Breast cancer precursors: why so radical?
"Something's wrong," said the doctor, after examining my chest with ultrasound. "Immediately for mammography." When creaming I discovered a tiny little bump on the underside of my left breast, the size of a pinhead. Definitely not bad, I thought. After all, I went to the mammography department regularly, most recently about one and a half years ago. But my doctor insisted on clarification. So I immediately made an appointment in a special practice. After a mammogram and another ultrasound examination, I was dismissed with the words: "There should be taken as soon as possible a sample, which looks quite like a DCIS."
DCIS? This abbreviation seals the fate of many women. Dorothee von Werder, 64, from Hamburg, who told ChroniquesDuVasteMonde WOMAN her story, is one of them. And since the introduction of mammography screening, it's more than ever. DCIS stands for "ductal carcinoma in situ", a tissue change limited to the breast ducts (lat. Ductulus = gait, in situ = locally), often associated with microcalcifications. A DCIS has not yet spread into the body, has not yet scattered and is rarely felt from outside. It is still harmless, not a malignant tumor, but a precursor of breast cancer.
Nevertheless, such a diagnosis has far-reaching consequences - paradoxically, it is often more drastic for the affected women than if a small carcinoma had been discovered. That's hard to understand. And with every new case, the question arises again: Does it really have to be this way?
Breast cancer precursors: It was said, the whole breast would have to
Already at the first intervention, a tissue area of four centimeters in diameter was taken out. The cut ran right over the chest. I was horrified. When the results of the tissue examination were there, it was said that the whole breast had to go down. I was thunderstruck. People constantly read about breast conserving surgery, and for me the entire breast should be radically removed because of a precursor to breast cancer. That was incredible to me. I just could not understand it. The doctor said, I could take my time. But the amputation would be the safest option.
"DCIS is a local problem that can be treated very well and cured to nearly one hundred percent," says Dr. Mahdi Rezai, one of the most renowned German breast cancer specialists, Medical Director of the Breast Center Düsseldorf Luisenkrankenhaus. How the doctors do it depends on how extensive and how aggressive the cell changes in the breast tissue are. The most harmless variant: a small area of less than two centimeters in diameter with slowly growing, relatively "benign" (experts speak of "low grade" as opposed to "high grade") cells. Here it is sufficient to remove the affected tissue with sufficient safety distance. The breast is preserved. Subsequent radiation to prevent relapses (relapses) is not always necessary in the opinion of Mahdi Rezai.
However, women who have had breast changes (DCIS) detected in various areas of the breast advise doctors to remove the mammary gland body immediately, or to completely remove the breast. The fact that such a radical therapy would be superfluous in a part of the patients, is thereby accepted approvingly. Because a DCIS is completely unpredictable, more unpredictable than a malignant tumor. "No one yet knows how a DCIS develops, and the prognosis is that medicine is still in the dark," says gynecologist Dr. med. Barbara Ehret, Managing Director of the International Center for Women's Health in Bad Salzuflen and co-author of the "ChroniquesDuVasteMondeBuch der Frauenheilkunde".
This means that no one can predict whether a newly discovered DCIS will actually develop a malignant tumor at some point - which is the case in about a quarter of the women affected. And nobody knows when that could happen - if it happens at all. The doctors therefore want to avoid any risk from the outset. The guidelines of the medical societies are therefore unanimous: Each DCIS is treated. It would not be like Russian roulette.
I felt like dancing on a volcano.
No one could tell me if and when the cell changes would become a dangerous tumor, six months, a year, five years, or maybe never. The sword of Damocles hovered over me. I was afraid that the diseased tissue could spread every day, suddenly become malignant. I felt like I was dancing on a volcano that could break out anytime. When my family also put pressure on me, I decided to go to the surgery.
Breast cancer is not an emergency - a DCIS certainly not!
Like Dorothee von Werder, many women are in this situation. They feel pressurized. From the partner, the family, not infrequently also from the doctor. "Very often the women with the diagnosis get their surgery appointment right away," says ChroniquesDuVasteMonde Overbeck-Schulte, chairperson of the women's self-help organization for cancer eV "This pressure is enormous, because even at a preliminary stage the shock is great. Having to do something immediately, and has little chance to tackle it. " That is fatal. Breast cancer is not an emergency - a DCIS certainly not! That's what all experts say.
