DCIS: The Treatment Debate

1. DCIS: The Treatment Debate Lesley Street Advisor: Dr. Hadley

2. What is it and why it is important? • Ductal • Carcinoma • In Situ • 1 in 8 women will be diagnosed with breast cancer

3. DCIS: on the rise • Medical Advances • Heightened Awareness • Better Mammogram Techniques

4. Risk Factors • Age • Family history • Personal history • Never given birth • First pregnancy after 30 • BRCA-1 or BRCA-2 • HRT?

5. Factors Determining Treatment • Age • Tumor size • Tumor grade • Cell structure: comedo vs non-comedo

6. Treatment Options • Breast conserving vs breast removing • Lumpectomy • Radiation-internal or external • Mastectomy • Tamoxifen

7. What is the controversy? • Main goals: • 1) remove tumor entirely • 2) eliminate the risk of recurrence

8. #1: Should all DCIS patients receive radiation with lumpectomy? • No • DCIS lesions are not aggressive and can be excised • No difference in survival for different treatments • Increased mortality from lung cancer or CV disease • If recurrence, it can decrease the likelihood radiation can be used again • Silverstein 2007

9. Should all DCIS patients receive radiation with lumpectomy? • YES • Three different Phase III independent clinical trails- all with the same results • Significantly lowered risk of recurrence from 32% to 16% • Half that did not receive radiation developed an invasive malignancy • Buchholz 2007

10. #2: Is there a low risk group that only requires lumpectomy? • Van Nuys Prognostic Index • Tool to determine the risk of ipsilateral recurrence after surgery alone • Patients divided according to risk • Results: Ipsilateral recurrence was equal among all labeled risk groups: low, medium and high • Not a useful tool! (But it is still being used…)

11. Attempts to Find a Low Risk Group • No prospective studies have been completed – every attempt has been stopped because of patient risk. • Only retrospective studies have been published

12. #3: Lack of Consensus on Risk Factors • Clear Margin width? • smaller clear margin + radiation vs larger clear margin and no radiation • Results: smaller clear margin + radiation = lower rates of recurrence • West 2007 • Genetic markers • BRCA-1 and BRCA-2 • p53: protein thought to be involved with neoplastic formation

13. #4: Lack of Understanding of Disease • Many women do not understand their disease and how treatable it is • Main finding in study was better clinician education • Help prevent unnecessary worries and distress • Improve quality of life • Patients need to educate themselves • Van Gestel 2007

14. In case you were curious… • http://www.msnbc.msn.com/id/23392207/

15. References • American College of Radiology. Practice guideline for the management of ductal carcinoma in-situ of the breast (DCIS). J Am Coll Surg. 2007 Jul;205(1):145-161. • Breastcancer.org, Ductal Carcinoma In Situ. Available at: http://www.breastcancer.org/symptoms/dcis/basics.jsp, Accessed on September 14, 2007. • Buchholz TA, Haffty BG, Harris JR. Should all patients undergoing breast conserving therapy for DCIS receive radiation therapy? Yes. Radiation therapy, an important component of breast conserving treatment for patients with ductal carcinoma in situ of the breast. J Surg Oncol. 2007 Jun 15; 95(8):610-3. • College of American Pathologists. Breast Cancer: Ductal Carcinoma in Situ. Dec. 2006. Available at: http://www.cap.org/apps/docs/reference/myBiopsy/BreastDuctalCarcinomaInSitu.pdf Accessed Nov. 11, 2007 • Daly MB. Tamoxifen in Ductal Carcinoma In Situ. Semin Oncol. 2006 Dec;33(6):647-9. • Hieken TJ, Cheregi J, Farolan M, Kim J, Velasco JM. Predicting relapse in ductal carcinoma in situ patients: an analysis of biologic markers with long-term follow-up. Am J Surg. 2007 Oct;194(4):504-6. • Hwang ES, McLennan JL, Moore DH, Crawford BB, Esserman LJ, Ziegler JL. Ductal carcinoma in situ in BRCA mutation carriers. J Clin Oncol. 2007 Feb 20;25(6):642-7. Epub 2007 Jan 8. • Macausland SG, Hepel JT, Chong FK, Galper SL, Gass JS, Ruthazer R, et al. An attempt to independently verify the utility of the Van Nuys Prognostic Index for ductal carcinoma in situ. Cancer 2007 Oct 24. • Mayo Clinic, Ductal Carcinoma In Situ. Available at: http://www.mayoclinic.com/health/dcis/DS00983, Accessed on September 14, 2007. • Mokbel K, Cutuli B. Heterogeneity of ductal carcinoma in situ and its effects on management. Lancet Oncol. 2006 Sep;7(9):756-65. • Patani N, Cutuli B, Mokbel K. Current management of DCIS: a review. Breast Cancer Res Treat. 2007 Sep 28. • Silverstein MJ, Lagios MD. Should all patients undergoing breast conserving therapy for DCIS receive radiation therapy? No. One size does not fit all: an argument against the routine use of radiation therapy for all patients with ductal carcinoma in situ of the breast who elect breast conservation. J Surg Oncol. 2007 Jun 15;95(8):605-9. • van Gestel YR, Voogd AC, Vingerhoets AJ, Mols F, Nieuwenhuijzen GA, van Driel OJ et al. A comparison of quality of life, disease impact and risk perception in women with invasive breast cancer and ductal carcinoma in situ. Eur J Cancer. 2007 Feb;43(3):549-56. Epub 2006 Nov 30. • Viani GA, Stefano EJ, Afonso SL, De Fendi LI, Soares FV, Leon PG et al. Breast-conserving surgery with or without radiotherapy in women with ductal carcinoma in situ: a meta-analysis of randomized trials. Radiat Oncol. 2007 Aug 2;2:28. • West JG, Qureshi A, Liao SY, Sutherland ML, Chen JW, Chacon M, et al. Multidisciplinary management of ductal carcinoma in situ: a 10-year experience. Am J Surg. 2007 Oct;194(4):532-4.