DCIS Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer.
Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer
that begins in the skin or other tissues (including breast tissue) that cover or line the internal
organs, and in situ means "in its original place." DCIS is called "non-invasive" because it
hasnt spread beyond the milk duct into any normal surrounding breast tissue. DCIS isnt
life-threatening, but having DCIS can increase the risk of developing an invasive breast
cancer later on.

When you have had DCIS, you are at higher risk for the cancer coming back or for
developing a new breast cancer than a person who has never had breast cancer before.
Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a
recurrence are under 30%.

Women who have breast-conserving surgery (lumpectomy) for DCIS without radiation
therapy have about a 25% to 30% chance of having a recurrence at some point in the future.
Including radiation therapy in the treatment plan after surgery drops the risk of recurrence to
about 15%. Learn what additional steps you can take to lower your risk of a new breast
cancer diagnosis or a recurrence in the Lower Your Risk section. If breast cancer does come
back after earlier DCIS treatment, the recurrence is non-invasive (DCIS again) about half the
time and invasive about half the time. (DCIS itself is NOT invasive.)

According to the American Cancer Society, about 60,000 cases of DCIS are diagnosed in
the United States each year, accounting for about 1 out of every 5 new breast cancer cases.

There are two main reasons this number is so large and has been increasing over time:

People are living much longer lives. As we grow older, our risk of breast cancer
increases.

More people are getting mammograms, and the quality of the mammograms has
improved. With better screening, more cancers are being spotted early.
On the following pages you can learn about:

Signs and Symptoms of DCIS

 Diagnosis of DCIS

Treatment for DCIS

Follow-Up Care for DCIS

Signs and Symptoms of DCIS

DCIS generally has no signs or symptoms. A small number of people may have a lump in
the breast or some discharge coming out of the nipple. According to the National Cancer
Institute, about 80% of DCIS cases are found by mammography.

Diagnosis of DCIS
iagnosing DCIS usually involves a combination of procedures:

Physical examination of the breasts: Your doctor may be able to feel a small lump
in the breast during a physical examination, although a noticeable lump is rare with
DCIS. In cases when DCIS cannot be felt during a physical exam, it can often be
detected using mammography.

Mammography: DCIS is usually found by mammography. As old cancer cells die off
and pile up, tiny specks of calcium (called "calcifications" or "microcalcifications") form
within the broken-down cells. The mammogram will show the cancer cells inside the
ducts as a cluster of these microcalcifications, which appear either as white specks or as
a shadow.

Biopsy: If you do have a suspicious mammogram, your doctor will probably want
you to have a biopsy. There are two ways to get a biopsy done with only a little bit of
surgery (more invasive biopsies are rarely needed for DCIS):

o Fine needle aspiration biopsy: A very small, hollow needle is inserted into
the breast. A sample of cells is removed and examined under the microscope. This
method leaves no scars.

o Core needle biopsy: A larger needle is inserted to remove several bigger

samples of tissue from the area that looks suspicious. In order to get the core needle
 through the skin, the surgeon must make a tiny incision. This leaves a very tiny scar
that is barely visible after a few weeks.

If a needle biopsy is not able to remove cells or tissue, or it does not give definite results
(inconclusive), a more involved biopsy may be necessary. These biopsies are more like
regular surgery than needle biopsies:

o Incisional biopsy: Incisional biopsy removes a small piece of tissue for

examination.

o Excisional biopsy: Excisional biopsy attempts to remove the entire

suspicious lump of tissue from the breast.
Biopsies are done only to make the diagnosis. If DCIS is diagnosed, more surgery is needed
to ensure all of the cancer is removed along with "clear margins," which means that a border
of healthy tissue around the cancer is also removed. Usually this means having lumpectomy,
or in some cases (a large area of DCIS, for example), mastectomy.

After the biopsy, the pathologist analyzes the piece of breast tissue and reports back on the:

type and grade of the DCIS: how abnormal the cells look when compared with
normal breast cells, and how fast they are growing

hormone-receptor status: Whether or not the cancer cells have receptors (proteins
in a cell that receive messages from hormones) for the hormones estrogen and/or
progesterone. If estrogen and/or progesterone receptors are present, this means that
the cancer cells' growth is fueled by these hormones.

Type and grade of DCIS

All DCIS is considered stage 0 breast cancer the earliest stage possible. "Stage"
describes how far the cancer has spread beyond the site of the original tumor. Even though
DCIS is always considered stage 0, it can be any size and be located in any number of
areas inside the breast.

Knowing the type and grade of DCIS can help you and your doctor decide on the best
treatment for you.

