965899 research-article2020 WHE0010.1177/1745506520965899Women’s HealthPoliti et al. Cancer Survivorship Among Women Women’s Health Readmissions and complications in breast Volume 16: 1­–9 © The Author(s) 2020 Article reuse guidelines: ductal carcinoma in situ: A retrospective sagepub.com/journals-permissions DOI: 10.1177/1745506520965899 https://doi.org/10.1177/1745506520965899 study comparing screen- and journals.sagepub.com/home/whe non-screen-detected patients Julieta Politi1,2, María Sala1,3,4 , Laia Domingo1,3, María Vernet-Tomas5, Marta Román1,3, Francesc Macià1 and Xavier Castells1,3 Abstract Objective: Population-wide mammographic screening programs aim to reduce breast cancer mortality. However, a broad view of the harms and benefits of these programs is necessary to favor informed decisions, especially in the earliest stages of the disease. Here, we compare the outcomes of patients diagnosed with breast ductal carcinoma in situ in participants and non-participants of a population-based mammographic screening program. Methods: A retrospective cohort study of all patients diagnosed with breast ductal carcinoma in situ between 2000 and 2010 within a single hospital. A total of 211 patients were included, and the median follow-up was 8.4 years. The effect of detection mode (screen-detected and non-screen-detected) on breast cancer recurrences, readmissions, and complications was evaluated through multivariate logistic regression analysis. Results: In the majority of women, breast ductal carcinoma in situ was screen-detected (63.5%). Screen-detected breast ductal carcinoma in situ was smaller in size compared to those non-screen-detected (57.53% < 20 mm versus 78.03%, p = 0.002). Overall, breast-conserving surgery was the most frequent surgery (86.26%); however, mastectomy was higher in non-screen-detected breast ductal carcinoma in situ (20.78% versus 9.7%, p = 0.024). Readmissions for mastectomy were more frequent in non-screen-detected breast ductal carcinoma in situ. Psychological complications, such as fatigue, anxiety, and depression, had a prevalence of 15% within our cohort. Risk of readmissions and complications was higher within the non-screen-detected group, as evidenced by an odds ratio = 6.25 (95% confidence interval = 1.95–19.99) for readmissions and an odds ratio = 2.41 (95% confidence interval = 1.95–4.86) for complications. Conclusions: Our findings indicate that women with breast ductal carcinoma in situ breast cancer diagnosed through population-based breast cancer screening program experience a lower risk of readmissions and complications than those diagnosed outside these programs. These findings can help aid women and health professionals make informed decisions regarding screening. Keywords breast ductal carcinoma in situ, hospital readmission, mastectomy, patient-relevant outcome, screening Date received: 2 June 2020; revised: 31 August 2020; accepted: 23 September 2020 1 5  epartment of Epidemiology and Evaluation, Hospital del Mar Medical D  reast Surgery, Obstetrics and Gynaecology Department, Hospital del B Research Institute (IMIM), Barcelona, Spain Mar, Barcelona, Spain 2 Preventive Medicine and Public Health Training Unit, Parc de Salut Corresponding author: Mar-Pompeu Fabra University-Agència de Salut Pública de Barcelona María Sala, Department of Epidemiology and Evaluation, Hospital del (PSMar-UPF-ASPB), Barcelona, Spain 3 Mar Medical Research Institute (IMIM), Passeig Marítim, 25-29, 08003 Research Network on Health Services in Chronic Diseases Barcelona, Spain. (REDISSEC), Barcelona, Spain 4 Email: MSalaSerra@parcdesalutmar.cat Universitat Autònoma de Barcelona, Barcelona, Spain Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Women’s Health Introduction were analyzed within the non-screen-detected group. The Spanish Breast Cancer Screening Program is a population- Breast cancer (BC) survival has notably improved over the based mammographic screening program that provides past few decades, partly because of the effectiveness of biennial mammography screening tests to women aged population-wide mammographic screening programs. 50–69 years. It started gradually in 1990 and was imple- These programs aim to detect early-stage BC, when treat- mented nationwide in 2005. Full coverage of the Hospital ment response is highest, providing a survival advantage del Mar’s area of influence was achieved in 1995. This compared to clinically detected patients and favoring less program follows the European Guidelines for Quality invasive treatment.1 Most tumors identified through Assurance in Mammographic Screening Recommendations screening programs are early-stage BCs.2 Of these, breast and achieves the required standards.6 ductal carcinoma in situ (DCIS) represents 20% of lesions.1 Within the non-screen-detected group, the presence of In general, women treated for DCIS have a relatively