Although breast cancer has been a human illness for thousands of years, ductal carcinoma in situ or DCIS (also known as intraductal carcinoma) is a relatively new diagnosis, and we are learning more about it all the time. Until mammography became a routine part of medical care, we didn’t see much DCIS. Now, we do. Approximately 24% of all new breast cancers diagnosed in the United States in 2002 were DCIS.
Most breast cancers (carcinomas) arise in cells that line the ducts and lobules of the breast. We still don’t know what happens exactly, but for some reason, the cells start growing when they are not supposed to be growing. When cells in the lining of breast ducts are growing inappropriately, this is called hyperplasia; when they grow inappropriately and do not appear normal under the microscope, they are called atypical.
DCIS is a term used to describe cells that are growing inappropriately inside the ducts of the breast (see diagram) and look like cancer cells under the microscope. These abnormal cells have not spread into the surrounding fatty breast tissue or to any other part of the body.
Some cell changes are important, while others are less important. DCIS cells lack the biological capacity to metastasize or spread elsewhere in the body as cancer cells do. So why do DCIS cells fall into the category of cancer cells?
Some DCIS cells can change genetically and become true cancers, and women should not be lulled into thinking that a DCIS diagnosis can be ignored or dismissed. We still do not know for sure which DCIS cells will change and become invasive and which will remain DCIS. It is probably most useful to view a diagnosis of DCIS as an indication that a woman has a greater risk of developing breast cancer, especially if she receives no treatment for the DCIS.
There are different kinds of DCIS. It is important for the individual who is diagnosed with DCIS to know how aggressive or risky her cell type is. For example, comedo is considered more aggressive (high-grade) than cribriform (low-grade). This information is part of an accurate diagnosis by the pathologist and helps define treatment options, which in turn affect whether DCIS becomes invasive breast cancer.
A diagnosis of DCIS depends on the pathologist, and the diagnosis may be controversial. Therefore, second opinions may be important. If a woman seeks a second opinion, she needs to take her slides and blocks that contain samples of the cells taken during her biopsy to another pathologist, and she must be prepared to pay for this additional opinion.
People often fail to get a second opinion on pathology. However, if the pathology is incorrect, the treatment choices are much more likely to be incorrect and possibly ineffective as well.
You can also request second opinions for mammography, ultrasound, and treatment. If you choose to have a second opinion for mammography or ultrasound, it is important to take the original films, not copies, to the physician, and to carry them to the radiologist yourself if possible.
Whether your doctor refers to DCIS as cancer or pre-cancer, it requires careful treatment and follow-up to avoid the possibility of invasive breast cancer developing. On this Web site, we refer to DCIS as cancer.
There is a lot of research going on that will help sort out which kinds of DCIS are aggressive and how to determine optimal treatment for each kind.
The initial treatment for DCIS is always surgery. There are two surgical approaches to DCIS treatment: lumpectomy, or a total mastectomy.
Lumpectomy is a surgical procedure that removes the breast lump or suspicious tissue seen on the mammogram and some surrounding tissue as well. Lumpectomy is also called “breast-sparing”, “breast-conserving” or “segmental mastectomy”.
Generally, lumpectomy is the first step in breast-conservation therapy. Lumpectomy is usually performed in an outpatient setting using local anesthesia. However, general anesthesia can be used for greater patient comfort. If cancer cells are present at the margin (the edge of the biopsied tissue), a re-excision needs to be done to remove the remaining cancer. If you are large-breasted, most of your breast can be preserved and you will still have the image you are accustomed to. If you are small-breasted and need additional surgery, lumpectomy may not result in a good cosmetic result; mastectomy with reconstruction can be a good option.
Lumpectomy alone is the adequate treatment if:
Only one area of abnormality is found on exam or on a mammogram.
The area of abnormality is very small.
The surgeon is able to remove the DCIS completely and no DCIS is left behind in the breast.
The mammogram of the breast shows no more suspicious findings after the lumpectomy.
The woman is elderly or has other serious illnesses and would not be able to tolerate more extensive surgery or breast radiation therapy.
The type of DCIS is a less aggressive, or non-comedo, type.
The woman consents to close follow-up and surveillance.
