Questions And Answers

My doctors told me that I was not a good candidate for breast sparing treatment, and must have a simple mastectomy. Does this mean that my cancer is more serious?

No. There are patients whose DCIS tumor is multifocal, or very large (in two or more quadrants of the breast), or whose tumor is very extensive comedocarcinoma. These patients should not undergo breast sparing treatment. These patients should have a simple mastectomy, because the mastectomy has such a high cure rate and a low recurrence rate. When patients with these multifocal or extensive DCIS tumors undergo breast sparing treatment, they have a very high risk ( greater than 20% ) of having a serious recurrence in the treated breast. Your doctors may be recommending the best treatment--simple mastectomy-- for a specific type of multifocal, extensive or extensive comedo type DCIS. Simple mastectomy for these particular tumors will provide the excellent 98% cure rate reported above.

This is the hardest aspect of management of DCIS for patients to grasp. The difficulty arises because it is hard for some patients to accept having to lose a breast for a less aggressive form of cancer , when there are more aggressive invasive breast cancers that can be treated with breast sparing lumpectomy and radiation therapy.

My lumpectomy specimen showed a "positive surgical margin". What does that mean?

When a surgeon removes a DCIS tumor, he or she tries to take the tumor and a surrounding rim of normal breast tissue. This is done to try to remove the tumor completely. The tumor specimen is sent to the laboratory, where a pathology physician studies the tissues under the microscope. If the pathologist sees tumor at the edge of the lumpectomy specimen, where the surgeon¹s knife cut, that is called a "positive surgical margin"--meaning that there was tumor, not normal breast tissue at the edge.
This finding suggests that not all of the DCIS tumor was removed in the first lumpectomy, and that microscopic tumor (tumor that cannot be seen with the naked eye) may remain behind in the remaining breast tissue.
If the patient wants to proceed with breast preservation therapy a second surgery, a "re-excision" lumpectomy needs to be performed, to try to remove the residual tumor.When a re-excision lumpectomy is performed and the final pathology results show only a minimum of residual tumor that was completely removed, with final clean surgical margins, then it is safe to proceed with breast sparing treatment.
If the re-excision lumpectomy shows extensive additional DCIS, and/or still yet more positive surgical margins, then breast preservation is not in the patient¹s best interest. The finding of extensive DCIS or the inability to get tumor-free surgical margins means that the DCIS is not solitary, but rather multifocal or extensive, and is best treated with simple mastectomy. To try and preserve the breast in this setting would cause an unacceptably high rate of tumor recurrence, even with the addition of radiation therapy.

After I have had appropriate treatment to the breast for DCIS, will I need chemotherapy or other drug therapy to prevent recurrence?

The overall prognosis (outcome) of appropriately treated DCIS is excellent. Since the tumor is not invasive, the risk of metastases should be close to zero. There is no clear role for chemotherapy or other drug treatment in the management of true DCIS.

If I have breast sparing treatment, will the doctors be able to detect a recurrence in the treated breast?

After lumpectomy or lumpectomy with radiation therapy, it is critical that the patient have regular breast exams performed by one of the doctors of the treatment team and at least annual mammography. Remember, only a minority of appropriately selected breast preservation patients experience a recurrence. The goal is to find these recurrences at the earliest time, when the tumors are small, so that effective treatment can be given.

What about my other breast?

Any woman who has had a cancer in one breast, whether it is DCIS or invasive cancer, is at a higher risk that the general population for getting another breast cancer in her opposite breast. Again, the patient should have regular breast exams performed by one of the doctors of the treatment team and at least annual mammography.
Unfortunately, if a patient with DCIS of one breast develops a tumor in her other breast , that tumor may not be a DCIS, but rather an invasive cancer. Early detection will always be her best protection against life-threatening complications of cancer.


Keeping Busy
by Rodney Warner, JD
December 08, 2015