Radiation after DCIS or not????

I'm still in the middle of trying to get clear margins (had a lumpectomy and a re-excision and need either more re-excision or a mastectomy). I have already decided to do radiation partly because of my DCIS grade and partly because it really does seem to drop recurrence. I don't think I am a good candidate for Tamoxifen so I think I need as much post-surgery help as possible. 

I don't love the idea of radiation but I don't feel like I have much choice. But this is my situation, my grade, my size, and so on. I think everyone's situation is different. ,When I need to make a decision like this I generally find a few doctors and get a consensus, and I try really hard for those doctors to be ones I really like and trust. I hope this helps.

Since the recent scientific findings in a study based in San Francisco, many DCIS patients are not prescribed radiation. Dr. Susan Love blogged about this, not realizing it was already put into practice.

Also, there is no survival value in radiation anyway. It just reduces local recurrence.

Radiation has a cardio risk, risk of esophageal cancer, risk of a radiation-caused second tumor. Radiation is not a procedure to be taken lightly. Coping with a procedure is one thing. The longer term side effects can be much more serious than the temporary burns and infection.

Sincere best wishes in your decisions whatever they are.

dsj, thanks for the link to the discussion.

If I'm correct, you're saying is a heterogeneous disease and you can't generalize about it. Then how do you turn observation into action and decision-making if the overall survival benefit is nil for a group?

The only way you could mathematically explain any possible survival advantage for radiation to any individual would be to to accept that there must be a negative survival effect on other individuals. That is, some individual patients lived shorter lives after radiation. That's the only way you could arrive at zero survival advantage for the study group as a whole which has been the agreed upon evidence for years.

The new biomarkers already make this decision-making easier and make DCIS a less diverse disease. The problem will be getting oncologists to use these biomarkers-- which could take ten years, according to Susan Love.

mathteacher, Here's how I explain the survival benefit of radiation for women who have DCIS:

1. A. DCIS is an in-situ pre-invasive cancer (but yes, it most definitely is cancer).  An in-situ breast cancer by definition cannot move outside of the breast.  What this therefore means is that if DCIS is fully removed and there is no recurrence, the survival rate will be 100%.  The long-term survival rate of women diagnosed with DCIS is not 100%, however.  Depending on the study, it's anywhere from 96% - 98%. 

1. B. This means that some women who are initially diagnosed with DCIS do die of breast cancer.  How?  Because they have a recurrence.  50% of recurrences are not found until they are invasive cancer.  Invasive cancer, as we all know, is life threatening.

2. In study after study, radiation has been shown to cut the recurrence rate by 50%.  So for women diagnosed with DCIS, which is not life-theatening, using radiation to reduce the number of recurrences, which can be life-threatening, therefore must lead to increased survival.

1 + 1 = 2.  I don't see any other way to explain it.  

ak818, I think that dsj and sandie explained it well.  Whether or not radiation makes sense for you depends on the pathology of your DCIS, the size of your margins and your age (cancer is more aggressive in those who are younger).  For some women who have lumpectomies, radiation isn't necessary.  But for others, their recurrence risk without radiation might be unacceptably high, putting them at significant risk of invasive cancer.  There is no one-size-fits-all answer. 

Some interesting reading:

http://www.oncologyreport.com/breast/70915b.html  This shoots to #@!! the idea that the survival rate from DCIS is 100%.  And it also shows that radiation, combined with Tamoxifen, can be as effective or more effective than a mastectomy in reducing recurrences and increasing survival.

http://www.ncbi.nlm.nih.gov/pubmed/11034242 This article presents data that supports the fact that DCIS mortality is driven by recurrences.

An abstract for everyone's consideration...

BACKGROUND: To identify prognostic indicators of local recurrence (LR) in patients with ductal carcinoma in situ (DCIS) of the breast treated with breast conserving surgery (BCS) alone.

http://www.ncbi.nlm.nih.gov/pubmed/20645008

Wyldblumusic, thank you. But there is a problem.

