Journal of Radiation Oncology

, Volume 3, Issue 1, pp 21–28

Is excision alone adequate for low-risk DCIS of the breast treated with breast conserving therapy

Reevaluating the role of adjuvant radiation therapy
  • Chirag Shah
  • Thomas B. Julian
  • J. Ben Wilkinson
  • Simona F. Shaitelman
  • Atif Khan
  • Steven Finkelstein
  • Frank A. Vicini
Review
  • 337 Downloads

Abstract

Background

Ductal carcinoma in situ (DCIS) represents a quarter of newly diagnosed breast neoplasms, with the majority of cases detected on routine screening mammography in asymptomatic women. Currently, most women with newly diagnosed DCIS are eligible for breast conserving therapy (BCT); however, significant controversy exists regarding whether or not to add radiation treatment (RT) after surgical excision in low-risk patients.

Results

While four older prospective randomized clinical trials have shown that the addition of RT after lumpectomy reduces the risk of ipsilateral breast tumor recurrence (IBTR) by approximately 50 %, recent studies have continued to attempt to identify a subset of patients with favorable risk DCIS who are at a sufficiently low-risk of IBTR that omitting RT might be reasonable. While a number of smaller studies have shown promising results, recent prospective data have consistently affirmed the increased risk of IBTR with the omission of RT, with no subset of patients consistently identified that can be safely observed without RT. While radiation after lumpectomy remains the “standard of care,” even in these low-risk patients, future directions include improvements in genetic assays to better identify low-risk patients and new RT techniques and schedules that can potentially reduce the duration of therapy and toxicity while improving quality of life for patients.

Conclusion

Based on the data available, we continue to recommend radiation therapy for low-risk patients with DCIS as no discernible subset has been identified that does not benefit from radiation therapy.

