Baxter Nancy N, Virnig Beth A, Durham Sara B, Tuttle Todd M
Division of Surgical Oncology and School of Public Health, University of Minnesota, Minneapolis 55455, USA.
J Natl Cancer Inst. 2004 Mar 17;96(6):443-8. doi: 10.1093/jnci/djh069.
An increase in incidence of ductal carcinoma in situ (DCIS) of the breast has been documented, and concerns regarding overly aggressive treatment have been raised. This study was designed to evaluate the use of surgery and radiation therapy in treating DCIS.
We used the National Cancer Institute's Surveillance, Epidemiology, and End Results database to assess treatment of patients with DCIS with no evidence of microinvasion who were diagnosed from January 1, 1992, through December 31, 1999. We assessed the rates of mastectomy, breast reconstruction, radiation therapy after lumpectomy, and axillary dissection. Associations were analyzed by logistic regression.
During the study period, 25 206 patients met selection criteria. The incidence of DCIS dramatically increased with time; however, the incidence of comedo lesions did not change. The rate of mastectomy decreased from 43% in 1992 to 28% in 1999, after controlling for age, race, tumor size, comedo histology, and geographic location. However, because of the increase in the diagnosis of DCIS, the age-adjusted incidence of mastectomy for DCIS in the population did not change (7.8 per 100 000 women in 1992 and 1999). Almost half the patients undergoing lumpectomy did not undergo radiation therapy (55% in 1992 and 46% in 1999); in those with comedo histology, 33% did not undergo radiation therapy after lumpectomy, even in 1999. Overall, patients were less likely to have axillary dissection over time (34% in 1992 versus 15% in 1999), yet the rate of axillary dissection was still high (30%) in patients undergoing mastectomy in 1999. Large, statistically and clinically significant variation by geographic location was found in treatment.
Treatment of DCIS changed in a clinically significant fashion between 1992 and 1999. Throughout this study, many patients were found to undergo aggressive surgical therapy, including mastectomy and axillary dissection, whereas others appeared to be undertreated, e.g., not receiving radiation therapy after lumpectomy, even in the presence of adverse histologic features. Variation in demographic and geographic factors indicates that at least some of these treatment differences reflect individual and institutional practice patterns that may be modifiable.
乳腺导管原位癌（DCIS）的发病率有所上升，人们对过度积极的治疗提出了担忧。本研究旨在评估手术和放射治疗在DCIS治疗中的应用。
我们使用美国国立癌症研究所的监测、流行病学和最终结果数据库，评估1992年1月1日至1999年12月31日期间诊断为无微浸润证据的DCIS患者的治疗情况。我们评估了乳房切除术、乳房重建术、保乳术后放射治疗以及腋窝淋巴结清扫术的发生率。通过逻辑回归分析相关性。
在研究期间，25206例患者符合入选标准。DCIS的发病率随时间显著增加；然而，粉刺样病变的发病率没有变化。在控制年龄、种族、肿瘤大小、粉刺样组织学类型和地理位置后，乳房切除术的比例从1992年的43%降至1999年的28%。然而，由于DCIS诊断率的增加，人群中DCIS乳房切除术的年龄调整发病率没有变化（1992年和1999年每10万名女性中均为7.8例）。几乎一半接受保乳手术的患者未接受放射治疗（1992年为55%，1999年为46%）；在粉刺样组织学类型的患者中，即使在1999年，33%的保乳术后患者未接受放射治疗。总体而言，随着时间的推移，患者进行腋窝淋巴结清扫的可能性降低（1992年为34%，1999年为15%），然而在1999年接受乳房切除术的患者中，腋窝淋巴结清扫率仍然很高（30%）。在治疗方面发现了按地理位置划分的具有统计学和临床意义的显著差异。
1992年至1999年间，DCIS的治疗在临床上发生了显著变化。在整个研究过程中，发现许多患者接受了积极的手术治疗，包括乳房切除术和腋窝淋巴结清扫术，而其他患者似乎治疗不足，例如保乳术后未接受放射治疗，即使存在不良组织学特征。人口统计学和地理因素的差异表明，这些治疗差异中至少有一些反映了个体和机构的实践模式，可能是可以改变的。
