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Is Ductal Carcinoma In Situ Cancer

Enhancing Healthcare Team Outcomes

Ductal Carcinoma in Situ

Ductal carcinoma in situ treatment is multifaceted and should be tailored to the patient based on pathology, overall health, comorbidities, age, genetics, cosmetic concerns, hormone receptor status, medical access, social support, and patient preference. It is, therefore paramount for the physician to have a careful discussion with the patient in order to come to an informed decision in regards to the treatment plan and ensure care coordination for each patient. These patients will need coordination with some or all of the following specialties:

  • General surgery/breast surgical oncology

Are There Any Adjuvant Treatments

After surgery, you may need other treatments. These are called adjuvant treatments and can include radiotherapy and, in some cases, hormone therapy.

The aim of these treatments is to reduce the risk of DCIS coming back or an invasive cancer developing.

Chemotherapy and targeted therapy are not used as treatment for DCIS.

Why Is Dcis Treated

DCIS is non-invasive, but without treatment, the abnormal cells could progress to invasive cancer over time.

Health care providers cannot predict which cases of DCIS will progress to invasive breast cancer and which will not. Because DCIS might progress to invasive breast cancer, almost all cases of DCIS are treated.

Komen Perspectives

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Molecular Cellular And Microenvironmental Aspects

Many studies have focussed on identifying molecular markers of the invasive process and recent studies have linked mutations in PIK3CA, TP53 and GATA3 genes with aggressive DCIS TP53 mutations were reported to be exclusively associated with high-grade DCIS., However, the requirement for fresh tissue and large amounts of DNA for whole-exome or genome sequencing has limited the extent of studies for determining the landscape of genetic mutations in DCIS.

One of the key molecular differences between DCIS and invasive breast cancer is the prevalence of HER2 amplification: 34% for DCIS versus 13% for invasive disease. HER2 amplification might be a prognostic factor in predicting an in situ recurrence after DCIS, but it seems not to be predictive for an invasive recurrence. That said, one study with a long follow-up counterintuitively demonstrated that HER2 positivity in primary DCIS was associated with a lower risk of late invasive breast cancer compared with HER2 negativity. In HER2-positive DCIS, TILs are present at higher levels, but an association with an invasive recurrence risk after DCIS has not been reported.

Looking ahead

Current Diagnosis And Imaging

Treatment Changes For DCIS Haven

DCIS is usually straightforward to detect by mammography because of its association with calcifications the proliferation of cells itself is not visible on the mammogram. However, as only 75% of all DCIS lesions contain calcifications, a substantial percentage of DCIS lesions will not be detected by mammography, implying that some lesions might be mammographically occult or that the diameter of the area containing calcifications underestimates the extent of DCIS., This suggests that DCIS might be left behind following breast-conserving treatment in a proportion of cases.

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Removal Of Part Of The Breast

Many women have surgery to remove the area of DCIS and a border of healthy tissue around it. This is called breast conserving surgery, or a wide local excision or sometimes a lumpectomy.

After this surgery, you might have radiotherapy to the rest of the breast tissue if the DCIS cells look very abnormal . The radiotherapy treatment aims to kill off any abnormal cells that might still be in the breast tissue. Your doctor or breast care nurse will discuss with you the possible benefits and risks of radiotherapy.

What Medication Treat Ductal Carcinoma In Situ

Tamoxifen may be prescribed for woman of all ages who have been treated for DCIS. In those women past menopause, the doctor may prescribe an aromatase inhibitor. These medications help lower the risk of DCIS or another type of cancer developing in either breast. If either is prescribed, it is suggested that these drugs be taken for five years after surgery.

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Hormone Therapy After Breast Surgery

If the DCIS is hormone receptor-positive , treatment with tamoxifen or an aromatase inhibitor, such as exemestane or anastrozole, for 5 years after surgery can lower the risk of another DCIS or invasive cancer developing in either breast. If you have hormone receptor-positive DCIS, discuss the reasons for and against hormone therapy with your doctor.

Proposed Mechanisms For The Development Of Invasive Breast Cancer

Ductal Carcinoma In Situ Defined

Although the natural course of the intraductal process is unknown, DCIS is considered to be a non-obligate precursor of invasive breast cancer. Four evolutionary models have been proposed to describe the progression of DCIS into invasive breast cancer .

Overview of models showing four different theories of progression from ductal carcinoma in situ to invasive breast cancer

The first model is the independent lineage model. On the basis of mathematical simulations of the observed frequencies of the histological grade of DCIS and the histological grade of invasive disease in the same biopsy sample, Sontag et al. proposed that in situ and invasive cell populations arise from different cell lineages and develop in parallel and independently of each other. In support of this theory, Narod et al. state that small clusters of cancer cells with metastatic ability spread concomitantly through various routes to different organs and can therefore give rise to DCIS, invasive breast cancer and metastatic deposits simultaneously. Recent studies elucidating molecular differences between DCIS and invasive breast cancer further support the relevance of this model.

These putative models illustrate the potential complexity of the invasion process in DCIS and indicate that indolent lesions might become invasive via a combination of more than one of the proposed mechanisms.

