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Are We Over-Treating DCIS?
Deanna J. Attai MD FACS
Assistant Clinical Professor of Surgery
David Geffen School of Medicine...
No Disclosures
What Is DCIS?
• Malignant cell appearance
• Non-obligate precursor
• Without surgery 15-50%
progress to invasive cancer
• ...
Presentation / Incidence
• Typical presentation –
mammographic calcifications
• Occasionally presents as
palpable mass
• ~...
Diagnosis Rare Before Mammography
Vernig et al 2009
http://www.ncbi.nlm.nih.gov/books/NBK32570/
Treatment Options
• Surgery
• Mastectomy, Lumpectomy
• SNB not routine unless mastectomy
• Radiation Therapy
• Radiation r...
Predictors of Recurrence
Euhus D Gen Surg News
http://www.generalsurgerynews.com/Web-Only/Article/04-16/Better-
Prognostic...
Treatment Effect / Risk of Invasive BC
Euhus D Gen Surg News
http://www.generalsurgerynews.com/Web-Only/Article/04-16/Bett...
DCIS / Metastatic Disease
• MDA 2011 0.14% of 2123
patients
• 34% no locoregional recurrence
• Narod et al 500/100,000
met...
Why the Confusion?
• DCIS is not one disease
• Hard to determine if over treating if we
don’t agree on endpoint
• Overall ...
How To Decide
• Treatment decisions require tradeoffs
• Current treatment may compromise
options if recurrence develops
• ...
Van Nuys Prognostic Index
Silverstein
Am J Surgery
186;4:337-343
• 4,5,6: excision alone
• Lack of consistent
external val...
Patient Prognostic Score
Sagara et al 2016
J Clin Onco 34:1190-1196
• Predict local recurrence,
magnitude of benefit of RT...
MSKCC Nomogram – Ipsilateral Recurrence
http://nomograms.mskcc.org/breast/
DuctalCarcinomaInSituRecurrencePage.aspx
Rudlof...
Oncotype Dx DCIS
• Predicts risk of local recurrence after lumpectomy
• Validated in:
• Grade 1-2 DCIS, ≤2.5cm or grade 3 ...
Decision Aids
• Majority of patients over-estimate
their risk of recurrence
• Differing degrees of risk tolerance
• Ideal:...
OnlineDeCISion.org
Not yet validated for clinical use
OnlineDeCISion.org
Not yet validated for clinical use
OnlineDeCISion.org
Not yet validated for clinical use
Clinical Trials
• Alliance NCT01439711
• Letrozole x 6 months
• MRI at baseline, 3, 6 months
• Surgical excision
• Allianc...
The Future
• Imaging
• Core biopsy
• Biomarkers
• Tailored / precision therapy
• ?No therapy for some
• ?Intraductal thera...
Are We Over-Treating DCIS?
• It depends…
• In some cases: yes
• Discussion of risks, unknowns
• Decision tools
• Incorpora...
Are We Overtreating DCIS?
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Are We Overtreating DCIS?

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The optimal treatment of DCIS is controversial given that some forms have a very indolent behavior and some have a very aggressive natural history.

Published in: Health & Medicine

Are We Overtreating DCIS?

