Ductal Carcinoma in Situ or ‘DCIS’

Ductal carcinoma in situ (DCIS), is the word physicians use when a biopsy shows that some breast cells appear to be cancer cells. However, these cancer cells are still confined within the breast duct or ducts.

Sometimes medics describe Ductal Carcinoma in Situ as a ‘pre-cancerous’ condition. But do not worry, this is not really the case.

DCIS means there are malignant cells present (carcinoma or cancer), but these have not yet spread to any areas beyond the affected duct (carcinoma in-situ).

Ductal carcinoma in situ is very early stage breast cancer. If treatment does not occur very quickly, the malignant cells may migrate into the breast tissue surrounding the milk ducts.

If breast cancer screening can detect Ductal Carcinoma in Situ before invasive cancer has a chance to develop the survival rates are considerably higher.

Visit our new and improved page on Ductal Carcinoma in Situ. It has more up-to-date information. However, this page is still great for research as well.

The picture is breast ducts filled with dark purple cancer cells.

Importantly, although these cells divide too quickly, they haven’t felt an urge to wiggle, squirm and invade outward through the duct wall.

Ductal Carcinoma in Situ is a ‘more advanced’ stage of Atypical Ductal Hyperplasia

Medics consider Ductal Carcinoma in Situ a more serious and escalated version of a condition known as atypical ductal hyperplasia (ADH).

Whilst medics consider Atypical Ductal Hyperplasia (ADH) to be a benign (non-cancerous) finding it is a high-risk indicator, but not an imminent threat.

Doctors consider DCIS to be a malignant finding. Treatment by surgical removal (or excisional biopsy) should begin right away.

From least risky to most ‘histological risk‘:

Starting the Ductal Hyperplasia – lowest risk
Atypical ductal hyperplasia (ADH)
Ductal Carcinoma in situ (DCIS)
Infiltrating Ductal carcinoma or Invasive Ductal Carcinoma.

Diagnosing Ductal Carcinoma in Situ

There are a number of factors influencing the diagnosis of DCIS. However, initially, DCIS is a follow-up diagnosis after initial screening mammography reveals the development of microcalcifications of some kind.

If the mammogram report says the only concern is a cluster of suspicious microcalcifications, then it is probably DCIS.

In fact, most microcalcifications turn out not to be cancerous or precancerous. However, certain kinds of microcalcifications have a higher probability of accompanying cellular findings of DCIS or cancer.

Did you notice Doc uses the words, “cluster of suspicious…”

If it is not a cluster and not suspicious … relax.

Many women with DCIS show no Symptoms

So, most women with a diagnosis of Ductal Carcinoma in Situ show no obvious signs or symptoms of the condition. However, some women with DCIS may present with a breast lump or a discharge from the nipple.

A physician should investigate any signs of a breast tumor, such as a lump or nipple discharge, immediately.

The Pathologist diagnoses DCIS

The pathologist generally likes to look for microcalcifications and then may find some abnormal cells building up inside ducts. It is the possible cancer cells in the breast ducts that matter – not the microcalcifications.

ductal carcinoma in situ microcalcifications-xray — A cluster of suspicious microcalcifications

Those tumor cells piling up in the breast ducts, near the microcalcifications, have to look like cancer cells. If they are not then the diagnosis will ease back to the lesser case of atypical ductal hyperplasia or ADH.

The ‘grey area’ between a diagnosis of ADH and DCIS uses at least these two factors:-

If the cells are dividing in an uncontrolled, unpredictable way
If the cancer cells are now affecting the ‘stroma’ or supporting tissues of the duct and not just the epithelial lining. Then it is DCIS and it is breast cancer.

‘Grading’ of DCIS

Physicians will often classify or grade DCIS as either:-

low grade
medium grade
high grade

A pathologist will usually determine the distinctions by histological differences and findings. These findings can predict how quickly cells are developing and how likely it is that DCIS cells will come back following surgery.

Basically, doctors will name the type and grade of DCIS according to the pattern of cancer cells distribution and their rate of growth.

Reminder, that a New page on DCIS grading has more information on grading.

Treatment of Ductal Carcinoma In Situ

DCIS treatment is described in more detail on other pages within this website, (look at Section 8). But, as is the case with all cancer treatments, there are many, many factors to consider, over and above the specific medical considerations.

