A comparison of risk perception and psychological morbidity in women with ductal carcinoma in situ and early invasive breast cancer

DCIS and LCIS: Are the Risk Factors for Developing In Situ Breast Cancer Different?

Ductal carcinoma in situ (DCIS) is widely accepted as a precursor of invasive ductal carcinoma (IDC). Lobular carcinoma in situ (LCIS) is considered a risk factor for invasive lobular carcinoma (ILC), and it is unclear whether LCIS is also a precursor. Therefore, it would be expected that similar risk factors predispose to both DCIS and IDC, but not necessarily LCIS and ILC. This study examined associations with risk factors using data from 3075 DCIS cases, 338 LCIS cases, and 1584 controls aged 35-60, recruited from the UK-based GLACIER and ICICLE case-control studies between 2007 and 2012. Analysis showed that breastfeeding in parous women was protective against DCIS and LCIS, which is consistent with research on invasive breast cancer (IBC). Additionally, long-term use of HRT in post-menopausal women increased the risk of DCIS and LCIS, with a stronger association in LCIS, similar to the association with ILC. Contrary to findings with IBC, parity and the number of births were not protective against DCIS or LCIS, while oral contraceptives showed an unexpected protective effect. These findings suggest both similarities and differences in risk factors for DCIS and LCIS compared to IBC and that there may be justification for increased breast surveillance in post-menopausal women taking long-term HRT.

The long-term psychosocial consequences of screen-detected ductal carcinoma in situ and invasive breast cancer

OBJECTIVE

Ductal carcinoma in situ (DCIS) is a risk factor for invasive breast cancer (IBC). The prognosis of DCIS is considerably better than for IBC, yet women do not distinguish between the threat. We aimed to compare the psychosocial consequences of screen-detected DCIS and IBC, and to examine this comparison over time.

METHODS

We surveyed a Danish mammography-screening cohort from 2004 to 2018. We assessed outcomes at six-time points: baseline, 1, 6, 18, 36 months, and 14 years after the screening. We measured psychosocial consequences with the Consequences Of Screening - Breast Cancer (COS-BC): a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions. We used weighted linear models with generalized estimating equations to compare responses between groups. We used a 1% level of significance.

RESULTS

170 out of 1309 women were diagnosed with breast cancer (13.0%). 23 were diagnosed with DCIS (13.5%) and 147 with IBC (86.5%). From baseline to six months after diagnosis, there were no significant differences between women with DCIS and IBC. However, mean scores indicated that IBC generally was more affected than DCIS. After six months, we observed that women with DCIS and IBC might be affected differently in the long term; mean scores and mean differences showed that IBC were more affected on some scales, while DCIS were on others.

CONCLUSION

Overall, the DCIS and IBC experienced similar levels of psychosocial consequences. Women might benefit from renaming DCIS to exclude cancer nomenclature.

Is palpable DCIS more aggressive than screen-detected DCIS?

Background

Palpable ductal carcinoma in-situ (pDCIS) is a subset of DCIS presenting with a clinical mass. We hypothesized pDCIS would have more aggressive clinical and pathological features, and higher rates of recurrence and upgrade to invasive disease compared to screen-detected DCIS.

Materials and methods

We performed a retrospective analysis of female patients (age 28-76) with DCIS on core-needle biopsy. pDCIS patients had a physician documented palpable mass prior to initial biopsy. Descriptive statistics were performed to compare groups.

Results

This study included 83 patients, 26 had pDCIS and 57 had screen-detected DCIS. Mean duration of follow-up was 49.4 months. pDCIS patients had significantly larger lesions (p = 0.03) which were more frequently biopsied via ultrasound (p = 0.002). In multivariate analysis, pDCIS was associated with ultrasound guided core needle biopsy, size of DCIS >2 cm, and comedo pattern (p = 0.001, p = 0.007 and p = 0.022, respectively). 7.7 % of pDCIS cases versus 3.5 % of screen-detected cases were upgraded to invasive cancer (p = 0.59). There was no difference in local recurrence (p = 0.55) between groups. Neither group experienced regional or distant recurrence.

Conclusions

pDCIS was associated with some aggressive pathologic and clinical features and was more frequently diagnosed by ultrasound guided core-needle biopsy than screen-detected DCIS. However, there was no significant difference in rate of recurrence or upgrade to invasive disease between groups.

Key message

Although pDCIS was associated with some aggressive pathologic and clinical features, there was no significant difference in rate of recurrence or upgrade to invasive disease compared to screen-detected DCIS.

One-year recovery from breast cancer: Importance of tumor and treatment-related factors, resilience, and sociodemographic factors for health-related quality of life

Aim

This study investigated the changes in health-related quality of life from diagnosis to 1 year after diagnosis in breast cancer (BC) patients and the influence of clinical, psychological, and sociodemographic variables. An additional aim was to explore the mediating and moderating effects of resilience on changes in health-related quality of life.

Methods

A longitudinal population-based study was conducted in southern Sweden. Newly diagnosed BC patients filled in measures of health-related quality of life, resilience, and sociodemographic variables at diagnosis (N = 980) and 1 year post-diagnosis (N = 780). Clinical variables were extracted from the Swedish national breast cancer quality registry. Mixed-model analyses were performed.

Results

Most health-related quality of life outcomes declined from diagnosis to 1 year post-diagnosis. Role limitations due to emotional problems remained the same, whereas mental health improved. Lower health-related quality of life outcomes were associated with symptomatic detection and axillary dissection. Patients with a higher TNM stage and histologic grade and estrogen receptor (ER)-negative and human epidermal growth factor 2 (HER2)-positive status, who received chemotherapy, antibody therapy, or bisphosphonate therapy, had a steeper decline in outcomes. Changes in resilience were positively associated with all outcomes but did not mediate or moderate changes in any. Resilience at baseline moderated changes in bodily pain, vitality, and mental health, with higher baseline resilience being associated with a steeper decline, possibly due to floor or ceiling effects. Patients with lower socioeconomic status, educational level, and older age had a lower health-related quality of life.

Conclusion

Physical health-related quality of life among breast cancer patients declined 1 year post-diagnosis, whereas mental health-related quality of life improved. Low resilient patients may be especially vulnerable at diagnosis. Biopsychosocial assessment at diagnosis can help identify patients who may require additional support. A multidimensional treatment plan should be started early to help overcome the problems in everyday activities.

Patient comprehension of breast pathology report terminology: The need for patient-centered resources

BACKGROUND

As health care continues to evolve toward information transparency, an increasing number of patients have access to their medical records, including result reports that were not originally designed to be patient-facing. Previous studies have demonstrated that patients have poor understanding of medical terminology. However, patient comprehension of terminology specific to breast pathology reports has not been well studied. We assessed patient understanding of common medical terms found in breast pathology reports.

