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Original Article| Volume 22, ISSUE 6, P547-552, August 2022

Treatment Patterns in Women Age 80 and Over With DCIS: A Report From the National Cancer Database

Published:April 21, 2022DOI:https://doi.org/10.1016/j.clbc.2022.04.004

      Abstract

      Background

      Despite an aging population, there are no established treatment guidelines for women with ductal carcinoma in situ (DCIS) age ≥80. Here we describe national treatment patterns and survival outcomes in older women with DCIS.

      Patients and Methods

      Women age ≥80 diagnosed with DCIS from 2005 to 2014 were identified using the National Cancer Database. χ2, Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Kaplan-Meier method and Cox proportional hazard models were used to evaluate overall survival (OS).

      Results

      A total of 6,070 women with DCIS met inclusion criteria, of which the majority (98%) received surgery. Receipt of surgery was independently associated with age <90. OS was higher for those who received surgery compared to those who did not (HR 2.2 [1.72-2.83] P < .001).

      Conclusion

      The vast majority of patients age ≥80 with DCIS in the National Cancer Database received primary surgical management, which was associated with a significant OS benefit. Considering comorbidities and patient fitness, surgical resection should be considered for all patients age ≥80 who are suitable operative candidates.

      Keywords

      Introduction

      Ductal carcinoma in situ (DCIS) is non-invasive, stage 0 breast cancer, where proliferation of malignant cells is limited to the ducts of the breast tissue.
      • Meijnen P
      • Oldenburg HSA
      • Peterse JL
      • Bartlelink H
      • Rutgers EJT.
      Clinical outcome after selective treatment of patients diagnosed with ductal carcinoma in situ of the breast.
      ,
      • Virnig BA
      • Tuttle TM
      • Shamliyan T
      • Kane RL.
      Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes.
      The optimal management of DCIS is frequently studied and debated and ongoing clinical trials are currently examining if omission of surgery may be suitable in select patients.
      • Hwang ES
      • Hyslop T
      • Lynch T
      • et al.
      The COMET (comparison of operative versus monitoring and endocrine therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS).
      In addition, the management of breast cancers in general, in older patients is often overlooked
      • Schonberg MA
      • Marcantonio ER
      • Li D
      • Silliman RA
      • Ngo L
      • McCarthy EP.
      Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival.
      • DeSantis CE
      • Ma J
      • Goding Sauer A
      • Newman LA
      • Jemal A
      Breast cancer statistics, 2017, racial disparity in mortality by state.

      National Comprehensive Cancer Network. Breast cancer (version 2.2022). Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 12 Jan 2022.

      with limited data, and even sparser data involving DCIS in women age ≥80.
      • Bouchardy C
      • Rapiti E
      • Fioretta G
      • et al.
      Undertreatment strongly decreases prognosis of breast cancer in elderly women.
      It is often questioned whether patients with DCIS should undergo treatment in accordance with guidelines, or whether some patients may forgo parts of treatment without an impact on mortality.
      • Hwang ES
      • Hyslop T
      • Lynch T
      • et al.
      The COMET (comparison of operative versus monitoring and endocrine therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS).
      ,
      • Ryser MD
      • Weaver DL
      • Zhao F
      • et al.
      Cancer outcomes in DCIS patients without locoregional treatment.
      These concerns are especially relevant for the older population, who, due to differences in life expectancy, competing comorbidities, and lifestyle values, may benefit from de-escalation in therapy.
      • Akushevich I
      • Yashkin AP
      • Greenup RA
      • Hwang ES.
      A medicare-based comparative mortality analysis of active surveillance in older women with DCIS.
      In a previous study of invasive cancer in women age ≥80, we found the majority of patients underwent surgery and this finding came with a significant overall survival (OS) advantage. Our findings highlighted that providing surgery should not be based on age alone.
      • Frebault J
      • Bergom C
      • Cortina CS
      • et al.
      Invasive breast cancer treatment patterns in women age 80 and over: a report from the national cancer database.
      As DCIS management is associated with more controversy, an investigation of treatment patterns in women age ≥80 is especially relevant. Thus, we used the National Cancer Database (NCDB) to identify women age ≥80 with DCIS to describe treatment patterns and examine OS to assess whether a survival advantage exists for patients who underwent surgical resection.

