title: Confirmation of double-peaked time distribution of mortality among Asian breast cancer patients in a population-based study.
abstract: BACKGROUND
  Double-peaked time distributions of the mortality hazard function have been reported for breast cancer patients from Western populations treated with mastectomy alone. These are thought to reflect accelerated tumour growth at micrometastatic sites mediated by angiogenesis after primary tumour removal as well as tumor dormancy. Similar data are not available for Asian populations. We sought to investigate whether differences exist in the pattern of mortality hazard function between Western breast cancer patients and their Asian counterparts in Singapore, which may suggest underlying differences in tumor biology between the two populations.
  
  
  METHODS
  We performed a retrospective cohort study of female unilateral breast cancer patients diagnosed in Singapore between October 1994 and June 1999. Data regarding patient demographics, tumour characteristics and death were available. Overall survival curves were calculated using the Kaplan-Meier method. The hazard rate was calculated as the conditional probability of dying in a time interval, given that the patient was alive at the beginning of the interval. The life table method was used to calculate the yearly hazard rates.
  
  
  RESULTS
  In the 2,105 women identified, 956 patients (45.4%) had mastectomy alone. Demographic characteristics were as follows: 86.5% were Chinese, 45.2% were postmenopausal, 38.9% were hormone receptor positive, 54.6% were node negative and 44.1% had high histological grade. We observed a double-peaked mortality hazard pattern, with a first peak in mortality achieving its maximum between years 2 and 4 after mastectomy, and a second large peak in mortality during year 9. Analyses by subgroups revealed a similar pattern regardless of T stage, or node or menopausal status. This pattern was also noted in high-grade tumors but not in those that were well to moderately differentiated. The double-peaked pattern observed in Singaporean women was quantitatively and qualitatively similar to those reported in Western series.
  
  
  CONCLUSIONS
  Our study confirms the existence of a double-peaked process in Asian patients, and it gives further support to the tumour dormancy hypothesis after mastectomy.
authors.affiliation: Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre, Singapore. ctegfe@nccs.com.sg
authors.forename: Fei
authors.initials: F
authors.lastname: Gao
authors.forename: Say Beng
authors.initials: SB
authors.lastname: Tan
authors.forename: David
authors.initials: D
authors.lastname: Machin
authors.forename: Nan Soon
authors.initials: NS
authors.lastname: Wong
mesh_terms: D000368:Aged; D044466:Asian People; D001943:Breast Neoplasms / Q000208:ethnology* / Q000401:mortality* / Q000628:therapy; D015331:Cohort Studies; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D008408:Mastectomy; D008875:Middle Aged; D016016:Proportional Hazards Models; D012107:Research Design; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors