Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group

Long-term follow-up of complex oncoplastic breast-conserving surgery, standard breast conservation and skin-sparing mastectomy in DCIS - a register-based study

BACKGROUND

Few studies evaluate oncological safety in complex oncoplastic breast-conserving surgery(C-OBCS) for DCIS. It still needs to be defined whether it is equivalent to standard breast conservation(S-BCS) or an alternative to skin-sparing mastectomy(SSM). This study compares local recurrence rates(LR), disease-free survival(DFS) and overall survival (OS) between the three surgical techniques.

METHODS

We conducted a retrospective register-based study on LR, DFS and OS of patients operated with S-BCS(n=1388), C-OBCS (n=106) or skin-sparing mastectomy (n=218) for DCIS diagnosed 2007-2020. Data was extracted from the Norwegian Breast Cancer Registry.

RESULTS

In the S-BCS, C-OBCS and SSM groups, median age was 60, 58 and 51 years (p<0.001), median size 15, 25, and 40 mm (p<0.001) and median follow-up 55, 48 and 76 months. At ten years, the overall LR was 12.7%, 14.3% for S-BCS, 11.2% for C-OBCS and 6.8% for SSM. Overall DFS at ten years was 82.3%, 80.5% for S-BCS, 82.4% for C-OBCS and 90.4% for SSM. At ten years, the OS was 93.8%, 93.0% in S-BCS, 93.3% in C-OBCS and 96.6% in the SSM group. Weighted Kaplan Meier plots showed that SSM had a significantly higher DFS than S-BCS (p=0.003) and C-OBCS (p=0.029). DFS in C-OBCS versus S-BCS and the difference in OS was not significant (p=0.264).

CONCLUSION

SSM had a significantly higher DFS than S-BCS and C-OBCS. The difference in DFS between S-BCS and C-OBCS, and OS between the three groups was not statistically significant. Our study suggests that C-OBCS is a safe alternative to S-BCS and SSM.

Locoregional Control Benefit of a Tumor Bed Boost for Ductal Carcinoma In Situ

Purpose

Radiation therapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) reduces invasive and in situ recurrences. Whereas landmark studies suggest that a tumor bed boost improves local control for invasive breast cancer, the benefit in DCIS remains less certain. We evaluated outcomes of patients with DCIS treated with or without a boost.

Methods and Materials

The study cohort comprised patients with DCIS who underwent BCS at our institution from 2004 to 2018. Clinicopathologic features, treatment parameters, and outcomes were ascertained from medical records. Patient and tumor characteristics were evaluated relative to outcomes using univariable and multivariable Cox models. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method.

Results

We identified 1675 patients who underwent BCS for DCIS (median age, 56 years; interquartile range, 49-64 years). Boost RT was used in 1146 cases (68%) and hormone therapy in 536 (32%). At a median follow-up of 4.2 years (interquartile range, 1.4-7.0 years), we observed 61 locoregional recurrence events (56 local, 5 regional) and 21 deaths. Univariable logistic regression demonstrated that boost RT was more common among younger patients (P < .001) with positive or close margins (P < .001) and with larger tumors (P < .001) of higher grade (P = .025). The 10-year RFS rate was 88.8% among those receiving a boost and 84.3% among those without a boost (P = .3), and neither univariable nor multivariable analyses revealed an association between boost RT and locoregional recurrence.

Conclusions

Among patients with DCIS who underwent BCS, use of a tumor bed boost was not associated with locoregional recurrence or RFS. Despite a preponderance of adverse features among the boost cohort, outcomes were similar to those of patients not receiving a boost, suggesting that a boost may mitigate risk of recurrence among patients with high-risk features. Ongoing studies will elucidate the extent to which a tumor bed boost influences disease control rates.

Outcomes of DCIS treated with breast conserving surgery without radiotherapy on recurrence, survival, and health-related quality of life

BACKGROUND

Sector resection for Ductal Carcinoma in Situ (DCIS) allows wide excision without compromising breast shape. There are concerns that radiotherapy for some DCIS after sector resection is unnecessary and reduces patient satisfaction and quality of life without affecting survival. This study aimed to investigate whether women with DCIS managed with sector resection without radiotherapy had acceptable rates of recurrence and health-related quality of life outcomes.

METHODS

Retrospective study of patients who underwent sector resection for DCIS without adjuvant radiotherapy from 1992 to 2021. Tumour size, grade, necrosis, margins, follow up and time to ipsilateral recurrence was recorded. Patients were posted a BREAST-Q to assess health-related quality of life.

RESULTS

One hundred and thirty-eight patients were treated for pure DCIS by two surgeons from 1992 to 2018. One hundred and sixteen patients underwent sector resection, 22 had mastectomy. Average age 61 years. Mean follow up 9.14 years. Recurrence rate after sector resection was 18.97%. 55% were DCIS. Annualized recurrence rate was 2.07%. There were no cancer-related deaths. BREAST-Q completion rate was 44%. Satisfaction with breasts, physical, psychosocial, and sexual well-being scores were significantly higher than normative Australian values and a mixed cohort of women who underwent breast conserving surgery with radiotherapy.

CONCLUSION

DCIS can be safely managed with sector resection without radiotherapy and regular long-term follow up. This approach results in low annualized recurrence rates, high levels patient satisfaction and health-related quality of life and should be considered a safe alternative for patients with DCIS to minimize morbidity without affecting cancer survival.

Can Molecular Biomarkers Help Reduce the Overtreatment of DCIS?

Ductal carcinoma in situ (DCIS), especially in the era of mammographic screening, is a commonly diagnosed breast tumor. Despite the low breast cancer mortality risk, management with breast conserving surgery (BCS) and radiotherapy (RT) is the prevailing treatment approach in order to reduce the risk of local recurrence (LR), including invasive LR, which carries a subsequent risk of breast cancer mortality. However, reliable and accurate individual risk prediction remains elusive and RT continues to be standardly recommended for most women with DCIS. Three molecular biomarkers have been studied to better estimate LR risk after BCS-Oncotype DX DCIS score, DCISionRT Decision Score and its associated Residual Risk subtypes, and Oncotype 21-gene Recurrence Score. All these molecular biomarkers represent important efforts towards improving predicted risk of LR after BCS. To prove clinical utility, these biomarkers require careful predictive modeling with calibration and external validation, and evidence of benefit to patients; on this front, further research is needed. Most trials do not incorporate molecular biomarkers in evaluating de-escalation of therapy for DCIS; however, one-the Prospective Evaluation of Breast-Conserving Surgery Alone in Low-Risk DCIS (ELISA) trial-incorporates the Oncotype DX DCIS score in defining a low-risk population and is an important next step in this line of research.

