Radiotherapy vs No Radiotherapy after breast conserving surgery

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

Clash of the titans Always RT after BCS RT often unnecessar RT often unnecessa Bernard Fisher Melvin Silverstein

EBCTCG: RT vs no RT for DCIS Study Name Inclusion criteria Entry # pts Prescription Margins clear? NSABP B-17 Lumpectomy 1985 -1990 818 50 Gy to breast No EORTC 10853 Local Excision; Age < 70 1986 -1996 1010 50 Gy to breast No Swedish DCIS Study Quadrantectomy 1988 1046 50 Gy to breast No Stockholm 8 Breast-Conserving Surgery 1990 -1999 188 50 Gy to breast No UK DCIS Trial Screen-Detected; Complete Local Excision; 1990 1030 50 Gy to breast Yes Total 4092 EBCTCG Preliminary results. Not for publication or citation

Results: Isolated local recurrence

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 Not for publication or citation Not for publication or

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 Not for publication or citation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

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

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 Not for publication or citation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

JCO 2006

Summary of the scientific evidence • 10. 6 % (p < 0. 0001) absolute gain in any recurrence by year 10. 50% 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.