symptoms and past mammograms were not consistently low BC-specific mortality and a normal life expectancy.2,3 registered or reported in charts. Women with screen- However, there has recently been much controversy sur- detected DCIS were 134 in total, while 77 were non- rounding to which extent the diagnosis and treatment of screen-detected. Both groups were diagnosed, treated, and DCIS prevent future invasive BC and there is a growing followed up within the same BC unit at a reference hospi- concern for overdiagnosis and overtreatment. tal, following the same protocols for all patients. To ascertain the effectiveness of screening programs, some studies have compared the effect of screening on DCIS, being mortality and disease-free survival as their Patient and tumor characteristics main focus.4 However, other outcomes that may be of significant interest from a patient’s point of view, such as Tumor and treatment variables were obtained from the treatment patterns, hospital readmissions, or other com- hospital cancer registry. Additional clinical information plications, have been less evaluated, and there is limited was extracted through a retrospective clinical chart review. observational information regarding complications for The “Shared clinical chart” (HC3) data source (storing all BC in general.5 Furthermore, to date, no previous study information on visits to publicly funded centers within has evaluated complications according to screening sta- Catalonia, Spain) was used to complete information on tus for DCIS. vital status, recurrences, readmissions, and complications. Our study aimed to compare readmissions, complica- Age at diagnosis and the presence of comorbidities tions, and recurrences of patients diagnosed with breast were obtained through hospital records. The Charlson DCIS in participants and non-participants of a population- index was used to evaluate comorbidities. Radiologic based mammographic screening program. mammography patterns were classified into presence or absence of calcifications. Pathology reports provided information on tumor focality (unifocal and multifocal), Materials and methods differentiation grade (I, II, and III), and tumor size (mil- limeter). Immunohistochemistry staining is routinely Study population performed at our hospital. Following standard guide- Women diagnosed with DCIS as a first BC event between lines, positivity for ER, PR, and P53 requires more than 2000 and 2010 were identified from the Hospital del Mar 10% of cells testing positive. HER2 scores were deter- cancer registry (Barcelona, Spain) and followed up to mined through the HerceptTest kit. Hercept scores of 3 2016. The Hospital del Mar is a public university hospital were considered positive, and scores of 0–1 were consid- in the city of Barcelona, which hosts 400 beds and pro- ered negative. Scores of 2 were considered positive vides coverage to a reference area of approximately when fluorescent in situ hybridization detected HER2/ 350,000 individuals. neu oncogene amplification. Molecular subtypes were constructed based on immunohistochemistry results, as proposed by Carey et al.7 Mode of detection Detection mode was classified into screen-detected DCIS Treatments (women diagnosed through mammograms performed within the population-based BC screening program) and Type of surgery was classified as breast-conserving sur- non-screen-detected DCIS (women with mammograms gery (BCS, consisting of tumoral excision only) and mas- performed outside of the population-based screening pro- tectomy (complete removal of the breast and including gram, such as opportunistic screening, presence of breast radical or simple procedures). Surgical margins corre- abnormalities/symptoms, and interval cancers). Interval sponded to the margin obtained at the final surgical proce- cancers (n = 3), defined as tumors arising after a negative dure. Margins were considered free of disease when screening episode and before the next screening invitation, excisions maintained at least 2 mm of distance to the Politi et al. 3 tumor. This criterion was evaluated retrospectively and used a two-sided 0.05 level of significance. All analyses based on current guidelines.8 Adjuvant radiotherapy and were performed with STATA/SE 13.1 (StataCorp LP, hormone therapy were also registered. College Station, TX, USA). Follow-up information Results Follow-up information was retrospectively reviewed from The study cohort included 211 women with DCIS BC. the hospital and HC3 charts to identify readmissions, Patient and tumor characteristics by detection mode are complications, and BC recurrences. Trained staff (doc- shown in Table 1. The majority of women were screen- tors) reviewed the clinical charts. Hospital readmissions detected (63.5%). Regarding age, 50% of screen-detected included admissions within 3 months after surgery and patients were aged between 