Associations of clinicopathological factors with local treatment and survival outcome in elderly patients with ductal carcinoma in situ

Background

Local treatment for ductal carcinoma in situ (DCIS) remains controversial for elderly patients. This study aims to evaluate the association of local treatment, clinicopathological factors, and survival in elderly DCIS patients.

Methods

Patients ≥ 60 years diagnosed with DCIS from January 2009 to December 2018 were retrospectively included. Local treatment including breast surgery, axillary lymph node (ALN) surgery, and radiotherapy were analyzed among subgroups (age of 60-69, 70-79, and ≥ 80 years), and their associations with clinicopathological features and prognostic outcome were further evaluated.

Results

A total of 331 patients were included. Eventually 86 patients received breast conserving surgery (BCS) and 245 patients received mastectomy. ALN surgery was omitted in 62 patients. Age and tumor size were independent factors that influenced the breast and ALN surgery (P < 0.05). Compared with patients aging 60-69, patients ≥ 80 years were more likely to receive BCS (OR 4.28, 95% CI 1.33-13.78, P = 0.015) and be exempt from ALN surgery (OR 0.19, 95% CI 0.05-0.69, P = 0.011). Patients with tumor >1.5 cm were significantly less likely to receive BCS (OR 0.45, 95%CI 0.25-0.83, P = 0.011) and more likely to receive ALN surgery (OR 4.41, 95%CI 1.96-10.48, P = 0.001) compared to patients with tumor ≤ 1.5 cm. Postoperative radiotherapy was performed in 48.8% patients who received BCS. Age was the only factor that associated with the radiotherapy decision after BCS in elderly DCIS patients (P = 0.025). No significant recurrence-free survival difference was observed among patients receiving different local treatments.

Conclusions

Age was related to the choice of local treatment in elderly DCIS patients, but different treatment patterns didn't impact disease outcome.

A dose planning study for cardiac and lung dose sparing techniques in left breast cancer radiotherapy: Can free breathing helical tomotherapy be considered as an alternative for deep inspiration breath hold?

Purpose

To investigate the possibility to be able to offer left sided breast cancer patients, not suitable for DIBH, an organ at risk saving treatment.

Materials and Methods

Twenty patients receiving radiotherapy for left breast cancer in DIBH were enrolled in the study. Planning CT scans were acquired in the same supine treatment position in FB and DIBH. 3DCRT_DIBH plans were designed and optimized using two parallel opposed tangent beams (with some additional segments) for the breast and chest wall and anterior-posterior fields for regional lymph nodes irradiation. Additionally, FB helical tomotherapy plans were optimized to minimize heart and lung dose. All forty plans were optimized with at least 95% of the total CTV covered by the 95% of prescribed dose of 50 Gy in 25 fractions.

Results

HT_FB plans showed significantly better dose homogeneity and conformity compared to the 3DCRT_DIBH specially for regional nodal irradiation. The heart mean dose was almost comparable in 3DCRT_DIBH and HT_FB while the volume (%) of the heart receiving 25 Gy had a statistically significant reduction from 7.90 ± 3.33 in 3DCRT_DIBH to 0.88 ± 0.66 in HT_FB. HT_FB was also more effective in left descending artery (LAD) mean dose reduction about 100% from 30.83 ± 9.2 Gy to 9.7 ± 3.1. The ipsilateral lung volume receiving 20 Gy has a further reduction of 43 % in HT_FB compared with 3DCRT_DIBH. For low dose comparison, 3DCRT_DIBH was superior for contralateral organ sparing compared to the HT_FB due to the limited angle for dose delivery.

Conclusion

For patients who cannot be a candidate for DIBH for any reason, HT in free breathing may be a good alternative and provides heart and ipsilateral lung dose sparing, however with the cost of increased dose to contralateral breast and lung.

Clinical Trials That Have Informed the Modern Management of Breast Cancer

Randomized controlled trials have informed the historical evolution of breast cancer management, distilling operative and nonoperative treatments to achieve disease control and improve survival while maximizing quality of life and minimizing complications. The authors describe landmark trials investigating and influencing the following aspects of breast cancer care: extent of breast surgery; axillary management; neoadjuvant and adjuvant therapies; and selection of chemotherapy versus endocrine therapy via application of genomic assays.

Clinical presentations and outcomes of young women aged <40 yrs with Ductal carcinoma in situ

INTRODUCTION

Ductal carcinoma in situ (DCIS) in young women is rare and not well studied. Since they do not qualify for mammographic screening, they are more likely to present with symptoms. Young women have also been associated with poorer outcomes, but it is unknown whether presentation mode affects outcome. We aimed to compare characteristics of DCIS patients <40 years of age presenting with symptoms versus those without, and determine whether presentation mode affects recurrence.

METHODS

Pure DCIS patients aged <40 years were retrospectively analyzed. Clinical presentation, pathology and recurrence data were collected. Statistical analysis was performed to investigate the correlation of presentation mode with outcomes.

RESULTS

40 patients with 41 cases were included. The mean age at diagnosis was 32.3 years (range 17-39). 73.2% and 26.8% presented with symptoms or abnormal imaging respectively. Of the cases who presented with symptoms, 86.7%, 10.0% and 3.3% had palpable lump, nipple discharge or breast pain, respectively. The average tumor size was 22.0 mm (range 2.0-86.9) and 12.2 mm (range 3-25) for patients who presented with symptoms and non-symptomatic group, respectively. Cases presenting with symptoms were statistically associated with higher grade (p = 0.0090). On median follow-up of 85 months, there were 3 (7.3%) recurrences, which were not statistically associated with presentation mode.

CONCLUSION

Young women with DCIS tend to present with symptoms, with breast lump as the commonest symptom. Symptomatic patients tend to be associated with grade III tumours, compared to non-symptomatic patients. On long-term follow-up, mode of presentation was not statistically associated with recurrence.

Long-term yogic intervention decreases serum interleukins IL-10 and IL-1β and improves cancer-related fatigue and functional scale during radiotherapy/chemotherapy in breast cancer patients: a randomized control study

PURPOSE

Yoga improved fatigue and immunological profile in cancer survivors and has been a promising alternative therapy. Breast cancer treatments are rapidly improving, along with their side effects. This article investigated the effect of the yogic intervention at a different time interval during radiotherapy/chemotherapy on the pro- and anti-inflammatory interleukins along with the cancer-related fatigue and functional scale among patients with stage II/III breast cancer.

METHODS

A total of 96 stage II/III breast cancer patients were enrolled in this study and randomly divided into two different groups. Group I (non-Yoga) received chemotherapy and/or radiotherapy and group II (Yoga) received an additional yogic intervention. Both groups were followed up for a period of 48 weeks and blood was collected at the time of enrollment, 16, 32, and 48 weeks, and serum was isolated to measure the pro- and anti-inflammatory interleukins, fatigue, and functional scale questionnaire obtained at each time point.