      Methods

      The NCDB was used to identify women age ≥80 with a diagnosis of DCIS from 2005-2014. The NCDB is a nation-wide, facility-based, comprehensive clinical oncology data set and captures approximately 70% of all newly diagnosed malignancies in the US annually.

      American College of Surgeons. 2020. About the national cancer database. Available at: https://www.facs.org/quality-programs/cancer/ncdb/about. Accessed 23 February 2020.

      NCDB data is de-identified and this investigation was deemed exempt by our Institutional Review Board.
      To ensure patients included in this analysis were diagnosed with DCIS pathology, patients whose International Classification of Disease for Oncology (ICD-O) histology codes that did not match DCIS histology were excluded, including women with Paget's disease without underlying DCIS. Women with invasive breast cancer histology or evidence of metastatic disease including clinical or pathologic stage M1, and those who received radiation directed outside of the breast, chest wall, or regional lymph nodes were excluded from analysis. The cohort was limited to women for whom breast cancer was their only documented malignancy and included only patients who received most or all of their treatment at the reporting facility (Figure 1).
      Figure 1
      Figure 1Flow chart of cohort inclusion and exclusion criteria for evaluation of women age ≥80 with DCIS in the National Cancer Database.
      Analysis included collection of demographic information including race/ethnicity, age, Charlson-Deyo comorbidity score, and care facility type. Cancer characteristics examined included tumor grade and estrogen receptor (ER) and progesterone receptor (PR) status. Treatment variables included type of breast surgery and receipt of radiation therapy and/or endocrine therapy. χ2 test, Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of surgery. Kaplan-Meier method and Cox proportional hazards models were used to evaluate OS.

