The need for epidemiologic studies of in-situ carcinoma of the breast

Probing variations of fibrous structures during the development of breast ductal carcinoma tissues via Mueller matrix imaging

Recently, we developed a label-free method to probe the microstructural information and optical properties of unstained thin tissue slices based on microscopic Mueller matrix imaging technique. In this paper, we take the microscopic Mueller matrix images of human breast ductal carcinoma tissue samples at different pathological stages, and then calculate and analyze their retardance-related Mueller matrix-derived parameters. To reveal the microstructural features more quantitatively and precisely, we propose a new method based on first-order statistical properties of image to transform the 2D images of Mueller matrix parameters into several statistical feature vectors. We evaluate each statistical feature vector by corresponding classification characteristic value extracted from the statistical features of Mueller matrix parameters images of healthy breast duct tissue samples. The experimental results indicate that these statistical feature vectors of Mueller matrix derived parameters may become powerful tools to quantitatively characterize breast ductal carcinoma tissue samples at different pathological stages. It has the potential to facilitate automating the staging process of breast ductal carcinoma tissue, resulting in the improvement of diagnostic efficiency.

The mammography screening detection of ductal carcinoma in situ and invasive breast cancer according to women's characteristics: is it the same?

PURPOSE

Detection of ductal carcinoma in situ (DCIS) has increased with the mammography dissemination. Given the potential role of DCIS as a precursor of invasive breast cancer (IBC), we aimed to assess whether women's characteristics have a different effect on the DCIS compared to IBC detection rate.

METHODS

This study included 3,609,569 screening mammograms performed from 2002 to 2015 in our organized breast cancer screening program, which actively invites women 50-69 years of age. The association between women's characteristics and the DCIS detection rate, the IBC detection rate and the odds ratio of DCIS among screen-detected cancers was assessed by logistic regression and generalized estimating equations with independent correlation matrix and sandwich estimator.

RESULTS

A total of 4173 DCIS and 15,136 IBC were screen-detected. Increasing women's age, current hormone replacement therapy use and higher body mass index were less associated with the DCIS than with IBC detection rates (p value for the odds of DCIS among screen-detected cancers of, respectively, < 0.0001, 0.0244 and < 0.0001). In contrast, having a previous breast aspiration or biopsy and increasing breast density were more strongly associated with DCIS than with IBC detection rates (p value of, respectively, 0.0050 and < 0.0001).

CONCLUSION

The results suggest that some women's characteristics could be playing a role in the initiation and other in the progression from in situ to invasive breast cancer. These characteristics can also affect the screening sensitivity, and this effect may differ depending on whether screen-detected cases were DCIS or IBC.

Vehicular Traffic-Related Polycyclic Aromatic Hydrocarbon Exposure and Breast Cancer Incidence: The Long Island Breast Cancer Study Project (LIBCSP)

BACKGROUND

Polycyclic aromatic hydrocarbons (PAHs) are widespread environmental pollutants, known human lung carcinogens, and potent mammary carcinogens in laboratory animals. However, the association between PAHs and breast cancer in women is unclear. Vehicular traffic is a major ambient source of PAH exposure.

OBJECTIVES

Our study aim was to evaluate the association between residential exposure to vehicular traffic and breast cancer incidence.

METHODS

Residential histories of 1,508 participants with breast cancer (case participants) and 1,556 particpants with no breast cancer (control participants) were assessed in a population-based investigation conducted in 1996-1997. Traffic exposure estimates of benzo[a]pyrene (B[a]P), as a proxy for traffic-related PAHs, for the years 1960-1995 were reconstructed using a model previously shown to generate estimates consistent with measured soil PAHs, PAH-DNA adducts, and CO readings. Associations between vehicular traffic exposure estimates and breast cancer incidence were evaluated using unconditional logistic regression.

RESULTS

The odds ratio (95% CI) was modestly elevated by 1.44 (0.78, 2.68) for the association between breast cancer and long-term 1960-1990 vehicular traffic estimates in the top 5%, compared with below the median. The association with recent 1995 traffic exposure was elevated by 1.14 (0.80, 1.64) for the top 5%, compared with below the median, which was stronger among women with low fruit/vegetable intake [1.46 (0.89, 2.40)], but not among those with high fruit/vegetable intake [0.92 (0.53, 1.60)]. Among the subset of women with information regarding traffic exposure and tumor hormone receptor subtype, the traffic-breast cancer association was higher for those with estrogen/progesterone-negative tumors [1.67 (0.91, 3.05) relative to control participants], but lower among all other tumor subtypes [0.80 (0.50, 1.27) compared with control participants].

