Waiting And Watching With Stage 0 Breast Cancer Put To Nationwide Test
Barbara Nickles and Ligia Toro de Stefani are both women in their early 60s who were diagnosed with abnormal cells in a breast, or Stage 0 breast cancer, as its sometimes labeled. Nickles decided to have a double mastectomy. Toro de Stefani opted for active surveillance and a twice-yearly battery of tests.
I wish I had breasts, but I am also happy they are gone so that I dont have to worry so much about breast cancer, says Nickles, whose grandmother had the disease.
Quality of life is the most important thing to me, says Toro de Stefani, an avid traveler and scuba diver.
The two illustrate the vexing questions facing the 60,000 women a year diagnosed in this country with ductal carcinoma in situ , a condition in which cancerous-looking cells are found in the breast duct. What exactly is it a pre-cancer, cancer or more a risk factor? How much treatment is too much? Too little? Which women can safely skip surgery? What about those who want more treatment than their doctors recommend?
But a growing group of oncologists, worried about overtreatment, is stepping up efforts to add another approach active surveillance to the anti-DCIS arsenal. Proponents are launching COMET, the nations first prospective, randomized clinical trial to test whether such close monitoring is safe and effective for many women.
If the answer is yes, backers say, it could spare thousands the pain, trauma and cost of intrusive therapies.
Treatment For Stage 1 Breast Cancer
Doctors can offer a variety of for stage 1 breast cancer, although surgery is the primary treatment.
Surgery
A lumpectomy or mastectomy are both viable surgical options for people with stage 1 breast cancer. A doctor will decide what surgery is most appropriate depending on the location of the primary tumor, how large it is, the size of the breast, family history, genetics, and the persons preference.
The doctor may also carry out a biopsy on one or more lymph nodes.
After removing the tissue, they will send it to a laboratory for further tests. The results will help inform decisions on the next stage of treatment.
Radiation therapy
Radiation therapy is a standard treatment for stage 1 breast cancer. However, the decision will depend on factors such the age of the person, the type of cancer, the size of the tumor, and whether there are cancer cells in the lymph nodes.
Hormone therapy
If the breast cancer is ER+ or PR+, hormone therapy may be effective. Hormone therapy works by preventing the growth of estrogen, which helps cancer grow, by blocking estrogen from attaching to tissue and fuelling cancer growth, or both.
Hormone therapy can reach cancer cells in the breast, as well as other areas of the body, and it can reduce the risk of cancer returning.
Chemotherapy
However, the
also has subcategories known as 2A and 2B.
Stage 2A breast cancer is invasive cancer:
What If My Report Mentions Sentinel Lymph Node
In a sentinel lymph node biopsy, the surgeon finds and removes the first lymph node to which a tumor drains. This lymph node, known as the sentinel node, is the one most likely to contain cancer cells if they have started to spread. This procedure may be done during surgery to remove a breast cancer. It is a way to check for the spread of cancer to underarm lymph nodes without removing as many of them.
The sentinel lymph node is then checked to see if it contains cancer cells. If there is no cancer in the sentinel node, it’s very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed.
If a sentinel lymph node does contain cancer, your report will say that cancer was present in the lymph node. It may also say how large the deposit of cancer cells is. In some cases, if cancer is found in a sentinel lymph node, you may then also need additional treatment such as surgery to remove more underarm lymph nodes or radiation therapy to the underarm region. You should discuss this with your doctor.
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Treatments For Breast Cancer
If you have breast cancer, your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for ductal carcinoma and lobular carcinoma, your healthcare team will consider:
- the stage
- if you have reached menopause
- the hormone receptor status of the cancer
- the HER2 status of the cancer
- the risk that the cancer will come back, or recur
- your overall health
Dcis Can Happen At Any Age
“DCIS can happen to anybody, anytime,” says Dr. Meyers, but it’s usually diagnosed in women over 40, the age at which many women begin getting mammograms. According to the American Cancer Society, DCIS rates increase with age, and peak around age 70 to 79.
Women diagnosed with DCIS under age 50 have a higher rate of recurrence or of an invasive cancer, and therefore more aggressive treatment is usually recommended, says Dr. White. Those over 50, on the other hand, can take comfort in knowing that a diagnosis does not raise their risk of early death.
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How Is Ductal Carcinoma In Situ Diagnosed
The sooner this type of cancer is found, the sooner it can be treated. The following tests or procedures are usually used to diagnose DCIS:
- Breast examination: A routine breast exam is usually part of a regular physical. It is the first step in detecting breast cancer. Although DCIS does not usually come with a noticeable lump, the doctor may be able to feel an abnormal growth in the breast, such as a small, hardened spot, during a physical examination. The doctor will also look for any skin changes, nipple changes or nipple discharge. Most times, though, the abnormal growth will show up on a mammogram.
- Mammogram: DCIS is usually found during a mammogram. As old cells die off and pile up within the milk duct, they leave tiny, hardened calcium spots which show up as a shadow or white spot on a mammogram.
