Implications of the COMET Trial for the Management of Atypical Ductal Hyperplasia

The recently reported results from the COMET trial investigating the nonoperative management of low-risk ductal carcinoma in situ (DCIS) question the need for routine excision of atypical ductal hyperplasia (ADH). This study aimed to examine the upgrade rates of patients with ADH who met applicable COMET trial criteria.

Cases of ADH managed with surgery at our institution between 2004 and 2022 were identified, and clinical variables were extracted from the medical record. Rates of ADH upgrade to in situ and invasive disease were compared between patients who met the selected COMET criteria for age, imaging findings, and personal history of breast cancer and those who did not.

Of the 362 ADH cases that met the inclusion criteria for this study; 233 (64.4 %) met the selective COMET criteria (cohort 1) and 129 (35.6 %) did not (cohort 2). The two cohorts did not differ significantly in terms of age, race, breast density, or size of lesion on imaging. The cohort 1 patients were more likely to have their diagnosis determined by mammography (94 % vs 72 %; p < 0.01) and more likely to present with calcifications (82 % vs 30.2 %; p < 0.01). The rate of upgrade to DCIS did not differ significantly between the cohorts, but the rate of invasive disease was significantly lower in cohort 1 (3.43 % vs 10.85 %; p < 0.01).

The study data showed a very low rate of ADH upgrade to invasive disease for the patients who met the COMET criteria for age, imaging findings, and breast cancer history, suggesting that such patients also could be considered a low-risk cohort for whom observation might be appropriate.