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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Byng D, Thomas SM, Rushing CN, Lynch T, McCarthy A, Francescatti AB, Frank ES, Partridge AH, Thompson AM, Retèl VP, van Harten WH, Grimm LJ, Hyslop T, Hwang ES, Ryser MD. Surveillance Imaging after Primary Diagnosis of Ductal Carcinoma in Situ. Radiology 2023; 307:e221210. [PMID: 36625746 PMCID: PMC10068891 DOI: 10.1148/radiol.221210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/13/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023]
Abstract
Background Guidelines recommend annual surveillance imaging after diagnosis of ductal carcinoma in situ (DCIS). Guideline adherence has not been characterized in a contemporary cohort. Purpose To identify uptake and determinants of surveillance imaging in women who underwent treatment for DCIS. Materials and Methods A stratified random sample of women who underwent breast-conserving surgery for primary DCIS between 2008 and 2014 was retrospectively selected from 1330 facilities in the United States. Imaging examinations were recorded from date of diagnosis until first distant recurrence, death, loss to follow-up, or end of study (November 2018). Imaging after treatment was categorized into 10 12-month periods starting 6 months after diagnosis. Primary outcome was per-period receipt of asymptomatic surveillance imaging (mammography, MRI, or US). Secondary outcome was diagnosis of ipsilateral invasive breast cancer. Multivariable logistic regression with repeated measures and generalized estimating equations was used to model receipt of imaging. Rates of diagnosis with ipsilateral invasive breast cancer were compared between women who did and those who did not undergo imaging in the 6-18-month period after diagnosis using inverse probability-weighted Kaplan-Meier estimators. Results A total of 12 559 women (median age, 60 years; IQR, 52-69 years) were evaluated. Uptake of surveillance imaging was 75% in the first period and decreased over time (P < .001). Across the first 5 years after treatment, 52% of women participated in consistent annual surveillance. Surveillance was lower in Black (adjusted odds ratio [OR], 0.80; 95% CI: 0.74, 0.88; P < .001) and Hispanic (OR, 0.82; 95% CI: 0.72, 0.94; P = .004) women than in White women. Women who underwent surveillance in the first period had a higher 6-year rate of diagnosis of invasive cancer (1.6%; 95% CI: 1.3, 1.9) than those who did not (1.1%; 95% CI: 0.7, 1.4; difference: 0.5%; 95% CI: 0.1, 1.0; P = .03). Conclusion Half of women did not consistently adhere to imaging surveillance guidelines across the first 5 years after treatment, with racial disparities in adherence rates. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Rahbar and Dontchos in this issue.
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Affiliation(s)
- Danalyn Byng
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Samantha M. Thomas
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Christel N. Rushing
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Thomas Lynch
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Anne McCarthy
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Amanda B. Francescatti
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Elizabeth S. Frank
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Ann H. Partridge
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Alastair M. Thompson
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Valesca P. Retèl
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Wim H. van Harten
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Lars J. Grimm
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Terry Hyslop
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - E. Shelley Hwang
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Marc D. Ryser
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
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Byng D, Eisemann N, Schüler D, Bunk S, Leibig C, Brehmer M, Elsner S, Katalinic A. Abstract OT3-18-03: The PRAIM study: A prospective multicenter observational study of an integrated Artificial Intelligence system with live monitoring. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-ot3-18-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background. Several retrospective studies have illustrated the potential clinical benefit of artificial intelligence (AI) systems for breast cancer screening. Some systems optimize normal mammography examination triaging, while others aim to improve cancer detection. However, no AI system has shown specificity high enough to replace human radiologists, suggesting that AI should play a different role in the breast screening pathway. The decision-referral approach is a promising alternative that has demonstrated the most potential to improve radiologist screening sensitivity and specificity while reducing workload. This collaborative human-AI approach combines AI pre-screening to triage normal examinations and post-screening to prevent missed cancers. The actual performance of decision-referral, including the interaction with human radiologists, can ideally be evaluated in a prospective real-world setting. Trial design. The PRAIM (PRospective, multicenter observational study of an integrated AI system with live monitoring to support breast cancer screening) study (German Trial Register: DRKS00027322) is a prospective controlled observational non-inferiority study to compare the use of CE-marked screening software including AI support (Vara) via the decision-referral approach, with standard screening for women participating in the German breast cancer screening program. Ethics approval was obtained from the University of Lübeck Research Ethics Committee (22-043). Examinations assessed by readers using Vara are compared to examinations without Vara (control). Eligibility criteria and target accrual. Women ages 50 to 69 years old undergoing biennial breast cancer screening within the national screening program are eligible for inclusion. We expect the inclusion of approximately 400,000 women within the inclusion period of 1.5 years. Statistical methods. The primary outcome is the screen-detected cancer rate, defined as biopsy-confirmed cancer diagnoses per 1000 screening examinations. For each screening site, rates over the prospective observation period are calculated for examinations read with AI and without. To control for systematically different screen-detected cancer rates across screening sites, a historical 5-year rate is computed for each site and subtracted from the corresponding prospective rates. Non-inferiority of the screen-detected cancer rate for the AI group compared to the control group is evaluated with a weighted, mixed-effects linear regression model. AI is considered as non-inferior if the lower bound of the two-sided 95 % confidence interval for the estimated difference in screen-detected cancer rates of AI and non-AI group is not below -10 %, which corresponds to a deviation of -0.6 screen-detected cancers per 1000 examinations.
