title: Declining recurrence among ductal carcinoma in situ patients treated with breast-conserving surgery in the community setting.
abstract: BACKGROUND
  Randomized trials indicate that adjuvant radiotherapy plus tamoxifen decrease the five-year risk of recurrence among ductal carcinoma in situ patients treated with breast-conserving surgery from about 20% to 8%. The aims of this study were to examine the use and impact of these therapies on risk of recurrence among ductal carcinoma in situ patients diagnosed and treated in the community setting.
  
  
  METHODS
  We identified 2,995 patients diagnosed with ductal carcinoma in situ between 1990 and 2001 and treated with breast-conserving surgery at three large health plans. Medical charts were reviewed to confirm diagnosis and treatment and to obtain information on subsequent breast cancers. On a subset of patients, slides from the index ductal carcinoma in situ were reviewed for histopathologic features. Cumulative incidence curves were generated and Cox regression was used to examine changes in five-year risk of recurrence across diagnosis years, with and without adjusting for trends in use of adjuvant therapies.
  
  
  RESULTS
  Use of radiotherapy increased from 25.8% in 1990-1991 to 61.3% in 2000-2001; tamoxifen increased from 2.3% to 34.4%. A total of 245 patients had a local recurrence within five years of their index ductal carcinoma in situ. The five-year risk of any local recurrence decreased from 14.3% (95% confidence interval 9.8 to 18.7) for patients diagnosed in 1990-1991 to 7.7% (95% confidence interval 5.5 to 9.9) for patients diagnosed in 1998-1999; invasive recurrence decreased from 7.0% (95% confidence interval 3.8 to 10.3) to 3.1% (95% confidence interval 1.7 to 4.6). In Cox models, the association between diagnosis year and risk of recurrence was modestly attenuated after accounting for use of adjuvant therapy. Between 1990-1991 and 2000-2001, the proportion of patients with tumors with high nuclear grade decreased from 46% to 32% (P = 0.03) and those with involved surgical margins dropped from 15% to 0% (P = 0.03).
  
  
  CONCLUSIONS
  The marked increase in the 1990s in the use of adjuvant therapy for ductal carcinoma in situ patients treated with breast-conserving surgery in the community setting only partially explains the 50% decline in risk of recurrence. Changes in pathology factors have likely also contributed to this decline.
authors.affiliation: Division of Research, Kaiser Permanente, Northern California, 2000 Broadway, Oakland, CA 94612, USA. laurel.habel@kp.org
authors.forename: Laurel A
authors.initials: LA
authors.lastname: Habel
authors.forename: Ninah S
authors.initials: NS
authors.lastname: Achacoso
authors.forename: Reina
authors.initials: R
authors.lastname: Haque
authors.forename: Larissa
authors.initials: L
authors.lastname: Nekhlyudov
authors.forename: Suzanne W
authors.initials: SW
authors.lastname: Fletcher
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Schnitt
authors.forename: Laura C
authors.initials: LC
authors.lastname: Collins
authors.forename: Ann M
authors.initials: AM
authors.lastname: Geiger
authors.forename: Balaram
authors.initials: B
authors.lastname: Puligandla
authors.forename: Luana
authors.initials: L
authors.lastname: Acton
authors.forename: Charles P
authors.initials: CP
authors.lastname: Quesenberry
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D002278:Carcinoma in Situ / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D018270:Carcinoma, Ductal, Breast / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016022:Case-Control Studies; D017024:Chemotherapy, Adjuvant / Q000639:trends; D005260:Female; D006801:Humans; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology*; D018714:Radiotherapy, Adjuvant / Q000639:trends; D012189:Retrospective Studies; D013629:Tamoxifen / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D018931:Antineoplastic Agents, Hormonal; D013629:Tamoxifen