Management of women with ductal carcinoma in situ of the breast: a population-based study

Time trends and inter-hospital variation in treatment and axillary staging of patients with ductal carcinoma in situ of the breast in the era of screening in Southern Netherlands

BACKGROUND

To examine variation in time and place in axillary staging and treatment of patients with ductal carcinoma in situ (DCIS) of the breast.

METHODS

Trends in patients with DCIS recorded in the Eindhoven Cancer Registry diagnosed in 1991-2010 (n = 2449) were examined.

RESULTS

The use of breast conserving surgery (BCS) went from 17% to 67% in 1991-2010 and administration of radiotherapy after BCS increased to 89%. Axillary lymph node dissection decreased to almost 0%, while sentinel node biopsy was performed in 65% of patients in 2010. The proportion who underwent BCS varied between hospitals from 49% to 80%; the proportion without axillary staging ranged from 21% to 60%. Patients with screen-detected DCIS were more likely to receive BCS.

CONCLUSION

There was considerable variation in the use of BCS, radiotherapy, and axillary staging of DCIS over time and between hospitals. Patients with DCIS were more likely to be treated with BCS if their disease was detected by screening.

A nation-wide multicenter retrospective study of the epidemiological, pathological and clinical characteristics of breast cancer in situ in Chinese women in 1999 - 2008

BACKGROUND

Compared with invasive breast cancer, breast cancer in situ (BCIS) is seldom life threatening. However, an increasing incidence has been observed in recent years over the world. The purpose of our study is to investigate the epidemiological, clinical and pathological profiles of BCIS in Chinese women from 1999-2008.

METHODS

Four thousand and two hundred-eleven female breast cancer (BC) patients were enrolled in this hospital-based nation-wide and multi-center retrospective study. Patients were randomly selected from seven hospitals in seven representative geographical regions of China between 1999 and 2008. The epidemiological, clinical and pathological data were collected based on the designed case report form (CRF).

RESULTS

There were one hundred and forty-three BCIS cases in four thousand and two hundred-eleven BC patients (3.4%). The mean age at diagnosis was 48.3 years and BCIS peaked in age group 40-49 yrs (39.9%). The most common subtype was ductal carcinoma in situ (DCIS) (88.0%). 53.8% were positive for estrogen receptor (ER). Human epidermal growth factor receptor 2 (HER2) positive status was observed in 23.8% of patients. All patients underwent surgeries and 14.7% of them had breast conservation therapies (BCT) (21/143), but 41.9% accepted chemotherapy (64/143). Much less patients underwent radiotherapy (16.0%, 23/143) and among patients who had BCT, 67% accepted radiotherapy (14/21). Endocrine therapy was taken in 44.1% patients (63/143).

CONCLUSIONS

The younger age of BCIS among Chinese women than Western countries and increasing number of cases pose a great challenge. BCT and endocrine therapy are under great needs.

Breast cancer risk 55+ years after irradiation for an enlarged thymus and its implications for early childhood medical irradiation today

BACKGROUND

Radiotherapy during childhood increases long-term cancer risk, but the risk from radiation as a result of relatively higher dose diagnostic procedures remains less well known. This study, which evaluates breast cancer incidence in a cohort treated with "lower dose" chest radiotherapy over 50 years ago, can assist with estimating lifetime breast cancer risk in young children exposed to radiation from procedures such as chest computed tomography (CT) or treatment with recent "lower dose" chest radiotherapy protocols.

METHODS

A population-based, longitudinal cohort of subjects exposed to thymic irradiation during infancy from 1926 to 1957 and of their unexposed siblings was re-established. Previously followed until 1987, we resurveyed cohort members from 2004 to 2008. Poisson regression models compared breast cancer incidence rates between women in the cohort by treatment and dose category groups.