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Removal Of The Whole Breast

You might have a mastectomy if:

  • the area of the DCIS is large
  • there are several areas of DCIS
  • you have small breasts and too much of the breast is affected by DCIS to make breast conserving surgery possible

You may have surgery to your armpit called a sentinel lymph node biopsy if you have a mastectomy. This means having about 1 to 3 lymph nodes removed.

If you want to, you can choose to have a new breast made at the time of the mastectomy, or some time afterwards.

Hormone therapy is recommended for 5 years if you have breast conserving surgery for DCIS and:

  • your cancer calls have oestrogen receptors
  • you do not have radiotherapy

Research shows that taking hormone therapy after breast conserving surgery for DCIS reduces the risk of it coming back .

Trials show that hormone therapy can reduce the number of further invasive breast cancers or DCIS. But in these trials, the people taking a hormone therapy tablet called tamoxifen did not live any longer than those who didn’t take it.

Whats The Most Effective Treatment For Dcis

Surgery is typically the first treatment for DCIS, and it is very effective. There are two types of surgery used for DCIS. The less-invasive option is a lumpectomy, in which a surgeon removes the area of DCIS as well as a little bit of the normal tissue around it, also referred to as a margin. The other option is a mastectomy, which involves removing the entire breast.

Most people with DCIS undergo a lumpectomy, possibly followed by additional treatments. In some cases, a mastectomy is recommended, especially if the DCIS covers a large area or appears in multiple spots throughout the breast. With either of these surgeries, the survival rate is excellent. Our job is to figure out which type of surgery is best for each patient.

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Coping With A Diagnosis Of Dcis

Being told you have DCIS can be a difficult and worrying time. Everyone reacts differently to their diagnosis and have their own way of coping.

Although DCIS is an early form of breast cancer with a very good prognosis, people understandably may feel very anxious and frightened by the diagnosis. People can often struggle to come to terms with being offered treatments such as a mastectomy, at the same time as being told their DCIS may never do them any harm.

Some people are reluctant to say theyre anxious about a diagnosis of DCIS because they worry others will see it as less important than other types of breast cancer. Because of this they might feel less able to ask for support. But there are people who can support you so dont be afraid to ask for help if you need it. By letting other people know how you feel, particularly your family and friends, they can be more supportive.

Some people find it helpful to discuss their feelings and concerns with their breast care nurse or specialist. If youd like to talk through your feelings and concerns in more depth over a period of time, a counsellor or psychologist may be more appropriate. Your breast care nurse, specialist or GP can arrange this.

Find out more about coping emotionally with breast cancer.

If you want to talk you can also call our Helpline on 0808 800 6000.

Dcis And Invasive Breast Cancer

Qiao

If DCIS is not treated, over time it may spread into the breast tissue surrounding the ducts. It then becomes an invasive breast cancer.

Not every untreated DCIS will develop into an invasive breast cancer. But breast specialists usually advise treating DCIS. This is because it is not possible to tell for certain which individual cases of DCIS will become an invasive cancer.

Having DCIS means you have a slightly higher risk of getting cancer elsewhere in the same breast or in your other breast.

See also

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Risk Of Developing Invasive Breast Cancer After Dcis

After treatment for DCIS, theres a small risk of:

  • DCIS recurrence
  • Invasive breast cancer

These risks are higher with lumpectomy plus radiation therapy than with mastectomy . However, overall survival is the same after either treatment .

Higher grade DCIS appears more likely than lower grade DCIS to progress to invasive cancer after treatment .

With close follow-up, invasive breast cancer is usually caught early and can be treated effectively.

Learn more about tumor grade.

If youve been diagnosed with DCIS, Susan G. Komen® has Questions to Ask Your Doctor resources that may be helpful. For example, we have a Questions to Ask Your Doctor About Breast Cancer Surgery resource and a Questions to Ask Your Doctor About Radiation Therapy and Side Effects resource.

You can download and print these resources and take them with you to your next doctor appointment. Theres plenty of space to write down the answers to these questions, which you can refer to later.

There are other Questions to Ask Your Doctor resources on many different breast cancer topics you may wish to download. They are a nice tool for people recently diagnosed with breast cancer, who may be too overwhelmed to know where to begin to gather information.

Stage Zero Breast Cancer: Whats The Optimal Treatment For Dcis

Before the advent of routine mammography, DCIS was rarely detected. But today, DCIS accounts for 20% of breast cancer diagnoses and would be the fifth most common cancer in women if classified independently.

Often called stage zero breast cancer, DCIS growths are confined to the inside of the breasts milk ducts, and many never develop into invasive cancers. Several treatment options are available, and opinions about the optimal treatment for DCIS vary widely among doctors.

A new study from researchers at Columbia University Vagelos College of Physicians and Surgeons may help women and their physicians narrow down the treatment choices.

DCIS is considered a pre-invasive cancer, but the current standard of care is to treat it like an early-stage invasive breast cancer, says Apar Gupta, MD, assistant professor of radiation oncology at Columbia University Vagelos College of Physicians and Surgeons and lead author of the study.

