2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

DCIS AND INFLUENCE OF RISK FACTORS
in the presence or absence of adverse prognostic factors. This
lack of differential effect can be seen for the most important
prognostic factors, including tumor grade and size and
comedo necrosis. 18 The key issue then becomes whether the
absolute benefit of RT for low-risk women is small enough to
justify use of BCS alone.
Although outcomes between mastectomy and BCS or BCS
plus RT were not studied in a randomized fashion, several
observational studies reported that women undergoing mastectomy
were less likely than women undergoing BCS or
BCS plus RT to experience local DCIS or invasive recurrence.
26,27 We found no study showing a mortality reduction
associated with mastectomy over BCS with or without
radiation.
The literature is still evolving regarding the use of accelerated
partial-breast irradiation (APBI) delivered via MammoSite
or balloon-based brachytherapy 28-30 and whether
it is associated with similar levels of control as whole-breast
irradiation.
The NSABP-24 assessed the value of tamoxifen following
DCIS diagnosis and found tamoxifen was associated with
statistically significant reductions in local recurrence (RR �
0.60) and contralateral disease (RR � 0.56). However, the
absolute risk reduction in ipsilateral and contralateral disease
was small. Ongoing studies such as the NSABP-37 are
examining the comparative effectiveness of tamoxifen and
aromatase inhibitors, and the NSABP B-43 is examining use
of trastuzumab for women with HER2-positive tumors.
Discussion
It is clear that many cases of DCIS either would not
develop into invasive disease or would do so much later in
life, perhaps never becoming clinically relevant. This issue
of overdiagnosed DCIS because of screening is not limited to
Authors’ Disclosures of Potential Conflicts of Interest
Author
Beth A. Virnig*
Shi-Yi Wang*
Todd M. Tuttle*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Brinton LA, Sherman ME, Carreon JD, Anderson WF. Recent trends in
breast cancer among younger women in the United States. J Natl Cancer Inst.
2008;100:1643-1648.
2. Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ
of the breast: A systematic review of incidence, treatment, and outcomes.
J Natl Cancer Inst. 2008;102:170-178.
3. Chlebowski RT, Hendrix SL, Langer RD, et al. Influence of estrogen plus
progestin on breast cancer and mammography in healthy postmenopausal
women: The Women’s Health Initiative Randomized Trial. JAMA. 2003;289:
3243-3253.
4. Collaborative Group on Hormonal Factors in Breast Cancer. Breast
cancer and hormone replacement therapy: Collaborative reanalysis of data
from 51 epidemiological studies of 52,705 women with breast cancer and
108,411 women without breast cancer. Lancet. 1997;350:1047-1059.
5. Reeves GK, Pirie K, Green J, et al. For the Million Women Study
Collaborators. Comparison of the effects of genetic and environmental risk
factors on in situ and invasive ductal breast cancer. Int J Cancer. Epub ahead
2011 Sept 27.
6. Ernster VL, Ballard-Barbash R, Barlow WE, et al. Detection of ductal
carcinoma in situ in women undergoing screening mammography. J Natl
Cancer Inst. 2002;94:1546-1554.
DCIS and is part of an active policy discussion related to
invasive breast cancer. There is also an aspect of underdiagnosis
that must be considered. In some instances, DCIS
may be underdiagnosed invasive cancer for which the pathology
sections simply missed the invasive area. Overall,
the arguments for a close relationship between in situ and
invasive breast cancer can be found in the similarity of risk
factors for both the incidence of the diseases and their
similar responses to treatment.
From a clinical perspective, it seems prudent to approach
DCIS and invasive breast cancer as being related. Given the
rate of sampling error in needle biopsies, presumptive DCIS
should be treated as potential invasive cancer until a more
definitive pathologic sample is available. In clinical settings,
efforts should be made to make full use of markers such as
estrogen and progesterone receptor status, and necrosis to
differentiate women at high risk from those at lower risk of
developing invasive disease. Effort should be undertaken to
evaluate whether HER2 status offers any promise for clinical
decision-making. Ultimately, these markers would allow
for focusing aggressive treatment on those who have the
greatest probability of benefit.
Note: Because of space limitations, the reference list is
necessarily incomplete. See the article by Virnig and colleagues
2 for a more complete review.
ACKNOWLEDGMENTS
Funding: Agency for Healthcare Research and Quality, US
Department of Health and Human Services (contract number
290-02-10064-I). The authors of this report are responsible for
its content. Statements in the report should not be construed as
endorsement by the Agency for Healthcare Research and Quality
or the U.S. Department of Health and Human Services.
Stock
Ownership Honoraria
REFERENCES
Research
Funding
Expert
Testimony
Other
Remuneration
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prophylaxis for breast cancer—96-month follow-up of the randomized IBIS-I
trial. J Natl Cancer Inst. 2007;99:272-282.
8. Powles TJ, Ashley S, Tidy A, et al. Twenty-year follow-up of the Royal
Marsden randomized, double-blinded tamoxifen breast cancer prevention
trial. J Natl Cancer Inst. 2007;99:283-290.
9. Vogel VG, Costantino JP, Wickerham DL, et al. Effects of tamoxifen vs
raloxifene on the risk of developing invasive breast cancer and other disease
outcomes: The NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial.
JAMA. 2006;295:2727-2741.
10. Martino S, Cauley JA, Barrett-Connor E, et al. Continuing outcomes
relevant to Evista: Breast cancer incidence in postmenopausal osteoporotic
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11. Hwang ES, Kinkel K, Esserman LJ, et al. Magnetic resonance imaging
in patients diagnosed with ductal carcinoma-in-situ: Value in the diagnosis of
residual disease, occult invasion, and multicentricity. Ann Surg Oncol.
2003;10:381-388.
12. Menell JH, Morris EA, Dershaw DD, et al. Determination of the
presence and extent of pure ductal carcinoma in situ by mammography and
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