Treatment and Recovery

Treatment for DCIS

• Depends on its size.
• Tiny droplets that are few millimeters may be excised in older patients and treated with anti estrogen medications if these tumors are estrogen positive.
• Most are treated with lumpectomy, which is the removal of the tumor and some of the local normal tissue, and radiation or a mastectomy (removal of breast) with low reappearance rates. The addition of anti estrogen treatment reduces the recurrences further.

The challenge with DCIS is to determine its extent. Most of these are radiologic lesions and one is sometimes uncertain of the extent of the disease since there may be areas of disease that are too small or scattered to detect by exam or any radiologic findings. MRI which is very sensitive for most cancer may not detect DCIS in the majority of cases.

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Treatment for LCIS

• More difficult to treat.
  LCIS does not necessarily turn into a cancer and cancers that develop later may be in a different area of that breast or in the opposite breast.
• Options ranging from simple excision to bilateral mastectomy (removal of both breasts) highlight the absurdity of these options.

I treat limited disease with excision with intent for an uninvolved margin followed by anti estrogen treatment. I have the patients go through thorough work up to detect any subtle invasive cancers that may guide us in how aggressive we need to be with this disease. In some cases we perform a mirror image biopsy of the opposite breast if that breast is completely negative by exam and by other tests such as mammograms, ultrasound and MRI.

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Additional Tools

Additional tools are available to us that help predict recurrence rates in the breast or the rest of the body. Such information help treatment decisions. A powerful tool I utilize frequently is called Adjuvant Online, available on www.adjuvantonline.com. Using this tool a patient can have a reasonable numerical estimate of her recurrence rate helping her make treatment decisions. This will be explained further later.

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Components of Breast Cancer

Defining the problems a breast cancer presents to a patient will give us an idea of how best to treat it. The “components” that we have to attend to are:

The Breast:

Also called “local disease.” Local disease is rarely a cause of death and local control with adequate treatment can reach over 95%. For many years now there has been a plethora of data documenting that a lumpectomy with negative margins followed by radiation has the same cure rate as a mastectomy but a slightly higher local recurrence rate. Seventy percent of my patients choose a lumpectomy and radiation. Most patients have very “good” to “excellent” cosmetic result. In addition to that, reconstructive surgery has provided us with excellent options for patients who need or choose to have a mastectomy.

*New techniques of partial breast irradiation are being investigated and I utilize them selectively at this time.

The Lymph Nodes:

Also called “regional disease.” Many breast cancers spread to the armpit (axillae) and the presence of cancer in the axillae is one of the best predictors of further growth of the cancer. Removing these nodes will thus have value in determining the prognosis and thus deciding on additional treatment. I also have a firm belief that such removal has a meaningful therapeutic effect as well, a view contested by many in the medical field.

In the past we used to do extensive axillary dissections removing mostly negative lymph nodes then we evolved into smaller random samples and finally reached an intelligent point where we can detect the sentinels or guards to the axillae. If the sentinels are uninvolved then there are outstanding chances that other nodes are not involved either. The sentinel nodes are detected by injecting a radioactive tracer (tiny amount of radiation) and a blue tracer into the breast and using a Geiger counter and visualization to detect these nodes. I have been performing that routinely since 2001 with great success saving the majority of my patients from the recovery and complications of more extensive axillary dissections.

Potential for metastasis or systemic disease:

It is very unusual for patients to present with metastasis but we know that a certain percentage of patients die from such metastasis. Although fool proof means of preventing such metastasis do not occur but chemotherapy, anti estrogen therapy and targeted treatments reduce the chance of such metastasis greatly. The difficult decision is where is the threshold, what and where are the complications, expense and pain associated with such therapy becomes worth it.

A half a centimeter cancer with negative lymph nodes have a tiny chance of metastasis, chemotherapy is not worth it. A 2.5 centimeter mass with positive lymph nodes may have one in three recurrence rate and chemotherapy reduces that in half. Since we do not know who are the patients who will have the recurrence we end up treating the 100 patients to help 15. Such use of treatment to prevent recurrence is called adjuvant therapy. Hormonal treatments and targeted treatments are used in addition to chemotherapy in an adjuvant setting.

Emotional issues:

Breast cancer is an emotionally charged disease and the ripples of that diagnosis reach the husband, companion, children, sisters and brothers, parents and friends. The course of treatment is very disruptive as well and thus psychological issues arise with good frequency and are often ignored or undetected by the patient or her care providers. I want to alert patients these issues and ask that they address them during their visits with me or other care providers.

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