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Engelhardt EG, Schmitz RSJM, Gerritsma MA, Sondermeijer CMT, Verschuur E, Houtzager JHE, Griffioen R, Bijker N, Mann RM, Retèl V, van Duijnhoven FH, Wesseling J, Bleiker EMA. DCIS knowledge of women choosing between active surveillance and surgery for low-risk DCIS. Breast 2024; 77:103764. [PMID: 38970983 PMCID: PMC11282980 DOI: 10.1016/j.breast.2024.103764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/11/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) can progress to invasive breast cancer (IBC), but often never will. As we cannot predict accurately which DCIS-lesions will or will not progress to IBC, almost all women with DCIS undergo breast-conserving surgery supplemented with radiotherapy, or even mastectomy. In some countries, endocrine treatment is prescribed as well. This implies many women with non-progressive DCIS undergo overtreatment. To reduce this, the LORD patient preference trial (LORD-PPT) tests whether mammographic active surveillance (AS) is safe by giving women with low-risk DCIS a choice between treatment and AS. For this, sufficient knowledge about DCIS is crucial. Therefore, we assessed women's DCIS knowledge in association with socio-demographic and clinical characteristics. METHODS LORD-PPT participants (N = 376) completed a questionnaire assessing socio-demographic and clinical characteristics, risk perception, treatment choice and DCIS knowledge after being informed about their diagnosis and treatment options. RESULTS 66 % of participants had poor knowledge (i.e., answered ≤3 out of 7 knowledge items correctly). Most incorrect answers involved overestimating the safety of AS and misunderstanding of DCIS prognostic risks. Overall, women with higher DCIS knowledge score perceived their risk of developing IBC as being somewhat higher than women with poorer knowledge (p = 0.049). Women with better DCIS knowledge more often chose surgery whilst most women with poorer knowledge chose active surveillance (p = 0.049). DISCUSSION Our findings show that there is room for improvement of information provision to patients. Decision support tools for patients and clinicians could help to stimulate effective shared decision-making about DCIS management.
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Affiliation(s)
- E G Engelhardt
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - R S J M Schmitz
- Division of Molecular Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - M A Gerritsma
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - C M T Sondermeijer
- Biometrics Department, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - E Verschuur
- Borstkanker Vereniging Nederland (breast cancer patient association), Domus Medica, Marecatorlaan 1200, 3528 BL Utrecht, the Netherlands
| | - J H E Houtzager
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - R Griffioen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - N Bijker
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam UMC, locatie AMC, Meibergdreef 9, 1105 AZ Amsterdam Zuidoost, Amsterdam, the Netherlands
| | - R M Mann
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Radiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - V Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - F H van Duijnhoven
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - J Wesseling
- Division of Molecular Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - E M A Bleiker
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Clinical Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands; Department op Clinical Genetics, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
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2
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Faupel-Badger J, Kohaar I, Bahl M, Chan AT, Campbell JD, Ding L, De Marzo AM, Maitra A, Merrick DT, Hawk ET, Wistuba II, Ghobrial IM, Lippman SM, Lu KH, Lawler M, Kay NE, Tlsty TD, Rebbeck TR, Srivastava S. Defining precancer: a grand challenge for the cancer community. Nat Rev Cancer 2024:10.1038/s41568-024-00744-0. [PMID: 39354069 DOI: 10.1038/s41568-024-00744-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2024] [Indexed: 10/03/2024]
Abstract
The term 'precancer' typically refers to an early stage of neoplastic development that is distinguishable from normal tissue owing to molecular and phenotypic alterations, resulting in abnormal cells that are at least partially self-sustaining and function outside of normal cellular cues that constrain cell proliferation and survival. Although such cells are often histologically distinct from both the corresponding normal and invasive cancer cells of the same tissue origin, defining precancer remains a challenge for both the research and clinical communities. Once sufficient molecular and phenotypic changes have occurred in the precancer, the tissue is identified as a 'cancer' by a histopathologist. While even diagnosing cancer can at times be challenging, the determination of invasive cancer is generally less ambiguous and suggests a high likelihood of and potential for metastatic disease. The 'hallmarks of cancer' set out the fundamental organizing principles of malignant transformation but exactly how many of these hallmarks and in what configuration they define precancer has not been clearly and consistently determined. In this Expert Recommendation, we provide a starting point for a conceptual framework for defining precancer, which is based on molecular, pathological, clinical and epidemiological criteria, with the goal of advancing our understanding of the initial changes that occur and opportunities to intervene at the earliest possible time point.
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Affiliation(s)
| | - Indu Kohaar
- Division of Cancer Prevention, National Cancer Institute, NIH, Rockville, MD, USA
| | - Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua D Campbell
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Li Ding
- Department of Medicine and Genetics, McDonnell Genome Institute, and Siteman Cancer Center, Washington University in St Louis, Saint Louis, MO, USA
| | - Angelo M De Marzo
- Department of Pathology, Urology and Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anirban Maitra
- Department of Translational Molecular Pathology, Sheikh Ahmed Center for Pancreatic Cancer Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel T Merrick
- Division of Pathology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ernest T Hawk
- Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Irene M Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Scott M Lippman
- Department of Medicine, University of California, La Jolla, San Diego, CA, USA
| | - Karen H Lu
- Department of Gynecological Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Mark Lawler
- Patrick G Johnson Centre for Cancer Research, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Thea D Tlsty
- Department of Medicine and Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Timothy R Rebbeck
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Sudhir Srivastava
- Division of Cancer Prevention, National Cancer Institute, NIH, Rockville, MD, USA.
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3
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Nguyen DL, Shelley Hwang E, Ryser MD, Grimm LJ. Imaging Changes and Outcomes of Patients Undergoing Active Monitoring for Ductal Carcinoma In Situ: Seven-Year Follow-up Study. Acad Radiol 2024; 31:2654-2662. [PMID: 38184419 PMCID: PMC11224137 DOI: 10.1016/j.acra.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/08/2024]
Abstract
RATIONALE AND OBJECTIVES To determine the imaging changes and their associated positive predictive value (PPV) for invasive breast cancer in women undergoing active monitoring for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS In this seven-year follow-up retrospective IRB-exempted cohort study, we reviewed patients diagnosed with DCIS who elected active monitoring between 2003 and 2022 at a single academic institution. Imaging characteristics, histopathology at initial diagnosis, and subsequent follow-up were recorded. Low-risk DCIS was defined as low or intermediate grade and hormone receptor (HR) positive (estrogen and/or progesterone receptor positive) disease diagnosed in women at least 40 years of age. Progression was defined as subsequent ipsilateral invasive breast cancer diagnosis. RESULTS There were 39 patients with a median age of 58.4 years (IQR: 51.1-69.6 years) and a median follow-up of 4.3 years (range: 0.6-16.4 years). Nearly two thirds of patients (64%, 25/39) had stable imaging (range: 0.6-16.4 years) and remained progression-free during active monitoring. Among the remaining 14 patients (36%), there were 24 imaging findings which prompted 22 subsequent core needle biopsies (range: 1-3 biopsies per patient) and two surgical biopsies. The PPV of invasive cancer was 29% (7/24) overall and 38% (3/8) for masses, 33% (3/9) for calcifications, 17% (1/6) for non-mass enhancement, and 0% (0/1) for architectural distortion. CONCLUSION Of the radiographic changes prompting an additional biopsy, development of a new mass (38%) and new calcifications (33%) had the highest PPV for invasive progression. Close imaging follow-up should be a critical component for patients undergoing monitoring for DCIS.
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Affiliation(s)
- Derek L Nguyen
- Department of Radiology, Duke University School of Medicine, 20 Duke Medicine Cir Durham, Durham, North Carolina, 27710, USA (D.L.N., L.J.G.).
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, 20 Duke Medicine Cir Durham, Durham, North Carolina, 27710, USA (E.S.H.)
| | - Marc D Ryser
- Department of Population Health Sciences and Mathematics, Duke University Medical Center, Duke University, 20 Duke Medicine Cir Durham, Durham, North Carolina, 27710, USA (M.D.R.)
| | - Lars J Grimm
- Department of Radiology, Duke University School of Medicine, 20 Duke Medicine Cir Durham, Durham, North Carolina, 27710, USA (D.L.N., L.J.G.)
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Wang J, Li B, Luo M, Huang J, Zhang K, Zheng S, Zhang S, Zhou J. Progression from ductal carcinoma in situ to invasive breast cancer: molecular features and clinical significance. Signal Transduct Target Ther 2024; 9:83. [PMID: 38570490 PMCID: PMC10991592 DOI: 10.1038/s41392-024-01779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 04/05/2024] Open
Abstract
Ductal carcinoma in situ (DCIS) represents pre-invasive breast carcinoma. In untreated cases, 25-60% DCIS progress to invasive ductal carcinoma (IDC). The challenge lies in distinguishing between non-progressive and progressive DCIS, often resulting in over- or under-treatment in many cases. With increasing screen-detected DCIS in these years, the nature of DCIS has aroused worldwide attention. A deeper understanding of the biological nature of DCIS and the molecular journey of the DCIS-IDC transition is crucial for more effective clinical management. Here, we reviewed the key signaling pathways in breast cancer that may contribute to DCIS initiation and progression. We also explored the molecular features of DCIS and IDC, shedding light on the progression of DCIS through both inherent changes within tumor cells and alterations in the tumor microenvironment. In addition, valuable research tools utilized in studying DCIS including preclinical models and newer advanced technologies such as single-cell sequencing, spatial transcriptomics and artificial intelligence, have been systematically summarized. Further, we thoroughly discussed the clinical advancements in DCIS and IDC, including prognostic biomarkers and clinical managements, with the aim of facilitating more personalized treatment strategies in the future. Research on DCIS has already yielded significant insights into breast carcinogenesis and will continue to pave the way for practical clinical applications.
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Affiliation(s)
- Jing Wang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Baizhou Li
- Department of Pathology, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Meng Luo
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Department of Plastic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jia Huang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Kun Zhang
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shu Zheng
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Suzhan Zhang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China.
| | - Jiaojiao Zhou
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China.
- Cancer Center, Zhejiang University, Hangzhou, China.
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5
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Alaeikhanehshir S, Schmitz RSJM, van den Belt-Dusebout AW, van Duijnhoven FH, Verschuur E, van Seijen M, Schaapveld M, Lips EH, Wesseling J. The effects of contemporary treatment of DCIS on the risk of developing an ipsilateral invasive Breast cancer (iIBC) in the Dutch population. Breast Cancer Res Treat 2024; 204:61-68. [PMID: 37964135 PMCID: PMC10806034 DOI: 10.1007/s10549-023-07168-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To assess the effects of contemporary treatment of ductal carcinoma in situ (DCIS) on the risk of developing an ipsilateral invasive breast cancer (iIBC) in the Dutch female population. METHODS Clinical data was obtained from the Netherlands Cancer Registry (NCR), a nationwide registry of all primary malignancies in the Netherlands integrated with the data from PALGA, the Dutch nationwide network and registry of histo- and cytopathology in the Netherlands, on all women in the Netherlands treated for primary DCIS from 2005 to 2015, resulting in a population-based cohort of 14.419 women. Cumulative iIBC incidence was assessed and associations of DCIS treatment type with subsequent iIBC risk were evaluated by multivariable Cox regression analyses. RESULTS Ten years after DCIS diagnosis, the cumulative incidence of iIBC was 3.1% (95% CI: 2.6-3.5%) in patients treated by breast conserving surgery (BCS) plus radiotherapy (RT), 7.1% (95% CI: 5.5-9.1) in patients treated by BCS alone, and 1.6% (95% CI: 1.3-2.1) in patients treated by mastectomy. BCS was associated with a significantly higher risk for iIBC compared to BCS + RT during the first 5 years after treatment (HR 2.80, 95% CI: 1.91-4.10%). After 5 years of follow-up, the iIBC risk declined in the BCS alone group but remained higher than the iIBC risk in the BCS + RT group (HR 1.73, 95% CI: 1.15-2.61). CONCLUSIONS Although absolute risks of iIBC were low in patients treated for DCIS with either BCS or BCS + RT, risks remained higher in the BCS alone group compared to patients treated with BCS + RT for at least 10 years after DCIS diagnosis.
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MESH Headings
- Female
- Humans
- Breast Neoplasms/epidemiology
- Breast Neoplasms/therapy
- Breast Neoplasms/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Mastectomy/methods
- Mastectomy, Segmental/methods
- Incidence
- Neoplasm Recurrence, Local/surgery
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Ductal, Breast/etiology
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Affiliation(s)
- Sena Alaeikhanehshir
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands
- Department of Surgical Oncology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Renée S J M Schmitz
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands
| | - Alexandra W van den Belt-Dusebout
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | | - Maartje van Seijen
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066 CX, Netherlands.
