Ductal Carcinoma In Situ (DCIS) with Dr Maen Farha

In our latest episode of MedStar Health DocTalk, Debra Schindler talks with MedStar Health breast surgeon, Maen Farha, MD, medical director of the Breast Center at MedStar Good Samaritan Hospital in Baltimore, about the most common breast cancer diagnosis: ductal carcinoma in situ (DCIS). 

Learn more about the contained, early-stage disease, the intricacies of diagnosis, and the personalized treatment options available. Dr. Farha shares valuable experience and a wealth of knowledge with hope for outstanding results, possible with proper care.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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>> Debra Schindler: 0:02

Comprehensive, relevant and insightful conversations about health and medicine happen here when MedStar Health doct talk real conversations with physician experts from around the largest healthcare system in the Maryland D.C. region. Most of us know someone who has been affected by breast cancer. The American Cancer Society estimates that over 4 million women in the US today have survived breast cancer or are living with some stage of the disease. Thanks to improved mammography and advances in treatment, more and more women are being diagnosed at an early stage. Of them, one in every six, according to a cancer.org report, is diagnosed at stage zero, where malignant cells are contained in a mammary gland, it known as douctal carcinoma in situ, or dcis. Today we will learn more about this early stage breast cancer and how it's treated with Dr. Man Farha, medical director of the Breast center at MedStar Good Samaritan Hospital in Baltimore. I'm your host, Debra Schindler. Dr. Farhal, welcome to MedStar Health doct.

>> Dr. Man Farha: 1:10

Talkg do this, I think, this interesting. A lot of patients have this disease and they want to hear about it.

>> Debra Schindler: 1:18

So ductile carcinoma in situ. In situ, What a strange name. What does it mean and how does it differ from invasive breast cancer?

>> Dr. Man Farha: 1:27

So, the structure of the breast is a mound of fibro connctive fatty tissue. And interspersed in the middle of all of that are ducts and lobules. The lobules are supposed to produce the milk and the ducts carry the milk from the lobules to the nipple. There's probably about 13 or 14 of these systems in the usual breast. the ducts and the lobules are contained with a very thin microscopic basement membrane. Outside that basement membrane are, lymphatics veins and arteries that supply the blood supply and cancers that form within that basement membrane do not have access to the circulation and therefore cannot spread. And that's why they called it ins sit to. The cancer cells are contained within the duct and therefore they have a near zero chance of spreading to the lymph nodes or somewhere else in the body.

>> Debra Schindler: 2:25

So they don't spread at all. Someone who has, a diagnosis with DCIS does not have to worry about it becoming more invasive or spreading outside that.

>> Dr. Man Farha: 2:35

Left alone, a lot of DCIs will turn into invasive cancer. So that's why the benefit of removing it and treating it before it turns into invasive cancer, certainly is valuable for patients to reduce the chances of, them showing up with the disease somewhere else in the body. The only caveat to that hypothesis is that if you take a piece of tissue, for example, one engine size, and you divide it and you take slices and you look under the microscope at these slices, you're only sampling maybe 5% or 10% of that tissue at maximum. Therefore, it is conceivable that some patients who have DCIs may have areas of invasion that may not show on these slices that have been done. So that's the caveat. But overall, if you take all commrs, the cure rate for DCIs that's properly treated is near 100%.

>> Debra Schindler: 3:34

Okay, this is a very early stage then, of a breast cancer.

>> Dr. Man Farha: 3:38

Correct. We call it stage zero.

>> Debra Schindler: 3:40

Stage zero.

>> Dr. Man Farha: 3:41

Some people argue that we shouldn't call it cancer, but that's a hypothetical discussion that's really irrelevant. The bottom line is these are cells that look like cancer cells and left alone, they will likely or very likely behave like cancer cells.

>> Debra Schindler: 3:57

It is interesting that you say that because while I was researching this topic, I read that on one site that it isn't really a cancer.

