title: Modeling the effectiveness of initial management strategies for ductal carcinoma in situ.
abstract: BACKGROUND
  The prevalence of ductal carcinoma in situ (DCIS) and the marked variability in patterns of care highlight the need for comparative effectiveness research. We sought to quantify the tradeoffs among alternative management strategies for DCIS with respect to disease outcomes and breast preservation.
  
  
  METHODS
  We developed a disease simulation model integrating data from the published literature to simulate the clinical events after six treatments (lumpectomy alone, lumpectomy with radiation, lumpectomy with radiation and tamoxifen, lumpectomy with tamoxifen, and mastectomy with and without breast reconstruction) for women with newly diagnosed DCIS. Outcomes included disease-free, invasive disease-free, and overall survival and breast preservation.
  
  
  RESULTS
  For a cohort of 1 million simulated women aged 45 years at diagnosis, both mastectomy and lumpectomy with radiation and tamoxifen were associated with a 12-month improvement in overall survival relative to lumpectomy alone. Adding radiation therapy to lumpectomy resulted in a 6-month improvement in overall survival but decreased long-term breast-preservation outcomes (likelihood of lifetime breast preservation = 0.781 vs 0.843 for lumpectomy alone). This decrement with radiation therapy was mitigated by the addition of tamoxifen (likelihood of lifetime breast preservation = 0.846).
  
  
  CONCLUSIONS
  Overall survival benefits of the six management strategies for DCIS are within 1 year, suggesting that treatment decisions can be informed by the patient's preference for breast preservation and disutility for recurrence. Our delineation of personalized outcomes for each strategy can help patients understand the implications of their treatment choice, so their decisions may reflect their own personal values and help improve the quality of care for patients with DCIS.
authors: Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA. dsoetema@hsph.harvard.edu
authors: Djøra I
authors: DI
authors: Soeteman
authors: Natasha K
authors: NK
authors: Stout
authors: Elissa M
authors: EM
authors: Ozanne
authors: Caprice
authors: C
authors: Greenberg
authors: Michael J
authors: MJ
authors: Hassett
authors: Deborah
authors: D
authors: Schrag
authors: Rinaa S
authors: RS
authors: Punglia
mesh_terms: D000328:Adult; D000368:Aged; D018931:Antineoplastic Agents, Hormonal / Q000008:administration & dosage*; D001943:Breast Neoplasms / Q000628:therapy*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000628:therapy*; D057186:Comparative Effectiveness Research; D003198:Computer Simulation; D003657:Decision Making; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D016462:Mammaplasty; D015411:Mastectomy, Modified Radical; D015412:Mastectomy, Segmental; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D010358:Patient Participation; D018714:Radiotherapy, Adjuvant; D013629:Tamoxifen / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D018931:Antineoplastic Agents, Hormonal; D013629:Tamoxifen
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