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Comparison of Operative to Monitoring and Endocrine Therapy (COMET) Trial For Low Risk DCIS

Overview

  • Study type

    Interventional

  • Study phase

    III

  • Study IDs

  • Study type

    Interventional

    Describes the nature of a clinical study. Types include:

    • Observational study — observes people and measures outcomes without affecting results.
    • Interventional study (clinical trial) — studies new tests, treatments, drugs, surgical procedures or devices.
    • Medical records research — uses historical information collected from medical records of large groups of people to study how diseases progress and which treatments and surgeries work best.

  • Study phase

    III

    During the early phases (phases 1 and 2), researchers assess safety, side effects, optimal dosages and risks/benefits. In the later phase (phase 3), researchers study whether the treatment works better than the current standard therapy. They also compare the safety of the new treatment with that of current treatments. Phase 3 trials include large numbers of people to make sure that the result is valid. There are also less common very early (phase 0) and later (phase 4) phases. Phase 0 trials are small trials that help researchers decide if a new agent should be tested in a phase 1 trial. Phase 4 trials look at long-term safety and effectiveness, after a new treatment has been approved and is on the market.

  • Study IDs

    Site IRB
    • Jacksonville, Florida: 17-010609
    • Rochester, Minnesota: 17-010609
    • Scottsdale/Phoenix, Arizona: 17-010609
    NCT ID: NCT02926911
    Sponsor Protocol Number: AFT-25

About this study

This study looks at the risks and benefits of active surveillance (AS) compared to guideline concordant care (GCC) in the setting of a pragmatic prospective randomized trial for low risk DCIS. Our overarching hypothesis is that management of low-risk Ductal Carcinoma in Situ (DCIS) using an AS approach does not yield inferior cancer or quality of life outcomes compared to GCC.

Participation eligibility

Participant eligibility includes age, gender, type and stage of disease, and previous treatments or health concerns. Guidelines differ from study to study, and identify who can or cannot participate. If you need assistance understanding the eligibility criteria, please contact the study team.

See eligibility criteria

Inclusion Criteria:

  • New diagnosis of DCIS without invasive cancer; date of diagnosis defined as the date of the first pathology report that diagnosed the patient with DCIS.
  • Unilateral, bilateral, unifocal, or multifocal DCIS.
  • ADH/borderline DCIS.
  • A patient who has had a lumpectomy with positive margins as part of their treatment for a current DCIS diagnosis is eligible (post-excision mammogram required at enrollment to establish a new baseline).
  • No previous history of breast cancer (DCIS or invasive cancer) in either breast prior to current DCIS diagnosis.
  • 40 years of age or older at time of DCIS diagnosis.
  • ECOG performance status 0 or 1.
  • No contraindication for surgery.
  • Baseline imaging:
    • Unilateral DCIS: contralateral normal mammogram ≤ 6 months of registration and ipsilateral breast imaging ≤ 120 days of registration (must include ipsilateral mammogram; can also include ultrasound or breast MRI);
    • Bilateral DCIS: bilateral breast imaging ≤ 120 days of registration (must include bilateral mammogram; can also include ultrasound or breast MRI).
  • Pathologic Criteria:
    • All grade I DCIS (irrespective of necrosis/comedonecrosis);
    • All grade II DCIS (irrespective of necrosis/comedonecrosis).
  • Absence of invasion or microinvasion.
  • Diagnosis confirmed on core needle, vacuum-assisted or surgery ≤ 120 days of registration.
  • ER(+) and/or PR(+) by IHC (≥ 10% staining or Allred score ≥ 4).
  • HER2 0, 1+, or 2+ by IHC if HER2 testing is performed.
  • Histology slides reviewed and agreement between two clinical pathologists (not required to be at same institution) that pathology fulfills COMET eligibility criteria. In cases of disagreement between the two pathology reviews about whether or not a case fulfills the eligibility criteria, a third pathology review will be required.
  • At least two sites of biopsy for those cases where mammographic extent of calcifications exceeds 4 cm, with second biopsy benign or both sites fulfilling pathology eligibility criteria.
  • Amenable to follow up examinations.
  • Ability to read, understand and evaluate study materials and willingness to sign a written informed consent document.
  • Reads and speaks Spanish or English.

Exclusion Criteria:

  • Male DCIS.
  • All Grade III DCIS.
  • Concurrent diagnosis of invasive or microinvasive breast cancer in either breast.
  • Documented mass on examination or imaging, or diagnosis of mass as cyst, at site of DCIS prior to biopsy yielding diagnosis of DCIS, with exception of fibroadenoma at a distinct/separate site from site of DCIS (or diagnosis of mass as a cyst). In cases of uncertainty about whether the mass was present on physical examination prior to biopsy, the following criteria should be applied: if mammogram noting abnormal findings is diagnostic MMG = symptomatic/if mammogram noting abnormal findings is screening MMG = asymptomatic.
  • Bloody nipple discharge (ipsilateral breast).
  • Mammographic finding of BIRADS 4 or greater within 6 months of registration at site other than that of known DCIS, without pathologic assessment.
  • Use of investigational cancer agents within 6 weeks prior to diagnosis.
  • Any serious and/or unstable pre-existing medical, psychiatric, or other existing condition that would prevent compliance with the trial or consent process.
  • Pregnancy. If a woman has been confirmed as pregnant she will not be eligible to take part in the trial. If she suspects there is a chance that she may be pregnant, a pregnancy test should be undertaken; however, a pregnancy test for all women of child-bearing potential is not mandatory.
  • Documented history of prior tamoxifen, aromatase inhibitor, or raloxifene in last 6 months.

