Management of Ductal Carcinoma in Situ (DCIS) Clinical Practice Guidelines (NCCN, 2022)

National Comprehensive Cancer Network

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 06, 2022

An updated guideline for management of ductal carcinoma in situ (DCIS) was published in June 2022 by the National Comprehensive Cancer Network (NCCN) in Journal of the National Comprehensive Cancer Network.[1]

Workup

Testing for estrogen receptor (ER) status in DCIS is recommended to determine the benefit of adjuvant endocrine therapy for risk reduction. Testing for human epidermal growth factor receptor 2 (HER2) status is not recommended.

Genetic counseling is recommended for patients at high risk for hereditary breast cancer.

Magnetic resonance imaging (MRI) of the breast is recommended only in select circumstances where additional information is warranted during the initial workup.

Primary Treatment

Management strategies for DCIS include surgery, radiation therapy (RT), and adjuvant endocrine therapy. Until it can be determined whether there might be a selected favorable biology subgroup in which surgical excision is not required, surgical excision is recommended for all DCIS.

Primary treatment options are as follows: (1) breast-conserving surgery (BCS) plus whole-breast RT (WBRT) with or without RT boost; (2) total mastectomy, with or without sentinel lymph node biopsy (SLNB) with optional reconstruction; (3) BCS plus accelerated partial breast irradiation (APBI) in carefully selected cases; and (4) BCS alone.

Complete resection should be documented by analysis of margins and specimen radiography.

For pure DCIS treated with BCS and WBRT, a quantitative description of any tumor close to the margin is helpful. Routinely obtaining margins > 2 mm to improve outcomes further is not supported. When there is only minimal or focal DCIS involvement near the margin, clinical judgment should be used to weigh the risks of reexcision against the likelihood of recurrence.

For DCIS treated with excision alone (no WBRT), the optimal margin width is unknown; however, a margin of least 2 mm is recommended.

For DCIS with microinvasion (DCIS-M; invasive focus ≤ 1 mm), the optimal margin width should refer to the DCIS margin definition (≥2 mm), and systemic therapy utilization should reflect the treatment pattern for pure DCIS more closely than that for invasive carcinoma.

Management After Primary Treatment

For ER-positive DCIS treated with breast-conserving therapy (BCT), endocrine therapy with tamoxifen or an aromatase inhibitor may be considered to reduce the risk of ipsilateral recurrence; the benefit of endocrine therapy for ER-negative DCIS is not known.

Follow-up should include interval history and physical examination every 6-12 months for 5 years and annually thereafter, as well as yearly diagnostic mammography. In patients treated with BCT, the first follow-up mammogram should be performed 6-12 months after completion of RT. Patients receiving endocrine therapy for risk reduction should be monitored according to NCCN guidelines.

For more information, please go to Breast Cancer and Surgical Treatment of Breast Cancer.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....