55–65 years. Among non- had to be related to the disease. Readmissions were clas- screen-detected, the majority (51.9%) were aged less sified into re-excision, mastectomy, reconstruction, and than 55 years. A total of 67 (50.0%) women within the others (which included unprogrammed causes for read- screen-detected group were initial screening participants, mission such as infection and bleeding). Other complica- 58 (43.3%) successive screening participants, and 9 tions were those developing 3 months after surgery until (6.7%) were successive screening participants who had the end of follow-up and were classified as follows: sur- missed a round. Compared to non-screen-detected DCIS, gery-related (seroma, recurrent skin infection, soft tissue screen-detected DCIS more frequently presented with necrosis, upper extremity paresthesia, upper extremity calcifications on mammography (57.9% versus 77.6%, dysfunction, and lymphedema); persistent pain (when p = 0.003) and were smaller in size (57.5% < 20 mm ver- present for more than 3 months after surgery and occur- sus 77.6%, p = 0.002). No statistically significant differ- ring in relation to the surgical area, upper extremity, or ences in tumor grade or immunophenotype were noted by chest); systemic complications (hypothyroidism, pneu- detection mode. monitis/pleural effusion, cardiac events, deep vein throm- Regarding treatment characteristics, as shown in Table 2, bosis, gynecologic events, cognitive dysfunction, the most common surgical procedure modality was BCS osteoporosis, and weight gain); and psychological events (86.3%). A higher proportion of women with non-screen- (fatigue/anxiety/depression). On follow-up, each patient detected DCIS underwent mastectomy (20.8% versus could present more than one type of complication. 9.7%, p = 0.024). Radiotherapy was more frequently used BC recurrence required pathology confirmation, and all in women with screen-detected DCIS (85.61% versus forms of BC recurrences (DCIS or invasive; local, regional, 71.2%, p = 0.013). Among the non-screen-detected group, or distant) were considered. Disease-free survival was 61 (79.2%) women were treated with BCS. Margin status defined from the date of diagnosis to the date of BC recur- was available for 59 women within this group, and a mar- rence or the date of the last follow-up. Median follow-up gin greater than 2 mm was attained in 44 (74.6%) patients. was 8.4 years (range: 0.4–16.5 years). Radiotherapy was used among 52 (71%) women within this group (unknown in four patients). Free margin status was high, with more than 72% of the cohort attaining Statistical analyses margins free of disease, and no differences were observed Women’s tumor characteristics, treatment, and out- by detection mode. comes were compared according to detection mode. The In Table 3, differences in postoperative outcomes in chi-square or Fisher’s exact tests were used where screen and non-screen-detected DCIS are presented. A appropriate. higher proportion of women with non-screen-detected The impact of detection mode on BC recurrence, hos- DCIS experienced readmissions (28.6% versus 7.5, pital readmission, and complications (total, surgical p < 0.0001). Among this group, mastectomy was the most complications, pain, psychological events, and systemic common procedure motivating readmission. Complications complications) was estimated through multivariate were higher within the non-screen-detected group. logistic regression analysis. Different models were per- However, when complications were categorized, while formed, one for each outcome, to obtain adjusted risks. proportions were higher within the non-screen-detected Models were constructed following an explanatory mod- group, these differences were no longer statistically sig- eling approach. For readmissions, Charlson score, type nificant. The prevalence of psychological complications of surgery, age, and tumor size, adjusted the model. For was almost 15% within the cohort, with a higher preva- complications, the model included Charlson score, type lence among women with non-screen-detected DCIS, of surgery, hormone and radiotherapy, and age. The although not statistically significant. Persistent pain was recurrence model was adjusted by age, tumor size type found to be 9.48% within the cohort. Regarding BC recur- of surgery, hormone and radiotherapy, and presence of rence, 28 women experienced recurrences during the fol- calcifications on mammography. All statistical testing low-up period (13.27%), 18 women in the screen-detected 4 Women’s Health Table 1. Comparison of baseline characteristics according to screening status. Overall Detection mode p-value Screen-detected Non-screen-detected n (%) 211 134 (63.5) 77 (36.5) Patient characteristics Age   <55 75 35 (26.1) 40 (51.9) <0.001a   55–65 72 67 (50.0) 5 (6.5)   >65 64 32 (23.9) 32 (41.6) Charlson score   0 