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Using Autopsy Series To Estimate the Disease “Reservoir” for Ductal Carcinoma in Situ of the Breast: How Much More Breast Cancer Can We Find?

H. Gilbert Welch, MD, MPH; and William C. Black, MD
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From the Department of Veterans Affairs Medical Center, White River Junction, Vermont; Dartmouth Medical School, Hanover, New Hampshire; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Acknowledgments: The authors thank Rick Haver, Chief of the Library Service, Department of Veterans Affairs Medical Center, White River Junction, Vermont, for performing the literature searches; Roger Goldstein for assistance in obtaining the articles; and Robert Pritchard, MD, Lisa Schwartz, MD, Wendy Wells, MD, and Steve Woloshin, MD, for thoughtful comments on the manuscript. Grant Support: Dr. Welch was supported by a Veterans Affairs Career Development Award in health services research and development. Requests for Reprints: H. Gilbert Welch, MD, MPH, VA Outcomes Group (111B), Department of Veterans Affairs Medical Center, White River Junction, VT 05009. Current Author Addresses: Dr. Welch: VA Outcomes Group (111B), Department of Veterans Affairs Medical Center, White River Junction, VT 05009.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;127(11):1023-1028. doi:10.7326/0003-4819-127-11-199712010-00014
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Purpose: To determine how many cases of breast cancer might be found if women not known to have the disease were thoroughly examined (the disease “reservoir”).

Data Sources: MEDLINE search from 1966 to the present.

Study Selection: Hospital-based and forensic autopsy series examining women not known to have had breast cancer during life.

Data Extraction: Observed prevalence of occult invasive breast cancer or ductal carcinoma in situ (DCIS) in which the number of women who were given a diagnosis was the numerator and the number of women examined was the denominator. For each autopsy series, we attempted to ascertain the level of scrutiny (sampling method, number of slides examined) given to the pathologic specimens.

Data Synthesis: Among seven autopsy series of women not known to have had breast cancer during life, the median prevalence of invasive breast cancer was 1.3% (range, 0% to 1.8%) and the median prevalence of DCIS was 8.9% (range, 0% to 14.7%). Prevalences were higher among women likely to have been screened (that is, women 40 to 70 years of age). The mean number of slides examined per breast ranged from 9 to 275; series that reported higher levels of scrutiny tended to discover more cases of cancer.

Conclusions: A substantial reservoir of DCIS is undetected during life. How hard pathologists look for the disease and, perhaps, their threshold for making the diagnosis are potentially important factors in determining how many cases of DCIS are diagnosed. The latter has important implications for what it means to have the disease.


Grahic Jump Location
Figure 1.
Results of Schnitt and colleagues' study ([29]) on interobserver agreement in the 10 cases in which at least one of six pathologists diagnosed ductal carcinoma in situ (DCIS).

Striped squares represent a DCIS diagnosis. The pathologists are ordered according to increasing propensity to diagnose DCIS. Agreement was much more common in the remaining cases (12 of 14), in which no pathologist diagnosed DCIS.

Grahic Jump Location




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