Abstract
Background
A recent SEER study identified significant variations in the care of women with DCIS, yet several potential confounding variables were not included. We report a patterns of care study of women with DCIS to better understand the gap between evidence-based knowledge and the management of DCIS.
Methods
We studied all cases of DCIS diagnosed through the Ontario Breast Screening Program from 1991 to 2000. Data was obtained by database linkage and chart abstraction. A logistic regression model using generalized estimating equations to adjust for clustering was used.
Results
About 320,236 women were screened and 727 individuals were diagnosed with DCIS. The rate of mastectomy was 30% and was associated with multifocality (OR: 3.5 [1.7, 7.1], P = 0.0005), tumor size (OR: >2 cm vs. ≤1 cm: 2.7 [1.3, 5.9], P = 0.01), high nuclear grade (OR: 2.4 [1.1, 5.2], P = 0.03) and surgeon’s practice pattern. The rate of axillary dissection (AND) decreased from 36% in 1991–1993 to 20% in 1998–2000. AND was associated with mastectomy, year of surgery and hospital volume (OR: 2.7 [1.3, 5.6], P = 0.01). The use of radiation (XRT) following breast-conserving surgery increased from 39% in 1991␣to 51% in 2000. XRT was associated with age<70 years, high nuclear grade (OR: 2.7 [1.2, 6.3], P = 0.02) and tumor size > 1 cm (OR: 2.4 [1.3, 4.4], P = 0.006). Half of cases with margins <1 cm did not receive XRT.
Conclusions
Our study corroborates previous reports on the persistent rates of mastectomy and axillary nodal dissection and the limited use of XRT in the treatment of DCIS.
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References
Ernster VL, Barclay J, Kerlikowske K, Wilkie H, Ballard-Barbas R (2000) Mortality among women with ductal carcinoma in situ of the breast in the population-based surveillance, epidemiology and end results program. Arch Intern Med 160:953–958
Ernster VL, Barclay J, Kerlikowske K, Grady D, Henderson C (1996) Incidence of and treatment for ductal carcinoma in situ of the breast. JAMA 275(12):913–918
Ernster VL, Barclay J (1997) Increases in ductal carcinoma in situ (DCIS) of the breast in relation to mammography: a dilemma [review] [34 Refs]. J Natl Cancer Inst Monogr (22):151–156
Silverstein MJ (1997) Van nuys experience by treatment. In: Silverstein MJ (Eds), Ductal carcinoma in situ. Williams & Wilkins, Baltimore, pp 443–447
Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, Fisher ER, Wickerham DL, Deutsch M, Margolese R, Dimitrov N, Kavanah M (1998) Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from national surgical adjuvant breast and bowel project B-17. J Clin Oncol 16(2):441–452
Fourquet A, Zafrani B, Campana F, Clough KB (1997) Institute curie experience. In: Silverstein MJ (Eds.), Ductal carcinoma in situ. Williams & Wilkins, Baltimore, pp 385–390
Solin LJ, Kurtz J, Fourquet A, Amalric R, Recht A, Bornstein BA, Kuske R, Taylor M, Barrett W, Fowble B, Haffty B, Schultz DJ, Yeh IT, McCormick B, McNeese M (1996) Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. J Clin Oncol 14(3):754–763
Lagios MD (1996) Duct carcinoma in situ: biological implications for clinical practice [review] [31 Refs]. Semin Oncol 23(1 Suppl 2):6–11
Holland R, Hendriks JH, Vebeek AL, Mravunac M, Schuurmans Stekhoven JH (1990) Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet 335(8688):519–522
Curran D, van Dongen JP, Aaronson NK, Kiebert G, Fentiman IS, Mignolet F, Bartelink H (1998) Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. The European organization for research and treatment of cancer (EORTC), Breast cancer co-operative group (BCCG). Eur J Cancer 34(3):307–314
Ratanawichitrasin A, Rybicki LA, Steiger E, Grundfest-Broniatowski S, Hermann RE, Crowe JP (1999) Predicting the likelihood of residual disease in women treated for ductal carcinoma in situ. J Am Coll Surg 188(1):17–21
Julien JP, Bijker N, Fentiman IS, Peterse JL, Delledonne V, Rouanet P, Avril A, Sylvester R, Mignolet F, Bartelink H, van Dongen JA (2000) Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC breast cancer cooperative group and EORTC radiotherapy group. Lancet 355(9203):528–533
Houghton J, George WD, Cuzick J, Duggan C, Fentiman IS, Spittle M (2003) UK coordinating committee on cancer research, ductal carcinoma in situ working party, and DCIS trialists in the UK, Australia and New Zealand. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New␣Zealand: randomised controlled trial. Lancet 362(9378):95–102
Hansen N, Giuliano AE (1997) Axillary dissection for ductal carcinoma in situ. In: Silverstein MJ (Eds) Ductal carcinoma in situ. Williams and Wilkins, Baltimore, pp 577–584
