What are their reasons? Some women opt for mastectomy because then they won’t need to undergo subsequent radiation treatment. One operation, they think, and they’ll be done. (The truth is that there’s still a small chance of DCIS or cancer recurrence in the scar.) “A diagnosed woman’s first reaction -often is, ‘Just cut off my breasts so I can get on with my life,’ ” says Susan Love, MD, president of the Dr. Susan Love Research Foundation, a nonprofit that promotes breast-cancer research. Sometimes women ask for both breasts to be removed when only one is diseased so that their reconstructions will match. “Doctors aren’t doing a great job of talking women out of the surgery,” Love says. “They’re not explaining the consequences of mastectomies, such as that a woman likely will not have feeling in her reconstructed breasts.”
What about the opposite approach—doing nothing? DCIS lesions are typically removed, so no one has studied the results of not taking them out. “We do know that if the cells stay in the duct, DCIS has no clinical significance whatsoever. It doesn’t cause symptoms, it doesn’t hurt you, it doesn’t kill you,” says E. Shelley Hwang, MD, chief of breast surgery at the University of California, San Francisco, School of Medicine. “The only reason we treat DCIS is we’re worried that if we don’t, it won’t stay in the duct and will become invasive. DCIS surgery is basically preventive surgery.”
Hopf’s DCIS diagnosis landed her in this maze of risk statistics and probabilities of recurrence. “I consulted eight specialists,” she says. “All recommended surgery and radiation. One said I should have a mastectomy. One told me the DCIS wasn’t really cancer, and another said it was about to explode from the duct and become invasive.” Hopf says that as she struggled with her decisions about treatment, “no one mentioned that my choice would have essentially no impact on my survival rate.” She chose lumpectomy with radiation. “I’m comfortable with my decision,” she says.
THE ANATOMY OF ABNORMAL CELLS
The confusion surrounding DCIS begins with those tiny white dots of calcium, a by-product of biological processes that can be caused by any number of events. The vast majority of these microcalcifications—about 70 percent—are associated with some kind of benign growth in the breast. The distribution and shape of the dots on the mammogram give some clues to their cause but cannot definitively identify DCIS. That diagnosis most often comes after what is known as a core-needle biopsy, in which a hollow needle is guided to the lesion by mammography, ultrasound or MRI. The needle draws out several samples of tissue, each about the size of a grain of salt. (See sidebar, “Get a Better Biopsy.”)
The samples go to a pathologist, who stains the cells and examines them with a microscope. Sometimes there’s a fine line between possible diagnoses. “Carcinogenesis is a process,” explains Debra Patt, MD, a breast-cancer specialist at Texas Oncology in Austin. Step one: Cells begin to grow abnormally in what is called atypical ductal hyperplasia (ADH). Those cells are not malignant, but they aren’t behaving normally either; nor do they look like normal tissue when examined under the microscope. The atypical cells can become so abundant that they begin to crowd their neighbors. “But your body has great ways of regulating itself, and it may be able to destroy the cellular abnormalities that people often develop,” Patt says.