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Chen Q, Campbell I, Elwood M, Cavadino A, Aye PS, Tin Tin S. Outcomes from low-risk ductal carcinoma in situ: a systematic review and meta-analysis. Breast Cancer Res Treat 2024; 208:237-251. [PMID: 39180592 PMCID: PMC11457553 DOI: 10.1007/s10549-024-07473-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
PURPOSE The current standard of treatment for ductal carcinoma in situ (DCIS) is surgery with or without adjuvant radiotherapy. With a growing debate about overdiagnosis and overtreatment of low-risk DCIS, active surveillance is being explored in several ongoing trials. We conducted a systematic review and meta-analysis to evaluate the recurrence of low-risk DCIS under various treatment approaches. METHODS PubMed, Embase, Web of Science, and Cochrane were searched for studies reporting ipsilateral breast tumour event (IBTE), contralateral breast cancer (CBC), and breast cancer-specific survival (BCSS) rates at 5 and 10 years in low-risk DCIS. The primary outcome was invasive IBTE (iIBTE) defined as invasive progression in the ipsilateral breast. RESULTS Thirty three eligible studies were identified, involving 47,696 women with low-risk DCIS. The pooled 5-year and 10-year iIBTE rates were 3.3% (95% confidence interval [CI]: 1.3, 8.1) and 5.9% (95% CI: 3.8, 9.0), respectively. The iIBTE rates were significantly lower in patients who underwent surgery compared to those who did not, at 5 years (3.5% vs. 9.0%, P = 0.003) and 10 years (6.4% vs. 22.7%, P = 0.008). Similarly, the 10-year BCSS rate was higher in the surgery group (96.0% vs. 99.6%, P = 0.010). In patients treated with breast-conserving surgery, additional radiotherapy significantly reduced IBTE risk, but not total-CBC risk. CONCLUSION This review showed a lower risk of progression and better survival in women who received surgery and additional RT for low-risk DCIS. However, our findings were primarily based on observational studies, and should be confirmed with the results from the ongoing trials.
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Affiliation(s)
- Qian Chen
- Faculty of Medical and Health Sciences, Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Ian Campbell
- Faculty of Medical and Health Sciences, Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mark Elwood
- Faculty of Medical and Health Sciences, Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Alana Cavadino
- Faculty of Medical and Health Sciences, Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Phyu Sin Aye
- Faculty of Medical and Health Sciences, Department of Pharmacology, University of Auckland, Auckland, New Zealand
| | - Sandar Tin Tin
- Faculty of Medical and Health Sciences, Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand.
- Cancer Epidemiology Unit, Oxford Population Health, The University of Oxford, Oxford, UK.
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2
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Almeida ND, Pepin A, Schrand TV, Shekher R, Goulenko V, Fung-Kee-Fung S, Farrugia MK, Shah C, Singh AK. Re-Evaluating the Omission of Radiation Therapy in Low-Risk Patients With Early-Stage Breast Cancer. Clin Breast Cancer 2024; 24:563-574. [PMID: 39179441 DOI: 10.1016/j.clbc.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/06/2024] [Accepted: 07/13/2024] [Indexed: 08/26/2024]
Abstract
Traditionally, management of early-stage breast cancer has required adjuvant radiation therapy following breast conserving surgery, due to decreased local recurrence and breast cancer mortality. However, over the past decade, there has been an increasing emphasis on potential overtreatment of patients with early-stage breast cancer. This has given rise to questions of how to optimize deintensification of treatment in this cohort of patients while maintaining clinical outcomes. A multitude of studies have focused on identification of a subset of patients with invasive breast cancer who were at low risk of local recurrence based on clinicopathologic features and therefore suitable for RT omission. These studies have failed to identify a subset that does not from RT with respect to local control. Several ongoing trials are evaluating alternative approaches to deintensification while focusing on tumor biology. With regards to ductal carcinoma in situ (DCIS), the role of RT has been questioned since breast conservation was utilized. Paralleling invasive disease studies, studies have sought to use clinicopathologic features to identify low risk patients suitable for RT omission but have failed to identify a subset that does not from RT with respect to local control. Use of new assays in patients with DCIS may represent the ideal approach for risk stratification and appropriate deintensification. At this time, when considering deintensification, individualizing treatment decisions with a focus on shared decision making is paramount.
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MESH Headings
- Humans
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Female
- Radiotherapy, Adjuvant/methods
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Recurrence, Local/pathology
- Mastectomy, Segmental
- Neoplasm Staging
- Risk Assessment
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Affiliation(s)
- Neil D Almeida
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Abigail Pepin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Tyler V Schrand
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY; Department of Chemistry, Bowling Green State University, Bowling Green, OH
| | - Rohil Shekher
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Victor Goulenko
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Simon Fung-Kee-Fung
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mark K Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
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3
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Choi BH, Kang S, Cho N, Kim SY. A Nomogram Using Imaging Features to Predict Ipsilateral Breast Tumor Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ. Korean J Radiol 2024; 25:876-886. [PMID: 39344545 PMCID: PMC11444850 DOI: 10.3348/kjr.2024.0268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 10/01/2024] Open
Abstract
OBJECTIVE To develop a nomogram that integrates clinical-pathologic and imaging variables to predict ipsilateral breast tumor recurrence (IBTR) in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS). MATERIALS AND METHODS This retrospective study included consecutive women with DCIS who underwent BCS at two hospitals. Patients who underwent BCS between 2003 and 2016 in one hospital and between 2005 and 2013 in another were classified into development and validation cohorts, respectively. Twelve clinical-pathologic variables (age, family history, initial presentation, nuclear grade, necrosis, margin width, number of excisions, DCIS size, estrogen receptor, progesterone receptor, radiation therapy, and endocrine therapy) and six mammography and ultrasound variables (breast density, detection modality, mammography and ultrasound patterns, morphology and distribution of calcifications) were analyzed. A nomogram for predicting 10-year IBTR probabilities was constructed using the variables associated with IBTR identified from the Cox proportional hazard regression analysis in the development cohort. The performance of the developed nomogram was evaluated in the external validation cohort using a calibration plot and 10-year area under the receiver operating characteristic curve (AUROC) and compared with the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram. RESULTS The development cohort included 702 women (median age [interquartile range], 50 [44-56] years), of whom 30 (4%) women experienced IBTR. The validation cohort included 182 women (48 [43-54] years), 18 (10%) of whom developed IBTR. A nomogram was constructed using three clinical-pathologic variables (age, margin, and use of adjuvant radiation therapy) and two mammographic variables (breast density and calcification morphology). The nomogram was appropriately calibrated and demonstrated a comparable 10-year AUROC to the MSKCC nomogram (0.73 vs. 0.66, P = 0.534) in the validation cohort. CONCLUSION Our nomogram provided individualized risk estimates for women with DCIS treated with BCS, demonstrating a discriminative ability comparable to that of the MSKCC nomogram.
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Affiliation(s)
- Bo Hwa Choi
- Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Soohee Kang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Nariya Cho
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Soo-Yeon Kim
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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4
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Hahn E, Sutradhar R, Paszat L, Nguyen L, Rodin D, Nofech-Mozes S, Trebinjac S, Jerzak KJ, Fong C, Rakovitch E. Molecular Expression Assays Improve the Prediction of Local and Invasive Local Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ. J Clin Oncol 2024; 42:3196-3206. [PMID: 38941575 DOI: 10.1200/jco.23.02276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/05/2024] [Accepted: 04/17/2024] [Indexed: 06/30/2024] Open
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) is routinely treated with adjuvant radiotherapy (RT) after breast-conserving surgery (BCS). The inability to accurately estimate an individual's risk of local recurrence (LR) and invasive LR using clinicopathologic factors (CPF) contributes to the overtreatment of DCIS. We examined the impact of the 12-gene DCIS Score (DS) and the 21-gene Recurrence Score (RS) on the accuracy of predicting LR and invasive LR. METHODS A population-based cohort diagnosed with pure DCIS treated with BCS ± RT from 1994 to 2003 was used. All patients had expert pathology review and assessment of the DS and RS. Predictive models (CPF alone, DS + CPF, and RS + CPF) were developed using multivariable Cox regression analyses to predict 10-year LR and invasive LR risks. Models were evaluated on the basis of c-statistic, -2log likelihood estimate (-2LLE), and Akaike information criterion. Calibration was performed using bootstrap resamples, with replacement. RESULTS The cohort includes 1,226 women treated with BCS; 712 received RT. 194 women (15.8%) experienced ipsilateral LR as a first event; 112 were invasive. Models including the DS or RS performed better in predicting the 10-year risk of LR compared with models on the basis of CPF alone with excellent calibration. The two molecular-based models also performed better in predicting invasive LR compared with the CPF model but the model incorporating the RS did not perform better in the prediction of invasive LR compared with the DS-based model. CONCLUSION Models incorporating the DS or RS more accurately predicted the 10-year risk of LR and invasive LR after BCS compared with models on the basis of CPF alone. Inclusion of the RS, compared with DS, did not improve the prediction of the 10-year risk of invasive LR.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/surgery
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Middle Aged
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/genetics
- Aged
- Radiotherapy, Adjuvant
- Adult
- Neoplasm Invasiveness
- Gene Expression Profiling
- Predictive Value of Tests
- Risk Assessment
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Affiliation(s)
- Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Rinku Sutradhar
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Lawrence Paszat
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sabina Trebinjac
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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5
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Warren LEG, Bellon JR. Individualized Local Recurrence Estimates for Ductal Carcinoma In Situ. J Clin Oncol 2024; 42:3167-3169. [PMID: 38991176 DOI: 10.1200/jco.24.00962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 07/13/2024] Open
Affiliation(s)
- Laura E G Warren
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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6
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Vicini F, Shah C, Mittal K, Abraham J, Kruse M, Weinmann S, Leo M, Rabinovitch R, Wärnberg F, Whitworth PW, Czerniecki BJ, Shivers SC, Bremer T. A 7-Gene Biosignature for Ductal Carcinoma in situ of the Breast Identifies Subpopulations of HER2-positive Patients With Distinct Recurrence Rates After Breast-Conserving Surgery and Radiation Therapy. Clin Breast Cancer 2024:S1526-8209(24)00227-1. [PMID: 39353799 DOI: 10.1016/j.clbc.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 07/25/2024] [Accepted: 08/19/2024] [Indexed: 10/04/2024]
Abstract
PURPOSE A subpopulation of women with ductal carcinoma in situ (DCIS) remains at risk for in-breast recurrence (IBR) following breast-conserving surgery (BCS) and radiation therapy (RT). The NSABP B-43 trial evaluated the role of concurrent RT and trastuzumab in patients with HER2-positive DCIS but did not reach the prespecified endpoint. We hypothesized that a 7-gene biosignature (DCISionRT) with its Residual Risk subtype (RRt) could identify 2 groups of HER2(3+) patients with significantly different IBR risks after BCS plus RT. PATIENTS AND METHODS All patients with HER2(3+) DCIS (n = 178) treated with BCS plus RT were selected from a combined multinational patient cohort. Treatment decisions were neither randomized nor strictly rules-based. Biosignature testing was performed on all patients and stratified with previously defined groups: (1) Combined Low Risk group (DS ≤ 2.8) and Elevated Risk group (DS > 2.8) without RRt or (2) Residual Risk subtype. Kaplan-Meier analysis was used to compute IBR curves. RESULTS Sixty-three percent of HER2(3+) patients (113/178) were classified into the Residual Risk subtype. These patients had significantly higher 10-year rates of IBR compared to the nonresidual risk group (16.2% vs. 1.6%, P = .01). The Residual Risk subtype had more nuclear grade 3 disease (87% vs. 63%, P < .001), but age, size, and grade were not associated with IBR rate (P = NS) on univariate and multivariable analysis. Only the Residual Risk group was associated with IBR (P = .05) in multivariate analysis. CONCLUSION The 7-gene biosignature with RRt identified a subset of HER2(3+) patients with greater IBR rates following BCS and RT beyond traditional clinical and pathologic features. Consideration of therapies to reduce these elevated IBR rates should be evaluated, including the incorporation of HER2-targeted therapy.
