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Patient age is an important prognostic variable for local recurrence after breast conservation for DCIS (15,42,117,127). In younger patients, DCIS more frequently contains adverse prognostic pathologic features and extends over a greater distance in the breast than in older patients (127). In series with adequate follow-up, younger patients treated with lumpectomy and radiation therapy had a significantly higher rate of local recurrence than older patients, especially for invasive local recurrences (127). Some studies have suggested that careful attention to margin status and excising larger volumes of tissue can reduce this difference substantially (117,127). No available data show that younger patients have better long-term cancer-free survival rates if treated by mastectomy rather than lumpectomy and radiation therapy. Successful treatment of younger patients with DCIS with lumpectomy and radiation therapy requires careful attention to patient evaluation, selection, and surgical technique. When this is done, age at diagnosis should not be a contraindication to breast-conserving therapy.


A number of recent studies have attempted to identify and treat patients with highly selected favorable tumor characteristics with excision alone (i.e., without whole-breast irradiation) and report 10-year local failure rates of 3% to 25% (109,111). A scoring system has been proposed (108) using histopathologic features including tumor size, grade, and margin width in an attempt to stratify patients according to local failure risk after excision plus or minus whole-breast irradiation. Each variable was assigned a score of 1 to 3, and the sum total defined the Van Nuys Prognostic Index. Although appealingly simple, this scheme (108) is drawn from the retrospective analysis of a patient cohort in which there exist a number of methodologic shortcomings and it has not been independently validated (29).


Wong et al. (134) performed a prospective study that attempted to identify patients with “low-risk” DCIS who can be spared whole-breast radiation therapy. This trial enrolled 158 patients with lesions that were mostly grade 1 or 2 and with a mammographic extent of ≤2.5 cm who were treated with wide excision, with final margins of ≥1 cm or a re-excision without residual DCIS. Tamoxifen was not permitted. The median age was 51 years and the median follow-up was 40 months. The rate of ipsilateral local recurrence was 2.4% per patient-year, corresponding to a 5-year rate of 12%. Nine patients (69%) experienced recurrence of DCIS and four (31%) experienced recurrence with invasive carcinoma. These data provide prospective evidence that, despite margins of >1 cm, the local recurrence rate is substantial even in patients with small, grade 1 or 2 DCIS following treatment with wide excision alone.

Presently, the Radiation Therapy Oncology Group is conducting a prospective randomized trial to further assess the need for radiotherapy in low-risk DCIS. Following lumpectomy with ≥3 mm clear margins of resection, patients are stratified according to age (<50 vs. ≥50 years), tumor size (≤1 vs. >1 to 2.5 cm), margin status (negative re-excision vs. 3 to 9 vs. ≥10 mm), grade, and the use of tamoxifen (at the discretion of the managing physician). Following stratification, patients are randomized to whole-breast irradiation versus observation. The NSABP and Radiation Therapy Oncology Group have jointly launched a phase III accelerated partial-breast irradiation trial that randomly allocates patients between standard whole-breast irradiation following lumpectomy versus accelerated partial-breast irradiation to determine if in-breast control rates are comparable. As the in-breast failure patterns for DCIS suggest that treatment directed to the primary lesion plus a 2-cm margin should achieve local control rates that equate to whole-breast treatment approaches, patients with pure DCIS or DCIS and LCIS will be eligible for stratified randomization.