Rinaa S. Punglia, MD, MPH

Rinaa S. Punglia, MD, MPH

Radiation Oncology

Contact Information

Office Phone Number

617-632-4739

Fax

617-394-2667

Appointments

617-632-4739

Researcher

Physician

Institute Physician
Associate Professor of Radiation Oncology, Harvard Medical School

Clinical Interests

Breast cancer, Health services and outcomes research

Diseases Treated

Board Certification

  • Radiation Oncology

Residency

  • Harvard Joint Center for Radiation Therapy, Radiation Oncology

Medical School

  • Harvard Medical School

Research

    Health services research, Radiation oncology, Breast oncology

    My research focuses on the comparative effectiveness of breast cancer treatments and is conducted at the Center for Outcomes and Policy Research at DFCI. Comparative effectiveness research (CER) includes the generation and synthesis of evidence to compare alternative methods of treatment.  CER is especially useful in bridging the gap between what we know from randomized trials and what we need to know to optimize treatment.  My work in CER includes decision analyses to define outcomes after omission of radiation therapy in post-menopausal women with early-stage breast cancer, to compare endocrine therapy sequencing strategies for hormone receptor- positive breast cancer, and to separate outcomes on tamoxifen by CYP2D6 genotype.  We have also used Medicare claims data to reveal that delay initiating radiation after breast-conserving surgery leads to increased local recurrence.

    My current focus of study has been the management of ductal carcinoma in situ (DCIS), one of the highest-priority topics for CER per the Institute of Medicine.  Despite a dramatic increase in the number of DCIS diagnoses, population-based analyses reveal vast discrepancies in its treatment.  We created a decision-analytic model to study the comparative effectiveness of lumpectomy alone versus lumpectomy and radiation for DCIS.  We found that radiation is associated with small improvements in survival outcomes, especially for younger women.  However, radiation paradoxically decreased the likelihood of lifetime breast preservation, since mastectomy is the standard surgical option for a recurrence or new diagnosis in a previously irradiated breast.  We recently completed multi-institutional contract from AHRQ to study the effectiveness of alternate treatment strategies for DCIS in a “real-world” setting, define treatment of recurrence, and translate information through construction of a web-based decision aid to improve and individualize decision-making. I have also recently received funding from PCORI to further characterize the impact of radiation therapy on DCIS outcomes.

    Publications

      • ASO Visual Abstract: Genomic Characterization of Aggressive Breast Cancer in Younger Women. Ann Surg Oncol. 2023 Nov; 30(12):7600-7601. View in: Pubmed

      • Genomic Characterization of Aggressive Breast Cancer in Younger Women. Ann Surg Oncol. 2023 Nov; 30(12):7569-7578. View in: Pubmed

      • Looking Back: International Practice Patterns in Breast Radiation Oncology From a Case-Based Survey Across 54 Countries During the First Surge of the COVID-19 Pandemic. JCO Glob Oncol. 2023 07; 9:e2300010. View in: Pubmed

      • Endocrine Therapy for Primary and Secondary Prevention After Diagnosis of High-Risk Breast Lesions or Preinvasive Breast Cancer. J Clin Oncol. 2023 06 10; 41(17):3092-3099. View in: Pubmed

      • Variation in Cardiac Dose Explains a "Fraction" of the Disparities Among Breast Cancer Patients. J Natl Cancer Inst. 2022 12 08; 114(12):1570-1571. View in: Pubmed

      • Regional Disparities in the Use and Delivery of Adjuvant Radiation Therapy after Lumpectomy for Breast Cancer in the Medicare Population. Adv Radiat Oncol. 2022 Nov-Dec; 7(6):101017. View in: Pubmed

      • Prediction Models and Decision Aids for Women with Ductal Carcinoma In Situ: A Systematic Literature Review. Cancers (Basel). 2022 Jul 02; 14(13). View in: Pubmed

      • Integration of Radiation and Reconstruction After Mastectomy. Semin Radiat Oncol. 2022 07; 32(3):237-244. View in: Pubmed

      • Breast cancer awareness among Afghan refugee women in Turkey. EClinicalMedicine. 2022 Jul; 49:101459. View in: Pubmed

