After mammography and fine needle biopsy, Jan was told that she had ductal carcinoma in situ in her left breast. “I went home and cried,” she said. “And I couldn’t sleep at all that night.”
What if she had been told instead that her diagnosis was ductal intraepithelial neoplasia? Or, simply, abnormal cells? “I would have been worried,” she said, “and would want more information. But that’s not cancer. Cancer means chemotherapy, losing your hair and, possibly, death.”
Actually, ductal carcinoma in situ (DCIS) and ductal intraepithelial neoplasia (the term used by the World Health Organization) are one and the same–abnormal cells (also called a lesion) in a milk duct of the breast. DCIS is not cancerous and, in 60 to 80 percent of cases, will never become cancer.
One of every four breast cancer diagnoses in the United States today is for DCIS, and patients are usually anxious to get rid of what they consider cancer as soon as possible.
In a study of 400 DCIS patients at Duke University, the terminology was an important factor in the woman’s prospective choice of treatment. Told that they had a non-invasive cancer, 47 perrcent said they would opt for surgery after weighing risks and benefits. When told that they had “a lesion” or “abnormal cells,” two thirds would choose another option–medication or watchful waiting.
Is Carcinoma Misleading?
Carcinoma is the most common type of cancer. It is one that begins in the tissue that lines the inner or outer surfaces of the body. In situ, though, means in place; in other words, it is not going anywhere, not invading nearby cells. As a result, some doctors believe the term carcinoma is misleading and should be dropped from the terminology.
A National Cancer Institute working group issued a controversial report calling for a less threatening term such as “indolent lesion of an epithelial origin.” According to the report, “use of the term ‘cancer’ should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated.” DCIS, according to the authors, is not such a lesion.
Along with the change of terminology has come a call for more watchful waiting, an option that recently has been recommended and used for prostate cancer. Would the same approach be useful–and safe–for DCIS?
There is, by no means, agreement on this issue. Even though ductal carcinoma in situ is non-invasive, the risk should not be minimized, some say. These are abnormal growths with many of the same traits as invasive cancer cells. They differ from normal cells in size, shape and architectural arrangement, and they can grow rather quickly. A significant number–20 to 40 percent–develop into cancer, and women who have one or more lesions often develop invasive cancers elsewhere in that breast or the other.
At this time, there is no certain way of telling which growths are potentially harmful and which are not. As a result, virtually all cases of DCIS are treated, usually with breast-conserving lumpectomy, sometimes followed by radiation therapy. Some patients, however, choose mastectomy, removal of one or even both breasts.
Once considered the standard treatment, mastectomy results in a one to two percent rate of recurrence, locally or at a distant site. Women having breast conserving lumpectomy alone have a 25 to 30 percent chance of recurrence at some time in the future. But having radiation therapy as well as lumpectomy reduces this risk to 15 percent.
When recurrence does occur, it is non-invasive (DCIS) about half the time. And even when it is invasive, it is nearly always treatable.
Those who favor mastectomy as treatment argue that “women undergoing [breast-conserving surgery] are likely to have diagnostic and invasive breast procedures in the conserved breast over an extended period of time,” according to an article published in the Journal of the National Cancer Institute [April 5, 2012].
DCIS is rarely discovered as a lump. In 1980, before the advent of widespread mammography screening, these lesions represented only about one percent of all breast cancers. As mammography has become more widely used and more sensitive, DCIS diagnoses have increased rapidly.
These are small cancers detected early; isn’t that the theory behind mammography screening? And when DCIS is treated, survival is virtually 100 percent. Considering the risk of invasive and metastatic cancer, why would you want anything but definitive treatment? Such is the thinking, apparently, of women who elect mastectomy, or even double mastectomy, as treatment.
Advanced technologies such as digital mammography and magnetic resonance imaging promise even greater ability to detect DCIS. But there is still uncertainty regarding how aggressively these should be treated. Since 60 to 80 percent of these lesions are benign and will never progress to the stage of invasive cancer, doctors realize that overtreatment is common.
Even though 60,000 new DCIS cases are being treated each year, there has been no corresponding decrease in the rate of invasive breast cancer. This suggests that there has been little or no value in treating DCIS as if it were early cancer, according to Laura Esserman, M.D., M.B.A., co-author of an essay published in the Journal of the American Medical Association [2009;302:1685-1692]. The article made a forceful case for the name change and for a less aggressive approach toward treating DCIS.
Although lumpectomy is breast conserving, it is certainly nothing to take lightly, particularly in comparison to watchful waiting. And even watchful waiting is likely to cause a great deal of anxiety if there is worry about a cancerous growth.
A joint news release from the Susan G. Komen for the Cure and the College of American Pathologists addressed some of the controversy. Mammography screening is still important, they point out, and should not be avoided because of fear of unnecessary therapy. Women should rather take an active role at every step of the process. Know what questions to ask and be confident about your ability to weigh your own individual risks and benefits.
REFERENCES:
“Ductal carcinoma in situ,” PDQ Health Professional Version, last modified April 11, 2014.
“Ductal carcinoma (invasive and in situ),” WebMD, reviewed by Amold Wax, M.D., June 26, 2012.
Carole VanSickle Ellis, “Elderly women with DCIS have better survival than women without cancer,” Medscape Medical News, May 20, 2010
Katherine Hobson, “The confusion over DCIS: what to do about ‘stage zero’ breast cancer?” U.S. News & World Report, October 22, 2009.
Mayo Clinic Staff, “Ductal carcinoma in situ (DCIS),” MayoClinic.com, July 23, 2011.
Nick Mulcahy, “Radiation for DCIS does not up CV disease at 10 years,” Medscape Medical News, September 5, 2013.
Nick Mulcahy, “In US, even more DCIS is coming: what should be done?” Medscape Medical News, March 12, 2013.
Nick Mulcahy, “DCIS is not like a rose: words affect treatment choice,” Medscape Medical News, August 26, 2013.
Nicky Mulcahy, “Take carcinoma out of DCIS and ease off treatment,” Medscape Medical News, January 21, 2010.
Nick Mulcahy, “Factors may predict which DCIS likely to be upstaged,” Medscape Medical News, November 17, 2010.
Nick Mulcahy, “For DCIS, outcomes with excision alone acceptable at 5 years,” Medscape Medical News, October 27, 2009.
Roxanne Nelson, “Radiotherapy after DCIS offers long-term protection,” Medscape Medical News, March 27, 2012.
Roxanne Nelson,. “Women with DCIS increasingly opt for contralateral prophylactic mastectomy,” Medscape Medical News, April 16, 2009.
Roxanne Nelson, “Problems with DCIS misdiagnosis: when cancer is not cancer,” Medscape Medical News, July 29, 2010.
Neil Osterweil, “Decisions with DCIS: it’s not ‘one and done’,” Medscape Medical News, April 5, 2012.
08/25/2014
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