Transcript Breast Cancer: Ductal Carcinoma In-Situ

2011
Oncology Services
Annual Report
Non-Invasive Breast Cancer:
Ductal Carcinoma In-situ
Vassi Gardikas, MD, FACS
Ellen Malek, CTR
®
Saint Agnes Medical Center
Cancer Registry
1303 East Herndon Avenue
Fresno, CA 93720
559 450-3570
www.samc.com
Introduction
(2)

Ductal carcinoma in situ (DCIS, also known as intraductal carcinoma) is
the most common type of non-invasive breast cancer or pre-cancer in
women. Ductal carcinoma refers to the development of cancer cells
within the milk ducts of the breast. In situ means “in place” and refers
to the fact that the cancer has not moved out of the duct and into any
surrounding tissue.

Ductal carcinoma in situ (DCIS) is non-invasive breast cancer that
encompasses a wide spectrum of diseases ranging from low grade
lesions that are not life threatening to high grade lesions that may
harbor foci of invasive breast cancer. DCIS has been classified according
to architectural pattern (solid, cribriform, papillary, and micropapillary),
tumor grade (high, intermediate, and low grade), and the presence or
absence of comedo histology.

DCIS is a Stage 0 cancer, the earliest form of breast cancer. Stage 0
breast cancer is a contained cancer that has not spread beyond the
ductal system (to the lymph nodes or other areas of the body). With
proper treatment, the chances of surviving DCIS are very high.
Resource: Wikipedia.org
Different Names
Ductal carcinoma in-situ
 Intraductal carcinoma
 Non-invasive
 Pre-cancer
 Stage 0

Resource: Wikipedia.org
Introduction

Ductal Carcinoma In-Situ is a highly curable form of breast cancer. Treatment
options include breast conserving surgery (partial mastectomy) or mastectomy
(removal of the whole breast).

Breast conserving surgery encompasses excision of the diseased portion of the
breast only or excision followed by radiation therapy, which is added to kill any
cancer cells that potentially remain following lumpectomy.

Radiation therapy accompanying wide local excision of DCIS is known to reduce
local recurrence by 50 percent.

Patients with ductal carcinoma in-situ who are treated with mastectomy seldom
recur locally or with distant metastatic disease.

2003 SEER comparison data indicated that nationally 35% underwent excision
alone, 39% excision plus radiation and 26% were treated by mastectomy.

Of the 794 cases of DCIS receiving treatment at SAMC between 1995-2010, a
significantly lower percentage of cases, 18.3% (146) were treated by excision
alone. Again by contrast to the 2003 SEER data, a higher percent, 51.8% (412)
were treated with excision plus radiation therapy. A similar, 28.7% (228)
underwent mastectomy.
Introduction

A recent study from researchers at Hoag Memorial Hospital Presbyterian in
Newport Beach (Melvin Silverstein, MD, et al), studied the patterns of recurrence
in DCIS patients treated with lumpectomy. They noted that while women treated
with radiation following breast conserving surgery had a significantly lower
recurrence rate, radiated patients experienced more invasive recurrences and had
a longer time from initial treatment to recurrence. (4)

An additional study published in the Annals of Surgical Oncology by some of the
same researchers analyzed the risk of recurrence after mastectomy for DCIS using
the USC/Van Nuys Prognostic Index. (5)

With the above studies in mind, this report further examines the experience for
Saint Agnes Medical Center from 1995-2010 with data compiled by the SAMC
Cancer Registry.
1995-2010 SAMC Ductal Carcinoma In-situ
N=794

As mentioned, over the sixteen year period, 794 analytic cases of ductal
carcinoma in situ (DCIS) were diagnosed and/or treated at Saint Agnes
Medical Center. Cases of Paget’s disease and lobular carcinoma in-situ
(LCIS) were excluded from the study unless specified.

Of these, 99.6% were female and 0.4% were male (3). Of the two men
in the study, one had two separate primaries, with DCIS involving both
breasts.

Median age at diagnosis was 61.

Racial/ethnic distribution demonstrated 83% Non-Hispanic White,
10.5% Hispanic, 4.5% Asian and 2% African American.
Resource: SAMC Cancer Registry
1995-2010 SAMC Ductal Carcinoma In-situ
cont.
N=794

1% received No surgery (7) or surgery was Unknown (1).

70% (558) underwent Partial Mastectomy (excision of the primary tumor,
lumpectomy, less than mastectomy).

Of the 558 who underwent Partial Mastectomy, 26% (146) had excision alone
and 74% (412) were treated with excision plus radiation therapy (inclusive of
8 MammoSite brachytherapy).

29% (228) were treated with Mastectomy (simple, total or *modified radical).

