3. DCIS
-‐
Ductal
carcinoma
in
situ
• ductal
carcinoma
in
situ
(DCIS)
has
become
one
of
the
most
commonly
diagnosed
breast
condi;ons.
• lack
of
understanding
of
its
natural
history
and
the
inability
to
determine
which
DCIS
will
progress
to
invasive
carcinoma.
• Cancer-‐specific
survival
for
the
woman
diagnosed
with
DCIS
exceeds
95%,
regardless
of
the
type
of
local
therapy
employed.
• Mastectomy
/
excision
alone
and
excision
plus
RT
is
curaAve
in
approximately
98%
of
pa;ents
regardless
of
age,
DCIS
presenta;on,
size,
or
grade.
4. Endocrine
Therapy
-‐
DCIS
• ER
is
present
in
about
80%
of
DCIS
lesions.
• two
poten<al
benefits
:
-‐
Reduc;on
in
local
recurrence
aNer
BCT.
-‐
preven;on
of
the
development
of
new
primary
breast
cancers
in
the
contralateral
breast.
• Two
trials:
NSABP
B-‐24
trial
&
UK/ANZ
trial.
5.
6.
7. LCIS
-‐
Lubolar
carcinoma
in
situ
• 1941
–
first
described.
• In
the
past,
LCIS
was
most
frequently
diagnosed
in
women
aged
40
to
50,
a
decade
earlier
than
DCIS,
but
recent
literature
indicates
that
the
incidence
in
postmenopausal
women
is
increasing.
• typically
not
associated
with
microcalcifica;ons
on
mammography.
• LCIS
is
both
mulAfocal
and
bilateral
in
a
large
percentage
of
cases.
• Typically
posiAve
for
ER
and
PR,
lacks
expression
of
E-‐cadherin.
8. LCIS
-‐
Lubolar
carcinoma
in
situ
• women
with
LCIS
have
anywhere
from
a
3.0-‐
to
8.0-‐fold
higher
risk
of
breast
cancer
• 10
years
folow
up:
15%
had
ipsilateral
invasive
ca
9.3%
had
contralateral
invasive
ca.
• 1%
to
2%
per
year
Increased
rate
of
development
of
invasive
ca
(with
a
life;me
risk
of
30%
to
40%
),
and
5.7%
of
the
pa;ents
developed
metasta;c
breast
cancer.
• Management
(When
LCIS
is
seen
on
an
excised
;ssue,
it
is
not
necessary
to
obtain
nega;ve
-‐margins
of
resec;on,
and
there
is
no
established
role
for
radia;on
therapy
in
pa;ents
with
LN).
9. • 1992
NSABP
started,
examined
the
ability
of
tamoxifen
to
prevent
breast
cancer
in
women
at
increased
risk.
• From
13,388
women
randomized
for
this
trail
826
had
LCIS:
risk
reduc;on
was
56
%
.
• The
benefits
of
tamoxifen
were
most
prominent
in
par;cipants
with
a
history
of
lobular
carcinoma
in
situ
and
atypical
hyperplasia.
• The
major
toxicity
was
an
increase
in
the
rate
of
endometrial
cancer
(risk
ra;o
2.53,
95%
CI:
1.35±4.97),
as
previously
demonstrated
in
treatment
trials
with
tamoxifen.
• The
rates
of
stroke,
pulmonary
embolism
and
deep
vein
thrombosis
were
elevated
in
the
tamoxifen
group.
Toxici;es
were
most
evident
in
women
over
50
years
of
age
10. • prospective, double-blind, randomized clinical trial
conducted beginning July 1, 1999, in nearly 200 clinical
centers throughout North America.
• 19, 747 postmenopausal women of mean age 58.5 years
with increased 5-year breast cancer risk.
• Intervention Oral tamoxifen (20 mg/d) or raloxifene (60
mg/d) over 5 years.
11. • The
trial
established
that
in
post-‐menopausal
women,
5
years
of
raloxifene
was
almost
as
efficacious
as
tamoxifen,
decreasing
invasive
and
non-‐invasive
breast
cancer
risk
by
about
38
%
• 893
par<cipants
gave
a
history
of
LCIS,
and
their
rates
of
subsequent
breast
cancer
were
similar
with
tamoxifen
and
raloxifene
12. ADH
-‐
atypical
hyperplasia
• While
some
studies
have
shown
no
difference
in
breast
cancer
risk
between
ADH
and
ALH,
most
suggest
that
the
risk
is
greater
with
ALH
• The
odds
raAo
(OR)
for
developing
breast
cancer
in
women
with
ADH
compared
with
women
without
ranges
from
1.47
to
4.88,
whereas
the
OR
with
ALH
ranges
from
4.21
to
5.71
13. ADH
-‐
atypical
hyperplasia
NSABP
P1
trial:
• 49%
risk
reduc;on
was
seen
with
tamoxifen.
• The
benefits
of
tamoxifen
were
observed
for
both
invasive
and
noninvasive
carcinoma
and
were
seen
in
women
of
all
ages.
• A
par;cular
benefit
was
seen
in
those
at
risk
because
of
atypical
hyperplasia,
with
an
84%
reducAon
in
cancer
incidence
in
this
group.
14. Management
of
the
High-‐Risk
PaAent
no
formal
defini;on
of
what
cons;tutes
high
risk.
• BRCA.
• These
include
premenopausal
women,
younger
postmenopausal
women
without
a
uterus,
and
those
at
risk
on
the
basis
of
atypical
hyperplasia
or
LCIS.
15.
16. • exemestane
in
invasive
and
pre-‐invasive
breast
cancer
in
postmenopausal
women.
• 4560
women
with
at
least
one
of
the
following:
Age
>
60
years;
Gail
score
>
1.66;
a
prior
diagnosis
of
atypical
ductal
hyperplasia
(ADH),
lobular
hyperplasia
(ALH),
lobular
carcinoma
in-‐situ
or
ductal
carcinoma
in-‐situ
(DCIS)
treated
with
mastectomy.
• At
a
median
follow-‐up
of
3
years:
Risk
reducAon
of
65%
(P
=
0.002).
MAP.3
Trial
