Rak wewnątrzprzewodowy in situ (dcis)

Rak wewnątrzprzewodowy in situ (dcis)
Epidemiologia

Rak wewnątrzprzewodowy in situ (DCIS) to heterogeniczna, przedinwazyjna forma raka piersi, ograniczona do przewodów i zrazików, bez naciekania błony podstawnej. W ostatnich dekadach częstość występowania DCIS wzrosła z 5,8 do 32,5 na 100 000 kobiet, głównie dzięki mammografii przesiewowej, która wykrywa około 90% przypadków, z czego 80% manifestuje się jako zwapnienia. Mediana wieku pacjentek wynosi 47-63 lata, a szczyt zachorowalności przypada na wiek 65-69 lat (96,7/100 000). Czynniki ryzyka DCIS pokrywają się z inwazyjnym rakiem piersi i obejmują wiek, wywiad rodzinny, czynniki hormonalne, gęstość tkanki piersi, ekspozycję na promieniowanie oraz styl życia. Naturalna historia DCIS jest zróżnicowana – od 14% do 50% przypadków może progresować do raka inwazyjnego, z czasem progresji od 0,2 do 2,5 roku, zależnie od stopnia złośliwości. Wykrywanie DCIS jest głównie bezobjawowe, a ryzyko nawrotu po leczeniu oszczędzającym pierś bez radioterapii wynosi 25-35% po 13-17 latach, z około połową nawrotów inwazyjnych.

Epidemiologia raka wewnątrzprzewodowego in situ (DCIS)

Zachorowalność na DCIS
Różnice demograficzne w zachorowalności na DCIS

Czynniki ryzyka DCIS
Naturalna historia DCIS i ryzyko progresji
Nadzór i badania przesiewowe w DCIS

Wykrywanie DCIS
Aktywny nadzór jako alternatywa dla leczenia chirurgicznego
Zalecenia dotyczące nadzoru po leczeniu DCIS

Rokowanie i przeżycie w DCIS
Aktualne wyzwania i kierunki badań

Problem nadrozpoznawalności i nadmiernego leczenia
Badania nad aktywnym nadzorem
Biomarkery i ocena ryzyka

Epidemiologia DCIS – kluczowe fakty

Kolejne rozdziały

Epidemiologia raka wewnątrzprzewodowego in situ (DCIS)

Rak wewnątrzprzewodowy in situ (DCIS) stanowi heterogeniczną grupę zmian nowotworowych ograniczonych do przewodów i zrazików piersi, różniących się wyglądem histologicznym i potencjałem biologicznym. DCIS jest uznawany za najwcześniejszą, przedinwazyjną formę raka piersi, często określaną jako rak piersi stadium 0. Charakteryzuje się proliferacją komórek nowotworowych w obrębie przewodów mlekowych, które nie przekraczają błony podstawnej i nie naciekają otaczających tkanek piersi.¹²³

Zachorowalność na DCIS

Częstość występowania DCIS znacząco wzrosła w ostatnich dekadach, głównie za sprawą wprowadzenia i upowszechnienia badań przesiewowych z wykorzystaniem mammografii. Zachorowalność wzrosła z 5,8 na 100 000 kobiet w latach 70. XX wieku do 32,5 na 100 000 kobiet w 2004 roku, po czym osiągnęła plateau.¹³ Obecnie DCIS stanowi około 20-25% wszystkich nowo diagnozowanych przypadków raka piersi w Stanach Zjednoczonych, a w 2023 roku spodziewano się 55 720 nowych przypadków.¹⁴ Według innych szacunków, w USA około 59 080 kobiet rocznie jest diagnozowanych z DCIS.⁵⁶

Przed wprowadzeniem programów badań przesiewowych z wykorzystaniem mammografii, DCIS stanowił mniej niż 5% nowo diagnozowanych przypadków raka piersi. Obecnie szacuje się, że około 90% wszystkich przypadków DCIS jest wykrywanych podczas badań mammograficznych.⁷⁸ Warto podkreślić, że wzrost wykrywalności DCIS nie przełożył się na proporcjonalny spadek występowania inwazyjnego raka piersi, co rodzi pytania o potencjalne nadrozpoznawanie i związane z tym nadmierne leczenie.⁹¹⁰

Różnice demograficzne w zachorowalności na DCIS

Mediana wieku pacjentek z DCIS waha się od 47 do 63 lat, co jest podobne do mediany wieku pacjentek z inwazyjnym rakiem piersi. Szczyt zachorowalności na DCIS (96,7 na 100 000 kobiet) występuje w grupie wiekowej 65-69 lat, co jest wcześniej niż w przypadku inwazyjnego raka piersi, gdzie szczyt zachorowalności (453,1 na 100 000 kobiet) przypada na wiek 75-79 lat.¹¹ W grupie wiekowej 50-64 lat ryzyko DCIS może sięgać nawet 88 na 100 000 kobiet.⁷

Istnieją różnice etniczne w zachorowalności na DCIS. W populacji USA kobiety rasy białej (nie-Latynoskie) mają najwyższą częstość występowania DCIS (45,3 na 100 000), następnie kobiety rasy czarnej (35,0), kobiety pochodzenia azjatyckiego (30,9), a najniższą częstość obserwuje się wśród kobiet pochodzenia latynoskiego (21,8 na 100 000).¹²

Chociaż DCIS jest przede wszystkim chorobą kobiet, może również występować u mężczyzn, choć jest to rzadkość. W analizowanym okresie wskaźniki zachorowalności na DCIS wzrosły o 123% u mężczyzn i o 555% u kobiet, co prawdopodobnie wiąże się z wprowadzeniem badań mammograficznych, które ułatwiają wykrywanie tej choroby u kobiet.¹³

Czynniki ryzyka DCIS

DCIS i inwazyjny rak piersi mają podobne czynniki ryzyka, co sugeruje wspólną etiologię obu chorób.¹³¹³ Do głównych czynników ryzyka DCIS należą:

Wiek – ryzyko DCIS wzrasta wraz z wiekiem, szczególnie u kobiet powyżej 50. roku życia¹⁴¹⁵
Wywiad rodzinny w kierunku raka piersi – częstość występowania raka piersi u krewnych pierwszego stopnia (10-35%) oraz częstość występowania mutacji w genach BRCA jest podobna u pacjentek z DCIS i inwazyjnym rakiem piersi¹¹¹³
Czynniki hormonalne – wczesna pierwsza miesiączka, późna menopauza, bezdzietność, pierwszy poród po 30. roku życia, długotrwałe stosowanie hormonalnej terapii zastępczej¹⁴¹⁶¹⁷
Gęsta tkanka piersi w mammografii¹⁴¹⁷
Przebyte choroby proliferacyjne piersi¹⁶
Osobisty wywiad raka piersi – wcześniejsze rozpoznanie raka piersi w jednej piersi zwiększa ryzyko rozwoju DCIS w drugiej piersi¹⁴¹⁵
Ekspozycja na promieniowanie – wcześniejsza radioterapia klatki piersiowej, szczególnie w dzieciństwie lub okresie dojrzewania¹⁴¹⁷
Czynniki związane ze stylem życia – otyłość, nadmierne spożycie alkoholu, brak aktywności fizycznej¹⁴¹⁷

Naturalna historia DCIS i ryzyko progresji

Naturalna historia DCIS bez leczenia jest trudna do określenia, ponieważ większość przypadków jest leczona chirurgicznie. Istnieją jednak dowody, że nie wszystkie przypadki DCIS progresują do inwazyjnego raka piersi.¹⁸¹⁹

Szacunki dotyczące odsetka przypadków DCIS, które mogą przekształcić się w inwazyjny rak piersi, wahają się od 14% do 50%.⁴²⁰ Oznacza to, że 50-80% przypadków DCIS nigdy nie stanie się rakiem inwazyjnym. W badaniu finansowanym przez NCI w 2020 roku, modelującym naturalną historię DCIS, wykazano, że od 36% do 100% przypadków DCIS progresuje do inwazyjnego raka piersi bez interwencji chirurgicznej, ze średnim czasem progresji wynoszącym od 0,2 do 2,5 roku.⁷