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Affiliation(s)
- Frank Vicini
- Michigan Healthcare Professionals, Farmington Hills, MI.
| | - Chirag Shah
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | | | - Jame Abraham
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Megan Kruse
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | | | - Michael Leo
- Kaiser Permanente Northwest Research Center, Portland, OR
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7
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Kanbayashi C, Iwata H. Update on the management of ductal carcinoma in situ of the breast: current approach and future perspectives. Jpn J Clin Oncol 2024:hyae122. [PMID: 39223698 DOI: 10.1093/jjco/hyae122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
The standard treatment for ductal carcinoma in situ became well established through the results of several valuable clinical trials, and its therapeutic benefits have now come to be taken for granted. Ductal carcinoma in situ has an extremely good prognosis with the current treatment approach, with a 10-year breast cancer-specific survival rate of 97-98%. According to one retrospective cohort study, the breast cancer-specific survival rate of patients with low-grade ductal carcinoma in situ does not differ significantly between patients undergoing and not undergoing surgery. Some patients with ductal carcinoma in situ are not at a risk of progression to invasive cancer, but the predictors of such progression have not yet been clearly identified. Therefore, the same therapeutic strategies have been used to treat ductal carcinoma in situ and under the assumption that they have risks of invasive breast cancer, and a well-balanced risk/benefit ratio in respect of treatment has not yet been achieved. Based on the results of several recent clinical trials aimed at ensuring provision of a well-balanced treatment for patients with ductal carcinoma in situ which carries a good prognosis, de-escalation of postoperative adjuvant therapy has now begun. Currently, not only is the optimization of postoperative adjuvant therapy accelerating, but also clinical trials to de-escalate basic surgical treatments are under way. There is a possibility of achieving individualized treatment for patients with ductal carcinoma in situ of the breast with reduced treatment intervention. In this review, we present an overview of the current treatment approaches and potential future management strategies for ductal carcinoma in situ of the breast.
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Affiliation(s)
- Chizuko Kanbayashi
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hiroji Iwata
- Department of Medical Research and Developmental Strategy, Core Laboratory, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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8
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Shah C, Whitworth P, Vicini FA, Narod S, Gerber N, Jhawar SR, King TA, Mittendorf EA, Willey SC, Rabinovich R, Gold L, Brown E, Patel A, Vargo J, Barry PN, Rock D, Friedman N, Bedi G, Templeton S, Brown S, Gabordi R, Riley L, Lee L, Baron P, Majithia L, Mirabeau-Beale KL, Reid VJ, Hirsch A, Hwang C, Pellicane J, Maganini R, Khan S, MacDermed DM, Small W, Mittal K, Borgen P, Cox C, Shivers SC, Bremer T. The Clinical Utility of a 7-Gene Biosignature on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery: An Updated Analysis of the DCISionRT ® PREDICT Study. Ann Surg Oncol 2024; 31:5919-5928. [PMID: 38916700 PMCID: PMC11300542 DOI: 10.1245/s10434-024-15566-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/13/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Breast-conserving surgery (BCS) followed by adjuvant radiotherapy (RT) is a standard treatment for ductal carcinoma in situ (DCIS). A low-risk patient subset that does not benefit from RT has not yet been clearly identified. The DCISionRT test provides a clinically validated decision score (DS), which is prognostic of 10-year in-breast recurrence rates (invasive and non-invasive) and is also predictive of RT benefit. This analysis presents final outcomes from the PREDICT prospective registry trial aiming to determine how often the DCISionRT test changes radiation treatment recommendations. METHODS Overall, 2496 patients were enrolled from February 2018 to January 2022 at 63 academic and community practice sites and received DCISionRT as part of their care plan. Treating physicians reported their treatment recommendations pre- and post-test as well as the patient's preference. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendation. The impact of the test on RT treatment recommendation was physician specialty, treatment settings, individual clinical/pathological features and RTOG 9804 like criteria. Multivariate logisitc regression analysis was used to estimate the odds ratio (ORs) for factors associated with the post-test RT recommendations. RESULTS RT recommendation changed 38% of women, resulting in a 20% decrease in the overall recommendation of RT (p < 0.001). Of those women initially recommended no RT (n = 583), 31% were recommended RT post-test. The recommendation for RT post-test increased with increasing DS, from 29% to 66% to 91% for DS <2, DS 2-4, and DS >4, respectively. On multivariable analysis, DS had the strongest influence on final RT recommendation (odds ratio 22.2, 95% confidence interval 16.3-30.7), which was eightfold greater than clinicopathologic features. Furthermore, there was an overall change in the recommendation to receive RT in 42% of those patients meeting RTOG 9804-like low-risk criteria. CONCLUSIONS The test results provided information that changes treatment recommendations both for and against RT use in large population of women with DCIS treated in a variety of clinical settings. Overall, clinicians changed their recommendations to include or omit RT for 38% of women based on the test results. Based on published clinical validations and the results from current study, DCISionRT may aid in preventing the over- and undertreatment of clinicopathological 'low-risk' and 'high-risk' DCIS patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03448926 ( https://clinicaltrials.gov/study/NCT03448926 ).
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MESH Headings
- Humans
- Female
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Mastectomy, Segmental
- Middle Aged
- Radiotherapy, Adjuvant
- Prognosis
- Prospective Studies
- Aged
- Follow-Up Studies
- Neoplasm Recurrence, Local/pathology
- Clinical Decision-Making
- Adult
- Decision Making
- Biomarkers, Tumor
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Pat Whitworth
- Nashville Breast Center, Nashville, TN, USA
- PreludeDX, Laguna Hills, CA, USA
| | - Frank A Vicini
- Michigan Healthcare Professionals, Farmington Hills, MI, USA
| | - Steven Narod
- Center for Global Health, University of Toronto, Toronto, ON, Canada
| | - Naamit Gerber
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, New York, NY, USA
| | - Sachin R Jhawar
- Department of Radiation Oncology, James Cancer Center, Ohio State University, Columbus, OH, USA
| | - Tari A King
- Department of Surgery, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Rachel Rabinovich
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Linsey Gold
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | - Eric Brown
- Comprehensive Breast Care, Michigan Healthcare Professionals, Troy, MI, USA
| | | | - John Vargo
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parul N Barry
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Gauri Bedi
- Mercy Medical Center, Baltimore, MD, USA
| | | | | | | | - Lee Riley
- St. Luke's Hospital, Allentown, PA, USA
| | - Lucy Lee
- Northwell Health, New Hyde Park, NY, USA
| | - Paul Baron
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | | | | | | | | | | | - William Small
- Department of Radiation Oncology, Loyola University, Chicago, IL, USA
| | | | | | - Charles Cox
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
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9
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Zhang M, Zhang FX, Yang XL, Liang Q, Liu J, Zhou WB. Comparative dosimetric study of h-IMRT and VMAT plans for breast cancer after breast-conserving surgery. Transl Oncol 2024; 47:102012. [PMID: 38889521 PMCID: PMC11231535 DOI: 10.1016/j.tranon.2024.102012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
AIM To compare the dosimetric advantages and disadvantages between hybrid intensity-modulated radiation therapy (h-IMRT) and the volumetric modulated arc therapy (VMAT) technique in hypofractionated whole-breast irradiation (HF-WBI) for early-stage breast cancer (BC). METHODS The dose distribution of h-IMRT and VMAT plans was compared in 20 breast cancer patients. This comparison included evaluation of dosimetric parameters using dose volume histograms (DVHs) for the planning target volume (PTV) and organs-at-risk (OARs). Additionally, the study examined the normal tissue complication probability (NTCP), the second cancer complication probability (SCCP) and the tumor control probability (TCP) based on different models. RESULTS Significant differences were detected between the two plans, in terms of Machine units (MUs), the control points, 95 % volume (V95 %), dose homogeneity index (DHI) and conformity index (CI). The endpoint of grade II radiation pneumonitis and cardiac death due to ischemic heart disease were assessed. In h-IMRT plan, the NTCP values were marginally lower for radiation pneumonitis and slightly higher for cardiac death compared to VMAT plan, as determined by the Lyman-Kutcher-Burman model. The Schneider model was employed to predict the SCCP for both the bilateral lungs and contralateral breast, the results demonstrate that the h-IMRT plan outperforms the VMAT plan, with statistical significance. Additionally, the LQ-Poisson model was employed to forecast the TCP of the PTV, showing that the h-IMRT plan outperformed the VMAT plan (P > 0.05). CONCLUSION The h-IMRT technique, offering superior dose coverage and better therapeutic efficacy with fewer side effects as calculated by models, is more suitable for HF-WBI compared to the VMAT technique.
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Affiliation(s)
- Min Zhang
- Xiangya Hospital, Central South University, Hunan 41000, PR China
| | - Fang-Xu Zhang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Xiao-Lei Yang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Qian Liang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Jian Liu
- Department of Otolaryngology-Head and Neck Surgery, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, PR China
| | - Wei-Bing Zhou
- Xiangya Hospital, Central South University, Hunan 41000, PR China.
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10
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Bilski M, Konat-Bąska K, Zerella MA, Corradini S, Hetnał M, Leonardi MC, Gruba M, Grzywacz A, Hatala P, Jereczek-Fossa BA, Fijuth J, Kuncman Ł. Advances in breast cancer treatment: a systematic review of preoperative stereotactic body radiotherapy (SBRT) for breast cancer. Radiat Oncol 2024; 19:103. [PMID: 39095859 PMCID: PMC11295558 DOI: 10.1186/s13014-024-02497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024] Open
Abstract
Breast conserving treatment typically involves surgical excision of tumor and adjuvant radiotherapy targeting the breast area or tumor bed. Accurately defining the tumor bed is challenging and lead to irradiation of greater volume of healthy tissues. Preoperative stereotactic body radiotherapy (SBRT) which target tumor may solves that issues. We conducted a systematic literature review to evaluates the early toxicity and cosmetic outcomes of this promising treatment approach. Secondary we reviewed pathological complete response (pCR) rates, late toxicity, patient selection criteria and radiotherapy protocols. We retrieved literature from PubMed, Scopus, Web of Science, Cochrane, ScienceDirect, and ClinicalTrials.gov. The study adhered to the PRISMA 2020 guidelines. Ten prospective clinical trials (7 phase II, 3 phase I), encompassing 188 patients (aged 18-75 years, cT1-T3 cN0-N3 cM0, primarily with ER/PgR-positive, HER2-negative status,), were analyzed. Median follow-up was 15 months (range 3-30). Treatment involved single-fraction SBRT (15-21Gy) in five studies and fractionated (19.5-31.5Gy in 3 fractions) in the rest. Time interval from SBRT to surgery was 9.5 weeks (range 1-28). Acute and late G2 toxicity occurred in 0-17% and 0-19% of patients, respectively, G3 toxicity was rarely observed. The cosmetic outcome was excellent in 85-100%, fair in 0-10% and poor in only 1 patient. pCR varied, showing higher rates (up to 42%) with longer intervals between SBRT and surgery and when combined with neoadjuvant systemic therapy (up to 90%). Preoperative SBRT significantly reduce overall treatment time, enabling to minimalize volumes. Early results indicate excellent cosmetic effects and low toxicity.
