title: Geographic variation in breast cancer incidence rates in a cohort of U.S. women.
abstract: BACKGROUND
  Breast cancer mortality and incidence rates vary by geographic region in the United States. Previous analytic studies have measured mortality, not incidence, and have used regional prevalences to control for geographic variation in risk factors rather than adjusting for risk factors measured at the level of the individual. We prospectively evaluated regional variation in breast cancer incidence rates in the Nurses' Health Study and assessed the influence of breast cancer risk factors measured at the individual level.
  
  
  METHODS
  The Nurses' Health Study cohort was established in 1976 when 121700 female nurses aged 30-55 years living in 11 U.S. states were enrolled. These states represent all four regions of the continental United States. We identified 3603 incident cases of invasive breast cancer through 1992 (1794565 person-years of follow-up). We calculated relative risks (RRs) adjusted for age and for age and established risk factors (i.e., multivariate-adjusted analysis), comparing California, the Northeast, and the Midwest with the South.
  
  
  RESULTS
  For premenopausal women, there was little evidence of regional variation in breast cancer incidence rates, either in age-adjusted or in multivariate-adjusted analyses. For postmenopausal women in California, age-adjusted risk was modestly elevated (RR = 1.24; 95% confidence interval [CI] = 1.05-1.47); after adjusting for age and for established risk factors, the excess rate in California was attenuated by 25% (RR = 1.18; 95% CI = 1.00-1.40). No excess of breast cancer incidence was observed for postmenopausal women in either the Northeast or the Midwest.
  
  
  CONCLUSIONS
  Little regional variation in age-adjusted breast cancer incidence rates was observed, with the exception of a modest excess for postmenopausal women in California. Adjustment for differences in the distribution of established risk factors explained some of the excess risk in California.
authors.affiliation: Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
authors.forename: F
authors.initials: F
authors.lastname: Laden
authors.forename: D
authors.initials: D
authors.lastname: Spiegelman
authors.forename: L M
authors.initials: LM
authors.lastname: Neas
authors.forename: G A
authors.initials: GA
authors.lastname: Colditz
authors.forename: S E
authors.initials: SE
authors.lastname: Hankinson
authors.forename: J E
authors.initials: JE
authors.lastname: Manson
authors.forename: C
authors.initials: C
authors.lastname: Byrne
authors.forename: B A
authors.initials: BA
authors.lastname: Rosner
authors.forename: F E
authors.initials: FE
authors.lastname: Speizer
authors.forename: D J
authors.initials: DJ
authors.lastname: Hunter
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000453:epidemiology*; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D015999:Multivariate Analysis; D009726:Nurses / Q000706:statistics & numerical data; D017698:Postmenopause; D017697:Premenopause; D011446:Prospective Studies; D012306:Risk; D012307:Risk Factors; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology