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Rajeswaran T, Gojsevic M, Chan AW, Wong HCY, Lee SF, Bernard R, Marta GN, Pogoda K, Kwan JYY, Kuszaj O, Day M, Behroozian T, Bleiker EMA, Wong C, Kikawa Y, Tane K, Velikova G, Marcou Y, Bjelic-Radisic V, Karam I, Al-Khaifi M, Kennedy SKF, Chow E. Quality of life issues in patients with ductal carcinoma in situ: a systematic review. Support Care Cancer 2024; 32:695. [PMID: 39352516 DOI: 10.1007/s00520-024-08864-x] [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: 04/12/2024] [Accepted: 09/07/2024] [Indexed: 10/20/2024]
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) of the breast is one of the most common pre-invasive cancers diagnosed in women. Quality of life (QoL) is extremely important to assess in studies including these patients due to the favorable prognosis of the disease. The primary objective of this systematic review was to compile a comprehensive list of QoL issues, all existing QoL assessment tools, and patient-reported outcome measures used to assess DCIS. METHODS A search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to August 2023, using keywords such as "ductal carcinoma in-situ", "quality of life", and "patient-reported outcomes." QoL issues and QoL tools in primary research studies were extracted. RESULTS A total of 67 articles identified issues pertaining to patients with DCIS spanning physical, functional, and psychosocial QoL domains. Physical and functional issues observed in patients included pain, fatigue, and impaired sexual functioning. Psychosocial issues such as anxiety, depression, and confusion about one's disease were also common. QoL tools included those that assessed general QoL, breast cancer-specific tools, and issue-specific questionnaires. CONCLUSION The current instruments available to assess QoL in patients with DCIS do not comprehensively capture the issues that are pertinent to patients. Thus, the modification of existing tools or the creation of a DCIS-specific QoL tool is recommended to ensure that future research will be sensitive towards challenges faced by patients with DCIS.
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Affiliation(s)
- Thenugaa Rajeswaran
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Milena Gojsevic
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adrian Wai Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Clinical Oncology, Tuen Mun Hospital, Hospital Authority, Tuen Mun, Hong Kong
| | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Hospital Authority, Kowloon, Hong Kong
| | - Shing Fung Lee
- Department of Clinical Oncology, Tuen Mun Hospital, Hospital Authority, Tuen Mun, Hong Kong
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rhys Bernard
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Katarzyna Pogoda
- Department of Breast Cancer and Reconstructive Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jennifer Y Y Kwan
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Olivia Kuszaj
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Marley Day
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tara Behroozian
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Cindy Wong
- Union Oncology Centre, Kowloon, Hong Kong
| | - Yuichiro Kikawa
- Department of Breast Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Kaori Tane
- Department of Breast Surgery, Hyogo Cancer Center, Hyogo, Japan
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Yiola Marcou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, Nicosia, Cyprus
| | - Vesna Bjelic-Radisic
- Breast Unit, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Irene Karam
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Muna Al-Khaifi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samantha K F Kennedy
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.
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Leonardi MC, Zerella MA, Lazzeroni M, Fusco N, Veronesi P, Galimberti VE, Corso G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Lorubbio C, Zaffaroni M, Vincini MG, Orecchia R, Jereczek-Fossa BA, Magnoni F. Tools to Guide Radiation Oncologists in the Management of DCIS. Healthcare (Basel) 2024; 12:795. [PMID: 38610216 PMCID: PMC11011767 DOI: 10.3390/healthcare12070795] [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: 02/01/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Similar to invasive breast cancer, ductal carcinoma in situ is also going through a phase of changes not only from a technical but also a conceptual standpoint. From prescribing radiotherapy to everyone to personalized approaches, including radiotherapy omission, there is still a lack of a comprehensive framework to guide radiation oncologists in decision making. Many pieces of the puzzle are finding their place as high-quality data mature and are disseminated, but very often, the interpretation of risk factors and the perception of risk remain very highly subjective. Sharing the therapeutic choice with patients requires effective communication for an understanding of risks and benefits, facilitating an informed decision that does not increase anxiety and concerns about prognosis. The purpose of this narrative review is to summarize the current state of knowledge to highlight the tools available to radiation oncologists for managing DCIS, with an outlook on future developments.