RESULTS

Breast cancer patients in group II showed a significant improvement (p < 0.05) in the functional scale and fatigue from baseline to 48 weeks compared to group I. The yogic intervention significantly decreased (p < 0.05) the level of pro-inflammatory interleukin IL-1β and pleiotropic interleukin IL-10 in group II compared to group I.

CONCLUSION

These finding suggested that improved fatigue and functional scale is associated with a lower level of IL-1β and IL-10. Yoga may be an important additional therapy along with the cancer treatment to help the patients with cancer-related fatigue and improve their overall immunological profile.

Patterns of Care and Utilization of Radiation for Women With Good-Risk Ductal Carcinoma In Situ: A National Cancer Database Analysis

Purpose/objective(s)

Lumpectomy followed by whole-breast radiation therapy (WBRT) provides a 50% recurrence rate reduction in ductal carcinoma in situ (DCIS) patients when compared to lumpectomy alone. Certain factors increase the risk of recurrence, including higher nuclear grade, large size, age less than 50, and close margins. RTOG 9804 demonstrated a reduction in local failure after WBRT with the use of adjuvant radiation in women with "good-risk disease" (mammographically detected, measuring less than or equal to 2.5 cm, with a predominant nuclear grade of 1 or 2, and a margin of greater than or equal to 1 cm, or a negative re-excision). The purpose of this study is to retrospectively identify the patterns of care in women with low-risk DCIS utilizing the National Cancer Database (NCDB). We hypothesize that with the utilization of hypofractionation, there may be an increase in the delivery of RT for these "good-risk" patients.

Materials/methods

The National Cancer Database was queried to identify women treated with lumpectomy for <2.5 cm, nuclear grade 1 or 2 DCIS of the breast from 2004 to 2016. Data were collected regarding age, tumor size, endocrine therapy use, ER receptor status, race, insurance type, and distance from the treatment center. The distance was stratified into quartiles consisting of 0-3.9, 4-8, 8.1-15.8, and > 15.8 miles, respectively. Radiation fractionation was collected and categorized as hypofractionation, standard fractionation, or other if fractionation could not be ascertained. Clinical and patient-related factors were compared between patients who received radiation and those who received no radiation. The frequency distributions between categorical variables were compared using the Chi-square test. Multivariable logistic regression was used to identify covariables that impacted the receipt of radiation.

Results

The eligibility criteria were met by a total of 12,846 patients. Of those, 6,600 (51.4%) received adjuvant WBRT. On multivariable regression, patients whose tumors were ER (OR 1.24, P<0.001) and those who had not received endocrine therapy (OR 2.24, P<0.001) were more likely to receive WBRT. Factors less likely to receive WBRT included increasing age over 50 (age 50-65 OR 0.83, P<0.001; age>65 OR 0.58, P<0.001), and distance of >15.8 miles (OR 0.78, P<0.001). The fractionation technique was categorized as standard or hypofractionated in 52.2% of patients. Of those, the use of hypofractionation increased from 0.4% in 2004 to 8.9% in 2010 and to 53.8% in 2016.

Conclusion

This NCDB analysis demonstrated that patients who meet the RTOG 9804 criteria for "good-risk" DCIS are less likely to receive RT as time progresses despite an increase in the utilization of hypofractionation techniques. Overall, slightly more than half of these patients receive adjuvant RT.

Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.

Molecular subtypes predict second breast events of ductal carcinoma in situ after breast‐conserving surgery

Purpose

Currently, the prognostic value of molecular subtypes in ductal carcinoma in situ (DCIS) remains unclear. In this study, we explored whether molecular subtypes could predict second breast events (SBEs) in patients after breast‐conserving surgery (BCS).

Methods

From January 2008 to December 2016, 291 DCIS patients treated with BCS were retrospectively analyzed. Patients were classified into four molecular subtypes: luminal A, luminal B, human epidermal growth factor receptor 2 (HER2) overexpression, and triple‐negative breast cancer (TNBC). The SBE incidence was calculated by the competing risk model and compared by Gray's test. The disease‐free survival rates were estimated by the Kaplan–Meier method and compared by the log‐rank test. Prognostic factors were evaluated by univariate and multivariate COX proportional hazards regression model.

Results

With a median follow‐up of 66 months, 12 SBEs were identified. The 5‐year overall SBE incidence of luminal A, luminal B, HER2 overexpression, and TNBC was 2.18%, 4.25%, 15.15%, and 0.00%, respectively. In the univariate analysis, the HER2 overexpression subtype was the predictor of overall (p = 0.005), in situ (p = 0.004), and ipsilateral SBEs (p = 0.008). Patients with endocrine therapy were less likely to develop in situ SBEs (p = 0.039). Additionally, patients with closed (<2 mm) or involved margins were related to a higher risk of contralateral SBEs (p = 0.029). In the multivariate analysis, the HER2 overexpression subtype remained of prognostic values for overall (p = 0.006), in situ (p = 0.029), and ipsilateral SBEs (p = 0.012).

Conclusions

The molecular subtype, especially the HER2 overexpression subtype, was the independent prognostic factor for DCIS patients who underwent BCS.

Influence of rurality on lymph node assessment among women diagnosed with ductal carcinoma in situ and treated with mastectomy, SEER 2000-2015

PURPOSE

Despite recommendations from national organizations supporting the use of lymph node assessment (LNA) among patients with ductal carcinoma in situ (DCIS) at time of mastectomy, variation in practice patterns across the United States has been observed. However, few studies have evaluated LNA differences and rurality.

METHODS

Data from the SEER Patterns of Care studies were used to identify women who underwent mastectomy for newly diagnosed DCIS during 2000, 2005, 2010, and 2015. Weighted multivariate logistic regression was used to evaluate the association between rural-urban residence and the use of LNA. A subgroup analysis was performed comparing the use of axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB).

RESULTS

Of the 504 patients included in the analysis, approximately 81% underwent LNA at time of mastectomy with lower rates of use observed among rural patients (66%) versus urban patients (82%). In multivariate analysis, LNA increased over time (p < 0.0001), and rural patients were less likely to receive LNA compared to urban patients [adjusted odds ratio (aOR) = 0.19; 95% confidence interval (CI) 0.06-0.66]. However, the likelihood of undergoing ALND relative to SLNB was lower among rural compared to urban patients (aOR = 0.16; 95% CI 0.03-0.73).

CONCLUSIONS

Over time, the use of LNA with mastectomy has increased among DCIS patients. However, significant rural-urban differences in the use and type of LNA persist. The findings of this study highlight the importance of continued research aimed at examining the impact of rurality on the receipt of high-quality cancer care.