      • Natural History and Characteristics of ERBB2-mutated Hormone Receptor-positive Metastatic Breast Cancer: A Multi-institutional Retrospective Case-control Study from AACR Project GENIE. Clin Cancer Res. 2022 05 13; 28(10):2118-2130. View in: Pubmed

      • Geospatial Disparities in the Treatment of Curable Breast Cancer Across the US. JAMA Oncol. 2022 Mar 01; 8(3):445-449. View in: Pubmed

      • Optimizing Decision Making for Ductal Carcinoma in Situ: Facts Over Fear. J Natl Cancer Inst. 2021 05 04; 113(5):511-512. View in: Pubmed

      • A Phase 1 Dose-Escalation Trial of Radiation Therapy and Concurrent Cisplatin for Stage II and III Triple-Negative Breast Cancer. Int J Radiat Oncol Biol Phys. 2021 09 01; 111(1):45-52. View in: Pubmed

      • Deep-learning system to improve the quality and efficiency of volumetric heart segmentation for breast cancer. NPJ Digit Med. 2021 Mar 05; 4(1):43. View in: Pubmed

      • Association between the 21-gene recurrence score and isolated locoregional recurrence in stage I-II, hormone receptor-positive breast cancer. Radiat Oncol. 2020 Aug 17; 15(1):198. View in: Pubmed

      • Author's Reply to Letters to the Editor by Ding and Li, and Sopik, Giannakeas, and Narod. J Natl Compr Canc Netw. 2020 05; 18(5):xliiib-xlivb. View in: Pubmed

      • Location as Destiny: Identifying Geospatial Disparities in Radiation Treatment Interruption by Neighborhood, Race, and Insurance. Int J Radiat Oncol Biol Phys. 2020 07 15; 107(4):815-826. View in: Pubmed

      • Neoadjuvant treatment strategies for HER2-positive breast cancer: cost-effectiveness and quality of life outcomes. Breast Cancer Res Treat. 2020 May; 181(1):43-51. View in: Pubmed

      • Commentary: Creating a patient-centered decision aid for ductal carcinoma in situ. Breast J. 2020 07; 26(7):1498-1499. View in: Pubmed

      • Cost Effectiveness of DCISionRT for Guiding Treatment of Ductal Carcinoma in Situ. JNCI Cancer Spectr. 2020 Apr; 4(2):pkaa004. View in: Pubmed

      • Mortality After Invasive Second Breast Cancers Following Prior Radiotherapy for DCIS. J Natl Compr Canc Netw. 2019 11 01; 17(11):1367-1371. View in: Pubmed

      • Patient-preferred outcomes measurement after post-mastectomy radiation therapy and immediate reconstruction. Breast J. 2020 02; 26(2):319-321. View in: Pubmed

      • Long-term outcomes of breast-conserving therapy for women with ductal carcinoma in situ. Breast Cancer Res Treat. 2019 Dec; 178(3):607-615. View in: Pubmed

      • Impact of Health-Related Quality of Life and Prediagnosis Risk of Major Depressive Disorder on Treatment Choice for Stage I Lung Cancer. JCO Clin Cancer Inform. 2019 09; 3:1-8. View in: Pubmed

      • Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction: Results of a Prospective Clinical Trial. Pract Radiat Oncol. 2019 Sep - Oct; 9(5):338-346. View in: Pubmed

      • Epidemiology, Biology, Treatment, and Prevention of Ductal Carcinoma In Situ (DCIS). JNCI Cancer Spectr. 2018 Nov; 2(4):pky063. View in: Pubmed

      • Cost Effectiveness of the Oncotype DX Genomic Prostate Score for Guiding Treatment Decisions in Patients With Early Stage Prostate Cancer. Urology. 2019 04; 126:89-95. View in: Pubmed

      • Impact of pre-diagnosis depressive symptoms and health-related quality of life on treatment choice for ductal carcinoma in situ and stage I breast cancer in older women. Breast Cancer Res Treat. 2019 Feb; 173(3):709-717. View in: Pubmed

