In situ duct carcinoma of the breast: clinical and histopathologic factors and association with recurrent carcinoma.

There has been a recent increase in the diagnosis of in situ duct carcinoma of the breast (DCIS) as a result of mammographic screening. DCIS is heterogeneous in appearance and likely in prognosis. There is no generally accepted model to predict progression to invasive carcinoma. We investigated the prognostic effect of clinical presentation and pathologic factors for women diagnosed with primary DCIS. A cohort of 124 patients was accrued between 1979 and 1994 and was followed to 1997; 78 had DCIS detected mammographically, and 88 underwent lumpectomy alone. In this article, we provide details about characteristics affecting the choice of primary therapeutic modality, and we examine the effects of factors on progression for the two patient subgroups. Presentation with bloody nipple discharge was associated with a significant increase in DCIS recurrence (p=0.07). The pattern of duct distribution was important: DCIS in which the involved ducts were more widely separated had a significantly greater recurrence of DCIS than when the involved ducts were more concentrated (p=0.08 for mammographically detected DCIS, p=0.07 for patients who underwent lumpectomy alone). For mammographically detected DCIS, younger patients had more DCIS recurrence (p=0.07). We found considerable heterogeneity in nuclear grade; 50% of patients exhibited more than one grade. Nuclear grade, necrosis, and architecture were not significantly associated with either recurrence of DCIS or development of invasive carcinoma. Longer follow-up will allow further evaluation of the prognostic relevance of the factors assessed.

Competing risks analyses for recurrence from primary breast cancer.

The effects of prognostic factors on local, regional or distant metastasis are standardly assessed separately. Competing risks analyses may be used to assess simultaneously the effects of factors on different types of first recurrence. Data for a cohort of 678 primary invasive breast cancer patients accrued between 1971 and 1990, updated to 1995, included type of first recurrence (local, regional, distant). We investigated the effects of the traditional factors of age, tumour size, nodal status, ER, PgR, adjuvant therapy (hormones, chemotherapy, radiotherapy) on type of recurrence and time to recurrence for all patients and for those aged > or = 65. For all ages of patients, there were five factors with significant associations with type or time to first recurrence. Adjuvant radiation was the only factor which had an effect (P < or = 0.05) on the type of first recurrence: being associated with a reduction in local recurrence. Age, nodal status, tumour size and adjuvant chemotherapy all had significant associations across all types of first recurrence, and in particular with time to recurrence for both local and distant metastasis. This indicates a potential lack of independence in these end-points. For patients > or = 65 years of age, there were no factors which differentially affected type of recurrence, while only nodal status and tumour size had significant associations with time to recurrence. Analyses were used to assess simultaneously the effects of traditional prognostic factors and treatment options on type of first recurrence and time to first recurrence. The extension to evaluations with newer prognostic factors would expedite the determination and mode of biologic activity for such factors.

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast.

BACKGROUND: Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation. METHODS: We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer. RESULTS: Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate; P=.07, for multivariate) and initial presentation (P=.05, for univariate; P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease. CONCLUSIONS: Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.

Assessment of tumor size for multifocal primary breast cancer.

BACKGROUND: Tumor size affects the choice of surgical procedure and patient prognosis. It is standardly assessed as the largest unidimensional measurement and, for multifocal disease, as the largest size of the largest focus. We examine some different methods of assessing tumor size: the standard method; the sum of the largest sizes for all foci; surface area; and volume. METHODS: Data for a cohort of 678 primary invasive breast cancer patients accrued from 1971 to 1990 were updated to 1996; there were 571 patients with unifocal disease and 107 patients with multifocal disease. We used step-wise Cox regression to investigate the effects on time to death of the prognostic factors tumor size (estimated in one of the four ways), age, nodal status, ER, PgR, adjuvant radiotherapy, adjuvant hormonal therapy, and adjuvant chemotherapy. We also examined the association between tumor focality and nodal status. RESULTS: For all patients, tumor size was included in the multivariate model, regardless of estimation method. For patients with multifocal disease, tumor size was included in the final model only when it was estimated as the total surface area (P = .03) or volume (P = .01) of the foci. More multifocal patients were N+ (P = .056). CONCLUSIONS: For patients with multifocal disease, the significance association with mortality for total surface area or volume may imply a biologic relevance or mode of tumor activity for the foci.

Competing causes of death for primary breast cancer.

BACKGROUND: A patient's likelihood of dying from breast cancer or another cause can be assessed with competing risks analyses. METHODS: Data for a cohort of 678 patients with primary invasive breast cancer accrued from 1971 to 1990, updated to 1995, included cause of death (e.g., breast cancer vs. other cause). We investigated the effects of age, tumor size, nodal status, ER, PgR, and adjuvant therapy (hormones, chemotherapy, radiotherapy) on type of death and time to death for patients of all ages and for those over the age of 65 years. RESULTS: Although there were no significant univariate differences in breast cancer death rates by age group (P=0.94), more patients over the age of 65 years died from other causes (41/207 [20%] of those older than 65 years vs. 16/471 [3%] of those younger than 65 years; P <.001). In competing risks analyses, older age was associated with non-breast cancer death, whereas larger tumor size was associated with breast cancer death. PgR was positively, and nodal status negatively, associated with survival, regardless of type. In the older patient group, the competing risks analyses identified similar effects for age and tumor size; in addition, higher ER assay values were less likely to be associated with breast cancer death. CONCLUSIONS: With increased lifespan, there will be more breast cancer cases in women older than 65 years; we have shown that women in this group have more non-breast cancer deaths. It becomes important, then, to delineate differential effects of prognostic factors on competing causes of death.

Incidence of Salmonellae in Raw Meat and Poultry Samples in Retail Stores.

An examination of 142 samples of raw beef, pork, and poultry from five retail stores in Athens, Georgia, showed an overall incidence of 14.8% contamination by salmonellae. Pork samples had the maximum contamination (21.5%). Samples were obtained in lots of about 25 over a 6-week period and the extent of contamination by salmonellae in the products purchased every week fluctuated over a narrow range (12.5 - 19.2%). Higher levels of contamination were observed in samples purchased from two national supermarkets than in samples purchased from a regional supermarket, a local grocery store and one national supermarket. Salmonella typhimurium and Salmonella agona were the serotypes isolated most frequently from the samples.