Long-term outcomes of women with large DCIS lesions treated with breast-conserving therapy

PURPOSE

The paucity of data on women with large (≥ 40 mm) DCIS tumors lead to uncertainty on the safety of breast-conserving surgery (BCS) for these patients. We evaluated the impact of large tumor size on local recurrence (LR) among women with DCIS treated with BCS ± radiotherapy (RT).

METHODS

Treatment and outcomes were ascertained through administrative databases for all women with DCIS in Ontario from 1994 to 2003 treated with BCS ± RT with negative margins; 82% had pathology review. Cox proportional hazards model was used to evaluate the impact of tumor size on LR. 10- and 15-year LR-free survival (LRFS) were calculated using Kaplan-Meier method.

RESULTS

The cohort includes 2049 women treated by BCS (N = 1073 with RT). Median follow-up is 14 years (IQR 9-17 years). Referenced to tumors ≤ 10 mm, the risk of LR following BCS was significantly higher for larger tumors: HR ≥ 40 mm = 3.67 (95% CI 2.13, 6.33; p < 0.001), HR 26-39 mm = 2.27 (95% CI 1.47, 3.50, p < 0.001), and HR 11-25 mm = 1.42 (95% CI 1.06, 1.92, p = 0.02). However, for individuals with BCS + RT, large tumor size was not associated with a significantly increased risk of LR (HR ≥ 40 mm = 1.92 (95% CI 0.97, 3.79); HR 26-39 mm = 1.81 (95% CI 1.09-2.99)). For women with tumors ≥ 40 mm, 10-year LRFS risk for those treated by BCS alone, BCS + RT without boost, and BCS + RT with boost was 58.9%, 82.8%, and 83.9%.

CONCLUSION

Large DCIS lesions ≥ 40 mm are associated with higher risks of LR following BCS, but high long-term LRFS rates can be achieved with the addition of breast RT.

Randomized Phase III Trial Evaluating Radiation Following Surgical Excision for Good-Risk Ductal Carcinoma In Situ: Long-Term Report From NRG Oncology/RTOG 9804

PURPOSE

To our knowledge, NRG/RTOG 9804 is the only randomized trial to assess the impact of whole breast irradiation (radiation therapy [RT]) versus observation (OBS) in women with good-risk ductal carcinoma in situ (DCIS), following lumpectomy. Long-term results focusing on ipsilateral breast recurrence (IBR), the primary outcome, are presented here.

PATIENTS AND METHODS

Eligible patients underwent lumpectomy for DCIS that was mammogram detected, size ≤ 2.5 cm, final margins ≥ 3 mm, and low or intermediate nuclear grade. Consented patients were randomly assigned to RT or OBS. Tamoxifen use was optional. Cumulative incidence was used to estimate IBR, log-rank test and Gray's test to compare treatments, and Fine-Gray regression for hazard ratios (HRs).

RESULTS

A total of six hundred thirty-six women were randomly assigned from 1999 to 2006. Median age was 58 years and mean pathologic DCIS size was 0.60 cm. Intention to use tamoxifen was balanced between arms (69%); however, actual receipt of tamoxifen varied, 58% RT versus 66% OBS (P = .05). At 13.9 years' median follow-up, the 15-year cumulative incidence of IBR was 7.1% (95% CI, 4.0 to 11.5) with RT versus 15.1% (95% CI, 10.8 to 20.2) OBS (P = .0007; HR = 0.36; 95% CI, 0.20 to 0.66); and for invasive LR was 5.4% (95% CI, 2.7 to 9.5) RT versus 9.5% (95% CI, 6.0 to 13.9) OBS (P = .027; HR = 0.44; 95% CI, 0.21 to 0.91). On multivariable analysis, only RT (HR = 0.34; 95% CI, 0.19 to 0.64; P = .0007) and tamoxifen use (HR = 0.45; 95% CI, 0.25 to 0.78; P = .0047) were associated with reduced IBR.

CONCLUSION

RT significantly reduced all and invasive IBR for good-risk DCIS with durable results at 15 years. These results are not an absolute indication for RT but rather should inform shared patient-physician treatment decisions about ipsilateral breast risk reduction in the long term following lumpectomy.

Association of the 12-Gene Breast DCIS Score® Assay With Local Recurrence in Patients With Ductal Carcinoma In Situ Treated on Accelerated Partial Breast Radiotherapy Protocols

Background

The following analysis explores clinicopathologic factors and the 12-gene Breast DCIS Score test result in order to better define an appropriate DCIS (ductal carcinoma in situ) population eligible for APBI (accelerated partial breast radiotherapy).

Methods

This exploratory analysis aimed to retrospectively measure the association between the 12-gene Oncotype DX Breast DCIS Score^® assay (Redwood City, CA) and relevant clinicopathologic factors with locoregional recurrence in a pooled cohort of women treated with local excision and APBI on prospective phase II (NCT01185145) and phase III (NCT01185132) clinical trials. Univariable Cox proportional hazards regression was used to determine whether there was an association between local recurrence and DCIS Score result risk group (≥ 39 vs < 39) and clinicopathologic factors.

Results

This analysis included 104 evaluable patients (n = 18 from NCT01185145 and n = 86 from NCT01185132). The median age was 60 years (range: 40-79). Seventy-nine percent of patients were postmenopausal. The median span of DCIS was 10 mm (range 2-45 mm). Two-thirds of the cohort presented with necrosis (71%). The distribution of DCIS Score^® results ranged from 0 to 82, with 69% of patients having a DCIS Score result < 39. The median follow-up time was 8.2 years in NCT01185145 versus 3.0 years in NCT01185132. There were 6 local ipsilateral breast recurrences. DCIS Score result was significantly associated with local recurrence in univariable modeling, hazard ratio = 10.3 (95% CI 1.7, 198.4); p = 0.010. None of the clinicopathologic characteristics resulted in any significant association with locoregional recurrence.

Conclusion

The Breast DCIS Score assay demonstrated risk stratification in this cohort of patients treated with local excision and APBI pooled from two clinical trials. These results are consistent with those recently published utilizing whole breast radiotherapy. Due to the small number of local recurrence events and limited follow-up time, further investigations are needed to confirm findings.

Prognostic Score-Based Stratification Analysis Reveals Universal Benefits of Radiotherapy on Lowering the Risk of Ipsilateral Breast Event for Ductal Carcinoma In Situ Patients with Different Risk Levels

BACKGROUND

We aimed to analyze the effects of radiotherapy (RT) on the incidence rate of ipsilateral breast event (IBE) in ductal carcinoma in situ (DCIS) patients with lumpectomy after being stratified by prognostic score.

METHODS

We identified DCIS patients who received lumpectomy, from the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2015. Cumulative incidence functions for competing risk were used to evaluate the effects of RT on IBE risk over time. Three multivariate regression models (weighted, non-weighted, and Fine-Gray) were applied to compare the IBE risk between the RT and non-RT groups after stratifying patients by prognostic score.

