David Wazer, Director at Brown Health Cancer Institute, shared on LinkedIn:
“Before We Omit Radiation for Breast DCIS: How Much Should We Trust DCISionRT?
A newly published point-counterpoint debate over DCISionRT (citations below) captures a larger challenge in modern oncology:
How much evidence should we require before incorporating biologically informed tools into treatment decisions?
O’Keefe and colleagues appropriately remind us that enthusiasm for precision medicine should not eclipse methodological rigor.
DCISionRT was developed largely from retrospective, nonrandomized data, and questions regarding training populations, patient exclusions, and performance in randomized datasets such as SweDCIS deserve attention.
Their most important challenge is whether the assay provides sufficient incremental value beyond the full spectrum of clinicopathologic information already available to experienced clinicians-and whether ipsilateral breast recurrence, rather than invasive recurrence, is the endpoint that matters most.
Yet Vicini and colleagues make the more compelling clinical argument. Traditional clinicopathologic criteria are imperfect surrogates for tumor biology
In their analysis, DCISionRT reclassified 51%-63% of patients considered low-risk by individual clinicopathologic criteria as biologically elevated-risk; these patients experienced absolute reductions in recurrence of at least 10% with radiation.
Conversely, 22%-31% classified as clinicopathologically high-risk were reclassified as low-risk, with low recurrence rates without radiation and no statistically significant RT benefit. That is precisely the type of information needed if we hope to move beyond “one-size-fits-all” treatment.
Importantly, DCISionRT should not be viewed as replacing clinical judgment. Rather, it adds another dimension to shared decision-making by integrating biology with conventional clinical factors. The assay is not the final word, and prospective randomized validation remains essential.
The appropriate response, however, is not to retreat to clinicopathologic criteria alone. It is to rigorously test whether molecular biology can improve upon them. NRG CC-016 provides exactly that opportunity, prospectively evaluating RT omission in DCISionRT low-risk patients.
Precision oncology advances through a combination of skepticism and innovation. DCISionRT has not yet crossed the finish line-but the available evidence suggests it is running in the right direction.
O’Keefe TJ et al. Int J Radiat Oncol Biol Phys 2026, 126(1):176-178
Vicini F et al. Int J Radiat Oncol Biol Phys 2026, 126(1): 179-181″
