A Test Can Help You Determine Your Risk
Sometimes doctors will recommend a genomic test, called the Oncotype DX test, to help determine a DCIS patient’s risk of getting another cancer in the future. A sample from the DCIS biopsy or lumpectomy is sent to a lab, where pathologists study the activity of 12 different cancer-related genes.
“You get back what’s called a DCIS score, from zero to 100, that tells you the likelihood of a DCIS recurrence or of an invasive cancer in the next 10 years,” says Dr. White. “I want to help patients keep their breasts, so if they have a high risk of recurrence we want to recommend radiation so they can prevent that invasive cancer in the future.”
Memorial Sloan Kettering Cancer Center has also developed a free online assessment tool to helps DCIS patients estimate their risk of another cancer, based on age, family history, and details about their specific tumor. “We want to help patients understand their individual risks, so they can make an informed decision about how much treatment they’re going to have,” says Dr. White.
Diagnosis Of Invasive Ductal Carcinoma
Diagnosing invasive breast cancer usually involves many steps. The first is a physical exam and medical history. Doctors can often feel the lump in your breast. Theyll check your armpits and surrounding areas for changes, too.
A mammogram is the next step. This is an x-ray of your breast tissue. It allows doctors to see any tumors or lumps of abnormal tissue. This is the same screening done in healthy women to detect breast cancer early. Ultrasounds and MRIs provide additional images if needed. The biopsy comes last. Doctors remove the lump during surgery. Then, they test the tumor to diagnose cancer.
Tumor Margins And Prognostic Factors: Latest Recommendations
Over the years, positive margins following surgery for DCIS have been associated with local recurrence of breast cancer. However, some cases of DCIS will not recur or progress to invasive ductal cancer.
This poses a dilemma for the surgeon with small, positive margins being associated with recurrence on one hand. However, on the other hand, DCIS patients may also be having unnecessary large resections with poor cosmetic outcomes. The optimal or best margin width for DCIS has caused a lot of controversy over the years.
One large 2016 meta-analysis examined 7,883 women with DCIS treated with breast-conserving therapy and radiation to the whole breast. The above study found that negative margins half the incidence of recurrence of cancer in the same breast.
Furthermore, the research suggests an optimal margin of 2mm.
Interestingly, it was also found that wider margins do not significantly decrease the recurrence of breast cancer. Finally, the study concluded that negative margins of less than 2mm are not an indication for mastectomy alone.
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What Are The Symptoms Of Dcis
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.
Dna And Rna Isolation
Total RNA and DNA was isolated using the QIAcube system with the AllPrep DNA/RNA Universal Kit with 30mg tissue as input. The tissue was manually minced with a scalpel on ice followed by homogenization using TissueLyzer LT and Qiashredder . RNA and DNA extraction was performed according to the protocol provided by the supplier. Nucleic acid concentrations were measured on a NanoDrop ND-1000 spectrophotometer and RNA integrity was analyzed using Agilent 2100 Bioanalyzer .
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What Is The Optimal Treatment For A Local Recurrence
Although local recurrences are uncommon after initial treatment for DCIS, they can be psychologically devastating for the patient, particularly if it is an invasive recurrence. The treatment of a recurrence depends on the initial treatment of DCIS, whether the recurrence is DCIS or invasive, and whether the patient has received radiotherapy to the breast. After diagnosis is confirmed histologically, a screen for distant metastatic disease is usually performed.
For a patient treated by BCS alone, management options may include re-excision followed by radiation or mastectomy with or without breast reconstruction. If BCS and XRT were used initially, then mastectomy is usually the only option available. If mastectomy alone was the original treatment modality, then surgical removal of a chest wall recurrence may be possible, followed by chest wall RT, but this situation is extremely rare. Treatment of the axilla and consideration of systemic therapy is also required. Most recurrences can be salvaged by mastectomy. One study showed that following mastectomy, subsequent freedom from chest wall recurrence was high .
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.
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How Likely Is Dcis To Come Back
The chance of the DCIS coming back depends on various factors. But after mastectomy DCIS almost never comes back. In women who have just the area of DCIS removed the chance of it coming back is a bit higher. But it depends on the grade and type of DCIS.
Your doctor can give you more information about the chance of the DCIS coming back in your case.
