CHICAGO--Despite an overall trend toward breast conservation, many breast
cancer authorities believe that ductal carcinoma in situ (DCIS) too often
is treated by mastectomy, and that axillary dissection and irradiation
frequently are performed unnecessarily.
In order to make the "punishment fit the crime," physicians
treating DCIS need to balance the extent of surgery and the application
of irradiation with a number of factors, William Wood, MD, said at the
50th Cancer Symposium of the Society for Surgical Oncology. These include
not only tumor size and margins, but also tumor grade and the patient's
Since DCIS can develop into invasive disease, "we can't take it
too lightly," said Dr. Wood, professor and chairman of the Department
of Surgery, Emory University School of Medicine. However, he said, a formal
treatment algorithm for DCIS "requires thoughtful application based
upon the number of years a woman would be at risk, the likely biology of
the tumor, and its extent."
The algorithm presented by Dr. Wood involves surgical excision of the
DCIS with a relatively small resection margin for biopsy; magnification
view mammog-raphy to make sure there is no stream of DCIS moving toward
the nipple or areola or going off elsewhere in the breast; and detailed
DCIS that has a 1- to 4-mm focus and 5- to 10-mm margin would be observed
after excision, according to this algorithm. "I would do nothing else;
I think any additional treatment is likely to be overtreatment," Dr.
For DCIS with a 5- to 20-mm focus and 5-mm to 10-mm margin, Dr. Wood
would add irradiation. Lumpectomy and radiation therapy would also be appropriate
for more than 20 mm of tumor as long as a 10-mm clear margin could be obtained
and the breast could be preserved in appearance.
The algorithm calls for more extensive treatment of a comedo or high-grade
tumor, particularly in a young patient. Less extensive treatment would
be indicated "in an older patient where a low-grade disease might
never become an event in her lifetime," he said.