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Affiliation(s)
- Maria Cristina Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Viviana Enrica Galimberti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Giovanni Corso
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Giulia Vincini
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Francesca Magnoni
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
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Green MD, Brenneman R, Powell SN, Bergom C. Harnessing the DNA Repair Pathway in Breast Cancer: Germline Mutations/Polymorphisms in Breast Radiation. Semin Radiat Oncol 2022; 32:298-302. [PMID: 35688528 DOI: 10.1016/j.semradonc.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Molecular profiling facilitates opportunities for personalization of breast cancer management. Increasing availability of germline and somatic sequencing provides insight into predictors of treatment efficacy and treatment tolerance of patients with breast cancer. The presence of pathologic mutations can guide patient selection for breast conserving surgery vs mastectomy. However, our understanding of the interplay between genetic variants and radiotherapy responses and side effects remains incomplete. Here we review the available data on germline mutations and polymorphisms in breast cancer. We also outline their association with treatment tolerance, locoregional outcomes, and ongoing efforts to transform these insights into more effective treatment strategies in combination with radiotherapy.
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Affiliation(s)
- Michael D Green
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI; Rogel Cancer Center, University of Michigan, Ann Arbor, MI; Department of Microbiology and Immunology, University of Michigan School of Medicine, Ann Arbor, MI; Graduate Program in Immunology, University of Michigan School of Medicine, Ann Arbor, MI; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Randall Brenneman
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | - Simon N Powell
- Department of Radiation Oncology and Molecular Biology Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO.
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Knowlton CA, Jimenez RB, Moran MS. Risk Assessment in the Molecular Era. Semin Radiat Oncol 2022; 32:189-197. [DOI: 10.1016/j.semradonc.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rakovitch E, Bonefas E, Nofech-Mozes S, Thompson AM. Ductal carcinoma in situ (DCIS)—precision medicine for de-escalation. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00407-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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: 2.5] [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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Piltin MA, Boughey JC. ASO Author's Reflections: Are Genomic Assays Informing the Management of Ductal Carcinoma in situ as They Have for Invasive Breast Cancer? Ann Surg Oncol 2021; 28:4304-4305. [PMID: 33527230 DOI: 10.1245/s10434-020-09573-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Mara A Piltin
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Piltin MA, Hoskin TL, Day CN, Shumway DA, Habermann EB, Davis J, Boughey JC. Use of the Twelve-Gene Recurrence Score for Ductal Carcinoma in Situ and Its Influence on Receipt of Adjuvant Radiation and Hormonal Therapy. Ann Surg Oncol 2021; 28:4294-4303. [PMID: 33462716 DOI: 10.1245/s10434-020-09517-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tumor genomic prognostic assays estimate 10-year local recurrence risk in ductal carcinoma in situ (DCIS) and can guide treatment decisions. This study aimed to evaluate which DCIS patients treated with breast-conserving surgery (BCS) underwent DCIS score genomic testing and the influence of the results on adjuvant treatment recommendations. METHODS The study identified patients from the National Cancer Database (NCDB) who had DCIS treated with BCS from 2010 to 2016. RESULTS Of 141,047 patients, 4255 (3%) had a DCIS score assessed, 0.3% in 2010 increasing to 5.8% in 2016 (p < 0.001). The patients most likely to undergo DCIS score assessment had more favorable tumor features in the multivariable analysis. The DCIS score result was documented for 91.4% of the tested patients (n = 3888): 70.5% of the low-risk, 14.9% of the intermediate-risk, and 14.6% of the high-risk patients. The patients with low-risk scores were less likely to have radiation than those with intermediate- or high-risk scores among the patients with either ER + (35.0% vs 71.0% or 81.1%) or ER- disease (48.1% vs 77.0% or 85.5%) (each p ≤ 0.001). The patients who had ER + disease with high- and intermediate-risk scores were most commonly treated with both radiation and hormone therapy (HT) (57.1% and 52.2%), whereas the most common treatment for those with a low-risk DCIS score was HT alone without radiation (37.1%). Comparison of genomic testing with clinicopathologic features showed an independent influence of genomic testing on treatment. CONCLUSIONS Use of the DCIS score increased over time, predominantly for favorable DCIS. Patients with a low-risk score were significantly less likely to receive radiation, supporting an impact of the DCIS score on treatment de-escalation.
