Quality of life over time in women diagnosed with ductal carcinoma in situ, early-stage invasive breast cancer, and age-matched controls

Little is known about quality-of-life (QOL) differences over time between incident ductal carcinoma in situ (DCIS) and early-stage invasive breast cancer (EIBC) cases as compared with same-aged women without breast cancer (controls). We prospectively recruited and interviewed 1,096 women [16.8% DCIS, 33.3% EIBC (25.7% Stage I; and 7.6% Stage IIA), 49.9% controls; mean age 58; 23.7% non-white] at mean 6.7 weeks (T1), and 6.2 (T2), 12.3 (T3), and 24.4 months (T4) after surgery (patients) or screening mammogram (controls). We tested two hypotheses: (1) DCIS patients would report lower levels of QOL compared with controls but would report similar QOL compared with EIBC patients at baseline; and (2) DCIS patients' QOL would improve during 2-year follow-up and approach levels similar to that of controls faster than EIBC patients. We tested hypothesis 1 using separate general linear regression models for each of the eight subscales on the RAND 36-item Health Survey, controlling for variables associated with at least one subscale at T1. Both DCIS and EIBC patients reported lower QOL at T1 than controls on all subscales (each P<0.05). We tested hypothesis 2 using generalized estimating equations to examine change in each QOL subscale over time across the three diagnostic groups adjusting for covariates. By T3, physical functioning, role limitations due to physical problems, energy/fatigue, and general health each differed significantly by diagnostic group at P<0.05, because of larger differences between EIBC patients and controls; but DCIS patients no longer differed significantly from controls on any of the QOL subscales. At T4, EIBC patients still reported worse physical functioning (P=0.0001) and general health (P=0.0017) than controls, possibly because of lingering treatment effects. DCIS patients' QOL was similar to that of controls two years after diagnosis, but some aspects of EIBC patients' QOL remained lower.     

Psychological distress and physical health in the year after diagnosis of DCIS or invasive breast cancer

Ductal carcinoma in situ (DCIS) has an excellent prognosis, but its management can resemble that of early invasive breast cancer. We compared aspects of quality of life of women with DCIS to that of women with invasive disease during the first year after treatment initiation. Participants came from consecutive series of women with newly diagnosed, non-metastatic breast cancer treated in eight Quebec hospitals in 2003. Psychological distress and health-related quality of life were measured using the Psychiatric Symptom Index (PSI) and the SF-12 mental and physical component scales (MCS, PCS). Data were obtained 1, 6, and 12 months after the start of treatment. We used generalized linear models to compare mean scores and explored the possible clinical significance of between-group differences with effect size (ES). Participation and retention among eligible women were high, 86 and 97%, respectively. Among the 800 women who completed all interviews, 13.4% (n = 107) had DCIS and 86.6% (693) invasive disease. No statistically significant between-group differences were found at 1, 6, or 12 months in psychological state (PSI and MCS: P values from 0.065 to 0.904; ES from −0.01 to −0.21). Women with DCIS reported significantly higher levels of physical health, particularly when compared at 1 month to women with invasive disease who had chemotherapy (P value < 0.0001; ES = 0.82). Measured in symptoms of psychological distress, the better prognosis or less aggressive management of DCIS does not offset the general psychological effects of a cancer diagnosis to any great degree.     

