LOS ANGELESA study of 839 patients presented at the San Antonio
Breast Cancer Symposium has found that women with ductal carcinoma in
situ (DCIS) run a very small risk of death from invasive recurrence
regardless of type of surgery.
Invasive recurrences in DCIS
patients are seen in a small minority of patients after breast
conservation, and, when it does recur, an even smaller number of
patients are destined for distant metastatic disease, said
James R. Waisman, MD, associate professor of medical oncology,
University of Southern California/Norris Comprehensive Cancer Center,
Of the 839 patients in this study, 316 patients had a mastectomy, 223
had excision and radiation therapy, and 300 were treated with
excision alone. Invasive recurrence was found in 2 women in the
mastectomy group, 22 in the excision/radiation group, and 19 in the
excision-alone group. With a median follow-up of 10.3 years, of these
43 patients with invasive recurrences, 8 have developed distant
metastases and 5 have now died of breast cancer. (There have been no breast-cancer-related
deaths among the 47 patients in this series who had a recurrence of DCIS.)
The stage at the point of invasive recurrence was stage I disease in
50% of patients, stage IIA disease in 14%, stage IIB in 21%, stage
IIIB in 14%, and stage IV in 2%.
The patients with invasive recurrence clearly present more
often with palpable disease, Dr. Waisman said. In the radiation
group, 45% of invasive recurrences were palpable, and in the
excision-alone group, 42% were palpable. And this is in
contradistinction to our patients with recurrent DCIS, which is so
infrequently palpable (4% to 10%).
Invasive recurrences were larger, with a median size of 28 mm in the
excision/radiation therapy patients and 14 mm in the excision-alone
group, compared with 10 to 11 mm in patients with recurring DCIS, he said.
Local recurrences were most difficult to diagnose in women
treated with excision/radiation in whom radiation fibrosis
developed, Dr. Waisman said. These recurrences were
larger, more likely to be palpable, and had a longer median time to
recurrence, compared with those in women treated by excision alone
(5.5 years vs 4.4 years).
Women treated with breast-conserving surgery had a 10% chance of
developing an invasive recurrence within 12 years after surgery,
compared with 1% for women who had a mastectomy, but
breast-cancer-specific mortality did not differ between the two
groups. Looking at the most significant outcome of breast
cancer, which is fatality, Dr. Weisman said, there was a 0%
fatality rate in the mastectomy group and 1.8% in the
Comparing these DCIS patients with invasive recurrence to our
series of 569 patients who presented with invasive disease (T1cN0),
the breast-cancer-specific survival curves at 12 years are remarkably
similar, Dr. Waisman said.
However, among the patients who originally had invasive disease and
then developed an invasive recurrence, distant disease-free survival
and breast-cancer-specific survival were markedly lower than in the
patients who originally had DCIS and later had an invasive
recurrence. How you interpret this and whether there is a lead
time bias is certainly open for further evaluation, Dr. Waisman commented.
At 12 years, breast-cancer-specific survival after an invasive
recurrence was 100% for mastectomy patients, 99.5% for excision-only
breast conservation patients, and 97.4% for excision plus radiation
Whether the small difference in the irradiated patients vs the
mastectomy patients is going to materialize as significant over time
is unclear, but certainly for now, these curves are basically
superimposable, Dr. Waisman said. He noted that overall
survival by treatment, whether mastectomy, or excision-radiation, or
excision alone, is also virtually the same.
Dr. Waisman concluded that DCIS patients who undergo
breast-conserving therapy should be followed closely, especially
those with progressive radiation fibrosis.