title: Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons.
abstract: BACKGROUND
  The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes.
  
  
  METHODS
  We collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided.
  
  
  RESULTS
  Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (P(diff) < .001 for each of the differences). Similarly, each of the differences at 10 years was statistically significant (P < .001).
  
  
  CONCLUSIONS
  Our work demonstrates the contributions of treatments and margin status to long-term ipsilateral disease-free survival and the link between surgeons and these key measures of care. Although variation by surgeon could be generated by patients' preferences, the extent of variation and its contribution to long-term health outcomes are troubling. Further work is required to determine why women with positive margins receive no additional treatment and why margin status and receipt of radiation therapy vary by surgeon.
authors.affiliation: The RAND Corporation, Pittsburgh, PA 15213, USA. andrew_dick@rand.org
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Dick
authors.forename: Melony S
authors.initials: MS
authors.lastname: Sorbero
authors.forename: Gretchen M
authors.initials: GM
authors.lastname: Ahrendt
authors.forename: James A
authors.initials: JA
authors.lastname: Hayman
authors.forename: Heather T
authors.initials: HT
authors.lastname: Gold
authors.forename: Linda
authors.initials: L
authors.lastname: Schiffhauer
authors.forename: Azadeh
authors.initials: A
authors.lastname: Stark
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Griggs
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000473:pathology* / Q000532:radiotherapy* / Q000601:surgery; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000473:pathology* / Q000532:radiotherapy* / Q000601:surgery; D057186:Comparative Effectiveness Research; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008408:Mastectomy / Q000379:methods*; D015411:Mastectomy, Modified Radical; D015412:Mastectomy, Segmental; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D018365:Neoplasm, Residual / Q000532:radiotherapy; D016017:Odds Ratio; D010819:Physician's Role; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D016896:Treatment Outcome