Ductal carcinoma in situ of the breast: finding the balance between overtreatment and undertreatment.

Ductal carcinoma in situ (DCIS) accounts for 15-25% of all breast cancer diagnoses. Its prognosis is excellent overall, the main risk being the occurrence of local breast events, as most cases of DCIS do not progress to invasive cancer. Systematic screening has greatly increased the incidence of this non-obligate precursor of invasion, lending urgency to the need to identify DCIS that is prone to invasive progression and distinguish it from non-invasion-prone DCIS, as the latter can be overdiagnosed and therefore overtreated. Treatment strategies, including surgery, radiotherapy, and optional endocrine therapy, decrease the risk of local events, but have no effect on survival outcomes. Active surveillance is being evaluated as a possible new option for low-risk DCIS. Considerable efforts to decipher the biology of DCIS have led to a better understanding of the factors that determine its variable natural history. Given this variability, shared decision making regarding optimal, personalised treatment strategies is the most appropriate course of action. Well designed, risk-based de-escalation studies remain a major need in this field.

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Declaration of interests SD reports institutional grants and non-financial support from Pfizer, Novartis, AstraZeneca, Seagen, and Roche Genentech; grants from Eli Lilly, Amgen, Sanofi, MSD, BMS, Exact Sciences, Rappta, the European Commission, the French National Cancer Institute, Fondation ARC, Banque des Territoires France 2023 (public entity), Besins, and Gilead outside the submitted work. SAK declares research funding from the National Cancer Institute (NCI) and from the Breast Cancer Research Foundation to her institution; personal honoraria from the University of Toronto, Japan Clinical Oncology Group, San Antonio Breast Cancer conference, and the Dana Farber Cancer Center for conferences; a patent for endoxifen transdermal therapy; travel funding from the NCI for the TMIST trial; and institutional drug supplies for a clinical trial from BHR Pharma. JW reports institutional research grants from Cancer Research UK, KWF Dutch Cancer Society, Antoni van Leeuwenhoek Investment Fund, ZonMW Healthcare innovation, and support for travel for international speaking from ESMO, UCSF, the National Physics Laboratory, Oslo University Hospital, and Maastricht University. JW is a member of the scientific advisory board of the KWF Dutch Cancer Society; is a review panel member for Cancer Research UK on an ad hoc basis; is a member of the scientific advisory board of the National Reference Center for Breast Cancer Screening; and is a member of the advisory board of the National Institute for Public Health and the Environment regarding population-based breast cancer screening. TW declares institutional research funding from Exact Sciences/Genomic Health and non-direct financial support for biomarker testing from Exact Sciences/Genomic Health for ongoing studies.