Ryzyko progresji zależy od stopnia złośliwości DCIS. Największe badania dotyczące naturalnej historii DCIS sugerują, że ponad 50% pacjentek z DCIS wysokiego stopnia złośliwości ma potencjał do progresji do raka inwazyjnego w ciągu mniej niż 5 lat, jeśli nie jest leczone. Z kolei DCIS niskiego stopnia złośliwości ma podobny potencjał progresji, ale u mniejszego odsetka pacjentek (35-50%) i w dłuższym okresie, nawet do 40 lat.¹⁸

W małym badaniu pacjentek z przeważnie niskozłośliwym DCIS, które zostały błędnie zdiagnozowane jako łagodne zmiany piersi i nie otrzymały interwencji chirurgicznej, 6 z 13 pacjentek rozwinęło ipsilateralny inwazyjny rak piersi, a średni czas do rozwoju raka inwazyjnego wynosił 9,0 lat.¹⁹

Nadzór i badania przesiewowe w DCIS

Wykrywanie DCIS

Większość przypadków DCIS jest wykrywana mammograficznie (70-90%), rzadko klinicznie. DCIS najczęściej prezentuje się jako bezobjawowe zwapnienia w mammografii, bez innych objawów klinicznych.²¹²² Około 80% przypadków DCIS prezentuje się jako zwapnienia, a 20% jako inne podejrzane zmiany mammograficzne, w tym masy i ogniskowe zmiany guzkowate.²²

Tylko 5% przypadków DCIS wiąże się z wyczuwalną zmianą, co czyni DCIS w dużej mierze niezamierzonym efektem zwiększonego nadzoru nad rakiem piersi.²² Szacuje się, że około 1 przypadek DCIS jest zazwyczaj identyfikowany na 1000 badań mammograficznych przesiewowych.²¹

Aktywny nadzór jako alternatywa dla leczenia chirurgicznego

W ostatnich latach coraz większą uwagę poświęca się koncepcji aktywnego nadzoru (active surveillance, AS) jako alternatywy dla leczenia chirurgicznego w wybranych przypadkach DCIS niskiego ryzyka. Aktywny nadzór polega na ścisłym monitorowaniu pacjentki za pomocą regularnych badań obrazowych, bez natychmiastowej interwencji chirurgicznej.²³²⁴²⁵

Globalnie prowadzone są co najmniej trzy duże badania kliniczne testujące hipotezę, że biopsja połączona z aktywnym nadzorem nie jest gorsza od natychmiastowego leczenia oszczędzającego pierś z radioterapią lub bez niej w przypadku DCIS:²⁶²⁷

COMET (Comparing an Operation to Monitoring with or without Endocrine Therapy) – badanie porównujące operację ze ścisłym monitorowaniem z lub bez terapii endokrynnej w DCIS niskiego ryzyka²⁸²⁹
LORIS (Low Risk DCIS) – badanie fazy III, randomizowane, badanie non-inferiority operacji vs aktywnego monitorowania u pacjentek z DCIS niskiego ryzyka³⁰
LORD (LOw Risk DCIS) – badanie badające bezpieczeństwo aktywnego nadzoru w DCIS niskiego ryzyka³¹

Wstępne wyniki badania COMET są obiecujące. Po dwóch latach skumulowany współczynnik inwazyjnego raka wynosił 5,9% u kobiet w grupie leczenia standardowego i 4,2% u kobiet z aktywnym monitorowaniem, co sugeruje, że aktywne monitorowanie nie jest gorsze od leczenia standardowego pod względem ryzyka inwazyjnego raka piersi w zajętej piersi.²⁸³²

Warto jednak zauważyć, że długoterminowe ryzyko rozwoju inwazyjnego raka w przypadku aktywnego monitorowania jest obecnie nieznane, ale na podstawie wcześniejszych badań może wynosić co najmniej 0,6% rocznie, a prawdopodobnie więcej, biorąc pod uwagę brak chirurgicznego wycięcia.³³ Dlatego przyjęcie aktywnego monitorowania jako standardowej strategii postępowania w DCIS niskiego ryzyka wymaga dłuższego okresu obserwacji dla większości pacjentek.³³

Zalecenia dotyczące nadzoru po leczeniu DCIS

Dla pacjentek poddawanych nadzorowi po leczeniu DCIS, wytyczne National Comprehensive Cancer Network (NCCN) dotyczące raka piersi zalecają coroczne badania obrazowe piersi i badanie fizykalne co 6-12 miesięcy przez 5 lat, a następnie co roku.³⁴

W badaniu kohortowym obejmującym 1550 kobiet z medianą wieku 59 lat w momencie diagnozy, podczas obserwacji 11,5% (n=179) kobiet rozwinęło drugi rak piersi. Spośród tych przypadków, 74,3% (n=133) zostało wykrytych obrazowo, 20,1% (n=36) przez pacjentkę, 2,2% (n=4) przez lekarza, a 3,4% (n=6) wykryto przypadkowo w badaniach obrazowych lub patologicznych z procedur niezwiązanych z opieką onkologiczną.³⁴

Wyniki te sugerują, że nadzór po leczeniu powinien koncentrować się na przestrzeganiu mammografii i edukacji pacjentek dotyczącej objawów drugiego raka piersi, w tym wyczuwalnych mas, zmian skórnych i wydzieliny z brodawki sutkowej.³⁵

Metoda wykrywania drugiego raka piersi po DCIS	Odsetek przypadków
Wykrycie obrazowe	74,3% (n=133)
Wykrycie przez pacjentkę	20,1% (n=36)
Wykrycie przez lekarza	2,2% (n=4)
Wykrycie przypadkowe	3,4% (n=6)

Rokowanie i przeżycie w DCIS

Rokowanie u pacjentek z DCIS jest generalnie bardzo dobre. Biorąc pod uwagę nieinwazyjny charakter DCIS, przerzuty lub zgon u kobiet z DCIS, które są leczone, są rzadkie.⁸ Większość pacjentek z DCIS ma doskonałe rokowanie z normalną oczekiwaną długością życia.⁸

Jednak badania wykazują, że diagnoza DCIS wiąże się ze zwiększoną śmiertelnością z powodu raka piersi. W badaniu z 2020 roku obejmującym ponad 100 000 pacjentek z rozpoznaniem DCIS, ogólny wskaźnik zgonów z powodu raka piersi 20 lat po diagnozie wynosił 3,3%, co stanowi trzykrotność wskaźnika obserwowanego w populacji ogólnej.⁸⁹

Ryzyko nawrotu ipsilateralnego po samym leczeniu oszczędzającym pierś bez radioterapii jest wysokie, wynosząc od 25% do 35% po 13-17 latach obserwacji, a około połowa wszystkich nawrotów ma charakter inwazyjny.²¹ 25-letnie skumulowane ryzyko inwazyjnego raka piersi w zależności od wieku w momencie diagnozy DCIS wynosi 27,3% dla ≤45 lat, 25,2% dla 45-49 lat, 21,7% dla 50-59 lat i 20,8% dla 60-70 lat.³⁶

Obecnie długoterminowy wskaźnik przeżycia dla kobiet z rakiem wewnątrzprzewodowym in situ wynosi prawie 100%.³⁷ Pacjentki z DCIS mają typowo zwiększone ryzyko nawrotu raka piersi po leczeniu, chociaż szansa nawrotu jest mniejsza niż 30%. Większość nawrotów występuje w ciągu 5-10 lat po początkowej diagnozie i może mieć charakter inwazyjny lub nieinwazyjny.³⁷

Aktualne wyzwania i kierunki badań

Pomimo znaczącego postępu w diagnostyce i leczeniu DCIS, nadal istnieje wiele wyzwań i kontrowersji dotyczących optymalnego postępowania z tą chorobą.²⁶³⁸

