Ductal carcinoma in situ (DCIS)

Definition

Ductal carcinoma in situ (DCIS) is the presence of abnormal cells inside a milk duct in the breast. DCIS is considered the earliest form of breast cancer. DCIS is noninvasive, meaning it hasn't spread out of the milk duct to invade other parts of the breast.

DCIS is usually found during a mammogram done as part of breast cancer screening. Because of increased screening with mammograms, the rate at which DCIS is diagnosed has increased dramatically in recent years.

While DCIS isn't life-threatening, it does require treatment to prevent the condition from becoming invasive. Most women with DCIS are effectively treated with breast-conserving surgery and radiation.

Breast anatomy

Breast anatomy

Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-...

Symptoms

DCIS doesn't cause any signs or symptoms in most cases. However, DCIS can sometimes cause signs and symptoms, such as:

• A breast lump
• Bloody nipple discharge

DCIS is usually found on a mammogram.

When to see a doctor
Make an appointment with your doctor if you notice a change in your breasts, such as a lump, an area of puckered or otherwise unusual skin, a thickened region under the skin, or nipple discharge. Contact your doctor to have it evaluated.

Ask your doctor when you should consider breast cancer screening and how often it should be repeated. Most groups recommend routine breast cancer screening beginning in your 40s. Talk with your doctor about what's right for you.

Breast anatomy

Breast anatomy

Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-...

Causes

It's not clear what causes DCIS. DCIS forms when genetic mutations occur in the DNA of breast duct cells. The genetic mutations cause the cells to appear abnormal, but the cells don't yet have the ability to break out of the breast duct.

Researchers don't know exactly what triggers the abnormal cell growth that leads to DCIS. It's likely that a number of factors may play a part, including genes passed to you from your parents, your environment and your lifestyle.

Risk factors

Factors that may increase your risk of DCIS include:

• Increasing age
• Personal history of benign breast disease, such as atypical hyperplasia
• Family history of breast cancer
• First pregnancy after age 30
• Taking combination estrogen-progestin hormone replacement therapy after menopause
• Genetic mutations that increase the risk of breast cancer, such as in the breast cancer genes BRCA1 and BRCA2

Preparing for your appointment

Make an appointment with your doctor if you notice a lump or any other unusual changes in your breasts.

If you have already had a breast abnormality evaluated by one doctor and are making an appointment for a second opinion, bring your original diagnostic mammogram images and biopsy results to your new appointment. These should include your mammography images, ultrasound CD and glass slides from your breast biopsy. Take these items to your new appointment, or request that the office where your first evaluation was performed send these items to your second-opinion doctor.

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down your medical history, including any benign breast conditions with which you've been diagnosed. Also mention any radiation therapy you may have received, even years ago.
• Note any family history of breast cancer, especially in a first-degree relative, such as your mother or sister.
• Make a list of your medications. Include any prescription or over-the-counter medications you're taking, as well as all vitamins, supplements or herbal remedies. If you're currently taking or have previously taken hormone replacement therapy, share this with your doctor.
• Ask a family member or friend to join you for the appointment. Just hearing the word "cancer" can make it difficult for most people to focus on what the doctor says next. Take someone along who can help absorb all the information.
• Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Below are some basic questions to ask your doctor about DCIS. If additional questions occur to you during your visit, don't hesitate to ask.

• Do I have breast cancer?
• What tests do I need to determine the type and stage of cancer?
• What treatment approach do you recommend?
• What are the possible side effects or complications of this treatment?
• In general, how effective is this treatment in women with a similar diagnosis?
• Am I a candidate for tamoxifen?
• Am I at risk of this condition recurring?
• Am I at risk of developing invasive breast cancer?
• How will you treat breast cancer if it does return?
• How often will I need follow-up visits after I finish treatment?
• What lifestyle changes can help reduce my risk of a cancer recurrence?
• Do I need a second opinion?
• Should I see a genetic counselor?

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:

• Have you gone through menopause?
• Are you using or have you used any medications or supplements to relieve the symptoms of menopause?
• Have you had other breast biopsies or operations?
• Have you been diagnosed with any previous breast conditions, including noncancerous conditions?
• Have you been diagnosed with any other medical conditions?
• Do you have any family history of breast cancer?
• Have you or your close female relatives ever been tested for the BRCA gene mutations?
• Have you ever had radiation therapy?
• What is your typical daily diet, including alcohol intake?
• Are you physically active?

