Early Stage Breast Cancer: Exploring Ductal Carcinoma in Situ (DCIS) with Dr. Stephanie Valente
Early Stage Breast Cancer: Exploring Ductal Carcinoma in Situ (DCIS) with Dr. Stephanie Valente
Scott Steele: Butts N’ Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. So welcome everybody to another episode of Butts N’ Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic, and I'm very happy to have Dr. Stephanie Valente here. Stephanie is an assistant professor of surgery at Cleveland Clinic Lerner College of Medicine and also the director of the breast surgical oncology fellowship program. Stephanie, welcome to Butts N’ Guts.
Stephanie Valente: Thank you, it's a pleasure to be here.
Scott Steele: So for those listeners out there, we've had your husband Michael Valente who's in my department. But tell us a little bit about you your background. Where'd you grow up? Where’d you train? How did it come to the point that you're here at Cleveland Clinic?
Stephanie Valente: Sure, I grew up on the west side of Cleveland so my family's still in Cleveland. I trained at Akron City Hospital in general surgery and then I did my fellowship training in breast surgical oncology at the University of Southern California. After I was done with fellowship I did come back to join Cleveland Clinic.
Scott Steele: So today our focus is going to be on DCIS. But before we delve right into DCIS, give me the ten-thousand foot view about breast masses, breast disorders in women. How common is this? Is this something that every woman needs to be aware of or every woman is going to experience?
Stephanie Valente: Unfortunately, breast cancer, DCIS included, is very common. So one out of eight women at some point in their life will be diagnosed with breast cancer. So that's a 12 percent risk lifetime. The interesting thing is that about 85 percent of women diagnosed with breast cancer do not have a family history. It's important for women to know their family history because obviously that plays a big role. I think the important thing for women and breast cancer is the importance of getting screening mammograms and what we call breast self-awareness. So this is knowing your breast so that you're aware if there are any changes in your breasts so that you can bring those to your doctor's attention.
Scott Steele: Breast lumps themselves: My wife feels a breast mass. Are there characteristics of a breast mass that are more or less concerning?
Stephanie Valente: Some of them are. But I would say any new breast mass is abnormal. So the most important thing is to get it checked out. So I always tell patients don't ever feel silly coming in to check out a mass and we say, “oh it's just a cyst,” or “it's something benign.” Because you're going to kick yourself in the butts or guts if you realize that you've been putting off something, and it actually is something abnormal. So anything that you didn't feel before needs to be checked out. Any changes in your skin, color, any lump or bump that's new or different that I always tell patients is there for more than three days needs to be evaluated. And any changes in the nipple, so if a nipple is normally everted and it becomes inverted or you've noticed any discharge from the nipple, those are things that need to be evaluated.
Scott Steele: You talked about great breast health, how often should this be done? Is at a certain time of the month for those who are having their menstrual cycle? Does the breast change over the course of the menstrual cycle?
Stephanie Valente: It does, and so that goes back to breast awareness. So usually for a woman doing a breast exam, it's just something simple in the shower in the morning: Do a breast exam, make sure they're not feeling anything abnormal. Again, just kind of noticing in relation to the menstrual period that breasts become a lot more tender and sensitive about a week before the beginning of the menstrual period. So it's always good to check after, because then the hormones and stuff in the breast have really settled down.
Scott Steele: Ok let's focus in now on DCIS. First of all very simple what is DCIS?
Stephanie Valente: So DCIS is ductal carcinoma in situ. This is a pre-breast cancer in the spectrum of breast cancers. By definition these are atypical breast cells that are still inside the lining of the milk ducts. So they have not gone outside of the milk duct into the surrounding breast tissue and so they are not an invasive breast cancer.
Scott Steele: When you take a look at DCIS, is this something that you can feel, or is this something that's routinely kind of picked up on a screening mammogram? What are the signs and symptoms of DCIS?