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Affiliation(s)
- Mara A Piltin
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Health Science Research and Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Health Science Research and Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Health Science Research and Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - John Davis
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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A Comparison of Predicted Ipsilateral Tumor Recurrence Risks in Patients With Ductal Carcinoma in Situ of the Breast After Breast-Conserving Surgery by Breast Radiation Oncologists, the Van Nuys Prognostic Index, the Memorial Sloan Kettering Cancer Center DCIS Nomogram, and the 12-Gene DCIS Score Assay. Adv Radiat Oncol 2020; 6:100607. [PMID: 33912731 PMCID: PMC8071725 DOI: 10.1016/j.adro.2020.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose To compare ipsilateral breast event (IBE) risks in patients with ductal carcinoma in situ of the breast (DCIS) post-lumpectomy, as estimated by breast radiation oncologists, the Van Nuys Prognostic Index, the Memorial Sloan Kettering Cancer Center (MSKCC) DCIS nomogram, and the 12-gene Oncotype DX DCIS score assay. Methods and Materials Consecutive DCIS cases treated with lumpectomy from November 2011 to August 2014 with available DCIS score results were identified. Three radiation oncologists independently estimated the 10-year IBE risk. The Van Nuys Prognostic Index and MSKCC nomogram 10-year IBE risk estimates were generated. Differences and correlations between the IBE estimates and clinicopathologic factors were evaluated. Results Ninety-one patients were identified for inclusion. Forty-eight percent would have been ineligible for the E5194 study. The mean risk of IBE from the DCIS score assay was 12.4%, compared with a range of 18.9% to 26.8% from other sources. The mean IBE risk from the DCIS score assay was lower regardless of E5194 eligibility. The MSKCC nomogram and DCIS score assay risk estimates were weakly correlated with each other (P = .23) and were each moderately correlated with the other risk estimates (P = .41-.56). When applying the radiation oncologists’ treatment recommendations based on their proposed risk cutoffs, evaluating risk according to the DCIS score assay led to the highest proportion of patients recommended excision alone. Conclusions IBE risk estimates for this general community cohort of DCIS cases vary significantly among commonly available clinical predictive tools and individual radiation oncologist estimates. Surgical margins and tumor size continue to factor prominently in radiation oncologist decision algorithms. The differences found between the IBE risk estimate methods suggests that they are not interchangeable and the methods that rely on clinicopathologic features may tend to overestimate risk.
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Mullooly M, Withrow DR, Curtis RE, Fan S, Liao LM, Pfeiffer RM, de González AB, Gierach GL. Association of lifestyle and clinical characteristics with receipt of radiotherapy treatment among women diagnosed with DCIS in the NIH-AARP Diet and Health Study. Breast Cancer Res Treat 2019; 179:445-457. [PMID: 31625031 DOI: 10.1007/s10549-019-05436-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/05/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The long-term risks and benefits of radiotherapy for ductal carcinoma in situ (DCIS) remain unclear. Recent data from the Surveillance, Epidemiology and End Results (SEER) registries showed that DCIS-associated radiotherapy treatment significantly increased risk of second non-breast cancers including lung cancer. To help understand those observations and whether breast cancer risk factors are related to radiotherapy treatment decision-making, we examined associations between lifestyle and clinical factors with DCIS radiotherapy receipt. METHODS Among 1628 participants from the NIH-AARP Diet and Health Study, diagnosed with incident DCIS (1995-2011), we examined associations between lifestyle and clinical factors with radiotherapy receipt. Radiotherapy and clinical information were ascertained from state cancer registries. Odds ratios (ORs) and 95% confidence intervals (CIs) for radiotherapy receipt (yes/no) were estimated from multivariable logistic regression. RESULTS Overall, 45% (n = 730) received radiotherapy. No relationships were observed for most lifestyle factors and radiotherapy receipt, including current smoking (OR 0.97, 95%CI 0.70, 1.34). However positive associations were observed for moderate alcohol consumption and infrequent physical activity. The strongest associations were observed for radiotherapy receipt and more recent diagnoses (2005-2011 vs. 1995-1999; OR 1.60, 95%CI 1.14, 2.25), poorly versus well-differentiated tumors (OR 1.69, 95%CI 1.16, 2.46) and endocrine therapy (OR 3.37, 95%CI 2.56, 4.44). CONCLUSIONS Clinical characteristics were the strongest determinants of DCIS radiotherapy. Receipt was largely unrelated to lifestyle factors suggesting that the previously observed associations in SEER were likely not confounded by these lifestyle factors. Further studies are needed to understand mechanisms driving radiotherapy-associated second malignancies following DCIS, to identify prevention opportunities for this growing population.