METHODS

A survey was administered electronically to patients scheduled for a screening mammogram within a multisite health care system. Participants were asked to objectively define and interpret 8 medical terms common to breast biopsy pathology reports. Patient perception of the utility of various educational tools was also assessed. Demographic information including health literacy, education level, previous cancer diagnosis, and primary language was collected.

RESULTS

In total, 527 patients completed the survey. Terms including "malignant" and "benign" were the most correctly defined at 80% and 73%, respectively, whereas only 1% correctly defined "high grade." Factors including race/ethnicity and education level were correlated with more correct scores. Patients preferred educational tools that were specific to their diagnosis and available at the time they were reviewing their results.

CONCLUSION

Patient comprehension of common medical terminology is poor. Potential assumptions of understanding based on patient factors including education, past medical history, and occupation are misinformed. With the newly mandated immediate release of information to patients, there is a pressing need to develop and integrate educational tools to support patients through all aspects of their care.

Patient Preferences for Outcomes Following DCIS Management Strategies: A Discrete Choice Experiment

PURPOSE

Ductal carcinoma in situ (DCIS), a nonobligate precursor of breast cancer, is often aggressively managed with multimodal therapy. However, there is limited research on patients' preferences for trade-offs among treatment-related outcomes such as breast appearance, side effects, and future cancer risk. We sought to investigate whether women consider treatment features aside from cancer risk when making treatment choices for ductal carcinoma in situ and if so, to what degree other features influence these decisions.

METHODS

A discrete choice experiment was administered to participants in a comprehensive cancer screening mammography clinic. The experimental design was used to generate constructed health profiles resulting from different management strategies. Health profiles were defined by breast appearance, severity of infection within the first year, chronic pain, hot flashes, and risk of developing or dying from breast cancer within 10 years.

RESULTS

One hundred ninety-four women without a personal history of breast cancer completed the choice task. Across 10 choice questions, 29% always selected the health profile with a lower risk of invasive breast cancer (ie, dominated on cancer risk), regardless of the effects of treatment. For nonrisk dominators, breast cancer risk remained the most important factor but was closely followed by chronic pain (24% [95% CI, 20 to 28]) and infection (22% [95% CI, 18 to 25]). Depending on treatment outcomes, the tolerable increase in breast cancer risk was as high as 3.4%.

CONCLUSION

Most women were willing to make some trade-offs between invasive cancer risk and treatment-related outcomes. Our findings highlight the importance of shared decision-making weighing risks and benefits between patient and provider management of low-risk disease.

Determinants of use of oral complementary-alternative medicine among women with early breast cancer: a focus on cancer-related fatigue

BACKGROUND

Despite the questionable effectiveness of oral complementary and alternative medicine (OCAM) in relieving cancer-related symptoms, including fatigue (CRF), many patients use it aiming to improve their quality of life. We assessed factors associated with OCAM use, focusing on CRF.

METHODS

Women with stage I-III breast cancer (BC) were included from CANTO (NCT01993498). OCAM use was defined as taking homeopathy, vitamins/minerals, or herbal/dietary supplements. Multivariable multinomial logistic regressions evaluated associations of CRF (EORTC QLQ-C30), patient, and treatment characteristics with OCAM use.

RESULTS

Among 5237 women, 23.0% reported OCAM use overall (49.3% at diagnosis, 50.7% starting post-diagnosis), mostly homeopathy (65.4%). Mean (SD) CRF score was 27.6 (24.0) at diagnosis and 35.1 (25.3) at post-diagnosis. More intense CRF was consistently associated with OCAM use at diagnosis and post-diagnosis [adjusted odds ratio (aOR) for 10-point increase 1.05 (95% Confidence interval 1.01-1.09) and 1.04 (1.01-1.09) vs. never use, respectively]. Odds of using OCAM at diagnosis were higher among older [for 5-year increase, 1.09 (1.04-1.14)] and more educated patients [college vs. primary 1.80 (1.27-2.55)]. Women with income > 3000 [vs. < 1500 euros/month, 1.44 (1.02-2.03)], anxiety [vs. not, 1.25 (1.01-1.54)], and those receiving chemotherapy [vs. not, 1.32 (1.04-1.68)] had higher odds of using OCAM post-diagnosis.

CONCLUSION

One-in-four patients reported use of OCAM. More severe CRF was consistently associated with its use. Moreover, older, better educated, wealthier, more anxious women, and those receiving chemotherapy seemed more prone to use OCAM. Characterizing profiles of BC patients more frequently resorting to OCAM may help deliver targeted information about its benefits and potential risks.

The impact of ductal carcinoma in situ on health services utilization

PURPOSE

To determine the intermediate-term impact of diagnosis and treatment of ductal carcinoma in situ of the breast (DCIS) on health services utilization, we compared utilization by cases of DCIS to unaffected controls.

METHODS

We identified a population-based cohort of Ontario females diagnosed with DCIS between 2010 and 2015. We matched 5 controls without any history of cancer to each case, on the date of diagnosis of the case (the index date), by age, annual mammography history, socioeconomic status, and comorbidity. We identified billing claims and hospital records, during the interval 13 to 60 months prior to, and subsequent to the index date, and computed rates per 100 person-years during both intervals, to conduct a difference-in-differences analysis. We used negative binomial regression to test if the change in rates in health services differed between cases and controls.

RESULTS

Visits with a breast diagnosis code, and claims for breast surgery and imaging, were significantly increased among cases compared to controls (all p values < 0.0001) after DCIS;however, there was no increase in visits for anxiety or depression (RR 1.13 (95% CI 0.97, 1.32, p = 0.11), visits to psychiatrists (RR 1.07 (95% CI 0.82, 1.40) p = 0.6), or hospital procedures other than breast surgery (RR 1.10 (95% CI 0.88, 1.37) p = 0.4).

CONCLUSIONS

DCIS is associated with more visits and procedures related to the breast compared to controls following diagnosis and treatment, but other health services utilization and visits related to anxiety and depression were not increased.

Identifying opportunities to support patient-centred care for ductal carcinoma in situ: qualitative interviews with clinicians

Background

Women with ductal carcinoma in situ (DCIS) report poor patient-clinician communication, and long-lasting confusion and anxiety about their treatment and prognosis. Research shows that patient-centred care (PCC) improves patient experience and outcomes. Little is known about the clinician experience of delivering PCC for DCIS. This study characterized communication challenges faced by clinicians, and interventions they need to improve PCC for DCIS.

Methods

Purposive and snowball sampling were used to recruit Canadian clinicians by specialty, gender, years of experience, setting, and geographic location. Qualitative interviews were conducted by telephone. Data were analyzed using constant comparison. Findings were mapped to a cancer-specific, comprehensive PCC framework to identify opportunities for improvement.