Molecular phenotypes of DCIS predict overall and invasive recurrence

Molecular phenotypes predict early recurrence in invasive breast cancer. Ductal carcinoma in situ (DCIS) progresses to invasive cancer after surgery in around half of all recurrences. Luminal A DCIS had a low rate of 5 year recurrence; the other phenotypes had significantly elevated risks. ER is regularly measured in DCIS but our data suggests that PR and HER2 should be measured for relapse risk.BackgroundMolecular phenotypes of invasive breast cancer predict early recurrence. Ductal carcinoma in situ (DCIS) exhibits similar phenotypes, but their frequency and significance remain unclear. To determine whether DCIS molecular phenotypes predict recurrence, 314 women (median age 57.7 years) with primary DCIS who were screened or entered DCIS trials in a specialist breast unit from 1990 to 2010 were studied.Patients and methodsExpression of Ki67, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) within primary DCIS was established using immunohistochemistry (IHC). Patients were subdivided into molecular phenotypes using IHC surrogates [Luminal A (ER/PR+HER2-), Luminal B (ER/PR+/HER2+), HER2 type (ER and PR-/HER2+) or triple negative (ER/PR/HER2)] and recurrence rates compared.ResultsOverall, there were 57 (18.2%) recurrences, 35 (11.2%) DCIS and 22 (7%) invasive cancer. A low rate of recurrence at 5 years was seen in Luminal A DCIS (7.6%), compared with 15.8%–36.1% in other phenotypes. Independent predictors of overall recurrence on multivariate analysis were involved (<1 mm) surgical margins (HR 4.31, P < 0.001), high-grade lesions (HR 2.28, P < 0.024) and molecular phenotype (HR 5.14, P = 0.001 for Luminal B; HR 6.46, P < 0.001 for HER2 type and HR 3.27, P = 0.028 for triple-negative disease compared with Luminal A DCIS). Independent predictors for invasive recurrence were high Ki67 expression (HR 1.04, P = 0.021) and molecular phenotype (HR 13.4, P = 0.014 for Luminal B; HR 11.4, P = 0.027 for HER2 type and HR 10.3, P = 0.031 for triple negative compared with Luminal A DCIS).ConclusionsDCIS molecular phenotype predicts for both overall and invasive recurrence. HER2 testing of DCIS could help clinicians individualise the treatment of patients with DCIS.     

A comparison of quality of life, disease impact and risk perception in women with invasive breast cancer and ductal carcinoma in situ

We compared the health-related quality of life, impact of the disease, risk perception of recurrence and dying of breast cancer, and understanding of diagnosis of patients with ductal carcinoma in situ (DCIS) and invasive breast cancer 2-3 years after treatment. We included all women (N=211) diagnosed with DCIS or invasive breast cancer TNM stage I (T1, N0, and M0) in three community hospitals in the southern part of The Netherlands in the period 2002-2003. After verifying the medical files, 180 disease free patients proved eligible for study entry, 47 of whom had DCIS and 133 stage I invasive breast cancer. One-hundred and thirty-five patients returned a completed questionnaire (75% response). No significant differences were found between women with DCIS and invasive breast cancer on the physical and mental component scale of the RAND SF-36, nor on the WHO-5, which assesses well-being. In contrast, women with DCIS reportedly had a better physical health, better sex life and better relationships with friends/acquaintances than women with invasive breast cancer. Despite their better prognosis, the DCIS-group had comparable perceptions of the risk of recurrence and dying of breast cancer as women with invasive breast cancer. However, this did not appear to affect their well-being significantly.     

Ductal carcinoma in situ in African American versus Caucasian American women

BACKGROUND:

Invasive breast carcinoma has a more aggressive phenotype and a higher mortality rate in African American (AA) than in Caucasian American (CA) women. The characteristics of ductal carcinoma in situ (DCIS) in the AA population have not been extensively studied.

METHODS:

The authors reviewed cases of DCIS diagnosed in AA and CA patients between 1996 and 2000 at their institution. Treatment and outcome were obtained from the clinical charts and the Surveillance, Epidemiology, and End Results database. They identified 217 AA (61%) and 141 CA (39%) patients.

RESULTS:

AA women were significantly older at diagnosis (61 years vs 56 years, P = .001), and the size of the tumor was larger in AA patients (P = .001). The other pathological features examined were not statistically different between the 2 groups. Treatments with surgery and radiation were also similar. However, the CA patients were more likely to receive hormone therapy. Recurrence rate as DCIS or invasive carcinoma was similar in both patient groups, as was death due to disease. Time to recurrence with invasive carcinoma, however, was shorter for AA patients (32.8 ± 13 vs 58 ± 9; P = .02). Only overall survival (OS) rate was higher for CA patients (92% vs 71% at 10 years; P = .003).

CONCLUSIONS:

Unlike invasive carcinoma, DCIS is diagnosed at a later age in AA patients. Except for larger size, DCIS does not have a more aggressive histology in AA patients. Treatment and recurrence rate were similar in both groups, as was death due to breast cancer. OS, however, was worse in AA women. Cancer 2009; 115:3181–8. © 2009 American Cancer Society.     

