DCIS, a non-invasive breast cancer, often raises challenging questions regarding its diagnosis, treatment, and patient understanding.
Fumiko Chino, M.D.
Assistant Professor, Department of Breast Radiation Oncology, MD Anderson Cancer Center
What is ductal carcinoma in situ (DCIS), and how does it differ from other types of breast cancer in terms of diagnosis and treatment?
DCIS is a precancer. DCIS in and of itself has never killed a single woman in the United States. DCIS is a screening disease that typically presents as tiny little calcifications that are trapped in the ducts of the breast. It is truly the earliest stage that we can put a stage on for breast cancer — Stage 0. “Pre-invasive breast cancer” is a contradiction that is confusing to a lot of people. In reality, we actually treat it very similarly to invasive breast cancer and potentially actually overtreat a lot of DCIS.
There is some debate about how to treat DCIS. Can you explain the main perspectives in the discussion? Why is this a complex issue?
I think that if you tell someone that they have pre-cancer in their body, understandably it’s like, “Oh my gosh. Get it out of my body, do everything that we can to make sure that it doesn’t become cancer.” It’s hard to de-escalate when your immediate thought is that you heard “cancer.” However, as a precancerous lesion, it is something that we have a lot of options for. The current standard of care is to always at least do surgery.
What I tell patients is that there’s a spectrum of normal breast tissue to invasive breast cancer. DCIS is closer to invasive breast cancer than normal breast tissue, but it’s not breast cancer yet. It hasn’t quite figured out how to become invasive, so as long as it’s still trapped in the ducts, it can’t really hurt people.
What are the key factors that doctors will consider when determining the course of treatment for a patient with DCIS? What are the tools that you can use to make that decision?
A lot of things factor into it, including the size and the grade of the DCIS that was found in the body. We typically do a biopsy first to give us an idea. “Is this high-risk or low-risk DCIS?” “Is it a large size?”
Typically, the first step is a surgical excision, so a lumpectomy or mastectomy. Mastectomies are usually only reserved for when you know there’s an extensive amount of DCIS or when the removal of that amount of DCIS would create some sort of displeasing visual change. If we can’t really preserve a natural-appearing breast, then sometimes mastectomy is the best option.
People who are younger and healthier may have a preference to be more aggressive. I think that may be one of the flaws of our current paradigm, which is very patient-empowered decision-making. Sometimes we’re not necessarily giving patients the right information so they can make the best decisions for themselves — for example, what mastectomies can look like for patients, what their outcomes may be, and what the complication rates may be. There is, unfortunately, this alarming trend of younger patients choosing bilateral mastectomies for something like DCIS, which, again, has never killed a single person in the United States.
Are there any new tools, research, or advancements that are helping clinicians figure out the appropriate way to treat this?
There are a lot of different tools now available, and many techniques have greatly improved. There is also a clinical trial to see if we can just watch DCIS through active monitoring, which would be a huge shift in terms of how we consider DCIS. We’re at a great time in DCIS in terms of really trying to rethink how we’ve classically addressed it. In its current state, we have a lot of options.
How can patients with DCIS be more involved in their treatment decisions and feel more empowered during the process?
It’s perfectly fine and reasonable to seek a second opinion if you don’t feel comfortable with the options that are presented to you. One of the benefits of having a pre-invasive disease is that you have a little bit of time to seek a second opinion, especially if you’re going to make a large decision like a big surgery. I think feeling empowered is really making sure that you can sit with the decision you’ve made.
Everything has risks and benefits, so make sure you know what all the options are. I also think it’s helpful to talk to other people who’ve been through the same process. there are people who regretted choosing more aggressive treatment because they experienced complications, but then you have people who are so happy with their decision.”
