DCIS Breast Cancer

Medical Intel

DCIS is sometimes called “stage zero breast cancer.” It’s contained to the milk ducts, and the primary concern is whether it comes back after treatment. Dr. Patricia Wehner discusses how we diagnose and treat this disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Patricia Wehner, a breast surgeon with fellowship training in surgical oncology for the MedStar Regional Breast Health Program. Today we’re discussing ductal carcinoma in situ, or DCIS, breast cancer. Welcome, Dr. Wehner.

Dr. Patricia Wehner: Thank you!

Host: What is ductal carcinoma in situ, or DCIS, breast cancer?

Dr. Wehner: So, ductal carcinoma in situ, which is referred to DCIS for short, is a stage 0 type of non-invasive breast cancer. And what that means is DCIS really is a type of breast cancer that’s confined to just the milk ducts of the breast. So, if you think of the composition of a breast, a breast is composed of multiple milk carrying pipes or tubes of the breast that come through the breast and join up at the nipple. DCIS is a cancer that’s contained just within those milk ducts.

Host: Is DCIS life-threatening, if it doesn’t spread?

Dr. Wehner: So, ductal carcinoma in situ, or DCIS, in and of itself is a non-invasive cancer. And that’s why we call it a Stage 0 cancer. Stage 0, again, meaning just confined to the milk ducts of the breast. If treated, then DCIS is not necessarily life-threatening. The concern for DCIS is in the recurrent form of DCIS, meaning after it’s treated, will it come back? And the concern there is if it comes back, will it come back as an invasive cancer? The difference is invasive cancers have the potential to spread. So, they have the potential to go to other places of the body and that could be anywhere – the lungs, the liver, the brain. DCIS, in and of itself, does not have that ability but when it morphs into an invasive cancer, that’s when it has the ability to spread to these other locations.

Host: How is DCIS detected if it’s just in the milk ducts?

Dr. Wehner: DCIS is generally just detected with screening mammography. So, within the United States, there’s about 55 million annual screening mammograms that are performed on a yearly basis. And, of those mammograms, about 1 in 1300 will show ductal carcinoma in situ. For the majority of patients, when we look at a screening mammogram, what we’re looking for is are there any new lumps or what we consider to be nodules or asymmetries that have shown up on mammograms. Or, are there new areas of calcium or calcifications that have showed up on mammograms. DCIS, in the majority of times, shows up as new calcium or calcifications. So, essentially, when we look at a mammogram, there are new little white dots that show up on the mammogram. White dots on a mammogram don’t necessarily equate to a cancer and that’s why, when we see them, we kind of ask a couple questions. And that is, “Are they new? Are they increasing in size or number? Are they fine and tiny or are they big and chunky?” If they’re big and chunky, then generally we don’t have to worry about them. But if they’re small and fine and kind of clustered or grouped together, that’s when we get concerned and will recommend to have a minimally invasive needle biopsy done to determine - is this DCIS or is this something that maybe we don’t need to worry about and it’s just representative of normal changes that we can see on the breast? Whenever we recommend a core needle biopsy, what is involved is coming into an imaging center. We take pictures, with the help of a mammogram machine. And then we place some local or some numbing medicine within the breast. Then a small needle’s placed within the breast, around the area where the calcium or calcifications is located, and a little bit of tissue is removed. That tissue is then looked at by the pathologist, under the microscope, and that’s what can give us our diagnosis of cancer or not cancer. So, going back to the number of annual screenings, about 1 in 1300 patients that get screened with a mammogram throughout the year will actually end up positive for DCIS. So, there’s about 51,000 new diagnosis of DCIS, or stage 0 breast cancer, each year.

Host: Do all women with DCIS require treatment, if they’re at average risk?

