The method of detection of ductal carcinoma in situ has no therapeutic implications: results of a population-based cohort study

Invasive breast cancer and breast cancer death after non-screen detected ductal carcinoma in situ from 1990 to 2018 in England: population based cohort study

OBJECTIVES

To evaluate the long term risks of invasive breast cancer and death related to breast cancer after non-screen detected ductal carcinoma in situ. Risks for women in the general population and for women diagnosed with ductal carcinoma in situ via the screening programme were compared.

DESIGN

Population based cohort study.

SETTING

Data from the National Disease Registration Service.

PARTICIPANTS

All 27 543 women in England who were diagnosed with ductal carcinoma in situ, outside the NHS breast screening programme, during 1990 to 2018.

MAIN OUTCOME MEASURES

Incident invasive breast cancer and death caused by breast cancer.

RESULTS

By 31 December 2018, 3651 women with non-screen detected ductal carcinoma in situ had developed invasive breast cancer, more than four times higher than expected from national cancer incidence rates (ratio of observed to expected rate was 4.21 (95% conference interval 4.07 to 4.35)). The ratio of observed to expected rate of developing invasive breast cancer remained increased throughout follow-up among women aged <45-70 years. The 25 year cumulative risks of invasive breast cancer by age at diagnosis of ductal carcinoma in situ were 27.3% for <45 years, 25.2% for 45-49 years, 21.7% for 50-59 years, and 20.8% for 60-70 years. 908 women died of breast cancer, almost four times higher than that expected from breast cancer death rates in the general population (ratio of observed to expected rate 3.83 (3.59 to 4.09)). The ratio of observed to expected rate of mortality attributed to breast cancer remained increased throughout follow-up. The 25 year cumulative risks of breast cancer death by age at ductal carcinoma in situ diagnosis were 7.6% for <45 years, 5.8% for 45-49 years, 5.9% for 50-59 years, and 6.2% for 60-70 years. Among women aged 50-64 years, and therefore eligible for breast screening by the NHS, the ratio of observed to expected rate of invasive breast cancer in women with non-screen detected compared with screen detected ductal carcinoma in situ was 1.26 (95% conference interval 1.17 to 1.35), while the ratio for mortality from breast cancer was 1.37 (1.17 to 1.60). Among 22 753 women with unilateral ductal carcinoma in situ undergoing surgery, those who had mastectomy rather than breast conserving surgery had a lower 25 year cumulative rate of ipsilateral invasive breast cancer (mastectomy 8.2% (95% conference interval 7.0% to 9.4%), breast conserving surgery with radiotherapy 19.8% (16.2% to 23.4%), and breast conserving surgery with no radiotherapy recorded 20.6% (18.7% to 22.4%)). However, reductions did not translate into a lower 25 year cumulative rate of deaths attributable to breast cancer (mastectomy 6.5% (4.9% to 10.9%), breast conserving surgery with radiotherapy 8.6% (5.9% to 15.5%), breast conserving surgery with no radiotherapy recorded 7.8% (6.3% to 11.5%)).

CONCLUSIONS

For at least 25 years after their diagnosis, women with non-screen detected ductal carcinoma in situ had higher long term risks of invasive breast cancer and breast cancer death than women in the general population. Additionally, they had higher long term risks than women with screen detected ductal carcinoma in situ. Mastectomy was associated with lower risks of invasive breast cancer than breast conserving surgery, even when accompanied by radiotherapy. However, risks of breast cancer death appeared similar for mastectomy, breast conserving surgery with radiotherapy, and breast conserving surgery with no radiotherapy recorded.

Evaluation of the Influence of Geodimensional and Histological Parameters on the Need for Margin Widening in Breast Lesions Marked With Magnetic Seeds

Objective

Breast cancer is an important topic worldwide, posing morbidity and mortality to women. Considerable efforts have been put in the early recognition of malignancy through different screening methods, such as mammography and ultrasound. The precise localization of infraclinical malignant lesions is key in surgical management and magnetic seeds gather particular interest for this purpose. As with other systems, a need for reintervention may be needed to obtain adequate surgical margins. This work evaluated the relation between the need for surgical reintervention in order to obtain negative margins and geodimensional and histological parameters. The main objective was the identification of parameters significantly associated with reintervention for margin widening.

Materials and Methods

A retrospective analysis of 198 patients from a single centre was performed. The association between pre-defined geodimensional and histological parameters and the need for margin widening in infraclinical lesions marked with magnetic seed was evaluated.

Results

Results showed that reintervention to widen margins was significantly higher in patients with ductal carcinoma in situ (DCIS) in the pre-operative biopsy when compared with invasive carcinoma (p = 0.03) in the bivariate analysis. No statistically significant differences were observed between the need for reintervention and lesion size (p = 0.197), breast quadrant location (p = 0.626) and distance of skin to lesion (p = 0.356).

