Treatment of ductal carcinoma in situ among patients cared for in large integrated health plans.

OBJECTIVE: To examine whether use of adjuvant therapy varies by race/ethnicity among patients with ductal carcinoma in situ (DCIS) at 3 integrated health plan delivery sites based in California and Massachusetts. STUDY DESIGN: Cross-sectional study nested within a cohort of women diagnosed as having DCIS between 1990 and 2001. METHODS: We reviewed medical records of 3000 non-Hispanic white (69%), black (10%), Hispanic (9%), and Asian or Pacific Islander (12%) women diagnosed as having DCIS between 1990 and 2001 and treated with breast-conserving therapy. chi(2) Test and multinomial logistic regression analysis were used to examine the association between race/ethnicity and use of adjuvant treatments after controlling for patient and clinical variables, including certain pathologic factors. RESULTS: We found no significant differences in DCIS adjuvant treatment among racial/ethnic groups in bivariate or multinomial analyses after adjusting for demographic characteristics, comorbidity, and clinical factors. Minority women were as likely to undergo adjuvant radiation therapy as non-Hispanic white women. However, women 70 years or older (odds ratio, 0.40; 95% confidence interval, 0.31-0.51) and women who lived in areas with low geocoded median family income (odds ratio, 0.65; 95% confidence interval, 0.48-0.89) were less likely to receive adjuvant radiation therapy. Tumor size and comedo histologic growth pattern were associated with increased likelihood of receiving radiation therapy. CONCLUSION: Use of adjuvant therapy by minority women in these managed care plans is similar to that by non-Hispanic white women, although use was less among older women and among women who lived in poorer neighborhoods.

[A case of ductal carcinoma of the prostate after transurethral resection of prostate].

A 66-year-old man visited our hospital complaining of a high prostate-specific antigen (PSA) (6.9 ng/ml) and dysuria. Prostatic needle biopsies revealed no malignancy in January 1998 and February 1999 (PSA 8.0 ng/ml). Transurethral resection of prostate (TURP) was performed in March 1999. Although none of the TURP specimen showed any malignancy, the PSA level remained high (3.7 ng/ml 1 year after the TURP), and gradually increased. About 3 years later, re-biopsy was done (PSA 13.2 ng/ml) and pathological finding was moderately differentiated adenocarcinoma (Gleason score 3 + 3 = 6). After 9-month MAB, radical prostatectomy (RP) was performed in January 2003 (PSA 4.2 ng/ml). Though the RP specimen showed moderately differentiated adenocarcinoma with negative capsule penetration and negative surgical margins, PSA decreased to 2.5 ng/ml and gradually increased. Computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy showed neither distant metastasis nor local recurrence. Review of the RP specimen revealed ductal carcinoma with positive capsular penetration and suspicion of positive surgical margins. Although the patient was treated with maximum androgen blockade, diethylstilbestrol diphosphate, and tegafururacil, PSA gradually increased and was kept at a high level (5-6 ng/ml). In December 2005, the patient complained of anal pain and MRI showed a 4.8 x 2.3 cm tumor in the prostatic bed. Needle biopsy of the tumor revealed ductal carcinoma (PSA 6.39 ng/ml). In January 2006 (PSA 11.9 ng/ml), we initiated a treatment with 66 Gy of intensity modulated radiation therapy. In November 2006, PSA decreased to 0.279 ng/ml, and the tumor reduced (3.8 x 1.0 cm) on MRI.

Neoadjuvant interstitial high-dose-rate (HDR) brachytherapy combined with systemic chemotherapy in patients with breast cancer.

BACKGROUND AND PURPOSE: This is the first study investigating neoadjuvant interstitial high-dose-rate (HDR) brachytherapy combined with chemotherapy in patients with breast cancer. The goal was to evaluate the type of surgical treatment, histopathologic response, side effects, local control, and survival. PATIENTS AND METHODS: 53 patients, who could not be treated with breast-conserving surgery due to initial tumor size (36/53) or due to an unfavorable breast-tumor ratio (17/53), were analyzed retrospectively. All but one were in an intermediate/high-risk group (St. Gallen criteria). The patients received a neoadjuvant protocol consisting of systemic chemotherapy combined with fractionated HDR brachytherapy (2 x 5 Gy/day, total dose 30 Gy). In cases, where breast-conserving surgery was performed, patients received additional external-beam radiotherapy (EBRT, 1.8 Gy/day, total dose 50.4 Gy). In patients, who underwent mastectomy but showed an initial tumor size of T3/T4 and/or more than three infiltrated lymph nodes, EBRT was also performed. RESULTS: In 30/53 patients (56.6%) breast-conserving surgery could be performed. The overall histopathologic response rate was 96.2% with a complete remission in 28.3% of patients. 49/53 patients were evaluable for follow-up. After a median of 58 months (45-72 months), one patient showed a mild fibrosis of the breast tissue, three patients had mild to moderate lymphatic edema of the arm. 6/49 (12.2%) patients died of distant metastases, 4/49 (8.2%) were alive with disease, and 39/49 (79.6%) were free from disease. Local recurrence was observed in only one case (2%) 40 months after primary therapy. After mastectomy, this patient is currently free from disease. CONCLUSION: The combination of interstitial HDR brachytherapy and chemotherapy is a well-tolerated and effective neoadjuvant treatment in patients with breast cancer. Compared to EBRT, treatment time is short. Postoperative EBRT of the whole breast -- if necessary -- is still possible after neoadjuvant brachytherapy. Even though the number of patients does not permit definite conclusions, the results are promising regarding survival and the very low rate of local recurrences.