Advocate Analysis: Are there factors that predict which DCIS will form subsequent invasive cancer or another DCIS?
May 13, 2010
This study was interesting to me insofar as the results appear to confirm the hypothesis that the current system of classifying DCIS as low, intermediate or high grade is quite inadequate in terms of predicting which DCIS is more or less likely to progress to invasive disease. The biomarker combinations themselves were also interesting, in that some markers usually associated with aggression in invasive disease did not appear to apply to DCIS, for example HER2+ DCIS was not more likely to recur as invasive disease although it did appear to be associated with a higher risk of DCIS recurrence.
Also of interest was the fact that DCIS detected by palpation rather than via a routine screening mammogram seemed more likely overall to recur as invasive disease, but that p16+, COX-2+, Ki67+ DCIS lesions were most likely of all to recur as invasive disease, independent of their means of detection.
While this study supplies some very interesting hypotheses, there are of course also difficulties and limitations. Ideally, these results should be validated in another group. But DCIS is now rarely treated by wide excision alone, as was the case here, so we are unlikely to have anything other than retrospective data. It is unclear also what effect either adjuvant radiotherapy or tamoxifen might have had on each of the biomarker profiles. There is also the question of data standardisation, e.g. regarding measurement of surgical margins, and also of the various biomarker tests themselves.
Overall, the study tells us nothing more about the natural history of DCIS if left untreated, and – as ever – much more research is needed in order to draw any firm conclusions. But it seems to me nevertheless an important first step towards a more accurate system of risk stratification for DCIS, one that could at the very least allow some patients to make the decision to forego adjuvant treatment or even – eventually – forego surgery altogether.
-Sara McKenna, Project LEAD® Madrid 2004, Clinical Trials Project LEAD® Paris 2008
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