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All TopicsForum: DCIS (Ductal Carcinoma In Situ) → Topic: 2nd opinion? Overtreatment?

Topic: 2nd opinion? Overtreatment?

Forum: DCIS (Ductal Carcinoma In Situ) — Just diagnosed, in treatment, or finished treatment for DCIS.

Posted on: Nov 19, 2012 11:48AM

slate5 wrote:

This is not the dilemma I expected to have. I posted a few weeks ago that my lumpectomy pathology showed no malignancy-- so I was fortunate that my dcis was removed via the core needle biopsy. It was described as a 3 mm area. The tumor board at the hospital discussed my case and recommended radiation as the standard of care. I did not discuss this with the MO in person (and now I wish I did b/c I feel so confused). She referred me to the RO who recommended 33 days full breast rads. When I expressed my concern about overtreatment, he explained the standard of care again and said I might feel better if I get a second opinion (which oddly made me feel worse). Now I am just freaking out about what to do. If it is the standard of care, won't all doctors say the same thing? I am 42. Does my age make the treatment a gray area? I am not sure where to start.

Dx 10/2/2012, DCIS, <1cm, Grade 1, ER+/PR+ Surgery 10/19/2012 Lumpectomy: Right
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Nov 29, 2012 09:39AM redsox wrote:

multifocal disease -- multiple tumors found in the same breast quadrant

multicentric disease -- multiple tumors are found in separate breast quadrants

Some definitions say that multifocal tumors are all from the same tumor and multicentric are from separate tumors, but that is not part of most definitions.

Also, how far apart they are matters.  For example, two small tumors near each other that happen to cross two quadrants may be more like multifocal.

Either one means a greater chance of more tumors still in the breast even with good margins.

Dx 2009, DCIS, Stage 0, ER+/PR+, HER2-
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Nov 29, 2012 09:44AM , edited Nov 29, 2012 09:46AM by BLinthedesert

I was using the "multifocal" in conjunction with large area - perhaps incorrectly -- to denote multicentric, what I was generally referring to was the case where there is an indication of multiple ductal or multi-quadrant involvement.  I understand what you mean.  I had multiple foci - but they were contained (hopefully, though this is one of the reasons my RO put me in an "intermediate" risk category since it is hard to say if there might have been more foci that they simply did not find) in one quadrant.  What I was describing was the case when there are multiple foci that might extend over a large area.  Younger women have ducts that have larger space between them -- as we age the ducts compress and it is easier, pathologically, to examine multiple ductal areas during biopsies/lumpectomies for examination to fully evaluate multifocal disease.  

Thank you for the clarification redsox!!  I had posted this at the same time as you!  

Dx 3/15/2012, DCIS, 1cm, Stage 0, Grade 2, ER-/PR- Surgery 4/20/2012 Lumpectomy: Right Radiation Therapy 5/21/2012
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Nov 29, 2012 02:07PM , edited Nov 29, 2012 02:07PM by Beesie

BL (and all!), thanks for your patience with my questions!  Your point that any risk evaluation model uses stats and isn't always error free for individuals is a critical point.  We always have to remember that any stats that we use are based on averages of those who came before us.  Stats and risk evaluation models provide us with guidance but should never be taken as a being a definitive answer. It does come down to exactly what you said, which is that "Decisions about treatment, though guided with personal experiences of others, and possibly information found online, really need to be made on a case-by-case basis with your medical team."  Every diagnosis is different, we each have our own health history and family health history that makes us more or less susceptible to the risks and side effects our both breast cancer and each treatment, and we each look at risk differently, with different fears and different risk tolerance levels. The right decision for one woman might be completely wrong for someone else, even thought it may appear, on the surface, that their diagnoses are almost exactly the same. 

The discussion of multi-focal vs. multi-centric reminded me of a discussion from a while back about whether having wide-spread (i.e. multi-centric) DCIS meant that DCIS had developed in more than one duct, or whether DCIS in just one duct could actually spread throughout the breast.  This actually came up as part of an LCIS discussion but since I had multi-centric DCIS, I wanted to see what I could found out.  I didn't find a direct answer but I found this fascinating (well, to me anyway) study of the branches of the ductal system of a single breast.  This study evaluated just one breast - so they warn readers to not over-interpret their findings - but the graphic of how each of the duct systems of the breast is laid out within the breast is really interesting.  It appears that some duct territories are narrow and short while others fill the length of the breast and are quite wide.  And there is everything in between.

Three dimensional anatomy of complete duct systems in human breast: pathological and developmental implications   Take a look at page 51.  I think this is really interesting.

Slate, sorry for taking this thread off topic!

Dx 9/15/05, DCIS-MI, 6cm+ Gr3 DCIS w/IDC microinvasion, Stage IA, 0/3 nodes, ER+/PR- “No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke
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Nov 29, 2012 03:25PM ballet12 wrote:

Thank you for sharing the article, Beesie, and sorry Slate for getting off topic, although this is very interesting and highly complex.  There is a complex interaction between the hormones and the breast tissue development, and in my layman's understanding, the breast parenchyma (ducts/lobules) becomes somehow more organized after the breasts are exposed to a pregnancy and breast feeding.  But there are also age effects, too, I imagine, as in women who have babies very young vs. women who have one or more babies much older--that "organizational" change might not occur as efficiently in those baby boomers (count me as one) who have a child after the age of 40. Anyway, although breast feeding allegedly can be a deterrent to development of bc, my mother breast fed four children and definitely got bc, so it didn't protect her completely.  I'll try to get off this topic, so we can get back to Slate's concerns.

Surgery 7/27/2012 Lumpectomy: Right Dx 8/2012, DCIS, Right, 5cm, Stage 0, Grade 3, ER+/PR- Surgery 10/5/2012 Lumpectomy: Right Surgery 10/26/2012 Lumpectomy: Right Radiation Therapy 1/11/2013
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Nov 30, 2012 11:55AM slate5 wrote:

I met with my MO, and she is no longer recommending rads and she is very comfortable with this recommendation.  I believe this is the way she wanted to go along (and felt rads were overtreatment), but was following the "by the book" treatment.  A couple of weird things came up though. The 2nd pathology report said ADH but actually suggested in the report that I get the opinion of other breast specialists. The other issue has something to do with the margins which I guess are under the recommended 1 cm (?). MO is not concerned about this, but I am now wondering why this wasn't mentioned earlier. (I did get a hint of it from the RO nurse but didn't understand.) MO is willing to get more opinions but thinks it is unnecessary because they will likely be divided anyway. Wants me to start Tamox and I still have some time to change my mind and go with rads also. 

Dx 10/2/2012, DCIS, <1cm, Grade 1, ER+/PR+ Surgery 10/19/2012 Lumpectomy: Right
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Nov 30, 2012 07:22PM , edited Nov 30, 2012 08:16PM by BLinthedesert

Hi Slate, it comes down to your comfort level with the current diagnosis.  If it is ADH, then margins might not be an issue, since there is no standard of care with respect to margins for ADH (or even a standard definition in what "margins" mean in the context of ADH, since generally it is diagnosed as focal areas that are pretty small).

There are many types of 2nd opinions (not that I am advocating them, I am just telling you there are options - and insurance pays for them all): pathologic, clinical (MO), even radiation consult (if DCIS were the agreed diagnosis, not for ADH).  As a patient, your insurance will, at your request, pay for any of these 2nd opinions.  

Otherwise, sit back, and enjoy the ride of life  Smile

Dx 3/15/2012, DCIS, 1cm, Stage 0, Grade 2, ER-/PR- Surgery 4/20/2012 Lumpectomy: Right Radiation Therapy 5/21/2012

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