Surgery

When diagnosed with DCIS, the word “carcinoma” in “ductal carcinoma in situ” is frightening. No wonder many women want it removed immediately. However, because DCIS is non-invasive, it is biologically incapable of leaving the milk duct, let alone spreading outside the breast. It is not necessary to rush into surgery.

Traditionally, women have been offered a choice of a lumpectomy or a mastectomy. The goal of either is to remove all DCIS plus a margin of normal tissue. However, not all DCIS is created equal. Surgery for low grade DCIS appears to improve an already outstanding overall survival by very little, while it seems to improve survival more substantially if the DCIS is high grade, according to a 2015 study in the Journal of Clinical Oncology by Yasuaki Sagara.

With a lumpectomy, usually a mammogram is used to place surgical guide wires. Too often a re-excision is needed because not all DCIS shows up on the mammogram. Instead, using MRI imaging, ultrasound guidance, immediate intraoperative pathology or radioactive markers might be ways to eliminate additional surgery.

After a lumpectomy, six weeks of daily radiation is often recommended, although this may not be necessary for all DCIS.

One way to decide between mastectomy and lumpectomy is to compare your recurrence risk for both. A tool that can be used is The Van Nuys Prognostic Index.

With a mastectomy, radiation is not usually recommended. However, the surgery and recovery times are longer. If reconstruction is done, this process requires several surgeries and may result in complications. A woman will also lose all feeling in her reconstructed breast.

Dealing with the loss, coping with a new body image and worrying about the cancer coming back are all emotional issues factoring into a surgery decision. Here are some helpful considerations when deciding on treatment options.

A 10 year study revealed no difference in long-term survival among women with DCIS who chose mastectomy over lumpectomy or visa versa.

Breast reduction oncoplasty is another surgical option. Dr. Melvin Silverstein pioneered this surgery, which offers better cosmetic results and is done in lieu of a mastectomy.

Recently, Suzanne Somers’ breast regrowth surgery, has also become available to the average woman. This amazing surgery regrows breast tissue taken from fat stem cells. Another up and coming alternative to traditional surgery is cryoablation, the use of extreme cold to destroy tissue. In a study published in the Annals of Surgical Oncology, cryoablation was successful for 92% of tumors measuring 2 cm or less.

For any surgery, a 1999 study showed that survival improves if it is performed during the luteal phase of a pre-menopausal patient, days 0-2 and days 13-32 based on a 32 day calendar.

Because it induces angiogenesis, inflammation and cell adhesion, and also suppresses the immune system, surgery itself may encourage recurrence. A Life Extension article offers prevention suggestions.

One non-surgical option for DCIS treatment may be tamoxifen. In a recent study, Dr. Shelley Hwang prescribed tamoxifen to shrink DCIS prior to surgery. Some women were able to avoid surgery altogether.

A few doctors recommend active surveillance instead of surgery.  Dr. Laura Esserman suggests “If it doesn’t look like high grade DCIS we should leave it alone.”

Treatment for DCIS is not one-size fits all. Women can and should choose individualized treatments right for them.

The good news is that for women who choose surgery without radiation, the recurrence rate for DCIS over the last 30 years has declined according to an abstract presented at the 2015 Breast Cancer Symposium. The 5-year recurrence rate for 1978–1998 was 13.6% versus 6.6% for 1999–2010.

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