How does DCIS become invasive?

[divan]

After benign mammograms yearly, this year I have a 2.5 cm ductal carcinoma(DCIS)located on the underside of my left breast just below the nipple area. Mammogram and Ultrasound rated it as a "level 5" suspicious tumor followed by Core needle biopsy which then rated it a Grade 3.  It is cancerous and my options are mastectomy followed by chemo, or lumpectomy with sentinel node biopsy followed  by chemo and radiation.  If DCIS is rarely invasive (and considered not even cancer by some), why does it warrant chemo?  Why is a 2.5 cm DCIS a Grade 3?  Medical informaton for DCIS is very contradictory; some claiming it is not even cancer at all because it stays within the duct and treatmet is totally unnecessary; and others recommending radiation and chemo because DCIS can already be invasive or become so?  Which is it?  If the medical community is so divided, how is the patient to know?  From what information I have provided does lumpectomy, sentinel node biopsy followed by radiation and chemo seem warranted?  Why?    

[Cleveland Clinic]

Dear divan:  DCIS or ductal carcinoma is situ is an “early malignancy.”  It is not “truly malignant” in that DCIS is contained within the duct and cannot metastasize.  Left alone, DCIS will most certainly progress to invasive cancer and this is why it is treated more like a cancer in terms of removing it.  In your case, the question is whether there is any invasive component to this tumor.  If there is any invasive component, this becomes the guide for treatment decisions.  Since you have had a core biopsy, the assumption is that this is representative of the whole but until the entire tumor is removed, one cannot be certain that there is no invasion.  DCIS is graded just like invasive cancer according to how the cells look under the microscope and this information helps to guide treatment decisions.  Without evaluation, including review of the pathology and the final pathology once the tumor is removed, we cannot speculate on what our treatment recommendations would be.  More information is needed in order to make definitive treatment recommendations. While the medical community may differ as to whether DCIS should be called a true malignancy or not, treatment guidelines are fairly straightforward and may include mastectomy or lumpectomy, usually followed by radiation and often followed by tamoxifen (hormonal therapy) to reduce recurrence risk. Chemotherapy is generally recommended only when invasive cancer is identified. Your doctors should be able to clarify your individual situation.

[stresscase123]

It sounds like there is an invasive component to your DCIS if chemo is being considered, as chemo provides *no* benefit to pre-invasive disease...

I agree w/ the comment about mastectomy having a greater rate of "cure".  w/lumpectomy the recurrence risk is higher, and the recurrence comes back as invasive about half of the time, if it chooses to return - not necessarily as "just DCIS" the second time around...

Check out breastcancer.org and find support there - it's an awesome site!  DCIS is the "golden ticket" of breast cancers - deal with it now, decrease your risks for future problems through meds, surgery, radiation or whatever, and plan on living a long, long time!

Good luck!

[divan]

Thank you all.  My surgeon was quite forthcoming and covered all my prepared list of questions before I asked any.  She even drew some things out for me.  The hormone level test was not back so she could not be specific about it, although did explain its significance.  I had a complete hysterectomy at age 30 (I am 60) and took premarin for quite a few years but was on the lowest dose available for the last few years and none for the past couple of years.  I do understand that overies are not our only source of hormones.  Unfortunately, it did not occur to me to inquire further as to the reason for its grade or invasion.  Only afterward have I learned more about DCIS causing me to wonder about the stringent projected treatment and, therefore, possibly an invasive component.  Part of the problem with a total mastectomy is that I have very, very large breasts.  Even with reconstruction on the left, the right breast would require very significant reduction as I would be too unsteady. If I am going to have that much surgery on both breasts at once, why not a bilateral which seems overkill at this point.  Especially if there isn't any invasion.  See my dilemma?  The medical community's diverse opinions regarding DCIS make this judgment call more difficult; I don't want all that cutting on both breasts if, as some maintain, it isn't even "really" cancer.  If I have the lumpectomy and there is any sign of invasion or lymph involvement which would mean more surgery, I would seriously consider a bilateral because, as I said, both breasts would require cutting anyway.

[boninclyde]

DCIS is cancer. It just hasn't invaded other areas of the body yet. Before you have any surgery see a plastic surgeon and let him inform you of your decision also. These guys work very closly with breast surgeons. I would sugest you visit the discussion board at breatcancer.org under the community support also and talk to other ladies that have been through the same thing. Again I wish you well.

[boninclyde]

Wanted to tell you my story. Doctors thought I only had DCIS but when I had my masectomy they found invasive cancer. I am truly glad I had the masectomy. Because I chose to have the breast removed and the invasion was so small 0.09mm. I did not have to have radiation (which could cause cancer and other side effects) or chemo which has all kinds of permanent side effects. I do take tamoxifen because my DCIS was being fed by hormones. I am 42. A 2.5cm is quite a bit of DCIS. I have seen ladies have lumpectomy, get clear margins and the cancer comes back. But other have sucess with lumpectomy. Some here will argue with me saying lumpectomy is as good as masectomy and research does show this but as for myself I wanted to be very aggressive. Go to breastcancer.org and search their site. They have lots of info on DCIS, Invasive DCIS, LCIS, inflammatory breast cancer, treatment info, testing and info with pictures of what DCIS really is. If you join the discussion board under community support their are lots of wonderful ladies there going through the same thing. You can learn allot from them. Do lots of research and fight with all you have now. You are very lucky to have caught this early. You have many treatment options. It is a personal choice.

[peekawho]

I too had ductal carcinoma, with microinvasion.  I didn't opt for a core biopsy, I had an excisional biopsy, so this was how the microinvasion was diagnosed.  

[labattsbaby]

Yesterday my mother was diagnosed with this VERY thing and has been told she has cancer. her mammogram revealed three lumps in the lower nipple area of her breast. today she will see the doctor and find out what is really happening. She is 73 with a heart condition, what are her options? I am saddened with thisnews as she just got a clean bill of health just last week. how could they give a clean bill of health and not see in her bloodwork that the readings was off?

[labattsbaby]

Oh, and I am sorry to hear this. We still do not know what stage mommy is at and what her options are. She had the same biopsy and the cancer cells were found. I thought cnacer did not hurt? How come she has been in pain for so long? Does this pain mean it is far gone? I am SCARED for her, I dont want to loose her, we just lost our father.

[boninclyde]

Cancer doesn't show up in blood work. Where exactly is your mothers pain?

[innajl]

Can you request MRI. Sometimes it can reveal more about presense of microinvasion. I am also surprised about chemo. I am diagnosed with DCIS grad2 with some of grade 3 and my surgeon does not intend to perform SNB. My pathology slides showed no sign of microinvasion. But of course it could still be there. The MRI also came back clean.
My oncologist also said that even if I had small microinvasion she would not advise chemo. So make sure you understand why chemo or get second opnion as well. Perhaps you have a large area of micronvasion.