>> Dr. Man Farha: 4:05

Well, that's why people argue that you shouldn't call it the cancer. It's really a hypothetical discussion. The cancer. The cells look like cancer cells. Genomically, they behave like cancer cells. They have the profile of cancer cells. But given the fact that they are contained within the duct, if you say cancer spreads, this does not spread. And that's why people argue that we shouldnt t really call it the cancer.

>> Debra Schindler: 4:30

Okay, so it's stage zero. it'not invasive. How do women know that they have of this? Or men. Men could get this too.

>> Dr. Man Farha: 4:37

Dcis, its rare, very rare in men. Most men who present with a breast cancer present with an invasive breast cancer, usually because they present with a mass and most masses are invasive breast cancer. Most DCIS is discovered on mammography, though most the large majority of patients with DCIS either are found on screening mammography followed by diagnostic mammography. Few patients present with a mass and some patients also a small number of patients may present with a bloody nipple discharge or clear nipple discharge.

>> Debra Schindler: 5:12

This might sound, sound like a dumb question, but I'm, going to ask anyway. Do men have milk ducks? Yes, they do, but they don't normally.

>> Dr. Man Farha: 5:20

Get dec as developed as the women's.

>> Debra Schindler: 5:23

which might explain why they don't.

>> Dr. Man Farha: 5:24

Really get the correct o very little amount of tissue.

>> Debra Schindler: 5:29

Okay, so there could be a bloody discharge from the nipple. What other symptoms might there be? And if there aren't any symptoms, how would a woman find out that she has ductal carcinoma?

>> Dr. Man Farha: 5:40

So the vast majority of DCIs is discovered on screening and diagnostic mammography.

>> Debra Schindler: 5:49

Routine. Usually a routine mammogram.

>> Dr. Man Farha: 5:52

Correct. Screening, mammogram is done. It shows calcifications or shows an area of architectural distortion. Then a diagnostic mammogram is done, and then a biopsy that would show dcis.

>> Debra Schindler: 6:06

What is a calcification? That's not cancer.

>> Dr. Man Farha: 6:09

Calcifications are frequent in the breast, and calcifications could deposit within the ducts, in vessels, areas of fat necrosis, areas of fibrocystic disease. There are certain types of calcifications that when we see them, recognize them, these are suspicious and need to be biopsied. So the calcifications indicate that something is going on in that area, and that's how we're alerted that there's a problem. The calcifications themselves are not the problem. They're just an indication that something is going on in that area. And this alerts us to the presence of the tumor.

>> Debra Schindler: 6:49

Okay, so the mammogram shows something suspicious, and then the next thing would be to get a biopsy.

>> Dr. Man Farha: 6:57

Correct. Most of these biopsies are done using stereotactic technique. This is, mammography guided technique. It's done under local anesthesia.

>> Debra Schindler: 7:09

So the patient is awake.

>> Dr. Man Farha: 7:10

Correct. Using an instrument, that we direct into the area of the suspicious lesion. And that instrument will cut small pieces of the tissue that samples the area and. And we send it to the pathology. Now, that's done under local anesthesia. It's really surprisingly extremely well tolerated, especially if you do the right level of local anesthetic. It's stressful, and the brave women go through it day in and day out successfully.

>> Debra Schindler: 7:40

Fortunately, I think I'd rather be under general anesthesia. Can't that be an option?

>> Dr. Man Farha: 7:45

this cannot be done under general anesthesia because you're sitting in the mammography machine with the breast and compression to do this biopsy. But that's the standard. We do hundreds of these every year here. Over half a million are done nationally, or maybe over a million are done nationally every year. It's all done under local anesthesia.

>> Debra Schindler: 8:03

I don't even like to have my blood drawn.

>> Dr. Man Farha: 8:07

I can imagine.

>> Debra Schindler: 8:08

What are the risk factors associated with dcis? Is there a, hereditary propensity for this?

>> Dr. Man Farha: 8:14

It's the usual risk factor for breast cancer. Inheritance is big. Age, smoking, elevated bmi, lack, of exercise. All the same risk factors that breast cancer would cause dcis.