The relationship between holding back from communicating about breast concerns and anxiety in the year following breast biopsy

Purpose: Evidence suggests open communication about breast cancer concerns promotes psychological adjustment, while holding back can lead to negative outcomes. Little is known about the relationship between communication and distress following breast biopsy. Design/ Sample: Women (N = 128) were assessed at the time of breast biopsy and again one week and three, six, and 12 months post-result. Methods: Linear mixed modeling examined relationships between holding back and anxiety for women with benign results (n = 94) or DCIS/invasive disease (n = 34) following breast biopsy. Findings: Anxiety increased among women with a benign result engaging in high but not low or average levels of holding back. Holding back was positively associated with anxiety post-result in breast cancer survivors, with anxiety decreasing over time. Conclusions/ Implications: Interventions to enhance communication are warranted, and knowledge of the differences among women with benign results and/or DCIS/invasive disease may allow for the development of tailored interventions.     

Micro-computed tomography enables rapid surgical margin assessment during breast conserving surgery (BCS): correlation of whole BCS micro-CT readings to final histopathology

Background

Approximately 1% of patients with ductal carcinoma in situ (DCIS) will die of breast cancer within 10 years. Women who develop an invasive breast cancer after DCIS have a much greater risk of dying than those who do not and it is often stated that these deaths are a consequence of metastases from the invasive in-breast recurrence. This progression is the result of a two-step process: first local invasive recurrence and then spread beyond the breast. A large proportion of women who die of DCIS have no record of invasive recurrence. We used SEER data and a simulation approach to test whether the actual mortality data are consistent with the two-step model.

Methods

First, we constructed Kaplan–Meier mortality curves for all patients with pure DCIS and with small node-negative invasive breast cancers in the Surveillance, Epidemiology and End Results (SEER) registries database (1998–2014). We then constructed, through simulation, theoretical breast cancer mortality curves. To model the two-step scenario, we applied the annual incidence rates of incident invasive cancer following DCIS and of death from invasive cancer after DCIS to a theoretical cohort of 100,000 women.

Results

The observed 15-year breast cancer-specific mortality rate for patients with pure DCIS in the SEER database was 2.0%. The expected mortality for DCIS patients (assuming a two-step process) was only 1.1% at 15 years. Assuming the mortality rates following DCIS were one-half of those observed for patients with small invasive breast cancers, the expected mortality at 15 years post-DCIS was 2.1%.

Conclusions

In the SEER database, we observed far more deaths from DCIS than would be expected under a model where all deaths from breast cancer occur amongst women who experience an invasive local recurrence. This lends support to the hypothesis that DCIS mortality is not restricted to those women who experience an in-breast invasive cancer and that DCIS has properties similar to small invasive breast cancers.

     

Tamoxifen added to radiotherapy and surgery for the treatment of ductal carcinoma in situ of the breast: A meta-analysis of 2 randomized trials

Background

Surgical excision with adequate margins is the treatment of choice for ductal, in situ carcinoma of the breast (DCIS). The addition of radiotherapy (RT) halved local in situ and invasive recurrence. The purpose of our meta-analysis is to evaluate the reduction in recurrence (in situ or invasive) with the addition of tamoxifen (T), in particular in patients with DCIS treated with surgery + RT.

Patients and methods

The eligible studies (NSABP-B24 and UK ANZ DCIS trials) included prospective, randomized, controlled trials in which the addition of T had been compared with surgery + RT without T in women with DCIS of the breast. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for both in situ and invasive recurrence (local and controlateral).

Results

Tamoxifen does not reduce breast cancer-specific or overall mortality when added to loco-regional therapy for DCIS of the breast (surgery plus or minus RT). Tamoxifen reduces overall breast cancer recurrence by 29% in all patients and by 33% in those treated with both surgery and RT. Only ipsilateral invasive (RR 0.61 [95% CI 0.41, 0.92]; p = 0.02) and controlateral in situ relapses (RR 0.40 [95% CI 0.16, 0.96]; p = 0.04) are significantly lowered when T is added to RT. Tamoxifen seems to exert a local synergistic effect with RT. Both young and older women (< and >50 years) achieve some benefit from the addition of T (RR 0.6 and 0.74, respectively).

Conclusion

The addition of T to surgery and RT for DCIS of the breast reduces the risk of local invasive and controlateral in situ relapses, but not the survival. The benefit is independent of age. In conclusion, surgery associated with RT and T is the treatment of choice for patients with (estrogen-receptor positive) DCIS of the breast.     

