The Nonsurgical Management of Ductal Carcinoma In Situ (DCIS)

  • Alastair M. ThompsonEmail author


National guidelines suggest excision of ductal carcinoma in situ (DCIS) followed by radiotherapy and endocrine therapy in selected patients, based on clinical trial evidence for invasive breast cancer and DCIS. The heterogeneous nature of DCIS is reflected in the natural history of some, but not all, progressing to invasive disease. Multiple trials of active surveillance versus surgical management are currently underway and will determine whether patients with low-risk DCIS, like those with selected prostate or thyroid cancer, may be managed without the potential morbidities and costs associated with surgical intervention. Alternative strategies harnessing immune responses, including vaccination, are underway. Quality of life and patient reported outcomes will also guide whether nonsurgical interventions may, in future, become standard of care for selected women with DCIS.


Ductal carcinoma in situ (DCIS) Radiotherapy Endocrine therapy Active surveillance 


  1. 1.
    Welch HG, Black W. Using autopsy series to estimate the disease “reservoir” for ductal carcinoma in situ of the breast: how much more breast cancer can we find? Ann Intern Med. 1997;127:1023–8. Scholar
  2. 2.
    Erbas B, Provenzano E, Armes J, Gertig D. The natural history of ductal carcinoma in situ of the breast: a review. Breast Cancer Res Treat. 2005;97:135–44. Scholar
  3. 3.
    Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. JNCI J Natl Cancer Inst. 2010;102:170–8. Scholar
  4. 4.
    Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet. 2012;380:1778–86. Scholar
  5. 5.
    Duffy SW, Dibden A, Michalopoulos D, Offman J, Parmar D, Jenkins J, et al. Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol. 2016;17:109–14. Scholar
  6. 6.
    Esserman LJ, Thompson IM Jr, Reid B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA. 2013;310(8):797–8.CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Partridge AH, Elmore JG, Saslow D, et al. Challenges in ductal carcinoma in situ risk communication and decision-making: report from an American Cancer Society and National Cancer Institute workshop. CA Cancer J Clin. 2012;62(3):203–10. Epub 2012 Apr 4.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Partridge A, Adloff K, Blood E, et al. Risk perceptions and psychosocial outcomes of women with ductal carcinoma in situ: longitudinal results from a cohort study. J Natl Cancer Inst. 2008;100(4):243–51. Epub 2008 Feb 12.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Kearins O, Pinder SE, Thomas J, Wallis MG, Thompson AM. Risk factors for the development of invasive cancer in unresected ductal carcinoma in situ. EJSO. 2018. Scholar
  10. 10.
    Fisher B, Dignam J, Wolmark N, Wickerham DL, Fisher ER, Mamounas E, et al. Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet. 1999;353:1993–2000.CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Cuzick J, Sestak I, Pinder SE, et al. 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. 2011;12(1):21–9. Epub 2010 Dec 7.CrossRefGoogle Scholar
  12. 12.
    National Comprehensive Cancer Network. Incorporated. Accessed 10 Feb 2018.
  13. 13.
    Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162–77. Scholar
  14. 14.
    Wapnir IL, Dignam JJ, Fisher B, et al. 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. 2011;103(6):478–88. Epub 2011 Mar 11.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Clements K, Dodwell D, Lawrence G, Ball G, Francis A, Pinder S, Sawyer E, Wallis M, Thompson AM, Sloane Project Steering Group. Radiotherapy after mastectomy for screen-detected ductal carcinoma in situ. Eur J Surg Oncol. 41(10):1406–10. 10/2015. e-Pub 8/2015. PMID: 26314790.Google Scholar
  16. 16.
    Romestaing P, Lehingue Y, Carrie C, et al. 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. 1997;15(3):963–8.CrossRefPubMedCentralGoogle Scholar
  17. 17.
    Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, White J, Harris JR. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73–9. Epub 2016 Sep 17.CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Kunkler IH, Williams LJ, Jack WJ, et al. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16(3):266–73. Epub 2015 Jan 28.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–7. Epub 2013 May 20.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Wallis MG, Clements K, Kearins O, Ball G, Macartney J, Lawrence GM. The effect of DCSI grade on rate, type and time to recurrence after 15 years of follow-up screen-detected DCIS. Br J Cancer. 2012;106:1611–7.CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Solin LJ, Gray R, Baehner FL, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 2013;105(10):701–10. Epub 2013 May 2.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Rakovitch E, Nofech-Mozes S, Hanna W, et al. A population-based validation study of the DCIS score predicting recurrence risk in individuals treated by breast-conserving surgery alone. Breast Cancer Res Treat. 2015;152(2):389–98. Epub 2015 Jun 29.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Warberg F, Garmo H, Emdin S, et al. Effect of radiotherapy after breast-conserving surgery for ductal carcinoma in situ: 20 years follow-up in the randomized SweDCIS trial. J Clin Oncol. 2014;32:3613–8.CrossRefGoogle Scholar
  24. 24.
