Characteristics and behaviour of screen-detected ductal carcinoma in situ of the breast: comparison with symptomatic patients

Abstract

Breast cancer is the most common malignancy in Singapore women. Ductal carcinoma in situ (DCIS) is the putative, non-obligate precursor of the majority of invasive breast cancers. The efficacy of the Singapore breast-screening pilot project in detecting early stage breast cancer led to the launch of a national breast-screening programme, BreastScreen Singapore (BSS), in January 2002. In this study, we compared clinicopathological and immunohistochemical characteristics, as well as clinical outcomes, between screen-detected and symptomatic DCIS. The study cohort comprised 1202 cases of DCIS diagnosed at Singapore General Hospital from 1994 to 2010. Comparison of clinicopathological parameters, immunohistochemical results of ER, PR, HER2, CK14, EGFR, and 34βE12, and clinical outcomes was carried out between the 2 groups. Amongst 1202 cases, 610 (50.7%) were screen-detected and 592 (49.3%) were symptomatic DCIS. Screen-detected cases were smaller in size (P < 0.001), of lower nuclear grade (P = 0.004), and more frequently expressed ER (P < 0.001). Luminal A phenotype was more frequently observed in screen-detected DCIS, while triple-negative and HER2 phenotypes were more common in symptomatic DCIS (P < 0.001). The basal-like phenotype was also more frequent in symptomatic DCIS (P = 0.041). Mean and median follow-up was 99.7 and 97.8 months, respectively, with a maximum follow-up of 246.0 months. More symptomatic patients developed invasive recurrences compared to screen-detected patients (P = 0.001). A trend for better disease-free survival was observed in screen-detected patients (P = 0.076). Patients who were screen-detected experienced better overall survival than those with symptomatic DCIS (P = 0.007). Our data indicate a more favourable outcome of screen-detected DCIS patients confirming the role of BSS in early identification of this curable disease.

The method of detection of ductal carcinoma in situ has no therapeutic implications: results of a population-based cohort study

“…Our results are in line with the study by Koh et al ( n  = 1202 subjects, median follow up 8.2 years), which showed that women with screen-detected DCIS had better overall survival than women with symptomatic DCIS [35]. The high overall survival rates (100% and 97.8% at 10 years, respectively) presented by the authors can be explained by the large proportion (45%) of women aged <50 years at diagnosis in their study.…”

“…Symptomatic presentation has been shown to be associated with larger lesion size and higher risk of estrogen receptor negativity [34, 35]. Triple-negative, human epidermal growth factor receptor 2 (HER2), and basal-like phenotypes were found to be more common in symptomatic DCIS, while the luminal A phenotype was more often observed in screen-detected DCIS [35]. Although there was a larger proportion of low-grade DCIS in the screen-detected group in one study, in others there was no difference in distribution by grade [34–36].…”

Risk of death from breast cancer after treatment for ductal carcinoma in situ

“…Symptomatic DCIS is more likely to harbour occult invasive disease and to have a poorer overall prognosis than screen‐detected DCIS. In the present study, detection outside screening included asymptomatic DCIS detected by mammography but not within the population‐based screening programme.…”

“…Of ten patients who developed distant metastasis without a preceding local recurrence or contralateral breast event, eight had undergone total mastectomy. Symptomatic DCIS is more likely to harbour occult invasive disease and to have a poorer overall prognosis than screen-detected DCIS 21,22 . In the present study, detection outside screening included asymptomatic DCIS detected by mammography but not within the population-based screening programme.…”

The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

“…A French study from 2004 showed that DCIS diagnosis via screening was more unusual for the "elderly" (83.6% vs 91.6%, p b .0001), despite that 13.4% of women treated for DCIS was older than 70 years [23]. A number of studies has shown that symptomatic DCIS may be related to a higher invasive recurrence rate and may therefore be associated to worse prognosis, should it recur as invasive disease [24][25][26]. That may have led to the belief that, screening detected, asymptomatic DCIS is clinically much more indolent, but this may not be accurate: In a population-based study from the Netherlands, it was shown that compared with non-screening-related DCIS, women with screen-detected DCIS had a lower risk of developing ipsilateral invasive breast cancer (hazard ratio (HR) = 0.75, 95% CI = 0.59-0.96) and lower all-cause mortality (HR = 0.85, 95% CI = 0.73-0.98), but a similar risk of contralateral invasive breast cancer (HR = 0.86, 95% CI = 0.67-1.10).…”