139 91 (67.9) 48 (62.3) 0.465b   1 45 27 (20.1) 18 (23.4)   2 9 7 (5.2) 2 (2.6)   ⩾3 18 9 (6.7) 9 (11.7) Tumor characteristics Calcifications   No 62 30 (22.4) 32 (42.1) 0.003a   Yes 148 104 (77.6) 44 (57.9)   Unknown 1 0 1 Tumor size   ⩽20 mm 145 103 (78.0) 42 (57.5) 0.002a   >20 mm 60 29 (22.0) 31 (42.5)   Unknown 6 2 4 Tumor focality   Unifocal 167 109 (81.3) 58 (75.3) 0.300a   Multifocal 44 25 (18.7) 19 (24.7) Differentiation grade   Low 46 28 (21.7) 18 (25.4) 0.839a   Intermediate 53 35 (27.1) 18 (25.4)   High 101 66 (51.2) 35 (49.2)   Unknown 11 5 6 P53   Positive 36 27 (20.7) 9 (12.2) 0.121a   Negative 168 103 (79.3) 65 (87.8)   Unknown 7 4 3 Immunophenotype   Luminal A 124 81 (61.8) 43 (58.9) 0.737a   Luminal B 26 16 (12.2) 10 (13.7)   Her2 37 25 (19.1) 12 (16.4)   Triple negative 17 9 (6.9) 8 (11.0)   Unknown 7 3 4 Percentages calculated over the total without unknown values. Statistically significant values are in bold (p < 0.05). a Chi-square test. b Fisher’s exact test. group (13.43%) and 10 (13%) in the non-screen-detected readmissions and an OR = 2.41 (95% CI = 1.95 - 4.86) for group (p = 0.927). complications. Figure 1 plots the adjusted odds ratio (OR) of the asso- ciation of mode of detection (non-screen-detected group) with recurrences, readmissions, and complications in Discussion women with DCIS. The risk of readmissions and overall While most of the discussion about BC screening pro- complications was higher within the non-screen-detected grams focus on recurrences and survival, our data suggest group compared to screen-detected, as evidenced by an that at the DCIS stage, other clinically relevant outcomes OR = 6.25 (95% confidence interval (CI) = 1.95–19.99) for are affected by participation in screening programs. In this Politi et al. 5 Table 2. Treatment characteristics according to screening status. Overall Detection mode p-value Screen-detected Non-screen-detected n (%) 211 134 77 Procedure Mastectomy 29 13 (9.7) 16 (20.8) 0.024a BCS 182 121 (90.3) 61 (79.2) Radiotherapy No 40 19 (14.4) 21 (28.8) 0.013a Yes 165 113 (85.6) 52 (71.2) Unknown 6 2 4 Hormone therapy No 101 59 (44.4) 42 (57.5) 0.070a Yes 105 74 (55.6) 31 (42.5) Unknown 5 1 4 Margin status Affected (<2 mm) 44 29 (28.2) 15 (25.4) 0.707a Free (⩾2 mm) 118 74 (71.8) 44 (74.6) Unknown 49 31 18 BCS: breast-conserving surgery. Percentages calculated over the total without unknown value. Mastectomy was considered as the definitive intervention. Statistically significant values are in bold (p < 0.05). a Chi-square test. Table 3. Differences in postoperative outcomes according to screening status. Overall Detection mode p-value Screen-detected Non-screen-detected n (%) 211 134 77 Readmissions No 179 (84.83) 124 (92.54) 55 (71.43) <0.0001a Yes 32 (15.17) 10 (7.46) 22 (28.57) Planned   Re-excision    Yes 10 (4.74) 5 (3.73) 5 (6.49) 0.502b   Mastectomy    Yes 11 (5.21) 2 (1.49) 9 (11.69) 0.002b   Reconstruction    Yes 5 (2.37) 1 (0.75) 4 (5.19) 0.061b Unplanned   Yes 6 (2.84) 2 (1.49) 4 (7.79) 0.119b Complications No 104 (49.29) 73 (54.48) 31 (40.26) Yes 107 (50.71) 61 (45.52) 46 (59.74) 0.047a Surgical complications   No 201 (95.26) 130 (97.01) 71 (92.21)   Yes 10 (4.74) 4 (2.99) 6 (7.79) 0.175b Pain   No 191 (90.52) 124 (92.54) 67 (87.01)   Yes 20 (9.48) 10 (7.46) 10 (12.99) 0.187a Fatigue/anxiety/depression   No 179 (84.83) 118 (88.06) 61 (79.22)   Yes 32 (15.17) 16 (11.94) 16 (20.78) 0.085a (continued) 6 Women’s Health Table 3. (Continued) Overall Detection mode p-value Screen-detected Non-screen-detected Systemic/clinical events   No 166 (78.67) 103 (76.87) 63 (81.82)   Yes 45 (21.13) 31 (23.13) 14 (18.18) 0.398a Recurrences No 183 (86.73) 116 (86.57) 67 (87.01) Yes 28 (13.27) 18 (13.43) 10 (12.99) 0.927a Statistically significant values are in bold (p < 0.05). a Chi-square test. b Fisher’s exact test. Figure 1. Adjusted OR for outcomes in women with non-screen-detected DCIS. BCS: breast-conserving surgery. Reference category is screen-detected breast DCIS. *Final adjusted model: age, tumor size, calcification on mammography, type of surgery, and hormone and radiotherapy. **Model adjusted by Charlson, type of surgery, age, and tumor size. ***Model adjusted by Charlson, type of surgery, hormone and radiotherapy, and age. study, we have shown that women with screen-detected group. In this sense, preoperative diagnosis may be dif- DCIS have a lower risk of readmissions and complications ficult in younger women due to greater breast density and following treatment; and to our knowledge, this is the first lower mammographic sensitivity leading to insufficient study to examine these outcomes for DCIS BC. resections.9 Alvarado et al.10 described that adverse histo- Given the early detection of screen-detected DCIS, logical features may favor the use of mastectomy among surgical treatment is less intense and lower complications this group; however, within