Results

Clinicians described approaches they used to address the PCC domains of fostering a healing relationship, exchanging information, and addressing emotions, but do not appear to be addressing the domains of managing uncertainty, involving women in making decisions, or enabling self-management. However, many clinicians described challenges or variable practices for all PCC domains but fostering a healing relationship. Clinicians vary in describing DCIS as cancer based on personal beliefs. When exchanging information, most find it difficult to justify treatment while assuring women of a good prognosis, and feel frustrated when women remain confused despite their efforts to explain it. While they recognize confusion and anxiety among women, clinicians said that patient navigators, social workers, support groups and high-quality information specific to DCIS are lacking. Despite these challenges, clinicians said they did not need or want communication interventions.

Conclusions

Findings represent currently unmet opportunities by which to help clinicians enhance PCC for DCIS, and underscore the need for supplemental information and supportive care specific to DCIS. Future research is needed to develop and test communication interventions that improve PCC for DCIS. If effective and widely implemented, this may contribute to improved care experiences and outcomes for women diagnosed with and treated for DCIS.

Valuing preferences for treating screen detected ductal carcinoma in situ

BACKGROUND

Mammographic screening reduces breast cancer mortality but may lead to the overdiagnosis and overtreatment of low-risk breast cancers. Conservative management may reduce the potential harm of overtreatment, yet little is known about the impact upon quality of life.

OBJECTIVES

To quantify women's preferences for managing low-risk screen detected ductal carcinoma in situ (DCIS), including the acceptability of active monitoring as an alternative treatment.

METHODS

Utilities (cardinal measures of quality of life) were elicited from 172 women using visual analogue scales (VASs), standard gambles, and the Euro-Qol-5D-5L questionnaire for seven health states describing treatments for low-risk DCIS. Sociodemographics and breast cancer history were examined as predictors of utility.

RESULTS

Both patients and non-patients valued active monitoring more favourably on average than conventional treatment. Utilities were lowest for DCIS treated with mastectomy (VAS: 0.454) or breast conserving surgery (BCS) with adjuvant radiotherapy (VAS: 0.575). The utility of active monitoring was comparable to BCS alone but was rated more favourably as progression risk was reduced from 40% to 10%. Disutility for active monitoring was likely driven by anxiety around progression, whereas conventional management impacted other dimensions of quality of life. The heterogeneity between individual preferences could not be explained by sociodemographic variables, suggesting that the factors influencing women's preferences are complex.

CONCLUSIONS

Active monitoring of low-risk DCIS is likely to be an acceptable alternative for reducing the impact of overdiagnosis and overtreatment in terms of quality of life. Further research is required to determine subgroups more likely to opt for conservative management.

Recommendations to improve patient-centred care for ductal carcinoma in situ: Qualitative focus groups with women

Background

Patient‐centred care (PCC) improves health‐care experiences and outcomes. Women with ductal carcinoma in situ (DCIS) and clinicians have reported communication difficulties. Little prior research has studied how to improve communication and PCC for DCIS.

Objective

This study explored how to achieve PCC for DCIS.

Design

Canadian women treated for DCIS from five provinces participated in semi‐structured focus groups based on a 6‐domain cancer‐specific PCC framework to discuss communication about DCIS. Data were analysed using constant comparative technique.

Setting and Participants

Thirty‐five women aged 30 to 86 participated in five focus groups at five hospitals.

Results

Women said their clinicians used multiple approaches for fostering a healing relationship; however, most described an absence of desired information or behaviour to exchange information, respond to emotions, manage uncertainty, make decisions and enable self‐management. Most women were confused by terminology, offered little information about the risks of progression/recurrence, uninformed about treatment benefits and risks, frustrated with lack of engagement in decision making, given little information about follow‐up plans or self‐care advice, and received no acknowledgement or offer of emotional support.

Discussion and Conclusions

By comparing the accounts of women with DCIS to a PCC framework, we identified limitations and inconsistencies in women's lived experience of communication about DCIS, and approaches by which clinicians can more consistently achieve PCC for DCIS. Future research should develop and evaluate informational tools to support PCC for DCIS.

Psychological morbidity in women diagnosed with ductal carcinoma in situ compared with women with early breast cancer receiving radiotherapy

PURPOSE

Despite having an excellent prognosis, patients with ductal carcinoma in situ (DCIS) report significant anxiety and depression following diagnosis. This study evaluated psychological morbidity using the Edmonton Symptom Assessment Scale (ESAS) in patients with DCIS compared with women with early-stage invasive breast cancer (EIBC) receiving radiotherapy (RT).

METHODS

We identified patients diagnosed with DCIS or EIBC (stage I or II breast cancer) from 2011 to 2017 who had at least one ESAS completed pre- and post-RT. Data on systemic treatment, radiation, patient demographics, and disease stage were extracted from existing databases. Psychological morbidity was evaluated through measurement of depression, anxiety, and overall wellbeing within the ESAS. The Wilcoxon rank-sum test or chi-square test was performed for continuous or categorical variables.

RESULTS

This study included 137 women with DCIS and 963 women with EIBC. ESAS was completed on average 28 days before RT (baseline) and 142 days after RT. Baseline ESAS scores showed significantly higher rates of depression among women with EIBC compared with those with DCIS (p = 0.006). Patients with EIBC also reported higher levels of anxiety and lower overall wellbeing than patients with DCIS, but this difference was not statistically significant. Post-RT ESAS scores showed significantly higher anxiety in patients with EIBC compared with DCIS (p = 0.049). Post-RT measures of anxiety and overall wellbeing were higher in patients with EIBC but differences were not statistically significant.

CONCLUSION

Women with DCIS experience relatively less psychological morbidity than women with EIBC, pre- and post-RT.

What does risk of future cancer mean to breast cancer patients?

PURPOSE

Newly diagnosed breast cancer patients greatly overestimate their risk of developing contralateral breast cancer (CBC). Better understanding of patient conceptions of risk would facilitate doctor-patient communication and surgical decision making. In this mixed methods study, we prospectively examined breast cancer patients' perceived risk of future cancer and the reported factors that drove their risk perceptions.

METHODS

Women age 21-60 diagnosed with breast cancer without a BRCA mutation or known distant metastases completed a study interview between surgical consult and surgical treatment. Participants completed a 12-item Perceived Risk Questionnaire, which assessed 10-year and lifetime risks of ipsilateral local recurrence, CBC, and distant recurrence. Patients provided qualitative explanations for their answers.

RESULTS

Sixty-three patients completed study interviews (mean age 50.3). Participants were primarily White (85.7%) and 90.5% had attended college. Patients estimated their 10-year risk of CBC as 22.0%, nearly 4 times the established 10-year risk. Women attributed their risk perceptions to "gut feelings" about future cancer, even when women knew those feelings contradicted medically established risk. Perceptions of risk also reflected beliefs that cancer is random and that risk for local recurrence, CBC, and distant recurrence are the same.