>> Debra Schindler: 8:28

What's the average age of your patients?

>> Dr. Man Farha: 8:30

I'd say around 55 on the average. But we see patients in their 80s who have DCIS. We see patients in their 30s who have DCIS.

>> Debra Schindler: 8:40

Would you treat a patient that in her 80s for this?

>> Dr. Man Farha: 8:43

So it depends on the amount of disease they have because it takes time for DCIS to turn into invasive cancer. So if you have a tiny bit of DCIS and you have a patient who has a lot of comorbidities, then you may say we can watch something like that. But if you have a robust 85 year old who is really active, and many of these are still doing screening mammography despite guidelines, you treat it.

>> Debra Schindler: 9:12

What do you mean? in spite, in spite of guidelines?

>> Dr. Man Farha: 9:14

Because guidelines generally tell you to stop doing screening mammography at a certain age. Maybe 75. Some people stretch it to 80, but some women just keep doing it. And you can't stop them if they want to. If they ask for a screening mammogram, they get it.

>> Debra Schindler: 9:31

Oh, interesting. I didn't realize there was a cutoff. How do we reduce the risks? And are there any preventive tips? You mentioned exercise. How would exercise prevent dcis? I'VERY curious about that.

>> Dr. Man Farha: 9:46

Well, whether it's affecting the hormonal environment, increasing obacity, not being consistent with a lot of smoking, and might have positive effect on the immune system. If you think of our body, we have trillions of cells in our body, and these cells keep dividing on an ongoing basis. And errors in the, division happen frequently. And many of these cells with errors would die, many would form into a cancerous growth that our immune system detects and suppresses them. So the immune system, the role of the immune system is really poorly defined, but there's no doubt in my mind that that plays a role in, in carcinogenesis.

>> Debra Schindler: 10:32

It comes up in every conversation, the need for exercise and sleep.

>> Dr. Man Farha: 10:37

Again, it might have its effects on the immune system. Inflammation is another factor. Diets that are associated with high inflammation or diseases that are associated with inflammation as well.

>> Debra Schindler: 10:49

It sounds like there isn't. the DCIS would not be life threatening. Is that fair to say itself?

>> Dr. Man Farha: 10:56

It's not life threatening.

>> Debra Schindler: 10:58

How long can someone go before they are then at risk for it spreading?

>> Dr. Man Farha: 11:02

It has to turn into an invasive cancer before it becomes life threatening. And that process might be one year, might be 10 years. And again, that depends on the amount of disease on the person's makeup and their immune system. And other factors, their hormonal environment, hormonal exposure, all these are factors that are poorly defined, but they Play a role in how frequently these turn into a cancer.

>> Debra Schindler: 11:31

Is it always stage zero? I guess if it elevates to another stage, then it's no longer dcis.

>> Dr. Man Farha: 11:38

Correct. If it changes into an invasive cancer, then the staging changes.

>> Debra Schindler: 11:44

Okay, so you talked about the biopsy once the biopsy results are back. And how long does that take?

>> Dr. Man Farha: 11:51

A couple of days. You get the result of the biopsy after it's done. And in addition to looking under the microscope, we test these for, estrogen and progesterone receptors. these are receptors within the cell that tells us, whether this tumor is dependent on the woman's hormonal environment. Although people might be postmanopausal, but their body still produces asrogenic hormones. And what we find is that suppressing these hormones reduces the recurrence rates for these tumors when they're estrogen and or progestne receptor positive.

>> Debra Schindler: 12:32

What if a woman is on a hormonal replacement therapy? Would that.

>> Dr. Man Farha: 12:35

So that's, a generally thought to be a mild risk factor for development of dcis and. Or breast cancer. This subject has been argued upon back and forth for years, but most people settle on the fact that hormonal therapy would increase the risk. But it's not an excessive increase in the risk. It'll be maybe 20%, 25%. So if somebody's risk is 10%, it'be 12 or 13%.

>> Debra Schindler: 13:05

It's a discussion about the risk benefit.