      Results

      The final cohort consisted of 6,070 patients (Figure 1 and Table 1). The majority of patients were White (79%), age 80 to 89 at diagnosis (95%), and were healthy (96%) as defined by a Charlson-Deyo score of 0 or 1. Almost all patients had breast surgery (98%), of which 78% underwent lumpectomy. While median follow-up was 55 months for those who had surgery, it was only 44 months for those who did not receive surgery (Table 1). On univariate analysis, White patients (P = .003), those age <85 (P < .001), and those with higher grade tumors (P = .003) were more likely to receive surgery. The most common reason for not receiving surgery was patient refusal (63% of those who provided reasoning). Only 40% of patients who underwent lumpectomy also received radiation. The most cited reason for omission of radiation was patient refusal (72% of those who provided reasoning). Seventy percent (n = 4267) of patients had hormone-receptor positive disease. Of those with hormone receptor-positive disease, only 62% (n = 27,128) received endocrine therapy. Additionally, 26% (n = 11,329) of patients with hormone receptor-positive DCIS received both endocrine therapy and radiation therapy. When compared with academic programs, surgical management of DCIS was more likely to be performed in community and comprehensive community cancer programs (P = .04, Table 1).
      Table 1Characteristics of Women Age ≥80 With DCIS by Receipt of Surgery.
      CharacteristicTotal N = 6070 (%)Surgery N = 5942 (%) (97.9%)No Surgery N = 128 (%) (2.1%)P-value
      Survival/Follow-up
      Average follow-up (months) Mean Median58.3 55.258.5 55.448.1 44.5
      Demographic
      Race/Ethnicity NH White NH Black Hispanic Other4779 (78.7) 527 (8.7) 157 (2.6) 607 (10)4694 (79) 508 (8.5) 154 (2.6) 586 (9.9)85 (66.4) 19 (14.8) 3 (2.3) 21 (16.4).003
      Age 80-84 85-89 90+4155 (68.5) 1589 (26.2) 326 (5.4)4086 (68.8) 1549 (26.1) 307 (5.2)69 (53.9) 40 (31.3) 19 (14.8)<.001
      Cancer characteristics
      Grade I II III Unknown980 (16.1) 2054 (33.8) 1760 (29.0) 163 (2.7)947 (15.9) 2007 (33.8) 1736 (29.2) 162 (2.7)33 (25.8) 47 (36.7) 24 (18.8) 1 (0.8).003
      Estrogen receptor Positive Negative Borderline Missing/Unknown4213 (69.4) 999 (16.5) 6 (0.1) 852 (2.7)4130 (69.5) 987 (16.6) 6 (0.1) 819 (13.8)83 (64.8) 12 (9.4) 0 (0) 33 (25.8).249
      Progesterone receptor Positive Negative Borderline Missing/Unknown3471 (57.2) 1520 (25) 18 (0.3) 1061 (17.5)3403 (57.3) 1500 (25.2) 17 (0.3) 1022 (17.2)68 (53.1) 20 (15.6) 1 (0.8) 39 (30.5).136
      Diagnosis/Treatment
      Breast surgery Lumpectomy Mastectomy No Surgery Unknown type4634 (76.3) 1305 (21.5) 128 (2.1) 3 (0.05)4634 (78) 1305 (22) 0 (0) 3 (0.05)- - - -
      Reason no surgery
      Reported percentages are percent of total available answers in scarcely reported variables
      Contraindicated Died prior to treatment Recommended, not given Patient refusal
      - - - -10 (24.4) 2 (4.9) 3 (7.3) 26 (63.4)
      Endocrine therapy Yes, No Unknown1114 (18.4) 4760 (78.4) 196 (3.2)1088 (18.3) 4664 (78.5) 190 (3.2)26 (20.3) 96 (75.0) 6 (4.7).523
      Reason no endocrine therapy Contraindicated Died prior to treatment Recommended, not given Patient refusal363 (7.6) 5 (0.1) 76 (1.6) 626 (13.2)359 (7.7) 2 (0.04) 74 (1.6) 614 (13.2)4 (4.2) 3 (3.1) 2 (2.1) 12 (12.5)<.001
      Radiation therapy Yes, No Unknown1865 (30.7) 4110 (67.7) 95 (1.6)1857 (31.3) 3994 (67.2) 91 (1.5)8 (6.3) 116 (90.6) 4 (3.1)<.001
      Reason no radiation therapy
      Reported percentages are percent of total available answers in scarcely reported variables
      Contraindicated Died prior to treatment Recommended, not given Patient refusal