CONCLUSIONS

Our findings point to the need for novel ways of presenting factual information regarding both risk of recurrence and of new primary cancers, as well as the necessity of acknowledging cognitive and affective processes many patients use when conceptualizing risk. By differentiating women's intuitive feelings about risk from their knowledge of medically estimated risk, doctors can enhance informed decision making.

Patient views and correlates of radiotherapy omission in a population-based sample of older women with favorable-prognosis breast cancer

BACKGROUND

The omission of radiotherapy (RT) after lumpectomy is a reasonable option for many older women with favorable-prognosis breast cancer. In the current study, we sought to evaluate patient perspectives regarding decision making about RT.

METHODS

Women aged 65 to 79 years with AJCC 7th edition stage I and II breast cancer who were reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries were surveyed (response rate, 70%) regarding RT decisions, the rationale for omitting RT, decision-making values, and understanding of disease recurrence risk. We also surveyed their corresponding surgeons (response rate, 77%). Patient characteristics associated with the omission of RT were evaluated using multilevel, multivariable logistic regression, accounting for patient clustering within surgeons.

RESULTS

Of 999 patients, 135 omitted RT (14%). Older age, lower tumor grade, and having estrogen receptor-positive disease each were found to be strongly associated with omission of RT in multivariable analyses, whereas the number of comorbidities was not. Non-English speakers were more likely to omit RT (adjusted odds ratio, 5.9; 95% confidence interval, 1.4-24.5). The most commonly reported reasons for RT omission were that a physician advised the patient that it was not needed (54% of patients who omitted RT) and patient choice (41%). Risk of local disease recurrence was overestimated by all patients: by approximately 2-fold among those who omitted RT and by approximately 8-fold among those who received RT. The risk of distant disease recurrence was overestimated by approximately 3-fold on average.

CONCLUSIONS

To some extent, decisions regarding RT omission are appropriately influenced by patient age, tumor grade, and estrogen receptor status, but do not appear to be optimally tailored according to competing comorbidities. Many women who are candidates for RT omission overestimate their risk of disease recurrence. Cancer 2018;124:2714-2723. © 2018 American Cancer Society.

Interventions are needed to support patient-provider decision-making for DCIS: a scoping review

PURPOSE

Prognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS communication experiences, needs and interventions among DCIS patients or physicians.

METHODS

MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched from inception to February 2017. English language studies that evaluated patient or physician DCIS needs, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings.

RESULTS

A total of 51 studies published from 1997 to 2016 were eligible for review, with a peak of 8 articles in year 2010. Women with DCIS lacked knowledge about the condition and its prognosis, although care partners were more informed, desired more information and experienced decisional conflict. Many chose mastectomy or prophylactic mastectomy, often based on physician's recommendation. Following treatment, women had anxiety and depression, often at levels similar to those with invasive breast cancer. Disparities were identified by education level, socioeconomic status, ethnicity and literacy. Physicians said that they had difficulty explaining DCIS and many referred to DCIS as cancer. Despite the challenges reported by patients and physicians, only two studies developed interventions designed to improve patient-physician discussion and decision-making.

CONCLUSIONS

As most women with DCIS undergo extensive treatment, and many experience treatment-related complications, the paucity of research on PE to improve and support informed decision-making for DCIS is profound. Research is needed to improve patient and provider discussions and decision-making for DCIS management.

Patient Experiences and Clinician Views on the Role of Radiation Therapy for Ductal Carcinoma In Situ

PURPOSE

To evaluate patient experiences with decisions regarding radiation therapy (RT) for ductal carcinoma in situ (DCIS), and to assess clinician views on the role of RT for DCIS with favorable features in the present era.

METHODS AND MATERIALS

A sample of women with newly diagnosed breast cancer from the population-based Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries were sent surveys approximately 2 months after undergoing breast-conserving surgery (BCS), with a 70% response rate. The analytic sample was limited to 538 respondents with unilateral DCIS. We also surveyed 761 surgeons and radiation oncologists treating breast cancer in those regions, of whom, 539 responded (71%).

RESULTS

After BCS, 23% of patients omitted RT, with twice the rate of omission in Los Angeles County relative to Georgia (31% vs 16%; P < .001). The most common reasons for omitting RT were advice from a clinician that it was not needed (62%) and concern about side effects (24%). Cost and transportation were not reported as influential considerations. After covariate adjustment, low- and intermediate-grade disease (odds ratio [OR] 5.5, 95% confidence interval [CI] 2.5-12; and OR 3.2, 95% CI 1.7-6.1, respectively) and Los Angeles County SEER site (OR 4.3, 95% CI 2.3-8.2) were significantly associated with greater RT omission. Of the responding clinicians, 62% would discuss RT omission for a patient with DCIS with favorable features. Clinicians in Los Angeles County were more likely to discuss RT omission than were those in Georgia (67% vs 56%; P = .01). Approximately one third of clinicians would obtain the Oncotype DX DCIS score.

CONCLUSIONS

The heterogeneity in RT omission after BCS for DCIS continues to be substantial, with systematic differences in provider opinions across the 2 regions we studied. Enhanced precision of recurrence estimates, guidance from professional organizations, and better communication are needed to improve the consistency of treatment in this controversial area.

The association between post-diagnosis health behaviors and long-term quality of life in survivors of ductal carcinoma in situ: a population-based longitudinal cohort study

PURPOSE

Women diagnosed with ductal carcinoma in situ (DCIS) often experience adverse changes in health-related behaviors following diagnosis. The impact of health behaviors on long-term quality of life (QoL) in DCIS survivors has not been investigated.

METHODS

We examined the association of post-diagnosis body mass index (BMI), physical activity, alcohol, and smoking with QoL among 1448 DCIS survivors aged 20-74 enrolled in the population-based Wisconsin in situ Cohort from 1997 to 2006. Health behaviors and QoL were self-reported during biennial post-diagnosis interviews. Physical and mental QoL were measured using the validated SF-36 questionnaire. Generalized linear regression was used to determine the association between behaviors and QoL with adjustment for confounders. Lagged behavior variables were used to predict QoL during follow-up and avoid reverse causation.

RESULTS

Women reported 3,536 QoL observations over an average 7.9 years of follow-up. Women maintaining a healthy BMI had on average a significantly higher summary measure score of physical QoL than obese women (normal versus obese: β = 3.02; 2.18, 3.85). Physical QoL scores were also elevated among those who were physically active (5 + h/week vs. none: β = 1.96; 0.72, 3.20), those consuming at least seven drinks/week of alcohol (vs. none; β = 1.40; 0.39, 2.41), and nonsmokers (vs. current smokers: β = 1.80; 0.89, 2.71). Summary measures of mental QoL were significantly higher among women who were moderately physically active (up to 2 h/week vs. none: β = 1.11; 0.30, 1.92) and nonsmokers (vs. current smokers: β = 1.49;0.45, 2.53).