- Department of Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands.
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6
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Hashiba KA, Mercaldo S, Venkatesh SL, Bahl M. Prediction of Surgical Upstaging Risk of Ductal Carcinoma In Situ Using Machine Learning Models. JOURNAL OF BREAST IMAGING 2023; 5:695-702. [PMID: 38046928 PMCID: PMC10689255 DOI: 10.1093/jbi/wbad071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Indexed: 12/05/2023]
Abstract
Objective The purpose of this study was to build machine learning models to predict surgical upstaging risk of ductal carcinoma in situ (DCIS) to invasive cancer and to compare model performance to eligibility criteria used by the Comparison of Operative versus Monitoring and Endocrine Therapy (COMET) active surveillance trial. Methods Medical records were retrospectively reviewed of all women with DCIS at core-needle biopsy who underwent surgery from 2007 to 2016 at an academic medical center. Multivariable regression and machine learning models were developed to evaluate upstaging-related features and their performance was compared with that achieved using the COMET trial eligibility criteria. Results Of 1387 women (mean age, 57 years; range, 27-89 years), the upstaging rate of DCIS was 17% (235/1387). On multivariable analysis, upstaging-associated features were presentation of DCIS as a palpable area of concern, imaging finding of a mass, and nuclear grades 2 or 3 at biopsy (P < 0.05). If COMET trial eligibility criteria were applied to our study cohort, then 496 women (42%, 496/1175) would have been eligible for the trial, with an upstaging rate of 12% (61/496). Of the machine learning models, none had a significantly lower upstaging rate than 12%. However, if using the models to determine eligibility, then a significantly larger proportion of women (56%-87%) would have been eligible for active surveillance. Conclusion Use of machine learning models to determine eligibility for the COMET trial identified a larger proportion of women eligible for surveillance compared with current eligibility criteria while maintaining similar upstaging rates.
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Affiliation(s)
| | - Sarah Mercaldo
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Sheila L Venkatesh
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Manisha Bahl
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
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7
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Schmitz RSJM, van den Belt-Dusebout AW, Clements K, Ren Y, Cresta C, Timbres J, Liu YH, Byng D, Lynch T, Menegaz BA, Collyar D, Hyslop T, Thomas S, Love JK, Schaapveld M, Bhattacharjee P, Ryser MD, Sawyer E, Hwang ES, Thompson A, Wesseling J, Lips EH, Schmidt MK. Association of DCIS size and margin status with risk of developing breast cancer post-treatment: multinational, pooled cohort study. BMJ 2023; 383:e076022. [PMID: 37903527 PMCID: PMC10614034 DOI: 10.1136/bmj-2023-076022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE To examine the association between size and margin status of ductal carcinoma in situ (DCIS) and risk of developing ipsilateral invasive breast cancer and ipsilateral DCIS after treatment, and stage and subtype of ipsilateral invasive breast cancer. DESIGN Multinational, pooled cohort study. SETTING Four large international cohorts. PARTICIPANTS Patient level data on 47 695 women with a diagnosis of pure, primary DCIS between 1999 and 2017 in the Netherlands, UK, and US who underwent surgery, either breast conserving or mastectomy, often followed by radiotherapy or endocrine treatment, or both. MAIN OUTCOME MEASURES The main outcomes were 10 year cumulative incidence of ipsilateral invasive breast cancer and ipsilateral DCIS estimated in relation to DCIS size and margin status, and adjusted hazard ratios and 95% confidence intervals, estimated using multivariable Cox proportional hazards analyses with multiple imputed data RESULTS: The 10 year cumulative incidence of ipsilateral invasive breast cancer was 3.2%. In women who underwent breast conserving surgery with or without radiotherapy, only adjusted risks for ipsilateral DCIS were significantly increased for larger DCIS (20-49 mm) compared with DCIS <20 mm (hazard ratio 1.38, 95% confidence interval 1.11 to 1.72). Risks for both ipsilateral invasive breast cancer and ipsilateral DCIS were significantly higher with involved compared with clear margins (invasive breast cancer 1.40, 1.07 to 1.83; DCIS 1.39, 1.04 to 1.87). Use of adjuvant endocrine treatment was not significantly associated with a lower risk of ipsilateral invasive breast cancer compared to treatment with breast conserving surgery only (0.86, 0.62 to 1.21). In women who received breast conserving treatment with or without radiotherapy, higher DCIS grade was not significantly associated with ipsilateral invasive breast cancer, only with a higher risk of ipsilateral DCIS (grade 1: 1.42, 1.08 to 1.87; grade 3: 2.17, 1.66 to 2.83). Higher age at diagnosis was associated with lower risk (per year) of ipsilateral DCIS (0.98, 0.97 to 0.99) but not ipsilateral invasive breast cancer (1.00, 0.99 to 1.00). Women with large DCIS (≥50 mm) more often developed stage III and IV ipsilateral invasive breast cancer compared to women with DCIS <20 mm. No such association was found between involved margins and higher stage of ipsilateral invasive breast cancer. Associations between larger DCIS and hormone receptor negative and human epidermal growth factor receptor 2 positive ipsilateral invasive breast cancer and involved margins and hormone receptor negative ipsilateral invasive breast cancer were found. CONCLUSIONS The association of DCIS size and margin status with ipsilateral invasive breast cancer and ipsilateral DCIS was small. When these two factors were added to other known risk factors in multivariable models, clinicopathological risk factors alone were found to be limited in discriminating between low and high risk DCIS.
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Affiliation(s)
- Renée S J M Schmitz
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | | | | | - Yi Ren
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Chiara Cresta
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Jasmine Timbres
- School of Cancer and Pharmaceutical Science, King's College London, London, UK
| | - Yat-Hee Liu
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Danalyn Byng
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Thomas Lynch
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
| | - Brian A Menegaz
- Department of Surgical Oncology, Baylor College of Medicine, Houston, TX, USA
| | | | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Jason K Love
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Schaapveld
- Division of Psycho-oncology and Epidemiology, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Proteeti Bhattacharjee
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Marc D Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
- Department of Mathematics, Duke University, Durham, NC, USA
| | - Elinor Sawyer
- School of Cancer and Pharmaceutical Science, King's College London, London, UK
| | - E Shelley Hwang
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
| | - Alastair Thompson
- Department of Surgical Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jelle Wesseling
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
- Division of Diagnostic Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Department of Pathology, Leiden University Medical Centre, Leiden, Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, Netherlands
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8
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Schmitz RSJM, Engelhardt EG, Gerritsma MA, Sondermeijer CMT, Verschuur E, Houtzager J, Griffioen R, Retèl V, Bijker N, Mann RM, van Duijnhoven F, Wesseling J, Bleiker EMA. Active surveillance versus treatment in low-risk DCIS: Women's preferences in the LORD-trial. Eur J Cancer 2023; 192:113276. [PMID: 37657228 PMCID: PMC10632767 DOI: 10.1016/j.ejca.2023.113276] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) can progress to invasive breast cancer (IBC), but most DCIS lesions remain indolent. However, guidelines recommend surgery, often supplemented by radiotherapy. This implies overtreatment of indolent DCIS. The non-randomised patient preference LORD-trial tests whether active surveillance (AS) for low-risk DCIS is safe, by giving women with low-risk DCIS a choice between AS and conventional treatment (CT). Here, we aim to describe how participants are distributed among both trial arms, identify their motives for their preference, and assess factors associated with their choice. METHODS Data were extracted from baseline questionnaires. Descriptive statistics were used to assess the distribution and characteristics of participants; thematic analyses to extract self-reported reasons for the choice of trial arm, and multivariable logistic regression analyses to investigate associations between patient characteristics and chosen trial arm. RESULTS Of 377 women included, 76% chose AS and 24% CT. Most frequently cited reasons for AS were "treatment is not (yet) necessary" (59%) and trust in the AS-plan (39%). Reasons for CT were cancer worry (51%) and perceived certainty (29%). Women opting for AS more often had lower educational levels (OR 0.45; 95% confidence interval [CI], 0.22-0.93) and more often reported experiencing shared decision making (OR 2.71; 95% CI, 1.37-5.37) than women choosing CT. CONCLUSION The LORD-trial is the first to offer women with low-risk DCIS a choice between CT and AS. Most women opted for AS and reported high levels of trust in the safety of AS. Their preferences highlight the necessity to establish the safety of AS for low-risk DCIS.
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Affiliation(s)
- Renée S J M Schmitz
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ellen G Engelhardt
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Miranda A Gerritsma
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Ellen Verschuur
- Dutch Breast Cancer Society ('Borstkanker Vereniging Nederland'), Utrecht, the Netherlands
| | - Julia Houtzager
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Rosalie Griffioen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Valesca Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nina Bijker
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ritse M Mann
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Radiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frederieke van Duijnhoven
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, Netherlands.
| | - Eveline M A Bleiker
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Clinical Genetics, Leiden University Medical Center, Leiden, Netherlands.
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9
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Poelhekken K, Lin Y, Greuter MJW, van der Vegt B, Dorrius M, de Bock GH. The natural history of ductal carcinoma in situ (DCIS) in simulation models: A systematic review. Breast 2023; 71:74-81. [PMID: 37541171 PMCID: PMC10412870 DOI: 10.1016/j.breast.2023.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVE Assumptions on the natural history of ductal carcinoma in situ (DCIS) are necessary to accurately model it and estimate overdiagnosis. To improve current estimates of overdiagnosis (0-91%), the purpose of this review was to identify and analyse assumptions made in modelling studies on the natural history of DCIS in women. METHODS A systematic review of English full-text articles using PubMed, Embase, and Web of Science was conducted up to February 6, 2023. Eligibility and all assessments were done independently by two reviewers. Risk of bias and quality assessments were performed. Discrepancies were resolved by consensus. Reader agreement was quantified with Cohen's kappa. Data extraction was performed with three forms on study characteristics, model assessment, and tumour progression. RESULTS Thirty models were distinguished. The most important assumptions regarding the natural history of DCIS were addition of non-progressive DCIS of 20-100%, classification of DCIS into three grades, where high grade DCIS had an increased chance of progression to invasive breast cancer (IBC), and regression possibilities of 1-4%, depending on age and grade. Other identified risk factors of progression of DCIS to IBC were younger age, birth cohort, larger tumour size, and individual risk. CONCLUSION To accurately model the natural history of DCIS, aspects to consider are DCIS grades, non-progressive DCIS (9-80%), regression from DCIS to no cancer (below 10%), and use of well-established risk factors for progression probabilities (age). Improved knowledge on key factors to consider when studying DCIS can improve estimates of overdiagnosis and optimization of screening.
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Affiliation(s)
- Keris Poelhekken
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands.
| | - Yixuan Lin
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands
| | - Marcel J W Greuter
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands
| | - Bert van der Vegt
- University of Groningen, University Medical Center Groningen, Groningen, Department of Pathology and Medical Biology, PO Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Monique Dorrius
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands
| | - Geertruida H de Bock
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands
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10
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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. JOURNAL OF BREAST IMAGING 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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11
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Ma T, Semsarian CR, Barratt A, Parker L, Pathmanathan N, Nickel B, Bell KJL. Should low-risk DCIS lose the cancer label? An evidence review. Breast Cancer Res Treat 2023; 199:415-433. [PMID: 37074481 PMCID: PMC10175360 DOI: 10.1007/s10549-023-06934-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/30/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Population mammographic screening for breast cancer has led to large increases in the diagnosis and treatment of ductal carcinoma in situ (DCIS). Active surveillance has been proposed as a management strategy for low-risk DCIS to mitigate against potential overdiagnosis and overtreatment. However, clinicians and patients remain reluctant to choose active surveillance, even within a trial setting. Re-calibration of the diagnostic threshold for low-risk DCIS and/or use of a label that does not include the word 'cancer' might encourage the uptake of active surveillance and other conservative treatment options. We aimed to identify and collate relevant epidemiological evidence to inform further discussion on these ideas. METHODS We searched PubMed and EMBASE databases for low-risk DCIS studies in four categories: (1) natural history; (2) subclinical cancer found at autopsy; (3) diagnostic reproducibility (two or more pathologist interpretations at a single time point); and (4) diagnostic drift (two or more pathologist interpretations at different time points). Where we identified a pre-existing systematic review, the search was restricted to studies published after the inclusion period of the review. Two authors screened records, extracted data, and performed risk of bias assessment. We undertook a narrative synthesis of the included evidence within each category. RESULTS Natural History (n = 11): one systematic review and nine primary studies were included, but only five provided evidence on the prognosis of women with low-risk DCIS. These studies reported that women with low-risk DCIS had comparable outcomes whether or not they had surgery. The risk of invasive breast cancer in patients with low-risk DCIS ranged from 6.5% (7.5 years) to 10.8% (10 years). The risk of dying from breast cancer in patients with low-risk DCIS ranged from 1.2 to 2.2% (10 years). Subclinical cancer at autopsy (n = 1): one systematic review of 13 studies estimated the mean prevalence of subclinical in situ breast cancer to be 8.9%. Diagnostic reproducibility (n = 13): two systematic reviews and 11 primary studies found at most moderate agreement in differentiating low-grade DCIS from other diagnoses. Diagnostic drift: no studies found. CONCLUSION Epidemiological evidence supports consideration of relabelling and/or recalibrating diagnostic thresholds for low-risk DCIS. Such diagnostic changes would need agreement on the definition of low-risk DCIS and improved diagnostic reproducibility.