Citation Format: Danalyn Byng, Nora Eisemann, Dominik Schüler, Stefan Bunk, Christian Leibig, Moritz Brehmer, Susanne Elsner, Alexander Katalinic. The PRAIM study: A prospective multicenter observational study of an integrated Artificial Intelligence system with live monitoring [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-18-03.
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Affiliation(s)
| | - Nora Eisemann
- 2Institute for Social Medicine and Epidemiology, University of Lübeck
| | | | | | | | | | - Susanne Elsner
- 7Institute for Social Medicine and Epidemiology, University of Lübeck
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Schmitz RS, van den Belt-Dusebout AW, Clements K, Ren Y, Cresta C, Timbres J, Liu YH, Byng D, Lynch T, Menegaz B, Collyar D, Hyslop T, Schaapveld M, Sawyer E, Hwang SE, Thompson A, Ryser MD, Wesseling J, Lips EH, Schmidt MK. Abstract 686: Subsequent invasive breast cancer risk after DCIS treatment in multinational PRECISION consortium cohorts comprising 48,576 patients. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Although DCIS is a precursor of invasive breast cancer (IBC), most DCIS lesions never will progress. As we cannot distinguish reliably progressive from harmless DCIS yet, almost all women with DCIS are treated extensively with surgery and often adjuvant radiotherapy or endocrine treatment, implying overtreatment of many thousands of women with harmless DCIS. PRECISION aims to reduce such overtreatment by identifying factors associated with subsequent ipsilateral IBC. Many factors have been implicated in subsequent DCIS and IBC risk, but most studies relied on small series with limited prognostic power. To overcome this, we conducted pooled analyses of four large cohorts with DCIS from three different countries.
Methods: Cohorts were pooled with data of 48,804 women with DCIS: a population-based cohort (NL, n=18,996), prospective, a population-based, screening cohort (Sloane, UK, n=8,462), a single center cohort (MDACC, USA, n=2,363), and a representative DCIS patient series from the National Cancer Database Special Study (USA, n=18,983). Patients with missing data on treatment and follow-up or follow-up shorter than six months were excluded from analyses. Risk of a subsequent ipsilateral invasive breast cancer (iIBC) was assessed in three DCIS lesion size groups (<20mm, 20-50mm and ≥50mm) and in patients who had clear surgical margins (<2mm) after final breast conserving surgery (BCS) versus patients who did not. Cox proportional hazards models were used to assess differences in risk of IBC, with a focus on DCIS size and margin status.
Results: In final analyses, 48,576 patients, diagnosed between 1999 and 2017, were included. Median follow-up was 7.6 years (range 0.5-21.1). In multivariable analyses, patients with smaller size of DCIS (<20mm) had a decreased risk of iIBC compared with women with larger lesion size (HR 0.81; 95% CI 0.68-0.97). In 33,091 BCS treated patients, patients with clear surgical margins had a decreased risk of iIBC (HR 0.68; 95% CI 0.52-0.90).