      • Association Between Very Small Tumor Size and Decreased Overall Survival in Node-Positive Pancreatic Cancer. Ann Surg Oncol. 2018 Dec; 25(13):4027-4034. View in: Pubmed

      • Estrogen-receptor status and risk of contralateral breast cancer following DCIS. Breast Cancer Res Treat. 2018 Oct; 171(3):777-781. View in: Pubmed

      • Multidisciplinary Management of the Axilla in Patients with cT1-T2 N0 Breast Cancer Undergoing Primary Mastectomy: Results from a Prospective Single-Institution Series. Ann Surg Oncol. 2018 Nov; 25(12):3527-3534. View in: Pubmed

      • Cost-Effectiveness Analysis of Intensity Modulated Radiation Therapy Versus Proton Therapy for Oropharyngeal Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys. 2018 07 15; 101(4):875-882. View in: Pubmed

      • Treating Second Breast Events After Breast-Conserving Surgery for Ductal Carcinoma in Situ. J Natl Compr Canc Netw. 2018 04; 16(4):387-394. View in: Pubmed

      • Modeling Ductal Carcinoma In Situ (DCIS): An Overview of CISNET Model Approaches. Med Decis Making. 2018 04; 38(1_suppl):126S-139S. View in: Pubmed

      • Clinical risk score to predict likelihood of recurrence after ductal carcinoma in situ treated with breast-conserving surgery. Breast Cancer Res Treat. 2018 02; 167(3):751-759. View in: Pubmed

      • Brain Metastases in Newly Diagnosed Breast Cancer: A Population-Based Study. JAMA Oncol. 2017 Aug 01; 3(8):1069-1077. View in: Pubmed

      • Cost-Effectiveness of Surveillance for Distant Recurrence in Extremity Soft Tissue Sarcoma. Ann Surg Oncol. 2017 Oct; 24(11):3264-3270. View in: Pubmed

      • Breast cancer prevention strategies in lobular carcinoma in situ: A decision analysis. Cancer. 2017 Jul 15; 123(14):2609-2617. View in: Pubmed

      • The Impact of Reexcision and Residual Disease on Local Recurrence Following Breast-Conserving Therapy. Ann Surg Oncol. 2017 Jul; 24(7):1868-1873. View in: Pubmed

      • Nature of Medical Malpractice Claims Against Radiation Oncologists. Int J Radiat Oncol Biol Phys. 2017 05 01; 98(1):21-30. View in: Pubmed

      • Association of Regional Intensity of Ductal Carcinoma In Situ Treatment With Likelihood of Breast Preservation. JAMA Oncol. 2017 Jan 01; 3(1):101-104. View in: Pubmed

      • Breast-cancer subtype, age, and lymph node status as predictors of local recurrence following breast-conserving therapy. Breast Cancer Res Treat. 2017 01; 161(1):173-179. View in: Pubmed

      • Cost Effectiveness of the Oncotype DX DCIS Score for Guiding Treatment of Patients With Ductal Carcinoma In Situ. J Clin Oncol. 2016 11 20; 34(33):3963-3968. View in: Pubmed

      • Reply to comparative effectiveness of stereotactic radiosurgery versus whole-brain radiation therapy for patients with brain metastases from breast or non-small cell lung cancer. Cancer. 2016 10 15; 122(20):3244-3245. View in: Pubmed

      • Comparative effectiveness of stereotactic radiosurgery versus whole-brain radiation therapy for patients with brain metastases from breast or non-small cell lung cancer. Cancer. 2016 Jul 01; 122(13):2091-100. View in: Pubmed

      • The Role of Intraoperative Pathologic Assessment in the Surgical Management of Ductal Carcinoma In Situ. Ann Surg Oncol. 2016 09; 23(9):2788-94. View in: Pubmed

      • Characteristics of second breast events among women treated with breast-conserving surgery for DCIS in the community. Breast Cancer Res Treat. 2016 Feb; 155(3):541-9. View in: Pubmed

      • Factors associated with radiation therapy incompletion for patients with early-stage breast cancer. Breast Cancer Res Treat. 2016 Jan; 155(1):187-99. View in: Pubmed

