Unilateral Ductal Carcinoma In Situ Research Articles

The Role of Residential Segregation in Treatment and Outcomes of Ductal Carcinoma in Situ of the Breast.

It remains unclear if residential segregation impacts on clinical treatment and outcomes for ductal carcinoma in situ (DCIS), a nonobligate precursor to invasive breast cancer (IBC). This population-based retrospective cohort study included adult non-Hispanic White (NHW) and Black (NHB) women diagnosed with unilateral DCIS between January 1990 and December 2015, followed through December 2016, and identified from the Surveillance, Epidemiology, and End Results dataset. County-level racialized economic segregation was measured using the Index of Concentration at the Extremes. Multilevel logistic regression and Cox proportional hazards regression accounting for county-level clustering were used to estimate the odds ratios (ORs) of local treatment, and hazard ratios (HRs) of subsequent IBC and mortality. Of 103,898 cases, mean age was 59.5 years, 12.5% were NHB, 87.5% were NHW, 97.5% underwent surgery, 64.5% received radiotherapy following breast-conserving surgery, 7.1% developed IBC, and 18.6% died from all causes. Among women living in the least vs most privileged counties, we observed higher odds of receiving mastectomy (vs breast-conserving surgery) (OR=1.51, 95% CI 1.35-1.69; Ptrend<0.001) and radiation therapy following breast-conserving surgery (OR=1.27, 95% CI 1.07-1.51; Ptrend<0.01); the risk was higher in subsequent ipsilateral IBC (HR=1.16, 95% CI 1.02-1.32; Ptrend=0.04), not in breast cancer-specific mortality (HR=1.04, 95% CI 0.88-1.23; Ptrend=0.56). The results provide evidence for disparities in clinical treatment for DCIS and prognostic outcomes among women in racially and economically segregated counties. Our findings may inform geographically targeted multilevel interventions to reduce breast cancer burden and improve breast cancer care and equity.

Preoperative breast MRI positively impacts surgical outcomes of needle biopsy–diagnosed pure DCIS: a patient-matched analysis from the MIPA study

ObjectivesTo investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS).MethodsThe MIPA observational study database (7245 patients) was searched for patients aged 18–80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs).ResultsOf 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111).ConclusionsCompared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation.Clinical relevance statementWhen confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies.Key Points• Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS.• When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI.• The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.

Endocrine therapy initiation among women diagnosed with ductal carcinoma in situ breast cancer from 2001-2016.

487 Background: Endocrine therapy (ET) initiation in people within 1 year of diagnosis of estrogen-receptor-positive (ER+) ductal carcinoma in situ (DCIS) has ranged from 21-45% in prior studies; however, these studies did not evaluate initiation post-2011 and may not reflect current patterns of use. ET use following ER+ DCIS diagnosis can reduce the relative risks of recurrence and contralateral breast cancer by 30-50%. We evaluated ET initiation over time and by demographic, tumor, and treatment characteristics in the Kaiser Permanente Breast Cancer Survivors Study between 2001-2016. Methods: We included people aged 20+ years diagnosed with unilateral DCIS with at least 1 year of cancer-free follow-up from three U.S. integrated health systems. We excluded people with ER-negative disease, no surgery, and those who received chemotherapy or unknown radiation therapy. ET dispensings (tamoxifen and aromatase inhibitors) were extracted from electronic pharmacy records within 1 year of a person’s initial DCIS breast cancer diagnosis. Using generalized linear models with a log link and Poisson distribution, we estimated relative rates (RRs) of ET use (vs none) over time and by demographic, tumor, and other treatment characteristics. Results: Among 1,782 pre- and postmenopausal people, 577 (32%) initiated ET within 1 year of diagnosis. From 2001-2016, ET use did not change over time (34% vs 36%), tamoxifen use declined slightly (34% vs 29%), and aromatase inhibitor use increased slightly (0% vs 7%). People were less likely to initiate ET if they were ≥65 years, Black, had borderline or unknown ER status, were not tested for ER, had breast conserving surgery (BCS) without radiation, or had a unilateral mastectomy. Conclusions: Only one-third of people with DCIS diagnosed in a community healthcare setting and potentially eligible for ET, initiated treatment within 1 year of their diagnosis. Previous studies have shown long-term benefits of ET use in people with DCIS; however, we saw no increase in use over time. Concerns about side-effects, overdiagnosis and overtreatment of DCIS, and confusion about treatment guidelines may explain relatively low ET initiation.[Table: see text]

Impact of germline mutations on surgical decision-making in women with DCIS.