Conclusion

This work suggests that a more invasive margin clearance in lesions with a pre-operative DCIS diagnosis might obviate the need for reintervention to obtain negative margins. On the other hand, it is not necessary to be surgically more invasive in larger lesions, deeply located or that are present in a certain quadrant, since there are no significant differences regarding the need for reintervention.

Detection method has independent prognostic significance in the PLCO lung screening trial

Prognostic models in cancer use patient demographic and tumor characteristics to predict survival and dynamic disease prognosis. Past work in breast cancer has shown that cancer detection method, screen-detected or symptom-detected, has prognostic significance. We investigate this phenomenon in the lung component of the Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial. Patients were randomized to intervention, receiving four annual chest x-rays (CXRs), or to control, receiving usual care. Patients were followed for a total of approximately 13 years. In PLCO, lung cancer detection method has independent prognostic value exceeding that of variables commonly used in lung cancer prognostic models, including sex, histology, and age. Results are robust to cohort selection and type of predictive model. These results imply that detection method should be considered when developing prognostic models in lung cancer studies, and cancer registries should routinely collect cancer detection method.

Readmissions and complications in breast ductal carcinoma in situ: A retrospective study comparing screen- and non-screen-detected patients

Objective:

Population-wide mammographic screening programs aim to reduce breast cancer mortality. However, a broad view of the harms and benefits of these programs is necessary to favor informed decisions, especially in the earliest stages of the disease. Here, we compare the outcomes of patients diagnosed with breast ductal carcinoma in situ in participants and non-participants of a population-based mammographic screening program.

Methods:

A retrospective cohort study of all patients diagnosed with breast ductal carcinoma in situ between 2000 and 2010 within a single hospital. A total of 211 patients were included, and the median follow-up was 8.4 years. The effect of detection mode (screen-detected and non-screen-detected) on breast cancer recurrences, readmissions, and complications was evaluated through multivariate logistic regression analysis.

Results:

In the majority of women, breast ductal carcinoma in situ was screen-detected (63.5%). Screen-detected breast ductal carcinoma in situ was smaller in size compared to those non-screen-detected (57.53% < 20 mm versus 78.03%, p = 0.002). Overall, breast-conserving surgery was the most frequent surgery (86.26%); however, mastectomy was higher in non-screen-detected breast ductal carcinoma in situ (20.78% versus 9.7%, p = 0.024). Readmissions for mastectomy were more frequent in non-screen-detected breast ductal carcinoma in situ. Psychological complications, such as fatigue, anxiety, and depression, had a prevalence of 15% within our cohort. Risk of readmissions and complications was higher within the non-screen-detected group, as evidenced by an odds ratio = 6.25 (95% confidence interval = 1.95–19.99) for readmissions and an odds ratio = 2.41 (95% confidence interval = 1.95–4.86) for complications.

Conclusions:

Our findings indicate that women with breast ductal carcinoma in situ breast cancer diagnosed through population-based breast cancer screening program experience a lower risk of readmissions and complications than those diagnosed outside these programs. These findings can help aid women and health professionals make informed decisions regarding screening.

Prognostic Score-Based Stratification Analysis Reveals Universal Benefits of Radiotherapy on Lowering the Risk of Ipsilateral Breast Event for Ductal Carcinoma In Situ Patients with Different Risk Levels

BACKGROUND

We aimed to analyze the effects of radiotherapy (RT) on the incidence rate of ipsilateral breast event (IBE) in ductal carcinoma in situ (DCIS) patients with lumpectomy after being stratified by prognostic score.

METHODS

We identified DCIS patients who received lumpectomy, from the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2015. Cumulative incidence functions for competing risk were used to evaluate the effects of RT on IBE risk over time. Three multivariate regression models (weighted, non-weighted, and Fine-Gray) were applied to compare the IBE risk between the RT and non-RT groups after stratifying patients by prognostic score.

RESULTS

Overall, 72,623 DCIS patients were identified from the SEER database and 49,206 (66.8%) patients received RT. During the follow-up period (ranging from 7 to 347 months), the cumulative probability of invasive and in situ IBE was significantly lower in the RT group than in the non-RT group (p < 0.001). After being stratified by prognostic score, the weighted IBE incidence rate increased as the risk level increased (p < 0.050). In multivariate regression models, RT lowered the IBE incidence rate by at least 30% in low-, moderate-, and high-risk DCIS (p < 0.010). In particular, the in situ and invasive IBE incidence rate decreased by over 50% in low-risk DCIS with RT (p < 0.001).

CONCLUSIONS

RT is associated with a lowered IBE incidence rate in DCIS patients, regardless of the assigned risk levels for patients. The significant reduction in the IBE incidence rate in low-risk DCIS patients also indicates the potential benefits for recommending RT to such a patient population in clinical practice.

