What exactly does "high grade" mean?

Well, I'm not Beesie (who knows everything) but I do know that no necrosis is good.  High grade isn't the best, but there are other factors.  I consulted Dr. Lagios, the known expert, about understanding the pathology.  I borrowed the $635 to consult with him, and felt it was well worth it.  There are several components that make a prognosis.  No necrosis is good, high grade not so much.  I think you have to ask someone (Dr. Lagios, your MO, someome) to make a real evaluation of your own personal prognosis.  Please don't worry.  We, who are in the DCIS/DCISMI catagory have a really good outcome.  I defer to Beesie, who will chime in, because she's a a saint. xx

Here's how breastcancer.org explains high grade DCIS:

"In the high-grade pattern, DCIS cells tend to grow more quickly and look
much different from normal, healthy breast cells. People with
high-grade DCIS have a higher risk of invasive cancer, either when the
DCIS is diagnosed or at some point in the future. They also have an
increased risk of the cancer coming back earlier — within the first 5
years rather than after 5 years."  http://www.breastcancer.org/symptoms/types/dcis/diagnosis

Now let's break that down to figure out what it means:

• People with
  high-grade DCIS have a higher risk of invasive cancer, either when the
  DCIS is diagnosed...   What this means is that if you have high grade DCIS found by a needle biopsy, there is a greater chance (than if you had low grade DCIS) that some invasive cancer will be found at the time of surgery.  But if you've had the surgery and no invasive cancer was found, then this risk no longer exists. 

• ...or at some point in the future.   What this means is that if high grade DCIS is not removed from the breast, it is highly likely to become invasive cancer, usually within a 5 year time frame.  But here again, if you have surgery to remove the high grade DCIS from the breast, this risk is eliminated.

• They also have an
  increased risk of the cancer coming back earlier — within the first 5
  years rather than after 5 years.  This means that after surgery (before other treatments), the risk of recurrence for someone with high grade DCIS is higher than the risk of recurrence for someone with intermediate or low grade DCIS.  But recurrence risk is affected by much more than just the grade. Margin size is a big factor, as is the size and focality of the DCIS.  Whatever grade of DCIS someone has, the objective is to get the recurrence risk down into the single digits, and possibly low single digits.  If someone has a small single focus of low grade DCIS, a low recurrence risk might be achieved with surgery alone, if the margins are sufficiently large.  Or perhaps if the margins are very narrow, rather than a re-excision, rads will be recommended.  For someone with high grade DCIS, it takes more to get the recurrence rate down to those same low levels.  Having a good margin is more important, and even with good margins, rads will always be recommended.  For those who are ER+, hormone therapy may be recommended.  But with these treatments, the recurrence risk for high grade DCIS often can be brought to similar levels as the recurrence risk for a lower grade DCIS.  So at that point, this extra risk is eliminated.  As for the fact that high grade DCIS is more likely to recur within 5 years, that's actually a good thing because it means that there is less risk of recurrence after 5 years than there would be for lower grades of DCIS. 

.

So, all in all, while having high grade DCIS is more concerning, with adequate treatment, all the extra risks associated with high grade DCIS can be eliminated.  And high grade DCIS is still DCIS - it's still a pre-invasive cancer, which means that just like any other DCIS, high grade DCIS cannot travel to the nodes or outside of the breast.  And that's the most important thing of all.

Hope this helps and makes sense!

Beesie,

I had a 6+cm high grade solid with necrosis.  I had a BMX but no radiation..they said I had good margins.  I read the Dr. Susan Love book and fired off several questions about why they had not performed hormone tests on my tumor and should I have radiation or tamoxifen. I still feel uneasy. I copied from your response...did I read it wrong...it looks like you are saying even with good margins rads is still recommended but is that lumpectomy only or mastectomy as well????

risk might be achieved with surgery alone, if the margins are sufficiently large. Or perhaps if the margins are very narrow, rather than a re-excision, rads will be recommended. For someone with high grade DCIS, it takes more to get the recurrence rate down to those same low levels. Having a good margin is more important, and even with good margins, rads will always be recommended. For those who are ER+, hormone therapy may be recommended. But with these treatments, the recurrence risk for high grade DCIS often can be brought to similar levels as the recurrence risk for a lower grade DCIS. So at that point, this extra risk is eliminated. As for the fact that high grade DCIS is more likely to recur within 5 years, that's actually a good thing because it means that there is less risk of recurrence after 5 years than there would be for lower grades of DCIS. 

romyles, just wanted to let you know Beesie might not respond for a while. I think she's on vacation and away from the boards for a few days.

romyles, I was responding specifically to Franny's question and her situation, having had a lumpectomy.  I probably should have been clearer in indicating that my comments referred to those who have a lumpectomy.

Rads is generally not required after a MX for DCIS.  It's only considered (and still often is not recommended) when the chest wall margins are very close or are positive. 

No rads and no hormone therapy is the standard of care after a BMX for DCIS.  At this point, for most women the risk to develop a recurrence or a new cancer is no more than 1% - 2%, and treatments such as rads and hormone therapy present possibly as much if not more risk.  So you would actually put yourself at a greater overall health risk by having additional treatments at this point, vs. not having them.