10576 Background: Ductal carcinoma in situ (DCIS) is both a malignant, yet pre-invasive disease of the breast. While the majority of DCIS have a low risk of recurrence, a subset of women with germline pathogenic variants (PV) in cancer predisposition genes are at increased risk for breast cancer recurrence. Uptake of genetic testing and treatment with risk-reducing surgeries (RRS), including bilateral mastectomy (BM), in women with DCIS, has not been well-studied. The aim of this study was to determine the prevalence of PVs in women with DCIS and the impact on surgical decision making. Methods: All women diagnosed with unilateral DCIS 2001-2020 enrolled in the Clinical Breast Care Project were identified. Demographic, genetic test results and surgical procedures were extracted from the database. Test-eligibility was assigned using National Comprehensive Cancer Network (NCCN) criteria. Panel genetic testing was performed in the research setting using DNA from 465 women. Statistical analyses were performed using Fisher’s exact tests and Chi-square analyses with p &lt; 0.05 defining significance. Results: The overall PV frequency in women with DCIS was 8.1%. Within the test-eligible group, 35.1% pursued clinical genetic testing, including 13.2% who pursued testing only after a second cancer event. Of the 39 women with PV, 20 (51.3%) were detected only in the research setting, with 11 (28.2%) of these women not eligible for genetic testing based on NCCN criteria. In the 419 women who did not undergo BM at diagnosis, recurrence was significantly higher (p = 0.001) in women with PV (33.3%) compared to those without PV (11.6%). Conclusions: Genetic testing is suboptimal in women with a primary diagnosis of DCIS. Twenty percent of women with PV, who may have benefited from BM, did not undergo genetic testing at the time of diagnosis and recurred. These data suggest that genetic testing at the time of diagnosis should be standard for all women with DCIS.

Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging

Guiding treatment decisions for women with ductal carcinoma in situ (DCIS) requires understanding patient preferences and the influence of preoperative magnetic resonance imaging (MRI) and surgeon recommendation. To identify factors associated with surgery preference and surgery receipt among a prospective cohort of women with newly diagnosed DCIS. A prospective cohort study was conducted at 75 participating institutions, including community practices and academic centers, across the US between March 25, 2015, and April 27, 2016. Data were analyzed from August 2 to September 24, 2021. This was an ancillary study of the ECOG-ACRIN Cancer Research Group (E4112). Women with recently diagnosed unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. Participants who had documented surgery and completed the baseline patient-reported outcome questionnaires were included in this substudy. Women received preoperative MRI and surgeon consultation and then underwent wide local excision or mastectomy. Participants will be followed up for recurrence and overall survival for 10 years from the date of surgery. Patient-reported outcome questionnaires assessed treatment goals and concerns and surgery preference before MRI and after MRI and surgeon consultation. Of the 368 participants enrolled 316 (86%) were included in this substudy (median [range] age, 59.5 [34-87] years; 45 women [14%] were Black; 245 [78%] were White; and 26 [8%] were of other race). Pre-MRI, age (odds ratio [OR] per 5-year increment, 0.45; 95% CI, 0.26-0.80; P = .007) and the importance of keeping one's breast (OR, 0.48; 95% CI, 0.31-0.72; P < .001) vs removal of the breast for peace of mind (OR, 1.35; 95% CI, 1.04-1.76; P = .03) were associated with surgery preference for mastectomy. After MRI and surgeon consultation, MRI upstaging (48 of 316 [15%]) was associated with patient preference for mastectomy (OR, 8.09; 95% CI, 2.51-26.06; P < .001). The 2 variables with the highest ORs for initial receipt of mastectomy were MRI upstaging (OR, 12.08; 95% CI, 4.34-33.61; P < .001) and surgeon recommendation (OR, 4.85; 95% CI, 1.99-11.83; P < .001). In this cohort study, change in patient preference for DCIS surgery and surgery received were responsive to MRI results and surgeon recommendation. These data highlight the importance of ensuring adequate information and ongoing communication about the clinical significance of MRI findings and the benefits and risks of available treatment options.