our cohort, tumor character- and readmissions could be expected. However, after istics did not differ significantly among age groups. adjusting for potential confounders (age, comorbidities, Finally, we could not account for patient or surgeons’ treatment, and size), the association between readmission preferences regarding treatment choice. risk and detection mode was still present. Reconstruction Our observed reoperation rates are lower than what has or unplanned readmissions are expected following mas- been previously reported for DCIS.11,12 However, these tectomy or extensive surgeries. Mastectomy was signifi- rates are similar to what has been reported for invasive BC cantly higher in the non-screen-detected group, compared in Catalonia during a similar period.13 to re-excision rates in which differences were non-signif- Complications were present in almost 50% of our icant. One hypothesis that could explain a higher mastec- cohort after more than 8 years of follow-up. Notably, tomy use among the non-screen-detected group is that complications were significantly higher in the non- younger patients may be overrepresented among this screen-detected group and reached almost 60%. While Politi et al. 7 these numbers initially seemed high, this is the first study information to aid informed decisions, it also highlights to analyze complications for DCIS broadly, so we relied that a significant proportion of women experience pain and on studies analyzing similar complications separately in psychological distress. These areas could be improved BC survivors to support our findings. With regards to sur- with specific interventions. In terms of psychological dis- gical complications and persistent pain, a systematic tress, several studies have noted inaccurate risk percep- review performed by Verbelen et al.14 found that impair- tions among women with DCIS diagnosis, which affect ments with the highest prevalence after 2 years following their quality of life.21,22 In this sense, an appropriate transi- sentinel lymph node-negative biopsy were pain (range: tion of BC survivors to primary care could have an impact 5%–51%), numbness (range: 8%–51%), loss of strength on disease risk and perception. For these reasons, we (0%–35%), and decreased mobility (0%–38%). These believe that readmissions and complications are relevant values are notably higher than the prevalence we identi- factors to consider when counseling women regarding fied within our cohort for surgical and persistent pain screening participation, treatment decisions, or adjusting complications combined. In line with our findings, the care in women with DCIS. prevalence of persistent pain reported by Romero et al.5 This study has some limitations. First, the sample size was approximately 11% for BC survivors overall and is small. However, in-depth information was available for 9% for DCIS. Surprisingly, despite the favorable prog- each patient. Second, our study data were drawn from a nosis for DCIS, fatigue, anxiety, and depression had a single institution, limiting the generalizability of our prevalence of 15% within our cohort. These results are results. However, treatment patterns within our institution similar to those reported in the previous studies.15,16 are similar to those recently reported for Catalonia.23 Interestingly, Gregorowitsch et al.17 have noted that Regarding potential losses to follow-up, we used addi- severe depression is more common in DCIS than in tional data sources (HC3) to minimize their impact. early-stage invasive BC. Relevant changes in DCIS diagnosis and treatment (such We observed a lower risk of complications in the as mammogram equipment, margin free of disease width, screen-detected group. While we initially hypothesized biomarker testing, and treatment) have occurred over the that this could be mediated by treatment (lower mastec- study period (which includes cancers diagnosed between tomies within this group), the association between detec- 2000 and 2010). However, analysis including a time-var- tion method and complications persisted after adjusting iable did not significantly modify the results (data not for several covariates. Notably, only psychological com- shown). Despite our intention to compare women with plications (fatigue, anxiety, and depression) were bor- DCIS detected within the population-based screening derline significant as a specific complication category in program with those detected through mammograms not the non-screen-detected group. While our numbers are performed within the program, it is possible that oppor- small, we hypothesize that different disease perceptions tunistic screening may have attenuated our results. may occur in women according to detection mode. In Information regarding complications was extracted from this sense, it is known that exposure to unexpected a review of clinical charts and not by questionnaires. stressors can have adverse psychological effects.18 Only Consequently, these results may be underestimated. a handful of studies have examined the effect of detec- Nonetheless, we consider that these complications were tion mode on distress levels in women with BC. Gibbons significant enough to be documented in the medical et al.19 compared stress anxiety and depression levels in records by the attending physicians. Furthermore, to our women with BC according to detection mode. In their knowledge, this is the first study to analyze readmissions study, the prevalence of anxiety declined and neared and complications in DCIS patients. 