confused about what happens after lumpectomy for DCIS

Scsa

I am scheduled for a lumpectomy for DCIS in less than two weeks. My surgeon said she would only recommend radiation therapy if it was necessary. What do they look for when deciding for or against radiation? If the margins are clean - no radiation? and if not clean then yes radiation? Also, if the margins are not clean, does that automatically mean the cancer type is upgraded to something worse? I'm confused... thanks for helping me sort this out.

Moderators

HI Scsa, and welcome to Breastcancer.org!

We're sure some others will be weighing in shortly, but we wanted to point you to the main Breastcancer.org site's page on Treatment for DCIS, which explains when radiation after lumpectomy might be suggested for DCIS, including information on Oncotype DX scores for DCIS.

We hope this helps!

--the Mods

Annette47

Generally, if they can't get clean margins they will recommend a re-excision or even a mastectomy. Getting wide clean margins may reduce the need for radiation, especially in older women with lower grade DCIS, but generally the standard of care following a lumpectomy for most women has always been radiation. That may be changing though, with more doctors being willing to forgo it in some cases. In addition to the size of the margins, they will look at the grade of the DCIS - higher grade is more likely to be recommended radiation. They may also look for the presence of a micro invasion which can affect the recommendation as well. They should have an idea of the grade of the DCIS from the biopsy, but since that only samples a tiny area, it is possible that your DCIS is made up of a mixture of grades, so they like to see the entire sample before giving you the official grade.

Not getting clean margins does not upgrade the cancer type from DCIS. That is ALWAYS Stage 0, no matter how large it gets unless an invasive component is found. What determines whether the cancer is invasive is whether or not it has broken through the ducts into the rest of the breast. DCIS can spread extensively through the ducts to the point where it covers large parts of the breast without actually breaking through and becoming invasive. Or, in some cases such as my own, it can start to break through the ducts very quickly after forming. No one knows exactly why/when that will happen, although they can identify some risk factors. Approximately 20% of the time a diagnosis of DCIS is upgraded after getting the complete pathology from the lumpectomy - which of course means 80% of the time it stays DCIS.

Hope that helps!

Scsa

Thank you Annette47 Your explanation helps. I'm 44 so not sure if that will make my doctor lean towards no radiation. She mentioned since you can only do radiation once she would not recommend it unless absolutely necessary. I'm going to MSKCC. The lab that analyzed the biopsy said intermediate grade. I transferred the biopsy slides to MSKCC and they said low grade. The doctor explained the difference between intermediate and low grades are somewhat subjective.

Annette47

MSKCC has an on-line nomogram you can use to calculate your recurrence risk with and without radiation and tamoxifen ... you won’t have exact information to plug in until your surgery, but you can play around with it so you’ll have some ideas about questions to ask ...

http://nomograms.mskcc.org/breast/DuctalCarcinomaInSituRecurrencePage.aspx

At 44 (I was 45 at diagnosis) they like to recommend radiation as cancers in younger women are more likely to be aggressive and we have that much longer to get recurrence, but as your doctor mentioned, the other factor to consider is “saving it” for next time. In my case, I also had a tiny amount of invasive cancer, and was predicted to have a fairly high (30% according to my radiation oncologist) recurrence risk without radiation, so it was recommended. With a low grade DCIS and (hopefully) no invasion, they may make a different recommendation in your case.

The “official” standard of care sets the age at which radiation is no longer “standard” after a lumpectomy for DCIS at 70, but that is starting to change as more concern is being shown about “over treatment” for DCIS.