RESULTS

Breast cancer occurred in 96 treated (mean breast dose, 0.71 Gy) and 57 untreated women during 159,459 person-years of follow-up. After adjusting for attained age and treatment/birth cohort, the rate ratio was 3.01 (2.18-4.21). The adjusted excess relative risk per Gy was 1.10 (95% confidence interval, 0.61-1.86). Traditional breast cancer risk factors did not contribute significantly to multivariate model fit.

CONCLUSION

Our results show that at radiation doses between those received by the breast from chest CT and cancer therapy during early childhood, breast cancer incidence rates remain elevated >50 years after exposure. This implies that increased breast cancer risk will remain a lifelong concern in females treated during childhood with currently reduced radiotherapy doses and for infants receiving multiple chest CTs.

Variations in treatment of ductal carcinoma in situ of the breast: A population-based study in the East Netherlands

AIMS

Differences in treatment of ductal carcinoma in situ (DCIS) of the breast were analysed for a geographically defined population in the East Netherlands.

METHODS

Data from the Cancer Registry of the Comprehensive Cancer Centre East Netherlands were analysed for treatment of DCIS in the period between January 1989 and December 2003. The study population consisted of 800 female patients with a first diagnosis of DCIS of whom 798 underwent surgical treatment. The distribution of tumour characteristics and treatment were compared for several time periods.

RESULTS

Surgical treatment was specified for 648 patients: 51% underwent breast-conserving surgery. The proportion of patients treated with breast-conserving surgery increased: 43% in the period 1994-1998 and 55 after 1999 (p<0.01). An axillary staging procedure was performed in 149 patients (19%), of whom 2 (1%) had tumour-involved lymph nodes. Of patients treated with breast-conserving surgery, 133 (40%) received radiation therapy: 7% in the period 1994-1998 compared to 62% after 1999 (p<0.01). Patients (60%) of 50 years or younger were treated with mastectomy compared to 44% in patients aged 50-69 years and 50% in patients of 70 years and older (p<0.01). The rate in use of radiation therapy after breast-conserving surgery was comparable to both age groups.

CONCLUSION

This study shows variability in the treatment of DCIS in a geographically defined region. Approximately half of all patients were treated with mastectomy and 19% underwent an axillary staging procedure; this may represent aggressive, unwarranted treatment. In contrast, 38% of patients treated with breast-conserving surgery were not treated with radiation therapy after 1999, which may represent under-treatment.

Factors Affecting Successful Breast Conservation for Ductal Carcinoma in Situ

BACKGROUND

Successful breast-conserving therapy in DCIS is restricted by high rates of residual disease resulting in the need for radiotherapy and/or re-excision. This study identifies patients with DCIS who are most at risk of compromised margins and of residual disease.

METHODS

All patients undergoing breast-conserving surgery for DCIS over a 6-year period were included. Method of diagnosis, mammographic size, pathological size, DCIS-margin distance and residual disease on re-excision were analysed.

RESULTS

One hundred and thirty-five patients underwent initial breast-conserving surgery for DCIS. The compromised margin rate was 72%, and the rate of residual disease on re-operation was 54%. On univariate analysis, underestimation of pathological size by mammography by >1 cm occurred in 40% of those with compromised margins undergoing a therapeutic operation compared to only 14% of those with clear margins (P = 0.02). However, on multivariate analysis only pathological size (P < 0.0001, OR = 1.0,95% CI 1.037-1.128) and lack of a preoperative diagnosis by core biopsy (P < 0.0001, OR = 5.3,95% CI 1.859-15.08) were predictive of compromised margins. The presence of residual disease on re-excision was associated with increasing pathological size (P < 0.0001, OR = 1.085,95% CI 1.038-1.134) and decreasing DCIS-margin distance (P = 0.03, OR = 6.694,95% CI 1.84-37.855). Twenty-nine percent (n = 13/45) of lesions < or =3 cm compared to 84% (n = 27/32) of lesions >3 cm had residual disease on re-operation (P < 0.0001). Residual disease was present in 62% (n = 34/55), 64% (n = 7/11) and 17% (n = 2/12) of patients with DCIS-margin distances < or =1, 1-2 and 2-5 mm, respectively.