- Biopsy: If a spot or a shadow is found on the mammogram, the doctor will recommend a biopsy.
- Core needle biopsy: With this procedure, the doctor inserts a large needle into the breast to get a big sample of the breast tissue that looked abnormal on the mammogram. The doctor will first numb the skin at the site of the biopsy and then make a small incision in the skin to help get the needle into the breast. Because the skin has been cut, there will be a tiny scar which will fade over time.
Biopsies are only used to diagnose that there is cancer within the breast. If cancer is found, surgery will be recommended to remove the abnormal cells.
What Is Stage 4 Breast Cancer
Also known as metastatic breast cancer, the cancer in this stage has spread beyond the breast, underarm and internal mammary lymph nodes to other parts of the body near to or distant from the breast. The cancer has spread elsewhere in the body. The affected areas may include the bones, brain, lungs or liver and more than one part of the body may be involved.
At stage 4, TNM designations help describe the extent of the disease. Higher numbers indicate more extensive disease. Most commonly, stage 4 breast cancer is described as:,
- T: T1, T2, T3 or T4 depends on the size and/or extent of the primary tumor.
- N1: Cancer has spread to the lymph nodes.
- M1: The disease has spread to other sites in the body.
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What If A Carcinoma Is Infiltrating Or Invasive
These words are used to mean that the cancer is not a pre-cancer , but is a true cancer.
The normal breast is made of tiny tubes that end in a group of sacs . Cancer starts in the cells lining the ducts or lobules, when a normal cell becomes a carcinoma cell. As long as the carcinoma cells are still confined to the breast ducts or lobules, without breaking out and growing into surrounding tissue, it is considered in-situ carcinoma .
Once the carcinoma cells have grown and broken out of the ducts or lobules, it is called invasive or infiltrating carcinoma. In an invasive carcinoma, the tumor cells can spread to other parts of your body.
Who Is Most At Risk For Dcis
We consider anyone who has previously had DCIS or other types of breast cancer, older women, and women with certain previous breast histories such as atypical hyperplasia, a precancerous condition that affects cells in the breast, to be most at risk for Stage 0 cancer, explains Helen Cappuccino, MD, FACS, Assistant Professor of Oncology. Also at risk are women with radial scars, the benign breast lesions that may be detected as a kind of star-shaped feature that can be detected by mammograms, and intraductal papillomas, benign tumors that grow within the milk ducts of the breast. We also look for a family history of breast cancer and prior breast biopsies, as well as women who have a child at age 30 or older, women who have never had a baby, and women who have had fewer full-term pregnancies.
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It’s Usually Found On A Mammogram
For most women, DCIS is picked up on routine mammograms. “Typically, the mammogram finds a calcificationa small cluster of cells with abnormal shapes and sizesand then it is diagnosed after a biopsy,” says Dr. Meyers.
Occasionally, though, DCIS grows large enough that it forms a noticeable lump. Some people with DCIS may also have unusual nipple discharge, or a condition called Paget’s disease that causes skin around the nipple to become thick and dry.
Is Surgery The Right Decision For Women With Dcis
Women with ductal carcinoma in situ face the difficult decision of howto treat the condition. Researchers at MD Anderson are studying ways tomake this tough choice easier.
Ligia Toro de Stefani, Ph.D., had just retired from a busy academic medical research career when a mammogram revealed a suspicious mass in her right breast. Her doctors in Brownsville, Texas, referred her to MD Anderson, where she was diagnosed with ductal carcinoma in situ, or DCIS, often called stage 0 breast cancer the very earliest stage.
Toro and her husband, Enrico Stefani, M.D., Ph.D., researched everything they could about the condition before meeting with MD Anderson surgeon Alastair Thompson, M.D., to discuss treatment options.
Investigating came naturally to the scientific couple. Toro is an emeritus professor of anesthesiology and molecular and medical pharmacology at the University of California, Los Angeles. Her husband is a former director of UCLAs anesthesiology division of molecular medicine.
We started reading a lot of papers, not just Googling the disease, but doing a serious literature search, Toro de Stefani says.
DCIS is a cluster of cancer cells inside a milk duct. The cells are held in place by the ducts wall, but they have the ability to break through the wall. Thats when they become invasive.
That wont happen to everyone, Toro de Stefani says, but theres no predicting when cells will break through the duct and spread, and when they wont.
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It Affects Cells In The Milk Ducts
Each breast has about 15 to 20 milk ducts, which, in women, act as a canal system to transport milk to nursing babies. DCIS occurs when cells in one of those milk ducts have mutated and multiplied to look like cancer cells.
About one in five newly diagnosed breast cancers is DCIS. Because those cells usually stay confined to the duct and do not spread to surrounding tissue, DCIS is also known as stage 0 breast cancer or sometimes pre-cancer.
“I make sure to tell patients that, even though DCIS has the word ‘carcinoma’ in it, it’s not actually cancer,” Marleen Meyers, MD, medical oncologist and director of the Perlmutter Cancer Center Survivorship Program at NYU Langone Health, tells Health.
