Tamoxifen? Radiaition? for DCIS

[Johnnykay1]

Hello. I have a couple of questions regarding our newly diagnosed DCIS.

My 46 year old premenapausal wife was diagnosed with DCIS last month and has had two surgeries to remove the lesion and clear the margins.

She had a 4 mm lesion, has large margins over 1 cm and has an intermediate grade lesion.

Pathology: very focal cribiform indraductal carcinoma, intermediate nuclear grade with punctal central necrosis and calcifications. It is 90% ER positive and 70% PR positive.  

Our surgeon told us that we do not need radiation, however the radiation oncologist recommended that we do. The RO also told us that they recommend radiation for all DCIS no matter what the Van Nuys grading the DCIS. We are at a 4 on Van Nuys which would suggest no radiation.

At this point we are leaning towards no radiation therapy.

We have an appointment with the medical oncologist today.

I would like to get opinions on whether we should try tamoxifen. We do not want to do this but if there is a strong reduction in recurrence percentages than we are open to trying it. There is so many differing opinions that we have been reading that we are really confused on tamoxifen at this point. We are also confused on if dietary changes such as more soy and flaxseed intake can take the place of tamoxifen without the risks and side effects. Of course, some studies show that soy is great and another study apparently shows that it can actually do harm.

Can we get opionions on both radiation and particularly tamoxifen?

Thank you.

[surgeon]

I'd assume this was discovered by calcifications on mammogram....DCIS remains a challenge: the van Nuys scale has helped, but still we can't say with absolute certainty how best to treat an individual. There remains no perfect way to decide what's undertreatment, and what's over treatment for a particular situation. It's still a matter of playing the odds, and it often boils down to individual feelings. Some families are uncomfortable with anything less than full treatment, others want nothing to do with it. Some doctors, likewise, -- sometimes based on the experience with a couple of noteworthy cases in their own practices -- tend to lean in one or another direction. Assuming it was indeed a mammographic finding, then recurrance would in theory be detectable in the same way. If it recurs, it may or may not be DCIS again; it can sometimes be invasive. My OPINION is that when necrosis is seen it denotes a more significant form with a higher chance of recurrance. On the other hand, 4mm is pretty small. I also lean toward more treatment for a premenopausal woman. If it were my wife (and assuming she wanted my opinion!) I'd suggest hormone therapy. I think the data for that are pretty convincing. Please note I'm a frequent but not the "official" answerer here. I'm a surgeon who has cared for thousands of women with breast problems, and am not above acting on "gut" feelings as well as science. The good news is that the reason there remains controversy is because the outlook is so good, not because it's bad.

[emtc]

A related discussion, DCIS and tamoxifen was started.

[CCF-RN,MSN-rf]

Dear Johnnykay1:  Whether or not to do radiation with a diagnosis of DCIS is somewhat controversial, as you have learned.  In general, if the histology is aggressive, such as comedo type, many will recommend radiation.  In other situations, there is more disagreement.  Consider a couple of radiation oncology opinions and have a thorough discussion with your oncologist (hopefully someone who specializes in breast cancer).  Hopefully, weighing the pros and cons will help you in coming to a decision.  Ultimately, it is up to you and your wife.  Regarding tamoxifen, there is good data to support its use in high risk women (these were women who never had DCIS but were considered high risk). These women had reductions in breast cancer of up to 49%.  This is fairly significant and in a situation where the DCIS is ER/PR positive, there may be great benefit both in terms of preventing recurrence and preventing breast cancer in the opposite breast.  Soy products should not be used medicinally.  I would not tell your wife to avoid soy but I would not recommend that she increase soy either.  Soy actually increases estrogen (natural or synthetic, it's still estrogen), which is the opposite of what you are trying to accomplish in an estrogen positive situation.