Breast cancer, also known as mammary carcinoma, is one of the most common cancers among women in Germany, with approximately 70,000 new cases diagnosed each year. In extremely rare cases, this disease also occurs in men. Treatment for the early stages of this disease is provided at the Essen I Breast Center at the West German Cancer Center (BWTZ) of Essen University Hospital. The Essen I Breast Center offers first-class diagnostics and treatment for breast diseases at the highest clinical and scientific level and, following an evaluation by an international panel, was designated by German Cancer Aid as one of Germany’s 12 leading oncology centers. Furthermore, the collaboration between Essen University Hospital and Marienhospital Bottrop enables the pooling of expertise to provide the best possible care for patients.
Professor Dr. Kimmig, Director of the University Women’s Hospital, an internationally recognized expert in gynecologic oncology and a specialist in breast cancer, is a driving force in both clinical practice and research. His contributions to the development of computer-assisted precision surgery and minimally invasive hysterectomy have brought him international recognition.
For this article, however, the editorial team of the Leading Medicine Guide took the opportunity to speak with Priv.-Doz. Dr. med. Oliver Hoffmann. As Senior Attending Physician for Plastic and Reconstructive Surgery at Essen University Hospital, he has been working at the Women’s Clinic since 1998. In addition to surgical and systemic treatment of breast cancer, his research focuses on minimal residual disease in the blood and bone marrow, as well as on therapeutic approaches to prevent the development of metastases. We wanted to take a closer look at the particularly important topic of ductal carcinoma in situ (DCIS), as it holds the key to preventing breast cancer.
Ductal carcinoma in situ (DCIS) is a form of breast cancer that develops in the milk ducts of the breast. “Carcinoma in situ” means that the abnormal cells are confined to the tissue and have not spread to the surrounding tissue or other parts of the body. DCIS is often considered an early form of breast cancer, as the abnormal cells exhibit characteristics of cancer cells but are not yet invasive. “DCIS can be understood as a precancerous condition. This is because a cancer cell goes through various stages before it develops into a full-blown cancer cell.” The effects of DCIS on the body can vary depending on the individual case. Since DCIS is a non-invasive form of breast cancer, the abnormal cells have not yet developed the ability to invade the surrounding tissue or spread to other parts of the body. This means that DCIS is generally less aggressive than invasive breast cancer,” notes Priv.-Doz. Dr. Hoffmann at the beginning of our conversation.
Important to know: DCIS—in situ—almost always remains in place within the milk ducts, but it can occasionally skip a section and continue elsewhere in the ducts.
If left untreated, DCIS can develop into invasive breast cancer.
That is why doctors generally recommend treatment to reduce the risk of progression. Treatment for DCIS may include surgical procedures such as a lumpectomy (removal of the affected area of the breast) or a mastectomy (removal of the entire breast). In some cases, radiation therapy or hormone therapy may also be considered to reduce the risk of recurrence. “You can’t feel DCIS. It is usually diagnosed through mammograms, such as during routine mammography screening. Sometimes, however, DCIS is also detected as a palpable mass (tumor), through bloody nipple discharge, or simply during an ultrasound examination. If a suspicious area is found on a mammogram, a tissue sample is usually taken to make an accurate diagnosis. It usually takes up to 3 business days to get the results, which can be quite emotionally stressful for most patients. Since the calcifications cannot be felt, DCIS is usually an incidental finding. Another problem is that it is impossible to know how long the calcifications have been present, and there are also different degrees of aggressiveness. Nevertheless, there is no need to panic immediately. If surgery is necessary, the patient can certainly wait a few weeks, since the cancer has not yet spread to the lymph nodes at this early stage. It is therefore important for women aged 50 and older to undergo regular mammography screening to detect a possible disease at an early stage,” explains PD Dr. Hoffmann.
DCIS can be classified into different grades based on cellular changes and the pattern of abnormal growth.
These grades provide an indication of how “aggressive” the DCIS is and how likely the disease is to recur. In some cases, it may be advisable to perform a breast MRI or an ultrasound to detect further changes in the breast. Generally, during the tissue examination, the pathologist determines the degree of change in the breast tissue compared to healthy tissue.
The effects of DCIS on the body can vary depending on the individual case. Since DCIS is a non-invasive form of breast cancer, the abnormal cells have not yet developed the ability to invade surrounding tissue or spread to other parts of the body. This means that DCIS is generally less aggressive than invasive breast cancer.