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Affiliation(s)
- Mateusz Bilski
- Department of Radiotherapy, Medical University of Lublin, Lublin, Poland
- Department of Brachytherapy, Lublin Cancer Center, Lublin, Poland
- Department of Radiotherapy, Lublin Cancer Center, Lublin, Poland
| | - Katarzyna Konat-Bąska
- Department of Brachytherapy, Lower Silesian Oncology Pulmonology and Hematology Center, Wrocław, Poland
| | - Maria Alessia Zerella
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Marcin Hetnał
- Department of Oncology, Faculty of Medicine, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
- Amethyst Radiotherapy Centre, Ludwik Rydygier Memorial Hospital, Kraków, Poland
| | | | - Martyna Gruba
- Department of Radiotherapy, Medical University of Lublin, Lublin, Poland
| | | | - Patrycja Hatala
- Department of Radiotherapy, Medical University of Lublin, Lublin, Poland
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jacek Fijuth
- Department of Radiotherapy, Medical University of Lodz, Lodz, Poland
- Department of External Beam Radiotherapy, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Pabianicka 62, 93-513, Lodz, Poland
| | - Łukasz Kuncman
- Department of Radiotherapy, Medical University of Lodz, Lodz, Poland.
- Department of External Beam Radiotherapy, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Pabianicka 62, 93-513, Lodz, Poland.
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11
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Bychkovsky BL, Myers S, Warren LEG, De Placido P, Parsons HA. Ductal Carcinoma In Situ. Hematol Oncol Clin North Am 2024; 38:831-849. [PMID: 38960507 DOI: 10.1016/j.hoc.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
In breast cancer (BC) pathogenesis models, normal cells acquire somatic mutations and there is a stepwise progression from high-risk lesions and ductal carcinoma in situ to invasive cancer. The precancer biology of mammary tissue warrants better characterization to understand how different BC subtypes emerge. Primary methods for BC prevention or risk reduction include lifestyle changes, surgery, and chemoprevention. Surgical intervention for BC prevention involves risk-reducing prophylactic mastectomy, typically performed either synchronously with the treatment of a primary tumor or as a bilateral procedure in high-risk women. Chemoprevention with endocrine therapy carries adherence-limiting toxicity.
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Affiliation(s)
- Brittany L Bychkovsky
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Sara Myers
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Laura E G Warren
- Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Pietro De Placido
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heather A Parsons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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12
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Pan K, Nelson RA, Chlebowski RT, Piela R, Mullooly M, Simon MS, Rohan TE, Wactawski-Wende J, Manson JE, Mortimer JE, Lane D, Kruper L. Ductal carcinoma in situ and cause-specific mortality among younger and older postmenopausal women: the Women's Health Initiative. Breast Cancer Res Treat 2024; 207:65-79. [PMID: 38730133 DOI: 10.1007/s10549-024-07327-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/28/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Whether DCIS is associated with higher breast cancer-specific and all-cause mortality is unclear with few studies in older women. Therefore, we examined DCIS and breast cancer-specific, cardiovascular (CVD)-specific, and all-cause mortality among Women's Health Initiative (WHI) Clinical Trial participants overall and by age (< 70 versus ≥ 70 years). METHODS Of 68,132 WHI participants, included were 781 postmenopausal women with incident DCIS and 781 matched controls. Serial screening mammography was mandated with high adherence. DCIS cases were confirmed by central medical record review. Adjusted multivariable Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI). Kaplan Meier (KM) plots were used to assess 10-year and 20-year mortality rates. RESULTS After 20.3 years total, and 13.2 years median post-diagnosis follow-up, compared to controls, DCIS was associated with higher breast cancer-specific mortality (HR 3.29; CI = 1.32-8.22, P = 0.01). The absolute difference in 20-year breast cancer mortality was 1.2% without DCIS and 3.4% after DCIS, log-rank P = 0.026. Findings were similar by age (< 70 versus ≥ 70 years) with no interaction (P interaction = 0.80). Incident DCIS was not associated with CVD-specific mortality (HR 0.77; CI-0.54-1.09, P = 0.14) or with all-cause mortality (HR 0.96; CI = 0.80-1.16, P = 0.68) with similar findings by age. CONCLUSIONS In postmenopausal women, incident DCIS was associated with over three-fold higher breast cancer-specific mortality, with similar findings in younger and older postmenopausal women. These finding suggest caution in using age to adjust DCIS clinical management or research strategies.
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Grants
- N01WH22110, 24152, 32100-2, 32105-6, 32108-9, 32111-13, 32115, 32118-32119, 32122, 42107-26, 42129-32 NHLBI NIH HHS
- N01WH22110, 24152, 32100-2, 32105-6, 32108-9, 32111-13, 32115, 32118-32119, 32122, 42107-26, 42129-32 NHLBI NIH HHS
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Affiliation(s)
- Kathy Pan
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | | | | | - Rita Piela
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | - Maeve Mullooly
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | - Michael S Simon
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | - Thomas E Rohan
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | | | - JoAnn E Manson
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | | | - Dorothy Lane
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
| | - Laura Kruper
- The Lundquist Institute, 1124 W. Carson St, Torrance, CA, USA
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13
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Delaloge S, Khan SA, Wesseling J, Whelan T. Ductal carcinoma in situ of the breast: finding the balance between overtreatment and undertreatment. Lancet 2024; 403:2734-2746. [PMID: 38735296 DOI: 10.1016/s0140-6736(24)00425-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 01/10/2024] [Accepted: 02/29/2024] [Indexed: 05/14/2024]
Abstract
Ductal carcinoma in situ (DCIS) accounts for 15-25% of all breast cancer diagnoses. Its prognosis is excellent overall, the main risk being the occurrence of local breast events, as most cases of DCIS do not progress to invasive cancer. Systematic screening has greatly increased the incidence of this non-obligate precursor of invasion, lending urgency to the need to identify DCIS that is prone to invasive progression and distinguish it from non-invasion-prone DCIS, as the latter can be overdiagnosed and therefore overtreated. Treatment strategies, including surgery, radiotherapy, and optional endocrine therapy, decrease the risk of local events, but have no effect on survival outcomes. Active surveillance is being evaluated as a possible new option for low-risk DCIS. Considerable efforts to decipher the biology of DCIS have led to a better understanding of the factors that determine its variable natural history. Given this variability, shared decision making regarding optimal, personalised treatment strategies is the most appropriate course of action. Well designed, risk-based de-escalation studies remain a major need in this field.
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Affiliation(s)
- Suzette Delaloge
- Department of Cancer Medicine, Interception Programme, Gustave Roussy, Villejuif, France.
| | - Seema Ahsan Khan
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Jelle Wesseling
- Divisions of Molecular Pathology & Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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14
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Buchheit JT, Schacht D, Kulkarni SA. Update on Management of Ductal Carcinoma in Situ. Clin Breast Cancer 2024; 24:292-300. [PMID: 38216382 DOI: 10.1016/j.clbc.2023.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/15/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024]
Abstract
Ductal carcinoma in situ (DCIS) represents 18% to 25% of all diagnosed breast cancers, and is a noninvasive, nonobligate precursor lesion to invasive cancer. The diagnosis of DCIS represents a wide range of disease, including lesions with both low and high risk of progression to invasive cancer and recurrence. Over the past decade, research on the topic of DCIS has focused on the possibility of tailoring treatment for patients according to their risk for progression and recurrence, which is based on clinicopathologic, biomolecular and genetic factors. These efforts are ongoing, with recently completed and continuing clinical trials spanning the continuum of cancer care. We conducted a review to identify recent advances on the topic of diagnosis, risk stratification and management of DCIS. While novel imaging techniques have increased the rate of DCIS diagnosis, questions persist regarding the optimal management of lesions that would not be identified with conventional methods. Additionally, among trials investigating the potential for omission of surgery and use of active surveillance, 2 trials have completed accrual and 2 clinical trials are continuing to enroll patients. Identification of novel genetic patterns is expanding our potential for risk stratification and aiding our ability to de-escalate radiation and systemic therapies for DCIS. These advances provide hope for tailoring of DCIS treatment in the near future.
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Affiliation(s)
- Joanna T Buchheit
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David Schacht
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Swati A Kulkarni
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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15
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Jagsi R, Griffith KA, Harris EE, Wright JL, Recht A, Taghian AG, Lee L, Moran MS, Small W, Johnstone C, Rahimi A, Freedman G, Muzaffar M, Haffty B, Horst K, Powell SN, Sharp J, Sabel M, Schott A, El-Tamer M. Reply to G.B. Mann et al and S. Sorscher. J Clin Oncol 2024; 42:1998-2000. [PMID: 38489573 DOI: 10.1200/jco.24.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 03/17/2024] Open
Affiliation(s)
- Reshma Jagsi
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kent A Griffith
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Eleanor E Harris
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jean L Wright
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Abram Recht
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Alphonse G Taghian
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Lucille Lee
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Meena S Moran
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - William Small
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Candice Johnstone
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Asal Rahimi
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Gary Freedman
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mahvish Muzaffar
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Bruce Haffty
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kathleen Horst
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Simon N Powell
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jody Sharp
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Michael Sabel
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Anne Schott
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mahmoud El-Tamer
- Reshma Jagsi, MD, DPhil, Emory University, Atlanta, GA, University of Michigan, Ann Arbor, MI; Kent A. Griffith, MS, University of Michigan, Ann Arbor, MI; Eleanor E. Harris, MD, St Luke's University Health Network, Easton, PA; Jean L. Wright, MD, Johns Hopkins University, Baltimore, MD; Abram Recht, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Lucille Lee, MD, Northwell, Lake Success, NY; Meena S. Moran, MD, Yale University, New Haven, CT; William Small Jr, MD, Loyola University Chicago, Maywood, IL; Candice Johnstone, MD, Medical College of Wisconsin, Milwaukee, WI; Asal Rahimi, MD, University of Texas, Southwestern, Dallas, TX; Gary Freedman, MD, University of Pennsylvania, Philadelphia, PA; Mahvish Muzaffar, MD, East Carolina University, Greenville, NC; Bruce Haffty, MD, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Kathleen Horst, MD, Stanford University, Stanford, CA; Simon N. Powell, MD, PhD, Memorial Sloan-Kettering Cancer Center, New York, NY; Jody Sharp, BS, Michael Sabel, MD, and Anne Schott, MD, University of Michigan, Ann Arbor, MI; and Mahmoud El-Tamer, MD, Memorial Sloan-Kettering Cancer Center, New York, NY
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16
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Leonardi MC, Zerella MA, Lazzeroni M, Fusco N, Veronesi P, Galimberti VE, Corso G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Lorubbio C, Zaffaroni M, Vincini MG, Orecchia R, Jereczek-Fossa BA, Magnoni F. Tools to Guide Radiation Oncologists in the Management of DCIS. Healthcare (Basel) 2024; 12:795. [PMID: 38610216 PMCID: PMC11011767 DOI: 10.3390/healthcare12070795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Similar to invasive breast cancer, ductal carcinoma in situ is also going through a phase of changes not only from a technical but also a conceptual standpoint. From prescribing radiotherapy to everyone to personalized approaches, including radiotherapy omission, there is still a lack of a comprehensive framework to guide radiation oncologists in decision making. Many pieces of the puzzle are finding their place as high-quality data mature and are disseminated, but very often, the interpretation of risk factors and the perception of risk remain very highly subjective. Sharing the therapeutic choice with patients requires effective communication for an understanding of risks and benefits, facilitating an informed decision that does not increase anxiety and concerns about prognosis. The purpose of this narrative review is to summarize the current state of knowledge to highlight the tools available to radiation oncologists for managing DCIS, with an outlook on future developments.
