Breast Cancer Research and Treatment

, Volume 166, Issue 2, pp 583–592 | Cite as

Trends in adjuvant therapies after breast-conserving surgery for hormone receptor-positive ductal carcinoma in situ: findings from the National Cancer Database, 2004–2013

  • Yasuaki Sagara
  • Rachel A. Freedman
  • Stephanie M. Wong
  • Fatih Aydogan
  • Anvy Nguyen
  • William T. Barry
  • Mehra Golshan
Epidemiology

Abstract

Purpose

Breast-conserving surgery (BCS) followed by radiotherapy (RT) with or without endocrine therapy (ET) is a standard treatment option for ductal carcinoma in situ (DCIS). We sought to investigate national patterns in the use of adjuvant therapy after BCS for hormone receptor (HR)-positive DCIS over time.

Patients and methods

Using data from the National Cancer Data Base, we identified patients diagnosed with DCIS and treated with BCS between 2004 and 2013. Multivariable logistic regression was used to estimate the odds of adjuvant therapy use controlling for clinicopathologic demographic and facility-level characteristics.

Results

We identified 66,079 patients who underwent BCS for DCIS. Overall, 21% received no adjuvant treatment, 71% received RT, 48% received ET, and 38% received the combination therapy. In adjusted analyses among the patients with HR-positive DCIS (n = 50,147), the administration of RT decreased (odds ratio [OR] 0.86, 95% CI 0.770.97), while the use of ET increased (OR 1.5, 95% CI 1.41.6) in 2013 compared to 2004. Young patients, elderly patients, positive margin status, and Medicare insurance were associated with lower use of both RT and ET. We observed both clinicopathologic and geographic variation in the use of adjuvant therapies. In the lowest risk subgroup, the use of RT decreased from 57% in 2004 to 48% in 2013 (OR 0.64, 95% CI 0.450.89).

Conclusion

Our study suggests a shift in patterns of care for DCIS that is impacted by both clinicopathologic and demographic factors, with the use of RT decreasing and the use of ET increasing in HR-positive DCIS patients. Current trials are designed to address the possible over-treatment of low-risk DCIS.

