Breast cancer specialists at Anglia Ruskin University are proposing the introduction of a new model to provide safer treatment for patients with ductal carcinoma in situ (DCIS), the most common form of non-invasive breast cancer.
Writing in the latest edition of The Lancet Oncology journal, Professor John Benson and Professor Gordon Wishart state that therapies such as radiotherapy and tamoxifen, which can impair quality of life and increase health-care costs, are not necessary for all patients.
DCIS is an early form of breast cancer which is commonly detected by screening programmes and is not life-threatening. The surgeons believe that recent research into molecular markers can be used to develop a model to identify the low risk cases that may avoid harmful treatment and high risk cases where therapy can be maximised.
Over the past 30 years, clinicians have benefited from the use of predictive models to treat early invasive breast cancer, which incorporate not only tumour size, grade, and lymph node status, but also variables such as age and molecular markers such as the oestrogen and HER2 receptor. Professor Benson and Professor Wishart say that a similar approach would help with decision-making for DCIS patients after initial breast-conserving surgery (lumpectomy).
The most contentious issue surrounds radiotherapy and whether all patients undergoing breast-conserving surgery should receive it. The authors believe that if toxic effects of radiotherapy exceed any oncological gains amongst DCIS patients, it is likely to lead to a higher all-cause mortality rate.
Gordon Wishart, Professor of Cancer Surgery at Anglia Ruskin, said: "A recent review of the NHS Breast Cancer Screening Programme raised awareness of the detection of low risk cancers that may never reduce a patient's life expectancy.
"A proportion of cases detected with routine screening would not have progressed to a life-threatening form of breast cancer during the patient's lifetime, and overdiagnosis of breast cancer is a cause for concern. In fact, within older age groups life expectancy is likely to be determined not by a diagnosis of DCIS, but by competing causes of death.
"Some of the key molecular events that characterise progression of DCIS to invasive cancer have been identified, and the next logical step is to develop and validate predictive models. These models should allow individualisation of treatments, meaning withholding not only radiotherapy and hormonal therapies, but even surgery for certain patients.
"A comprehensive management strategy should integrate clinicopathological features and molecular profiling, and take into account patient-related factors such as age, other illnesses, breast size and personal preference.
"Present treatment options for DCIS are acknowledged as being excessive for many patients, and the aim of molecular profiling is to ensure that additional treatments such as radiotherapy are restricted to patients at highest risk of invasive recurrence."