Conclusion: In our quest to reduce overtreatment for women with DCIS, we have identified free surgical margins and smaller lesion size as independent factors reducing the risk of subsequent ipsilateral invasive breast cancer, irrespective of the treatment received. Knowledge of these, and additional, factors could aid in selecting patients suitable for less invasive management strategies such as active surveillance or omitting radiotherapy. This work was supported by Cancer Research UK and by KWF Dutch Cancer Society (ref.C38317/A24043); Web site: https://cancergrandchallenges.org/teams/precision
Citation Format: Renee S. Schmitz, Alexandra W. van den Belt-Dusebout, Karen Clements, Yi Ren, Chiara Cresta, Jasmine Timbres, Yat-Hee Liu, Danalyn Byng, Thomas Lynch, Brian Menegaz, Deborah Collyar, Terry Hyslop, Michael Schaapveld, Elinor Sawyer, Shelley E. Hwang, Alastair Thompson, Marc D. Ryser, Jelle Wesseling, Esther H. Lips, Marjanka K. Schmidt, Grand Challenge PRECISION Consortium. Subsequent invasive breast cancer risk after DCIS treatment in multinational PRECISION consortium cohorts comprising 48,576 patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 686.
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Affiliation(s)
| | | | | | - Yi Ren
- 3Duke University, Durham, NC
| | - Chiara Cresta
- 1Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Yat-Hee Liu
- 1Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Danalyn Byng
- 1Netherlands Cancer Institute, Amsterdam, Netherlands
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Lopes Cardozo JMN, Byng D, Drukker CA, Schmidt MK, Binuya MA, van 't Veer LJ, Cardoso F, Piccart M, Smorenburg CH, Poncet C, Rutgers EJT. Outcome without any adjuvant systemic treatment in stage I ER+/HER2- breast cancer patients included in the MINDACT trial. Ann Oncol 2021; 33:310-320. [PMID: 34861376 DOI: 10.1016/j.annonc.2021.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/26/2021] [Accepted: 11/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adjuvant systemic treatments (AST) reduce mortality, but have associated short- and long-term toxicities. Careful selection of patients likely to benefit from AST is needed. We evaluated outcome of low-risk breast cancer patients of the EORTC 10041/BIG 3-04 MINDACT trial who received no AST. PATIENTS AND METHODS Patients with estrogen receptor-positive, HER2-negative, lymph node-negative tumors ≤2 cm who received no AST were matched 1 : 1 to patients with similar tumor characteristics treated with adjuvant endocrine therapy (ET), using propensity score matching and exact matching on age, genomic risk (70-gene signature) and grade. In a post hoc analysis, distant metastasis-free interval (DMFI) and overall survival (OS) were assessed by Kaplan-Meier analysis and hazard ratios (HR) by Cox regression. Cumulative incidences of locoregional recurrence (LRR) and contralateral breast cancer (CBC) were assessed with competing risk analyses. RESULTS At 8 years, DMFI rates were 94.8% [95% confidence interval (CI) 92.7% to 96.9%] in 509 patients receiving no AST, and 97.3% (95% CI 95.8% to 98.8%) in 509 matched patients who received only ET [absolute difference: 2.5%, HR 0.56 (95% CI 0.30-1.03)]. No statistically significant difference was seen in 8-year OS rates, 95.4% (95% CI 93.5% to 97.4%) in patients receiving no AST and 95.6% (95% CI 93.8% to 97.5%) in patients receiving only ET [absolute difference: 0.2%, HR 0.86 (95% CI 0.53-1.41)]. Cumulative incidence rates of LRR and CBC were 4.7% (95% CI 3.0% to 7.0%) and 4.6% (95% CI 2.9% to 6.9%) in patients receiving no AST versus 1.4% (95% CI 0.6% to 2.9%) and 1.5% (95% CI 0.6% to 3.1%) in patients receiving only ET. CONCLUSIONS In patients with stage I low-risk breast cancer, the effect of ET on DMFI was limited, but overall significantly fewer breast cancer events were observed in patients who received ET, after the relatively short follow-up of 8 years. These benefits and side-effects of ET should be discussed with all patients, even those at a very low risk of distant metastasis.
