Breast Cancer in Women: Incidence, Mortality and Treatment Management in Puerto Rico

Abstract

Background: Data on trends in breast cancer incidence and mortality in Puerto Rico are limited, as is information on therapeutic services available to women with breast cancer on the Island. Such data is necessary to evaluate the success of the recent expansion in health insurance coverage and public health efforts to increase breast cancer screening and reduce breast cancer mortality. Expanding on reports from the Puerto Rico Central Cancer Registry (PRCCR), this dissertation analyzes breast cancer incidence and mortality trends in Puerto Rico for the period 2000-2013 by geographic health service region and clinical tumor characteristics, during which Medicare Advantage was introduced in Puerto Rico. It also evaluates therapeutic services provided over this period in one Medicare Advantage program. Methods: Breast cancer cases data was obtained from the PRCCR and population data from the Puerto Rican State Planning Board tables. A total of 20,228 females in whom invasive breast cancer was diagnosed during 2000 and 2013 were analyzed by age group, health service region, and clinical characteristics, including histological type, the grade of tumor, and disease stage at diagnosis. Incidence rates were analyzed using Joinpoint analysis to study the trends during this period after age-adjusting to the female population of the United States. In addition, a utilization claims-based analysis was performed to document the frequency of medical and therapeutic services rendered in a Medicare Advantage Health Plan in Puerto Rico, MMM Holdings, from 2007 to 2016 after the introduction of the Medicare Advantage Program. Results: Incidence rates significantly increased after 2007 with an Annual Percent Change of 3.6% (p-value <0.00016), reaching an incidence rate in 2013 of 81 per 100,000 females. Significant increases were found in rates of infiltrating duct cell carcinoma well and moderately differentiated tumors, in each stage of breast cancer. Mortality rates increased after 2007 with an Annual Percent Change of 2% (p-value = 0.2), reaching a rate in 2014 of 25 per 100,000 females. Increases in mortality were explicitly observed in ductal cell carcinomas and for poorly differentiated and moderately differentiated tumors. Medical and pharmacy services increased for the female Medicare breast cancer population in Puerto Rico. A higher proportion of services and prescriptions, including injectable treatments, were rendered by physicians from their office setting during this time. Conclusion: The introduction of the Medicare Advantage Program in Puerto Rico has impacted the ascertainment of more breast cancer cases and improved documentation of clinical characteristics of tumors. These findings enhance the understanding of breast cancer in Puerto Rico and guide efforts to improve medical care quality, especially among elderly females with breast cancer. With this study methodology, we expect that describing breast cancer incidence and mortality rates by histological types, grade, and staging will become an integrated section in the reporting of future cancer publications in Puerto Rico. Another recommendation is to increase the awareness among medical providers of the relevance of histological type, the grade of the tumor, and staging when evaluating the preventive services and treatment in breast cancer patients. A detailed evaluation of treatment episodes can be suggested as a next step, complementing the claims-based and electronic medical record information in breast cancer patients in Puerto Rico.