CONCLUSIONS

In our population-based study, we observed positive associations between vehicular traffic-related B[a]P exposure and breast cancer incidence among women with comparatively high long-term traffic B[a]P exposures, although effect estimates were imprecise.

CITATION

Mordukhovich I, Beyea J, Herring AH, Hatch M, Stellman SD, Teitelbaum SL, Richardson DB, Millikan RC, Engel LS, Shantakumar S, Steck SE, Neugut AI, Rossner P Jr., Santella RM, Gammon MD. 2016. Vehicular traffic-related polycyclic aromatic hydrocarbon exposure and breast cancer incidence: the Long Island Breast Cancer Study Project (LIBCSP). Environ Health Perspect 124:30-38; http://dx.doi.org/10.1289/ehp.1307736.

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register (2 June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (2 June 2011), EMBASE (2 June 2011) and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP; 2 June 2011). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

The burden of breast cancer in Italy: mastectomies and quadrantectomies performed between 2001 and 2008 based on nationwide hospital discharge records

Background

Where population coverage is limited, the exclusive use of Cancer Registries might limit ascertainment of incident cancer cases. We explored the potentials of Nationwide hospital discharge records (NHDRs) to capture incident breast cancer cases in Italy.

Methods

We analyzed NHDRs for mastectomies and quadrantectomies performed between 2001 and 2008. The average annual percentage change (AAPC) and related 95% Confidence Interval (CI) in the actual number of mastectomies and quadrantectomies performed during the study period were computed for the full sample and for subgroups defined by age, surgical procedure, macro-area and singular Region. Re-admissions of the same patients were separately presented.

Results

The overall number of mastectomies decreased, with an AAPC of −2.1% (−2.3 -1.8). This result was largely driven by the values observed for women in the 45 to 64 and 65 to 74 age subgroups (−3.0%, -3.4 -3.6 and −3.3%, -3.8 -2.8, respectively). We observed no significant reduction in mastectomies for women in the remaining age groups. Quadrantectomies showed an overall +4.7 AAPC (95%CI:4.5–4.9), with no substantial differences by age. Analyses by geographical area showed a remarkable decrease in mastectomies, with inter-regional discrepancies possibly depending upon variability in mammography screening coverage and adherence. Quadrantectomies significantly increased, with Southern Regions presenting the highest average rates. Data on repeat admissions within a year revealed a total number of 46,610 major breast surgeries between 2001 and 2008, with an overall +3.2% AAPC (95%CI:2.8-3.6).

Conclusions

In Italy, NHDRs might represent a valuable supplemental data source to integrate Cancer Registries in cancer surveillance.

Postmenopausal hormone therapy and ductal carcinoma in situ: a population-based case-control study

BACKGROUND AND AIM

The relationship between hormone therapy (HT) and invasive breast cancer has been extensively investigated, but the relationship between HT and in situ breast cancer has received relatively little attention. We examined the relationship between HT and ductal carcinoma in situ (DCIS) among postmenopausal women who participated in a population-based case-control study in Connecticut, USA.

METHODS

This analysis included 1179 post-menopausal women (603 controls and 576 cases), who comprised a subset of a population-based case-control study that included all incident cases of breast carcinoma in situ (BCIS) in Connecticut and frequency-matched controls by 5-year age intervals.

RESULTS

We found no association between DCIS and ever use of any HT (adjusted odds ratio (OR)=0.85, 95% confidence interval (CI): 0.65-1.11); of estrogen alone (adjusted OR=0.93; 95% CI: 0.68-1.29) or of estrogen and progesterone (adjusted OR=0.75; 95% CI: 0.52-1.08). There was also no association between DCIS and current use of these hormones. In addition, estimated risk of DCIS did not increase with duration of use of these preparations.

CONCLUSIONS

These results add to a small literature that remains inconclusive. To determine whether HT poses risk of in situ breast cancer, larger studies with greater power and precise control of important covariates (e.g., mammography screening) are needed, as are meta-analyses of available data.

