Is radiotherapy necessary for intermediate risk ductal carcinoma in situ after breast conserving surgery?

Abstract

Identifying ductal carcinoma in situ (DCIS) patients at highest risk for recurrence after breast conserving surgery (BCS) remains a clinical concern. Subjecting all such patients to radiotherapy may be unnecessary. The Van Nuys Prognostic Index (VNPI) is a simple scoring system for predicting the risk of local recurrence in patients with DCIS. We reviewed patients with DCIS applying the VNPI score system. A total of 184 DCIS patients who underwent surgery at our institution between January 2003 and December 2011 were identified. Patients were not treated according to VNPI guidelines; rather, radiation therapy was applied at each surgeon’s discretion. All patients with hormonal receptor positive tumors were treated with hormonal therapy. Pathology reports were reviewed and VNPI scores of each DCIS calculated. Of the 184 patients, 52 (28.3%), 115 (62.5%) and 17 (9.2%) had low, intermediate and high VNPI scores, respectively. Six of the 184 patients (3.3%) developed ipsilateral local recurrence, five in the intermediate and one in the high VNPI score group. Of the five in the intermediate group, three (60%) were in patients with ER-negative tumors. VNPI score itself was not associated with recurrence (P = 0.145). Factors associated with recurrence included tumor size (hazard ratio [HR] 6.88), grade (HR 9.07) and hormone receptor status (HR 11.75). Radiotherapy did not significantly improve recurrence rates in patients with low and intermediate risk DCIS, especially in those with ER-positive tumors. Radiotherapy can be omitted in patients with ER-positive intermediate score DCIS and in patients with low score DCIS.

Ductal carcinoma in-situ arising within benign phyllodes tumours

“…47 Interestingly, a more recent study by Kim et al showed that patients with intermediate risk DCIS who did not undergo radiotherapy had no recurrence. 48 Fortunately, a 2015 analysis assessing 20-year mortality outcomes in patients with DCIS demonstrated no survival benefit to radiation, although it did reduce local recurrence risks significantly. 49 Radiation-related risks of thyroid, breast, brain, skin cancers, as well as leukaemia in children have been demonstrated in a linear dose-response relationship, with risks of cancer greatest for those exposed early in life, and these risks appear to persist throughout life.…”

Surgical management of ductal carcinoma in situ of the breast: A large retrospective study from a single institution

“…However, studies report women treated with BCS have up to 15% risk of recurrence within 10 years and half of these recurrences are invasive disease with subsequent mortality risk . RT following BCS decreases the risk of recurrence to less than 10% at 10 years although clear guidelines for its indications in specific risk groups continue to be debated . Over‐ or under‐treatment of DCIS remains a problem and numerous trials have been developed to assess more personalized therapy .…”

“…7,8 RT following BCS decreases the risk of recurrence to less than 10% at 10 years although clear guidelines for its indications in specific risk groups continue to be debated. [9][10][11][12][13] Over-or under-treatment of DCIS remains a problem and numerous trials have been developed to assess more personalized therapy. 14,15 Various factors affecting outcome of treated DCIS have been analyzed and different risk groups can be stratified accordingly, aiding treatment decisions.…”

Multidisciplinary Shared Decision Making in the Management of Ductal Carcinoma In Situ of the Breast

“…Similarly, randomized clinical trials have shown that adjuvant tamoxifen reduces the risk of all breast cancer events (ipsilateral plus contralateral) by approximately 30%, also with no clear survival advantage [ 7 ] [ 8 ] [ 5 ] [ 9 ]. Nonetheless, a substantial proportion of patients are treated with lumpectomy alone [ 10 ] [ 11 ].…”