5 Pathology of Precancerous Changes and DCIS NormalHyperplasiaAtypical HyperplasiaTypes of DCISCribriformMicropapillarySolidComedo
6 DCIS versus Invasive Breast Cancer Ductal Carcinoma in situMeans milk duct cancer “in place”Cancer cells fill the milk ducts but do not “invade” through the wall of the milk ductStage 0 breast cancerInvasive Breast CancerCancer cells invade through the wall of the milk ductCan get into lymphatic channels and lymph nodesCan get into blood stream and other organs
9 Risk Factors DCIS Invasive Cancer Peak Age 60 -74 75 – 79 Race CaucasianFamily HistoryYesMammographic DensityObesityNoNo childrenLate age at childbirthHormone replacement
10 Should I have a Breast MRI After I am Diagnosed with DCIS? About 10% of breast MRIs will prompt additional imaging or a biopsy (3/4 of those biopsies will be benign).MRI may overestimate the size of the DCIS leading to more extensive surgery.I only order an MRI if the mammogram or exam make me suspicious that there is more there than meets the eye.
11 Should I have a Sentinel Lymph Node Biopsy as Part of My DCIS Surgery? If DCIS was initially diagnosed by core needle biopsy there is a 15% chance that there is actually an invasive breast cancer in the neighborhood.If all you have is DCIS there is <1% chance that the SLN will be positive.I don’t do SLN biopsy for pure DCIS if the patient is having a lumpectomy.I do SLN for DCIS if the patient is having a mastectomy.
12 What are the Options for Treating DCIS? Breast Conserving SurgeryLumpectomy + Radiation+ Tamoxifen (for ER+ DCIS)Mastectomy
13 What Happens if I decide Not to Get Treatment for a DCIS? 28 Small low grade cases treated by biopsy only24 year median follow-upPage DL, Cancer 1995;76:
17 But radiation can cut the recurrence rate in half. If I Have a Lumpectomy for DCIS do I Have to Have 6 ½ Weeks of Radiation Treatments?Radiation is not as effective against DCIS as it is against invasive cancer.But radiation can cut the recurrence rate in half.Some women are appropriately treated with 5 days of focused radiationDCIS < 2 cmAge > 50Not high gradeNegative marginsCyberKnifeBallon Catheter Radiation
18 Van Nuys Prognostic Index If I Have a Lumpectomy for DCIS can I skip the Radiation Treatments All Together?Van Nuys Prognostic IndexDCIS size < 1.5 cmNegative margin > 1 cmNot high gradeNo comedo necrosisAge > 61OncoTypeDx DCIS Recurrence Score
19 A New Test for Estimating Recurrence Risk After Lumpectomy with No Radiation OncoTypeDXScoreAny RecurrenceInvasive RecurrenceLow Risk12%5%Intermediate Risk25%9%High Risk27%19%In my mind the recurrence risk is too high even with a low score.I have not used this test.
20 Double Mastectomy for DCIS More and more women with DCIS are choosing to have both breasts removed- About 5% of all DCIS patients- About 18% of women who need one mastectomy
22 What is the Risk of Recurrence after DCIS Treatment? After lumpectomy and radiation there is a 10 – 24% chance that DCIS will recur.Half of these recurrences are invasive cancerAfter mastectomy the risk of recurrences is 2%The chance of dying of breast cancer after DCIS treatment is <2%May be a bit higher for African-American women.
23 Do Some Women with DCIS Have a Higher Recurrence Risk? Factors Associated with Greater Recurrence RiskNot getting “negative” margins at surgeryYounger age (e.g. <45)High grade DCIS (very disorganized cells)Estrogen receptor negative DCISHer-2/neu positive DCISLarger DCIS
24 Are there Medications to Prevent DCIS of Reduce the Recurrence Rate? Tamoxifen (for ER positive)Reduces DCIS rate by 50% in high risk womenReduces recurrence after treatment by 40%RaloxifeneDoes not appear to reduce DCIS riskNo recurrence data; not usedAromatase InhibitorsClinical trials being done nowHerceptin (for Her-2/neu positive)
25 SummaryDCIS is diagnosed almost exclusively from mammographic screening.Inadequately treated DCIS can become invasive breast cancer.Not every DCIS presents a health threat.We can’t tell which ones are not a threat.Treating DCIS significantly reduces the risk for invasive breast cancer.The challenge is not to over treat.
26 Summary for Young Women DCIS is very uncommon in young womenRecurrence rates tend to be higher in young women.A DCIS diagnosis does not impact survivalLumpectomy + radiation (+ tamoxifen for ER positive DCIS) is a treatment option.More young women are choosing double mastectomy.