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Affiliation(s)
- Maeve Mullooly
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Diana R Withrow
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Rochelle E Curtis
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Shaoqi Fan
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Linda M Liao
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | | | - Gretchen L Gierach
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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Li H, Whitney J, Bera K, Gilmore H, Thorat MA, Badve S, Madabhushi A. Quantitative nuclear histomorphometric features are predictive of Oncotype DX risk categories in ductal carcinoma in situ: preliminary findings. Breast Cancer Res 2019; 21:114. [PMID: 31623652 PMCID: PMC6798488 DOI: 10.1186/s13058-019-1200-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 09/13/2019] [Indexed: 01/23/2023] Open
Abstract
Background Oncotype DX (ODx) is a 12-gene assay assessing the recurrence risk (high, intermediate, and low) of ductal carcinoma in situ (pre-invasive breast cancer), which guides clinicians regarding prescription of radiotherapy. However, ODx is expensive, time-consuming, and tissue-destructive. In addition, the actual prognostic meaning for the intermediate ODx risk category remains unclear. Methods In this work, we evaluated the ability of quantitative nuclear histomorphometric features extracted from hematoxylin and eosin-stained slide images of 62 ductal carcinoma in situ (DCIS) patients to distinguish between the corresponding ODx risk categories. The prognostic value of the identified image signature was further evaluated on an independent validation set of 30 DCIS patients in its ability to distinguish those DCIS patients who progressed to invasive carcinoma versus those who did not. Following nuclear segmentation and feature extraction, feature ranking strategies were employed to identify the most discriminating features between individual ODx risk categories. The selected features were then combined with machine learning classifiers to establish models to predict ODx risk categories. The model performance was evaluated using the average area under the receiver operating characteristic curve (AUC) using cross validation. In addition, an unsupervised clustering approach was also implemented to evaluate the ability of nuclear histomorphometric features to discriminate between the ODx risk categories. Results Features relating to spatial distribution, orientation disorder, and texture of nuclei were identified as most discriminating between the high ODx and the intermediate, low ODx risk categories. Additionally, the AUC of the most discriminating set of features for the different classification tasks was as follows: (1) high vs low ODx (0.68), (2) high vs. intermediate ODx (0.67), (3) intermediate vs. low ODx (0.57), (4) high and intermediate vs. low ODx (0.63), (5) high vs. low and intermediate ODx (0.66). Additionally, the unsupervised clustering resulted in intermediate ODx risk category patients being co-clustered with low ODx patients compared to high ODx. Conclusion Our results appear to suggest that nuclear histomorphometric features can distinguish high from low and intermediate ODx risk category patients. Additionally, our findings suggest that histomorphometric features for intermediate ODx were more similar to low ODx compared to high ODx risk category.
