Breast interventional devices: how they evolve and define new subspecialities

Image-guided breast biopsy programs are a clinical reality at breast care centers throughout the world. Because image-guided biopsy is a departure from traditional surgical breast biopsy, the quality of each new image-guided breast biopsy program should be measured. A generalized scheme for quality evaluation will be presented. The most complex part of this scheme is the comparison of tissue samples obtained by image-guided biopsy with tissue samples subsequently obtained during surgery. Because image-guided biopsy programs retrieve histology specimens that are microscopically as valid as histology obtained from open surgery, comparing the histology from an image-guided breast biopsy with the histology from an open surgical biopsy is complex. One cannot use the well-known method of determining false-negative and false-positive rates. In addition, breast histology, itself, is quite complex. Some benign breast disease is quite focal and specific, such as fibroadenomas. Other benign breast disease is diffuse and not very specific, such as fibrocystic abnormalities. Furthermore, malignant breast disease is part of a histology spectrum starting with normal-looking breast tissue with atypical features, progressing to carcinoma in situ, and ending, finally, with infiltrating breast cancer. To illustrate how histological comparisons should be made for breast tissue, published results from a large, nationally funded study will be re-examined using the proposed scheme. Although the breast biopsy, itself, may seem like the hard work of a new breast biopsy program, it is not. After the first year of the program, follow-up of women who have been biopsied is the true, back-breaking, hard work. How a breast center should perform air-tight follow-up will be described.

Cohn et al. (2008) suggested that birth cohort trends in breast cancer rates for women under 50 years of age are consistent with declining use of DDT (dichloro-diphenyltrichloroethane) after 1959. They cited Weiss (2007) in claiming that increased detection and treatment of in situ breast cancer must be considered when interpreting recent trends in breast cancer mortality rates in young women. The remarks of Weiss (2007) relate to women 40–49 years of age, and earlier detection and improved treatment of breast cancer has had a marked impact on breast cancer mortality rates in these women since 1990 (Berry et al. 2005; Chu et al. 1996). The birth cohort trends relevant to examining the possible impact of childhood DDT exposure on U.S. breast cancer rates, however, were firmly established well before 1990 in women < 40 years of age (Tarone 2007). Cohn et al. (2007) reported a large increase in breast cancer risk estimates for p,p′-DDT [1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane] exposure with successive birth cohorts after 1930. Their reported odds ratio estimates by period of birth for the highest tertile of p,p′-DDT exposure were 0.6 for women born in 1931 or earlier (i.e., ≥ 14 years of age in 1945), 3.9 for women born in 1932–1937 (i.e., 8–13 years of age in 1945), 9.6 for women born in 1938–1941 (i.e., 4–7 years of age in 1945), and 11.5 for women born in 1942 or later (i.e., 0.25), and there was a marginally significant decrease in rates for women 35–39 years of age (p = 0.04). Thus the trends in breast cancer mortality rates among women born in 1930–1945 are not consistent with the sharply increasing trend in odds ratios for childhood DDT exposure by birth period reported by Cohn et al. (2007). The most recent mortality rate contributing to the reported regression analyses (corresponding to women in the 35- to 39-year age group born in 1945) was for 1983, well before improvements in detection and treatment would have had any impact on breast cancer mortality rates. Women born after 1945 were exposed to DDT for each of the first 13 years of life (and all years thereafter). In addition, DDT exposure increased from 1945 through 1959, when DDT use peaked (with dietary exposure peaking in 1965) (Wolff et al. 2005). If DDT exposure early in life markedly increases breast cancer risk, then some evidence of the increasing DDT use after 1945 might be expected in breast cancer mortality rate trends for young women born from 1946 through 1959 (Tarone 2007). Breast cancer mortality rates decreased significantly among women 20–24 years of age (p = 0.009) and 25–29 years of age (p = 0.0002) born between 1946 and 1959 (SEER 2006; Tarone 2007). The most recent rate contributing to these regression analyses was for 1987 (corresponding to women in the 25-to 29-year age group born in 1959). Breast cancer mortality rates decreased even more markedly (p < 0.0001) for women in the 30- to 34-year and 35- to 39-year age groups born from 1946 through 1959; some of the recent rates in these latter age groups were almost certainly affected by improved breast cancer detection and treatment, although decreasing trends were apparent in both age groups for rates well before 1990 (Tarone 2007). Thus, U.S. breast cancer mortality rates in women between the ages of 20 and 39 who were born between 1930 and 1959 show no evidence of an increase in breast cancer risk associated with their marked increase in DDT exposure during childhood. The observed birth cohort trends in breast cancer rates do not refute a possible association between childhood DDT exposure and breast cancer risk, and contrary to the implication of Cohn et al. (2008), no such claim was made in my earlier letter (Tarone 2008). The regression analyses reported above suffer the weaknesses of all ecologic analyses, and in fact, the decreasing birth cohort risk of breast cancer in baby boomers has been observed in spite of trends in established risk factors (e.g., parity, age at first birth, and oral contraceptive use) that would predict increasing breast cancer rates among U.S. women born after 1945. If, as suggested by Cohn et al. (2007), the public health significance of DDT exposure early in life is large, then this would provide additional evidence that the factor or factors responsible for the paradoxical decrease in birth cohort risk of breast cancer observed among U.S. baby boomers must have a very powerful impact on breast cancer etiology, large enough to turn an expected increasing trend in breast cancer rates among baby boomers into a decreasing trend.

