Abstract
PurposeThe future of non-operative management of DCIS relies on distinguishing lesions requiring treatment from those needing only active surveillance. More accurate preoperative staging and grading of DCIS would be helpful. We identified determinants of upstaging preoperative breast biopsies showing ductal carcinoma in situ (DCIS) to invasive breast cancer (IBC), or of upgrading them to higher-grade DCIS, following examination of the surgically excised specimen.MethodsWe studied all women with DCIS at preoperative biopsy in a large specialist cancer centre during 2000–2014. Information from clinical records, mammography, and pathology specimens from both preoperative biopsy and excised specimen were abstracted. Women suspected of having IBC during biopsy were excluded.ResultsAmong 606 preoperative biopsies showing DCIS, 15.0% (95% confidence interval 12.3–18.1) were upstaged to IBC and a further 14.6% (11.3–18.4) upgraded to higher-grade DCIS. The risk of upstaging increased with presence of a palpable lump (21.1% vs 13.0%, pdifference = 0.04), while the risk of upgrading increased with presence of necrosis on biopsy (33.0% vs 9.5%, pdifference < 0.001) and with use of 14G core-needle rather than 9G vacuum-assisted biopsy (22.8% vs 7.0%, pdifference < 0.001). Larger mammographic size increased the risk of both upgrading (pheterogeneity = 0.01) and upstaging (pheterogeneity = 0.004).ConclusionsThe risk of upstaging of DCIS in preoperative biopsies is lower than previously estimated and justifies conducting randomized clinical trials testing the safety of active surveillance for lower grade DCIS. Selection of women with low grade DCIS for such trials, or for active surveillance, may be improved by consideration of the additional factors identified in this study.
Highlights
The introduction of breast screening programmes has resulted in a dramatic increase in the annual incidence of ductal carcinoma in situ (DCIS), which currently accounts for approximately one fifth of screen-detected breast cancers in many countries worldwide [1,2,3]
The publication of findings from three on-going randomised trials of non-operative treatment in DCIS are anticipated in the coming decade and they will determine whether a further paradigm shift in its treatment is appropriate
Our findings provide reassurance to healthcare providers and patients alike regarding participation in both ongoing and future trials of non-operative management of DCIS by demonstrating lower proportions of upstaged preoperative biopsies than previously reported, an absence of missed invasive breast cancer (IBC) from interobserver variation amongst pathologists reviewing preoperative biopsies, and favourable prognostic features amongst the minority of cases that were upstaged
Summary
Extended author information available on the last page of the article. Since many DCIS lesions would never have become clinically significant in the Breast Cancer Research and Treatment (2019) 178:409–418 absence of screening [4], this combination of therapies may constitute substantial overtreatment—especially since each treatment carries risks in addition to its intended benefits. Research in the field of DCIS management focuses on finding ways to distinguish DCIS lesions requiring active treatment from those that can safely be left under surveillance and treated only if there is a change in morphology, grade, or invasive status [5, 6]
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