CONCLUSIONS

Our results demonstrate that maintaining healthy behaviors following DCIS treatment is associated with modest improvements in long-term QoL. These results inform interventions aimed at promoting healthy behaviors and optimizing QoL in DCIS survivors.

Quality of life and anxiety in women with breast cancer before and after treatment

Objectives:

to determine the quality of life and anxiety in patients with breast cancer and the changes they experience after treatments.

Method:

prospective study. Breast cancer statistics (n=339, confidence=95%, accuracy= ± 5.32%). The quality of life questionnaires (QLQ) used were QLQ C-30 and QLQ Br23, and the State-Trait Anxiety Inventory (STAI) was used for anxiety. A multivariate analysis was performed to identify variables associated with baseline quality of life and anxiety as well as pre- and post-treatment differences. Authorization was obtained from the Ethics Committee, and informed consent was provided by all patients.

Results:

the baseline quality of life dimensions with the lowest score were future prospects (46.0/100) and sexual enjoyment (55.7/100). The dimensions with the highest score were body image (94.2/100) and role (93.3/100). The most disturbing symptoms were insomnia, fatigue and concern about hair loss. After treatment, the dimensions of physical function, role, body image, financial concerns and symptomatology worsened, whereas emotional function and future prospects improved. Severe anxiety presented as a state (48.6%) and as a trait (18.2%). The highest baseline state anxiety was associated with married-widowed status and anxiolytic medication. The greatest trait anxiety was associated with an inactive work situation, anxiolytic medication, breast swelling and advanced stage at diagnosis. After treatment, anxiety significantly decreased.

Conclusions:

After treatment, the quality of life score was positively modified, while state and trait anxiety decreased.

A Patient-centered Approach to Evaluate the Information Needs of Women With Ductal Carcinoma In Situ

OBJECTIVE

To evaluate the information needs of ductal carcinoma in situ (DCIS) patients.

METHODS

Four focus groups involving 24 previously treated DCIS patients were conducted to develop a comprehensive list of questions they felt were important to have answered at the time of diagnosis. Using a survey, a separate group of patients treated for DCIS then rated the importance of having each of these questions addressed before treatment decision making. Response options were "essential," "desired," "not important," "no opinion," and "avoid." For each essential/desired question, respondents specified how addressing it would help them: "understand," "decide," "plan," "not sure," or "other."

RESULTS

Focus group participants generated 117 questions used in the survey. Fifty-seven patients completed the survey (55% response rate). Respondents rated a median of 66 questions as essential. The most commonly cited reason for rating a question essential was to "understand," followed by to "decide." The top questions women deemed essential to help them understand were disease specific, whereas the top questions deemed essential to help women decide were predominantly treatment specific, pertaining to available options, recurrence and survival outcomes, and timelines to decide and start treatment.

CONCLUSIONS

DCIS patients want a large number of questions answered, mostly for understanding, and also for deciding and planning. A core set of questions that most patients consider essential for decision making has been formulated and may be used in the clinical setting and in research to develop educational resources and decision-making tools specific to DCIS.

Treatment decision-making in ductal carcinoma in situ: A mixed methods systematic review of women's experiences and information needs

OBJECTIVE

Decision-making in ductal carcinoma in situ (DCIS) is complex due to the heterogeneity of the disease. This study aimed to understand women's experience of making treatment decisions for DCIS, their information and support needs, and factors that influenced decisions.

METHODS

We searched six electronic databases, conference proceedings, and key authors. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Thematic analysis was used to combine and summarise findings.

RESULTS

We identified six themes and 28 subthemes from 18 studies. Women with DCIS have knowledge deficits about DCIS, experience anxiety related to information given at diagnosis and the complexity of decision-making, and have misconceptions regarding risks and outcomes of treatment. Women's decisions are influenced by their understanding of risk, the clinical features of their DCIS, and the benefits and harms of treatment options. Women are dissatisfied with the decisional support available.

CONCLUSIONS

Informed and shared decision-making in this complex decision setting requires clear communication of information specific to DCIS and individual's, as well as decision support for patients and clinicians.

PRACTICE IMPLICATIONS

This approach would educate patients and clinicians, and assist clinicians in supporting patients to an evidence-based treatment plan that aligns with individual values and pReferences.

Contralateral Breast Cancer Risk in Women with Ductal Carcinoma In Situ: Is it High Enough to Justify Bilateral Mastectomy?

BACKGROUND

Women with ductal carcinoma in situ (DCIS) are increasingly choosing bilateral mastectomy. We sought to quantify rates of contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) for DCIS, and to compare risk factors for CBC and IBTR.

METHODS

From 1978 to 2011, DCIS patients undergoing BCS with a contralateral breast at risk were identified from a prospectively maintained database. The association of clinicopathologic and treatment factors with CBC and IBTR were evaluated using Kaplan-Meier analysis, multivariable Cox regression, and competing risk regression (CRR).

RESULTS

Of 2759 patients identified, 151 developed CBC and 344 developed IBTR. Five- and 10-year Kaplan-Meier CBC rates were 3.2 and 6.4%. Overall, 10-year IBTR rates were 2.5-fold higher than CBC rates, and, without radiation, 4-fold higher. On CRR, 5- and 10-year rates were 2.9 and 5.8% for CBC, and 7.8 and 14.5% for IBTR. CBC risk and invasive CBC risk were not significantly associated with age, family history, presentation, nuclear grade, year of surgery, or radiation. By multivariable Cox regression, endocrine therapy was associated with lower CBC risk (hazard ratio 0.57, p = 0.03). Ten-year risk of subsequent CBC in the subset of patients who developed IBTR was similar to the cohort as a whole (8.1 vs. 6.4%).

CONCLUSIONS

CBC rates were low across all groups, including those who experienced IBTR. CBC was not associated with factors that increase IBTR risk. While factors associated with IBTR risk are important in decision making regarding management of the index DCIS, they are not an indication for contralateral prophylactic mastectomy.

Risk communication and decision-making in the prevention of invasive breast cancer

Risk communication surrounding the prevention of invasive breast cancer entails not only understanding of the disease, risks and opportunities for intervention. But it also requires understanding and implementation of optimal strategies for communication with patients who are making these decisions. In this article, available evidence for the issues surrounding risk communication and decision making in the prevention of invasive breast cancer are reviewed and strategies for improvement are discussed.

