Ductal carcinoma in situ: treatment or active surveillance?

Abstract

Ductal carcinoma-in situ (DCIS) is a non-obligate precursor for invasive breast cancer and concern exists regarding the potential for overdiagnosis and overtreatment as the natural history of DCIS progression to invasive breast cancer may never occur or take decades in some cases. Preoperative systemic therapy window studies may provide powerful clues to best uncover which particular DCIS lesions respond to systemic therapies and allow for future selective personalized management recommendations. One of the main challenges for instituting active surveillance for DCIS with vacuum-assisted core needle biopsy alone and no surgery is concern for leaving untreated occult invasive carcinoma. Breast MRI lacks sufficient diagnostic ability to differentiate pure DCIS from invasive cancer with DCIS. Current novel randomized trials investigating active surveillance versus active management are described. Multigene expression assays may someday prove useful in stratifying patients at increased risk for progression to invasive breast cancer in the absence of surgery.

Keywords:

• atypical ductal hyperplasia
• breast cancer therapy
• breast pathology
• breast radiation
• breast surgery
• clinical trials
• DCIS
• ductal carcinoma in situ
• prognosis
• tamoxifen

Financial & competing interests disclosure

Supported by the NIH/NCI under award number P30CA016672 and used the clinical trials support resource and the biostatistics resource group. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Ductal carcinoma-in-situ (DCIS) is a non-obligate precursor for invasive breast cancer and an increasingly made diagnosis among populations of women undergoing screening mammography.

• Concern exists regarding potential overtreatment of patients with DCIS with respect to extensive surgery, use of radiotherapy and endocrine therapy as the natural history of DCIS progression to invasive breast cancer may not exist or in some cases could be decades.

• A diagnosis of atypical ductal hyperplasia is rendered when a core needle biopsy specimen reveals atypical epithelial cells quantitatively insufficient for a diagnosis of DCIS. Current guidelines suggest all lesions be excised; however some multidisciplinary groups are beginning to selectively allow for active surveillance of atypical ductal hyperplasia with or without endocrine therapy.

• Preoperative systemic therapy window studies may provide powerful clues to best uncover which particular DCIS lesions respond to systemic therapies so selective personalized management recommendations regarding which patients to safely offer active surveillance to, with or without the use of pharmacologic intervention.

• One of the main obstacles with just core needle biopsy alone for DCIS is concern for leaving occult invasive carcinoma within the breast and without adequate treatment, depending on the clinical characteristics; this may occur in 15–20% of cases. Current imaging modalities, including breast MRI, lack sufficient diagnostic ability to differentiate DCIS from invasive cancer with DCIS.

• Novel randomized trials investigating active surveillance versus active management for DCIS have begun or will begin shortly including the UK LORIS clinical trial and the EORTC/Dutch Breast Cancer Group LORD trial.

• Multigene expression assays have been tested in patients with DCIS who have had breast conserving surgery without radiotherapy and is another method for predicting the risk of local recurrence. These tests may someday prove useful in stratifying patients at increased risk for progression to invasive breast cancer in the absence of surgery.