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Brief Report
January 2017

Association of Regional Intensity of Ductal Carcinoma In Situ Treatment With Likelihood of Breast Preservation

Author Affiliations
  • 1Department of Radiation Therapy, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
  • 2Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
  • 3Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
  • 4The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire
  • 5Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine, Madison
  • 6Dana-Farber/Harvard Center Breast Cancer Advocacy Group, Dana-Farber Cancer Institute, Boston, Massachusetts
JAMA Oncol. 2017;3(1):101-104. doi:10.1001/jamaoncol.2016.2164
Key Points

Question  Do regional practice patterns of radiotherapy for ductal carcinoma in situ (DCIS) affect the likelihood of eventual mastectomy in women who receive breast-conserving surgery (BCS) without radiotherapy for DCIS?

Findings  In this study using 2 population-based databases, Surveillance, Epidemiology, and End Results (SEER) and SEER-Medicare, residence in a health service area characterized by greater radiotherapy use for DCIS increased the likelihood of women undergoing mastectomy vs BCS at subsequent breast event even among those who had not previously received radiotherapy for DCIS.

Meaning  This association of regional radiotherapy with the use of mastectomy suggests that provider-related factors are affecting the likelihood of breast preservation.

Abstract

Importance  Large regional variation exists in the use of radiotherapy after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Although patients who do not receive initial radiotherapy for DCIS are candidates for subsequent BCS if they experience a second breast event, many undergo mastectomy instead.

Objective  To examine whether regional practice patterns of radiotherapy for DCIS affect the use of mastectomy in these patients.

Design, Setting, and Participants  A retrospective analysis of population-based databases (Surveillance, Epidemiology, and End Results [SEER] and SEER-Medicare). Data were obtained for 2679 women in SEER with a diagnosis of DCIS between 1990 and 2011 and for 757 women in SEER-Medicare with a DCIS diagnosis between 1991 and 2009 who had not undergone radiotherapy for DCIS and experienced a subsequent breast cancer or DCIS diagnosis.

Exposures  Treatment intensity for primary DCIS (high, medium, low), as defined by separating health service areas (HSAs) into 3 clusters based on radiotherapy use.

Main Outcomes and Measures  Mastectomy vs BCS at a second breast event defined as DCIS recurrence or new invasive cancer.

Results  The median (SD) ages of the participants was 64 (13) years for the 2679 SEER population and 79 (6) years for the SEER-Medicare cohort. Residence in an HSA characterized by greater radiotherapy use for DCIS increased the likelihood of receiving mastectomy vs BCS at a subsequent breast event, even among women who had not previously received radiotherapy for DCIS. Adjusted odds ratios for receiving mastectomy were 1.43 (95% CI, 1.10-1.85) and 1.90 (95% CI, 1.27-2.84) in SEER and SEER-Medicare databases, respectively, among women residing in an HSA with the greatest radiotherapy use vs the least, corresponding to an adjusted increase from 40.8% to 49.6%, and from 38.6% to 54.5%.

Conclusions and Relevance  Areas with more radiotherapy use for DCIS had increased use of mastectomy at the time of a second breast event even among patients eligible for breast conservation. This association suggests that physician-related factors are affecting the likelihood of breast preservation.

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