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Practice Uncertainties

Should patients with ductal carcinoma in situ be treated with adjuvant whole breast radiotherapy after breast conservation surgery?

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1410 (Published 17 May 2018) Cite this as: BMJ 2018;361:k1410
  1. Jessamy Bagenal, senior medical editor, The Lancet1,
  2. Nicola Roche, consultant breast surgeon1,
  3. Gill Ross, consultant clinical oncologist1,
  4. Anna Kirby, consultant clinical oncologist1,
  5. David Dodwell, consultant clinical oncologist2
  1. 1The Royal Marsden Hospital, London, UK
  2. 2Nuffield Department of Population Health, University of Oxford, Oxford, UK
  1. Correspondence to J Bagenal jessamy.bagenal{at}googlemail.com

What you need to know

  • Women with ductal carcinoma in situ are usually offered breast conserving surgery (BCS), often followed by whole breast radiotherapy (WBRT).

  • WBRT reduces ipsilateral breast events but there is insufficient evidence that it improves breast cancer specific or overall mortality.

  • Patients will have different perceptions of the risks and benefits of WBRT and should be assisted in their decision making by clear presentation of the information.

Ductal carcinoma in situ (DCIS) affects around 8000 women a year in the UK.1 Since the introduction of mammographic screening, the incidence of DCIS has increased and it now represents around 20% of all new screen detected breast cancers.2

DCIS is categorised into low, intermediate, and high grade based on histological features. Most cases of DCIS are treated with breast conserving surgery (BCS), often followed by whole breast radiotherapy (WBRT). An individual patient level meta-analysis (four randomised controlled trials, 3729 women) found that WBRT approximately halved the rate of ipsilateral DCIS or invasive recurrence at 10 years compared with no radiotherapy following BCS.3 However, WBRT can cause side effects such as impaired cosmesis, skin changes, and late cardiac toxicity4 Patients might also find WBRT inconvenient and expensive.

National Institute of Health and Care Excellence (NICE) guidelines recommend offering WBRT to all patients with DCIS treated by BCS.5 The European Society of Medical Oncology guidelines suggest that WBRT might be omitted in some low risk patients.6

However, observational studies done in the UK, US, and Europe note wide variations in the use of adjuvant radiotherapy in these patients.7 This variation possibly reflects uncertainty as to whether the benefits of WBRT are large enough to warrant the blanket use of adjuvant WBRT or whether WBRT can be safely omitted in a subset of lower risk patients.

In this article we discuss the evidence surrounding radiotherapy use in …

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