Patient-Reported Testing Burden of Breast Magnetic Resonance Imaging Among Women With Ductal Carcinoma In Situ

The use of magnetic resonance imaging (MRI) in pretreatment planning of ductal carcinoma in situ (DCIS) remains controversial. Understanding changes in short-term health-related quality of life associated with breast MRI would allow for a more complete comparative effectiveness assessment. To assess whether there are changes in patient-reported quality of life associated with breast MRI among women diagnosed with DCIS. This cohort study was a substudy of a nonrandomized clinical trial conducted at 75 participating US institutions from March 2015 to April 2016. Women recently diagnosed with unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. A total of 355 women met the eligibility criteria and underwent the study MRI. Data analysis was performed from June 3, 2020, to July 1, 2021. Participants underwent bilateral breast MRI within 30 days of study registration and before surgery. Information on patient-reported testing burden for breast MRI was collected after MRI and before surgery. The primary outcome of this substudy was the patient-reported testing burden of breast MRI, measured by the Testing Morbidities Index (TMI) summated scale score. The TMI is a 7-item instrument that evaluates the temporary changes in quality of life associated with imaging before, during, and after the test (0 represents the worst possible, 100 the hypothetical ideal test experience). Of the 355 women who met the eligibility criteria, 244 (69%) completed both questionnaires and were included in this analysis. The median age was 59 years (range, 34-85 years). The mean MRI TMI summated scale score was 85.9 (95% CI, 84.6-87.3). Of the 244 women, 142 (58%) experienced at least some fear and anxiety before the examination, and 120 women (49%) experienced fear and anxiety during the examination. A total of 156 women (64%) experienced pain or discomfort during the examination. In multivariable analyses, greater test-related burden was associated with higher levels of cancer worry (regression coefficient, -2.75; SE, 0.94; P = .004). In this cohort study, a clinically meaningful breast MRI testing burden among women with DCIS was revealed that was significantly associated with cancer worry. Understanding the potential quality-of-life reduction associated with MRI, especially when used in combination with mammography, may allow development of targeted interventions to improve the patient experience.

Predictors of surgery preference and quality of life in DCIS after breast MRI: A trial of the ECOG-ACRIN Cancer Research Group (E4112).

6564 Background: Management of ductal carcinoma in situ (DCIS) remains variable, requiring an understanding of patient preferences and concerns to enhance the treatment decision-making process. Pre-operative MRI and surgeon recommendation can further inform surgery choice. Quality of life (QoL) is also an important consideration in treatment decision-making. The aims of this study were to assess patients’ treatment preferences before and after MRI and surgeon consultation, concordance between treatment preference and surgery received, and trends in health-related QoL (HRQL) among a prospective cohort of women newly diagnosed with DCIS. Methods: A prospective nonrandomized clinical trial by the ECOG-ACRIN Cancer Research Group (E4112) enrolled women diagnosed with unilateral DCIS from 75 institutions between March 2015 and April 2016. Participants underwent either wide local excision (WLE) or mastectomy. Surveys queried patient-reported outcomes (PRO) including treatment preference and concerns, and HRQL before and after surgery. Logistic regression models were used to associate surgery preference and actual surgery received with demographic, clinical and PRO data. Change from baseline in HRQL was assessed using linear regression. Results: At study entry, age (OR 0.39, per 5-year increment, 95%CI, 0.21-0.75; p = 0.005) and treatment goals related to the importance of keeping one’s breast (OR 0.51, 95%CI 0.34-0.76; p = 0.001) and removal of the breast for peace of mind (OR 1.46, 95%CI 1.09-1.95; p = 0.01) drove surgery preference for mastectomy vs. WLE. After receipt of MRI and surgeon consultation, surgery preference was primarily mediated by MRI upstaging (OR 11.18, 95%CI 3.19-39.16; p &lt; 0.001). Only 4% of women received a type of surgery that did not match their final treatment preference. The strongest predictors of actual surgery received were MRI upstaging (OR 15.80, 95%CI 4.85-51.46) and surgeon recommendation of mastectomy (OR 4.60, 95%CI 1.52-13.94). Receipt of a single surgery was associated with significantly improved mental health from baseline to one year after definitive surgery (p = 0.02 for mastectomy; p = 0.003 for single WLE). Self-reported Black race was an independent predictor of worsened mental (p = 0.001) and physical (p = 0.04) health at one year after definitive surgery, despite no significant racial differences in baseline HRQL. Conclusions: Our findings highlight the importance of communication between providers and patients regarding treatment preferences and goals, the clinical significance of MRI findings, and the benefits/risks of available treatment options. Future research to identify modifiable factors associated with declining mental and physical health is needed to inform targeted interventions to mitigate racial disparities and enhance HRQL in patients with DCIS.

