19)*** |
Year of diagnosis | ||
2010 | 1.00 (reference) | 1.00 (reference) |
2011 | 1.20 (0.93–1.56)ns | 1.26 (0.97–1.64)ns |
2012 | 1.44 (1.13–1.84)** | 1.51 (1.18–1.93)** |
2013 | 1.35 (1.058–1.731)* | 1.45 (1.13–1.87)** |
2014 | 1.45 (1.134–1.84))** | 1.61 (1.25–2.06)*** |
2015 | 1.87 (1.489–2.357)*** | 2.09 (1.66–2.65)*** |
2016 | 1.95 (1.55–2.44)*** | 2.26 (1.79–2.85)*** |
2017 | 2.00 (1.60–2.51)*** | 2.25 (1.79–2.84)*** |
Median income | ||
< $35,000 | 1.00 (reference) | 1.00 (reference) |
$35,000–$44,999 | 1.05 (0.62–1.76)ns | 1.08 (0.632–1.85)ns |
$45,000–$54,999 | 1.27 (0.774–2.079)ns | 1.52 (0.89–2.57))ns |
$55,000–$64,999 | 1.03 (0.63–1.676)ns | 1.20 (0.71–2.06)ns |
$65,000–$74,999 | 1.22 (0.746–1.984)ns | 1.48 (0.86–2.54)ns |
> $75,000 | 1.33 (0.82–2.16)ns | 1.85 (1.08–3.16)* |
Urban–Rural | ||
Counties in metropolitan areas greater than 1 million | 1.00 (reference) | 1.00 (reference) |
Counties in metropolitan areas of 250 k to 1 million | 1.04 (0.918–1.181)ns | 1.17 (1.02–1.337)* |
Counties in metropolitan areas less than 250 k | 0.83 (0.662–1.031)ns | 0.91 (.712–1.159)ns |
Non-metropolitan counties adjacent to a metropolitan area | 0.81 0(.638–1.035)ns | 0.96 (.728–1.265)ns |
Non-metropolitan counties non-adjacent to a metropolitan area | 0.91 (0.70–1.20)ns | 1.02 (0.75–1.40)ns |
Radiation therapy | ||
No | 1.00 (reference) | 1.00 (reference) |
Yes | 0.01 (0.01–0.02)*** | 0.02 (0.01–0.02)*** |
Chemotherapy | ||
No | 1.00 (reference) | 1.00 (reference) |
Yes | 0.14 (0.12–0.17)*** | 0.17 (0.13–0.20)*** |
Secondary outcome on mortality
All-cause mortality
Variable | Overall Mortality | Breast cancer mortality | |||||||
---|---|---|---|---|---|---|---|---|---|
Crude Proportional Hazard Ratio (95% CI) | Model 1 adjusted proportional Hazard Ratio (95% CI) | Model 2 adjusted proportional Hazard Ratio (95% CI) | Model 3 adjusted proportional Hazard Ratio (95% CI) | Crude Proportional Hazard Ratio (95% CI) | Model 1 adjusted proportional Hazard Ratio (95% CI) | Model2 adjusted proportional Hazard Ratio (95% CI) | Model 3 adjusted proportional Hazard Ratio (95% CI) | ||
Surgery type | |||||||||
No surgery | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
Breast conservatory surgery (BCS) | 0.12 (0.11–0.13)*** | 0.23 (0.21–0.25)*** | 0.26 (0.23–0.28)*** | 0.34 (0.31–0.37)*** | 0.07 (0.06–0.08)*** | 0.10 (0.09–0.12)*** | 0.13 (0.11–0.14)*** | 0.14 (0.13–0.16)*** | |
Mastectomy | 0.19 (0.18–0.21)*** | 0.40 (0.37–0.44)*** | 0.34 (0.31–0.37)*** | 0.37 (0.34–0.40)*** | 0.18 (0.16–0.20)*** | 0.27 (0.25–0.30)*** | 0.20 (0.18–0.22)*** | 0.21 (0.19–0.23)*** | |
Race and ethnicity | |||||||||
