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home : features : health November 20, 2014

Health Watch: DCIS - Is It Breast Cancer Or Not?

After mammography and fine needle biopsy, my co-worker was told that she had ductal carcinoma in situ in her left breast. "I went home and cried," she said. "And I couldn't sleep at all that night."

What if she had been told instead that her diagnosis was ductal intraepithelial neoplasia? Or, simply, abnormal cells? "I would have been worried," she said, "and would want more information. But that's not cancer. Cancer means chemotherapy, losing your hair and, possibly, death."

Actually, ductal carcinoma in situ (DCIS) and ductal intraepithelial neoplasia (the term used by the World Health Organization) are one and the same -- abnormal cells (also called a lesion) in a milk duct of the breast. DCIS is not cancerous and, in 60 to 80 percent of cases, will never become cancer.

One of every four breast cancer diagnoses in the United States today is for DCIS, and patients are usually anxious to get rid of what they consider cancer as soon as possible.

In a study of 400 DCIS patients at Duke University, the terminology was an important factor in the woman's prospective choice of treatment. Told that they had a non-invasive cancer, 47 percent said they would opt for surgery after weighing risks and benefits. When told that they had "a lesion" or "abnormal cells," two thirds would choose another option -- medication or watchful waiting.

Carcinoma is cancer that begins in the tissue that lines the inner or outer surfaces of the body. In situ, though, means in place; in other words, it is not going anywhere, not invading nearby cells. As a result, some doctors believe the term carcinoma is misleading and should be dropped from the terminology.

A National Cancer Institute working group issued a controversial report calling for a less threatening term such as "indolent lesion of an epithelial origin." According to the report, "use of the term 'cancer' should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated."

Along with the change of terminology has come a call for more watchful waiting, an option that recently has been recommended and used for prostate cancer. Would the same approach be useful -- and safe -- for DCIS?

There is, by no means, agreement on this issue. Even though ductal carcinoma in situ is non-invasive, the risk should not be minimized, some say. These are abnormal growths with many of the same traits as invasive cancer cells. A significant number -- 20 to 40 percent -- develop into cancer, and women who have one or more lesions often develop invasive cancers elsewhere.

At this time, there is no certain way of telling which growths are potentially harmful and which are not. As a result, virtually all cases of DCIS are treated, usually with breast-conserving lumpectomy, sometimes followed by radiation therapy. Some patients, however, choose mastectomy, removal of one or even both breasts.

DCIS is rarely discovered as a lump. In 1980, before the advent of widespread mammography screening, these lesions represented only about one percent of all breast cancers. As mammography has become more widely used and more sensitive, DCIS diagnoses have increased rapidly.

These are small cancers detected early; and when DCIS is treated, survival is virtually 100 percent. But there is still uncertainty regarding how aggressively these should be treated. Since 60 to 80 percent of these lesions are benign and will never progress to the stage of invasive cancer, doctors realize that overtreatment is common.

Even though 60,000 new DCIS cases are being treated each year, there has been no corresponding decrease in the rate of invasive breast cancer. This suggests that there has been little or no value in treating DCIS as if it were early cancer, according to Laura Esserman, M.D., M.B.A., co-author of an essay published in the Journal of the American Medical Association [2009;302:1685-1692].

A joint news release from the Susan G. Komen for the Cure and the College of American Pathologists addressed some of the controversy. Mammography screening is still important, they point out, and should not be avoided because of fear of unnecessary therapy. Women should rather take an active role at every step of the process. Know what questions to ask and be confident about your ability to weigh your own individual risks and benefits.

This information was submitted by Northeastern Vermont Regional Hospital in St. Johnsbury and is meant to complement, not replace, the advice and care you receive from your health care provider.

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