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Affiliation(s)
- J M N Lopes Cardozo
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - D Byng
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C A Drukker
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - M K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M A Binuya
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - L J van 't Veer
- Department of Laboratory Medicine, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, USA
| | - F Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - M Piccart
- Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - C H Smorenburg
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Poncet
- European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - E J T Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Byng D, Retèl VP, Engelhardt EG, Groothuis-Oudshoorn CGM, van Til JA, Schmitz RSJM, van Duijnhoven F, Wesseling J, Bleiker E, van Harten WH. Preferences of Treatment Strategies among Women with Low-Risk DCIS and Oncologists. Cancers (Basel) 2021; 13:3962. [PMID: 34439126 PMCID: PMC8394332 DOI: 10.3390/cancers13163962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 12/27/2022] Open
Abstract
As ongoing trials study the safety of an active surveillance strategy for low-risk ductal carcinoma in situ (DCIS), there is a need to explain why particular choices regarding treatment strategies are made by eligible women as well as their oncologists, what factors enter the decision process, and how much each factor affects their choice. To measure preferences for treatment and surveillance strategies, women with newly-diagnosed, primary low-risk DCIS enrolled in the Dutch CONTROL DCIS Registration and LORD trial, and oncologists participating in the Dutch Health Professionals Study were invited to complete a discrete choice experiment (DCE). The relative importance of treatment strategy-related attributes (locoregional intervention, 10-year risk of ipsilateral invasive breast cancer (iIBC), and follow-up interval) were discerned using conditional logit models. A total of n = 172 patients and n = 30 oncologists completed the DCE. Patient respondents had very strong preferences for an active surveillance strategy with no surgery, irrespective of the 10-year risk of iIBC. Extensiveness of the locoregional treatment was consistently shown to be an important factor for patients and oncologists in deciding upon treatment strategies. Risk of iIBC was least important to patients and most important to oncologists. There was a stronger inclination toward a twice-yearly follow-up for both groups compared to annual follow-up.
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Affiliation(s)
- Danalyn Byng
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (V.P.R.); (E.G.E.); (E.B.); (W.H.v.H.)
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (C.G.M.G.-O.); (J.A.v.T.)
| | - Valesca P. Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (V.P.R.); (E.G.E.); (E.B.); (W.H.v.H.)
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (C.G.M.G.-O.); (J.A.v.T.)
| | - Ellen G. Engelhardt
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (V.P.R.); (E.G.E.); (E.B.); (W.H.v.H.)
- Division of Molecular Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.)
| | - Catharina G. M. Groothuis-Oudshoorn
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (C.G.M.G.-O.); (J.A.v.T.)
| | - Janine A. van Til
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (C.G.M.G.-O.); (J.A.v.T.)
| | - Renée S. J. M. Schmitz
- Division of Molecular Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.)
| | - Frederieke van Duijnhoven
- Division of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands;
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.)
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Eveline Bleiker
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (V.P.R.); (E.G.E.); (E.B.); (W.H.v.H.)
- Department of Clinical Genetics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Wim H. van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (V.P.R.); (E.G.E.); (E.B.); (W.H.v.H.)
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (C.G.M.G.-O.); (J.A.v.T.)
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Byng D, Retel VP, van Harten W, Rushing CN, Thomas SM, Lynch T, McCarthy A, Francescatti AB, Frank ES, Partridge AH, Thompson AM, Grimm L, Hyslop T, Hwang ESS, Ryser MD. Disparities in surveillance imaging after breast conserving surgery for primary DCIS. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.6516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6516 Background: Due to the elevated risk of ipsilateral invasive breast cancer (iIBC) after diagnosis with primary ductal carcinoma in situ (DCIS), professional guidelines recommend surveillance screening within 6-12 months (mo) after completion of initial local treatment and annually thereafter. To characterize adherence to these guidelines, we explored longitudinal patterns of utilization and factors associated with the use of surveillance imaging (mammography, MRI, ultrasound) for women with primary DCIS treated with breast conserving surgery (BCS) ± radiotherapy (RT) within 6 mo of diagnosis. Methods: A treatment-stratified random sample of patients diagnosed with screen-detected and biopsy-confirmed DCIS in 2008-15 was