      • onlineDeCISion.org: a web-based decision aid for DCIS treatment. Breast Cancer Res Treat. 2015 Nov; 154(1):181-90. View in: Pubmed

      • Prospective assessment of deep inspiration breath-hold using 3-dimensional surface tracking for irradiation of left-sided breast cancer. Pract Radiat Oncol. 2015 Nov-Dec; 5(6):358-65. View in: Pubmed

      • Biological Subtype Predicts Risk of Locoregional Recurrence After Mastectomy and Impact of Postmastectomy Radiation in a Large National Database. Int J Radiat Oncol Biol Phys. 2015 Nov 01; 93(3):622-30. View in: Pubmed

      • Effect of lymph node metastasis size on breast cancer-specific and overall survival in women with node-positive breast cancer. Breast Cancer Res Treat. 2015 Jul; 152(1):209-216. View in: Pubmed

      • Medical Malpractice Claims in Radiation Oncology: A Population-Based Study 1985-2012. Int J Radiat Oncol Biol Phys. 2015 Oct 01; 93(2):241-50. View in: Pubmed

      • Outcome following local-regional recurrence in women with early-stage breast cancer: impact of biologic subtype. Breast J. 2015 Mar-Apr; 21(2):161-7. View in: Pubmed

      • Management of older women with early-stage breast cancer. Am Soc Clin Oncol Educ Book. 2015; 48-55. View in: Pubmed

      • Management of the regional lymph nodes following breast-conservation therapy for early-stage breast cancer: an evolving paradigm. Int J Radiat Oncol Biol Phys. 2014 Nov 15; 90(4):772-7. View in: Pubmed

      • Dosimetric Inhomogeneity Predicts for Long-Term Breast Pain After Breast-Conserving Therapy. Int J Radiat Oncol Biol Phys. 2015 Dec 01; 93(5):1087-95. View in: Pubmed

      • Cost-effectiveness analysis of SBRT versus IMRT for low-risk prostate cancer. Am J Clin Oncol. 2014 Jun; 37(3):215-21. View in: Pubmed

      • Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ. Ann Surg Oncol. 2014 Nov; 21(12):3766-73. View in: Pubmed

      • Decision analysis and cost-effectiveness analysis for comparative effectiveness research--a primer. Semin Radiat Oncol. 2014 Jan; 24(1):14-24. View in: Pubmed

      • Treatment of ductal carcinoma in situ after excision: would a prophylactic paradigm be more appropriate? J Natl Cancer Inst. 2013 Oct 16; 105(20):1527-33. View in: Pubmed

      • Personalized medicine in breast cancer: tamoxifen, endoxifen, and CYP2D6 in clinical practice. Breast Cancer Res Treat. 2013 Oct; 141(3):421-7. View in: Pubmed

      • Margin status and the risk of local recurrence in patients with early-stage breast cancer treated with breast-conserving therapy. Breast Cancer Res Treat. 2013 Jul; 140(2):353-61. View in: Pubmed

      • Modeling the effectiveness of initial management strategies for ductal carcinoma in situ. J Natl Cancer Inst. 2013 Jun 05; 105(11):774-81. View in: Pubmed

      • Trade-offs associated with axillary lymph node dissection with breast irradiation versus breast irradiation alone in patients with a positive sentinel node in relation to the risk of non-sentinel node involvement: implications of ACOSOG Z0011. Breast Cancer Res Treat. 2013 Feb; 138(1):205-13. View in: Pubmed

      • American Society for Radiation Oncology's Performance Assessment for the Advancement of Radiation Oncology Treatment: A practical approach for informing practice improvement. Pract Radiat Oncol. 2013 Apr-Jun; 3(2):e37-43. View in: Pubmed

      • Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States. Int J Radiat Oncol Biol Phys. 2013 Feb 01; 85(2):e109-16. View in: Pubmed

      • Trade-offs associated with axillary lymph node dissection: Implications of the eligibility versus enrollment in ACOSOG Z0011. J Clin Oncol. 2012 Sep 20; 30(27_suppl):151. View in: Pubmed

      • Impact of margin status on local recurrence after mastectomy for ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2013 Mar 15; 85(4):948-52. View in: Pubmed