Keywords

Ductal carcinoma in situ (DCIS) Adjuvant therapy Radiotherapy Endocrine therapy 

References

  1. 1.
    Welch HG, Prorok PC, O’Malley AJ et al (2016) Breast-cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med 375(15):1438–1447. doi:10.1056/NEJMoa1600249 CrossRefPubMedGoogle Scholar
  2. 2.
    Siegel R, Miller K, Jemal A (2015) Cancer statistics, 2015. CA Cancer J Clin 65(1):29. doi:10.3322/caac.21254 CrossRefGoogle Scholar
  3. 3.
    Virnig BA, Shamliyan T, Tuttle TM et al (2009) Diagnosis and management of ductal carcinoma in situ (DCIS). Evid Rep Technol Assess (Full Rep). 185:1–549Google Scholar
  4. 4.
    Narod SA, Iqbal J, Giannakeas V et al (2015) Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol 1(7):888–896. doi:10.1001/jamaoncol.2015.2510 CrossRefPubMedGoogle Scholar
  5. 5.
    Sagara Y, Freedman RA, Vaz-Luis I et al (2016) Patient prognostic score and associations with survival improvement offered by radiotherapy after breast-conserving surgery for ductal carcinoma in situ: a population-based longitudinal cohort study. J Clin Oncol 34(11):1190–1196. doi:10.1200/JCO.2015.65.1869 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Correa C, McGale P, Taylor C et al (2010) Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr 2010(41):162–177CrossRefPubMedGoogle Scholar
  7. 7.
    McCallum I, Craig W, Bruce J (2012) Postoperative tamoxifen for ductal carcinoma in situ. Cochrane Database Syst Rev 10:CD007847. doi:10.1002/14651858.CD007847.pub2 PubMedGoogle Scholar
  8. 8.
    Lo AC, Truong PT, Wai ES et al (2015) Population-based analysis of the impact and generalizability of the NSABP-B24 study on endocrine therapy for patients with ductal carcinoma in situ of the breast. Ann Oncol 26(9):1898–1903. doi:10.1093/annonc/mdv251 CrossRefPubMedGoogle Scholar
  9. 9.
    Nichols HB, Bowles EJA, Islam J et al (2016) Tamoxifen initiation after ductal carcinoma in situ. Oncologist 21(2):134–140. doi:10.1634/theoncologist.2015-0310 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Punglia RS, Schnitt SJ, Weeks JC (2013) Treatment of ductal carcinoma in situ after excision: would a prophylactic paradigm be more appropriate? J Natl Cancer Inst 105(20):1527–1533. doi:10.1093/jnci/djt256 CrossRefPubMedGoogle Scholar
  11. 11.
    NCCN Clinical Practice Guidelines in Oncology—Breast Cancer version 2. 2017. National Comprehensive Cancer Network. http://www.nccn.com. Accessed 24 May 2017
  12. 12.
    Sagara Y, Mallory MA, Wong S et al (2015) Survival benefit of breast surgery for low-grade ductal carcinoma in situ: a population-based cohort study. JAMA Surg 150(8):739–745. doi:10.1001/jamasurg.2015.0876 CrossRefPubMedGoogle Scholar
  13. 13.
    American College of Surgeons: National Cancer Database. American College of Surgeons. https://www.facs.org/quality-programs/cancer/ncdb. Accessed 24 May 2017
  14. 14.
    Silverstein MJ, Lagios MD, Craig PH et al (1996) A prognostic index for ductal carcinoma in situ of the breast. Cancer 77(11):2267–2274. doi:10.1002/(SICI)1097-0142(19960601)77:11<2267:AID-CNCR13>3.0.CO;2-V CrossRefPubMedGoogle Scholar
  15. 15.
    Silverstein MJ (2003) The University of Southern California/Van Nuys prognostic index for ductal carcinoma in situ of the breast. Am J Surg 186(4):337–343CrossRefPubMedGoogle Scholar
  16. 16.
    Extermann M, Overcash J, Lyman GH et al (1998) Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 16(4):1582–1587. doi:10.1200/JCO.1998.16.4.1582 CrossRefPubMedGoogle Scholar
  17. 17.
    Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383CrossRefPubMedGoogle Scholar
  18. 18.
    Baxter NN, Virnig BA, Durham SB et al (2004) Trends in the treatment of ductal carcinoma in situ of the breast. J Natl Cancer Inst 96(6):443–448CrossRefPubMedGoogle Scholar
  19. 19.
    Worni M, Akushevich I, Greenup R et al (2015) Trends in treatment patterns and outcomes for ductal carcinoma in situ. J Natl Cancer Inst 107(12):djv263. doi:10.1093/jnci/djv263 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Fisher B, Dignam J, Wolmark N et al (1999) Tamoxifen in treatment of intraductal breast cancer: national surgical adjuvant breast and bowel project B-24 randomised controlled trial. Lancet 353(9169):1993–2000. doi:10.1016/S0140-6736(99)05036-9 CrossRefPubMedGoogle Scholar
  21. 21.
    Cuzick J, Sestak I, Pinder SE et al (2011) Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 12(1):21–29. doi:10.1016/S1470-2045(10)70266-7 CrossRefPubMedGoogle Scholar
  22. 22.
    Allred DC, Anderson SJ, Paik S et al (2012) Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol 30(12):1268–1273. doi:10.1200/JCO.2010.34.0141 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Hughes LL, Wang M, Page DL et al (2009) Local excision alone without irradiation for ductal carcinoma in situ of the breast: a trial of the Eastern Cooperative Oncology Group. J Clin Oncol 27(32):5319–5324. doi:10.1200/JCO.2009.21.8560 CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Anders CK, Hsu DS, Broadwater G et al (2008) Young age at diagnosis correlates with worse prognosis and defines a subset of breast cancers with shared patterns of gene expression. J Clin Oncol 26(20):3324–3330. doi:10.1200/JCO.2007.14.2471 CrossRefPubMedGoogle Scholar
  25. 25.
    McCormick B, Winter K, Hudis C et al (2015) RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol 33(7):709–715. doi:10.1200/JCO.2014.57.9029 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Wong JS, Chen YH, Gadd MA et al (2014) Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat 143(2):343–350. doi:10.1007/s10549-013-2813-6 CrossRefPubMedGoogle Scholar
  27. 27.
    Francis A, Thomas J, Fallowfield L et al (2014) Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer 51(16):2296–2303. doi:10.1016/j.ejca.2015.07.017 CrossRefGoogle Scholar
  28. 28.
    Mallin K, Palis BE, Watroba N et al (2013) Completeness of American cancer registry treatment data: implications for quality of care research. J Am Coll Surg 216(3):428–437. doi:10.1016/j.jamcollsurg.2012.12.016 CrossRefPubMedGoogle Scholar
  29. 29.
    Freedman RA, Fedewa SA, Punglia RS et al (2016) Factors associated with radiation therapy incompletion for patients with early-stage breast cancer. Breast Cancer Res Treat 155(1):187–199. doi:10.1007/s10549-015-3660-4 CrossRefPubMedGoogle Scholar
  30. 30.
    Partridge AH, LaFountain A, Mayer E et al (2008) Adherence to initial adjuvant anastrozole therapy among women with early-stage breast cancer. J Clin Oncol 26(4):556–562. doi:10.1200/JCO.2007.11.5451 CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of SurgeryBrigham and Women’s HospitalBostonUSA
  2. 2.Harvard T.H Chan School of Public HealthBostonUSA
  3. 3.Department of Medical OncologyDana-Farber Cancer InstituteBostonUSA
  4. 4.Department of SurgeryMcGill University Health CentreMontrealCanada
  5. 5.Department of General Surgery, Cerrahpasa Medical SchoolIstanbul UniversityIstanbulTurkey
  6. 6.Department of Biostatistics and Computational BiologyDana-Farber Cancer InstituteBostonUSA
  7. 7.Dana-Farber/Brigham and Women’s Cancer CenterBostonUSA

Personalised recommendations