Controversies in the treatment of ductal carcinoma in situ

Breast-conserving therapy for ductal carcinoma in situ of the breast: the French Cancer Centers' experience

PURPOSE

To assess the long-term outcome for women with ductal carcinoma in situ of the breast treated in current clinical practice by conservative surgery with or without definitive breast irradiation.

METHODS AND MATERIALS

We analyzed 705 cases of ductal carcinoma in situ treated between 1985 and 1995 in nine French regional cancer centers; 515 underwent conservative surgery and radiotherapy (CS+RT) and 190 CS alone. The median follow-up was 7 years.

RESULTS

The 7-year crude local recurrence (LR) rate was 12.6% (95% confidence interval [CI] 9.4-15.8) and 32.4% (95% CI 25-39.7) for the CS+RT and CS groups, respectively (p <0.0001). The respective 10-year results were 18.2% (95% CI 13.3-23) and 43.8% (95% CI 30-57.7). A total of 125 LRs occurred, 66 and 59 in the CS+RT and CS groups, respectively. Invasive or microinvasive LRs occurred in 60.6% and 52% of the cases in the same respective groups. The median time to LR development was 55 and 41 months. Nine (1.7%) and 6 (3.1%) nodal recurrences occurred in the CS+RT and CS groups, respectively. Distant metastases occurred in 1.4% and 3% of the respective groups. Patient age and excision quality (final margin status) were both significantly associated with LR risk in the CS+RT group: the LR rate was 29%, 13%, and 8% among women aged < or =40, 41-60, and > or =61 years (p <0.001). Even in the case of complete excision, we observed a 24% rate of LR (6 of 25) in women <40 years. Patients with negative, positive, or uncertain margins had a 7-year crude LR rate of 9.7%, 25.2%, and 12.2%, respectively (p = 0.008). RT reduced the LR rate in all subgroups, especially in those with comedocarcinoma (17% vs. 59% in the CS+RT and CS groups, respectively, p <0.0001) and mixed cribriform/papillary tumors (9% vs. 31%, p <0.0001). In the multivariate Cox regression model, young age and positive margins remained significant in the CS+RT group (p = 0.00012 and p = 0.016). Finally, the relative LR risk in the CS+RT group compared with the CS group was 0.35 (95% CI 0.25-0.51, p = 0.0001). Subsequent contralateral breast cancer occurred in 7.1% and 7.5% of the patients in the CS+RT and CS groups, respectively.

CONCLUSION

Despite the absence of randomization, our results are extremely consistent with the updated National Surgical Adjuvant Breast Project B17 and European Organization for Research and Treatment of Cancer 10853 trials. We also noted that the LR risk was very high in women <40 years and/or in the case of incomplete excision.

Optimal Management of Primary Breast Cancer

The diagnosis and treatment of breast cancer have changed in response to not only new technologies but also cultural and social aspects of the disease. While breast-conserving surgery and adjuvant therapy are the preferred treatments for many breast cancers, neoadjuvant therapy is often used in advanced disease. In this review we examine the treatment options that are influenced by pathologic and clinical factors. Invasive breast cancer is a potentially curable disease if it is regarded and managed by a multidisciplinary approach from the outset.

Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ

BACKGROUND

Breast conserving surgery (BCS) is common practice for unifocal ductal carcinoma in situ (DCIS) less than 4 cm in size, but the extent of tumor free margin width around DCIS necessary to minimize recurrence is unclear.

METHODS

Clinical and pathologic details were recorded from all patients with pure DCIS < 4 cm in size, treated with BCS between 1978 and 1997. Histologic margins were measured by using an ocular micrometer. Patients with clear margins (> 1 mm) were divided up into 3 groups for analysis based on margin of normal tissue excised: 1.1-5 mm, 5.1-10 mm, and 10.1-40 mm.