Pathologic characteristics of second breast cancers after breast conservation for ductal carcinoma in situ

BACKGROUND:

The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. Although many eventually develop a second breast cancer (SBC), little is known about the characteristics of SBCs. The authors described the characteristics of SBC and examined associations between the pathologic features of SBC and index DCIS cases.

METHODS:

Women were identified in the National Comprehensive Cancer Network Outcomes Database who were diagnosed with DCIS from 1997 to 2008 and underwent lumpectomy and who subsequently developed SBC (including DCIS or invasive disease that occurred in the ipsilateral or contralateral breast). The Fisher exact test and the Spearman test were used to examine associations between the pathologic characteristics of SBC and index DCIS cases.

RESULTS:

Among 2636 women who underwent lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow‐up. Of these 150 women, 105 (70%) received adjuvant radiotherapy, and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of women and invasive in 50.7% of women. Among the index DCIS cases, 60.6% were estrogen receptor (ER)‐positive, and 54% were high grade, whereas 77.5% of SBCs were ER‐positive, and 48.2% were high grade. Tumor grade (P = .003) and ER status (P = .02) were associated significantly between index DCIS and SBC, whereas tumor size was not (P = .87).

CONCLUSIONS:

After breast conservation for DCIS, SBC in either breast exhibited pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype. Cancer 2012. © 2012 American Cancer Society.     

Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study

AimsThis study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation.Materials and methodsThe study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I–IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations.ResultsAmong 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3–77.3%), but varied less for the high-risk (range 77.1–91.6%) and low-risk groups (range 4.1–32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree.ConclusionsRates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.     

Predictive factors for BRCA1/BRCA2 mutations in women with ductal carcinoma in situ

BACKGROUND:

It is unclear whether women with ductal carcinoma in situ (DCIS), like their counterparts with invasive breast cancer, warrant genetic risk assessment and testing on the basis of high‐risk variables. The authors of this report identified predictive factors for mutations in the breast cancer‐susceptibility genes BRCA1 and BRCA2 in women who were diagnosed with DCIS.

METHODS:

One hundred eighteen women with DCIS who were referred for genetic counseling and underwent genetic testing for BRCA1/BRCA2 mutations between 2003 and 2010 were included in the study. Logistic regression models were fit to determine the associations between potential predictive factors and BRCA status.

RESULTS:

Of 118 high‐risk women with DCIS, 27% (n = 32) tested positive for BRCA1/BRCA2 mutations. Of those, 10% (n = 12) and 17% (n = 20) had BRCA1 and BRCA2 mutations, respectively. Age, race, and tumor characteristics did not differ between BRCA noncarriers and carriers. In a multivariate logistic model, ≥2 relatives with ovarian cancer (OC) (odds ratio [OR], 8.81; 95% confidence interval [CI], 1.38‐56.29; P = .034), and a score ≥10% according to the BRCAPRO mathematical model for calculating the probability that a particular family member carries a germline BRCA mutation (OR, 6.37; 95% CI, 2.23‐18.22; P = .0005) remained as independent significant predictors for a BRCA mutation. Fifty‐seven percent of mutation carriers but only 25% of noncarriers underwent prophylactic mastectomy(P = .0037). This difference remained significant for patients aged ≤40 years (P = .025).

CONCLUSIONS:

Women who had DCIS and a family history of OC or who had BRCAPRO scores ≥10% had a high rate of BRCA positivity regardless of age at diagnosis. These findings suggest that high‐risk patients with DCIS are appropriate candidates for genetic testing for BRCA mutations in the presence of predictive factors even if they do not have invasive breast cancer. Cancer 2011;. © 2011 American Cancer Society.     

HER2/neu and Ki-67 expression predict non-invasive recurrence following breast-conserving therapy for ductal carcinoma in situ

Background:

Ductal carcinoma in situ (DCIS) is a non-invasive form of breast cancer that may progress to invasive cancer. Identification of factors that predict recurrence and distinguish DCIS from invasive recurrence would facilitate treatment recommendations. We examined the prognostic value of nine molecular markers on the risks of local recurrence (DCIS and invasive) among women treated with breast-conserving therapy.

