Are you recommending XRT to all DCIS patients with good PS?

[Mandelin Rain]

If not, on what criteria/test are you discriminating?

I know what's out there. I'm wondering what people are actually doing in practice.

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[medgator]

Yes.

Really wish oncotype DX for dcis could amass the data needed to make it into the nccn guidelines.. until then, I'm not really ordering it/using it to make rt decisions.

 

[Sheldor]

I tell women that even the good risk DCIS folks have a 1% per year risk of recurrence with no RT with no signs of plateau on the study. I've had some women who are in their late 70's, early 80's who have opted not to have RT which seems reasonable. (Though in a few of them I've offered hypofrac as an intermediate option.) However, most of these women are in their 60's and so they understand that if they live until their 80's they'd rather not have a 15-20% recurrence risk.

 

[Mandelin Rain]

FWIW: I freely hypofractionate DCIS without a second thought. Have for years.

 

[OTN]

I like Van Nuys. Sure, it has some problems (homogenous population, optical pathology), but I think it did a pretty good job of finding a subset of patients who might not benefit from XRT.

I also hypofractionate.

 

[scarbrtj]

For low-risk DCIS patients, you need to treat about 10 patients to prevent any recurrence risk in one. You need to treat about 25 patients to prevent an invasive recurrence in one. One way to say this is: there's a 4-10% chance you will impact any particular patient's outcome with XRT. Another way to say this is: radiation reduces your recurrence risk by about 75%. By the time you've said all these things, you have perhaps thoroughly confused your patient. So I say: just recommend the dang XRT.

 

[Burt Radnolds]

Some of the local breast surgeons will order Oncotype DCIS and if its low risk, will tell the patient they don't need radiation but still refer to me. I give them the numbers from the trials, no survival benefit etc, discuss caveats of Oncotype DCIS, and let them decide. They are often very convinced they don't need radiation prior to seeing me. If they are high grade and younger, I will push them pretty hard to reconsider. It used to be that with low risk tumors, the recurrence risk provided by Oncotype DCIS was ~10% still with omission. They have now refined their supposed algorithm to include other factors such as size and will give recurrence numbers that are low single digits on their printout.

The primary risk is losing your breast and/or having to undergo the stress of a local recurrence. Omitting radiation puts the patient at minimal risk in regards to survival. The chance of the patient having an aggressive invasive local recurrence that cannot be salvaged is so low that it has never been born out in any of the studies to my knowledge. I don't lose sleep if they choose not to do radiation.

 

[medgator]

The primary risk is losing your breast and/or having to undergo the stress of a local recurrence. Omitting radiation puts the patient at minimal risk in regards to survival. The chance of the patient having an aggressive invasive local recurrence that cannot be salvaged is so low that it has never been born out in any of the studies to my knowledge. I don't lose sleep if they choose not to do radiation.

Agree. I frame the conversation in terms of mastectomy free survival benefit

 

[RadOncDoc21]

I tell them I need them on my machine so I don't have to work at Wendy's.

 

[evilbooyaa]

Offer it to all, say that there is no survival advantage but to prevent local recurrence. Patient preference at that point. Some say do everything, others say I heard bad things or saw radiation burns. Hypofrac for all. If they meet Van Nuys criteria I wouldn't boost.

 

[Palex80]

Yes, I do. Sole exception are old (>80yo) patients, where I consult based on competing risks in low–risk DCIS. There was a nice trial shown at ASTRO this year.

 

[seper]

what do you usually say to young women (40's), who have left-sided lower risk DCIS (low grade, screen-detected, good margin)?

 

[medgator]

what do you usually say to young women (40's), who have left-sided lower risk DCIS (low grade, screen-detected, good margin)?

Get XRT

 

[fiji128]

I typically just review the numbers with the patient but basically have to boil it down to it will decrease the probability of tumor recurrence by 50% or so at 5 to 10 years. I feel if you start getting into all the nuisances about data, dcis subtypes, ect that most patients won't really understand what your talking about. Also, by the time they see me most patient where I practice pretty much already know what they want to do after already having this discussion with their surgeon. FWIW, I find it very hard to talk someone out of RT when they have already been told they need it.