    Warberg F, Garmo H, Folkvaljon Y, et al. A validation of DCIS biological risk profile in randomised study for radiation therapy with 20 year follow up (SweDCIS). In: San Antonio breast cancer symposium GS5-08, 2017 Dec 5–9; San Antonio, USA.Google Scholar
  25. 25.
    Fisher B, Land S, Mamounas E, et al. 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. 2001;28(4):400–18.CrossRefPubMedCentralGoogle Scholar
  26. 26.
    Margolese RG, Cecchini RS, Julian TB, et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial. Lancet. 2016;387(10021):849–56. Epub 2015 Dec 11.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Cuzick J, Sestak I, Forbes JF, et al. Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial. Lancet. 2014;383(9922):1041–8. Epub 2013 Dec 12.CrossRefGoogle Scholar
  28. 28.
    Hwang ES, Duong S, Bedrosian I, et al. Primary endocrine therapy for ER-positive ductal carcinoma in situ (DCIS) CALGB 40903 (Alliance). In: San Antonio breast cancer symposium GS5-05, 2017 Dec 5–9; San Antonio, USA.Google Scholar
  29. 29.
    Neoadjuvant Herceptin for Ductal Carcinoma In Situ of the Breast. Identifier:NCT00496808.
  30. 30.
    Neoadjuvant Trial of Lapatinib for the Treatment of Women With DCIS Breast Cancer. Identifier:NCT00555152.
  31. 31.
    Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1(7):888–96. Scholar
  32. 32.
    Sagara Y, Mallory MA, Wong S, Aydogan F, Desantis S, Barry WT, et al. Survival benefit of breast surgery for low-grade ductal carcinoma in situ. JAMA Surg. 2015;150:739. Scholar
  33. 33.
    Bruce J, Thornton AJ, Scott NW, et al. Chronic preoperative pain and psychological robustness predict acute postoperative pain outcomes after surgery for breast cancer. Br J Cancer. 2012;107(6):937–46. Epub 2012 Jul 31.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Bruce J, Thornton AJ, Powell R, et al. Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: a population-based cohort study. Pain. 2014;155(2):232–43. Epub 2013 Oct 4.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localised prostate cancer. N Engl J Med. 2016;375:1415–24.CrossRefPubMedCentralGoogle Scholar
  36. 36.
    Leapman MS, Cowan JE, Nguyen HG, et al. Active surveillance in younger men with prostate cancer. J Clin Oncol. 2017;35:1898–904.CrossRefPubMedCentralGoogle Scholar
  37. 37.
  38. 38.
    LORIS A phase III trial of surgery versus active monitoring for low risk ductal carcinoma in situ (DCIS). Accessed 10 Feb 2018.
  39. 39.
  40. 40.
    Kanbayashi C, Iwata H. Current approach ad future perspective for ductal carcinoma in situ of the breast. Jpn J Clin Oncol. 2017;47(8):671–7. Scholar
  41. 41.
    Brennan ME, Turner RM, Ciatto S, et al. Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology. 2011;260(1):119–28. Epub 2011 Apr 14.CrossRefGoogle Scholar
  42. 42.
    Nicholson S, Hanby A, Clements K, et al. Variations in the management of the axilla in screen-detected ductal carcinoma in situ: evidence from the UK NHS breast screening programme audit of screen detected DCIS. Eur J Surg Oncol. 2015;41(1):86–93. Epub 2014 Oct 16.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Doebar SC, de Monye C, Stoop H, et al. Ductal carcinoma in situ diagnosed by breast needle biopsy: predictors of invasion in the excision specimen. Breast. 2016;27:15–21. Epub 2016 Mar 20.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Park HS, Kim HY, Park S, et al. A nomogram for predicting underestimation of invasiveness in ductal carcinoma in situ diagnosed by preoperative needle biopsy. Breast. 2013;22(5):869–73. Epub 2013 Apr 17.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Lee SK, Yang JH, Woo SY, et al. Nomogram for predicting invasion in patients with a preoperative diagnosis of ductal carcinoma in situ of the breast. Br J Surg. 2013;100(13):1756–63. Scholar
  46. 46.
    Pilewskie M, Stempel M, Rosenfeld H, et al. Do LORIS trial eligibility criteria identify a ductal carcinoma in situ patient population at low risk of upgrade to invasive carcinoma? Ann Surg Oncol. 2016;23(11):3487–93. Epub 2016 May 12.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Grimm LJ, Ryser MD, Partridge AH, Thompson AM, Thomas JS, Wesseling J, Hwang ES. Surgical upstaging rates for vacuum assisted biopsy proven DCIS: implications for active surveillance trials. Ann Surg Oncol. 24(12):3534–40. 11/2017. e-Pub 8/2017. PMID: 28795370.Google Scholar
  48. 48.
    Bower JE, Ganz PA, Desmond KA, et al. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol. 2000;18(4):743–53.CrossRefPubMedCentralGoogle Scholar
  49. 49.
    Hawley ST, Janz NK, Griffith KA, et al. Recurrence risk perception and quality of life following treatment of breast cancer. Breast Cancer Res Treat. 2017;161(3):557–65. Epub 2016 Dec 21.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Montazeri A. Health-related quality of life in breast cancer patients: a bibliographic review of the literature from 1974 to 2007. J Exp Clin Cancer Res. 2008;27:32. Scholar
  51. 51.
    King MT, Winters ZE, Olivotto IA, et al. Patient-reported outcomes in ductal carcinoma in situ: a systematic review. Eur J Cancer. 2017;71:95–108. Epub 2016 Dec 15.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    A HER-2/neu pulsed DC1 vaccine for patients With DCIS. Identifier:NCT00107211.
  53. 53.
    A randomized trial of HER-2/neu pulsed DC1 vaccine for patients with DCIS. Identifier:NCT02061332.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Breast Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonUSA

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