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

Hormones and progeny of breast tumor cells

The rudimentary human glandular breast, with the approach of puberty, starts to grow both at glandular and stromal sites. Full differentiation is a gradual process and takes many years, and is only fully attained by pregnancy. The risk of breast cancer is inversely related to parity. Women during adolescence have the highest susceptibility to breast cancer development. This appears to be the period when the mammary gland has the highest number of stem cells. Stem cells may represent important targets for transformational events. Immunohistochemistry allows for identification of the lineage-specific precursor glandular and myoepithelial cells and their differentiated progeny. Both estrogen receptor subtypes are found in epithelial cells of alveoli and ducts as well as in stromal cells. Immunophenotypia of benign proliferative breast disease favors a fundamentally different epithelial composition from that of most malignant epithelial proliferations such as atypical ductal hyperplasia, ductal carcinoma in situ, lobular neoplasia and invasive breast carcinoma. Immunophenotypical characterization of these lesions assists in distinguishing benign from malignant disease. Based on the observation of bilateral risks and frequent multifocality with atypical ductal hyperplasia, atypical lobular hyperplasia and lobular carcinoma in situ, it is suggested that these may represent risk factors as well as precursors. One should, however, realize that ductal as well as lobular premalignant breast lesions ultimately arise from stem cells in the terminal duct lobular units. Estrogen receptor-beta (ERbeta)-positive and ERalpha-negative expression characterizes the highest levels of proliferative cancer cell activity. Point mutations and alterations of co-activators and co-repressors will also determine hormone sensitivity. There is evidence for different genetic pathways in the development of ductal carcinoma in situ and lobular carcinoma in situ. While they share recurrent 16q losses, a second hit in the E-cadherin gene explains the advent of lobular lesions and their common existence with the primary ductal type. Based on our immunocytochemical observations, the most likely target cell of malignant transformation is the Ck18/18-positive and ER-negative transient cell of normal breast epithelium. Pregnancy confers a different genomic imprint to breast epithelial stem cells. Further elucidation of this mechanism may assist in developing appropriate means of breast cancer prevention. This paper is the Pieter van Keep Memorial Lecture given by Professor Hermann Schneider at the 11th World Congress on the Menopause, October 18-22, 2005, in Buenos Aires, Argentina.

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.59, P < 0.00001) and ipsilateral DCIS recurrence (HR 0.64; 95% CI 0.41 to 1.01, P = 0.05). Pooled analysis for invasive recurrence did not reach statistical significance. All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

Differentiation of tumours of ductal and lobular origin: II. Genomics of invasive ductal and lobular breast carcinomas

Breast cancer is considered to be a multifactorial disorder caused by both genetic and non-genetic factors. Different histological types of breast cancer differ in response to treatment and may have a divergent clinical course. Breast tissue is heterogeneous, with components of epithelial, mesenchymal, endothelial and lymphopoietic derivation. The genetic heterogeneity of invasive breast cancer is reflected by the wide spectrum of histological types and differentiation grades. Nevertheless, the influences of these cell types on the tumour's total pattern of gene expression can be estimated analytically. Microarrays permit total tissue analysis and provide a stable molecular portrait of tumours. Some investigations suggest differences in the gene expression profiling for ductal and lobular carcinomas. It has been reported that inactivating mutations of the E-cadherin gene are very frequent in infiltrating lobular breast carcinomas. Other than altered expression of E-cadherin, little is known about the underlying biology that distinguishes ductal and lobular tumour subtypes. However, about 8 genes have been identified differentially which are expressed in lobular and ductal cancers: E-CD, survivin, cathepsin B, TPI1, SPRY1, SCYA14, TFAP2B, and thrombospondin 4, osteopontin, HLA-G, and CHC1. Expression profiling of breast cancers can be used diagnostically to distinguish individual histologic subclassifications and may guide the selection of target therapeutics. However, future approaches will need to include methods for high throughput clinical validation and the ability to analyze microscopic samples.

Breast-conserving surgery and radiotherapy: a possible treatment for lobular carcinoma in situ?

Lobular carcinoma in situ (LCIS) is generally treated by conservative surgery alone and less often by mastectomy. We report our experience using conservative surgery and whole breast irradiation (WBI) for the treatment of patients with LCIS. From 1980 to 1992, 25 women with a median age of 54 years underwent lumpectomy (20) or quadrantectomy (5) and WBI (median dose: 52 Gy) for treatment of their LCIS. Five cases had palpable lesions, 19 were found by mammography alone and one case was found due to nipple discharge. Twelve women received tamoxifen at 20 mg/day for 2 years. With a median follow-up of 153 months (range 58-240), only one local recurrence was observed. The global rate of bilateral carcinoma was 17.6% (two synchronous and one metachronous). Until now, no case of LCIS treated by lumpectomy and radiation therapy has been reported in detail in the literature. After biopsy alone for LCIS, a subsequent infiltrating carcinoma occurs in approximately 15% of cases. Thus, classical radiosurgical therapy should represent an interesting alternative both for limited surgery alone and mastectomy, both of which have been proposed as sole treatments for LCIS.

