Post on 01-Jan-2016
LESLEY STREETADVISOR: DR. HADLEY
DCIS: The Treatment Debate
What is it and why it is important?
Ductal
Carcinoma
In Situ
1 in 8 women will be diagnosed with breast cancer
DCIS: on the rise
Medical Advances
Heightened Awareness
Better Mammogram Techniques
Risk Factors
AgeFamily historyPersonal historyNever given birthFirst pregnancy after 30BRCA-1 or BRCA-2HRT?
Factors Determining Treatment
Age
Tumor size
Tumor grade
Cell structure: comedo vs non-comedo
Treatment Options
Breast conserving vs breast removing
LumpectomyRadiation-internal or externalMastectomyTamoxifen
What is the controversy?
Main goals: 1) remove tumor entirely 2) eliminate the risk of recurrence
#1: Should all DCIS patients receive radiation with lumpectomy?
No DCIS lesions are not aggressive and can be excised No difference in survival for different treatments Increased mortality from lung cancer or CV disease If recurrence, it can decrease the likelihood radiation
can be used again Silverstein 2007
Should all DCIS patients receive radiation with lumpectomy?
YES Three different Phase III independent clinical trails-
all with the same results Significantly lowered risk of recurrence from 32% to
16% Half that did not receive radiation developed an
invasive malignancy Buchholz 2007
#2: Is there a low risk group that only requires lumpectomy?
Van Nuys Prognostic Index Tool to determine the risk of ipsilateral recurrence
after surgery alone Patients divided according to risk Results: Ipsilateral recurrence was equal among all
labeled risk groups: low, medium and high Not a useful tool! (But it is still being used…)
Attempts to Find a Low Risk Group
No prospective studies have been completed – every attempt has been stopped because of patient risk.
Only retrospective studies have been published
#3: Lack of Consensus on Risk Factors
Clear Margin width? smaller clear margin + radiation vs larger clear
margin and no radiation Results: smaller clear margin + radiation = lower
rates of recurrence West 2007
Genetic markers BRCA-1 and BRCA-2 p53: protein thought to be involved with neoplastic
formation
#4: Lack of Understanding of Disease
Many women do not understand their disease and how treatable it is
Main finding in study was better clinician education
Help prevent unnecessary worries and distress
Improve quality of lifePatients need to educate themselvesVan Gestel 2007
In case you were curious…
http://www.msnbc.msn.com/id/23392207/
References
American College of Radiology. Practice guideline for the management of ductal carcinoma in-situ of the breast (DCIS). J Am Coll Surg. 2007 Jul;205(1):145-161. Breastcancer.org, Ductal Carcinoma In Situ. Available at: http://www.breastcancer.org/symptoms/dcis/basics.jsp, Accessed on September 14, 2007. Buchholz TA, Haffty BG, Harris JR. Should all patients undergoing breast conserving therapy for DCIS receive radiation therapy? Yes. Radiation therapy, an important component
of breast conserving treatment for patients with ductal carcinoma in situ of the breast. J Surg Oncol. 2007 Jun 15; 95(8):610-3. College of American Pathologists. Breast Cancer: Ductal Carcinoma in Situ. Dec. 2006. Available at:
http://www.cap.org/apps/docs/reference/myBiopsy/BreastDuctalCarcinomaInSitu.pdf Accessed Nov. 11, 2007 Daly MB. Tamoxifen in Ductal Carcinoma In Situ. Semin Oncol. 2006 Dec;33(6):647-9. Hieken TJ, Cheregi J, Farolan M, Kim J, Velasco JM. Predicting relapse in ductal carcinoma in situ patients: an analysis of biologic markers with long-term follow-up. Am J Surg.
2007 Oct;194(4):504-6. Hwang ES, McLennan JL, Moore DH, Crawford BB, Esserman LJ, Ziegler JL. Ductal carcinoma in situ in BRCA mutation carriers. J Clin Oncol. 2007 Feb 20;25(6):642-7. Epub
2007 Jan 8. Macausland SG, Hepel JT, Chong FK, Galper SL, Gass JS, Ruthazer R, et al. An attempt to independently verify the utility of the Van Nuys Prognostic Index for ductal carcinoma
in situ. Cancer 2007 Oct 24. Mayo Clinic, Ductal Carcinoma In Situ. Available at: http://www.mayoclinic.com/health/dcis/DS00983, Accessed on September 14, 2007. Mokbel K, Cutuli B. Heterogeneity of ductal carcinoma in situ and its effects on management. Lancet Oncol. 2006 Sep;7(9):756-65. Patani N, Cutuli B, Mokbel K. Current management of DCIS: a review. Breast Cancer Res Treat. 2007 Sep 28. Silverstein MJ, Lagios MD. Should all patients undergoing breast conserving therapy for DCIS receive radiation therapy? No. One size does not fit all: an argument against the
routine use of radiation therapy for all patients with ductal carcinoma in situ of the breast who elect breast conservation. J Surg Oncol. 2007 Jun 15;95(8):605-9. van Gestel YR, Voogd AC, Vingerhoets AJ, Mols F, Nieuwenhuijzen GA, van Driel OJ et al. A comparison of quality of life, disease impact and risk perception in women with invasive
breast cancer and ductal carcinoma in situ. Eur J Cancer. 2007 Feb;43(3):549-56. Epub 2006 Nov 30. Viani GA, Stefano EJ, Afonso SL, De Fendi LI, Soares FV, Leon PG et al. Breast-conserving surgery with or without radiotherapy in women with ductal carcinoma in situ: a meta-
analysis of randomized trials. Radiat Oncol. 2007 Aug 2;2:28. West JG, Qureshi A, Liao SY, Sutherland ML, Chen JW, Chacon M, et al. Multidisciplinary management of ductal carcinoma in situ: a 10-year experience. Am J Surg. 2007
Oct;194(4):532-4.