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Original Investigation |

Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ

Steven A. Narod, MD, FRCPC1,2; Javaid Iqbal, MD1; Vasily Giannakeas, MPH1,2; Victoria Sopik, MSc1; Ping Sun, PhD1
[+] Author Affiliations
1Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
2Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
JAMA Oncol. 2015;1(7):888-896. doi:10.1001/jamaoncol.2015.2510.
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Published online

Importance  Women with ductal carcinoma in situ (DCIS), or stage 0 breast cancer, often experience a second primary breast cancer (DCIS or invasive), and some ultimately die of breast cancer.

Objective  To estimate the 10- and 20-year mortality from breast cancer following a diagnosis of DCIS and to establish whether the mortality rate is influenced by age at diagnosis, ethnicity, and initial treatment received.

Design, Setting, and Participants  Observational study of women who received a diagnosis of DCIS from 1988 to 2011 in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. Age at diagnosis, race/ethnicity, pathologic features, date of second primary breast cancer, cause of death, and survival were abstracted for 108 196 women. Their risk of dying of breast cancer was compared with that of women in the general population. Cox proportional hazards analysis was performed to estimate the hazard ratio (HR) for death from DCIS by age at diagnosis, clinical features, ethnicity, and treatment.

Main Outcomes and Measures  Ten- and 20-year breast cancer–specific mortality.

Results  Among the 108 196 women with DCIS, the mean (range) age at diagnosis of DCIS was 53.8 (15-69) years and the mean (range) duration of follow-up was 7.5 (0-23.9) years. At 20 years, the breast cancer–specific mortality was 3.3% (95% CI, 3.0%-3.6%) overall and was higher for women who received a diagnosis before age 35 years compared with older women (7.8% vs 3.2%; HR, 2.58 [95% CI, 1.85-3.60]; P < .001) and for blacks compared with non-Hispanic whites (7.0% vs 3.0%; HR, 2.55 [95% CI, 2.17-3.01]; P < .001). The risk of dying of breast cancer increased after experience of an ipsilateral invasive breast cancer (HR, 18.1 [95% CI, 14.0-23.6]; P < .001). A total of 517 patients died of breast cancer following a DCIS diagnosis (mean follow-up, 7.5 [range, 0-23.9] years) without experiencing an in-breast invasive cancer prior to death. Among patients who received lumpectomy, radiotherapy was associated with a reduction in the risk of ipsilateral invasive recurrence at 10 years (2.5% vs 4.9%; adjusted HR, 0.47 [95% CI, 0.42-0.53]; P < .001) but not of breast cancer–specific mortality at 10 years (0.8% vs 0.9%; HR, 0.86 [95% CI, 0.67-1.10]; P = .22).

Conclusions and Relevance  Important risk factors for death from breast cancer following a DCIS diagnosis include age at diagnosis and black ethnicity. The risk of death increases after a diagnosis of an ipsilateral second primary invasive breast cancer, but prevention of these recurrences by radiotherapy does not diminish breast cancer mortality at 10 years.

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Figure 1.
Twenty-Year Breast Cancer–Specific Survival After Ductal Carcinoma In Situ (DCIS) by Race/Ethnicity

Death occurred by 20 years after a diagnosis of DCIS for 623 of 76 188 whites, 59 of 8839 Hispanic whites, 185 of 10 943 blacks, and 61 of 10 036 Asians.

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Figure 2.
Twenty-Year Breast Cancer–Specific Survival After Ductal Carcinoma In Situ (DCIS) by Estrogen Receptor (ER) Status

Death occurred by 20 years after a diagnosis of DCIS for 82 of 8908 patients with ER-negative disease and 157 of 46 002 patients with ER-positive disease.

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Evidence for Informed Consent
Posted on August 28, 2015
Robert Weiss M.S.
Independent Lymphedema Patient Advocate
Conflict of Interest: None Declared
Among the common long-term effects of over-treatment of DCIS is breast lymphedema, truncal lymphedema and delayed breast cellulitis. In discussions with the patient prior to DCIS or early stage invasive breast cancer the physician must give the patient enough information with which to make a decision on radiotherapy which weighs the risk of (salvageable) local recurrence against the risk of lifelong lymphedema.

I raised this issue in 2008 in a poster at the NLN Conference and am gratified that the evidence is finally being collected to support this unpopular position.

See http://www.lymphactivist.org/breast_lymphedema-1.pdf
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