Transcript 1995-2010 SAMC 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
•
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
N=558
Mastectomy
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
Distant
Local, Invasive
N=5
N=1
3%
4
2%
10
1%
0.5%
0.5%
0.5% 0.5% 0.5%
2
2
Excis Alone
N=146
2
Excis + XRT
N=412
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
*multifocal
Grade
Margins
VNPI
Score
Recurrence
(Recurrence
Unknown
excluded N=6)
Type
Year
Recurred
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
2.5 yrs
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
2 yrs
19
Partial
Yes
2.2 cm
High
< 1 mm
9
LOCAL
NOS
4.5 yrs
20
Partial
Yes
8.5 cm
Intermed
Negative
9
LOCAL
In-situ
4 yrs
3.5 yrs
1995-2010 SAMC Ductal Carcinoma In-situ
Recurrence Following Mastectomy
N=228
# of
Pts
Surgery
XRT
Largest
Tumor
Dimension
*multifocal
1
MAST
NO
2.0cm
High
NEG
8
2
MAST
NO
9.0cm
High
CLOSE
3
MAST
NO
*2.5cm
High
NEG
Recurrence
(Recurrence
Unknown
excluded
N=1)
Type
Year
Recurred
LOCAL
In-situ
2 yrs
11
LOCAL
Invasive
2.5 yrs
7
DISTANT
CNS
4 yrs
Grade
Margins
VNPI
Score
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
34%
11
2.2%
•
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.
228
29%
3
1.3%
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.