Non-Hispanic White | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
Non-Hispanic Black | 1.40 (1.36 -–1.45)*** | 1.72 (1.49–1.99)* | 1.18 (1.02–1.37)* | 1.18 (1.01–1.37)* | 1.88 (1.80–1.98)*** | 2.05 (1.64–2.54)*** | 1.13 (0.90–1.41)ns | 1.13 (0.90–1.42)ns | |
Hispanic (All races) | 0.91 (0.87–0.95)*** | 0.87 (0.73–1.05)ns | 0.80 (0.66–0.97)* | 0.80 (0.66–0.96)* | 1.22 (1.16–1.30)*** | 0.91 (0.69–1.20)ns | 0.79 (0.60–1.05)ns | 0.82 (0.62 –- 1.08)ns | |
Other | 0.63 (0.60–0.66)*** | 0.59 (0.47–0.75)*** | 0.59 (0.47–0.74)*** | 0.59 (0.47–0.75)*** | 0.78 (0.73–0.84)*** | 0.45 (0.31–0.65) | 0.45 (0.31–0.65) | 0.47 (0.32–0.68)*** | |
Subtypes | |||||||||
Luminal A | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | |
Luminal B | 1.00 (0.95–1.04)ns | – | 1.29 (1.06–1.56)** | 1.25 (1.03–1.52)* | 1.40 (1.31–1.49)*** | – | 1.66 (1.23–2.27)** | 1.56 (1.14–2.15)** | |
HER2 enriched | 1.37 (1.29–1.45)*** | – | 2.85 (2.27–3.58)*** | 2.71 (2.15–3.42)*** | 2.42 (2.25–2.61)*** | – | 5.69 (4.12–7.86)*** | 5.31 (3.82–7.40)*** | |
Triple negative | 2.21 (2.15–2.28)*** | – | 5.78 (5.11–6.56)*** | 5.81 (5.12–6.60)*** | 4.20 (4.03–4.37)*** | – | 13.23 (10.92–16.04)*** | 12.93 (10.62–15.73)*** | |
Age at diagnosis | |||||||||
40–49 | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
50–59 | 1.16 (1.11–1.22)*** | 1.00 (0.81–1.24)ns | 1.03 (0.83–1.27)ns | 1.01 (0.81–1.26)ns | 0.99 (0.94–1.05)ns | 0.90 (0.68–1.20)ns | 0.92 (0.69–1.22)ns | 0.92 (0.69–1.22)ns | |
60–69 | 1.44 (1.38–1.51)*** | 1.33 (1.08–1.62)*** | 1.56 (1.27–1.91)*** | 1.57 (1.27–1.93)*** | 0.83 (0.79–0.88)*** | 1.27 (0.95–1.68)ns | 1.63 (1.23–2.17)** | 1.65 (1.23–2.20)** | |
70–79 | 2.70 (2.58–2.83)*** | 2.28 (1.86–2.78)*** | 2.83 (2.31–3.45)*** | 2.73 (2.22–3.35)*** | 1.06 (1.00–1.13)* | 3.09 (2.31–4.12)*** | 4.34 (3.26–5.79)*** | 4.44 (3.30–5.95)*** | |
80+ | 7.96 (7.62–8.32)*** | 5.92 (4.86–7.20)*** | 6.46 (5.31–7.86)*** | 5.45 (4.45–6.67)*** | 2.38 (2.24 –2.54)*** | 8.44 (6.33–11.27)*** | 9.60 (7.18–12.82)*** | 9.97 (7.41–13.41)*** | |
Tumor grade | |||||||||
Grade I; well differentiated | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | |
Grade II; moderately differentiated | 1.32 (1.28–1.37)*** | – | 1.17 (1.13–1.22)*** | 1.20 (1.16–1.24)*** | 2.82 (2.61–3.05)*** | – | 2.09 (1.93–2.26)*** | 2.09 (1.93–2.27)*** | |
Grade III; poorly differentiated | 2.29 (2.21–2.37)*** | – | 1.82 (1.75–1.89)*** | 1.86 (1.79–1.94)*** | 8.71 (8.09–9.39)*** | – | 4.51 (4.16–4.89)*** | 4.42 (4.07–4.80)*** | |
Tumor site | |||||||||
Nipple | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | |
