Ductal Carcinoma in Situ (DCIS)

 

Yes. It is quite a shock to patients isn’t it, that you can have something where everybody says your future outlook, your prognosis, is ever so good; your survival should be very good, but then in the next sentence suggest that you need a breast removed to achieve that.

 

And even for, if we call them “ordinary cancers,” in other words invasive cancers, the type of surgery or the extent of surgery that is done is not related to how aggressive the cancer is. It is related to its width. And again, in very straightforward terms, what the surgery is trying to do is to remove everything that’s cancerous. So if that area that is cancerous is a narrow piece, then taking a piece of the breast will be adequate. If the cancer change in your breast extends over a wide area, then removing a piece won’t achieve removal of all the cancer, nor will it allow afterwards a good cosmetic outcome for the patient because so much of it would have been removed that the breast wouldn’t look right.

 

So people can still have a wonderful outlook and survival in the future but need a mastectomy now because their cancer is wider than a piece or wide excision, as it’s called, would allow.

 

 

The mastectomy, as we were mentioning earlier, is to solve the straightforward question that any patient would say, “I’ve had my operation, have you removed everything that was wrong within the breast?” And if you can do that by taking a piece of the breast, conservation surgery as it’s called, then you’ve achieved your goal. But if it’s over a wide area, then you need to remove all of the area that’s abnormal and that may mean a mastectomy. And there isn’t a way around that, you can’t, if you like, just take part of the area that’s wrong and reassure patients that that’s been enough. Because it won’t be of benefit to them.

 

So the mastectomy, the surgical option is based very much on the width of the tumour. The over treatment therefore as in how a patient balances the loss of their breast compared to the worry, would they develop cancer in the future that would shorten their life, is ever so difficult, because none of us really can say from one patient how they’re going to progress or what’s going to happen to them over time. Everyone varies slightly and it’s a very good question, it’s the crystal ball saying, “What’s going to happen to me in the future?” And none of us have the ability to be able to predict that.

 

 

Yes, if we again take that from it’s start in the sense that we are presuming that that lady has only DCIS to begin with, and therefore we assume that the picture we have on the x-ray is giving us the full information, which it will in many instances, but there maybe some of those patients who already have some invasion and therefore already have some invasive cancer. So we are categorising them all the same from the start, without being able to say for certain that that is the case.

 

The role for anti-hormonal tablet treatment, the best of which or the most well known of which is tamoxifen, is usually when you’ve had the abnormal area removed, and you’re trying to prevent a further cancer occurrence in that breast or even a brand new one happening in the opposite breast in the future. There isn’t a great deal of information that if you treat the DCIS in the breast without any operation and just give the patient tamoxifen, as to how effective that will be, and the problem for the patient is they want you to be able to do something just at the moment when they think something’s gone wrong. So at the moment that things are becoming invasive is when they’d want you to do more. And we have no way of measuring that, you would have to wait for example till they develop a lump or a mass on the x-ray, at that stage say you now have an invasive cancer and therefore you do need more done. And they may still do very well in the future, but their outcome would be slightly less favourable because they’ve now developed a lump and they may feel they’ve missed a great chance at an earlier stage of having it cured with treatment.

And a lot of women also wondered why the different, in different hospitals women seemed to get treated in different ways for DCIS.

I suppose part of that is how people present, and every patient is different. And sometimes ladies will say, “I didn’t quite have that treatment, but this lady had a different treatment,” and that’s how it should be because I know there are a number of ways of treating somebody, many of which would be effective for different reasons. And the treatment the patient gets should be specific for them; it should be for the problem that they’ve come with. Much like we said earlier, some patients would have a small piece of the breast removed, others would have a mastectomy with a reconstruction because it was over a wider area.

So every lady’s treatment will differ, be it DCIS or be it invasive cancer. Now it is true that people then look on things differently from a clinician point of view and, as we said earlier, when you have a situation where the evidence isn’t cast iron that an extra treatment of radiotherapy or tamoxifen is always of use. And people have different beliefs as regards to the benefits that patients get, so there will be some variation.

 And have you come across many women who didn’t want to have any treatment at all?

Very few actually, in essence, and we often say to patients that, for example when a lady goes to a breast screening unit for her mammogram, most will go in the belief that they’re going to be told that everything’s alright. They don’t go really thinking that this process may well find something that’s severe. They’ll think about it when the question’s asked, but the normal way of things to go is to be told they’re alright, it’s not part of the plan to be told that maybe things aren’t alright.  And therefore patients when they come usually feel that something’s been found and it needs to be dealt with. Now they have the information, the diagnosis, it’s very difficult then not to do something about it. If they didn’t know, they would be alright. But once they know, they find it very difficult to ignore.

 

They’ll have a suggestion from the small pieces done by the biopsy, when the patient is first diagnosed. And you’ll have an impression that it’s DCIS because on the mammogram, which is now how most are diagnosed, there’ll be the absence of any “mass” as the jargon calls it. In other words, the equivalent of a lump, there will just be change in the mammogram without any ‘mass’ or lump on the mammogram. And with that type of change the expert radiologist will often say, “It looks as if there could be cancer change in the breast, and if there is, it’s likely to be DCIS.” They’ll then proceed to do a biopsy taking small pieces for the x-ray department, and when they’re looked at under the microscope, the pathologist would be able to say, “Yes there is cancer change, and yes it does look like DCIS, and the type of DCIS that I see looks high grade.” So you’d have a good idea at that stage, but we wouldn’t know for certain until the piece has been fully removed and then analysed under the microscope.

 

Yes. There’s two aspects to that I suppose and again they are very sensible and valid questions. The first is, we don’t know exactly what it is that is in the breast until the pathologist has fully examined all of that change. And the only way the pathologist can examine it is if it is removed. Everything else is a best estimate, based on the x-ray, and based on the biopsy. But you don’t know for certain what the cancer change in that breast is, if it’s all DCIS or if there’s little areas of invasion, or if the DCIS is high or intermediate or low grade, till it’s all been fully examined. So we are very dependent on the situation where you have it removed to have the best category put on it.

 

Now the natural history of DCIS will vary from person to person. Some will go on and develop a proper or invasive cancer as it’s called in that area of DCIS. But others won’t, and we’ll never know at what stage of evolution the patient has come. They may have had it for 15 years or 10 years or 3 years or 6 months. And therefore we don’t know where they are on that road and the rate of change in it with invasive cancer you cannot say from one individual.

 

You do know with high-grade DCIS that there is an increased chance of a breast cancer being present there at the start, in small areas the invasive we spoke about earlier, or it developing in the future. Or even the DCIS coming back or recurring in that breast in the future.

 

With the low grade it’s probably much slower, more indolent, and whether it’ll really ever cause harm to that patient longer term, or shorten their life, is very doubtful. The difficulty is knowing that all they have is low grade because, as we said, you don’t know that for certain until the thing has been removed.