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Affiliation(s)
- Tara Ma
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Caitlin R Semsarian
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Alexandra Barratt
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
- Wiser Healthcare, Sydney, Australia
| | - Lisa Parker
- Sydney School of Pharmacy, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Radiation Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Nirmala Pathmanathan
- Western Sydney Local Health District, Sydney, Australia
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Australia
| | - Brooke Nickel
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Katy J L Bell
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia.
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12
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Co M, Cheng KCK, Yeung YH, Lau KC, Qian Z, Wong CM, Wong BY, Sin ELK, Wong HYS, Ma CH. Clinical Outcomes of Conservative Treatment for Low-Risk Ductal Carcinoma in Situ: A Systematic Review and Pooled Analysis. Clin Oncol (R Coll Radiol) 2023; 35:255-261. [PMID: 36764879 DOI: 10.1016/j.clon.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/05/2022] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
AIMS The current gold standard of treatment for ductal carcinoma in situ (DCIS) is surgical resection with or without adjuvant radiotherapy. However, the increased detection and radical treatment of DCIS did not result in a declined incidence of invasive breast cancers, leading to the debate if DCIS has been overtreated. While ongoing randomised controlled trials on active surveillance of DCIS are still in progress, this systematic review aims to evaluate the best evidence on conservative treatment for DCIS from the literature. MATERIALS AND METHODS This systematic review was conducted in line with the PRISMA statement. We included all relevant studies published up to June 2022 for analysis. The primary outcomes were overall survival and breast cancer-specific survival (BCSS) of conservative treatment for DCIS. RESULTS Three studies, with a total of 34 007 women with low-risk DCIS, were included in the analysis. Active and conservative treatments both resulted in excellent 10-year BCSS, with no statistically insignificant difference (98.6% versus 96.0%, 31 478 women). One study comparing 5-year BCSS of active and conservative treatments only in subjects aged over 80 years also reported [AQ1]an insignificant difference (98.2% versus 96.0%, 2529 women). One study measuring 5- and 10-year overall survival between the treatment groups also reported [AQ1]an insignificant difference (5-year: 96.2% versus 92.4%; 10-year: 85.6% versus 86.7%, 31 106 women). CONCLUSION BCSS between active and conservative treatment for women with low-risk DCIS is both excellent and comparable, suggesting that conservative treatment is a possible alternative without compromising survival.
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Affiliation(s)
- M Co
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong; Division of Breast Surgery, Queen Mary Hospital, Hong Kong.
| | - K C K Cheng
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - Y H Yeung
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - K C Lau
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - Z Qian
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - C M Wong
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - B Y Wong
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - E L K Sin
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - H Y S Wong
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
| | - C H Ma
- Center for Education and Training, Department of Surgery, University of Hong Kong, Hong Kong
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13
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De-escalation in DCIS Care. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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14
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Chen DW, Rob FI, Mukherjee R, Giordano TJ, Haymart MR, Banerjee M. Variation in the Diagnosis of Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features. J Clin Endocrinol Metab 2022; 107:e4072-e4077. [PMID: 35918064 PMCID: PMC9516041 DOI: 10.1210/clinem/dgac466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Noninvasive encapsulated follicular variant of papillary thyroid cancer was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in January 2017. The impact of this nomenclature change at a population level remains unknown. OBJECTIVE Examine use of NIFTP across different US regions and populations. DESIGN Descriptive epidemiology study using SEER-22 data (2000-2019). PARTICIPANTS Individuals diagnosed with papillary or follicular thyroid cancer (2000-2019) or NIFTP (2017-2019). MAIN OUTCOME MEASURES Annual incidence rates of thyroid cancer by subtype and NIFTP. Using 2018-2019 data, (1) rates of NIFTP at the 17 SEER-22 sites and (2) comparison of demographics for patients diagnosed with NIFTP vs papillary and follicular thyroid cancer. RESULTS NIFTP comprised 2.2% and 2.6% of cases in 2018 and 2019, respectively. Between 2018 and 2019, large heterogeneity was observed in the regional use of NIFTP diagnosis, with site-specific incidence rates between 0.0% and 6.2% (median 2.8%, interquartile range 1.3-3.6%). A diagnosis of NIFTP (vs papillary and follicular thyroid cancer) in 2018 and 2019 was significantly associated with older age (P = 0.012 and P = 0.009, respectively), Black race (both Ps < 0.001), and non-Hispanic ethnicity (both Ps < 0.001). CONCLUSIONS Marked variation exists in the use of the NIFTP diagnosis. The recent 2021 coding change that resulted in NIFTP, a tumor with uncertain malignant potential and for which there is no long-term outcome data available, no longer being a reportable diagnosis to SEER will disproportionately affect vulnerable patient groups such as older patients and Black patients, in addition to patients who reside in regions with higher rates of NIFTP diagnoses.
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Affiliation(s)
- Debbie W Chen
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Farizah I Rob
- University of Michigan College of Literature, Science and the Arts, Ann Arbor, MI, USA
| | - Rik Mukherjee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Thomas J Giordano
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
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15
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Schmitz RSJM, Wilthagen EA, van Duijnhoven F, van Oirsouw M, Verschuur E, Lynch T, Punglia RS, Hwang ES, Wesseling J, Schmidt MK, Bleiker EMA, Engelhardt EG, PRECISION Consortium GC. Prediction Models and Decision Aids for Women with Ductal Carcinoma In Situ: A Systematic Literature Review. Cancers (Basel) 2022; 14:cancers14133259. [PMID: 35805030 PMCID: PMC9265509 DOI: 10.3390/cancers14133259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Ductal carcinoma in situ (DCIS) is a potential precursor to invasive breast cancer (IBC). Although in many women DCIS will never become breast cancer, almost all women diagnosed with DCIS undergo surgery with/without radiotherapy. Several studies are ongoing to de-escalate treatment for DCIS. Multiple decision support tools have been developed to aid women with DCIS in selecting the best treatment option for their specific goals. The aim of this study was to identify these decision support tools and evaluate their quality and clinical utility. Thirty-three studies were reviewed, in which four decision aids and six prediction models were described. While some of these models might be promising, most lacked important qualities such as tools to help women discuss their options or good quality validation studies. Therefore, the need for good quality, well validated decision support tools remains unmet. Abstract Even though Ductal Carcinoma in Situ (DCIS) can potentially be an invasive breast cancer (IBC) precursor, most DCIS lesions never will progress to IBC if left untreated. Because we cannot predict yet which DCIS lesions will and which will not progress, almost all women with DCIS are treated by breast-conserving surgery +/− radiotherapy, or even mastectomy. As a consequence, many women with non-progressive DCIS carry the burden of intensive treatment without any benefit. Multiple decision support tools have been developed to optimize DCIS management, aiming to find the balance between over- and undertreatment. In this systematic review, we evaluated the quality and added value of such tools. A systematic literature search was performed in Medline(ovid), Embase(ovid), Scopus and TRIP. Following the PRISMA guidelines, publications were selected. The CHARMS (prediction models) or IPDAS (decision aids) checklist were used to evaluate the tools’ methodological quality. Thirty-three publications describing four decision aids and six prediction models were included. The decision aids met at least 50% of the IPDAS criteria. However, most lacked tools to facilitate discussion of the information with healthcare providers. Five prediction models quantify the risk of an ipsilateral breast event after a primary DCIS, one estimates the risk of contralateral breast cancer, and none included active surveillance. Good quality and external validations were lacking for all prediction models. There remains an unmet clinical need for well-validated, good-quality DCIS risk prediction models and decision aids in which active surveillance is included as a management option for low-risk DCIS.
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Affiliation(s)
- Renée S. J. M. Schmitz
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
| | - Erica A. Wilthagen
- Department of Scientific Information Service, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | | | - Marja van Oirsouw
- Borstkanker Vereniging Nederland, 3511 DT Utrecht, The Netherlands; (M.v.O.); (E.V.)
| | - Ellen Verschuur
- Borstkanker Vereniging Nederland, 3511 DT Utrecht, The Netherlands; (M.v.O.); (E.V.)
| | - Thomas Lynch
- Division of Surgical Oncology, Duke University, Durham, NC 27708, USA; (T.L.); (E.S.H.)
| | - Rinaa S. Punglia
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - E. Shelley Hwang
- Division of Surgical Oncology, Duke University, Durham, NC 27708, USA; (T.L.); (E.S.H.)
| | - Jelle Wesseling
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Pathology, Nethelands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Marjanka K. Schmidt
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
| | - Eveline M. A. Bleiker
- Department of Psycho-Oncology and Epidemiology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
- Correspondence:
| | - Ellen G. Engelhardt
- Department of Psycho-Oncology and Epidemiology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
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16
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Treatment Patterns in Women Age 80 and Over with DCIS: A Report from the National Cancer Database. Clin Breast Cancer 2022; 22:547-552. [DOI: 10.1016/j.clbc.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022]
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17
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A web-based personalized decision support tool for patients diagnosed with ductal carcinoma in situ: development, content evaluation, and usability testing. Breast Cancer Res Treat 2022; 192:517-527. [PMID: 35107714 DOI: 10.1007/s10549-022-06512-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/31/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Patients diagnosed with ductal carcinoma in situ (DCIS) face trade-offs when deciding among different treatments, including surgery, radiation, and endocrine therapy. A less chosen option is active monitoring. While evidence from clinical trials is not yet available, observational studies show comparable results for active monitoring and immediate treatment on cancer outcomes in select subgroups of patients. We developed and tested a web-based decision support tool (DST) to help patients explore current knowledge about DCIS and make an informed choice. METHODS The DST, an interactive web application, was informed by literature reviews and formative work with patients, breast surgeons, and health communication experts. We conducted iterative interviews to evaluate the DST content among women with and without a history of breast cancer, as well as breast cancer experts. For usability testing, we conducted an online survey among women with and without a history of breast cancer. RESULTS For content evaluation, 5 women with and 10 women without a history of DCIS were interviewed. The sample included 11 White and 4 non-White women, with a mean age of 64 years. The expert sample consisted of 5 attendings and a physician assistant. The feedback was used to add, clarify, or reorganize information in the DST. For usability testing, 22 participants with a mean age of 61 years were recruited including 15 White and 7 Black women and 6 women with a history of DCIS. The mean usability score was 3.7 out of 5. Most participants (86%) found that the DST provided unbiased information about treatments. To improve usability, we reduced the per-page content and added navigation cues. CONCLUSION Content and usability evaluation showed that the DST helps patients explore trade-offs of active monitoring and immediate treatment. By adopting a personalized approach, the tool will enable informed decisions aligned with patients' values and expectations.
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Grimm LJ, Rahbar H, Abdelmalak M, Hall AH, Ryser MD. Ductal Carcinoma in Situ: State-of-the-Art Review. Radiology 2021; 302:246-255. [PMID: 34931856 PMCID: PMC8805655 DOI: 10.1148/radiol.211839] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ductal carcinoma in situ (DCIS) is a nonobligate precursor of invasive cancer, and its detection, diagnosis, and management are controversial. DCIS incidence grew with the expansion of screening mammography programs in the 1980s and 1990s, and DCIS is viewed as a major driver of overdiagnosis and overtreatment. For pathologists, the diagnosis and classification of DCIS is challenging due to undersampling and interobserver variability. Understanding the progression from normal breast tissue to DCIS and, ultimately, to invasive cancer is limited by a paucity of natural history data with multiple proposed evolutionary models of DCIS initiation and progression. Although radiologists are familiar with the classic presentation of DCIS as asymptomatic calcifications at mammography, the expanded pool of modalities, advanced imaging techniques, and image analytics have identified multiple potential biomarkers of histopathologic characteristics and prognosis. Finally, there is growing interest in the nonsurgical management of DCIS, including active surveillance, to reduce overtreatment and provide patients with more personalized management options. However, current biomarkers are not adept at enabling identification of occult invasive disease at biopsy or accurately predicting the risk of progression to invasive disease. Several active surveillance trials are ongoing and are expected to better identify women with low-risk DCIS who may avoid surgery.
