If all margins clear, why radiation?

Radiation reduces the chance of a local recurrence. All it takes is one little cancer cell to sneak out and create further trouble. Consider it "life insurance".

 Congratulations on your good news, surgery over, no re-excision necessary!

The mantra is lumpectomy + radiation.

Yet, with DCIS there have been studies regarding this question - are there women who have had lumpectomies whose prognosis for recurrance won't be improved all that much by radiation? This is called the Van Nuys prognostic indicator chart for DCIS. http://www.breastdiseases.com/dcispath.htm

There are other versions on the internet as well - so  a nice visual for you to see what some of the thinking is out there regarding dcis/lumpectomy and radiation. Age, size of dcis, grade of dcis, actual size of margins are factors which were found to be significant.

and here is a general page on DCIS http://www.nccn.com/Breast_cancer_noninvasive.aspx

Julie E

My former business partner didn't have radiation after her first BC surgery, and guess what?  They didn't get all the stray cells.  So she got to have a second surgery....make that a third surgery..... because of a dispute over margins.  So go for radiation.

It has been four years after that fiasco and all is well with her.  But talk about not getting the right counsel!

She was very lucky that nothing went beyond Stage 1 so she didn't need chemo.

I had a double lumpectomy in May then a partial mastecomy in June and the margins were clear

from the second surgery. My Medical Oncologist and my Radiation Oncologist both agreed because of stage, age, class, size etc. of the tumor  not to have me go through radiation. This was a group decision.

I am on the lovely Tamoxifen  for the next five years. I have had friends who have had the kitchen sink approach but every year the thinking changes and new information makes for better informed decisions. Twenty or so years ago, regardless of the size, stage etc. it was still the Red Queen approach

"Off with her Boob"

As someone above has mentioned - research the VNPI (Van Nuys Prognostic Indicator) developed by Dr. Mel Silverstein (with the help of others, I'm sure).  If you feel like flying to SoCal, you can probably get a consult with him.  I think he only sees patients on Fridays, so you can make a weekend of it.

Also, he trained Dr. Laura Klein (in Paramus NJ - close to Manhattan but on the other side of the George Washington Bridge).  I thnk she was on maternity leave but returning in Feb. 

I was diagnosed in Oct 2009 with a small DCIS in right breast. I am 49 and still have my period.  I had lumpectomy and breast reduction. My Dr and Oncologist both agreed NO RADIATION and NO TAMOXIFEN.  I am just going to be monitored very closely now. I know they say that if you have lumpectomy you have to have radiation. But, some Dr's are beginning to think that Dcis stage 0 with wide margins can sometimes be treated with lumpectomy alone. I am glad I can skip rads but I do worry because I know this is a fairly new concept. 

Deli, I'm happy for you. If grade 0 was my type of DCIS I think I'd opt out of the rad (esp with two doctors recommending that course) very gladly and not worry. Of course you'll continue monitoring. But these are most often slow-growing tumors.... it took a long time for yours even to emerge as stage 0... try not to worry. I think in Western medicine treatment most often moves from "most aggressive" to "less aggressive" with the passage of time. Once upon a time, DCIS was treated with mastectomy. 

Linda, the information that your doctor gave you is very different from anything I've seen or heard.  The fact is that it's impossible to know what someone's recurrence risk is without understanding their full pathology.  Perhaps your doctor was referring to your situation specifically, although if she gave you that information before surgery (i.e. before she knew the size of the surgical margins), then I really don't understand.  If she gave you this information after surgery, then it might very well be accurate, but these recurrence risk numbers would apply to you only.

It is true that the recurrence risk for someone who has DCIS and just a lumpectomy, without radiation, could be as high as 50%, but from everything I've read (and I've read a lot over 4 years) that would only happen if the DCIS was high grade and if the margins were very small (<1m).  And in fact for those who have low grade DCIS and margins that are 10mm or greater, the recurrence risk, even without radiation, will be 5% or less.  Adding radiation to either situation will reduce the recurrence risk, usually by about 50%, although I've seen articles that suggest a higher benefit from radiaton and others that suggest a lower benefit.  Honestly though I've never seen a study that suggests that radiation alone could take recurrence risk down from 50% to 8%.