Quality control review was performed to explain *modified radical mastectomy for the treatment of
DCIS. Findings indicate that this was a result of coding practice at the time sentinel lymph node
biopsy was introduced (approximately 1999). Subsequently when this became standard of care,
coding rules were updated and, confirmed to be applied appropriately in accordance with data
standards set forth by the California Cancer Registry and Commission on Cancer.
Resource: SAMC Cancer Registry
1995-2010 SAMC Ductal Carcinoma In-situ
Type of Surgery by Tumor Grade
N=794
Partial
Mastectomy
N=558
N=228
52%
43.4%
35.5%
26.5%
14.5% 15.5%
6.6%
Low
6%
Intermediate
High
Not Determined
Resource: SAMC Cancer Registry
1995-2010 SAMC Ductal Carcinoma In-situ
Recurrence Type by Surgery
N=794
Local, In-Situ
Local, Nos
N=2
N=15
Local, Invasive
Distant
N=5
N=1
3%
4
2%
10
1%
2
0.5%
2
Excis Alone
N=146
0.5%
2
Excis + XRT
N=412
0.5% 0.5% 0.5%
1
1
1
Mastectomy
N=228
Resource: SAMC Cancer Registry
USC/Van Nuys Prognostic Index

USC/Van Nuys Prognostic Index is an
algorithm based on DCIS size, nuclear
grade, necrosis, margin width and
patient age. A calculation of these factors
is summed into a single number which
then places the case into one of the
three primary treatment groups.

USC/VN PI score can be used to aid in
the decision making process when
considering the patient’s wishes and the
doctor’s assessment of the most
appropriate care based on the individual.

For the purposes of our study USC/VN PI
score was retrospectively applied for
each SAMC case of recurrence and
included in the following graphs.

Although some scores were high, our
findings were not consistent due to the
lack of detail collected in the earlier
years of the study period.
1995-2010 SAMC Ductal Carcinoma In-situ
Observations

Of the 794 patients with ductal carcinoma in-situ treated at Saint Agnes during this
period there were a total of 23 recurrences the majority of which were local (22)
with one distant recurrence.

As expected the bulk of recurrences (20) were observed in those who underwent
partial mastectomy (wide local excision, lumpectomy, less than total mastectomy).

Of those treated by excision alone (146) there were 6 (4%) recurrences. The
average time to recurrence was less than 24 months. Two of the recurrences were
invasive, observed at two and six years following initial treatment.

The excision plus radiation therapy (412) group noted 14 (3.4%) recurrences with
two being invasive. The average time to recurrence was four years.

For those who had a mastectomy there were 3 (1.3%) recurrences. Two had local
recurrence, one being in-situ and the other invasive. The third case experienced
uncommon distant recurrence.

When compared to national data for the years 2000-2009 Saint Agnes Medical
Center matched standard of care in the detection of breast cancer at its earliest
stage (Stage 0), treatment by all modalities and in the surgical treatment of ductal
carcinoma in-situ.
1995-2010 SAMC Ductal Carcinoma In-situ
Partial Mastectomy by Pattern of Recurrence N=558
# of
Pts
Surgery
XRT
Largest Tumor
Dimension
Grade
Margins
VNPI
Score
*multifocal
Recurrence
Type
Year
Recurred
(Recurrence Unknown
excluded N=6)
1
Partial
NO
5.5 cm
High
Negative
8
LOCAL
In-situ
10 mo
2
Partial
NO
0.25 cm
Intermed
Negative
6
LOCAL
In-situ
8 mo
3
Partial
NO
1.2 cm
Unk
Negative
5
LOCAL
In-situ
13 mo
4
Partial
NO
1.4 cm
Low
Negative
4
LOCAL
Invasive
6 yrs
5
Partial
NO
0.1 cm
Unknown
Negative
6
LOCAL
Invasive
2 yrs
6
Partial
NO
1.8 cm
High
Negative
8
LOCAL
In-situ
17 mo
7
Partial
Yes
2.0 cm
High
Negative
8
LOCAL
In-situ
10 yrs
8
Partial
Yes
2.5 cm
High
Negative
8
LOCAL
In-situ
4 yrs
9
Partial
Yes
Unknown
High
Close
8
LOCAL
In-situ
9 yrs
10
Partial
Yes
1.5 cm
High
Close
7
LOCAL
NOS
11
Partial
Yes
Unknown
High
Close
7
LOCAL
In-situ
1 yr
12
Partial
Yes
*0.3 cm
Intermed
Unknown
6
LOCAL
In-situ
5 yrs
13
Partial
Yes
0.5 cm
High
Negative
7
LOCAL
Invasive
14
Partial
Yes
1.1 cm
High
Negative
6
LOCAL
In-situ
1 yr
15
Partial
Yes
1.5 cm
High
Negative
7
LOCAL
In-situ
1.5 yrs
16
Partial
Yes
Unknown
High
Negative
8
LOCAL
In-situ
2.5 yrs
17
Partial
Yes
2.5 cm
High
Negative
8
LOCAL
Invasive
4.5 yrs
18
Partial
Yes
*1.0 cm
Intermed
Negative
6
LOCAL
In-situ
19
Partial
Yes
2.2 cm
High
< 1 mm
9
LOCAL
NOS
20
Partial
Yes
8.5 cm
Intermed
Negative
9
LOCAL
In-situ
2.5 yrs
3.5 yrs
2 yrs
4.5 yrs
4 yrs
1995-2010 SAMC Ductal Carcinoma In-situ
Recurrence Following Mastectomy
N=228
Recurrence
# of
Pts
Surgery
XRT
Largest
Tumor
Dimension
*multifocal
1
MAST
NO
2.0cm
High
NEG
8
LOCAL
In-situ
2 yrs
2
MAST
NO
9.0cm
High
CLOSE
11
LOCAL
Invasive
2.5 yrs
3
MAST
NO
*2.5cm
High
NEG
7
DISTANT
CNS
4 yrs
Grade
Margins
VNPI
Score
(Recurrence
Unknown excluded
N=1)
Type
Year
Recurred
Resource: SAMC Cancer Registry
Risk of Recurrence After Mastectomy for DCIS
Comparison Melvin J. Silverstein, et al (5)
TOTAL
MAST
RECUR
MJS
SAMC
1472
794
496
228
34%
29%
11
3
2.2%
1.3%

