A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers

Abstract

BACKGROUND: Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) might be diagnosed with invasive breast cancer at excision, a phenomenon known as underestimation. Patients with DCIS are treated based on the risk of underestimation or progression to invasive cancer. The aim of our study was to expand the knowledge on underestimation and to develop a prediction model. METHODS: Population-based data were retrieved from the Dutch Pathology Registry and the Netherlands Cancer Registry for DCIS between January 2011 and June 2012. RESULTS: Of 2892 DCIS biopsies, 21% were underestimated invasive breast cancers. In multivariable analysis, risk factors were highgrade DCIS (odds ratio (OR) 1.43, 95% confidence interval (CI): 1.05-1.95), a palpable tumour (OR 2.22, 95% CI: 1.76-2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5 (OR 2.36, 95% CI: 1.80-3.09) and a suspected invasive component at biopsy (OR 3.84, 95% CI: 2.69-5.46). The predicted risk for underestimation ranged from 9.5 to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had unfavourable features. CONCLUSIONS: The risk for an underestimated diagnosis of invasive breast cancer after a biopsy diagnosis of DCIS is considerable. With our prediction model, the individual risk of underestimation can be calculated based on routinely available preoperatively known risk factors (https://www.evidencio.com/models/show/1074). BACKGROUNDPatients with ductal carcinoma in situ (DCIS) are treated based on the risk of underestimation or progression to invasive cancer. The standard treatment for patients with a biopsy diagnosis of DCIS is wide local excision with radiation or mastectomy. Often a sentinel lymph node (SLN) biopsy is advised for axillary staging. 1,2 Both the standard treatment and the use of the SLN biopsy can constitute overtreatment. The standard treatment might be disproportionate for screen-detected DCIS patients who have a high chance that the DCIS would not even have been detected during their lifetime. 3 It has been estimated that between 14 and 53% of DCIS progress into invasive breast cancer. 4,5 To address overtreatment, phase III trials investigate the safety of active surveillance of DCIS patients at low risk for developing or having invasive breast cancer. 6-11 Active surveillance is based on the result of the biopsy. By modelling of active surveillance of DCIS patients, the disease-specific cumulative mortality was related to underestimation. 12,13 Underestimation is the phenomenon that the invasive breast cancer is undetected at preoperative biopsy and only becomes evident after pathological examination of the excision material. The use of the SLN biopsy can also constitute overtreatment. The SLN biopsy is done if a mastectomy is chosen, and also for patients undergoing wide local excision who are at high risk of having an underestimated invasive breast cancer. 1,2 The reported risk of underestimation varies from 14 to 43% 14,15 , and in a meta-analysis it was estimated to be 25.9% (95% confidence inte...

Preoperative breast MRI in management of patients with needle biopsy-proven ductal carcinoma in situ (DCIS)

“…The large differences in underestimate rates, from 14 to 55%, indicate the likelihood of bias in these studies [9e16]. In most of these studies, the underestimation rate was between 20 and 25%, which is in line with the underestimation rate of 20% that we found [1,2]. As far as we know, the only other prospective study is a study by Deurloo et al, but it is not clear how patients in that study were selected for MRI [11].…”

“…Ductal carcinoma in situ (DCIS) diagnosed at core needle biopsy may represent occult invasive breast cancer. In 20e25% of patients with biopsy-proven DCIS, underestimation occurs, and invasive breast cancer is detected in the surgical specimen [1,2]. In the management of invasive breast cancer, nodal staging is standard of care, therefore several guidelines recommend the use of a sentinel lymph node biopsy (SLNB) in selected patients with a high risk of underestimation [3,4].…”

An Updated Nomogram for Predicting Invasiveness in Preoperative Ductal Carcinoma In Situ of the Breast

“…Therefore, more accurate and accessible methods are needed to predict invasiveness in preoperative diagnosed DCIS. In 2013, we published a nomogram that predicted the invasiveness of breast cancer diagnosed as pre-operative DCIS, and several other studies utilized it in the past few years 10121314. However, since the previous model had some limitations, it had to be updated using recent data.…”

“…To enhance shared decision-making, predicting upstaging of preoperative DCIS can be helpful for patients and surgeons. Several studies have been conducted to establish a nomogram for predicting the possibility of preoperative DCIS upstaging to invasive ductal carcinoma after surgery 91011121314. However, previous nomograms have had several limitations, including the lack of external validation, lack of clinical utility based on sophisticated variables, and lack of popularity or accessibility.…”

Response to Meurs, Menke-Pluijmers, Seisling, and Westenend

“…We agree that research identifying patients with a biopsy diagnosis of DCIS who harbor invasive breast cancer is needed. However, older patients with biopsy-proven DCIS have a low risk of being upstaged to invasive breast cancer ( 6 ) as well as a low likelihood of benefiting from SLNB. The authors argued that finding a lymph node that contains cancer (and thus treating invasive cancer rather than DCIS) affects the ultimate outcome in our target population, yet our data suggest similar outcomes without SLNB.…”