Surgery Preference and Surgery Received in Women With DCIS

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In an ancillary study of the ECOG-ACRIN Cancer Research Group E4112 study reported in JAMA Network Open, Fazeli et al found that patient preference of type of surgery and type of surgery received for ductal carcinoma in situ (DCIS) were influenced by preoperative magnetic resonance imaging (MRI) results and consultation with a surgeon.

Study Details

The prospective cohort study enrolled 368 women with recently diagnosed unilateral DCIS who were eligible for wide local excision and who had a diagnostic mammogram within 3 months between March 2015 and April 2016. Patients were to receive preoperative MRI and surgical consultation, and then undergo wide local excision or mastectomy. Questionnaires were to be completed at baseline (T0) and after MRI and surgical consultation but before surgery (T1).

Key Findings

Of the 368 women enrolled, 355 (96%) completed the MRI and 339 (92%) had surgery with known final status; of the 339, 316 (93%) completed the T0 questionnaire and 250 (74%) completed both the T0 and T1 questionnaires.

At T0, 252 (80%) of the 316 women preferred wide local excision, 11 (3%) preferred mastectomy, and 50 (16%) were unsure of preference (3 responses were missing). On multivariate analysis, older age (odds ratio [OR] per 5-year increase = 0.45, 95% confidence interval [CI] = 0.26–0.80, P = .007) and the importance of keeping one’s breast (OR = 0.48,  95% CI = 0.31–0.72, P < .001) were associated with not preferring mastectomy, and the importance of removing the entire breast for peace of mind was associated with preferring mastectomy (OR = 1.35, 95% CI = 1.04–1.76, P = .03).

Among 250 women who completed questionnaires at both T0 and T1, 219 (88%) preferred wide local excision, 22 (9%) preferred mastectomy, and 8 (3%) were unsure of preference (1 missing response). A total of 13 women changed preference from wide local excision to mastectomy; of these 13, 8 (62%) had MRI upstaging and the same percentage had a surgeon’s recommendation of mastectomy. Four women changed preference from mastectomy to wide local excision; none had MRI upstaging or a surgeon’s recommendation of mastectomy. MRI upstaging was the sole significant factor in surgery preference at T1, with upstaging increasing odds of preferring mastectomy (OR = 8.09, 95% CI = 2.51–26.1, P < .001).

Among 316 patients with known final surgery status and T0 data, 48 (15%) had upstaging by MRI. A higher percentage of patients with MRI upstaging received a mastectomy (27 of 48, 56%) compared with those without upstaging (19 of 261, 7%). On multivariate analysis, the two variables with the highest odds ratios for receiving mastectomy were MRI upstaging (OR = 12.08, 95% CI = 4.34–33.6, P < .001) and a surgeon’s recommendation (OR = 4.85, 95% CI = 1.99–11.83, P < .001).

The investigators concluded, “In this cohort study, change in patient preference for DCIS surgery and surgery received were responsive to MRI results and surgeon recommendation. These data highlight the importance of ensuring adequate information and ongoing communication about the clinical significance of MRI findings and the benefits and risks of available treatment options.”

Ruth C. Carlos, MD, MS, of the University of Michigan, Ann Arbor, is the corresponding author for the JAMA Network Open article.  

Disclosure: The study was supported by grants from the National Cancer Institute. For full disclosures of the study authors, visit

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