Advertisement
ADVANCED SEARCH

This Article Full Text (PDF) [Full Guidelines] Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Olivotto, I. Articles by Levine, M. Search for Related Content PubMed PubMed Citation Articles by Olivotto, I. Articles by Levine, M.

Clinical practice guidelines for the care and treatment of breast cancer: the management of ductal carcinoma in situ (summary of the 2001 update)

Dr. Olivotto is with the Screening Mammography Program of British Columbia and the Division of Radiation Oncology, University of British Columbia, Vancouver, BC. Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.

Correspondence to: Dr. Mark Levine, c/o Ms. Humaira Khan, Faculty of Health Sciences, McMaster University Health Sciences Centre, Rm. 2C6, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 577-0017

This article provides a summary of changes made by Health Canada's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer to the article "Clinical practice guidelines for the care and treatment of breast cancer: 5. The management of ductal carcinoma in situ (DCIS)," originally published in 1998¹ (the 2001 update can be found online at www.cma.ca/cmaj/vol-165/issue-7/breastcpg/guideline5rev.htm). Although there are not many changes to the guideline, new studies have provided more evidence to support the original recommendations.

DCIS of the breast is a proliferation of malignant- appearing cells of the ducts and terminal lobular units of the breast that have not breached the ductal basement membrane. Since more women are having screening mammography, DCIS is being diagnosed more frequently. In 1996, over 200 000 Canadian women aged 50–69 participated in 7 provincial screening programs. Of the 991 cancers detected, 171 were DCIS (17%, or 0.8 cases per 1000 women screened).² DCIS can be considered a precursor of invasive breast cancer and, if left untreated, can develop into invasive disease in up to 35% of cases within 10 years.

Again the steering committee emphasizes the importance of careful surgical removal of the area of DCIS and attention to meticulous pathological processing and reporting.³ The most clinically useful factors in terms of predicting local recurrence of the DCIS and progression to invasive cancer are nuclear grade, presence of necrosis, involvement of surgical margins and lesion size.

The original guideline recommended mastectomy, breast-conserving surgery (BCS) plus radiotherapy or BCS alone as treatment options for DCIS, and this recommendation has not changed substantially. The use of breast irradiation after BCS was supported by the results of 1 randomized trial in the 1998 guideline.⁴ A report has since been published of a second randomized trial, in which the European Organisation for Research and Treatment of Cancer randomly assigned 1010 women with DCIS to either BCS or BCS plus breast irradiation.⁵ At a median follow-up of 4 years, the rate of local recurrence was significantly lower in the group treated by BCS plus radiotherapy than in the group treated by BCS alone (9% v. 16%, p = 0.005). The survival rate was 99% in both groups. A large retrospective study has emphasized the importance of ensuring that there is a wide rim of normal tissue around the excised tumour if there is consideration that a woman treated with BCS might not have radiotherapy.⁶ The steering committee feels that it is difficult to identify patients at such a low risk of breast cancer recurrence that radiotherapy could be omitted after BCS even though in such women the risk reduction in absolute terms associated with radiotherapy may be small. The 1998 guideline stated that "omission of radiotherapy may be considered when lesions are small and low grade, and when pathological assessment shows clear margins." The updated recommendation (Table 1) states that "BCS should usually be followed by radiotherapy. Patients with a sufficiently low risk of local recurrence with BCS alone are difficult to identify. However, BCS alone may be considered after a careful discussion with the patient, if detailed pathological assessment confirms that the lesion is small and does not have high-grade nuclei or comedo-type necrosis and the surgical margins are clear of disease. In addition, in such circumstances the surgical excision should be cosmetically acceptable."

In 1998 the steering committee concluded that evidence was not available to support the use of tamoxifen in the treatment of women with DCIS. Since then, the results were published of the National Surgical Adjuvant Breast Project B-24 trial, in which 1804 women with DCIS who received BCS plus radiotherapy were randomly assigned to receive tamoxifen or placebo.⁷ At 5 years the incidence of invasive breast cancer was significantly lower in the tamoxifen group than in the placebo group (4.1% v. 7.2%, p = 0.004); the corresponding incidence rates of recurrent DCIS were 4.2% and 6.2% (p = 0.08). Tamoxifen can be associated with side effects (see guideline 12, on the chemoprevention of breast cancer⁸). The updated recommendation for DCIS states that "the role of tamoxifen in the management of patients with DCIS continues to evolve. The potential benefits and risks should be discussed with patients."

Footnotes

The patient version of these guidelines has also been updated and can be found online at www.cma.ca/cmaj/vol-165/issue-7/breastcpg/guideline5revpt.htm.

Competing interests: None declared.

References

1. Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 5. The management of ductal carcinoma in situ (DCIS). CMAJ 1998;158(3 Suppl):S27-34.
2. Olivotto IA, Bancej C, Goel V, Snider J, McAuley RG, Irvine B, et al. Waiting times from abnormal breast screen to diagnosis in 7 Canadian provinces. CMAJ 2001;165(3):277-83. Available: www.cma.ca/cmaj/vol-165/issue-3/0277.asp[Abstract/Full Text]
3. The Consensus Conference Committee (Schwartz GF, Lagios MD, Carter D, Connolly J, Israel B, Ellis IO, et al). Consensus conference on the classification of ductal carcinoma in situ. Cancer 1997;80:1798-802.[Medline]
4. Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 1998;16:441-52.[Abstract]
5. Julien JP, Bijker N, Fentiman IS, Peterse JL, Delledonne V, Rouanet P, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet 2000;355:528-33.[Medline]
6. Silverstein MJ, Lagios MD, Groshen S, Waisman JR, Lewinsky BS, Martino S, et al. The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 1999;340:1455-61.[Abstract/Full Text]
7. Fisher B, Dignam J, Wolmark N, Wickerham DL, Fisher ER, Mamounas E, et al. Tamoxifen in the treatment of intraductal breast cancer: NSABP protocol B-24 randomized control trial. Lancet 1999;353:1993-2000.[Medline]
8. Levine M, Moutquin JM, Walton R, Feightner J. Chemoprevention of breast cancer. A joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. CMAJ 2001; 164(12):1681-90. Available: www.cma.ca/cmaj/vol-164/issue-12/1681.asp[Abstract/Full Text]

This article has been cited by other articles:

				J. Pu, C. D. McCaig, L. Cao, Z. Zhao, J. E. Segall, and M. Zhao EGF receptor signalling is essential for electric-field-directed migration of breast cancer cells J. Cell Sci., October 1, 2007; 120(19): 3395 - 3403. [Abstract] [Full Text] [PDF]

				G. D. Leonard and S. M. Swain Ductal Carcinoma In Situ, Complexities and Challenges J Natl Cancer Inst, June 16, 2004; 96(12): 906 - 920. [Abstract] [Full Text] [PDF]

				E. Wooltorton Tamoxifen for breast cancer prevention: safety warning Can. Med. Assoc. J., August 1, 2002; 167(4): 378 - 379. [Full Text] [PDF]

This Article Full Text (PDF) [Full Guidelines] Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Olivotto, I. Articles by Levine, M. Search for Related Content PubMed PubMed Citation Articles by Olivotto, I. Articles by Levine, M.

HOME	CURRENT ISSUE	PAST ISSUES	COLLECTIONS	HELP	SEARCH
Copyright 1995-2001, Canadian Medical Association. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p) All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.