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Affiliation(s)
- Lars J. Grimm
- From the Departments of Radiology (L.J.G.), Pathology (M.A., A.H.H.), and Population Health Sciences (M.D.R.), Duke University, 2301 Erwin Rd, Box 3808, Durham, NC 27710; and Department of Radiology, University of Washington, Seattle, Wash (H.R.)
| | - Habib Rahbar
- From the Departments of Radiology (L.J.G.), Pathology (M.A., A.H.H.), and Population Health Sciences (M.D.R.), Duke University, 2301 Erwin Rd, Box 3808, Durham, NC 27710; and Department of Radiology, University of Washington, Seattle, Wash (H.R.)
| | - Monica Abdelmalak
- From the Departments of Radiology (L.J.G.), Pathology (M.A., A.H.H.), and Population Health Sciences (M.D.R.), Duke University, 2301 Erwin Rd, Box 3808, Durham, NC 27710; and Department of Radiology, University of Washington, Seattle, Wash (H.R.)
| | - Allison H. Hall
- From the Departments of Radiology (L.J.G.), Pathology (M.A., A.H.H.), and Population Health Sciences (M.D.R.), Duke University, 2301 Erwin Rd, Box 3808, Durham, NC 27710; and Department of Radiology, University of Washington, Seattle, Wash (H.R.)
| | - Marc D. Ryser
- From the Departments of Radiology (L.J.G.), Pathology (M.A., A.H.H.), and Population Health Sciences (M.D.R.), Duke University, 2301 Erwin Rd, Box 3808, Durham, NC 27710; and Department of Radiology, University of Washington, Seattle, Wash (H.R.)
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19
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De-escalating treatment for ductal carcinoma in situ - Has the pendulum swung too far? (Invited Opinion). Cancer Treat Res Commun 2021; 28:100438. [PMID: 34298429 DOI: 10.1016/j.ctarc.2021.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022]
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20
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Lee SE, Kim HY, Yoon JH, Kim EK, Kim JY, Kim MJ, Kim GR, Park YV, Moon HJ. Chronological Trends of Breast Ductal Carcinoma In Situ: Clinical, Radiologic, and Pathologic Perspectives. Ann Surg Oncol 2021; 28:8699-8709. [PMID: 34196861 DOI: 10.1245/s10434-021-10378-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Because no prior studies have evaluated the chronological trends of ductal carcinoma in situ (DCIS) despite the increasing number of surgeries performed for DCIS, this study analyzed how the clinical, radiologic, and pathologic characteristics of DCIS changed during a 10-year period. METHODS Of 7123 patients who underwent primary breast cancer surgery at a single institution from 2006 to 2015, 792 patients with pure DCIS were included in this study. The chronological trends of age, symptoms, method for detecting either mammography or ultrasonography, tumor size, nuclear grade, comedonecrosis, and molecular markers were calculated using Poisson regression for all patients and asymptomatic patients. RESULTS During 10 years, DCIS surgery rates significantly increased (p < 0.001). Despite the high percentage of DCIS detected on mammography, the detection rate for DCIS by mammography significantly decreased (97.3% in 2006 to 67.6% in 2015; p = 0.025), whereas the detection rate by ultrasound significantly increased (2.7% to 31.0%; p < 0.001). Conservation surgery rates (odds ratio [OR], 1.058), low-to-intermediate nuclear grade rates (OR, 1.069), and the absence of comedonecrosis (OR, 1.104) significantly increased over time (all p < 0.05). Estrogen receptor (ER) negativity (OR, 0.935) and human epidermal growth factor receptor 2 (HER2) positivity rates (OR, 0.953) significantly decreased (all p < 0.05). The same trends were observed for the 613 asymptomatic patients. CONCLUSION The rate of DCIS detected on ultrasound only significantly increased during 10 years. Low-to-intermediate nuclear grade rates significantly increased, whereas ER negativity and HER2 positivity rates significantly decreased during the same period. These findings suggest that DCIS detected on screening ultrasound is less aggressive than DCIS detected on mammography.
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Affiliation(s)
- Si Eun Lee
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jee Ye Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ga Ram Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youngjean Vivian Park
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.
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21
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Jiwa N, Takats Z, Leff DR, Sutton C. Breast health screening: a UK-wide questionnaire. BMJ Nutr Prev Health 2021; 4:206-212. [PMID: 34308128 PMCID: PMC8258049 DOI: 10.1136/bmjnph-2021-000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Currently, there is an unmet clinical need in identifying and screening women at high risk of breast cancer, where tumours are often aggressive and treatment intervention is too late to prevent metastasis, recurrence and mortality. This has been brought into sharp focus by the SARS-CoV-2 global pandemic, constantly changing hospital policies and surgical guidelines in reducing access to established screening and treatment regimens. Nipple aspirate fluid (NAF), is thought to provide a unique window into the biological processes occurring within the breast, particularly in the context of a developing neoplasm. Evaluation of NAF in asymptomatic women, for novel chemical biomarkers of either early disease and/or cancer risk offers tremendous promise as a tool to facilitate early detection and to supplement screening. However, it is acceptability as a method of collection and screening by women is critical and yet unknown. A breast health questionnaire was disseminated to women through breast cancer charities, patient support groups and social media platforms, with the aim of collecting opinions on the acceptability of use of NAF as a potential screening tool. Method Following ethical approval a questionnaire was prepared using online surveys consisting of four parts: (a) introduction on breast health screening in the UK, (b) core demographic data, (c) questions regarding screening and the acceptability of using NAF and (d) opinions about the process of collecting and using nipple fluid for screening. The voluntary and anonymous questionnaire was disseminated through social media, professional networks, charity websites and by individuals between October 2019 and December 2020. Survey responses were collected electronically, and the data analysed using online surveys statistical tools. Results A total of 3178 women completed the questionnaire (65.9% Caucasian, 27.7% Asian/British Asian, 0.6% black and 5.0% other). Of these, 2650 women (83.4%) had no prior knowledge of NAF and 89.4% were unaware that NAF can be expressed in up to 90% of all women. Concerning their risk of breast cancer, 89.8% of women were keen to know their future risk of breast cancer, 8.5% were unsure whether they wanted to know their risk and a further, 1.6% did not want to know. Regarding screening, 944 women (29.8%) were unaware of the lack of routine National Health Service Breast Screening for those under the age of 47 years. Furthermore, 53.0% of women were unaware that mammographic screening is affected by breast density. In terms of the acceptability of home testing for breast health, 92.0% were keen to undergo a home test. Both 79.7% and 70.9% stated they would consider hand massage and a breast pump to acquire nipple fluid samples, respectively. A further 48.6% of women would consider the use of a hormonal nasal spray for the same purpose. However, with regards to acquiring results from NAF testing, 42.6% of women would prefer to receive results at home and 34.2% in a medical facility. Finally, 91.6% of women believed that breast health should be incorporated as part of school education curriculum. Conclusion Public awareness regarding breast screening protocols and limitations of mammography could be improved. Many women were unaware that NAF might be a useful biofluid for future risk prediction, and yet the concept of self-testing of nipple fluid, with either hand massage or a breast pump was well received. Efforts should be made to increase awareness of the benefits of alternative and supplementary tests, especially in the context of high-risk individuals and younger patients.
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Affiliation(s)
- Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Christopher Sutton
- Department of Chemistry and Biosciences, University of Bradford, Bradford, UK
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22
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DUCHESS: an evaluation of the ductal carcinoma in situ score for decisions on radiotherapy in patients with low/intermediate-risk DCIS. Breast Cancer Res Treat 2021; 188:133-139. [PMID: 33830392 DOI: 10.1007/s10549-021-06187-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Identification of women with DCIS who have a very low risk of local recurrence risk (LRR) after breast-conserving surgery (BCS) is needed to de-escalate therapy. We evaluated the impact of 10-year LRR estimates after BCS, calculated by the integration of a 12-gene molecular expression assay (Oncotype Breast DCIS Score®) and clinicopathological features (CPFs), on its ability to change radiation oncologists' recommendations for RT after BCS for DCIS. METHODS Prospective cohort study of women with DCIS treated with BCS. Eligibility criteria were as follows: age > 45 years, tumor ≤ 2.5 cm, and margins ≥ 1 mm. Radiation oncologists provided 10-year LRR estimates without RT and recommendation for RT pre- and post-assay. Primary outcome was change in RT recommendation. RESULTS 217 patients were evaluable, with mean age = 63 years, mean tumor size = 1.1 cm, and mean DCIS Score = 32; 140 (64%) were in the low-risk (<39), 32 (15%) were in the intermediate-risk (39-54), and 45 (21%) were in the high-risk groups (≥55). The assay led to a change in treatment recommendation in 76 (35.2%) (95%CI 29.1-41.8%) patients. RT recommendations decreased from 79% pre-assay to 50% post-assay (difference = 29%; 95%CI 22-35%) due to a significant increase in the proportion of patients with a predicted low LRR (< 10%) post-assay and recommendations to omit RT for those with a low predicted risk. The assay was associated with improved patient satisfaction and reduced decisional conflict. CONCLUSION The DCIS Score assay combined with CPFs identified more women with an estimated low (<10%) 10-yr LR risk after BCS, leading to a significant decrease in recommendations for RT compared to estimates based on CPFs alone.
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23
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Heller SL, Plaunova A, Gao Y. Ductal Carcinoma In Situ and Progression to Invasive Cancer: A Review of the Evidence. JOURNAL OF BREAST IMAGING 2021; 3:135-143. [PMID: 38424826 DOI: 10.1093/jbi/wbaa119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Indexed: 03/02/2024]
Abstract
Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.
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Affiliation(s)
- Samantha L Heller
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
| | | | - Yiming Gao
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
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24
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Curtius K, Dewanji A, Hazelton WD, Rubenstein JH, Luebeck GE. Optimal Timing for Cancer Screening and Adaptive Surveillance Using Mathematical Modeling. Cancer Res 2020; 81:1123-1134. [PMID: 33293425 DOI: 10.1158/0008-5472.can-20-0335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 09/08/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023]
Abstract
Cancer screening and early detection efforts have been partially successful in reducing incidence and mortality, but many improvements are needed. Although current medical practice is informed by epidemiologic studies and experts, the decisions for guidelines are ultimately ad hoc. We propose here that quantitative optimization of protocols can potentially increase screening success and reduce overdiagnosis. Mathematical modeling of the stochastic process of cancer evolution can be used to derive and optimize the timing of clinical screens so that the probability is maximal that a patient is screened within a certain "window of opportunity" for intervention when early cancer development may be observable. Alternative to a strictly empirical approach or microsimulations of a multitude of possible scenarios, biologically based mechanistic modeling can be used for predicting when best to screen and begin adaptive surveillance. We introduce a methodology for optimizing screening, assessing potential risks, and quantifying associated costs to healthcare using multiscale models. As a case study in Barrett's esophagus, these methods were applied for a model of esophageal adenocarcinoma that was previously calibrated to U.S. cancer registry data. Optimal screening ages for patients with symptomatic gastroesophageal reflux disease were older (58 for men and 64 for women) than what is currently recommended (age > 50 years). These ages are in a cost-effective range to start screening and were independently validated by data used in current guidelines. Collectively, our framework captures critical aspects of cancer evolution within patients with Barrett's esophagus for a more personalized screening design. SIGNIFICANCE: This study demonstrates how mathematical modeling of cancer evolution can be used to optimize screening regimes, with the added potential to improve surveillance regimes. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/81/4/1123/F1.large.jpg.
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Affiliation(s)
- Kit Curtius
- Centre for Genomics and Computational Biology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom. .,Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, San Diego, California
| | - Anup Dewanji
- Applied Statistics Unit, Indian Statistical Institute, Kolkata, India
| | - William D Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joel H Rubenstein
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan.,Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Georg E Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
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25
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Genco IS, Ozgultekin B, Hosseini H, Hackman K, Ferreira L, Santagada E, Wahl S, Hajiyeva S. High EZH2 expression in ductal carcinoma in situ diagnosed on breast core needle biopsy is an independent predictive factor for upgrade on surgical excision. Pathol Res Pract 2020; 216:153283. [PMID: 33197837 DOI: 10.1016/j.prp.2020.153283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Approximately 25 % of DCIS diagnosed on breast core needle biopsy (CNB) is upgraded to invasive carcinoma on surgical excision. Risk factors to predict the upgrade on excision are not well established, leading many patients to be over or under-treated. EZH2 was shown to be associated with aggressive behavior of cancer from many sites, including breast cancer. We aimed to analyze EZH2 expression and tumor infiltrating lymphocytes (TILs) in DCIS as predictive factors for an upgrade on excision. METHODS We assessed EZH2 expression in 34 DCIS cases diagnosed on CNB and upgraded to invasive carcinoma on excision. Then, we compared these cases with 60 control cases that were not upgraded on excision. A staining score for DCIS (0-12) was obtained by multiplying the staining intensity (0-3) and the percentage of positive cells (1-4). The nuclear staining score ≥6 was considered as 'high' expression. RESULTS 46 of 94 (49 %) DCIS on CNB showed high EZH2 expression. EZH2 expression was directly correlated with TILs density, nuclear grade, HER2 expression, Ki-67 index and negative ER status. On univariate analysis, upgrade on excision was associated with high EZH2 expression, high TILs density, negative ER status and high Ki-67 index. Multivariate analysis revealed the high EZH2 expression as the only independent predictive factor for upgrade on excision. CONCLUSIONS Our study revealed the high EZH2 expression as the only independent predictive factor for an upgrade on excision. Future studies should focus on the evaluation of EZH2 expression in tumor-microenvironment interaction in terms of diagnostic, treatment and prognostic purposes.
