Radiotherapy for Ductal Carcinoma In Situ After Breast-Conserving Surgery

Summary and Comment |
October 20, 2014

Radiotherapy for Ductal Carcinoma In Situ After Breast-Conserving Surgery

  1. Henry Mark Kuerer, MD, PhD, FACS

At 20-year follow-up, radiotherapy reduced absolute risk for local recurrence but did not improve survival; concerns about overtreatment remain.

  1. Henry Mark Kuerer, MD, PhD, FACS

The original SweDCIS trial of whole-breast radiotherapy versus observation after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) involved 1046 patients treated from 1987 to 1999 (Acta Oncol 2006; 45:536). In a prior update of that trial (J Clin Oncol 2008; 26:1247), the authors reported that, at 10 years, the use of radiotherapy reduced the absolute risk for local recurrence by 16% compared with observation (95% confidence interval, 10.3–21.6) but did not improve distant metastasis-free survival.

In a new update, the authors report that, at 20 years, the use of radiotherapy reduced the absolute risk for local recurrence by 12% (10% for in situ disease and 2% for invasive breast cancer; 95% confidence interval, 6.5–17.7) and did not improve breast cancer–specific survival and overall survival.

Comment

Principal controversies surrounding the diagnosis and management of DCIS include concerns that patients, especially older ones, may be overtreated, either with mastectomy or radiotherapy after BCS for small low- and intermediate-grade lesions. Radiotherapy is highly effective for preventing DCIS recurrences after BCS, but it does not affect survival. Moreover, the absolute risk for DCIS recurrence of smaller lesions without radiotherapy, particularly among postmenopausal women, appears to be lower in more recent studies that incorporate advances in mammography and techniques to ensure negative margins of resection (Int J Radiat Oncol Biol Phys 2012 Nov; 84:S5 and Ann Surg Oncol 2012 Nov; 19:3777). The next wave of DCIS trials in Europe has begun to address the safety of observing core biopsy-proven DCIS without surgical excision, radiotherapy, or endocrine therapy. For example, the UK Low Risk DCIS trial (LORIS) is randomizing patients with low- and intermediate-grade DCIS of any size to active monitoring (biopsy alone without surgical intervention) or standard therapy.

Editor Disclosures at Time of Publication

  • Disclosures for Henry Mark Kuerer, MD, PhD, FACS at time of publication Speaker's bureau Physicians’ Education Resource, LLC Grant / Research support Susan G. Komen Breast Cancer Foundation Editorial boards Annals of Surgical Oncology Leadership positions in professional societies Alliance for Clinical Trials in Oncology (Chair, Education Committee); Society of Surgical Oncology (Chair, Curriculum Ad Hoc Committee, Breast Program Directors

Citation(s):

Reader Comments (1)

Victor Kantariya Physician, Family Medicine/General Practice

Among older patients with small DCIS and severe comorbidities RT with cardiopulmonary toxicity can increase mortality from other causes. Multidisciplinary treatment for such patients must be strictly individualized. Getting Second Opinion is Essential. Dr. V KANTARIYA MD

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