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Active Surveillance for DCIS

What is active surveillance?

Active surveillance is a program of monitoring. It offers a different approach to managing low-risk DCIS. Active surveillance involves frequently monitoring a patient’s condition. Treatment is delayed unless test results show that the condition has got worse. It aims to protect quality of life by delaying surgery.

Active surveillance means that doctors will monitor patients more often than usual (for example, every six months). It may be better for patients concerned about the side effects of standard care. These include physical, emotional and/or psychological side effects. For some women, the side effects of treatment may outweigh any potential benefit. A clinical trial called the COMET Study (Comparison of Operative to Monitoring and Endocrine Therapy for low-risk DCIS) is testing whether or not active surveillance may result in the same outcomes as surgery/radiation. It is increasingly used for a number of other conditions. For example, active surveillance is standard of care for low-level changes to the thyroid. It is also standard of care for early prostate cancer.

There are a number of different terms used for active surveillance. It may be called active monitoring, close monitoring or watchful waiting.All these terms can mean something slightly different. Active surveillance is generally considered to be a more active approach. It also involves routine or targeted testing more often. Watchful waiting usually involves a less intensive type of monitoring. It also involves fewer follow-up tests. Active surveillance may be best thought of as an ongoing intervention. It is not a passive option, which means receiving no medical care at all.

Which women are eligible for active surveillance for their DCIS?

Currently, active surveillance is not considered standard of care for DCIS. Active Surveillance is also not generally recommended for high-risk DCIS. Most women are not offered active surveillance as an option for DCIS. However, it may be an alternative to surgery for some women. Low-risk DCIS grows slowly and may not be noticed during a woman's lifetime. Many women live out their life span before their DCIS requires treatment. Older women may therefore be good candidates for active surveillance. Those with additional health problems may also choose active surveillance.

How will DCIS be monitored?

If you participate in the COMET trial and are randomized to the active surveillance study group, your DCIS will be monitored by your study physician and your medical team. You will have regular clinical examinations and imaging tests. These tests will help doctors to see if the DCIS has changed in any way. Mammograms will be conducted regularly to find any DCIS changes. Magnetic resonance imaging (MRI) and ultrasound may also be recommended. These monitor you for any DCIS changes but avoid surgery. If your DCIS does not change, no surgery is necessary.

What are the benefits/risks of active surveillance?

There is increasing concern about the overtreatment of low-risk DCIS. Many women with the condition may gain little benefit from treatment. Active surveillance may spare women from the side effects of surgery and radiation. DCIS (especially low-risk DCIS) represents very few dangers. However, it is possible that active surveillance may not be better than standard care. The Comparison of Operative to Monitoring and Endocrine Therapy for low-risk DCIS (COMET) trial is studying this question.

You may wish to consider the trade-off between active surveillance and standard care. Active surveillance involves no immediate treatment. There is a slightly greater risk of changes to your DCIS over time. Standard care involves immediate treatment. However, there could be potential side effects from the treatment. You must carefully consider how these trade-offs could impact your quality of life. In the COMET Study you will not be able to choose which intervention you receive. So, it is important for you to be willing to receive either surgery or active surveillance. You can also decide not to participate at any time.

What happens if my DCIS changes?

If there are signs that your DCIS has changed, you may need further tests. If symptoms develop, or if tests indicate the DCIS is progressing, treatment might be needed. Tests may show the DCIS has changed to invasive cancer. Even if it has this change will have been detected early. If you are in the active surveillance group, your treatment at this stage will often be the same as if you had chosen treatment at the time of your original DCIS diagnosis. If at any point your DCIS has changed, you will be provided information about treatment options. You and your physician can make a joint decision about potential treatment. This will probably involve surgery and radiation. It may also include endocrine therapy.

 

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