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Affiliation(s)
- Haojia Li
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA.
| | - Jon Whitney
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Kaustav Bera
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Hannah Gilmore
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.,School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Sunil Badve
- Department of Pathology and Laboratory Medicine, Indiana University, Indianapolis, IN, USA
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
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GÜZELÖZ Z, ARICAN ALICIKUŞ Z, AKTÜRK N, GÜRAY M, SEVİNÇ Aİ, BALCI P, BİLKAY GÖRKEN İ. Treatment results in patients with ductal carcinoma in situ treated with adjuvant radiotherapy. Turk J Med Sci 2019; 49:1151-1156. [PMID: 31382732 PMCID: PMC7018213 DOI: 10.3906/sag-1810-53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background/aim The aim of this study was to evaluate the treatment results of patients undergoing adjuvant radiotherapy (ART) after breast surgery with the diagnosis of ductal carcinoma in situ (DCIS). Materials and methods A total of 61 women who had undergone radiotherapy following extensive surgical excision were enrolled. All patients underwent 50 Gy ART. Survival analysis was performed using Kaplan–Meier analysis and SPSS 20.0. Results The median age was 52 years (range: 28–86). The median follow-up period after RT was 92 months (range: 23–237). The median overall survival and distant and regional recurrence-free and disease-specific survival was 96 months (range: 26–240), while disease-free and local recurrence-free survival was 96 months (range: 22–240). While the 15-year and 20-year overall survival rates were 87% and 87%, respectively, the recurrence-free survival rates were 98% and 98%, respectively; the rates of disease-specific survival were 100% and 100%, respectively. Conclusion The results of this study with a long follow-up period have shown that ART in DCIS is an effective treatment method to provide local disease control. However, further large studies are needed to identify the prognostic factors.
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Affiliation(s)
- Zeliha GÜZELÖZ
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Radiation Oncology, Tepecik Regional Training and Research Hospital, University of Health Sciences, İzmirTurkey
| | - Zümre ARICAN ALICIKUŞ
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Radiation Oncology, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
| | - Nesrin AKTÜRK
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Radiation Oncology, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
| | - Merih GÜRAY
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Pathology, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
| | - Ali İbrahim SEVİNÇ
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of General Surgery, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
| | - Pınar BALCI
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Radiology, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
| | - İlknur BİLKAY GÖRKEN
- Dokuz Eylül University Medical School/Dokuz Eylül University Breast Tumor Group, İzmirTurkey
- Department of Radiation Oncology, Faculty of Medicine, Dokuz Eylül University, İzmirTurkey
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Bhutiani N, Vuong B, Egger ME, Eldredge-Hindy H, McMasters KM, Ajkay N. Evaluating patterns of utilization of gene signature panels and impact on treatment patterns in patients with ductal carcinoma in situ of the breast. Surgery 2019; 166:509-514. [PMID: 31337506 DOI: 10.1016/j.surg.2019.04.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Broad patterns of use of the gene signature panel Oncotype DX DCIS and its large-scale impact on postoperative administration of radiation therapy in women with ductal carcinoma in situ of the breast remain unclear. This study sought to evaluate the patterns of use of this gene signature panel in women with ductal carcinoma in situ and the impact of these tools on postoperative radiation therapy administration. METHODS The National Cancer Database was queried for women with ductal carcinoma in situ treated with breast-conserving therapy who had information regarding whether a gene signature panel was performed between 2010 and 2015. Demographic characteristics, the characteristics of their ductal carcinoma in situ, and whether they received postoperative radiation therapy were compared among patients who did have a gene signature panel performed and those who did not. Patterns of radiation therapy administration were also evaluated based on the recurrence risk score by the gene signature panel. RESULTS Gene signature panel use increased over time, with a sharp increase in utilization occurring in 2015 (8.0% in 2015 vs 4.4% in 2014, P < .001). Patients with estrogen receptor-positive ductal carcinoma in situ were somewhat more likely to have a gene signature panel ordered (3.9% estrogen receptor positive vs 1.7% estrogen receptor negative, P < .001), as were patients with lower-grade ductal carcinoma in situ (4.5% grade I/II vs 3.1% grade III, P < .001). Gene signature panel utilization was associated with a decrease in the administration of postoperative radiation therapy (48.6% gene signature panel vs 83.4% no gene signature panel, P < .001). Among patients in whom a gene signature panel was performed, postoperative radiation therapy was administered in 81.9%, 72.0%, and 35.9% of patients with high-, intermediate-, and low-recurrence scores, respectively. CONCLUSION Gene signature panel use in patients with ductal carcinoma in situ has increased over time and is more commonly used in women with lower-risk, clinicopathologic features to determine the magnitude of benefit afforded by radiation therapy. Gene signature panel use is associated with decreased rates of postoperative radiation therapy administration, particularly among patients with scores suggesting a low rate of recurrence.