Methods:

A total of 213 women who were treated with breast-conserving therapy between 1982 and 2000 were included; 141 received breast-conserving surgery alone and 72 cases received radiotherapy. We performed immunohistochemical staining on the DCIS specimen for nine markers: oestrogen receptor, progesterone receptor, Ki-67, p53, p21, cyclinD1, HER2/neu, calgranulin and psoriasin. We performed univariable and multivariable survival analyses to identify markers associated with the recurrence.

Results:

The rate of recurrence at 10 years was 36% for patients treated with breast-conserving surgery alone and 18% for women who received breast-conserving surgery and radiotherapy. HER2/neu+/Ki-67+ expression was associated with an increased risk of DCIS recurrence, independent of grade and age (HR=3.22; 95% CI: 1.47–7.03; P=0.003). None of the nine markers were predictive of invasive recurrence.

Conclusion:

Women with a HER2/neu/neu+/Ki67+ DCIS have a higher risk of developing DCIS local recurrence after breast-conserving surgery.     

Risk of second primary breast cancers among women with ductal carcinoma in situ of the breast

Background The diagnosis of ductal carcinoma in situ (DCIS) has become increasingly common, but it is not clear which factors predict the development of subsequent breast cancers in these women. The risk of second primary breast tumors was examined in a large, ethnically diverse population-based cohort of women with DCIS. Methods California Cancer Registry data on 23,547 women with first DCIS diagnosed in 1988–1999 were examined to estimate the incidence of second DCIS and invasive breast cancer relative to women in the general population. Relative risks were calculated using Poisson regression to estimate which women with DCIS were likely to develop a second DCIS or invasive breast cancer. Results Compared to the general population, women with DCIS had significantly increased risk of contralateral DCIS (standardized incidence ratio [SIR] 4.2, 95% confidence interval [CI] 3.7–4.7), contralateral invasive cancer (SIR 1.4, 95% CI 1.2–1.5), ipsilateral DCIS (SIR 4.2, 95% CI 3.5–5.0), and ipsilateral invasive cancer (SIR 1.7, 95% CI 1.4–2.1). Variation by race/ethnicity, age, time, and tumor and treatment characteristics were observed. Black women were 1.9-fold more likely to develop ipsilateral invasive cancer than white women. Young age at onset, comedo histology and having received partial mastectomy only or having neither surgical nor radiation treatment for first DCIS were predictive of ipsilateral cancers. Conclusions Close follow-up of women with DCIS is warranted, particularly those who are Black or diagnosed at young age. Investigations should continue to clarify the underlying mechanisms of racial, age, and other differences in second cancer risk.     

A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen-detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast-conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So-called “recurrences” are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.     

Expression of androgen receptor in breast cancer and its significance as a prognostic factor

BackgroundBreast cancer is an extraordinarily hormone-dependent tumor. This study was to evaluate androgen receptor (AR) status and its significance in breast cancer in Chinese women.MethodsThree hundred and thirty-five consecutive cases of invasive ductal breast carcinoma, 34 ductal carcinoma in situ (DCIS), and 82 DCIS adjacent to invasive tissues were involved in this study. The expression of AR was analyzed by immunohistochemistry and compared with patient outcome, and its implications were evaluated in five molecular subgroups of invasive ductal carcinoma (IDC) and in DCIS lesions.ResultsAR expression was related to that of estrogen receptor (P < 0.001) and progesterone receptor (P = 0.035) but not correlated with the other conventional parameters. AR retained independent prognostic significance (hazard ratio 0.309, 95% confidence interval, 0.192–0.496; P < 0.001). The majority (61.0%) of basal-like breast cancers showed loss of AR expression (P < 0.001), which had poor prognosis. The percentage of AR-positive cases was significantly higher in DCIS adjacent to IDC group than in pure DCIS and IDC groups (93.9%, 79.4%, and 72.5%; P = 0.046 and P < 0.001, respectively).ConclusionsOur data suggest that AR may provide another specific definition of breast cancer subtypes and reveal a potential role in DCIS progression. These findings may help develop new therapies.     

