HOLLYWOOD, FLA. — All women with ductal carcinoma in situ should have the choice of foregoing radiation therapy, according to updated breast cancer guidelines announced at the annual conference of the National Comprehensive Cancer Network.
Previously, the guidelines distinguished between the majority of women who have a typical ductal carcinoma in situ (DCIS) and the few women who have a very small DCIS that is less than 0.5 centimeters, unicentric, and of low grade, said Dr. Stephen B. Edge.
For that small subset of women, the guidelines had stipulated treatment by lumpectomy alone with omission of radiation therapy. All other women with DCIS were to be treated with total mastectomy without lymph node dissection or by lumpectomy plus radiation therapy.
The updated guidelines incorporate lumpectomy without radiation therapy as an option of for all women with DCIS. “This is a major change,” said Dr. Edge, interim chair of the department of surgical oncology, and chair of the department of health services and outcomes research at Roswell Park Cancer Institute in Buffalo, N.Y.
The three treatment options for early stage DCIS with no nodal involvement now comprise:
▸ Lumpectomy without lymph node surgery, plus whole breast radiation therapy (offered as a category 1 recommendation).
▸ Total mastectomy with or without sentinel node biopsy, and with or without breast reconstruction.
▸ Lumpectomy alone, with no lymph node surgery and no radiation therapy (offered as a category 2b recommendation).
The new guidelines place the onus on the physician to have a discussion with the patient as to whether or not to choose radiation therapy for DCIS, said Dr. Edge, who is also a professor of surgery at the State University of New York at Buffalo.
They also make recommendations about postmastectomy radiation, an issue neglected in past years. The breast cancer guidelines committee now urges the use of radiation therapy for women who have 1–3 positive nodes, although it stopped short of making this a category 1 recommendation.
“Previously we said patients should consider this, now we've gone so far as to say women should strongly consider radiation therapy after mastectomy,” Dr. Edge said.
Also new are recommendations on the use of breast reconstruction. The guidelines now warn that reconstruction has the potential to affect delivery of radiation therapy. In one study, 52% of women who received radiation after reconstruction had some compromise in the application of radiation, either in terms of the field or the dosing to underlying structures (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:76–82).
In general, women undergoing autologous tissue reconstruction should strongly consider delaying reconstruction until after radiation, because reconstruction before radiation may lead to a worse cosmetic outcome. The guidelines advise that reconstruction before radiation can spare expansion of nonirradiated skin, but they also caution that radiation may lead to capsular contraction.
Dr. Edge said he had no financial conflicts of interest to disclose.