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Treatment

Ductal carcinoma in situ is not a benign disease. As we said at the beginning of our discussion, the cells that are growing out of control in DCIS are in a pre-malignant phase. If these cells are not treated effectively there is a real risk that the patient will develop a true invasive breast cancer in that same breast over time.

The goals of treatment in DCIS are to eliminate the DCIS and give the patient the chance of never developing an invasive, life-threatening breast cancer.

Using Surgery to Treat DCIS

Breast Sparing Surgery

Lumpectomy alone: A lumpectomy is a fairly small surgery, in which the surgeon removes only the breast lump, or the area of abnormality seen on the mammogram , and a small margin of normal breast tissue around it.

When is Lumpectomy alone adequate treatment for DCIS?

  • When there is only one area of abnormality in the breast either on exam or on mammogram

  • When the area of abnormality on exam or mammogram is very small

  • When the surgeon is able to remove the DCIS completely, and no DCIS is left behind in the breast.

  • When a mammogram of the involved breast shows no more suspicious findings after the lumpectomy

  • When a patient is very elderly, or has other serious illnesses, and would not be able to tolerate more extensive surgery or breast radiotherapy

  • When the type of DCIS is less aggressive, that is, non-comedo type

Pros And Cons Of Lumpectomy Alone

    Pros:

  • The patient keeps her breast

  • The lumpectomy is a very simple surgery, which can usually be done as an outpatient under local anesthetic.

    Cons:

  • Because the remaining breast tissue is not treated with any other intervention, there is reasonable chance that if the patient lives long enough (one or more years), she can develop cancer--either DCIS or invasive cancer in the same breast.

  • This option is only effective for very carefully selected patients with very early, small DCIS lesions with very easily interpreted mammograms.

  • Because comedocarcinomas tend to be more aggressive careful judgment needs to be used in offering lumpectomy alone for women with comedocarcinoma.

Lumpectomy and post-operative radiation therapy:

In order to offer the patient a breast sparing surgical option, but to minimize the chance of having cancer return in the treated breast, radiation therapy can be given after the lumpectomy. Radiation therapy (also called radiotherapy) is the used of high energy rays to damage cancer cells and stop them from growing. Radiation treat-ments do help to decrease the chances of DCIS or invasive cancer growing back in the treated breast.

When is Lumpectomy and radiation therapy adequate treatment for DCIS?

  • When there is only one area of abnormality in the breast either on exam or on mammogram

  • When the surgeon is able to remove the DCIS completely, and no DCIS is left behind in the breast. Sometimes, after the initial lumpectomy, the microscopic evaluation of the tumor removed shows that not all of the tumor was taken out. In that case, the surgeon may have to perform a re-excision of the lumpectomy site to make sure all the DCIS was removed.

  • When a mammogram of the involved breast shows no more suspicious findings after the lumpectomy

  • When the size of the DCIS tumor is small enough so that after its removal, there is enough breast tissue left behind to provide the patient with a cosmetically acceptable breast.

Pros And Cons Of Lumpectomy And Radiation Therapy:

    Pros:

  • The patient keeps her breast. Overall, about 90 - 92% of women with DCIS who are appropriately selected to undergo this treatment, will never need to lose that breast.-- The lumpectomy is a very simple surgery, which can usually be done as an outpatient under local anesthetic, sparing the patient a bigger surgery.

  • The addition of radiation therapy to treat the remaining breast tissue does decrease the risk of recurrence of either DCIS or invasive cancer.

  • Slightly larger DCIS tumors than can be safely treated with lumpectomy alone can be effectively treated with breast sparing by adding radiation.

    Cons:

  • Radiation therapy is time consuming. The treatments are daily for 5-6 weeks.

  • While the risk of recurrence is reduced by adding radiation therapy to the lumpectomy, about 8-10% of women who are selected for this treatment will have tumor reoccur in the treated breast. Half of these women who have a recurrence will have invasive cancer when the cancer returns. Women with comedocarcinomas may have an even higher chance of local recurrence.

  • The overall chance of a woman who undergoes breast preserving treatment with radiation experiencing a recurrence of invasive cancer, and ultimately dying of that cancer is 3-5%.

  • This is not a treatment option for all patients with DCIS. Patients must be carefully selected so that the ultimate tumor control chances and cosmetic results will be good.

When is Breast sparing (either lumpectomy alone or lumpectomy and radiation ) therapy inappropriate treatment for DCIS?:

  • This is not adequate treatment for multifocal DCIS or DCIS that is extensive (involving more than one quarter of the breast.

  • This is particularly not adequate treatment for extensive comedocarcinoma. There is a slightly higher recurrence rate for comedo type DCIS with breast sparing.

  • This is not adequate therapy when the mammogram of the involved breast has diffuse microcalcifications evident. This mammographic finding suggests that the DCIS is extensive throughout the breast.

  • Radiation therapy is not recommended therapy for a few special situations:

  • Radiation therapy cannot be safely delivered when a woman is pregnant.

  • Radiation therapy may not be safe for women with certain rare collagen vascular diseases such as Scleroderma and Systemic Lupus Erythematosus.

Surgery That Does Not Spare The Breast

Simple mastectomy: Because DCIS may be multifocal, one way of eradicating it is to remove the entire involved breast. Unlike invasive breast cancer, DCIS does not spread to the axillary lymph nodes. So when a simple mastectomy is performed, your surgeon will not have to remove lymph nodes from under the arm. When a patient has invasive breast cancer and a mastectomy is necessary, it is a more extensive mastectomy than the simple mastectomy.

Invasive breast cancer requires a modified radical mastectomy, which not only removes the breast, but also removes some of the axillary lymph nodes at the same time. The simple mastectomy, because it is less extensive than the modified radical mastectomy has fewer side-effects. Women who undergo simple mastectomy rarely have any difficulties with decreased shoulder movement or arm swelling after surgery. The simple mastectomy is a shorter surgery and has a faster recovery time than the modified radical mastectomy.

When is simple mastectomy appropriate treatment for DCIS?

Simple mastectomy is appropriate management for any case of DCIS. It is the only recommended treatment for multifocal DCIS, extensive DCIS, or DCIS that has reoccurred after lumpectomy and radiation therapy.

Pros And Cons Of Simple Mastectomy:

    Pros:

  • Simple mastectomy is the most effective form of therapy for DCIS. After simple mastectomy, the recurrence rate and overall chance of dying from cancer is between 0 and 2%.

  • Simple mastectomy is a relatively short surgery with a short hospital stay and a speedy recovery. Compared to a 6 week course of radiation, simple mastectomy is much more time efficient.

  • After a simple mastectomy, a patient can very successfully have breast reconstruction surgery to recreate a breast on the side of the surgery. Reconstruction surgery can be done immediately at the time of mastectomy, or at a later date.

    Cons:

  • The major drawback to simple mastectomy is that the patient loses her breast. This will result in a major cosmetic loss and change in body image for the patient.

  • This is a major surgery that requires general anesthesia.




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