Beesie,  this study only addresses breast cancer survival, not overall survival (deaths from all causes). We are discussing whether radiation has any overall survival value--if it helps patients live longer from all causes.

Also, this study only goes out a little over nine years. The cardiac problems and secondary cancers show up a little later contributing to raising the death of non breast cancer causes. I sent you the Fisher study which showed at 20 years, radiation makes no difference. The serious side effects of radiation, mostly on the heart, cancel out the early benefits regarding local recurrence.

That's why breastcancer.org has a page which talks about radiation benefiting recurrence but not survival.

Scroll down on: http://www.breastcancer.org/treatment/radiation/new_research/20060217a.jsp

to where the doctors point out: There was no difference in overall survival in either trial between women who had radiation treatment and women who did not.

Can I ask a kind of  off=topic question?  My rads onc told me if I didn't do rads he put my rate of recurrance at "at least 35%" and with rads it would go down to 4%.  My bs told me if I didn't do rads it would come back of that she felt certain.  While I am happy with 4% I'm not sure how half of 35 equals 4!

ak818,

Go to:  http://www.mskcc.org/mskcc/html/15938.cfm  (Memorial Sloan-kettering).  Click the box on the right for Risk Calculators.  Follow through to the DCIS calculator.  Fill in your information and it will calculate your risk percentage. Fill it out one time checking "yes" for radiation.  Look at your risk percentage.  Fill it out again checking "no" for radiation.  Look at your risk percentage again. You can print it out and bring it in to discuss the results with your oncologist.

I feel for you.  After gathering and evaluating all of my medical records, and then assessing my tolerance (or lack thereof), I made a huge swing from thoughts of "watchful waiting", to a choice of a double mastectomy.  Do what you feel is the best choice for you!

Love & Light 

Huh, that calculator was pretty neat.  I entered all my info and without rads it gave me a recurrance rate of 35% (after 5 yrs) and 50% (10yrs).  With rads it came up with 15% and 23% (10yr).  Maybe my mast helped bring the 15 down to 4?  Cause I like 4 a whole lot better than 15!  My med onc said I would not need Tamoxifen (yea!) because I opted for the bi-lat.  Thanks for the info.

mathteacher,

I was going to respond, but I think Fearless_One's post pretty much covers the answers to your questions.

mathteacher,

Didn't understand what you were trying to say, or where you were leading in your previous posts.  One of the major reasons I had a double mastectomy, rather than a lumpectomy, was that I wanted nothing to do with radiation because of how hard it can be on the body.   

Mathteacher,

You are falsely representing the Fisher article that you cited.  Here is the summary on survival:

"The hazard ratio for death among

the women who underwent lumpectomy alone, as

compared with those who underwent total mastectomy,

was 1.05 (95 percent confidence interval, 0.90 to

1.23; P=0.51). The hazard ratio for death among the

women who underwent lumpectomy followed by

breast irradiation, as compared with those who underwent

total mastectomy, was 0.97 (95 percent confidence

interval, 0.83 to 1.14; P=0.74). Among the lumpectomy-

treated women whose surgical specimens

had tumor-free margins, the hazard ratio for death

among the women who underwent postoperative

breast irradiation, as compared with those who did

not, was 0.91 (95 percent confidence interval, 0.77 to

1.06; P=0.23). Radiation therapy was associated with

a marginally significant decrease in deaths due to

breast cancer. This decrease was partially offset by an

increase in deaths from other causes."

This article in fact shows that of the three arms of the study, the overall survival rates were not different enough to be statistically significant but they were:

1. best for the lumpectomy with irradiation group

2. next best for mastectomy

3. worst for lumpectomy without irradiation

Again these differences are not statistically significant.  That the result was not statistically significant is not surprising since the study did not have sufficient power to expect to find a difference at a 95% level of confidence. 

For those who want to try to investigate themselves the reference is:

http://www.nejm.org/doi/pdf/10.1056/NEJMoa022152

redsox, you and I think alike - and are on the same schedule.  Here's a copy of a response to mathteacher that I just posted in the Alternate Treatment forum:

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The Fisher study, which seems to be the primary study that is driving this belief that radiation doesn't lead to increased survival, actually comes to the following conclusion:  "Lumpectomy followed by breast irradiation continues to be appropriate therapy for women with breast cancer, provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained."