Keywords

Ductal carcinoma in situ Radiation therapy Excision Breast conserving therapy 

References

  1. 1.
    DeSantis C, Siegel R, Bandi P et al (2011) Breast cancer statistics. CA Cancer J Clin 61:409–418PubMedCrossRefGoogle Scholar
  2. 2.
    Fisher B, Anderson S, Bryant J et al (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–1241PubMedCrossRefGoogle Scholar
  3. 3.
    Solin LJ, Fourquet A, Vicini FA et al (2005) Long term outcome after breast-conservation treatment with radiation for mammographically detected ductal carcinoma in situ of the breast. Cancer 103:1137–1146PubMedCrossRefGoogle Scholar
  4. 4.
    Wu X, Chen VW, Ruiz B et al (2003) Patterns of treatment for ductal carcinoma in situ of the breast in Louisiana, 1988–1999. J La State Med Soc 155:206–213PubMedGoogle Scholar
  5. 5.
    National Comprehensive Cancer Network. Guidelines: breast cancer. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast. Accessed August 30, 2012.
  6. 6.
    Punglia RS, Weeks JC, Neville BA et al (2008) Effect of distance to radiation treatment facility on use radiation therapy after mastectomy in elderly women. Int J Radiat Oncol Biol Phys 66:56–63CrossRefGoogle Scholar
  7. 7.
    Shroen AT, Brenin DR, Kelly MD et al (2005) Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer. J Clin Oncl 23:7074–7080CrossRefGoogle Scholar
  8. 8.
    Dean CT, Jubelirer SJ, Plants BA et al (2009) Use of radiation after breast conserving surgery (BCS) for DCIS and early invasive breast cancer at Charleston Area Medical Center (CAMC). A study of compliance with National Comprehensive Center Network (NCCN) guidelines. W V Med J 105:39Google Scholar
  9. 9.
    Fisher B, Land S, Mamounas E et al (2001) Prevention of invasive breast cancer in women with ductal carcinoma in situ: an update of the National Surgical Adjuvant Breast and Bowel Project experience. Semin Oncol 28:400–418PubMedCrossRefGoogle Scholar
  10. 10.
    Bijker N, Meijnen P, Peterse JL et al (2006) Breast-conserving treatment with or without radiotherapy in ductal carcinoma in-situ: ten-Year results of the European Organisation for Research and Treatment of Cancer Randomized Phase III Trial 10853 — a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 24:3381–3387PubMedCrossRefGoogle Scholar
  11. 11.
    Holmberg L, Garmo H, Granstrand B et al (2008) Absolute risk reduction for local recurrence after postoperative radiotherapy after sector resection for ductal carcinoma in situ of the breast. J Clin Oncol 26:1247–1252PubMedCrossRefGoogle Scholar
  12. 12.
    Cuzick J, Sestak I, Pinder SE et al (2011) Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 12:21–29PubMedCrossRefGoogle Scholar
  13. 13.
    Wapnir IL, Dignam JJ, Fisher B et al (2011) Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst 103:478–488PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Clarke M, Collins R, Darby S et al (2005) Effects of radiotherapy and differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366(9503):2087–2106PubMedCrossRefGoogle Scholar
  15. 15.
    Correa C, McGale P, Taylor C et al (2010) Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr 2010:162–177PubMedCrossRefGoogle Scholar
  16. 16.
    Julian TV, Land SR, Wang Y, et al. Is boost therapy necessary in the treatment of DCIS? American Society of Clinical Oncology: Breast Symposium. Abstract 146. San Francisco, California, September 7–8, 2007.Google Scholar
  17. 17.
    Rudloff U, Brogi E, Reiner AS et al (2010) The influence of margin width and volume of disease near margin on benefit of radiation therapy for women with DCIS treated with breast-conserving therapy. Ann Surg 251:583–591PubMedCrossRefGoogle Scholar
  18. 18.
    Dick AW, Sorbero MS, Ahrendt GM et al (2011) Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons. J Natl Cancer Inst 103:92–104PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Morrow M, Katz SJ (2012) Margins in ductal carcinoma in situ: is bigger really better? J Natl Cancer Inst 104:494–495PubMedCrossRefGoogle Scholar
  20. 20.
    Fisher B, Dignam J, Wolmark N et al (1999) Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet 353:1993–2000PubMedCrossRefGoogle Scholar
  21. 21.
    Hetelekidis S, Collins L, Silver B et al (1999) Predictors of local recurrence following excision alone for ductal carcinoma in situ. Cancer 85:427–431PubMedCrossRefGoogle Scholar
  22. 22.
