DCIS – the “wannabe” cancer that confounds physicians and patients

The debate rages… The diagnosis is duct carcinoma in situ (DCIS), “google doc” and other sites confuse and confound. Carcinoma equals cancer, yet what should one do when the cancer is asleep?

DCIS is a family or more accurately a group of jailed felons, jailed within the walls of a breast duct. I am not sure I know the collective noun for prisoners. But I do know that in a prison there are many prisoners in for a variety of crimes, some who may be in for life. Some hardened and dangerous criminals are granted bail or escape and go back to committing crimes, others are released and just commit petty felonies…

So, whereas the family of DCIS are technically cancer prisoners stuck behind the walls of the duct, we often don’t know who will escape when and what they will do once outside the walls of the prison. We do know, however, that once they are outside the duct (prison) they are now invading cancers.

I have battled for a long time, as to how to explain DCIS to people, what analogies to use, where to start the story and why there are so many different treatment options offered by so many renowned specialists.

The place to start is probably with the diagnosis and an explanation as to what is DCIS. The diagnosis of DCIS is made in a variety of different ways.

Firstly the type of biopsy needed to identify DCIS is a core needle biopsy. This biopsy gives a view of the architecture of the breast tissue (the pathologist visualises the ducts with the abnormal cells seen inside the duct and not outside (in the breast tissue). A FNA (fine needle aspiration) is a needle biopsy that sucks out cells and battles to differentiate whether those cells are invading cancer cells or not. Some very good cytologists (doctors who specialise at looking at cells) can tell this by how the cells cling together, but for the most part, the diagnosis is easiest with a core needle biopsy. As has been said many times, surgically cutting into the breast, is an unnecessarily, aggressive way to make a diagnosis.

Historically before the era of mammographic screening, DCIS was diagnosed clinically in three different ways.

A lump: Occasionally a woman presented with a breast mass and with a biopsy the diagnosis of DCIS was made. Today it is uncommon for DCIS to be diagnosed as a palpable mass, as many women are in breast screening programmes.

A nipple discharge: Nipple discharges need an entire article, but in about 10% of women who present with a spontaneous nipple discharge (a discharge seen without her squeezing her nipples) may have the diagnosis of DCIS made when the little duct is removed that is causing the discharge. Ninety percent of the time a small papilloma is found in this setting (not cancerous).

Pagets Disease of the Nipple: Even more uncommon is for a woman to present with a scaly change or scab-like area on the top of the nipple, or on the side of the nipple, not on the areola (which is the brown, pinkish area that the nipple sits on like a little mountain or hill, depending on what your nipple looks like). On biopsy of the scaly area, a diagnosis of Pagets disease is made and this is a type of DCIS, sleeping cancer. Occasionally even though the mammogram is normal, there may be an invading cancer or a DCIS in the breasts, at the same time as the Pagets. The cancer crawls up the breast ducts and out onto the nipple.

Today most women diagnosed with DCIS are diagnosed at the time of a screening mammogram, where the radiologist sees (usually some calcification) and performs a stereotactic needle biopsy.

Diagnosed and now “what is this dagger that sits before me” – Misquoted Macbeth

The word DCIS means duct carcinoma in situ and literally translated means a cancer sitting within a duct, or a cancer sitting in one place. Just like an invasive cancer, DCIS is a term for naked sleeping cancer cells. The clothes they wear gives a better idea of their nature – “Clothes maketh the man…”

So the well-dressed DCIS (supposedly well behaved) are the low grade, strongly oestrogen and progesterone sensitive ones (ER, PR positive). DCIS that is high grade, ER, PR negative, HER 2 positive (3+), or with comedonecrosis, is basically sleeping cancers dressed to move, army gear on and sometimes with camouflage.

Pathologists when looking down the microscope, may battle to differentiate low grade DCIS from a typical ductal hyperplasia – the description involves what percentage of the duct is filled with abnormal cells. Many good clinicians use analogies to explain technical terms. I have heard DCIS been described as lion cubs, eventually growing into lions (predators). Technically this can’t be so, as lion cubs are living, mobile and busy and unless through an act of fate, will all grow up to be lions.

I have too used the incorrect analogy of babies sleeping in a crèche, they too will wake and also don’t sleep for long, giving the misrepresentation that these cells wake rapidly or grow up rapidly.

A better analogy is bulbs (plant bulbs)… As a wannabe gardener, I often see pictures of tulips and daffodils and think I must buy bulbs for the garden. On the rare occasion I do, I mostly forget to plant them or do so at the end of the season, not allowing the best opportunity for growth.

DCIS is like a packet of bulbs. The plants that grow are not flowers but weeds and some are truly out of “little shop of Horrors,” man eating or women eating actually… Audrey 2’s (the name of the man eating plant).

Planted under the correct conditions for growth (soil… breast tissue), fertilisers such as hormones, ones in your body and those taken by you, fertilizers such as alcohol, etc., will cause growth of the bulbs (DCIS). But as you know, if you plant 10 bulbs under ideal conditions eight will grow, and two won’t (who knows how this happens). But some DCIS, if left, may never develop into breast cancer – we just can’t predict which will or won’t. If bulbs are left in the packet in the garage (poor conditions), most will not grow. This is akin to using medication to possibly prevent the growth of DCIS. Hear and read the word “most” as sometimes bulbs grow into plants in the packet (without the best conditions for growth).

So, at this stage we can’t conclusively know which DCIS’s will grow and at what rate. We can predict that low grade DCIS and ER, PR positive DCIS will probably convert at a slower rate to invasive cancer that high grade DCIS, ER PR negative DCIS, HER 2 positive DCIS, and DCIS with comedonecrosis. It also makes sense that the larger the area of DCIS, the more likely that within the mass of sleeping cancer, there may be an area of invasion.

So how do we treat this condition?

Due to our poor ability to determine which cells will wake when, the mainstay of treatment is still surgery.

The surgical options depend on the size of the area of DCIS, the presentation of the DCIS, the grade of the DCIS, the size of the woman’s breasts and also her personal choices.

It is critical for physicians managing patients with DCIS, to stress that time should be taken with decisions.

Aesthetic issues should be carefully discussed when removing areas of DCIS.

A clear margin from the DCIS to the surrounding tissue is one of the most important aspects of the surgical treatment of DCIS. Clear surgical margins, particularly in women who undergo breast saving surgery, may often result in surgery being the only treatment required.

Many old studies showed that if a woman had a breast saving operation for DCIS, she required radiation treatment (just like the treatment protocols for an invading cancer). Review of these studies show that for many women who have a breast saving operation (I don’t like the term lumpectomy as it congers a picture of something taken out with no margin) do not require radiation treatment.

As with any condition, each woman should be taken as an individual, as should each DCIS.

Some physicians suggest that women with low grade hormone sensitive DCIS, should not undergo surgery but rather be placed on hormone blocking medicines such as Tamoxifen. Again this may be an option for some women, but until we can determine which cells won’t wake up and are turned off or killed by the Tamoxifen, we generally have no proof of absolute all abnormal cell death. Follow up radiology (mammograms and ultrasound) may show if the DCIS has not increased in size, but often times the DCIS is diagnosed when calcifications are seen on a mammogram. These calcifications won’t disappear if medication is used alone to manage DCIS, thus creating anxiety for the patient.

So now we have an understanding of why DCIS is a concern, why we should not underestimate this “wannabe” terrorist, why we should deal with this terrorist while it is in training by either conversion to the good side of the force (by drugs), or by just removing it from the training camp in your breast.

Don’t rush decisions – remember your body, your temple – and time is on your side!


Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.