Instead of panicking and getting under the scalpel at the first surgeon, it is better to get informed first. Because, as absurd as it sounds: Especially in a breast cancer precursor, a skilled person should do the work. Otherwise, there is a risk that women will have to be operated two, three times.
"The problem is that often only a mammogram is used to diagnose and plan the procedure," criticized Professor Christiane Kuhl of the Radiological University Hospital Bonn. "Most of the DCIS are much bigger, they expand in the duct, in some places they grow faster, at others slower, but they can infiltrate a whole duct system What an x-ray picture alone does not show. "
So it happens that at the edge of the cut out tissue still changed cells are to be found. And that means having to have surgery again and more breast tissue removed. "The women are at the mercy of a salami tactic, which is unworthy!" Says Christiane Kuhl. To avoid this, patients should insist that the procedure be scheduled using magnetic resonance imaging (MRI). The contrast agent used collects wherever growth processes take place. Not only is it better to see the full extent of a DCIS, but it is also possible to differentiate between aggressive ("high grade") and slowly growing changes. Unfortunately, an MRI is not paid by the coffers (cost about 450 euros). A good breast center, however, will always make her before an intervention. "If a center does not offer an MRI, women should look for another - especially at DCIS," advises Christiane Kuhl. Only then can the exact segment be found and removed from the breast that is affected. "With an experienced surgeon, very good treatment is possible today with little effort," says Mahdi Rezai. "If the whole milk duct is cut out like the slice of a cake, all flocks are captured."
At the second surgery, my breast was amputated. I had decided to have a breast build immediately. But the implant, too large, shifted. The operation went awry. It was not even healed yet, it was said that I needed surgery again to remove the implant. When I heard that, I collapsed. I have always been proud of my body. Now I have no more breasts and am disfigured.
"Everybody has to find their own way"
"It's very different how women handle it when a DCIS needs to be treated radically," says ChroniquesDuVasteMonde Overbeck-Schulte. Above all, many want to be safe and are therefore willing to take therapeutic steps that they may eventually regret. On the other hand, the result may be better for very extensive findings, if amputation is performed immediately followed by breast reconstruction. "There is not the DCIS and the therapy for it," says the federal chairman of women's self-help after cancer. "Every precursor has its own specific characteristics, and every woman is different, each one has to find their own way." It is helpful to seek a second opinion, to listen to the experiences of other stakeholders and to ask the attending physician if the case has been discussed at a tumor conference. However, treatment in a breast center alone is not a guarantee of quality. "Every breast center needs appropriate surgery numbers to be certified," says ChroniquesDuVasteMonde Overbeck-Schulte. And Mahdi Rezai criticizes: "Not every certified breast center in Germany has adequately trained doctors, which is a deception of the patients, so it's not the clinic that should receive a certificate, but the doctor - like star chefs." Rezai recently founded the European Academy of Senology in Düsseldorf for such training. He advises affected women to look for doctors with such training, but above all to a doctor they really trust.
It is still unbelievable to me.
Meanwhile, I have decided not to undergo surgery again. In the other breast are also lime deposits. But there the doctor sees no need for action. I have to go back to control in a year. It is still unbelievable to me what happened. And it has long since crossed my mind that all this might not have been necessary. But now it is too late. What should one judge by that? That's a difficult decision!
Whether actually all DCIS must be operated on immediately, even experts can not say with certainty. Recently, participants in a meeting of the National Institute of Health in Bethesda, Maryland, in the face of the good prognosis of many DCIS, advocated regular monitoring of such precursors, for example with an MRI. If the findings are unchanged after half a year, there are some indications that this is a slow-growing, less aggressive DCIS that can initially be observed. And one more thing the US experts emphasized: pressure and fear mongering were out of place. Instead, doctors should take the patient's request more seriously. Unfortunately, this is also often not the case with us. Although the German guidelines provide that the patient should decide for herself how radical she wants to be treated: Does she want to consistently rule out any risk for herself personally, or does she not want to become a cancer patient prematurely? Is she afraid of the potential danger in her breast, or is she optimistic and brave enough to hope that nothing malicious will come of it? Anyone who makes informed choices can live better with this decision - however it turns out. "The aftermath is then significantly lower," says gynecologist Barbara Ehret. "The women do not feel so incapacitated and raped."
Mammography Screening: What does it really bring?
