Surgical Strategy Queried for Low-Grade DCIS Patients

Patients with low-grade ductal carcinoma in situ may not benefit from surgery

medwireNews: Researchers question the role of surgery for women with low-grade ductal carcinoma in situ (DCIS), on finding no survival evidence for operative over nonoperative treatment in this population.

By contrast, patients with intermediate- and high-grade DCIS derived a significant 10-year breast cancer-specific survival gain with surgery compared with nonsurgical options, the team reports in JAMA Surgery.

“Our findings justify a subsequent prospective study aimed at investigating new approaches for the management of low-grade DCIS”, say Yasuaki Sagara, from Brigham and Women’s Hospital in Boston, Massachusetts, USA, and co-investigators.

“Such a study may include active surveillance with an imaging arm that includes recommendations for delayed surgery only after confirming progression of the disease,” they suggest.

Analysis of data for 57,222 DCIS patients registered in the US Surveillance, Epidemiology, and End Results database gave an overall 10-year breast cancer-specific survival rate of 98.5%, and this was significantly higher for the 98% of patients who underwent surgery compared with those who received conservative treatment, at 98.5% versus 93.4%.

Ten-year rates were comparable among low-grade DCIS patients who did and did not receive surgery, at 98.6% and 98.8%, respectively, whereas there were significant differences of 4 and 8 percentage points for intermediate- and high-grade patients in favour of surgery, respectively.

This pattern was confirmed by multivariate analysis, adjusting for a raft of patient and tumour characteristics, such as age and race, tumour size and receipt of radiotherapy, the researchers say.

US clinicians Julie Margenthaler, from Washington University in St Louis, Missouri, and Aislinn Vaughan, from SSM Breast Care in Missouri, argue, however, “that DCIS grade is not an appropriate surrogate for genomic profile and biologic outcomes”.

Writing in an accompanying comment, they cite earlier multivariate analysis results indicating that the risk of ipsilateral breast events is significantly predicted only by tumour size, menopausal status and a DCIS risk score for recurrence based on a 12-Gene profile.  

“We advocate for less treatment in those patients who have a low risk for invasive recurrence and/or progression”, the commentators say, but emphasise: “That knowledge is unlikely to come from our standard clinicopathologic characteristics. For now, surgeons should hold onto their scalpels.”

References

Sagara Y, Mallory MA, Wong S, et al. Survival benefit of breast surgery for low-grade ductal carcinoma in situ. A population-based cohort study. JAMA Surg 2015; Advance online publication 3 June. doi:10.1001/jamasurg.2015.0876

Margenthaler JA, Vaughan A. No surgery for low-grade ductal carcinoma in situ? JAMA Surg 2015; Advance online publication 3 June. doi:10.1001/jamasurg.2015.0895.

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