Mitigating overtreatment of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) represents a pathologic continuum between a high-risk lesion of the breast and an invasive cancer. Because death from breast cancer is linked to its metastatic spread, the major significance of DCIS is its potential to progress to an invasive cancer and the risk of an occult invasive cancer unrecognized until surgical excision is performed. The standard of care management for DCIS is a minimum of surgical excision, often coupled with adjuvant treatments. For approximately half of the DCIS cases that are at low risk for progression, standard-of-care treatment represents a potential overtreatment and the source of one of the main criticisms against screening. To minimize overtreatment, the tumor biology of any individual's DCIS should be considered in the context of the patient's age, medical comorbidities, and tolerance for risk to tailor personalized treatments. Just as the management of some high-risk lesions of the breast have evolved to include nonsurgical options, it makes sense to personalize the management offered to patients with DCIS. This article reviews the epidemiology, imaging, pathology, ongoing trials, current and possible future treatments of DCIS, comparing and contrasting it with classic high-risk breast lesions and invasive breast cancers.