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Affiliation(s)
- Maria Cristina Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Viviana Enrica Galimberti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Giovanni Corso
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Giulia Vincini
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Francesca Magnoni
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
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17
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Wang J, Li B, Luo M, Huang J, Zhang K, Zheng S, Zhang S, Zhou J. Progression from ductal carcinoma in situ to invasive breast cancer: molecular features and clinical significance. Signal Transduct Target Ther 2024; 9:83. [PMID: 38570490 PMCID: PMC10991592 DOI: 10.1038/s41392-024-01779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 04/05/2024] Open
Abstract
Ductal carcinoma in situ (DCIS) represents pre-invasive breast carcinoma. In untreated cases, 25-60% DCIS progress to invasive ductal carcinoma (IDC). The challenge lies in distinguishing between non-progressive and progressive DCIS, often resulting in over- or under-treatment in many cases. With increasing screen-detected DCIS in these years, the nature of DCIS has aroused worldwide attention. A deeper understanding of the biological nature of DCIS and the molecular journey of the DCIS-IDC transition is crucial for more effective clinical management. Here, we reviewed the key signaling pathways in breast cancer that may contribute to DCIS initiation and progression. We also explored the molecular features of DCIS and IDC, shedding light on the progression of DCIS through both inherent changes within tumor cells and alterations in the tumor microenvironment. In addition, valuable research tools utilized in studying DCIS including preclinical models and newer advanced technologies such as single-cell sequencing, spatial transcriptomics and artificial intelligence, have been systematically summarized. Further, we thoroughly discussed the clinical advancements in DCIS and IDC, including prognostic biomarkers and clinical managements, with the aim of facilitating more personalized treatment strategies in the future. Research on DCIS has already yielded significant insights into breast carcinogenesis and will continue to pave the way for practical clinical applications.
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Affiliation(s)
- Jing Wang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Baizhou Li
- Department of Pathology, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Meng Luo
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Department of Plastic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jia Huang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Kun Zhang
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shu Zheng
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
| | - Suzhan Zhang
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China.
| | - Jiaojiao Zhou
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Department of Breast Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China.
- Cancer Center, Zhejiang University, Hangzhou, China.
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18
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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19
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Wright JL, Gray R, Rahbar H, Comstock CE, Tjoe JA, Badve S, Recht A, Sparano JA, Davidson NE, Wolff AC. Lumpectomy without radiation for ductal carcinoma in situ of the breast: 20-year results from the ECOG-ACRIN E5194 study. NPJ Breast Cancer 2024; 10:16. [PMID: 38396024 PMCID: PMC10891055 DOI: 10.1038/s41523-024-00622-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
We report the 20-year rate of ipsilateral breast event (IBE) for patients with ductal carcinoma in situ (DCIS) treated with lumpectomy without radiation on a non-randomized prospective clinical trial. Patients were enrolled in cohort 1: low- or intermediate-grade DCIS, size ≤ 2.5 cm (n = 561); or cohort 2: high-grade DCIS, size ≤ 1 cm (n = 104). The Kaplan-Meier method was used to estimate time-to-event distributions. Cox proportional hazard methods were used to estimate hazard ratios (HRs) and tests for significance for event times. 561 patients were enrolled in cohort 1 and 104 in cohort 2. After central pathology review, 26% in cohort 1 were recategorized as high-grade and 26% in cohort 2 as low- or intermediate-grade. Mean DCIS size was similar at 7.5 mm in cohort 1 and 7.8 mm in cohort 2. Surgical margin was ≥3 mm in 96% of patients, and about 30% received tamoxifen. Median follow-up was 19.2 years. There were 104 IBEs, of which 54 (52%) were invasive. The IBE and invasive IBE rates increased in both cohorts up to 15 years, then plateaued. The 20-year IBE rates were 17.8% for cohort 1 and 28.7% for cohort 2 (p = 0.005), respectively. Invasive IBE occurred in 9.8% and 15.1% (p = 0.09), respectively. On multivariable analysis, IBE risk increased with size and was higher in cohort 2, but grade and margin width were not significantly associated with IBE. For patients with DCIS treated with excision without radiation, the rate of IBE increased with size and assigned cohort mostly in the first 15 years.
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Affiliation(s)
- Jean L Wright
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Robert Gray
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Habib Rahbar
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Judy A Tjoe
- Department of Surgical Oncology, Green Bay Oncology, Green Bay, WI, USA
| | - Sunil Badve
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Emory University Winship Cancer Institute, Atlanta, GA, USA
| | - Abram Recht
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph A Sparano
- Division of Hematology and Medical Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nancy E Davidson
- Fred Hutchinson Cancer Center and University of Washington, Seattle, WA, USA
| | - Antonio C Wolff
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Wang Y, Peng D, Zhou X, Hu W, Li F. Treatments and Prognosis of the Breast Ductal Carcinoma In Situ. Clin Breast Cancer 2024; 24:122-130.e2. [PMID: 38016910 DOI: 10.1016/j.clbc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION With progress in treatments, breast ductal carcinoma in situ (DCIS) outcomes have substantially improved. However, as various treatment methods are used in different countries and institutions, consensus on the optimal treatment method is lacking. This study aimed to analyze the prognostic factors and provide a reference for optimizing the clinical treatment of DCIS. PATIENTS AND METHODS This retrospective clinical study collected data from DCIS patients at the Sun Yat-sen University Cancer Center from 2010 to 2017. The Kaplan-Meier method and Cox regression model were used to assess disease-free survival (DFS), overall survival (OS), and local control (LC) rates. RESULTS Among the 483 included patients, 83.6% (404) underwent mastectomies. The median follow-up time was 101 months. The number of patients undergoing breast-conserving surgery (BCS) with radiotherapy has gradually increased. Axillary lymph node dissection was the main surgery performed from 2010 to 2015, and the proportion of sentinel lymph node biopsies (SLNBs) has increased. LC and DFS rates with BCS without radiotherapy were significantly lower than those with mastectomy (P = .002; P < .001). Additionally, the patients who did not undergo axillary surgery had worse LC and OS rates than those who underwent SLNB (P = .028 and P = .038). Endocrine therapy (ET) or its duration had no significant effect on prognosis. CONCLUSION In conclusion, BCS without radiotherapy and lack of axillary surgery were independent prognostic factors. We recommend performing BCS with radiotherapy and SLNB more in clinical practice, as well as shortening the ET duration.
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Affiliation(s)
- Yaxue Wang
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Dingsheng Peng
- Department of Radiation Oncology, Huizhou Central People's Hospital, Huizhou, PR China
| | - Xinhui Zhou
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Wendie Hu
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Fengyan Li
- State Key Laboratory of Oncology, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China.
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21
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O’Keefe T, Yau C, Iaconetti E, Jeong E, Brabham C, Kim P, McGuire J, Griffin A, Wallace A, Esserman L, Harismendy O, Hirst G. Duration of Endocrine Treatment for DCIS impacts second events: Insights from a large cohort of cases at two academic medical centers. RESEARCH SQUARE 2024:rs.3.rs-3403438. [PMID: 38260526 PMCID: PMC10802747 DOI: 10.21203/rs.3.rs-3403438/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Ductal carcinoma in situ (DCIS) incidence has risen rapidly with the introduction of screening mammography, yet it is unclear who benefits from both the amount and type of adjuvant treatment (radiation therapy, (RT), endocrine therapy (ET)) versus what constitutes over-treatment. Our goal was to identify the effects of adjuvant RT, or ET+/- RT versus breast conservation surgery (BCS) alone in a large multi-center registry of retrospective DCIS cases (N = 1,916) with median follow up of 8.2 years. We show that patients with DCIS who took less than 2 years of adjuvant ET alone have a similar second event rate as BCS. However, patients who took more than 2 years of ET show a significantly reduced second event rate, similar to those who received either RT or combined ET+RT, which was independent of age, tumor size, grade, or period of diagnosis. This highlights the importance of ET duration for risk reduction.
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Affiliation(s)
- Thomas O’Keefe
- Department of Surgery, University of California, San Diego
| | - Christina Yau
- Department of Surgery, University of California, San Francisco, CA
| | - Emma Iaconetti
- Department of Surgery, University of California, San Francisco, CA
| | - Eliza Jeong
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Case Brabham
- Department of Surgery, University of California, San Francisco, CA
| | - Paul Kim
- Department of Surgery, University of California, San Francisco, CA
| | | | - Ann Griffin
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Anne Wallace
- Department of Surgery, University of California, San Diego
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA
| | - Olivier Harismendy
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Gillian Hirst
- Department of Surgery, University of California, San Francisco, CA
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22
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Hauswald H, Schempp M, Liebig P, Hoefel S, Debus J, Huber PE, Zwicker F. Long-term Outcome After Helical Tomotherapy Following Breast Conserving Surgery for Ductal Carcinoma In Situ. Technol Cancer Res Treat 2024; 23:15330338241264847. [PMID: 39043035 PMCID: PMC11271168 DOI: 10.1177/15330338241264847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/09/2024] [Accepted: 05/31/2024] [Indexed: 07/25/2024] Open
Abstract
Background: This retrospective study aimed to investigate the outcomes and adverse events (AEs) associated with adjuvant radiotherapy with helical tomotherapy (hT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Methods: Twenty-eight patients with DCIS underwent postoperative hT between 2011 and 2020. hT was chosen since it provided optimal target coverage and tolerable organ-at-risk doses to the lungs and heart when tangential 3-dimensional conformal radiotherapy (3D-CRT) was presumed to provide unfavorable dosimetry. The median total (single) dose was 50.4 Gy (1.8 Gy). The median time between BCS and the start of hT was 5 weeks (range, 4-38 weeks). Statistical analysis included local recurrence-free survival, overall survival (OS), and secondary cancer-free survival. AEs were classified according to the Common Toxicity Criteria for Adverse Events, version 5. Results: The patients' median age was 58 years. The median follow-up period was 61 months (range, 3-123 months). The 1-, 3-, and 5-year OS rates were 100% each. None of the patients developed secondary cancer, local recurrence, or invasive breast cancer during follow-up. The most common acute AEs were dermatitis (n = 27), fatigue (n = 4), hyperpigmentation (n = 3), and thrombocytopenia (n = 4). The late AE primarily included surgical scars (n = 7) and hyperpigmentation (n = 5). None of the patients experienced acute or late AEs > grade 3. The mean conformity and homogeneity indices were 0.9 (range, 0.86-0.96) and 0.056 (range, 0.05-0.06), respectively. Conclusion: hT after BCS for DCIS is a feasible and safe form of adjuvant radiotherapy for patients in whom 3D-CRT is contraindicated due to unfavorable dosimetry. During follow-up, there were no recurrences, invasive breast cancer diagnoses, or secondary cancers, while the adverse effects were mild.