Rather than take the conclusion of the study's authors, some women here have reached their own conclusions.  If I understand correctly, the argument being made is that there is no long term survival difference between the lumpectomy only group and the lumpectomy + radiation group and therefore radiation is not necessary.  Furthermore, the case is being made that it's the radiation itself that causes increased mortality over the long term in the lumpectomy + radiation group. Reading the study report, I don't come to these same conclusions.  In fact, mathteacher, to your request that I produce evidence, let me use the Fisher study.

What the study found is:  1) At 20 years, there is a statistically significant survival benefit within the lumpectomy + radiation group, as it relates to breast cancer mortality. In other words, over the long term there were fewer deaths from breast cancer among those who had radiation; and  2) Despite the previous finding, at 20 years there is no statistically significant difference in overall survival between the lumpectomy group and the lumpectomy + radiation group.  This is because the decrease in breast cancer deaths "was partially offset by an increase in deaths from other causes."  Key words: "Statistically significant."  "Partially offset."

Here's how I interpret the results. While there was no statistically significant difference in overall survival, the significant reduction in breast cancer deaths in the radiation group was only partially offset, thereby leading to a directional difference in overall survival favoring the lumpectomy + radiation group.  As I calculate it, the 20 year total mortality rate for the lumpectomy group was 53.33% (304 deaths, 570 sample size) vs. only 49.91% (283 deaths, 567 sample size) for the lumpectomy + radiation group.  These results are not statistically significant; this means that we can't be 90% sure that this difference was caused by the addition of the radiation.  If the difference had been just a bit larger - 54.3% vs. 49.5%, for example - the result would be statistically significant. Alternately, if the sample size had been larger and the results unchanged, the difference would be statistically significant.  Of course if the sample size had been larger it's also possible that the results would have been different - the difference in mortality between the groups might have been lessened or it might have been increased.

In other words, the Fisher study does not prove and is not saying that there is no difference in overall survival.  The study is saying that there is no significant difference.  That's another way of saying that they could not prove whether there is a difference or not.  The directional results lean towards showing a survival difference in favor of the radiation group but the only fair conclusion is to say that we just don't know. So I guess the study doesn't really support either position, although the data leans towards supporting the long-term benefit of radiation  - and that must be why the authors continue to recommend "lumpectomy followed by breast irradiation".

As for the idea that it's the radiation that is causing the additional deaths within the lumpectomy + radiation group, the authors do not say this.  Instead, what they say is that "(o)ur findings also indicate the need for information about the cause of death in clinical trials with long-term follow-up"  In other words, they don't know what led to the higher death rate (non-breast cancer related) in the radiation group.  Without examining and comparing the cause of death of the women in both groups, it's impossible to say that it was the radiation that led to the higher non-breast cancer mortality rate in the radiation group.

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To all those with DCIS, please note that this study has nothing to do with DCIS patients - this was a study done on patients who have invasive cancer.  For that reason I wasn't going to post this reply here but since mathteacher came to this forum and keeps bringing up these non-DCIS examples, I figured that I might as well respond here as well as in the Alternate Treatment forum (which an identify discussion is going on).

mathteacher, it's also not fair to suggest that Dr. Weiss passed on radiation because of any concerns she might have about radiation.  We know nothing about her diagnosis. If she had invasive cancer along with a lot of DCIS, or perhaps a multi-centric breast cancer, a mastectomy might have been her only viable option.  That was the case for me.  I had a mastectomy and I didn't have radiation but what I did - out of necessity - is not a reflection of my feelings about those treatments.  Given a choice, I would have chosen to have a lumpectomy + radiation instead of a mastectomy.  Looking back now, 5 years later, I'd still say the same thing. 

Again that is still consistent with what I said.  The studies do not have the statistical power to show a difference in survival.  The primary endpoint is recurrence.