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DCIS – the Controversial Breast Cancer

Everyone has heard of Breast Cancer. Those 2 words are enough to scare any of us, men or women, as we all know someone who has had a fight with this disease. With this disease everyone always thinks about lumps being detected, and then being removed followed by further treatment.

How many of you have heard about Ductal Carcinoma in situ (DCIS)? If you have heard about it, how much do you really know?

I had come across this disease through my studies and work, and thought I knew lots about it, that is until I had to deal with the disease when it struck someone close to me.

DCIS is a much debated subject amongst the specialists, and the definition and treatment varies from consultant to consultant as well from country to country. There is a fair amount of information on the internet, but again a lot of this varies. What I’m going to discuss below is from my personal experience and research.

 

Definition of DCIS

DCIS is described in the UK as a non-invasive breast cancer. In other words, there are cancer cells present, but they are enclosed within the milk ducts and haven’t become invasive (ie a tumour), therefore are ‘in situ’.

In the USA many of the doctors refer to this as a “pre-cancer”, however this can be highly mis-leading making many people believe it’s something that isn’t yet cancerous so shouldn’t be taken as seriously. There are cancer cells present, they’re just not invasive yet but have the potential to do so.

 

Diagnosis of DCIS

DCIS cannot usually be detected by palpation on the skin, as there isn’t often a lump, and most people don’t notice any symptoms what so ever. It is usually only detectable using imaging such as mammograms, MRI, ultrasound or thermographs. Therefore, it’s often found when women go for their routine breast screening. For those women who miss their screening, or are too young for routine screening, it may not be detected until after it’s become invasive. Usually the area of DCIS is found surrounding small crystals called microcalcifications in the breast area. These areas are viewed under ultrasound and biopsies taken to examine them. It is from this that the final diagnosis is made.

In the UK it makes up 20% of breast cancers that are diagnosed by screening mammograms (information from Breast Cancer Care).

 

Types of DCIS

Invasive breast cancer is graded from 1 to 3, with 1 being the least advanced. An invasive cancer can change from grade 1 to 3, so can change and get progressively worse.

DCIS is graded as low, intermediate or high.

Low is as it sounds, it is the least likely to become invasive, whereas high means that there is a greater chance of the DCIS becoming invasive. Unlike with invasive cancer the DCIS cannot change or progress from low to intermediate to high – it is either low or medium or high and remains as such.

If left untreated then it is thought that many of the DCIS cases could become invasive, this is especially true for high grade DCIS. The grading is given after the tissue is examined in a lab following the biopsy.

Treatments for DCIS

The first thing that the medical team usually do is work out how large an area is affected and what grade the DCIS is, and then they make their decision about further treatment.

The main idea of the treatment is to clear the breast area of all DCIS. If this is not done then there may be a chance that the DCIS could become invasive. For some people the DCIS may never progress and may go away on its own. Much of this depends on the type, size and area it covers, but there is no real way to know for sure.

It is due to these reasons that the decision about whether to treat, and what sort of treatment to have can be very difficult. Some women may feel that they are being “over treated” if there is a chance that the DCIS will not get worse.

Surgery

Many consultants try to remove the DCIS under ultrasound if the area affected is low. However most of the time women are offered a breast conserving surgery called the wide local excision (or lumpectomy). Quite often there is a guide wire inserted into the breast just before the surgery so that the surgeon can pin point the exact area that needs to be removed, so reducing the chances of removing too much tissue. This is done when the DCIS cannot be felt from the outside. The area that is removed is the DCIS plus an extra surrounding area called the clear margin. This whole tissue sample is taken off to the laboratory for testing and the histology results will decide upon the rest of the course of treatment.

A good result from this is that the histology result shows that the DCIS has been removed in total and that the clear margin shows only healthy cells. However, if the clear margin has DCIS present or if there are any invasive cells found in the main area itself then this will mean further treatment.

The patient could be offered another wide local excision or a mastectomy. This very much depends upon the size of the area affected, the type of DCIS and if there are any invasive cells found (and what type these are too).