    Silverstein MJ, Lagios MD, Groshen S et al (1999) The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 340:1455–1461PubMedCrossRefGoogle Scholar
  23. 23.
    Macdonald HR, Silverstein MJ, Lee LA et al (2006) Margin width as the sole determinant of local recurrence after breast conservation in patients with ductal carcinoma in situ of the breast. Am J Surg 192:420–422PubMedCrossRefGoogle Scholar
  24. 24.
    Rampaul R, Valasiadou P, Pinder S et al (2001) Wide local excision with 10 mm clearance without radiotherapy for DCIS. Eur J Surg Oncol 27:788CrossRefGoogle Scholar
  25. 25.
    van der Velden AP S, van Vugt R, Van Dijck JA et al (2007) Local recurrences after different treatment strategies for ductal carcinoma in situ of the breast: a population-based study in the East Netherlands. Int J Radiat Oncol Biol Phys 69:703–710CrossRefGoogle Scholar
  26. 26.
    Cutuli B, Cohen-Solal-le Nir C, de Lafontan B et al (2002) Breast-conserving therapy for ductal carcinoma in situ of the breast: the French Cancer Centers’ experience. Int J Radiat Oncol Biol Phys 53:868–879PubMedCrossRefGoogle Scholar
  27. 27.
    Hughes LL, Wang M, Page DL et al (2009) Local excision alone without irradiation for ductal carcinoma in situ of the breast: a trial of the Eastern Cooperative Oncology Group. J Clin Oncol 27:5319–5324PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Solin L, Gray R, Baehner FL, et al. A quantitative multigene RT-PCR assay for predicting recurrence risk after surgical excision alone without irradiation for ductal carcinoma in situ (DCIS): a prospective validation study of the DCIS score from ECOG E5194. 34th Annual San Antonio Breast Cancer Symposium. Abstract S4-6. San Antonio, Texas, December 6–10, 2011.Google Scholar
  29. 29.
    Wong JS, Kaelin CM, Troyan SL et al (2006) Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol 24:1031–1036PubMedCrossRefGoogle Scholar
  30. 30.
    McCormick B (2012) RTOG 9804: A prospective randomized trial for “good risk” ductal carcinoma in situ (DCIS), comparing radiation (RT) to observation (OBS). J Clin Oncol 30(s):1004Google Scholar
  31. 31.
    Hughes KS, Schnaper LA, Cirrincione C et al (2010) Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer. J Clin Oncol 28(s):507Google Scholar
  32. 32.
    Fyles AW, McCready DR, Manchul LA et al (2004) Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med 35:963–970CrossRefGoogle Scholar
  33. 33.
    Potter R, Gnant M, Kwasny W et al (2007) Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer. Int J Radiat Oncol Biol Phys 68:334–340PubMedCrossRefGoogle Scholar
  34. 34.
    Silverstein MJ, Lagios MD (2010) Choosing treatment for patients with ductal carcinoma in sit: fine tuning the University of Southern California/Van Nuys Prognostic Index. J Natl Cancer Inst Monogr 41:193–196CrossRefGoogle Scholar
  35. 35.
    Silverstein MJ (2003) An argument against routine use of radiotherapy for ductal carcinoma in situ. Oncology (Williston Park) 17:1511–1533Google Scholar
  36. 36.
    McAusland SG, Hepel JT, Chong FK et al (2007) An attempt to independently verify the utility of the Van Nuys Prognostic Index for ductal carcinoma in situ. Cancer 110:2648–2653CrossRefGoogle Scholar
  37. 37.
    Di Saverio S, Catena F, Santini D et al (2008) 259 patients with DCIS of the breast applying USC/Van Nuys prognostic index: a retrospective review with long term follow up. Breast Cancer Res Treat 109:405–416PubMedCrossRefGoogle Scholar
  38. 38.
    Rudloff U, Jacks LM, Goldberg JI et al (2010) Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol 28:3762–3769PubMedCrossRefGoogle Scholar
  39. 39.
    Yi M, Meric-Bernstam F, Kuerer HM et al (2012) Evaluation of a breast cancer nomogram for predicting risk of ipsilateral breast tumor recurrence in patients with ductal carcinoma in situ after local excision. J Clin Oncol 30:600–607PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Knauer M, Mook S, Rutgers JT et al (2010) The predictive value of the 70-gene signature for adjuvant chemotherapy in early breast cancer. Breast Cancer Res Treat 120:655–661PubMedCrossRefGoogle Scholar
  41. 41.
    Mook S, Schmidt MK, Weigelt B et al (2010) The 70-gene prognosis signature predicts early metastasis in breast cancer patients between 55 and 70 years of age. Ann Oncol 21:717–722PubMedCrossRefGoogle Scholar
  42. 42.
