Published: Thursday, May 03, 2007

1. Recommended treatment for lobular carcinoma in situ (LCIS)
2. Recommended treatment for ductal carcinoma in situ (DCIS)
3. Recommended treatment for Paget's disease

1. Recommended treatment for lobular carcinoma in situ (LCIS)

For women with lobular carcinoma in situ, the "average risk of developing an invasive breast cancer is 20-30% over the next 20 years."¹ The risk is related to the extent of LCIS present. If a biopsy shows focal deposits, the risk of developing breast cancer is about the same as the average woman. If the LCIS is extensive, the risk can be four to ten times higher than the risk for the average woman. If an invasive cancer develops, it is likely to develop in both breasts.¹

Treatment choices are regular screening and observation or bilateral prophylactic mastectomy. For those who choose monitoring only, recommendations includes "physical examinations every 6 to 12 months for 5 years and then annually as well as annual diagnostic mammography."¹ Bilateral mastectomy may be the right choice for women whose "fear of developing breast cancer outweighs her desire to save her breasts."¹ Women treated with bilateral mastectomy may choose to have breast reconstruction.

Lobular carcinomas are almost always estrogen receptor positive. Recent data from the NSABP Breast Cancer Prevention Trial show that tamoxifen given for five years is associated with an approximately 56% reduction in the risk of developing invasive breast cancer among women with a history of LCIS. Therefore, the use of tamoxifen 20 mg. daily for five years should be considered as a risk reduction strategy in women with LCIS who are followed with observation.² "Women with a family history of breast cancer, extensive LCIS, and no history of phlebitis may benefit sufficiently from tamoxifen or warrant taking it for 5 years."¹

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2. Recommended treatment for ductal carcinoma in situ (DCIS) ³

• Treatment options for DCIS are mastectomy, breast conserving surgery (BCS) plus radiotherapy or BCS alone. The treatment should aim to achieve a high degree of local control. The optimal treatment for an individual woman should take into consideration the extent and type of disease, the ability of a cosmetically acceptable excision to achieve clear margins, and the woman’s preference for breast conservation or avoidance of further treatment or breast cancer recurrence risk. The choice of local therapy does not significantly affect survival if local control is achieved. Compared with BCS, mastectomy is associated with more acute surgical morbidity, including pain, occasional delayed wound healing and seroma collection. In addition, the loss of the breast can have a profound and long-lasting psychosocial effect
• Patients with DCIS treated by BCS should have a wide excision to remove all mammographically and pathologically evident DCIS. Mammographic imaging of the involved breast is required if the radiograph of the specimen does not clearly show all microcalcifications
• The risk of local recurrence is greater after BCS than after mastectomy. This risk can be reduced, but not eliminated, by patient selection and the use of adjuvant radiotherapy
• Patients with a sufficiently low risk of local recurrence with BCS alone are difficult to identify. However, BCS alone may be considered after a careful discussion with the patient, if detailed pathologic assessment confirms that the lesion is small and does not have high-grade nuclei or comedo-type necrosis and the surgical margins are clear of disease. In addition, in such circumstances the surgical excision should be cosmetically acceptable. The BC Cancer Agency (BCCA) Breast Tumour Group recommends:⁴
  • Adjuvant radiotherapy is recommended for women with DCIS tumour >1 cm in diameter or comedo carcinoma who are interested in breast conservation, and in all patients with close margins (<5mm) of excision
  • Wide excision alone may be indicated for women with well differentiated DCIS (cribriform, solid, papillary), <1cm in diameter with complete radiographic and pathologic excision (at least 5 mm of normal breast tissue between foci of DCIS and the inked margins)
  • Adjuvant radiotherapy after wide excision or mastectomy is recommended for women with very diffuse areas of DCIS (e.g., >5 cm or greater than or equal to ¼ of the breast on mammogram) due to their substantial risk of recurrence
• Patients should be informed of the role of radiotherapy, its side effects and the associated logistic requirements before they are expected to make the decision for BCS or mastectomy
• Mastectomy is an option for all women with DCIS. Mastectomy should be recommended when lesions are so large or diffuse that they cannot be completely removed without causing an unacceptable cosmetic effect or when there is persistent margin involvement after two or more attempts at excision. If mastectomy is undertaken, breast reconstruction is an option
• Mastectomy is generally not followed by adjuvant local radiotherapy or systemic therapy
• Bilateral mastectomy is not normally indicated for patients with unilateral DCIS
• Axillary surgery, whether a full or limited procedure, generally should not be performed in women with DCIS. However, axillary lymph node dissection or sentinel node biopsy may be appropriate in a patient with DCIS >5cm in diameter due to their higher risk of micro-invasive disease
• The role of tamoxifen in the management of patients with DCIS continues to evolve. The potential benefits and risks should be discussed with patients. The BCCA Breast Tumour Group recommends:⁴
  • Adjuvant Tamoxifen should be offered to women with DCIS, after consideration of known risk factors in particular age and margin status, and after confirmation of ER positivity. The tamoxifen dose should be 20 mg/day for five years
  • Adjuvant Tamoxifen should not be considered for women with bilateral mastectomies, with an increased risk of endometrial cancer or thromboembolic events, or for women with a life expectancy of <10 years or who have recently been on tamoxifen for prevention
• Patients should be offered participation in clinical trials whenever possible

The following table provides a summary of surgical treatment options for DCIS.

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3. Recommended treatment for Paget ’s Disease

Standard management of Paget's disease is surgical excision. Since Paget's disease of the nipple is often associated with an underlying breast mass, the breast should be imaged with a mammogram and ultrasound, and if these investigations are non-diagnostic, an MRI of the breast should be considered. A partial mastectomy may be offered to patients if breast conservation will lead to an adequate cosmetic result. A sample of underlying breast tissue should be taken with the nipple to evaluate if an associated in-situ or invasive cancer is present. Patients considering partial mastectomy should be referred to a radiation oncologist pre-operatively to discuss post-operative radiation.⁴

References:

1.Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor.Vancouver (BC): Intelligent Patient Guide Limited; 2006, pg.119.

2. Breast cancer: practice guidelines in oncology, Version 2.2006, 12-05-05 © 2005, National Comprehensive Cancer Network, Inc.

3. Clinical practive guidelines for the care and treatment of breast cancer, Guideline 5: The Management of ductal carcinoma in situ (DCIS), Rev. Oct. 2, 2001, © 2006 CMA Media Inc. or its licensors.

4. BC Cancer Agency (http://www.bccancer.bc.ca). Vancouver (BC): 2006. (cited Sep 22, 2006). Available from: http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Breast/Management/InSituDisease.htm

5. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor. Vancouver (BC): Intelligent Patient Guide Limited; 2006, pg.120.

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