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Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery

Dilemma in management of DCIS. Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery University of Pennsylvania. The Dilemma of DCIS. 96-98% of women with DCIS are cured with local therapy, yet …

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Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery

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  1. Dilemma in management of DCIS Julia Tchou, M.D., Ph.D. Abramson Cancer Center Rena Rowan Breast Center Department of Surgery University of Pennsylvania

  2. The Dilemma of DCIS 96-98% of women with DCIS are cured with local therapy, yet … Local recurrence rate after BCT of DCIS is ~ 2 fold higher than Invasive cancer.

  3. Standard Treatment in DCIS •Mastectomy •Excision + RT •Excision + Tamoxifen Which Rx for which patient?

  4. Key questions in management of DCIS • Can we identify a subset of patient not benefiting from radiation therapy? • What is an adequate margin?

  5. Survival in DCIS by Treatment L L+RT B17 L+RT+TAM EORTC M B17; EORTC % Deaths Breast Ca B24 B24 Years

  6. Effects of XRT on survival EBCTCG meta-analsyis, Lancet 2005

  7. Key Management Concepts in DCIS • Prevention of local recurrence (invasive and noninvasive) is a major goal of the treatment of DCIS The use of RT reduces LR in DCIS

  8. Can we identify a subset of patient not benefiting from RT?

  9. Can DCIS be treated by excision alone?

  10. Local recurrence risk stratification • ECOG – < 2.5 cm Grade I & II DCIS • EORTC – no subgroup does not benefit from radiation • VNPI - Silverstein Bijker, N. JCO 2006;24:3381

  11. Van Nuys Prognostic Index Silverstein, M 2003

  12. Silverstein M 2003

  13. Outcome in DCIS Patients withLow VNPI Low VNPI (3 or 4) Silverstein de Mascarel # patients 101 195 Local recurrence 2% 9% Invasive 0 50% Br Ca Res Treat 2000

  14. Is there a DCIS subgroup that does not benefit from XRT? • Age • Margins (uniform and meticulous assessment not done in randomized trials) • VNPI score 4, 5 or 6 • Low grade DCIS • Biomarkers for risk stratification • Utility of MRI in preoperative assessment (JNCI consensus statement, 2009) Morrow M 2008

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