The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

Ductal cancer in situ (DCIS) is mainly a screen-detected disease and although the risk for breast cancer is age-dependent, most screening programs do not include women over the age of 75 years. Older women are usually excluded from clinical trials and treatment practices are largely based on observational studies or extrapolation of trial results from younger patients, leading to either over- or under-treatment of this population. We systematically reviewed available electronic databases for DCIS treatment patterns and outcomes in older patients 15 years. Inclusion criteria allowed for randomised controlled trials, cohort studies, case-control and cross-sectional studies, as well as meta-analyses, systematic reviews and position papers. Results showed that, although elderly are not necessarily frail, they are generally treated as such by physicians, aiming to de-escalate therapeutic interventions. After adjusting for frailty, age seems to be a significant factor for less surgery; however, older women with DCIS are more probable to receive surgery than their counterparts with early invasive cancer. DCIS biology and subtypes are independent risk factors for local recurrence or progression to invasive carcinoma, if DCIS is under-treated. The end-benefit of surgery, radio- and endocrine-therapy depend on additional parameters, such as life expectancy, co-morbidities and competing risks of death. Screen-detected DCIS in older women is a challenging clinical problem, mainly due to the lack of high-level data. Therapeutic strategies should be tailored to life expectancy and performance status, DCIS features and patient preference, aiming at combining optimal oncological outcomes with maintenance of quality of life.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Breast cancer screening: Impact on care pathways

Background

Controversy persists concerning screening programs (SPs), related to a potential risk of overdiagnosis or the impact on survival. One of the main questions to be addressed concerns the aggressiveness of the related treatments.

Methods

Using the "Cancer Cohort,” a national‐based cohort (medico‐administrative database), all women between the ages of 50 and 74 years and treated in 2014 for incident breast cancer were compared, according to whether their diagnosis was made following a mammogram performed within the framework of the SP (SP group) or outside it (NSP group).

Results

A total of 23 788 women were identified: 13 530 (57%) in the SP group and 10 258 (43%) in the NSP group. The women in the SP group had a higher rate of in situ or localized invasive breast cancer. They had a higher rate of breast‐conserving surgery (82% vs 70%), and a lower rate of chemotherapy (34% vs 53%). These findings were observed irrespective of the stage. They had a higher rate of pathways involving breast‐conserving surgery followed by radiotherapy. Among women with metastatic cancer, those in the SP group had a lower proportion of liver, lung, brain, and bone metastases, and a higher proportion of lymph node metastases (other than axillary), irrespective of the time to onset of the metastases.

Conclusion

The women in whom cancer was diagnosed following a mammogram performed in the context of the SP had less advanced cancer and less aggressive treatments. This observational study helps illustrate the benefit of the SP in France using a different approach.

Comparison of Clinical and Pathologic Characteristics of Ductal Carcinoma in Situ Detected on Mammography versus Ultrasound Only in Asymptomatic Patients

The main purpose of this study was to retropectively compare the clinical and pathologic characteristics of ductal carcinoma in situ (DCIS) detected on mammography and ultrasound (US) in asymptomatic patients. From February 2014 to September 2016, 236 asymptomatic patients with primary pure DCIS and dense breasts were included. The patients were classified into two groups. The mammography group (n = 165) included patients with DCIS detected on mammography, and the US group (n = 71) included patients with DCIS detected on US only. Clinicopathologic characteristics were compared between the two groups. Subgroup analyses were performed with a cutoff age of 50 y and a cutoff tumor size of 20 mm. In 236 patients, younger age, smaller tumor size, low nuclear grade, no comedo necrosis and progesterone receptor positivity were observed more in the US group (p < 0.05). HER2 and Ki67 positivity was observed more frequently in the mammography group (p < 0.05). Similar results were obtained in 168 patients with DCIS <20 mm and in patients ≥50 y. In patients <50 y, smaller tumor size, low nuclear grade and no comedo necrosis were observed significantly more often in the US group. DCIS in the US group significantly more often manifested low nuclear grade, no comedo necrosis and hormone receptor positivity, whereas HER2 and Ki67 positivity was observed significantly more often in the mammography group.

Ductal Carcinoma In Situ Biology, Biomarkers, and Diagnosis

Ductal carcinoma in situ (DCIS) is an often-diagnosed breast disease and a known, non-obligate, precursor to invasive breast carcinoma. In this review, we explore the clinical and pathological features of DCIS, fundamental elements of DCIS biology including gene expression and genetic events, the relationship of DCIS with recurrence and invasive breast cancer, and the interaction of DCIS with the microenvironment. We also survey how these various elements are being used to solve the clinical conundrum of how to optimally treat a disease that has potential to progress, and yet is also likely over-treated in a significant proportion of cases.