For Most with DCIS, Less Is More

August 25, 2015

For Most with DCIS, Less Is More

  1. William J. Gradishar, MD

Aggressive treatment with surgery and radiotherapy for ductal carcinoma in situ did not reduce breast cancer mortality at 10 years.

  1. William J. Gradishar, MD

For women diagnosed with ductal carcinoma in situ (DCIS), the likelihood of dying from breast cancer is very low but is increased substantially if invasive disease develops. To determine what factors predict breast cancer mortality in DCIS patients and whether aggressive treatment to prevent invasive recurrence reduces disease mortality, investigators conducted an observational study of more than 180,000 women (median age, 53.8) in the Surveillance, Epidemiology, and End Results database who were newly diagnosed with DCIS between 1988 and 2011.

At mean follow-up of 7.5 years, breast cancer–specific mortality at 20 years was 3.3% overall; however, for those who developed subsequent ipsilateral, invasive breast cancer, the risk for dying was 18 times higher than for women without recurrence. The use of surgical excision and radiation therapy versus surgical excision alone was associated with a reduction in the development of invasive breast cancer at 10 years (2.5% vs. 4.9%; P<0.001) but not with a reduction in breast cancer–specific mortality. Subsets of DCIS patients were identified who do require greater intervention, as breast cancer mortality is increased in very young women (<35 years at diagnosis); black patients; and those with high-grade lesions, comedo necrosis features, and larger DCIS lesions.

Comment

This analysis is limited by a lack of information on all details of pathology, including margin status, and tamoxifen use. Nevertheless, these observations identify a need to re-evaluate our largely one-size-fits-all approach to managing DCIS. Many individuals who have microcalcifications could avoid extensive imaging and even biopsy, particularly if the calcifications are amorphous and in elderly patients. Even among women diagnosed with DCIS, those with more favorable histologies may be able to avoid radiation therapy, as it is unlikely to affect outcome. However, the focus on more rather than less therapy, including prevention strategies, should remain for patients with unfavorable characteristics.

Editor Disclosures at Time of Publication

  • Disclosures for William J. Gradishar, MD at time of publication Consultant / Advisory board Biologics, Inc. Editorial boards Clinical Breast Cancer; Journal of Clinical Oncology; Oncology Leadership positions in professional societies National Comprehensive Cancer Network (Chair, Breast Cancer Panel)

Citation(s):

Reader Comments (1)

WILLIAM RUTENBERG Physician, Other, Private practice

Per recent journal watch if 50% of pathological diagnoses are wrong, this study is invalid and needs to incorporate this data. Evidence base Do!

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