Stephanie Valente: That's a good question. So DCIS can present in numerous different ways. About 20 percent of all breast cancer, 1 in 5 breast cancers will be a DCIS. And a majority of the time these are what are picked up on a mammogram because it's the earliest signs of a breast cancer. And so I use DCIS interchangeably with breast cancer but it's a stage 0 breast cancer because it hasn't learned how to get outside the milk duct, but it's something that's going to be picked up on mammogram.
And so usually it's an asymmetry in the mammogram. Most likely it's what we call calcifications in the mammogram they say suspicious, abnormal branching or linear calcifications. And these changes on mammogram are something that a woman cannot feel. And so that's why it's important to get a mammogram every year. Other changes: Sometimes women can feel the mass, and it can be DCIS. The other way that it can present is nipple changes. So DCIS of the nipple is called Paget's Disease, and so what it is a crusting of the nipple or a bloody or clear discharge that really doesn't get better with time.
Scott Steele: So lots of different terminology especially in relation to all medical things but specifically with the breast. Can you touch a little bit about the difference between LCIS and DCIS and then this whole hyperplasia-type thing?
Stephanie Valente: Every day probably there's a new paper out about the difference of that, and that's really an area of research right now: What's the difference between atypical ductal hyperplasia, ductal carcinoma in situ, lobular carcinoma in situ? So in the spectrum on the way to an invasive cancer the normal milk ducts regenerate and the cells grow just like our hair, skin, nails grow. And so on a microscopic level our milk ducts are making new cells, and old cells die. A more simplified version is that the cells in the milk duct learn how to not die.
So what happens is you get an overgrowth of these milk ducts, and they become atypical ductal hyperplasia, which is an abnormal growth of the duct cells. And what happens is that in some patients over time those atypical cells eventually start to change and not look like breast cells anymore but start to change into what are precancerous cells. And so that's the difference between atypical ductal hyperplasia and ductal carcinoma in situ is the number of milk ducts that appear to be involved and the size are the real criteria.
So if you have ten different pathologists look at these specimens, you might have ten different opinions, and so usually for that diagnosis between atypical ductal hyperplasia and DCIS, the surgery would be recommended to remove a bigger area so they have a better area to look at. And the pathologist always get a second opinion to make sure that they're agreeing of that diagnosis because the difference in diagnosis is a difference in treatment.
Scott Steele: And then LCIS.
Stephanie Valente: So LCIS is what we consider a red flag or a marker for increased risk of breast cancer over your lifetime in either breast. A lot of times LCIS, if it's diagnosed, the recommendation is for surgery to remove it just to make sure that there's nothing else going on in the breast in that area. But once that is diagnosed that woman has a higher risk — 20 to 40 percent lifetime risk — of developing breast cancer in either breast.
Scott Steele: Okay so I'm a young woman, I do a breast exam just like you said, and I feel a breast mass. I’m going to go into my doctor. What can they expect during that doctor's visit?
Stephanie Valente: If you feel a lump, you’d get a diagnostic mammogram. So the difference between a screening mammogram and a diagnostic mammogram: A screening mammogram is nothing's wrong. You go in for your annual mammogram, and they do what's called a two view mammogram. A diagnostic mammogram is if you feel something, then you go in to get your mammogram, and you can point to that area and say “I've got pain here or I feel a mass here.” And what they'll do is put a marker on your breasts so that when they do the mammogram the radiologist will focus specifically on that area. If there's a mass that's identified or something that's felt in addition to a mammogram, most times the radiologist will also perform an ultrasound.
Scott Steele: Let's debunk a few myths here. I know many women out there that said I'm not getting a mammogram. I don't want that. Then you ask them what is a mammogram and they may not even know how it's done or how it's performed. What's a mammogram and how is it performed?
Stephanie Valente: So a mammogram is radiation. It's what's called two views, so two different views of each breast that's performed. So the breast is put in what's called compression which is kind of two plates, and then they perform essentially an X-ray of the breast. It takes literally about five minutes to perform. It's not painful. Many patients would say different, but it really is very minimal risk to get done, and the good thing is especially here at Cleveland Clinic you don't need an appointment. There are many sites where it's just a walk-in, you don't need a doctor's order and you can get a mammogram performed that day.