    Mamounas EP, Tang G, Fisher B et al (2010) Association between the 21-gene recurrence score assay and risk of locoregional recurrence in node-negative, estrogen receptor-positive breast cancer: results from the NSABP B-14 and NSABP B-20. J Clin Oncol 28:1677–1683PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Tang G, Cuzick J, Constantino JP et al (2011) Risk of recurrence and chemotherapy benefit for patients with node-negative, estrogen receptor-positive breast cancer: recurrence score alone and integrated with pathologic and clinical factors. J Clin Oncol 29:4365–4372PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Badve SS, Gray RJ, Baehner FL et al (2012) Correlation between the DCIS score and traditional clinicopathologic features in the prospectively designed E5194 clinical validation study. J Clin Oncol 30:1005CrossRefGoogle Scholar
  45. 45.
  46. 46.
    Whelan TJ, Pignol JP, Levine MN et al (2010) Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 362:513–520PubMedCrossRefGoogle Scholar
  47. 47.
    Williamson D, Dinniwell R, Fung S et al (2010) Local control with conventional and hypofractionated adjuvant radiotherapy after breast-conserving surgery for ductal carcinoma in-situ. Radiother Oncol 95:317–320PubMedCrossRefGoogle Scholar
  48. 48.
    Smith BD, Bentzen SM, Correa CR et al (2011) Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guidelines. Int J Radiat Oncol Biol Phys 81:59–68PubMedCrossRefGoogle Scholar
  49. 49.
    Polgar C, Fodor J, Major T et al (2007) Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast carcinoma — 5-year results of a randomized trial. Int J Radiat Oncol Biol Phys 69:694–702PubMedCrossRefGoogle Scholar
  50. 50.
    Vicini F, Shah C, Wilkinson JB, et al (2013) Should ductal carcinoma in situ be removed from the ASTRO cautionary group for off-protocol use of accelerated partial breast irradiation (APBI)? A pooled analysis of outcomes for 300 patients with DCIS treated with APBI. Ann Surg Oncol 20:1275–81Google Scholar
  51. 51.
    Goyal S, Vicini F, Beitsch PD et al (2011) Ductal carcinoma in situ treated with breast-conserving surgery with accelerated partial breast irradiation: comparison of the Mammosite registry trial with intergroup study E5194. Cancer 117:1149–1155PubMedCrossRefGoogle Scholar
  52. 52.
    Vaidya JS, et al. (2012) Targeted intraoperative radiotherapy for early breast cancer: TARGIT-A trial-updated analysis of local recurrence and first analysis of survival. SABCS; Abstract S4-2.Google Scholar
  53. 53.
    Orecchia R (2012) Eliot trials in Milan: results. Radiother Oncol 103:S4CrossRefGoogle Scholar
  54. 54.
    Bartelink H, Horiot JC, Poortmans PM et al (2007) Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881–10882 trial. J Clin Oncol 25:3259–3265PubMedCrossRefGoogle Scholar
  55. 55.
    Romestaing P, Lehinque Y, Carrie C et al (1997) Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon. France J Clin Oncol 15:963–968Google Scholar
  56. 56.
    Julian TB, Land SR, Wang Y, et al. Is boost therapy necessary in the treatment of DCIS? http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=52&abstractID=40258. Accessed December 11, 2012.
  57. 57.
    Wong P, Lambert C, Agnihotram RV et al (2012) Ductal carcinoma in situ — the influence of the radiotherapy boost on local control. Int J Radiat Oncol Biol Phys 82:e153–e158PubMedCrossRefGoogle Scholar
  58. 58.
    Omlin A, Amichetti M, Azria D et al (2006) Boost radiotherapy in young women with ductal carcinoma in situ: a multicentre, retrospective study of the Rare Cancer Network. Lancet Oncol 7:652–656PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Chirag Shah
    • 1
  • Thomas B. Julian
    • 2
  • J. Ben Wilkinson
    • 3
  • Simona F. Shaitelman
    • 4
  • Atif Khan
    • 5
  • Steven Finkelstein
    • 6
  • Frank A. Vicini
    • 7
  1. 1.Department of Radiation OncologyWashington University School of MedicineSaint LouisUSA
  2. 2.Department of Surgical OncologyDrexel University College/Allegheny General HospitalPittsburghUSA
  3. 3.Department of Radiation OncologyOakland University William Beaumont School of MedicineRoyal OakUSA
  4. 4.University of Texas M.D. Anderson Cancer CenterHoustonUSA
  5. 5.Department of Radiation Oncology, The Cancer Institute of New JerseyRobert Wood Johnson University HospitalNew BrunswickUSA
  6. 6.21st Century OncologyScottsdaleUSA
  7. 7.Michigan Healthcare Professionals/21st Century OncologyFarmington HillsUSA

Personalised recommendations