Ductal carcinoma in situ (DCIS) may often be overtreated in older women with limited life expectancy, according to research presented during the 2024 Society of Surgical Oncology (SSO) Annual Meeting.1 The retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set found that nearly 20% of older women (≥ 70 years) with DCIS underwent lumpectomy and axillary surgery, which is not indicated in this population.
“Life expectancy should be considered when making treatment decisions for older women with DCIS, and we found that overall, the older adult population is more likely to receive lower-intensity locoregional therapy,” said lead study author Eliza Hersh Lorentzen, MD, Surgical Resident at Brigham and Women’s Hospital, Boston. “However, a large percentage of older women, including those with a life expectancy of less than 5 years, still receive radiation therapy and axillary surgery, suggesting potential overtreatment.”
Eliza Hersh Lorentzen, MD
As Dr. Lorentzen explained, DCIS is a noninvasive breast cancer that has become increasingly prevalent with the advent of screening mammography, accounting for at least 20% of detected breast cancers in the United States. Although DCIS harbors certain risks, such as the potential for progression to invasive breast cancer and about a 20% upstage rate at the time of excision, said Dr. Lorentzen, low rates of locoregional recurrence and mortality among older adults suggest an opportunity for de-escalation of therapy.
The current standard of care involves surgery to decrease the risk of disease progression and to treat unrecognized cases of invasive cancer, followed by radiation in most cases of breast-conserving surgery to reduce the chance of recurrence by up to 70%.
For this study, Dr. Lorentzen and her colleagues examined the association between life expectancy and extent of locoregional treatment among older women with DCIS. The researchers utilized the SEER-Medicare data set to identify 5,346 women aged 70 years and older diagnosed with DCIS tumors smaller than 5 cm between 2010 and 2015. Patients were categorized based on their life expectancy, with 17.3% (n = 927) having a life expectancy of less than 5 years. The primary outcome of the study was the intensity of locoregional therapy.
Optimizing Care for Vulnerable Populations
The researchers found that, in general, treatment was being tailored appropriately. Patients with a life expectancy of less than 5 years were more likely to undergo lumpectomy only (39.4% vs 27.0%, P < .001), mastectomy without axillary surgery (8.1% vs 5.3%, P < .001), or no treatment (5.8% vs 3.2%, p < .001), compared to those with a life expectancy greater than 5 years.
After adjusting for various factors such as estrogen receptor status, tumor grade, race/ethnicity, SEER region, and income, women with a life expectancy of less than 5 years had a significantly greater likelihood of undergoing lumpectomy only (odds ratio = 1.90). Upon deeper analysis, however, the researchers found that 17.6% of women underwent lumpectomy with axillary surgery, which is not indicated in this population.
Dr. Lorentzen acknowledged several limitations to the study, including the inability to account for patient preferences and nuances not captured in large data sets. Nevertheless, these findings underscore the need for better integration of life expectancy measures into clinical shared decision-making to avoid overtreatment in older women with DCIS.
“Treatment of breast cancer is not one size fits all,” said Dr. Lorentzen. “There is an opportunity in many cases to tailor treatment to the individual, not only based on their preferences, but also based on additional competing risks that a patient may have such as a limited life expectancy.”
Frailty and Life Expectancy Screening Program
To address this issue, Dr. Lorentzen and colleagues at the Brigham Cancer Center, led by Christina Minami, MD, MS, principal investigator for the study presented at the SSO meeting, have implemented a screening program for patients aged 70 and older who have a scheduled consult with a breast surgeon. The screening process, which takes approximately 8 minutes, uses tools such as the G8 geriatric screening tool and the Schonberg index to assess frailty and life expectancy. The results are then provided to the surgeon in real time, before the consultation.
Christina Minami, MD, MS
The team has collected quantitative data assessing whether the screening information changed surgeons’ management plans and conducted semistructured interviews with surgeons to better understand how these tools may have reshaped their conversations with patients and influenced their decision-making processes. They are also beginning to conduct similar interviews with patients to gain further insights into the shared decision-making process. The next step in this research is to qualitatively analyze the factors that play into shared decision-making in older adults with breast cancer.
“By understanding these factors and integrating life expectancy measures into clinical practice, oncologists can work toward providing more personalized care for older women with breast cancer, avoiding overtreatment, and improving patient outcomes,” Dr. Lorentzen concluded.
Expert Point of View
Julie A. Margenthaler, MD, FACS
Julie A. Margenthaler, MD, FACS, Professor of Surgery at Washington University School of Medicine, St. Louis, emphasized the recent trend toward de-escalation among patients with breast cancer.
“Surgical therapy for breast cancer has seen dramatic strides in de-escalation over the past decade, especially with the Choosing Wisely campaign,” Dr. Margenthaler told The ASCO Post. “However, we continue to overtreat women who are far more likely to suffer non–breast cancer mortality. This study highlights a critical area where we need to develop consensus guidelines for women with limited life expectancy who have early breast cancer and could safely be offered no treatment or limited treatment without compromise on overall survival.”
DISCLOSURE: Dr. Lorentzen reported no conflicts of interest. Dr. Margenthaler reported no conflicts of interest.
REFERENCE
1. Lorentzen EH, Chen Y-J, King T, et al: Potential overtreatment of DCIS in patients with limited life expectancy. Society of Surgical Oncology 2024 Annual Meeting. Abstract 10. Presented March 22, 2024.
