Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons

Abstract

Background The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes. Method sWe collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided. Results Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (Pdiff