CONCLUSION

Considerable underestimation of DCIS extent by mammography occurs in a high proportion of patients with compromised margins in breast conservation. Patients at particularly high risk of residual disease on re-excision are those with lesions >3 cm and those with DCIS-margin distances of < or = 2mm.

Ductal Carcinoma in Situ: Trends in Geographic, Temporal, and Demographic Patterns of Care and Survival

While long-term prognosis is excellent, treatment of ductal carcinoma in situ (DCIS) remains controversial and inconsistent. The purpose of this study was to track geographic and temporal patterns of care for women diagnosed with DCIS, and analyze subsequent cancer-specific risk of mortality. Subjects for this study were 41,245 women diagnosed with primary DCIS in the National Surveillance, Epidemiology, and End Results (SEER) program from 1973 through 2000. Variables analyzed included patient age, year of diagnosis, SEER site of residence at the time of diagnosis, treatment (surgery, radiation), race, age, and hormone (estrogen and progesterone) receptor status. The percentage of women diagnosed with DCIS out of the total number of women diagnosed with breast cancer increased steadily between 1973 and 2000, with the largest increase occurring around 1985. Breast conserving surgery (BCS) utilization increased over time for each SEER site to the current proportions, ranging from 49.5% in Utah to 76.9% in Connecticut. Younger women were significantly more likely to receive mastectomy and had significantly lower risk of death. Women receiving BCS who also had radiation therapy (RT) had a significantly lower risk of death, although those receiving mastectomy had the lowest risk of death. Black women and Asian/Pacific island women were significantly more likely to receive BCS, although black women were less likely to receive follow-up RT and had a significantly increased risk of death. Racial and age differences in the treatment of DCIS resulted in significantly disparate rates of survival, which should be considered in public health programming. Mastectomy utilization resulted in improved survival, although additional studies may elucidate the interaction of treatment with patient age.

CHANGES IN THE MANAGEMENT OF DUCTAL CARCINOMA IN SITU BEFORE THE RELEASE OF CLINICAL PRACTICE RECOMMENDATIONS IN AUSTRALIA: THE CASE IN VICTORIA

BACKGROUND

This study examines changes in the management of ductal carcinoma in situ between 1995 and 1999 in the Australian State of Victoria. This period was before the release of Australian treatment recommendations.

METHODS

All new cases of ductal carcinoma in situ diagnosed between 1 April and 30 September in 1995 and 1999 were identified from the population cancer registry. Treating surgeons completed a questionnaire on the presentation and management of each case. In 1995, 64 out of 70 surgeons returned questionnaires for 137 cases (case response, 94%). In 1999, 68 surgeons treated 159 registered cases and 141 completed surveys were returned (case response, 89%).

RESULTS

More cases underwent an image-guided biopsy in 1999 (54%) than in 1995 (34%). Breast-conserving surgery (BCS) was used to treat 69% of cases in 1999 and 63% in 1995. The use of axillary procedures (clearance or sampling) for women treated by mastectomy decreased from 61% in 1995 to 30% in 1999. More patients treated with BCS had margins simply described as "clear" in 1995 (49%) than in 1999 (21%). In 1995, only 7% of cases treated with BCS had radiotherapy, and this was 25% in 1999.

CONCLUSION

In both 1999 and 1995, the majority of patients were treated by BCS, but only a minority received radiotherapy.

