Elsevier

European Journal of Cancer

Volume 71, January 2017, Pages 95-108
European Journal of Cancer

Review
Patient-reported outcomes in ductal carcinoma in situ: A systematic review

https://doi.org/10.1016/j.ejca.2016.09.035Get rights and content

Highlights

  • Treatment modalities for ductal carcinoma in situ affect patient-reported outcomes variably.

  • Many aspects of quality of life are initially affected, but recover by 2 years.

  • Fears of breast cancer recurrence and death are exaggerated and persistent.

  • Depression, sexual and body image issues are uncommon, can be severe and co-occur.

  • Evidence about differences in patient-reported outcomes between alternative ductal carcinoma in situ treatments is lacking.

Abstract

Ductal carcinoma in situ (DCIS) is a pre-invasive breast cancer with excellent prognosis but with potential adverse impacts of diagnosis and treatment on quality of life and other patient-reported outcomes (PROs). We undertook a systematic review to synthesise current evidence about PROs following diagnosis and treatment for DCIS. We searched five electronic databases (from database inception to November 2015), cross-referenced and contacted experts to identify studies that reported PROs after DCIS treatment. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Of 2130 papers screened, 23 were eligible, reporting 17 studies. Short- and long-term PRO evidence about differences between DCIS treatment options was lacking. Evidence pooled across treatments indicated core aspects of quality of life (physical, role, social, emotional function, pain, fatigue) and psychological distress (anxiety, depression) were impacted significantly initially, with most aspects returning to population norms by 6–12 months, and all by 2 years post-operatively. Fears of recurrence and dying from breast cancer were exaggerated, occurred early and persisted for many years. Sexuality and body image impacts were generally low and resolved within 1–3 months after surgery. A minority of women experienced considerable impact, including depression and sexual issues associated with body image problems. Well-powered PRO studies are required to track recovery trajectories and long-term impacts of the range of contemporary and emerging local and systemic treatments for DCIS. PRO data would enable care providers to prepare patients for short-term sequelae and enable patients who have treatment options to exercise preferences in choosing among them.

Introduction

Ductal carcinoma in situ (DCIS) is a heterogeneous disease, variously described as pre-cancerous, pre-invasive or non-invasive intra-ductal breast cancer [1]. It accounts for 12–25% of screen-detected breast cancers [2], [3], [4], [5], [6], [7]. Breast cancer-specific mortality of patients treated with currently available therapies is low [8], [9]. Treatment for DCIS reduces the risk of recurrence [10], [11] but can have adverse consequences [12], [13], [14]. There is growing concern about overtreatment of low-risk patients [15], [16], [17], with clinical trials underway to test the safety of observation alone [13], [18], [19]. Since prognosis is excellent [8], patient-reported outcomes (PROs) and impact of treatment on quality of life are particularly relevant to the cost-benefit analysis of DCIS treatment [9]. Understanding the psychological impact of diagnosis is also relevant, for example in relation to effective communication about the risks of invasive disease- and breast cancer-specific mortality.

Treatment options for DCIS are comparable to early stage invasive breast cancer except that axillary dissection and adjuvant chemotherapy are not indicated. Surgical options include breast conserving surgery (BCS) or mastectomy ± breast reconstruction and sometimes sentinel node biopsy. Many women have radiotherapy (RT) following BCS. Some women also receive endocrine therapy.

Abundant high quality evidence about PROs in invasive breast cancer suggests that adverse consequences of DCIS treatment may include pain, fatigue and reduced physical function during recovery, and in the longer term, arm and shoulder dysfunction, and body image and sexuality issues [20]. However, several factors limit the direct application of this evidence to women with DCIS. Treatment for invasive breast cancer more often includes axillary surgery with attendant morbidity, and chemotherapy causing fatigue and loss of physical, role, social and cognitive functioning [21], [22], [23], [24], [25], [26]. While these problems tend to resolve, some deficits may persist for years [27]. In contrast to patients with DCIS, breast reconstruction for invasive disease is more often postponed until after by post-mastectomy radiotherapy and/or chemotherapy are completed [28], [29]. In addition, women with invasive breast cancer have a higher risk of mortality, with attendant psychological impacts, including anxiety about cancer recurrence [30], [31]. These, in turn, may influence perception of other psychosocial outcomes such as emotional, social and cognitive function, fatigue, body image and sexual functioning [32].

As the survival benefit of treatment for DCIS is much smaller than for invasive breast cancer, quality of life consequences are a pertinent consideration in treatment decision-making. Treatment decisions in DCIS are often guided by tumour pathology [11], [33], [34], [35], but with considerable scope for patient preferences. Thus, it is important to understand the impact of different treatments for DCIS on PROs including quality of life, to inform patient decision-making and provide appropriate care, support and information [9].

We conducted a systematic review of PROs in DCIS. Specific objectives were to:

  • 1.

    Identify and synthesise qualitative evidence about the experience of women diagnosed with DCIS;

  • 2.

    Identify and synthesise quantitative evidence about the impacts of diagnosis of DCIS and consequent treatments on PROs from diagnosis to survivorship; and

  • 3.

    Compare and contrast these outcomes for women receiving different treatments for DCIS.

Section snippets

Methods

We searched five electronic databases: MEDLINE; PsycInfo; CINAHL; EMBASE; and Scopus from database inception to 12th November 2015. Our search strategy comprised a comprehensive set of terms for ‘DCIS’ and ‘PROs’ (Online Appendix A). No language restrictions were applied. To supplement this, we: 1) searched the reference lists of all studies included in this review and of other relevant systematic reviews; 2) conducted an electronic search by author of key researchers identified; and 3)

Results

Twenty-three papers were eligible (Fig. 1); four informed objective 1 (Table 1), and 19 informed objectives 2 and 3 (Table 2). Table 1, Table 2 summarise the study design and methods of the qualitative and quantitative studies, respectively.

Discussion

We found 23 papers reporting 17 studies of PROs after treatment for DCIS. Evidence pooled across treatments indicated that core aspects of quality of life (physical, role, social, emotional function, pain, fatigue) and psychological distress (anxiety, depression) were impacted initially, but most returned to population norm levels by 6–12 months, and all by 2 years. However, fear of breast cancer recurrence and dying of breast cancer were exaggerated, occurred early and persisted for many

Conclusions and future directions

Clearly interpretable evidence about the comparative impact of treatment options for DCIS on PROs has not been published. Well-powered PRO studies are required to track acute to intermediate recovery trajectories and long-term impacts of the range of contemporary and emerging treatment options. Several randomised trials that are active or awaiting activation [13], [18], [19], [66] will provide valuable PRO data, as well as important new data on other outcomes relevant to DCIS treatment

Funding

This work was conducted without grant funding. Professor King is supported by the Australian Government through Cancer Australia.

Conflict of interest statement

The authors have no conflict of interest to declare.

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