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Affiliation(s)
- Iskender Sinan Genco
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States.
| | | | - Hossein Hosseini
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Kayla Hackman
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Lisa Ferreira
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Eugene Santagada
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Samuel Wahl
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Sabina Hajiyeva
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States.
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26
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Akushevich I, Yashkin AP, Greenup RA, Hwang ES. A medicare-based comparative mortality analysis of active surveillance in older women with DCIS. NPJ Breast Cancer 2020; 6:57. [PMID: 33145400 PMCID: PMC7599206 DOI: 10.1038/s41523-020-00199-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 09/17/2020] [Indexed: 12/22/2022] Open
Abstract
Over 97% of individuals diagnosed with ductal carcinoma in situ (DCIS) will choose to receive guideline concordant care (GCC), which was originally designed to treat invasive cancers and is associated with treatment related morbidity. An alternative to GCC is active surveillance (AS) where therapy is delayed until medically necessary. Differences in mortality risk between the two approaches in women age 65+ are analyzed in this study. SEER and Medicare information on treatment during the first year after diagnosis was used to identify three cohorts based on treatment type and timing: GCC (N = 21,772; immediate consent for treatment), AS1 (N = 431; delayed treatment within 365 days), and AS2 (N = 205; no treatment/ongoing AS). A propensity score-based approach provided pseudorandomization between GCC and AS groups and survival was then compared. Strong influence of comorbidities on the treatment received was observed for all age-groups, with the greatest burden observed in the AS2 group. All-cause and breast-cancer-specific mortality hazard ratios (HR) for AS1 were not statistically different from the GCC group; AS2 was associated with notably higher risk for both all-cause (HR:3.54; CI:3.29, 3.82) and breast-cancer-specific (HR:10.73; CI:8.63,13.35) mortality. Cumulative mortality was substantially higher from other causes than from breast cancer, regardless of treatment group. Women managed with AS for DCIS had higher all-cause and breast-cancer-specific mortality. This effect declined after accounting for baseline comorbidities. Delays of up to 12 months in initiation of GCC did not underperform immediate surgery.
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Affiliation(s)
- Igor Akushevich
- Biodemography of Aging Research Unit, Social Science Research Institute, Durham, NC USA
| | - Arseniy P. Yashkin
- Biodemography of Aging Research Unit, Social Science Research Institute, Durham, NC USA
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27
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Weedon-Fekjær H, Li X, Lee S. Estimating the natural progression of non-invasive ductal carcinoma in situ breast cancer lesions using screening data. J Med Screen 2020; 28:302-310. [PMID: 32854582 DOI: 10.1177/0969141320945736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In addition to invasive breast cancer, mammography screening often detects preinvasive ductal carcinoma in situ (DCIS) lesions. The natural progression of DCIS is largely unknown, leading to uncertainty regarding treatment. The natural history of invasive breast cancer has been studied using screening data. DCIS modeling is more complicated because lesions might progress to clinical DCIS, preclinical invasive cancer, or may also regress to a state undetectable by screening. We have here developed a Markov model for DCIS progression, building on the established invasive breast cancer model. METHODS We present formulas for the probability of DCIS detection by time since last screening under a Markov model of DCIS progression. Progression rates were estimated by maximum likelihood estimation using BreastScreen Norway data from 1995-2002 for 336,533 women (including 399 DCIS cases) aged 50-69. As DCIS incidence varies by age, county, and mammography modality (digital vs. analog film), a Poisson regression approach was used to align the input data. RESULTS Estimated mean sojourn time in preclinical, screening-detectable DCIS phase was 3.1 years (95% confidence interval: 1.3, 7.6) with a screening sensitivity of 60% (95% confidence interval: 32%, 93%). No DCIS was estimated to be non-progressive. CONCLUSION Most preclinical DCIS lesions progress or regress with a moderate sojourn time in the screening-detectable phase. While DCIS mean sojourn time could be deduced from DCIS data, any estimate of preclinical DCIS progressing to invasive breast cancer must include data on invasive cancers to avoid strong, probably unrealistic, assumptions.
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Affiliation(s)
- Harald Weedon-Fekjær
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Xiaoxue Li
- Department of Data Sciences, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts, USA
| | - Sandra Lee
- Department of Data Sciences, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
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28
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Long-term Survival Outcomes of 'Low Risk' Ductal Carcinoma in situ from a Territory-wide Cancer Registry. Clin Oncol (R Coll Radiol) 2020; 33:40-45. [PMID: 32713775 DOI: 10.1016/j.clon.2020.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/13/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Abstract
AIMS The LORIS trial is an ongoing phase III clinical trial on low risk ductal carcinoma in situ (DCIS). DCIS patients aged ≥46 years with screen-detected low/intermediate nuclear grade were considered low risk and were randomised into surveillance or standard surgery. Here we review the 10-year territory-wide breast cancer registry database and evaluate the clinical outcomes of low versus high risk DCIS patients. MATERIALS AND METHODS This was a retrospective study of a prospectively maintained territory-wide breast cancer registry in Hong Kong. RESULTS Between 1997 and 2006, 1391 DCIS patients were identified from the Hong Kong cancer registry breast cancer database. The mean age at diagnosis was 49.2 years (range 30-70). In total, 372 patients were classified as 'low risk', whereas the remaining 777 patients were classified as 'high risk'. After a median follow-up of 11.6 years, the 10-year overall breast cancer-specific survival of the entire DCIS cohort was 1136/1149 (98.9%). Overall breast cancer-specific survival of low risk DCIS was 99.5%, whereas that in high risk DCIS was 98.6% (Log-rank test, P = 0.208). Forty-six (12.4%) patients in the LORIS low risk group did not receive surgery, whereas 93 (12%) patients in the LORIS high risk group did not receive surgery. The 10-year breast cancer-specific survival in the non-operated low risk DCIS group was 97.8%; that in the non-operated high risk DCIS group was 96.7% (P = 1). CONCLUSION Long-term survival of DCIS was excellent, especially in low risk DCIS, regardless of surgical treatment.
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29
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Ryser MD, Weaver DL, Zhao F, Worni M, Grimm LJ, Gulati R, Etzioni R, Hyslop T, Lee SJ, Hwang ES. Cancer Outcomes in DCIS Patients Without Locoregional Treatment. J Natl Cancer Inst 2020; 111:952-960. [PMID: 30759222 PMCID: PMC6748726 DOI: 10.1093/jnci/djy220] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/26/2018] [Accepted: 11/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The vast majority of women diagnosed with ductal carcinoma in situ (DCIS) undergo treatment. Therefore, the risks of invasive progression and competing death in the absence of locoregional therapy are uncertain. METHODS We performed survival analyses of patient-level data from DCIS patients who did not receive definitive surgery or radiation therapy as recorded in the US National Cancer Institute's Surveillance, Epidemiology, and End Results program (1992-2014). Kaplan-Meier curves were used to estimate the net risk of subsequent ipsilateral invasive cancer. The cumulative incidences of ipsilateral invasive cancer, contralateral breast cancer, and death were estimated using competing risk methods. RESULTS A total of 1286 DCIS patients who did not undergo locoregional therapy were identified. Median age at diagnosis was 60 years (inter-quartile range = 51-74 years), with median follow-up of 5.5 years (inter-quartile range = 2.3-10.6 years). Among patients with tumor grade I/II (n = 547), the 10-year net risk of ipsilateral invasive breast cancer was 12.2% (95% confidence interval [CI] = 8.6% to 17.1%) compared with 17.6% (95% CI = 12.1% to 25.2%) among patients with tumor grade III (n = 244) and 10.1% (95% CI = 7.4% to 13.8%) among patients with unknown grade (n = 495). Among all patients, the 10-year cumulative incidences of ipsilateral invasive cancer, contralateral breast cancer, and all-cause mortality were 10.5% (95% CI = 8.5% to 12.4%), 3.9% (95% CI = 2.6% to 5.2%), and 24.1% (95% CI = 21.2% to 26.9%), respectively. CONCLUSION Despite limited data, our findings suggest that DCIS patients without locoregional treatment have a limited risk of invasive progression. Although the cohort is not representative of the general population of patients diagnosed with DCIS, the findings suggest that there may be overtreatment, especially among older patients and patients with elevated comorbidities.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor
- Breast Neoplasms/epidemiology
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/etiology
- Carcinoma, Intraductal, Noninfiltrating/mortality
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Disease Progression
- Female
- Humans
- Middle Aged
- Neoplasm Grading
- Neoplasm Staging
- Prognosis
- SEER Program
- Survival Analysis
- Young Adult
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Affiliation(s)
- Marc D Ryser
- Correspondence to: Marc D. Ryser, PhD, Department of Population Health Sciences and Department of Mathematics, Duke University Medical Center, 215 Morris St., Durham, NC 27701 (e-mail: )
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30
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Chootipongchaivat S, van Ravesteyn NT, Li X, Huang H, Weedon-Fekjær H, Ryser MD, Weaver DL, Burnside ES, Heckman-Stoddard BM, de Koning HJ, Lee SJ. Modeling the natural history of ductal carcinoma in situ based on population data. Breast Cancer Res 2020; 22:53. [PMID: 32460821 PMCID: PMC7251719 DOI: 10.1186/s13058-020-01287-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background The incidence of ductal carcinoma in situ (DCIS) has increased substantially since the introduction of mammography screening. Nevertheless, little is known about the natural history of preclinical DCIS in the absence of biopsy or complete excision. Methods Two well-established population models evaluated six possible DCIS natural history submodels. The submodels assumed 30%, 50%, or 80% of breast lesions progress from undetectable DCIS to preclinical screen-detectable DCIS; each model additionally allowed or prohibited DCIS regression. Preclinical screen-detectable DCIS could also progress to clinical DCIS or invasive breast cancer (IBC). Applying US population screening dissemination patterns, the models projected age-specific DCIS and IBC incidence that were compared to Surveillance, Epidemiology, and End Results data. Models estimated mean sojourn time (MST) in the preclinical screen-detectable DCIS state, overdiagnosis, and the risk of progression from preclinical screen-detectable DCIS. Results Without biopsy and surgical excision, the majority of DCIS (64–100%) in the preclinical screen-detectable state progressed to IBC in submodels assuming no DCIS regression (36–100% in submodels allowing for DCIS regression). DCIS overdiagnosis differed substantially between models and submodels, 3.1–65.8%. IBC overdiagnosis ranged 1.3–2.4%. Submodels assuming DCIS regression resulted in a higher DCIS overdiagnosis than submodels without DCIS regression. MST for progressive DCIS varied between 0.2 and 2.5 years. Conclusions Our findings suggest that the majority of screen-detectable but unbiopsied preclinical DCIS lesions progress to IBC and that the MST is relatively short. Nevertheless, due to the heterogeneity of DCIS, more research is needed to understand the progression of DCIS by grades and molecular subtypes.
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Affiliation(s)
- Sarocha Chootipongchaivat
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
| | - Nicolien T van Ravesteyn
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Xiaoxue Li
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hui Huang
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Harald Weedon-Fekjær
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Marc D Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.,Department of Mathematics, Duke University, Durham, NC, USA
| | - Donald L Weaver
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont and UVM Cancer Center, Burlington, VT, USA
| | - Elizabeth S Burnside
- Radiology Department, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Sandra J Lee
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Hwang ES, Malek V. Estimating the magnitude of clinical benefit of local therapy in patients with DCIS. Breast 2020; 48 Suppl 1:S34-S38. [PMID: 31839157 DOI: 10.1016/s0960-9776(19)31120-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
DCIS represents a heterogeneous disease with a wide range of outcomes according to biology. Without treatment, it is estimated that only 20-30% of DCIS will progress to invasive cancer. Long-term outcomes following treatment are at least as favorable as those for some other early stage cancer types such as prostate cancer, for which active surveillance is routinely offered as a standard of care option. However, active surveillance has not yet been tested in relation to DCIS. Worldwide, there are three international trials (LORIS, COMET, LORD) which are evaluating whether DCIS with favorable biologic features may be managed with close monitoring, with treatment only undertaken upon disease progression. These trials will determine whether there may be some women with low-risk DCIS who do not substantially benefit from treatment and who could thus be safely managed with close surveillance. If active monitoring for DCIS is deemed to be safe and feasible, additional work must be done to optimally implement this approach, involving effective communication between patients and their physicians about the risks and benefits of treatment versus surveillance. Importantly, these treatment decisions must take into account patient factors such as risk tolerance, age, and competing causes of mortality. Tailoring treatment to biology for early screen-detected cancers such as DCIS is an important goal of ongoing research. An improved understanding of the biology and clinical implications of this heterogeneous disease will improve the overall health and quality of life for hundreds of thousands of future women who will be diagnosed with DCIS.