selected from 1,330 Commission on Cancer-accredited facilities (up to 20/site) in the US. All imaging exams coded as asymptomatic were collected from 6 mo up to 10 years (yr) post-diagnosis. Time was defined according to 12-mo long surveillance periods. To be included in a given surveillance period, women had to be alive and free of a new breast cancer diagnosis through the end of the period. Women were classified as “consistent” screeners if they had at least one surveillance screen during each period, for the first 5 yr post-treatment or until censoring, whichever occurred first. Repeated measures multivariable logistic regression with generalized estimating equations was used to model receipt of surveillance breast imaging over time. The model included clinical and socioeconomic features. Results: The final analytic cohort contained 12,559 women; 8,989 (71.6%) received RT after BCS. Median age was 60 yr (interquartile range: 52-69) and median follow-up was 5.6 yr (95% confidence interval [CI] 5.6-5.7). Among women who received BCS (instead of BCS+RT), 62.5% (79.7%) underwent surveillance imaging within 6-18 mo after diagnosis. 38.7% (54.0%) were categorized as “consistent” screeners. Compared to white women, Black women were less likely to receive surveillance screening after treatment for primary DCIS (odds ratio [OR] 0.85, 95% CI 0.77-0.94). Hispanic ethnicity had a similar association (OR 0.86, 95% CI 0.74-0.99) compared to non-Hispanic ethnicity. Women with private insurance, compared to government insurance, were more likely to receive screening (OR 1.20, 95% CI 1.11-1.30). Prognostic tumor features indicative of a higher risk of subsequent iIBC, including higher grade, presence of comedonecrosis, and hormone receptor-negative DCIS, were not associated with screening uptake. Conclusions: Despite guidelines recommending annual surveillance imaging, many women with primary DCIS do not undergo regular imaging after BCS. The findings from this US-based study suggest that disparities in screening uptake are associated with race/ethnicity and insurance status rather than prognostic tumor features.
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Affiliation(s)
- Danalyn Byng
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - Samantha M. Thomas
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Durham, NC
| | | | | | | | | | | | | | - Lars Grimm
- Duke University Medical Center, Durham, NC
| | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
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Cardozo JMNL, Byng D, Drukker CA, Schmidt MK, van 't Veer LJ, Cardoso F, Piccart M, Poncet C, Rutgers EJT. Abstract PS11-01: Outcome without adjuvant systemic treatment in breast cancer patients included in the MINDACT trial. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps11-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Adjuvant systemic treatments have played an important role in the decline of breast cancer mortality over the years. Because of the extensive short- and long-term toxicities associated with these treatments, careful selection of patients likely to benefit from them is needed. Studies have shown excellent survival in subgroups of patients receiving no adjuvant systemic treatments. Some national guidelines advise no adjuvant systemic treatments in specific groups of patients with clinical low risk breast cancer. The aim of this study is to investigate the survival of breast cancer patients who received no adjuvant treatment (chemotherapy nor endocrine therapy) using data from the EORTC 10041/BIG 3-04 MINDACT trial. Material and methods: Of the 6693 patients enrolled in the MINDACT trial, accrued 2007-2011, 509 patients with hormone receptor positive, HER2 negative, lymph node negative tumors <2cm received no adjuvant systemic treatment, mostly following local recommendations. Median follow-up was 8.7 years. Using propensity score matching and exact matching, we will identify groups of patients treated with adjuvant endocrine therapy and/or chemotherapy with similar tumor characteristics to the untreated patients. We will use the Kaplan-Meier method to estimate distant metastasis free interval and overall survival at 5 and 8 years for each group. Differences between groups will be evaluated using the log-rank test, and hazard ratios with 95% CI derived from Cox proportional hazards models. Planned analyses: The long-term data of the MINDACT trial has recently become available. The date of planned analysis is August 10th 2020.For this study, the primary clinical endpoint will be distant metastasis free interval, which will be assessed in the matched groups of untreated patients, patients who received endocrine therapy only, and patients who received chemotherapy with or without endocrine therapy. Kaplan-Meier estimates will be provided at 5 years, and at 8 years to assess the long-term outcomes in this population. A statistical plan for this analysis was specifically developed and approved prior to performing any analysis.
Citation Format: Josephine MN Lopes Cardozo, Danalyn Byng, Caroline A Drukker, Marjanka K Schmidt, Laura J van 't Veer, Fatima Cardoso, Martine Piccart, Coralie Poncet, Emiel JTh Rutgers. Outcome without adjuvant systemic treatment in breast cancer patients included in the MINDACT trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-01.