Treatment Options
Treatment options for patients with ductal carcinoma in situ (DCIS) may vary depending on the individual case. DCIS is a non-invasive form of breast cancer in which abnormal cells are present in the milk ducts of the breast but have not invaded the surrounding tissue or spread to other parts of the body. The choice of treatment depends on factors such as the size and grade of the DCIS, the patient’s age, her overall health, and her personal preferences. “About 25 years ago, radical surgery was the standard, and most women had their breasts removed. Today, a more nuanced approach is taken, as this precancerous condition can grow in a discontinuous pattern. There are three possible treatment options—surgery, radiation therapy, and drug therapy,” explains PD Dr. Hoffmann, adding: “During surgery, a 2-mm safety margin must be maintained. This means that in the final pathological examination of the tissue removed during surgery, the pathologist should document a distance of at least 2 mm between the DCIS and the surrounding healthy tissue. If the distance is less than that, a so-called secondary resection—that is, another surgery—is usually recommended to achieve this margin. Unfortunately, these margins cannot be verified during the brief duration of the surgery. Radiation therapy reduces the risk of recurrence—that is, the cancer returning—by 50%, and for oral therapy, hormonal receptivity must be present. In such cases, tamoxifen can be used, which causes competitive inhibition of estrogen receptors as well as stimulation of progesterone receptors.” Tamoxifen works by binding to these estrogen receptors and, so to speak, “blocking” them. This means that the hormone estrogen can no longer bind to the receptors as easily, and thus the cells receive fewer growth signals. This can help prevent or slow the uncontrolled growth of breast cells.
The removal of lymph nodes, which is often required during breast cancer surgery, is generally not necessary during DCIS surgery. In cases of very extensive disease, where the entire glandular tissue is removed, so-called sentinel lymph nodes are also removed. Chemotherapy or radiation therapy is usually not necessary. DCIS does not metastasize. Once the tumor or lump has been removed, the DCIS—which is classified as a precancerous condition—is considered cured.
The selection of the best treatment options depends on various factors, including the size and grade of the DCIS, the individual risk of recurrence, the patient’s preferences, and her overall health. Close collaboration with a multidisciplinary medical team—comprising gynecologists, radiation oncologists, medical oncologists, pathologists, and other specialists—is crucial for making the best treatment decision. The patient should understand all the advantages and disadvantages of each option in order to make an informed choice that meets her individual needs and wishes.
Risk factors for developing ductal carcinoma in situ.
The exact causes of ductal carcinoma in situ (DCIS) are not fully understood, but there are several risk factors associated with an increased risk of developing DCIS. Women generally have a significantly higher risk of DCIS than men, as breast cancer occurs primarily in women. The risk of DCIS increases with age and is more commonly diagnosed in women over 40. “The causes of DCIS are usually multifactorial, a combination of lifestyle and genetic factors. For example, people who are severely overweight have a significantly higher risk, as their body fat tissue causes them to produce more hormones. Smokers and people who are continuously exposed to higher levels of radiation also face a higher risk. Furthermore, women who started menstruating early and those who entered menopause late also have a higher risk of breast cancer. Taking the birth control pill, however, likely does not increase the likelihood of cancer. Diet, on the other hand, definitely plays a role. Burgers, fries, and mayo simply aren’t good for our bodies. As always, the guiding principle applies: everything in moderation. But the modern Western approach to nutrition is problematic. Even low-carb diets cannot prevent cancer. That’s nonsense. The cancer will simply get its energy from somewhere else. But giving blanket assurances is always difficult in principle,” explains PD Dr. Hoffmann.
Measures to reduce the risk:
Healthy lifestyle: A healthy diet, regular physical activity, and avoiding tobacco and excessive alcohol consumption can reduce the risk of breast cancer, including DCIS.
Early detection: Regular mammograms and breast exams can help detect DCIS early, when it is still in its early stages.
Avoiding hormone replacement therapy: If possible, hormone replacement therapy after menopause should be limited or avoided to reduce the risk of breast cancer.
Genetic counseling: Women with a family history of breast or ovarian cancer or genetic risk factors should consider genetic counseling to understand their individual risk and take appropriate measures.
Recommendations for regular follow-up examinations after treatment for ductal carcinoma in situ.
Follow-up care after treatment for ductal carcinoma in situ (DCIS) is important for detecting and treating potential recurrences or other issues early. The exact recommendations may vary depending on the individual case, so it is important to follow the instructions and recommendations of your medical team. These checkups may include breast exams and physical examinations. “Follow-up care for DCIS is similar to that for breast cancer. A quarterly visit to the gynecologist is important, and a mammogram and ultrasound should be performed once a year. After three years, the intervals can be adjusted,” recommends PD Dr. Hoffmann. Patients should also continue to perform regular breast self-exams to detect changes or lumps early on. It is important to note that follow-up exams are not only intended to detect possible recurrences but also to ensure that you are monitoring your overall health. The specific recommendations for follow-up care depend on various factors, including the type and stage of DCIS, your health, and other individual characteristics.
Future Prospects
“What would be very helpful is the option of a liquid biopsy—that is, taking a blood sample to detect possible cancer cells or precancerous cells. However, this is really difficult to implement, since a large number of tumor cells would have to be examined. However, the time will come when surgical treatment for invasive breast cancer will be even less radical than it is today. Perhaps, with increasingly specific and effective systemic therapies, we will reach a point where some cases of invasive breast cancer will no longer require surgery at all. DCIS is also already being treated with less radical surgery over time; however, if removal of the glandular tissue is still necessary, reconstruction is almost always possible, and health insurance companies cover the resulting costs,” says PD Dr. Hoffmann optimistically, bringing our conversation to a close.
Dr. Hoffmann, thank you for this very engaging conversation and for shedding light on DCIS, a condition that is unfamiliar to many!