Ductal carcinoma in situ, complexities and challenges

The incidence of ductal carcinoma in situ (DCIS), a noninvasive form of breast cancer, has increased markedly in recent decades, and DCIS now accounts for approximately 20% of breast cancers diagnosed by mammography. Laboratory and patient data suggest that DCIS is a precursor lesion for invasive cancer. The appropriate classification of DCIS has provoked much debate; a number of classification systems have been developed, but there is a lack of uniformity in the diagnosis and prognostication of this disease. Further investigation of molecular markers should improve the classification of DCIS and our understanding of its relationship to invasive disease. Controversy also exists with regard to the optimal management of DCIS patients. In the past, mastectomy was the primary treatment for patients with DCIS, but as with invasive cancer, breast-conserving surgery has become the standard approach. Three randomized trials have reported a statistically significant decrease in the risk of recurrence with radiation therapy in combination with lumpectomy compared with lumpectomy alone, but there was no survival advantage with the addition of radiotherapy. Two randomized trials have suggested an additional benefit, in terms of recurrence, with the addition of adjuvant tamoxifen therapy, although in one trial the benefit was not statistically significant. Current data suggest that tamoxifen use should be restricted to patients with estrogen receptor-positive DCIS. Neither trial demonstrated a survival benefit with adjuvant tamoxifen. Ongoing and recently completed studies should provide information on outcomes in patients treated with lumpectomy alone and on the effectiveness of aromatase inhibitors as an alternative to tamoxifen.

Lifetime recreational exercise activity and risk of breast carcinoma in situ

BACKGROUND

The incidence rates of breast carcinoma in situ (BCIS) have increased dramatically over the past two decades, primarily because of increased mammography screening. Ductal carcinoma in situ, which accounts for approximately 85% of BCIS and 10-20% of all breast carcinomas, is generally recognized as the final step in the progression to invasive disease. To the authors' knowledge, few studies have been conducted to date to evaluate BCIS risk factors. Because of its potential effects on circulating sex hormones, physical activity has been proposed as a modifiable risk factor for invasive breast carcinoma. However, the relation to BCIS risk is poorly understood.

METHODS

The authors analyzed data from a population-based case-control study conducted in Los Angeles County. Personal interviews were conducted with 567 white and black women (age range, 35-64 years) who had been newly diagnosed with BCIS between March 1, 1995 and May 31, 1998 and with 1026 control subjects, of whom 616 were screened within 2 years of identification.

RESULTS

After excluding unscreened control subjects (n = 410) and adjusting for potential confounding factors, the risk of BCIS was approximately 35% lower among women with any exercise activity compared with inactive women, although no significant trend was observed. The association between exercise activity and the risk of BCIS was modified by a family history of breast carcinoma. No reduction in risk was observed among women reporting a first-degree family history of breast carcinoma (homogeneity of trends P value = 0.02).

CONCLUSIONS

The findings of the current study suggest that exercise activity may modify the risk of BCIS, particularly among women without a family history of breast carcinoma.

Oral Contraceptives and the Risk of Ductal Breast Carcinoma in situ

Recent evidence suggests that oral contraceptive use is associated with little to no increased risk of invasive breast carcinoma. No study has examined the relationship between oral contraceptive use and the risk of non-invasive breast carcinoma, that is, breast carcinoma in situ.

OBJECTIVE

To define the role of oral contraceptive use in the development of breast carcinoma in situ.

METHODS

The data are 875 ductal carcinoma in situ (DCIS) cases diagnosed among residents of the state of Connecticut from September 15, 1994 to March 14, 1998 and between the age of 20 and 79 years as well as 999 control subjects. Controls are female Connecticut residents collected via random-digit-dial and frequency matched to the cases by 5-year age intervals. Telephone interviews were used to collect information on risk factors and cancer screening history. Logistic regression was used to provide maximum likelihood estimates of the odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

The risk of being diagnosed with DCIS for women who had ever used oral contraceptives was not increased relative to women who had never used them (OR: 1.0, 95% CI: 0.8, 1.2). The risk did not significantly increase with duration of oral contraceptive use, nor with duration of high estrogen use, time since last use, progestin or estrogen type, or age at first use. Furthermore, the association between oral contraceptive use and DCIS risk did not vary by the presence of a family history of breast cancer or by menopausal status.