Invasive breast cancer and breast cancer mortality after ductal carcinoma in situ in women attending for breast screening in England, 1988-2014: population based observational cohort study

ObjectiveTo evaluate the long term risks of invasive breast cancer and death from breast cancer after ductal carcinoma in situ (DCIS) diagnosed through breast screening.DesignPopulation based observational cohort study.SettingData from...

Trends in Unilateral and Contralateral Prophylactic Mastectomy Use in Ductal Carcinoma In Situ of the Breast: Patterns and Predictors.

Increased use of contralateral prophylactic mastectomy (CPM) as treatment for ductal carcinoma in situ (DCIS) in the US was first noted in the early 2000s. Optimization of treatment guidelines for DCIS requires an understanding of current surgical treatment trends, particularly as they may differ by patient sociodemographic and community resource factors. The aim of this study was to evaluate surgical treatment trends among US women with DCIS and to assess the impact of sociodemographic and community resource factors on surgical treatment choice. The Surveillance, Epidemiology, and End Results dataset was queried for women aged 40years and older who were diagnosed with unilateral DCIS between 2000 and 2014. Annual mastectomy rates were compared over time by age and race/ethnicity. Multivariable logistic regressions were performed to identify predictors of mastectomy use, with patient sociodemographics, tumor characteristics, and community resource factors (i.e. plastic surgeon density) as covariates. A total of 130,731 women with DCIS met the inclusion criteria. Overall mastectomy rates remained relatively unchanged over the study period (25-30%). CPM use increased for all age and race/ethnic groups, with the greatest increase exhibited by women aged 40-49years [relative to 2000; 2014 odds ratio (OR) 10.6]. With respect to community resource factors, CPM use, as opposed to unilateral mastectomy, was associated with counties of higher education level (OR 1.52), higher income level (OR 1.22), and lower plastic surgeon density (OR 1.26). While the popularity of mastectomy in the management of DCIS has remained relatively unchanged since the turn of the century, the use of CPM has risen substantially. Younger women with DCIS have seen the greatest increase in CPM use, a choice that remains influenced by race/ethnicity as well as income, education, and health resource availability. Until clinical risk stratifiers of DCIS are identified, the surgical decision-making paradigm must be improved so that treatment choice remains sensitive to cultural differences but becomes independent of income, education, and health resource availability.

Surgery and adjuvant radiotherapy for unilateral ductal carcinoma in situ (DCIS) in women aged over 70 years: A population based cohort study

BackgroundThere is little clinical evidence to guide treatment decisions for ductal carcinoma in situ (DCIS) in older women. This study evaluated how the management of DCIS in women aged 70 or more compared with women aged 50–69 in England and Wales. MethodThe study identified women aged ≥50 years with new unilateral DCIS diagnosed between 2014 and 2016 from linked cancer registration and routine hospital datasets for England and Wales. Rates of surgery and adjuvant radiotherapy were examined by age, deprivation, fitness measures (comorbidity and frailty), method of presentation and tumour grade using multilevel logistic regression. Results12,716 women were diagnosed with unilateral DCIS between 2014 and 2016, of whom 2,754 (22%) were aged ≥70 years and 74% were screen detected. High grade DCIS was common, irrespective of age and method of presentation. Fewer women aged ≥70 had surgery compared to women aged 50–69 (81% vs. 94%), which was only partly explained by poor fitness. Use of radiotherapy following breast conserving surgery was strongly associated with grade, and was received by less than 16% of all patients with low grade tumours. Over 70% of women aged 50–69 with high grade DCIS received radiotherapy, but this fell to 35% among women aged ≥80. Use of radiotherapy was not associated with patient fitness. ConclusionTreatment decisions for women with DCIS varied by age at diagnosis. Lower rates of surgery and adjuvant radiotherapy in older women were only partly explained by patient fitness. Better evidence is needed to aid treatment selection for older women with DCIS.

