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. 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. 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. According to the American Cancer Society, about 60, cases of DCIS are diagnosed in the United States each year, accounting for about 1 out of every 5 new breast cancer cases.
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Currently, all DCIS lesions are treated, and treatment comprises either mastectomy or breast-conserving surgery supplemented with radiotherapy. However, most DCIS lesions remain indolent. Difficulty in discerning harmless lesions from potentially invasive ones can lead to overtreatment of this condition in many patients. To counter overtreatment and to transform clinical practice, a global, comprehensive and multidisciplinary collaboration is required.
Here we review the incidence of DCIS, the perception of risk for developing invasive breast cancer, the current treatment options and the known molecular aspects of progression. This international effort will seek to determine which DCISs require treatment and prevent the consequences of overtreatment on the lives of many women affected by DCIS. Individual lesions differ in aspects of the disease: presentation, histology, progression, and genetic features.
Therefore, conventional management includes mastectomy or breast-conserving surgery supplemented with radiotherapy; in some countries, adjuvant endocrine therapy is added. Owing to the uncertainty regarding which lesions run the risk of progression to invasive cancer, current risk perceptions are misleading and consequently bias the dialogue between clinicians and women diagnosed with DCIS, resulting in overtreatment for some, and potentially many, women.
Improving the management and treatment of DCIS presents a central challenge: distinguishing indolent, harmless DCIS lesions from potentially hazardous ones.
To answer this question, we need to adopt an interdisciplinary and translational approach, merging fields of epidemiology, molecular biology, clinical research and psychosocial studies. How low does the risk need to be to refrain from treating DCIS?
What are the prognostic markers and read-outs we can rely on? How do we frame and communicate the risks involved? In this review, we describe the current approaches to diagnosing DCIS, the perception of the risk of developing invasive breast carcinoma, the treatment options available following a diagnosis and a current knowledge of the progression of DCIS, before outlining future endeavours and the need for an integrated approach that blends clinical and patient insights with scientific advances.
Despite the good prognosis and normal life-expectancy, women diagnosed with DCIS may experience substantial psychological distress 29 and overestimate the implications of a DCIS diagnosis. And, finally, iii what is the impact on quality of life for active surveillance of women diagnosed with low-grade DCIS? Addressing these questions requires central involvement of patient voices to improve clarity not only for patients but also for healthcare providers about the implications and risks of a diagnosis of DCIS.
Current diagnosis and imaging DCIS is usually straightforward to detect by mammography because of its association with calcifications; the proliferation of cells itself is not visible on the mammogram. After detection, the lesion is classified by the pathologist by histological features as low, medium or high grade, which is assumed to correspond to the level of aggressiveness.
Surprisingly, many grading systems exist. Despite an excellent prognosis and normal life-expectancy, women diagnosed with DCIS experience stress and anxiety. The need for effective doctor—patient communication is therefore essential for patients to understand the risk of recurrence. The development of a prediction tool could help to classify patients into risk groups and provide accurate guidance to patients, as well as healthcare professionals, in their choice of an appropriate treatment option.
A mastectomy is advised if the DCIS is too extensive to allow breast conservation. According to Elshof et al. Adding radiotherapy to breast-conserving treatment reduces local recurrence rates but does not influence overall survival or breast-cancer-specific survival.
In general, such a procedure is done with mastectomy for DCIS since there is no opportunity to perform a subsequent sentinel node biopsy or where there is a high suspicion for invasive disease even where DCIS alone is present in the preoperative biopsy. In addition, the notion of systemic treatment for a localised disease with an excellent outcome is perceived as being counterintuitive. Although anastrozole administration more often causes side effects such as musculoskeletal pain, hypercholesterolaemia and strokes, tamoxifen is associated with muscle spasm, deep vein thrombosis and the development of gynaecological symptoms and gynaecological cancers.
A prospective study with long-term follow-up is the only way to gain confidence regarding the natural course of DCIS, and therefore the potential need for interventions. Patients receive annual mammography in COMET biannual mammography in the active surveillance arm to monitor the lesions. Patients in the control arm will get conventional treatment surgery often supplemented with radiotherapy.
From DCIS to invasive breast cancer Proposed mechanisms for the development of invasive breast cancer Although the natural course of the intraductal process is unknown, DCIS is considered to be a non-obligate precursor of invasive breast cancer.
Four evolutionary models have been proposed to describe the progression of DCIS into invasive breast cancer Fig. On the basis of mathematical simulations of the observed frequencies of the histological grade of DCIS and the histological grade of invasive disease in the same biopsy sample, Sontag et al. Recent studies elucidating molecular differences between DCIS and invasive breast cancer further support the relevance of this model. Furthermore, this model assumes that all the cells within the DCIS duct have the same genetic aberrations but that the combination of aberrations could differ between ducts within the same DCIS lesion.
However, in some cases, DCIS and adjacent invasive breast cancer differ in copy number and gene mutations, supporting the notion that, at least in some cases, progression is driven by specific clones leading to the same phenotype.
Shifts in clonal frequencies were observed, suggesting that some genotypes are more invasive than others. The same subclones were present in both in situ and in invasive regions with no additional copy number aberrations acquired during invasion and few invasion-specific mutations. These findings are, however, limited by their small sample size and comparison of contemporaneous DCIS and invasive disease.
Some molecular analyses have shown that pre-invasive lesions and invasive breast cancer display remarkably similar patterns,.
Ductal carcinoma in situ: to treat or not to treat, that is the question
Breast Cancer Res Treat. In some cases, DCIS may become invasive and spread to other tissues, but there is no way of determining which lesions will remain stable without treatment, and which will go on to become invasive. Our data suggest that physicians are more successful at conveying the risks conferred by DCIS than the nuances of DCIS as a non-life-threatening diagnosis. Was this article helpful?
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Ductal Carcinoma In Situ (DCIS)