Nuclear Grade Of Dcis Matters Too
Healthcare professionals will also consider the nuclear grade of DCIS, which is determined by looking closely at the nuclei of the cells removed during a biopsy. According to the ACS, there are three grades of DCIS: low, or grade 1 moderate, or grade 2 and high, or grade 3 .
High-grade DCIS is sometimes described as “comedo” or “comedo necrosis,” which means that dead cells have built up inside the fast-growing tumor. The higher the grade, the greater chance a person has of also having invasive breast cancer, either with the DCIS or at some point in the future.
What Every Physician Needs To Know:
Stage 0 breast cancer includes non-invasive breast cancer ductal carcinoma in situ , and lobular carcinoma in situ . Physicians should understand the following:
Incidence and clinical significance of DCIS and LCIS.
Pathologic findings of both DCIS and LCIS.
Differences in management of DCIS versus LCIS.
Incidence of in situ cancer
In 2012, 63,300 new cases of in situ cancer will be diagnosed in the United States compared to the 229,060 cases of invasive cancer. Often when breast cancer statistics are quoted, these in situ cases are not included, despite the fact that they represent an increasing proportion of breast cancer cases. In the early 1980s, in situ cancer accounted for 3-4% of all breast cancers compared to 22% currently.
Most in situ cancers are DCIS. DCIS accounted for 83% of in situ cancers diagnosed between 2004-2008. The incidence of DCIS has been increasing over time. The DCIS rate increased about 2% per year between 1973 and 1982. From 1982 to 1988, the DCIS rate increased dramatically, about 28% per year, at the same time mammography screening was increasing. After this, the DCIS rate increased more slowly at about 6% per year.
Since 1999, incidence rates of in situ breast cancer stabilized among women over 50, but continue to increase in younger women. The stabilization in incidence among women over 50 years of age may correlate with trends in mammography screening, which peaked in 2000.
What Is Dcis Breast Cancer
In This Article
DCIS breast cancer is a non-invasive breast cancer. Ductal carcinoma refers to cancerous growth initiates from milk duct and surrounded breast tissue that covers the internal organs. The term in situ refers to in its original place.
The growth of Ductal carcinoma in situ is restricted only in the milk duct and does not spread to internal organs. therefore the risk of a fatal outcome is negligible. But there is always a risk of progression of an invasive breast cancer later stage of life1.
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A Mammogram Can Reveal Dcis
A routine mammogram is usually the way DCIS is discovered and diagnosed. When DCIS is present, it will typically show up as a cluster of calcifications of varying shapes and sizes within a breast duct .
These calcifications are the result of tiny specks of calcium that form in the cells of old cancer cells that have died off and piled up. If calcifications are seen on a mammogram, a biopsy will then be performed to confirm the diagnosis of DCIS.
While the incidence of DCIS has risen sharply since the 1970s, this increase has been attributed primarily to the increased use of screening mammograms.
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Stage 0 Breast Cancer Treatment
Because its not possible to predict whether a stage 0 breast cancer will invade the breast tissue around it, most people undergo treatment, which may include surgery, radiation therapy and hormone therapies such as tamoxifen.
Surgical options for stage 0 breast cancer include breast-conserving surgery to remove the area of the breast with abnormal cells, or a mastectomy to remove the entire breast. In treating Pagets disease, the nipple and areola are removed. Many factors are considered when determining the type of surgery that will be recommended, including the size and extent of the DCIS growth, and whether the patient has any family history of breast cancer or BRCA gene mutations. During a mastectomy, the doctor may also remove one or more lymph nodes to be analyzed in a lab for signs of cancer.
Radiation therapy treatments often follow breast-conserving surgery to destroy remaining cancer cells, though its not usually required after a mastectomy. Stage 0 breast cancer treatment doesnt typically include chemotherapy.
If the abnormal cells are hormone receptor-positive, the next step may involve long-term treatment with a hormone-based drug. This medication, which is typically taken for five years, is designed to reduce the chances of cancer recurring or spreading.
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Meeting With The Breast Surgeon
A few days after I got my biopsy results, my husband and I met with the surgeon, Dr. Suzanne Hoekstra. She explained that the biopsy had removed some, but not all of the calcifications. What was left appeared quite small, which relieved me greatly for a few seconds. Because on the flip side, what they could see on the mammogram taken after the biopsy might only be the tip of the iceberg.
We agreed that a lumpectomy was the best next step and wed wait for the pathology results before deciding about any further treatment. It was really hard not to flip out then and there.
One the day of my surgery, I was essentially on autopilot and more afraid of the wire localization procedure I had to have than going to the operating room. Because there was no lump to feel, just microcalcifications, Dr. Hoekstra needed something to lead the way to the abnormal cells.
