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How to individualize cancer risk reduction after a diagnosis of DCIS

OBG Management. 2015 October;27(10):20,22,24
October 30, 2015|ObGyn
Laila Samiian, MD;Andrew M. Kaunitz, MD
Author and Disclosure Information

Laila Samiian, MD, and Andrew M. Kaunitz, MD

Dr. Samiian is Assistant Professor and Chief, Section of Breast Surgery, at the University of Florida College of Medicine–Jacksonville. Dr. Samiian serves as the Director of the University of Florida Health Jacksonville Multidisciplinary Breast Conference.

Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He is also Director of Menopause and Gynecologic Ultrasound Services, UF Women’s Health Specialists–Emerson. He serves on the OBG Management Board of Editors.

The authors report no financial relationships relevant to this article.

With proper patient counseling and careful decision making, you can reduce the risk of recurrence and invasive disease without overtreating the condition

    In this Article

  • What is DCIS?
  • Why did some deaths occur after diagnosis of DCIS?
  • Why did some deaths occur after diagnosis of DCIS?

Counsel precisely and accurately. Beyond such testing, we should focus on what is important to our patients in explaining the diagnosis:

  • Our patients want to know that they are going to survive. Explain that DCIS is not a life-threatening cancer but a significant risk factor and is fully treatable with a long-term survival rate of 97%.
  • Do not omit surgery. Follow-up surgical excision is still recommended after a core needle biopsy diagnosis of DCIS, as there is a 25% risk of finding invasive disease upon surgical excision.11,12 In our opinion, surgical excision represents the standard of care for DCIS, as some lesions may harbor invasive breast cancer.
  • Explain the pros and cons of radiation to the patient once surgical excision has confirmed the diagnosis of pure DCIS. If the patient’s goal is to avoid any recurrence, then radiation can be useful and is particularly appropriate for women with high-grade, large, and estrogen-receptor–negative DCIS. However, patients in this setting need to recognize that radiation will not improve their already excellent rate of survival. For many patients, any recurrence, whether it’s DCIS or invasive disease, can be a devastating emotional event. But even in patients who experience a recurrence, early detection and treatment portend a very good outcome.
  • Be aware of the fear of chemotherapy. Avoiding chemotherapy is a paramount (and understandable) desire for many women diagnosed with breast cancer. Women who choose radiation reduce their likelihood of invasive recurrence and potentially avoid the need for chemotherapy in the future.
  • Know when mastectomy is indicated. Multicentric extensive DCIS is still an indication for mastectomy. The safety of avoiding mastectomy in this setting needs to be assessed by randomized trials. It may be safe for some women with DCIS, such as elderly patients with low-grade lesions, to undergo lumpectomy to rule out underlying invasive disease and be treated with endocrine therapy and observation, with or without radiation therapy. The issue of multiple re-excisions for close margins is also being re-evaluated.

Informed and shared 
decision making is key
DCIS is an increasingly common and usually non–life-threatening condition. Radical surgery such as bilateral mastectomy for small unifocal DCIS is excessive and will not improve a patient’s outcome. As a prominent breast surgeon has written:

A high level of anxiety regarding breast cancer is associated with rates of contralateral prophylactic mastectomy that are as high as those seen among women with two first-degree relatives with breast cancer or known mutations. Contralateral prophylactic mastectomy is an extremely expensive, resource-intensive way of treating anxiety, and we need to find better ways of communicating the lack of benefit of this procedure to patients.13

We must balance the small risk of breast cancer recurrence after lumpectomy for DCIS with patients’ quality of life concerns. This goal is best accomplished by using an informed and shared decision-making strategy to help our patients make sound decisions regarding DCIS.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

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