Jacky Luiten

General discussion and future perspectives | 133 9 Future perspectives The purpose of treatment of patients with DCIS is to prevent development of invasive breast cancer. The increasing number of patients with DCIS detected through screening mammography raised the question about the clinical significance of these lesions. Studies on patients in whom DCIS was initially misdiagnosed as benign resulting in no additional treatment following biopsy, suggest that between 50–85% of all DCIS will never progress to invasive cancer. 56 However, effective tools to distinguish between DCIS that will progress, and non ‐ hazardous DCIS are presently lacking. The future goal is to prevent overtreatment by safely omitting invasive treatment. Or, even better, biopsy should be made redundant by better interpretation based on imaging. In this future perspective we philosophize about possible future developments within the mammography screening, biopsies, follow ‐ up with surveillance only, diagnostic criteria, genetic profiling and patients’ perspectives. 1. Mammography screening At the moment it is not possible to identify which subclinical lesions detected at mammographic screening will progressive into invasive carcinoma. Therefore, almost all patients with suspicious mammographic findings – indicating the likelihood of presence of DCIS – are all recalled for biopsy. If DCIS is confirmed, these patients are generally offered surgical treatment. The most cost ‐ effective way to prevent overtreatment lies at the beginning of the process; the mammographic screening. The introduction of the more sensitive digital mammography resulted in an increased detection of small lesions, such as microcalcifications. However, not all microcalcifications are related to underlying DCIS. Recent studies found a relationship between the morphology and distribution of microcalcifications and the clinical and histopathologic features of the underlying DCIS. High grade DCIS is more often associated with specific abnormal mammographic features, such as necrosis, rod and linear branch shapes or coarse granular microcalcifications 31, 57 ‐ 59 . Conversely, low grade DCIS is associated with round of punctate more diffusely spread microcalcifications. A future step might thus be to classify microcalcifications by radiologic features to prevent an invasive biopsy for suspected low grade DCIS.