However, not all treatments for invasive breast cancer may be optimal for DCIS, Gupta says. His study suggests that in most cases of DCIS, the side effects of hormone therapy may outweigh its benefits.

The CUIMC Newsroom spoke with Gupta to learn how the studys findings can help providers and their patients navigate treatment for DCIS. Below are excerpts from the conversation:

Why is DCIS treatment controversial?

How does your study help women make a decision about treatment after lumpectomy?

Is there a role for hormone therapy?

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Other Treatment And Prognosis

Endocrine therapy is part of the recommended treatment for ductal carcinoma in situ. Research has shown that, with some variants of DCIS, endocrine therapy significantly reduces breast cancer reoccurrence. Some therapies have significant side effects, including stroke, endometrial cancer, and pulmonary embolism. Patients must ensure they discuss the risks and benefits with their doctors. If caught early, the prognosis for DCIS is excellent. With successful treatment, women can have a normal life expectancy. If DCIS is not caught early or is aggressive, it can transform into invasive breast cancer, which has a much higher mortality rate.

Treatment Of Ductal Carcinoma In Situ

Ductal Carcinoma In Situ

Ductal carcinoma in situ means the cells that line the milk ducts of the breast have become cancer, but they have not spread into surrounding breast tissue.

DCIS is considered non-invasive or pre-invasive breast cancer. DCIS cant spread outside the breast, but it is often treated because if left alone, some DCIS cells can continue to undergo abnormal changes that cause it to become invasive breast cancer .

In most cases, a woman with DCIS can choose between breast-conserving surgery and simple mastectomy. But sometimes, if DCIS is throughout the breast, a mastectomy might be a better option. There are clinical studies being done to see if observation instead of surgery might be an option for some women.

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How Is Dcis Detected And Diagnosed

Most DCIS is detected from a mammogram that shows abnormal calcifications in the breast. The doctor may need to conduct additional imaging tests, such as ultrasound or MRI. These are used to determine the full extent of the disease.

DCIS is diagnosed by a needle biopsy. Pathologists examine the abnormal cells to determine the grade of the DCIS and the hormone-receptor status. DCIS is classified as low, intermediate, or high grade, depending on how abnormal the cells look under a microscope. High-grade DCIS cells are the most abnormal and grow the fastest.

Hormone-receptor status refers to whether the cancer cells have receptors for estrogen, progesterone, or both. The presence of these receptors on the DCIS suggests that these hormones fuel the growth of the cells, which affects how well the DCIS responds to certain hormone-blocking drugs.

How Is Ductal Carcinoma In Situ Diagnosed

About 80% of cases are found by mammograms. On the mammogram, it appears as a shadowy area.

If your mammogram suggests that you may have DCIS, your doctor should order a biopsy to analyze the cells and confirm the diagnosis. Biopsies for DCIS are typically done using needles to remove tissue samples from the breast.

If you have DCIS, your doctor may do more tests to gather information about your cancer. These tests may include an ultrasound or MRI. Based on the results of various tests, your doctor will be able to tell the size of your tumor and how much of your breast is affected by the cancer.

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Lessening The Wait Time Can Reduce Stress

Waiting for results can be stressful, and advanced breast centers keep that in mind and try to minimize the time between testing and results.

At Johns Hopkins, we are sensitive to the anxiety a possible diagnosis of DCIS creates for our patients, Sun says. If the radiologist who read your mammogram suspects you have DCIS, he or she will arrange for you to have a stereotactic biopsy as soon as possible. Biopsy results are usually returned in about a week.

What Are The Symptoms Of Dcis

Ductal carcinoma in situ of the breast

DCIS usually has no symptoms. Most cases of DCIS are found during routine breast screening or if a mammogram is done for some other reason.

Occasionally DCIS is found when someone has a breast change such as a lump or discharge from the nipple. However, if someone with DCIS has a breast change its more likely they will also have an invasive breast cancer.

Some people with DCIS also have a type of rash involving the nipple known as Pagets disease of the nipple, although this is rare.

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Ductal Carcinoma In Situ: Stage 0 Breast Cancer

Ductal carcinoma in situ or intraductal carcinoma is sometimes known as stage 0 breast cancer. It is non-invasive, only affecting the cells that line the milk ducts, though it can spread if undetected or untreated. Diagnosis of DCIS has been on the rise due to the widespread use of mammography. Previously, DCIS made up about 5% of new breast cancer diagnoses. Today, about 20% of all breast cancer diagnosed in the United States is DCIS.

The Good News About Dcis

DCIS is sometimes classified as Stage 0 of breast cancer, the earliest stage of the disease. The question for women with this diagnosis is not “Will I live?” but “How much treatment will I need?” One of the biggest risks today is overtreatment. That, too, is changing, as researchers get better at distinguishing the types of tumors that can be subdued without extensive surgery or radiation. DCIS is one cancer that can truly be considered curable.

If you have DCIS, you might consider entering a clinical trial. You would get the best available care and might benefit from a new type of therapy or approach. At the very least, you would be contributing to much-needed knowledge about this condition. Check the National Cancer Institute’s registry of clinical trials at www.cancer.gov/clinicaltrials for a site near you.

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