Ernster V L, Barclay J, Kerlikowske K, Grady D, Henderson C
Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, 94143-0560, USA.
JAMA. 1996 Mar 27;275(12):913-8.
To describe trends in incidence and treatment for ductal carcinoma in situ (DCIS) of the breast in the United States between 1973 and 1992 and to estimate total numbers of in situ cases diagnosed and numbers treated by mastectomy since 1983, when screening mammography for breast cancer began to become widespread.
Analysis of population-based breast cancer incidence data collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program since 1973 and treatment data collected by the SEER program since 1983.
All women in the geographic areas af the United States included in the SEER program.
Annual age-adjusted and age-specific incidence rates for DCIS; time trends in distribution of cases by type of treatment; percentage of cases treated by mastectomy by geographic area; and estimated numbers for the entire United States of DCIS cases, mastectomies for DCIS, and cases attributable to mammography.
There was a marked increase in DCIS incidence beginning in the early 1980s. Average annual increases in rates between 1973 and 1983 and between 1983 and 1992 changed from 0.3% to 12.0% among women aged 30 to 39 years, from 0.4% to 17.4% among women aged 40 to 49, and from 5.2% to 18.1% among women aged 50 years or older. The total estimated number of DCIS cases in the United States in 1992 (23,368) was 200% higher than expected based on 1983 rates and trends between 1973 and 1983. Between 1983 and 1992, there was a marked decline in the proportion of DCIS cases treated by mastectomy (from 71% to 43.8%) and an increase in those treated by lumpectomy (from 25.6% to 53.3%). In 1992, 23.3% of cases were treated by lumpectomy and radiation, 30.2% by lumpectomy alone, and 2.6% with no surgery. Treatment patterns varied substantially by geographic area, with 57.7% of cases in New Mexico treated by mastectomy in 1992 compared with 28.8% in Connecticut. Despite the decline in the proportion of cases treated by mastectomy, the increased DCIS incidence rates resulted in an increase in the absolute number of cases treated by mastectomy until 1990 (n=10,657); in 1992, there were an estimated 10,242 DCIS cases treated by mastectomy.
Incidence rates of DCIS of the breast have increased dramatically since 1983. This increase correlates with the widespread adoption of modern mammographic screening. While early detection of invasive breast cancer is beneficial, the value of DCIS detection is currently unknown. There is cause for concern about the large number of DCIS cases that are being diagnosed as a consequence of screening mammography, most of which are treated by some form of surgery. In addition, the proportion of cases treated by mastectomy may be inappropriately high, particularly in some areas of the United States.
描述1973年至1992年间美国乳腺导管原位癌（DCIS）的发病率及治疗趋势，并估算自1983年乳腺癌筛查性乳房X线摄影开始广泛应用以来原位癌确诊病例总数及接受乳房切除术治疗的病例数。
分析美国国立癌症研究所监测、流行病学和最终结果（SEER）项目自1973年起收集的基于人群的乳腺癌发病率数据，以及自1983年起收集的治疗数据。
SEER项目所涵盖的美国地理区域内的所有女性。
DCIS的年度年龄调整发病率和特定年龄发病率；按治疗类型划分的病例分布时间趋势；不同地理区域接受乳房切除术治疗的病例百分比；以及全美国DCIS病例、DCIS乳房切除术病例和归因于乳房X线摄影的病例估计数。
自20世纪80年代初开始，DCIS发病率显著上升。1973年至1983年以及1983年至1992年期间，30至39岁女性的发病率年均增长率从0.3%变为12.0%，40至49岁女性从0.4%变为17.4%，50岁及以上女性从5.2%变为18.1%。1992年美国DCIS病例估计总数（23368例）比基于1983年发病率及1973年至1983年趋势预期的数量高出200%。1983年至1992年期间，接受乳房切除术治疗DCIS的病例比例显著下降（从71%降至43.8%），而接受肿块切除术治疗的病例比例上升（从25.6%升至53.3%）。1992年，23.3%的病例接受肿块切除加放疗，30.2%仅接受肿块切除术，2.6%未接受手术治疗。治疗模式因地理区域差异很大，1992年新墨西哥州57.7%的病例接受乳房切除术，而康涅狄格州为28.8%。尽管接受乳房切除术治疗的病例比例下降，但DCIS发病率上升导致直至1990年接受乳房切除术治疗的病例绝对数增加（n = 10657）；1992年，估计有10242例DCIS病例接受乳房切除术。
自1983年以来，乳腺DCIS发病率急剧上升。这种上升与现代乳房X线摄影筛查的广泛应用相关。虽然早期发现浸润性乳腺癌有益，但目前DCIS检测的价值尚不清楚。因筛查性乳房X线摄影而被诊断出的大量DCIS病例令人担忧，其中大多数通过某种形式的手术治疗。此外，接受乳房切除术治疗的病例比例可能过高，尤其是在美国的一些地区。