      154 (22.4) 0 (0) 41 (6.0) 494 (71.7)152 (22.7) 0 (0) 39 (5.8) 480 (71.5)2 (11.1) 0 (0) 2 (11.1) 14 (77.8).374
      Socioeconomic
      Comorbidity score 0 1 2 3+4895 (80.6) 967 (15.9) 171 (2.8) 37 (0.6)4786 (80.5) 953 (16.0) 167 (2.8) 36 (0.6)109 (85.2) 14 (10.9) 4 (3.1) 1 (0.8).478
      Facility type
      Abbreviations: ARP = academic/research program; CCP = community cancer program; CCCP = comprehensive community cancer program; INCP = integrated network cancer program, NH=non-Hispanic.
      CCP CCCP ARP INCP
      707 (11.6) 3212 (52.9) 1449 (23.9) 702 (11.6)695 (11.7) 3151 (53.0) 1405 (23.6) 691 (11.6)12 (9.4) 61 (47.7) 44 (34.4) 11 (8.6).041
      a Reported percentages are percent of total available answers in scarcely reported variables
      b Abbreviations: ARP = academic/research program; CCP = community cancer program; CCCP = comprehensive community cancer program; INCP = integrated network cancer program, NH=non-Hispanic.
      On multivariate analysis, those age <90 were more likely to undergo surgery as well as those with higher grade tumors (P < .05, Table 2). Black women were half as likely to receive surgery vs. White women (P = .01), and women who received care at an academic research program were less likely to undergo surgery (P = .04, Table 2).
      Table 2Multivariate Analysis of Factors That are Associated With Receipt of Surgery in Women Age ≥80 With DCIS.
      VariableOR95% CIP-value
      Race/Ethnicity NH White Black Hispanic Other1 (Ref) 0.51 1.1 0.610.3-0.9 0.26-4.58 0.35-1.08.012 .018 .898
      Age 90+ 85-89 80-841 (Ref) 2.33 3.811.25-4.32 2.13-6.82.008 <.001
      Comorbidity Score 3+ 2 1 01 (Ref) 1.39 2.15 1.260.14-14.31 0.26-17.84 0.16-9.70.783 .479 .827
      Facility Type
      Abbreviations: ARP = academic/research program; CCP = community cancer program; CCCP = comprehensive community cancer program; INCP = integrated network cancer program.
      INCP ARP CCP CCCP
      1 (Ref) 0.44 0.69 0.740.20-0.96 0.27-1.76 0.34-1.59.04 .441 .437
      Grade III II I1 (Ref) 0.59 0.400.36-0.97 0.23-0.69.039 <.001
      a Abbreviations: ARP = academic/research program; CCP = community cancer program; CCCP = comprehensive community cancer program; INCP = integrated network cancer program.
      Multivariate analysis of factors associated with mortality demonstrated surgery was an independent predictor of OS (P < .001; HR 0.46, 95% CI: [0.34-0.63]). Increasing age was associated with decreased OS as was the presence of increasing number of comorbidities (Table 3). In addition, those who received radiation had improved OS (P < .001, HR 0.67, 95% CI: [0.59-0.76], Table 3). On Kaplan-Meier analysis, OS was higher for women who received surgery compared to those who did not (P < .001) with a hazard ratio of 2.2 (95% CI: [1.72-2.83], Figure 2).
      Table 3Multivariate Analysis of Factors That are Associated With Mortality in Women Age ≥80 With DCIS.
      VariableHR95% CIP-value
      Surgery No Yes1 (Ref) 0.460.34-0.63<.001
      Race NH White Black Hispanic Other1 (Ref) 1.12 0.86 0.960.93-1.35 0.58-1.27 0.8-1.14.24 .442 .635
      Age 80-84 85-89 90+1 (Ref) 1.49 3.011.32-1.67 2.48-3.64<.001 <.001
      Estrogen Receptor Positive Negative Borderline1 (Ref) 0.88 0.90.74-1.05 0.12-6.77.166 .917
      Progesterone Receptor Positive Negative Borderline1 (Ref) 1.24 0.591.06-1.45 0.22-1.63.007 .308
      Radiation No Yes1 (Ref) 0.670.59-0.76<.001
      Comorbidity Score 0 1 2 3+1 (Ref) 1.26 2.31 2.021.09-1.45 1.74-3.07 1.08-3.78.002 <.001 .027
      Tumor Size ≤2 cm 2-5 cm ≥5 cm1 (Ref) 1.12 1.210.97-1.28 0.95-1.56.117 .131
      Figure 2
      Figure 2Kaplan-Meier survival curves women age ≥80 with DCIS who underwent surgery compared to those that did not.