Factors associated with the increasing trend of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ: Analysis of Surveillance, Epidemiology, and End Results data

PurposeOur study aimed to investigate the factors influencing trends of contralateral prophylactic mastectomy (CPM) among patients with unilateral ductal carcinoma in situ (DCIS). Patients and MethodsWe used the Surveillance, Epidemiology, and End Results (SEER) data to identify patients with unilateral DCIS diagnosed from 1998 to 2013. Patients were categorized as breast-conserving surgery (BCS), Unilateral Mastectomy and CPM group. Univariate and multivariate logistic regressions were applied to assess the factors associated with undergoing CPM among mastectomy patients. The trends of CPM among mastectomy patients through year were presented by different subgroups of sociodemographic and pathological characteristics. ResultsOf those, 105326 patients with DCIS were identified, and 6370 patients underwent CPM. The proportion of CPM was 6.05% for all surgically-treated patients and 21.09% for mastectomy patients, and it increased more than six-fold between 1998 and 2013 (from 1.74% to 10.89% for all surgically-treated patients and from 5.44% to 37.47% for mastectomy patients). Younger age, white race, married status, smaller tumor size, positive ER and PR status were significantly associated with higher CPM proportion among mastectomy patients. The proportion of CPM was increasing through year, and the increasing trends were obvious in the subgroups of younger, white, married, metropolitan, with higher bachelor degree and higher median family income patients, while there were no apparent differences in the trends between subgroups of pathological characteristics. ConclusionThe trends of CPM among mastectomy patients were increasing through years and influenced by patients’ sociodemographic characteristics, but not pathological characteristics.

Patient Experiences and Clinician Views on the Role of Radiation Therapy for Ductal Carcinoma In Situ

To evaluate patient experiences with decisions regarding radiation therapy (RT) for ductal carcinoma in situ (DCIS), and to assess clinician views on the role of RT for DCIS with favorable features in the present era. A sample of women with newly diagnosed breast cancer from the population-based Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries were sent surveys approximately 2months after undergoing breast-conserving surgery (BCS), with a 70% response rate. The analytic sample was limited to 538 respondents with unilateral DCIS. We also surveyed 761 surgeons and radiation oncologists treating breast cancer in those regions, of whom, 539 responded (71%). After BCS, 23% of patients omitted RT, with twice the rate of omission in Los Angeles County relative to Georgia (31% vs 16%; P<.001). The most common reasons for omitting RT were advice from a clinician that it was not needed (62%) and concern about side effects (24%). Cost and transportation were not reported as influential considerations. After covariate adjustment, low- and intermediate-grade disease (odds ratio [OR] 5.5, 95% confidence interval [CI] 2.5-12; and OR 3.2, 95% CI 1.7-6.1, respectively) and Los Angeles County SEER site (OR 4.3, 95% CI 2.3-8.2) were significantly associated with greater RT omission. Of the responding clinicians, 62% would discuss RT omission for a patient with DCIS with favorable features. Clinicians in Los Angeles County were more likely to discuss RT omission than were those in Georgia (67% vs 56%; P=.01). Approximately one third of clinicians would obtain the Oncotype DX DCIS score. The heterogeneity in RT omission after BCS for DCIS continues to be substantial, with systematic differences in provider opinions across the 2 regions we studied. Enhanced precision of recurrence estimates, guidance from professional organizations, and better communication are needed to improve the consistency of treatment in this controversial area.

Subsequent risk of ipsilateral and contralateral invasive breast cancer after treatment for ductal carcinoma in situ: incidence and the effect of radiotherapy in a population-based cohort of 10,090 women.

PurposeTo assess the effect of different treatment strategies on the risk of subsequent invasive breast cancer (IBC) in women diagnosed with ductal carcinoma in situ (DCIS).MethodsUp to 15-year cumulative incidences of ipsilateral IBC (iIBC) and contralateral IBC (cIBC) were assessed among a population-based cohort of 10,090 women treated for DCIS in the Netherlands between 1989 and 2004. Multivariable Cox regression analyses were used to evaluate associations of treatment with iIBC risk.ResultsFifteen years after DCIS diagnosis, cumulative incidence of iIBC was 1.9 % after mastectomy, 8.8 % after BCS+RT, and 15.4 % after BCS alone. Patients treated with BCS alone had a higher iIBC risk than those treated with BCS+RT during the first 5 years after treatment. This difference was less pronounced for patients <50 years [hazard ratio (HR) 2.11, 95 % confidence interval (CI) 1.35–3.29 for women <50, and HR 4.44, 95 % CI 3.11–6.36 for women ≥50, P interaction < 0.0001]. Beyond 5 years of follow-up, iIBC risk did not differ between patients treated with BCS+RT or BCS alone for women <50. Cumulative incidence of cIBC at 15 years was 6.4 %, compared to 3.4 % in the general population.ConclusionsWe report an interaction of treatment with age and follow-up period on iIBC risk, indicating that the benefit of RT seems to be smaller among younger women, and stressing the importance of clinical studies with long follow-up. Finally, the low cIBC risk does not justify contralateral prophylactic mastectomies for many women with unilateral DCIS.Electronic supplementary materialThe online version of this article (doi:10.1007/s10549-016-3973-y) contains supplementary material, which is available to authorized users.