Central portion of the breast | 0.86 (0.73–1.00)ns | – | 1.05 (0.90–1.23)ns | 1.11 (0.94–1.30)ns | 0.97 (0.75–1.25)ns | – | 1.16 (0.90–1.50)ns | 1.19 (0.92–1.55)ns | |
Upper-inner quadrant of the breast | 0.56 (0.48–0.66)*** | – | 1.08 (0.92–1.22)ns | 1.14 (0.97–1.34)ns | 0.60 (0.46–0.77)*** | – | 1.25 (0.97–1.61)ns | 1.28 (0.99–1.65)ns | |
Lower-inner quadrant of the breast | 0.64 (0.55–0.75)*** | – | 1.11 (0.94–1.30)ns | 1.17 (1.00–1.38)ns | 0.70 (0.54–0.90)** | – | 1.33 (1.03–1.71)* | 1.37 (1.05–1.77)* | |
Upper-outer quadrant of the breast | 0.60 (0.51–0.70)*** | – | 1.05 (0.90–1.22)ns | 1.11 (0.95–1.30)ns | 0.66 (0.51–0.84)** | – | 1.13 (0.88–1.44)ns | 1.16 (0.90–1.49)ns | |
Lower-outer quadrant of the breast | 0.62 (0.53–0.73)*** | – | 1.07 (0.91–1.26)ns | 1.13 (0.96–1.33)ns | 0.71 (0.55–0.91)** | – | 1.22 (0.95–1.57)ns | 1.24 (0.95–1.60)ns | |
Axillary tail of the breast | 0.70 (0.56–0.87)** | – | 1.11 (0.89–1.39)ns | 1.19 (0.95–1.48)ns | 0.79 (0.56–1.11)ns | – | 1.11 (0.79–1.57)ns | 1.16 (0.82–1.64)ns | |
Overlapping lesion of the breast | 0.64 (0.55–0.75)*** | – | 1.09 (0.93–1.27)ns | 1.15 (0.98–1.35)ns | 0.69 (0.54–0.88)** | – | 1.17 (0.91–1.50)ns | 1.21 (0.94–1.56)ns | |
Tumor stage | |||||||||
Localized only | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | – | 1.00 (reference) | 1.00 (reference) | |
Regional, direct extension only | 4.00 (3.75–4.28)*** | – | 2.31 (2.17–2.47)*** | 4.76 (3.67–6.17)*** | 5.92 (5.34–6.56)*** | – | 3.35 (3.01–3.73)*** | 3.35 (3.01–3.73)*** | |
Regional, lymph nodes only | 1.75 (1.70–1.79)*** | – | 1.80 (1.75–1.85)*** | 2.41 (2.14–2.71)*** | 3.86 (3.71–4.02)*** | – | 3.17 (3.04–3.31)*** | 3.20 (3.06–3.34)*** | |
Regional, both direct extension and lymph nodes | 4.80 (4.60–5.00)*** | – | 3.48 (3.32–3.64)*** | 6.90 (5.80–8.21)*** | 11.88 (11.23–- 12.56)*** | – | 6.88 (6.48–7.31)*** | 7.11 (6.67–7.58)*** | |
Marital status | |||||||||
Married/Domestic Partner | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
Divorced | 1.50 (1.45–1.56)*** | 1.38 (1.33–1.43)*** | 1.35 (1.30–1.41)*** | 1.34 (1.29–1.39)*** | 1.39 (1.32–1.48)*** | 1.29 (1.22–1.36)*** | 1.23 (1.16–1.30)*** | 1.24 (1.17–1.31)*** | |
Widowed | 3.35 (3.26–3.45)*** | 1.51 (1.47–1.56)*** | 1.47 (1.43–1.52)*** | 1.45 (1.41–1.50)*** | 1.97 (1.88–2.07)*** | 1.35 (1.28–1.43)*** | 1.28 (1.21–1.35)*** | 1.29 (1.22–1.36)*** | |
Separated | 1.48 (1.32–1.66)*** | 1.57 (1.40–1.77)*** | 1.50 (1.35–1.69)*** | 1.53 (1.36–1.72)*** | 1.62 (1.39–1.90)*** | 1.39 (1.20–1.63)*** | 1.31 (1.12–1.53)*** | 1.35 (1.16—1.58)*** | |
Never married | 1.52 (1.47–1.58)*** | 1.50 (1.44–1.55)*** | 1.46 (1.41–1.51)*** | 1.45 (1.39–1.50)*** | 1.59 (1.51–1.67)*** | 1.40 (1.34–1.48)*** | 1.34 (1.27–1.40)*** | 1.35 (1.28–1.42)*** | |