Trends in breast cancer incidence, survival, and mortality

Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials

The UK Age trial compared annual mammography screening of women ages 40 to 49 years with no screening and found a statistically significant breast cancer mortality reduction at the 10-year follow-up but not at the 17-year follow-up. The objective of this study was to compare the observed Age trial results with the Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer model predicted results. Five established CISNET breast cancer models used data on population demographics, screening attendance, and mammography performance from the Age trial together with extant natural history parameters to project breast cancer incidence and mortality in the control and intervention arm of the trial. The models closely reproduced the effect of annual screening from ages 40 to 49 years on breast cancer incidence. Restricted to breast cancer deaths originating from cancers diagnosed during the intervention phase, the models estimated an average 15% (range across models, 13% to 17%) breast cancer mortality reduction at the 10-year follow-up compared with 25% (95% CI, 3% to 42%) observed in the trial. At the 17-year follow-up, the models predicted 13% (range, 10% to 17%) reduction in breast cancer mortality compared with the non-significant 12% (95% CI, -4% to 26%) in the trial. The models underestimated the effect of screening on breast cancer mortality at the 10-year follow-up. Overall, the models captured the observed long-term effect of screening from age 40 to 49 years on breast cancer incidence and mortality in the UK Age trial, suggesting that the model structures, input parameters, and assumptions about breast cancer natural history are reasonable for estimating the impact of screening on mortality in this age group.