Tests and diagnosis

Breast imaging
DCIS is most often discovered during a mammogram used to screen for breast cancer. If suspicious areas such as shadows or bright white specks (microcalcifications) are identified on your mammogram, your radiologist likely will recommend additional breast imaging. You may have a diagnostic mammogram, which takes views at higher magnification from more angles, to take a closer look at the microcalcifications and to evaluate both breasts. If the area of concern needs further evaluation, the next step could be an ultrasound, magnetic resonance imaging (MRI) test or breast biopsy.

Removing breast tissue samples for testing
To collect breast tissue for testing, you may undergo one or more types of breast biopsy procedures:

• Core needle biopsy. A radiologist or surgeon uses a hollow needle to remove tissue samples from the suspicious area. The tissue samples are sent to a lab for analysis.
• Stereotactic biopsy. This type of biopsy also involves removing tissue samples with a hollow needle, but with the help of stereo images — mammogram images of the same area obtained from different angles — to find (localize) the area of concern.
• Surgical biopsy (wide local excision or lumpectomy). If results from a core needle biopsy or stereotactic biopsy show areas of DCIS, you'll likely be referred to a surgeon to discuss your options for surgically removing a wider area of breast tissue for analysis.

A pathologist will analyze the breast tissue from your biopsy to determine whether abnormal cells are present and how aggressive those abnormal cells appear. If your mammogram showed microcalcifications, the pathologist will examine the biopsy sample for those abnormalities.

Stereotactic breast biopsy

Stereotactic breast biopsy

During a stereotactic breast biopsy, your breast will be firmly compressed between two plates. Your radiologist takes X-rays (mammograms) to determine the exact location for the biopsy. ...

Breast calcifications

Breast calcifications

Calcifications are small calcium deposits in the breast that show up as white spots on a mammogram. Large, round, well-defined calcifications (left column) are more likely to be noncancerous (benign)....

Treatments and drugs

Treatment of DCIS has a high likelihood of success, in most instances removing the tumor and preventing any recurrence.

In most cases, treatment options for DCIS include:

• Lumpectomy and radiation therapy
• Simple mastectomy

In some cases, treatment options may include:

• Lumpectomy only
• Lumpectomy and the drug tamoxifen

Surgery
If you're diagnosed with DCIS, one of the first decisions you'll have to make is whether to treat the condition with breast-conserving surgery (lumpectomy) or breast-removing surgery (mastectomy).

• Lumpectomy. Lumpectomy is surgery to remove the area of DCIS and a margin of healthy tissue that surrounds it. The procedure allows you to keep as much of your breast as possible, and depending on the amount of tissue removed, usually eliminates the need for breast reconstruction.

  Lumpectomy followed by radiation therapy is the most common treatment for DCIS. Research suggests that, while women treated with lumpectomy have slightly higher recurrence rates than women who undergo mastectomy, survival rates between the two groups are very similar.

  For older women with multiple medical conditions, lumpectomy plus tamoxifen therapy, lumpectomy alone or no treatment may be an option.

• Mastectomy. For treating DCIS, a simple mastectomy — removing the breast tissue, skin, areola and nipple, and possibly the underarm lymph nodes (sentinel node biopsy) — is one option. Breast reconstruction after mastectomy, if desired, can be performed in most cases. Because lumpectomy combined with radiation is equally effective, simple mastectomy is less common than it once was for treating DCIS.

Most women with DCIS are candidates for lumpectomy. However, mastectomy may be recommended if:

• You have a large area of DCIS. If the area is large compared with the size of your breast, a lumpectomy may not produce acceptable cosmetic results.
• There's more than one area of DCIS (multifocal or multicentric disease). It's difficult to remove multiple areas of DCIS with a lumpectomy. This is especially true if DCIS is found in different sections — or quadrants — of the breast.
• Tissue samples taken for biopsy show cancer cells at or near the edge (margin) of the tissue specimen. There may be more DCIS than originally thought, meaning that a lumpectomy might not be adequate to remove all areas of DCIS. If the area of DCIS is large, relative to the size of your breast, lumpectomy may produce unacceptable cosmetic results.
• You're not a candidate for radiation therapy. Radiation is usually given after a lumpectomy. You may not be a candidate if you're diagnosed in the first trimester of pregnancy, you've received prior radiation to your chest or breast, or you have a condition that makes you more sensitive to the side effects of radiation therapy.
• You prefer to have a mastectomy rather than a lumpectomy. For instance, you might not want a lumpectomy if you don't want to have radiation therapy.

