History Of Ductal Carcinoma In Situ Research Articles

A web-based personalized decision support tool for patients diagnosed with ductal carcinoma in situ: development, content evaluation, and usability testing.

Patients diagnosed with ductal carcinoma in situ (DCIS) face trade-offs when deciding among different treatments, including surgery, radiation, and endocrine therapy. A less chosen option is active monitoring. While evidence from clinical trials is not yet available, observational studies show comparable results for active monitoring and immediate treatment on cancer outcomes in select subgroups of patients. We developed and tested a web-based decision support tool (DST) to help patients explore current knowledge about DCIS and make an informed choice. The DST, an interactive web application, was informed by literature reviews and formative work with patients, breast surgeons, and health communication experts. We conducted iterative interviews to evaluate the DST content among women with and without a history of breast cancer, as well as breast cancer experts. For usability testing, we conducted an online survey among women with and without a history of breast cancer. For content evaluation, 5 women with and 10 women without a history of DCIS were interviewed. The sample included 11 White and 4 non-White women, with a mean age of 64years. The expert sample consisted of 5 attendings and a physician assistant. The feedback was used to add, clarify, or reorganize information in the DST. For usability testing, 22 participants with a mean age of 61years were recruited including 15 White and 7 Black women and 6 women with a history of DCIS. The mean usability score was 3.7 out of 5. Most participants (86%) found that the DST provided unbiased information about treatments. To improve usability, we reduced the per-page content and added navigation cues. Content and usability evaluation showed that the DST helps patients explore trade-offs of active monitoring and immediate treatment. By adopting a personalized approach, the tool will enable informed decisions aligned with patients' values and expectations.

Association between antidepressant use and second breast cancer event after ductal carcinoma in situ diagnosis: a nested case-control study.

Controversy exists regarding the potential relationship between antidepressant use and risk of breast cancer. No previous studies have evaluated the relationship between antidepressant use after diagnosis of ductal carcinoma in situ (DCIS) and risk of a subsequent breast cancer restricted to women with a history of DCIS. We conducted a population-based, nested case-control study in western Washington State. Cases included 337 women diagnosed with DCIS and a subsequent breast cancer and they were compared to 592 individually matched controls (on age, year of DCIS diagnosis, primary treatment, histology, grade, and disease-free survival time) who were diagnosed with DCIS but not a subsequent breast cancer. Information on antidepressant use after DCIS diagnosis was obtained from comprehensive medical records reviews. Antidepressant use was defined as greater or equal to 3 months of duration. Antidepressant use after initial DCIS was associated with a 1.4-fold increased risk of a subsequent breast cancer event (adjusted OR 1.41, 95% CI 1.02, 1.95). Similar risks were observed when assessing individual antidepressant classes, however, there was no sufficient power across specific classes of antidepressants. Antidepressant use after DCIS diagnosis was associated with an increased risk of subsequent breast cancer in women. Further studies are needed to confirm the associations observed.

Bisphosphonate Use and Breast Cancer Risk among Women with Ductal Carcinoma In Situ

Women with a history of ductal carcinoma in situ (DCIS) have an elevated risk of a subsequent invasive breast cancer, but there are few established potentially modifiable factors known to lower this risk. Bisphosphonates are a commonly used treatment for patients with osteoporosis and have been shown to lower risks of recurrence and mortality in patients with invasive breast cancer; however, their use has not previously been investigated within the context of DCIS. Utilizing a population-based nested case-control design, we compared 301 cases of women diagnosed with DCIS and a subsequent breast cancer and 587 individually matched controls (on age, DCIS diagnosis year, primary treatment, histology, grade, and disease-free survival time) who were diagnosed with DCIS but never a subsequent breast cancer. Information on recency and duration of bisphosphonate use was ascertained from patient interviews and medical record reviews. Current users of bisphosphonates had a reduced risk of developing an invasive breast cancer compared with never users [OR = 0.50; 95% confidence interval (CI): 0.26-0.99]. Users of bisphosphonates for ≥48 months had a similar reduction in risk (OR = 0.45; 95% CI, 0.24-1.06). This is the first study to document that bisphosphonate use is associated with a lower risk of subsequent invasive breast cancer among women with a history of DCIS. This finding is consistent with the protective effect of bisphosphonates observed in other breast cancer settings. If validated by others, bisphosphonates may be an effective risk-reducing approach with the potential added benefits of its positive impacts on bone health and fracture risk. SIGNIFICANCE: This study finds that bisphosphonate use among women with a history of DCIS is associated with lower risk of subsequent invasive breast cancer, providing a potential preventative approach for this high-risk population.