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32
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Oseni TO, Smith BL, Lehman CD, Vijapura CA, Pinnamaneni N, Bahl M. Do Eligibility Criteria for Ductal Carcinoma In Situ (DCIS) Active Surveillance Trials Identify Patients at Low Risk for Upgrade to Invasive Carcinoma? Ann Surg Oncol 2020; 27:4459-4465. [PMID: 32418079 DOI: 10.1245/s10434-020-08576-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials. METHODS A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials. RESULTS During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28-89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative. CONCLUSIONS Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials.
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Affiliation(s)
- Tawakalitu O Oseni
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Constance D Lehman
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Charmi A Vijapura
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Niveditha Pinnamaneni
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
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33
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Bachawal S, Bean GR, Krings G, Wilson KE. Evaluation of ductal carcinoma in situ grade via triple-modal molecular imaging of B7-H3 expression. NPJ Breast Cancer 2020; 6:14. [PMID: 32377564 PMCID: PMC7190737 DOI: 10.1038/s41523-020-0158-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/25/2020] [Indexed: 01/19/2023] Open
Abstract
Ductal carcinoma in situ (DCIS) will account for 62,930 cases of breast cancer in 2019. DCIS is a pre-invasive lesion which may not progress to invasive carcinoma, yet surgery remains the mainstay treatment. Molecular imaging of a specific marker for DCIS grade for detection and active surveillance are critically needed to reduce potential overtreatment. First, breast cancer marker B7-H3 (CD276) expression was evaluated by immunohistochemical staining in 123 human specimens including benign epithelium (H-score 10.0 ± 8.2) and low (20.8 ± 17.7), intermediate (87.1 ± 69.5), and high (159.1 ± 87.6) grade DCIS, showing a positive association with DCIS nuclear grade (P < 0.001, AUC 0.96). Next, a murine DCIS model was combined with ultrasound molecular imaging of B7-H3 targeted microbubbles to differentiate normal glands from those harboring DCIS (n = 100, FVB/N-Tg(MMTVPyMT)634Mul, AUC 0.89). Finally, photoacoustic and fluorescence molecular imaging with an anti-B7-H3 antibody-indocyanine green conjugate were utilized for DCIS detection (n = 53). Molecular imaging of B7-H3 expression may allow for active surveillance of DCIS.
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Affiliation(s)
- Sunitha Bachawal
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, School of Medicine, Stanford, CA USA
| | - Gregory R. Bean
- Department of Pathology, Stanford University, School of Medicine, Stanford, CA USA
| | - Gregor Krings
- Department of Pathology, University of California San Francisco, San Francisco, CA USA
| | - Katheryne E. Wilson
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, School of Medicine, Stanford, CA USA
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34
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Grimm LJ, Destounis SV, Rahbar H, Soo MS, Poplack SP. Ductal Carcinoma In Situ Biology, Language, and Active Surveillance: A Survey of Breast Radiologists' Knowledge and Opinions. J Am Coll Radiol 2020; 17:1252-1258. [PMID: 32278849 DOI: 10.1016/j.jacr.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To understand how breast radiologists perceive ductal carcinoma in situ (DCIS). MATERIALS AND METHODS A 19-item survey was developed by the Society of Breast Imaging Patient Care and Delivery Committee and distributed to all Society of Breast Imaging members. The survey queried respondents' demographics, knowledge of DCIS biology, language used to discuss a new diagnosis of DCIS, and perspectives on active surveillance for DCIS. Five-point Likert scales (1 = strongly disagree, 3 = neutral, 5 = strongly agree) were used. RESULTS There were 536 responses for a response rate of 41%. There was agreement that DCIS is the primary driver of overdiagnosis in breast cancer screening (median 4), and respondents provided mean and median overdiagnosis estimates of 29.7% and 25% for low-grade DCIS as well as 4.2% and 0% for high-grade DCIS, respectively. Responses varied in how to describe DCIS but most often used the word "cancer" with a qualifier such as "early" (32%) or "pre-invasive" (25%). Respondents disagreed (median 2) with removing the word "carcinoma" from DCIS. Finally, there was agreement that current standard of care therapy for some forms of DCIS is overtreatment (median 4) and that active surveillance as an alternative management strategy should be studied (mean 4), but felt that ultrasound (median 4) and MRI (median 4) should be used to exclude women with occult invasive disease before active surveillance. CONCLUSIONS Breast radiologists' opinions about DCIS biology, language, and active surveillance are not homogenous, but general trends exist that can be used to guide research, education, and advocacy efforts.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | | | - Habib Rahbar
- Clinical Director of Breast Imaging, Seattle Cancer Care Alliance; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Mary Scott Soo
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Steven P Poplack
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St Louis, Saint Louis, Missouri
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35
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Salvatorelli L, Puzzo L, Vecchio GM, Caltabiano R, Virzì V, Magro G. Ductal Carcinoma In Situ of the Breast: An Update with Emphasis on Radiological and Morphological Features as Predictive Prognostic Factors. Cancers (Basel) 2020; 12:E609. [PMID: 32155777 PMCID: PMC7139619 DOI: 10.3390/cancers12030609] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 12/19/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) shows overlapping epidemiology with invasive ductal carcinoma of the breast, sharing similar risk factorssuch as age, mammographic density, family history, and hormonal therapy as well as genetic factors such as BRCA1/BRCA2, histotypes, and molecular subtypes such as luminal A and B, HER2 enriched, and basal-type, thus suggesting its potential precursor role. A small percentage of patients with a history of DCIS die without a documented intermediate diagnosis of invasive breast carcinoma (IBC). The increased risk of death is usually associated with ipsilateral recurrence such as IBC. The slightly variable incidence of DCIS in different countries is mainly due to a different diffusion of mammographic screening and variability of the risk factors. The majority of DCIS lesions are not palpable lesions, which can be only radiologically detected because of the association with microcalcifications. Mammography is a highly sensitive diagnostic procedure for detecting DCIS with microcalcifications, while magnetic resonance imaging (MRI) is considered more sensitive to detect DCIS without calcifications and/or multifocal lesions. The aim of the present overview was to focus on the clinical, radiological, and pathological features of DCIS of the breast, with an emphasis on the practical diagnostic approach, predictive prognostic factors, and therapeutic options.
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Affiliation(s)
- Lucia Salvatorelli
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Azienda Ospedaliero-Universitaria “Policlinico Vittorio Emanuele”, Anatomic Pathology, School of Medicine, University of Catania, 95123 San Giovanni Galermo, Italy; (L.P.); (G.M.V.); (R.C.); (G.M.)
| | - Lidia Puzzo
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Azienda Ospedaliero-Universitaria “Policlinico Vittorio Emanuele”, Anatomic Pathology, School of Medicine, University of Catania, 95123 San Giovanni Galermo, Italy; (L.P.); (G.M.V.); (R.C.); (G.M.)
| | - Giada Maria Vecchio
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Azienda Ospedaliero-Universitaria “Policlinico Vittorio Emanuele”, Anatomic Pathology, School of Medicine, University of Catania, 95123 San Giovanni Galermo, Italy; (L.P.); (G.M.V.); (R.C.); (G.M.)
| | - Rosario Caltabiano
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Azienda Ospedaliero-Universitaria “Policlinico Vittorio Emanuele”, Anatomic Pathology, School of Medicine, University of Catania, 95123 San Giovanni Galermo, Italy; (L.P.); (G.M.V.); (R.C.); (G.M.)
| | - Valentina Virzì
- U.F. Radiodiagnostica Casa di cura Regina Pacis, 93017 San Cataldo, Italy;
| | - Gaetano Magro
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Azienda Ospedaliero-Universitaria “Policlinico Vittorio Emanuele”, Anatomic Pathology, School of Medicine, University of Catania, 95123 San Giovanni Galermo, Italy; (L.P.); (G.M.V.); (R.C.); (G.M.)
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Lazzeroni M, DeCensi A. De-Escalating Treatment of Low-Risk Breast Ductal Carcinoma In Situ. J Clin Oncol 2020; 38:1252-1254. [PMID: 32125939 DOI: 10.1200/jco.20.00124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Andrea DeCensi
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology, IRCCS, Milan, Italy.,Division of Medical Oncology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy.,Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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37
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The impact of patient characteristics and lifestyle factors on the risk of an ipsilateral event after a primary DCIS: A systematic review. Breast 2020; 50:95-103. [PMID: 32120064 PMCID: PMC7073883 DOI: 10.1016/j.breast.2020.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/10/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The majority of ‘low-risk’ (grade I/II) Ductal Carcinoma In Situ (DCIS) may not progress to invasive breast cancer during a women’s lifetime. Therefore, the safety of active surveillance versus standard surgical treatment for DCIS is prospectively being evaluated in clinical trials. If proven safe and selectively implemented in clinical practice, a significant group of women with low-risk DCIS may forego surgery and radiotherapy in the future. Identification of modifiable and non-modifiable risk factors associated with prognosis after a primary DCIS would also enhance our care of women with low-risk DCIS. Methods To identify modifiable and non-modifiable risk factors for subsequent breast events after DCIS, we performed a systematic literature search in PUBMED, EMBASE and Scopus. Results Six out of the 3870 articles retrieved were included for final data extraction. These six studies included a total of 4950 patients with primary DCIS and 640 recorded subsequent breast events. There was moderate evidence for an association of a family history of breast cancer, premenopausal status, high BMI, and high breast density with a subsequent breast cancer or further DCIS. Conclusion There is a limited number of recent studies published on the impact of modifiable and non-modifiable risk factors on subsequent events after DCIS. The available evidence is insufficient to identify potential targets for risk reduction strategies, reflecting the relatively small numbers and the lack of long-term follow-up in DCIS, a low-event condition. Need for risk management strategies for untreated DCIS patients. Limited evidence for association between lifestyle factors and prognosis after DCIS. Positive family history, premenopausal status, high breast density associated with prognosis.
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38
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Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.
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Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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Rockne RC, Hawkins-Daarud A, Swanson KR, Sluka JP, Glazier JA, Macklin P, Hormuth DA, Jarrett AM, Lima EABF, Tinsley Oden J, Biros G, Yankeelov TE, Curtius K, Al Bakir I, Wodarz D, Komarova N, Aparicio L, Bordyuh M, Rabadan R, Finley SD, Enderling H, Caudell J, Moros EG, Anderson ARA, Gatenby RA, Kaznatcheev A, Jeavons P, Krishnan N, Pelesko J, Wadhwa RR, Yoon N, Nichol D, Marusyk A, Hinczewski M, Scott JG. The 2019 mathematical oncology roadmap. Phys Biol 2019; 16:041005. [PMID: 30991381 PMCID: PMC6655440 DOI: 10.1088/1478-3975/ab1a09] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Whether the nom de guerre is Mathematical Oncology, Computational or Systems Biology, Theoretical Biology, Evolutionary Oncology, Bioinformatics, or simply Basic Science, there is no denying that mathematics continues to play an increasingly prominent role in cancer research. Mathematical Oncology-defined here simply as the use of mathematics in cancer research-complements and overlaps with a number of other fields that rely on mathematics as a core methodology. As a result, Mathematical Oncology has a broad scope, ranging from theoretical studies to clinical trials designed with mathematical models. This Roadmap differentiates Mathematical Oncology from related fields and demonstrates specific areas of focus within this unique field of research. The dominant theme of this Roadmap is the personalization of medicine through mathematics, modelling, and simulation. This is achieved through the use of patient-specific clinical data to: develop individualized screening strategies to detect cancer earlier; make predictions of response to therapy; design adaptive, patient-specific treatment plans to overcome therapy resistance; and establish domain-specific standards to share model predictions and to make models and simulations reproducible. The cover art for this Roadmap was chosen as an apt metaphor for the beautiful, strange, and evolving relationship between mathematics and cancer.
