Nonsurgical management of ductal carcinoma in situ (DCIS) is on the rise, and imaging may have an important role in the trend, suggest findings published February 10 in JAMA Network Open.

Researchers led by Dezheng Huo, MD, PhD, from the University of Chicago reported several trends over the past two decades for managing DCIS, including increases in nonsurgical management and bilateral mastectomy, adjuvant radiotherapy becoming genomic risk-adapted since 2018, and endocrine therapy increasing from 2004 to 2020 but declining after that.

“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,” Huo and colleagues wrote.

Emerging evidence suggests that active surveillance could be a feasible de-escalation strategy for women with low-risk DCIS. Digital mammography is recommended for surveillance imaging, though recent studies have shown the potential of contrast-enhanced mammography (CEM) and digital breast tomosynthesis (DBT) in this area.

Proponents of active surveillance say this approach could help reduce overtreatment while also maintaining favorable patient outcomes.

The Huo team studied trends and sociodemographic variations in nonsurgical management and other treatment approaches for low-risk (grade 1 or 2), HR-positive DCIS. The group used National Cancer Database data collected between 2004 and 2022 from 316,50 women with an average age of 60.8 years. The women had at least 12 months of follow-up since initial diagnosis.

Women included in the study fell into the following racial and ethnic backgrounds: 73.3% white, 13.9% Black, 6.1% Hispanic, 5.8% Asian or Pacific Islander, and 0.9% “other.”

The team reported the following trends during the study period:

• Nonsurgical management increased from 2.1% to 3.5%.

• Bilateral mastectomy increased from 4.1% to 8.7%.

• Lumpectomy increased from 22% to 25.1%, while lumpectomy plus adjuvant radiotherapy decreased from 50.9% to 45.6%.

• Unilateral mastectomy decreased from 20.9% to 17.1%.

Nonsurgical management was more common among Black women (20.5%) and women with no insurance (2.4%).

And since 2018, radiotherapy use has increased and become progressively more risk-adapted. This includes increasing use with higher Oncotype DX DCIS scores (low risk, 34.5%; intermediate risk, 63.9%; and high risk, 73.1%).

The database the team used did not include information on imaging frequency, surveillance intensity, patient preference, and clinician rationale. However, the study authors highlighted the importance of imaging access to better manage patients with DCIS.

“The growing heterogeneity in clinical DCIS management highlights the need for precision prevention, including refined risk stratification, equitable access to genomic and imaging tools, and shared decision-making frameworks, that aligns the type and intensity of intervention with each patient’s risk profile and personal preferences to advance individualized management of low-risk DCIS,” they concluded.

Read the full study here.