Abstract SS2-02: Patient perception of breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study

Abstract Background: The 2019 novel coronavirus has become a world-wide pandemic which has disproportionately affected patients undergoing treatment for cancer. Within the field of medical oncology, dramatic changes in practice patterns occurred rapidly to accommodate transition of resources, while maintaining safety of oncology patients. At our large cancer treatment center in NYC, there have been significant changes in the delivery of surgical and medical treatments, with a shift towards neo-adjuvant therapy, oral chemotherapy administration, extended ovarian suppression, as well as closure or delay of many clinical trials. This study aims to determine the impact of the COVID-19 pandemic on the perceived oncology related care of patients with breast/gynecologic cancers as measured by survey results, as well as the impact on quality of life (QOL) and overall health (OH). Methods: A 34-question survey was administered to all patients receiving care at our outpatient center between March 1, 2020 and June 30, 2020. Of the 622 patients who received the survey via RedCap online or physical copy in clinic, 211 (34%) completed the survey. Survey questions were answered on a 5-point Likert scale and 7-point EORTC QLQ-C30 QOL scale. There is no existing COVID specific questionnaire, therefore we designed several original questions. Difference in mean QOL scores prior to the pandemic and at the end of the response period were evaluated using a paired t-test. Results: Of the 184 patients who responded to the question about their diagnostic history, 54 (30%) of patients had a history of DCIS (ductal carcinoma in situ)/ADH (atypical ductal hyperplasia)/LCIS (lobular carcinoma in situ), 94 (51%) had a history of invasive breast cancer, 6 (3%) had a gynecologic malignancy and 30 (16%) responded “other.” Due to the COVID pandemic, 121 patients (58%) reported that they had a medical oncology visit cancelled, delayed or changed from in-person to video telehealth. Of the 156 respondents that had endocrine therapy or chemotherapy scheduled, 26 (17%) reported a cancellation or delay of their medical treatment. As a result of the pandemic, 186 (91%), 110 (57%) and 119 (60%) of patients reported new or increased levels of anxiety, depression and mood swings, respectively. A minority of patients (n=39, 19%) felt that the COVID pandemic negatively impacted their cancer care, and a majority (n=151, 73%) felt that the changes in delivering cancer care during the pandemic were in their best interest (somewhat/strongly agree). Overall, QOL was reported with a mean (SD) of 5.5 (1.3) out of 7 (1=very poor, 7-excellent) prior to the pandemic, and 5.1 (1.4) out of 7 by the end of the pandemic period (March 1 through June 30, 2020); p<0.0001. Fifty-three (26%) of patients reported having excellent (7) QOL prior to pandemic which decreased to 32 (16%) after the pandemic period; p<0.0001. Overall health was reported with a mean (SD) of 5.3 (1.3) out of 7 prior to the pandemic, and 5.1 (1.3) out of 7 by the end of the response period; p=0.0368. Conclusions: The COVID-19 pandemic required major changes in the care of patients with breast and gynecologic cancer in order to balance continued oncologic care with safety of COVID exposure. In our study population, 17% of patients at our center reported a delay or cancellation in their medical treatment and 58% reported a change to their medical oncology visits. Despite this, only 19% of all patients felt that the changes in care delivery as a result of the COVID-19 pandemic negatively impacted their cancer care, and the large majority (73%) felt that the changes were made in their best interest. The QOL for our patients was significantly affected by the pandemic, with increases in anxiety, depression and mood swings, and a numeric decrease in QOL and OH. Citation Format: Brittney S Zimmerman, Danielle Seidman, Natalie Berger, Krystal P Cascetta, Michelle Nezolosky, Kara Trlica, Alisa Ryncarz, Caitlin Keeton, Erin Moshier, Amy Tiersten. Patient perception of breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study [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 SS2-02.