Median income | |||||||||
< $35,000 | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
$35,000–$44,999 | 0.87 (0.80–0.96)** | 0.85 (0.77–0.93)* | 0.89 (0.81–0.98)* | 0.89 (0.81–0.98)* | 0.83 (0.72–0.95)** | 0.86 (0.75–0.99)* | 0.93 (0.81–1.07)ns | 0.92 (0.80–1.06)ns | |
$45,000–$54,999 | 0.79 (0.72–0.86)*** | 0.83 (0.76–0.91)** | 0.87 (0.79–0.95)** | 0.87 (0.79—0.95)** | 0.74 (0.65–0.84)*** | 0.87 (0.76–1.00)ns | 0.95 (0.83–1.09)ns | 0.94 (0.82–1.09)ns | |
$55,000–$64,999 | 0.67 (0.61–0.73)*** | 0.78 (0.71–0.85)*** | 0.79 (0.72–0.87)*** | 0.79 (0.72–0.87)*** | 0.68 (0.60–0.77)*** | 0.83 (0.73–0.96)* | 0.93 (0.81—1.07)ns | 0.92 (0.80–1.06)ns | |
$65,000–$74,999 | 0.61 (0.56–0.66)*** | 0.73 (0.66–0.80)*** | 0.76 (0.69–0.83)*** | 0.76 (0.69–0.83)*** | 0.57 (0.50–0.65)*** | 0.75 (0.65–0.87)*** | 0.83 (0.71–0.96)* | 0.83 (0.71–0.96)* | |
> $75,000 | 0.53 (0.48–0.57)*** | 0.67 (0.61–0.74)*** | 0.70 (0.63–0.77)*** | 0.70 (0.63–0.77)*** | 0.50 (0.44–0.57)*** | 0.69 (0.60–0.81)*** | 0.78 (0.67–0.90)*** | 0.77 (0.66–0.89)*** | |
Urban–Rural | |||||||||
Counties in metropolitan areas greater than 1 million | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |
Counties in metropolitan areas of 250 k to 1 million | 1.07 (1.03–1.10)*** | 1.02 (1.01–1.07)ns | 1.02 (0.99–1.06)* | 1.04 (1.01–1.07)* | 0.97 (0.93–1.02)ns | 0.97 (0.91–1.01)ns | 0.96 (0.91–1.00)ns | 0.97 (0.92–1.02)ns | |
Counties in metropolitan areas less than 250 k | 1.26 (1.21–1.32)*** | 1.06 (1.01–1.11)* | 1.08 (1.03–1.13)** | 1.08 (1.03–1.14)** | 1.16 (1.08–1.24)*** | 1.01 (0.94–1.09)ns | 1.03 (0.96–1.11)ns | 1.03 (0.96–1.12)ns | |
Non-metropolitan counties adjacent to a metropolitan area | 1.28 (1.22–1.34)*** | 1.03 (0.97–1.08)ns | 1.04 (0.99–1.10)ns | 1.05 (0.99–1.10)ns | 1.15 (1.06–1.23)*** | 0.98 (0.90–1.07)ns | 0.99 (0.91–1.08)ns | 1.00 (0.92–1.09)ns | |
Non-metropolitan counties non-adjacent to a metropolitan area | 1.37 (1.30–1.45)*** | 1.08 (1.02–1.15)* | 1.09 (1.03–1.16)* | 1.07 (1.00–1.14)* | 1.30 (1.20–1.41)*** | 1.11 (1.01–1.22) | 1.13 (1.03–1.25)* | 1.12 (1.02–1.23)* | |
Radiation therapy | |||||||||
No | 1.00 (reference) | – | – | 1.00 (reference) | 1.00 (reference) | – | – | 1.00 (reference) | |
Yes | 0.53 (0.52–0.55)*** | – | – | 0.69 (0.67–0.71)*** | 0.66 (0.63–0.68)*** | – | – | 0.81 (0.77–0.84)*** | |
Chemotherapy | |||||||||
No | 1.00 (reference) | – | – | 1.00 (reference) | 1.00 (reference) | – | – | 1.00 (reference) | |
Yes | 0.95 (0.92–0.97)*** | – | – | 0.93 (0.90–0.96)*** | 2.44 (2.36–2.54)*** | – | – | 1.16 (1.11–1.22)*** |