Three recent studies explored how smoking is related to certain breast and lung cancer risks. In the first study, postmenopausal women who were current or former smokers were found to have a 16% higher risk of developing breast cancer than never-smokers.1 The study also found that women who had extensive exposure to passive smoking, either as children or adults, had an excess risk of developing breast cancer. Although previous studies have indicated a link between smoking and breast cancer, passive smoking risk remains controversial. Researchers, led byJuhua Luo, MD, of West Virginia University in Morgantown, and Karen Margolis, MD, of Health-Partners Research Foundation in Minneapolis, Minnesota, used data from the 1993-1998 Women's Health Initiative Observational Study to determine links between smoking, passive smoking, and breast cancer They analyzed data from nearly 80,000 women between the ages of 50 and 79 years across 40 clinical centers nationwide, identifying a total of 3250 cases of invasive breast cancer diagnosed over 10 years. Participants were asked a variety of questions, including whether they had ever smoked, at what age they began smoking, how many cigarettes they smoked each day, and at what age they quit smoking. They also were asked if they had lived in smoking households as children or adults and whether they had worked in smoking environments. Researchers found that smokers had a 16% increased risk of developing breast cancer after menopause; former smokers had a 9% increased risk. Those women who had smoked for 50 years or more had the highest risk compared with lifetime nonsmokers. Women who started smoking as teenagers also had a particularly high risk. The increased risk continued for 20 years after a person had stopped smoking. Nonsmoking women who had been exposed to extensive passive smoking had a 32% excess risk of breast cancer “Extensive” was defined as more than 10 years' exposure in childhood, more than 20 years' exposure as an adult at home, and more than 10 years' exposure as an adult at work. However, because their analysis of secondhand smoke was limited to the most extensive passive smoking category, the authors say more research is needed to confirm these findings. In another study by Kenneth Piazza, MD, MPH, and Andrew Hyland, PhD, at Roswell Park Cancer Institute in Buffalo, New York, smoke free homes and workplaces were linked to reductions in breast cancer incidence and mortality rates.2 The study found a statistically significant decrease in breast cancer mortality, particularly among younger premenopausal women, as the number of smoke- free homes and workplaces increased. An estimated 20% of the change in breast cancer mortality rates was due to changes in smoke-free home and workplace policies. Similar to the first group of researchers, Drs. Piazza and Hyland cited the lack of definitive evidence regarding passive smoke and risk of breast cancer However, the study also found that states with higher percentages of women working and living in smoke-free environments had lower breast cancer rates. In a third study, researchers found that many longtime smokers quit spontaneously shortly before their lung cancer was diagnosed.3 As a result, they speculate that sudden smoking cessation may be a symptom of lung cancer The study found that most patients who quit did so before noticing any cancer symptoms. They also often quit with no difficulty, despite having tried to quit unsuccessfully in the past, notes lead author Barbara Campling, MD, a medical oncologist at Thomas Jefferson University in Philadelphia, Pennsylvania. Researchers interviewed 115 lung cancer patients from the Philadelphia Veterans Affairs Medical Center, all of whom had been smokers. Of these, 55 patients (48%) had quit smoking before diagnosis and only 6 (11%) of these patients had experienced symptoms before they quit. The patients who quit were as dependent on nicotine as those who continued to smoke, yet 31% said they quit without difficulty. Investigators compared these results with those found in patients with prostate cancer and heart attack survivors. In the patients with lung cancer, the median time elapsed between quitting smoking and lung cancer diagnosis was 2.7 years. The interval between quitting and the event was 24.3 years for patients with prostate cancer and 10 years for heart attack survivors. Dr. Campling and colleagues speculated that smoking cessation may be caused by tumor secretion of a substance that interferes with nicotine addiction. She cautions that these results should not be misinterpreted to suggest that heavy smokers should continue smoking; they still should be strongly encouraged to quit.

BackgroundThe aim of this study was to analyse breast cancer incidence and mortality in Tyrol from 1970 to 2006, namely after performing more than a decade of opportunistic mammography screening and just before piloting an organised screening programme. Our investigation was conducted on a population level.MethodsTo study time trends in breast cancer incidence and mortality, we applied the age-period-cohort model by Poisson regression to the official mortality data covering more than three decades from 1970 to 2006 and to the incidence data ranging from 1988 to 2006. In addition, for incidence data we analysed data on breast cancer staging and compared these with EU guidelines.ResultsFor the analysis of time trend in breast cancer mortality in age groups 40-79, an age-period-cohort model fits well and shows for years 2002-2006 a statistically significant reduction of 26% (95% CI 13%-36%) in breast cancer mortality as compared to 1992-1996.We see only slight non-significant increases in breast cancer incidence. For the past five years, incidence data show a 10% proportion of in situ cases, and of 50% for cases in stages II+.ConclusionsThe opportunistic breast cancer screening programme in Tyrol has only in part exploited the mortality reduction known for organised screening programmes. There seems to be potential for further improvement, and we recommend that an organised screening programme and a detailed screening database be introduced to collect all information needed to analyse the quality indicators suggested by the EU guidelines.

