Research Article| Volume 49, ISSUE 3, P575-582, March 2023

Oncological outcomes after simple and skin-sparing mastectomy of ductal carcinoma in situ: A register-based cohort study of 576 Norwegian women

Published:November 30, 2022DOI:



      For Ductal Carcinoma in Situ (DCIS), recurrence is shown to be higher after skin-sparing (SSM) versus simple (SM) mastectomy. This study aimed to compare the two groups recurrence rates, disease-free survival (DFS), and overall (OS) survival.


      We conducted a retrospective register-based cohort study of women operated with SSM (n = 338) or SM (n = 238) for DCIS between 2007 and 2017. Data from the Norwegian Breast Cancer Registry was used to estimate recurrences rates, DFS and OS.


      Mean age was 51 and 61 years in the SSM and SM groups, respectively. Median follow-up time was 77 months for SSM (range: 21–152 months) vs 84 months for SM (range: 7–171 months). After five years of follow-up, the overall recurrence rate (OR) was 2.1%; 3.9% for SSM and 0.9% for SM. After ten years, the rates were 3.0%, 6.2% for SSM and still 0.9% for SM. DFS was after ten years 92.2%; 91.8% for SSM, and 92.4% for SM. OS was 95.0%; 97.5% for SSM and 93.3% for SM at ten years. For SSM, involved margins represented a significant risk for recurrence.