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MESH Headings
- Humans
- Female
- Middle Aged
- Mastectomy, Segmental
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Breast Neoplasms/mortality
- Aged
- Radiotherapy, Intensity-Modulated/methods
- Radiotherapy, Intensity-Modulated/adverse effects
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Adult
- Retrospective Studies
- Radiotherapy, Adjuvant/adverse effects
- Radiotherapy, Adjuvant/methods
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/pathology
- Treatment Outcome
- Radiotherapy Dosage
- Follow-Up Studies
- Combined Modality Therapy
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Affiliation(s)
- Henrik Hauswald
- Clinical Cooperation Unit Molecular Radiation Oncology (E055), German Cancer Research Center (DKFZ), Heidelberg, Germany
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
| | - Michael Schempp
- Clinic and Practice of Radiation Oncology/Practice of Radiology, Konstanz, Germany
| | - Pauline Liebig
- Clinic and Practice of Radiation Oncology/Practice of Radiology, Konstanz, Germany
| | - Sebastian Hoefel
- Clinic and Practice of Radiation Oncology/Practice of Radiology, Konstanz, Germany
| | - Jürgen Debus
- Clinical Cooperation Unit Molecular Radiation Oncology (E055), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter E. Huber
- Clinical Cooperation Unit Molecular Radiation Oncology (E055), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Zwicker
- Clinical Cooperation Unit Molecular Radiation Oncology (E055), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Clinic and Practice of Radiation Oncology/Practice of Radiology, Konstanz, Germany
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23
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de Sousa CFPM, Pereira AAL, Arruda GV, Gouveia AG, Hanna SA, Cruz MRDS, Dos Anjos CH, Bevilacqua JLB, Alcantara Filho P, de Moraes FY, Marta GN. Real-World Evidence on the Use of Endocrine Therapy for Ductal Carcinoma In Situ in Patients Treated With Breast-Conserving Surgery Followed by Postoperative Radiation Therapy: A Brazilian Retrospective Cohort Study. Clin Breast Cancer 2023; 23:e499-e506. [PMID: 37758557 DOI: 10.1016/j.clbc.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/06/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION/BACKGROUND This study aims to evaluate the reproducibility of findings from randomized controlled trials regarding adjuvant hormone therapy (HT) for breast ductal carcinoma in situ (DCIS) in a real-life scenario. MATERIALS/METHODS This retrospective cohort study used Fundação Oncocentro de São Paulo database. It included DCIS patients DCIS who received breast-conserving surgery and postoperative radiation therapy. The endpoints were local control (LC), breast cancer-specific survival (BCSS), and overall survival (OS). RESULTS We analyzed 2192 patients treated between 2000 and 2020. The median FU was 48.99 months. Most patients (53.33%; n = 1169) received adjuvant HT. Patients not receiving adjuvant HT tend to be older (P = .021) and have a lower educational level (P < .001). At the end of FU, 1.5% of patients had local recurrence, and there was no significant difference between groups (P = .19). The 10-year OS and BCSS were 89.4% and 97.5% for adjuvant HT versus 91.5% and 98.5% for no adjuvant HT, respectively, and there were no significant differences between groups. The 10-year OS was 93.25% for medium/high education level versus 87.31% for low (HR for death 0.51; 95% CI, 0.32-0.83; P = .007). CONCLUSIONS The benefits of adjuvant HT for DCIS were not reproduced in a Brazilian cohort. Education significantly impacted survival and HT usage, reflecting the influence of socioeconomic factors. These findings can allow for more precise interventions.
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MESH Headings
- Female
- Humans
- Antineoplastic Agents, Hormonal/therapeutic use
- Brazil/epidemiology
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/pathology
- Radiotherapy, Adjuvant
- Randomized Controlled Trials as Topic
- Reproducibility of Results
- Retrospective Studies
- Cohort Studies
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Affiliation(s)
| | | | - Gustavo Viani Arruda
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP, Ribeirão Preto, SP, Brazil
| | - Andre Guimaraes Gouveia
- Department of Oncology, Division of Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | | | | | | | | | | | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio Libanês, São Paulo, SP, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, RS, Brazil
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24
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Kantor O, King TA, Jones A, Glass C, Leonard SJ, Ogayo ER, Mayer EL, Chavez-MacGregor M, Newman LA, Freedman RA, Mittendorf EA. Racial and Ethnic Disparities in Outcomes After Breast-Conserving Therapy and Endocrine Therapy for DCIS: A Post-Hoc Analysis of the NSABP B-35 Randomized Clinical Trial. Ann Surg Oncol 2023; 30:8404-8411. [PMID: 37777685 DOI: 10.1245/s10434-023-14344-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Racial and ethnic disparities in outcomes after treatment for ductal carcinoma in situ (DCIS) are largely unknown. The objective of this study was to examine breast cancer outcomes by race and ethnicity in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-35 clinical trial. PATIENTS AND METHODS The NSABP B-35 trial randomized postmenopausal women with hormone receptor-positive DCIS treated with breast-conserving therapy to 5 years of tamoxifen or anastrozole. In total, 3104 women were enrolled between 2003 and 2006. For this analysis, patients without complete self-reported race and ethnicity or with immediate trial dropout were excluded. Kaplan-Meier curves and adjusted Cox-proportional hazards models were used for analyses. RESULTS Of the 3061 women included, 2614 (85.4%) were non-Hispanic white (NHW), 255 (8.3%) were non-Hispanic Black (NHB), 95 (3.1%) were Hispanic, and 96 (3.1%) were Asian or Pacific Islander (API). Endocrine therapy assignment and duration were well balanced between racial and ethnic groups. Median follow-up was 9 years; unadjusted Kaplan-Meier curves did not show any racial differences in disease events. Adjusted Cox-proportional hazards models found API (versus NHW) race to be associated with higher local recurrence [hazard ratio (HzR) 2.45, p = 0.035] and NHB race to be associated with higher distant recurrence (HzR 5.03, p = 0.020) and breast cancer mortality (HzR 3.83, p = 0.046). CONCLUSIONS Despite similar locoregional treatments and standard endocrine therapy in a clinical trial population, racial and ethnic disparities exist in long-term outcomes for hormone-receptor-positive DCIS. These findings suggest that factors outside of access and treatment may impact DCIS outcomes by race and ethnicity.
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Affiliation(s)
- Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alyssa Jones
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Charity Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Saskia J Leonard
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Esther R Ogayo
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Erica L Mayer
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa A Newman
- Department of Surgery, Weill-Cornell Medicine, New York, NY, USA
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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25
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Nakashima A, Yamazaki H, Suzuki G, Yamada K, Norihiro A, Kimoto T, Masui K, Nakatsuka K, Taguchi T, Naoi Y. The Feasibility of Omitting Postoperative Radiotherapy in Japanese Patients With Ductal Carcinoma In Situ of Breast Treated With Breast-Conserving Surgery. Cureus 2023; 15:e48187. [PMID: 38054154 PMCID: PMC10695091 DOI: 10.7759/cureus.48187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Background To analyze the feasibility of omitting postoperative radiotherapy (PORT) after breast-conserving surgery (BCS) in Japanese patients with ductal carcinoma in situ (DCIS). Materials and methods We retrospectively analyzed 88 patients with small pure DCIS (median diameter 1.1 cm, ≤ 4 cm) who underwent BCS with (n = 39) or without (n = 49) PORT. The primary and secondary endpoints were ipsilateral breast tumor recurrence (IBTR) and overall survival (OS), respectively, between the groups that received PORT and those that did not. Results The PORT group included a high number of margin-positive cases. The incidence of IBTR was 2.4% (95% confidence interval (CI), 0.3-15.7%) and 2.8% (95% CI, 0.4-18.2%) at five years and 5.5% (95% CI, 1.4-20.6%) and 2.8% (95% CI, 0.4-18.2%) at 10 years in patients without and with PORT, respectively (p = 0.686). In the margin-negative group, only one patient showed IBTR without RT (2.3%), whereas no patient with PORT experienced IBTR (0%). To date, there have been no regional or distant metastases; therefore, no patient has experienced breast cancer-related deaths. The OS rates were 97.7% (95% CI, 84.9-99.6%) and 100% at 10 years in patients without and with PORT, respectively (p = 0.372). Conclusion This study suggests that the omission of PORT after BCS could be a feasible option for selected Japanese patients but requires further investigation to identify the low-risk factor in patients who can omit PORT.
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Affiliation(s)
| | - Hideya Yamazaki
- Radiology, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Gen Suzuki
- Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Kei Yamada
- Radiology, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Aibe Norihiro
- Radiology, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Takuya Kimoto
- Radiology, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Koji Masui
- Radiology, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Katsuhiko Nakatsuka
- Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Tetsuya Taguchi
- Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Yasuto Naoi
- Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kyoto, JPN
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26
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Gligorov J, Benderra MA, Barthere X, de Forceville L, Antoine EC, Cottu PH, Delaloge S, Pierga JY, Belkacemi Y, Houvenaegel G, Pujol P, Rivera S, Spielmann M, Penault-Llorca F, Namer M. Recommandations francophones pour la pratique clinique concernant la prise en charge des cancers du sein de Saint-Paul-de-Vence 2022-2023. Bull Cancer 2023; 110:10S1-10S43. [PMID: 38061827 DOI: 10.1016/s0007-4551(23)00473-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
With more than 60,000 new cases of breast cancer in mainland France in 2023 and 8% of all cancer deaths, breast cancer is the leading cancer in women in terms of incidence and mortality. While the number of new cases has almost doubled in 30 years, the percentage of patients at all stages alive at 5 years (87%) and 10 years (76%) testifies to the major progress made in terms of screening, characterisation and treatment. However, this progress, rapid as it is, needs to be evaluated and integrated into an overall strategy, taking into account the characteristics of the disease (stage and biology), as well as those of the patients being treated. These are the objectives of the St Paul-de-Vence recommendations for clinical practice. We report here the summary of the votes, discussions and conclusions of the Saint-Paul-de-Vence 2022-2023 RPCs.
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Affiliation(s)
- Joseph Gligorov
- Institut universitaire de cancérologie AP-HP Sorbonne université, Paris, France.
| | | | - Xavier Barthere
- Institut universitaire de cancérologie AP-HP Sorbonne université, Paris, France
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27
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Chen K, Sun W, Han T, Yan L, Sun M, Xia W, Wang L, Shi Y, Ge C, Yang X, Li Y, Wang H. Robustness of hypofractionated breast radiotherapy after breast-conserving surgery with free breathing. Front Oncol 2023; 13:1259851. [PMID: 38023210 PMCID: PMC10644368 DOI: 10.3389/fonc.2023.1259851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose This study aimed to evaluate the robustness with respect to the positional variations of five planning strategies in free-breathing breast hypofractionated radiotherapy (HFRT) for patients after breast-conserving surgery. Methods Twenty patients who received breast HFRT with 42.72 Gy in 16 fractions were retrospectively analyzed. Five treatment planning strategies were utilized for each patient, including 1) intensity-modulated radiation therapy (IMRT) planning (IMRTpure); 2) IMRT planning with skin flash tool extending and filling the fluence outside the skin by 2 cm (IMRTflash); 3) IMRT planning with planning target volume (PTV) extended outside the skin by 2 cm in the computed tomography dataset (IMRTePTV); 4) hybrid planning, i.e., 2 Gy/fraction three-dimensional conformal radiation therapy combined with 0.67 Gy/fraction IMRT (IMRThybrid); and 5) hybrid planning with skin flash (IMRThybrid-flash). All plans were normalized to 95% PTV receiving 100% of the prescription dose. Six additional plans were created with different isocenter shifts for each plan, which were 1 mm, 2 mm, 3 mm, 5 mm, 7 mm, and 10 mm distally in the X (left-right) and Y (anterior-posterior) directions, namely, (X,Y), to assess their robustness, and the corresponding doses were recalculated. Variation of dosimetric parameters with increasing isocenter shift was evaluated. Results All plans were clinically acceptable. In terms of robustness to isocenter shifts, the five planning strategies followed the pattern IMRTePTV, IMRThybrid-flash, IMRTflash, IMRThybrid, and IMRTpure in descending order. V 95% of IMRTePTV maintained at 99.6% ± 0.3% with a (5,5) shift, which further reduced to 98.2% ± 2.0% with a (10,10) shift. IMRThybrid-flash yielded the robustness second to IMRTePTV with less risk from dose hotspots, and the corresponding V 95% maintained >95% up until (5,5). Conclusion Considering the dosimetric distribution and robustness in breast radiotherapy, IMRTePTV performed best at maintaining high target coverage with increasing isocenter shift, while IMRThybrid-flash would be adequate with positional uncertainty<5 mm.