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Affiliation(s)
- Neal Bhutiani
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY
| | - Brooke Vuong
- Department of Surgery, Division of Surgical Oncology, Kaiser Permanente Sacramento, Sacramento, CA
| | - Michael E Egger
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY
| | | | - Kelly M McMasters
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY
| | - Nicolás Ajkay
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY.
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Choi SH, Choi JS, Han BK, Ko EY, Ko ES, Park KW. Long-term Surveillance of Ductal Carcinoma in Situ Detected with Screening Mammography versus US: Factors Associated with Second Breast Cancer. Radiology 2019; 292:37-48. [PMID: 31038406 DOI: 10.1148/radiol.2019181844] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The relationship between method of breast cancer screening (mammography or US) and survival outcome in patients with screening-detected ductal carcinoma in situ (DCIS) has not been determined. Purpose To investigate whether different methods of breast cancer screening are associated with different survival outcomes in patients with screening-detected DCIS and to evaluate clinical-pathologic and imaging factors associated with second breast cancer. Materials and Methods We retrospectively identified women who underwent surgery to treat DCIS initially detected with screening mammography or US between July 2004 and December 2011 in a single institution. Overall survival (OS) and disease-free survival (DFS) were assessed. Factors associated with second breast cancer (invasive carcinoma or DCIS) were found with multivariable Cox proportional hazards regression analysis. Subgroups were analyzed according to screening method. Results A total of 814 women (median age, 47 years; age range, 25-81 years) were included; 627 underwent treatment for screening mammography-detected DCIS (mammography-detected group), and 187 underwent treatment for screening US-detected DCIS (US-detected group). During follow-up (median, 7 years; interquartile range, 5-8 years), 26 ipsilateral and 26 contralateral second breast cancers (6.4%, 52 of 814) were found, with 44 in the mammography-detected group and eight in the US-detected group. The overall 5-year OS and DFS rates were 100% and 95.3%, respectively. DFS rates did not differ according to screening method (P = .21, 5-year DFS rates were 94.9% in the mammography-detected group and 96.5% in the US-detected group). In the mammography-detected group, higher nuclear grade (intermediate grade: hazard ratio [HR], 5.7; 95% confidence interval [CI]: 1.3, 24.3; P = 0.02) (high grade: HR, 8.0; 95% CI: 1.9, 34.2; P = .01) and dense breast (HR, 3.5; 95% CI: 1.1, 11.4; P = 0.04) were associated with second breast cancer. In the US-detected group, human epidermal growth factor receptor 2 positivity was associated with second breast cancer (HR, 9.2; 95% CI: 2.2, 38.5; P = .002). Conclusion Disease-free survival of patients who underwent treatment for screening-detected ductal carcinoma in situ (DCIS) did not differ according to screening detection method. In patients with screening mammography-detected DCIS, higher nuclear grade and dense breast were associated with second breast cancer, and in patients with screening US-detected DCIS, human epidermal growth factor 2 positivity was associated with second breast cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Fowler in this issue.