My other comforts were Barry and my sister Becky, who watched over and entertained me throughout the long morning. Humor is right up there with hugging.
Going into surgery and later the recovery room are mostly a blur. Before I knew it, I was on my way home, my chest completely enveloped by an ace bandage. More comfort was waiting for me when I arrived my sister Debi with a steaming bowl of homemade chicken soup loaded with fresh vegetables from her garden.
Difficult Decisions For Patients
Toro de Stefani is one of 60,000 U.S. women diagnosed with DCIS each year. Each must decide on a treatment option.
Current guidelines that recommend lumpectomy and radiation are causing concerns that the condition may be overtreated, since most cases never become invasive.
This gives medical professionals enormous uncertainty about how to advise women on an individual basis, says Thompson, professor of Surgery at MD Anderson. And therefore, historically the treatments have ranged from active surveillance on one end of the pectrum all the way to mastectomies on the other.
Thompson says DCIS diagnoses have increased as breast imaging has become more accurate and frequent. The National Institutes of Health estimates that by 2020, more than 1 million women in the U.S. will be living with a DCIS diagnosis, compared to 500,000 in 2005.
Before mammograms became common, many women had the condition for years without being aware of it, because it grows so slowly and causes no symptoms.
Perhaps, surprisingly, given that breast screening has been around for three or four decades, were only now really coming to grips with the fact that we often diagnose some conditions like DCIS as breast cancer even though theyre not conventional, invasive breast cancers, Thompson says.
Hes participating in three DCIS research studies that he hopes will make treatment decisions easier.
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Size Grade And Hormone Receptor Status Matter
When assessing the risk of recurrence after surgical removal of DCIS, the size of the lesion is very important. If the total size of the DCIS is determined to be greater than 20 to 25 millimeters, additional treatmentincluding radiation and hormone therapywill generally be recommended.
Likewise, your health care provider will consider the hormone status of your lesion. If your tumors cells are found on biopsy to have hormone receptors for estrogen or progesterone, hormone therapy may be recommended.
In addition, your health care provider will also consider the nuclear grade of your DCIS, which is determined using a biopsy as well. To establish the grade, the nuclei of the cells are examined to see how closely they resemble the nuclei of normal breast cells.
There are currently three grades used to classify DCIS:
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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After Dcis The Risk Of Another Cancer Is Higher
Stage 0 breast cancer still comes with risks. “When you have DCIS, it means your risk of developing another DCIS or an invasive breast cancer is higher than the general population,” Dr. Meyers said.
In a May 2020 BMJ study, the researchers found that in comparison to women in the general population, women who were diagnosed with DCIS were more at long term risk for invasive breast cancer and death due to breast cancer within 20 years of finding the diagnosis detected during a breast cancer screening.
“Whatever caused the cells to mutate will generally occur in more than one ductand sometimes, those mutated cells can break through a duct and become invasive breast cancer,” Dr. Meyers added. “We don’t know why some DCIS have the ability to do this while others don’t, so right now we want to treat all of them with at least surgery, and maybe more.”
Surgery And Radiation Therapy
Currently, breast-conserving treatment for DCIS is frequently recommended. A mastectomy is advised if the DCIS is too extensive to allow breast conservation.43 According to Thompson et al.,21 the recurrence rates with 5 years median follow-up are 0.8% after mastectomy, 4.1% after breast-conserving surgery followed by radiotherapy and 7.2% after breast-conserving surgery alone. According to Elshof et al.,22 invasive recurrence rates are 1.9, 8.8 and 15.4%, respectively, after 10 years median follow-up. The 15-year cumulative incidence in the National Surgical Adjuvant Breast and Bowel Project 17 trial of patients with clear margins is 19.4% after breast-conserving surgery alone and 8.9% after breast-conserving surgery followed by radiotherapy.44 Four randomised clinical trials have been performed to investigate the role of radiotherapy in breast-conserving treatment for DCIS after complete local excision of the lesion. In a meta-analysis, these trials show a 50% reduction in the risk of local recurrences after radiotherapy.45 Radiotherapy was reported to be effective in reducing the risk of local recurrence in all analysed subgroups according to age, clinical presentation, grade and type of DCIS.
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What Should You Tell The Patient And The Family About Prognosis
Ductal carcinoma in situ
DCIS is curable and the prognosis is excellent. Because it is non-invasive, the tumor does not have the capacity to spread distantly. In rare cases, particularly with large DCIS lesions greater than 4cm, metastatic disease to lymph nodes or distant sites may occur. This is likely due to unidentified areas of micro-invasion that are not seen during pathologic sampling.