When a pathologist looks at the tissue removed during the biopsy, he or she determines
whether or not any abnormal cells are present. If abnormal cells are present, the pathologist
will note how different the cells look compared with normal, healthy breast cells. The image
shows the range of possible findings, from normal cells all the way to invasive ductal cancer.

Normal cells

Ductal hyperplasia or "overgrowth" means that too many cells are present.

Atypical ductal hyperplasia means that there are too many cells (hyperplasia) and
they are starting to take on an abnormal appearance (atypical or "not typical").

Ductal carcinoma in situ means that there are too many cells and they have the
features of cancer, but they are still confined to the inside of the duct.
 DCIS-MI (DCIS with microinvasion) means that a few of the cancer cells have
started to break through the wall of the duct. This is considered to be a slightly more
serious form of DCIS.

Invasive ductal cancer means that the cancer cells have broken beyond the breast
duct. The breast cancer is no longer a DCIS but an invasive ductal carcinoma, the most
common type of breast cancer.

There are three grades of DCIS: low or grade I; moderate or grade II; and high or grade III.
The lower the grade, the more closely the cancer cells resemble normal breast cells and the
more slowly they grow. Sometimes it's difficult to figure out where the cells are on in the
range from normal to abnormal. If the cells are in between grades, they may be called
"borderline."

Grade I (low grade) or grade II (moderate grade)

Grade I or low-grade DCIS cells look very similar to normal cells or atypical ductal
hyperplasia cells. Grade II or moderate-grade DCIS cells grow faster than normal cells and
look less like them. Grade I and grade II DCIS tend to grow slowly and are sometimes
described as "non-comedo" DCIS. The term non-comedo means that there are not many
dead cancer cells in the tumor. This shows that the cancer is growing slowly, because there
is enough nourishment to feed all of the cells. When a tumor grows quickly, some of its cells
begin to die off.

People with low-grade DCIS are at increased risk of developing invasive breast cancer in
the future (after 5 years), compared to people without DCIS. Compared to people with high-
grade DCIS, however, people with low-grade DCIS are less likely to have the cancer return
or have a new cancer develop. If more cancer does develop, it typically takes longer for this
to happen in cases of low-grade DCIS versus high-grade.

There are different patterns of low-grade and moderate-grade DCIS:

 PapillaryLarger Version

Papillary DCIS: The cancer cells are arranged in a finger-like pattern within the ducts. If the
cells are very small, they are called micropapillary.

CribriformLarger Version

Cribriform DCIS: There are gaps between cancer cells in the affected breast ducts (like the
pattern of holes in Swiss cheese).

SolidLarger Version

Solid DCIS: Cancer cells completely fill the affected breast ducts.

Grade III (high-grade) DCIS

In the high-grade pattern, DCIS cells tend to grow more quickly and look much different from
normal, healthy breast cells. People with high-grade DCIS have a higher risk of invasive
cancer, either when the DCIS is diagnosed or at some point in the future. They also have an
increased risk of the cancer coming back earlier within the first 5 years rather than after 5
years.

ComedoLarger Version

High-grade DCIS is sometimes described as "comedo" or "comedo necrosis." Comedo

refers to areas of dead (necrotic) cancer cells, which build up inside the tumor. When cancer
cells grow quickly, some cells dont get enough nourishment. These starved cells can die off,
leaving areas of necrosis.

Hormone-receptor status
In addition to figuring out the type and grade of DCIS, the pathologist also will test your
biopsy tissue for hormone receptors. This test determines whether or not the breast cancer
has receptors for the hormones estrogen and progesterone. A positive result means that
estrogen or progesterone (or both) fuels the cancer cells' growth. If the cancer is hormone-
receptor-positive, your doctor is likely to recommend treatments that block the effects of
estrogen or lower estrogen levels in the body.

Testing DCIS for hormone receptors is relatively new, however. Don't assume that your
hospital will automatically perform this test. Be sure to ask your doctor to have the cancer
tested this way.

Treatment for DCIS

Standard treatment options for DCIS include:

Lumpectomy followed by radiation therapy: This is the most common treatment

for DCIS. Lumpectomy is sometimes called breast-conserving treatment because most
of the breast is saved.
 Mastectomy: Mastectomy, or removal of the breast, is recommended in some cases.

Lumpectomy alone

Hormonal therapy after surgery: These treatments, which block or lower the
amount of estrogen in the body, are typically used if the DCIS tests positive for hormone
receptors.
Chemotherapy, a form of treatment that sends anti-cancer medications throughout the body,
is generally not needed for DCIS. DCIS is non-invasive and remains within the breast duct,
so there is no need to treat cancer cells that might have traveled to other areas of the body.