      • Pathologic characteristics of second breast cancers after breast conservation for ductal carcinoma in situ. Cancer. 2012 Dec 15; 118(24):6022-30. View in: Pubmed

      • Improved outcomes of breast-conserving therapy for patients with ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2012 Mar 15; 82(4):e581-6. View in: Pubmed

      • Accelerated partial breast irradiation using brachytherapy for breast cancer: patterns in utilization and guideline concordance. J Natl Cancer Inst. 2012 Jan 04; 104(1):29-41. View in: Pubmed

      • Accelerated partial breast irradiation using brachytherapy (APBIb) for breast cancer (bca): Predictors of use and guideline concordance. J Clin Oncol. 2011 Sep 20; 29(27_suppl):84. View in: Pubmed

      • Should a sentinel node biopsy be performed in patients with high-risk breast cancer? Int J Breast Cancer. 2011; 2011:973245. View in: Pubmed

      • Radiation therapy for ductal carcinoma in situ: a decision analysis. Cancer. 2012 Feb 01; 118(3):603-11. View in: Pubmed

      • Adjuvant therapy for elderly patients with resected gastric adenocarcinoma: population-based practices and treatment effectiveness. Cancer. 2012 Jan 01; 118(1):248-57. View in: Pubmed

      • Effect of very small tumor size on cancer-specific mortality in node-positive breast cancer. J Clin Oncol. 2011 Jul 01; 29(19):2619-27. View in: Pubmed

      • Accelerated partial-breast irradiation using brachytherapy (APBIb) for breast cancer (BCA): Predictors of use and guideline concordance. J Clin Oncol. 2011 May 20; 29(15_suppl):6080. View in: Pubmed

      • Pathologic characteristics of second breast cancers (SBC) among women previously treated for ductal carcinoma in situ (DCIS) with breast conservation. J Clin Oncol. 2011 May 20; 29(15_suppl):1042. View in: Pubmed

      • Adoption of intensity-modulated radiation therapy for breast cancer in the United States. J Natl Cancer Inst. 2011 May 18; 103(10):798-809. View in: Pubmed

      • Cost-effectiveness analysis of stereotactic body radiotherapy and radiofrequency ablation for medically inoperable, early-stage non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2011 Dec 01; 81(5):e767-74. View in: Pubmed

      • Using lifetime risk estimates to recommend magnetic resonance imaging screening for breast cancer survivors. J Clin Oncol. 2010 Sep 20; 28(27):4108-10. View in: Pubmed

      • Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis. BMJ. 2010 Mar 02; 340:c845. View in: Pubmed

      • Cost-effectiveness of CT and PET-CT for determining the need for adjuvant neck dissection in locally advanced head and neck cancer. Ann Oncol. 2010 May; 21(5):1072-7. View in: Pubmed

      • Cost effectiveness and screening interval of lipid screening in Hodgkin's lymphoma survivors. J Clin Oncol. 2009 Nov 10; 27(32):5383-9. View in: Pubmed

      • Partial-breast irradiation versus whole-breast irradiation for early-stage breast cancer: a cost-effectiveness analysis. Int J Radiat Oncol Biol Phys. 2009 Jun 01; 74(2):440-6. View in: Pubmed

      • Influence of year of diagnosis, patient age, and sociodemographic status on recommending adjuvant radiation treatment for stage I testicular seminoma. J Clin Oncol. 2008 Aug 20; 26(24):3937-42. View in: Pubmed

      • Factors associated with guideline-concordant use of radiotherapy after mastectomy in the national comprehensive cancer network. Int J Radiat Oncol Biol Phys. 2008 Dec 01; 72(5):1434-40. View in: Pubmed

      • Cost-effectiveness of partial breast irradiation versus whole breast irradiation for early-stage breast cancer. J Clin Oncol. 2008 May 20; 26(15_suppl):6530. View in: Pubmed

      • Predictors and effect of delay in initiation of radiation therapy (RT) after breast-conserving surgery (BCS) in elderly women. J Clin Oncol. 2008 May 20; 26(15_suppl):6515. View in: Pubmed