Dcis Has The Same Risk Factors As Invasive Breast Cancers
“The same things that increase a woman’s risk for DCIS are really the same things that increase her risk of invasive breast cancer,” says Dr. Meyers. For example, having a strong family history can be a factorespecially if a woman tests positive for a high-risk BRCA gene mutation.
Women who have a longer period of estrogen stimulation, meaning they started menstruation early and/or entered menopause late, also have an increased risk of DCIS as well as invasive cancer. That also goes for women who don’t have children, or who have their first pregnancy after age 30.
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Are You Sure Your Patient Has Stage 0 Breast Cancer What Should You Expect To Find
Ductal carcinoma in situ
DCIS is usually asymptomatic and identified first with an abnormal mammogram. In modern times, DCIS will rarely present as a palpable mass. A spontaneous nipple discharge which is bloody, pink tinged, clear or serous in nature may be a presenting symptom.
Lobular carcinoma in situ
LCIS is usually asymptomatic and will be found as an incidental finding on biopsy of the breast for other findings. LCIS is found in approximately 1% of all excisional breast biopsy specimens. About 80% of LCIS occurs in pre-menopausal women .
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Cancer Staging Before 2018
Before 2018, cancer staging included less information about the tumor than it does now.
Pre 2018 stagingincluded information about the physical characteristics of the tumor but didnt take into account any additional information about the biology of the cancer.
- T- Tumor Size
- M- Metastases (whether it has spread to other parts of the body
These three pieces of information are combined to determine a cancer stage between 0-IV.
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Are Any Additional Treatments Required
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.
For women who have a mastectomy for DCIS, there is usually no need for additional treatment, because the risk of the cancer coming back is very low.
The main argument for a mastectomy is that it is curative in nearly all patients, but may represent overtreatment for many women. In a large review, 1.6% of the 1565 patients treated with mastectomy developed a local recurrence, of which 72% were invasive. Survival was excellent at 98100%. A meta-analysis elicited a similar local failure rate of 1.4% for studies involving mastectomy alone.
Future Directions In Dcis
DCIS research is directed mainly at improving treatment and, above all, at preventing progression to invasive disease. As researchers continue to study the pathology of DCIS, they are finding that certain tumor characteristics help predict the treatment most likely to reduce the chance of recurrence. For example, some forms of breast cancer require estrogen in order to grow tumors that do are termed estrogen receptorpositive . Tamoxifen belongs to a class of drugs called selective estrogen-receptor modulators , which act by blocking estrogen receptors. Tamoxifen is more likely to prevent a recurrence in women with ER-positive DCIS than in women with ER-negative disease.
The use of aromatase inhibitors, which block estrogen production in the peripheral tissues and breast tissue, is being investigated in a trial of postmenopausal women with ER-positive DCIS. For women whose DCIS is ER-negative but who have the HER-2/neu gene, researchers are exploring the use of trastuzumab and lapatinib , which block the tumor growth factors produced by that gene.
A new way to administer radiation that is showing some promise in clinical trials is accelerated partial breast irradiation, in which the tumor site alone is treated for five days with a lighter dose of radiation. In another approach, intraoperative radiation therapy, a one-time dose of radiation is delivered to the involved area of the breast after the tumor has been removed but before the incision is closed.
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What Is The Prognosis For Dcis
Women with DCIS have an excellent prognosis. At Johns Hopkins Medicine, our pathologists are scrupulous at identifying DCIS and strive to reduce the risk that any invasive cancer was missed. By treating DCIS at a comprehensive breast center, you ensure your health is in the best possible hands.
It is important to maintain a rigorous screening schedule to monitor for local recurrence in the original breast and to monitor the healthy breast. By definition, there is no risk of distant recurrence since the cancer is noninvasive. For women having lumpectomy with radiation, the risk of local recurrence ranges from 5-15 percent. For women having mastectomy, the risk of local recurrence is less than 2 percent. Women who take hormonal therapy after surgery further reduce their risk of recurrence by half.
Breast cancer may develop in the womans other breast, so careful monitoring is important. This happens only to about five percent of women diagnosed with breast cancer. If a cancer develops in the patients other breast, it is not referred to as recurrence, but is a new primary breast cancer. It can also be a different type of breast cancer than the original cancer.
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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.