      The recurrence rate was higher in the SSM versus the SM group. Whether the difference is due to the operating procedures or underlying risk factors remains unknown. When stratifying for the difference in age, there was no statistical difference in DFS or OS. Involved margins in the SSM group were associated with an increased risk of recurrence.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Broders A.C.
        • Sr .,
        Carcinoma of the breast (including carcinoma in situ) and its grades of malignancy and prognosis.
        W Va Med J. 1953; 49: 311-316
        • Tabár L.
        • et al.
        A proposal to unify the classification of breast and prostate cancers based on the anatomic site of cancer origin and on long-term patient outcome.
        Breast Cancer Basic Clin Res. 2014; 8 (BCBCR.S13833)
        • Lynge E.
        • et al.
        Variation in detection of ductal carcinoma in situ during screening mammography: a survey within the International Cancer Screening Network.
        Eur J Cancer. 2014; 50: 185-192
        • Cancer Registry of Norway
        Annual report 2021 with results and improvements from the Norwegian breast cancer registry.
        Årsrapport 2021 med resultater og forbedringstiltak fra Nasjonalt kvalitetsregister for brystkreft. 2022; ([cited 2022; Available from:)
        • Norwegian Breast Cancer Group
        National guidelines for diagnosis, treatment and follow-up of breast cancer patients.
        Nasjonalt handlingsprogram for med retningslinjer for diagnostikk, behandling og oppfølging av brystkreft. 2021; ([cited 6/10/21 22/10/21]; Available from:)
        • Mannu G.S.
        • et al.
        Invasive breast cancer and breast cancer mortality after ductal carcinoma in situ in women attending for breast screening in England, 1988-2014: population based observational cohort study.
        BMJ. 2020; 369 (m1570-m1570)
        • Elshof L.E.
        • et al.
        Cause-specific mortality in a population-based cohort of 9799 women treated for ductal carcinoma in situ.
        Ann Surg. 2018; 267: 952-958
        • Goodwin A.
        • et al.
        Post-operative radiotherapy for ductal carcinoma in situ of the breast.
        Cochrane Database Syst Rev. 2013; : CD000563
        • Morrow M.
        • et al.
        Society of surgical oncology-American society for radiation oncology-American society of clinical oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ.
        Ann Surg Oncol. 2016; 23: 3801-3810
        • Childs S.K.
        • et al.
        Impact of margin status on local recurrence after mastectomy for ductal carcinoma in situ.
        Int J Radiat Oncol Biol Phys. 2013; 85: 948-952
        • Boyages J.
        • Delaney G.
        • Taylor R.
        Predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis.
        Cancer. 1999; 85: 616-628
        • Stuart K.E.
        • et al.
        Long-term outcomes of ductal carcinoma in situ of the breast: a systematic review, meta-analysis and meta-regression analysis.
        BMC Cancer. 2015; 15: 890
        • Campbel E.J.
        • Romics L.
        Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery, a review of the best level of evidence literature.
        Breast Cancer. 2017; 9: 521-530
        • Seth A.K.
        • Cordeiro P.G.
        Stability of long-term outcomes in implant-based breast reconstruction: an evaluation of 12-year surgeon- and patient-reported outcomes in 3489 nonirradiated and irradiated implants.
        Plast Reconstr Surg. 2020; 146: 474-484
        • Carlson G.W.
        • et al.
        Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy.
        J Am Coll Surg. 2007; 204: 1074-1078
        • FitzSullivan E.
        • et al.
        Incidence and consequence of close margins in patients with ductal carcinoma-in situ treated with mastectomy: is further therapy warranted?.
        Ann Surg Oncol. 2013; 20: 4103-4112
        • Timbrell S.
        • et al.
        Comparison of local recurrence after simple and skin-sparing mastectomy performed in patients with ductal carcinoma in situ.
        Ann Surg Oncol. 2017; 24: 1071-1076
        • Galimberti V.
        • et al.
        Oncological outcomes of nipple-sparing mastectomy: a single-center experience of 1989 patients.
        Ann Surg Oncol. 2018; 25: 3849-3857
        • Lhenaff M.
        • et al.
        A single-center study on total mastectomy versus skin-sparing mastectomy in case of pure ductal carcinoma in situ of the breast.
        Eur J Surg Oncol. 2019; 45: 950-955
        • Wu Z.-Y.
        • et al.
        Locoregional recurrence following nipple-sparing mastectomy with immediate breast reconstruction: patterns and prognostic significance.
        Eur J Surg Oncol. 2021; 47: 1309-1315
        • Larsen I.K.
        • et al.
        Data quality at the Cancer Registry of Norway: an overview of comparability, completeness, validity and timeliness.
        Euro J Cancer. 2009; 45: 1218-1231
        • Silverstein M.J.
        • et al.
        Prognostic classification of breast ductal carcinoma-in-situ.
        Lancet. 1995; 345: 1154-1157
        • Matsen C.B.
        • et al.
        Skin flap necrosis after mastectomy with reconstruction: a prospective study.
        Ann Surg Oncol. 2015; 23: 257-264
        • Tramm T.
        • et al.
        Superficial margins in skin sparing and nipple sparing mastectomies for DCIS: a margin of potential concern.
        Radiother Oncol. 2021; 161: 177-182
        • Papassotiropoulos B.
        • et al.
        Prospective evaluation of residual breast tissue after skin- or nipple-sparing mastectomy: results of the SKINI-trial.
        Ann Surg Oncol. 2019; 26: 1254-1262
        • Kaidar-Person O.
        • et al.
        Residual glandular breast tissue after mastectomy: a systematic review.
        Ann Surg Oncol. 2020; 27: 2288-2296
        • Torresan R.Z.
        • et al.
        Evaluation of residual glandular tissue after skin-sparing mastectomies.
        Ann Surg Oncol. 2005; 12: 1037-1044
        • Cao D.
        • et al.
        The superficial margin of the skin-sparing mastectomy for breast carcinoma: factors predicting involvement and efficacy of additional margin sampling.
        Ann Surg Oncol. 2008; 15: 1330-1340
        • Barton Jr., F.E.
        • et al.
        Glandular excision in total glandular mastectomy and modified radical mastectomy: a comparison.
        Plast Reconstr Surg. 1991; 88 (; discussion 393-4): 389-392
        • Tramm T.
        • Zuckerman K.
        • Tavassoli F.A.
        Skip lesion of DIN (DCIS) in the nipple in a case of breast cancer.
        Int J Surg Pathol. 2011; 19: 817-821
        • Bundred J.
        • et al.
        Do surgical margins matter after mastectomy? A systematic review and meta-analysis.
        Euro J Cancer. 2020; 138: S42
        • Chadha M.
        • et al.
        Is there a role for postmastectomy radiation therapy in ductal CarcinomaIn situ?.
        Int J Surg Oncol. 2012; 2012: 1-5
        • Chan L.W.
        • et al.
        Is radiation indicated in patients with ductal carcinoma in situ and close or positive mastectomy margins?.
        Int J Radiat Oncol Biol Phys. 2011; 80: 25-30
        • Klein J.
        • et al.
        Close or positive resection margins are not associated with an increased risk of chest wall recurrence in women with DCIS treated by mastectomy: a population-based analysis.
        SpringerPlus. 2015; 4
        • Carlson G.W.M.D.F.
        • et al.
        Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy.
        J Am Coll Surg. 2007; 204: 1074-1078
        • Visser L.L.
        • et al.
        Predictors of an invasive breast cancer recurrence after DCIS: a Systematic Review and Meta-analyses.
        Cancer Epidemiol Biomarkers Prev. 2019; 28: 835-845
        • Fisher B.
        • et al.
        Tamoxifen in treatment of intraductal breast cancer: national Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial.
        Lancet. 1999; 353: 1993-2000
        • Cuzick J.P.
        • et al.
        Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial.
        Lancet Oncol. 2011; 12: 21-29
        • Silver S.A.
        • Tavassoli F.A.
        Mammary ductal carcinoma in Situ with microinvasion.
        Cancer. 1998; 82: 2382-2390
        • Shaaban A.M.
        • et al.
        Pathological features of 11,337 patients with primary ductal carcinoma in situ (DCIS) and subsequent events: results from the UK Sloane Project.
        Br J Cancer. 2021; 124: 1009-1017