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Affiliation(s)
- Kunzhi Chen
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Wuji Sun
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Tao Han
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Lei Yan
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Minghui Sun
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Wenming Xia
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Libo Wang
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Yinghua Shi
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Chao Ge
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Xu Yang
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Yu Li
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
| | - Huidong Wang
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, China
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Shah C, Vicini F. Adjuvant Radiation Therapy for Ductal Carcinoma In Situ of the Breast: A Clinician's Dilemma. Ann Surg Oncol 2023; 30:6281-6283. [PMID: 37280311 DOI: 10.1245/s10434-023-13691-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
MESH Headings
- Humans
- Female
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Radiotherapy, Adjuvant
- Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/pathology
- Carcinoma in Situ/pathology
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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Dreyfuss AD, Max D, Flynn J, Zhang Z, Gillespie EF, Xu A, Cuaron J, Mueller B, Khan AJ, Cahlon O, Powell SN, McCormick B, Braunstein LZ. Locoregional Control Benefit of a Tumor Bed Boost for Ductal Carcinoma In Situ. Adv Radiat Oncol 2023; 8:101254. [PMID: 37250283 PMCID: PMC10220256 DOI: 10.1016/j.adro.2023.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandra D. Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Danielle Max
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, UCLA Health, Los Angeles, California
| | - Jessica Flynn
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Wärnberg F, Wadsten C, Karakatsanis A, Olofsson Bagge R, Holmberg E, Lindman H, Sawyer E, Vicini F, Mann GB, Karlsson P. Outcome of different radiotherapy strategies after breast conserving surgery in patients with ductal carcinoma in situ (DCIS). Acta Oncol 2023; 62:1045-1051. [PMID: 37571927 DOI: 10.1080/0284186x.2023.2245552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Adjuvant radiotherapy (RT) after breast-conserving surgery for DCIS lowers the relative local recurrence risk by half. To identify a low-risk group with the minimal benefit of RT could avoid side effects and spare costs. In this study, the outcome was compared for different RT-strategies using data from the randomized SweDCIS trial. MATERIAL AND METHODS Five strategies were compared in a Swedish setting: RT-to-none or all, RT to high-risk women defined by DCISionRT, modified Radiation Therapy Oncology Group (RTOG) 9804 criteria, and Swedish Guidelines. Ten-year recurrence risks and cost including adjuvant RT and local recurrence treatment cost were calculated. RESULTS The mean age at recurrence was 64.4 years (36-90) and the mean cost for treating a recurrence was $21,104. In the SweDCIS cohort (n = 504), 59 women developed DCIS, and 31 invasive recurrence. Ten-year absolute local recurrence risk (invasive and DCIS) according to different strategies varied between 18.6% (12.5-23.6%) and 7.8% (5.0-12.6%) for RT-to-none or to-all, with an additional cost of $2614 US dollars per women and $24,201 per prevented recurrence for RT-to-all. The risk differences between other strategies were not statistically significant, but the larger proportion receiving RT, the fewer recurrences. DCISionRT spared 48% from RT with 8.1% less recurrences compared to RT-to-none, and a cost of $10,534 per prevented recurrence with additional cost depending on the price of the test. RTOG 9804 spared 39% from RT, with 9.7% less recurrences, $9525 per prevented recurrence and Swedish Guidelines spared 13% from RT, with 10.0% less recurrences, and $21,521 per prevented recurrence. CONCLUSION It seems reasonable to omit RT in pre-specified low-risk groups with minimal effect on recurrence risk. Costs per prevented recurrence varied more than two-fold but which strategy that could be considered most cost-effective needs to be further evaluated, including the DCISionRT-test price.
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Affiliation(s)
- Fredrik Wärnberg
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Charlotta Wadsten
- Department of Surgery, Sundsvall Hospital, Umeå University, Umeå, Sweden
| | | | - Roger Olofsson Bagge
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Henrik Lindman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Elinor Sawyer
- Guys Cancer centre, Kings College London, London, UK
| | - Frank Vicini
- Regional Oncologic Centre, NRG, Oncology, and 21st Century Oncology, Pontiac, MI, USA
| | - G Bruce Mann
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Lange T, Knöchelmann AC, Bremer M. [Adjuvant radiation therapy for breast cancer]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:693-702. [PMID: 37581632 DOI: 10.1007/s00117-023-01198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Adjuvant radiotherapy is an integral part of multimodal therapy for early breast cancer. It contributes to the reduction of local recurrences across all disease stages. (Moderate) hypofractionated whole-breast irradiation is the standard of care. In low-risk situations, partial breast irradiation can be an option. The indication for adjuvant radiotherapy after mastectomy or additional irradiation of regional lymph nodes depends on the patient's individual risk profile. Long-term results of treatment and further development of irradiation techniques now allow shorter, individualized and well-tolerated treatments with the aim of therapy de-escalation.
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Affiliation(s)
- Tim Lange
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Anne Caroline Knöchelmann
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Michael Bremer
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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32
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Smith BL, Hunt KK, Carr D, Blumencranz PW, Hwang ES, Gadd MA, Stone K, Dyess DL, Dodge D, Valente S, Dekhne N, Clark P, Lee MC, Samiian L, Lesnikoski BA, Clark L, Smith KP, Chang M, Harris DK, Schlossberg B, Ferrer J, Wapnir IL. Intraoperative Fluorescence Guidance for Breast Cancer Lumpectomy Surgery. NEJM EVIDENCE 2023; 2:EVIDoa2200333. [PMID: 38320161 DOI: 10.1056/evidoa2200333] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Although lumpectomy and mastectomy provide equivalent survival for patients with breast cancer, local recurrence after lumpectomy increases breast cancer mortality. Positive lumpectomy margins, which imply incomplete tumor removal, are the strongest predictor of local recurrence and are identified days after surgery, necessitating a second surgery. METHODS: In this prospective trial, we assessed margin status with or without pegulicianine fluorescence-guided surgery (pFGS) for stages 0 to 3 breast cancers. To prevent surgeons from performing smaller than standard lumpectomies in anticipation of pFGS assistance, patients were randomly assigned 10:1 to pFGS or control groups, thus randomization was not designed to provide a control group for evaluating device performance. In patients undergoing pFGS, additional pFGS-guided cavity margins were excised at sites of pegulicianine signal. We evaluated three coprimary end points: the percentage of patients for whom pFGS-guided margins contained cancer, sensitivity, and specificity. RESULTS: Overall, 406 patients received 1.0 mg/kg intravenous pegulicianine followed by lumpectomy. Among 392 patients randomly assigned, 316 had invasive cancers, and 76 had in situ cancers. In 27 of 357 patients undergoing pFGS, pFGS-guided margins removed tumor left behind after standard lumpectomy, 22 from cavity orientations deemed negative on standard margin evaluation. Second surgeries were avoided by pFGS in 9 of 62 patients with positive margins. On per-margin analysis, pFGS specificity was 85.2%, and sensitivity was 49.3%. Pegulicianine administration was stopped for adverse events in six patients. Two patients had grade 3 serious adverse events related to pegulicianine. CONCLUSIONS: The use of pFGS in breast cancer surgery met prespecified thresholds for removal of residual tumor and specificity but did not meet the prespecified threshold for sensitivity. (Funded by Lumicell, Inc. and the National Institutes of Health; Clinicaltrials.gov number, NCT03686215.)
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lynne Clark
- Christian Health Initiatives Franciscan, Tacoma, WA
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Abstract
Breast cancer is the most prevalent cancer in women, and the second leading cause of cancer death in women in the United States. Radiation therapy is an important component in the multimodal management of breast cancer, including early stage and locally advanced breast cancers, as well as metastatic cases. Breast cancer radiation therapy has seen significant advancements over the past 20 years. This article discusses the latest advances in the radiotherapeutic management of breast cancer, especially focusing on the technological advances in radiation treatment planning and techniques that have exploited the understanding of radiation biology.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital D259, 460 W 10th Avenue, Columbus, OH 43210, USA
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, 1145 Olentangy River Road, Columbus, OH 43212, USA.
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34
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Hahn E, Rodin D, Sutradhar R, Nofech-Mozes S, Trebinjac S, Paszat LF, Rakovitch E. Can Molecular Biomarkers Help Reduce the Overtreatment of DCIS? Curr Oncol 2023; 30:5795-5806. [PMID: 37366916 DOI: 10.3390/curroncol30060433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/23/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
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.
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Affiliation(s)
- Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Sabina Trebinjac
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Lawrence Frank Paszat
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
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Dabbs D, Mittal K, Heineman S, Whitworth P, Shah C, Savala J, Shivers SC, Bremer T. Analytical validation of the 7-gene biosignature for prediction of recurrence risk and radiation therapy benefit for breast ductal carcinoma in situ. Front Oncol 2023; 13:1069059. [PMID: 37274253 PMCID: PMC10236475 DOI: 10.3389/fonc.2023.1069059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/11/2023] [Indexed: 06/06/2023] Open
Abstract
Purpose Ductal carcinoma in situ (DCIS), is a noninvasive breast cancer, representing 20-25% of breast cancer diagnoses in the USA. Current treatment options for DCIS include mastectomy or breast-conserving surgery (BCS) with or without radiation therapy (RT), but optimal risk-adjusted treatment selection remains a challenge. Findings from past and recent clinical trials have failed to identify a 'low risk' group of patients who do not benefit significantly from RT after BCS. To address this unmet need, a DCIS biosignature, DCISionRT (PreludeDx, Laguna Hills, CA), was developed and validated in multiple cohorts. DCISionRT is a molecular assay with an algorithm reporting a recurrence risk score for patients diagnosed with DCIS intended to guide DCIS treatment. In this study, we present results from analytical validity, performance assessment, and clinical performance validation and clinical utility for the DCISionRT test comprised of multianalyte assays with algorithmic analysis. Methods The analytical validation of each molecular assay was performed based on the Clinical and Laboratory Standards Institute (CLSI) guidelines Quality Assurance for Design Control and Implementation of Immunohistochemistry Assays and the College of American Pathologists/American Society of Clinical Oncology (CAP/ASCO) recommendations for analytic validation of immunohistochemical assays. Results The analytic validation showed that the molecular assays that are part of DCISionRT test have high sensitivity, specificity, and accuracy/reproducibility (≥95%). The analytic precision of the molecular assays under controlled non-standard conditions had a total standard deviation of 6.6 (100-point scale), where the analytic variables (Lot, Machine, Run) each contributed <1% of the total variance. Additionally, the precision in the DCISionRT test result (DS) had a 95%CI ≤0.4 DS units under controlled non-standard conditions (Day, Lot, and Machine) for molecular assays over a wide range of clinicopathologic factor values. Clinical validation showed that the test identified 37% of patients in a low-risk group with a 10-year invasive IBR rate of ~3% and an absolute risk reduction (ARR) from RT of 1% (number needed to treat, NNT=100), while remaining patients with higher DS scores (elevated-risk) had an ARR for RT of 9% (NNT=11) and 96% clinical sensitivity for RT benefit. Conclusion The analytical performance of the PreludeDx DCISionRT molecular assays was high in representative formalin-fixed, paraffin-embedded breast tumor specimens. The DCISionRT test has been analytically validated and has been clinically validated in multiple peer-reviewed published studies.
