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How Long Do Brazilian Women with Breast Cancer Survive? The Value of Publishing Institutional Outcomes

Breast cancer survival is a comprehensive indicator of the performance of the cancer care continuum, reflecting not only treatment effectiveness but also access to diagnosis, disease stage, and timely interventions. In this context, the cohort study published by Makdissi et al.¹, which evaluated 5,095 women treated at A.C.Camargo Cancer Center between 2000 and 2012, represents a substantial contribution to the Brazilian literature. It is one of the largest Brazilian institutional series, based on hospital cancer registry data, with a loss to follow-up rate of less than 6.5%, and has become one of the most widely recognized articles published in Mastology.

The findings demonstrate favorable improvements throughout the study period. Five-year overall survival (OS) among patients with invasive ductal carcinoma increased from 82.7% (2000–2004) to 89.9% (2010–2012), accompanied by a 58% reduction in the adjusted hazard of death in the most recent period (HR 0.42; 95% CI 0.34–0.53). Particularly substantial improvements were observed in advanced-stage disease: among patients with stage III breast cancer, five-year OS increased from 69.0% to 86.2%, while among those with stage IV disease, it increased from 20.7% to 40.8%. Approximately 77% of the cohort had stage 0–II disease, 17% had stage III disease, and 5% had stage IV disease.

A.C.Camargo in the Brazilian Context

Placing these findings in the context of other Brazilian studies is essential, although comparisons require caution because of differences in patient populations, study periods, and survival estimation methods (Table 1).

In the population-based CONCORD-3 study, five-year net survival in Brazil increased from 68.7% (2000–2004) to 75.2% (2010–2014).² Hospital-based studies reported five-year survival rates of 76.2% in Santa Catarina (2000–2002)³ and, in Juiz de Fora (2003–2005), 68.5% among patients treated through Brazil's Unified Health System (Sistema Único de Saúde [SUS]) and 80.6% among those receiving private health care.⁴ In the interior of São Paulo state, five-year OS was 78.5% at Barretos Cancer Hospital and 94.5% at a private institution in the same region between 2003 and 2011.⁵

A substantial proportion of this heterogeneity is related to disease stage at diagnosis. Among women treated at SUS-affiliated hospitals in São Paulo state between 2000 and 2015, 38% presented with stage III or IV disease.⁶ In Barretos, 40.3% of patients with nonmetastatic disease had stage III breast cancer, compared with 17.5% at the private institution.⁵ The AMAZONA III study identified more advanced stages at diagnosis among patients treated through the SUS across different Brazilian regions,⁷ while AMAZONA I had previously associated public health care coverage with poorer survival outcomes.⁸

In the A.C.Camargo cohort, approximately 22% of patients presented with stage III or IV disease, representing a relatively favorable stage distribution that may have contributed to the observed outcomes. The institution treats patients from both private (mainly) and public health care systems; however, the study did not allow survival to be stratified by health care coverage. Therefore, even when similar treatments are provided, differences in access to care and stage at diagnosis may influence comparisons across institutions.

This interpretation is supported by an earlier study comparing patients treated at Barretos Cancer Hospital with data from the US Surveillance, Epidemiology, and End Results (SEER) Program. Although overall survival was lower at the Brazilian institution, the survival curves became more similar when stratified by disease stage, suggesting a substantial influence of the initial stage distribution⁹, where the poorer survival reflects the high number of patients with advanced-stage disease at diagnosis.

A.C.Camargo in the International Context

The five-year OS of 89.9% observed at A.C.Camargo in 2010–2012 was numerically close to the CONCORD-3 estimates of five-year net survival for the United States (90.2%) and Australia (89.5%) in 2010–2014, and exceeded those reported for Argentina (84.4%) and Chile (75.5%).²

According to the SEER Program, five-year relative survival among patients diagnosed between 2007 and 2013 was 89.7%, ranging from 98.9% for localized disease to 85.2% for regional disease and 26.9% for distant disease.¹⁰ However, it is essential to emphasize that overall, net, and relative survival are not equivalent measures and that a cohort from a specialized referral center does not necessarily represent the general population.