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How Is Dcis Diagnosed
DCIS is usually diagnosed by a stereotactic core needle biopsy. This is a biopsy of the breastthat is guided by mammography.
Same Day Results
At the Johns Hopkins Breast Center, we are sensitive to the anxiety a possible diagnosis of breast cancer creates for our patients. If the radiologist who read your mammogram suspects you have DCIS, he or she will arrange for you to have a stereotactic biopsy. The biopsy can sometimes be done the same day, but is always done within a week. On the day of your breast biopsy, you will be given the probability that the biopsy is a breast cancer. Firm confirmation will follow within 24 hours.
Dcis Breast Cancer Treatment
The treatment plan is not same for every individual. The considerable options for standard treatment of DCIS are as follows:
- Lumpectomy followed by radiation therapy:
In a lumpectomy, only a portion of the breast where the cancerous lump is sited is removed out, without surgical removal of the whole breast. After a lumpectomy, radiation therapy is prescribed to complete destruction of cancerous cells and reduce the risk of recurrence.
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How Is It Diagnosed
Most of the time, DCIS is diagnosed through a routine breast cancer screening.
If your doctor thinks you might have DCIS, youll probably need further tests to confirm the diagnosis. These tests may include:
- a diagnostic mammogram
- an MRI
- a biopsy
The report that comes back from the pathologists in the lab may contain some unfamiliar terms, like the ones described below:
A biopsy will also be able to determine the hormone receptor status of the DCIS cells. Many times, DCIS will have receptors that respond to the hormones estrogen or progesterone.
If these hormone receptors are present, it can help your doctor decide whether to offer you anti-estrogen medication to reduce the risk of recurrence.
Breast Cancer Survival Rates For All Types Of Breast Cancers
Breast cancer survival rates and prognosis are determined by so many different factors that it is always difficult to make generalizations.
NOTE: this page has been recently updated with the most up-to-date statistics. Prognosis has improved so much because breast cancer treatments have become more effective since this page was first created. Remember that survival is better than listed here. Most importantly, ask your oncologist and specialist team, who keep current with the latest statistics and best treatments.
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Its Usually Found On A Mammogram
For most women, DCIS is picked up on routine mammograms. âTypically, the mammogram finds a calcificationa small cluster of cells with abnormal shapes and sizesand then it is diagnosed after a biopsy,â 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 Pagetâs disease that causes skin around the nipple to become thick and dry.
What Does The New Research Mean For A Woman Who Is Diagnosed With Dcis
This study showed that increased cancer risk persisted for more than 15 years after a diagnosis of DCIS, and that more intensive therapy than lumpectomy alone whether with mastectomy, radiation therapy, or endocrine therapy reduced the risk of invasive breast cancer among women with DCIS. The lowest risk of invasive breast cancer was in women who chose mastectomy.
The risk of invasive breast cancer was seen regardless of severity of DCIS. Women who had low- or moderate-grade DCIS, as well as high-grade DCIS, had long-term increased risk.
Women who are recently diagnosed with DCIS should work with their treatment team to weigh the best individual treatment strategies based on their preferences and other health conditions. This new research validates the need to consider the long-term consequences of DCIS when making treatment decisions, and it may prompt doctors and patients to consider more intensive treatments to reduce later risk of invasive breast cancer and risk of dying of breast cancer. While no details on surveillance strategies, such as regular mammograms or other exams, were presented in this study, based on these results, patients with DCIS should continue active surveillance for breast cancer for decades after their diagnosis.
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And Tumor Grade And Necrosis At Diagnosis Of Dcis
There are 3 grades of Ductal Carcinoma In-Situ . If you have been diagnosed with DCIS you will be able to find the Grade on your Pathology Report.
1.Low Grade DCIS 2. Moderate Grade DCIS 3. High Grade DCIS
A Brazilian medical study examined 403 cases of Ductal Carcinoma In-Situ between the years of 2003 to 2008.
This study found that a solid morphology was the most common feature found in 42.2% of the cases. Furthermore, high-grade DCIS was also common and discovered in 72.7% of patients.
A subtype of DCIS, comedo necrosis, associated with necrosis was present in just over half of the cases . In addition, this feature was more common in solid tumors.
Both high-grade DCIS and comedo necrosis were identified more often in younger patients.
In conclusion, this study found high-grade DCIS to be associated with progression to invasive breast cancer.
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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