Abstract C46: Racial disparities in risk of second breast tumors after ductal carcinoma in situ: A population-based analysis

Abstract Importance: The impact of race and ethnicity on second breast tumors among women with ductal carcinoma in situ (DCIS) has not been well defined. Objective: To examine racial disparity in DCIS outcomes according to clinical characteristics of tumors. Design, Setting, and Patients: Data from 18 US Surveillance, Epidemiology and End Results registries included 102,489 women diagnosed with primary unilateral DCIS from 1988 through 2009 (white 73.6%, black 9.7%, Asian 9.0%, and Hispanic 7.7%). Patients undergoing mastectomy (n=31,899) were excluded from the analysis of ipsilateral breast recurrence. Main Outcomes and Measures: Relative risks (RRs) and their 95% confidence intervals (CI) of ipsilateral breast recurrence and contralateral breast tumors adjusted for pathologic factors, treatment, age at the diagnosis of DCIS, year of diagnosis, and registry. Results: Among 74,809 women treated with breast conserving surgery or with no surgical treatment, 2,925 (3.9%) developed ipsilateral breast recurrence during a median follow-up of 66 months. Compared with white women, black (RR=1.46; 95% CI, 1.29-1.65) and Hispanic (RR=1.18; 95% CI, 1.03-1.36) women experienced elevated risk of ipsilateral recurrence, which was similar for invasive cancer vs DCIS. A significant increase in risk of ipsilateral recurrence among black women persisted, regardless of age at the diagnosis of DCIS, treatment, tumor grade, tumor size, and histology. Overall, 3,723 (3.6%) of 102,489 women with DCIS developed contralateral breast tumors during a median follow-up of 70 months. The risk for contralateral breast tumors was significantly increased among black (RR=1.21; 95% CI, 1.08-1.36) and Asian (RR=1.16; 95% CI, 1.02-1.31) women compared with white women. Such association depended on type of events (Pheterogeneity&amp;lt;.0001); it was stronger for invasive cancer vs DCIS among black women and for DCIS vs invasive cancer among Asian women. The elevated risk of contralateral breast tumors associated with black race was more obvious among women ≥50 years at the diagnosis of DCIS and those with comedo DCIS; in contrast, a significant increase in risk among Asian women was restricted to those&amp;lt;50 years at the diagnosis of DCIS and those with noncomedo DCIS. Conclusions and Relevance: Black women with DCIS had disproportionately excess risks of second breast tumors in the ipsilateral and contralateral breasts, which could not be explained by pathologic features and treatment. The elevated risk of ipsilateral recurrence among black and Hispanic women suggests their need for more intensive follow-up and surveillance. Citation Format: Ying Liu, Graham Colditz. Racial disparities in risk of second breast tumors after ductal carcinoma in situ: A population-based analysis. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C46. doi:10.1158/1538-7755.DISP13-C46

Positive enhancement integral values in dynamic contrast enhanced magnetic resonance imaging of breast carcinoma: Ductal carcinoma in situ vs. invasive ductal carcinoma

ObjectivesThe aim of this study was to contribute to the standardization of the numeric positive enhancement integral (PEI) values in breast parenchyma, ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) and to evaluate the significance of the difference in PEI values between IDC and parenchyma, DCIS and parenchyma and IDC and DCIS. Materials and MethodsIn the prospective trial, we analyzed the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of 60 consecutive patients with histologically confirmed unilateral DCIS (n=30) and IDC (n=30) and defined the PEI values (range; mean±SD) for the lesions and the breast parenchyma. Tumor-to-non-tumor (T/NT) ratios were calculated for DCIS and IDC and compared. PEI color maps (PEICM) were created. The differences in PEI values between IDC and parenchyma and between DCIS and parenchyma were tested according to t-test. Analysis of variance (ANOVA) was used to test the differences between the mean PEI values of parenchyma, DCIS and IDC. ResultsIDC showed highly statistically different PEI numeric values compared to breast parenchyma (748.7±32.2 vs. 74.6±17.0; p<0.0001). The same applied to the differences in the group of patients with DCIS (428.0±25.0 vs. 66.0±10.6; p<0.0001). The difference between IDC, DCIS and parenchyma were also considered highly statistically significant (p<0.0001) and so were the T/NT ratios for IDC and DCIS (10.1±2.4 vs. 6.6±1.4; p<0.0001). ConclusionsPEI numeric values may contribute to differentiation between invasive and in situ breast carcinoma.

