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Introduction
Since the 1990s, profound changes have taken place in the clinical presentation and management of breast cancer due to mammography screening, implementation of effective hormone treatments and chemotherapy, and progress in radiotherapy and surgery. These innovations have probably contributed to the observed improvements in breast cancer survival in Europe, 1 2 but the contribution of each factor is unknown. The implementation of mammography screening, the availability of new treatments, and healthcare expenditures vary greatly across Europe. 3 4 5 6 7 One consequence could be that mortality decreases between countries will also vary, and the highest decreases are likely to be observed in countries characterised by early implementation and high attendance to breast screening combined with rapid uptake of anticancer drugs.
In this study we analysed breast cancer mortality in 30 European countries from 1980 to 2006 and examined temporal trends in rates for all women, and for women aged <50, 50-69, and >=70 years to help decipher the effect of the contributing factors.
Methods
Breast cancer deaths registered in the World Health Organization mortality database at December 2009 were extracted for European countries. 8 The quality of mortality data has been evaluated by the WHO. 9 England and Wales, Scotland, and Northern Ireland were considered as three separate countries. Cyprus was excluded as data were available for only four years (1999, 2000, 2004, and 2006). Malta was not included because abrupt changes in trends occurred in 1979 and 1995, which seem to coincide with classification changes from ICD-8 (international classification of diseases, eighth revision) to ICD-9 and from ICD-9 to ICD-10. For almost all other countries, data up to 2006 were available, and for some countries, mortality data for 2007 and 2008 were also available.
In addition to the WHO data, we obtained information on mortality statistics for several countries, which allowed enhancement of quality. For Switzerland, a change in coding practice in 1994 resulted in an overestimation of cancer mortality before 1994, and, as recommended, we therefore applied a correction factor of 0.85 on rates before 1995. 10 For Belgium, country-specific mortality was recorded until 1997, but thereafter mortality data were available for Flanders (60% of the population) and for Brussels (10% of the population), whereas for Wallonia (30% of the population),...