What is the recommended treatment for a patient with breast ductal carcinoma in situ (DCIS) grade 2 and strongly positive estrogen receptors (ER+)?

From the Guidelines

The recommended treatment for a patient with grade 2 ductal carcinoma in situ (DCIS) with strongly positive estrogen receptors typically involves breast-conserving surgery (lumpectomy) followed by radiation therapy and endocrine therapy. After surgical removal of the DCIS, whole breast radiation therapy is usually administered over 3-6 weeks to reduce the risk of local recurrence, as supported by the most recent guidelines 1. Following radiation, endocrine therapy with tamoxifen (20mg daily for 5 years) is recommended for premenopausal women, while postmenopausal women may receive either tamoxifen or an aromatase inhibitor such as anastrozole (1mg daily), letrozole (2.5mg daily), or exemestane (25mg daily) for 5 years, as suggested by the NCCN guidelines 1. This endocrine therapy targets the estrogen receptor positivity of the tumor, blocking estrogen's growth-promoting effects on any remaining cancer cells.

Key considerations in the treatment plan include:

• The use of radiation therapy after breast-conserving surgery to reduce recurrence risk, with moderately hypofractionated treatment schedules being as effective as standard fractionation treatment schedules in management of DCIS 1.
• The potential benefit of adding a boost to radiation therapy in cases with larger areas of DCIS or other factors associated with increased risk of recurrence, such as margins <2 mm and the presence of comedonecrosis 1.
• The recommendation for endocrine therapy in women with ER-positive DCIS treated with breast-conserving therapy, especially those undergoing breast-conserving surgery plus radiation therapy, as supported by the NCCN guidelines 1.
• Regular follow-up mammography should be performed every 6-12 months for the first 1-2 years, then annually thereafter, as part of the surveillance plan 1.

The strongly positive ER status makes this DCIS particularly responsive to hormonal therapy, which can reduce recurrence risk by approximately 50%, as indicated by studies on the effectiveness of tamoxifen in reducing recurrence risk in patients with ER-positive DCIS 1. Some patients with very small, low-risk DCIS may be candidates for surgery alone, while those with extensive disease might require mastectomy, but these decisions should be made through multidisciplinary discussion considering the specific characteristics of the disease and patient preferences.

From the FDA Drug Label

The recommended dose is tamoxifen 20 mg daily for 5 years. Ductal Carcinoma in Situ (DCIS) The decision regarding therapy with tamoxifen for the reduction in breast cancer incidence should be based upon an individual assessment of the benefits and risks of tamoxifen therapy. Current data from clinical trials support 5 years of adjuvant tamoxifen therapy for patients with breast cancer Tamoxifen citrate tablets are indicated to reduce the risk of invasive breast cancer in women with DCIS, following breast surgery and radiation

The recommended treatment for a patient with breast ductal carcinoma in situ (DCIS) grade 2 and strongly positive estrogen receptors (ER+) is tamoxifen 20 mg daily for 5 years 2, 2.

• The treatment decision should be based on an individual assessment of the benefits and risks of tamoxifen therapy.
• Tamoxifen is indicated to reduce the risk of invasive breast cancer in women with DCIS, following breast surgery and radiation 2.
• The patient should be informed of the potential benefits and risks of tamoxifen therapy 2.

From the Research

Treatment Options for Breast Ductal Carcinoma In Situ (DCIS) Grade 2 with Strongly Positive Estrogen Receptors (ER+)

• The recommended treatment for DCIS grade 2 with strongly positive estrogen receptors (ER+) typically involves a combination of surgical excision, radiotherapy, and endocrine therapy 3, 4, 5.
• Surgical options include breast-conserving surgery (lumpectomy) or total mastectomy, depending on the size and location of the tumor, as well as the patient's personal preferences 5, 6.
• Radiotherapy is often used to reduce the risk of local recurrence, especially in patients who undergo breast-conserving surgery 3, 4, 6.
• Endocrine therapy, such as tamoxifen or anastrozole, is recommended for patients with ER-positive DCIS to reduce the risk of recurrence and invasive progression 4, 7.
• The selection of endocrine therapy depends on the patient's clinical characteristics, underlying disease, and potential side effects of the medication 4.

Factors Influencing Treatment Decisions

• The presence of HER2 protein overexpression in ER-positive DCIS may impact the effectiveness of tamoxifen therapy, although this requires further investigation 7.
• The grade of DCIS, with higher-grade lesions potentially requiring more aggressive treatment, is an important factor in treatment decisions 5, 7.
• Patient lifestyle, family history, and genetic mutations may also influence treatment choices 5.

Ongoing Research and Controversies

• There is ongoing debate about the optimal treatment approach for DCIS, with some studies suggesting that more conservative approaches may be suitable for selected patients 3.
• Further research is needed to identify patients who are at low risk of progression to invasive carcinoma and may not require aggressive treatment 3, 5.
• The development of new biologic agents and molecular-targeted therapies may offer additional treatment options for DCIS in the future 5.