Treatment of Ductal Carcinoma In Situ: Considerations for Tailoring Therapy in the Contemporary Era

Abstract

Standard options for the treatment of ductal carcinoma in situ (DCIS) include breast-conserving surgery (BCS) alone; BCS with radiotherapy or endocrine therapy, or both; and mastectomy. Survival is excellent with all options, but rates of local recurrence (LR) vary, as do quality-of-life measures. Here we discuss treatment outcomes, risk factors for LR, and tools for risk estimation. After BCS, radiotherapy reduces the risk of LR by half, and endocrine therapy reduces the risk by a third. Young age, inadequate margins, and greater volume of disease are associated with higher risk of LR after BCS, while young age, high grade, and microinvasion are associated with higher risk of locoregional recurrence after mastectomy. Clinical tools, including the Memorial Sloan Kettering Cancer Center (MSKCC) DCIS nomogram, provide LR risk estimates after BCS that appear more accurate than current genomic assays. The safety of active surveillance for seemingly low-risk patients remains uncertain. Estimation of LR risk, utilizing a multitude of clinicopathologic and treatment factors, can help a woman balance that risk with her values and priorities, and allow her to choose the optimal treatment option for her.