Problem nadrozpoznawalności i nadmiernego leczenia

Wzrost liczby diagnoz DCIS w wyniku wprowadzenia programów badań przesiewowych piersi wzbudził obawy dotyczące nadrozpoznawalności i związanego z tym nadmiernego leczenia.²³⁹ Nadrozpoznawalność to diagnostyka choroby, która nigdy nie wywoła objawów ani nie zagrozi życiu.³⁹

Według niektórych szacunków, odsetek nadrozpoznawalności w przypadku DCIS waha się od 3,1% do 65,8%.⁷ Niedawne szacunki nadrozpoznawalności wynoszą 15%, głównie z powodu DCIS.³⁹

Badanie oparte na analizie danych z Amerykańskiego Rejestru Nowotworów obejmującego 100 000 kobiet zdiagnozowanych z DCIS sugeruje, że agresywne leczenie może nie być konieczne dla ratowania życia.³⁸ Pomimo to, obecnie ponad 95% kobiet zdiagnozowanych z DCIS decyduje się na leczenie polegające na kombinacji chirurgii i leczenia uzupełniającego (radioterapia i/lub terapia endokrynna).²⁰

Badania nad aktywnym nadzorem

Aktywny nadzór staje się obiecującą alternatywą dla standardowego leczenia chirurgicznego w wybranych przypadkach DCIS niskiego ryzyka.⁴⁰²⁹ Odsetek kobiet z biologicznie korzystnym DCIS, które nie są poddawane operacji w momencie diagnozy, wzrósł w czasie, osiągając szczyt 4,2% w 2017 roku.⁴¹

Obecnie prowadzone są liczne badania kliniczne mające na celu określenie bezpieczeństwa i skuteczności aktywnego nadzoru w DCIS:²³³¹

COMET – porównuje operację z aktywnym monitorowaniem w DCIS niskiego ryzyka²⁹
LORIS – bada bezpieczeństwo aktywnego monitorowania w porównaniu z operacją w DCIS niskiego ryzyka³⁰
LORD – ocenia bezpieczeństwo aktywnego nadzoru w DCIS niskiego ryzyka³¹
DCIS: RECAST (Re-Evaluating Conditions for Active Surveillance Suitability as Treatment) – ma na celu określenie, czy nowatorska terapia endokrynna zwiększa frakcję pacjentek, które będą odpowiednie do długoterminowego aktywnego nadzoru⁴²

Wstępne wyniki tych badań mogą być dostępne już w 2025 roku.³⁹ Wstępne wyniki badania COMET sugerują, że aktywne monitorowanie może być bezpieczną alternatywą dla operacji w wybranych przypadkach DCIS niskiego ryzyka.³²

Biomarkery i ocena ryzyka

Jednym z głównych wyzwań w aktywnym monitorowaniu jest identyfikacja utajonego raka inwazyjnego i pacjentek zagrożonych progresją do raka inwazyjnego.²³ Obecnie nie ma dobrego sposobu na przewidzenie, które przypadki DCIS przekształcą się w raka inwazyjnego, a które nie.⁴³

Prowadzone są badania nad biomarkerami, które mogłyby pomóc w lepszej stratyfikacji ryzyka i identyfikacji pacjentek, które mogłyby bezpiecznie uniknąć leczenia chirurgicznego.³¹⁴⁴ Obiecującym kierunkiem badań jest wykorzystanie rezonansu magnetycznego (MRI) do oceny ryzyka DCIS i kierowania decyzjami terapeutycznymi u kobiet, które decydują się na leczenie endokrynne i nadzór obrazowy zamiast standardowego leczenia chirurgicznego.⁴⁵

Ważnym wnioskiem klinicznym z badań jest obserwacja, że zapobieganie rozwojowi inwazyjnego raka piersi u kobiet z rozpoznaniem DCIS nie zmniejsza szans na zgon z powodu raka piersi, co jest najważniejszym wynikiem.⁴⁶ Sugeruje to, że lokalne leczenie DCIS może nie wpływać na ryzyko zgonu.⁴⁶

Epidemiologia DCIS – kluczowe fakty

Rak wewnątrzprzewodowy in situ (DCIS) stanowi istotny problem zdrowia publicznego, którego częstość znacząco wzrosła w wyniku wprowadzenia mammografii przesiewowej.¹³ Obecnie DCIS stanowi około 20-25% wszystkich diagnozowanych raków piersi.⁷⁴

Większość przypadków DCIS (90%) jest wykrywana podczas badań mammograficznych przesiewowych, a jedynie 5% wiąże się z wyczuwalnymi zmianami.⁸²² Czułość mammografii w wykrywaniu DCIS jest wysoka, a częstość wykrywania DCIS w programach przesiewowych wynosi około 1 przypadek na 1000 mammografii.²¹

Większość pacjentek z DCIS ma doskonałe rokowanie, z 20-letnim wskaźnikiem zgonów z powodu raka piersi wynoszącym 3,3%, co jest trzykrotnie wyższe niż w populacji ogólnej.⁸ Ryzyko nawrotu po leczeniu jest niskie, wynoszące około 1% rocznie w DCIS niskiego ryzyka i około 2% w DCIS wysokiego ryzyka lub wysokiego stopnia złośliwości.⁴⁷

Aktywny nadzór staje się obiecującą alternatywą dla standardowego leczenia chirurgicznego w wybranych przypadkach DCIS niskiego ryzyka, a prowadzone badania kliniczne pomogą określić, które pacjentki mogą bezpiecznie uniknąć leczenia chirurgicznego.⁴⁸³⁹

