National and subnational burden of female and male breast cancer and risk factors in Iran from 1990 to 2019: results from the Global Burden of Disease study 2019
Authors: Aryannejad Armin , Saeedi Moghaddam Sahar , Mashinchi Baharnaz , Tabary Mohammadreza , Rezaei Negar , Shahin Sarvenaz , Rezaei Nazila ,   GBD 2019 Iran Breast Cancer Collaborators, Abbasi-Kangevari Mohsen , Abbasi-Kangevari Zeinab , Abbastabar Hedayat , Abidi Hassan , Abolhassani Hassan , Aghaali Mohammad , Ahadinezhad Bahman , Ahmadi Ali , Ahmadi Sepideh , Ajami Marjan , Akbari Mohammad Esmaeil , Alimohamadi Yousef , Alipour Sadaf , Alipour Vahid , Amini Saeed , Anoushirvani Ali Arash , Arabloo Jalal , Arab-Zozani Morteza , Ataeinia Bahar , Athari Seyyed Shamsadin , Azadmehr Abbas , Azadnajafabad Sina , Azangou-Khyavy Mohammadreza , Azari Jafari Amirhossein , Bagheri Nader , Bagherieh Sara , Bahadory Saeed , Besharat Sima , Bohlouli Somayeh , Cruz-Martins Natália , Dianatinasab Mostafa , Didehdar Mojtaba , Djalalinia Shirin , Dorostkar Fariba , Eskandarieh Sharareh , Eslami Bita , Falahi Shahab , Farahmand Mohammad , Fatehizadeh Ali , Fereidoonnezhad Masood , Galehdar Nasrin , Ghamari Seyyed-Hadi , Ghashghaee Ahmad , Gholamalizadeh Maryam , Gholami Ali , Goleij Pouya , Golitaleb Mohamad , Hafezi-Nejad Nima , Haj-Mirzaian Arvin , Halimi Aram , Hassanipour Soheil , Heidari Mohammad , Heidarymeybodi Zahra , Heydari Keyvan , Hosseini Mohammad-Salar , Jamshidi Elham , Janghorban Roksana , Kabir Ali , Kalankesh Leila R. , Kavetskyy Taras , Keikavoosi-Arani Leila , Keykhaei Mohammad , Khalilov Rovshan , Khanali Javad , Khodadost Mahmoud , Kolahi Ali-Asghar , Kompani Farzad , Koohestani Hamid Reza , Letafat-nezhad Mozhgan , Livani Somayeh , Maali Amirhosein , Madadizadeh Farzan , Mahjoub Soleiman , Mahmoodpoor Ata , Malekpour Mohammad-Reza , Malekzadeh Reza , Mansournia Mohammad Ali , Masoudi Sahar , Masoumi Seyedeh Zahra , Mehrabi Nasab Entezar , Mirmoeeni Seyyedmohammadsadeq , Mohammadi Esmaeil , Mohammadian-Hafshejani Abdollah , Mohseni Mohammad , Momtazmanesh Sara , Moradi Abdolvahab , Moradi Maryam , Moradi Yousef , Moradpour Farhad , Moradzadeh Rahmatollah , Mosapour Abbas , Moshtagh Mozhgan , MousaviIsfahani Haleh , Murray Christopher J. L. , Nazari Javad , Nejadghaderi Seyed Aria , Noori Maryam , Okati-Aliabad Hassan , Oladnabi Morteza , Pakbin Babak , PashazadehKan Fatemeh , Pazoki Toroudi Hamidreza , Pourtaheri Naeimeh , Rabiee Navid , Rafiei Sima , Rahim Fakher , Rahmanian Vahid , Raoofi Samira , Rashidi Mahsa , Rashidi Mohammad-Mahdi , Razeghinia Mohammad Sadegh , Rezaei Nima , Rezaei Saeid , Rezapour Aziz , Roshandel Gholamreza , Sabour Siamak , Sahebazzamani Maryam , Sahebkar Amirhossein , Sajadimajd Soraya , Sepanlou Sadaf G. , Shahabi Saeed , Shahraki-Sanavi Fariba , Sharifi-Rad Javad , Shirkoohi Reza , Shobeiri Parnian , Soltani-Zangbar Mohammad Sadegh , Tabibian Elnaz , Taheri Majid , Taheri Abkenar Yasaman , Tavakoli Ahmad , Tiyuri Amir , Tohidast Seyed Abolfazl , Valadan Tahbaz Sahel , Valizadeh Rohollah , YahyazadehJabbari Seyed Hossein , Zaki Leila , Zamanian Maryam , Zare Iman , Zoladl Mohammad , Naghavi Mohsen , Larijani Bagher , Farzadfar Farshad 
Published: April 2023

Abstract
Background
Breast cancer (BC) is one of the most burdensome cancers worldwide. Despite advancements in diagnostic and treatment modalities, developing countries are still dealing with increasing burdens and existing disparities. This study provides estimates of BC burden and associated risk factors in Iran at the national and subnational levels over 30 years (1990–2019).

Methods
Data on BC burden for Iran were retrieved from the Global Burden of Disease (GBD) study from 1990 to 2019. GBD estimation methods were applied to explore BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to risk factors based on the GBD risk factors hierarchy. Moreover, decomposition analysis was performed to find the contribution of population growth, aging, and cause-specific incidence in the total incidence change. Age-standardized rates (per 100,000 population) and 95% uncertainty intervals (UI) were reported based on sex, age, and socio-demographic index (SDI).

Results
Age-standardized incidence rate (ASIR) increased from 18.8 (95% UI 15.3–24.1)/100,000 in 2019 to 34.0 (30.7–37.9)/100,000 in 2019 among females and from 0.2/100,000 (0.2–0.3) to 0.3/100,000 (0.3–0.4) among males. Age-standardized deaths rate (ASDR) increased slightly among females from 10.3 (8.2–13.6)/100,000 in 1990 to 11.9 (10.8–13.1)/100,000 in 2019 and remained almost the same among males—0.2/100,000 (0.1–0.2). Age-standardized DALYs rate also increased from 320.2 (265.4–405.4) to 368.7 (336.7–404.3) among females but decreased slightly in males from 4.5 (3.5–5.8) to 4.0 (3.5–4.5). Of the 417.6% increase in total incident cases from 1990–2019, 240.7% was related to cause-specific incidence. In both genders, the BC burden increased by age, including age groups under 50 before routine screening programs, and by SDI levels; the high and high-middle SDI regions had the highest BC burden in Iran. Based on the GBD risk factors hierarchy, high fasting plasma glucose (FPG) and alcohol were estimated to have the most and the least attributed DALYs for BC among females, respectively.

Conclusions
BC burden increased from 1990 to 2019 in both genders, and considerable discrepancies were found among different provinces and SDI quintiles in Iran. These increasing trends appeared to be associated with social and economic developments and changes in demographic factors. Improvements in registry systems and diagnostic capacities were also probably responsible for these growing trends. Raising general awareness and improving screening programs, early detection measures, and equitable access to healthcare systems might be the initial steps to tackle the increasing trends.