Abstract B117: Risk factors of second breast cancer among patients with ductal carcinoma in situ

Abstract Background: Women with ductal carcinoma in situ (DCIS) are at increased risk of breast cancer in either ipsilateral or contralateral breasts. However, it is inconclusive about the factors predicting the risk of second breast cancer after DCIS. Methods: We used US Surveillance, Epidemiology, and End Results data on women with first unilateral DCIS diagnosed between 1988 and 2009. Relative risks (RRs) were estimated using cox regression models to identify the factors associated with the risks of second DCIS and second invasive breast cancer (IBC). Results: Of the 74,285 eligible DCIS patients, 6,140 (8.3%) had subsequent breast cancer during 8.5 years of follow-up (714 ipsilateral DCIS, 2,003 ipsilateral IBC, 997 contralateral DCIS, and 2,426 contralateral IBC). Patients &amp;lt;50 years (RR=1.45; 95% confidence interval (CI), 1.29-1.64), black patients (RR=1.60; 95% CI, 1.39-1.83), patients with comedo DCIS (RR=1.19; 95% CI, 1.07-1.32), and patients with poorly differentiated DCIS (RR=1.45; 95% CI, 1.15-1.82) were more likely to develop ipsilateral breast cancer. Solid histologic type was more strongly associated with increased risk of ipsilateral IBC (RR=1.49; 95% CI, 1.12-1.99). The risk of contralateral breast cancer was increased among black women (RR=1.33; 95% CI, 1.16-1.52) and was decreased among young women and women with comedo DCIS, which was more obvious for contralateral IBC. Conclusion: The risk factors were different for second breast cancer in the ipsilateral breast and in the contralateral breast. Improved follow-up of young patients, black patients, patients with poorly differentiated DCIS, and patients with comedo or solid DCIS may reduce the risk of second IBC. Further investigations are needed to identify molecular features of DCIS that predict risk of second breast cancer and/or mediate racial and age differences in second cancer risk. Citation Format: Ying Liu, Graham Colditz. Risk factors of second breast cancer among patients with ductal carcinoma in situ. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr B117.

Multicentric and Contralateral Invasive Tumors Identified with Pre-op MRI in Patients Newly Diagnosed with Ductal Carcinoma In Situ of the Breast

Preoperative breast MRI in newly diagnosed cancer patients has several potential benefits. Improved survival for patients with invasive disease as the index lesion is unlikely to be one of these benefits, given what is known from variations in locoregional management in the historic conservation trials. However, this may not be the case for patients with ductal carcinoma in situ (DCIS), as the discovery of unsuspected invasive cancer located elsewhere from the biopsy-proven DCIS could result in decreased survival if left undetected and untreated. In support of this hypothesis, a previous observational study of a large cohort of DCIS patients revealed the development of invasive cancer to be the most common event after unilateral DCIS treatment, occurring in 3.9%, mostly in the opposite breast. These cancers appeared on mammography or clinical exam within a short time frame (median 2.9 years) and were associated with a diminution in survival. Given these second events occurring so soon after DCIS treatment, it must be considered that invasive cancers were present elsewhere, but mammographically occult, at the time of DCIS diagnosis. To examine this possibility, 288 consecutive patients with newly diagnosed DCIS underwent preoperative MRI, with the discovery of separate foci of invasive cancer, either multicentric or contralateral, occurring in 3.5% of patients, a similar incidence to the short-term observational study. These "elsewhere" invasive cancers are presented here with details of pathology such that both Stage I and Stage II disease can be seen as clinically significant, with the usual stage-based survival implications.