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Materiały źródłowe

#1 Breast ductal carcinoma in situ: Epidemiology, clinical manifestations, and diagnosis – UpToDate
https://www.uptodate.com/contents/breast-ductal-carcinoma-in-situ-epidemiology-clinical-manifestations-and-diagnosis/print
Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions confined to the breast ducts and lobules that differ in histologic appearance and biological potential. The diagnosis increased dramatically with the introduction of screening mammography. The goal of therapy of DCIS is to prevent the occurrence of an invasive breast cancer. […] The incidence of DCIS markedly increased from 5.8 per 100,000 women in the 1970s to 32.5 per 100,000 women in 2004 and then reached a plateau. Approximately 25 percent of breast cancers diagnosed in the United States are DCIS, and 55,720 new cases are expected in 2023. This increase is attributed primarily to the utilization of breast cancer screening by mammography. […] DCIS is less common than invasive breast cancer, but the risk factors for DCIS and invasive breast cancer are similar.
#2 Ductal carcinoma in situ (DCIS) – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/dcis/symptoms-causes/syc-20371889
Ductal carcinoma in situ is a very early form of breast cancer. In ductal carcinoma in situ, the cancer cells are confined inside a milk duct in the breast. The cancer cells haven’t spread into the breast tissue. Ductal carcinoma in situ is often shortened to DCIS. It’s sometimes called noninvasive, preinvasive or stage 0 breast cancer. […] DCIS is usually found during a mammogram done as part of breast cancer screening or to investigate a breast lump. DCIS has a low risk of spreading and becoming life-threatening. However, it does require an evaluation and a consideration of treatment options. […] Several factors may increase the risk of ductal carcinoma in situ, also called DCIS. DCIS is an early form of breast cancer. Risk factors for breast cancer may include: […] Healthcare professionals don’t know exactly what causes the changes in the cells that leads to DCIS. Factors that may play a part include lifestyle, environment and DNA changes that run in families.
#3 Breast ductal carcinoma in situ: Epidemiology, clinical manifestations, and diagnosis – UpToDate
https://www.uptodate.com/contents/breast-ductal-carcinoma-in-situ-epidemiology-clinical-manifestations-and-diagnosis
Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions confined to the breast ducts and lobules that differ in histologic appearance and biological potential. The diagnosis increased dramatically with the introduction of screening mammography. The goal of therapy of DCIS is to prevent the occurrence of an invasive breast cancer. […] The incidence of DCIS markedly increased from 5.8 per 100,000 women in the 1970s to 32.5 per 100,000 women in 2004 and then reached a plateau. Approximately 25 percent of breast cancers diagnosed in the United States are DCIS, and 55,720 new cases are expected in 2023. This increase is attributed primarily to the utilization of breast cancer screening by mammography. […] DCIS is less common than invasive breast cancer, but the risk factors for DCIS and invasive breast cancer are similar.
#4 Ductal Carcinoma In Situ (DCIS) | BCRF
https://www.bcrf.org/about-breast-cancer/dcis-ductal-carcinoma-in-situ/
Breast cancer is the most common cancer in women living in the U.S. Of all breast cancer diagnoses in the country, 20-25 percent are ductal carcinoma in situ (DCIS). An estimated 59,080 new cases of DCIS will be diagnosed in women this year. […] DCIS diagnosis has increased significantly since routine screening mammograms became widespread. Before screening mammography, less than five percent of newly diagnosed breast cancers were DCIS, whereas now 20-25 percent of diagnosed breast cancers are DCIS. From 1973-1975, before routine mammography, the incidence of DCIS was 1.87 per 100,000 people screened. This rose dramatically to 32.5 by 2004 and has since plateaued. […] Estimates of DCIS cases that will become invasive breast cancer range from 20-50 percent. Put another way, 50-80 percent of DCIS cases will not become invasive. […] Compared to invasive breast cancer, DCIS has been understudied, resulting in uncertainties about the best ways to manage a stage 0 breast cancer/DCIS diagnosis.
#5 Ductal Carcinoma In Situ (DCIS): Epidemiology – Rodrigo Arrangoiz MS, MD, FACS, FSSO
https://arrangoizmd.com/2025/05/01/ductal-carcinoma-in-situ-dcis-epidemiology/
One in eight women in the United States (US): Will be diagnosed with breast cancer in her lifetime: 20% to 25% of these newly diagnosed cases will be DCIS […] In 2025: An estimated 59, 080 cases of DCIS will be diagnosed in US […] Widespread use of screening mammography: Has resulted in a 10-fold increase in the reported incidence of DCIS since the mid-1980s: However, since 2003: The incidence of DCIS has declined in women aged 50 years and older: Possibly due to decreased use of hormone replacement therapy […] The incidence in women aged under 50 years continues to increase […] Approximately 1 in every 1,300 mammography examinations performed in US: Will lead to a diagnosis of DCIS: Representing 17% to 34% of all mammographically detected breast cancers […] Before the introduction of screening mammography,: Most cases of DCIS were not detected until a palpable mass formed: But today, 80% to 85% of DCIS cases are detected on screening
#6 Ductal carcinoma in situ: a comprehensive review on current and future management for the surgeon and non-surgeon – Bonev – AME Surgical Journal
https://asj.amegroups.org/article/view/55219/html
Ductal carcinoma in situ (DCIS) comprises 20% of all newly diagnosed breast cancers in the U.S. It is diagnosed with increasing frequency due to widespread screening mammography and approximately one in every 1,300 mammograms leads to a DCIS diagnosis. […] The annual incidence of DCIS in the U.S. is estimated at 60,290 women. […] The risk of ipsilateral invasive recurrence at 20 years was 5.9% and the risk of contralateral invasive recurrence was 6.2%. At 20 years, the breast cancer-specific mortality was 3.3% and was higher for women diagnosed before 35 years old and for blacks. […] The management of ductal carcinoma in situ (DCIS) continues to evolve. […] Several large clinical trials are investigating if management can be deescalated by identifying patients with low-risk DCIS who can be safely managed with active surveillance by mammography.
#7 Breast Ductal Carcinoma in Situ – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK567766/
Ductal carcinoma in situ (DCIS) of the breast represents neoplastic lesions, typically localized to the breast ducts with no evidence of invasion into the surrounding tissue. The diagnosis of DCIS has significantly increased in the recent past since the implementation of routine screening mammograms. […] Overall, breast cancer is the most common cancer in women in the United States. In women aged 50 to 64 years of age, the risk of DCIS is as high as 88 per 100,000 women. Today, 20% to 25% of breast cancer diagnosed in the United States is DCIS. This has increased concurrently with screening mammography, as a significant percentage of DCIS is first identified on screening mammography. In the pre-screening mammography era, less than 5% of newly diagnosed breast cancers were DCIS. A recent 2020 NCI-funded study modeled the natural history of DCIS using a combination of 2 population models and 6 submodels. They found that 36% to 100% of DCIS progressed to invasive breast cancer without surgical excision or treatment, with a mean progression time of 0.2 to 2.5 years. DCIS overdiagnosis ranged from 3.1% to 65.8%. They concluded that the majority of DCIS would progress to invasive breast cancer. However, the wide variation has to do with the heterogeneity and subtype variation within DCIS, and more studies need to be done on various subtypes.
#8 Breast Ductal Carcinoma in Situ – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK567766/
DCIS most commonly presents without a palpable mass and is commonly found via screening mammograms. Ninety percent of all cases of DCIS are detected from screening mammograms. […] Treatment for DCIS is multimodal and involves a combination of surgery, radiation therapy, and hormone therapy that is personalized to the patient’s specific diagnosis and preferences. Surgical treatment options for DCIS broadly include breast-conserving surgery followed by radiation or a simple mastectomy. With either treatment option, it is important to emphasize that there is equivalent long-term survival. […] Given the noninvasive nature of DCIS, metastases or death in women with DCIS who are treated are rare. If untreated, however, DCIS usually transforms into invasive cancer that may be deadly. There is an excellent prognosis with a normal life expectancy for the vast majority of patients with DCIS who undergo treatment. However, there is still an increased breast cancer mortality with the diagnosis of DCIS. In a recent 2020 study published in JAMA Oncology of over 100,000 patients diagnosed with DCIS, the overall death rate from breast cancer 20 years after diagnosis was 3.3%, a rate treble that of the general population.
#9 Ductal carcinoma in situ: to treat or not to treat, that is the question | British Journal of Cancer
https://www.nature.com/articles/s41416-019-0478-6