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Affiliation(s)
| | | | | | - Pat Whitworth
- University of Tennessee, Knoxville, TN, United States
- Nashville Breast Center, Nashville, TN, United States
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
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Laws A, Punglia RS. Endocrine Therapy for Primary and Secondary Prevention After Diagnosis of High-Risk Breast Lesions or Preinvasive Breast Cancer. J Clin Oncol 2023:JCO2300455. [PMID: 37126767 DOI: 10.1200/jco.23.00455] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.Patients with high-risk breast lesions (HRLs) or preinvasive breast cancers face an elevated risk of future breast cancer diagnoses. Endocrine therapy in this setting reduces the risk of a future diagnosis but does not confer improved survival, thus the side effects of primary/secondary prevention must be considered relative to the benefits. Here, we discuss the available chemoprevention regimens for patients with HRLs and considerations for selecting a regimen, as well as the decision making surrounding use of adjuvant endocrine therapy for patients with ductal carcinoma in situ (DCIS). For patients with HRLs, available chemoprevention regimens differ by menopausal status, including tamoxifen 20 mg once daily for 5 years and more recently tamoxifen 5 mg once daily for 3 years in both premenopausal and postmenopausal women as well as raloxifene or aromatase inhibitors for postmenopausal women. We recommend a shared decision-making approach with attention to patient preferences related to risk tolerance and side-effect profiles. Low-dose tamoxifen appears to be a particularly favorable choice that is well tolerated, without risk of serious adverse events and offers comparable risk reduction to other regimens. For DCIS, the benefit of endocrine therapy in addition to radiation is small, and appears to be driven mainly by a reduction in contralateral breast diagnoses or new breast cancers. A strategy that reduces the side-effect profile of chemoprevention such as low-dose tamoxifen may be especially appealing in the setting of secondary prevention.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Rinaa S Punglia
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
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37
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Nash AL, Hwang ES. The Landmark Series-Ductal Carcinoma in Situ: The Evolution of Treatment. Ann Surg Oncol 2023; 30:3206-3214. [PMID: 37024766 DOI: 10.1245/s10434-023-13370-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/06/2023] [Indexed: 04/08/2023]
Abstract
The evolution of ductal carcinoma in situ (DCIS) management has been driven by a parallel evolution in our understanding of its natural history. Early trials established the benefit of adjuvant therapies in all patients with DCIS. In contrast, subsequent studies have stratified patients to determine their eligibility for progressively less invasive and less intensive therapies. Large, randomized trials and meta-analyses have supported this shift away from treating DCIS as an homogenous disease treated with similar intensity to invasive breast cancer. This review describes the landmark studies on which current DCIS management is based.
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Affiliation(s)
- Amanda L Nash
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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38
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Kalwaniya DS, Gairola M, Gupta S, Pawan G. Ductal Carcinoma in Situ: A Detailed Review of Current Practices. Cureus 2023; 15:e37932. [PMID: 37220466 PMCID: PMC10200127 DOI: 10.7759/cureus.37932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/25/2023] Open
Abstract
Ductal carcinoma in situ is a challenge for breast surgeons, beginning with its difficult radiological detection and continuing with its contentious multimodal treatment and management. It is becoming more common as a result of widespread screening mammography and usually manifests as a cluster of calcifications. Patients are usually asymptomatic or present with a small, palpable lump. It is, however, a premalignant lesion that has the potential to progress to invasive carcinoma and is treated similarly with multimodal therapy. Treatment options currently include total or simple mastectomy with sentinel lymph node biopsy or lumpectomy with radiation. Tamoxifen and human epidermal growth factor receptor two suppression therapy are examples of adjuvant therapy. A review of consensus guidelines and literature was performed, in which we included the available online literature on the concerned topic from 2000-2022. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic and its current management guidelines.
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Affiliation(s)
- Dheer S Kalwaniya
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Madhur Gairola
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Sumedha Gupta
- Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - G Pawan
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
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Byng D, Thomas SM, Rushing CN, Lynch T, McCarthy A, Francescatti AB, Frank ES, Partridge AH, Thompson AM, Retèl VP, van Harten WH, Grimm LJ, Hyslop T, Hwang ES, Ryser MD. Surveillance Imaging after Primary Diagnosis of Ductal Carcinoma in Situ. Radiology 2023; 307:e221210. [PMID: 36625746 PMCID: PMC10068891 DOI: 10.1148/radiol.221210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/13/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023]
Abstract
Background Guidelines recommend annual surveillance imaging after diagnosis of ductal carcinoma in situ (DCIS). Guideline adherence has not been characterized in a contemporary cohort. Purpose To identify uptake and determinants of surveillance imaging in women who underwent treatment for DCIS. Materials and Methods A stratified random sample of women who underwent breast-conserving surgery for primary DCIS between 2008 and 2014 was retrospectively selected from 1330 facilities in the United States. Imaging examinations were recorded from date of diagnosis until first distant recurrence, death, loss to follow-up, or end of study (November 2018). Imaging after treatment was categorized into 10 12-month periods starting 6 months after diagnosis. Primary outcome was per-period receipt of asymptomatic surveillance imaging (mammography, MRI, or US). Secondary outcome was diagnosis of ipsilateral invasive breast cancer. Multivariable logistic regression with repeated measures and generalized estimating equations was used to model receipt of imaging. Rates of diagnosis with ipsilateral invasive breast cancer were compared between women who did and those who did not undergo imaging in the 6-18-month period after diagnosis using inverse probability-weighted Kaplan-Meier estimators. Results A total of 12 559 women (median age, 60 years; IQR, 52-69 years) were evaluated. Uptake of surveillance imaging was 75% in the first period and decreased over time (P < .001). Across the first 5 years after treatment, 52% of women participated in consistent annual surveillance. Surveillance was lower in Black (adjusted odds ratio [OR], 0.80; 95% CI: 0.74, 0.88; P < .001) and Hispanic (OR, 0.82; 95% CI: 0.72, 0.94; P = .004) women than in White women. Women who underwent surveillance in the first period had a higher 6-year rate of diagnosis of invasive cancer (1.6%; 95% CI: 1.3, 1.9) than those who did not (1.1%; 95% CI: 0.7, 1.4; difference: 0.5%; 95% CI: 0.1, 1.0; P = .03). Conclusion Half of women did not consistently adhere to imaging surveillance guidelines across the first 5 years after treatment, with racial disparities in adherence rates. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Rahbar and Dontchos in this issue.
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Affiliation(s)
- Danalyn Byng
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Samantha M. Thomas
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Christel N. Rushing
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Thomas Lynch
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Anne McCarthy
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Amanda B. Francescatti
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Elizabeth S. Frank
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Ann H. Partridge
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Alastair M. Thompson
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Valesca P. Retèl
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Wim H. van Harten
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Lars J. Grimm
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Terry Hyslop
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - E. Shelley Hwang
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
| | - Marc D. Ryser
- From the Division of Psychosocial Research and Epidemiology, the
Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam,
the Netherlands (D.B., V.P.R., W.H.v.H.); Health Technology and Services
Research Department, Technical Medical Centre, University of Twente, Enschede,
the Netherlands (D.B., V.P.R., W.H.v.H.); Duke Cancer Institute Biostatistics
Shared Resource (S.M.T., C.N.R., T.H.) and Department of Mathematics (M.D.R.),
Duke University, Durham, NC; Department of Biostatistics and Bioinformatics
(S.M.T., T.H.), Division of Surgical Sciences, Department of Surgery (T.L.,
E.S.H.), Department of Radiology (L.J.G.), and Department of Population Health
Sciences (M.D.R.), Duke University Medical Center, 215 Morris St, Durham, NC
27701; Cancer Programs, American College of Surgeons, Chicago, Ill (A.M.,
A.B.F.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston,
Mass (E.S.F., A.H.P.); and Department of Surgery, Baylor College of Medicine,
Houston, Tex (A.M.T.)
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Hepel JT, Loap P, Fourquet A, Kirova YM. DCIS Update: Escalation or De-escalation? Boost, Fractionation, and Omission of Radiation. Int J Radiat Oncol Biol Phys 2023; 115:813-816. [PMID: 36822780 DOI: 10.1016/j.ijrobp.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 02/23/2023]
Affiliation(s)
- Jaroslaw T Hepel
- Department of Radiation Oncology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island.
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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De-escalation in DCIS Care. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Ouattara D, Mathelin C, Özmen T, Lodi M. Molecular Signatures in Ductal Carcinoma In Situ (DCIS): A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12052036. [PMID: 36902822 PMCID: PMC10004217 DOI: 10.3390/jcm12052036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
CONTEXT Adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) is debated as benefits are inconstant. Molecular signatures for DCIS have been developed to stratify the risk of local recurrence (LR) and therefore guide the decision of RT. OBJECTIVE To evaluate, in women with DCIS treated by BCS, the impact of adjuvant RT on LR according to the molecular signature risk stratification. METHODOLOGY We conducted a systematic review and meta-analysis of five articles including women with DCIS treated by BCS and with a molecular assay performed to stratify the risk, comparing the effect of BCS and RT versus BCS alone on LR including ipsilateral invasive (InvBE) and total breast events (TotBE). RESULTS The meta-analysis included 3478 women and evaluated two molecular signatures: Oncotype Dx DCIS (prognostic of LR), and DCISionRT (prognostic of LR and predictive of RT benefit). For DCISionRT, in the high-risk group, the pooled hazard ratio of BCS + RT versus BCS was 0.39 (95%CI 0.20-0.77) for InvBE and 0.34 (95%CI 0.22-0.52) for TotBE. In the low-risk group, the pooled hazard ratio of BCS + RT versus BCS was significant for TotBE at 0.62 (95%CI 0.39-0.99); however, it was not significant for InvBE (HR = 0.58 (95%CI 0.25-1.32)), Discussion: Molecular signatures are able to discriminate high- and low-risk women, high-risk ones having a significant benefit of RT in the reduction of invasive and in situ local recurrences, while in low-risk ones RT did not have a benefit for preventing invasive breast recurrence. The risk prediction of molecular signatures is independent of other risk stratification tools developed in DCIS, and have a tendency toward RT de-escalation. Further studies are needed to assess the impact on mortality.
