Overuse of Axillary Surgery in Patients with Ductal Carcinoma In Situ: Opportunity for De-escalation

Ductal Carcinoma In Situ (DCIS) and Microinvasive DCIS: Role of Surgery in Early Diagnosis of Breast Cancer

Advances in treatments, screening, and awareness have led to continually decreasing breast cancer-related mortality rates in the past decades. This achievement is coupled with early breast cancer diagnosis. Ductal carcinoma in situ (DCIS) and microinvasive breast cancer have increasingly been diagnosed in the context of mammographic screening. Clinical management of DCIS is heterogenous, and the clinical significance of microinvasion in DCIS remains elusive, although microinvasive DCIS (DCIS-Mi) is distinct from "pure" DCIS. Upfront surgery has a fundamental role in the overall treatment of these breast diseases. The growing number of screen-detected DCIS diagnoses with clinicopathological features of low risk for local recurrence (LR) allows more conservative surgical options, followed by personalised adjuvant radiotherapy plans. Furthermore, studies are underway to evaluate the validity of surgery omission in selected low-risk categories. Nevertheless, the management, the priority of axillary surgical staging, and the prognosis of DCIS-Mi remain the subject of debate, demonstrating how the paucity of data still necessitates adequate studies to provide conclusive guidelines. The current scientific scenario for DCIS and DCIS-Mi surgical approach consists of highly controversial and diversified sources, which this narrative review will delineate and clarify.

Shifting paradigms for the treatment of ductal carcinoma in situ: Less is more

Ductal carcinoma in situ is a diverse disease in which only 50% of lesions progress to invasive carcinoma, but unfortunately, all patients receive similar treatment recommendations independent of the disease variability. De-escalation is the philosophy that treatment for this disease should be differentiated based on the likelihood of future progression and recurrence. Four surgical trials are looking at the possibility of removing surgical intervention, the current mainstay of treatment, from the algorithm. Molecular assays have been developed to help differentiate the risk of an ipsilateral breast tumor recurrence and potentially guide the postsurgical utility of radiation therapy. Primary endocrine therapy is also being explored as an alternative to standard local therapy. Ductal carcinoma in situ therapy is a very complicated algorithm that should be discussed and treated through shared decision-making.