Ductal carcinoma in situ (DCIS) now represents 20-25% of all breast cancers consequent upon detection by population-based breast cancer screening programmes. […] Over 60,000 women are diagnosed with DCIS each year in the USA, 7000 in the UK and 2500 in the Netherlands. […] The number of women diagnosed with DCIS over the past few decades largely follows the introduction of population-based breast cancer screening. […] Nevertheless, the incidence of mortality from early-stage breast cancer has not decreased concurrently with DCIS detection and treatment, indicating that managing DCIS does not reduce breast-cancer-specific mortality and therefore could be considered as overtreatment. […] Generally, patients diagnosed with DCIS have an excellent long-term breast-cancer-specific survival of around 98% after 10 years of follow-up and a normal life expectancy.
#10 Current Trends in the Management of Ductal Carcinoma In Situ
https://www.cancernetwork.com/view/current-trends-management-ductal-carcinoma-situ
Ductal carcinoma in situ (DCIS), once a rare entity, now comprises up to 30% of newly diagnosed breast cancers detected on mammography. […] In the United States, over 50,000 patients are diagnosed with DCIS annually. […] This is in large part due to the widespread implementation of screening mammography, where DCIS most commonly presents as microcalcifications in the absence of other clinical findings. […] DCIS is traditionally considered to be a precursor to invasive disease; however, this paradigm has been challenged by the fact that although the incidence and treatment of DCIS have risen, there has not been a concomitant decline in the incidence of invasive breast cancer. […] The clinical and molecular discriminants between low-risk DCIS and high-risk DCIS are under active investigation.
#11 Ductal Carcinoma In Situ (DCIS): Epidemiology – Rodrigo Arrangoiz MS, MD, FACS, FSSO
https://arrangoizmd.com/2025/05/01/ductal-carcinoma-in-situ-dcis-epidemiology/
The incidence of DCIS in autopsy studies is higher than in the general population: Suggesting that not all DCIS lesions are clinically significant: Supporting concerns that most of the increase in DCIS incidence is due to the detection of nonaggressive subtypes: That are unlikely to progress to invasive cancer […] The median age reported for patients with DCIS: Ranges from 47 to 63 years: Similar to that reported for patients with invasive carcinoma […] However, the age of peak incidence for DCIS: 96.7 per 100,000 women: Occurs between the ages of 65 and 69 years: Which is younger than for invasive breast cancer: For which peak incidence: 453.1 per 100,000 women: Occurs between the ages of 75 and 79 years […] The frequency of first-degree relatives having breast cancer (10% to 35%) as well as rates of deleterious mutations in the breast cancer-associated (BRCA) genes are: Similar for patients with DCIS as for women with invasive breast cancer
#12 Epidemiology of Ductal Carcinoma In Situ | Oncohema Key
https://oncohemakey.com/epidemiology-of-ductal-carcinoma-in-situ/
Epidemiology of Ductal Carcinoma In Situ […] As breast-screening programs have been implemented in many countries around the world, the rates of DCIS have similarly increased. […] In a study of women aged 5069 years from 15 screening programs across 12 International Cancer Screening Network (ICSN) countries between 2004 and 2008, the overall incidence of DCIS averaged 16% (0.82 per 1000 examinations) with incidence being the highest in the USA (24%; 95% confidence interval (CI): 2225%) and the lowest in Finland (9%; 95% CI: 810%). […] The proportion of cases in whom DCIS was found was higher among screen-detected cases than the non-screen-detected cases (18% vs. 5.5%), after NBCSP was fully implemented. […] Non-Hispanic white women tend to have the highest incidence of DCIS in the US population, followed by black and Asian women, while Hispanic women have the lowest incidence. […] Innos et al., for example, evaluated the trends in racial and ethnic differences in the incidence on DCIS in California in women 40 years, from 1988 to 1999. They observed an average annual age-adjusted incidence of DCIS of 45.3 per 100,000 in white women, 35.0 in black women, 30.9 in Asian-Pacific Islander women, and 21.8 in Hispanic women.
#13 Epidemiology of Ductal Carcinoma In Situ | Oncohema Key
https://oncohemakey.com/epidemiology-of-ductal-carcinoma-in-situ/
While DCIS is primarily considered a disease of women, it can also occur in men. […] In situ rates rose 123% for men and 555% for women over this time period, perhaps due to screening mammography which would make it more detectable in women. […] In addition to race/ethnicity and gender, other sociodemographic factors have also been linked to higher rates of DCIS. […] It is plausible that these trends may be due to increasing use of mammography. […] DCIS and invasive breast cancer have similar risk factors, suggesting a common etiology for both diseases. […] A first-degree family history of breast cancer is associated with an increased risk of DCIS, and this risk increases with the number of affected family members, particularly if there is a family history of breast cancer being diagnosed at a young age. […] Prior to the introduction of national BCS programs, the incidence of DCIS was very low and nearly all diagnosed cases were symptomatic. […] Currently, DCIS accounts for 2025% of all newly diagnosed breast cancers and only 1314% of these cancers are symptomatic; the majority are screen detected.
#14
https://www.aurorahealthcare.org/services/cancer/breast-cancer/ductal-carcinoma-in-situ
Other risk factors for DCIS include: Age: While DCIS can occur at any age, women over 50 are more likely to develop it. Dense breast tissue: Women with dense breast tissue on mammograms face an increased risk of both DCIS and invasive breast cancer. Hormonal factors: Factors that affect hormone levels, like early menstruation, late menopause, childbirth after 30 and prolonged use of hormone replacement therapy may escalate DCIS risk. Lifestyle factors: Obesity, excessive alcohol consumption and a lack of exercise can also contribute to a higher DCIS risk. Personal history of breast cancer: A prior diagnosis of breast cancer in one breast increases your risk of developing DCIS in the opposite breast. Radiation exposure: Past radiation therapy to the chest, especially during childhood or teenage years, increases the likelihood of DCIS later in life.
#15
https://www.advocatehealth.com/health-services/cancer-institute/cancers-we-treat/breast-cancer/ductal-carcinoma-in-situ
Ductal carcinoma in situ (DCIS) is non-invasive breast cancer but can become invasive meaning it can spread into your surrounding breast tissue if not promptly managed. […] Ductal carcinoma in situ (DCIS) is a non-invasive cancer that grows inside the milk ducts of the breast. […] DCIS is one of the four types of breast cancer. […] With DCIS, the abnormal cancer cells grow within the lining of a breast milk duct. These abnormal cells dont spread beyond the duct. Although DCIS is non-invasive, treatment is important to prevent it from progressing into invasive breast cancer. […] Several factors, such as age, family history and hormonal factors may increase the risk of developing DCIS. […] Women over the age of 50 are more likely to develop DCIS, although it can occur at any age. […] If you have previously been diagnosed with breast cancer in one breast, you may have an increased risk of developing DCIS in the other breast.
#16 Ductal Carcinoma In Situ (DCIS): Epidemiology – Rodrigo Arrangoiz MS, MD, FACS, FSSO
https://arrangoizmd.com/2025/05/01/ductal-carcinoma-in-situ-dcis-epidemiology/
Other risk factors for DCIS: Including older age, proliferative breast disease, increased breast density, nulliparity, older age at primiparity, history of breast biopsy, early menarche, late menopause, long-term use of postmenopausal hormone replacement therapy, and elevated body mass index in postmenopausal women: Are the same as those for invasive breast cancer.
#17
https://www.advocatehealth.com/health-services/cancer-institute/cancers-we-treat/breast-cancer/ductal-carcinoma-in-situ
If you’ve had radiation therapy to the chest, particularly during childhood or adolescence, it increases your risk of developing DCIS later in life. […] Factors that affect hormone levels, such as early menstruation, late menopause, never giving birth or having a first child after the age of 30, and using hormone replacement therapy for an extended period, may increase the risk of DCIS. […] Women with dense breast tissue, as seen on mammograms, have a higher risk of developing both DCIS and invasive breast cancer. […] Factors such as obesity, excessive alcohol consumption and a inactive lifestyle may also contribute to an increased risk of DCIS. […] Regular breast self-exams and mammograms are crucial for early detection and treatment of DCIS and other types of breast cancer. […] Diagnosing DCIS can be tricky since it typically doesn’t have any noticeable symptoms.
#18 Ductal Carcinoma In Situ of the Breast: An Update with Emphasis on Radiological and Morphological Features as Predictive Prognostic Factors
https://www.mdpi.com/2072-6694/12/3/609
It is extremely difficult to trace the natural history of DCIS. […] The largest studies on the natural history of DCIS suggest that more than 50% of patients with high-grade DCIS have the potential to progress to an invasive carcinoma in less than 5 years if left untreated, while low-grade DCIS has a similar progression but in a small percentage of patients (35â50%) and in a more prolonged time course, up to 40 years. […] DCIS treatment is still controversial, with a wide possibility of options, including surveillance, breast-conserving surgery (BCS), BCS in association with radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy.