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Affiliation(s)
- Seung Hee Choi
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Ji Soo Choi
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Boo-Kyung Han
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Eun Young Ko
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Eun Sook Ko
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Ko Woon Park
- From the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
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Chin C, Hirji S, Onishi M, Ha R, Taback B, Horowitz DP, Connolly EP. A Single-Institution Experience in the Preoperative Selection of DCIS Patients for IORT using the ASTRO Consensus Guidelines. Adv Radiat Oncol 2019; 4:253-260. [PMID: 31011670 PMCID: PMC6460097 DOI: 10.1016/j.adro.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/07/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose Intraoperative radiation therapy (IORT) as a form of accelerated partial breast irradiation (APBI) is controversial given the limited evidence to support its efficacy. However, it remains an attractive option for low-risk patients with ductal carcinoma in situ (DCIS), who derive a small absolute benefit in local control with standard whole breast irradiation (WBI). We examine how the American Society for Therapeutic Radiation Oncology (ASTRO) APBI consensus guidelines (CG) may be applied to the preoperative selection of patients with DCIS for IORT and determine treatment outcomes by CG group. Methods and Materials We identified patients with biopsy-proven pure DCIS enrolled in an institutional prospective registry IORT database using the Zeiss Intrabeam® device between September 2013 and February 2017. Based on available preoperative clinicopathologic information, patients were deemed suitable, cautionary, or unsuitable for IORT according to the ASTRO CG. Change in CG group based on final pathologic diagnosis was determined, and additional therapy was recommended for unsuitable patients. Outcome in terms of ipsilateral breast tumor recurrence was determined. Results A total of 61 DCIS lesions in 60 patients were treated with IORT. Preoperatively, 21 patients (35%) were suitable and 36 (59%) were cautionary. Four (6%) were unsuitable because of lesion size but declined WBI. Final pathologic diagnosis changed the CG grouping of 10 patients (16%) because of either occult high-grade disease in 2 (3%) or close/positive margins in 8 (13%). Ultimately 12 patients total were considered unsuitable, of whom 8 (66%) accepted additional WBI after IORT. At a median follow-up of 2.2 years, ipsilateral breast tumor recurrence was identified among 2 suitable, 1 cautionary, and no unsuitable patients. Conclusion Further investigation is necessary to refine selection of patients with DCIS who may be optimally treated with IORT alone. High acceptance of additional therapy among unsuitable patients resulted in excellent outcomes. The use of biomarkers in addition to traditional clinical and pathologic factors may help to better select patients for IORT.
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Affiliation(s)
- Christine Chin
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Sitara Hirji
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Maika Onishi
- Medical Oncology, Sutter Health Network, Palo Alto Foundation Medical Group, Sunnyvale, California
| | - Richard Ha
- Department of Radiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Bret Taback
- Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - David P. Horowitz
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Eileen P. Connolly
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
- Corresponding author. Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th St, CHONY North B-Level, Room 11, New York, NY 10032.
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Shee K, Muller KE, Marotti J, Miller TW, Wells WA, Tsongalis GJ. Ductal Carcinoma in Situ Biomarkers in a Precision Medicine Era: Current and Future Molecular-Based Testing. THE AMERICAN JOURNAL OF PATHOLOGY 2018; 189:956-965. [PMID: 30385093 DOI: 10.1016/j.ajpath.2018.08.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/09/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022]
Abstract
Historically, ductal carcinoma in situ (DCIS) of the breast has been managed aggressively with surgery and radiotherapy because of a risk of progression to invasive ductal carcinoma. However, this treatment paradigm has been challenged by overtreatment concerns and evidence that suggests that DCIS can be stratified according to risk of recurrence or risk of progression to invasive disease. Traditional methods of risk stratification include histologic grade and hormone receptor status. Recent technological advancements have enabled an era of precision medicine, where DCIS can be molecularly analyzed by tools, such as next-generation DNA and RNA sequencing, to identify molecular biomarkers for risk stratification. These findings have led to the development of tools such as the Oncotype DX Breast DCIS Score, a gene expression-based assay with the potential to prevent overtreatment in low-risk disease.
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Affiliation(s)
- Kevin Shee
- Department of Molecular & Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon
| | - Kristen E Muller
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jonathan Marotti
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Todd W Miller
- Department of Molecular & Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon
| | - Wendy A Wells
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gregory J Tsongalis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
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Kuerer HM. Navigating treatment controversies for DCIS in the era of genomic profiling and active surveillance trials. Eur J Surg Oncol 2018; 44:386-387. [PMID: 29398321 DOI: 10.1016/j.ejso.2017.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Henry M Kuerer
- The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, United States.