However, the ‘first-order’ standard of treatment for DCIS will be surgical removal of the affected breast tissue. For the decision-making process of which treatment options are best for each individual case, the whole multidisciplinary team should be involved.

My page on cancer treatment has a section on DCIS treatment halfway down the page at section 8.7.1. Surgery for everyone with radiation only for high grade DCIS and no chemotherapy, apparently.

The treatment for DCIS is usually surgery

Surgery usually involves removing not just the affected cells, but also an expanded area (called a ‘margin’) of the normal breast tissue surrounding it.

Doctors may call this procedure a ‘wide local excision’ or WLE for short. If DCIS is affecting a large portion of the breast, doctors will recommend breast removal (mastectomy).

If DCIS affects more than one region of the breast then breast removal might also be undertaken.

Radiation therapy for High-Grade DCIS tumors

Oncologists may use radiation therapy after surgery for women with high–grade DCIS. Studies show that radiation therapy reduces the likelihood of the condition recurring.

Note that DCIS does not generally spread into the lymph nodes, this is more typical for lobular carcinoma in situ (LCIS) or ‘lobular neoplasia‘). However, some kind of lymph node biopsy might be undertaken just to be sure, (see sentinel node biopsy)

Hormonal treatment for DCIS

Another treatment that doctors may use in the treatment of DCIS is hormonal therapy. DCIS cells typically have ‘estrogen receptors’ that help to signal and regulate cell growth.

If this tendency for the cells to grow and divide can be slowed down, the cancer cells themselves will often stop growing, or grow at a much slower rate.

Tamoxifen is a chemical agent that specifically attacks the estrogen receptors and may be of some benefit for women with DCIS. However, hormone therapy does not work well for all women and is not effective at all for women who have had radiotherapy.

The cure rate of DCIS is near 100%

There has been a dramatic increase in the incidence of DCIS, mainly due to greater participation in breast cancer screening programs.

However, there is some risk of ‘overdiagnosis’ or at least ‘over-treatment’ of DCIS. The cure rate of DCIS is now close to 100 %. Furthermore, there is virtually no conclusive evidence to indicate the risk of lymph node metastasis with DCIS.

Nonetheless, left untreated, DCIS will usually progress to invasive ductal breast cancer. Potential risk factors for an increase in the risk of DCIS progressing to invasive cancer are:-

a larger tumor size
the younger the age at the time of diagnosis
the presence of comedo necrosis.

Additionally, micropapillary carcinoma (DCIS) is a particularly aggressive form of the disease. For full prognostic factors and survival rates for DCIS click HERE.

But, with early diagnosis, breast cancer DCIS is almost always curable.

Here are a bunch of common Q&A’s…

How do doctors find Ductal Carcinoma in Situ?

DCIS is usually found during a mammogram, as part of breast cancer screening, or when there is another concern with a woman’s breast.

The rate at which DCIS is diagnosed has increased dramatically over recent years. This is not because DCIS is becoming more common, but because the mammogram technology can see the microcalcifications better.

Is ductal carcinoma in situ life-threatening?

No, in the early stages DCIS stays in the breast duct or ducts so at this point it is non-invasive breast cancer. DCIS does require treatment to prevent the condition from becoming invasive, however.

How is ductal carcinoma in situ treated?

Treatment for most women with DCIS is breast-conserving surgery and some will undergo radiation too.

What are the Symptoms of Ductal Carcinoma in Situ?

DCIS sometimes can cause signs and symptoms such as a breast lump and/or a nipple discharge (often with blood). However, DCIS does not cause any signs or symptoms in the majority of cases.

What does ductal carcinoma in situ look like on a mammogram?

DCIS appear as clusters of calcifications that have irregular shapes and sizes.

What causes ductal carcinoma in situ?

It is not clear what causes DCIS. Indeed, DCIS forms when genetic mutations occur in the DNA of breast duct cells. The genetic cell mutations cause the epithelial cells in the lining of the breast duct to appear abnormal, but the cells do not yet have the ability to break out of the breast duct.

What triggers ductal carcinoma in situ?

Researcher’s do not know exactly what triggers the abnormal cell growth that leads to DCIS. It is most likely that a number of factors may play a part, including genes passed to you from your parents, your environment and your lifestyle.

What are the risk factors?

