Purpose The increased breast cancer risk conferred by a diagnosis of lobular carcinoma in situ (LCIS) is poorly understood. Here we review our 29-year longitudinal experience with LCIS to evaluate factors associated with breast cancer risk. Methods Patients participating in surveillance following an LCIS diagnosis are followed in a prospectively maintained database. Comparisons were made among women choosing surveillance, with or without chemoprevention, and those undergoing bilateral prophylactic mastectomies between 1980 and 2009. Results 1060 patients with LCIS without concurrent breast cancer were identified. Median age at LCIS diagnosis was 50 years (range, 27–83). 56 (5%) underwent bilateral prophylactic mastectomy; 1004 chose surveillance with (n=173) or without (n=831) chemoprevention. At a median follow-up of 81 months (6–368 months), 150 patients developed 168 breast cancers (63% ipsilateral, 25% contralateral, 12% bilateral), with no dominant histology (ductal carcinoma in situ 35%, infiltrating ductal carcinoma 29%, infiltrating lobular carcinoma 27%, other 9%). Breast cancer incidence was significantly reduced in women taking chemoprevention (10-year cumulative risk: 7% chemoprevention; 21% no chemoprevention, p<.0001). In multivariate analysis, chemoprevention was the only clinical factor associated with breast cancer risk (hazard ratio 0.27, 95% confidence interval 0.15–0.50). In a subgroup nested case-control analysis, volume of disease defined as the ratio of slides with LCIS to total number of slides reviewed was also associated with breast cancer development (p=0.008). Conclusion We observed a 2% annual incidence of breast cancer among women with LCIS. Common clinical factors used for risk prediction including age and family history were not associated with breast cancer risk. The lower breast cancer incidence in women opting for chemoprevention highlights the potential for risk reduction in this population.

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Women with lobular carcinoma in situ (LCIS) have an elevated breast cancer risk, yet the benefit of MRI screening is unclear. We examined cancer detection rates with mammography alone versus mammography plus MRI in this high-risk population. From a prospectively maintained, single-institution database, we identified 776 patients diagnosed with LCIS after the adoption of screening MRI in April 1999. In addition to annual mammography and breast exam, MRI was used at the discretion of the physician and patient. Kaplan–Meier methods and landmark analyses at 1, 2, and 3 years following LCIS diagnosis were performed to compare rates of cancer detection with or without MRI. MRI screening was performed in 455 (59 %) patients (median, 3/patient). Median time from LCIS diagnosis to first MRI was 9 months (range 0.3–137 months). Patients undergoing MRI were younger (p < 0.0001), premenopausal (p < 0.0001), and more likely to have ≥1 first-degree relative with breast cancer (p = 0.009). At a median follow-up of 58 months, 98/776 (13 %) patients developed cancer. The crude cancer detection rate in both screening groups was 13 %. MRI was not associated with earlier stage, smaller size, or node negativity. Landmark analyses at 1, 2, and 3 years after LCIS diagnosis failed to demonstrate increased cancer detection rates among women having MRI (p = 0.23, 0.26, and 0.13, respectively). Although a diagnosis of LCIS remains a significant risk factor for breast cancer, the routine use of MRI does not result in increased cancer detection rates (short-term), nor does it result in earlier stage at diagnosis, illustrating the importance of defining optimal screening strategies for high-risk patients based on tumor biology rather than numerical risk.

BACKGROUNDEvolving concepts of cancer biology and emerging evidence of a potential survival benefit from local surgery have raised the question of an expanded role for surgery in select patients with metastatic breast cancer (MBC). To determine whether such developments have influenced clinical practice, the authors evaluated surgical practice patterns in the study institution over the last 15 years.METHODSTwo institutional databases were screened to identify patients with MBC who underwent breast surgery (1990–2005). Retrospective review was conducted to assess trends over time and to evaluate the role of surgery in the more modern era (1995–2005).RESULTSThe overall frequency of mastectomy remained stable over time (1.7%); however, between early (1990–1995) and late (2000–2005) periods the rate of ‘symptom control’ mastectomy decreased (41% to 25%), whereas the rate of ‘local control’ mastectomy increased (34% to 66%). Conversely, the overall frequency of wide‐local excision (WLE) increased over time (1995–2001), from 1% to 9% (P < .001) with no differences noted between rates of symptom control or local control procedures. In the modern era (1995–2005), 256 of 12,529 patients (2%) with MBC underwent breast surgery (33% mastectomy, 52% WLE); most frequently to ‘optimize local control’ (50%) and primarily in the setting of limited/stable distant disease. Surgery was performed for palliation in only 19% of patients. At a median follow‐up of 33.9 months (range, 0–198.7 months), 136 of 256 patients (53%) in this cohort remained alive; 88% were free of local disease.CONCLUSIONSAlthough surgery in MBC has historically been reserved for palliation, the authors observed a decreasing rate of traditional ‘toilet mastectomy’ and a broadened surgical approach to the asymptomatic patient. When viewed in parallel with evolving concepts in cancer biology, these data reflect a change in the traditional approach to patients with MBC and warrant further investigation. Cancer 2008. ©2008 American Cancer Society.

MRI screening can be a useful adjunct to CBE and MMG in patients with high-risk family histories of breast cancer, yet it has low yield in patients with lower-risk family histories. These data suggest that MRI screening should be reserved for those at highest risk.