In this prospective study by MJS
group 1,472 patients were
observed. None received any form
of post mastectomy adjuvant
treatment. Cited average length of
follow up was 83 months.

Mastectomy was selected as
treatment of choice 5% more
frequently by MJS group.

SAMC patients with DCIS treated by
mastectomy exhibited overall
similar risk of recurrence.
2000-2009 NCDB Benchmark Comparison
Non-Invasive Breast Cancer (all histologies)
18.4%
SAMC
19%
NCDB
N=602
N=355,964
Stage 0
2000-2009 NCDB Benchmark Comparison
Non-Invasive Breast Cancer (all histologies)
First Course Treatment
SAMC
NCDB
45%
38%
28%
22%
18%
18%
13%
9%
0.2%
2%
None
2.8%
Surg
Surg/H
Surg/XRT Surg/XRT/H
4%
Other
2000-2009 NCDB Benchmark Comparison
Non-Invasive Breast Cancer (all histologies)
First Course Surgery
69% 68%
SAMC
NCDB
24% 23.2%
0.5%
6% 5.5%
2.3%
No Surg
0.5% 1%
Partial
Total
Modified
Mast,Nos/
Other
Recommendations

It is suggested by the findings of this report that the USC/Van Nuys Prognostic
Index may be a useful aid in the decision making process for those patients
diagnosed with DCIS. ‘With advancing technology, there will come a time when
patients with DCIS can be better defined as to whether or not their disease is likely
to progress. Those patients will likely need treatment, whereas others can simply
be monitored.’ ~ Medscape Medical News, July 10, 2010, Roxanne Nelson.

American Cancer Society recommendations for early detection of breast cancer
include for women age 20 – 39 a clinical breast examination every 3 years, and
annual mammography beginning at age 40. Optional recommendation was
starting at age 20, monthly breast self-examination.

Saint Agnes reminds women to Never Keep A Lump Secret; ‘Don’t keep it a secret.
TELL YOUR DOCTOR IMMEDIATELY. Instead of a screening mammogram, you will
be scheduled for a diagnostic mammogram. This is the only type of mammogram
that provides the of detail necessary to adequately examine the area in question.
When you arrive for your appointment, TELL THE TECHNICIAN ABOUT THE LUMP
and where it’s located SO SHE CAN ALERT THE RADIOLOGIST.’
If you ever detect a lump in your breast, TELL YOUR DOCTOR RIGHT AWAY, and
when you arrive for the mammogram BE SURE AND TELL THE TECHNICIAN. Some
things deserve to be kept secret. A LUMP IS NEVER ONE OF THEM.
Resources

(1)
SAMC Cancer Registry database; www.samc.com
*Comment: This report is developed from our hospital based registry experience which is not
‘population based’ data.

(2)
Ductal Carcinoma In-situ definition and anatomy; www.wikipedia.org

(3)
National Cancer Data Base Benchmark Comparison Reports; www.facs.org

(4)
‘Difference in Recurrence Patterns by Treatment in Patients with DCIS’,
Janie Wong Grumley MD, Melvin J. Silverstein MD, Michael D. Lagios MD,
Jessica Rayhanabad MD, Stephanie F. Valente DO.

(5)
‘Analyzing Risk of Recurrence after Mastectomy for DCIS: A New Use for
USC/Van Nuys Prognostic Index’, Leah Kelley MD, Melvin J. Silverstein MD,
Lisa Guerra MD.