What question did this study set out to answer?

To evaluate the role of various imaging modalities in detecting ductal carcinoma in situ and their implications for treatment strategies.

March 7, 2026Open Access

Imaging Ductal Carcinoma In Situ in the Era of De-Escalation: Role, Limits, and Clinical Implications for Risk-Adapted Management

Key Points

To evaluate the role of various imaging modalities in detecting ductal carcinoma in situ and their implications for treatment strategies.
Reviewed the roles of mammography, ultrasound, MRI, and emerging AI in DCIS management.
Discussed the importance of imaging in assessing disease extent and monitoring outcomes.
Evaluated active surveillance trials like LORIS, COMET, LORD, and LORETTA.
Imaging serves primarily as a risk-filtering tool, helping to identify radiologically unsafe scenarios.
Current imaging modalities often overestimate disease severity, risking inappropriate treatment.
Effective integration of imaging data is crucial for safe treatment de-escalation and patient-centered care.

Abstract

The widespread implementation of population-based mammographic screening has markedly increased the detection of ductal carcinoma in situ (DCIS), without a proportional reduction in breast cancer-specific mortality. This divergence has intensified concerns regarding overdiagnosis and overtreatment and has prompted increasing interest in treatment de-escalation and active surveillance strategies. Breast imaging remains indispensable for DCIS detection, extent assessment, and longitudinal monitoring. However, although imaging features correlate with histopathologic risk factors at the population level, their ability to predict individual biological progression is inherently probabilistic and limited. Overinterpretation of imaging phenotypes as surrogates of invasive destiny risks inappropriate reassurance or unjustified therapeutic escalation, particularly in the context of high-sensitivity modalities that may overestimate disease extent or trigger additional interventions without proven outcome benefits. This review examines the modality-specific roles of mammography, ultrasound, breast magnetic resonance imaging (MRI), contrast-enhanced mammography (CEM), and emerging artificial intelligence (AI) approaches within contemporary DCIS management, with particular attention to their implementation in active surveillance trials such as LORIS, COMET, LORD, and LORETTA. Across modalities, imaging primarily reflects lesion morphology, spatial distribution, and vascular behaviour, and functions most reliably as a risk-filtering and safety-gating instrument aimed at excluding radiologically unsafe scenarios, including occult invasion, underestimated disease extent, or imaging evolution incompatible with continued observation. By delineating both the capabilities and the epistemological limits of imaging, this review proposes a structured clinical decision framework in which imaging supports—but does not independently determine—risk-adapted management. Disciplined integration of imaging into multidisciplinary decision-making is essential to enable safe de-escalation, prevent false reassurance, and align DCIS care with patient-centred and value-based principles.

Imaging Ductal Carcinoma In Situ in the Era of De-Escalation: Role, Limits, and Clinical Implications for Risk-Adapted Management

Key Points

Abstract

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