Are We Overtreating DCIS?
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Are We Over-Treating DCIS?
Deanna J. Attai MD FACSAssistant Clinical Professor of Surgery
David Geffen School of Medicine UCLA
24 June 2016
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No Disclosures
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What Is DCIS?
• Malignant cell appearance• Non-obligate precursor • Without surgery 15-50%
progress to invasive cancer• ~20% upgrade rate• 15% autopsies women 20-56
Wood JOP 2016 12;4;309-311Cowell Mol Oncol 2013 7;5:859-869
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Presentation / Incidence
• Typical presentation – mammographic calcifications
• Occasionally presents as palpable mass
• ~60,000 / year in US
2009 NIH Consensus Conferencehttps://consensus.nih.gov/2009/dcisstatement.htm
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Diagnosis Rare Before Mammography
Vernig et al 2009http://www.ncbi.nlm.nih.gov/books/NBK32570/
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Treatment Options• Surgery
• Mastectomy, Lumpectomy• SNB not routine unless mastectomy
• Radiation Therapy• Radiation reduced I-IBTR 19.4% ->8.5% (B17)• Other studies show I-IBTR 14-25% without RT
• Tamoxifen (B24)• Addition tamoxifen to L + RT reduced I-IBTR 32% vs. placebo• I-IBTR associated with increased risk of death HR 1.75• Recurrence of DCIS no increased risk of death
• Aromatase Inhibitors (B35, IBIS-II DCIS)
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Predictors of Recurrence
Euhus D Gen Surg Newshttp://www.generalsurgerynews.com/Web-Only/Article/04-16/Better-
Prognostic-Tools-Are-Needed-for-DCIS/36064/ses=ogst
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Treatment Effect / Risk of Invasive BC
Euhus D Gen Surg Newshttp://www.generalsurgerynews.com/Web-Only/Article/04-16/Better-
Prognostic-Tools-Are-Needed-for-DCIS/36064/ses=ogst
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DCIS / Metastatic Disease
• MDA 2011 0.14% of 2123 patients
• 34% no locoregional recurrence• Narod et al 500/100,000
metastatic without locoregional recurrence
Roses et al Ann Surg Oncol (2011) 10:10; 2873-2878
Narod et al JAMA Oncol2015:1(7);888-896
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Why the Confusion?• DCIS is not one disease• Hard to determine if over treating if we
don’t agree on endpoint• Overall survival• Breast cancer specific survival• Invasive vs. in-situ recurrence
• Breast cancer specific survival approaches 100% regardless of treatment choice
Moran M December 2015 ASCO Posthttp://www.ascopost.com/issues/december-25-2015/ductal-carcinoma-in-situ-and-relevant-
endpoints-for-omission-of-standard-treatments-are-we-there-yet/
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How To Decide• Treatment decisions require tradeoffs
• Current treatment may compromise options if recurrence develops
• What endpoint most important to patients – local recurrence, toxicity from treatment, survival, others
• Difficult (impossible?) to have evidence based shared decision making when natural history of individual patient’s disease unknown
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Van Nuys Prognostic Index
SilversteinAm J Surgery186;4:337-343
• 4,5,6: excision alone• Lack of consistent
external validation – limits clinical utility
Rudloff U, et alJ Clin Oncol
28;23;2762-3769
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Patient Prognostic Score
Sagara et al 2016J Clin Onco 34:1190-1196
• Predict local recurrence, magnitude of benefit of RT
• Survival improvements in RT group only seen w/high grade, younger age, larger tumor size.
• Magnitude of survival difference with RT correlated with score
“As an oncology community we must be cognizant of overtreatment for this disease process that has low breast cancer mortality”
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MSKCC Nomogram – Ipsilateral Recurrence
http://nomograms.mskcc.org/breast/DuctalCarcinomaInSituRecurrencePage.aspx
Rudloff U, et alJ Clin Oncol 28;23;2762-3769
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Oncotype Dx DCIS
• Predicts risk of local recurrence after lumpectomy• Validated in:
• Grade 1-2 DCIS, ≤2.5cm or grade 3 ≤1cm; ≥3mm margin• 97% ER+, 29% treated with tamoxifen
• Complement to traditional clinical / pathology features
Solin LJ et alJ Natl Cancer Inst2013 105:701-710
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Decision Aids• Majority of patients over-estimate
their risk of recurrence • Differing degrees of risk tolerance • Ideal: tailor treatment to individual
risk of recurrence• Decision aids increase knowledge,
reduce decisional conflict, decisions aligned with goals and values
Ozanne EM, et alBreast Cancer Res Treat
(2015) 154:181-190
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OnlineDeCISion.orgNot yet validated for clinical use
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OnlineDeCISion.orgNot yet validated for clinical use
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OnlineDeCISion.orgNot yet validated for clinical use
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Clinical Trials• Alliance NCT01439711
• Letrozole x 6 months• MRI at baseline, 3, 6 months• Surgical excision
• Alliance COMET• Standard vs. observational therapy +/- endocrine therapy
• UK LORIS• Low risk DCIS• Surgery vs. active surveillance (annual mammogram)
• EORTC LORD • Standard treatment vs. active surveillance
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The Future
• Imaging• Core biopsy• Biomarkers • Tailored / precision therapy• ?No therapy for some• ?Intraductal therapy
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Are We Over-Treating DCIS?• It depends…
• In some cases: yes• Discussion of risks, unknowns• Decision tools• Incorporate patient preferences• Support clinical trials
•Don’t forget lifestyle counseling
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