# Imaging Ductal Carcinoma In Situ in the Era of De-Escalation: Role, Limits, and Clinical Implications for Risk-Adapted Management

## TL;DR

This paper reviews how breast imaging can help manage ductal carcinoma in situ while avoiding unnecessary treatments.

## Contribution

The paper proposes a structured framework for integrating imaging into risk-adapted DCIS management, emphasizing its limits and clinical implications.

## Key findings

- Breast imaging helps detect and monitor DCIS but cannot reliably predict individual biological progression.
- Imaging functions best as a risk-filtering tool to exclude unsafe scenarios in DCIS management.
- Disciplined use of imaging is essential for safe de-escalation and patient-centered care.

## Abstract

The widespread implementation of population-based mammographic screening has markedly increased the detection of ductal carcinoma in situ (DCIS), without a proportional reduction in breast cancer-specific mortality. This divergence has intensified concerns regarding overdiagnosis and overtreatment and has prompted increasing interest in treatment de-escalation and active surveillance strategies. Breast imaging remains indispensable for DCIS detection, extent assessment, and longitudinal monitoring. However, although imaging features correlate with histopathologic risk factors at the population level, their ability to predict individual biological progression is inherently probabilistic and limited. Overinterpretation of imaging phenotypes as surrogates of invasive destiny risks inappropriate reassurance or unjustified therapeutic escalation, particularly in the context of high-sensitivity modalities that may overestimate disease extent or trigger additional interventions without proven outcome benefits. This review examines the modality-specific roles of mammography, ultrasound, breast magnetic resonance imaging (MRI), contrast-enhanced mammography (CEM), and emerging artificial intelligence (AI) approaches within contemporary DCIS management, with particular attention to their implementation in active surveillance trials such as LORIS, COMET, LORD, and LORETTA. Across modalities, imaging primarily reflects lesion morphology, spatial distribution, and vascular behaviour, and functions most reliably as a risk-filtering and safety-gating instrument aimed at excluding radiologically unsafe scenarios, including occult invasion, underestimated disease extent, or imaging evolution incompatible with continued observation. By delineating both the capabilities and the epistemological limits of imaging, this review proposes a structured clinical decision framework in which imaging supports—but does not independently determine—risk-adapted management. Disciplined integration of imaging into multidisciplinary decision-making is essential to enable safe de-escalation, prevent false reassurance, and align DCIS care with patient-centred and value-based principles.