RESULTS

Overall, 72,623 DCIS patients were identified from the SEER database and 49,206 (66.8%) patients received RT. During the follow-up period (ranging from 7 to 347 months), the cumulative probability of invasive and in situ IBE was significantly lower in the RT group than in the non-RT group (p < 0.001). After being stratified by prognostic score, the weighted IBE incidence rate increased as the risk level increased (p < 0.050). In multivariate regression models, RT lowered the IBE incidence rate by at least 30% in low-, moderate-, and high-risk DCIS (p < 0.010). In particular, the in situ and invasive IBE incidence rate decreased by over 50% in low-risk DCIS with RT (p < 0.001).

CONCLUSIONS

RT is associated with a lowered IBE incidence rate in DCIS patients, regardless of the assigned risk levels for patients. The significant reduction in the IBE incidence rate in low-risk DCIS patients also indicates the potential benefits for recommending RT to such a patient population in clinical practice.

Ductal Carcinoma In Situ of the Breast: Perspectives on Tumor Subtype and Treatment

Objective

To evaluate ductal carcinoma in situ (DCIS) characteristics and the effect of different treatment strategies. Patients and Methods. Using data with known hormone receptor (HoR) and human epidermal growth factor receptor 2 (HER2) status obtained by the Surveillance, Epidemiology, and End Results (SEER) program from 2010-2014, the study was conducted to investigate tumor subtype-specific differences in various characteristics, overall survival (OS), and breast cancer-specific mortality (BCSM).

Results

A total of 3415 patients with DCIS were eligible. Compared with HoR+/HER- subgroup, patients with triple-negative (TN) and HoR-/HER+ were commonly higher in grade, larger in size, and tended to receive mastectomy (P < 0.05). The multivariate analysis revealed that patients with TN were more likely to have a poorer OS and show a higher breast cancer-specific mortality compared with the HoR+/HER- subgroup (P < 0.05). Multivariate analysis on the history of local treatment and surgery showed patients receiving breast-conserving surgery (BCS) plus radiotherapy (R) and BCS plus axillary lymph node dissection was likely to improve OS without affecting breast cancer-specific mortality (P < 0.05).

Conclusion

The results demonstrate that DCIS associated with TN subtype portends poor prognosis. Meanwhile, BCS plus R was a preferable option and resulted in survival rates better than those achieved with mastectomy, and SLNB should be considered as an appropriate assessment of axillary staging in patients with DCIS.

Duct carcinoma in situ: A personal perspective

In the recent past, DCIS was a rare diagnosis established by biopsy of palpable breast masses or nipple changes. Mammography increased the frequency of a DCIS diagnosis by 20 × resulting in a tsunami of small circa 10 mm lesions detected only by mammography. The impact of pathologic technique in examining and characterizing such lesions is reviewed, and the development of algorithms incorporating prognostic factors and histology based on serial sequential processing techniques are described and contrasted with those which relied on tissue sampling. The development of the initial clinical trails of irradiation all demonstrated the significant benefit of irradiation but none could identify subsets with a more favorable outcome. The latter was precluded by their common practice of tissue sampling: Size could not be calculated and margin width and microinvasion could not be reliable demonstrated. Multigene signature assays are increasingly being utilized, most prominently Oncotype DCIS. However, these assays must be interpreted in conjunction with the limitations set forth in the validating studies-in the case of Oncotype DCIS-the size, margin width, and grade which defined the baseline study (E5194). Tamoxifen and other anti-hormonal agents (aromatase inhibitor therapy) have been shown to have a limited impact on ipsilateral recurrence which makes their use given their morbidities problematic. Such interventions do impact the frequency of contralateral occult in situ and invasive lesions. In the one study which permitted a comparison of local recurrence in irradiated vs nonirradiated breast, there was no added benefit of Tamoxifen in irradiated breasts. Some are attempting to identify a low-risk subset of DCIS which can be treated without surgical re-excision for margins or adjuvant irradiation. These studies are in progress but surrogates identified within the Van Nuys prospective series defined by grade and inadequate margins (≤ 1 mm) would suggest a significant recurrence and progression rate. DCIS remains a work in progress both in terms of classification and treatment. However, limited our progress in these areas we have certainly advanced from the oft-proclaimed mantra: "Radiation and Tamoxifen are standard of care."

The impact of radiation on lymphedema: a review of the literature

Radiation therapy (RT) is a common adjunct therapy in oncology. However, it carries a significant risk of lymphedema when utilized in some anatomic locations. Recent studies have provided insight into lymphedema pathophysiology, diagnostic techniques, and RT. This review will examine the role of RT in upper and lower extremity lymphedema. Radiation's role in increasing the risk of lymphedema through decreased lymphatic proliferation potential, interstitial fibrosis compressing lymphatic vessels, and mechanical insufficiency of the lymphatic system will be reviewed.

Ductal Carcinoma In Situ and Margins <2 mm: Contemporary Outcomes With Breast Conservation

OBJECTIVE

To determine the relationship between negative margin width and locoregional recurrence (LRR) in a contemporary cohort of ductal carcinoma in situ (DCIS) patients.

BACKGROUND

Recent national consensus guidelines recommend an optimal margin width of 2 mm or greater for the management of DCIS; however, controversy regarding re-excision remains when managing negative margins <2 mm.

METHODS

One thousand four hundred ninety-one patients with DCIS who underwent breast-conserving surgery from 1996 to 2010 were identified from a prospectively managed cancer center database and analyzed using univariate and multivariate Cox proportional hazard models to determine the relationship between negative margin width and LRR with or without adjuvant radiation therapy (RT).

RESULTS

A univariate analysis revealed that age <40 years (n = 89; P = 0.02), no RT (n = 298; P = 0.01), and negative margin width <2 mm (n = 120; P = 0.005) were associated with LRR. The association between margin width and LRR differed by adjuvant RT status (interaction P = 0.02). There was no statistical significant difference in LRR between patients with <2 mm and ≥2 mm negative margins who underwent RT (10-yr LRR rate, 4.8% vs 3.3%, respectively; hazard ratio, 0.8; 95% CI, 0.2-3.2; P = 0.72). For patients who did not undergo RT, those with margins <2 mm were significantly more likely to develop a LRR than were those with margins ≥2 mm (10-yr LRR rate, 30.9% vs 5.4%, respectively; hazard ratio, 5.5; 95% CI, 1.8-16.8, P = 0.003).

CONCLUSIONS

Routine additional surgery may not be justified for patients with negative margins <2 mm who undergo RT but should be performed in patients who forego RT.

