To explore the evolving management of ductal carcinoma in situ (DCIS) and the potential for active monitoring instead of immediate surgery.
Approach:
Historical Context: DCIS has traditionally been managed with surgical excision, often followed by radiation and/or endocrine therapy.
Emerging Evidence: The COMET trial provides prospective evidence supporting active monitoring for selected low-risk DCIS patients.
Risk Stratification: Identifying low-risk DCIS is crucial for determining candidates for active monitoring.
Surveillance Protocols: Active monitoring requires structured surveillance and predefined triggers for diagnostic escalation.
Surgical Timing: Surgical excision remains important, but timing may become more individualized for low-risk patients.
Key Findings:
The two-year cumulative rate of ipsilateral invasive cancer was 4.2% in the active-monitoring group versus 5.9% in the surgery group, meeting the trial's prespecified criterion for noninferiority.
Active monitoring is not suitable for all DCIS patients; careful risk stratification is essential.
Mammography is critical for surveillance but cannot predict which lesions will progress.
Interpretation:
Current evidence supports risk-adapted management and shared decision-making for selected DCIS patients.
Limitations:
The median follow-up in the COMET trial was approximately three years, with longer-term outcomes still pending.
Mammographic stability does not guarantee biological certainty regarding disease progression.
Conclusion:
While surgery remains a cornerstone of DCIS management, the approach may shift towards more individualized timing and active monitoring for low-risk patients.
Harold Burstein, MD, PhD, and Jennifer A. Ligibel, MD discuss new research from the Breast Cancer Weight Loss (BWEL) trial, as well as recommendations for lifestyle, diet and GLP1 agonists.