Tamoxifen Acceptance and Adherence among Patients with Ductal Carcinoma In Situ (DCIS) Treated in a Multidisciplinary Setting

Tamoxifen and other endocrine agents have proven benefits for women with ductal carcinoma in situ (DCIS), but low patient acceptance is widely reported. We examined factors associated with tamoxifen acceptance and adherence among DCIS patients who received a recommendation for therapy in a multidisciplinary setting. Using our institutional database, we identified women diagnosed with DCIS, 1998 to 2009, who were offered tamoxifen. We recorded data on demographics, tumor and therapy variables, tamoxifen acceptance, and adherence to therapy for ≥4 years. Univariable and multivariable analyses were conducted using logistic regression to identify factors specific to each group that were related to acceptance and adherence. A total of 555 eligible women identified, of whom 369 were offered tamoxifen; 298 (81%) accepted, among whom 214 (72%) were adherent, 59 of 298 (20%) were nonadherent, and for 25 (8%), adherence was undetermined. After stepwise elimination in adjusted logistic regression models, acceptance of breast radiotherapy was associated with acceptance of tamoxifen [OR, 2.22; 95% confidence interval (CI), 1.26-3.90; P < 0.01], as was a medical oncology consultation (OR, 1.76; 95% CI, 0.99-3.15; P = 0.05). Insured patients were more likely to adhere to tamoxifen (OR, 6.03; 95% CI, 2.60-13.98; P < 0.01). The majority of nonadherent women (n = 38/56, 68%) discontinued the drug during the first year of treatment with 48 (86%) citing adverse effect(s) as the reason. In a multidisciplinary, tertiary care setting, we observed relatively high rates of acceptance and adherence of tamoxifen. Acceptance of tamoxifen and radiotherapy were associated, and adherence was influenced by insurance status.Key Message: Tamoxifen acceptance and adherence following resection of DCIS of the breast is related to acceptance of radiotherapy and may be improved by confirmation of the recommendation by a medical oncologist. Despite the low cost of tamoxifen, adherence to therapy is significantly impacted by lack of insurance; those who discontinue therapy report adverse effects as a major reason. Cancer Prev Res; 10(7); 389-97. ©2017 AACR.

Patient-reported outcomes in ductal carcinoma in situ: A systematic review

Ductal carcinoma in situ (DCIS) is a pre-invasive breast cancer with excellent prognosis but with potential adverse impacts of diagnosis and treatment on quality of life and other patient-reported outcomes (PROs). We undertook a systematic review to synthesise current evidence about PROs following diagnosis and treatment for DCIS. We searched five electronic databases (from database inception to November 2015), cross-referenced and contacted experts to identify studies that reported PROs after DCIS treatment. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Of 2130 papers screened, 23 were eligible, reporting 17 studies. Short- and long-term PRO evidence about differences between DCIS treatment options was lacking. Evidence pooled across treatments indicated core aspects of quality of life (physical, role, social, emotional function, pain, fatigue) and psychological distress (anxiety, depression) were impacted significantly initially, with most aspects returning to population norms by 6-12 months, and all by 2 years post-operatively. Fears of recurrence and dying from breast cancer were exaggerated, occurred early and persisted for many years. Sexuality and body image impacts were generally low and resolved within 1-3 months after surgery. A minority of women experienced considerable impact, including depression and sexual issues associated with body image problems. Well-powered PRO studies are required to track recovery trajectories and long-term impacts of the range of contemporary and emerging local and systemic treatments for DCIS. PRO data would enable care providers to prepare patients for short-term sequelae and enable patients who have treatment options to exercise preferences in choosing among them.

Time-dependent risk of depression, anxiety, and stress-related disorders in patients with invasive and in situ breast cancer

Despite concerns about the mental health of breast cancer patients, little is known regarding the temporal risk pattern and risk factors of common mental disorders among these patients. We estimated standardized incidence ratios (SIRs) of depression, anxiety and stress-related disorders in a Swedish nationwide cohort of 40,849 women with invasive and 4,402 women with in situ breast cancer (2001-2010, median follow-up = 4.5 years). The impact of patient, tumor and treatment characteristics was analyzed using flexible parametric survival models in a regional cohort of 7,940 invasive breast cancer patients (2001-2013, median follow-up = 7.5 years). Women with invasive breast cancer showed increased rates of depression, anxiety and stress-related disorders [overall SIR (95% CI) = 1.57 (1.46-1.69), 1.55 (1.43-1.68) and 1.77 (1.60-1.95), respectively]. SIRs were highest shortly after diagnosis, but remained increased up to 5 years. Younger age at diagnosis, comorbidity, higher-grade disease, lymph node involvement and chemotherapy were independently associated with the risk of depression and anxiety in invasive cancer patients, with chemotherapy and higher-grade disease conferring short-term risk only, while comorbidities were mainly associated with late-onset events. No clinical risk factors were identified for stress-related disorders except for a greater risk associated with younger age. Patients with in situ cancer only showed an increased incidence of stress-related disorders during the first 6 months after diagnosis [SIR (95% CI) = 2.76 (1.31-5.79)]. The time-dependent risk profile of invasive cancer patients may guide health care professionals for timely and targeted psycho-oncologic interventions.

Psychosocial distress affecting patients with ductal carcinoma in situ compared to patients with early invasive breast cancer

Psychological distress in patients with a diagnosis of ductal carcinoma in situ (DCIS) or early invasive breast cancer (EIBC) can emanate from perceived risk of recurrence and is accompanied by perceived risk of death from the diseases. These factors can impart a lower quality of life that can result in poorer health outcomes. In addition, inaccurate risk perceptions can have an effect on decision making, psychosocial outcomes, and subsequent health behaviors. The purpose of this study is to assess patients with DCIS and EIBC and their perceived risk of recurrence and perceived risk of dying, and evaluate their outlook for the future, the degree of social support from spouses and significant others of patients who have been diagnosed with DCIS and EIBC, and the relationship to the patient's perceived risk perception of recurrence and dying from the diseases.

Differences between Breast Conservation-Eligible Patients and Unilateral Mastectomy Patients in Choosing Contralateral Prophylactic Mastectomies

There has been an increasing use of bilateral mastectomy (BM) for breast cancer. We sought to examine our trends among breast conservation (BCT) candidates and women recommended for unilateral mastectomy (UM). Our prospective breast cancer database was queried for women with a first-time, unilateral breast cancer. Patient and histologic factors and surgical treatment, including reconstruction, were evaluated. A detailed chart review was performed among patients from two representative time periods as to the reasons the patient underwent mastectomy. We identified 3,892 women between 2000 and 2012 of whom 60% underwent BCT, 1092 (28%) had UM and 12% underwent BM. BM rose from 4% in 2000 to a high of 19% in 2011, increasing around 2002 for women <40. BCT was less likely with decreasing age (p < 0.0001), lobular histology (p < 0.0001), higher stage (p < 0.0001) and decreasing BMI (p < 0.0001). Among mastectomy patients, contralateral mastectomy was associated with decreasing age (p < 0.0001), Caucasian race (p < 0.0001), and lower stage (p = 0.005). Over time, indications for mastectomy decreased while patients deemed BCT-eligible opting for UM or BM increased dramatically. Increases in the use of BM are in large part among women who were otherwise BCT-eligible. Factors associated with BM use are different for BCT-eligible patients and those recommended for UM. A better understanding of the factors driving individual patient choices is needed.