>> Dr. Man Farha: 13:08

correct. It's. It's always a discussion about risk benefit.

>> Debra Schindler: 13:12

So when you get the biopsy back, do you call the patient, or do. Does she have to come in and you sit down and you tell her what you found?

>> Dr. Man Farha: 13:19

Depends on the patient. Most patients would prefer that to meet them face to face and discuss the result with them. in the patient's mind, even the mere mention of a suspicious mammogram, creates the emotional response as if you have a cancer.

>> Debra Schindler: 13:36

True.

>> Dr. Man Farha: 13:37

Then you tell them on the phone, you have dcis, and you try to explain it. That's not going to work. There are few patients, though, who are sophisticated their knowledge enough. They've already ingested the fact they've already done their research, and they say, yeah, you can call me. I understand what DCIS is. These. You can tell them the result on the phone, obviously. and then they have to come in to discuss their treatment.

>> Debra Schindler: 14:03

Okay, let's go through that. What are the treatment options?

>> Dr. Man Farha: 14:06

The. Unfortunately, the treatment options are similar to some degree to invasive cancer.

>> Debra Schindler: 14:12

A lumpectomy would be your first Lumpectomy.

>> Dr. Man Farha: 14:15

Is what most of our patients will undergo.

>> Debra Schindler: 14:18

Okay, explain that for anyone who may not know what al lumpectomy is.

>> Dr. Man Farha: 14:21

So if the tumor is localized, we take the tumor with a margin around it. Most of these tumors we don't feel. So the radioloerss will have to, either put a little wire or a special chip in the area of the tumor so we can find it. So after the patient goes to sleep, we go in and take that tissue, take an X ray of it to make sure we got what we came after. I usually cut the specimen myself with the pathologist to look grossly if I need to get additional margins, hoping to reduce the chance of having to go back in. And then you close the incision, patients go home. Recovery from something like that is usually very simple and the risk of the surgery is very small. The biggest unknown is when the pathology comes back. So, something about dcis, since it's microscopic, it's not a mass that you could feel. And many times or sometimes it's much more extensive than the imaging tells you. Now, we do get an MRI before the surgery that gives us a hint or a suggestion about the extent of the disease, but even that is not 100% accurate.

>> Debra Schindler: 15:31

Is that when radiation would come in.

>> Dr. Man Farha: 15:33

So after the surgery, pathology comes back, margins are negative. A large majority of the patients will be offered radiation. Now, there are some patients who we don't offer radiation to or we don't recommend because there isn't enough benefit from it. And there's a couple of ways to tell that. We talked about the 85 year old with 3,4 millimeters of DCIS. we talked about, patients with very limited amount of disease who are not able to get the radiation. And there's also, we do some genetic profiling of the tumor that gives us a score. It's called decision rt, which we use to decide whether there's meaningful benefit or not a meaningful benefit from radiation. Meaning they've looked at large number of cases and created a statistical model where doing a bunch of receptors and so on, they give us a score if the score is less than 3. The research has shown that these patients have very little benefit from m the radiation. If the score is above three, there's increasing benefit of the radiation. So it's not a straightforward decision. And then there are the patients also who have localized disease, who are not willing or who have really limited disease, where we might do intraoperative radiation, do the radiation for them while they're under general anesthesia.

>> Debra Schindler: 17:04

also Known as I its share with us what that is.

>> Dr. Man Farha: 17:08

So the usual course of radiation extends from three to six weeks. And, the usual course of radiation radiates the whole breast. And studies have shown that in many patients, radiating the normal tissue does not reduce the incidence of new cancers. So when we know the disease is very well localized, whether it's invasive or dcis, when we have a good feel that this is a localized disease, we just radiate the rim around the tumor bed. Intraoperatively, over the span of eight or ten minutes, it delivers one dose of radiation, which is biologically equivalent to the three to six weeks of radiation to that area. there's some nice things about it. One is convenience. Two patients.

