J. C. Weeks

The use of radiation as a component of breast conservation therapy in national comprehensive cancer network centers

PURPOSEnBenchmark data regarding quality measures of breast cancer management are needed. We investigated rates of radiation use after breast conservation therapy (BCT) for patients treated for ductal carcinoma-in-situ (DCIS) or invasive breast cancer at National Comprehensive Cancer Network (NCCN) centers.nnnPATIENTS AND METHODSnWe studied 3,333 consecutive patients treated between 1997 and 2002 with BCT for DCIS (n = 587) or for stage I or II breast cancer (n = 2,746) in eight NCCN centers.nnnRESULTSnThe overall rate of radiation therapy use was 91%, with a lower frequency of radiation use in DCIS versus invasive breast cancers (82% v 94%; odds ratio [OR] = 0.31; P < .0001). In a multivariable analysis of the patients with DCIS, the only factor significantly associated with lower rates of radiation use was low/intermediate grade (OR = 0.19; P = .0003). For patients with invasive breast cancer, significant factors were presence of comorbidity (OR = 0.53; P = .0005), tubular histology (OR = 0.39; P = .02), type of health insurance (P = .0072), and the NCCN institution (P = .0005). The model also showed lower rates of radiation use in patients with stage II disease who did not receive systemic therapy (OR = 0.01; P = .0001), younger patients who did not receive systemic therapy (P = .003); and older patients with stage I disease (P < .0001).nnnCONCLUSIONnRadiation use as a component of BCT was high for patients seen at NCCN centers; however, there was variability in practice patterns noted across institutions. Radiation was most commonly omitted in patients with favorable disease characteristics, patients with comorbidities, and patients who also did not receive guideline-recommended systemic treatment.

Impact of Randomized Clinical Trial Results in the National Comprehensive Cancer Network on the Use of Tamoxifen After Breast Surgery for Ductal Carcinoma in Situ

PURPOSEnThe National Surgical Adjuvant Breast and Bowel Project B-24 trial, published in June 1999, demonstrated that tamoxifen after breast-conserving surgery (BCS) and radiotherapy for ductal carcinoma in situ (DCIS) reduced the absolute occurrence of ipsilateral and contralateral breast cancer. We assessed the impact of B-24 on practice patterns at selected National Comprehensive Cancer Network (NCCN) centers.nnnPATIENTS AND METHODSnTamoxifen use after surgery was examined among 1,622 patients presenting for treatment of unilateral DCIS between July 1997 and December 2003 at eight NCCN centers. Associations of clinicopathologic and treatment factors with tamoxifen use were assessed in univariate and multivariable logistic regression analyses.nnnRESULTSnOverall, 41% of patients (665 of 1,622) received tamoxifen. The proportion increased from 24% before July 1, 1999, to 46% on or after July 1, 1999. Factors significantly associated with receipt of tamoxifen included diagnosis on or after July 1, 1999 (odds ratio [OR], 3.85; P < .0001), BCS in patients younger than 70 years (OR, 3.21; P = .0073), no history of cerebrovascular or peripheral vascular disease (OR, 3.13; P = .0071), receipt of radiotherapy (OR, 1.82; P = .0009), and previous hysterectomy (OR, 1.34; P = .0459). Tamoxifen use varied significantly by center, from 34% to 74% after BCS and 17% to 53% after mastectomy (P < .0001).nnnCONCLUSIONnTamoxifen use after surgery for DCIS at NCCN centers increased after presentation of the B-24 results. Rates varied substantially by institution, suggesting that physicians differ in how they weigh the modest reduction in breast cancer risk with tamoxifen against its potential adverse effects in this population.

Pathologic characteristics of second breast cancers (SBC) among women previously treated for ductal carcinoma in situ (DCIS) with breast conservation.

1042 Background: While the number of women in the U.S. diagnosed with DCIS is increasing and many go on to develop SBC, pathologic characteristics of SBC and the degree of pathologic correlation with index DCIS are not well characterized.nnnMETHODSnWe identified women in the National Comprehensive Cancer Network (NCCN) Outcomes Database diagnosed with DCIS from 1997-2008 and treated with breast conserving surgery (BCS) who subsequently developed SBC (DCIS or invasive; ipsilateral or contralateral) at one of eight NCCN institutions. We describe the pathologic characteristics of SBC and examine the degree of correlation with the index DCIS using Fisher exact and Spearman tests.nnnRESULTSnAmong 2,636 women receiving BCS for DCIS with a median follow-up of 55.5 months, 150 women (5.7%) experienced SBC at a median of 33.2 months after index DCIS. Of these 150 women, 105 (70.0%) had received adjuvant radiotherapy (RT) and 50 (33.3%) had received tamoxifen (Tam) for index DCIS. SBC was ipsilateral in 54.7% of cases and invasive in 50.7% of cases. For index DCIS and SBC, 60.6% and 77.5% were estrogen receptor (ER) positive, and 54.0% and 48.2% were high grade, respectively. Among all cases, grade of the index DCIS was highly correlated with grade of the SBC (p = .003), and ER status was also highly correlated between index DCIS and SBC (p = .020). There was no significant correlation for tumor size (p = .873), progesterone receptor status (p = .227), or comedo subtype (p = .074).xa0 After stratification, tumor grade remained significantly correlated among early (less than the median follow-up time) but not late SBC, and ER status was not significantly correlated among women who received RT. Tam had no significant impact on any pathologic correlations, but among women who had received Tam and developed SBC, the SBC was more likely to be a contralateral event (p = .015).nnnCONCLUSIONSnAfter BCS for DCIS, SBC are likely to exhibit grade and ER status concordant with the index DCIS. xa0This information could be complementary to estimates of overall recurrence risk for a given patient receiving BCS for DCIS, by helping predict prognostic features of a SBC and potentially influencing management of the index event.