title: Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ.
abstract: BACKGROUND
  Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS).
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided.
  
  
  RESULTS
  One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%).
  
  
  CONCLUSIONS
  We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Mathias
authors.initials: M
authors.lastname: Worni
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Igor
authors.initials: I
authors.lastname: Akushevich
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Rachel
authors.initials: R
authors.lastname: Greenup
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Deba
authors.initials: D
authors.lastname: Sarma
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Marc D
authors.initials: MD
authors.lastname: Ryser
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
authors.forename: Evan R
authors.initials: ER
authors.lastname: Myers
authors.affiliation: Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW). shelley.hwang@duke.edu.
authors.forename: E Shelley
authors.initials: ES
authors.lastname: Hwang
mesh_terms: D000328:Adult; D000368:Aged; D014408:Biomarkers, Tumor / Q000032:analysis; D001943:Breast Neoplasms / Q000737:chemistry / Q000208:ethnology / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000737:chemistry / Q000208:ethnology / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D015986:Confounding Factors, Epidemiologic; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008408:Mastectomy / Q000379:methods / Q000706:statistics & numerical data*; D015411:Mastectomy, Modified Radical / Q000706:statistics & numerical data; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D016017:Odds Ratio; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data*; D011960:Receptors, Estrogen / Q000032:analysis; D011980:Receptors, Progesterone / Q000032:analysis; D018426:SEER Program; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data / Q000639:trends; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D014408:Biomarkers, Tumor; D011960:Receptors, Estrogen; D011980:Receptors, Progesterone