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Younger women, black women face greater risk for mortality after DCIS
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Black women and women aged younger than 35 years who are diagnosed with ductal carcinoma in situ have a higher 20-year breast cancer-specific death rate than other women diagnosed with the disease, according to results of a SEER analysis.
Ductal carcinoma in situ (DCIS) accounts for approximately 20% of the breast cancers detected by a mammography. Women with DCIS sometimes develop a second malignancy and a small percentage of women ultimately die from the disease. However, it is unclear to what degree cancer-specific mortality after DCIS diagnosis can be attributed to an invasive recurrence or the initial DCIS diagnosis.
Thus, Steven A. Narod, MD, FRCPC, FRSC, senior scientist and director of the familial breast cancer research unit at Women’s College Research Institute and professor in the department of medicine and the Dalla Lana School of Public Health at University of Toronto, and colleagues sought to estimate the 10- and 20-year mortality from breast cancer following a DCIS diagnosis and to identify the risk factors associated with death in this setting.
Steven A. Narod
The researchers identified 108,196 women with DCIS diagnosed between 1988 and 2011 using the SEER database. The mean age at diagnosis was 53.8 years (range, 15-69 years) and mean follow-up was 7.5 years (range, 0-23.9 years).
The 20-year breast cancer-specific death rate in the overall study population was 3.3% (95% CI, 3.0-3.6).
Black women had a greater 20-year mortality rate than non-Hispanic white women (7% vs. 3%; HR = 2.55; 95% CI, 2.17-3.01). Also, the mortality rate appeared greater among women diagnosed with DCIS before the age of 35 years than women diagnosed at age 35 years or older (7.8% vs. 3.2%; HR = 2.58; 95% CI, 1.85-3.60).
Women who experienced ipsilateral invasive recurrence (HR = 18.1; 95% CI, 14-23.5) or a contralateral invasive recurrence (HR = 13.8; 95% CI, 11.5-16.6) following a diagnosis of DCIS also faced a greater risk for mortality.
Among women who underwent lumpectomy, radiation appeared associated with a reduced risk for ipsilateral invasive recurrence at 10 years (2.5% vs. 4.9%; adjusted HR = 0.47; 95% CI, 0.42-0.53) and a nonsignificant reduction in breast cancer-specific mortality (0.8% vs. 0.9%; HR = 0.86; 95% CI, 0.67-1.1).
“The finding of greatest clinical impact was that prevention of ipsilateral invasive recurrence did not prevent death from breast cancer,” Narod and colleagues wrote. “Women with DCIS who developed an ipsilateral invasive in-breast recurrence were 18.1 times more likely to die of breast cancer than women who did not.”
Of the 956 women who died of breast cancer during follow-up, 517 (54.1%) never experienced an in-breast invasive recurrence prior to death.
“Some cases of DCIS have an inherent potential for distant metastatic spread,” Narod and colleagues wrote. “It is therefore appropriate to consider these as de facto breast cancers and not as pre-invasive markers predictive of a subsequent invasive cancer. The outcome of breast cancer mortality for DCIS patients is of importance in itself and potential treatments that affect mortality are deserving of study.”
These findings help fuel a growing concern that clinicians should rethink their strategy for the detection and treatment of DCIS, Laura J. Esserman, MD, MBA, professor in the departments of surgery and radiology, affiliate faculty in the institute for health policy studies, director of the Carol Franc Buck Breast Cancer Center and co-leader of the breast oncology program at University of California San Francisco (UCSF) Helen Diller Comprehensive Cancer Center, and Christina Yau, PhD, assistant professor in the department of surgery at UCSF School of Medicine, wrote in an accompanying editorial.
“The large numbers [from this study] and long-term follow-up provide a compelling case that it is time for change,” they wrote. “The community of radiologists and surgeons needs to be part of the call for change. Given the low breast cancer mortality risk, we should stop telling women that DCIS is an emergency and that they should schedule definitive surgery within 2 weeks of diagnosis.” – by Anthony SanFilippo
Disclosure: The researchers, Esserman and Yau all report no relevant financial disclosures.
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