      • Pharmacogenomic variation of CYP2D6 and the choice of optimal adjuvant endocrine therapy for postmenopausal breast cancer: a modeling analysis. J Natl Cancer Inst. 2008 May 07; 100(9):642-8. View in: Pubmed

      • Prostate-specific antigen velocity and the detection of gleason score 7 to 10 prostate cancer. Cancer. 2007 Nov 01; 110(9):1973-8. View in: Pubmed

      • Partial breast irradiation versus whole breast radiotherapy for early-stage breast cancer: a decision analysis. Int J Radiat Oncol Biol Phys. 2008 Feb 01; 70(2):469-76. View in: Pubmed

      • Local therapy and survival in breast cancer. N Engl J Med. 2007 Jun 07; 356(23):2399-405. View in: Pubmed

      • Variability among breast radiation oncologists in delineation of the postsurgical lumpectomy cavity. Int J Radiat Oncol Biol Phys. 2007 Apr 01; 67(5):1299-308. View in: Pubmed

      • Cost-effectiveness analysis of computerized tomography in the routine follow-up of patients after primary treatment for Hodgkin's disease. J Clin Oncol. 2006 Sep 01; 24(25):4116-22. View in: Pubmed

      • Radiation therapy after mastectomy between 1991 and 1999 in elderly women: response to clinical trial information. J Clin Oncol. 2006 Jul 20; 24(21):3474-82. View in: Pubmed

      • Effect of distance to radiation treatment facility on use of radiation therapy after mastectomy in elderly women. Int J Radiat Oncol Biol Phys. 2006 Sep 01; 66(1):56-63. View in: Pubmed

      • Effect of distance to radiation treatment facility on use of radiation therapy after mastectomy in elderly women. J Clin Oncol. 2006 Jun 20; 24(18_suppl):6030. View in: Pubmed

      • The impact of tumor progesterone receptor status on optimal adjuvant endocrine therapy for postmenopausal patients with early-stage breast cancer: a decision analysis. Cancer. 2006 Jun 15; 106(12):2576-82. View in: Pubmed

      • Impact of age, benign prostatic hyperplasia, and cancer on prostate-specific antigen level. Cancer. 2006 Apr 01; 106(7):1507-13. View in: Pubmed

      • Operating characteristics of prostate-specific antigen and verification bias. JAMA. 2005 Dec 07; 294(21):2698; author reply 2698-9. View in: Pubmed

      • Optimizing adjuvant endocrine therapy in postmenopausal women with early-stage breast cancer: a decision analysis. J Clin Oncol. 2005 Aug 01; 23(22):5178-87. View in: Pubmed

      • Optimizing endocrine therapy in postmenopausal women with early stage breast cancer: A decision analysis for biological subsets of tumors. J Clin Oncol. 2005 Jun; 23(16_suppl):529. View in: Pubmed

      • Determination of mean population values of the prostate-specific antigen test after correcting for verification bias. J Clin Oncol. 2005 Jun; 23(16_suppl):6031. View in: Pubmed

      • . Choosing the best adjuvant endocrine treatment strategy for patients with postmenopausal breast cancer: A decision analysis. In: Perry MC, ed. American Society of Clinical Oncology Educational Book. 2005; 40-44. View in: Pubmed

      • Factors associated with appropriate use of radiation therapy after mastectomy in women with Stage I-II breast cancer treated within the National Comprehensive Cancer Network (NCCN). J Clin Oncol. 2004 Jul 15; 22(14_suppl):6032. View in: Pubmed

      • Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen. N Engl J Med. 2003 Jul 24; 349(4):335-42. View in: Pubmed

      • Radiation therapy plus tamoxifen versus tamoxifen alone after breast-conserving surgery in postmenopausal women with stage I breast cancer: a decision analysis. J Clin Oncol. 2003 Jun 15; 21(12):2260-7. View in: Pubmed

      • Integrating surgery and radiotherapy to reduce toxicity while maintaining local control for breast cancer: a fine balance. Ann Surg Oncol. 2002 Jul; 9(6):526-8. View in: Pubmed

      • Regulation of vascular endothelial growth factor expression by insulin-like growth factor I. Diabetes. 1997 Oct; 46(10):1619-26. View in: Pubmed

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