Cause-specific Mortality in a Population-based Cohort of 9799 Women Treated for Ductal Carcinoma In Situ

Supplemental Digital Content is available in the text

Objective:

To assess cause-specific mortality in women treated for ductal carcinoma in situ (DCIS).

Background:

From screening and treatment perspective, it is relevant to weigh the low breast cancer mortality after DCIS against mortality from other causes and expected mortality in the general population.

Methods:

We conducted a population-based cohort study comprising 9799 Dutch women treated for primary DCIS between 1989 and 2004 and estimated standardized mortality ratios (SMRs).

Results:

After a median follow up of 9.8 years, 1429 patients had died of whom 284 caused by breast cancer (2.9% of total cohort). DCIS patients <50 years experienced higher mortality compared with women in the general population (SMR 1.7; 95% confidence interval, CI: 1.4–2.0), whereas patients >50 had significantly lower mortality (SMR 0.9; 95% CI: 0.8–0.9). Overall, the risk of dying from general diseases and cancer other than breast cancer was lower than in the general population, whereas breast cancer mortality was increased. The SMR for breast cancer decreased from 7.5 (95% CI: 5.9–9.3) to 2.8 (95% CI: 2.4–3.2) for women aged <50 and >50 years, respectively. The cumulative breast cancer mortality 10 years after DCIS was 2.3% for women <50 years and 1.4% for women >50 years treated for DCIS between 1999 and 2004.

Conclusions:

DCIS patients >50 years had lower risk of dying from all causes combined compared with the general female population, which may reflect differences in health behavior. Women with DCIS had higher risk of dying from breast cancer than the general population, but absolute 10-year risks were low.

Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies

Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.

Oncoplastic Level 2 Mammoplasty for Large DCIS: 5-Year Results

BACKGROUND

Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS).

METHOD

From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up.

RESULTS

The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p < 0.001). On multivariable analysis, only tumor size > 50 mm [odds ratio (OR) 95.400; p < 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%).

CONCLUSIONS

OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.

The axillary flap in oncoplastic resection of breast cancers located in the upper-outer quadrants: a new surgical technique

Background

The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.

Methods

During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.

Results

At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.

Conclusions

The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.

Sweet syndrome induced by radiations during breast cancer treatment

During the follow-up of a woman treated by radiotherapy for an in situ carcinoma of her left breast, radio-induced skin lesions were diagnosed. They appeared not to be simple radiodermatitis but radio-induced Sweet syndrome. Discussions were led on the benefit of completing the last session of radiotherapy for such a low-grade malignancy while considering the risk of complication from radio-induced disease. General and local corticotherapy rapidly eradicated the fever and asthenia, while the skin lesions disappeared gradually. Moreover, biological improvement was noticed. The presented features of Sweet syndrome are almost similar in their initial phase to the radiodermatitis that is seen in common medical conditions.

Is pectus excavatum a risk factor for radiation-induced lung disease in patients undergoing radiation therapy following breast-conserving surgery?

Background

The relationship between radiation dose to the ipsilateral lung and subsequent radiation‐induced lung disease (RILD) in breast cancer patients with pectus excavatum (PE) undergoing radiation therapy (RT) to residual breast tissue after breast‐conserving surgery has not yet been established. The incidence of RILD in such patients with PE, meaning that a large volume of the lung is within the radiation field, has not been determined. Therefore, the aim of this study was to determine the relationship between these factors.

Methods

The study cohort comprised 133 women who underwent three‐dimensional conformal RT to residual breast tissue after breast‐conserving surgery for breast cancer. Diagnoses of PE were based on Haller's, frontosagittal, and Monden's depression indices. Radiation doses to the ipsilateral lung were established from dose‐volume histograms.

Results

Fifty of the 133 participants (37.6%) were diagnosed with RILD; all were asymptomatic. Multivariate analysis revealed a significant correlation between the incidence of RILD and the administration of > 30 Gy (V30). Surprisingly, although patients with PE received higher ipsilateral lung doses, they were less likely to develop RILD than those without PE.

Conclusions

Our data indicate that the incidence of RILD is correlated with the administration of > 30 Gy (V30) and that PE is not a risk factor for RILD after RT to residual breast tissue after breast‐conserving surgery for breast cancer. Surprisingly, individuals with PE may have a lower incidence of RILD than those without this condition.

Clinical Trials for Ductal Carcinoma In Situ of the Breast

Ductal carcinoma in situ (DCIS) of the breast is a non-obligatory precursor to invasive breast carcinoma, with a variable natural history and biological potential for progression to invasive disease. Over the past 30 years, clinical trials have applied the therapeutic principles used for invasive carcinoma to treat DCIS (surgery, with or without breast radiotherapy, and post-operative endocrine therapy), with excellent survival outcomes, and in-breast recurrence rates that range from 0.5 to 1% annually. However, half of such recurrences are again in-situ lesions, and intensive therapy is likely not necessary for all patients. Current clinical research is focused on a better characterization of the potential of individual lesions to progress to invasive disease, and to identify women who would do well with lesser treatment. Three ongoing trials in the United States and Europe randomize women to active surveillance (with or without endocrine therapy) versus usual treatment with surgery and radiotherapy. The use of pre-operative endocrine therapy has been evaluated in a recently completed trial of letrozole use in postmenopausal women with DCIS; and in on-going trials of tamoxifen, used either orally, or as a 4-hydroxytamoxifen gel formulation for application to the breast skin. This review summaries the major past and current clinical trials of DCIS, and the likely trajectories of DCIS management in the near future.

Reconstruction in Breast Conservation Therapy-Single Tertiary Care Institution Experience with 472 Patients

Breast conservation therapy (BCT) is now internationally accepted treatment for early breast cancer. Despite of high incidence of carcinoma breast in India, BCT rates are very low as compared to the west. In this article, we wish to share our experience of breast conservation with oncoplasty in Indian women. A retrospective analysis of case records of patients treated with oncoplastic breast conservation from January 2009 to June 2014 in a single surgical oncology unit in a tertiary cancer institute. Demographic patient data, stage of disease, location of primary tumour, use of neo-adjuvant chemotherapy if received, tumour size and breast size ratio, reconstruction method used, post-operative complications and aesthetic score of patients were analysed. Various methods of oncoplasty and partial breast reconstruction used are discussed. Four hundred and seventy-two patient records were found suitable for analysis. Most common stage of presentation was T2N0 in 189 patients (40%). Forty-one patients received neo-adjuvant chemotherapy (NACT). Tumour arising in upper outer quadrant was most common site, seen in 268 (56.7%). The most common method of reconstruction was volume displacement, done in 57.6% patients. Overall surgical complications included wound infection with or without dehiscence, seroma formation, partial flap necrosis and fat necrosis. Cosmesis was found to be excellent in 23.09% and good in 58.47% at 6-month follow-up. Breast conservation with oncoplasty is oncologically safe for early breast cancer treatment and has good cosmetic outcome with high patient satisfaction rates. Its practice should be encouraged in Indian set-up also.