In the Women's Health Initiative (WHI) randomized trial, dietary intervention significantly reduced breast cancer mortality, especially in women with more metabolic syndrome (MetS) components. Therefore, this study investigated the associations of MetS and obesity with postmenopausal breast cancer after long-term follow-up in the WHI clinical trials. A total of 68,132 postmenopausal women, without prior breast cancer and with normal mammogram, were entered into WHI randomized clinical trials; 63,330 women with an entry MetS score comprised the study population. At entry, body mass index (BMI) was determined; MetS score (0, 1-2, and 3-4) included the following: (1) high waist circumference (≥88 cm), (2) high blood pressure (systolic ≥130 mm Hg and/or diastolic ≥85 mm Hg, or hypertension history), (3) high-cholesterol history, and (4) diabetes history. Study outcomes included breast cancer incidence, breast cancer mortality, deaths after breast cancer, and results by hormone receptor status. After a >20-year mortality follow-up, a higher MetS score (3-4), adjusted for BMI, was significantly associated with more poor prognosis, estrogen receptor (ER)-positive, progesterone receptor (PR)-negative cancers (p=.03), 53% more deaths after breast cancer (p<.001), and 44% higher breast cancer mortality (p=.03). Obesity status, adjusted for MetS score, was significantly associated with more good prognosis, ER-positive, PR-positive cancers (p<.001), more total breast cancers (p<.001), and more deaths after breast cancer (p<.001), with higher breast cancer mortality only in women with severe obesity (BMI, ≥35 kg/m2; p<.001). MetS and obesity status have independent, but differential, adverse associations with breast cancer receptor subtypes and breast cancer mortality risk. Both represent separate targets for breast cancer prediction and prevention strategies.

Time trends of breast cancer mortality in Spain during the period 1977–2001 and Bayesian approach for projections during 2002–2016

Breast cancer incidence and mortality: trends over 40 years among women in Shanghai, China

Background: Missouri is burdened by high breast cancer (BC) mortality rates, particularly among women from disparate populations (individuals living in poverty, rural areas, and African Americans). In a prior study, we found that women diagnosed with BC from disparate populations have a high prevalence of comorbidities and these commonly diagnosed comorbidities were associated with worse BC prognosis. We now hypothesize that the frequency of hospitalizations may be an early indicator of increased mortality and may be used to identify at risk BC patients with co-morbid conditions. Methods: Women age 18+ diagnosed with invasive BC in Missouri during 2004–2012 were identified from the Missouri Cancer Registry. Data were merged with hospital discharge data from the state Patient Abstract System. A comorbidity score was constructed to reflect the number of inpatient admissions for the 3 most prevalent conditions (Type-2 diabetes, hypertension, and CVD) among patients. We identified women who experienced an inpatient hospitalization &amp;gt; 1 year after their BC diagnosis to ensure hospitalizations were not due to reasons associated with their primary BC diagnosis. For risk of BC mortality, adjusted hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazards regression models overall and stratified by race, poverty level, rural/urban residence, and age. Results: A total of 36,581 women with incident invasive BC and comorbidity data at the time of BC diagnosis were analyzed. After a median follow-up time of 78 months, 11,102 deaths occurred, of which 6,232 were BC deaths. Approximately 31% of patients had ≥1 comorbidity and 17% had been hospitalized once. Increasing number of comorbidities was significantly associated with the likelihood of being hospitalized after BC diagnosis (p-trend &amp;lt; 0.001). BC patients with ≥ 5 hospitalizations post diagnosis compared to no hospitalization after adjusting for comorbidities and prognostic factors had increased BC mortality risk (HR, 2.62; 95% CI 2.31-2.97). Having just one hospitalization significantly increased the risk of BC death by 34% compared to women without a hospitalization. In stratified analyses, we observed significant differences in associations between hospitalizations and BC mortality by race (p=0.02), residential location (p &amp;lt; 0.01), and age (p &amp;lt; 0.001). Women &amp;lt; 50 years of age and with ≥ 5 hospitalizations had over 600% increase in risk of BC death (HR, 6.51; 95% CI 5.12-8.29) compared to women &amp;lt; 50 years without hospitalizations. Among women with ≥ 1 comorbidity, ≥ 5 hospitalizations increased risk of BC death by 83% (HR, 1.83; 95% CI 1.54-2.17) compared to women without a hospitalization. Conclusion: BC patients who have comorbidities and experience a hospitalization post diagnosis are at increased risk of BC mortality. Further, hospitalizations could be used to identify high risk survivors that could benefit from targeted interventions. Analyses evaluating diseases contributing to hospitalizations are ongoing. Citation Format: Avonne E Connor, Betty May, Chester Schmaltz, Jeannette Jackson-Thompson, Kala Visvanathan. Hospitalization may be an early indicator of worse breast cancer survival among women from disparate populations [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B120.