Relationship Between Anthropometric Factors and Risk of Second Breast Cancer Among Women With a History of Ductal Carcinoma In Situ.

BackgroundWomen with ductal carcinoma in situ (DCIS) have an elevated risk of a second breast cancer, but few data are available regarding the impact of modifiable lifestyle factors on this risk.MethodsIn a population-based case–control patient study of women with a history of DCIS in western Washington diagnosed between 1996 and 2013, 497 patients diagnosed with DCIS and a second ipsilateral or contralateral invasive or in situ breast cancer were enrolled. There were 965 matched control patients with one DCIS diagnosis. Associations between anthropometric factors and risk of an invasive or in situ second breast cancer event were evaluated using conditional logistic regression. Statistical tests were two-sided.ResultsObesity (body mass index [BMI] ≥ 30 kg/m2) at initial DCIS diagnosis was associated with a 1.6-fold (95% confidence interval [CI] = 1.2 to 2.2) increased risk of any second breast cancer and a 2.2-fold increased risk of a contralateral second breast cancer (95% CI = 1.4 to 3.3) compared with normal weight women (BMI < 25 kg/m2). BMI and weight, both at initial DCIS diagnosis and at the time of the second breast cancer diagnosis, were positively associated with risk of any second and second invasive breast cancers (odds ratio = 1.01–1.04, all P ≤ .03).ConclusionsAlthough additional confirmatory studies are needed, obesity appears to be an important contributor to the risk of second breast cancers within the growing population of women with DCIS. This has potential clinical relevance with respect to identifying which women with a history of DCIS may require more careful monitoring and who may benefit from lifestyle modifications.

Long-Term Risk Perceptions of Women With Ductal Carcinoma In Situ

Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years. In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort. One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading. Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.

The management of preinvasive breast cancer

SUMMARY Ductal carcinoma in situ (DCIS) is a preinvasive breast cancer in which the proliferations of malignant ductal epithelial cells have not breached the ductal basement membrane. Currently there is controversy over the optimum management of DCIS, with suggestions that there may be an element of ‘overdiagnosis’ of some low-risk cases that may never progress to invasive cancer within a patient’s lifetime. This review discusses the biology and natural history of DCIS and current management strategies, addresses the risk factors for recurrence and how these can be minimized, highlights areas of controversy and suggest the possible direction of future research.

Abstract P2-15-01: Long-Term Risk Perceptions and Quality of Life of Women with Ductal Carcinoma In Situ