American Society of Breast Surgeons' Practice Patterns After Publication of the SSO-ASTRO-ASCO DCIS Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation

BACKGROUND

The SSO-ASTRO-ASCO consensus guideline on margins for breast-conserving surgery with whole breast irradiation in ductal carcinoma in situ (DCIS) recommended a 2-mm margin. We sought to determine the impact of guideline publication on clinician practice.

METHODS

A total of 3081 members of the American Society of Breast Surgeons (ASBrS) received a survey. Respondents' clinical practice type and duration, guideline familiarity, and margin width preferences before and after publication were assessed. Clinical practice pattern differences before and after publication were investigated using McNemar's test.

RESULTS

A total of 767 (24.9%) of those surveyed responded. Most (92.4%) indicated guideline familiarity. Of those familiar, re-excision preference for DCIS and a positive margin remained the same before (94.4%) and after (94.3%) publication (McNemar's test p = 1.0). Following publication, surgeons were more likely to avoid re-excision to achieve margins wider than 2-mm (82.3% pre versus 87.5% post, p = 0.002). More surgeons performed re-excision for a close margin with pure DCIS (25.9% pre versus 36.5% post, p < 0.001) and with DCIS with microinvasion (DCIS-M) (40.7% pre versus 52.3% post, p < 0.001). For patients with invasive disease with extensive intraductal component (EIC) and a close margin, preference to avoid re-excision was similar (51.2% per versus 55.2% post, p = 0.071).

CONCLUSION

Since guideline publication, surgeons are less likely to perform re-excision to obtain a margin greater than 2-mm and more likely to perform re-excision to obtain a 2-mm margin for both pure DCIS and DCIS-M. Preference to avoid re-excision with a close margin and EIC was similar before and after publication.

Risk of ischemic heart disease after radiotherapy for ductal carcinoma in situ

PURPOSE

The use of adjuvant radiotherapy (RT) in the management of ductal carcinoma in situ (DCIS) is increasing. Left-sided breast irradiation may involve exposure of the heart to ionising radiation, increasing the risk of ischemic heart disease (IHD). We examined the incidence of IHD in a population-based cohort of women with DCIS.

METHODS

The Breast Cancer DataBase Sweden (BCBase) cohort includes women registered with invasive and in situ breast cancers 1992-2012 and age-matched women without a history of breast cancer. In this analysis, 6270 women with DCIS and a comparison cohort of 31,257 women were included. Through linkage with population-based registers, data on comorbidity, socioeconomic status and incidence of IHD was obtained. Hazard ratios (HR) for IHD with 95% confidence intervals (CI) were analysed.

RESULTS

Median follow-up time was 8.8 years. The risk of IHD was not increased for women with DCIS versus women in the comparison cohort (HR 0.93; 95% CI 0.82-1.06), after treatment with radiotherapy versus surgery alone (HR 0.77; 95% CI 0.60-0.98) or when analysing RT by laterality (HR 0.85; 95% CI 0.53-1.37 for left-sided versus right-sided RT).

CONCLUSIONS

The risk of IHD was lower for women with DCIS allocated to RT compared to non-irradiated women and to the comparison cohort, probably due to patient selection. Comparison of RT by laterality did not show any over-risk for irradiation of the left breast.

Margins in breast cancer: How much is enough?

The appropriate negative margin width for women undergoing breast-conserving surgery for both ductal carcinoma in situ (DCIS) and invasive carcinoma is controversial. This review examines the available data on the margin status for invasive breast cancer and DCIS, and highlights the similarities and differences in tumor biology and standard treatments that affect the local recurrence (LR) risk and, therefore, the optimal surgical margin. Consensus guidelines support a negative margin, defined as no ink on tumor, for invasive carcinoma treated with breast-conserving therapy. Because of differences in the growth pattern and utilization of systemic therapy, a margin of 2 mm has been found to minimize the LR risk for women with DCIS undergoing lumpectomy and radiation therapy (RT). Wider negative margins do not improve local control for DCIS or invasive carcinoma when they are treated with lumpectomy and RT. Re-excision for negative margins should be individualized, and the routine practice of performing additional surgery to obtain a wider negative margin is not supported by the literature. Cancer 2018;124:1335-41. © 2018 American Cancer Society.

Hypofractionated volumetric modulated arc therapy in ductal carcinoma in situ: toxicity and cosmetic outcome from a prospective series

OBJECTIVE

Hypofractionated radiotherapy in early stage breast cancer is an effective adjuvant treatment, but there is a lack of randomized data for patients with ductal carcinoma in situ (DCIS). The aim of this study is the evaluation of skin toxicity and cosmesis, and early clinical outcome of DCIS patients enrolled in an institutional Phase II trial of hypofractionated breast irradiation.

METHODS

137 DCIS patients were enrolled in the trial. All patients underwent volumetric modulated arc therapy (VMAT) to the whole breast with a total dose of 40.5 Gy in 15 fractions over 3 weeks, without tumour bed boost. Acute and late skin toxicities were recorded. Cosmetic outcomes were assessed as excellent/good or fair/poor. Early clinical outcome was reported.

RESULTS

Median age was 58 y.o. (range 30-86). The median follow-up time was 22 months (range 6-45). At the end of the radiotherapy, skin toxicity was grade G1 in 56% of the patients, G2 in 15%, no patients presented G3 toxicity. In the range of 3-9 months of follow-up, the skin toxicity was G1 in 28% of patients, no G2-G3 cases; cosmetic outcome was good/excellent in 95% of patients. In the follow-up interval of 9-24 months, the skin toxicity was G1 in 12% of patients, no G2-G3 toxicity; cosmetic outcome was good/excellent in 96% of patients. After an early evaluation of clinical outcomes, 5 patients (3.6%) presented an in-breast recurrence.

CONCLUSION

Hypofractionated radiotherapy using VMAT is a viable option for DCIS. A longer follow-up is needed to assess clinical outcomes and late toxicity. Advances in knowledge: The use of hypofractionated VMAT is dosimetrically feasible for treating breast DCIS.

Breast carcinoma in situ: An observational study of tumor subtype, treatment and outcomes

Background & Aims

To evaluate the clinical presentation, treatment and outcome of patients with breast carcinoma in situ (BCIS) with special emphasis on the role of the tumor subtype and local treatment in these patients.

Methods

Using data obtained by the Surveillance, Epidemiology, and End Results (SEER) program from 2010-2013, a retrospective, population-based cohort study was conducted to investigate tumor subtype-specific differences in various characteristics, overall survival (OS) and breast cancer-specific mortality (BCSM).