>> Debra Schindler: 17:58

Y. Sounds like a great option.

>> Dr. Man Farha: 17:59

Yeah. Patients, who are unwilling to go. You'worried they're not going to cooperate with the radiation or they just can't raise their arm enough to. To have that standard radiation or the older patient where you want to radiate them, but, it's very hard for them to do that. Cover some geographical areas. People have ve treated patients who live far from here, and they wouldn't come every day for four weeks or five weeks. So we do the intraoperative radiation, if appropriate. So there are bad, and it saves money as well. It's cheaper than the, standard radiation.

>> Debra Schindler: 18:35

What about chemo? Is chemo a part of the plan?

>> Dr. Man Farha: 18:38

Not for, dcis.

>> Debra Schindler: 18:39

That's. That's a comfort, I'm sure, for your pat.

>> Dr. Man Farha: 18:41

So the. The indication for chemotherapy is when there is concern about the disease showing somewhere else in the body, because surgery and, radiation will take care of the local regional of disease in the breast. But if there are cells hiding in the liver or the lung that will show up later, that's where chemotherapy comes in play. And since DCIS has a near zero chance of doing that, then there's no benefit from chemotherapy.

>> Debra Schindler: 19:09

But I have read that mastectomy is an option for dcis and if there's little concern about it spreading, why would someone opt for a mastectomy?

>> Dr. Man Farha: 19:19

So there's a number of factors there. One of them, the woman can decide on having a mastectomy if that's what she wants. Some women say, I don't want to deal with this. And it's surprising the profile of people who say that. you think that a younger patient might never want to say that, but the younger patient might say, you know, I have two daughters who are 7 and 8, and I don't want to worry about this for the next 20 years.

>> Debra Schindler: 19:42

Right.

>> Dr. Man Farha: 19:43

And they might say, I'm going to have a bilateral mastectomy. Some do that. And, so that's first. The patient has that choice, of course. But then suppose, you have a lot of disease in the breast. we have a patient a couple weeks ago. There's about 15 centimeters, 6 inches of DCIS. You have to have a huge breast to be able to take that with negative margins. Then the ratio of the disease to the size of the breast also. And how can you come out with a, cosmetically acceptable outcome? Acceptable to the patient, of course.

>> Debra Schindler: 20:18

Right.

>> Dr. Man Farha: 20:19

So all these are factors in deciding for. Some patient would say, you know, this is pretty localized. You could do just an lumpectomy, or you can do a mastectomy if you want. But some patients say, you know, you're not the optimal candidate for this. And despite that, they might say, I want to try it. We try it. If it doesn't work, we go back and do the mastectom.

>> Debra Schindler: 20:39

What did you decide with the patient who had the six inches of D.C. well, she.

>> Dr. Man Farha: 20:44

She decided that she wants to give it a shot. We gave it a shot. We told her, there's a very high chance of this not working. Lump me is not goingn work.

>> Debra Schindler: 20:53

Okay.

>> Dr. Man Farha: 20:53

And sure enough, the margins showed a lot of disease and unexpected disease. So we'll have to go back and do a mastectomy for her with a reconstruction.

>> Debra Schindler: 21:04

Can you reach reconstruct if you have to take that much bre away?

>> Dr. Man Farha: 21:07

yeah, you can reconstruct the breast as long as you can. You leave. You leave a nice skin envelope. You can reconstruct the breast, or you can use implants to stretch the skin to create enough of an envelope.

>> Debra Schindler: 21:20

And because it's in the milk duct or the mammary gland, are you able to keep the nipple or does that have to go to.

>> Dr. Man Farha: 21:26

Depends on the location of the lesion. I see, lesions that are close to the nipple areola complex would require to have the nipple areola complex removed. Lesions that are further away. You can save the nipple. You don't have to remove it.

>> Debra Schindler: 21:41

Once a patient goes through a treatment for dcis, what is the likelihood that they're going to have the same disease come back?