CONCLUSIONS

In these data, no evidence was found for an increased risk of ductal carcinoma in situ associated with the use of oral contraceptives.

Breast carcinoma in situ: risk factors and screening patterns

BACKGROUND

Risk factors associated with invasive breast cancer are well documented, but those associated with breast carcinoma in situ are not well defined.

METHODS

We conducted a population-based, case-control study among female residents of Connecticut to identify risk factors for breast carcinoma in situ. Case patients, diagnosed with ductal carcinoma in situ (DCIS) (n = 875) or lobular carcinoma in situ (LCIS) (n = 123), were matched by 5-year age groups with control subjects (n = 999). Case patients were diagnosed between September 15, 1994, through March 14, 1998, and all subjects were between the ages of 20 and 79 years. Information on risk factors and cancer-screening history was collected by telephone interviews. Conditional logistic regression was used to determine odds ratios (ORs) for the association of these factors with the risk of DCIS and LCIS.

RESULTS

Case patients with DCIS were more likely than control subjects to report a family history of breast cancer (OR = 1.48; 95% confidence interval [CI] = 1.19 to 1.85) or previous breast biopsy (OR = 3.56; 95% CI = 2.86 to 4.43). They also had fewer full-term pregnancies (OR = 0.86; 95% CI = 0.80 to 0.93) and were older at first full-term pregnancy (OR for being 20-29 years old relative to being <20 years old = 1.68; 95% CI = 1.17 to 2.43) and at menopause (OR for being > or =55 years old relative to being <45 years old = 1.71; 95% CI = 1.05 to 2.77). DCIS case patients were more likely than control subjects to have had a mammographic examination (OR = 2.46; 95% CI = 1.78 to 3.40) or an annual clinical breast examination (OR = 1.83; 95% CI = 1.48 to 2.26). DCIS patients and control subjects did not differ with respect to oral contraceptive use, hormone replacement therapy, alcohol consumption or smoking history, or breast self-examination. Associations for LCIS were similar.

CONCLUSIONS

The risk factors associated with DCIS and LCIS are similar to those associated with invasive breast cancer. Diagnosis of DCIS is associated with increased mammography screening.

Correlates of surgical treatment type for women with noninvasive and invasive breast cancer

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.

Contribution of germline MLH1 and MSH2 mutations to lobular carcinoma in situ of the breast

Lobular carcinoma in situ (LCIS) is an unusual histological pattern of non-invasive neoplastic disease of the breast occurring predominantly in women aged between 40 and 50 years. LCIS is frequently multicentric and bilateral suggesting a genetic basis to the disease. The high frequency of microsatellite instability in lobular breast cancers, coupled with increased risk of breast cancer associated with germline mismatch repair gene mutations raises the possibility that mutations MSH2 or MLH1 might confer susceptibility to LCIS. To explore this possibility we have examined a series of 71 LCIS patients for germline MSH2 and MLH1 mutations. No mutations were detected in MSH2. Two sequence variants were identified in MLH1. The first was a CTT-->CAT substitution, codon 607 (exon 16) changing leucine to histidine. The other mutation detected in MLH1 was a TAC-->TAA substitution codon 750 (exon 19) creating a stop codon, predicted to generate a truncated protein. These findings suggest that mutations in MLH1 may underlie a subset of LCIS cases.

Disparate E-cadherin mutations in LCIS and associated invasive breast carcinomas

AIMS

The relation between lobular carcinoma in situ (LCIS) and invasive breast cancer is unresolved. In an attempt to establish whether LCIS is a precursor of invasive cancer the mutational status and the expression of E-cadherin was analysed in LCIS and associated invasive breast carcinoma in 23 patients.

METHODS

Foci of LCIS and associated invasive carcinoma were individually microdissected from tissue from 23 patients. Exons 4-16 of the E-cadherin gene were analysed using single strand conformation polymorphism (SSCP); protein expression and the localisation of E-cadherin and beta-catenin were assessed with the use of immunohistochemistry.