      Discussion

      Treatment patterns and outcomes for DCIS in older women is an area that is not well-studied. Here, we describe these patterns for women age ≥80 diagnosed with DCIS over a 10-year period using the NCDB.

      American College of Surgeons. 2020. About the national cancer database. Available at: https://www.facs.org/quality-programs/cancer/ncdb/about. Accessed 23 February 2020.

      In this cohort, the vast majority (98%) underwent primary surgical management, which was associated with a significant OS benefit. While some studies have demonstrated that older women are less likely than younger patients to undergo breast cancer surgery,
      • Bouchardy C
      • Rapiti E
      • Fioretta G
      • et al.
      Undertreatment strongly decreases prognosis of breast cancer in elderly women.
      many analyses, including this, show the vast majority of older patients do undergo surgery,
      • Cyr A
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      Breast cancer in elderly women (≥ 80 Years): variation in standard of care?.
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      • Mogal HD
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      with associated survival benefit.
      • Kong AL
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      • McGinley E
      • Pezzin LE.
      The relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among elderly women with incident breast cancer.
      . In this analysis, lumpectomy was performed more often than mastectomy (78% and 22%, respectively). This finding is in concordance with other studies, although this study specifically describes this trend in older women with DCIS and is expected given the lower morbidity of lumpectomy.
      Despite these results, the question of appropriate candidacy for surgery in older patients with DCIS remains. This data demonstrates a survival benefit, and the decision to offer surgery should not be based on age alone. While it has been shown that omission of certain therapies in some situations does not negatively affect survival, such as the omission of axillary staging in older women with node-negative early-stage invasive breast cancer who are candidates for endocrine therapy,

      Society of Surgical Oncology. Choosing Wisely. 2016. Available at: http://www.choosingwisely.org/clinician-lists/sso-sentinel-node-biopsy-in-node-negative-women-70-and-over/. Accessed December 18, 2018.

