Five Year Survival of Women with Breast Cancer in Yazd

Cancer is a non-communicable disease that has been considered as one of the most deadly diseases in the world in recent decades (Bland et al., 2005). Current treatments for cancer often having multiple complications and high costs but the response to treatment in many cases is not complete (Vahdaninia et al., 2003). The global burden of cancer is a growing trend in the coming years. The number of new cases is expected increase from ten million in 2000 to 15 million in 2020 that approximately 60% of these cases will occur in developing countries (Saki et al., 2011). Breast cancer is increasingly regarded as a heterogeneous disease which can be classified into distinct molecular subtypes with prognostic significance (Lv et al., 2011). Breast cancer is the most common cause of death for middle-aged women in developed and developing countries and its prevalence rate increased rapidly in the 50 years and older. In recent years, the mortality rate from breast cancer has increased rapidly in all countries (Fouladi et al., 2011). Gynecologic and breast cancer cases account for 7.8% and 25.6% of total female cancers in Iran, respectively which are lower in comparison with those of some other countries (Arab et al., 2014). Except in cases of genetics, breast cancer is rarely observed in women before 25 years old. Risk factors


Five Year Survival of Women with Breast Cancer in Yazd
Hossein Fallahzadeh 1 , Mahdieh Momayyezi 1 *, Razie Akhundzardeini 2 , Sadegh Zarezardeini 2 associated with this cancer include increasing age, genetic background and less important factors include exposure to radiation, geographical influences, parity, late menopause, early menarche and obesity (Bland et al., 2005;Iglehart and Kaelin,2001).
The highest rates of death from breast cancer have been reported in North America and Northern Europe, in South America and Southern Europe is medium and lowest in Asian and African countries (Akbari et al., 2006). In the United States of America in 2003, found 203,500 new breast cancer and 39,600 women died from this disease (Akbari et al., 2006).
Breast cancer is the second cause of death due to cancer. Incidence of Breast cancer is 10 cases per 100,000 people and 7,000 new cases annually in Iran (Akbari et al., 2008). Thus, in recent years the service of prevention, early detection and appropriate treatment of cancer has been considered to improve the survival rate of cancer (Vahdaninia et al., 2003).
There are many ways to treat breast cancer, which are different according to the grading and staging of the cancer and the patient's physical condition and his demand (Yaghmaei et al., 2008). Researchers have done a lot of research for the estimated five years survival in breast cancer patients. Survival rates indicate the percentage of patients with a particular type of cancer that are live in the fifth year of diagnosis (Vahdaninia et al., 2003). This 6598 rate is 80-90% if If the lymph nodes are not involved. But this rate is 60-75% if axillary lymph nodes are involved (Yaghmaei et al., 2008).
Due to the relatively high rate of breast cancer in women and also the importance of determine the survival rate after diagnosis and treatment of breast cancer, this study conducted to determine five year survival of women with breast Cancer in Yazd.

Materials and Methods
This study is a prospective study (survival analysis). Patients who participate in this study were that Cancer was confirmed in during the diagnosis process and pathology. A total of 200 patients were selected from 2002-2007 and followed up for 5 years.
Data for this study were obtained from the patient's medical records with breast cancer that were referred for treatment to the Shahid Sadoughi hospital and radiotherapy center in Yazd .
The study took place in Yazd, one of the large cities of the Islamic Republic of Iran, is the center of Yazd Province. Yazd province is located 750 km south of the capital Tehran. It has a hot and dry weather and a population of 750,000, of whom 84% are literate (Fallahzadeh H, 2010).
Initially the forms were designed to collect information. Patients were divided into the following groups according to the age: younger than 50, 50-59 years, 60 and years older.
This information form was included: pathological type (ductal carcinoma, lobular carcinoma and medullary carcinoma), lymph node involvement (yes/no), affected side (right, left, both), type of treatment (chemotherapy, surgery & chemotherapy, surgery & chemotherapy & radiotherapy), type of surgery (Simple mastectomy, Radical mastectomy, Modified radical mastectomy, Lumpectomy and No surgery) and tumor size.
Then Patient records were collected from archive hospital and Department of Pathology and Their data entered to information forms and incomplete information was collected through telephone contact with the patient or their family.
After 5 years, the patient's vital status (alive -dead) were asked through telephone contact with patients or their families and in cases of death, date of death was asked from the patient. Accordingly, survival t is calculated from date of diagnosis to the end of the study period (5 years).
The data collected were analyzed by spss/16. The survival time according to variables was determining by using the Kaplan-Meier test and also, log-rank test was used to compare survival time in subgroups. Cox proportional hazard model was used to assess the effects of independent variables on survival time and risk of each of the variables.

Results
All cases of breast cancer diagnosed until 2002 were identified from Shahid Sadoughi hospital and radiotherapy center in Yazd. The closing data follow up was 14 June, 2007.
The mean age of the patients was 48.29±11.7 years. More than half (58.9%) of patients were younger than 50 years. 5.95% of the patients were married, and 4.5% were single. After five years, 62.5% of women diagnosed with  breast cancer are a live and 37.5% of them are death. The 1-year until 5-year cumulative survival for breast cancer patients was 95%, 86%, 82%, 76% and 70%, respectively. There were significant differences in age distribution and survival rates (p=0.006). The Survival rates have shown a decreasing trend with increasing age.
The patients younger than 50 years had better survival as compared with the patients older, so advancing age at diagnosis associated with lower survival. Clinical characteristics and average of the survival rate based on the variables was shown in Table 1.
There were significant differences between lymph node involvement and survival rates. (p=0.002) A significant decrease in the 5-year survival in patients with involvement of lymph nodes was observed. So that, 40.1% of patients with lymph node involvement and only 17.5% of the patients without lymph node involvement died during the study (5 years) The results showed that the survival rate is lower when both sides (right and left breast) were involved. (p=0.04) Women who had not undergo surgery and those only treated by Chemotherapy were associated with better survival. Also, women who had smaller tumor size had a higher survival rate, but there was no significant a significant relationship. Table 2 showed the relative factors affecting on 5-year survival rate for breast cancer patients. According to the result of multivariable Cox proportional hazard regression, age at diagnosis was significant predictors of survival rate in women with breast cancer. Although lymph node involvement and the sides involved had high odds ratio but there was no a significant relationship.

