De-Escalating the Management of In Situ and Invasive Breast Cancer

Abstract

It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.

Active surveillance versus treatment in low-risk DCIS: Women’s preferences in the LORD-trial

“…Another limitation might be that the LORD-trial is a national study, meaning these results might not necessarily be applicable to other cultures and countries as treatment preferences and attitude towards de-escalation might differ. However, the increasing attention for de-escalation of DCIS-management in literature [2] , [43] , [44] , [45] , [46] , indicates that this interest extends beyond the Netherlands.…”

Tools to Guide Radiation Oncologists in the Management of DCIS

“…The challenge for the decision making revolves around not only the omission of treatment but also around the modality of RT delivery, including de-escalation (boost omission, partial breast irradiation-PBI) or escalation (dose intensification) programs [8][9][10][11].…”

The Evolving Approach to Breast Cancer: Moving toward De-Escalating Treatment and Personalized Medicine

“…Moreover, they explained the issues with the design of these studies, particularly with the inherited difficulty in differentiating between ADH and DCIS and between intermediate and high-grade DCIS. A real concern was raised regarding the possibility of leaving significant disease without treatment, such as invasive carcinoma or worse metastatic carcinoma to the axillary lymph node (ALN) [ 1 , 2 ]. Nonetheless, these trials are expected to provide some insight into the natural history of low-risk DCIS.…”

“…De-escalating the surgical approach in BC has evolved over the years from the first type of surgery, radical mastectomy, to selectively excising multiple lesions or even to no surgery at all. Angarita et al [ 2 ] updated these approaches by reviewing clinical trials that compared mastectomy and breast-conserving therapy (BCT). They iterated that BCT with RT is safe and achieves similar results to mastectomy.…”

“…However, there are several obstacles, including the lack of a robust method or algorithm that reliably predicts pCR with a very low false negative rate; the fact that pCR is not a guarantee of disease-free survival; and where RT fits in this approach. Furthermore, surveillance strategies will be required, as the false negative rate will never be 0% and some cancers will be missed [ 2 ].…”