Compliance with guidelines is related to better local recurrence-free survival in ductal carcinoma in situ

The aim was to study the effect of compliance with guidelines on local recurrence (LR)-free survival in patients treated for ductal carcinoma in situ (DCIS). From January 1992 to December 2003, 251 consecutive patients had been treated for DCIS in two hospitals in the North Netherlands. Every case in this two-hospital sample was reviewed in retrospect for its clinical and pathological parameters. It was determined whether treatment had been carried out according to clinical guidelines, and outcomes in follow-up were assessed. In addition, all patients treated for DCIS in this region (n=1389) were studied regarding clinical parameters, in order to determine whether the two-hospital sample was representative of the entire region. In the two-hospital sample, 31.4% (n=79) of the patients had not been treated according to the guidelines. Positive margins were associated with LR (hazard ratio (HR)=4.790, 95% confidence interval (CI) 1.696–13.531). Breast-conserving surgery and deviation from the guidelines were independent predictors of LR (HR=7.842, 95% CI 2.126–28.926; HR=2.778, 95% CI 0.982–6.781, respectively). Although the guidelines changed over time, time was not a significant factor in predicting LRs (HR=1.254, 95% CI 0.272–5.776 for time period 1992–1995 and HR=1.976, 95% CI 0.526–7.421 for time period 1996–1999). Clinical guidelines for the treatment of patients with DCIS have been developed and updated from existing literature and best evidence. Compliance with the guidelines was an independent predictor of disease-free survival. These findings support the application of guidelines in the treatment of DCIS.

Clinical experience of patients with ductal carcinoma in situ of the breast treated with breast-conserving surgery plus radiotherapy: a preliminary report

PURPOSE

Breast-conserving therapy (BCT) is a practical alternative to mastectomy for treating ductal carcinoma in situ (DCIS). We reviewed our experience for treating patients with DCIS of the breast to evaluate the outcome after performing breast-conserving surgery plus radiotherapy (BCS-RT).

MATERIALS AND METHODS

Between January 1983 and December 2002, 25 patients with clinically or mammographically detected DCIS were treated by BCS-RT. One patient was diagnosed with bilateral DCIS. Thirteen cases (50%) had symptomatic lesions at presentation. All 26 cases of 25 patients underwent BCS such as lumpectomy, partial mastectomy or quadrantectomy. All of them received whole breast irradiation to a median dose of 50.4 Gy. Twenty-four cases (92.3%) received a boost to the tumor bed for a median total dose of 59.4 Gy. The median follow up period was 67 months (range: 38 to 149 months).

RESULTS

Two cases (7.7%) experienced ipsilateral breast tumor recurrence (IBTR) after BCS-RT. The histology results at the time of IBTR showed invasive ductal carcinoma (IDC), and the median time to IBTR was 25.5 months. On the univariate analysis, there were no significant factors associated with IBTR in the DCIS patients. The three-year local recurrence free survival rate was 96.0% and the overall survival rate was 96.3%.

CONCLUSION

After the treatment for DCIS, the IBTR rate in our study was similar to other previous studies. Considering that we included patients who had many symptomatic lesions, close or positive margins and less that complete early data, our result is comparable to the previous studies. We could not find the prognostic significant factors associated with IBTR after BCS-RT. A longer follow up period with more patients would be required to evaluate the role of any predictive factors and to confirm these short-term results.

Surgery and outcomes of ductal carcinoma in situ of the breast: a population-based study in Australia

We examined surgery and outcome in a population-based series of 2109 women newly diagnosed with ductal carcinoma in situ (DCIS) in 1995-2000 in New South Wales (NSW), Australia. The sole data source for the study was pathology records in the NSW Cancer Registry. Most DCIS was treated with breast-conserving surgery (BCS); use of breast conservation increased throughout the 6 years of the study. Women who were younger, had higher grade DCIS or had larger lesions were significantly and independently less likely to have BCS than other women. Eighteen percent of women had lymph nodes removed, most often with mastectomy. The NSW Cancer Registry does not collect information about radiotherapy. Based on cancer registrations alone, 97.7% of women were free of ipsilateral invasive cancer after three years; more women who had mastectomy were cancer-free (100%) than women who had breast-conserving surgery (97.2%; P=0.05).