Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging: An Ancillary Study of the ECOG-ACRIN Cancer Research Group (E4112)

Abstract

Importance: Guiding treatment decisions for women with ductal carcinoma in situ (DCIS) requires understanding patient preferences and the influence of preoperative magnetic resonance imaging (MRI) and surgeon recommendation.

Objective: To identify factors associated with surgery preference and surgery receipt among a prospective cohort of women with newly diagnosed DCIS.

Design, setting, and participants: A prospective cohort study was conducted at 75 participating institutions, including community practices and academic centers, across the US between March 25, 2015, and April 27, 2016. Data were analyzed from August 2 to September 24, 2021. This was an ancillary study of the ECOG-ACRIN Cancer Research Group (E4112). Women with recently diagnosed unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. Participants who had documented surgery and completed the baseline patient-reported outcome questionnaires were included in this substudy.

Exposures: Women received preoperative MRI and surgeon consultation and then underwent wide local excision or mastectomy. Participants will be followed up for recurrence and overall survival for 10 years from the date of surgery.

Main outcomes and measures: Patient-reported outcome questionnaires assessed treatment goals and concerns and surgery preference before MRI and after MRI and surgeon consultation.

Results: Of the 368 participants enrolled 316 (86%) were included in this substudy (median [range] age, 59.5 [34-87] years; 45 women [14%] were Black; 245 [78%] were White; and 26 [8%] were of other race). Pre-MRI, age (odds ratio [OR] per 5-year increment, 0.45; 95% 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) vs removal of the breast for peace of mind (OR, 1.35; 95% CI, 1.04-1.76; P = .03) were associated with surgery preference for mastectomy. After MRI and surgeon consultation, MRI upstaging (48 of 316 [15%]) was associated with patient preference for mastectomy (OR, 8.09; 95% CI, 2.51-26.06; P < .001). The 2 variables with the highest ORs for initial receipt of mastectomy were MRI upstaging (OR, 12.08; 95% CI, 4.34-33.61; P < .001) and surgeon recommendation (OR, 4.85; 95% CI, 1.99-11.83; P < .001).

Conclusions and relevance: 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.

Figure 1.. Study Flow Diagram

MRI indicates magnetic resonance imaging; PRO, patient-reported outcomes; T0, time of registration; T1, time after MRI and surgeon consultation and before surgery.

Figure 2.. Adjusted Odds Ratios (ORs) From Multivariable Logistic Regression Models for Surgery Preference at Time of Registration (T0), Surgery Preference After Magnetic Resonance Imaging (MRI) and Surgeon Consultation and Before Surgery (T1), and Initial Surgery Received

Firth penalized maximum likelihood logistic regression models were used. The x-axis is on the log scale, where odds ratios greater than 1 favor mastectomy. For categorical variables, the OR is interpreted in association with the indicated reference level. For age, the OR is interpreted per 5-year increase; for area deprivation index (ADI), the OR is interpreted per 10-percentile increase; for patient-reported outcome (PRO) variables modeled as continuous covariates (keep breast, remove breast, radiation, sex life, Assessment of Survivor Concerns [ASC] cancer worry subscale), the OR is interpreted per 1-unit increase on the respective scale. ^aFor race (non-White vs White), there were limitations as to the number of covariates that could be included in the statistical models based on the smaller number of women who preferred mastectomy, and this includes the number of categories for categorical covariates. Given that, race was conceived as binary as White (the predominant racial category) versus all other categories. All other categories include American Indian/Alaskan Native, Asian, Black, multiple races, not reported, and unknown.

Figure 3.. Classification Tree for Initial Surgery Received

Using internal validation, the overall misclassification rate was 9% (29 of 316), with 97% (258 of 267) of women who initially received wide local excision (WLE) correctly classified, and 59% (29 of 49) of women who initially received mastectomy correctly classified. ASC indicates Assessment of Survivor Concerns; MRI, magnetic resonance imaging; PRO, patient-reported outcome; T0, time of registration.