RESULTS

Immunohistochemistry revealed a lack of expression of E-cadherin and beta-catenin in most LCIS samples and invasive foci. In all but four cases, the staining pattern was identical in the LCIS and associated invasive areas. When E-cadherin was absent, beta-catenin was also undetected, suggesting a lack of expression of alternative classic cadherin members in these lesions. Coincident E-cadherin mutations in LCIS and associated invasive carcinoma were not identified in this series of patients. However, mutational analysis of E-cadherin in multiple foci of carcinoma in situ surrounding an invasive lesion provided evidence to support ductal carcinoma in situ as a precursor of invasive ductal carcinoma.

CONCLUSION

These data support the hypothesis that LCIS is not a precursor of invasive breast carcinoma but a marker of increased risk of developing invasive disease.

Genetic relation of lobular carcinoma in situ, ductal carcinoma in situ, and associated invasive carcinoma of the breast

AIMS

The mutual relation of lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) of the breast, as accepted precursor lesions of invasive breast cancer, is controversial. Because they display genetic heterogeneity, it is not clear how genetically advanced these entities are and what causes the transition to an invasive carcinoma.

METHODS

Six cases of LCIS, four of them with associated lobular invasive carcinoma, four cases of intermediately differentiated DCIS with an associated invasive lobular carcinoma, and nine cases of intermediately and poorly differentiated DCIS with associated ductal invasive carcinoma were investigated by means of comparative genomic hybridisation (CGH) after microdissection and immunohistochemical staining of E-cadherin.

RESULTS

LCIS was characterised by a low average rate of copy number changes, no evidence of amplifications, and a high rate of gains and losses of chromosomal material at 1q and 16q, respectively. A high degree of genetic homology with well differentiated DCIS was obvious, as reported previously. The cases of intermediately differentiated DCIS with associated lobular invasive components and lobular differentiation revealed striking homologies, and a significant difference of E-cadherin expression. The comparison of preinvasive and invasive breast lesions, irrespective of differentiation within the same patient, revealed no specific alteration that might be associated with invasion. Genetic alterations seen in invasive carcinoma were not necessarily seen in the adjacent precursor lesions.

CONCLUSIONS

These results provide strong evidence that invasive breast cancer is a disease with multiple cytogenetic subclones already present in preinvasive lesions. Moreover, specific CGH alterations associated with invasion were not observed. Furthermore, the close genetic association between well differentiated and a subgroup of intermediately differentiated DCIS and LCIS led to the hypothesis that LCIS and a subgroup of DCIS are different phenotypic forms of a common genotype.

The potential and limitations of data from population-based state cancer registries

Cancer incidence varies markedly among states because of population heterogeneity regarding risk, genetic, and demographic factors. Population-based cancer registries are essential to monitoring cancer trends and control. The Centers for Disease Control and Prevention and the North American Association of Central Cancer Registries, through the National Program of Cancer Registries, are helping state registries generate more and better data nationwide. The National Program of Cancer Registries has supported the enhancement of 36 registries and the creation of 13 new registries in 45 states, 3 territories, and the District of Columbia, providing national standards for completeness, timeliness, and quality; financial support; and technical assistance. Users must be aware of diverse issues that influence collection and interpretation of cancer registry data, such as multiple cancer diagnoses, duplicate reports, reporting delays, misclassification of race/ethnicity, and pitfalls in estimations of cancer incidence rates. Attention to these issues and intense use of the available data for cancer surveillance will enable maximum societal benefit from the emerging network of population-based state cancer registries.

Lobular carcinoma in situ of the breast is not caused by constitutional mutations in the E-cadherin gene

Lobular carcinoma in situ (LCIS) is an unusual histological pattern of non-invasive neoplastic disease of the breast occurring predominantly in women aged between 40 and 50 years. LCIS is frequently multicentric and bilateral, and there is evidence that it is associated with an elevated familial risk of breast cancer. Although women with LCIS suffer an increased risk of invasive breast disease, this risk is moderate suggesting that LCIS may result from mutation of a gene or genes conferring a high risk of LCIS, but a lower risk of invasive breast cancer. The high frequency of somatic mutations in E-cadherin in LCIS, coupled with recent reports that germline mutations in this gene can predispose to diffuse gastric cancer, raised the possibility that constitutional E-cadherin mutations may confer susceptibility to LCIS. In order to explore this possibility we have examined a series of 65 LCIS patients for germline E-cadherin mutations. Four polymorphisms were detected but no pathogenic mutations were identified. The results indicate that E-cadherin is unlikely to act as a susceptibility gene for LCIS.