Dr. Wehner: So, when DCIS is found, so when you have a new diagnosis of ductal carcinoma in situ, the standard recommendation does require or recommend to have a multidisciplinary approach to the treatment of this. This may include surgery, it may include radiation therapy, and it may include a pill that’s considered essentially an anti-hormone pill, or an endocrine therapy. Chemotherapy is not something that we will ever use for ductal carcinoma in situ. And chemotherapy is what everybody thinks of when they think of cancer treatment, because chemotherapy is the stuff that can make you feel kind of sick and make your hair fall out, make you kind of sick to your stomach. We don’t use that for DCIS. Standard, if it’s small – so the area of calcifications or the area of known cancer is small - then we can generally remove it by doing something that’s called a partial mastectomy. Now, a partial mastectomy – there’s a lot of terms that mean the same thing, and so you may hear it called as a lumpectomy or as removal of just the cancer or as breast conservation therapy. All of those terms mean the exact same thing. And, that just means the goal is to remove where the cancer cells are living and to get a little bit of healthy, non-cancerous tissue around them. Whenever we remove just part of the breast and we leave the rest of the breast behind, then generally we do recommend radiation therapy to be followed. Radiation generally doesn’t start ‘til a month or so after the completion of surgery and after healing, and then that can be anywhere from 3 weeks to 6 weeks, on a daily basis. That’s not standard for each and every patient but that’s the general guideline we use. Now currently, we do have a clinical trial that has just opened that’s actually looking at observation alone for certain ductal carcinoma in situs, rather than moving forward with surgery. And that particular trial is called the COMET trial. And so, for certain patients that have fairly favorable DCIS, and favorable just refers to various things that we see under the microscope, for some of those patients now rather than moving to a surgery first, those patients can be observed with mammograms every 6 months. And, as long as nothing is changing on the imaging, then we can continue to observe them.

Host: Why is radiation therapy preferred over chemotherapy for DCIS?

Dr. Wehner: So, radiation therapy and chemotherapy treat cancer in very different ways. When we talk about cancer treatments, we talk about treatments that are local/regional treatments or we talk about treatments that are systemic treatments. And what that means is certain treatments are given just to the breast and the surrounding breast tissue and other treatments are given to the entire body. The point of both of those treatments is the same, which means the point of both of those treatments is to treat the breast cancer. They just go about it in a different way. So, for stage 0 ductal carcinoma in situ, to give a systemic treatment or a whole-body treatment through chemotherapy we know doesn’t work. It doesn’t affect the recurrence of this stage 0 cancer and it doesn’t affect the overall lifetime survival of this type of breast cancer. That’s not true for other invasive cancers, but for DCIS, chemotherapy just has no real added benefit, which is why we don’t use it. Radiation therapy, however, is a treatment that’s directed just to the breast and the surrounding breast tissue. And the point of radiation is to reduce the risk of recurrence. So, what we want to do is reduce the risk of DCIS coming back because we know when it comes back, about half of the time it comes back as that invasive form. And, it’s the invasive form that we worry about the most because that’s the form that can spread to other parts of the body.

Host: There’ve been discussions for several years about the over or under treatment of DCIS. What is your opinion about whether it should be treated and how do you help women make that choice?

Dr. Wehner: So, breast cancer is no longer a ‘one size fits all’ approach. So, historically, when we treated breast cancer, way back when, we used to treat it with a modified radical mastectomy. So, everybody lost their breast, most patients got chemotherapy, and most patients got radiation therapy, regardless of the type of breast cancer they had. In today’s era, we are much more specific about the types of treatments that we recommend and that’s because it’s not a ‘one size fits all’ criteria any longer. DCIS, we know, is a non-invasive type of breast cancer that has a chance of turning into an invasive type of breast cancer. And so, historically, we have always treated DCIS with at least a minimum of surgery. Current trials do show us that treating it with surgery and then adding radiation will decrease the risk of recurrence but doesn’t necessarily change the overall survival. And so, with that type of data, is where people start to say, ‘well maybe we’re overtreating this.’ So maybe we don’t need radiation therapy. Or maybe we don’t even need surgery. Radiation, for certain patients with DCIS, is no longer a standard recommendation. So, if patients are a little bit older, if patients have a really low-grade type of breast cancer that seems favorable, for those patients we are potentially not recommending radiation therapy. There’s also a new genetic test that has recently come on the market that’s given us sort of a discussion point as to what somebody’s risk of recurrence of the DCIS is. And, that may help us decide adjuvant treatments. But again, this also goes back to the current clinical trial that we have open, which is the COMET trial, and that’s really trying to answer that question of - are there certain patients that we don’t need to treat with radiation and don’t even need to treat with surgery? And are these patients that we choose to just follow with imaging, such as mammography, do they do okay overall? And there’s no real way for us to answer that question without enrolling patients on this trial. And so, we have a lot of high hopes that we can get patients to enroll in this trial and then we can really have a good answer to that question.

Host: Could you tell us a little bit about your patient population – what are the ages of women that you’re seeing with DCIS?

Dr. Wehner: So, women with DCIS can be any age. So, they can be as young as in their 30s and we can see them up to the age of 103, I think is the oldest patient I’ve treated. So, it’s not that it is necessarily an age criterion that we see for patients. We do know that the number one risk factor for developing breast cancer is age. So, the older we get, the more likelihood we have, or we become, to develop a breast cancer. And, there’s nothing you’re going to do about that because nobody can magically become younger. So, we do see it throughout a wide variety of patients.