>> Dr. Man Farha: 21:48

So the recurrence rates for DCIs that are properly treated vary. for the usual limited disease, the recurrence rates for lumpectomy and radiation followed by endocrine therapy is about maybe 5%. For a mastectomy is about 2%. The patients may choose based on that factor. But when we looked at long term survival data, there is no difference in survival between the lumpectomy with radiation versus mastectomy. And there are many hypotheses why that is so, despite the higher recurrence rate. Now remember that after lumpectomy with radiation for DCIs, although the recurrence rates are small, when they recur, 50% of the time, it's TCIs. 50% of the time it's invasive cancer.

>> Debra Schindler: 22:38

But it's a new cancer. Right. It would't have been.

>> Dr. Man Farha: 22:41

So it could be a cancer in the bed of the tumor within a short period of time, two, three, four, five years. That's a true recurrence. Or it could be a new cancer. What we see more, I'd say there's 50, 50. Some of them are new cancers, some of them are true, what we call true recurrences. Now, to reduce the chances of new cancer or recurrence, patients who are estrogen or progestne receptor positive are offered endocrine therapy. So these are pills that by blocking the synthesis of estrogen or blocking the estrogen receptor will reduce the recurrence rates by 50%. and most patients will take them. They have some side effects. About 30% of the patients cannot tolerate them very well because of body aches or hot flashes or they just don't want to take anything.

>> Debra Schindler: 23:33

What are the most common concerns that your patients share with you when you inform them that they have dcis?

>> Dr. Man Farha: 23:40

The first concern for everybody is a life and death concern.

>> Debra Schindler: 23:45

Sure.

>> Dr. Man Farha: 23:47

The second concern is, am I going to need chemotherapy? The third concern is am I going to lose my breast? And how is it going to look after surgery and radiation? These are the commonest concerns that patients express.

>> Debra Schindler: 24:02

Canagine.

>> Dr. Man Farha: 24:03

And they vary depending on the age and the personality, and the background of the person. There's no doubt it's very personalized.

>> Debra Schindler: 24:11

I'm sure after you talk with them, they go from panic to relief.

>> Dr. Man Farha: 24:14

So they're always relieved. And we want to make sure that this is not life threatening. We know how to deal with it, and you're going to be fine. That's always a very relieving thing. And then when you get the details of all the things that you have to do, that's kind of bothersome. I wish there were. I mean, there was a study looking at just doing endocrine therapy for some DCIS patient. The results of that study are not out yet. Meaning no surgery, no radiation, just take the pill. That study has not matured yet. I think they completed Enrollment of the patients and we'll see what the results. Takes 10, 15 years to show to study these outcomes. So it's not. They don't come out very quickly.

>> Debra Schindler: 24:54

What do you think we can hope for in terms of what's on the horizon for this kind of cancer or non cancer as it is, this kind of breast disease. And what about clinical trials? Are there any clinical trials that patients should know about if they have a diagnosis of dcis?

>> Dr. Man Farha: 25:10

There are some clinical trials. One of them would be radiation. No radiation for limited amount of disease. one of them is that trial that closed now, trying standard treatment versus just endocrine therapy. That should mature. We should start getting results over the next four or five years. What? Ideally, could we come up with something that a biologic that might just stop DCIS in its tracks? We don't have that, yet, but there's the promise of that. We've seen enough progress and so many things with breast cancer that I wouldn't be surprised if something like that comes up over the next 10 years.

>> Debra Schindler: 25:49

A woman who gets this kind of diagnosis, what is your projection as far as how long this journey will last for her? From the time that she's diagnosed until the time that she is free,

>> Dr. Man Farha: 26:00

Of dcis, meaning until she completed treatment.

>> Debra Schindler: 26:04

I talked to a young woman many years ago who, I mean, she had invasive breast cancer and had the mastectomy. And look, she took that in such strides. She. She told me, I told myself, I'm giving myself six months. I'm going to take six months out of my life to take care of this. And then I'm going to get on with my life and put this behind me. She predicted a six month, and I'm sure she predicted this six month journey based on her conversations with her care team, but dci, seems like it may not be as long as that.

