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Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery PowerPoint Presentation
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Dilemma in management of DCIS. Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery University of Pennsylvania. The Dilemma of DCIS. 96-98% of women with DCIS are cured with local therapy, yet …

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Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery


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slide1

Dilemma in management of DCIS

Julia Tchou, M.D., Ph.D.

Abramson Cancer Center

Rena Rowan Breast Center

Department of Surgery

University of Pennsylvania

the dilemma of dcis
The Dilemma of DCIS

96-98% of women with DCIS are cured with local therapy, yet …

Local recurrence rate after BCT of DCIS is ~ 2 fold higher than Invasive cancer.

slide3

Standard Treatment in DCIS

•Mastectomy

•Excision + RT

•Excision

+ Tamoxifen

Which Rx for which patient?

key questions in management of dcis
Key questions in management of DCIS
  • Can we identify a subset of patient not benefiting from radiation therapy?
  • What is an adequate margin?
survival in dcis by treatment
Survival in DCIS by Treatment

L

L+RT

B17

L+RT+TAM

EORTC

M

B17; EORTC

% Deaths Breast Ca

B24

B24

Years

effects of xrt on survival
Effects of XRT on survival

EBCTCG meta-analsyis, Lancet 2005

key management concepts in dcis
Key Management Concepts in DCIS
  • Prevention of local recurrence (invasive and noninvasive) is a major goal of the treatment of DCIS

The use of RT reduces LR in DCIS

local recurrence risk stratification
Local recurrence risk stratification
  • ECOG – < 2.5 cm Grade I & II DCIS
  • EORTC – no subgroup does not benefit from radiation
  • VNPI - Silverstein

Bijker, N. JCO 2006;24:3381

van nuys prognostic index
Van Nuys Prognostic Index

Silverstein, M 2003

slide13

Outcome in DCIS Patients withLow VNPI

Low VNPI (3 or 4)

Silverstein de Mascarel

# patients 101 195

Local recurrence 2% 9%

Invasive 0 50%

Br Ca Res Treat 2000

is there a dcis subgroup that does not benefit from xrt
Is there a DCIS subgroup that does not benefit from XRT?
  • Age
  • Margins (uniform and meticulous assessment not done in randomized trials)
  • VNPI score 4, 5 or 6
  • Low grade DCIS
  • Biomarkers for risk stratification
  • Utility of MRI in preoperative assessment (JNCI consensus statement, 2009)

Morrow M 2008