Increasing Rates of Contralateral Prophylactic Mastectomy Among Patients With Ductal Carcinoma In Situ

Some women with unilateral ductal carcinoma in situ (DCIS) undergo contralateral prophylactic mastectomy (CPM) to prevent cancer in the opposite breast. The use and trends of CPM for DCIS in the United States have not previously been reported. We used the Surveillance, Epidemiology, and End Results database to analyze the initial treatment (within 6 months) of patients with unilateral DCIS diagnosed from 1998 through 2005. We determined the CPM rate as a proportion of all surgically treated patients and as a proportion of all patients who underwent mastectomy. We compared demographic and tumor variables in women with unilateral DCIS who underwent surgical treatment. We identified 51,030 patients with DCIS; 2,072 patients chose CPM. The CPM rate was 4.1% for all surgically treated patients and 13.5% for patients undergoing mastectomy. Among all surgically treated patients (including breast-conserving surgery), the CPM rate increased by 148% from 1998 (2.1%) to 2005 (5.2%). Among patients who underwent mastectomy to treat DCIS (excluding patients undergoing breast-conserving surgery), the CPM rate increased by 188% from 1998 (6.4%) to 2005 (18.4%). Young patient age, white race, recent year of diagnosis, and the presence of lobular carcinoma in situ were significantly associated with higher CPM rates among all surgically treated patients and all patients undergoing mastectomy. Large tumor size and higher grade were significantly associated with increased CPM rates among all surgically treated patients but lower CPM rates among patients undergoing mastectomy. The use of CPM for DCIS in the United States markedly increased from 1998 through 2005.

Impact of Randomized Clinical Trial Results in the National Comprehensive Cancer Network on the Use of Tamoxifen After Breast Surgery for Ductal Carcinoma in Situ

The National Surgical Adjuvant Breast and Bowel Project B-24 trial, published in June 1999, demonstrated that tamoxifen after breast-conserving surgery (BCS) and radiotherapy for ductal carcinoma in situ (DCIS) reduced the absolute occurrence of ipsilateral and contralateral breast cancer. We assessed the impact of B-24 on practice patterns at selected National Comprehensive Cancer Network (NCCN) centers. Tamoxifen use after surgery was examined among 1,622 patients presenting for treatment of unilateral DCIS between July 1997 and December 2003 at eight NCCN centers. Associations of clinicopathologic and treatment factors with tamoxifen use were assessed in univariate and multivariable logistic regression analyses. Overall, 41% of patients (665 of 1,622) received tamoxifen. The proportion increased from 24% before July 1, 1999, to 46% on or after July 1, 1999. Factors significantly associated with receipt of tamoxifen included diagnosis on or after July 1, 1999 (odds ratio [OR], 3.85; P < .0001), BCS in patients younger than 70 years (OR, 3.21; P = .0073), no history of cerebrovascular or peripheral vascular disease (OR, 3.13; P = .0071), receipt of radiotherapy (OR, 1.82; P = .0009), and previous hysterectomy (OR, 1.34; P = .0459). Tamoxifen use varied significantly by center, from 34% to 74% after BCS and 17% to 53% after mastectomy (P < .0001). Tamoxifen use after surgery for DCIS at NCCN centers increased after presentation of the B-24 results. Rates varied substantially by institution, suggesting that physicians differ in how they weigh the modest reduction in breast cancer risk with tamoxifen against its potential adverse effects in this population.

Variations in treatment for ductal carcinoma in situ in elderly women.

The objective of this study is to quantify variation and variability in treatment of ductal carcinoma in situ (DCIS) over time and across registries of the Surveillance, Epidemiology, and End Results (SEER) program; to assess diffusion of treatments (breast-conserving surgery [BCS], BCS with radiotherapy, and mastectomy); and to identify correlates of treatment choice. The linked SEER-Medicare database from 1991 to 1996 includes 2701 women aged 65 and older diagnosed with unilateral DCIS. 1990 census data provide socioeconomic variables at the zip-code level, and the 1999 Dartmouth Atlas of Health Care provides number of radiation oncologists. Bivariate and multivariate analyses of retrospective cohort data assess factors that explain treatment choice. The multivariate model includes controls for comorbidity, marital status, age, race, education, poverty, rural, and radiation oncologists per 100,000 population. Chi-squared tests assess differences in treatment rates by registry and by year. Diffusion of treatments is analyzed by predicting yearly mean treatment rates and yearly variation in treatment rates across geographic areas and over time. There are significant geographic and temporal differences in treatment rates for DCIS with increasing use of BCS alone. Treatment choice is explained by SEER registry, diagnosis year, marital status, race, age, urban/rural status, educational attainment, and number of radiation oncologists. Variability in treatment of DCIS is increasing during the study period. Findings indicate that diagnosis year and socioeconomic factors explain treatment choice for DCIS, but unexplained variation at the geographic-region level remains. Increasing variability in treatment implies continued uncertainty about optimal treatment of DCIS.