Scott Steele: So after they've gotten the ultrasound and the mammogram, what are the next steps if something at all looks like it's concerning that they don't know what exactly what it is or it looks more along the lines of those calcifications you talked about before that are a little bit more concerning that they may be thinking that this is something that needs further evaluation?
Stephanie Valente: If there is something that's identified on imaging, whether it's mammogram or ultrasound, the next step would be for the breast radiologist to perform a biopsy. We try and get as much information as we can before somebody needs to go to surgery, because the treatment for something like atypical ductal hyperplasia is different than a treatment for breast cancer as far as surgery options.
And so what the radiologist will do is a minimally invasive procedure called a core needle biopsy, and they'll either do that using mammogram guidance called a stereotactic biopsy or under ultrasound guidance called an ultrasound-guided biopsy. And that's where they use a needle and they actually sample a piece of that tissue that looks suspicious.
Scott Steele: So when they do that it's going to get read, and it comes back as DCIS, what then?
Stephanie Valente: The patient gets the diagnosis of DCIS, and then they're set up to see a surgeon. And usually when they have the diagnosis of DCIS or cancer in addition to seeing a surgeon, they’re setup to see what we call our multidisciplinary consultation team. So they're scheduled to see a breast cancer surgeon, a plastic surgeon, a radiation oncologist and a medical oncologist, and many times they're able to see them all on the same day.
Scott Steele: Does everybody have to see a surgeon? Is there something that the radiologists do, can they take a bigger chunk of tissue or something that they don't have to undergo any further evaluation?
Stephanie Valente: That's another area of research whether or not we have to excise surgically all DCIS. But just to be safe patients, need to know their options, and so the radiologist does the diagnosis, and then they send the patients to the surgeon to have that discussion in greater detail.
Scott Steele: Okay, so now they're in this multidisciplinary discussion you just walked me through. So what's the surgery all about? You mentioned radiation therapy, even mentioned the medical oncologists, which I'm assuming chemotherapy or hormonal therapy. What are the different treatment options for a woman with DCIS?
Stephanie Valente: So for a woman with DCIS, the first item to discuss is surgery. So removal of this area that's identified on imaging. And so for a woman with DCIS the options for surgery are a mastectomy, which is complete removal of the breast, or a lumpectomy, which is removal of the area that's abnormal within normal ream of tissue around. The goal that we aim for for DCIS is a two-millimeter clear margin of normal tissue. And for women who elect lumpectomy, a majority of the time that's followed by radiation therapy.
Now radiation therapy helps to prevent it from coming back. Literature shows that for a women with DCIS, if they just have surgery to remove it their risk of it coming back into their breast in that area is about 40 percent in the next 20 years. Radiation drops that risk down to 14 percent. So again, our risk of getting breast cancer just because we're women is 12 percent. So 14 is pretty back down to normal.
Scott Steele: Is it only involved just taking out that portion of the DCIS as well or is there anything they have to do with the armpit lymph nodes or sentinel lymph nodes is that all about DCIS or is that cancer? What's the difference there?
Stephanie Valente: Yeah, so by definition, ductal carcinoma in situ is precancerous that hasn't gotten outside of the milk ducts into the breast tissue. So if it hasn't gotten outside the milk ducts, it should not be able to spread into the lymph nodes. If we're doing a lumpectomy for DCIS, we do not have to worry about checking the lymph nodes. The upgrade rate — meaning that when we remove the whole area of tissue and the pathologist looks at it under the microscope — about 30 percent of the time they might identify an area in the milk duct where the cancer has made its way out. So that would be an upgrade from ductal carcinoma in situ to invasive cancer. And if that's the case then you do need to have a lymph node check to make sure that cancer hasn't made its way there.
