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Chapter 11

comedo tumor,” Bloodgood preferred the term comedo- adenoma. Treatment by local excision was recommended “when the palpable tumor is small and can be completely excised by cutting through normal breast tissue and closing the wound without injury to the symmetry of the breast.” 8 This ranks as one the earliest descriptions of breast con- servation surgery for DCIS. Needle aspiration cytologic ex- amination was used by Bloodgood for the diagnosis of breast tumors, especially so that “older women may be spared the complete operation for cancer by an aspiration biopsy, when pure comedo tumor involving a large part of, or the entire breast, is recognized.” 8 However, he found that aspiration cytology could not be relied upon for making a distinction between intraductal and invasive carcinoma. In the case of a woman with 1.5-cm lesion, The tumor had been aspirated before it was explored and from examination of the stained aspirated cells we could only decide that they suggested a malignant tumor. We did not recognize the comedo tumor. 8 In 1938, Lewis and Geschickter 9 described 40 patients treated for comedocarcinoma, reporting an 85% 5-year cure rate, with most 5-year survivors having remained well for 10 years. Included were eight women whose initial treatment was only local excision. Six of these eight women developed recurrent carcinoma within 1 to 4 years. Unfortunately, the authors did not distinguish between lesions that were entirely intraductal and those with concomitant invasive carcinoma. Until about 30 years ago there was little clinical interest in the histologic subtypes of DCIS. This situation most likely derived from the fact that almost all patients were treated by mastectomy and the observation that the lesions rarely con- sisted of a single growth pattern, for as Cheatle 10 observed, “whole sections reveal that all these varieties may occur in the same mass of disease.” Those interested in the history of DCIS, a disease that has seen an exponential increase in incidence and prevalence in recent decades, will find Fechner’s 11 overview to be particu- larly helpful. Concepts regarding various aspects of DCIS continue to evolve. Indeed, some observers find it difficult to accept the in- traductal neoplastic proliferation of cells as “carcinoma,” advo- cate the use of the acronym DIN, that is, ductal intraepithelial neoplasia, and argue that since N andM categories are not typ- ically applicable for these lesions, there is no reason to retain them within the tumor (size), regional node (involvement), (distant) metastases (TNM) system. 12 Perhaps, as a reflection of the inherent weakness of this argument, the DIN terminol- ogy has not gained wide acceptance (and has been eliminated from the latest WHO 13 classification of mammary neoplasms).

United States in 2012; during the same year, there will be 226,870 new cases of invasive breast carcinoma, and about 39,510 women will die of the disease. 14 In 1975, 5.8 Ameri- can women per 100,000 women were diagnosed with DCIS, and in 2012, the age-adjusted incidence rate of DCIS was 32.5 women per 100,000. 15 The reported frequency of DCIS in different studies is in- fluenced by clinical circumstances. A review of approximately 1,000 consecutive women treated at a cancer center in the United States in the late 1970s revealed that 5% had DCIS. 16 Data from nine population-based registries included in the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program for 1975 indicated that 2.9% of patients had DCIS. 17 A review of SEER data published in 1996 demonstrated a striking increase in the incidence of DCIS after 1983. 18 This change was observed in all age groups. Among women 30 to 39 years of age, the average annual in- crease in the incidence rate changed from 0.3% between 1973 and 1983 to 12.0% between 1983 and 1992. Similar increases were found for women 40 to 49 years of age (0.4% to 17.4%) and for women 50 years and older (5.2% to 18.1%). The esti- mated total number of cases of DCIS in 1992 was 200% higher than expected based on 1983 rates. In this series, the anatomi- cal distribution of DCIS in the breast was similar to that of invasive carcinomas, with 44% of lesions in the upper-outer quadrant. Further analysis of the SEER data indicated that the estimated number of new cases of DCIS in 1993 was 23,275. 19 Approximately 4,676 were in women 40 to 49 years of age, representing about 15% of breast carcinoma in this age group. The National Cancer Database reported in 1997 that 3.7% of 31,930 breast carcinomas registered were classified as intraductal. 20 The percentage rose to 7.0% and 9.5%, re- spectively, in 1990 (65,255 cases) and 1993 (93,915 cases). During the same period, the reported frequency of lobular carcinoma in situ (LCIS) was stable, accounting for 1.3% to 1.6% of cases annually. A population-based study of Danish women in the 1980s revealed that 4% of newly diagnosed carcinomas were intra- ductal. 21 Review of the records of the Connecticut Tumor Registry revealed a yearly increase in the reported num- ber of patients with DCIS. 22 In 1979, the 33 diagnoses of DCIS represented 1.8% of breast carcinomas, and in 1988 the 200 cases constituted 7.4% of breast carcinomas. Data from the New Mexico Tumor Registry revealed stable in- cidence values for DCIS in Hispanic White, non–Hispanic White, and Native American women for more than a de- cade before 1984. 23 Thereafter, the incidence rate increased annually in each ethnic group. In 1994, the incidence rates per 100,000 were 13.8, 9.7, and approximately 7.0, respec- tively, for non–­Hispanic White, Hispanic White, and Native American women. The lower incidence rates in the latter groups may reflect less access to mammography rather than intrinsic ethnic differences in the biology of DCIS. African ­Americans with DCIS have higher rates of breast carcinoma recurrence, as well as mortality. Analyses of SEER data show that overall mortality is 35% higher in African American versus Caucasian women. The risk of advanced invasive car- cinoma was 130% higher in Hispanic and 170% higher in African ­American versus Caucasian women with DCIS. 24

Clinical Presentation Frequency

Approximately one-quarter of newly diagnosed breast car- cinomas are noninvasive. By American Cancer Society’s estimation, there will be 63,300 new cases of DCIS in the