10% after 12 months following diagnosis, however, this decreasing trend was notably less pronounced within the Conclusion screen-detected group, suggesting a slower adjustment process. These findings contrast with our results, in Our findings indicate that women with DCIS BC diag- which prevalence was higher among the non-screen- nosed through population-based BC screening program detected group, but could be explained by differences in experience a lower risk of readmissions and complications patient inclusion criteria (disease stage, length of fol- than those diagnosed outside these programs. These find- low-up, and the percentage of symptomatic women). ings can help aid women, and health professionals make However, another possibility is that these findings repre- informed decisions regarding the advantages of screening sent a self-selection bias, in which screening participants as well as to target specific interventions that improve adopt an overall healthier lifestyle or adherence to treat- women’s disease knowledge and understanding. ments and recommendations.20 Taken together, these findings highlight the need for Acknowledgements specific interventions that can improve women’s quality of The authors would like to acknowledge Mercè Comas and Javier life at the DCIS stage. While these findings can provide Louro for their contributions to this article. 8 Women’s Health Author contributions implications: results of a population-based cohort study. Breast Cancer Res 2017; 19: 26. J.P., M.S., and X.C. designed the study; J.P. wrote the article, and 5. Romero A, Torà-Rocamora I, Baré M, et al. Prevalence of M.S. and L.D. collaborated in drafting the article. J.P. performed persistent pain after breast cancer treatment by detection the statistical analyses and M.S., L.D., M.V.-T., and M.R. con- mode among participants in population-based screening tributed to the analyses and interpretation of results. J.P., L.D., programs. BMC Cancer 2016; 16: 735. and F.M. were involved in data acquisition. All authors revised 6. Perry N, Broeders M, de Wolf C, et al. European guidelines the article critically for important intellectual content. All authors for quality assurance in breast cancer screening and diagno- read and approved the final article. sis. Fourth edition—summary document. Ann Oncol 2008; 19(4): 614–622. Declaration of conflicting interests 7. Carey LA, Perou CM, Livasy CA, et al. Race, breast cancer The author(s) declared no potential conflicts of interest with subtypes, and survival in the Carolina Breast Cancer Study. respect to the research, authorship, and/or publication of this J Am Med Assoc 2006; 295: 2492–2502. article. 8. Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology-American Society for Radiation Oncology- Funding American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast The author(s) disclosed receipt of the following financial support irradiation in ductal carcinoma in situ. J Clin Oncol 2016; for the research, authorship, and/or publication of this article: This 34: 4040–4046. study was supported by grants from Instituto de Salud Carlos III 9. Wang J, Kollias J, Boult M, et al. Patterns of surgical treat- FEDER (Grant Nos. PI11/01296, PI15/00098, PI16/0024, and ment for women with breast cancer in relation to age. Breast PI19/00056) and by the Research Network on Health Services in J 2010; 16(1): 60–65. Chronic Diseases (REDISSEC: RD16/0001/0013). 10. Alvarado R, Lari SA, Roses RE, et al. Biology, treatment, and outcome in very young and older women with DCIS. Ethical approval Ann Surg Oncol 2012; 19(12): 3777–3784. All procedures reported in this study were performed in accord- 11. Jeevan R, Cromwell DA, Trivella M, et al. Reoperation ance with the ethical standards of the institutional research com- rates after breast conserving surgery for breast cancer mittee and with the 1964 Helsinki declaration and its later among women in England: retrospective study of hospital amendments or comparable ethical standards. This study was episode statistics. BMJ 2012; 345: e4505. approved by the ethics committee of Parc de Salut Mar (CEIC- 12. Kryh CG, Pietersen CA, Rahr HB, et al. 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