Dilemma in management of DCISDilemma in management of DCIS

Julia Tchou, M.D., Ph.D.Abramson Cancer Center

Rena Rowan Breast CenterDepartment of Surgery

University of Pennsylvania

The Dilemma of DCISThe 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.

Standard Treatment in DCIS

• Mastectomy

• Excision + RT

• Excision

+ Tamoxifen

Which Rx for which patient?

Key questions in management of DCISKey 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 TreatmentSurvival in DCIS by Treatment

0

1

2

3

4

5

5 7 10 12

Years

% D

eath

s B

rea

st

Ca

B17

EORTC

B17; EORTC

B24

B24

L

L+RT

L+RT+TAM

M

Effects of XRT on survivalEffects of XRT on survival

EBCTCG meta-analsyis, Lancet 2005

Key Management Concepts in DCISKey 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

Can we identify a subset of patient not benefiting from

RT?

Can DCIS be treated by excision alone?Can DCIS be treated by excision alone?

Study LE alone LE + XRT Tamoxifen use

Margins IBT rate

NSABP B-17, 1998

403 411 no free 27% vs. 12% at 8 years

UK Trial, 2003 508 522 yes free 20 % vs. 10% at 5 years

EORTC 10853, 2006

503 507 no free 26% vs. 15% at 10 years

Harvard, 2006 158 no 1 cm 12% at 5 years

ECOG, 2009 565 yes 3 mm 6.1% vs. 15% (5 year rate)

Local recurrence risk stratificationLocal 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 IndexVan Nuys Prognostic Index

Silverstein, M 2003

Silverstein M 2003

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 Is there a DCIS subgroup that does not benefit from XRT?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