Lawrence J. Solin, MD
More than 60,000 women are diagnosed annually with ductal carcinoma in situ (DCIS) of the breast, a non-invasive form of breast cancer. A new guideline for DCIS recently published by three leading national cancer organizations now has the potential to reduce unnecessary surgery, improve clinical outcomes after treatment, and reduce the overall costs of care for these women.
Lawrence J. Solin, MD, chair of Radiation Oncology at the Einstein Healthcare Network, was one of the expert physicians involved in developing the new guideline. In endorsing the new guideline as a major advance to aid physicians and to help women with DCIS receive the best care, Dr. Solin said, “The new statement provides important guidance to improve outcomes for patients, while also allowing for physicians to use clinical judgment and flexibility in treating individual patients.”
"Women with DCIS often get more surgery than is beneficial, including even some unnecessary mastectomies, because doctors have not had clear recommendations as to how wide the margins should be.”
DCIS is typically diagnosed in an asymptomatic woman on routine screening mammography, and is considered the earliest stage of breast cancer (stage 0). DCIS is commonly removed by a lumpectomy, a surgical procedure that spares the breast and removes only the DCIS tumor with a small rim of normal breast tissue. However, medical opinions have differed greatly as to how wide a margin of normal breast tissue should be excised with the DCIS tumor, ranging from minimal margins to as wide as 10 mm margins. To obtain such negative margins, some women have had to undergo additional surgery (called a re-excision) after their initial excision.
“Margin width for DCIS has been a highly controversial topic,” Dr. Solin said. “Physicians have been debating for decades what amount of healthy tissue should be removed with the DCIS tumor for lumpectomy to be most effective in combination with radiation treatment. Women with DCIS often get more surgery than is beneficial, including even some unnecessary mastectomies, because doctors have not had clear recommendations as to how wide the margins should be.”
Issued jointly by the American Society of Clinical Oncology (ASCO), the Society of Surgical Oncology (SSO), and American Society for Radiation Oncology (ASTRO), the new recommendations provide more clarity and guidance for treating women with DCIS. A multidisciplinary panel for this effort included expert physicians from surgery, radiation oncology, medical oncology, and pathology. The primary goal was to address the question: “What margin width minimizes the risk of [local recurrence] in patients with DCIS receiving breast-conserving surgery?”
Based on its comprehensive review of the medical evidence and published literature, the panel determined that a 2 mm negative margin compared to more narrow margins reduces the risk of local recurrence in the breast after lumpectomy followed by whole breast radiation treatment. The panel also determined that margins wider than 2 mm are not required, as they do not further reduce the risk of local recurrence. The panel concluded that the recommended 2 mm negative margin achieves a low risk of local recurrence, and “has the potential to decrease re-excision rates, improve cosmetic outcome, and decrease health care costs. Clinical judgment should be used in determining the need for further surgery in patients with negative margins < 2 mm.”
The full guideline can be found at: