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This page contains information about cases in
which a biopsy has been done,
whether for a lump or other abnormality on exam,
or for an abnormal mammogram, and the biopsy
shows ductal carcinoma in situ (DCIS). This is
different from “ductal carcinoma” or “invasive ductal carcinoma”.
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I had a
breast biopsy that showed ductal carcinoma in
situ (DCIS). What should be done now?
Although no one
ever wants to be told that they have cancer, the
finding of ductal carcinoma in situ (DCIS) is
one of those situations where we truly have
found a cancer at a stage where it can be nipped
in the bud. The “in situ” phrase means that we
can tell for sure that these cells have the
POTENTIAL to do their cancer thing (which means,
to invade into surrounding tissue and eventually
spread elsewhere), but that they have not yet
invaded even the tissue right around the DCIS
cells. You can think of these cells as “cancer
seeds”, which haven’t yet sprouted, but have all
the capability of doing so if left in place.
When DCIS is
seen on a biopsy, you will need to have more
tissue removed from your breast
(usually the additional tissue removed is about
the size of an ice cream scoop). This is almost
always done as on open surgical excision in the
operating room, either with sedation or general
anesthesia, though sometimes under local
anesthesia. This surgical excision is the most
important treatment, and it is necessary to
remove enough tissue so that none of the DCIS is
seen along any of the margins of the removed
tissue.
This is not
always as simple as it might seem, because the
DCIS can only be seen under the microscope, and
the tissue is not usually examined under the
microscope until after preserving the removed
tissue in formalin overnight. This method gives
more reliable information than trying to examine
the tissue immediately (called a frozen
section). This means that there are some women
in whom the margins will show some more DCIS,
and this will require another trip to the
operating room to remove more tissue. This
return to the operating room is necessary more
often than you might think, as often as 50% of
the time at some centers, whether here in
Atlanta, or at an academic center. At DeKalb
Surgical, this is only necessary about 10% of
the time. I wish it would never happen, but
sometimes even the non-invasive cancer cells can
extend along the breast ducts in various
directions. Obtaining clear margins is a matter
of experience, compulsion with orientation of
the tissue for the pathologist, and to some
extent, how much additional breast tissue is
removed. Our technique involves the use of a
customized surgical device that is not yet
available for general use, which helps to
minimize the likelihood that you would need a
second procedure.
In some cases,
when the surgical excision is done, there may be
some actual invasion seen in an adjacent area,
and so not seen on the initial biopsy. In such
cases, the situation changes a bit. In most
cases of invasive cancer, even if only a tiny
area, it is usually recommended to also
surgically check some of the lymph nodes under
your arm, to be sure there are no cancer cells
seen there. You will find more information
about this on the invasive cancer
page.
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Although
surgical excision for clear margins is the most
important treatment for DCIS, radiation therapy
AND 5 years of hormonal therapy (with tamoxifen)
is fairly standard additional treatment,
with the
intention of minimizing the possibility that you
might ever develop another cancer in your
breast. There is no need for chemotherapy
in these very early stage cases. Your surgeon
should discuss these issues with you in more
detail. Probably the most important thing to
remember if you have DCIS is that essentially
all women are cured of their cancer when it is
found at this stage.
You may wonder
why radiation therapy and hormone-blocking
treatment are recommended if all the DCIS is
surgically removed. That’s a good question, and
the answer comes from what we have learned over
the past several decades of treating such
patients. Studies have compared treatment with
lumpectomy only versus lumpectomy plus giving
radiation therapy, and also with or without
giving hormone blocking treatment (tamoxifen).
These studies showed that a higher percentage of
patients who only had lumpectomy had cancer come
back again over the following 5-10 years. And
when the cancer comes back, sometimes it is
invasive instead of non-invasive. After
lumpectomy only, the recurrence rate is about
35%. If radiation therapy and tamoxifen are
added, the recurrence risk is under 5%.
I like to think
of the radiation therapy in this case as
analogous to the weed preventive that you might
apply to your yard in the spring. You might
have had one sprig of crabgrass that you pulled
out completely. You don’t see any other
crabgrass in your yard, but you know that it
could pop up at a later date. The weed
preventive will do just that—help prevent you
from having more crabgrass in the future.
In the same way, just removing the seeds of
breast cancer (DCIS) might not be enough to keep
some seeds sprouting and taking root elsewhere
in your breast in the future. Radiation
therapy decreases that risk considerably.
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