A brief overview of typical treatments for pre-invasive malignant breast cancer

There are literally dozens of factors affecting treatment options for breast cancer. However, from a clinical perspective the treatment team will look for specific, proven indicators of severity and risk, and take prudent, necessary measures.

Remember that treating breast cancer is always a balance between treating what is presented at the moment, and the threat of future breast cancer development and spread. This is why breast cancer treatment at different levels or stages of presentation must be carefully considered, as there is always a danger or overestimation and overtreatment.

If one considers the range of typical ‘evolutions‘ of breast cancer, from DCIS and LCIS, to infiltrating ductal carcinoma, and considering also inflammatory ductal carcinoma, one can observe that the decision to perform a full mastectomy is made after careful reflection and analysis, with factors pointing toward a clear threat of invasive breast carcinoma.

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Treatment of DCIS

The treatment of ductal carcicnoma in situ seems to be a topic of great interest among breast cancer researchers. Remember that about 98% of DCIS is cured, and the typical course of treatment is tumorectomy.

Surgeons try to remove the DCIS with about 1 cm surgically clear margins. Whether or not to also treat the lesion post-surgery with radiation therapy is a variable decision, and the practice will change from institution to institution. However, by and large a course of radiotherapy is used in addition to the lumpectomy for treating DCIS, and positive outcome statistics tend to support this approach.

Radiation treatments usually begin 3-4 weeks following the surgery. But if the DCIS lesion is large and diffuse then treatment by mastectomy without radiotherapy is an option. Axillary dissection, however, should generally not be performed with DCIS. Chemical therapy is generally also not used for DCIS treatment.

Treatment of LCIS, not without controversy

LSIS is considered a high risk lesion, but not a cancer. It is generally now considered an incidental finding requiring clinical followup but no invasive therapies. Lobular carcinoma in situ tends to be asymptomatic, and is usually only found on a biopsy because it usually doesn’t develop into a mass that would show on mammography.

The interesting aspect of lobular carcinoma in situ is that when an invasive cancer develops, it is just as likely to develop in the contralateral breast as in the biopsied breast, and an invasive ductal carcinoma would be far more likely than a lobular carcinoma. But since LCIS lesions do not go on to invasion in most patients, (only 15% become invasive carcinoma) LCIS is considered a high risk factor only, and the some suggest that the only treatment that might be considered, normally, is a kind of ‘chemoprevention‘. LCIS lesions should not be treated surgically unless there are rare and compelling additional indicators.

Yet a large percentage (up to 80% in some studies) of LCIS cases are treated with lumpectomy, and many of these with whole breast irradiation as well. Given that only about 15% of LCIS cases subsequently result in invasive breast cancers, one would have to consider that LCIS tends to be grossly overtreated.

Efforts are presently underway to better idenfity that 15% of individuals who are at highest risk for invasive breast cancer development, and only to treat those cases with aggressive, invasive measures.

Infiltrating Ductal Carcinoma

Infiltrating ductal carcinoma is very serious. It means that cancer cells are in the breast duct walls, and threatening to invade the surrounding tissue. In fact, in many cases invasion has already occurred, but has not yet materialized in an obvious way. These cancers, which are usually described as stage II breast cancers, tend to be treated with partial mastectomy and radiotherapy.

Axillary dissection (for evaluative purposes) is often performed, and the tumor bed is often treated with supplementary radiation therapy. If the tumor is greater than 5cm, multicentric, or extensive, then a radical mastectomy might be performed, especially if radiation therapy had been used in previous treatments.

In terms of whether or not to treat infiltrating ductal carcinoma with chemotherapy and/or endocrine therapy, that would quite often depend upon the menopausal status of the patient. Women who are pre-menopausal tend to be given chemotherapy, but post-menopausal women quite often receive tamoxifen hormon-therapy, especially if the tumor is ER positive. Post-menopausal women with tumors which are estrogen receptor negative, however, are often given chemotherapy.

Infiltrating Lobular Carcinoma

The basic treatments for infiltrating lobular carcinoma will generally be the same as that for infiltrating ductal carcinoma, namely, breast conserving surgery with radiation therapy. This type of breast cancer is often multifocal and bilateral.

It is a serious diagnosis that is treated seriously. Infiltrating lobular tend to be ER and PR positive more often than ductal carcinomas, and also tend to occur in slightly older women. And, development of breast carcinoma in the contralateral breast is a bit more common with infiltrating lobular carcinomas. On the whole, treatment with breast preservation rather than full mastectomy tends to be a little less common for infiltrating lobular breast carcinoma, and the survival rates tend to be very similar, with perhaps a slightly higher rate for infiltrating lobular carcinoma. Relapse rates for infiltrating lobular breast carcinoma tend to be about the same whether mastectomy or breast conserving surgery is given, which may account for the slightly higher rate of breast conserving surgery. Chemotherapy is also quite commonly applied for treatment of infiltrating lobular carcinomas, dependant upon individual tumor characteristics and threat of metastasis. Patients with infiltrating lobular breast carcinoma are also a little more likely to be given anti-estrogen hormone therapy.

Inflammatory Carcinoma

Inflammatory carcinoma is diagnosed usually by incisional biopsy of the skin and of the underlying glandular tissue. Or, diagnosis can be made from a ‘punch biopsy‘ of the skin, with a core biopsy of the lesion in stereotaxy, or with ultrasound.

Inflammatory breast cancer is perhaps the most aggressive presentation of primary breast cancer, and is treated as though there was a direct threat of rapid proliferation. Treatment is usually a combination of pre and post surgery chemotherapy (neoadjuvant chemotherapy). Tamoxifen hormonotherapy is sometimes given if estrogen receptors are positive. Most often the effected breast is treated by radical mastectomy (which tries to preserve the pectoral muscle , but with ablation of the aponeurosis and axillary dissection) and post surgery radiation therapy.

Inflammatory breast carcinoma is also the subject of quite a few experimental biological and hormonal treatments aimed at reducing the proliferative opportunities for inflammatory breast carcinoma.

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For further reading on Pre-Invasive Breast Cancers, I suggest you visit this page with useful information and Q&A.

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References

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13. Arpino, G., Bardou, V., Clark, GM., Elledge, RM. Infiltrating Lobular Carcinoma of the Breast: Tumor Characteristics and Clinical Outcome. Breast Cancer Research. 2004;6(3)
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