Each individual situation is different. You and your doctor will decide what treatment is best
for your situation. If the DCIS is large, high-grade, and comedo type, for example, it is likely
to be more aggressive, and your doctor may recommend more extensive treatment. The
same holds true if you are under age 40, since younger age may increase the risk of
recurrence.

The Oncotype DX DCIS test is a genomic test that can help you and your doctor make
decisions about treatments after surgery for DCIS. The Oncotype DX DCIS test analyzes the
activity of a group of genes that can help doctors figure out a womans risk of DCIS coming
back and/or the risk of a new invasive cancer developing in the same breast, as well as how
likely she is to benefit from radiation therapy after lumpectomy.

The Oncotype DX DCIS test results assign a Recurrence Score -- a number between 0 and
100 -- to the DCIS. You and your doctor can use the following ranges to interpret your
results:

Recurrence Score lower than 39: The DCIS has a low risk of recurrence. The
benefit of radiation therapy is likely to be small and will not outweigh the risks of side
effects.

Recurrence Score between 39 and 54: The DCIS has an intermediate risk of
recurrence. Its unclear whether the benefits of radiation therapy outweigh the risks of
side effects.

Recurrence Score greater than 54: The DCIS has a high risk of recurrence, and
the benefits of radiation therapy are likely to be greater than the risks of side effects.
You and your doctor will consider the Recurrence Score in combination with other factors,
such as the size and grade of the DCIS, whether or not the DCIS is hormone-receptor-
positive, and your age. Together you can make a decision about whether or not you should
have radiation therapy.

Before surgery, you may need to have a diagnostic test to "localize" the tumor. When DCIS
can only be seen by a mammogram or ultrasound and cannot be felt, the exact location of
the tumor has to be pinpointed before the surgeon can remove it. A localizing needle is
placed near the area of concern and then guided to the cancer with the aid of mammogram
or ultrasound. If the DCIS is only seen by MRI (magnetic resonance imaging), it may need to
be localized with the help of an MRI machine.

Lumpectomy followed by radiation therapy

Most people with DCIS have a lumpectomy followed by radiation therapy. This is usually a
very good option if the DCIS only appears in one area of the breast and can be completely
removed with clear margins of healthy tissue. A clear margin is a rim of healthy tissue
around the tumor that is completely free of cancer cells. How wide do these margins need to
be? In February 2014, the American Society for Radiation Oncology and the Society of
Surgical Oncology issued new guidelines saying that clear margins, no matter how small as
long as there was no ink on the cancer tumor, should be the standard for lumpectomy
surgery.

Lumpectomy, and in some cases a second procedure called re-excision lumpectomy, is

used to completely remove the cancer.

Lumpectomy removes the entire area of DCIS as well as a margin of normal,

healthy breast tissue around it. The whole area that contained cancer cells is removed,
even when there's no lump present.

Re-excision lumpectomy is a second surgery that may be necessary after

lumpectomy to remove extra tissue in order to ensure that there is a clear margin of
healthy tissue around the tumor.
If you've had lumpectomy, you may have a dent, bulge, or other distortion of the breast
shape near the surgical site. Or your breast may have a different size or position compared
to the other breast. Learn about options for reconstruction after lumpectomy.
If the DCIS has been removed with lumpectomy, radiation is usually given to reduce the risk
of cancer returning. Your doctor may discuss a couple of radiation options with you:

External radiation is given to the entire breast by a machine called a linear

accelerator. Radiation treatment is usually given as daily treatments 5 days per week
over 5 to 7 weeks. Treating the whole breast with radiation after lumpectomy remains
the standard of care. In cases of DCIS, radiation therapy can reduce the risk of the
cancer coming back by about 60%. For example, after lumpectomy alone, the risk of the
cancer returning is about 30%, although it may be lower or higher, depending on the
situation. Radiation can reduce that risk to 10% or less for a return of invasive cancer
and to about 15% for a return of DCIS.

Internal partial-breast irradiation is a form of treatment in which radioactive

materials such as seeds or pellets are temporarily placed in the breast. Theres a lot of
interest in partial breast radiation for DCIS, because treatment is shorter and side effects
occur in a smaller part of the breast. However, its effectiveness is still being studied.

External partial-breast irradiation is a method of therapy that zeroes in on the area

around where the cancer was. This area is at highest risk of recurrence. Partial-breast
radiation takes only 5 to 10 days for treatment, versus 5 to 7 weeks for whole breast
radiation. Researchers are studying partial-breast radiation for use after lumpectomy to
see how the benefits compare to the current standard of radiation to the whole breast.

Women may be able to take part in a clinical trial studying external partial-breast
radiation if they have only one area of DCIS that's completely removed with clear
margins. The trial is called NSABP B-39 and is available in many cancer centers. Ask
your doctor for more information about this trial if you feel you might qualify. You can
also visit our Clinical Trials section to learn more about how trials work.