The risk of recurrence of in situ or invasive cancer in the ipsilateral breast is related to the extent of surgical treatment:
less than 1% with total mastectomy
7-11% at 10 years with breast conserving surgery and radiation.
For patients with Van Nuys scores of 4-6, recurrence risk is 6% or less. The most serious adverse consequence of recurrence is that the lesion may be invasive 50% of the time when it recurs, which then exposes the patient to the risk of distant disease.
Lobular carcinoma in situ
LCIS is a risk factor for the development of subsequent breast cancer in either breast. The risk of subsequent invasive breast cancer ranges from 7% to 17% at 10-15 years after LCIS diagnosis. Slightly more than half of these cases occur in the contralateral breast. This risk can be reduced by endocrine systemic therapy, with tamoxifen for pre-menopausal women, and tamoxifen, raloxifene or exemestane for post-menopausal women.
Current Diagnosis And Imaging
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,15 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.16,17 This suggests that DCIS might be left behind following breast-conserving treatment in a proportion of cases.
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Personalized Treatment Is Key For Stage 0 Breast Cancer
An early form of breast cancer called ductal carcinoma in situ has stirred controversy in the medical community nationwide.
DCIS, also known as Stage 0 breast cancer, is abnormal cells that are confined to the milk ducts of the breast. The debate is whether all cases of DCIS should be treated immediately with surgery and additional therapy, or if patients should be monitored instead and treated only if the cancer spreads.
A New York Times article from August 2015 has fanned the flames of this controversy. The article features DCIS patients reacting with a mix of gratitude and outrage about their cancer treatment. Some felt their treatment was unnecessary or too severe others were glad they received proactive care.
Both sides of the debate have a viable argument: of course we dont want to perform surgeries that arent needed or expose women to radiation or hormonal therapy unnecessarily, and DCIS in some women will never spread beyond the milk ducts.
But this is our concern: DCIS has a significant chance of turning into invasive cancer. There is currently no way to know which cases will become invasive. Until we have a way to determine that, we cant just sit back and watch women develop breast cancer. We favor a personalized, case-by-case approach to treating Stage 0 breast cancer over watching and waiting.
Ive asked four of our breast cancer experts to explain our position and clear up some misconceptions about the treatment of DCIS.
I Was Diagnosed With Dcis Stage 0 Breast Cancer
Im religious about getting my annual mammogram. Thats because I have a history of fibrocystic disease and in my 20s had a fibroadenoma removed from my right breast. Every year, I worry that something not so benign will show up and every year I sigh with relief when I get a letter saying everything is normal. Not this year. Instead, I got a phone call from the Mammography Department at Mercy Hospital. The radiologist wanted me to come back for additional views. My heart sank.
My husband Barry took time off from work so he could go with me. If there was any bad news to be delivered, I didnt want to hear it alone. Renee, the kind and wonderful mammography tech who had done my screening mammogram told me she was going to take some magnification views so they could look at an area in my right breast more closely.
After she was done, Barry and I were ushered into the viewing room to talk with the radiologist, who pointed out a sprinkling of tiny white dots near the middle of my mammogram and explained that they were microcalcifications. Some of them looked normal, but others could go either way. Either way? I tried to remain calm and stared at the image intently. You can look too. The picture at the beginning of this post is a copy of the magnified view.
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Stage 0 Breast Cancer: When Should You Wait And See
In cancer, as in other areas of medicine, early detection can save lives. But the screening tests used to find early tumors also detect disease that would never cause problems disease youll die with but not from. Managing those cases means giving potentially harmful treatment to patients who wont benefit.
DCIS, or ductal carcinoma in situ, is the poster child of this dilemma. Before routine mammograms, only about 1 percent of U.S. breast cancer cases were DCIS. Now nearly 65,000 women a year about 22 percent of those with breast cancer are diagnosed with DCIS.
DCIS, also known as Stage 0 breast cancer, is not life-threatening, and not all cases will progress to invasive cancer. But because there is no reliable way to determine which ones will, nearly all DCIS is surgically removed with a lumpectomy or mastectomy . Most DCIS patients also are offered radiation and drugs.
While many experts believe this simply is the price that must be paid to save lives, an increasingly vocal minority are working to find ways to reduce overdiagnosis and overtreatment, especially of DCIS.
A small minority women under 35, African-Americans and those with especially aggressive molecular features had a significantly higher chance of dying of breast cancer. Ironically, they did so despite the aggressive treatment they received.
A few U.S. centers already are allowing some low-risk DCIS patients to skip surgery after being informed of the risks and benefits.