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Affiliation(s)
- Russell C Rockne
- Department of Computational and Quantitative Medicine, Division of Mathematical Oncology, City of Hope National Medical Center, Duarte, CA 91010, United States of America. Author to whom any correspondence should be addressed
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Altrock PM, Ferlic J, Galla T, Tomasson MH, Michor F. Computational Model of Progression to Multiple Myeloma Identifies Optimum Screening Strategies. JCO Clin Cancer Inform 2018; 2:1-12. [PMID: 30652561 PMCID: PMC6873949 DOI: 10.1200/cci.17.00131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Recent advances have uncovered therapeutic interventions that might reduce the risk of progression of premalignant diagnoses, such as monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM). It remains unclear how to best screen populations at risk and how to evaluate the ability of these interventions to reduce disease prevalence and mortality at the population level. To address these questions, we developed a computational modeling framework. MATERIALS AND METHODS We used individual-based computational modeling of MGUS incidence and progression across a population of diverse individuals to determine best screening strategies in terms of screening start, intervals, and risk-group specificity. Inputs were life tables, MGUS incidence, and baseline MM survival. We measured MM-specific mortality and MM prevalence after MGUS detection from simulations and mathematic modeling predictions. RESULTS Our framework is applicable to a wide spectrum of screening and intervention scenarios, including variation of the baseline MGUS to MM progression rate and evolving MGUS, in which progression increases over time. Given the currently available point estimate of progression risk reduction to 61% risk, starting screening at age 55 years and performing follow-up screening every 6 years reduced total MM prevalence by 19%. The same reduction could be achieved with starting screening at age 65 years and performing follow-up screening every 2 years. A 40% progression risk reduction per patient with MGUS per year would reduce MM-specific mortality by 40%. Specifically, screening onset age and screening frequency can change disease prevalence, and progression risk reduction changes both prevalence and disease-specific mortality. Screening would generally be favorable in high-risk individuals. CONCLUSION Screening efforts should focus on specifically identified groups with high lifetime risk of MGUS, for which screening benefits can be significant. Screening low-risk individuals with MGUS would require improved preventions.
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Affiliation(s)
- Philipp M. Altrock
- Philipp M. Altrock, Moffitt Cancer Center and Research Institute; Morsani College of Medicine, University of South Florida, Tampa, FL; Jeremy Ferlic and Franziska Michor, Dana-Farber Cancer Institute and Harvard University; Harvard T.H. Chan School of Public Health, Boston; Franziska Michor, Center for Cancer Evolution, Dana-Farber Cancer Institute, and The Ludwig Center at Harvard, Boston; Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA; Tobias Galla, University of Manchester, Manchester, United Kingdom; and Michael H. Tomasson, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Jeremy Ferlic
- Philipp M. Altrock, Moffitt Cancer Center and Research Institute; Morsani College of Medicine, University of South Florida, Tampa, FL; Jeremy Ferlic and Franziska Michor, Dana-Farber Cancer Institute and Harvard University; Harvard T.H. Chan School of Public Health, Boston; Franziska Michor, Center for Cancer Evolution, Dana-Farber Cancer Institute, and The Ludwig Center at Harvard, Boston; Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA; Tobias Galla, University of Manchester, Manchester, United Kingdom; and Michael H. Tomasson, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Tobias Galla
- Philipp M. Altrock, Moffitt Cancer Center and Research Institute; Morsani College of Medicine, University of South Florida, Tampa, FL; Jeremy Ferlic and Franziska Michor, Dana-Farber Cancer Institute and Harvard University; Harvard T.H. Chan School of Public Health, Boston; Franziska Michor, Center for Cancer Evolution, Dana-Farber Cancer Institute, and The Ludwig Center at Harvard, Boston; Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA; Tobias Galla, University of Manchester, Manchester, United Kingdom; and Michael H. Tomasson, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Michael H. Tomasson
- Philipp M. Altrock, Moffitt Cancer Center and Research Institute; Morsani College of Medicine, University of South Florida, Tampa, FL; Jeremy Ferlic and Franziska Michor, Dana-Farber Cancer Institute and Harvard University; Harvard T.H. Chan School of Public Health, Boston; Franziska Michor, Center for Cancer Evolution, Dana-Farber Cancer Institute, and The Ludwig Center at Harvard, Boston; Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA; Tobias Galla, University of Manchester, Manchester, United Kingdom; and Michael H. Tomasson, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Franziska Michor
- Philipp M. Altrock, Moffitt Cancer Center and Research Institute; Morsani College of Medicine, University of South Florida, Tampa, FL; Jeremy Ferlic and Franziska Michor, Dana-Farber Cancer Institute and Harvard University; Harvard T.H. Chan School of Public Health, Boston; Franziska Michor, Center for Cancer Evolution, Dana-Farber Cancer Institute, and The Ludwig Center at Harvard, Boston; Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA; Tobias Galla, University of Manchester, Manchester, United Kingdom; and Michael H. Tomasson, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
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Punglia RS, Bifolck K, Golshan M, Lehman C, Collins L, Polyak K, Mittendorf E, Garber J, Hwang SE, Schnitt SJ, Partridge AH, King TA. Epidemiology, Biology, Treatment, and Prevention of Ductal Carcinoma In Situ (DCIS). JNCI Cancer Spectr 2018; 2:pky063. [PMID: 30627695 PMCID: PMC6307658 DOI: 10.1093/jncics/pky063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) is a highly heterogeneous disease. It presents in a variety of ways and may or may not progress to invasive cancer, which poses challenges for both diagnosis and treatment. On May 15, 2017, the Dana-Farber/Harvard Cancer Center hosted a retreat for over 80 breast specialists including medical oncologists, surgical oncologists, radiation oncologists, radiologists, pathologists, physician assistants, nurses, nurse practitioners, researchers, and patient advocates to discuss the state of the science, treatment challenges, and key questions relating to DCIS. Speakers and attendees were encouraged to explore opportunities for future collaboration and research to improve our understanding and clinical management of this disease. Participants were from Dana-Farber Cancer Institute, Brigham and Women's Hospital, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Duke University Medical Center, and MD Anderson Cancer Center. The discussion focused on three main themes: epidemiology, detection, and pathology; state of the science including the biology of DCIS and potential novel treatment approaches; and risk perceptions, communication, and decision-making. Here we summarize the proceedings from this event.
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Affiliation(s)
| | | | - Mehra Golshan
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
| | - Constance Lehman
- Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Laura Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Elizabeth Mittendorf
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Shelley E Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Stuart J Schnitt
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
- Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
| | | | - Tari A King
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
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Meurs CJC, van Rosmalen J, Menke-Pluijmers MBE, Ter Braak BPM, de Munck L, Siesling S, Westenend PJ. A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers. Br J Cancer 2018; 119:1155-1162. [PMID: 30327564 PMCID: PMC6219477 DOI: 10.1038/s41416-018-0276-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 02/08/2023] Open
Abstract
Background Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS)
might be diagnosed with invasive breast cancer at excision, a phenomenon known as
underestimation. Patients with DCIS are treated based on the risk of
underestimation or progression to invasive cancer. The aim of our study was to
expand the knowledge on underestimation and to develop a prediction model. Methods Population-based data were retrieved from the Dutch Pathology
Registry and the Netherlands Cancer Registry for DCIS between January 2011 and
June 2012. Results Of 2892 DCIS biopsies, 21% were underestimated invasive breast
cancers. In multivariable analysis, risk factors were high-grade DCIS (odds ratio
(OR) 1.43, 95% confidence interval (CI): 1.05–1.95), a palpable tumour (OR 2.22,
95% CI: 1.76–2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5
(OR 2.36, 95% CI: 1.80–3.09) and a suspected invasive component at biopsy (OR
3.84, 95% CI: 2.69–5.46). The predicted risk for underestimation ranged from 9.5
to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had
unfavourable features. Conclusions The risk for an underestimated diagnosis of invasive breast cancer
after a biopsy diagnosis of DCIS is considerable. With our prediction model, the
individual risk of underestimation can be calculated based on routinely available
preoperatively known risk factors (https://www.evidencio.com/models/show/1074).
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Affiliation(s)
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | | | - Bert P M Ter Braak
- Department of Radiology, Albert Schweitzer Hospital, PO Box 444, 3300 AK, Dordrecht, The Netherlands
| | - Linda de Munck
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Pieter J Westenend
- Laboratory of Pathology Dordrecht, Karel Lotsyweg 145, 3318 AL, Dordrecht, The Netherlands. .,Regional screening organization South West the Netherlands, Maasstadweg 12, 3079 DZ, Rotterdam, The Netherlands.
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van Ravesteyn NT, van den Broek JJ, Li X, Weedon-Fekjær H, Schechter CB, Alagoz O, Huang X, Weaver DL, Burnside ES, Punglia RS, de Koning HJ, Lee SJ. Modeling Ductal Carcinoma In Situ (DCIS): An Overview of CISNET Model Approaches. Med Decis Making 2018; 38:126S-139S. [PMID: 29554463 PMCID: PMC5862063 DOI: 10.1177/0272989x17729358] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) can be a precursor to invasive breast cancer. Since the advent of screening mammography in the 1980's, the incidence of DCIS has increased dramatically. The value of screen detection and treatment of DCIS, however, is a matter of controversy, as it is unclear the extent to which detection and treatment of DCIS prevents invasive disease and reduces breast cancer mortality. The aim of this paper is to provide an overview of existing Cancer Intervention and Surveillance Modelling Network (CISNET) modeling approaches for the natural history of DCIS, and to compare these to other modeling approaches reported in the literature. DESIGN Five of the 6 CISNET models currently include DCIS. Most models assume that some, but not all, lesions progress to invasive cancer. The natural history of DCIS cannot be directly observed and the CISNET models differ in their assumptions and in the data sources used to estimate the DCIS model parameters. RESULTS These model differences translate into variation in outcomes, such as the amount of overdiagnosis of DCIS, with estimates ranging from 34% to 72% for biennial screening from ages 50 to 74 y. The other models described in the literature also report a large range in outcomes, with progression rates varying from 20% to 91%. LIMITATIONS DCIS grade was not yet included in the CISNET models. CONCLUSION In the future, DCIS data by grade from active surveillance trials, the development of predictive markers of progression probability, and evidence from other screening modalities, such as tomosynthesis, may be used to inform and improve the models' representation of DCIS, and might lead to convergence of the model estimates. Until then, the CISNET model results consistently show a considerable amount of overdiagnosis of DCIS, supporting the safety and value of observational trials for low-risk DCIS.
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Affiliation(s)
| | - Jeroen J van den Broek
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Xiaoxue Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Harald Weedon-Fekjær
- Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Clyde B Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Donald L Weaver
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA
| | - Elizabeth S Burnside
- Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Rinaa S Punglia
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sandra J Lee
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Kearins O, Pinder SE, Thomas J, Wallis MG, Thompson AM. Risk factors for the development of invasive cancer in unresected ductal carcinoma in situ. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:429-435. [PMID: 29398324 DOI: 10.1016/j.ejso.2017.12.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/04/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The natural history of ductal carcinoma in situ (DCIS) remains uncertain. The risk factors for the development of invasive cancer in unresected DCIS are unclear. METHODS Women diagnosed with DCIS on needle biopsy after 1997 who did not undergo surgical resection for ≥1 year after diagnosis were identified by breast centres and the cancer registry and outcomes were reviewed. RESULTS Eighty-nine women with DCIS diagnosed 1998-2010 were identified. The median age at diagnosis was 75 (range 44-94) years with median follow-up (diagnosis to death, invasive disease or last review) of 59 (12-180) months. Twenty-nine women (33%) developed invasive breast cancer after a median interval of 45 (12-144) months. 14/29 (48%) with high grade, 10/31 (32%) with intermediate grade and 3/17 (18%) with low grade DCIS developed invasive cancer after median intervals of 38, 60 and 51 months. The cumulative incidence of invasion was significantly higher in high grade DCIS than other grades (p = .0016, log-rank test). Invasion was more frequent in lesions with calcification as the predominant feature (23/50 v. 5/25; p = .042) and in younger women (p = .0002). Endocrine therapy was associated with a lower rate of invasive breast cancer (p = .048). CONCLUSIONS High cytonuclear grade, mammographic microcalcification, young age and lack of endocrine therapy were risk factors for DCIS progression to invasive cancer. Surgical excision of high grade DCIS remains the treatment of choice. Given the uncertain long-term natural history of non-high grade DCIS, the option of active surveillance of women with this condition should be offered within a clinical trial.
