Ductal carcinoma in-situ (DCIS) accounts for one-fifth of breast cancer cases in the United States, according to the American Cancer Society. Given that it is a non-invasive form of breast cancer, there are implications that the disease is potentially over treated – especially in those with smaller, more favorable tumors (also known as good-risk DCIS). In what is believed to be a first-of-its-kind cost-effectiveness analysis, Rutgers Cancer Institute of New Jersey investigators and other collaborators evaluated all treatment strategies for both standard-risk and good-risk DCIS. They found that the most commonly recommended combination treatment for DCIS represents low-value care, while radiation therapy alone was cost-effective.
The work's lead author Apar Gupta, MD, radiation oncology resident at Rutgers Robert Wood Johnson Medical School, and Bruce G. Haffty, MD, MS, professor and chair, Department of Radiation Oncology at Rutgers Cancer Institute, Rutgers Robert Wood Johnson Medical School and Rutgers New Jersey Medical School;and associate vice chancellor for cancer programs at Rutgers Cancer Institute, share more on the findings that are part of a poster presentation at the San Antonio Breast Cancer Symposium this week.
Q: Why is this topic important to explore?
A: DCIS is a very early form of breast cancer – abnormal cells inside the milk ducts. Yet in most cases it is treated the same way early breast cancer is: with surgery, radiation treatment, and hormonal therapy for five years. Many trials have found that this combination of treatment leads to the highest cure rates and the lowest rates of progression to a potentially lethal invasive cancer. However, newer research has shown that in fact some of these pre-invasive tumors have very low recurrence rates, and if they do recur, can be successfully treated at that time. Thus some patients are potentially being over treated for DCIS, leading to not only higher health care costs but also unnecessary side effects from treatment. There may be ways to treat DCIS that still enable very high cure rates while reducing the length and intensity of treatment for many patients.
Q: Tell us about the work and what you and your colleagues found.
A: We conducted a cost-effectiveness analysis, which utilizes a time-dependent model incorporating recurrence risks, costs, and side effects, to examine the risks and benefits of each treatment strategy for patients who have underwent surgical excision for DCIS. For those with standard- or good-risk DCIS, we found that the combination treatment of radiation therapy and hormone therapy was not cost-effective, largely because the relatively small improvement in recurrence risk afforded by hormones did not outweigh the detriment in quality-of-life that it brought with five years of daily treatment. Thus, for standard-risk DCIS, radiation therapy alone was the most cost-effective treatment strategy, meaning that it was the treatment option with an optimal combination of treatment effects and long-term costs.
The results are more nuanced for good-risk DCIS, which is associated with lower recurrence risks. For these patients, we found that radiation therapy alone was only cost-effective for younger patients, who have more time to develop a recurrence, or for those patients who are eager to receive comprehensive treatment. For those who are older or who would derive less of a quality-of-life benefit from radiation therapy (for example, patients who are anxious about side effects), observation was in fact the most cost-effective option. In no case was hormone therapy alone cost-effective, although this is sometimes prescribed for patients with good-risk DCIS who do not wish to receive radiation therapy. Our results suggest that these patients would derive greater benefit from observation rather than hormone therapy alone.
Q: Why are these results significant?
A: These results are important in helping us to reexamine the treatments we recommend. While there is randomized, level one evidence to support combination treatment for all types of DCIS, it may not necessarily represent the best management decision when taking into account treatment costs and side effects. Further, in our age of personalized medicine, it is especially important to consider patient preferences and then tailor treatments accordingly, rather than sticking to a one-size-fits-all approach. At the same time, there is increasing scrutiny within the health care system to rein in costs and deliver treatments that are found to be of high value; that is, treatments in which the long-term benefits exceed long-term costs. These results help to inform patients and providers alike that radiation therapy alone, or even observation, may be sufficient management for certain types of DCIS.
- Wapnir IL, Dignam JJ, Fisher B, Mamounas EP, Anderson SJ, Julian TB, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478-488.
- McCormick B, Winter K, Hudis C, Kuerer HM, Rakovitch E, Smith BL, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33(7):709-15.