#19 Genetic predisposition to ductal carcinoma in situ of the breast | Breast Cancer Research | Full Text
https://breast-cancer-research.biomedcentral.com/articles/10.1186/s13058-016-0675-7
As most DCIS is treated surgically, the natural progression of untreated DCIS is not known. However, in one small study of patients with predominantly low-grade DCIS misdiagnosed as benign breast disease and who received no surgical intervention, 6 out of 13 patients developed ipsilateral invasive carcinoma with mean time to the development of invasive carcinoma being 9.0 years. In two specific DCIS trials in which DCIS was treated with breast-conserving surgery alone with no radiotherapy, long-term follow up shows that up to 30 % of women develop a recurrence (half of which will be DCIS and half invasive cancer) by 10 years. […] Methods for accurately predicting the behavior of DCIS are poor. Although grade has not been shown to be a good predictor of recurrence many clinicians use this classification to determine the use of radiotherapy following breast-conserving surgery. There is a strong correlation between the grade of the in situ and co-existing invasive components in IDC, suggesting that DCIS does not progress from low through to high grade before becoming invasive.
#20 Surgical Treatments for Ductal Carcinoma In Situ (DCIS) in Elderly Patients | Anticancer Research
https://ar.iiarjournals.org/content/43/4/1555
The widespread breast cancer screening and implementation of digital mammography led to an increase in the detection of ductal carcinoma in situ (DCIS) (1). This condition is considered the earliest detectable breast cancer (stage 0) and is probably underdiagnosed prior to breast cancer screening (2). Pure DCIS is defined as proliferating malignant breast cells without evidence of basement membrane invasion (3). Theoretically, DCIS does not possess metastatic potential, yet it could represent an underdiagnosis of invasive breast cancer, or progress to it (4). The risk of progression to invasive cancer ranges from 14% to 50 % (4, 5). […] According to the current guidelines, over 95% of women diagnosed with DCIS will choose to receive a combination of surgery and adjuvant treatments (radiation and/or endocrine therapy) (6). Lymph node evaluation for stage 0 breast cancer is controversial, and sentinel lymph node biopsy (SNLB) should be reserved for invasive cancer (4). Due to the risk of upstaging to invasive breast cancer and in order to avoid a potential second surgical procedure, a large proportion of women with a DCIS diagnosis undergo unnecessary SLNB (7). Despite DCIS often receiving similar treatments as ductal invasive cancer, all these measures have not been shown to reduce overall mortality in large observational studies (8). According to these studies, surgery may not be the optimal treatment choice, especially for elderly patients with high levels of comorbidity and a DCIS diagnosis whose disease course differs significantly from that of invasive breast cancer (9).
#21 Ductal Carcinoma In Situ of the Breast: An Update with Emphasis on Radiological and Morphological Features as Predictive Prognostic Factors
https://www.mdpi.com/2072-6694/12/3/609
It has been calculated that one case of DCIS is usually identified per 1000 screening mammograms. […] Most DCIS lesions are diagnosed mammographically (70â90%), being rarely detected clinically. […] Mammography is a highly sensitive diagnostic procedure for detecting DCIS. […] Magnetic resonance imaging (MRI) has been considered more sensitive than mammography for detecting DCIS without calcifications and multifocal lesions. […] The standard treatment of DCIS is primarily surgical, including BCS for localized lesions, and mastectomy for extensive or multicentric disease. […] Local recurrence rates (LRs) after BCS alone are high, ranging from 25% to 35% at 13â17 years of follow-up, and approximately half of all recurrences are invasive. […] The Society of Surgical Oncology (SSO), the American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO) concluded that a positive margin, defined as ink on tumor (DCIS), is associated with an increased risk in LR and that such risk is not nullified by the use of WBRT.
#22 Current Trends in the Management of Ductal Carcinoma In Situ
https://www.cancernetwork.com/view/current-trends-management-ductal-carcinoma-situ
Ideally, better risk stratification would allow patients with low-risk DCIS to be treated with a more minimalistic approach, including omission of radiation therapy (RT) or surgery in favor of active surveillance. […] The vast majority of DCIS cases are diagnosed as asymptomatic microcalcifications on screening mammography, with 80% presenting as microcalcifications alone and 20% as other suspicious mammographic findings, including masses and focal nodular patterns. […] Only 5% of DCIS cases are associated with a palpable finding, making DCIS largely an unintended consequence of increased breast cancer surveillance. […] The role of MRI in the management of DCIS is not clearly established. […] Currently, National Comprehensive Cancer Network guidelines for the treatment of DCIS include excision of all disease to negative margins with either mastectomy or, alternatively, BCT with or without RT.
#23 :: KJR :: Korean Journal of Radiology
https://kjronline.org/DOIx.php?id=10.3348/kjr.2024.0117
Ductal carcinoma in situ (DCIS) accounts for approximately 30% of new breast cancer diagnoses. […] The increase in DCIS diagnoses since the adoption of organized breast cancer screening programs has raised concerns about overdiagnosis and subsequent overtreatment. […] Active monitoring, a nonsurgical management strategy for DCIS, avoids surgery in favor of close imaging follow-up to de-escalate therapy and provides more treatment options. […] However, the two major challenges in active monitoring are identifying occult invasive cancer and patients at risk of invasive cancer progression. […] Subsequently, four prospective active monitoring trials are ongoing to determine the feasibility of active monitoring and refine the patient eligibility criteria and follow-up intervals. […] Active monitoring acknowledges that some DCIS lesions are overdiagnosed and aims to reduce overtreatment by deescalating therapy and offering more personalized treatment options to patients.
#24
https://scholars.duke.edu/display/pub1111190
Ductal carcinoma in situ (DCIS) is a noninvasive breast lesion with uncertain risk for invasive progression. […] One strategy to reduce overtreatment is active surveillance (AS), whereby DCIS is treated only upon detection of invasive disease. […] AS could be a viable management strategy for carefully selected DCIS patients, particularly among older age groups and those with substantial competing mortality risks. The effectiveness of AS could be markedly improved by reducing the rate of understaging.
#25
https://www.aurorahealthcare.org/services/cancer/breast-cancer/ductal-carcinoma-in-situ
Non-surgical treatments may include: Active surveillance: Sometimes active surveillance may be an option for low-grade DCIS. This involves closely monitoring the condition with regular mammograms and checkups with your doctor to ensure that it doesn’t progress. If there are any signs of changes or progression, treatment may be reconsidered.
#26 Controversies and Clinical Trials for DCIS: Margins and Active Surveillance
https://www.onclive.com/view/controversies-and-clinical-trials-for-dcis-margins-and-active-surveillance
The management of ductal carcinoma in situ is one of the most controversial areas in breast cancer management. […] Pure DCIS is a high-risk breast lesion as it can sometimes be associated with later development of invasive breast cancer in the absence of treatment. […] Recent national practice guidelines suggest that adequate margins for DCIS should be 2 mm after breast-conserving surgery followed by radiotherapy (RT). […] Globally, there are at least 3 clinical trials ongoing that are testing the hypothesis that biopsy alone with active surveillance is not inferior to immediate breast-conserving surgery with or without radiotherapy for DCIS. […] DCIS in and of itself is not harmful to patients. […] Screening mammography, since its introduction in the mid-1980s, has resulted in about a 500-fold increase in detection of DCIS, and perhaps a significant proportion of these patients, particularly with low-grade and intermediate-grade DCIS, will not go on to develop invasive breast cancers during the patients lifetime.
#27 Controversies and Clinical Trials for DCIS: Margins and Active Surveillance
https://www.onclive.com/view/controversies-and-clinical-trials-for-dcis-margins-and-active-surveillance
To address this clinical scenario, there are at least 3 currently ongoing clinical trials globally that are testing the hypothesis that biopsy alone with active surveillance is not inferior to immediate breast-conserving surgery with or without RT for DCIS. […] Finally, several key international trials are now addressing the hypothesis that the outcomes of patients with percutaneous biopsy alone for low-risk DCIS are not inferior to outcomes of surgery with or without RT.
#28 Active Monitoring Promising for Women with Low-Risk Ductal
https://www.esmo.org/oncology-news/active-monitoring-promising-for-women-with-low-risk-ductal-carcinoma-in-situ