Many women who have more than 1 wide local excision will be offered a course of radiotherapy to ensure all the cells have been removed.

If a mastectomy is indicated then reconstructive surgery will also be offered, which can be done either at the same time or later.

If invasive cells were detected in the pathology report then the lymph nodes will also need to be tested prior to the mastectomy, a procedure called the sentinel lymph node biopsy.
Further treatment may or may not include radiotherapy and/or hormonal treatment such as tamoxifen for all patients.

 

Debate about Screening and DCIS treatment

There is a great debate amongst the experts about whether breast screening is more helpful or more harmful. The diagnosis of DCIS has increased following the introduction of routine mammograms, as most of the time this could not have been seen or felt without the imaging. Once diagnosed it will be dealt with using medical intervention. Some experts feel that this puts many patients through a lot of un-necessary stress and treatments, especially if it proves that there wasn’t a high incidence of DCIS and its low grade. There is always the chance that if left alone the DCIS could just be dealt with by the body or may not get worse so no treatment would have been needed. So the debate is whether routine mammograms are useful in detecting early breast cancer or more harmful by putting some women through unnecessary treatments and stress.
Also, the actual DCIS definition and treatment is in great debate. Does a woman with non-invasive breast cancer really need a mastectomy, a surgery which could lead to a lot of mental anguish and body dysmorphia?
This article was written about the treatment of DCIS in the March issue of the British Medical Journal (BMJ), which most doctors in the UK subscribe to. This article was good at showing the debating points and how doctors come about to their conclusion about treatment.

 

 

Case study

Below is an outline of what one woman went through. Below is roughly her story:

 

  • Routine mammogram done in December
  • 1 week after mammogram receive a letter asking her to go and see a specialist to discuss results, appointment for 1 week later.
  • Meet with consultant and has an ultrasound. Microcalcifications confirmed in 1 breast and biopsy done
  • 2 weeks later has another consultant appointment where DCIS is confirmed and further imaging and biopsies are done
  • 1 week later has another consultant appointment to discuss treatment. Confirmed that the DCIS is high grade and wide spread.
  • 1st February – wide local excision done using guide wire.
  • 2 weeks later – consultant confirms that the DCIS is more extensive than first thought and was up to the clear margin. In addition a number of invasive cells were detected. Advised to have a further wide local excision
  • 1st March – second wide local excision done.
  • 2 weeks after – histology report shows no more invasive cells but there isn’t a clear margin. Advised to consider a mastectomy due to the size of the area affected, the type and the fact invasive cells were found. Told that a 3rd wide local excision with radiotherapy is also an option
  • 12th April – sentinel lymph node biopsy done where 3 lymph nodes are removed, results were clear, no lymph involvement.
  • 1st May – mastectomy and reconstructive surgery preformed
  • 2 weeks later – histology show the breast tissue was clear

 

The consultant will review and monitor her every 6 months, as he has to keep an eye on the other breast too as there is a greater chance of the cancer forming in that breast as well.

So after 5 months since the mammogram the main part of the treatment is over. There is a long recovery period with other treatments and appointments.
When I ask her about her feelings about what’s happened to her and if she feels routine mammograms are unnecessary she tells me that even though this has been one of the most stressful periods in her life, she is so thankful that we are offered free routine screenings in this country as it has probably saved her life.

So despite having to undergo 3 surgeries, 1 of which was a very big one, in the course of 3 ½ months plus various other invasive testing, this lady is absolutely confident that this has been for the best in her case. She is a total advocate for cancer screening and is advising everyone who is eligible to make sure that they go.

 

So the debate will continue about DCIS, but one thing to remember is that this is a form of cancer as cancer cells are present. However, the options about whether to treat or how to treat are based on very individual circumstances and there is no one size fits all.

 

 

Further information can be found:

Breast Cancer Care

British Medical Journal

Breakthrough Breast Cancer

Macmillan Cancer Care

Cancer Research UK

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  1. […] is a form of breast cancer called Ductal Carcinoma in situ, which I have blogged about […]

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