Results

In all, 6867 patients with BCIS were eligible during the 2010-2013 study period. Compared with the hormone receptor (HoR)+/HER- subgroup, patients with triple negative (TN) breast cancer were more likely to have tumors that were higher in grade and larger in size; they were also more likely to have tumors with ductal and comedo histology and were less likely to have tumors with cribriform and papillary histology (each P < 0.05). During the follow-up period, patients with TN breast cancer had an OS of 97.0% compared with 98.6 % in the HoR+/HER- subgroup (P < 0.05). Furthermore, the BCSM rate was 1.0% for the TN group compared with 0.1% for the HoR+/HER- subgroup (P < 0.05). Multivariate analysis revealed that patients with TN MBC had a poorer OS and BCSM (P <0.05). Multivariate analysis of OS with respect to the local treatment history showed that patients who received breast-conserving surgery (BCS) combined with radiotherapy (R) were more likely to have an improved OS (P < 0.05). Moreover, the results demonstrated that patients who underwent SLNB were more likely to have a lower BCSM (P < 0.05).

Conclusions

The results demonstrate that BCIS appears to alter the prognosis associated with the TN subtype. Meanwhile, BCS plus R was a preferable option and resulted in survival rates that were better than those achieved with mastectomy; thus, SLNB should be considered as an appropriate assessment of axillary staging in patients with BCIS.

Genomic Assays in Ductal Carcinoma In Situ: Implications for Management Decisions

OBJECTIVES

Breast cancer is the most common cancer in women and a leading cause of cancer death worldwide. The management of breast cancer depends on clinical and pathologic prognostic factors that help guide patient treatment. Ductal carcinoma in situ (DCIS) is a noninvasive form of breast cancer with an unpredictable risk of either progression to invasive disease or recurrence. To evaluate the utilization of the DCIS score in a large single-institution population and understand reasons for avoidance in eligible patients.

METHODS

A retrospective chart review of eligible patients with pure DCIS treated by lumpectomy (January 2011-May 2015) was performed. Patients were considered eligible for the assay if they met the Eastern Cooperative Oncology Group E5194 pathology criteria. All of the patients underwent breast-conserving surgery and were estrogen receptor positive.

RESULTS

Of 182 estrogen receptor-positive patients with DCIS who underwent breast-conserving surgery, 31 (17%) had a DCIS assay performed; however, most of the patients did not have a DCIS score assay performed, yet 47.9% of this cohort would have met the pathologic eligibility criteria. Conversely, 82.5% of the patients having the DCIS score evaluated actually met these criteria.

CONCLUSIONS

Tumor size, grade, ER status, and calcifications were drivers of patient selection for 12-gene assay use. E5194 eligibility criteria selected for low risk population. Although a large proportion of patients met eligibility criteria, DCIS Score was infrequently considered for recurrence risk estimation. When performed, assay scores supported omission of radiation for over 75% of cases.

Evaluating the efficacy of post-surgery adjuvant therapies used for ductal carcinoma in situ patients: a network meta-analysis

OBJECTIVE

Post-surgery adjuvant therapies are very important for patients suffering from ductal carcinoma in situ (DCIS). In this study we conducted a network meta-analysis (NMA) to evaluate the efficacy of different post-surgery adjuvant therapies including tamoxifen, anastrozole and radiation therapy (RT) and their combinations (RT+ tamoxifen and RT+ anastrozole).

METHODS

We searched several databases, including Embase, MEDLINE / PUBMED, Cochrane Library, and Science Citation Index, for relevant studies. We then extracted the data from eligible studies in order to perform our NMA. We measured the comparative efficacy of each treatment option based on the calculated odds ratios (ORs) and the corresponding 95% credibility interval (95%CrI) for each treatment option. We calculated the surfaces under the cumulative ranking curves (SUCRA) in order to rank the therapies according to their different outcomes.

RESULTS

In this study, local recurrence (LC) was chosen as the primary outcome. Metastasis, contralateral-breast cancer (CBC), ipsilateral-breast cancer (IBC) and death were secondary outcomes. Patients treated with RT and RT + tamoxifen exhibited a lower risk of LC compared with control group (OR=0.54, 95%CrI: 0.40-0.73; OR=0.41, 95%CrI: 0.19-0.90). Patients treated by RT and RT + tamoxifen also exhibited a significantly lower risk of IBC compared with control group (OR=0.55, 95%CrI: 0.37-0.82; OR=0.42, 95%CrI: 0.18-0.99). Results from the SUCRA indicated that RT + anastrozole and RT + tamoxifen were potentially the best adjuvant treatments for patients with DCIS.

CONCLUSIONS

In conclusion, the RT + anastrozole and RT + tamoxifen are recommended for their performance and effectiveness.

Delay in radiotherapy is associated with an increased risk of disease recurrence in women with ductal carcinoma in situ

BACKGROUND

The current study was conducted to examine the association between ipsilateral breast tumor recurrence (IBTR) and the timing of radiotherapy (RT) in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery (BCS).

METHODS

Women with DCIS who were treated with BCS and RT from 1980 through 2010 were identified from a prospectively maintained database. IBTR rates, measured from the time of RT completion, were compared between those who initiated RT ≤8 weeks, >8 to 12 weeks, and >12 weeks after the completion of surgery. The association between RT timing and IBTR was evaluated by Kaplan-Meier and log-rank analyses; Cox modeling was used for multivariable analysis.

RESULTS

A total of 1323 women met the inclusion criteria. The median follow-up was 6.6 years, with 311 patients followed for ≥10 years. A total of 126 IBTR events occurred. Patients were categorized by RT timing: 806 patients (61%) with timing of ≤8 weeks, 386 patients (29%) with timing of >8 to 12 weeks, and 131 patients (10%) with timing >12 weeks. The 5-year and 10-year IBTR rates were 5.8% and 13.0%, respectively, for RT starting ≤8 weeks after surgery; 3.8% and 7.6%, respectively, for RT starting >8 to 12 weeks after surgery; and 8.8% and 23.0%, respectively, for an RT delay >12 weeks after surgery (P = .004). On multivariable analysis, menopause (hazard ratio [HR], 0.54; P = .0009) and endocrine therapy (HR, 0.45; P = .002) were found to be protective against IBTR, whereas a delay in RT >12 weeks compared with ≤8 weeks was associated with a higher risk of IBTR (HR, 1.92; P = .014). There was no difference in IBTR noted between RT initiation at ≤8 weeks and initiation at >8 to 12 weeks after BCS (P = .3).

CONCLUSIONS

A delay in RT >12 weeks is associated with a significantly higher risk of IBTR in women undergoing BCS for DCIS. Efforts should be made to avoid delays in starting RT to minimize the risk of disease recurrence. Cancer 2018;124:46-54. © 2017 American Cancer Society.