Background: The breast cancer and cervical cancer mortality rates among women in Mississippi are higher than the national averages. Early detection and early treatment are associated with longer survival rates among women who are diagnosed with breast cancer or cervical cancer. However, the percentage of women in Mississippi who report having regular mammograms and in cervical cancer screenings is lower than the national average. Purpose: Clinicians and investigators at UMMC are actively working within transdisciplinary teams to implement evidence-based interventions aimed at reducing breast and cervical cancer mortality disparities in the state. Methods: See, Test, and Treat was a community-based cancer screening event that occurred on June 1, 2019 at the UMMC Cancer Center and Research Institute. The UMMC team provided breast, cervical and oral cancer screenings to 103 women. Healthy cooking and exercise demonstrations, were conducted to actively engage patients in health education activities. Participants completed a brief exit survey that was used to gather data on the effect of the program on the patients’ knowledge and attitudes towards cancer screenings, and intentions to changed cancer related health behaviors. Results: The short-term outcomes showed that 21 patients had abnormal mammograms. All of the patients with abnormal mammograms were immediately linked to follow-up care. No Pap tests were returned with abnormal results. However, the clinicians diagnosed 8 patients with Trichomonas. The majority of the patients indicated that their knowledge of and attitudes towards breast and cervical cancer screening changed positively and the majority intended to change their cancer related health behaviors. Conclusion: See, Test, and Treat is an effective community-based activity that can increase access to breast, cervical and oral cancer screenings by uninsured and underinsured women. Citation Format: Michelle S Williams, Jimmie Wells, Roy Duhe, Timothy Allen. See, Test, and Treat: Engaging vulnerable populations in cancer screening [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B030.

Image-guided breast biopsies are safe, efficient, and reliable. However, patients are often anxious about these procedures, particularly those who have never undergone a prior biopsy. This prospective IRB-approved study surveyed 163 patients undergoing their first breast biopsy. Participants provided informed consent and completed a short written survey prior to and immediately after their procedure. Level of anxiety as well as anticipated and actual levels of pain prior to and following the procedure were assessed using a 0-10-point Likert scale. Correlation, bivariate, and regression analyses were performed. Regarding the biopsy experience, 133/163 (81.6%) of patients reported it as better than expected. Anxiety decreased significantly from a prebiopsy mean score of 5.52 to a postbiopsy mean score of 2.25 (P < 0.001). Average and greatest pain experienced during the procedure had mean scores of 2.03 and 2.77, respectively, both significantly lower compared to preprocedural expectation (mean 4.53) (P < 0.001). Lower pain scores were reported in US-guided procedures compared to stereotactic- and MRI-guided biopsies (P < 0.001). No significant differences in pain scores were seen in those undergoing single versus multiple biopsies, or when benign, elevated-risk, or malignant lesions were sampled. Positive correlations were seen with prebiopsy anxiety levels and procedural pain as well as with anticipated pain and actual procedural pain. Image-guided biopsies are often better tolerated by patients than anticipated. We stress the benefit of conveying this information to patients prior to biopsy, as decreased anxiety correlates with lower levels of pain experienced during the procedure.

