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A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers



Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) might be diagnosed with invasive breast cancer at excision, a phenomenon known as underestimation. Patients with DCIS are treated based on the risk of underestimation or progression to invasive cancer. The aim of our study was to expand the knowledge on underestimation and to develop a prediction model.


Population-based data were retrieved from the Dutch Pathology Registry and the Netherlands Cancer Registry for DCIS between January 2011 and June 2012.


Of 2892 DCIS biopsies, 21% were underestimated invasive breast cancers. In multivariable analysis, risk factors were high-grade DCIS (odds ratio (OR) 1.43, 95% confidence interval (CI): 1.05–1.95), a palpable tumour (OR 2.22, 95% CI: 1.76–2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5 (OR 2.36, 95% CI: 1.80–3.09) and a suspected invasive component at biopsy (OR 3.84, 95% CI: 2.69–5.46). The predicted risk for underestimation ranged from 9.5 to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had unfavourable features.


The risk for an underestimated diagnosis of invasive breast cancer after a biopsy diagnosis of DCIS is considerable. With our prediction model, the individual risk of underestimation can be calculated based on routinely available preoperatively known risk factors (

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The authors thank the Netherlands Comprehensive Cancer Organization and the PALGA foundation for providing a registration database and for their efforts in making the research database for this study.

Author contributions

Study conception: C.J.C.M/P.J.W., study design: C.J.C.M./J.v.R./M.B.E.M.-P./P.J.W., data coding: C.J.C.M./P.J.W., data analyses: C.J.C.M./J.v.R., data interpretation: C.J.C.M./J.v.R./M.B.E.M.-P./B.A.M.t.B./L.d.M./S.S./P.J.W., drafting article: C.J.C.M., revision article: J.v.R./M.B.E.M.-P./B.A.M.t.B./L.d.M./S.S./P.J.W.

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Competing interests

The authors declare no competing interests.

Ethics approval

The study was approved by the scientific committee of PALGA (14.025 LZV1073) and the Privacy Review Board of IKNL (K14.021).

Data availability

The dataset generated for this current study are not publicly available due additional research questions to be answered, but is available from the corresponding author on reasonable request. The prediction model is available for external validation via Evidencio (model 1074).


This work was supported by the Dutch Cancer Foundation (KWF), grant SLP2015-7769.


This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).

Correspondence to Pieter J. Westenend.

Electronic supplementary material

  1. Supplementary info 1 - associations risk factors

  2. Supplementary info 2 - predicted risks

  3. Supplementary info 3 - calibration plot

  4. Supplementary info 4 - tumour characteristics

  5. Technical problem authors information

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