Abstract P2-13-24: DCIS in low resource settings: The black swan of breast health care?
Authors: Mutebi Miriam , Cairncross Lydia , Panieri Eugenio , Simonds Hannah 
Published: May 2015

Abstract
In situ carcinomas of the breast may constitute between 25-30% of all screen detected tumors in countries that practice routine screening. Of the in situ tumors, at least 80% are ductal carcinomas in situ (DCIS). In the United States, DCIS accounts for at least 25% of all newly diagnosed breast cancers. Presentations may vary in non screened populations.
Aim: To determine the clinical presentation and surgical management of patients presenting with isolated ductal carcinoma in situ at a single tertiary centre in the Western Cape, South Africa over a 5 year period.
( Jan 2008-Dec 2012)
Secondary: To review the diagnostic techniques most commonly used.
Results:
42 patients with isolated DCIS were identified (41 females and 1 male) with an average age of 58 years. DCIS comprised less than 1% (42/3768) of all breast malignancies managed in this period. Most patients presented with a breast lump (23/42). 6 patients presented with nipple ulceration and 5 patients with a
nipple discharge. 8 patients had their lesions picked on mammography.
The diagnosis was made on core biopsy in 14 patients while 8 patients required excision of the palpable lump to make the diagnosis. 6 patients had a punch biopsy, 4 patients underwent a micro-ductectomy and 8 patients required a stereotactic biopsy. 2 patients had a diagnostic ROLL performed.
In terms of primary surgical management, 23 patients underwent a primary mastectomy, 6 patients had a WLE and 6 patients had a ROLL with therapeutic intent. 3 patients declined surgery and 1 was transferred to a different unit. 3 patients were poor surgical candidates and were placed on tamoxifen only. In terms of axillary management, 9 patients had a concurrent axillary clearance and 9 patients had a sentinel lymph node biopsy.
Of the 12 patients who had initial BCT (either ROLL or WLE), half required mastectomy for close or involved margins and 2 patients required re-excision of margins. 2 patients had an immediate reconstruction and 2 underwent a delayed reconstruction. All the axillary node clearances and sentinel lymph nodes were negative for metastatic disease.
Considerations: The spectrum of presentation of breast malignancies differs markedly in resource limited and unscreened populations. The commonest clinical presentation for DCIS was a breast lump and our incidence of isolated DCIS (1%) was much lower than that reported in international series.
A number of patients with failed core biopsies required excision biopsies for diagnosis. ROLLs and stereotactic biopsies were also used to make a diagnosis, but the skills and equipment for this are frequently lacking in most regional centers. The inappropriately high axillary clearance rate for our patients could be explained by diagnostic concerns over concurrent invasive disease and the previously limited availability of sentinel lymph node biopsy facilities.
Conclusion: Though rare, the management of DCIS in this set up serves to highlight the challenges of diagnosing and managing breast malignancies in LMICs. Practical interventions like increasing health worker training in core biopsy methods, and in the use of supportive aids like ultrasound, alongside increasing human capacity in cancer diagnostics, could help to improve the management scope of cancers in LMICs.
Citation Format: Miriam Mutebi, Lydia Cairncross, Eugenio Panieri, Hannah Simonds. DCIS in low resource settings: The black swan of breast health care? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-24.