Mastectomy
Mastectomy removes the entire breast. Although many cases of DCIS are treated with
lumpectomy, your doctor might recommend mastectomy if the DCIS covers a large area or
appears in multiple areas of the breast. In most DCIS cases requiring mastectomy, simple or
total mastectomy (removal of breast tissue but no lymph nodes) is performed. Radiation is
usually not necessary after mastectomy for DCIS.

Some situations in which doctors might recommend mastectomy for DCIS:

 There is a large area of DCIS.

There is more than one area of DCIS in the breast (called multifocal disease).

A biopsy shows DCIS cells near or at the margin of healthy tissue, in which case
taking more tissue to achieve acceptable margins would result in poor cosmetic
outcome.

If you have a strong family history of breast cancer, or you have tested positive for a
gene mutation that increases breast cancer risk, you might choose mastectomy to guard
against your higher risk of developing future breast cancers.

Not being a candidate for radiation therapy: Most of the time, people treated with
lumpectomy for DCIS also receive radiation therapy. If youve had previous radiation to
the chest or breast, if you have a condition that makes you more sensitive to radiation,
or if you are in your first trimester of pregnancy when diagnosed, you might not be
eligible to receive radiation therapy.
If you are thinking about mastectomy for DCIS, you may also want to considerbreast
reconstruction options as youre planning your surgery.

Checking the lymph nodes for any signs of cancer spread is not a standard part of treatment
for DCIS, although it does happen in some cases. Early research shows that in some DCIS
cases, there may be a benefit in having sentinel node biopsy (removing only the first 1 to 3
nodes closest to the cancer). Some factors that may lead to sentinel or underarm lymph
node biopsy:

the breast has widespread areas of DCIS

there is a significant amount of high-grade DCIS in the breast

microinvasion (small amounts of cancer have spread beyond the milk duct)

diagnosis of DCIS happened at a young age (under 40)

Lumpectomy alone
Having no radiation after lumpectomy may be an option for you if your risk of recurrence
is very low after lumpectomy alone. In this situation, adding radiation may offer only minimal
benefit. This may be true if:
 You have a very small area of low-grade DCIS (just a few millimeters) that was
completely removed with wide negative margins of resection (1 centimeter or more).

You are over 70 with other active medical problems that are more serious than DCIS.
Radiation to be sure the DCIS is completely gone may be a relatively low priority.
If you decide on lumpectomy only, then close follow-up and observation will be particularly
important. This involves visiting your doctor regularly for breast examination and imaging
studies such as mammograms, ultrasound, or MRIs.

The decision not to have radiation treatment must be considered very carefully with your
medical team. It can also be helpful to seek a second opinion.

Hormonal therapy
People with DCIS have a slightly higher risk of developing another breast cancer in the
future than people who have not had DCIS. Adding hormonal therapy to surgery and
radiation for DCIS can reduce this risk if the tumor tests positive for hormone receptors.

Not all hospitals automatically test DCIS for hormone receptors, so make sure to ask your
doctor to have the DCIS tested this way.

Tamoxifen (brand name: Nolvadex) can be used for early-stage cancers that are
hormone-receptor-positive, instead of or following radiation treatment after lumpectomy.
Tamoxifen "pretends" to be estrogen and attaches to the receptors on the breast cancer
cells, taking the place of real estrogen. As a result, the cells don't receive the signal to
grow. People with hormone-receptor-positive cancer who take tamoxifen can lower their
risk of having an invasive cancer or a non-invasive cancer come back.

Aromatase inhibitors such as Arimidex (chemical name: anastrozole), Femara

(chemical name: letrozole), and Aromasin (chemical name: exemestane) are being
studied in clinical trials to find out if they are effective in reducing the risk of recurrence in
people with DCIS. These medications reduce the amount of estrogen produced in a
woman's body after she goes through menopause. The main sources of the hormone for
those women are the adrenal glands and fat tissue, not the ovaries.

Follow-Up Care for DCIS

After surgery and radiation therapy, you and your doctor will work together to develop a plan
for your follow-up care. If you had a mastectomy and are undergoing breast reconstruction,
you will have a series of office visits to check on your healing. If you are taking tamoxifen or
another form of hormonal therapy, this usually continues for a period of about 5 years, so
your doctor will want to monitor you throughout that time.

Although follow-up care plans can vary from person to person, your plan is at least likely to
include:

a checkup and physical exam by your doctor every 6 to 12 months for 5 years and
then once a year after that

a mammogram every 12 months and possibly other screening methods depending

on your doctors recommendations