title: Adjuvant therapy in patients with ductal carcinoma in situ of the breast: The Pandora's box.
abstract: Most patients with ductal carcinoma in situ of the breast (DCIS) are eligible for breast conservation treatment. The key management decision is whether to add radiotherapy and/or endocrine therapy to minimize the risk of a subsequent recurrence. Recent analyses indicating a lack of benefit in terms of breast cancer-associated mortality have suggested that more conservative approaches, omitting adjuvant therapy or even surgery, may be advisable in selected patients. These mortality observations are directly influenced by widespread use of mammographic screening which has opened a Pandora's box of subclinical DCIS and early invasive lesions. Confusion as to how aggressively such possibly indolent lesions should be treated has led to misunderstandings among patients and medical professionals. While awaiting further prospective evidence from clinical trials, we endorse an active treatment of DCIS as the standard of care. Our rationale is twofold: invasive recurrences are associated with an increase in breast cancer mortality, which is not the only relevant endpoint for DCIS. The benefit of complete surgical excision, adjuvant radiotherapy and endocrine treatment in preventing recurrence and invasive progression has been demonstrated in DCIS. The challenge now is how to identify DCIS patients who will not progress to invasive carcinoma even without complete excision and, at the other extreme, those patients at the highest risk who require mastectomy for local control. The current controversies over whether and which adjuvant therapy should be implemented can at least in part be addressed by developing effective doctor-patient communications that enable mutual understanding about the management of this biologically heterogeneous disease.
authors.affiliation: Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Lazzeroni
authors.affiliation: Division of Cancer Prevention, National Cancer Institute, Bethesda, MD 20892, USA.
authors.forename: Barbara K
authors.initials: BK
authors.lastname: Dunn
authors.affiliation: Pathology, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Pruneri
authors.affiliation: Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy.
authors.forename: Barbara Alicja
authors.initials: BA
authors.lastname: Jereczek-Fossa
authors.affiliation: Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Orecchia
authors.affiliation: Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy.
authors.forename: Bernardo
authors.initials: B
authors.lastname: Bonanni
authors.affiliation: Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom. Electronic address: andrea.decensi@galliera.it.
authors.forename: Andrea
authors.initials: A
authors.lastname: DeCensi
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000628:therapy*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000628:therapy*; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D015412:Mastectomy, Segmental; D018714:Radiotherapy, Adjuvant
chemical_list: D018931:Antineoplastic Agents, Hormonal
keywords: Aging; Aromatase inhibitors; DCIS; Radiotherapy; Tamoxifen