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Affiliation(s)
- Anthony J Maxwell
- Nightingale Centre, Wythenshawe Hospital, Manchester, M23 9LT, UK; Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT, UK.
| | - Karen Clements
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Bridget Hilton
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - David J Dodwell
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Andrew Evans
- Ninewells Hospital and Medical School, Mailbox 4, Level 6, Dundee, DD1 9SY, UK.
| | - Olive Kearins
- Screening Quality Assurance Service (Midlands and East), Public Health England, 1st Floor, 5 St Philip's Place, Birmingham, B3 2PW, UK.
| | - Sarah E Pinder
- Cancer Studies, King's College London, 9th Floor, Innovation Hub, Comprehensive Cancer Centre, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK.
| | - Jeremy Thomas
- Department of Pathology, Western General Hospital, Edinburgh, EH4 2XU, UK.
| | - Matthew G Wallis
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge & NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK.
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Chavez de Paz Villanueva C, Bonev V, Senthil M, Solomon N, Reeves ME, Garberoglio CA, Namm JP, Lum SS. Factors Associated With Underestimation of Invasive Cancer in Patients With Ductal Carcinoma In Situ: Precautions for Active Surveillance. JAMA Surg 2017; 152:1007-1014. [PMID: 28700803 DOI: 10.1001/jamasurg.2017.2181] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Recent recognition of the overdiagnosis and overtreatment of ductal carcinoma in situ (DCIS) detected by mammography has led to the development of clinical trials randomizing women with non-high-grade DCIS to active surveillance, defined as imaging surveillance with or without endocrine therapy, vs standard surgical care. Objective To determine the factors associated with underestimation of invasive cancer in patients with a clinical diagnosis of non-high-grade DCIS that would preclude active surveillance. Design, Setting, and Participants A retrospective cohort study was conducted using records from the National Cancer Database from January 1, 1998, to December 31, 2012, of female patients 40 to 99 years of age with a clinical diagnosis of non-high-grade DCIS who underwent definitive surgical treatment. Data analysis was conducted from November 1, 2015, to February 4, 2017. Exposures Patients with an upgraded diagnosis of invasive carcinoma vs those with a diagnosis of DCIS based on final surgical pathologic findings. Main Outcomes and Measures The proportions of cases with an upgraded diagnosis of invasive carcinoma from final surgical pathologic findings were compared by tumor, host, and system characteristics. Results Of 37 544 women (mean [SD] age, 59.3 [12.4] years) presenting with a clinical diagnosis of non-high-grade DCIS, 8320 (22.2%) had invasive carcinoma based on final pathologic findings. Invasive carcinomas were more likely to be smaller (>0.5 to ≤1.0 cm vs ≤0.5 cm: odds ratio [OR], 0.73; 95% CI, 0.67-0.79; >1.0 to ≤2.0 cm vs ≤0.5 cm: OR, 0.42; 95% CI, 0.39-0.46; >2.0 to ≤5.0 cm vs ≤0.5 cm: OR, 0.19; 95% CI, 0.17-0.22; and >5.0 cm vs ≤0.5 cm: OR, 0.11; 95% CI, 0.08-0.15) and lower grade (intermediate vs low: OR, 0.75; 95% CI, 0.69-0.80). Multivariate logistic regression analysis demonstrated that younger age (60-79 vs 40-49 years: OR, 0.84; 95% CI, 0.77-0.92; and ≥80 vs 40 to 49 years: OR, 0.76; 95% CI, 0.64-0.91), negative estrogen receptor status (positive vs negative: OR, 0.39; 95% CI, 0.34-0.43), treatment at an academic facility (academic vs community: OR, 2.08; 95% CI, 1.82-2.38), and higher annual income (>$63 000 vs <$38 000: OR, 1.14; 95% CI, 1.02-1.28) were significantly associated with an upgraded diagnosis of invasive carcinoma based on final pathologic findings. Conclusions and Relevance When selecting patients for active surveillance of DCIS, factors other than tumor biology associated with invasive carcinoma based on final pathologic findings may need to be considered. At the time of randomization to active surveillance, a significant proportion of patients with non-high-grade DCIS will harbor invasive carcinoma.
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Affiliation(s)
| | - Valentina Bonev
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Maheswari Senthil
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Naveenraj Solomon
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Mark E Reeves
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Carlos A Garberoglio
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Jukes P Namm
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Sharon S Lum
- Division of Surgical Oncology, Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California
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Imaging Features of Patients Undergoing Active Surveillance for Ductal Carcinoma in Situ. Acad Radiol 2017; 24:1364-1371. [PMID: 28705686 DOI: 10.1016/j.acra.2017.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to describe the imaging appearance of patients undergoing active surveillance for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS We retrospectively identified 29 patients undergoing active surveillance for DCIS from 2009 to 2014. Twenty-two patients (group 1) refused surgery or were not surgical candidates. Seven patients (group 2) enrolled in a trial of letrozole and deferred surgical excision for 6-12 months. Pathology and imaging results at the initial biopsy and follow-up were recorded. RESULTS In group 1, the median follow-up was 2.7 years (range: 0.6-13.9 years). Fifteen patients (68%) remained stable. Seven patients (32%) underwent additional biopsies with invasive ductal carcinoma diagnosed in two patients after 3.9 and 3.6 years who developed increasing calcifications and new masses. In group 2, one patient (14%) was upstaged to microinvasive ductal carcinoma at surgery. Among the patients in both groups with calcifications (n = 26), there was no progression to invasive disease among those with stable (50%, 13/26) or decreased (19%, 5/26) calcifications. CONCLUSIONS Among a DCIS active surveillance cohort, invasive disease progression presented as increasing calcifications and a new mass following more than 3.5 years of stable imaging. In contrast, there was no progression to invasive disease among cases of DCIS with stable or decreasing calcifications. Close imaging is a key follow-up component in active surveillance.
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Grimm LJ, Ryser MD, Partridge AH, Thompson AM, Thomas JS, Wesseling J, Hwang ES. Surgical Upstaging Rates for Vacuum Assisted Biopsy Proven DCIS: Implications for Active Surveillance Trials. Ann Surg Oncol 2017; 24:3534-3540. [PMID: 28795370 DOI: 10.1245/s10434-017-6018-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE This study was designed to determine invasive cancer upstaging rates at surgical excision following vacuum-assisted biopsy of ductal carcinoma in situ (DCIS) among women meeting eligibility for active surveillance trials. METHODS Patients with vacuum-assisted, biopsy-proven DCIS at a single center from 2008 to 2015 were retrospectively reviewed. Imaging and pathology reports were interrogated for the imaging appearance, tumor grade, hormone receptor status, and presence of comedonecrosis. Subsequent surgical reports were reviewed for upstaging to invasive disease. Cases were classified by eligibility criteria for the COMET, LORIS, and LORD DCIS active surveillance trials. RESULTS Of 307 DCIS diagnoses, 15 (5%) were low, 95 (31%) intermediate, and 197 (64%) high nuclear grade. The overall upstage rate to invasive disease was 17% (53/307). Eighty-one patients were eligible for the COMET Trial, 74 for the LORIS trial, and 10 for the LORD Trial, although LORIS trial eligibility also included real-time, multiple central pathology review, including elements not routinely reported. The upstaging rates to invasive disease were 6% (5/81), 7% (5/74), and 10% (1/10) for the COMET, LORIS, and LORD trials, respectively. Among upstaged cancers (n = 5), four tumors were Stage IA invasive ductal carcinoma and one was Stage IIA invasive lobular carcinoma; all were node-negative. CONCLUSIONS DCIS upstaging rates in women eligible for active surveillance trials are low (6-10%), and in this series, all those with invasive disease were early-stage, node-negative. The careful patient selection for DCIS active surveillance trials has a low risk of missing occult invasive cancer and additional studies will determine clinical outcomes.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University, Durham, NC, USA
| | - Marc D Ryser
- Department of Mathematics, Duke University, Durham, NC, USA
| | - Ann H Partridge
- Division of Oncology, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alastair M Thompson
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremy S Thomas
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Jelle Wesseling
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E Shelley Hwang
- Department of Surgery, Duke University Comprehensive Cancer Center, Durham, NC, USA.
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Haymart MR, Miller DC, Hawley ST. Active Surveillance for Low-Risk Cancers - A Viable Solution to Overtreatment? N Engl J Med 2017; 377:203-206. [PMID: 28723330 PMCID: PMC5921045 DOI: 10.1056/nejmp1703787] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Megan R Haymart
- From the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (M.R.H.), the Institute for Healthcare Policy and Innovation (M.R.H., D.C.M., S.T.H.), the Department of Urology (D.C.M.), and the Division of General Medicine, Department of Internal Medicine (S.T.H.), University of Michigan, Ann Arbor
| | - David C Miller
- From the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (M.R.H.), the Institute for Healthcare Policy and Innovation (M.R.H., D.C.M., S.T.H.), the Department of Urology (D.C.M.), and the Division of General Medicine, Department of Internal Medicine (S.T.H.), University of Michigan, Ann Arbor
| | - Sarah T Hawley
- From the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (M.R.H.), the Institute for Healthcare Policy and Innovation (M.R.H., D.C.M., S.T.H.), the Department of Urology (D.C.M.), and the Division of General Medicine, Department of Internal Medicine (S.T.H.), University of Michigan, Ann Arbor
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Chang TT, Thakar D, Weaver VM. Force-dependent breaching of the basement membrane. Matrix Biol 2016; 57-58:178-189. [PMID: 28025167 DOI: 10.1016/j.matbio.2016.12.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/20/2016] [Accepted: 12/12/2016] [Indexed: 12/24/2022]
Abstract
Clinically, non-invasive carcinomas are confined to the epithelial side of the basement membrane and are classified as benign, whereas invasive cancers invade through the basement membrane and thereby acquire the potential to metastasize. Recent findings suggest that, in addition to protease-mediated degradation and chemotaxis-stimulated migration, basement membrane invasion by malignant cells is significantly influenced by the stiffness of the associated interstitial extracellular matrix and the contractility of the tumor cells that is dictated in part by their oncogenic genotype. In this review, we highlight recent findings that illustrate unifying molecular mechanisms whereby these physical cues contribute to tissue fibrosis and malignancy in three epithelial organs: breast, pancreas, and liver. We also discuss the clinical implications of these findings and the biological properties and clinical challenges linked to the unique biology of each of these organs.
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Affiliation(s)
- Tammy T Chang
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA; Liver Center, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Dhruv Thakar
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA; Center for Bioengineering and Tissue Regeneration, University of California San Francisco, San Francisco, CA 94143, USA.
| | - Valerie M Weaver
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA; Center for Bioengineering and Tissue Regeneration, University of California San Francisco, San Francisco, CA 94143, USA; Department of Anatomy, UCSF, San Francisco, CA 94143, USA; Department of Bioengineering and Therapeutic Sciences, UCSF, San Francisco, CA 94143, USA; Department of Radiation Oncology, UCSF, San Francisco, CA 94143, USA; Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, UCSF, San Francisco, CA 94143, USA; The Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA 94143, USA.
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Pilewskie M, Olcese C, Patil S, Van Zee KJ. Women with Low-Risk DCIS Eligible for the LORIS Trial After Complete Surgical Excision: How Low Is Their Risk After Standard Therapy? Ann Surg Oncol 2016; 23:4253-4261. [PMID: 27766556 DOI: 10.1245/s10434-016-5595-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identifying DCIS patients at low risk for disease progression could obviate need for standard therapy. The LORIS (surgery versus active monitoring for low-risk DCIS) trial is studying the safety of monitoring low-risk DCIS, although ipsilateral breast tumor recurrence (IBTR) rates in patients meeting enrollment criteria after complete surgical excision are unknown. METHODS Women with pure DCIS treated with breast-conserving surgery (BCS) with/without radiation therapy (RT) from 1/1996-1/2011 were included from a prospectively maintained database. IBTR rates were compared between those who did and did not meet LORIS eligibility criteria (age ≥ 46 years, screen-detected calcifications, nipple discharge absence, minimal family history, non-high-grade DCIS) after complete surgical excision. RESULTS A total of 2394 women were identified; 401 met LORIS criteria. Median follow-up was 5.9 years; 431 had ≥10 years follow-up. LORIS cohort median age was 61 years (range 46-86 years); 207 (52 %) underwent RT, 79 (20 %) received endocrine therapy. Of 401 patients, 24 experienced an IBTR. Overall 10-year IBTR rates were 10.3 % (LORIS) versus 15.4 % (non-LORIS) (p = 0.08); without RT, 12.1 versus 21.4 %, respectively (p = 0.06). The 10-year invasive-IBTR rates for women meeting LORIS criteria were: 5.3 % BCS overall, 6.0 % without RT. CONCLUSIONS Women meeting LORIS criteria (after complete surgical excision) are at somewhat lower risk for IBTR. Among such women undergoing excision without RT, the 10-year invasive-IBTR rate was 6 %. Given that approximately 20 % of women with core biopsy-proven non-high-grade DCIS have invasive cancer at excision, women managed without excision would be expected to incur higher invasive cancer rates. Additional criteria are needed to identify women not requiring intervention for DCIS.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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