Description:
Following breast-conserving surgery (BCS) for localized ductal carcinoma in situ (DCIS) of
the breast, whole-breast irradiation (WBRT) is a standard of care, reducing the absolute rate
of in-breast recurrences (IBR) by more than 15% at 10 years, from 28% without radiotherapy to
13 % with radiotherapy. Half of the recurrences occurred as invasive disease. Whereas in the
comparative trials, WBRT did not impact on overall survival, survival of patients who
recurred with invasive cancers was impaired in comparison to patients who did not recur, or
to patients with DCIS-only recurrences.
Using criteria based on age, tumor size, nuclear grade, and margins status, several trials
and cohort studies failed to identify subgroups of patients at low risk, who could be safely
spared the need for WBRT. The Radiation Therapy Oncology Group (RTOG) DCIS trial included
patients treated with BCS for low- or intermediate grade DCIS revealed by unifocal
microcalcifications, size ≤25 mm, margins ≥3 mm, and no residual microcalcifications after
surgery. The 5-year rates of IBR were 3.5 % without radiotherapy, versus 0.4 % with
radiotherapy, and 6.7 % and 0.9 % at 7 years, respectively (p <0.001). Sixty percent of the
patients received tamoxifen in both groups.
Several studies showed that the same molecular classes were identified in DCIS as in invasive
cancers. Studies suggested that low proliferation, hormone receptors expression, and lack of
ERBB2 amplification were associated with a low risk of IBR in patients not receiving
radiotherapy. A combined signature was tested in the Eastern Cooperative Oncology Group
(ECOG) trial, showing a 10% IBR rate at ten years in patients with a low-risk.
Identifying very low-risk DCIS, using biological markers in addition to the clinical and
histological markers of low-risk DCIS, could help to select patients who could be safely
avoided WBRT following BCS. It would avoid over-treatment in these women and could decrease
the cost of management.
Title
- Brief Title: Radiotherapy Omission in Low Risk Ductal in Situ Carcinoma Breast
- Official Title: Prospective Study of Omission of Whole-breast Radiotherapy Following Breast-conserving Surgery in Patients With Very Low Risk Ductal Carcinoma in Situ of the Breast
Clinical Trial IDs
- ORG STUDY ID:
UC-0107/1803
- NCT ID:
NCT03878342
Conditions
- DCIS
- Breast Cancer
- Low Risk DCIS
- Breast Conserving Surgery
- Radiotherapy Omission
Purpose
Following breast-conserving surgery (BCS) for localized ductal carcinoma in situ (DCIS) of
the breast, whole-breast irradiation (WBRT) is a standard of care, reducing the absolute rate
of in-breast recurrences (IBR) by more than 15% at 10 years, from 28% without radiotherapy to
13 % with radiotherapy. Half of the recurrences occurred as invasive disease. Whereas in the
comparative trials, WBRT did not impact on overall survival, survival of patients who
recurred with invasive cancers was impaired in comparison to patients who did not recur, or
to patients with DCIS-only recurrences.
Using criteria based on age, tumor size, nuclear grade, and margins status, several trials
and cohort studies failed to identify subgroups of patients at low risk, who could be safely
spared the need for WBRT. The Radiation Therapy Oncology Group (RTOG) DCIS trial included
patients treated with BCS for low- or intermediate grade DCIS revealed by unifocal
microcalcifications, size ≤25 mm, margins ≥3 mm, and no residual microcalcifications after
surgery. The 5-year rates of IBR were 3.5 % without radiotherapy, versus 0.4 % with
radiotherapy, and 6.7 % and 0.9 % at 7 years, respectively (p <0.001). Sixty percent of the
patients received tamoxifen in both groups.
Several studies showed that the same molecular classes were identified in DCIS as in invasive
cancers. Studies suggested that low proliferation, hormone receptors expression, and lack of
ERBB2 amplification were associated with a low risk of IBR in patients not receiving
radiotherapy. A combined signature was tested in the Eastern Cooperative Oncology Group
(ECOG) trial, showing a 10% IBR rate at ten years in patients with a low-risk.
Identifying very low-risk DCIS, using biological markers in addition to the clinical and
histological markers of low-risk DCIS, could help to select patients who could be safely
avoided WBRT following BCS. It would avoid over-treatment in these women and could decrease
the cost of management.
Trial Arms
Name | Type | Description | Interventions |
---|
Radiotherapy | Active Comparator | two fractionation regimens will be allowed for whole-breast irradiation: 50 Gy in 25 fractions over 5 weeks or 40 Gy in 15 fractions over 3 weeks. The delivery of an additional dose to the tumour bed (boost) will be at the referring physician discretion, according to the guidelines | |
No Radiotherapy | Experimental | No Irradiation- Active surveillance | |
Eligibility Criteria
Inclusion Criteria:
1. Woman aged ≥50 years,
2. ECOG performance status ≤2
3. Microcalcifications on pre-biopsy mammography, unifocal, ≤25 mm or opacity without
microcalcifications and no clinical palpable tumour
4. Absence of suspicious residual microcalcifications either on post-biopsy/ preoperative
localization mammography, or on post-operative mammography Note: if absence of
residual microcalcifications on post-biopsy/pre-operative mammography, post-operative
mammography is not mandatory;
5. Breast-conserving surgical excision;
6. Histologically proven DCIS of the breast without an invasive component; Note
Incidental histological finding of DCIS lesions developed within a benign breast
lesion as well as an association with classical lobular carcinoma in situ (LCIS)
associated with the DCIS are accepted.
