Variation among Spanish teaching hospitals in ductal carcinoma in situ treatment: results of a national survey

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Abstract

Objective

To investigate current management of ductal carcinoma in situ (DCIS) of the breast in Spanish teaching hospitals and to evaluate prognostic factors for recurrence.

Study design

: To allow follow-up of 5 years or more, cases diagnosed and treated during 2004 were considered, in order to evaluate the recurrence and death rates due to the disease. Data were reported corresponding to 473 cases, which represents 9.8% of all diagnosed breast carcinomas in the 23 participating centers. Only 425 could be ultimately evaluated, corresponding to approximately 27% of all incident in situ breast carcinoma cases in Spain during 2004.

Results

About two-thirds of patients were surgically treated by lumpectomy, and one-third by mastectomy. A strikingly high number of patients had their axillary lymph nodes studied, by means of either sentinel node biopsy (21.9%) or lymphadenectomy (19.3%). Five-year global survival was 99.5%, and disease-free survival 96.9%. The only factor significantly associated with tumor recurrence was tumor microinvasion (p = 0.05). In a second, restricted model stratified by microinvasion, the only factor emerging as significantly associated with a better outcome was having received hormonal therapy (p = 0.03), but only in the group of pure in situ carcinomas, without microinvasion.

Conclusions

Prospective randomized trials are mandatory to achieve an agreement about the best treatment for DCIS. As long as the current discrepancy exists, we should probably err on the conservative side, and not subject our patients to unnecessary therapeutic aggressiveness.

Introduction

Ductal carcinoma in situ (DCIS) of the breast is the only known true premalignant condition in the breast eventually leading to invasive ductal carcinoma, as shown by the similarity in gene expression between invasive ductal carcinoma and its surrounding in situ component [1]. The diagnosis of DCIS has increased exponentially during the past three decades due to the generalized implementation of mass screening campaigns in developed countries [2]. It has passed from being a sporadic finding to comprise up to 30% of breast carcinoma diagnoses [3].

Despite its increasing frequency, the treatment of DCIS is highly controversial. Depending on where it is diagnosed, treatment for the same condition may range from simple excision to mastectomy. This absence of universally accepted treatment guidelines creates insecurity not only for the patients, but also for the treating physicians. Moreover, it is not infrequently found that, at the same center, the mastectomy rate is higher for DCIS, a premalignant condition, than for its frankly invasive counterpart. Attempts have been made to systematize indications for surgery of DCIS, most notably through the implementation of the van Nuys prognostic index (VNPI) [4], but its use is far from generalized. Consequently, every center has its own management protocol, and believes in good conscience that it provides the best available treatment for DCIS, although protocols, as has been mentioned, may vary in the extreme.

We believe that this situation, which pertains in many countries, is exactly the same in Spain, and therefore the present survey has been carried out under the auspices of the Spanish Society of Gynecology and Obstetrics (SEGO). The aim was to provide a “snapshot” of current management of DCIS in Spanish teaching hospitals, i.e., hospitals with state-approved residency training programs. SEGO guarantees before the State the homogeneity of residents’ training programs, and consequently one of its main concerns is that treatment protocols are based on the best available evidence and show minimal variations among the different teaching hospitals.

Section snippets

Materials and methods

An online questionnaire was made available to all Obstetrics & Gynecology services of registered Spanish teaching hospitals through the SEGO homepage. The questionnaire was kept purposefully simple, in order to maximize the compliance rate. Only cases diagnosed and treated during 2004 were considered, to allow a follow-up of 5 years or more, to evaluate the recurrence and death rates due to the disease. In all, 60 investigators from 23 centers (Supplementary Material 1), representing all but

Results

Virtually all (97.2%) DCIS cases were diagnosed by means of mammography, of which approximately two-thirds (69.0%) corresponded to screening mammography and one-third to medically indicated mammography. The diagnostic methods employed are summarized in Table 1.

The treatment modalities employed are summarized in Table 2. Around two-thirds of patients were surgically treated by means of lumpectomy, and one-third by means of mastectomy. We found that 9.2% underwent other treatments such as

Comments

Regional variation in breast cancer treatment policies in Spain is a known fact, as exemplified by the recent report by Ridao-López et al. on conservative breast cancer surgery in this country [6]. It must also be said, however, that there exists no worldwide consensus on the adequate treatment of DCIS. Although several prospective randomized trials [7], [8] have shown that local excision with adequate margins, followed by radiotherapy, significantly improves patient outcome (especially in

Conflicts of interest statement

The authors declare they do not have any conflict of interest.

Acknowledgment

All Spanish Society of Gynecology and Obstetrics (SEGO) ENSITU investigators (list attached).

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