If a woman has a lumpectomy, you can always go back for a second surgery in that case because the drainage pattern to the breast to identify what we call the sentinel node or the first lymph nodes that drain the breast can always be identified if they've got their breasts there. Now if we do a mastectomy for DCIS, we're removing that breast. So we're potentially removing that drainage pattern. So if by chance when they look at the mastectomy and they say “oh we found an invasive cancer,” we really don't know how to identify those lymph nodes afterwards. So if a woman is choosing a mastectomy for DCIS then we will perform a sentinel node biopsy during that surgery just because we can't go back and do that after.
Scott Steele: So walk me through what is a lumpectomy what do you actually do? What is it, what does that mean and what can a woman expect post-operatively. Do they got to take time off of work? Is there a scar or what are the risks associated with that?
Stephanie Valente: Yeah so a lumpectomy is just removing that portion of tissue with a normal ream of tissue around it. So if a woman has a two-centimeter area of calcifications in her breasts that are DCIS, then the goal of surgery is to remove that area with the normal ream tissue.
Now I always tell women our breast is a yellow color, yellow-white, and it's not like other cancers where once you get in there you can see and say “oh this is cancer this is not cancer or DCIS,” it's really under the microscope. So the woman starts in radiology, and they get this area what we call localized. So the radiologist will numb up their skin and their breast and use either wires which are flexible bendable wires about the diameter of a paperclip or small little what we call seeds which are about a third of the size of a staple.
And they'll put those in the breast and those are what we're trained to do as surgeons to go and take out that area so that we’re specific for that area to remove just that area and leave the normal breast tissue behind. So once the patient is asleep and we remove that area, we'll actually send that tissue back to the radiologist so they can do an X-ray and make sure that we have exactly what they need before we close that tissue and wake the patient up.
Scott Steele: And then postoperatively what can they expect and what are some of the potential complications associated with this type of surgery?
Stephanie Valente: The good thing is, our breasts are on the outside of our bodies, so when a woman wakes up she can eat, drink, walk around, doesn't ever have really a lot of those other issues that most people have with surgery. There's a little bit of pain associated with it, but it's really not too bad. Most patients can manage their pain, and for a lumpectomy most patients take a few days off to about a week out of work because the lumpectomy is about an hour, hour-and-a-half surgery. They go home the same day.
If a woman has a mastectomy it could be about a two-to-three hour surgery depending on if they're getting reconstruction, and they're out of work for maybe two to four weeks. So a little bit longer recovery time. After surgery, if it's just ductal carcinoma in situ, this is where the medical oncologist comes in, you know whether or not the patient needs radiation depending on their surgery choice.
A patient for ductal carcinoma in situ does not need chemotherapy. But as you alluded to, they do need some type of endocrine therapy. One of the receptors or signaling pathways for ductal carcinoma in situ is whether or not this is growing in response to estrogen. So we do test the estrogen receptor on DCIS cells, and if it is present we want it to be there it means that this is growing in response to hormones and we do have a way to block that to help prevent it from coming back. And so many times women will be offered what we call endocrine therapies. So this is if you're premenopausal, tamoxifen, and if you're postmenopausal, an aromatase inhibitor, and both of those are endocrine therapies they just work on different ways depending on whether or not you still get your menstrual period.
Scott Steele: So does everybody with DCIS have to get radiation therapy or have to get chemotherapy?
Stephanie Valente: Usually it's recommended for women over the age of 70. Looking at margins and the grade, you know is it a slow growing DCIS, maybe they might be able to not have to take an anti-hormone therapy like the aromatase inhibitor. Maybe they might not have to do radiation, and the good thing about breast cancer is it's very individualized, so there's not just one cookie cutter pattern for all patients. So really that's why when you meet with the team they say okay this is you, this is your health status, this is your age, this is the type of DCIS that you have. And based on all of those things together the patients work with the multidisciplinary team to come up with a plan that's appropriate for them.
Scott Steele: And what's the follow-up care that's generally needed for DCIS?
Stephanie Valente: So these women get followed closely. They get a clinical breast exam and meet with their medical team every six months. They get a mammogram once a year and they're usually on their endocrine therapy for about five years after their surgery.
