History
The patient's age should be noted.
Presenting Complaint
Most patients present with a mammographically detected mass; this has usually been excised by the surgeon prior to attending the radiotherapy department.
In a small number of patients (< 10%), a mass may have been self detected, or they may have developed nipple discharge, often bloody.
Past Medical/Surgical History
The past history should establish:
- Significant co-morbidities that may limit life expectancy or complicate treatment delivery (such as end-stage, inoperable heart disease or severe COPD)
- These patients may not live long enough to benefit from the addition of radiotherapy
- Medical problems which may impact on the early and late effects of radiotherapy
- Connective tissue disorders
- Conditions requiring treatment with cytotoxic agents such as methotrexate
Past O&G History
This may provide insight into the development of the cancer in a particular woman; women who have had a hysterectomy are also at low risk of endometrial cancer induced by tamoxifen!
Include:
- Menarche / menopause
- Number of pregnancies
- Breastfeeding
Past Radiation History
- Any previous radiotherapy
Medications
There should be no surprises here but ensure that patient is not taking any cytotoxic agents that may impact on the effect of radiation.
Allergies
Nothing specific.
Family History
A history of breast cancer in first degree relatives raises the risk of future breast cancers in the patient. Consider genetic testing if there is a strong family history. In some women
Social History
Although not specific to DCIS, the social history should establish the ability of the patient to attend treatment and their social supports.
Examination
As most patients have clinically undetectable lesions, and most have undergone surgical excision anyway, detection of a mass within the breast is usually impossible. It is important to evaluate for the presence of seroma or post-operative infection which may lead to a delay in the administration of radiotherapy. Examination of axillary and supraclavicular nodes to exclude regional disease is important. The contralateral breast should also be assessed for a synchronous malignancy. Finally, distant metastases should be evaluated (chest/abdominal examination).
Imaging
Mammogram and ultrasound findings should be reviewed to gauge the extent of the lesion. No other imaging is required.
Histological Diagnosis
Most patients have undergone a core biopsy using a mammotome (given the difficulty with visualisation of the disease on ultrasound). The majority of the patients in the radiotherapy department will have also undergone a wide local excision for their disease.
The important histopathological features to examine are:
- The size of the disease
- The presence of micro invasive disease (treat as per invasive breast cancer)
- The status of the margins (involved/close ie. < 2 mm/clear ie. > 2 mm/well clear ie. > 1 cm)
- The grade of the disease (high/intermediate/low)
These factors influence the decision for management when combined with the age of the patient. High grade, close or involved margins and a large volume of disease all raise the risk of local recurrence.
Staging
DCIS is staged by the TNM system: Tis (DCIS).