In an intention-to-treat (ITT) analysis of the prospective, randomised non-inferiority COMET study, the 2-year cumulative rate of invasive cancer was 5.9% for women with low-risk ductal carcinoma in situ (DCIS) randomised to guideline-concordant care and 4.2% for active monitoring. These results show that at 2 years, patients randomised to active monitoring have non-inferior invasive breast cancer risk in the affected breast compared with those randomised to guideline-concordant care. […] The COMET is a prospective, randomised, pragmatic non-inferiority trial designed for women with newly diagnosed low-risk DCIS comparing guideline-concordant care, including surgery, with active monitoring, with surgery reserved only for disease progression to invasive cancer. The primary objective was to assess whether active monitoring was non-inferior to guideline-concordant care as defined by the invasive cancer rate in affected breasts at 2 years.
#29 Study Reveals Short Term Safety of Active Monitoring for DCIS | Duke Health
https://corporate.dukehealth.org/news/study-reveals-short-term-safety-active-monitoring-dcis
The first study comparing surgery to active monitoring as treatment for ductal carcinoma in situ (DCIS) finds women who carefully monitor the precancerous cells are no more likely to develop breast cancer after two years than women who undergo surgery to remove them. […] The early results of the Comparing an Operation to Monitoring with or without Endocrine Therapy (COMET) study suggest women and their doctors may consider active monitoring as a safe, less-aggressive alternative for treating low-risk DCIS. […] DCIS accounts for roughly one in five new breast cancer cases in the U.S., affecting more than 50,000 women every year. […] Currently, nearly all women with DCIS are treated with surgery, and as many as one-third undergo a mastectomy, which can result in long-term symptoms and altered body image.
#30 Current Trends in the Management of Ductal Carcinoma In Situ
https://www.cancernetwork.com/view/current-trends-management-ductal-carcinoma-situ
One-third of patients diagnosed with DCIS in the United States will be treated with mastectomy. […] Two-thirds of patients diagnosed with DCIS undergo surgical treatment with BCT. […] Several trials have evaluated the use of tamoxifen in DCIS. […] The appreciation of the wide heterogeneity of DCIS with variable malignant potential has generated interest in delineating which patients should be treated aggressively vs safely, or followed with close monitoring. […] The low risk (LORIS) DCIS trial is a phase III, randomized, noninferiority trial of surgery vs active monitoring in low-risk DCIS patients, which was initiated in Europe in 2014. […] The significant rise in the incidence of DCIS since the implementation of routine screening mammography has resulted in the appreciation of the vast biologic heterogeneity of this disease entity.
#31 Ductal carcinoma in situ: a comprehensive review on current and future management for the surgeon and non-surgeon – Bonev – AME Surgical Journal
https://asj.amegroups.org/article/view/55219/html
Current clinical trials are investigating which subgroups of DCIS patients can potentially avoid multimodal therapy and have deescalated treatment or be managed with surveillance. […] The COMET, LORIS, and LORD clinical trials are currently investigating if management can be deescalated. The goal of these trials is to identify low risk DCIS patients who can be safely managed with active surveillance by mammography.
#32 Study Reveals Short Term Safety of Active Monitoring for DCIS | Duke Health
https://corporate.dukehealth.org/news/study-reveals-short-term-safety-active-monitoring-dcis
Active monitoring is an alternative to surgery and radiation that involves performing mammograms routinely to check for early changes. […] At two years, the rate of invasive cancer in women in the surgery group was 5.9%, compared to 4.2% in women who did active monitoring. […] These early results are provocative and potentially exciting for patients, but we clearly need more long-term follow-up, Hwang said. If these results hold up over time, most patients who have this type of low-risk disease will have the option of avoiding invasive treatments. That would be a complete change in how we care for these patients and think about this disease.
#33 Active Monitoring Promising for Women with Low-Risk Ductal
https://www.esmo.org/oncology-news/active-monitoring-promising-for-women-with-low-risk-ductal-carcinoma-in-situ
The authors commented that these findings have important implications for future inclusion of active monitoring as an option for low-risk DCIS, particularly in patients who may consider endocrine therapy as part of active monitoring or who have multiple competing comorbidities. […] The long-term risk of invasive cancer development with active monitoring is unknown at this time but, based on ECOG-ACRIN E5194 and RTOG 9804, will be at least 0.6% per year, and possibly higher given the absence of surgical excision. […] Meanwhile, adoption of active monitoring as a standard management strategy for low-risk DCIS requires longer follow-up for most patients. The initial report of COMET does not provide the safety data necessary to omit surgery as part of DCIS management according to the editorialists.
#34 Mode of Detection of Second Breast Cancers in Patients Undergoing Surveillance After Treatment of Ductal Carcinoma in Situ in: Journal of the National Comprehensive Cancer Network Volume 22 Issue 1 (2023)
https://jnccn.org/abstract/journals/jnccn/22/1/article-e237082.xml
For patients undergoing posttreatment surveillance after ductal carcinoma in situ (DCIS), the NCCN Guidelines for Breast Cancer recommend annual breast imaging and physical examination every 6 to 12 months for 5 years, and then annually. […] Our study cohort consisted of 1,550 women, with a median age of 59 years at diagnosis. […] During follow-up, 11.5% (n=179) of women developed a second breast cancer. […] Second breast cancers were imaging-detected in 74.3% (n=133) of cases, patient-detected in 20.1% (n=36), physician-detected in 2.2% (n=4), and detected incidentally on imaging or pathology from procedures unrelated to oncologic care in 3.4% (n=6). […] In our cohort of patients undergoing surveillance following diagnosis and treatment of DCIS, 2% of second breast cancers were detected by a clinical breast examination.
#35 Mode of Detection of Second Breast Cancers in Patients Undergoing Surveillance After Treatment of Ductal Carcinoma in Situ in: Journal of the National Comprehensive Cancer Network Volume 22 Issue 1 (2023)
https://jnccn.org/abstract/journals/jnccn/22/1/article-e237082.xml
Our findings suggest that posttreatment surveillance should focus on compliance with mammography and patient education regarding symptoms of a second breast cancer, including palpable masses, skin changes, and nipple discharge. […] Our finding that CBE is low yield for diagnosing second breast cancers in this population has important implications for in-person health care utilization and offers an opportunity to harness telehealth as a cost-effective and time-effective option for DCIS survivorship care. […] In this retrospective study with a median follow-up of 10 years, we found that 94.4% of second breast cancers were detected via mammography or as a result of patient-reported symptoms, and only 2.2% of second breast cancers were detected via routine CBE.
#36 Invasive breast cancer and breast cancer death after non-screen detected ductal carcinoma in situ from 1990 to 2018 in England: population based cohort study | The BMJ
https://www.bmj.com/content/384/bmj-2023-075498
By 31 December 2018, 3651 women with non-screen detected ductal carcinoma in situ had developed invasive breast cancer, more than four times higher than expected from national cancer incidence rates (ratio of observed to expected rate was 4.21 (95% conference interval 4.07 to 4.35)). […] The 25 year cumulative risks of invasive breast cancer by age at diagnosis of ductal carcinoma in situ were 27.3% for 45 years, 25.2% for 45-49 years, 21.7% for 50-59 years, and 20.8% for 60-70 years. […] 908 women died of breast cancer, almost four times higher than that expected from breast cancer death rates in the general population (ratio of observed to expected rate 3.83 (3.59 to 4.09)). […] For at least 25 years after their diagnosis, women with non-screen detected ductal carcinoma in situ had higher long term risks of invasive breast cancer and breast cancer death than women in the general population.
#37 Most Common Breast Cancer Types: Carcinomas
https://www.cancercenter.com/cancer-types/breast-cancer/types/common-breast-cancer-types
DCIS is the most common type of noninvasive breast cancer, with about 60,000 new cases diagnosed in the United States each year. About one in every five new breast cancer cases is ductal carcinoma in situ. […] Patients with ductal carcinoma in situ are typically at higher risk for seeing their cancer return after breast cancer treatment, although the chance of a recurrence is less than 30 percent. Most recurrences occur within five to 10 years after the initial breast cancer diagnosis and may be invasive or noninvasive. DCIS also carries a heightened risk for developing a new breast cancer in the other breast. A recurrence of ductal carcinoma in situ would require additional treatment. […] Currently, the long-term survival rate for women with ductal carcinoma in situ is nearly 100 percent.
#38 Ductal carcinoma in situ: to treat or not to treat, that is the question | British Journal of Cancer
https://www.nature.com/articles/s41416-019-0478-6
