Ductal Carcinoma In Situ: How Much Treatment Is Enough, How Much Is Too Much?
Bibliographic record
Abstract
In the accompanying article, Wood concisely reviews currentmanagement of ductal carcinoma in situ (DCIS), with a focus on the use of radiotherapy (RT) after breastconserving surgery (BCS). The crux of his argument is that because RT does not prolong survival, its usemust be considered optional and the risks and benefits of RT considered in the context of patient values. Henotes that“nearly twice asmanywomen will have an inferior cosmetic outcome result as will benefit from avoiding a recurrent breast lesion,” and that the use of RT for initial treatment necessitates mastectomy for any subsequent recurrence. The importance of considering patient preference in decision making when there is equipoise in survival outcomes is inarguable.Wesurveyedpatients aboutpriorities and treatment choices in a population-based study of 1,629 patientswithDCIS and stage I and II breast cancer. Concern about disease recurrence was the most important factor in treatment choice, greatly influencing 37%, whereas concerns about radiation or body image greatly influenced only 15% and5%of patients, respectively. Prevention of local recurrence in DCIS is particularly relevant to patient concerns, because 50% of these recurrences are invasive carcinoma, and randomized trials have demonstrated a significant increase in mortality in patients experiencing invasive recurrence after DCIS treatment. Thus, it is not particularly surprising that risk-averse patients opt for RTor, increasingly, forbilateralmastectomy. Endocrine Therapy Wood also notes that endocrine therapy is an alternative to RT for risk reduction in women with DCIS. Endocrine therapy has the advantage of reducing the incidence of both ipsilateral and contralateral breast events, but the absolute benefit of 5 years of treatment is modest. In a meta-analysis of the National Surgical Adjuvant Breast and Bowel Project B24 trial and the United Kingdom, Australia, New Zealand trials of adjuvant tamoxifen in DCIS, no significant difference in all-cause mortality was seen with tamoxifen treatment compared with placebo, but tamoxifen treatment did statistically significantly reduce ipsilateral and contralateral DCIS events and contralateral invasive cancers, with a trend toward reduction of ipsilateral invasive cancer. The number needed to treat for a protective effect against all breast events was 15. However, ameta-analysis of 10-year event rates in9,404patientswithDCIS found that the local recurrence rate after BCS and RTwas 14.4%, compared with 24.7% with BCS and tamoxifen, suggesting that if the goal is to minimize recurrence, RT is the more effective strategy. A decision to use tamoxifen (or an aromatase inhibitor) also subjects the patient to 5 years of the welldocumented side effects of endocrine therapy. Most importantly, the acceptance of tamoxifen among patients with DCIS is limited. In a Canadian population-based cohort of women with DCIS treated in
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".