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Affiliation(s)
| | - Danalyn Byng
- 1Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - Fatima Cardoso
- 4Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Martine Piccart
- 5Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Byng D, Retèl VP, Schaapveld M, Wesseling J, van Harten WH. Treating (low-risk) DCIS patients: What can we learn from real-world cancer registry evidence? Breast Cancer Res Treat 2021; 187:187-196. [PMID: 33389397 PMCID: PMC8062323 DOI: 10.1007/s10549-020-06042-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Results from active surveillance trials for ductal carcinoma in situ (DCIS) will not be available for > 10 years. A model based on real-world data (RWD) can demonstrate the comparative impact of non-intervention for women with low-risk features. METHODS Multi-state models were developed using Surveillance, Epidemiology, and End Results Program (SEER) data for three treatment strategies (no local treatment, breast conserving surgery [BCS], BCS + radiotherapy [RT]), and for women with DCIS low-risk features. Eligible cases included women aged ≥ 40 years, diagnosed with primary DCIS between 1992 and 2016. Five mutually exclusive health states were modelled: DCIS, ipsilateral invasive breast cancer (iIBC) ≤ 5 years and > 5 years post-DCIS diagnosis, contralateral IBC, death preceded by and death not preceded by IBC. Propensity score-weighted Cox models assessed effects of treatment, age, diagnosis year, grade, ER status, and race. RESULTS Data on n = 85,982 women were used. Increased risk of iIBC ≤ 5 years post-DCIS was demonstrated for ages 40-49 (Hazard ratio (HR) 1.86, 95% Confidence Interval (CI) 1.34-2.57 compared to age 50-69), grade 3 lesions (HR 1.42, 95%CI 1.05-1.91) compared to grade 2, lesion size ≥ 2 cm (HR 1.66, 95%CI 1.23-2.25), and Black race (HR 2.52, 95%CI 1.83-3.48 compared to White). According to the multi-state model, propensity score-matched women with low-risk features who had not died or experienced any subsequent breast event by 10 years, had a predicted probability of iIBC as first event of 3.02% for no local treatment, 1.66% for BCS, and 0.42% for BCS+RT. CONCLUSION RWD from the SEER registry showed that women with primary DCIS and low-risk features demonstrate minimal differences by treatment strategy in experiencing subsequent breast events. There may be opportunity to de-escalate treatment for certain women with low-risk features: Hispanic and non-Hispanic white women aged 50-69 at diagnosis, with ER+, grade 1 + 2, < 2 cm DCIS lesions.
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Affiliation(s)
- Danalyn Byng
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, The Netherlands.
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, The Netherlands
| | - Michael Schaapveld
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, The Netherlands
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Byng D, Retèl V, Schaapveld M, Wesseling J, van Harten W. Non-intervention vs. surgical interventions in (Low-Risk) Ductal Carcinoma In Situ: A DCIS multi-state model for decision analytics. Eur J Cancer 2020. [DOI: 10.1016/s0959-8049(20)30584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Byng D, Lutter JI, Wacker ME, Jörres RA, Liu X, Karrasch S, Schulz H, Vogelmeier C, Holle R. Determinants of healthcare utilization and costs in COPD patients: first longitudinal results from the German COPD cohort COSYCONET. Int J Chron Obstruct Pulmon Dis 2019; 14:1423-1439. [PMID: 31308648 PMCID: PMC6616193 DOI: 10.2147/copd.s201899] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/30/2019] [Indexed: 12/25/2022] Open
Abstract
Background In light of overall increasing healthcare expenditures, it is mandatory to study determinants of future costs in chronic diseases. This study reports the first longitudinal results on healthcare utilization and associated costs from the German chronic obstructive pulmonary disease (COPD) cohort COSYCONET. Material and methods Based on self-reported data of 1904 patients with COPD who attended the baseline and 18-month follow-up visits, direct costs were calculated for the 12 months preceding both examinations. Direct costs at follow-up were regressed on baseline disease severity and other co-variables to identify determinants of future costs. Change score models were developed to identify predictors of cost increases over 18 months. As possible predictors, models included GOLD grade, age, sex, education, smoking status, body mass index, comorbidity, years since COPD diagnosis, presence of symptoms, and exacerbation history. Results Inflation-adjusted mean annual direct costs increased by 5% (n.s., €6,739 to €7,091) between the two visits. Annual future costs were significantly higher in baseline GOLD grades 2, 3, and 4 (factors 1.24, 95%-confidence interval [1.07–1.43], 1.27 [1.09–1.48], 1.57 [1.27–1.93]). A history of moderate or severe exacerbations within 12 months, a comorbidity count >3, and the presence of dyspnea and underweight were significant predictors of cost increase (estimates ranging between + €887 and + €3,679, all p<0.05). Conclusions Higher GOLD grade, comorbidity burden, dyspnea and moderate or severe exacerbations were determinants of elevated future costs and cost increases in COPD. In addition we identified underweight as independent risk factor for an increase in direct healthcare costs over time.