Host: Have you ever had a patient who was maybe on the fence or had a cancer that you felt needed to be treated and she just wasn’t sure? Could you tell us about that experience with her and how you helped?

Dr. Wehner: So, we have a lot of women who come in that are very anxious about their diagnosis of cancer, and rightfully so. However, what I try to explain to patients is breast cancer is a very different cancer compared to something like a brain cancer or a pancreatic cancer. And that just is because breast cancer is very, very treatable. So, most patients with a DCIS treatment, are alive and well five years, ten years later. And that’s just partially the nature of the disease and partially because our treatment options have gotten so good at treating this, that while nobody wants to say that they have a cancer and they have to undergo therapy for a cancer, it really has become very streamlined and fairly minimal. For most patients that have a lumpectomy or a partial mastectomy - the two mean the same thing - it’s actually an outpatient procedure. It only takes us really about one to two hours in the OR to perform this procedure. For most patients, we don’t even have to put them fully to sleep for this procedure, meaning – we give them anesthesia but not so much anesthesia where we have to put a breathing tube down. And then, patients go home the same day. So, patients really do incredibly well from this sort of surgery and they recover very, very quickly. And so, I find a lot of anxiety and fear of treatment is because they just don’t understand what’s really involved with the treatment of it.

Host: Is there anything that women need to know about selfcare and recovery? What does the recovery look like for DCIS, if you have a procedure?

Dr. Wehner: So, for a partial mastectomy, I send everybody home essentially with just a small band aid that covers the incision and then we send them home in a tight, supportive bra. The key that I tell everybody is they should wear this supportive bra at least for a week after surgery – that includes sleeping in the bra – and that’s just because we do use some deeper sutures within the breast. And so, it’s just more comfortable to provide support to your breasts via this compression bra. And that can be the one we send you home in, that can be one that you have at home – it’s just something that provides compression and support. Patients are allowed to shower the day after surgery. It’s completely fine to get it wet with warm soapy water and then just kind of pat it dry and put your bra back on. There’s not a lot of restrictions. Patients can use their arms. They can brush their hair. They can cook meals. They’re not allowed to drive if they’re taking narcotic pain medicine or if they cannot sit comfortably in a car with the seatbelt on. But, the recovery time actually is pretty minimal. And that’s what most patients end up coming back in to the hospital saying, “You know, I only really needed a pain medicine for maybe one evening and then extra strength Tylenol worked just fine for me.” And patients are pretty surprised at how well they feel afterwards. So, to do a mastectomy is a very different procedure than a partial mastectomy and that’s because a mastectomy, the goal of that is to remove all of the breast tissue, whereas the goal of a partial mastectomy is just to remove part of the breast instead of the entire breast. When we remove an entire breast, then things become a little bit more complicated when we start talking reconstruction, meaning rebuilding another breast. And that can come in the form of an implant-based reconstruction or autologous reconstruction, which really just means we’re taking tissue from someplace else on your body and moving it to where your former breast used to be. Those surgeries are very different and much more complex and much more involved. Those surgeries, some of them, means a hospital stay of four or five days. It really just kind of depends on what type of reconstruction is going on. To do a very simple mastectomy, where the goal is to make it flat and not reconstruct, those patients stay in the hospital one night and go home the next day.

Host: Why is MedStar Washington Hospital Center the best place to seek DCIS expertise?

Dr. Wehner: So, all breast cancer needs to be treated in a very multidisciplinary approach. And, as I alluded a little bit earlier, we have a lot of different treatment options for the way we treat breast cancer. Here, at MedStar Washington Hospital Center, we have a very active and very robust multidisciplinary team. And part of that is because our patient population here just isn’t always the healthiest. And they have a lot of comorbidities and social factors, things that inhibit them from being able to come to the hospital to get treatments. And so, when you come here to have your breast cancer treated, you really come here to have everything treated and everything looked at. When we meet on a weekly basis, which we do as a multidisciplinary team every Wednesday morning, we have about thirty practitioners that come to our meeting. And that includes breast surgeons, breast medical oncologists, breast radiation oncologists, breast imagers, physical therapists, nutritionists, social workers, nurse navigators. We have a lot of just additional people that really take part in your care that you don’t even realize are working behind the scenes. And that really is just to make certain that you, as a person, is taken care of and not just you as a breast cancer patient.

Host: Thanks for joining us today, Dr. Wehner.

Dr. Wehner: Absolutely.

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