© 2004 by Oxford University Press
© 2004 Oxford University Press
CORRESPONDENCE |
RESPONSE: Re: Trends in the Treatment of Ductal Carcinoma In Situ of the Breast
Correspondence to: Nancy N. Baxter, MD, PhD, FRCSC, Division of Surgical Oncology, Department of Surgery, University of Minnesota, 420 Delaware St., SE, MMC 450, Minneapolis, MN 55455 (e-mail: baxte025{at}umn.edu)
Women with ductal carcinoma in situ (DCIS) who receive treatment are at a low risk of dying from breast cancer, and certainly this fact should temper all treatment approaches in this population (1). However, as in invasive breast cancer, the goal of radiation after lumpectomy for DCIS is not to improve survival but rather to improve local control of disease. Local recurrence after lumpectomy is associated with substantial psychological morbidity, generally necessitates mastectomy, and in DCIS will result in a diagnosis of invasive breast cancer in 50% of cases (1). Local recurrence is considered a primary end point (not a surrogate marker for mortality) in DCIS trials because local control is important. On the basis of the best evidence available (from three randomized trials) (2–4), radiation therapy after lumpectomy is effective in reducing local recurrence and the development of invasive breast cancer. Of course, consistent with the nature of adjuvant treatment, if radiation therapy after lumpectomy is given to all women with DCIS, many women will be treated unnecessarily. The relatively low rate of radiation after lumpectomy found in our study may reflect community equipoise with respect to the value of radiation therapy, particularly in women at low risk of recurrence (although in 1999, 33% of women with a predicted high risk of local recurrence, those with comedo histology, did not undergo radiation therapy after lumpectomy). Dr. Silverstein's group has certainly provided hypothesis-generating data that are based on their experience with a single cohort (5); their results may lead to improvements in patient selection for radiation therapy in the future. However, given that other centers using current pathologic standards have had less success in selecting women at low risk of local disease recurrence after lumpectomy alone (6–7), the need for evidence from a randomized trial before widespread adoption of such practice is clear.
I share Dr. Gøtzsche's concerns regarding the need to balance the benefits and harms of breast cancer screening and agree that the potential harms of screening are rarely communicated as effectively or understood as well as the potential benefits. However, when a patient is diagnosed with DCIS, it is not currently possible to determine whether the disease is "real" or is a case of overdiagnosis. Similarly, it is not currently possible to determine which individual patient with DCIS is overtreated, which patient is undertreated, and which patient receives only the precise care necessary. Although we treat our patients without the benefit of a crystal ball, we should treat our patients with the benefit of evidence from randomized studies. For women at a low risk of DCIS recurrence, the need for randomized evidence must be addressed. Given the dramatic increase in the incidence of DCIS, demonstrated in our study, at least one barrier to such trials is gone.
REFERENCES
1 Burstein HJ, Polyak K, Wong JS, Lester SC, Kaelin CM. Ductal carcinoma in situ of the breast. N Engl J Med 2004;350:1430–41.
2 Fisher B, Costantino J, Redmond C, Fisher E, Margolese R, Dimitrov N, et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993;328:1581–6.
3 Julien JP, Bijker N, Fentiman IS, Peterse JL, Delledonne V, Rouanet P, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet 2000;355:528–33.[CrossRef][ISI][Medline]
4 Houghton J, George WD, Cuzick J, Duggan C, Fentiman IS, Spittle M; UK Coordinating Committee on Cancer Research; Ductal Carcinoma in situ Working Party; DCIS trialists in the UK, Australia, and New Zealand. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet 2003;362:95–102.[CrossRef][ISI][Medline]
5 Silverstein MJ, Lagios MD, Craig PH, Waisman JR, Lewinsky BS, Colburn WJ, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer 1996;77:2267–74.[CrossRef][ISI][Medline]
6 Boland GP, Chan KC, Knox WF, Roberts SA, Bundred NJ. Value of the Van Nuys Prognostic Index in prediction of recurrence of ductal carcinoma in situ after breast-conserving surgery. Br J Surg 2003;90:426–32.[CrossRef][ISI][Medline]
7 Wong JS, Gadd MA, Gelman R, Kaelin CM, Lester S, Schnitt SJ, et al. Wide excision alone for ductal carcinoma in situ (DCIS) of the breast. Proc ASCO 2003;22:12.
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Del.icio.us What's this?
J Natl Cancer Inst 2004 96: 1257.
J Natl Cancer Inst 2004 96: 1258.
J Natl Cancer Inst 2004 96: 1258-1259.
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