 

Participating Mayo Clinic locations

Study statuses change often. Please contact us for help.

Mayo Clinic Location Status Contact

Jacksonville, Fla.

Mayo Clinic principal investigator

Sandhya Pruthi, M.D.

Open for enrollment

Contact information:

Pulkit Mathur

(904)953-3803

Mathur.Pulkit@mayo.edu

Rochester, Minn.

Mayo Clinic principal investigator

Sandhya Pruthi, M.D.

Open for enrollment

Contact information:

Jean Jensen

(507)538-1115

Jensen.Jean@mayo.edu

Scottsdale/Phoenix, Ariz.

Mayo Clinic principal investigator

Sandhya Pruthi, M.D.

Open for enrollment

Contact information:

Cancer Center Clinical Trials Referral Office

855-776-0015

More information

Publications

  • Elissa M EM. Ozanne, Yiwey Y. Shieh, James J. Barnes, Colleen C. Bouzan, E Shelley ES. Hwang, Laura J LJ. Esserman. Breast cancer research and treatment 2011 Aug; (129):165-73 1

    The significant increase in the detection and treatment of ductal carcinoma in situ (DCIS) since the introduction of screening mammography has not been accompanied by the anticipated reduction in invasive breast cancer (IBC) incidence. The prevalence of DCIS requires a reexamination of the population level effects of detecting and treating DCIS. To further our understanding of the possible impact of DCIS diagnosis and treatment on IBC incidence in the U.S., we simulated breast cancer incidence over 25 years under various assumptions regarding the baseline incidence of IBC and the progression of DCIS to IBC. The simulations demonstrate a tradeoff between the expected increased incidence of IBC absent any DCIS detection and treatment and the rate of progression of DCIS to IBC. Our analyses indicate that a high progression of DCIS to IBC implies a significant increase in incidence of IBC over what is observed had we not detected and treated DCIS. Conversely, if we assume that there would not have been a significant increase over and above the observed incidence evident in SEER, then our model indicates that the rate of DCIS progression to clinically significant IBC is low. Given the tradeoff illustrated by our model, we must reevaluate the assumption that DCIS is a short-term obligate precursor of invasive cancer and instead focus on further exploration of the true natural history of DCIS.

  • Bircan B. Erbas, Elena E. Provenzano, Jane J. Armes, Dorota D. Gertig. Breast cancer research and treatment 2006 May; (97):135-44 2

    Ductal carcinoma in situ represents about 20% of all tumours diagnosed within mammographic screening programs. The natural history of DCIS is poorly understood, as it cannot be observed directly. Estimates of the proportion of DCIS that progress to invasive cancer, as well as factors that may influence progression, are important for clinical management. Here we review various sources of evidence regarding the natural history of DCIS.

  • Virginia L VL. Ernster, Rachel R. Ballard-Barbash, William E WE. Barlow, Yingye Y. Zheng, Donald L DL. Weaver, Gary G. Cutter, Bonnie C BC. Yankaskas, Robert R. Rosenberg, Patricia A PA. Carney, Karla K. Kerlikowske, Stephen H SH. Taplin, Nicole N. Urban, Berta M BM. Geller. Journal of the National Cancer Institute 2002 Oct; (94):1546-54 20

    With the large number of women having mammography-an estimated 28.4 million U.S. women aged 40 years and older in 1998-the percentage of cancers detected as ductal carcinoma in situ (DCIS), which has an uncertain prognosis, has increased. We pooled data from seven regional mammography registries to determine the percentage of mammographically detected cancers that are DCIS and the rate of DCIS per 1000 mammograms.

  • L L. Nyström, L E LE. Rutqvist, S S. Wall, A A. Lindgren, M M. Lindqvist, S S. Rydén, I I. Andersson, N N. Bjurstam, G G. Fagerberg, J J. Frisell. Lancet (London, England) 1993 Apr; (341):973-8 8851

    Despite encouraging results from screening trials the efficacy of mammography in reducing mortality remains somewhat controversial. Five studies have been done in Sweden. This overview, based on 282,777 women followed for 5-13 years in randomised trials in Malmö, Kopparberg, Ostergötland, Stockholm, and Gothenburg, reveals a 24% (95% confidence interval 13-34%) significant reduction of breast cancer mortality among those invited to mammography screening compared with those not invited. To avoid the potential risk of differential misclassification causes of death were assessed by an independent end-point committee after a blinded review of all fatal breast cancer cases. The mortality reduction was similar, irrespective of the end-point used for evaluation ("breast cancer as underlying cause of death" or "breast cancer present at death"). There was a consistent risk reduction associated with screening in all studies, although the point estimate of the relative risk for all ages varied non-significantly between 0.68 and 0.84. The cumulative breast cancer mortality by time since randomisation was estimated at 1.3 per 1000 within 6 years in the invited group compared with 1.6 in the control group. The corresponding figures after 9 years are 2.6 and 3.3 and after 12 years 3.9 and 5.1. The largest reduction of breast cancer mortality (29%) was observed among women aged 50-69 at randomisation. Among women 40-49 there was a non-significant 13% reduction. In this younger age group cumulative breast cancer mortality was similar in the invited and control group during the first 8 years of follow-up. After 8 years there was a difference in favour of the invited women. There was no evidence of any detrimental effect of screening in terms of breast cancer mortality in any age group. Among women aged 70-74 years screening seems to have had only a marginal impact.

Study Results Summary

Not yet available

Supplemental Study Information

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