  1. 1. Are We Over-Treating DCIS? Deanna J. Attai MD FACS Assistant Clinical Professor of Surgery David Geffen School of Medicine UCLA 24 June 2016
  2. 2. No Disclosures
  3. 3. What Is DCIS? • Malignant cell appearance • Non-obligate precursor • Without surgery 15-50% progress to invasive cancer • ~20% upgrade rate • 15% autopsies women 20-56 Wood JOP 2016 12;4;309-311 Cowell Mol Oncol 2013 7;5:859-869
  4. 4. Presentation / Incidence • Typical presentation – mammographic calcifications • Occasionally presents as palpable mass • ~60,000 / year in US 2009 NIH Consensus Conference https://consensus.nih.gov/2009/dcisstatement.htm
  5. 5. Diagnosis Rare Before Mammography Vernig et al 2009 http://www.ncbi.nlm.nih.gov/books/NBK32570/
  6. 6. Treatment Options • Surgery • Mastectomy, Lumpectomy • SNB not routine unless mastectomy • Radiation Therapy • Radiation reduced I-IBTR 19.4% ->8.5% (B17) • Other studies show I-IBTR 14-25% without RT • Tamoxifen (B24) • Addition tamoxifen to L + RT reduced I-IBTR 32% vs. placebo • I-IBTR associated with increased risk of death HR 1.75 • Recurrence of DCIS no increased risk of death • Aromatase Inhibitors (B35, IBIS-II DCIS)
  7. 7. Predictors of Recurrence Euhus D Gen Surg News http://www.generalsurgerynews.com/Web-Only/Article/04-16/Better- Prognostic-Tools-Are-Needed-for-DCIS/36064/ses=ogst
  8. 8. Treatment Effect / Risk of Invasive BC Euhus D Gen Surg News http://www.generalsurgerynews.com/Web-Only/Article/04-16/Better- Prognostic-Tools-Are-Needed-for-DCIS/36064/ses=ogst
  9. 9. DCIS / Metastatic Disease • MDA 2011 0.14% of 2123 patients • 34% no locoregional recurrence • Narod et al 500/100,000 metastatic without locoregional recurrence Roses et al Ann Surg Oncol (2011) 10:10; 2873-2878 Narod et al JAMA Oncol 2015:1(7);888-896
  10. 10. Why the Confusion? • DCIS is not one disease • Hard to determine if over treating if we don’t agree on endpoint • Overall survival • Breast cancer specific survival • Invasive vs. in-situ recurrence • Breast cancer specific survival approaches 100% regardless of treatment choice Moran M December 2015 ASCO Post http://www.ascopost.com/issues/december-25-2015/ductal-carcinoma-in-situ-and-relevant- endpoints-for-omission-of-standard-treatments-are-we-there-yet/
  11. 11. How To Decide • Treatment decisions require tradeoffs • Current treatment may compromise options if recurrence develops • What endpoint most important to patients – local recurrence, toxicity from treatment, survival, others • Difficult (impossible?) to have evidence based shared decision making when natural history of individual patient’s disease unknown
  12. 12. Van Nuys Prognostic Index Silverstein Am J Surgery 186;4:337-343 • 4,5,6: excision alone • Lack of consistent external validation – limits clinical utility Rudloff U, et al J Clin Oncol 28;23;2762-3769
  13. 13. Patient Prognostic Score Sagara et al 2016 J Clin Onco 34:1190-1196 • Predict local recurrence, magnitude of benefit of RT • Survival improvements in RT group only seen w/high grade, younger age, larger tumor size. • Magnitude of survival difference with RT correlated with score “As an oncology community we must be cognizant of overtreatment for this disease process that has low breast cancer mortality”
  14. 14. MSKCC Nomogram – Ipsilateral Recurrence http://nomograms.mskcc.org/breast/ DuctalCarcinomaInSituRecurrencePage.aspx Rudloff U, et al J Clin Oncol 28;23;2762-3769
  15. 15. Oncotype Dx DCIS • Predicts risk of local recurrence after lumpectomy • Validated in: • Grade 1-2 DCIS, ≤2.5cm or grade 3 ≤1cm; ≥3mm margin • 97% ER+, 29% treated with tamoxifen • Complement to traditional clinical / pathology features Solin LJ et al J Natl Cancer Inst 2013 105:701-710
  16. 16. Decision Aids • Majority of patients over-estimate their risk of recurrence • Differing degrees of risk tolerance • Ideal: tailor treatment to individual risk of recurrence • Decision aids increase knowledge, reduce decisional conflict, decisions aligned with goals and values Ozanne EM, et al Breast Cancer Res Treat (2015) 154:181-190
  17. 17. OnlineDeCISion.org Not yet validated for clinical use
  18. 18. OnlineDeCISion.org Not yet validated for clinical use
  19. 19. OnlineDeCISion.org Not yet validated for clinical use
  20. 20. Clinical Trials • Alliance NCT01439711 • Letrozole x 6 months • MRI at baseline, 3, 6 months • Surgical excision • Alliance COMET • Standard vs. observational therapy +/- endocrine therapy • UK LORIS • Low risk DCIS • Surgery vs. active surveillance (annual mammogram) • EORTC LORD • Standard treatment vs. active surveillance
  21. 21. The Future • Imaging • Core biopsy • Biomarkers • Tailored / precision therapy • ?No therapy for some • ?Intraductal therapy 21
  22. 22. Are We Over-Treating DCIS? • It depends… • In some cases: yes • Discussion of risks, unknowns • Decision tools • Incorporate patient preferences • Support clinical trials •Don’t forget lifestyle counseling

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