Does DCIS breast cancer need radiation treatment?

   Credit for bringing this topic to mind goes to Nancy F. Smith at More Magazine for her article A Breast Cancer You May Not Need to Treat in the August 2011 issue. Because DCIS (ductal carcinoma in situ) is a noninvasive type of cancer, it barely even qualifies as cancer. The aberrant cells are confined to the milk ducts in the breast tissue, and because of its minimal potential for invasiveness it is called stage 0 on the breast cancer scale. There is a small but real chance that after removing the area of DCIS, it could come back, or that it could reappear as an invasive variety; but its nonaggressive nature is what creates a dilemma for clinicians.
   The traditional treatments are lumpectomy followed by a full course of radiation treatment, or mastectomy. Most often radiation is recommended as “breast-conserving” treatment, but radiation has significant drawbacks. These include fatigue, skin burns, and radiation fibrosis which is a hardening of the breast tissue that can result in deformity. What’s more, depending on the tumor cell type, long-term medication such as the estrogen blocker tamoxifen may be indicated. This too carries its own list of potential side-effects.
   Of course all of these well-intentioned interventions are meant to save lives, so my view as a plastic surgeon has to temper aesthetic considerations with the bigger picture. All would be worth it if lives were being saved, but here’s the thing: it’s really hard to prove that the radiation treatment adds very much. There is a small statistical benefit in the studies that have been done, but the recurrence rates are still lower than for the overall population risk for breast cancer. How much treatment is too much?
   A recent analysis from Harvard Medical School shed some interesting light on the question. The authors agreed that there was evidence of “slight improvements in invasive disease-free and overall survival” while noting that radiation therapy paradoxically decreased the likelihood of having both breasts over a woman’s lifetime. That is because the recurrences after radiation tended to be of a more invasive variety, meaning mastectomy was the only remaining option. The conclusion was that radiation should not be offered routinely after removal of the initial tumor, but that the patient’s age and preferences should be considered.
Of course with a mastectomy and reconstruction, there isn’t any breast tissue to worry about. Though seemingly a radical option, with a skin-sparing technique and direct to implant reconstruction, the whole process is over and done with. So the moral of the story is how important it is for a woman with DCIS to know her options before deciding on a course of treatment.