Transcript DCIS - A Breast Surgeon`s Perspective

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 …
Local recurrence rate after BCT of DCIS
is ~ 2 fold higher than Invasive cancer.
Standard Treatment in DCIS
• Mastectomy
• Excision + RT
+ Tamoxifen
• Excision
Which Rx for which patient?
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
% Deaths Breast Ca
5
4
3
L
L+RT
L+RT+TAM
B17
EORTC
M
B17; EORTC
2
B24
1
B24
0
5
7
Years
10
12
Effects of XRT on survival
EBCTCG meta-analsyis, Lancet 2005
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
Can we identify a subset of
patient not benefiting from
RT?
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 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
Silverstein, M 2003
Silverstein M 2003
Outcome in DCIS Patients with
Low VNPI
Low VNPI (3 or 4)
Silverstein
# patients
de Mascarel
101
195
Local recurrence 2%
9%
Invasive
Br Ca Res Treat 2000
0
50%
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