Another relevant consideration is the proportion of patients diagnosed at an early stage. The World Health Organization's Global Breast Cancer Initiative has established a target of diagnosing at least 60% of invasive breast cancers at stage I or II.¹¹ Based on the published data for 2010–2012, this proportion was estimated at approximately 73% among invasive breast cancer cases with known stage at A.C.Camargo.

Achieving similar outcomes more broadly within Brazil's public health care system will require effective early-diagnosis strategies, reduced barriers to access, and stronger patient navigation throughout the cancer care network.

Why Should Institutions Publish Their Outcomes?

The significance of the study by Makdissi et al. extends beyond its numerical findings. It also lies in the institution's decision to systematically collect, analyze, and publicly report its clinical outcomes. Publishing a cohort of this magnitude contributes to a better understanding of breast cancer care in Brazil, encourages critical reflection, and provides benchmarks against which other institutions can evaluate their own performance.

In Brazil, breast surgeons practice in a wide range of settings, including High-Complexity Oncology Centers (Centros de Assistência de Alta Complexidade em Oncologia [CACON]), High-Complexity Oncology Units (Unidades de Assistência de Alta Complexidade em Oncologia [UNACON]), university hospitals, philanthropic institutions, and private health care facilities.

Despite the widespread availability of hospital cancer registries, institutional publications capable of supporting context-sensitive comparisons and local quality improvement initiatives remain relatively scarce. Large population-based and administrative databases, such as those maintained by the Brazilian Ministry of Health, the Brazilian National Cancer Institute (INCA), and SEER, are indispensable for health policy planning and evaluation. However, they address questions that differ from those faced by clinical teams seeking an in-depth understanding of their own care quality indicators.

The attention received by the A.C.Camargo article among Mastology readers highlights the strong interest in studies that translate everyday clinical practice into measurable outcomes. Publishing institutional results is not merely about demonstrating favorable performance indicators. It also means acknowledging limitations, identifying disparities, and creating tangible opportunities for improvement.

In this regard, the A.C.Camargo experience deserves recognition both for the quality of its reported outcomes and for its contribution to transparency and a culture of performance evaluation in oncology.

We therefore encourage members of the Brazilian Society of Mastology and health care professionals across Brazilian institutions to transform their clinical records into scientific knowledge by sharing their outcomes and experiences.

Measurement is essential for improvement; publication is fundamental for comparison, learning, and collective progress.

Mastology remains a leading platform for scientific dissemination and professional dialogue among Brazilian breast specialists.

Renato Cagnacci Neto

Breast Cancer Reference Center, A.C.Camargo Cancer Center, São Paulo, Brazil.

 

Table 1. Five-Year Survival in Selected Breast Cancer Cohorts

Study or cohort	Diagnosis period	Survival measure	Five-year survival (%)
A.C.Camargo, São Paulo¹	2000–2004 / 2010–2012	OS, invasive ductal carcinoma	82.7 / 89.9
Brazil, CONCORD-3²	2000–2004 / 2010–2014	Population-based net survival	68.7 / 75.2
Santa Catarina³	2000–2002	Hospital-based OS	76.2
Juiz de Fora, SUS / private health care⁴	2003–2005	Hospital-based survival	68.5 / 80.6
Barretos / private institution, São Paulo state⁵	2003–2011	OS, stages I–III	78.5 / 94.5
United States / Australia, CONCORD-3²	2010–2014	Population-based net survival	90.2 / 89.5
Argentina / Chile, CONCORD-3²	2010–2014	Population-based net survival	84.4 / 75.5
United States, SEER¹⁰	2007–2013	Population-based relative survival	89.7

OS: overall survival; SUS: Brazilian Unified Health System. Different survival measures are not directly comparable.

References

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