onlineDeCISion.org: a web-based decision aid for DCIS treatment

Women diagnosed with DCIS face complex treatment decisions and often do so with inaccurate and incomplete understanding of the risks and benefits involved. Our objective was to create a tool to guide these decisions for both providers and patients. We developed a web-based decision aid designed to provide clinicians with tailored information about a patient’s recurrence risks and survival outcomes following different treatment strategies for DCIS. A theoretical framework, microsimulation model (Soeteman et al., J Natl Cancer 105:774–781, 2013) and best practices for web-based decision tools guided the development of the decision aid. The development process used semi-structured interviews and usability testing with key stakeholders, including a diverse group of multidisciplinary clinicians and a patient advocate. We developed onlineDeCISion.​org to include the following features that were rated as important by the stakeholders: (1) descriptions of each of the standard treatment options available; (2) visual projections of the likelihood of time-specific (10-year and lifetime) breast-preservation, recurrence, and survival outcomes; and (3) side-by-side comparisons of down-stream effects of each treatment choice. All clinicians reviewing the decision aid in usability testing were interested in using it in their clinical practice. The decision aid is available in a web-based format and is planned to be publicly available. To improve treatment decision making in patients with DCIS, we have developed a web-based decision aid onlineDeCISion.​org that conforms to best practices and that clinicians are interested in using in their clinics with patients to better inform treatment decisions.

Clinical and pathological assessment of high-risk ductal and lobular breast lesions: What surgeons must know

Terminology in pathology is sometimes over-complicated and may be misinterpreted by clinicians facing patients and having difficulty answering questions posed by them. This may especially be true for some breast lesions with an increased risk of malignant transformation, the complex terminology of which reflects attempts to stratify them according to potential risk. On the basis of morphological and molecular features, both ductal and lobular proliferations have been classified and named in different ways by pathologists, and this often makes it difficult for the treating physicians and the patients to fully understand the nature of the lesions and their associated risks. In order to clarify pathology reports, unambiguous and simple terms are needed.

Risk prediction for local versus regional/metastatic tumors after initial ductal carcinoma in situ diagnosis treated by lumpectomy

Among women diagnosed with ductal carcinoma in situ (DCIS), we identified factors associated with local invasive cancer (LIC) and regional/metastatic invasive cancer (RMIC) and provide 10-year risks based on clinically relevant factors. We created a retrospective, population-based cohort of 1492 women with an initial diagnosis of DCIS (1983-1996) treated by lumpectomy alone. Histological and molecular markers (Ki67, ER, PR, COX-2, p16, ERBB2) were collected on DCIS cases with a subsequent tumor (DCIS, LIC, or RMIC) and a subsample of frequency-matched controls without subsequent tumors. Competing risks methods were used to identify factors associated with LIC and RMIC and cumulative incidence methods to estimate 10-year risks for combinations of factors. Median follow-up time was 12.6 years (range 0.5-29.5 years). The overall 10-year risk of LIC (11.9 %) was higher than for RMIC (3.8 %). About half of women with initial DCIS lesions are detected by mammography and p16 negative and have a 10-year risk of LIC of 6.2 % (95 % CI 5.8-6.8 %) and RMIC of 1.2 % (95 % CI 1.1-1.3 %). Premenopausal women whose DCIS lesion was p16 positive or p16 negative and detected by palpation had high 10-year risk of LIC of 23.0 % (95 % CI 19.3-27.4 %). Ten-year risk of RMIC was highest at 22.5 % (95 % CI 13.8-48.1 %) for those positive for p16, COX-2, and ERRB2, and negative for ER, but prevalence of this group is low at 3 %. Ten-year risk of LIC and RMIC is low for the majority diagnosed with DCIS. Combinations of molecular markers and method of detection of initial DCIS lesion can differentiate women at low and high risk of LIC and RMIC.

The relationship between illness representations, risk perception and fear of cancer recurrence in breast cancer survivors

OBJECTIVE

Fear of cancer recurrence, although distinct from distress continues to be under-evaluated, captured, or treated when standard distress scales are used to assess concerns of cancer survivors. We tested a model assessing the association of demographic and clinical factors, illness representations, and perceived risk with fear of cancer recurrence in breast cancer survivors.

METHODS

We recruited 117 breast cancer survivors at least one year after completing breast cancer treatment from Internet discussion boards for this cross-sectional, descriptive, correlational study. Participants completed a survey that assessed their level of fear of cancer recurrence as well as their illness representations, perceived risk of recurrence, and demographic and medical characteristics.

RESULTS

Our model explained 62% of the variance in fear of cancer recurrence. Emotional representations (β = .46, p < .01), symptom attribution (β = .21, p < .01), timeline (β = .23, p < .01), and consequences (β = .16, p < .03) were significantly related to fear of recurrence. By contrast, the majority of clinical and demographic variables were not significant contributors to fear of recurrence.

CONCLUSIONS

Upon completion of cancer treatment, survivors with more emotional representations of the experience and those who attribute unrelated symptoms to their breast cancer have a higher level of fear of recurrence. Evaluation of these factors during treatment may help mitigate fear of recurrence in the survivorship phase of the breast cancer trajectory. Copyright © 2016 John Wiley & Sons, Ltd.

Trends in Health-Related Quality of Life After a Diagnosis of Ductal Carcinoma In Situ

PURPOSE

Studies of quality of life (QoL) are scarce among survivors of ductal carcinoma in situ (DCIS). The objective of this study was to assess long-term QoL in DCIS survivors in relation to age at diagnosis, time since diagnosis, and treatments received.

METHODS

We assessed physical and mental measures of health-related QoL in 1,604 patients with DCIS diagnosed in 1997 to 2006 with up to four follow-up interviews. We further compared baseline QoL to 1,055 control patients without DCIS. QoL was measured using the validated Medical Outcomes Study Short Form 36 Health Status Survey questionnaire. Among patients with DCIS, we examined trends in QoL over time since diagnosis using generalized linear regression models, adjusting for confounders. We tested for effect modification by surgical treatment choice, post-treatment endocrine therapy use, and age at diagnosis.

RESULTS

Both physical and mental measures of QoL among DCIS survivors at fewer than 2 years after diagnosis were comparable to controls. Mental measures of QoL among patients with DCIS declined at ≥ 10 years after diagnosis and were significantly lower than at less than 2 years after diagnosis (47.4 v 52.0; P < .01). In the first 5 years after a DCIS diagnosis, mental QoL was significantly higher among women diagnosed at ages 50 to 74 years compared with those diagnosed at ages 28 to 49 years, although this difference was not sustained in later time periods.

CONCLUSION

QoL after a DCIS diagnosis was generally comparable to that of women of similar age without a personal history of DCIS. Our findings suggest that DCIS survivors, and particularly those diagnosed at a younger age, may benefit from support for mental QoL.

