Predicting Progression of DCIS to Invasive Cancer
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- Опубликовано: 30 июн 2024
- Dr Ettienne Myburgh, Panorama Centre for Surgical Oncology (www.pacso.co.za) explains our current understanding of biology of DCIS and how to guide treatment for patients.
Part of the Cape Town Breast Cancer forum talks Feb 2023
0:47 Introduction
5:03 Why treat DCIS
5:52 Clinical Pathological Predictors
8:26 Van Nuys Prognostic Index
9:22 Nomogram to predict recurrence
9:55 Traditional view of how cancer develops
10:34 New models of understanding about progression to invasive cancer
12:25 Genetic evaluation of DCIS and invasive cancer
15:21 Spesific genetic changes
16:03 Importance of germline testing
17:04 Molecular Testing - MammaPrint or OncotypeDx
20:43 Micro-environment
24:15 Clinical decision making in DCIS
26:00 Prospective Analysis of VNPI
28:45 Online Nomogram for DCIS by MSK
29:12 Final Thoughts
Corrections: 25:16 Please note Age in col 1 should be over 60 
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This is incredibly helpful information Doctor. Thank you for your time in doing this presentation.
I’ve had 3 lumpectomies to remove the dcis around a tiny IDC found during mammogram. No node involvement. Radiation and hormone blocker.
The microinvasion in the lab findings made me concerned because there is no way to treat that other than the hormone blockers?
To determine the phenotype sounds brilliant But I’m sure it’s not done because they don’t have a treatment plan established for treating based on the information.
Tks Dr. Ettienne,for that important info. I want to know more about when to decide to biopsy a microcalcification (birads 4b) without mass, and if there is active surveillance in these cases
Hi, a biopsy is the only way to know if the microcslcificstions are malignant. There are specific cases, where there are competing health concerns where we would opt to continue survalance with the intention of reacting to signs of invasive cancer. Active survalance might be option in younger, healthier patients but only after biopsy has confirmed the reason for the microcalcifications. This is a decision which needs to be taken within a Multidisciplinary team only.
Thank you for this post
You're welcome
25:25 Van Nuys Prognostic Index - Age in the 3rd column is supposed to read ">60" I believe
Hello Dr Ettienne - I just stumbled on your podcast. I had a mastectomy last month though I cud hv gone for a lumpectomy instead if MRI was correct!
Biopsy result showed the specimen consists of 4 cores of tissue measuring 0.9 cm to 1.6 cm.
MRI result was "...core measures approximately 24 (CC) x 23 (L-R) x 20 (AP) mm. The spiculations, which are seen as areas of faint non-mass enhancement, together with the mass, cover an area that measures approximately 56 mm (CC) x 23 (L-R) x 40 (Se 815/61, 815/68). The spiculations extend approximately 1 cm superior and approximately 28 mm inferior to the central core."
The post op lab result showed the size of the invasive tumor is 13 mm in maximum dimension. The whole size of the tumor (Invasive & DCIS) is 26 mm in maximum dimension.
I'm really disappointed to note the vast difference as i didn't need to go for Mastectomy. At that time I was even contemplating a reconstruction!
Hi, thank you for your comment. I understand your disappointment. Unfortunately,one has to make decisions based on the information available prior to surgery and in your case is seems the MRI was more concerning. Imaging does not correlate with the pathology in all cases. My experience is that MRI can overestimate the lesion size, especially if done after biopsy has been performed. DCIS is even more difficult. In general we try to consider the option of breast conservation in these cases through an oncoplastic type of operation where one can remove a whole segment of the breast while still getting a good result. In our unit, immediate reconstruction is always considered and discussed for all patients where mastectomy is planned.
I hope your team have discussed your reconstructive options with you. My suggestion is to focus on the better than expected results and plan further treatment carefully, I wish you well with your further treatment.
Thank you for your reply Dr Ettienne. I did speak with the plastic surgeon but after weighing the options i decided to just go flat. I thought its a done deal after mastectomy and didnt realise chemo is next! After reviewing the post op surgery report which indicated my cancer was early stage 1 but a grade 3 so chemo is next! I've accepted this unfortunate outcome and will continue with the treatment as proposed by the oncologist.
Did my 1st chemo on 23 Oct with 3 more to go. Hopefully no further surprises as far as treatment is concerned.
I had the side effects of chemo and had mild constipation, sore throat, aches ard my neck and light headedness for the 1st 3 days and thankfully I'm feeling ok now.