What it comes down to is that recurrence risk after a lumpectomy, with or without radiation. can vary hugely by individual, based on the specifics of their pathology.  As for those who have a mastectomy, the majority of studies on DCIS women who've had mastectomies put the recurrence rate at 1% - 2%.  There have been rare studies where the rate is higher, and some where the rate is lower but 1% - 2% seems to be a good average of all the studies done on this, covering thousands and thousands of women.

Sorry to disagree, and I'm not suggesting that radiation wasn't necessary for you and might not be necessary for Jane.  But the information that you provided is so far from anything else I've seen, and so far from my understanding of DCIS recurrence rates, that I had to comment.

Hi Beesie and June...I absolutely stand corrected.  The advice my surgeon gave me was based on my particular situation...IDC and under 2cm (and I am post menopause).  She was prepared to take out more than the lump if she had to once she "got in there" but was quite certain based on what she could see by the MRI and the ultrasound and biobsy...that I'd require a lumpectomy along with radiation. 

I appologize immediately if I've caused you concern, June.  I was over-reacting as I did not stop long enough to note that you were stage 0 and you don't have ICM.  Again, please accept my appology.  I guess my heart went into my mouth as soon as I read that you had a lumpectomy and didn't want radiation.  Oh my....foot in the mouth disease yet again. 

Beesie is right...we are all diagnosed and treated according to our specific case...and each and every one of us are a little bit different...

Thanks so much....again...I'm sorry 

Hi June,

I feel your pain in trying to make a decision. I think that's the hardest part of our whole ordeal! 

I had DCIS,1 cm,grade 2 and my SN was clear. I had clear margins too (after a lumpectomy). I decided against rads; I knew from day one almost that I did not want them. (My DCIS was in the left breast.)  Even though my "case" wasn't terribly bad-- in that it could have been worse, I decided to have a mast. As it turned out, all the tissue removed was totally clear. So maybe my decision was "overkill"--but there was no way to know that beforehand. I have no regrets. My BS told me that I have a less than 1% chance of recurrence. I'll take that!!!  It is a HUGE, final decision, but I would do it again. Good luck in your decision. It really is a very personal, individual decision. From my time of dx to the time of the mx, I took 2 months to decide.

Hi June,

 Before you make your decision, you should get a second opinion from Dr. Michael Lagios in Tiburon, CA. He is an expert on DCIS and a world famous pathologist. He will have your films and slides Fed Exed to him and he will re-write your pathology and tell you your VNPI score. He will give you a written report and a 45 minute phone consultation. He actually worked with Mel Silverstein to invent the VNPI. The thought behind it is that everyone was getting radiation for DCIS and there was a group of woman that didn't need it and wouldn't benefit from it. He will look at the size of your margins, the size and grade of your DCIS, your age...and he will give you a score. Based on that score, he can tell you if you are a candidate for skipping the rads. I researched his consult service very well before going foward, and it was the best thing I ever did. It will give you clarity on what you are dealing with. My surgeon sends everyone for radiation, so I wanted to make sure I really needed it and I wasn't being herded along. I was told I was a 6 by the radiologist and Dr. Lagios rated me a 7. The cut off for skipping rads is a 6...so I went ahead with it after much debate. I had a terrible experience and quit after 6 treatments of 33. I will have to make a decision on what to do after my MRI at the end of March. I will be going with close observation, but I might even have a second consult in person with Dr. Lagios before I make any further decisions. Good luck!

Hi June:
I had radiation recently for grade 3 DCIS on my left side after going through so much torment. I think I burned a hole in my computer screen from all the googling I did on the subject. When all was said and done, I felt more comfortable with my decision. I had an excellent surgeon and a wonderful radiation oncologist who spent lots of time with me and acknowledged my concerns. He even showed me the "hot spots" and how they were positioned away from my heart and lungs. Because I had such clear margins, he "promoted" me to only 28 treatments and no boosts (you may want to ask about this as an option). I had few side effects and minimal burning and it is now in the past. I know others who say the same thing - not as bad as we thought it would be. With grade 3, I just don't think there is any point in NOT having the rads. With any grade less than grade 2, I very well may have skipped it. All the best to you.

J