Summary:

Survival Benefit of Breast Surgery for Low-Grade Ductal Carcinoma In Situ: A Population-Based Cohort Study

Authors: Sagara Y, Mallory MA, Wong S, Aydogan F, DeSantis S, Barry T,  Golshan M

Source: JAMA Surg. August 2015;150:739-745.

Ductal carcinoma in situ (DCIS) is known as a stage 0 breast cancer with more than 60,000 cases a year currently being diagnosed in the United States, as compared to 7,000 cases in the early 1980s. The increase in diagnoses is mostly due to the widespread use of screening mammography.

The survival rate for DCIS is greater than 99%. In general, the following surgeries have been recommended for the treatment of DCIS:

• Lumpectomy with Radiation
• Mastectomy
• Lumpectomy alone

If the DCIS is shown to be estrogen-positive, tamoxifen has been recommended. 

There is a sense that certain women with DCIS may be overtreated for this disease, because most patients diagnosed with DCIS have excellent long-term outcomes. The authors sought to quantify the benefit of surgery for women with DCIS based on nuclear grade (how different the cells look from normal cells).  Using the Surveillance Epidemiology and End Results (SEER) data set, they found that 1,169 cases of the 57,222 cases overall were not managed with surgery.  When they adjusted for factors that may influence outcome, they found that women with low-grade disease who did not undergo surgical removal of DCIS did just as well as those who did, in terms of survival from breast cancer.  This raises the question of whether we can identify a group of patients with DCIS who can be treated with either active surveillance or nonsurgical treatment strategies. 

The study is retrospective and cannot be considered definitive or practice-changing; however, we believe that prospective trials are warranted to ask and answer the question of what is the treatment for DCIS. Standard surgical treatment may not be necessary for all women with DCIS and future research should be done to deliver patient- centered decision-making and personalized treatment options. Trials (for example, LORIS in the United Kingdom and LORD, which is in development in Europe) may be able to determine which patients can undergo active surveillance versus surgical, radiation, and endocrine-type therapies.