Invasive breast cancer and breast cancer mortality after ductal carcinoma in situ in women attending for breast screening in England, 1988-2014: population based observational cohort study
Invasive breast cancer and breast cancer mortality after ductal carcinoma in situ in women attending for breast screening in England, 1988-2014: population based observational cohort study
复制标题
DOI：
10.1136/bmj.m1570
复制
发表时间：
2020-05-27
影响因子：
105.7
通讯作者：
Darby, Sarah C.
中科院分区：
文献类型：
--
作者：
Mannu, Gurdeep S.;Wang, Zhe;Darby, Sarah C.
目的评估通过乳腺筛查诊断出导管原位癌（DCIS）后发生浸润性乳腺癌和乳腺癌死亡的长期风险。设计基于人群的观察性队列研究。设置数据来自 NHS 乳腺筛查计划和国家癌症登记和分析服务。参与者从 1988 年开始到 2014 年 3 月，NHS 乳腺筛查计划诊断为患有 DCIS 的英格兰所有 35 024 名女性。主要结果指标浸润性乳腺癌事件和乳腺癌死亡。结果截至 2014 年 12 月，有 13 606 名女性已被跟踪长达五年，十 5至9年为998，10至14年为6861，15至19年为2620，至少20年为939。在这些女性中，有 2076 人罹患浸润性乳腺癌，相应的发病率为每 1000 名女性每年 8.82 例（95% 置信区间 8.45 至 9.21），是全国癌症发病率预期的两倍多（观察率与预期率之比 2.52，95% 置信区间 2.41 至 2.63）。这种增加从诊断 DCIS 后的第二年开始，一直持续到随访结束。在同一组女性中，有 310 人死于乳腺癌，相当于每年每 1000 名女性中有 1.26 人（1.13 至 1.41）人的死亡率，比全国乳腺癌死亡率的预期高出 70%（观察值：预期比率 1.70、1.52 至 1.90）。在DCIS诊断后的前五年内，乳腺癌死亡率与全国死亡率的预期相似（观察值：预期比值0.87、0.69至1.10），但随后有所上升，逐年值为1.98（1.65至2.37）、2.99（2.41至3.70）和2.77（2.01至3.80） DCIS 诊断后，5 至 9 个、10-14 个、15 个或更多。在 29 044 名接受手术的单侧 DCIS 女性中，接受更强化治疗（乳房切除术、保乳手术女性的放疗、雌激素受体阳性疾病的内分泌治疗）和最终手术切缘较大的女性患浸润性乳腺癌的几率较低。 结论迄今为止，通过筛查发现的 DCIS 女性平均患浸润性乳腺癌的长期风险较高， 在诊断后至少二十年期间，乳腺癌死亡率高于一般人群中的女性。更强化的治疗和更大的最终手术切缘与更低的浸润性乳腺癌风险相关。
OBJECTIVETo evaluate the long term risks of invasive breast cancer and death from breast cancer after ductal carcinoma in situ (DCIS) diagnosed through breast screening. DESIGN Population based observational cohort study.SETTINGData from the NHS Breast Screening Programme and the National Cancer Registration and Analysis Service.PARTICIPANTSAll 35 024 women in England diagnosed as having DCIS by the NHS Breast Screening Programme from its start in 1988 until March 2014.MAIN OUTCOME MEASURESIncident invasive breast cancer and death from breast cancer.RESULTSBy December 2014, 13 606 women had been followed for up to five years, 10 998 for five to nine years, 6861 for 10-14 years, 2620 for 15-19 years, and 939 for at least 20 years. Among these women, 2076 developed invasive breast cancer, corresponding to an incidence rate of 8.82 (95% confidence interval 8.45 to 9.21) per 1000 women per year and more than double that expected from national cancer incidence rates (ratio of observed rate to expected rate 2.52, 95% confidence interval 2.41 to 2.63). The increase started in the second year after diagnosis of DCIS and continued until the end of follow-up. In the same group of women, 310 died from breast cancer, corresponding to a death rate of 1.26 (1.13 to 1.41) per 1000 women per year and 70% higher than that expected from national breast cancer mortality rates (observed:expected ratio 1.70, 1.52 to 1.90). During the first five years after diagnosis of DCIS, the breast cancer death rate was similar to that expected from national mortality rates (observed:expected ratio 0.87, 0.69 to 1.10), but it then increased, with values of 1.98 (1.65 to 2.37), 2.99 (2.41 to 3.70), and 2.77 (2.01 to 3.80) in years five to nine, 10-14, and 15 or more after DCIS diagnosis. Among 29 044 women with unilateral DCIS undergoing surgery, those who had more intensive treatment (mastectomy, radiotherapy for women who had breast conserving surgery, and endocrine treatment in oestrogen receptor positive disease) and those with larger final surgical margins had lower rates of invasive breast cancer.CONCLUSIONSTo date, women with DCIS detected by screening have, on average, experienced higher long term risks of invasive breast cancer and death from breast cancer than women in the general population during a period of at least two decades after their diagnosis. More intensive treatment and larger final surgical margins were associated with lower risks of invasive breast cancer.