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Affiliation(s)
- Danalyn Byng
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, GmbH - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research , 85764 Neuherberg, Germany.,Institute for Medical Informatics, Biometry and Epidemiology (IBE), Ludwig-Maximilians-University Munich (LMU) , 81377 Munich, Germany
| | - Johanna I Lutter
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, GmbH - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research , 85764 Neuherberg, Germany
| | - Margarethe E Wacker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, GmbH - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research , 85764 Neuherberg, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich , 80336 Munich, Germany
| | - Xiaofei Liu
- Institute for Biostatistics, Hannover Medical School , 30625 Hannover, Germany
| | - Stefan Karrasch
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich , 80336 Munich, Germany.,Institute of Epidemiology, Helmholtz Zentrum München (GmbH) - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL) , 85764 Neuherberg, Germany
| | - Holger Schulz
- Institute of Epidemiology, Helmholtz Zentrum München (GmbH) - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL) , 85764 Neuherberg, Germany
| | - Claus Vogelmeier
- Department of Respiratory Medicine, University of Marburg, University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research, 35043 Marburg, Germany
| | - Rolf Holle
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, GmbH - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research , 85764 Neuherberg, Germany
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Kohler JC, Mitsakakis N, Saadat F, Byng D, Martinez MG. Does Pharmaceutical Pricing Transparency Matter? Examining Brazil's Public Procurement System. Global Health 2015; 11:34. [PMID: 26238110 PMCID: PMC4523918 DOI: 10.1186/s12992-015-0118-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We review procurement and pricing transparency practices for pharmaceutical products. We specifically focus on Brazil and examine its approach to increasing pricing transparency, with the aim of determining the level of effectiveness in lower prices using a tool (Banco de Preços em Saúde, BPS) that only reveals purchase prices as compared to other tools (in other countries) that establish a greater degree of price transparency. METHODS A general report of Preços em Saúde (BPS) and Sistema Integrado de Administração de Serviços Gerais (SIASG) pricing data was created for 25 drugs that met specific criteria. To explore the linear time trend of each of the drugs, separate regression models were fitted for each drug, resulting in a total of 19 models. Each model controlled for the state variable and the interaction between state and time, in order to accommodate expected heterogeneity in the data. Additionally, the models controlled for procurement quantities and the effect they have on the unit price. Secondary analysis using mixed effects models was also carried out to account for the impact that institutions and suppliers may have upon the unit price. Adjusting for these predictor variables (procurement quantities, supplier, purchasing institution) was important to determine the sole effect that time has had on unit prices. A total of 2 x 19 = 38 models were estimated to explore the overall effect of time on changes in unit price. All statistical analyses were performed using the R statistical software, while the linear mixed effects models were fitted using the lme4 R package. RESULTS The findings from our analysis suggest that there is no pattern of consistent price decreases within the two Brazilian states during the five-year period for which the prices were analyzed. CONCLUSIONS While the BPS does allow for an increase in transparency and information on drug purchase prices in Brazil, it has not shown to lead to consistent reductions in drug purchase prices for some of the most widely used medicines. This is indicative of a limited model for addressing the challenges in pharmaceutical procurement and puts into question the value of tools used globally to improve transparency in pharmaceutical pricing.
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Affiliation(s)
- Jillian Clare Kohler
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON, M5S 3M2, Canada. .,Munk School of Global Affairs, University of Toronto, 1 Devonshire Place, Toronto, ON, M5S 3K7, Canada.
| | - Nicholas Mitsakakis
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON, M5S 3M2, Canada. .,Toronto Health Economics and Technology Assessment (THETA) Collaborative, 144 College St., Toronto, ON, M5S 3M2, Canada.
| | - Faridah Saadat
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON, M5S 3M2, Canada
| | - Danalyn Byng
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON, M5S 3M2, Canada. .,Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada.
| | - Martha Gabriela Martinez
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON, M5S 3M2, Canada.
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