Lumpectomy alone carries special concerns and considerations. Because the remaining breast tissue is not treated with any other intervention, there is the possibility that if the woman lives many more years, she can develop cancer — either DCIS or invasive cancer in the same breast. This option is only effective for carefully selected patients with early, small DCIS lesions with very easily interpreted mammograms. Comedo-type DCIS tends to be more aggressive and careful judgment needs to be used in offering lumpectomy alone in women with this cell type of DCIS.
Simple (total) mastectomy
This is a surgical procedure in which the entire breast is removed but not the lymph nodes under the arm or the muscle tissue from beneath the breast. The nipple will be removed in this procedure, but much of the original skin of the breast may be preserved.
Simple mastectomy is used to treat noninvasive breast cancer and is one way to remove DCIS that is multifocal (appears in many places within the breast). The surgeon does not need to remove lymph nodes from under the arm, because DCIS does not spread to the axillary lymph nodes.
If the DCIS is high grade and larger, your surgeon may suggest a sentinel node biopsy at the time of lumpectomy or mastectomy. This is because of the possibility of invasive cancer. By doing the sentinel node biopsy at this time, the need for additional surgery may be eliminated.
If invasive cancer is found, the surgeon will remove the entire breast tissue and some lymph nodes, which is important to determine the spread of the disease. This is called a modified radical mastectomy. When lymph nodes are removed, there is a small risk of lymphedema, or swelling in the arm.
Simple mastectomy is appropriate management for all kinds of DCIS. It is the only recommended treatment for multifocal DCIS, extensive DCIS, or DCIS that has recurred after lumpectomy and radiation therapy. This procedure is a relatively short surgery, requires general anesthesia, with a short hospital stay followed by a quick recovery. Reconstructive surgery to recreate the breast can be done immediately at the time of mastectomy or at a later date. The recurrence rate and overall chance of dying from cancer after simple mastectomy is between 0 and 2%.
Women who have the simple mastectomy procedure rarely have difficulties with shoulder movement or arm swelling after surgery. As compared to a modified radical mastectomy, the surgery time is shorter and the recovery period faster.
If a simple mastectomy is chosen as a treatment for DCIS, radiation therapy is not needed following the surgery.
Modified radical mastectomy
Modified radical mastectomy is a surgical procedure in which the entire breast and some or all of the nearby lymph nodes are removed. Underlying muscles are left intact. This procedure is not usually used for the treatment of DCIS, but may be used if invasive breast cancer is found.
Postoperative radiation therapy
If lumpectomy is chosen as the surgical method, the remainder of the breast is usually treated with radiation to minimize the chances of having a recurrence of DCIS in the breast. If, after biopsy, there are cancer cells present at the margin (the edge of biopsied tissue), and excision can usually be done again to remove the remaining cancer cells. Radiation treatment is usually begun three to four weeks after the lumpectomy or when the wound has healed.
Radiation therapy is used to destroy any cancer cells that may be left behind in the breast. Radiation treatments are usually given five days a week for six to seven weeks. The daily sessions take only a few minutes each.
The side effects of radiation can include swelling and heaviness in the breast, sunburn-like skin changes in the treated area, fatigue, and loss of appetite. For some women, the breast may become smaller, firmer, and more tender after radiation therapy.
These common side effects generally begin toward the middle of the treatment and continue for a short time after the completion of radiation. The side effects are usually gone within six months to a year. Radiation can only be used once for primary treatment because the breast does not tolerate repeated radiation therapy at the doses required to eradicate cancer.
Radiation therapy after lumpectomy is considered an adequate treatment in the following situations:
When there is only one area of abnormality in the breast, either on physical exam or mammogram.
When the surgeon is able to remove all of the DCIS cleanly, and this is verified by mammogram after the surgery. When additional DCIS is found, re-excision (additional surgery) is necessary.
When the size of the DCIS is small enough in relation to the size of the breast so that the woman is left with a cosmetically acceptable result.
Some of the problems with having lumpectomy and radiation therapy are:
Radiation therapy is time-consuming, with treatments lasting five to seven weeks.
While risk of recurrence is reduced by adding the radiation therapy to lumpectomy, about 8% to 10% of women with this treatment will have a recurrence in the treated breast. Half of the women who have recurrence will have invasive cancer when the cancer returns. Women with comedo DCIS have the highest risk of developing invasive recurrences. Cosmetic results may be of concern. While lumpectomy and radiation therapy may preserve the breast and breast sensation and “feel,” radiation and surgery sometimes result in a change in the texture of the breast, a poor cosmetic result and deformity.