Abstract Background: Research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk of future breast cancer events. However, no prior studies have evaluated risk perceptions in long-term follow-up. Methods: As part of a multicenter longitudinal cohort study, we mailed long-term follow-up surveys to 315 of 392 women who had previously responded to a survey 18 months after they were diagnosed with DCIS (33 of the 392 were excluded because they were receiving follow-up care at outside centers, and 44 because of recurrence/death). We evaluated psychosocial distress by Hospitalized Anxiety and Depression Scale (HADS) and Revised Impact of Events Scale (RIES), quality of life (QOL) by Short Form Health Survey (SF-36), and risk perceptions with items used previously in the cohort. Results: One hundred ninety-three women (61%) responded. They were a median age of 53 yrs (range 31-89) and a median of 5.8 yrs from diagnosis (range 4.3-7.0). Twelve were excluded due to report of recurrence. Of the 181 remaining, 32% perceived at least a moderate risk of developing DCIS again within 5 yrs; 43% perceived at least a moderate lifetime risk of developing DCIS again; 27% perceived at least a moderate risk of developing invasive breast cancer within 5 yrs; 38% perceived at least a moderate lifetime risk of developing invasive breast cancer; 24% perceived at least a moderate risk of DCIS spreading to other parts of their bodies. For qualitative responses of ≥ moderate perceived risk, median quantitative risk perception was 10% regarding 5-yr risk of DCIS or invasive cancer, 20% regarding lifetime risk, and 50% pertaining to risk of DCIS spreading. The proportion of women reporting ≥ moderate perceived risk of DCIS spreading remained stable over time (25% at baseline; 26% at 18 mos), but this proportion decreased for other perceptions of risk (e.g., at baseline and 18 mos, 51% and 50% of these same women perceived ≥ moderate risk of developing DCIS again within 5 yrs). In a multivariable model, worse financial status (OR 2.6, 95% CI 1.3-5.3) and higher perceived risk on earlier surveys (OR 24.4, 95% CI 12.7-47.2) were the only predictors of ≥ moderate perception of risk of DCIS spreading to other parts of the body in long-term follow-up. Non-significant covariates included age, race, education, grade of DCIS, comedonecrosis, mastectomy, radiation, marital status, employment status, comorbidity, and HADS and RIES scores. This contrasted with earlier survey data, which demonstrated an association between higher risk perceptions and anxiety by HADS and RIES. In long-term follow-up, only 7% were found to be anxious (HADS Anxiety ≥11) and 0.6% were depressed (HADS Depression ≥11). Median SF-36 scores were 48.9 (range 15.7-58.2) and 47.1 (range 23.6-60.3) for the physical and mental components, respectively, consistent with overall good QOL. Conclusions: Women with a history of DCIS continue to harbor inaccurate perceptions of risk of future breast cancer events even at 6 yrs follow-up. Future research should evaluate how these excessive risk perceptions impact health behaviors. Interventions to improve risk perceptions are warranted. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-15-01.

Ductal carcinoma in situ (DCIS): are we overdetecting it?

DCIS constitutes approximately one-quarter of screen-detected cancer. The proportion of screen-detected cancer that is DCIS decreases with the age of the screening population. Whether detecting DCIS at mammographic screening is of benefit depends on the natural history of the DCIS detected at screening and whether DCIS detection enables the detection of invasive foci already present within DCIS lesions. The natural history of DCIS varies according to the grade of the DCIS detected. The natural history of low grade DCIS is that approximately 60% of lesions will become invasive at 40 years follow-up. The natural history of high grade DCIS derived from local recurrence rates within high grade DCIS lesions, which have been inadequately resected and not given radiotherapy, suggests an invasive risk of at least 50% at 7 years follow-up. Given the average life expectancy of women with screen-detected DCIS is 25 years, this suggests high grade DCIS is an obligate precursor of invasive disease. There is a strong correlation between the grading of invasive cancer and the grade of DCIS from which it arose. This suggests that approximately 50% of low grade DCIS detected at screening will represent overdiagnosis while overdiagnosis of high grade DCIS would be rare. The natural history of intermediate grade DCIS is as yet unknown. Only 15% of screen-detected DCIS is low grade, suggesting that overdiagnosis is uncommon. Approximately 60% of screen-detected DCIS is high grade and in the vast majority of these patients adequate treatment will be preventing the occurrence of high grade invasive breast cancer. Approximately one-third of malignant calcification clusters detected at screening mammography already has an invasive focus. These invasive foci are usually small and high grade. Data gathered from all the units in the National Health Service Breast Screening Programme indicate a strong correlation between the detection of DCIS and the detection of small invasive cancers. These data indicate that for every two cases of DCIS detected, one case of a small invasive cancer is also detected. These data indicate that DCIS detection within a mammographic screening programme prevents the occurrence of high grade invasive cancer and aides the detection of small invasive cancers at a size where treatment can be successful. Overdiagnosis will occur in approximately one-half of the cases of low grade DCIS detected. This represents approximately 2% of screen-detected lesions. If one assumes the natural history of intermediate grade DCIS is intermediate between low and high grade disease then overdiagnosis of DCIS within a screening programme may represent 3% of screen-detected lesions.