There is controversy on whether former smokers have increased risk for breast cancer recurrence or all-cause mortality, regardless of how much they smoked. Data were from three US cohorts in the After Breast Cancer Pooling Project, with detailed information on smoking among 9975 breast cancer survivors. Smoking was assessed an average of 2 years after diagnosis. Delayed entry Cox proportional hazards models were used to examine the relationships of smoking status, cigarettes per day, years of smoking, and pack years with breast cancer prognosis. Endpoints included breast cancer recurrence (n = 1727), breast cancer mortality (n = 1059), and overall mortality (n = 1803). Compared with never smokers, former smokers with less than 20 pack-years of exposure had no increased risk of any outcome. However, former smokers with 20 to less than 34.9 pack-years of exposure had a 22% increased risk of breast cancer recurrence (hazard ratio [HR] = 1.22; 95% confidence interval [CI] = 1.01 to 1.48) and a 26% increased risk of all-cause mortality (HR = 1.26; 95% CI = 1.07 to 1.48). For former smokers with 35 or more pack-years of exposure, the probability of recurrence increased by 37% (HR = 1.37; 95% CI = 1.13 to 1.66), breast cancer mortality increased by 54% (HR = 1.54; 95% CI = 1.24 to 1.91), and all-cause mortality increased by 68% (HR = 1.68; 95% CI = 1.44 to 1.96). Current smoking increased the probability of recurrence by 41% (HR = 1.41; 95% CI = 1.16 to 1.71), increased breast cancer mortality by 60% (HR = 1.61; 95% CI = 1.28 to 2.03), and doubled the risk of all-cause mortality (HR = 2.17; 95% CI = 1.85 to 2.54). Lifetime cigarette smoking was statistically significantly associated with a poor prognosis among women diagnosed with breast cancer, dose-dependent increased risks of recurrence, and breast cancer and all-cause mortality.

To investigate the changes and development of surgical treatment for breast cancer from 1999 to 2008 in China, and compare the differences between the surgical methods used in high-resource and low-resource areas. Clinicopathological data of surgical treatment for female primary breast cancer was collected via medical chart review at hospitals in seven geographic areas in China. Chi-square test and chisqure test for linear trends were used to analyze the changes and development of the surgical methods used for breast cancer in the 10 years. A total of 4211 primary breast cancer patients were selected from the 10-year database, including 4078 women (97.5%) treated by surgical operation. Among 3271 women (80.21%) treated with modified radical mastectomy, the surgical rate was rising from 68.89% in 1999 to 80.17% in 2008, ascending by 11.28% (χ(2) = 31.143, P < 0.001). In high-resource areas, the surgical rate of modified radical mastectomy was rising from 45.64% in 1999 to 76.13% in 2008, ascending by 30.49% (χ(2) = 89.393, P < 0.001), while in low-resource areas it kept a steady rate at 80% in the ten years (χ(2) = 2.113,P = 0.146). Among 231 women (5.66%) treated with breast-conserving surgery, the surgical rate was rising from 1.29% in 1999 to 11.57% in 2008, ascending by 10.28% (χ(2) = 102.835, P < 0.001). In high-resource areas, the surgical rate of breast-conserving surgery was rising from 2.68% in 1999 to 16.87% in 2008, ascending by 14.19% (χ(2) = 69.544, P < 0.001), while in low-resource areas it was rising from 0.42% in 1999 to 6.22% in 2008, ascending by 5.80% (χ(2) = 30.003, P < 0.001). Among 469 women (11.50%) treated with Halsted radical mastectomy, the surgical rate was declining from 28.28% in 1999 to 4.96% in 2008, descending by 23.32% (χ(2) = 206.202, P < 0.001). In high-resource areas, the surgical rate of Halsted radical mastectomy was declining from 50.34% in 1999 to 3.29% in 2008, descending by 47.05% (χ(2) = 274.830, P < 0.001), while in low-resource areas it was declining from 14.58% in 1999 to 6.64% in 2008, descending by 7.94% (χ(2) = 8.166, P = 0.004). Among 3786 women treated with breast mastectomy (including modified radical mastectomy and Halsted radical mastectomy), the surgical rate was declining from 98.46% in 1999 to 86.36% in 2008, descending by 12.10% (χ(2) = 95.744, P < 0.001). In high-resource areas, the surgical rate of breast mastectomy was declining from 96.64% in 1999 to 80.66% in 2008, descending by 15.98% (χ(2) = 53.446, P < 0.001), while in low-resource areas it was declining from 99.58% in 1999 to 92.12% in 2008, descending by 7.46% (χ(2) = 36.758,P < 0.001). The main primary surgical treatment for breast cancer is modified radical mastectomy during the period 1999 - 2008. Halsted radical mastectomy is gradually replaced by modified radical mastectomy and breast-conserving surgery. The rate of changes for breast-conserving surgery and mastectomy is higher in high-resource areas than that in low-resource areas. Breast-conserving surgery will become the main treatment for early-stage breast cancer.