Clinical Review
Atypical hyperplasia of the breast: Cancer risk-reduction strategies
Women with atypical hyperplasia are at increased risk for breast cancer. We need to characterize that risk for patients and ensure appropriate...
Counsel precisely and accurately. Beyond such testing, we should focus on what is important to our patients in explaining the diagnosis:
- Our patients want to know that they are going to survive. Explain that DCIS is not a life-threatening cancer but a significant risk factor and is fully treatable with a long-term survival rate of 97%.
- Do not omit surgery. Follow-up surgical excision is still recommended after a core needle biopsy diagnosis of DCIS, as there is a 25% risk of finding invasive disease upon surgical excision.11,12 In our opinion, surgical excision represents the standard of care for DCIS, as some lesions may harbor invasive breast cancer.
- Explain the pros and cons of radiation to the patient once surgical excision has confirmed the diagnosis of pure DCIS. If the patient’s goal is to avoid any recurrence, then radiation can be useful and is particularly appropriate for women with high-grade, large, and estrogen-receptor–negative DCIS. However, patients in this setting need to recognize that radiation will not improve their already excellent rate of survival. For many patients, any recurrence, whether it’s DCIS or invasive disease, can be a devastating emotional event. But even in patients who experience a recurrence, early detection and treatment portend a very good outcome.
- Be aware of the fear of chemotherapy. Avoiding chemotherapy is a paramount (and understandable) desire for many women diagnosed with breast cancer. Women who choose radiation reduce their likelihood of invasive recurrence and potentially avoid the need for chemotherapy in the future.
- Know when mastectomy is indicated. Multicentric extensive DCIS is still an indication for mastectomy. The safety of avoiding mastectomy in this setting needs to be assessed by randomized trials. It may be safe for some women with DCIS, such as elderly patients with low-grade lesions, to undergo lumpectomy to rule out underlying invasive disease and be treated with endocrine therapy and observation, with or without radiation therapy. The issue of multiple re-excisions for close margins is also being re-evaluated.
Informed and shared
decision making is key
DCIS is an increasingly common and usually non–life-threatening condition. Radical surgery such as bilateral mastectomy for small unifocal DCIS is excessive and will not improve a patient’s outcome. As a prominent breast surgeon has written:
A high level of anxiety regarding breast cancer is associated with rates of contralateral prophylactic mastectomy that are as high as those seen among women with two first-degree relatives with breast cancer or known mutations. Contralateral prophylactic mastectomy is an extremely expensive, resource-intensive way of treating anxiety, and we need to find better ways of communicating the lack of benefit of this procedure to patients.13
We must balance the small risk of breast cancer recurrence after lumpectomy for DCIS with patients’ quality of life concerns. This goal is best accomplished by using an informed and shared decision-making strategy to help our patients make sound decisions regarding DCIS.
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