Trends in Nonsurgical Management for Low-Risk, Hormone Receptor–Positive Ductal Carcinoma In Situ

TL;DR

The study shows increasing use of nonsurgical treatments for low-risk breast cancer and highlights the need for personalized care based on patient risk and preferences.

Contribution

The study identifies recent trends and disparities in nonsurgical management of low-risk DCIS and emphasizes the need for precision-based treatment strategies.

Findings

Nonsurgical management and bilateral mastectomy increased from 2004 to 2022.

Endocrine therapy use increased until 2020 but declined afterward.

Radiotherapy use became more genomic risk-adapted since 2018.

Abstract

What are the trends and patterns of nonsurgical management and other treatment modalities for low-risk, hormone receptor–positive ductal carcinoma in situ (DCIS) in the US?

In this cross-sectional study of 316 590 patients with grade 1 to 2 DCIS, nonsurgical management and bilateral mastectomy increased from 2004 to 2022, adjuvant radiotherapy became genomic risk adapted since 2018, and endocrine therapy increased from 2004 to 2020 but declined thereafter. Sociodemographic variations were observed across treatment modalities.

These findings highlight growing heterogeneity in DCIS management and the need for precision-prevention frameworks that align treatment intensity with cancer risk, patient preferences, and evolving evidence.

This cross-sectional study examines trends and sociodemographic variations in nonsurgical management and other treatment modalities for low-risk, hormone receptor–positive ductal carcinoma in situ in the US.

Active surveillance has emerged as a deescalation strategy for low-risk ductal carcinoma in situ (DCIS) to reduce overtreatment while maintaining favorable outcomes. Emerging data in low-risk DCIS, eg, the COMET trial, have highlighted growing interest in surveillance-based management for carefully selected patients. However, recent clinical adoption and national trends in managing low-risk, hormone receptor (HR)–positive DCIS have not been evaluated in the US.

To examine trends and sociodemographic variations in nonsurgical management and other treatment modalities for low-risk, HR-positive DCIS.

This cross-sectional study analyzed data from the National Cancer Database from January 1, 2004, to December 31, 2022, and included patients aged 18 years or older with grade 1 to 2, HR-positive DCIS and at least 12 months of follow-up since initial diagnosis. Analyses were performed between January 10 and August 31, 2025.

Year of diagnosis and sociodemographic characteristics.

Nonsurgical management, lumpectomy alone, lumpectomy plus adjuvant radiotherapy, unilateral mastectomy, bilateral mastectomy, and endocrine therapy were measured using descriptive statistics.

A total of 316 590 female patients were included (mean [SD] age, 60.8 [12.0] years; 5.8% Asian or Pacific Islander, 13.9% Black, 6.1% Hispanic, 73.3% White, and 0.9% other race and ethnicity). From 2004 to 2022, nonsurgical management increased from 2.1% to 3.5%, bilateral mastectomy increased from 4.1% to 8.7%, and lumpectomy increased from 22.0% to 25.1%, while lumpectomy plus adjuvant radiotherapy decreased from 50.9% to 45.6% and unilateral mastectomy decreased from 20.9% to 17.1%. Nonsurgical management was more common among Black patients and patients with no insurance. Bilateral mastectomy was common in younger, White, and privately insured patients and those who lived in higher-income areas. Endocrine therapy use increased from 2004 to 2020 but declined thereafter. Endocrine therapy was highest after lumpectomy plus adjuvant radiotherapy (69.6%), followed by lumpectomy alone (43.9%), unilateral mastectomy (35.3%), and nonsurgical management (29.2%), with the lowest use in patients younger than 50 years in the no surgery (15.2%) and lumpectomy alone (38.6%) groups. Since 2018, radiotherapy use has increased and become progressively more risk adapted, with increasing use with higher Oncotype DX DCIS scores (low risk, 34.5%; intermediate risk, 63.9%; high risk, 73.1%).

This cross-sectional study highlights increasing trends and socioeconomic disparities in the nonsurgical management of and the need for precision-based, patient-centered care for low-risk DCIS. Precision prevention may enhance the identification of patients who could benefit most from preventive surgery, prolonged endocrine therapy, or treatment deescalation, paving the way for individualized strategies.

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