RESULTS

There were 66 patients with close margins (< or = 1 mm), of which 25 cases (37.9%) recurred. The recurrence rates for the 3 clear margin groups ranged from 4.5-7.1%. Median followup was 47 months (range 12-197 mos). Risk of recurrence in the group with close margins was greater than the subgroups with clear margins (P < 0.001); no differences in recurrence was seen between the individual subgroups with clear margins. Nuclear Grade 3 was predictive of recurrence (P = 0.03). Following excision alone, the recurrence rate was 18.6%, compared with 11.1% when radiotherapy was given as adjuvant therapy. Women with clear margins following excision had a recurrence rate of only 8.1%.

CONCLUSION

After BCS for DCIS, close margins were associated with a high risk of local recurrence. Radiotherapy did not compensate for inadequate surgical clearance.

Dermatologic diseases of the breast and nipple

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.

A cross-cultural consumer-based decision aid for screening mammography

BACKGROUND

"Women should have mammograms" is the usual perspective of educational interventions about screening. The perspective that "women should be informed" about potential risks and benefits so they can make value- and evidence-integrated personal decisions has recently been advocated. However, this perspective has not previously been operationalized. We developed an evidence-based cross-cultural mammography decision aid (MDA), for European American and Mexican American women who are 50-70 years old, at average risk of breast cancer, of varying educational levels, and English- or Spanish-speaking.

METHODS

MDA development included: (1) content development by a multidisciplinary team and lay women and (2) testing for validity and reliability. Four parts include: (1) introduction; (2) information about logistics (cost, time, discomfort) and risks (sequelae of false-positive or negative results; (3) probability of developing breast cancer; and (4) benefit of mammography regarding breast cancer outcomes (e.g., death and recurrence). We assessed reliability (stability of decisions with the same information) after 1-2 weeks. We assessed validity (comprehension of information) quantitatively (probabilities were changed to see whether preferences changed predictably) and qualitatively (focus groups, standardized probes for comprehension). Subjects were a convenience sample of 49 European American (50-81 years old) and 54 Mexican American (49-89 years old) women from administrative staff at a medical school, the waiting room of an indigent primary care clinic, and a community center.

RESULTS

Reliability was 100%. In quantitative validity testing, 22 of 28 women (89%) changed preference as predicted with changed probabilities. Comprehension was confirmed qualitatively in all phases of testing with both Spanish and English versions.

CONCLUSION

The decision aid is valid and reliable in English and Spanish for southwestern Mexican American and European American women at average risk of breast cancer, including those of low educational levels.

The Current Status of the Treatment of Ductal Carcinoma In Situ of Japanese Women, Especially Breast Conserving Operation in Relation to the Surgical Margin and Short Term Outcome

The indications for a breast conserving operation in the treatment of ductal carcinoma in situ (DCIS) of the breast with clinical manifestations other than mammographically detected calcifications are controversial. A positive surgical margin has been suggested to be an improtant risk factor for local recurrence after a breast conserving operation. We attempted to clarify the frequency of positive surgical margins when performing breast conserving operations for DCIS, identify the risk factors for positive margins, and also to evaluate the short-term outcome. Between 1988 and 1992, 5571 breast cancer cases were surgically treated at the 7 institutions of the authors, of which 375 cases (6.7%) were histologically diagnosed as DCIS. The most frequent clinical manifestation was a tumor in 64% of the cases, followed by nipple discharge in 23% and calcification on mammography in 12%. Of these 375 cases, 242 cases were analyzed. Sixty-six cases had undergone a breast conserving operation. Axillary dissection was not performed in 29 cases. The median follow up period was 61.4 months. The initial surgical margin was positive in 29% of the cases. The most significant factor for a positive surgical margin was young age fllowed by large tumor size. There were four cases with local recurrence. Three recurrences developed in the same quadrant. All four cases remain alive after total mastectomy. There were no cases with distant metastasis or axillary recurrence. Breast cancerving operation for DCIS have shown satisfactory results to date, and when clear surgical margins can be obtained, this procedure, without axillary dissection, should be considered even for patients with clinical manifestations other than mammographically detected calcifications.