>> Dr. Man Farha: 26:34

So if the patient choose a lumpectomy after two, three weeks, they're fine if their margins are negative, and if they do the standard radiation that's designed around their schedules, usually the radiation episodes are short. You come get treated, takes about 15 minutes and you leave, you go back to work, you go back to life. The radiation oncolog will see these patients once a week, during the treatment. So that is not disruptive. M. Mastectomy requires more to recover from. You add reconstruction, that adds another month to the, to the mastectomy.

>> Debra Schindler: 27:09

You wouldn't do the reconstruction at the time of the mastectomy.

>> Dr. Man Farha: 27:11

You could do it. So. But if you do it at the same time, the recovery becomes longer. Also, if the recovery from a mastectomy alone is four to six weeks, add four to six weeks to that to really recover over the reconstruction.

>> Debra Schindler: 27:26

Do you have a story of hope for us that you could share?

>> Dr. Man Farha: 27:29

Yeah. Patients do very well. The vast majority of patients don't see the disease. And we can, to a good degree, predict the extent of the disease, how dangerous it is, and what needs to be done for it to be treated and cured. And, patients do very well.

>> Debra Schindler: 27:47

There seems to be some controversies involving the guidelines for DCIS management. Can you share any insight to that?

>> Dr. Man Farha: 27:55

Are we doing too much is the question. We always want to be as economic as possible. We want to inflict as little suffering, pain, treatment on patients as is necessary for that particular patient. And the question is, which patients don't need radiation? Maybe patients don't need five years of endocrine therapy. maybe some patients don't need it altogether. So these are questions that have not been answered. And research needs to be done to answer these questions, because not only is there an economic cost, but also personal cost for the patients. body aches, arthritic symptoms are not easy for active people who want to run, who want, who lead active lives. so, reducing that cost to the patient is very important.

>> Debra Schindler: 28:44

Who would make those decisions? Her care team? M. I guess. I mean, a patient can't know what she doesn't know, so she needs input from other specialists.

>> Dr. Man Farha: 28:54

So, as you can see, in the care of this patient, you'll have a radiologist often involved in the diagnosis, a pathologist reading the slides and doing the testing, ass surion operating on the patient, a radiation oncologist who gives an opinion about radiation and gives the radiation. A medical oncologist usually takes care of the endocrine therapy for the patients. And we work together as a team. So once we work up the patients, we see them together, we discuss them in conference, and we see them together as a team. And they usually bring their families with them, their support, their spouses, their neighbor, whatever. And we'll have a real live discussion about their treatment. And there's some authenticity about it and immediacy. Instead of going to four or five appointments, different times, different days, where there could be confusion and uncertainty.

>> Debra Schindler: 29:53

And that's what we call comprehensive care, comprehensive, multidisciplinary care. Very important. Is the patient also offered advocacy or, community support?

>> Dr. Man Farha: 30:03

There are support groups. I see smaller uptake. People are taking more onto social media, for support.

>> Debra Schindler: 30:11

Interesting.

>> Dr. Man Farha: 30:12

And most patients will have their own circle of support is, which is important for them.

>> Debra Schindler: 30:17

Okay, so what are the key takeaways? Let's summarize.

>> Dr. Man Farha: 30:21

The key takeaways is make sure the disease is limited and there isn't anything else missed. And if it is all DCIs, the vast majority of patients will do extremely well, and the vast majority of patients will have choices of keeping their breast. What you have to do is, learn about your disease to make the best decision that's optimal for you personally.

>> Debra Schindler: 30:44

Perfect. Thank you, Dr. Clorhad.

>> Dr. Man Farha: 30:47

You are welcome, Debra.

>> Debra Schindler: 30:48

We've been talking with Dr. Man Farha at Admin, our Good Samaritan Hospital in Baltimore. Thank you for sharing your expertise with us here on Doc Taller. To learn more about DCIS, visit medstarcancer.org or call the Breast center at MedStar Good Samaritan Hospital at 443-444-4673.