With use of
mammography as the 'gold standard' imaging - more and more women are being
diagnosed with DCIS "Ductal
Carcinoma In Situ".
This is,
however, a double-edge sword.
Early
diagnosis of breast cancer is the ONLY reason that women are willing to submit
to mammography. But along with early
detection – are we truly identifying those who have a ‘true breast cancer’ or
are we willing to sacrifice women with a general diagnosis of DCIS and
commit them to surgery, radiation and possibly chemotherapy – in the chance
they will – in the future –convert to invasive breast cancer?
The
diagnosis of DCIS – is rarely discussed in terms of ‘not yet a breast cancer’.
Following
the call-back after a diagnostic mammogram – the patient is usually in a state
of shock – and presents with a ‘deer in the headlights’ condition. Is this really the best time for a discussion
to take place? However – whether it is
the ‘optimal’ time or not --- the only words women appear to hear is ‘breast
cancer’. There is no IN SITU
explanation what-so-ever.
When all patients with ductal carcinoma in situ are considered, the overall
mortality from breast
cancer is extremely low, only about 1–2%. When conservative treatment fails, approximately
50% of all local recurrences are invasive breast cancer. In spite of this, the
mortality rate following invasive local recurrence is relatively low, about 12%
with eight years of actuarial follow-up.
The management of
ductal carcinoma in situ of the breast: Endocrine-Related Cancer (2001) 8 33–45
K A Skinner and M J Silverstein
92% of all newly
diagnosed patients had nonpalpable lesions, most of which were detected
mammographically [4]. High-quality mammography is capable of finding a range of
nonpalpable, asymptomatic, noninvasive lesions, many smaller, of lower nuclear
grade, and with subtler mammographic findings than had been seen in the past.
The concept of DCIS as a single disease entity is clearly not valid. DCIS is a
heterogeneous group of lesions with diverse malignant potential.
Ductal Carcinoma In
Situ of the Breast: Controversial Issues. Melvin J. Silverstein. 1998 The Oncologist.
Until
recently --- there is usually an opportunity for the woman to receive an MRI
with and without contrast. The MRI
conducted in this manner would help to identify if the IN SITU identified by
mammography was, in fact, the only area of potential abnormal cells or if there
are other areas of ‘DCIS’ in the same or potentially both breasts that
mammography did not detect.
I say until
recently --- because a recent study sends the message
that the MRI may not be needed. “
Pre-op MRI ineffective in preventing further breast cancer surgery” September 19, 2012 | By Susan D. Hall
But
– the question that I pose is “not necessary” according to whom?
MRI
with contrast not only identifies those areas of suspicious cells – but aids in
the detection of neoangiogenic support. According
to most if not all medical literature – cancer is unable to grow without the
expression of angiogenesis. Mammography
is UNABLE to detect the presence and or the absence of
neoangiogenesis for any mammographic abnormality. The utilization of Doppler Ultrasound usually
follows a questionable mammogram to identify blood flow associated with the
questionable area. If we are denied the
Ultrasound and now denied the MRI prior to biopsy or surgery --- how is the
extent of the cancer determined prior to the “first cut”?
The
primary issue regarding the diagnosis of DCIS – is this: DCIS MUST BE
IDENTIFIED BY THE CELL TYPE AND THE STAGE... Without this information and the
education related to these facts the woman is making a treatment decision based
on fear alone. The radiologist or the
surgeon that does not educate the patient with regard to the current cell
status and the true potential for future invasive cancer is being
deceptive. They are treating DCIS as an
invasive cancer when it very well may not have the propensity for conversion.
Prior
to mammographic detection of DCIS – pre 1990’s almost all DCIS was treated by
mastectomy. The true reason for this is
most women who presented with what was diagnosed as DCIS already displayed
palpable lesions. Most of the “DCIS” was
growing and more than likely was already an invasive disease. But with mammographic detection of
non-palpable lesions, the only true way to discern the potential threat is by
Grade and cell type. The biopsy will provide this information. Ask about the Grade and the 'comedo subtype'.
“Danish studies estimated
that about 25% of all women will develop in situ carcinomas, predominantly in
the form of DCIS. Only a fraction of
these lesions will evolve into a clinical manifest form”
WOMEN
– educate yourself about DCIS prior to getting a mammogram. Statistically -- one in four women will be given
this diagnosis. Be prepared and ask
questions – don’t be driven by fear.
Thermography
is currently the only non-invasive way to detect the pattern of neoangiogenesis
in an abnormal thermogram. DCIS with no neoangiogenesis present has a higher probability of being Low Grade or benign. MRI with
contrast will help identify the presence and extent of neoangiogenesis in the
breast.
Thermography
as a monitoring tool can aide in identifying early changes that are potentially
breast cancers. MRI is currently the
only definitive test for localization of neoangiogenesis within the structure
of the breast.
Next Blog: Detection of DCIS by Thermograpy: True or False?