Surgery for DCIS typically doesn't involve removal of lymph nodes from under your arm because it's a noninvasive cancer. The chance of finding cancer in the lymph nodes is extremely small. If tissue obtained during surgery leads your doctor to think cancer may have spread outside the breast duct or you are having a mastectomy, then a sentinel node biopsy or removal of some lymph nodes may be done as part of the surgery.

Radiation therapy
Radiation therapy uses high-energy beams, such as X-rays, to kill cancer cells. Radiation therapy after lumpectomy reduces the chance that DCIS will come back (recur) or that it will progress to invasive cancer. A type of radiation therapy called external beam radiation is most commonly used to treat DCIS.

Radiation is typically used after lumpectomy. But for some women, radiation may not be necessary. This might include those with only a small area of DCIS that is considered low grade and was completely removed during surgery, or it may include older women with other significant health problems.

Tamoxifen
The drug tamoxifen blocks the action of estrogen — a hormone that fuels some breast cancer cells and promotes tumor growth — to reduce your risk of developing invasive breast cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone receptor positive cancers).

Tamoxifen isn't a treatment for DCIS in and of itself, but it can be considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the future. If you choose to have a mastectomy, there's less reason to use tamoxifen. With a mastectomy, the risk of invasive breast cancer or recurrent DCIS in the small amount of remaining breast tissue is very small. Any potential benefit from tamoxifen would apply only to the opposite breast. Discuss the pros and cons of tamoxifen with your doctor.

Lumpectomy

Lumpectomy

During a lumpectomy, your surgeon makes an incision large enough to remove the tumor and a margin of healthy tissue surrounding the tumor. The rest of your breast remains intact. ...

Simple mastectomy and modified radical mastectomy

Simple mastectomy and modified radical mastectomy

A simple, or total, mastectomy (left) removes the breast tissue, nipple, areola and skin, but not all the lymph nodes. A modified radical mastectomy (right) removes the entire breast, including ...

Radiation therapy

Radiation therapy

External beam radiation uses high-powered beams to kill cancer cells. Beams of radiation are precisely aimed at the breast cancer using a machine that moves around your body. ...

Alternative medicine

No alternative medicine treatments have been found to cure DCIS or to reduce the risk of being diagnosed with an invasive breast cancer. Instead, complementary and alternative medicine treatments may help you cope with your diagnosis and the side effects of your treatment, such as anxiety.

Women with DCIS may experience anxiety as they worry what the diagnosis means for their health. Anxiety may make it difficult for you to concentrate and to sleep at night. You may find yourself constantly thinking about your diagnosis. To help you cope with your anxiety, you might try:

• Massage
• Meditation
• Music therapy
• Hypnosis
• Relaxation techniques, such as guided imagery
• Tai chi
• Yoga

Coping and support

A diagnosis of DCIS can be overwhelming and frightening. To better cope with your diagnosis, it may be helpful to:

• Learn enough about DCIS to make decisions about your care. Ask your doctor questions about your diagnosis and your pathology results. Use this information to research your treatment options. Look to reputable sources of information, such as the National Cancer Institute and the American Cancer Society, to find out more. This may help you feel more confident as you make choices about your care.
• Get support when needed. Don't be afraid to ask for help or to turn to a trusted friend when you need to share your feelings and concerns. Talk with a counselor or medical social worker if you need a more objective listener. Join a support group — in your community or online — of women going through a situation similar to yours.
• Control what you can about your health. Make healthy changes to your lifestyle, so you can feel your best. Choose a healthy diet that focuses on fruits, vegetables and whole grains. Try to be active for 30 minutes most days of the week. Get enough sleep each night so that you wake feeling rested. Find ways to cope with stress in your life.