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18
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Krug D, Baumann R. Radiotherapy for Ductal Cancer In Situ (DCIS) of the Breast. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_58-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Ductal carcinoma in situ (DCIS), the noninvasive form of breast cancer (BC), comprises just over 20% of breast cancer cases diagnosed each year in the USA. Most patients are treated with local excision of the disease followed by whole breast radiation therapy. Total mastectomy is not an uncommon approach, and total mastectomy with a contralateral risk-reducing mastectomy has been on the rise in the past decade. In estrogen receptor-positive disease, patients are often offered endocrine ablative therapy with a selective estrogen receptor modulator or an aromatase inhibitor as both treatment and prevention. Local regional treatment options have no impact upon ultimate overall survival. Long-term survival rates are higher in patients with DCIS than with any other form of the disease. Are these strikingly high success rates a testament to effective treatment strategies or is there a significant subset of DCIS that was unlikely to ever progress to invasive ductal carcinoma? DCIS was not seen in the US prior to the advent of screening mammography. When compared to other countries, the USA has the highest utilization of screening mammography and the incidence rate of DCIS. Other lines of evidence include autopsy series examining the breast tissue of women who died of other causes, missed-diagnosis series and current retrospective reviews of DCIS, all align in support of the concept of DCIS as indolent in the majority of cases [3-14]. The evidence suggests that both patient and physician misconceptions about DCIS have led to overdiagnosis and over-treatment of DCIS. Recently, a gene expression profiling tool (12 gene assay, Oncotype DCIS) has emerged that shows considerable promise in predicting class in DCIS patients.
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Affiliation(s)
- Joshua Feinberg
- Department of Surgery, Maimonides Breast Center, Maimonides Medical Center, Research Fellow, Oxford University, Oxford, England
| | - Rachel Wetstone
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Dana Greenstein
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Patrick Borgen
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA.
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20
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Gorringe KL, Fox SB. Ductal Carcinoma In Situ Biology, Biomarkers, and Diagnosis. Front Oncol 2017; 7:248. [PMID: 29109942 PMCID: PMC5660056 DOI: 10.3389/fonc.2017.00248] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/02/2017] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Kylie L. Gorringe
- Cancer Genomics Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Stephen B. Fox
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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21
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Kuerer HM, Smith BD, Chavez-MacGregor M, Albarracin C, Barcenas CH, Santiago L, Edgerton ME, Rauch GM, Giordano SH, Sahin A, Krishnamurthy S, Woodward W, Tripathy D, Yang WT, Hunt KK. DCIS Margins and Breast Conservation: MD Anderson Cancer Center Multidisciplinary Practice Guidelines and Outcomes. J Cancer 2017; 8:2653-2662. [PMID: 28928852 PMCID: PMC5604195 DOI: 10.7150/jca.20871] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/14/2017] [Indexed: 12/31/2022] Open
Abstract
Recent published guidelines suggest that adequate margins for DCIS should be ≥ 2 mm after breast conserving surgery followed by radiotherapy (RT). Many groups now use this guideline as an absolute indication for additional surgery. This article describes detailed multidisciplinary practices including extensive preoperative/intraoperative pathologic/histologic image-guided assessment of margins, offering some patients with small low/intermediate grade DCIS no RT, the use/magnitude of radiation boost tailoring to margin width, and endocrine therapy for ER-positive DCIS. Use of these protocols over the past 20-years has resulted in 10-year local recurrence rates below 5% for patients with negative margins < 2 mm who received RT. Patients with margins < 2 mm who do not receive RT experience significantly higher local failure rates. Thus, there is not an absolute need to achieve wider negative surgical margins when < 2 mm for patients treated with RT and this should be determined by the multidisciplinary team. Utilization of these multidisciplinary treatment protocols and techniques may not be exportable and extrapolated to all hospitals, breast programs and systems as they can be complex and resource intensive.
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Affiliation(s)
- Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Constance Albarracin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lumarie Santiago
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary E. Edgerton
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gaiane M. Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aysegul Sahin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Savitri Krishnamurthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wendy Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debasish Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei T. Yang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly K. Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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