Table 3.

An example of clinical case which can have different treatment recommendations.

A Postmenopausal Woman Aged 52 Years, Undergoing Breast-Conserving Surgery for DCIS with the Following Features: Size 1.8 cm, Grade 2, 3 mm Negative Margins, no Comedonecrosis
According to the risk factors, she may be candidate for: -Whole breast RT without boost according to ASTRO guidelines for Whole Breast RT [83] -Whole breast RT with boost according to BIG 3-07/TROG 07.01 study [49] -PBI according to ASTRO guidelines [50,79] -RT omission according to RTOG 9804 study [21]
Decision-supporting tools:
-Van Nuys redefined score 7 [91] ->	LR risk 16% at 12 years
-Smith [156] 2/6 points ->	Moderate risk
-MSK nomogram [52]	With endocrine therapy	4% at 5 y; 7% at 10 y
	Without endocrine therapy	9% at 5 y; 15% at 10 y
Additional parameters
Positive estrogen receptor status	If endocrine therapy, RT omission or PBI may be a viable option [112]
HER2 overexpression	Whole breast RT may be a viable option, RT is effective in reducing in situ recurrence [109]
High Ki67 (≥14)	Whole breast RT may be a viable option, RT is effective in reducing both in situ and invasive recurrence [104]
Highly needed additional tools
-Biosignature and genomic tests which can be used to tip the scales either in favour of RT omission or RT recommendation [13,23]. Oncotype DX gives an estimate of LR risk. The DCISionRT (PreludeDx) may also provide information for RT intensification. In the setting of clinicopathologically low-risk DCIS, the DCISionRT reclassified 42% of patients into the Elevated-Risk Group [13], while 12-gene Oncotype DX reclassified about 10% of patients as a high-risk DS, which resulted in a 10-year risk of LR after BCS alone of more than 19% [168]. Biosignature and genomic tests may become greatly impactful in DCIS management once they are prospectively validated in randomized clinical trials.