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Radiotherapy After Breast Conserving Surgery: Is It Always Necessary for DCIS?

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This presentation discusses the debate surrounding the necessity of adjuvant radiotherapy (RT) after breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Renowned experts like Bernard Fisher and Melvin Silverstein examine preliminary results from the EBCTCG and NSABP B-17 studies. The findings reveal that RT significantly reduces local recurrence rates but raises questions about whether certain patient subgroups—based on age, tumor size, margin width, and differentiation—may not benefit significantly from additional treatment. The evidence highlights the need for more precise patient selection.

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Radiotherapy After Breast Conserving Surgery: Is It Always Necessary for DCIS?

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  1. Radiotherapy vs.No Radiotherapyafter breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

  2. Clash of the titans Always RT after BCS RT oftenunnecessary Bernard Fisher Melvin Silverstein

  3. EBCTCG Preliminary results. Not for publication or citation EBCTCG: RT vs no RT for DCIS

  4. Results: Isolated local recurrence

  5. Preliminary results. Not for publication or citation EBCTCG Preliminary results. Not for publication or citation

  6. EBCTCG Preliminary results. Not for publication or citation

  7. EBCTCG Preliminary results. Not for publication or citation

  8. RT prevents only clinically unimportant non-invasive recurrences? NSABP B-17 JCO 1998

  9. Can we select patients that would not or very little benefit from RT • Does DCIS size matter? • > Only for DCIS > 5 cm • Does patient age matter? • > Unnecessary for patients older than 70 • Does margin width matter? • > Margins more than 1 cm is OK • Does differentiation matter? • > Only for patients with Grade 3

  10. What about theVan Nuys Prognostic Index (VNPI)? Margin width < 1 cm Silverstein et al. NEJM 1999

  11. EBCTCG Preliminary results. Not for publication or citation Does DCIS size matter?

  12. Does age matter? NSABP B-17 JCO 1998

  13. UKNZL DCIS Study: Always re-excision when margins are positive Lancet 2003

  14. EORTC 10 yrs FU of local recurrence JCO 2006

  15. JCO 2006

  16. Summary of the scientific evidence • 10.6 % (p < 0.0001) absolute gain in any recurrence by year 10. 50% relative reduction of the risk of recurrence. • no difference in breast cancer mortality or any death by year 10. • The gain in recurrence is statistically significant in any subgroup analysed. • There are no prospectively verified prognostic indices for local recurrence. • We cannot (yet) define a subgroup of patients with sufficiently low risk to exclude radiation after BCS.

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