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Risk for DCIS recurrence has declined over time
The risk for recurrence among women diagnosed with ductal carcinoma in situ has declined over the last 30 years, according to study results scheduled for presentation at the 2015 Breast Cancer Symposium.
Researchers attributed these declines to improved radiologic detection and pathologic assessment.
Kimberly J. Van Zee MD, FACS, surgical oncologist at Memorial Sloan Kettering Cancer Center, and colleagues sought to examine recurrence rates of ductal carcinoma in situ (DCIS) following breast-conserving surgery at a single institution over a span of 30 years.
The analysis included data from 2,996 patients who underwent breast-conserving surgery between 1978 and 2010. Of these patients, 363 (12%) experienced disease recurrence.
The median follow-up for patients without recurrence was 75 months (range, 0-30 years) with 732 patients followed for 10 years or more.
The 5-year recurrence rate for women treated between 1978 and 1998 was 13.6%, which was significantly greater than the 6.6%-recurrence rate that occurred between 1999 and 2010 (HR = 0.62; P < .0001).
When the researchers controlled for factors known to impact recurrence — such as age, family history, nuclear grade and necrosis — the significant reduction in recurrences among women treated in the last decade persisted (HR = 0.74; P = .02).
Researchers then stratified patients by radiation receipt and other factors. Results of this analysis showed the decrease in recurrence was limited to patients who had not undergone radiation therapy (HR = 0.62; P = .003), whereas no decline in recurrence occurred among patients who had received radiation (HR = 1.13).
Van Zee and colleagues thus concluded that the decline in recurrence could not be explained by improvements in the efficacy of radiation, but may be explained by improved radiologic detection and pathologic assessment.
“The lower recurrence risk observed for DCIS patients treated in more recent years is important for patient education, especially in view of the widely reported recent increase in use of mastectomy,” Van Zee and colleagues wrote.
These data demonstrate that great progress has been made in lowering the risk for breast cancer recurrence after treatment over the last 3 decades, Harold J. Burstein, MD, PhD, FASCO, senior physician at Dana-Farber Cancer Institute, associate professor of medicine at Harvard Medical School and an ASCO expert, said in a press release.
Harold J. Burstein
“This study demonstrates that multidisciplinary care, combined with advances in management and detection, is making a tangible difference for women with DCIS,” Burstein said. – by Anthony SanFilippo
Disclosure: One researcher reports honoraria from Genomic Health.
Perspective
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The older randomized trials evaluating local therapy for ductal carcinoma in situ (DCIS) illustrated that recurrence risks at 10 years were approximately 28% for patients managed with conservative surgery alone and 13% for patients managed with conservative surgery and radiation therapy.
The abstract, presentation and accompanying manuscript by Van Zee and colleagues demonstrate the remarkable progress that has been made in successfully treating DCIS. Specifically, risks of in-breast tumor recurrence were approximately one-third lower in women diagnosed in the current era, with the primary reduction noted in patients opting for conservative surgery alone.
There are likely multiple underlying factors contributing to this lower risk of in-breast tumor recurrence in the current era, including higher quality preoperative imaging and biopsy, greater attention to complete excision of all radiographically abnormal microcalcifications, more careful margin assessment and intent to achieve widely negative margins, and use of endocrine therapy in ER-positive DCIS.
Collectively, lower risks of in-breast tumor recurrence with lumpectomy alone have important implications for treatment decisions. First, as pointed out by Van Zee, outcomes of lumpectomy alone in appropriately selected patients are outstanding. These findings underscore that mastectomy — and particularly bilateral mastectomy — are likely to be overtreatment for many patients with low-risk DCIS, exposing patients to unnecessary harm with minimal potential for benefit.
Patients need to be educated regarding the outstanding outcomes with lumpectomy (with or without radiation) and encouraged toward this path. Second, as recurrence risks decline with lumpectomy alone, the incremental benefit of radiation is likely decreased.
It seems fairly clear at this juncture that low-risk DCIS confers a very low risk for in-breast tumor recurrence, on the order of 1% per year. This low risk may be sufficiently low to justify routine omission of radiation.
Third, lower risks of in-breast tumor recurrence should be remembered when the Oncotype DX DCIS test (Genomic Health) is ordered. Although this test is novel and interesting from a conceptual perspective, it is likely to overestimate risk of in-breast tumor recurrence with lumpectomy alone in the current era, as its data were derived from patients diagnosed and treated primarily in the 1990s.
In summary, the lower risks for in-breast tumor recurrence are great news for patients. Advances in breast imaging, surgery and pathology are directly benefiting countless patients every year. For those with low-risk DCIS, minimal treatment — often lumpectomy alone with widely negative margins — is sufficient to yield a low risk for future events. Radiation can still be considered in this setting as a part of shared decision making, but should not be considered mandatory.
EBCTCG, et al. J Natl Cancer Inst Monogr. 2010;doi:10.1093/jncimonographs/lgq039.