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Non-invasive Breast Cancer

Treatment of Non-invasive Breast Cancer

In non-invasive breast cancer, the cancer cells remain confined to the ducts or lobules. The medical name for non-invasive breast cancer is ductal carcinoma in situ (DCIS) if it occurs in the milk gland ducts (tubes), or lobular carcinoma in situ (LCIS) if it occurs in the gland lobules.

LCIS is not considered cancer as such. The presence of this abnormality in a breast biopsy means that the patient has an increased risk of developing breast cancer. The risk means that about 1 in 3 women with LCIS will develop breast cancer within 30 years of being diagnosed with the original condition.

DCIS usually appears as small white spots on the mammogram, called micro-calcifications (Figure 10). Occasionally, it shows as a lump in the breast or as a blood stained nipple discharge. However, this type of cancer does not usually spread beyond the breast. It is a relatively commonly finding in women participating in the screening programme. The likelihood of non-invasive cancer/DCIS spreading to the lymph glands in the armpit is approximately 1 in 200 cases. This small number is why armpit surgery (axillary dissection) is not routinely performed for DCIS, unlike the invasive type of breast cancer.

Figure 10. A mammogram showing white spots of calcium (micro-calcifications) suggestive of non-invasive breast cancer (DCIS).

Like invasive breast cancer, DCIS is graded as low, intermediate or high. High-grade DCIS is relatively aggressive, especially if associated with cell death, and is thought to be more likely to progress into invasive cancer.

What Happens if DCIS is Left Untreated?

We do not know precisely what happens if DCIS is left untreated. Various studies suggest that the risk of DCIS developing into invasive cancer (raising the possibility of widespread disease and death) is approximately 65% if left untreated for 10 years. The risk is higher for high-grade DCIS with cell death (necrosis).

What are the Treatment Options for DCIS?

Non-invasive cancer/DCIS can be treated by mastectomy or by a limited, but complete, removal of the abnormal area, called a wide local excision. Mastectomy is required for widespread DCIS or DCIS located behind the nipple area. The cure rate is approximately 98% for mastectomy. As mentioned earlier, removal of the glands of the armpit is not usually necessary for non-invasive cancer/DCIS. For those women who have a lumpectomy (removal of tumour lump) rather than a mastectomy (removal of breast), radiotherapy is recommended in most cases. The use of tamoxifen may also be necessary in some cases where the risk of recurrence is high.

Treatment Cure rate
Lumpectomy alone 76%
Lumpectomy + radiotherapy 87%
Lumpectomy + radiotherapy (+ / - tamoxifen) 92%
Total mastectomy 98%

Table 8 lists the over-all cure rates. Some DCIS lesions that are small and low grade can be cured completely by local removal alone, with no additional treatment.

Special Cases of Breast Cancer

Breast Cancer During Pregnancy

Breast cancer in pregnant women is no more aggressive than in non-pregnant women and cannot be transmitted to the baby. However, breast cancer during pregnancy tends to be discovered at a more advanced stage. This is because it is more difficult to discover new lumps in the breasts of pregnant women as their breasts will naturally become large and lumpy during pregnancy. Lumps discovered during pregnancy should be investigated thoroughly with scans and needle biopsies in order to avoid delay in breast cancer diagnosis. Mastectomy, with the removal of the armpit lymph glands, is an acceptable treatment. Radiotherapy should be avoided during pregnancy, however chemotherapy can be safely given during second and third trimesters. Other treatments, such as chemotherapy and radiation, can be delayed until after the completion of the pregnancy.

Chemotherapy and radiation treatment can adversely affect the growing baby if given during pregnancy, especially in the first three months. Termination of pregnancy (TOP) is an option if aggressive chemotherapy is considered necessary during the first three months of pregnancy.

It is safe to have pregnancy after breast cancer treatment. However, it is preferred to delay this for at least 18 months after treatment. Inflammatory Breast Cancer

Inflammatory Breast Cancer

This rare form of breast cancer is associated with redness of the overlying skin, and has a poor outlook. It is treated mainly with upfront chemotherapy followed by mastectomy with removal of the glands in the armpit and then radiotherapy. Skin-saving mastectomy and immediate breast reconstruction is not encouraged in such cases.

Paget's Disease

This usually presents with nipple changes which including itching, redness, bleeding and discharge. There may also be an underlying breast lump. The nipple changes result from cancer cells travelling from the underlying breast along the milk ducts and to the nipple. The outlook for the disease is determined by the underlying breast cancer. If it is non-invasive (DCIS) then there is a high chance of cure by simple mastectomy. This is not essential in all cases, and some patients can be treated by removal of the nipple and underlying cancer without removing the whole breast. In such cases, post-operative radiotherapy is usually recommended.

It is important that all women with nipple change should seek the advice of a breast specialist so as to exclude this condition. Attributing skin changes of the nipple to conditions such as eczema can lead to a delay in diagnosis and a poorer outcome.