The Impact of Adding Radiation Treatment After Breast Conservation Surgery for Ductal Carcinoma In Situ of the Breast

Department of Radiation Oncology, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141, USA.
JNCI Monographs 10/2010; 2010(41):187-92. DOI: 10.1093/jncimonographs/lgq020
Source: PubMed

ABSTRACT Ductal carcinoma in situ (DCIS; intraductal carcinoma) is most commonly detected as suspicious microcalcifications on routine
screening mammography in an asymptomatic woman. As most women with newly diagnosed DCIS are eligible for breast conservation
treatment, a major decision for most women is whether or not to add radiation treatment after surgical excision (lumpectomy).
In four prospective randomized clinical trials, the addition of radiation treatment after lumpectomy reduced the risk of local
recurrence by approximately 50%, both for overall local recurrence and for the subset of invasive local recurrence. Nonetheless,
efforts have continued to attempt to identify a subset of patients with favorable DCIS who are at sufficiently low risk of
local recurrence that omitting radiation treatment is reasonable. Prospective and retrospective studies have demonstrated
excellent long-term outcomes at 10 and 15 years after breast conservation treatment with radiation. Careful follow-up, including
yearly surveillance mammography, after initial breast conservation treatment with radiation is warranted for the early detection
of potentially salvageable local and local-regional recurrences.

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    ABSTRACT: The NSABP (National Surgical Adjuvant Breast and Bowel Project) B-24 study demonstrated significant benefit with adjuvant tamoxifen in patients with ductal carcinoma in situ (DCIS) after lumpectomy and radiation. Patients were enrolled without knowledge of hormone receptor status. The current study retrospectively evaluated the relationship between receptors and response to tamoxifen. Estrogen (ER) and progesterone receptors (PgR) were evaluated in 732 patients with DCIS (41% of original study population). An experienced central laboratory determined receptor status in all patient cases with available paraffin blocks (n = 449) by immunohistochemistry (IHC) using comprehensively validated assays. Results for additional patients (n = 283) determined by various methods (primarily IHC) were available from enrolling institutions. Combined results were evaluated for benefit of tamoxifen by receptor status at 10 years and overall follow-up (median, 14.5 years). ER was positive in 76% of patients. Patients with ER-positive DCIS treated with tamoxifen (v placebo) showed significant decreases in subsequent breast cancer at 10 years (hazard ratio [HR], 0.49; P < .001) and overall follow-up (HR, 0.60; P = .003), which remained significant in multivariable analysis (overall HR, 0.64; P = .003). Results were similar, but less significant, when subsequent ipsilateral and contralateral, invasive and noninvasive, breast cancers were considered separately. No significant benefit was observed in ER-negative DCIS. PgR and either receptor were positive in 66% and 79% of patients, respectively, and in general, neither was more predictive than ER alone. Patients in NSABP B-24 with ER-positive DCIS receiving adjuvant tamoxifen after standard therapy showed significant reductions in subsequent breast cancer. The use of adjuvant tamoxifen should be considered for patients with DCIS.
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