Lumpectomy with postoperative radiation therapy may not be appropriate for:
Women with a local recurrence or new primary DCIS or breast cancer who have already had radiation therapy to the affected breast or chest.
Women with two or more areas of DCIS in the same breast, too far apart to be removed by one incision.
Women whose first excision biopsy — or when needed, their re-excision — has not completely removed the DCIS, or whose re-excision may result in an unsatisfactory appearance of the breast.
Women with certain autoimmune diseases that make body tissues especially sensitive to the side effects of radiation therapy. Ask your doctor if you have one of these conditions.
If a woman is pregnant when diagnosed with DCIS, radiation therapy may be delayed until after completion of her pregnancy because DCIS is not an emergency. Although radiation is often delayed, surgery can be safely performed during her pregnancy or can be done after the birth of her child with no compromise to the mother.
Choosing your DCIS treatment
If you are choosing which kind of surgery to have, here are some facts that will assist you in your decision-making:
For anyone choosing mastectomy it is important to know that it is almost impossible to remove all of the breast tissue, and therefore a recurrence is still possible in the remaining tissue.
Possible short-term side effects of both lumpectomy and mastectomy include wound infection, hematoma (accumulation of blood in the wound), and seroma (accumulation of clear fluid in the wound).
About 95% of women with DCIS do not require a mastectomy.
The survival rates for a combination of lumpectomy with radiation therapy have shown that is it just as effective as mastectomy.
Local recurrence with total mastectomy is rare.
Women who opt to preserve their breast with a combination of lumpectomy and radiation therapy have a higher rate of recurrence than women who have a mastectomy, but there is no proven impact on survival.
Following lumpectomy or mastectomy, some women experience discomfort or pain that comes and goes. It is not uncommon to feel discomfort at the site of the incision when there are significant climate changes. Women may also experience breast tenderness after radiation therapy.
Information. Before discussing treatment options, the doctor needs to conduct a physical examination and ask your medical history. This will include questions about your family history, such as the following:
Relatives who have had breast cancer
Their age at diagnosis and whether one or both breasts had cancer
Whether any relatives had ovarian cancer or other cancers
Any history of radiation to the breast area
Any history of vascular disease
Whether you have breast implants
The date of your first menstrual period
The date of your last menstrual period
The possibility of present or future pregnancy
Your use of hormone replacement therapy
Your use of oral contraceptives
Whether you have had fertility or gynecologic surgeries
Whether you have nipple discharge
The doctor will use this information and the pathology results to determine which therapies are most suitable for you, and will then discuss treatment options with you. To summarize: Most women and their doctors prefer lumpectomy and radiation therapy rather than mastectomy. The advantage of lumpectomy is that it may save the appearance of your breast. The disadvantage of a lumpectomy is that it is followed by several weeks of radiation therapy. Unfortunately, for some small-breasted women, a lumpectomy may be very disfiguring, and a simple mastectomy with reconstruction may be a better cosmetic option.
Your individual feelings, attitudes and values may be just as important as the scientific facts in weighing your options. As you consider your choices, think about the following questions:
How do you feel about losing your breast?
How much breast tissue will need to be removed?
How far will you have to travel for radiation therapy?
Do you want or are you willing to have reconstructive surgery after mastectomy?
Are you thinking of mastectomy as a way to rid yourself of your cancer as quickly as possible? Or is it because it represents the least chance that cancer will reappear?
How important is it to have a normal-appearing breast when all treatment is complete? If your breast is small or the amount of tissue that must be removed is large, a mastectomy with or without reconstruction may yield a more pleasing appearance.
Remember, lumpectomy and radiation for the treatment of DCIS are not appropriate if:
You have had previous radiation to the breast or chest wall.
You are pregnant (although radiation can be performed after delivery).
The disease is in several areas of your breast.
There are suspicious areas of calcium throughout your breast on a mammogram or breast MRI.
Furthermore, lumpectomy and radiation as treatment for DCIS may not be appropriate if:
Two separate incisions are needed to remove the disease.
You have an autoimmune disease such as scleroderma or systemic lupus.