Overcoming Barriers in Ductal Carcinoma In Situ Management: From Overtreatment to Optimal Treatment

Factors associated with ductal carcinoma in situ (DCIS) treatment patterns and patient-reported outcomes across a large integrated health network

“…The major contributing factor to the current results showing less variation in treatment patterns could be due to clinical pathways and peer review policies implemented in all the UPMC-integrated health plan sites to guide DCIS treatment. Contrary to recent reports, including from SEER and NCDB, for DCIS treatments, RT utilization rate in our cancer center network was 50% (Table 1 ), lower than the commonly reported RT utilization rate (70%), [ 26 – 28 ] likely reflecting that standardized care with clinical pathways may reduce overtreatment with RT. However, high-grade DCIS patients received more RT than low/intermediate patients, in line with national trends and randomized trials that show high rates of recurrence without RT in high-grade DCIS [ 29 , 30 ].…”

Ductal Carcinoma In Situ and Breast Cancer Overdiagnosis

“…Wright et al 1 acknowledge that ductal carcinoma in situ (DCIS) is a major driver of breast cancer overdiagnosis, and they allude to the 2009 National Institutes of Health State of the Science Conference that recommended concerted efforts to decrease indolent DCIS diagnosis as a means of reducing the risk of overdiagnosis. 1,2 Yet, after that conference, novel breast cancer screening technologies that increase tumor detection rates, both DCIS and invasive breast cancer (IBC), have been rapidly adopted into clinical practice, although there is no evidence that these newer screening methods will reduce mortality. 3,4 Tumor detection has never been validated as a proper surrogate outcome measure for breast cancer mortality and use of tumor detection end points as the sole basis for implementing novel screening strategies will very likely exacerbate the risk of breast cancer overdiagnosis and overtreatment.…”

“…Moreover, Wright et al 1 expressed the prevailing view that DCIS does not metastasize but some will become IBC. However, this paradigm does not seem to consider population-based incidence trends.…”

Reply to I. Jatoi

“…

Reply to I. JatoiWe thank Dr Jatoi 1 for highlighting additional areas of controversy regarding ductal carcinoma in situ (DCIS) in response to our article. 2 We agree that improved understanding of DCIS natural history is needed to determine the impact of its detection and treatment on invasive breast cancer (IBC) development and mortality. Many models of DCIS and IBC exist and are debated, 3,4 and the exact relationship of individual DCIS lesions with future risk of IBC remains unclear.

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“…5 However, we agree that universal expansion of screening without carefully considering individual risk can lead to greater overdiagnosis and overtreatment. This is the thrust of our article 2 in which we focused on an immediate path forward—the need to better understand biology and learn how to better use some of the advanced clinical and research tools now available, such as breast magnetic resonance imaging, tissue-based assays for tumor profiling, and more nuanced frameworks for understanding disparities in outcomes. The ultimate goal is to achieve a more optimal approach to DCIS diagnosis and treatment, and we look forward to partnering with our multidisciplinary field and the patients we serve to make this goal a reality.…”