      • Esposito E
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      • et al.
      Can axillary node dissection be safely omitted in the elderly? a retrospective study on axillary management of early breast cancer in older women.
      • Limite G
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      • Sollazzo V
      • et al.
      Clinically cN0 breast cancer in elderly: what surgery?.
      questions remain in elucidating which patients are ideal operative candidates. Active surveillance has been shown to be an appropriate management strategy for patients with multiple competing comorbidities
      • Ryser MD
      • Weaver DL
      • Zhao F
      • et al.
      Cancer outcomes in DCIS patients without locoregional treatment.
      ,
      • Ryser MD
      • Worni M
      • Turner EL
      • Marks JR
      • Durrett R
      • Hwang ES.
      Outcomes of active surveillance for ductal carcinoma in situ: a computational risk analysis.
      and is likely best suited for those with low-grade, hormone-receptor positive DCIS.
      • Hwang ES
      • Hyslop T
      • Lynch T
      • et al.
      The COMET (comparison of operative versus monitoring and endocrine therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS).
      ,
      • Grimm LJ
      • Hwang ES.
      Active surveillance for DCIS: the importance of selection criteria and monitoring.
      ,
      • Byng D
      • Retel VP
      • Schaapveld M
      • Wesseling J
      • van Harten WH.
      Treating (low-risk) DCIS patients” what can we learn from real-world cancer registry evidence?.
      Our study demonstrates those with lower grade DCIS were less likely to undergo surgery, consistent with physician comfort with active surveillance as low grade disease is unlikely to impact mortality. There are ongoing investigations to examine if there may be certain forms of DCIS in which surgery can omitted. The Alliance COMET (Comparison of Operative to Monitoring and Endocrine Therapy) trial is currently investigating whether surgery for low-risk, hormone-receptor positive DCIS is warranted.
      • Hwang ES
      • Hyslop T
      • Lynch T
      • et al.
      The COMET (comparison of operative versus monitoring and endocrine therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS).
      This clinical question is particularly relevant to the older population as surgery may possibly be omitted in many older patients, especially those who are suboptimal surgical candidates.
      Conversely, prevention of disease progression, even in older patients, may be beneficial in those with otherwise high projected survival (ie, no competing comorbidities and high functional status). Our data show no difference in survival based on ER status and worsened survival with PR negative disease, however surgical management of DCIS remains the only option for whom endocrine therapy is not a possibility (ie, hormone receptor-negative or contraindication to endocrine therapy). In addition, it should also be considered for those with high grade disease,
      • Ward EP
      • Weiss A
      • Blair SL.
      Incidence and treatments of DCIS in octogenarians: grade matters.
      and in those who are otherwise good candidates for surgery. It has been shown that survival correlates more strongly with extent of surgical therapy compared with patient age, indicating that factors outside of age are greater drivers of outcomes.
      • Ho A
      • Goenka A
      • Ishill N
      • et al.
      The effect of age in the outcome and treatment of older women with ductal carcinoma in situ.
      Comorbid conditions are prevalent in the older population and taking time for medical optimization may be of benefit prior to surgery since relatively brief delays in DCIS treatment does not affect survival or disease progression.
      • Ryser MD
      • Weaver DL
      • Zhao F
      • et al.
      Cancer outcomes in DCIS patients without locoregional treatment.
      ,
      • Ryser MD
      • Worni M
      • Turner EL
      • Marks JR
      • Durrett R
      • Hwang ES.
      Outcomes of active surveillance for ductal carcinoma in situ: a computational risk analysis.
      In our study, the median follow-up was 55 months for those who received surgery and 45 months for those who did not, representing an almost 1-year increase in follow-up and survival benefit in those who had surgery. The shorter follow-up duration in the non-surgical group may indicate a selection bias with inclusion of patients who were deemed unfit for surgery and died prior to receiving treatment. It has been shown that the majority of morbidity in older patients with DCIS is due to causes other than breast cancer,
      • Akushevich I
      • Yashkin AP
      • Greenup RA
      • Hwang ES.
      A medicare-based comparative mortality analysis of active surveillance in older women with DCIS.
      confirming the need to identify all health factors which may contribute to a patient's candidacy for surgery. In our study, comorbidity was assessed using Charlson-Deyo scores, which does not encompass the entire health status of a patient, and does not include frailty, which is a highly important factor in the multidisciplinary oncological decision-making process for older patients. Guideline-concordant treatment including surgery and/or radiation therapy can pose a potentially significant morbidity burden which may be more severe in patients with underlying comorbid conditions.
      The use of adjuvant radiation therapy for DCIS in older women is also controversial. We found radiation therapy was used in 40% of lumpectomy patients, which is similar to rates described in other older cohorts but lower than rates seen in younger women.
      • Jauhari Y
      • Gannon MR
      • Tsang C
      • et al.
      Surgery and adjuvant radiotherapy for unilateral ductal carcinoma in situ (DCIS) in women aged over 70 years: a population based cohort study.
      Radiation therapy did confer a survival advantage in this cohort. A SEER-Medicare review of patients age ≥65 found that patients with ER-positive DCIS do receive endocrine therapy more often when they undergo lumpectomy with radiation therapy,
      • Anderson C
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      • Nichols HB.
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      indicating a preference to follow guideline-concordant therapy for patients who undergo surgery. A similar SEER-Medicare analysis of DCIS patients demonstrated receipt of lumpectomy as well as radiation therapy was shown to decrease breast cancer-specific mortality compared with those who received lumpectomy alone.
      • Giannakeas V
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      • Narod SA.
      Association of radiotherapy with survival in women treated for ductal carcinoma in situ with lumpectomy or mastectomy.
      ,
      • Smith BD
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      This finding may support receipt of full guideline-concordant treatment in healthy patients with high-risk DCIS.
      In patients with invasive breast cancer, the CALGB 9343 study revealed no change in mortality with omission of radiation therapy in patients age ≥70 with early stage, clinically-node negative, hormone receptor-positive invasive breast cancer who underwent lumpectomy followed by endocrine therapy.
      • Hughes KS
      • Schnaper LA
      • Berry D
      • et al.
      Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with elderly breast cancer.
      Omission of therapies in older patients with DCIS is best implemented in those with low risk disease and significant competing comorbidities who are unlikely to die of DCIS. However, identifying patients with low-risk DCIS in which de-escalation of therapy may be warranted, remains to be entirely understood,
      • Rakovitch E
      • Nofech-Mozes S
      • Narod SA
      • et al.
      Can we select individuals with low risk ductal carcinoma in situ (DCIS)? a population-based outcomes analysis.
      and weighing comorbidities in comparison with cancer treatment can be difficult. The International Society of Geriatric Oncology and European Society of Breast Cancer Specialists, acknowledge no proven survival advantage for patients ≥70 with DCIS who receive radiation therapy and recommend full consideration of an individual's comorbidities and the potential harms of radiation.
      • Biganzoli L
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      Shared decision-making and full understanding of patient functional status are both important elements of care in older patients, and there have been tools established which have demonstrated effectiveness in these areas.
      • Wyld L
      • Reed M
      • Collins K
      • et al.
      Cluster randomized trial to evaluate the clinical benefits of decision support interventions for older women with operable breast cancer.
      ,
      • Clough-Gorr KM
      • Stuck AE
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      Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up.
      The limitations of this study are largely due to the retrospective nature of the data with dependence on accuracy of data input from multiple sources. Additionally, our analysis was based on outcomes and survival data, but the NCDB does not report disease-specific survival. Given the indolent nature of breast cancers in older patients and the more limited life expectancy of this population compared to younger women, older patients are more likely to die of competing comorbidities,
      • Kimmick G
      • Li X
      • Fleming ST
      • et al.
      Risk of cancer death by comorbidity severity and use of adjuvant chemotherapy among women with locoregional breast cancer.
      and the risk of dying related to breast cancer decreases with age,
      • Kong AL
      • Nattinger AB
      • McGinley E
      • Pezzin LE.
      The relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among elderly women with incident breast cancer.
      ,
      • Diab SG
      • Elledge RM
      • Clark GM.
      Tumor characteristics and clinical outcome of elderly women with breast cancer.
      ,
      • Richardson LC
      • Henley SJ
      • Miller J
      • Massetti G
      Thomas CC. Patterns and trends in age-specific black-white differences in breast cancer incidence and mortality - United States, 1999-2014.
      making cancer-specific survival likely less important here compared with a study of younger patients. Additionally functional status of patients is not available in the NCDB, however it is important to identify vulnerabilities in patients prior to planning treatment
      • Mohile S
      • Dale W
      • Somerfield MR
      • et al.
      Practical assessment and management of vulnerabilities in older patients receiving chemotherapy.
      that may affect quality of life for individual patients, and it must be presumed that this was taken into account when planning treatments for these older patients. Future prospective studies of DCIS in older patients will continue to identify candidates for omission of therapies to preserve quality of life without influencing survival, further delineate optimal treatment patterns specific to older women, and recognize pathologic elements unique to DCIS and how they may impact treatment options.