Increasing age
personal history of benign disease such as atypical hyperplasia
family history of breast cancer
first pregnancy after age 30
taking combination estrogen-progestin hormone replacement therapy for more than 3-5 years after menopause
genetic mutations that increase the risk of breast cancer, such as in the breast cancer genes BRCA1 and BRCA2,
obesity

What are the tests/diagnosis done?

Radiologists often discover DCIS during a mammogram. After this, medics will recommend additional breast imaging if there are any suspicious areas. If the area of concern needs further evaluation, the next step may be an ultrasound and breast biopsy.

To collect breast tissue for testing you may undergo one or more types of biopsy procedures such as core needle biopsy, stereotactic biopsy or surgical biopsy (wide local excision or lumpectomy).

What is the treatment for DCIS

In most cases lumpectomy and radiation therapy or simple mastectomy. In some cases lumpectomy only or lumpectomy and the drug Tamoxifen.

Are there any alternative medicines that are recommended?

No, so far studies show alternative medicine treatments do not cure DCIS or reduce the risk of diagnosis with invasive carcinoma.

But most women may experience anxiety and to cope with this you might want to try

massage
meditation
music therapy
hypnosis
relaxation techniques
tai chi
yoga
aromatherapy
exercise

Are there any ways I can cope with my diagnosis?

Yes, a diagnosis of DCIS can be overwhelming and frightening. However, to better cope with your diagnosis it may be helpful to learn enough about DCIS to make decisions about your care. Also, it may help to get some emotional support (join a support group or talk with a counsellor).

Remember DCIS is very early-stage breast cancer, you can start getting in top health and making lifestyle changes if you need to. So control what you can about your health by making healthy changes to your lifestyle so you can feel your best. Choose a healthy diet (focus most on fruits, vegetables and whole grains). Try to be active for 30 minutes most days of the week and get enough sleep each night.

So, Sleep, good food, exercise, socializing, friends and family, emotional support are REAL, EFFECTIVE, PROVEN ways to improve your own body’s ability to help cure this cancer.

And get the surgery too, of course.

References

Chapman JA, Miller NA, Lickley HL, Qian J, Christens-Barry WA, Fu Y, Yuan Y, Axelrod DE. (2007) Ductal carcinoma in situ of the breast (DCIS) with heterogeneity of nuclear grade: prognostic effects of quantitative nuclear assessment. BMC Cancer.(sp. 2007)10;7:174 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001197/
Doyle B, Al-Mudhaffer M, Kennedy MM, O’Doherty A, Flanagan F. (et al). (2009) Sentinel lymph node biopsy in patients with a needle core biopsy diagnosis of DCIS – is it justified? J Clin
Pathol. (Jun 2009) 62(6):534-8 https://www.ncbi.nlm.nih.gov/pubmed/19190009
Kretschmer C, Sterner-Kock A, Siedentopf F, Schoenegg W, Schlag PM, Kemmner W. (2011) Identification of early molecular markers for breast cancer. Mol Cancer. (FEb. 2011)1;10(1):15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045364/
Lari SA, Kuerer HM. (2011) Biological Markers in DCIS and Risk of Breast Recurrence: A Systematic Review. J Cancer (2011); 2:232-261 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088863/
Mossa-Basha M, Fundaro GM, Shah BA, Ali S. (2010) Pantelic MV. Ductal carcinoma in situ of the breast: MR imaging findings with histopathologic correlation. Radiographics. (Oct. 2010) 30(6):1673-87. https://www.ncbi.nlm.nih.gov/pubmed/21071382
Ringber A, Anagnostaki L, Anderson H, Idvall I, Ferno M. (2001) Cell biological factors in ductal carcinoma in situ (DCIS) of the breast-relationship to ipsilateral local recurrence and histopathological characteristics . European Journal of Cancer (Aug. 2001) Volume 37, Issue 12 , Pages 1514-1522. https://www.ncbi.nlm.nih.gov/pubmed/11506959
Rudloff U, Jacks LM, Goldberg JI, Wynveen CA, Brogi E, Patil S, Van Zee KJ. (2010) Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol. (Aug. 2010)10;28(23):3762-9. https://www.ncbi.nlm.nih.gov/pubmed/20625132
Silverstein, Lippincott Williams and Wilkins. (2002) Ductal Carcinoma in Situ of the Breast (2nd Edition).
Souhami and Tobias. (2005) Cancer and Its Management (4th edition). Blackwell Scientific Publications , Oxford