Clinical Challenges in Breast Surgery: The Management of Ductal Carcinoma In Situ (DCIS)

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Sep 8, 2025

In this insightful discussion, Dr. Melissa Pilewskie and Dr. Stephanie Downs-Canner delve into the complexities of managing ductal carcinoma in situ (DCIS). They tackle crucial topics like the balance between over-treatment and preventing invasive cancer. With new data from the COMET trial, they explore personalized treatment strategies and the importance of active surveillance. The conversation also highlights risk assessment tools, the impact of radiation, and patient preferences, emphasizing the need for tailored approaches in breast surgical oncology.

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INSIGHT

What DCIS Actually Is

DCIS is malignant cells confined within the ductal basement membrane and therefore non-invasive by definition.
It is a potential precursor to invasive cancer but not all DCIS will progress.

INSIGHT

Screening Drives DCIS Rates

Screening mammography dramatically increased DCIS detection because most cases are asymptomatic and found on screening.
Incidence rose from ~1.5 to ~35 per 100,000 after routine mammography, reflecting detection not necessarily true disease increase.

INSIGHT

Two Core Questions For DCIS

Two central DCIS questions are immediate upgrade risk on excision and long-term progression risk to invasive disease.
Determining which DCIS lesions matter remains the key clinical challenge.

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Ductal carcinoma in situ (DCIS) represents a clinical crossroads in breast surgery—balancing the risks of over-treatment with the need to prevent invasive cancer. With new data from active monitoring trials, the pressure is on for surgeons to personalize care. Tune in to this essential episode to stay ahead of the curve on DCIS management and to hear expert insights from two leading breast surgical oncologists.

Hosts:
- Rashmi Kumar, MD, PhD
Resident, University of Michigan General Surgery Residency Program
Twitter/X: @RashmiJKumar
- Melissa Pilewskie, MD
Attending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine
Twitter/X: @MPilewskie
- Stephanie Downs-Canner, MD
Attending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program
Twitter/X: @SDownsCanner

Learning Objectives:
- Define DCIS and explain its significance as a precursor to invasive breast cancer.
- Discuss challenges in diagnosing and risk-stratifying DCIS.
- Review current standards for surgical and adjuvant management of DCIS.
- Understand the implications of new research, including the COMET trial, for low-risk DCIS.
- Evaluate patient-centered strategies for managing DCIS and preventing over-treatment.

References:
- Worni M, Akushevich I, Greenup R, et al. Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ. J Natl Cancer Inst. 2015;107(12):djv263. PubMed
- Francis A, Thomas J, Fallowfield L, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer. 2015 Jan;51(16):2296-303. PubMed
- Elshof LE, Tryfonidis K, Slaets L, et al. Feasibility of a non-surgical management strategy for low-grade DCIS: The LORD study. Eur J Cancer. 2015;51(12):1497–1510. PubMed
- Toss MS, et al. Ductal carcinoma in situ (DCIS): current management and future directions. Cancer Treat Rev. 2020;90:102091. PubMed
- Comparative Effectiveness of Surgery versus Active Monitoring for Low-Risk DCIS (COMET) Trial Results. Early COMET Results: King TA, et al. Surgical excision versus active monitoring for low-risk ductal carcinoma in situ (DCIS): 2-year results of the COMET randomized trial. J Clin Oncol. 2024; e2400110. PubMed

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