Trends in Nonsurgical Management for Low-Risk, Hormone Receptor-Positive Ductal Carcinoma In Situ.

Importance: Active surveillance has emerged as a deescalation strategy for low-risk ductal carcinoma in situ (DCIS) to reduce overtreatment while maintaining favorable outcomes. Emerging data in low-risk DCIS, eg, the COMET trial, have highlighted growing interest in surveillance-based management for carefully selected patients. However, recent clinical adoption and national trends in managing low-risk, hormone receptor (HR)-positive DCIS have not been evaluated in the US. Objective: To examine trends and sociodemographic variations in nonsurgical management and other treatment modalities for low-risk, HR-positive DCIS. Design, Setting, and Participants: This cross-sectional study analyzed data from the National Cancer Database from January 1, 2004, to December 31, 2022, and included patients aged 18 years or older with grade 1 to 2, HR-positive DCIS and at least 12 months of follow-up since initial diagnosis. Analyses were performed between January 10 and August 31, 2025. Exposures: Year of diagnosis and sociodemographic characteristics. Main Outcomes and Measures: Nonsurgical management, lumpectomy alone, lumpectomy plus adjuvant radiotherapy, unilateral mastectomy, bilateral mastectomy, and endocrine therapy were measured using descriptive statistics. Results: A total of 316 590 female patients were included (mean [SD] age, 60.8 [12.0] years; 5.8% Asian or Pacific Islander, 13.9% Black, 6.1% Hispanic, 73.3% White, and 0.9% other race and ethnicity). From 2004 to 2022, nonsurgical management increased from 2.1% to 3.5%, bilateral mastectomy increased from 4.1% to 8.7%, and lumpectomy increased from 22.0% to 25.1%, while lumpectomy plus adjuvant radiotherapy decreased from 50.9% to 45.6% and unilateral mastectomy decreased from 20.9% to 17.1%. Nonsurgical management was more common among Black patients and patients with no insurance. Bilateral mastectomy was common in younger, White, and privately insured patients and those who lived in higher-income areas. Endocrine therapy use increased from 2004 to 2020 but declined thereafter. Endocrine therapy was highest after lumpectomy plus adjuvant radiotherapy (69.6%), followed by lumpectomy alone (43.9%), unilateral mastectomy (35.3%), and nonsurgical management (29.2%), with the lowest use in patients younger than 50 years in the no surgery (15.2%) and lumpectomy alone (38.6%) groups. Since 2018, radiotherapy use has increased and become progressively more risk adapted, with increasing use with higher Oncotype DX DCIS scores (low risk, 34.5%; intermediate risk, 63.9%; high risk, 73.1%). Conclusions and Relevance: This cross-sectional study highlights increasing trends and socioeconomic disparities in the nonsurgical management of and the need for precision-based, patient-centered care for low-risk DCIS. Precision prevention may enhance the identification of patients who could benefit most from preventive surgery, prolonged endocrine therapy, or treatment deescalation, paving the way for individualized strategies.