Ductal Carcinoma In Situ of the Breast: A Systematic Review
Ductal Carcinoma In Situ of the Breast: A Systematic Review
Background The National Institutes of Health Office of Medical Applications of Research commissioned a structured literature review on the incidence, treatment, and outcomes of ductal carcinoma in situ (DCIS) as a background article for the State of the Science Conference on Diagnosis and Management of DCIS.
Methods Published studies were identified and abstracted from MEDLINE and other sources. We include articles published between 1965 and January 31, 2009; 374 publications were identified that addressed DCIS incidence, staging, treatment, and outcomes in adult women.
Results In the United States, DCIS incidence rose from 1.87 per 100 000 in 1973–1975 to 32.5 in 2004. Incidence increased in all ages but more so in women older than 50 years. Increased use of mammography explains some but not all of the increased incidence. Risk factors for incident DCIS include older age and family history. Although tamoxifen treatment prevented both invasive breast cancer and DCIS, raloxifene treatment decreased incidence of invasive breast cancer but not DCIS. Among patients with DCIS, magnetic resonance imaging was more sensitive than mammography for detecting multicentric disease and estimating tumor size. Because about 15% of patients with DCIS identified on core needle biopsy are diagnosed with invasive breast cancer after excision or mastectomy, the accuracy of sentinel lymph node biopsy after excision is relevant to surgical management of DCIS. Most studies demonstrated that sentinel lymph node biopsy is feasible after breast-conserving surgery (BCS). Younger age, positive surgical margins, tumor size and grade, and comedo necrosis were consistently related to DCIS recurrence. DCIS outcomes after either mastectomy or BCS plus radiation therapy were superior to BCS alone. Tamoxifen treatment after DCIS diagnosis reduced risk of recurrent disease.
Conclusions Scientific questions deserving further investigation include the relationship between mammography use and DCIS incidence and whether imaging technologies and treatment guidelines can be modified to focus on lesions that are most likely to become clinically problematic.
Ductal carcinoma in situ (DCIS) is noninvasive 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 is characterized histologically by the proliferation of malignant epithelial cells that are bounded by the basement membrane of the breast ducts. DCIS is typically classified according to architectural pattern (solid, cribriform, papillary, and micropapillary), tumor grade (high, intermediate, and low), and the presence or absence of comedo necrosis. Before the advent of widespread screening mammography, DCIS was usually diagnosed by surgical removal of a suspicious breast mass. DCIS was rarely diagnosed before 1980, but currently about 25% of breast cancers that are diagnosed in the United States are DCIS (Figure 1).
(Enlarge Image)
Figure 1.
Trends in the age-adjusted incidence of ductal carcinoma in situ (DCIS) and invasive cancer (1975–2005).
The fundamental question underlying treatment and detection of DCIS is whether it should be considered a direct precursor of invasive breast cancer. Although studies of the natural history of invasive breast cancer are rare, there is general consensus that DCIS represents an intermediate step between normal breast tissue and invasive breast cancer. Because excisional biopsy (and, to a lesser extent, core needle biopsy) removes a substantial portion of the targeted lesion, the natural history of untreated DCIS is unknown. Data from population-based studies indicate that the 10-year breast cancer mortality rate for patients with DCIS is less than 2% after excision or mastectomy.
The following is a summary of a report requested by the National Institutes of Health Office of Medical Applications of Research as a background paper for the State of the Science Conference on Diagnosis and Management of DCIS. The report, which is available at http://www.ahrq.gov//clinic/epcix.htm, addresses four key questions: 1) What are the incidence and prevalence of DCIS and its specific pathologic subtypes, and how are incidence and prevalence influenced by mode of detection, population characteristics, and other risk factors? 2) How does the use of magnetic resonance imaging (MRI) or sentinel lymph node biopsy (SLNB) impact important outcomes in patients diagnosed with DCIS? 3) How do local control and systemic outcomes vary in DCIS based on tumor and patient characteristics? 4) In patients with DCIS, what is the impact of surgery, radiation, and systemic treatment on outcomes?
