Prognostic factors for DCIS

Diagnosis of breast cancer while still in the DCIS stage is always a kind of 'good news' for the patient. The prognosis for DCIS is always very very good, regardless of the exact nature of the breast carcinoma and the treatment method utilized. There will always be ongoing research and speculation as to the 'most risky' types of DCIS, or those most likely to either progress or recur as something worrisome, but regardless of specific characteristics and treatment choices, the overall chance of survival is close to 100%.

DCIS xray

Age of development can effect DCIS survival, though minimally

Some of the factors which effect the prognosis with very early breast cancer presentation (DCIS) include the type of DCIS involved (aggressive or non-aggressive), whether the DCIS is unifocal or multifocal, grade of the DCIS tumor, younger age at time of diagnosis, and in some cases the hormone receptor status of the tumor. (Estrogen and Progesterone receptor 'positive' breast cancer tumors tend to have a slightly better prognosis because they respond well to hormone therapies.)

Tumor size, however, has not proven to be a reliable prognostic indicator for DCIS. But, it has been shown that the the 8-year risk of subsequent invasive cancer following DCIS treatment was highest (around 20%) for women whose breast tumor expressed p16, COX-2, and Ki67 proteins. There is also some evidence to support the notion the women with tumors clincally detectable by palpation also have a slightly higher risk of local recurrence. However, the prognosis for any women with DCIS is always excellent, with survival rates usually mentioned as 98% or even higher.

The 'sojourn time' for early breast tumor develpment is faster in younger women.

Breast tumors in younger women do seem to progress faster than with older women, particularly in the pre-clinical phases. This is sometimes called the 'sojourn time', and is the differerence between mammographic detectability alone, and clinical detectability (detected later, as the breast cancer tumor has grown to a palpable lump) Sojourn time (sometimes formally defined as the mean duration of preclinical disease) has been consistently shown to be longer for older women and for slower-growing breast tumors.

Younger women are more likely to progress to high grade breast tumors

There is also considerable evidence which shows that a higher proportion of cancers progress to grade III in younger women during this 'preclinical' period. This of course underlines the importance of early detection through regular mammographic breast cancer screening. However, early detection is more difficult in younger women, especially if the screening interval is only two years. A young women with DCIS is at almost double the risk for recurrence than for a 65 year old women.

 

ductal carcinoma in situ

 

Hormone replacement therapy has not been associated with DCIS

The age of menarche is not associated with DCIS incidence. It is also much more likely (3.7 times) for women over 60 to develop DCIS. In terms of the issue of 'hormone replacement therapy', there is no consistent relationship demonstrated between their use and DCIS development. By contrast, there is considerable evidence which associates hormone replacement therapy with invasive breast cancer development.

Lives are saved by early diagnosis of DCIS

There are many claims as to the number of lives saved by early detection and treatment of DCIS. In some cases these estimates are as high as up to 30% less mortalities. However, it is also thought that up to 94% of these lives saved would also have occured if treatment began at the invasive stage.

Most cases of DCIS will progress towards invasive breast cancer if left untreated

There is a general consensus that DCIS may represent a transitional stage between normal breast tissue and invasive breast carcinoma. It is largely still unknown, however, which types of DCIS are 'non-progressing' towards invasive breast cancer if left untreated. One recent study has estimated at only between 100-270 cases of DCIS per 100000 will not progress to invasive breast cancer if left untreated. 'Progressive' DCIS will tend to evolve into invasive breast cancer on average in just under three years between first incidence and clinical presentation.

 

Treatment options for DCIS: lumpectomy or mastectomy

In most cases the first line of treatment when DCIS is diagnosed is some form of breast surgery. There are two basic surgical approaches for DCIS treamtment; breast conserving surgery (called 'lumpectomy') or a breast removal (or called 'total mastectomy'.) Lumpectomy is usually adequate if the area of breast abnormality is very small and only one abnormality is found on a mammogram. Also, lumptectomy is usually recommended if the DCIS is of a less aggressive type (such as non-comedo DCIS) if if the surgeon feels he or she will be able to remove the carcinoma completely with no trace still remaining within the breast. Lumpectomy is most effective for carefully in breast patients with small, early DCIS which is very easily visualized on the mammogram. In some cases the amount of DCIS is so small that the first 'exploratory excisional biopsy' is enough to remove all of the carcinoma, and a subsquent excision or lumpectomy is not required.

No risk of distant metastasis with DCIS

Since ductal carcinoma in situ is non-invasive, by definition there will be no risk of distant recurrence of the breast cancer. In terms of local recurrence, women who are treated by lumpectomy with radiation are only at a 5%-15% percent risk. For women treated by mastectomy the risk of local recurrence is below 2 percent.

Treatment by lumpectomy with radiation

Sometimes the recommended treatment for DCIS may involve lumpectomy, but with subsequent radiation therapy. This type of treatment would tend to be reserved for more aggressive types DCIS or higher risk presentations. Approximately 8% to 10% of women who opt for this treatment approach may experience a local recurrence. Women who choose to preserve their breast through a combination of lumpectomy with radiation therapy do show a higher rate of breast cancer recurrence than women who have a mastectomy. However, there is little convincing evidence to show an improvement in overall survival by one method or the other.

DCIS treated by mastectomy

Treatment by simple mastecomy (removal of the breast but no other regions or lymph nodes) is used for non-invasive breast cancers. Less than 5% of women with DCIS will require a mastectomy. The rate of breast cancer recurrence, as well as a woman's overall chance of dying from breast cancer following simple mastectomy is less than 2%. Overall, about 25% of DCIS patients are treated by complete mastectomies.

 

Triple therapy (lumpectomy, radiation, tamoxifen) greatly reduces the risk of invasive breast cancer following DCIS

In those rare cases when breast carcinoma does recur after DCIS treatment, data has tended to show that about 50% of these recurrences come in the form of invasive breast cancer rather than DCIS. Some breast cancer treatment centers are now implementing a 'triple therapy' form of breast conserving DCIS treatment, which has been shown to reduce the rist of subsequent invasive breast cancer recurrance by about half again. So called 'triple therarpy', in which a patient is treated by lumpectomy, radiation, and tamoxifen, has been shown to reduce the risk of local recurrence of invasive breast cancer to between 8% to 9% over a 15 year period. In addition,triple therapy has in some cases reduced the number of mortalties from invasive breast cancer following DCIS treatment to less than 1%.

The prognosis for DCIS is always good; near 100%

The most important thing to remember is that the overall survival rate for women diagnosed with DCIS is just about 100%, regardless of treatment. Women with ductal carcinoma in situ are at very little risk of dying from breast cancer.

 

References

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