Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Clash of the titans Bernard FisherMelvin Silverstein

EBCTCG: RT vs no RT for DCIS Study NameInclusion criteriaEntry# ptsPrescriptionMargins clear? NSABP B-17Lumpectomy Gy to breastNo EORTC 10853Local Excision; Age < Gy to breastNo Swedish DCIS Study Quadrantectomy Gy to breastNo Stockholm 8Breast-Conserving Surgery Gy to breastNo UK DCIS TrialScreen-Detected; Complete Local Excision; Gy to breastYes Total4092 EBCTCG Preliminary results. Not for publication or citation

Results: Isolated local recurrence

Preliminary results. Not for publication or citation EBCTCG Preliminary results. Not for publication or citation

RT prevents only clinically unimportant non-invasive recurrences? NSABP B-17 JCO 1998

Can we select patients that would not or very little benefit from RT Does DCIS size matter? => Only for DCIS > 5 cm Does patient age matter? => Unnecessary for patients older than 70 Does margin width matter? => Margins more than 1 cm is OK Does differentiation matter? => Only for patients with Grade 3

Margin width < 1 cm Silverstein et al. NEJM 1999 What about the Van Nuys Prognostic Index (VNPI)?

Does DCIS size matter? EBCTCG Preliminary results. Not for publication or citation

Does age matter? NSABP B-17 JCO 1998

UKNZL DCIS Study: Always re-excision when margins are positive Lancet 2003

EORTC 10 yrs FU of local recurrence JCO 2006

Summary of the scientific evidence 10.6 % (p < ) absolute gain in any recurrence by year % relative reduction of the risk of recurrence. no difference in breast cancer mortality or any death by year 10. The gain in recurrence is statistically significant in any subgroup analysed. There are no prospectively verified prognostic indices for local recurrence. We cannot (yet) define a subgroup of patients with sufficiently low risk to exclude radiation after BCS.