Sentinel lymph node biopsy (SLNB) remains controversial in ductal carcinoma in situ (DCIS) management. Although pure DCIS lacks metastatic potential, SLNB is frequently performed during surgical resection of DCIS for concern of occult invasive disease. This review examines current evidence regarding SLNB omission, when it remains appropriate, and emerging strategies to further de-escalate axillary surgery for DCIS. Contemporary studies demonstrate low rates of nodal metastases with DCIS, even among patients undergoing mastectomy despite pathologic upstaging to invasive disease. These findings highlight that risk of invasion does not equate to risk of clinically meaningful nodal disease. Delayed SLNB using superparamagnetic iron oxide (SPIO) tracers offers a potential approach to preserve accurate nodal mapping while avoiding unnecessary upfront axillary surgery. SLNB should be omitted during breast-conserving surgery for DCIS and selectively considered for mastectomy. Risk-adapted and delayed staging strategies may further reduce axillary overtreatment in DCIS.
This review defines the evidence boundaries for active monitoring of low-risk ductal carcinoma in situ after COMET and examines patient selection, surveillance, diagnostic reassessment, and reasons for later surgery while preserving clear boundaries between evidence and clinical judgment. COMET provides short-term randomized evidence for considering protocolized active monitoring as a preference-sensitive option in selected patients, but differences in eligibility, imaging, endocrine exposure, allocation, ascertainment, and follow-up limit direct comparison with LORD, LORIS, LORETTA, and observational cohorts. Adequate sampling and imaging-pathology concordance remain central at entry. New surveillance abnormalities warrant diagnostic confirmation rather than automatic treatment, and biomarkers or imaging thresholds lack prospective decision utility across care settings. Complete excision remains the guideline-supported standard. Active monitoring is most defensible within a reliable pathway with informed choice, prompt reassessment, and documented reasons for crossover. Future research should establish long-term invasive outcomes, treatment consequences, validated intervention thresholds, patient-important outcomes, and equitable implementation.
Endocrine chemoprevention can substantially reduce the incidence of breast cancer in women with high-risk breast lesions, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS). Yet, despite decades of evidence demonstrating efficacy, uptake and persistence remain strikingly limited. This review examines the disconnect between proven preventive efficacy and real-world implementation and evaluates emerging strategies for personalized prevention. Evidence from pivotal trials, including NSABP P-1, STAR, IBIS-II, and MAP.3, confirms clinically meaningful breast cancer risk reduction with tamoxifen, raloxifene, anastrozole, and exemestane, with benefits particularly relevant to women with hormonally responsive high-risk lesions. However, preventive benefit is frequently undermined by treatment-related adverse effects, inaccurate risk perception, uncertainty regarding absolute individual benefit, inconsistent clinician counseling, and systemic barriers to preventive care. Recent advances in multivariable risk prediction, polygenic risk scores, molecular biomarkers, digital health, and artificial intelligence provide opportunities to move beyond lesion-based risk categorization toward individualized benefit–risk assessment. The central challenge in breast cancer chemoprevention is no longer demonstrating that prevention works, but determining for whom, with which agent, and at what intensity prevention delivers the greatest net benefit. Integrating clinicopathological risk, genetic and molecular information, toxicity susceptibility, and patient preferences could transform chemoprevention from a broadly recommended intervention into a precision prevention strategy, closing the gap between therapeutic efficacy and population-level cancer prevention.
Breast cancer is the most common malignancy in reproductive-age women, and its incidence is rising fastest in those under 50 as early-stage survival exceeds 90
To evaluate contemporary upgrade rates of atypical ductal hyperplasia diagnosed on core biopsy and assess whether active surveillance may be appropriate for selected low-risk patients. Recent studies report overall upgrade rates ranging from approximately 10
