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Postoperative radiotherapy after DCIS: Useful for whom?

Per Karlsson1

  • 1Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, S-413 45, Sweden.

Breast (Edinburgh, Scotland)
|July 1, 2017
PubMed
Summary

Radiotherapy after breast conserving surgery significantly reduces ipsilateral events in ductal carcinoma in situ (DCIS) patients. However, it does not impact breast cancer mortality, and long-term side effects occur in a small percentage of patients.

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Area of Science:

  • Oncology
  • Radiotherapy
  • Breast Cancer Research

Background:

  • Ductal carcinoma in situ (DCIS) diagnosis is increasing due to mammography screening.
  • DCIS represents about 20% of new breast cancer diagnoses.
  • The natural history and optimal management of DCIS remain areas of active investigation.

Purpose of the Study:

  • To evaluate the efficacy and long-term outcomes of radiotherapy in patients with DCIS.
  • To identify subgroups of DCIS patients who may or may not benefit from radiotherapy.
  • To assess the impact of radiotherapy on ipsilateral events and breast cancer mortality.

Main Methods:

  • Analysis of data from four large randomized trials, including the SweDCIS trial (n=1046) with 20-year follow-up.
  • Review of RTOG 9804 trial data for a good-risk DCIS subset.
  • Examination of factors influencing ipsilateral event risk and prognostic indices.

Main Results:

  • Radiotherapy halved the risk of ipsilateral events in DCIS patients across trials.
  • The SweDCIS trial showed a 37.5% relative risk reduction and 12% absolute reduction in ipsilateral events over 20 years.
  • Radiotherapy did not significantly affect breast cancer mortality; local failure rates were lower in radiotherapy arms (e.g., 0.9% vs. 6.7% in RTOG 9804).
  • Long-term side effects like breast pain affect about 10% of patients, but modern techniques minimize cardiac dose.
  • No difference in non-breast cancer mortality was observed in meta-analyses.

Conclusions:

  • Postoperative radiotherapy is standard for most DCIS patients after breast conserving surgery, significantly reducing local recurrence.
  • Identifying specific subgroups who do not benefit from radiotherapy remains challenging, though prognostic indices and genomic assays may aid this.
  • For select low-risk DCIS patients, omitting radiotherapy after thorough patient discussion about risks and benefits is a reasonable consideration.