Evolving uses of hormonal agents for breast cancer therapy

Background: During the past decade, a number of new hormonal therapies (HTs) have been developed, including the selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and estrogen receptor (ER) antagonists. Their uses in breast cancer are continually evolving as new clinical trial results become available. Although tamoxifen, the most widely used HT for breast cancer, was originally approved for and used in the treatment of metastatic breast cancer (MBC), its effectiveness as MBC therapy led to its subsequent assessment and use as adjuvant and risk-reduction therapy for breast cancer. However, tamoxifen is not universally effective in these settings and is associated with infrequent known toxicities such as increased risk of thromboembolism and endometrial cancer; therefore, a search for more effective and more tolerable HTs has evolved. Objective: This article reviews the data supporting the use of newer HTs as initial treatment of MBC and their potential use as adjuvant, neoadjuvant, and chemopreventive therapies. Methods: Articles for inclusion in this manuscript were identified through the following searches, limited to English-language publications: MEDLINE (mid 1960s to January 2002), American Society of Oncology abstracts (1997–2001), and San Antonio Breast Cancer Symposium abstracts (2001 and 2002). The following search terms were used: breast cancer, breast cancer guidelines, hormonal therapies, tamoxifen, toremifine, letrozole, anastrozole, exemestane, megestrol acetate, fulvestrant, and ICI 182,780. Results: Recent studies have focused on newer agents as initial and subsequent treatment of MBC, adjuvant or neoadjuvant treatments of breast cancer, and chemopreventive agents in both healthy women and women with a history of ductal carcinoma in situ (DCIS). Results of clinical trials comparing AIs with tamoxifen as first-line MBC treatment show that AIs are as effective as, or more effective than, tamoxifen and are associated with fewer serious adverse events. Tamoxifen remains the gold standard for adjuvant therapy. However, preliminary results of ongoing clinical trials comparing tamoxifen with anastrozole suggest that anastrozole may be the superior agent. Both tamoxifen and the AIs have been shown to be active in the neoadjuvant treatment of breast cancer. Trial results have shown that tamoxifen is effective for breast cancer prevention in patients at high risk of developing breast cancer but who are otherwise healthy, patients with a history of DCIS, and patients with lobular carcinoma in situ. Conclusions: Although tamoxifen has been the gold standard of HT for breast cancer, results of ongoing trials assessing the newer HTs as initial, neoadjuvant, adjuvant, and chemopreventive therapies may substantially change our current clinical practice patterns.

In situ breast cancer.

The clinical expression of in situ cancer varies widely but is usually occult. Diagnosis can be made by a variety of minimally invasive techniques. Treatment of lobular carcinoma in situ (LCIS) is patient-directed but generally requires only close follow-up. Mastectomy is the gold standard for ductal carcinoma in situ (DCIS) and is associated with low recurrence rates. Breast conservation therapy (BCT) has become an acceptable alternative. This choice of definitive therapy for DCIS depends largely on the ability to obtain negative margins. Any attempt at BCT should be coupled with the caveat of close postoperative long-term follow-up. Patients diagnosed with LCIS or who have a history of DCIS should be given the options for the use of tamoxifen for the reduction of subsequent development of invasive breast cancer. Risk versus benefits should be clearly defined.

Ductal Carcinoma In Situ of the Breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) is detected more often since the advent of mammography. A standardized pathologic staging and grading system does not exist, but nuclear grade is assuming greater importance. The history of DCIS is long, and its treatment is a controversial issue in breast cancer today. METHODS: Data have been reviewed regarding the role of HER-2 expression as a prognostic variable, as a predictive factor for response to chemotherapy and hormonal therapies, and as a directed therapeutic target for breast cancer. RESULTS: The NSABP protocol B06 revealed a recurrence rate of 43% in patients treated with local excision alone. Half of recurrences are still DCIS, but 50% are invasive. Local control is markedly improved by the addition of radiation. Recurrence is also minimized by careful cytologic review of margins. Sentinel lymph node biopsy has resulted in more accurate nodal staging. CONCLUSIONS: As a heterogeneous lesion, DCIS may not lend itself to a uniform treatment approach. Careful analysis of resection margins is required. As our understanding of the diagnosis and treatment of this disease develops, a coordinated team approach is optimal.