Article

Fisher B, Land S, Mamounas E, Dignam J, Fisher ER, Wolmark NPrevention of invasive breast cancer in women with ductal carcinoma in situ: an update of the national surgical adjuvant breast and bowel project experience. Semin Oncol 28: 400-418

National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA, USA.
Seminars in Oncology (Impact Factor: 3.9). 09/2001; 28(4):400-18. DOI: 10.1053/sonc.2001.26151
Source: PubMed

ABSTRACT

The National Surgical Adjuvant Breast and Bowel Project (NSABP) conducted two sequential randomized clinical trials to aid in resolving uncertainty about the treatment of women with small, localized, mammographically detected ductal carcinoma in situ (DCIS). After removal of the tumor and normal breast tissue so that specimen margins were histologically tumor-free (lumpectomy), 818 patients in the B-17 trial were randomly assigned to receive either radiation therapy to the ipsilateral breast or no radiation therapy. B-24, the second study, which involved 1,804 women, tested the hypothesis that, in DCIS patients with or without positive tumor specimen margins, lumpectomy, radiation, and tamoxifen (TAM) would be more effective than lumpectomy, radiation, and placebo in preventing invasive and noninvasive ipsilateral breast tumor recurrences (IBTRs), contralateral breast tumors (CBTs), and tumors at metastatic sites. The findings in this report continue to demonstrate through 12 years of follow-up that radiation after lumpectomy reduces the incidence rate of all IBTRs by 58%. They also demonstrate that the administration of TAM after lumpectomy and radiation therapy results in a significant decrease in the rate of all breast cancer events, particularly in invasive cancer. The findings from the B-17 and B-24 studies are related to those from the NSABP prevention (P-1) trial, which demonstrated a 50% reduction in the risk of invasive cancer in women with a history of atypical ductal hyperplasia (ADH) or lobular carcinoma in situ (LCIS) and a reduction in the incidence of both DCIS and LCIS in women without a history of those tumors. The B-17 findings demonstrated that patients treated with lumpectomy alone were at greater risk for invasive cancer than were women in P-1 who had a history of ADH or LCIS and who received no radiation therapy or TAM. Although women who received radiation benefited from that therapy, they remained at higher risk for invasive cancer than women in P-1 who had a history of LCIS and who received placebo or TAM. Thus, if it is accepted from the P-1 findings that women at increased risk for invasive cancer are candidates for an intervention such as TAM, then it would seem that women with a history of DCIS should also be considered for such therapy in addition to radiation therapy. That statement does not imply that, as a result of the findings presented here, all DCIS patients should receive radiation and TAM. It does suggest, however, that, in the treatment of DCIS, the appropriate use of current and better therapeutic agents that become available could diminish the significance of breast cancer as a public health problem.

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    • "The impact of a tumour-bed boost to further improve local control is being tested in two on-going randomised trials [100] [101]. The value of adjuvant tamoxifen is limited, at the best [42] [43] [47] [66] [82]. Current uncertainties regarding the optimal treatment of DCIS result from persistent inconsistencies across prospective and observational studies about the predictive value of risk factors currently used in statistical analyses. "
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    ABSTRACT: Often considered an "indolent" disease for which a treatment de-escalation is advocated, ductal carcinoma in situ (DCIS) of the breast has been recently shown to be associated with a significant increase in long-term mortality in case of invasive local recurrence (LR). The publication of data from four randomised trials did not prevent the continuation of the debates about the pros and cons of postoperative radiation therapy (PORT) for optimal DCIS management. Actually only partial answers regarding the impact of PORT on local control had been brought by these randomised trials among others due to differences in pathological assessment among these controlled studies. A biologically heterogeneous disease, DCIS is characterised by a large variation in clinical behaviour, which hampers the identification of those patients for whom PORT might be considered as an overtreatment. At the light of the most recent biological and clinical studies, this review tries to identify accurately the LR risks associated with both tumour- and patient-related factors and to analyse the treatment-related parameters impacting significantly on the patient outcome.
    Full-text · Article · Jul 2014 · Radiotherapy and Oncology
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    • "In the French and International studies [20] [48], the LR rates in women over 60 years were 8% and 5% after local excision + PORT, with 84-and 120-month follow-ups, respectively. In NSABP B-17 and Houston series, the rates in women over 70 were 9% and 2%, with 90-and 60-month follow-ups respectively [14] [35] [47]. A retrospective analysis of SEER data including 3409 women over 66 treated by BCS for DCIS between 1992 and 1999 [52] showed that PORT lowered local recurrence risk with a HR = 0.32 (95% CI: 0.24–0.44). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Often considered an “indolent” disease for which a treatment de-escalation is advocated, ductal carcinoma in situ (DCIS) of the breast has been recently shown to be associated with a significant increase in long-term mortality in case of invasive local recurrence (LR). The publication of data from four randomised trials did not prevent the continuation of the debates about the pros and cons of postoperative radiation therapy (PORT) for optimal DCIS management. Actually only partial answers regarding the impact of PORT on local control had been brought by these randomised trials among others due to differences in pathological assessment among these controlled studies. A biologically heterogeneous disease, DCIS is characterised by a large variation in clinical behaviour, which hampers the identification of those patients for whom PORT might be considered as an overtreatment. At the light of the most recent biological and clinical studies, this review tries to identify accurately the LR risks associated with both tumour- and patient-related factors and to analyse the treatment-related parameters impacting significantly on the patient outcome.
    Full-text · Article · Jan 2014
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    • "Standard treatment for early-stage breast cancer is breast conserving surgery followed by postoperative radiation therapy to the whole breast. This approach has resulted in comparable local control and survival rates after a mastectomy [2,3]. "
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    ABSTRACT: To observe long-term clinical outcomes for patients with early-stage breast cancer treated with forward intensity-modulated radiation therapy (IMRT), including local control and clinical toxicities. We retrospectively analyzed a total of 214 patients with stage I-II breast cancer who were treated with breast conserving surgery followed by adjuvant breast radiation therapy between 2001 and 2008. All patients were treated using forward IMRT. The whole breast was irradiated to a dose of 50 to 50.4 Gy followed by an 8 to 12 Gy electron boost to the surgical bed. The median age was 46 years (range, 21 to 82 years) and the medial follow-up time was 7.3 years (range, 2.4 to 11.7 years). Stage T1 was 139 (65%) and T2 was 75 (35%), respectively. Ipsilateral breast recurrence was observed in 3 patients. The 5- and 10-year local control rates were 99.1% and 97.8%, respectively. The cosmetic outcome was evaluated according to the Harvard scale and 89.4% of patients were scored as excellent or good. The whole breast radiation therapy as an adjuvant treatment using a forward IMRT technique showed excellent long-term local control as well as favorable outcomes of toxicity and cosmesis.
    Full-text · Article · Dec 2013
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