The Ductal Carcinoma In Situ (DCIS) Dilemma

Abstract

Detecting, classifying (grading), treating, and managing ductal carcinoma in situ (DCIS), and other high-risk abnormalities (eg, atypical ductal hyperplasia [ADH]), of the breast remains an ever-evolving, complicated, extremely expensive, and controversial area of interest. I recently attended a National Institutes of Health workshop on the topic of ‘‘Diagnosis and Management of Ductal Carcinoma In Situ (DCIS)’’ (1) with the hope of gaining a new perspective mixed with a critical assessment through open discussion about the ‘‘big picture issues’’ we face, only to be surprised as to how little is known about the natural history of this disease (or better yet diseases) and as to the best course of treatment and management of DCIS. As far as I was concerned, this lack of knowledge regarding optimal management of DCIS (which I personally saw as the ‘‘huge white elephant in the room’’) was briefly mentioned (and largely glanced over or completely ignored) by several speakers rather than being the clear and primary focus of the meeting. In 11 single-spaced pages of the draft statement that came out of the meeting, there were several indirect comments about the lack of understanding as to how should DCIS be optimally managed, but there was only one clear recommendation (on page 10) that specifically mentioned the need to ‘‘develop and validate risk-stratification models to identify subsets of women who have DCIS who are candidates for (1) active surveillance only, (2) local excision only, (3) local excision with radiotherapy, and (4) mastectomy’’ (2). One could argue that the current diagnosis and management of DCIS is optimal because mortality from breast cancer is indeed declining and the general consensus is that early detection leads to a better chance for a cure. It is therefore understandable why we may not wish to challenge our current thinking and admit that we truly do not know if treating ADH and DCIS primarily as an invasive cancer has any effect on survival, and perhaps consider the possibility that the vast majority of those treated may have indeed been overtreated.