European Journal of Obstetrics & Gynecology and Reproductive Biology
Variation among Spanish teaching hospitals in ductal carcinoma in situ treatment: results of a national survey
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).
References (16)
- et al.
Changing patterns in diagnosis and treatment of ductal carcinoma in situ of the breast
Eur J Surg Oncol
(2005) The University of Southern California/Van Nuys prognostic index for ductal carcinoma in situ of the breast
Am J Surg
(2003)- et al.
Breast cancer-specific mortality after invasive local recurrence in patients with ductal carcinoma-in-situ of the breast
Am J Surg
(2006) - et al.
Rationalization and regionalization of treatment for ductal carcinoma in situ of the breast
Int J Radiat Oncol Biol Phys
(2006) - et al.
Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial
Lancet
(2003) - et al.
Tumor markers in breast carcinoma correlate with grade rather than with invasiveness
Br J Cancer
(2001) - et al.
La situación del cáncer en España
(2005)