Consult Breast DCIS

Options for care of DCIS include simple mastectomy (local recurrence rates < 5%), partial mastectomy with post-operative whole breast radiation (local recurrence rates ~12%), partial mastectomy with partial breast irradiation, and hormonal therapy for ER or PR positive tumors were discussed. Effectiveness of TAM on ER/PR- patients will be discussed with the medical oncologist.

Published recurrence rates for DCIS range from 15-50%. With a diagnosis of DCIS, the subsequent risk of IDC is incrased by 8-10 folds. This risk is higher with comedo histology. Three prospective trials have all shown that rate of local recurrence was reduced with radiation. Subgroup analysis have shown that the absolute benefits of radiotherapy are greater for women with positive margin, younger women, and those with high-grade tumors. However, RT lowers the incidence of recurrence in all subgroups, regardless of the baseline risk.

Silverstein and colleagues have non-randomized reports of excellent local recurrence-free survival in women who's DCIS was excised with > 10 mm of margin. However their methods are difficult to duplicated and have not been independently validated. A prospective study of "low-risk" DCIS with grade 1 and 2 and ≤ 2.5 cm with ≥ 1 cm margin without RT showed ipsilateral local recurrence rate of 2.4% per patien-year corresponding to 5-year rate of 12%. (Wong et al. 2000) Subgroup analysis of randomized trials by EORTC nor NSABP have not been able to identify a subgroup of patients who will be served with excision alone. Another prospective single-arm study by ECOG 5194 showed 5-year local recurrence rate in "low-risk" group to be 6.8% vs. 13.7% among those with small high-grade DCIS.

I explained that in my best estimation, 10 year local recurrence for "low-risk" DCIS appears to be 13-24% with wide local resection alone. The recurrence rate with radiation should reduce the rate of recurrence by about 65%. Tamoxifen would reduce the local recurrence rate by 20%. A 4-arm study by UKCCCR local relapse rates were 22%, 18%, 8% and 6% for surgery (BCS) alone, BCS+TAM, BCS + RT, and BCS + TAM + RT. TAM appears to reduce locally recurrence by additional 25%. TAM has much more significant impact on all breast cancer events.

Given the patient's age, performance status, and pathological findings I would recommend __.

We recommended whole breast radiation to a dose of 4680 cGy in 26 fractions. Controversy exists concerning the need for delivering an additional boost dose to the primary site. I explained that although boost irradiation often is used, the precise indications for its use are not well defined. Never-the-less, I did recommend a boost 1260 cGy in 7 fractions for a total dose of 5940 cGy to the post-surgical site. The risks, benefits and complications of radiation were discussed in detail including acute and chronic effects; written consent was obtained.

Thank you Ref. MD again for asking us to see Patient Name. It was my pleasure.
Best Regards,

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