Scott Steele: A couple other things, can DCIS if left alone, is that the natural evolution to cancer or you can have DCIS and cancer? Is it a continuous pathway? Is there something that we can do to kind of halt the progression? Does everybody have to have surgery or is there a pill we can just take that doesn't have any of that?
Stephanie Valente: Again that's another area of research where we're looking at where we say okay just because you have pre-cancer, just because you have stage 0 DCIS, does everybody need surgery? And so there are actually a lot of trials that are going on right now to look at that. But I think from just an average, everyday surgeon’s standpoint you say, you can't look at somebody and say you're going to progress the cancer if you don't have surgery or you're not.
And so I think the safe thing is to recommend right now until we have, you know, these large clinical trials that we say we don't really know who's going to progress to cancer or who it's never going to be an issue with. And so I think the safe thing to say is that surgery relatively is safe, and so if we can, and it's easy for these patients, then we should be taking this area out until we get literature that suggests otherwise.
Scott Steele: And what about those patients that get a biopsy that it turns out to be nothing. Will that biopsy effect future screening studies such as a mammography is there a higher rate of having false positives?
Stephanie Valente: We do have what are called these risk calculators, and they say “What’s your risk of getting breast cancer?” And some of these look at your lifetime exposure to estrogen, when did you start your menstrual period? How many kids did you have? And one of the things that looks at is how many biopsies you've had. And what that says is, how many changes are we seeing on the mammogram that the radiologists are worried about that over your lifetime you've had a biopsy for?
And so for a woman you know who's having multiple biopsies you have to wonder, are you having some changes in your breasts that eventually are going to lead to some atypical changes that eventually will lead you down the path to having abnormal cells that could eventually turn it into cancer? So getting a biopsy by itself does not increase your risk of getting breast cancer, but we think that the more biopsies a woman has it's just saying that the more changes we're seeing in their breasts for the biopsy being recommended in the first place.
Scott Steele: So we've been talking a lot about women but I have to ask you can men get DCIS and can get men get breast cancer?
Stephanie Valente: Yes. So although it's not very common men do have ducts. Men don't produce milk, so they don't have lobules. So men don't get lobular cancer but men get ductal cancer. So they can get ductal carcinoma in situ, an invasive ductal cancer. Men don't get screening mammograms so really DCIS is not that common in men because they're not getting those mammograms. So majority of the time when a man feels a mass by that time it's already an invasive cancer.
Scott Steele: Then we're going to end up here with some quick hitters, Stephanie, and so things to get to know you a little bit better. So first of all what's your favorite sport or activity?
Stephanie Valente: So my favorite sport is volleyball, especially beach volleyball.
Scott Steele: And favorite meal.
Stephanie Valente: I'm a vegetarian. It's not salads. I would have to say it’s pasta.
Scott Steele: The last book that you read.
Stephanie Valente: Let's go with my favorite book. I've got three kids so reading is a little bit difficult right now. But my favorite book is Never Eat Alone by Keith Ferrazzi.
Scott Steele: And what's the best thing you like living here, you’re a Clevelander so what's the best thing you like about living here in Cleveland?
Stephanie Valente: Being close to family. I think that there's nothing better than being close to family.
Scott Steele: Okay so sum up DCIS for the audience, some take home points. They’re listening to this podcast what do you really want to emphasize to them?
Stephanie Valente: So I think the most important thing is to get your annual screening mammogram. So if you don't go you don't know. The benefit of getting a mammogram, heaven forbid chance you do get breast cancer, one in eight chance that it's going to be caught early where a surgery a lot of times is the main thing that you need to do.
Scott Steele: Wonderful information. So to learn more about DCIS please visit Clevelandclinic.org/breast cancer. That's ClevelandClinic.org/breastcancer, and to make an appointment with a Cleveland Clinic specialist please call 1.866,223.8100. That's 1.866.223.8100. As Dr. Valente said, Cleveland Clinic also offers walk-in mammography screening without an appointment. Stephanie, thanks again for joining us on Butts N’ Guts.
Stephanie Valente: Thanks for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts N’ Guts.