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.