Despite an excellent prognosis and normal life-expectancy, women diagnosed with DCIS experience stress and anxiety. […] A recent study based on an analysis of data from the American Cancer Registry of 100,000 women diagnosed with DCIS suggests that aggressive treatment might not be necessary to save lives. […] To address the question whether some patients with DCIS are overtreated, a group of patients not treated with conventional therapies should be studied. […] Uncertainty exists about how DCIS develops, and global consensus is lacking as to how best to optimally manage this disease. […] Current perceptions of the risk-framing dialogue between clinicians and women diagnosed with DCIS are currently resulting in the overdiagnosis and overtreatment of DCIS.
#39 :: KJR :: Korean Journal of Radiology
https://kjronline.org/DOIx.php?id=10.3348/kjr.2024.0117
Overdiagnosis is the diagnosis of a disease that will never present symptoms or be life-threatening. […] Notably, recent overdiagnosis estimates are 15%, primarily due to DCIS. […] Since the adoption of organized screening, a dramatic increase has been observed in DCIS diagnoses. […] Active monitoring requires the identification of eligible patients who do not have occult invasive cancer and are at low risk invasive cancer progression. […] Multiple prospective clinical trials are ongoing to determine the safety and feasibility of active monitoring. […] The initial results of these trials may be available as early as 2025. […] The next few years will witness the publication of major trial results and potentially chart a new course of DCIS management.
#40 Survival outcomes after omission of surgery for ductal carcinoma in situ | npj Breast Cancer
https://www.nature.com/articles/s41523-024-00689-5
Clinical trials of active surveillance (AS) for Ductal Carcinoma in Situ (DCIS) are underway. […] The proportion of patients with DCIS treated with AS has remained small but is increasing over time. AS of biologically favorable DCIS in younger, healthier women is not associated with adverse survival. […] In the United States, the diagnosis of ductal carcinoma in situ (DCIS) has significantly increased since screening mammography was introduced in the 1970s, and DCIS now comprises about 20-25% of new breast cancer diagnoses. […] However, this increase in diagnosis of DCIS has not led to a decrease in the incidence of invasive breast cancer, and models have suggested the rate of progression of DCIS to clinically significant invasive cancer is low. […] In addition, the breast cancer specific survival from studies using large population cohorts with DCIS has been shown to be excellent at 10 and 20 years.
#41 Survival outcomes after omission of surgery for ductal carcinoma in situ | npj Breast Cancer
https://www.nature.com/articles/s41523-024-00689-5
Therefore, some have suggested that clinicians are over-diagnosing and overtreating some patients with DCIS that may be inconsequential. […] Despite these concerns, surgery currently remains the cornerstone of guideline concordant care for DCIS, with radiation therapy and endocrine therapy utilized where appropriate. […] The aim of our study was to use a large national cancer database to retrospectively analyze the trends over time of treating patients with biologically favorable DCIS without surgery, and to determine the impact of omission of surgery on OS. […] The proportion of women with biologically favorable DCIS who are not undergoing surgery at time of diagnosis has increased overtime, peaking at 4.2% in 2017, the final year of our study. […] Our data also suggested that patients with biologically favorable DCIS and less than 50 years of age treated with AS have favorable long-term OS, comparable to those seen with surgical intervention.
#42 UCSF Ductal Carcinoma in Situ Trial â DCIS: RECAST Trial Ductal Carcinoma In Situ: Re-Evaluating Conditions for Active Surveillance Suitability as Treatment
https://clinicaltrials.ucsf.edu/trial/NCT06075953
The goal of this trial is to see if active surveillance monitoring and hormonal therapy in patients diagnosed with ductal cell carcinoma in situ (DCIS), an early stage of breast cancer, can be an effective management of the disease. […] The current management of most patients with DCIS involves surgical intervention with or without radiation, similar to more aggressive breast cancers. These treatments can come with some significant health effects. The main question this study aims to answer is: to determine whether novel endocrine therapy increases the fraction of patients who will be suitable for long-term active surveillance. […] Participants will be followed annually for 10 years.
#43 Ductal Carcinoma in Situ (DCIS) | American Cancer Society
https://www.cancer.org/cancer/types/breast-cancer/about/types-of-breast-cancer/dcis.html
About 1 in 5 new breast cancers will be ductal carcinoma in situ (DCIS). Nearly all women with this early stage of breast cancer can be cured. […] DCIS is a non-invasive or pre-invasive breast cancer. This means the cells that line the ducts have changed to cancer cells but they have not spread through the walls of the ducts into the nearby breast tissue. […] Because DCIS hasnt spread into the breast tissue around it, it cant spread (metastasize) beyond the breast to other parts of the body. […] Right now, theres no good way to know for sure which will become invasive cancer and which ones wont, so almost all women with DCIS will be treated.
#44 Detecting When DCIS will Progress to IDC | UCSF Radiology
https://radiology.ucsf.edu/blog/detecting-when-dcis-will-progress-idc
While screening mammography is effective in detecting DCIS and targeting lesions for removal, this standard practice hasn’t led to a decrease in invasive cancer incidence. This suggests that the majority of DCIS lesions are low-risk and amenable to non-surgical treatment strategies. […] Greenwood explains, Currently we do not have the ability to predict which DCIS lesions will progress to invasive cancer and which will not. Our research is aiming to see how we may be able to use specific MR imaging features to help determine risk of DCIS lesions, in order to better personalize care. […] Greenwood and her team hope that the use of MRI imaging will contribute to better personalized therapy and reduce the risk of surgical overtreatment for women with ductal carcinoma in situ.
#45 Detecting When DCIS will Progress to IDC | UCSF Radiology
https://radiology.ucsf.edu/blog/detecting-when-dcis-will-progress-idc
Ductal carcinoma in situ (DCIS) is a non-invasive form of breast cancer that can potentially progress to invasive cancer if left untreated. Early detection and treatment are therefore crucial. […] In a retrospective study of patients with DCIS who declined surgery and received endocrine therapy, published in njp: Breast Cancer, researchers highlighted the importance of MRI in assessing DCIS risk and guiding treatment decisions in women who elect not to undergo standard surgical management and instead opt for endocrine treatment and imaging surveillance. […] The study found that active monitoring of patients undergoing endocrine therapy allows radiologists to identify high-risk lesions. This approach is safe and provides valuable information for patients and clinicians, as many at-risk patients already receive six months of neoadjuvant endocrine therapy.
#46 Risk of Breast Cancer Death is Low After DCIS Diagnosis – NCI
https://www.cancer.gov/news-events/cancer-currents-blog/2015/dcis-low-risk
This suggests that what you do locally to treat DCIS may not affect the risk of dying, which is the most important outcome. […] In another finding, 517 women diagnosed with DCIS died of breast cancer without ever developing an invasive cancer in the same or other breast prior to death. […] The finding, Drs. Esserman and Yau concluded, suggests that our current approach of surgical removal and radiation therapy may not suffice for the rare cases that lead to breast cancer mortality and thus new approaches are needed. […] Dr. Kramer agreed that new approaches to managing DCIS are needed and said the new results help set the stage for this work.
#47 Optimizing the Management of DCIS – The ASCO Post
https://ascopost.com/issues/june-10-2024/optimizing-the-management-of-dcis/
Ductal carcinoma in situ (DCIS), once a rare entity, now comprises 20% to 30% of newly diagnosed breast cancers detected on mammography and is appreciated to be a widely heterogeneous disease, said E. Shelley Hwang, MD, MPH, the Mary and Deryl Hart Distinguished Professor at Duke University, who updated attendees on the topic at the 2024 Miami Breast Cancer Conference. […] […] Recurrence rates are about 1% per year in low-risk DCIS and about twice that for high-risk or high-grade DCIS so about 12% over 10 years, rising to 27% in high-risk patients. […] […] In the United States, almost half of women with DCIS undergo lumpectomy with radiotherapy; about 20% each receive unilateral mastectomy or lumpectomy without radiotherapy; around 8% undergo bilateral mastectomy; and 5% opt for no treatment. None of these treatments appears to make any difference in terms of breast cancer-specific survival. […]
#48 Survival outcomes after omission of surgery for ductal carcinoma in situ | npj Breast Cancer
https://www.nature.com/articles/s41523-024-00689-5
Collectively these data, together with observations from our study, underscore that there are subsets for whom AS may be appropriate without compromise of long-term survival, although which subsets of DCIS can be considered low risk and thus appropriate for AS remain to be conclusively defined. […] To definitively address the appropriateness of AS, a number of large, randomized control trials have recently been undertaken that are examining the outcomes of omitting surgery for biologically favorable DCIS.