2011 Oncology ServicesAnnual Report

Non-Invasive Breast Cancer:

Ductal Carcinoma In-situ

Vassi Gardikas, MD, FACSEllen Malek, CTR

Saint Agnes Medical CenterCancer Registry

1303 East Herndon AvenueFresno, CA 93720

559 450-3570www.samc.com

®

• 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. 

Introduction

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-situN=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-situcont.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

6.6% 6%

35.5%

26.5%

43.4%

52%

14.5% 15.5%

Low Intermediate High Not Determined

Partial Mastectomy

Resource: SAMC Cancer Registry

N=558 N=228

1995-2010 SAMC Ductal Carcinoma In-situRecurrence Type by SurgeryN=794

3%

1%

0.5%

2%

0.5% 0.5% 0.5% 0.5%

Excis AloneN=146

Excis + XRTN=412

MastectomyN=228

Local, Nos Local, In-Situ Local, Invasive Distant

4

Resource: SAMC Cancer Registry

2

10

2 2 1 1 1

N=1N=5N=15N=2

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-situPartial 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 3.5 yrs

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

1995-2010 SAMC Ductal Carcinoma In-situ Recurrence Following Mastectomy N=228

# of Pts Surgery XRT

Largest Tumor

Dimension *multifocal

Grade Margins VNPI Score

Recurrence(Recurrence

Unknown excluded

N=1)

TypeYear Recurred

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

Resource: SAMC Cancer Registry

Risk of Recurrence After Mastectomy for DCISComparison Melvin J. Silverstein, et al (5)

MJS SAMC

TOTAL 1472 794

MAST 496 34%

228 29%

RECUR 11 2.2%

3 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 N=602

19%NCDB

N=355,964

Stage 0

2000-2009 NCDB Benchmark ComparisonNon-Invasive Breast Cancer (all histologies)First Course Treatment

0.2%2%

38%

45%

13%

9%

18%22%

28%

18%

2.8%4%

None Surg Surg/H Surg/XRT Surg/XRT/H Other

SAMC NCDB

2000-2009 NCDB Benchmark ComparisonNon-Invasive Breast Cancer (all histologies) First Course Surgery

0.5% 2.3%

69% 68%

24% 23.2%

6% 5.5%0.5% 1%

No Surg Partial Total Modified Mast,Nos/Other

SAMCNCDB

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.