Risk perception and psychological morbidity in men at elevated risk for prostate cancer

OBJECTIVE

As prostate-specific antigen (psa) makes prostate cancer (pca) screening more accessible, more men are being identified with conditions that indicate high risk for developing pca, such as elevated psa and high-grade intraepithelial neoplasia (hgpin). In the present study, we assessed psychological well-being and risk perception in individuals with those high-risk conditions.

METHODS

A questionnaire consisting of a psychological symptom survey, a trait risk-aversion survey, and a cancer-specific risk perception survey was administered to 168 patients with early-stage localized pca and 69 patients at high risk for pca (n = 16 hgpin, n = 53 psa > 4 ng/mL). Analysis of variance was used to examine differences in psychological well-being and appraisal of risk between the groups.

RESULTS

Compared with the pca group, the high-risk group perceived their risk of dying from something other than pca to be significantly lower (p = 0.007). However, pca patients reported significantly more clinically important psychological symptoms.

CONCLUSIONS

The identification of prostate conditions that predict progression to cancer might not result in the psychological symptoms commonly experienced by pca patients, but does appear to be related to a distorted perception of the disease's mortal risk. Patients with pca experience reduced psychological well-being, but better understand the risks of pca recurrence and death. Education on the risks and outcomes of pca can help at-risk men to view health assessments with reduced worry.

Partnership Status and Socioeconomic Factors in Relation to Health Behavior Changes after a Diagnosis of Ductal Carcinoma In Situ

BACKGROUND

Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking.

METHODS

The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables.

RESULTS

Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes.

CONCLUSION

Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis.

IMPACT

The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis.

Health behavior change following a diagnosis of ductal carcinoma in situ: An opportunity to improve health outcomes

Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer that comprises approximately 20% of new breast cancer diagnoses. DCIS is predominantly detected by screening mammography prior to the development of any clinical symptoms. Prognosis following a DCIS diagnosis is excellent, due to both the availability of effective treatments and the frequently benign nature of the disease. However, a DCIS diagnosis and its treatment have psychological and physical impacts that often lead to adverse changes in health-related behaviors, including changes in physical activity, body weight, alcohol intake, and smoking, which may represent a greater threat to the woman's overall health than the DCIS itself. Depending on age at diagnosis, women diagnosed with DCIS are 3-13 times more likely to die from non-breast cancer related causes, such as cardiovascular disease, than from breast cancer. Thus, the maintenance and improvement of healthy behaviors that influence a variety of outcomes after diagnosis may warrant increased attention during DCIS management. This may also represent an important opportunity to promote the adoption of healthy behaviors, given that DCIS carries the psychological impact of a cancer diagnosis but also a favorable prognosis. Particular focus is needed to address these issues in vulnerable patient subgroups with pre-existing higher rates of unhealthy behaviors and demonstrated health disparities.

How different terminology for ductal carcinoma in situ (DCIS) impacts women's concern and management preferences: A qualitative study

OBJECTIVE

There are increasing rates of mastectomy and bi-lateral mastectomy in women diagnosed with ductal carcinoma in situ (DCIS). To help women avoid decisions that lead to unnecessary aggressive treatments, there have been recent calls to remove the cancer terminology from descriptions of DCIS. We investigated how different proposed terminologies for DCIS affect women's perceived concern and management preferences.

MATERIALS AND METHODS

Qualitative study using semi-structured interviews with a community sample of 26 Australian women varying by education and cancer screening experience. Women responded to a hypothetical scenario using terminology with and without the cancer term to describe DCIS.

RESULTS

Among a sample of women with no experience of a DCIS diagnosis, a hypothetical scenario involving a diagnosis of DCIS elicited high concern regardless of the terminology used to describe it. Women generally exhibited stronger negative reactions when a cancer term was used to describe DCIS compared to a non-cancer term, and most preferred the diagnosis be given as a description of abnormal cells. Overall women expressed interest in watchful waiting for DCIS but displayed preferences for very frequent monitoring with this management approach.

CONCLUSION

Communicating a diagnosis of DCIS using terminology that does not include the cancer term was preferred by many women and may enable discussions about more conservative management options. However, women's preference for frequent monitoring during watchful waiting suggests women need more education and reassurance about this management approach.

Perceptions of Contralateral Breast Cancer Risk: A Prospective, Longitudinal Study

PURPOSE

An increasing proportion of breast cancer patients undergo contralateral prophylactic mastectomy (CPM) to reduce their risk of contralateral breast cancer (CBC). Our goal was to evaluate CBC risk perception changes over time among breast cancer patients.

METHODS

We conducted a prospective, longitudinal study of women with newly diagnosed unilateral breast cancer. Patients completed a survey before and approximately 2 years after treatment. Survey questions used open-ended responses or 5-point Likert scale scoring (e.g., 5 = very likely, 1 = not at all likely).

RESULTS

A total of 74 women completed the presurgical treatment survey, and 43 completed the postsurgical treatment survey. Baseline characteristics were not significantly different between responders and nonresponders of the follow-up survey. The mean estimated 10-year risk of CBC was 35.7 % on the presurgical treatment survey and 13.8 % on the postsurgical treatment survey (p < 0.001). The perceived risks of developing cancer in the same breast and elsewhere in the body significantly decreased between surveys. Both CPM and non-CPM (breast-conserving surgery or unilateral mastectomy) patients' perceived risk of CBC significantly decreased from pre- to postsurgical treatment surveys. Compared with non-CPM patients, CPM patients had a significantly lower perceived 10-year risk of CBC (5.8 vs. 17.3 %, p = 0.046) on postsurgical treatment surveys.

CONCLUSIONS

The perceived risk of CBC significantly attenuated over time for both CPM and non-CPM patients. These data emphasize the importance of early physician counseling and improvement in patient education to provide women with accurate risk information before they make surgical treatment decisions.

Impact of Prophylactic Mastectomy in BRCA1/2 Mutation Carriers

Unlike the general decrease in invasive oncologic care, the trend for prophylactic bilateral mastectomy in healthy women and prophylactic contralateral mastectomy in women with unilateral breast cancer is steadily rising. This is even more surprising when considering that for e.g. prophylactic contralateral mastectomy no clear survival benefit has been demonstrated so far. The decision-making process around risk-reducing surgery may be influenced by several conflicting parameters such as the patient's fears and desire to achieve a survival advantage, the surgeon's financial motivations, or the oncologist's paternalistic approach to the above trend. Physicians should support their patients throughout the decision-making process, guide them through the dense fog of information, and encourage them to reconsider all options and alternatives before embarking on an irreversible surgical intervention. Healthy and diseased women should be comprehensively informed about their absolute individual risks for cancer, the benefits and harms of the surgery, alternative preventive strategies, and last but not least the competing risks of preceding carcinomas and cancer in general. Within the framework of non-directive counseling in the specialized centers of the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC), decision-making aids are being developed with grants from the Federal Ministry of Health and the German Cancer Aid to support women in making conclusive and satisfactory decisions.