Discussion
The present study showed the 5-years relative survival rate of breast cancer patients an epidemiological review of articles from 1998 to 2005 that examined was performed to study the characteristics of breast cancer in Iran showed that 5-years survival rate of breast cancer ranged 65-73% (Mousavi et al., 2007). Fouladi and et al. in their study showed that the overall 5-years survival was 51% for breast cancer in Ardabil (North-West of Iran) (Fouladi et al., 2011). The overall 5-years survival rate was for breast cancer in Semnan(Iran) province was 58% (Yaghmaei et al., 2008). However,Akbari and et al. showed 5-years survival rate of breast cancer patients referred to Shohadae-tajrish and Jorjani hospitals in Tehran was 76.5% (Akbari et al., 2006). The overall 5-year survival rate of breast aancer patients in Malaysia was 49% which was lower comparing to studies in Iran.
Survival rates have increased in recent years due to improvements in health care services. So that, the studies were conducted to assess the cancer statistics in united state showed that survival rate of breast cancer has increased from 85% in 1989-1994to 90% in 2001years (Landis et al., 1998Siegel et al., 2012). The 5-years survival was found 88.1% in Germany in (Holleczek and Brenner, 2012. The findings presented here suggest that survival rate in our study was lower than developed countries such as United State and Germany and was higher than developing countries such as India (Gajalakshmi et al., 1997) which may be due to the differences in the Population pyramid in various countries (that has been confirmed by studies in this field in Iran (Gohari et al., 2006;Vahdaninia and Montazeri, 2004), appropriate awareness of patients about self-examination and disease risk, advanced technology and differences in race of people in the world.
The finding indicated that the mean age at diagnosis was 48.29±11.7 year, similar to other Iranian study such as  (Parkin and Fernandez, 2006;Smigal et al., 2006). The majority of cases were below the 50 years which have the same pattern with a number of studies (Mousavi et al., 2008;Yaghmaei et al., 2008;Sajadi et al., 2009;Najafi et al., 2013). Also, the reduction in the incidence of breast cancer in the elderly patients has been investigated in other studies (Tomatis et al., 1990).  The finding indicated that age of incidence of breast cancer was a significant prognostic factor. We found that woman aged less than 50 years old had better survival compared to women aged more than 50 years old which has been indicated in other studies (Fisch et al., 2005;Abdullah et al., 2013). The better survival rate in women which were younger than 50 years observed in present study that may be due to proper awareness of disease signs, self-examination and diagnosis in early stage.
The result showed that 68.5% of patients had lymph node involvement. A literature review indicated 63% of the mentioned patients had lymph node involvement (Mousavi et al., 2007). Other studies conducted in Iran have reported different numbers. For example, in Afsharfard's study 87.3% patients showed evidences of lymph invasion (Afsharfard et al., 2013). Also, Najafi et al showed that 57.7% of cases had lymph node involvement. (Najafi et al., 2013) Also, patients who hadn't lymph node involvement significantly associated with high survival rate and the mortality rate were lower in them. Lack of lymph node involvement was suggested as a prognostic factor for breast cancer in the similar studies (Thomson et al., 2004;Thomson et al., 2004;Webb et al., 2004;Clayforth et al., 2007). The findings showed that patients who had a tumor in left breast had the better survival rate than right breast. This result also indicated in a similar study by Akbari and et al (Akbari et al., 2006).
The majority of patients with smaller tumor size had the better survival. Clayforth and et al. found that small tumor size contributed to survival rate (Clayforth et al., 2007). Treatment with lumpectomy surgery was also associated with the better survival which was similar with result of fouladi's study (Fouladi et al., 2011). Modified radical mastectomy was the most common method of surgery compared to other method which was similar with the result of another study done in Iran. (Afsharfard et al., 2013) Ductal carcinoma was found in 85% of the mentioned patients so that, their survival rate was higher than other type of pathology. This finding also indicated by a review study was conducted in Iran (Mousavi et al., 2007;Afsharfard et al., 2013;Najafi et al., 2013). Limitation of this study were did not examine the survival rates and mortality rates according to disease stage Therefore, early diagnosis of the breast cancer by different approaches at early stages of disease and finding cancer before lymph node involvement can lead to a considerable reduction in mortality for women. Imparting a high quality breast cancer awareness and early diagnosis initiative at this juncture can help to consolidate the gains and also tackle knowledge, resource and psychosocial barriers (Sreedevi et al., 2014). Najafi et al. showed that the mortality rate will be reduced by using screening mammography and useful adjuvant therapy. (Najafi et al., 2013) The results of other studies indicate a need to develop health promotion programs directed at the female population so as to increase periodic health exams and improving access for disadvantaged communities to preventive health exams (Peltzer and Phaswana-Mafuya, 2014). In this context, the role of health educators and health center staff is decisive to improve survival rate.