Circulating levels of biomarkers and risk of ductal carcinoma in situ of the breast in the UK Biobank study

Observational studies have shown associations between circulating levels of various biomarkers (eg, total cholesterol [TC], low-density lipoprotein cholesterol [LDL], insulin-like growth factor-1 [IGF-1], C-reactive protein [CRP] and glycated hemoglobin-1c [HbA1c]) and the risk of invasive breast cancer (IBC). Ductal carcinoma in situ of the breast (DCIS) is a nonobligate precursor of IBC and shares several risk factors with it. However, the relationship between these biomarkers and DCIS risk remains unexplored. We studied the association between circulating levels of TC, LDL-C, high-density lipoprotein cholesterol (HDL-C), Lipoprotein (a) (Lp-(a)), IGF-1, CRP and HbA1c, with the risk of DCIS in 156801women aged 40 to 69 years and breast cancer-free at enrolment when blood samples and information on demographic and health-related factors were collected. Incident cases of DCIS were ascertained during the follow-up via linkage to the UK cancer registries Multivariable-adjusted Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations of interest. In all, 969 DCIS incident cases were diagnosed during 11.4 years of follow-up. Total cholesterol was inversely associated with the risk of DCIS (HR_{quintile(Q)5vsQ1} = 0.47, 95% CI: 0.27-0.82, P_trend = .008). Conversely, LDL-C was positively associated with DCIS risk (HR_Q3vsQ1 = 1.43, 95% CI: 1.01-2.04, HR_Q4vsQ1 = 1.60, 95% CI: 1.04-2.47, HR_Q5vsQ1 = 2.29, 95% CI: 1.36-3.88, P_trend = .004). In postmenopausal women, CRP had a weak positive association with DCIS risk, while HbA1c showed a nonlinear association with the risk. These results, in conjunction with those from previous studies on IBC, provide support for the association of several biomarkers with the risk of an early stage of breast cancer.     

Complementary and alternative medicine use is associated with an increased perception of breast cancer risk and death

Purpose. Complementary and alternative medicines (CAMS) are frequently used by patients with breast cancer and their use may be related to the presence of psychosocial distress. The objective of this study is to assess the presence of anxiety and depression in breast cancer patients who use CAM and assess how they perceive their risks of recurrence and dying from breast cancer compared to non-users.Methods. Breast cancer patients attending ambulatory clinics at a single cancer center were approached by their oncologist. Participants completed a self-administered survey regarding CAM usage, beliefs associated with CAM, views of their risks of developing recurrent cancer, and of dying of breast cancer. The presence of anxiety and depression was scored using the Hospital Anxiety and Depression Scale (HADS). Responses were scored and compared between CAM users and non-users.Results. A total of 251 patients completed the survey. CAM usage was reported by 43% of patients. Individuals who used CAM were younger [53.1 versus 63.0 year (p < 0.001)], had higher education (p < 0.001), were more likely to have full time employment [25.7 versus 16.3% (p < 0.001)] and have private insurance for medications (76 versus 60%, p=0.007) compared to non-users. CAM users perceived their risk of recurrence (p = 0.011) and death from breast cancer (p=0.0001) as being significantly greater than non-users. There were no significant differences in anxiety or depression scores between CAM and non-users.Conclusion. CAM use is associated with an increased perception of breast cancer recurrence and of breast cancer-related death. There was no association between the presence of anxiety or depression and CAM use. Improved patient understanding of actual risks of recurrence and death are required such that women will be able to make more informed decisions about using CAMs.     

Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients

Until now, less than 5% of the patients with breast ductal carcinoma in situ (DCIS) have been enrolled in clinical trials. Consequently, we have analysed the results of ‘current practice’ among 716 women treated in eight French Cancer Centres from 1985 to 1992: 441 cases (61.6%) corresponded to impalpable lesions, 92 had a clinical size of less than or equal to 2 cm and 70 from 2 to 5 cm; in 113 cases, the size was unspecified. Median age was 53.2 years (range: 21–87 years). 145 patients underwent mastectomy (RS) and 571 conservative surgery (CS) without (136) or with (435) radiotherapy (CS+RT). The mean histological tumour sizes in these three groups were 25.6, 8.2, 14.8 mm, respectively (P<0.0001). After a 91-month median follow-up, local recurrence (LR) rates were 2.1, 30.1 and 13.8% in the RS, CS and CS +RT groups, respectively (P=0.001); LR were invasive in 59 and 60% in the CS and CS+RT groups, respectively. In these groups, the 8-year LR rates were 31.3 and 13.9%, respectively (P=0.0001). Nodal recurrence occurred in 3.7 and 1.8% in the CS and CS+RT groups. Metastases rates were 1.4, 4.4 and 1.4% in the RS, CS and CS+RT groups. Among the 60 cases of invasive LR, in CS and CS+RT groups 19% developed metastases. After multivariate analysis, we did not identify any significant LR risk factor in the CS group, whereas young age (<40years) and incomplete excision were significant in the CS+RT group (P=0.012 and P=0.02, respectively).     

