In Reply We thank Hwang and colleagues for their views on the nonoperative management of ductal carcinoma in situ (DCIS) provided in response to our Viewpoint on the de-escalation of breast cancer surgery.1 This is an area of great controversy with many conflicting studies. We concur that there are some invasive carcinomas that are indolent and unlikely to cause problems during a woman’s lifetime. Unfortunately, at this time we are unable to identify these indolent cancers. In the randomized clinical trials of patients with an initial diagnosis of DCIS performed by the National Surgical Adjuvant Breast and Bowel Project2 and the European Organisation for Research and Treatment of Cancer,3 development of an invasive recurrence resulted in decreased breast cancer–specific survival, suggesting a possible risk associated with backing off on therapy. In patients with stage I hormone receptor–positive cancers enrolled in the randomized clinical trials of tamoxifen in the Early Breast Cancer Trialists’ Collaborative Group overview,4 the 15-year mortality after 5 years of tamoxifen treatment was 13%, emphasizing that even small hormone receptor–positive cancers have definite metastatic potential.
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Morrow M, Winer E. De-Escalating Breast Cancer Surgery for Low-Risk Ductal Carcinoma in Situ—Reply. JAMA Oncol. 2020;6(7):1118. doi:10.1001/jamaoncol.2020.0819
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