You may be interested to know I was originally diagnosed with DCIS, high grade, 140 MM. This really worried me & I convinced myself that part of it would be invasive. Post masectomy histology showed that the mammogram images were incorrect. I had 5.6 CM DCIS, NOT 14 CM. There was no invasive element. I think I was extremely lucky in some respects. In the UK, with DCIS, we are treated as cancer patients. I suspect I was in the high-risk bracket. I was told it's an early form of cancer, stage 0. In the UK they do not check for makers, neither do they do any genetic testing for DCIS. I think a universal decision needs to made re whether DCIS is or isn't cancer. If it isn't cancer, why do such drastic surgery?
Thanks for your comment. DCIS, like all In-situ cancer, is cancer without the possibility of spread. The problem is that DCIS is not seen on breast imaging and even if we see changes that suggest DCIS, the imaging is poor at predicting the extent thereof and presence of micro invasion. One usually only know the true extent of it after surgery.
I think a lot of treatment guidelines are based on outcomes which do not always reflect the patient's experience. Things like recurrence risk. If an asymptomatic, non-life treating problem recurs, it makes no difference in the lived experience of the person. Shared decision making is the answer, where the well informed patient is an equal partner in the process. Some countries / medical systems are better at this than others.
@DrEttienne In my case, it was very clear on the mammograms, but in your video, you say it isn't cancer, yet in your comment, you say it is cancer.
To be correct, I said it is not a disease yet, in the sense of causing symptoms or loss of function. Cancer cell are just cells which proliferate uncontrollably, but some cancer may remain asymptomatic indefinitely. The challenge in DCIS is predicting when we can treat it less aggressively. I hope that makes sense?
@DrEttienne It does, but in the UK, cancer is legally protected against discrimination. The problem is, even though I've been treated as a cancer patient, some people think I haven't had cancer. It could cause legal issues. The health community needs to decide if DCIS is or isn't cancer.
i’m so
What is the prediction of the progress of High Grade DCIS with microinvasion her2+ ER/PR- to invasive carcinoma?
Good day, I somehow did not see your question, so I appologize for the late reply. Microinvasion is already invasive although at a very early stage. Cancer spesific survival is lower than pure DCIS but better than T1a invasive breast cancer. ER/PR negative, HER2 positive microinvasion is seen more frequently than in DCIS and does seem to increase future risk for recurrence / progression.
I don’t think there is an over-treatment 30:53 of the disease if we can not truly tell whether or not it will spread. So for me please continue to over-treat I am not willing to leave it up to chance that I will not have further spread
That is why careful discussion with each patient is so important. In some, their anxiety prompts more aggressive treatment, but that doesn't mean it is appropriate for everyone. As long as the doctor and patient are clear on the reasons a specific option is chosen. Most women would prefer less destructive treatment options and are happy to trust the evidence that is makes no difference in their outcome.
Exactly why I opted for mastectomy. Less cells with ER receptors…. Less bombs available to do their own rogue behavior.
I would not want to be treated for a “cancer” that I dont have when the treatment is the same as if I have cancer. IF it becomes invasive, then give me the treatment….
I had DCIS stage 1a with .7mm microinvasion . Clear margins, lymph nodes and genetics. I had double mast. ER + 90% . Taking anastrasole for 5 years . Do I have good prognosis ? Could there be a recurrence ?
Hi, you are very fortunate to have such good results. It would seem you have an excellent prognosis. The risk for recurrence should be very very low but it is never completely impossible.
Mine was just like yours…8mm. Rest same. I was told my recurrence rate would be 4percent if I took the pill 5 years and 10 percent if I didn’t. I had an oncotype dx score of 15 so they said no chemo.
@@sheila7814 Oncologist said if I take the meds for 5 years, 2% recurrence . 🙏🏼
@@teresa8363 I like those odds even better. ❤️🙏🏼😃
I had stage one Dcis with microinvasive is that bad
Can I ask what treatment did you have for this diagnosis
DCIS with microinvasion increases the risk for future invasive breast cancer and does require appropriate treatment of which removal with clear margins is the most important. Fortunatly it has an excedingly good cancer specific survival. It is important to continue with appropriate follow-up.
@@maryheffernan2627 I had a lump removed removed and arimadex for 10 year's and and 6 weeks radiation
I am glad for and English man besides and Indian man so I could understand