Steering Committee on Clinical Practice Guidelines for the Care, Treatment of Breast Cancer (1998) The management of ductal carcinoma in situ (DCIS). Can Med Assoc J 158(3 Suppl):S27–S34
Baxter NN, Virnig BA, Durham SB, Tuttle TM (2004) Trends in the treatment of ductal carcinoma in situ of the breast. J Nat Cancer Inst 96(6):443–448
O’Connor GT, Quinton HB, Traven ND, Ramunno LD, Dodds TA, Marciniak TA, Wennberg JE (1999) Geographic variation in the treatment of acute myocardial infarction: the cooperative cardiovascular project. JAMA 281(7):627–633
Potosky AL, Merrill RM, Riley GF, Taplin SH, Barlow W, Fireman BH, Barbash R (1997) Breast cancer survival and treatment in health maintenance organization and fee-for-service settings. JNCI Cancer Spectrum 89(22):1683–1691
Goel V, Olivotto I, Hislop TG, Sawka C, Coldman A, Holowaty EJ (1997) Patterns of initial management of node-negative breast cancer in two Canadian provinces. British Columbia/Ontario working group. CMAJ 156(1):25–35
Schroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL Jr (2005) Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. J Clin Oncol 23(28):7074–7080
Silverstein MJ, Lagios MD, Groshen S, Waisman JR, Lewinsky BS, Martino S, Gamagami P, Colburn WJ (1999) The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 340(19):1455–1461
Zeger SL, Liang KY (1986) Longitudinal data analysis for discrete and continuous outcomes. Biometrics 42(1):121–130
Eusebi V, Feudale E, Foschini MP, Micheli A, Conti A, Riva C, Di Palma S, Rilke F (1994) Long-term follow-up of in situ carcinoma of the breast. Semin Diagn Pathol 11(3):223–235
Page DL, Dupont WD, Rogers LW, Jensen RA, Schuyler PA (1995) Continued local recurrence of carcinoma 15–25 years after a diagnosis of low grade ductal carcinoma in situ of the breast treated only by biopsy. Cancer 76(7):1197–1200
Fisher ER, Dignam J, Tan-Chiu E, Costantino J, Fisher B, Paik S, Wolmark N (1999) Pathologic findings from the National surgical adjuvant breast project (NSABP) eight-year update of protocol B-17: intraductal carcinoma. Cancer 86(3):429–438
Lagios MD, Silverstein MJ (2001) Sentinel node biopsy for patients with DCIS: a dangerous and unwarranted direction [Editorial]. Ann Surg Oncol 8(4):275–277
Lagios MD, Margolin FR, Westdahl PR, Rose MR (1989) Mammographically detected duct carcinoma in situ. Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer 63(4):618–624
Solin LJ, Schultz DJ, Fowble BL (1995) Ten-Year results of the treatment of early-stage breast carcinoma in elderly women using breast-conserving surgery and definitive breast irradiation. Int J Radiat Oncol Biol Phys 33(1):45–51
Fisher B, Costantino J, Redmond C, Fisher E, Margolese R, Dimitrov N, Wolmark N, Wickerham DL, Deutsch M, Ore L (1993) Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 328(22):1581–1586
Rakovitch E, Franssen E, Kim J, Ackerman I, Pignol JP, Paszat L, Pritchard KI, Ho C, Redelmeier DAA (2003) Comparison of risk perception and psychological morbidity in women with ductal carcinoma in situ and early invasive breast cancer [Report]. Breast Cancer Res Treat 77(3):285–293
SchwartzGF (1994) The role of excision and surveillance alone in subclinical DCIS of the breast. Oncology (Huntingt) 8(2):21–26 discussion
Silverstein MJ, Lagios MD, Craig PH, Waisman JR, Lewinsky BS, Colburn WJ, Poller DN (1996) A prognostic index for ductal carcinoma in situ of the breast. Cancer 77(11):2267–2274
Silverstein MJ, Lagios MD, Martino S, Lewinsky BS, Craig PH, Beron PJ, Gamagami P, Waisman JR (1998) Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast. J Clin Oncol 16(4):1367–1373
Solin LJ, Fourquet A, McCormick B, Haffty B, Recht A, Schultz DJ, Barrett W, Fowble BL, Kuske R, Taylor M (1994) Salvage treatment for local recurrence following breast-conserving surgery and definitive irradiation for ductal carcinoma in situ (intraductal carcinoma) of the breast. Int J Radiat Oncol Biol Phys 30(1):3–9
Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Salem B, Lakhani I, Morrow M (2005) Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 23(24):5526–5533
Acknowledgments
This work was supported by grants from the Canadian Breast Cancer Foundation and the Canadian Breast Cancer Research Alliance. The authors would like to thank Ms. Barb Zurowski for her assistance in manuscript preparation and Ms. Angela Uzun for her assistance at the OBSP.
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Rakovitch, E., Pignol, JP., Chartier, C. et al. The management of ductal carcinoma in situ of the breast: a screened population-based analysis. Breast Cancer Res Treat 101, 335–347 (2007). https://doi.org/10.1007/s10549-006-9302-0
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DOI: https://doi.org/10.1007/s10549-006-9302-0