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When women with noninvasive breast cancer had radiation treatment after their tumors were removed, the chance that the cancer would come back dropped from 31 percent to 13 percent, according to an update of a national research trial.



The eight-year update of the National Surgical Adjuvant Breast Project Protocol B-17 included women with ductal carcinoma in situ (DCIS), a noninvasive breast cancer. The participants were randomly chosen to receive either breast irradiation following lumpectomy or no further treatment after lumpectomy. The findings were reported in the journal Cancer (Vol. 86, No. 3).

DCIS is the earliest stage of breast cancer, said Debbie Saslow, PhD, director of breast and cervical cancer for the American Cancer Society (ACS). "The standard treatment is to remove it. Most women will be absolutely fine, but for some women, DCIS is a precursor to a worse cancer. For most women with DCIS, you do a lumpectomy and follow up with radiation."

In some women, DCIS occurs all over the breast, making it impossible to do a lumpectomy. Instead, these patients must have a mastectomy, but they don’t need the follow-up radiation because DCIS is noninvasive.

The research team that worked on the trial update, headed by Edwin R. Fisher, MD, of Allegheny University in Pittsburgh, found the presence of a type of DCIS called comedo carcinoma or comedo necrosis – which contains areas of dead or degenerating cells – can predict the chance of cancer recurrence.

"A moderate to marked degree of comedo necrosis is high risk for recurrence, and absent to slight comedo necrosis is low risk for recurrence," Dr. Fisher said.

The study also offers some information about whether women with this low-risk cancer need radiation, he said.

"The difference in recurrence between the irradiated group and the non-irradiated group was only seven to 10 percent. It is statistically significant yet some could argue this may be a group that does not need radiation. If it were 20 percent, there wouldn’t be any debate about it. At seven to 10 percent most clinicians would still give radiation. But, if a woman lives in a place where she can’t get treatment, or if she is an older woman, she might want to forgo the radiation," Dr. Fisher said.

However, Dr. Saslow said women should have the option of getting radiation. "My view is that a woman should be presented with the facts and assisted in making the decision that’s right for her. She should have the choice. Just because you have an older woman or somebody in a remote area doesn’t mean it’s not worth it to them to go to the trouble and the risks of radiation."

Women should be aware that radiation has the potential side effect of lymphedema, Dr. Saslow added. "It’s pretty serious for a younger person, and they’re at risk for the rest of their life. So that might be something additional to add to the equation," she said.



In an editorial accompanying Dr. Fisher's report, Monica Morrow, MD, of the department of surgery in the Lynn Sage Breast Center at Northwestern University Medical School in Chicago, stressed the importance of another point emphasized by the B-17 trial. "The risk of breast cancer death after a diagnosis of DCIS was only 1.6 percent at eight years. Having faced numerous terrified women over the years who were convinced that the ‘bad’ characteristics of their DCIS (high-grade comedo necrosis and large tumor size) doomed them to death from breast carcinoma, this point cannot be overemphasized," she wrote. Dr. Morrow concluded the study is an important first step toward understanding the progression of cancerous changes in the breast. "It is now time to move on, and reach a consensus regarding what future studies will allow us to define the appropriate intensity of therapy for the individual woman with DCIS," she wrote.