      Conclusion

      Here, we describe treatment patterns and survival outcomes in women age ≥80 with DCIS using the NCDB. Almost all patients received surgery, of which the majority underwent lumpectomy, and those who underwent surgery had an improved OS compared to those who did not. Therefore, surgical intervention should be considered in patients who are appropriate surgical candidates despite increased age. The inclusion of treatment options for older women with DCIS should be a careful balance of risks and benefits, comprehensive health and functionality assessment, and discussion of goals with patients, their families, and the multidisciplinary breast cancer treatment team. Continued evaluation of treatment patterns, in conjunction with improved understanding of DCIS pathology and its impact on older patients, is necessary for complete understanding of treatment of this disease in this population.

      Clinical Practice Points

      • Determining the optimal clinical care of DCIS is ongoing. Given the paucity of data on national treatment patterns and survival outcomes in older breast cancer patients, there is a need for a greater understanding of the management and outcomes of older women with DCIS.
      • Using the National Cancer Database, we describe an overall survival benefit to receipt of surgery in patients with DCIS who are age ≥80. This study identifies an overall healthy cohort of women ≥80 with DCIS, with increased utilization of surgical treatment in those who are younger and with fewer comorbidities.
      • Given the independent survival advantage to receiving surgery ± radiation therapy, emphasis should be placed on the importance of considering interventions in a shared decision-making manner and not based on age alone.

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