“In order for something to be cancer, it has to be able to spread and grow unabated,” says Dr. Meyers. “But in the duct, it’s like being in a small tube or straw, and it usually can’t spread anywhere.”
Because of that, people shouldn’t be as frightened of DCIS as they are of invasive breast cancer, she adds. “It still comes with risks, so it should still be respected,” she says, “but really, we want to decriminalize DCIS and let patients know they shouldn’t be so scared.”
What Should The Initial Definitive Therapy For The Cancer Be
Ductal carcinoma in situ
Surgical procedures
DCIS may be treated with breast conserving surgery or mastectomy with or without immediate reconstruction. The decision for type of surgery is based on the extent of the lesion relative to breast size, whether adequate clear margins can be achieved with partial mastectomy, ability to receive radiation therapy, and patient preference.
With mastectomy, skin sparing techniques can be utilized to facilitate reconstruction with excellent cosmesis. However, it is important that anterior margins of the mastectomy are clear of calcifications and tumor. for thin patients with large areas of microcalcifications, skin sparing may result in a positive margin on the mastectomy specimen if skin over these calcifications is not taken in the resection.
Radiation Therapy
For DCIS treated with breast conserving surgery, radiation is indicated in most circumstances to reduce risk of local recurrence. Clinical trials have demonstrated a 50-60% reduction in local recurrence. However, for certain tumors, that absolute benefit is low.
The following factors should be considered in determining the role of radiation therapy:
-
size of the DCIS
-
tumor grade and extent of comedonecrosis
-
width of margins
Circumstances in which sentinel node biopsy should be considered even with breast conserving surgery include:
Endocrine therapy
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What Is Vascular Lymphovascular Or Angiolymphatic Invasion What If My Report Mentions D2
If cancer cells are seen in small blood vessels or lymph vessels under the microscope, it is called vascular, angiolymphatic, or lymphovascular invasion. When cancer is growing in these vessels, there is an increased risk that it has spread outside the breast. If your report does not mention this type of invasion, it means it is not there. Even if it is there, it does not always mean that your cancer has spread. How this finding affects your treatment is best discussed with your doctor.
D2-40 and CD34 are special tests that the pathologist may use to help identify these types of vascular invasion. These tests are not needed in every case.
Managing Your Mental Health
When you learn you have stage 0 breast cancer, you have some big decisions to make. Its important to talk with your doctor about your diagnosis in depth. Ask for clarification if you dont quite understand the diagnosis or your treatment options. You can also take the time to get a second opinion.
Theres a lot to think about. If youre feeling anxious, stressed, or experiencing difficulty coping with the diagnosis and treatment, talk with your doctor. They can refer you to support services in your area.
Here are some other things to consider:
- Reach out to friends and family for support.
Stage 0 breast cancer can be very slow growing and may never progress to invasive cancer. It can be successfully treated.
According to the American Cancer Society, women whove had DCIS are approximately to develop invasive breast cancer than women whove never had DCIS.
In 2015, an observational study looked at more than 100,000 women who had been diagnosed with stage 0 breast cancer. The researchers estimated the 10-year breast cancer-specific negative outlook at 1.1 percent and the 20-year negative outlook at 3.3 percent.
For all these reasons, your doctor may recommend screening more frequently than if you never had DCIS.
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Treatment For Stage 0 Breast Cancer
Not everyone with stage 0 breast cancer needs treatment. If tests suggest that treatment is a good idea, include:
Surgery
A lumpectomy involves removing cancerous cells from the breast. It is an option when the cells remain in one area. This is a relatively short and simple procedure, and a person should be able to go home after the surgery on the same day.
If cancerous cells appear throughout the breast, the doctor may recommend a mastectomy, which involves removing the entire breast. Plastic surgeons can rebuild the breast at the same time or a later date.
Hormone therapy
The hormone estrogen, found naturally in the body, can impact some types of breast cancer. If a person has estrogen receptor-positive or progesterone receptor-positive breast cancer, a doctor may suggest hormone treatment in addition to surgery.
, the cancerous cells have invaded the surrounding breast tissue. Stage 1 breast cancer has two subcategories 1A and 1B.
How Do Doctors Determine Different Stages Of Breast Cancer
Cancer doctors or oncologists determine the stage of a breast cancer based on several factors including the following:
Once a patient has been diagnosed with breast cancer, her doctor may request several tests or screenings to determine if cancer cells have spread into other parts of the breast and/or other parts of the body. These may include blood tests, X-rays, mammograms, ultrasounds, magnetic resonance imaging , computerized tomography scans and/or positron emission tomography scans.
Cancer doctors use a staging system called the TNM, , when trying to find out the location and size of the primary tumor and the size and location of lymph nodes where cancer cells are present. It uses numbers from 0-4 to assign a value to the cancer.
Cancer doctors follow a grading system that helps determine how fast a primary tumor can grow and spread within the breast or in other parts of the body.
Cancer doctors also use biomarker testing to determine whether breast cancer cells have specific receptors. The biomarker status is combined with the TNM system and the grading system to diagnose the breast cancer stage.
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