Abstract and Introduction
Abstract
Background The National Institutes of Health Office of Medical Applications of Research commissioned a structured literature review on the incidence, treatment, and outcomes of ductal carcinoma in situ (DCIS) as a background article for the State of the Science Conference on Diagnosis and Management of DCIS.
Methods Published studies were identified and abstracted from MEDLINE and other sources. We include articles published between 1965 and January 31, 2009; 374 publications were identified that addressed DCIS incidence, staging, treatment, and outcomes in adult women.
Results In the United States, DCIS incidence rose from 1.87 per 100 000 in 1973–1975 to 32.5 in 2004. Incidence increased in all ages but more so in women older than 50 years. Increased use of mammography explains some but not all of the increased incidence. Risk factors for incident DCIS include older age and family history. Although tamoxifen treatment prevented both invasive breast cancer and DCIS, raloxifene treatment decreased incidence of invasive breast cancer but not DCIS. Among patients with DCIS, magnetic resonance imaging was more sensitive than mammography for detecting multicentric disease and estimating tumor size. Because about 15% of patients with DCIS identified on core needle biopsy are diagnosed with invasive breast cancer after excision or mastectomy, the accuracy of sentinel lymph node biopsy after excision is relevant to surgical management of DCIS. Most studies demonstrated that sentinel lymph node biopsy is feasible after breast-conserving surgery (BCS). Younger age, positive surgical margins, tumor size and grade, and comedo necrosis were consistently related to DCIS recurrence. DCIS outcomes after either mastectomy or BCS plus radiation therapy were superior to BCS alone. Tamoxifen treatment after DCIS diagnosis reduced risk of recurrent disease.
Conclusions Scientific questions deserving further investigation include the relationship between mammography use and DCIS incidence and whether imaging technologies and treatment guidelines can be modified to focus on lesions that are most likely to become clinically problematic.
Introduction
Ductal carcinoma in situ (DCIS) is noninvasive 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 is characterized histologically by the proliferation of malignant epithelial cells that are bounded by the basement membrane of the breast ducts. DCIS is typically classified according to architectural pattern (solid, cribriform, papillary, and micropapillary), tumor grade (high, intermediate, and low), and the presence or absence of comedo necrosis. Before the advent of widespread screening mammography, DCIS was usually diagnosed by surgical removal of a suspicious breast mass. DCIS was rarely diagnosed before 1980, but currently about 25% of breast cancers that are diagnosed in the United States are DCIS (Figure 1).
(Enlarge Image)
Figure 1.
Trends in the age-adjusted incidence of ductal carcinoma in situ (DCIS) and invasive cancer (1975–2005).
The fundamental question underlying treatment and detection of DCIS is whether it should be considered a direct precursor of invasive breast cancer. Although studies of the natural history of invasive breast cancer are rare, there is general consensus that DCIS represents an intermediate step between normal breast tissue and invasive breast cancer. Because excisional biopsy (and, to a lesser extent, core needle biopsy) removes a substantial portion of the targeted lesion, the natural history of untreated DCIS is unknown. Data from population-based studies indicate that the 10-year breast cancer mortality rate for patients with DCIS is less than 2% after excision or mastectomy.
The following is a summary of a report requested by the National Institutes of Health Office of Medical Applications of Research as a background paper for the State of the Science Conference on Diagnosis and Management of DCIS. The report, which is available at http://www.ahrq.gov//clinic/epcix.htm, addresses four key questions: 1) What are the incidence and prevalence of DCIS and its specific pathologic subtypes, and how are incidence and prevalence influenced by mode of detection, population characteristics, and other risk factors? 2) How does the use of magnetic resonance imaging (MRI) or sentinel lymph node biopsy (SLNB) impact important outcomes in patients diagnosed with DCIS? 3) How do local control and systemic outcomes vary in DCIS based on tumor and patient characteristics? 4) In patients with DCIS, what is the impact of surgery, radiation, and systemic treatment on outcomes?
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