After treatments, can non-invasive DCIS metastasize?

CancerStinks

I am 5 years out from treatment (two lumpectomies and 25 rounds of radiation) and just got a bit of a scare today: a friend told me her sister's stage 4 BC came back after 15 years ... in her hip. Well, of course, I have been having sudden and unexplained hip pain so my ears perked up. Then reason came in: She had stage 4 and I had stage 0 non-invasive. (therefore did not have chemo.) I was offered Tamoxifen, but after much research and discussion, we decided that the negatives of it outweighed the positive in my particular case. So I chose not to take the drug. I know there is always a chance of mets, but is that true too with a non-invasive cancer? And of course my MO has retired so I am not sure who to even ask. Any and all insights are appreciated. (and yes, I did Google arthritis in hip, hip pain etc.) Many thanks.

MTwoman

hi cancerstinks,

the short answer is yes, it's possible. there is at least one women on these boards who I believe is now stage 4 after initial stage 0 with treatment, never having presented with another primary. There is actually a thread about it the theory behind your question, but I'll have to search to find it. There is great info there that you may be interested in.

Okay, found this one: https://community.breastcancer.org/forum/73/topics/851261?page=1#idx_20

but for some reason, I thought there might be another one as well. Maybe someone will come along soon and post a link (or info) from that one.

BarredOwl

Hi CancerStinks:

Here is a long answer.

A person diagnosed with DCIS can suffer from recurrent or new disease. A subsequent recurrence can be in situ disease and/or invasive breast cancer (in the same breast). They can also suffer a new invasive breast cancer (a new primary tumor in the same breast or in the contralateral breast). Such recurrent invasive disease or new invasive disease could be either early stage or metastatic breast cancer.

Because such recurrent or new invasive breast cancer can arise in between routine screenings ("interval cancers") and because of the limitations of imaging, having had a clear mammogram some time in the last year may not be definitive. You should seek medical advice and evaluation of the symptoms you have in light of your prior breast cancer diagnosis. If your insurance requires referrals, start with requesting a prompt appointment with your Primary Care Physician.

To your question about DCIS, by the assessment of the pathologist, pure DCIS (with no evidence of invasion) is confined to the inside of the ducts. Therefore, pure DCIS is considered to be "non-invasive," and it usually behaves that way.

The "conventional linear model of cancer progression states that the cells of a developing tumour gradually pick up genetic mutations, with cells that accumulate optimal [their word, not mine] variants eventually acquiring the ability to migrate to and colonize other tissues in the body as metastases" (News and Views). Thus, according to the conventional linear model, tumor cells acquire metastatic potential later in their evolution, and DCIS cells are not believed to have acquired the genetic changes that confer invasive and/or metastatic capabilities.

However, some recent preclinical studies, performed in artificial in vitro systems using cultured cells and in animal models having certain artificial genetic changes (e.g., Harper et al.; Hosseini et al.), have been interpreted to suggest that some early breast cancers might acquire metastatic potential earlier than previously thought. These preclinical observations are seen as being consistent with certain clinical studies in humans reporting on relatively unusual cases in which patients initially formally diagnosed as having DCIS (Stage 0), were later diagnosed with metastatic disease, without an intervening diagnosis of invasive disease (see, e.g., Narod (2015) and citations therein).

Narod (2015): http://jamanetwork.com/journals/jamaoncology/article-abstract/2427491

(Paywall; Available for purchase)

Narod (2015) was a very large, retrospective, observational study that relied on data in the SEER18 database, which covers approximately 28% of the US population (based on the 2010 Census). In this observational study of 108,196 women with DCIS (diagnosed from 1988 to 2011) there were 956 women (less than 1%) who died of breast cancer in the follow-up period. This number (956) includes both those with and those without a documented invasive diagnosis of recurrent or new ipsilateral or contralateral disease. The mean (range) duration of follow-up was 7.5 years (Range: 0 to 23.9 years).

That some women died without documented intervening invasive breast cancer is not consistent with a view that DCIS is always purely "non-invasive" and is incapable of distant spread. Narod proposed the existence of a small subset of DCIS (Stage 0) that is actually capable of distant metastasis. However, other possible explanations have not been eliminated, including the presence of invasive disease that was either not recorded properly or not appreciated (e.g., initial mis-diagnosis (failure to identify invasive disease); errors in medical records or the SEER database; or "occult" breast cancer).

In practice, for those with a final diagnosis of pure DCIS (Stage 0), based on combined finding of all biopsies and surgeries, their prognosis is excellent and the odds are in their favor. However, the ordinarily very favorable prognosis of pure DCIS (Stage 0) does not mean that a person should ignore symptoms of potential concern.

Hopefully, you can obtain prompt evaluation of what is going on and that is something benign and treatable.

BarredOwl

[Edited: to add "in humans"]

CancerStinks

Thank you both so much for your posts. Do you think I should call my family doctor or .. the radiologist? My MO has retired and the surgeon won't know any thing. The radiologist has also switched practices so I'm not sure if I can go with her or have to stay with the Cancer Center where she worked previously. Any insights are appreciated.

MinusTwo

I would call your GP to get a recommend for a new MO. Actually your surgeon many be able to give you a recommend for a good MO since those two specialties work closely together. Also you can a recommend from your radiation oncologist. You are not required to stay with a specific treatment center other than the restrictions of your insurance.

CancerStinks

Thanks MinusTwo. Sounds like the best plan.

MTwoman

Yay! I hoped BarredOwl would come along and give a good (actually excellent) long answer!

Mariangel43

Cancerstinks, yes, cancer may return and please read the info BarredOwl gave you. All cancers have the capacity to come back later in life. The day a physician tells us one is cancer free permanently, we should ask how and why he/she knows it. The only answer I accept as true is if he or she says God told him/her. BC can spread to the bones, lungs, brain, all my docs told me.

If you used biphosphonates to help you with some side effects, check that out too. Get a new MO through your surgeon.

We all be in solidarity with you. I will be praying for you, Don't get scared, just be diligent with the situation and take care of yourself.

Maria