Ductal Carcinoma In-situ of the Breast
My mother has a diagnosis of ductal carcinoma in-situ and has been given an option for a mastectomy or lumpectomy followed by XRT. She is leaning towards mastectomy, but is still unsure. Can you help us weigh the options?
John Han-Chih Chang, MD and Kenneth Blank, MD, OncoLink Editorial Assistants, respond:
Thank you for your interest and question.
The major issue in the management of ductal carcinoma in-situ (DCIS) is the risk for progression to invasive cancer. Recurrences after lumpectomy (removal of the tumor + margin of soft tissue) alone have demonstrated a 25 - 30% risk of recurrence. Half of those will be invasive cancer not DCIS when they come back. So lumpectomy alone is an option, but it may not be the best one.
Lumpectomy alone was compared to Lumpectomy + Radiation Therapy (XRT) in a randomized trial (NSABP 17 study) of 818 patients. There was a statistically significant improvement (reduction) in overall local failures (recurrent cancer in the same breast) from 27% to 12% at 10 years. Survival was not different, because those that had a local failure went on to a second chance at cure (mastectomy) which usually is very successfulover 95% cancer specific survival. Here at the University of Pennsylvania, we have published our 15-yr. data on patients treated with XRT after lumpectomy. Our cancer specific survival was 96%. Our 15-yr. local failure rate was 19%. Those that failed went on to a mastectomy. The cure rate with mastectomy at the outset is over 95% in DCIS.
If you have DCIS alone, there is no need for an axillary (under arm) lymph node dissection (surgery). The risk of DCIS going to lymph nodes is less than 1%many studies in the past of patients that had their lymph nodes removed have demonstrated this (Dr Silverstein of Van Nuys Cancer Center reported on 189 consecutive axillary dissections done on DCISno positive lymph nodes). Axillary lymph node dissections have a high complication rate of lymphedema.
The Bottom Line:
How important is it to your mother that she save the breast? If she wants a chance at sparing the breast, then lumpectomy and XRT will give you a 80 - 85% chance at sparing the breast and being curedknowing that the final cure rate is greater than 95% (should it come back, you would most likely get mastectomy). If for your own peace of mind, you want the breast removed so there is a less than 5% chance of it coming back (it still can come back in the chest wall after mastectomy), you would have a greater than 95% chance of being cured. As far as cosmetic result, reconstruction could be discussed with your surgeona plastic surgeon should perform this NOT a general surgeon. Reconstruction can be done at the time of mastectomy or afterwards.
One other thing to factor into the situation is the amount of time for the radiation therapy. The typical time scheme is for the lumpectomy to happen and the radiation to start 2 - 4 weeks after. The radiation is done to whole breast initially and then to the tumor bed. These are daily treatments lasting approximately 5-15 minutes per day Monday - Friday for approximately 5-7 weeks. The first session is a mapping session, which can last 1/2 to 1 hour, but daily sessions are quick. Most people are able to continue working during treatment and go on with their daily lives as normal. Breast radiation acute side effects mainly have to do with skin irritation, which is usually minimal. It is usually very well tolerated.
Mastectomy is a very good choice. There is a high likelihood your mother will never hear from this cancer again. She will need to continue yearly mammograms and monthly self-exams on the other breast. Please have her discuss all of these options with her physicians.