It used to be coincidence. After the start of the mammography screening program in 2005 for all women between the ages of 50 and 69 years, the number of discovered breast cancer precursors (DCIS = ductal carcinoma in situ) increased dramatically. Nearly 20 percent make these findings in the screening, as the recently presented first evaluation report shows. Many doctors see this as a success. Because of the good prognosis can be prevented by treatment of these precursors, the development of cancer. Since the screening also more small malignant tumors of a maximum of ten millimeters in size (today 33 percent, previously 14 percent) are discovered and in 76.7 percent of all findings, the lymph nodes are not affected, according to co-operation mammography (KoopG) more women have one Chance to be completely healed. With a gentle and usually breast-conserving therapy.
The fact that a part of the tumors without the program would never have become conspicuous and women are made unnecessarily or too early to breast cancer patients by such overdiagnosis, even recognize the responsible of the screening. Likewise, the uncertainty and mental stress of women, in which screening findings by ultrasound and tissue samples must be further clarified.
However, critics see another problem: "The screening does not have the significance that one has hoped for. If the mammography alone is not as well suited as a diagnostic method for all women," says the Hamburg gynecologist Dr. med. Karin Rudzki, Member of the Board of the German Medical Association e.V. Especially in women who still have a dense glandular tissue even with more than 50, it is difficult or impossible to find a tumor in the chest due to X-ray images. "These women are in false positives when told that screening has not yielded any findings," says Karin Rudzki. According to the guidelines, these women would also have to undergo an ultrasound examination, but neither they nor their gynecologists will be informed of the breast density with the screening findings, except in a few regions. " The Ärztinnenbund therefore pleads, in addition to the screening, to have an ultrasound scan made by the doctor of his trust - even if the fund does not pay for it (cost about 40 euros).
The benefits of mammography are overestimated
The Bonn radiologist Professor Christiane Kuhl complains that the mammography is not meaningful enough, especially in the breast cancer precursors. "Our studies show that magnetic resonance imaging provides significantly more DCIS than x-rays, especially the right ones, the aggressive ones we need to find to prevent cancer." With the mammography would be, so ChrisChristiane Kuhl, rather slow-growing DCIS discovered that often not all degenerate into malignant tumors and therefore would not necessarily (immediately) have to be treated. The fact that MRI, as a more sensitive examination method, delivers even more false positive findings is the lesser evil for them.
Recognized as a screening method to detect as early as possible in women without any symptoms cancer, but so far only mammography. However, many women are not aware that it is not enough to protect against breast cancer. "More than half of the participants overestimate the benefits," says Berlin-based medical psychologist Dr. med. Beate Schultz-Zehden. They believe, as a representative study has shown, that could completely prevent breast cancer. A mistake. "Mammography is always just a snapshot, and so-called interval cancers also occur between two screening appointments.Barbara Marnach-Kopp from the Cooperation Community Mammography. "It's important that women pay attention to themselves and go to the doctor as early as possible in case of changes."
More information on breast cancer precursors and mammography screening
Brand new is the patient's guideline "Breast cancer: the Ersterkrankung and DCIS" of the German Cancer Society (available from the Landeskrebsgesellschaften, addresses under www.krebsgesellschaft.de)
New research results of a study by the University of Bonn can be read here. One result: For women with an increased risk of breast cancer, a real early detection is possible only with the so-called magnetic resonance tomography (MRI). The hit rate of this method therefore clearly exceeds both mammography and ultrasound.
An information brochure about mammography screening is available from GPs and gynecologists and at www.mammo-programm.de
Contact with self-help groups, information material and advice is provided by the women's self-help after Krebs e. V. under Tel. 02 28/33 88 94 00 and www.frauenselbsthilfe.de
To read more: "Women's Body Health Life: The Great ChroniquesDuVasteMonde Book of Obstetrics" by Barbara Ehret and Mirjam Roepke-Buncsak (2008, 384 p., 21.95 euros, Diana)
Movie tip: "Life would be nice"
Breast cancer is also the theme of the movie "Life would be nice". Grimme winner Dagmar Manzel plays in the single Manja, who visits her best friend Uta in Iceland. There she begins an affair with Uta's brother-in-law Ragna. But her luck is clouded: Manja feels a knot in her chest and hides her feelings out of fear. The single DVD "Life would be nice" is on sale from February 2010. The entire ChroniquesDuVasteMonde film edition with ten great films and the ten best-known German actresses such as Iris Berben, Hannelore Elsner and Nadja Uhl is now available for 49.95 euros at www.ChroniquesDuVasteMonde.com/shop.