Radiation after double mastectomy?

Hello Bulebirdgirl,

I was diagnosed with DCIS at age 49, before turning 50. I choose unilateral mastectomy. I was told that I don't need radiation because the lymph nodes were negative. There was nothing to radiate. I regret not having BMX. Good luck!

Amie

Hi Bluebirdgirl,

You will want appointments with both (a) a radiation oncologist, who is the doc with the actual expertise to conclude that radiation does (or does not) have anything to offer you; and (b) a medical oncologist, who is the doc with the expertise to decide whether hormonal therapy (since you're ER+/PR+) is appropriate, and to follow you over the next years.

HTH,

LisaAlissa

Annette47:

May I ask what recent guideline you are referring to that addresses margins for DCIS in the mastectomy setting and post-mastectomy radiation therapy ("PMRT")?

BarredOwl

Thanks Annette47. I would be concerned that it might not be appropriate to extrapolate from different settings with potentially different risk profiles.

I note that the featured document in the link you posted is a guideline pertaining to margins for breast-conserving surgery ("lumpectomy") with whole-breast irradiation in stages I and II invasive breast cancer.

SSO / ASTRO (2014): Society of Surgical Oncology American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer

http://www.redjournal.org/article/S0360-3016(13)03315-4/pdf

ASCO endorsed this guideline with some qualifications here:

ASCO (2014): Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast Cancer: American Society of Clinical Oncology Endorsement of the Society of Surgical Oncology/American Society for Radiation Oncology Consensus Guideline

http://jco.ascopubs.org/content/32/14/1502.full.pdf

Denise-G recently posted a link to a guideline pertinent to margin sizes for those receiving breast-conserving surgery ("lumpectomy") and whole breast irradiation ("WBRT") for DCIS:

ASCO (2016): http://jco.ascopubs.org/content/early/2016/08/10/JCO.2016.68.3573.full

(A pdf version is available there also)

[EDIT 10/26/2016: A PDF version was also published here: http://www.practicalradonc.org/article/S1879-8500(16)30109-6/pdf ]

"There are limitations to this guideline. It applies to patients with DCIS and DCIS-M treated with WBRT. The findings should not be extrapolated to DCIS patients treated with APBI or those with invasive carcinoma for whom a separate guideline has been developed.(33) While studies including patients treated with and without WBRT were included in the meta-analysis, a meta-analysis of studies of treatment with excision alone was not conducted. Additionally, all of the studies included in the meta-analysis were retrospective. However, in the absence of any planned prospective randomized trials addressing the question of margin width and local recurrence, these studies represent the best available evidence for clinical decision making."

Thus, with breast conserving therapy ("BCT"), those with DCIS should look to the BCT / DCIS guideline, while those with invasive disease should in general look to the BCT / invasive guidelines. There is overlap between the DCIS Margin Guideline and the Invasive Cancer Margin Guideline for DCIS with micro-invasion (DCIS-M or DCIS-MI), a point to discuss with one's Radiation Oncologist perhaps.

NCCN guidelines (Version 2.2016) include a completely separate algorithm for post-mastectomy radiation in the setting of invasive disease (Stage I, IIA, or IIB disease OR T3, N1, M0), which takes into account nodal status, tumor size, and margin status. [EDIT (Sept 19, 2016): See also, this recent ASCO–ASTRO–SSO guideline update regarding post-mastectomy radiotherapy in invasive T1-T2 size tumors:

ASCO–ASTRO–SSO (2016): http://jco.ascopubs.org/content/early/2016/09/15/JCO.2016.69.1188.full#ref-3

ASCO–ASTRO–SSO(2016): PDF version

[EDIT 10/26/2016): A PDF version is also available here (upper right): http://link.springer.com/article/10.1245/s10434-016-5558-8 ]

T1 Tumor ≤ 20 mm in greatest dimension;

T2 Tumor > 20 mm but ≤ 50 mm in greatest dimension. ]

For DCIS with mastectomy, the adequacy of margins is based on different studies done in a different patient population. The clinical studies of the adequacy of margins in patients with DCIS treated by mastectomy do not appear to be entirely consistent, including recent publications in 2015 and 2013. Thus, if there is a question about the adequacy of mastectomy margins and whether post-mastectomy radiation should be considered or not, consultation with a Radiation Oncologist is the probably the best approach to ensure receipt of up-to-date, accurate, case-specific advice, based on expert interpretation of the relevant clinical studies in the DCIS mastectomy setting.

BarredOwl

You may have trouble finding an oncologist that will follow you given you had DCIS And a BMX; I did. One just told me to come back if my bones start to hurt. I finally found someone that takes my case seriously, and it's helpful to have someone to schedule imaging for monitoring and who I can come to in case something comes up.

HI Bluebirdgirl:

I am very sorry you are going through more fear and anxiety. Will be hoping for answers and a clearly benign finding for you.

BarredOwl

I'm so sorry to hear that you are back in the waiting and worrying mode, Bluebirdgirl. I will be so happy to hear your good news when this is resolved. Keep us posted.

I just read a summary of that--thanks, BarredOwl.

He is just insensitive. Glad you are getting a second opinion.

I was dx with dcis high grade with comedo necrosis 6+cm. I had a Dmx not nipple sparing. My pathology came back with one positive margin and 2 close <1mm margins. I just finished radiation. The doctors said it was pretty rare to have radiation after double mastectomy. So sorry you have to deal with all this.