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Affiliation(s)
- Drissa Ouattara
- Surgery Department, Point G University Hospitals, Bamako P.O. Box 251, Mali
| | - Carole Mathelin
- Strasbourg University Hospital, 1 Avenue Molière, 67200 Strasbourg, France
- Surgical Oncology Department, ICANS Institute of Oncology Strasbourg Europe, 17 Avenue Albert Calmette, CEDEX, 67200 Strasbourg, France
- IGBMC Institute of Genetics, Molecular and Cellular Biology, CNRS, UMR7104 INSERM U964, Strasbourg University, 1 Rue Laurent Fries, 67400 Illkirch-Graffenstaden, France
| | - Tolga Özmen
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Massimo Lodi
- Strasbourg University Hospital, 1 Avenue Molière, 67200 Strasbourg, France
- Surgical Oncology Department, ICANS Institute of Oncology Strasbourg Europe, 17 Avenue Albert Calmette, CEDEX, 67200 Strasbourg, France
- IGBMC Institute of Genetics, Molecular and Cellular Biology, CNRS, UMR7104 INSERM U964, Strasbourg University, 1 Rue Laurent Fries, 67400 Illkirch-Graffenstaden, France
- Correspondence:
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Kim H, Wang H, Demanelis K, Clump DA, Vargo JA, Keller A, Diego M, Gorantla V, Smith KJ, Rosenzweig MQ. Factors associated with ductal carcinoma in situ (DCIS) treatment patterns and patient-reported outcomes across a large integrated health network. Breast Cancer Res Treat 2023; 197:683-692. [PMID: 36526807 PMCID: PMC9883362 DOI: 10.1007/s10549-022-06831-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To examine associations between ductal carcinoma in situ (DCIS) patients' characteristics, treating locations and DCIS treatments received and to pilot assessing quality-of-life (QoL) values among DCIS patients with diverse backgrounds. METHODS We performed a retrospective tumor registry review of all patients diagnosed and treated with DCIS from 2018 to 2019 in the UPMC-integrated network throughout central and western Pennsylvania. Demographics, clinical information, and administered treatments were compiled from tumor registry records. We categorized contextual factors such as different hospital setting (academic vs. community), socioeconomic status based on the neighborhood deprivation index (NDI) as well as age and race. QoL survey was administered to DCIS patients with diverse backgrounds via QoL questionnaire breast cancer module 23 and qualitative assessment questions. RESULTS A total of 912 patients were reviewed. There were no treatment differences noted for age, race, or NDI. Mastectomy rate was higher in academic sites than community sites (29 vs. 20.4%; p = 0.0045), while hormone therapy (HT) utilization rate was higher in community sites (74 vs. 62%; p = 0.0012). QoL survey response rate was 32%. Only HT side effects negatively affected in QoL scores and there was no significant difference in QoL domains and decision-making process between races, age, NDI, treatment groups, and treatment locations. CONCLUSION Our integrated health network did not show chronically noted disparities arising from social determinates of health for DCIS treatments by implementing clinical pathways and system-wide peer review. Also, we demonstrated feasibility in collecting QoL for DCIS women with diverse backgrounds and different socioeconomic statuses.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women's Hospital, 300 Halket Street, Pittsburgh, PA, 15213, USA.
| | - Hong Wang
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kathryn Demanelis
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - David A Clump
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Mia Diego
- Department of Breast Surgery, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Vikram Gorantla
- Department of Medical Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research On Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margaret Q Rosenzweig
- Department of Nursing, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Garg N, Thorat MA. HER2 expression should be routinely evaluated in DCIS to avoid under or overtreatment! Oncoscience 2023; 10:1-3. [PMID: 36733476 PMCID: PMC9890724 DOI: 10.18632/oncoscience.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/15/2023] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - Mangesh A. Thorat
- Correspondence to:Mangesh A. Thorat, Breast Services, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom; Centre for Cancer Prevention, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom; School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom email:
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45
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Woodward WA, Mitchell MP. The Elusive Prize of Radiation Therapy Predictive Assays in Breast Cancer. Int J Radiat Oncol Biol Phys 2023; 115:103-105. [PMID: 36526377 DOI: 10.1016/j.ijrobp.2022.07.2311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Wendy A Woodward
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
| | - Melissa P Mitchell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
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46
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Park HJ, Kim K, Kim YB, Chang JS, Shin KH. Patterns and Longitudinal Changes in the Practice of Breast Cancer Radiotherapy in Korea: Korean Radiation Oncology Group 22-01. J Breast Cancer 2023. [DOI: 10.4048/jbc.2023.26.e15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Affiliation(s)
- Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
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47
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Vicini FA, Mann GB, Shah C, Weinmann S, Leo MC, Whitworth P, Rabinovitch R, Torres MA, Margenthaler JA, Dabbs D, Savala J, Shivers SC, Mittal K, Wärnberg F, Bremer T. A Novel Biosignature Identifies Patients With DCIS With High Risk of Local Recurrence After Breast Conserving Surgery and Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 115:93-102. [PMID: 36115740 DOI: 10.1016/j.ijrobp.2022.06.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/01/2022] [Accepted: 06/12/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE There is an unmet need to identify women diagnosed with ductal carcinoma in situ (DCIS) with a low risk of in-breast recurrence (IBR) after breast conserving surgery (BCS), which could omit radiation therapy (RT), and also to identify those with elevated IBR risk remaining after BCS plus RT. We evaluated a novel biosignature for a residual risk subtype (RRt) to help identify patients with elevated IBR risk after BCS plus RT. METHODS AND MATERIALS Women with DCIS treated with BCS with or without RT at centers in the US, Australia, and Sweden (n = 926) were evaluated. Patients were classified into 3 biosignature risk groups using the decision score (DS) and the RRt category: (1) Low Risk (DS ≤2.8 without RRt), (2) Elevated Risk (DS >2.8 without RRt), and (3) Residual Risk (DS >2.8 with RRt). Total and invasive IBR rates were assessed by risk group and treatment. RESULTS In patients at low risk, there was no significant difference in IBR rates with or without RT (total, P = .8; invasive IBR, P = .7), and there were low overall 10-year rates (total, 5.1%; invasive, 2.7%). In patients with elevated risk, IBR rates were decreased with RT (total: hazard ratio [HR], 0.25; P < .001; invasive: HR, 0.28; P = .005); 10-year rates were 20.6% versus 4.9% (total) and 10.9% versus 3.1% (invasive). In patients with residual risk, although IBR rates decreased with RT after BCS (total: HR, 0.21; P < .001; invasive: HR, 0.29; P = .028), IBR rates remained significantly higher after RT compared with patients with elevated risk (HR, 2.5; 95% CI, 1.2-5.4; P = .018), with 10-year rates of 42.1% versus 14.7% (total) and 18.3% versus 6.5% (invasive). CONCLUSIONS The novel biosignature identified patients with 3 distinct risk profiles: Low Risk patients with a low recurrence risk with or without adjuvant RT, Elevated Risk patients with excellent outcomes after BCS plus RT, and Residual Risk patients with an elevated recurrence risk remaining after BCS plus RT, warranting potential intensified or alternative treatment approaches.
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Affiliation(s)
| | - G Bruce Mann
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest Research Center, Portland, Oregon
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest Research Center, Portland, Oregon
| | | | - Rachel Rabinovitch
- Department of Radiation Oncology, University of Colorado, Colorado Springs, Colorado
| | - Mylin A Torres
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Julie A Margenthaler
- Department of General Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | - Fredrik Wärnberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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48
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Wu TC, McCloskey SA. Established and new horizons in radiotherapy for breast cancer. Ther Adv Med Oncol 2023; 15:17588359231161415. [PMID: 36950271 PMCID: PMC10026101 DOI: 10.1177/17588359231161415] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/16/2023] [Indexed: 03/24/2023] Open
Abstract
Modern advances in diagnostics, surgery, systemic therapies, and radiotherapy (RT) have drastically revolutionized treatment strategies for breast cancer. This review outlines current and evolving treatment paradigms for RT in the breast-conserving therapy and post-mastectomy setting. In early-stage breast cancer, there is active investigation in expanding eligibility for omission of RT in women with more biologically favorable tumors and growing options to effectively irradiate less breast tissue and shorten RT treatment courses. For locally advanced breast cancer, we discuss several patient cohorts in which the necessity of post-mastectomy RT (PMRT) is commonly debated. Ongoing efforts to better refine indications for PMRT and evaluate the feasibility of hypofractionated PMRT are being studied. Metastasis-directed therapy with ablative RT is an emerging topic of interest in many cancers, including its role and impact in oligometastatic breast cancer. In this review, we will discuss the rationale for current standard of care and address in greater detail the aforementioned concepts.
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Affiliation(s)
- Trudy C. Wu
- Department of Radiation Oncology, University of
California, Los Angeles, Los Angeles, CA, USA
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49
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Kim R, Kawai A, Wakisaka M, Shimoyama M, Yasuda N, Ito M, Kin T, Arihiro K. Outcomes in patients with non‐invasive breast carcinoma. Cancer Rep (Hoboken) 2022; 6:e1768. [PMID: 36494178 PMCID: PMC10075290 DOI: 10.1002/cnr2.1768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIM Non-invasive breast carcinoma is considered to be localized disease and is distinguished from invasive ductal and lobular carcinomas. The local recurrence of non-invasive carcinoma after surgery may lead to development of invasive carcinoma and promote distant metastasis, which worsens the prognosis for breast cancer mortality. The distant metastasis of non-invasive carcinoma may involve the ductal microvasculature without invasion. The outcomes of non-invasive breast carcinoma were examined in this retrospective cohort study. METHODS AND RESULTS Of 872 primary breast cancers diagnosed at a single center between May 2008 and March 2022, 93 (10.6%) were found to be non-invasive carcinomas and were examined in this study. The breast cancer recurrence and survival rates of patients with non-invasive carcinoma were analyzed retrospectively. The median follow-up period was 1891 (range, 5-4804) days. All patients underwent surgical treatment [mastectomy with sentinel lymph node biopsy (SLNB) and partial mastectomy with or without SLNB, tumorectomy, and microdochectomy]. Postoperatively, radiation therapy was administered to 73 (78.4%) of the patients and endocrine therapy was administered to 64 (81.0%) of 79 patients with hormone-receptor positivity. Of 26 patients who underwent partial mastectomy with SLNB, 24 (92.3%) showed isolated tumor cells in the SLNs on one-step nucleic acid amplification. Local recurrence was observed in three (0.3%) patients; no distant metastasis was observed. One patient died of a noncancerous disease. The overall survival rate was 98.0% and the breast cancer-specific survival rate was 100.0%. CONCLUSIONS Non-invasive breast carcinoma, like invasive breast carcinoma, causes local recurrence, but has a good prognosis without distant metastasis. The clinical significance of isolated tumor cells in the SLNs as a systemic component of non-invasive breast carcinoma remains to be elucidated.
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Affiliation(s)
- Ryungsa Kim
- Department of Breast Surgery Hiroshima Mark Clinic Hiroshima Japan
| | - Ami Kawai
- Department of Breast Surgery Hiroshima Mark Clinic Hiroshima Japan
| | - Megumi Wakisaka
- Department of Breast Surgery Hiroshima Mark Clinic Hiroshima Japan
| | - Mika Shimoyama
- Department of Breast Surgery Hiroshima Mark Clinic Hiroshima Japan
| | - Naomi Yasuda
- Department of Breast Surgery Hiroshima Mark Clinic Hiroshima Japan
| | - Mitsuya Ito
- Department of Breast Surgery Hiroshima City Hospital Hiroshima Japan
| | - Takanori Kin
- Department of Breast Surgery Hiroshima City Hospital Hiroshima Japan
| | - Koji Arihiro
- Department of Anatomical Pathology Hiroshima University Hospital Hiroshima Japan
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[Boost and hypofractionation in DCIS]. Strahlenther Onkol 2022; 198:1122-1124. [PMID: 36264356 PMCID: PMC9700622 DOI: 10.1007/s00066-022-02016-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 12/02/2022]
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