7. Free margins (≥2 mm), or free margins following re-excision;
8. Low or Intermediate nuclear grade; Note: In case of nuclear grade heterogeneity within
the same sample or between the biopsy or the surgical specimen, the highest nuclear
grade score will prevail.
9. Tumour tissue sample availability; Note: Surgical specimen is mandatory unless no
residual disease on the surgical specimen. In this instance, the initial diagnosis
biopsy is required.
10. Absence of extensive necrosis (≤30% of the lumen diameter);
11. Immunohistochemical characteristics of luminal A subtype: ER≥10 %, PR ≥20 %, HER2
negative (0/1+) or 2+ not amplified (confirmed by fluorescent in situ hybridization
(FISH) or chromogenic in situ hybridization (CISH)), Ki67 <15%.
12. Patient willing and able to comply with the protocol for the duration of the study
including undergoing treatment, scheduled visits and examinations and including
follow-up;
13. Written informed consent.
14. Affiliation to the French social security.
Exclusion Criteria:
1. Endocrine treatment for breast cancer.
2. Previous invasive breast cancer including contralateral breast cancer, either
metachronous or synchronous
3. Previous DCIS except contralateral DCIS in complete and continuous remission for more
than 5 years
4. Previous other cancers (except basal-cell, carcinoma in situ of the cervix or
endometrium), not in complete and continuous remission for more than 10 years
5. Known breast-cancer predisposing germ-cell mutation;
6. Palpable tumour with a diagnosis of DCIS on biopsy
7. Bloody nipple discharge;
8. Histological size >25 mm in one or multiple foci
9. High nuclear grade, including high nuclear grade in heterogeneous tumours;either on
biopsy or on surgical specimen
10. Associated microinvasive or invasive component;
11. Presence of tumour cells in lymph nodes detected using H&E or immunohistochemical
examination (if lymph node sentinel biopsy or dissection has been performed);
12. Absolute contra-indication to whole-breast irradiation as determined by the referring
physician;
13. Patient unable to comply with study obligations for geographic, social, or physical
reasons, or who is unable to understand the purpose and procedures of the study.
14. Pregnant women or breast feeding mothers,
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 50 Years |
Eligible Gender: | Female |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | 5-year cumulative incidence of in-breast cancer recurrences |
Time Frame: | 5 years |
Safety Issue: | |
Description: | Incidence of breast recurrence is determined from the date of last surgery to the date of breast recurrence. |
Secondary Outcome Measures
Measure: | Overall survival (OS) |
Time Frame: | 10 years |
Safety Issue: | |
Description: | OS is defined as the interval between the date of last surgery and the date of death from any cause; |
Measure: | Breast cancer-specific survival (BCSS) |
Time Frame: | 10 years |
Safety Issue: | |
Description: | BCSS is defined as the interval between the date of last surgery and the date of death from breast cancer |
Measure: | Relapse-free survival (RFS) |
Time Frame: | 10 years |
Safety Issue: | |
Description: | RFS is defined as the interval between the date of last surgery and the date of ipsilateral breast recurrence, regional nodes recurrence, distant metastases, of death from breast cancer, whichever occurs first |
Measure: | Rate of in-breast recurrences (IBR). |
Time Frame: | 10 years |
Safety Issue: | |
Description: | In-breast recurrence defined as any carcinoma (invasive or in situ) occurring in the treated breast |
Measure: | Rate of Contralateral breast |
Time Frame: | 10 years |
Safety Issue: | |
Description: | Contralateral breast cancer defined as any carcinoma (invasive or in situ) occurring in the contralateral breast. |
Measure: | Quality of life of the patients using EORTC-QLQ-C 30 |
Time Frame: | 3 years |
Safety Issue: | |
Description: | Quality of life will be assessed using QLQ-C 30 questionnaire from the European Organization for Research and Treatment of Cancer (EORTC). It is a 30-item self-reporting questionnaire developed to assess the quality of life of cancer patients. It is grouped into five functional subscales (role, physical, cognitive, emotional and social functioning). In addition, there are three multi-item symptom scales (fatigue, pain, and nausea and vomiting), individual questions concerning common symptoms in cancer patients,and two questions assessing overall Quality of Life |
Measure: | Quality of life of the patients using EORTC-QLQ-BR23 |
Time Frame: | 3 years |
Safety Issue: | |
Description: | Quality of Life of Patients will be assessed using a EORTC-QLQ BR23.It is a 23-item self-reporting specific questionnaire developed to assess the quality of life of breast cancer patients. It permits to evaluate the symptoms of breast cancer and the side effects of treatment. |
Measure: | Cosmetics Evaluation |
Time Frame: | 3 years |
Safety Issue: | |
Description: | cosmetic results will be evaluated by centralized photographic analysis. |
Details
Phase: | N/A |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | UNICANCER |
Last Updated
July 29, 2021