Barcelona, Spain – For decades, a diagnosis of ductal carcinoma in situ, or DCIS, has often been treated with the same urgency as invasive breast cancer, typically involving surgery. But emerging research suggests a more nuanced approach may be safe – and preferable – for many women. Early results from the LORD trial, presented Friday at the 15th European Breast Cancer Conference (EBCC15), indicate that active surveillance – regular monitoring instead of immediate surgery – shows promising outcomes for those with low-risk DCIS.
DCIS involves abnormal cells within the milk ducts of the breast, but these cells haven’t yet spread to surrounding tissue. While DCIS *can* progress to invasive cancer, studies estimate that roughly four out of five cases will never turn into life-threatening. This realization has prompted researchers to question whether all patients with low-risk DCIS require immediate surgical intervention, potentially avoiding unnecessary treatment and its associated side effects.
The LORD trial, led by Professor Jelle Wesseling of The Netherlands Cancer Institute and Leiden University Medical Center, is attempting to answer that question. “As a doctor, I am guided by the principle ‘first, do no harm’,” Professor Wesseling explained during his presentation. “My motivation for starting the LORD trial was simple: to help build care safer and more balanced. We wanted to locate out whether carefully selected women with low-risk DCIS can be safely monitored with regular check-ups, known as active surveillance, instead of having immediate surgery.”
A Shift in Approach: From Automatic Surgery to Active Monitoring
The trial, which began in 2017, initially randomized 73 patients to either standard treatment (surgery) or active surveillance. Still, after gathering initial feedback, the study design was adapted to allow patients to choose their preferred approach. To date, 1,423 patients with low-risk DCIS – defined as grade 1 or 2 DCIS detected through breast screening – from approximately 60 hospitals across The Netherlands have participated. A significant majority, around 75 percent (1,025 patients), opted for active surveillance, while 330 chose immediate surgery.
The data presented at EBCC15 revealed some key findings. Among the 363 patients who underwent immediate surgery, 29 were found to have signs of invasive breast cancer at the time of diagnosis. An additional four patients developed invasive cancer after surgery. In the active surveillance group of 1,060 patients, 63 have been diagnosed with invasive breast cancer, leading to the study’s planned halt as per its protocol – which stipulated a stop once 60 invasive cancers were detected in the surveillance arm.
Interestingly, the overall rates of invasive cancer diagnosis were comparable between the two groups: 33 out of 363 (9%) in the surgery group versus 63 out of 1060 (6%) in the active surveillance group. Researchers also noted that tumors detected in the active surveillance group were, on average, slightly larger (6mm compared to 9mm) but were not more aggressive.
Reassuring, But Not Definitive: What the Results Mean
Professor Wesseling emphasized that these interim results are “reassuring” for women with low-risk DCIS. “There is currently no indication that active surveillance leads to worse early outcomes compared with immediate surgery,” he stated. He clarified that active surveillance isn’t about withholding treatment, but rather closely monitoring patients with the option of surgery remaining available at any time. Cancer Research UK provides further information on DCIS and its treatment options.
The findings contribute to a growing discussion about reducing overtreatment in breast cancer care. However, Professor Wesseling cautioned that longer follow-up is crucial before changes can be made to existing clinical guidelines. The research team is continuing to monitor all participants to assess the long-term safety of both approaches and to identify which patients are most likely to benefit from active surveillance.
Expert Perspective: A Potential Shift Towards De-escalated Care
Professor Isabel Rubio, Head of Breast Surgical Oncology at the Clínica Universidad de Navarra in Madrid, Spain, and Chair of EBCC15, who was not involved in the study, echoed the cautious optimism. “The LORD trial is one of the largest prospective studies worldwide focusing specifically on patients with low-risk DCIS,” she said. “The early results are helpful. They show that a small number of invasive cancers are being picked up in patients having active surveillance… So far, these numbers are comparable with those in patients who had surgery.”
Professor Rubio added that the trial demonstrates a clear patient preference for active surveillance, with many women choosing monitoring over immediate surgery. She believes that with longer follow-up, the findings could support a more “de-escalated approach to care,” offering carefully monitored active surveillance as a viable alternative to surgery for selected patients.
Looking Ahead: Continued Monitoring and Refinement
The LORD trial represents a significant step towards personalized breast cancer care, acknowledging that not all DCIS requires the same aggressive treatment. While these initial results are encouraging, ongoing monitoring and further research are essential to refine patient selection criteria and optimize the active surveillance protocol. The next phase of the study will focus on identifying specific characteristics that predict which women can safely avoid immediate surgery, paving the way for more informed and individualized treatment decisions.
This research underscores the importance of shared decision-making between patients and their healthcare providers, ensuring that treatment plans align with individual risk profiles and preferences. If you have concerns about your breast health, please consult with your physician.
Disclaimer: This article provides information for general knowledge and informational purposes only, and does not constitute medical advice. It is essential to consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.
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