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Treatments and drugs
By Mayo Clinic staffTreatment of DCIS has a high likelihood of success, in most instances removing the tumor and preventing any recurrence, particularly a recurrence that spreads beyond the original site.
In most cases, treatment options for DCIS include:
- Lumpectomy and radiation therapy
- Simple mastectomy
In some cases, treatment options may include:
- Lumpectomy only
- Lumpectomy and the drug tamoxifen
Surgery
If you're diagnosed with DCIS, one of the first decisions you'll have to make is whether to treat the condition with breast-conserving surgery (lumpectomy) or breast-removing surgery (mastectomy).
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Lumpectomy. Lumpectomy removes only a portion of your breast. The procedure allows you to keep as much of your breast as possible, and depending on the amount of tissue removed, usually eliminates the need for breast reconstruction.
Lumpectomy followed by radiation therapy is the most common treatment for DCIS. Research suggests that, while women treated with lumpectomy have slightly higher recurrence rates than women who undergo mastectomy, survival rates between the two groups are very similar.
For older women with multiple medical conditions, lumpectomy plus tamoxifen therapy or lumpectomy alone may be an option.
- Mastectomy. For treating DCIS, a simple mastectomy — removing the breast tissue, skin, areola and nipple, and possibly the underarm lymph nodes (sentinel node biopsy) — is one option. Breast reconstruction after mastectomy, if desired, can be performed in most cases. Because lumpectomy combined with radiation is equally effective simple mastectomy is less common than it once was for treating DCIS.
Most women with DCIS are candidates for lumpectomy. However, mastectomy may be recommended if:
- You have a large area of DCIS. If the area is large compared with the size of your breast, a lumpectomy may not produce acceptable cosmetic results.
- There's more than one area of DCIS (multifocal or multicentric disease). It's difficult to remove multiple areas of DCIS with a lumpectomy. This is especially true if DCIS is found in different sections — or quadrants — of the breast.
- Tissue samples taken for biopsy show cancer cells at or near the edge (margin) of the tissue specimen. There may be more DCIS than originally thought, meaning that a lumpectomy might not be adequate to remove all areas of DCIS. If the area of DCIS is large, relative to the size of your breast, lumpectomy may produce unacceptable cosmetic results.
- You're not a candidate for radiation therapy. Radiation is usually given after a lumpectomy. You may not be a candidate if you're diagnosed in the first trimester of pregnancy, you've received prior radiation to your chest or breast, or you have a condition that makes you more sensitive to the side effects of radiation therapy.
- You prefer to have a mastectomy rather than a lumpectomy for any reason. For instance, you might not want a lumpectomy if you don't want to have radiation therapy.
Surgery for DCIS typically doesn't involve removal of lymph nodes from under your arm because it's a noninvasive cancer. The chance of finding cancer in the lymph nodes is extremely small. If tissue obtained during surgery leads your doctor to think cancer may have spread outside the breast duct or you will be having a mastectomy, he or she may then recommend a sentinel node biopsy or removal of some lymph nodes at the time of surgery.
Radiation therapy
Radiation therapy after lumpectomy reduces the chance that DCIS will come back (recur) or that it will progress to invasive cancer. Radiation therapy uses high-energy X-rays to kill cancer cells or damage them to the point where they lose their ability to grow and divide. Because cancer cells multiply rapidly, they're more vulnerable to the effects of radiation than are normal cells. A type of radiation therapy called external beam radiation is most commonly used to treat DCIS.
Women whose cancer has the following low-risk characteristics may be effectively treated with lumpectomy without radiation:
- Small affected area
- Low-grade tumor
- Large, cancer-free surgical margins
Tamoxifen
The drug tamoxifen (Nolvadex) blocks the action of estrogen — a hormone that fuels breast cancer and promotes tumor growth — to reduce your risk of developing invasive breast cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone receptor positive cancers).
Tamoxifen isn't a treatment for DCIS in and of itself, but it can be considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the future. If you choose to have a mastectomy, there's less reason to use tamoxifen. With a mastectomy, the risk of invasive breast cancer or recurrent DCIS in the small amount of remaining breast tissue is very small. Any potential benefit from tamoxifen would apply only to the opposite breast. Discuss the pros and cons of tamoxifen with your doctor.
Factors that influence treatment
Several factors may influence treatment of DCIS. Researchers are attempting to identify which women are at high risk of recurrence and which are at low risk, based on the following factors:
- Pathologic margins. If cancer cells extend close to the edge of the tissue samples removed during lumpectomy surgery, there's a higher likelihood that some cancer cells have been left behind. In such a situation, a re-excision — removing an additional, larger area of breast tissue — or a mastectomy may be necessary.
- Tumor size. A small tumor has a better chance of being adequately removed with lumpectomy than does a larger tumor.
- Grade. High-grade tumors have a higher rate of developing into invasive breast cancer than do low-grade tumors.
- Cell structure. Tumors with comedo necrosis have a higher rate of recurrence than do DCIS tumors without comedo necrosis.
- What is breast cancer? American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_breast_cancer_5.asp?sitearea=. Accessed May 7, 2009.
- Lagios MD. Breast ductal carcinoma in situ and microinvasive carcinoma. http://www.uptodate.com/home/index.html. Accessed May 7, 2009.
- Meisner ALW, et al. Breast disease: Benign and malignant. Medical Clinics of North America. 2008;92:1115.
- Do we know what causes breast cancer? American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Do_we_know_what_causes_breast_cancer_5.asp?rnav=cri. Accessed May 7, 2009.
- Costanza ME, et al. Epidemiology and risk factors for breast cancer. http://www.uptodate.com/home/index.html. Accessed May 7, 2009.
- The basics of DCIS. Breastcancer.org. http://www.breastcancer.org/symptoms/types/dcis/basics.jsp. Accessed May 7, 2009.
- Can breast cancer be found early? American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri. Accessed May 7, 2009.
- Hulvat MC, et al. Multidisciplinary care for patients with breast cancer. Surgical Clinics of North America. 2009;89:133.
- How is breast cancer treated? American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_of_stage_0_breast_cancer.asp?rnav=cri. Accessed May 7, 2009.
- The emotional impact of a cancer diagnosis. American Cancer Society. http://www.cancer.org/docroot/MBC/content/MBC_4_1X_The_Emotional_Impact_of_A_Cancer_Diagnosis.asp?sitearea=MBC. Accessed May 7, 2009.
- What are the risk factors for breast cancer? American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_breast_cancer_5.asp?rnav=cri. Accessed May 7, 2009.