The Association Between Survival and Receipt of Post-mastectomy Radiotherapy According to Age at Diagnosis Among Women With Early Invasive Breast Cancer: A Population-Based Cohort Study

AimsClinical trials of post-mastectomy radiotherapy (PMRT) for early invasive breast cancer (EIBC) have included few older women. This study examined whether the association between overall survival or breast cancer-specific survival (BCSS) and receipt of PMRT for EIBC altered with age.Materials and methodsThe study used patient-level linked cancer registration, routine hospital and radiotherapy data for England and Wales. It included 31 243 women aged ≥50 years diagnosed between 2014 and 2018 with low- (T1-2N0), intermediate- (T3N0/T1-2N1) or high-risk (T1-2N2/T3N1-2) EIBC who received a mastectomy within 12 months from diagnosis. Patterns of survival were analysed using a landmark approach. Associations between overall survival/BCSS and PMRT in each risk group were analysed with flexible parametric survival models, which included patient and tumour factors; whether the association between PMRT and overall survival/BCSS varied by age was assessed using interaction terms.ResultsAmong 4711 women with high-risk EIBC, 86% had PMRT. Five-year overall survival was 70.5% and BCSS was 79.3%. Receipt of PMRT was associated with improved overall survival [adjusted hazard ratio (aHR) 0.75, 95% confidence interval 0.64–0.87] and BCSS (aHR 0.78, 95% confidence interval 0.65–0.95) compared with women who did not have PMRT; associations did not vary by age (overall survival, P-value for interaction term = 0.141; BCSS, P = 0.077). Among 10 814 women with intermediate-risk EIBC, 59% had PMRT; 5-year overall survival was 78.4% and BCSS was 88.0%. No association was found between overall survival (aHR 1.01, 95% confidence interval 0.92–1.11) or BCSS (aHR 1.16, 95% confidence interval 1.01–1.32) and PMRT. There was statistical evidence of a small change in the association with age for overall survival (P = 0.007), although differences in relative survival were minimal, but not for BCSS (P = 0.362).ConclusionsThe association between PMRT and overall survival/BCSS does not appear to be modified by age among women with high- or intermediate-risk EIBC and, thus, treatment recommendations should not be modified on the basis of age alone.     

Impact of race and ethnicity on features and outcome of ductal carcinoma in situ of the breast

BACKGROUND:

The impact of race and ethnicity on the biologic features and outcome variables of women who are diagnosed with preinvasive breast cancer—ductal carcinoma in situ (DCIS)—has not been addressed widely in the published literature.

METHODS:

Patient demographic, clinical, and pathologic features and outcome variables were analyzed with respect to the patient's initial self‐reported race/ethnicity among women who received treatment for a diagnosis of pure DCIS from 1996 to 2009.

RESULTS:

Of 1902 patients, 1411 were white (74.2%), 214 were African American (11.3%), 175 were Hispanic (9.1%), and 102 were Asian/Pacific Islander (5.4%). The majority of patients were between ages 41 and 70 years (83%). Patients of Hispanic and Asian/Pacific Islander descent were significantly younger than white and African American patients (P < .001). DCIS size and grade, the presence of necrosis, and the frequency of breast‐conserving surgery did not differ significantly between groups. African American patients aged >70 years and Hispanic patients aged <50 years were significantly more likely to have estrogen receptor‐positive DCIS than patients of other races in the same age categories (P < .001). Adjuvant radiotherapy and tamoxifen were received significantly less often by white women (P < .001). At a median follow‐up of 4.8 years (range, 1‐14 years), recurrence rates and the development of contralateral breast cancer did not differ significantly among racial/ethnic groups when stratified by treatments received.

CONCLUSIONS:

There was variation in age at presentation, biologic features, and treatment of DCIS among the different ethnic groups. Additional studies with larger numbers of ethnic minority patients are needed to confirm whether the consistent application of evidence‐based treatment practices presents an opportunity for reducing disparities in patients with DCIS. Cancer 2013. © 2012 American Cancer Society.