In the Journals

Delayed surgery linked to progression, worse outcomes in ductal carcinoma in situ

Richard J. Bleicher, MD, FACS
Richard J. Bleicher

Delays to surgery for ductal carcinoma in situ appeared associated with increased risk for progression to invasive disease and worse survival outcomes, according to findings published in Annals of Surgical Oncology.

“Delays in treatment time matter in DCIS, although the outcome decrease due to delays is small. As the time to surgery increases, we see an increase in the likelihood of finding invasive disease upon excision,” Richard J. Bleicher, MD, FACS, professor in the department of surgical oncology and director of the Breast Fellowship Program at Fox Chase Cancer Center, told HemOnc Today. “Every day patients ask me how long they have until they have to schedule surgery for their breast cancer, but the answer has been unknown for patients with DCIS. It was assumed that there was no difference in outcome with increasing delays to treatment of DCIS, but surprisingly, there were small, yet real, decreases in survival.”

In the population-based study, Bleicher and colleagues used the National Cancer Database to collect data on 123,947 women (mean age, 58.7 years) who received a pathologic diagnosis of DCIS between 2004 and 2014 and 16,668 women (mean age, 57.3 years) with invasive ductal carcinoma.

To assess OS, the researchers used five time intervals that represented delays in time to surgery— less than 30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and 121 to 365 days.

Median follow-up was 57.7 months.

Results showed 5-year OS of 95.8% (95% CI, 95.7-96) overall; 96% (95% CI, 95.9-96.1) among those with noninvasive disease, after adjusting for 7,422 deaths; and 94.9% (95% CI, 94.6-95.3) among those with invasive disease, after adjusting for 2,730 deaths.

The unadjusted median delay from diagnosis to surgery was 38 days.

Characteristics independently associated with increased time to surgery included black (12.1%) and Asian race (4.1%), and Hispanic ethnicity (5%; P < .001 for all).

For each delay interval increase, researchers observed an added relative risk for death of 7.4% (HR = 1.07; 95% CI, 1.05-1.1). Moreover, increasing delay in time to surgery appeared to be an independent predictor of invasion (OR = 1.13; 95% CI, 1.11-1.15).

“Three ongoing clinical trials are evaluating the nonoperative management of DCIS — the COMET, LORD and LORIS trials,” Bleicher told HemOnc Today. “Because nonoperative management is the equivalent of infinite delay, it suggests that careful follow-up in these trials is imperative. We ultimately need to determine how to predict whether a particular DCIS lesion is likely to be inconsequential, never become invasive and can be watched, or whether it is likely to become invasive, have the capability to spread and pose risk to the patient.” – by Jennifer Southall

For more information:

Richard J. Bleicher, MD, FACS, can be reached at Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA 19111; email: richard.bleicher@fccc.edu.

Disclosures: Bleicher reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Richard J. Bleicher, MD, FACS
Richard J. Bleicher

Delays to surgery for ductal carcinoma in situ appeared associated with increased risk for progression to invasive disease and worse survival outcomes, according to findings published in Annals of Surgical Oncology.

“Delays in treatment time matter in DCIS, although the outcome decrease due to delays is small. As the time to surgery increases, we see an increase in the likelihood of finding invasive disease upon excision,” Richard J. Bleicher, MD, FACS, professor in the department of surgical oncology and director of the Breast Fellowship Program at Fox Chase Cancer Center, told HemOnc Today. “Every day patients ask me how long they have until they have to schedule surgery for their breast cancer, but the answer has been unknown for patients with DCIS. It was assumed that there was no difference in outcome with increasing delays to treatment of DCIS, but surprisingly, there were small, yet real, decreases in survival.”

In the population-based study, Bleicher and colleagues used the National Cancer Database to collect data on 123,947 women (mean age, 58.7 years) who received a pathologic diagnosis of DCIS between 2004 and 2014 and 16,668 women (mean age, 57.3 years) with invasive ductal carcinoma.

To assess OS, the researchers used five time intervals that represented delays in time to surgery— less than 30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and 121 to 365 days.

Median follow-up was 57.7 months.

Results showed 5-year OS of 95.8% (95% CI, 95.7-96) overall; 96% (95% CI, 95.9-96.1) among those with noninvasive disease, after adjusting for 7,422 deaths; and 94.9% (95% CI, 94.6-95.3) among those with invasive disease, after adjusting for 2,730 deaths.

The unadjusted median delay from diagnosis to surgery was 38 days.

Characteristics independently associated with increased time to surgery included black (12.1%) and Asian race (4.1%), and Hispanic ethnicity (5%; P < .001 for all).

For each delay interval increase, researchers observed an added relative risk for death of 7.4% (HR = 1.07; 95% CI, 1.05-1.1). Moreover, increasing delay in time to surgery appeared to be an independent predictor of invasion (OR = 1.13; 95% CI, 1.11-1.15).

“Three ongoing clinical trials are evaluating the nonoperative management of DCIS — the COMET, LORD and LORIS trials,” Bleicher told HemOnc Today. “Because nonoperative management is the equivalent of infinite delay, it suggests that careful follow-up in these trials is imperative. We ultimately need to determine how to predict whether a particular DCIS lesion is likely to be inconsequential, never become invasive and can be watched, or whether it is likely to become invasive, have the capability to spread and pose risk to the patient.” – by Jennifer Southall

For more information:

Richard J. Bleicher, MD, FACS, can be reached at Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA 19111; email: richard.bleicher@fccc.edu.

Disclosures: Bleicher reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.