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More women getting diagnosed with breast cancer at younger ages
Austin woman describes what her diagnosis and treatment has been like.
Cancer is typically treated with surgery, radiation and sometimes chemotherapy. But a new study suggests this standard protocol might not be necessary for a common form of early-stage breast cancer.
Ductal carcinoma in situ, or DCIS, accounts for up to 25% of diagnosed breast cancers and affects more than 50,000 women each year, according to the American Cancer Society.
Often called “stage-zero breast cancer” or “precancer,” the Breast Cancer Research Foundation reports a 98% survival rate after 10 years.
The new study, published Thursday in JAMA, found patients who didn’t undergo the recommended treatment of surgery and radiation had comparable rates of invasive cancer as those who did after two years.
“These early results are provocative and potentially exciting for patients,” said Dr. E. Shelley Hwang, co-principal investigator and vice-chair of research at Duke Cancer Institute’s surgery department. “If these results hold up over time, most patients who have this type of low-risk disease will have the option of avoiding invasive treatments.
“That would be a complete change in how we care for these patients and think about this disease.”
What is DCIS and how is it treated?
DCIS is a condition that affects the cells lining the milk ducts but has not spread outside the breast, according to the American Cancer Society.
There’s controversy about whether DCIS should be considered a type of cancer, since by definition, cancer spreads throughout the body and DCIS does not, said Dr. Neil Iyengar, a breast medical oncologist at Memorial Sloan Kettering Cancer Center in New York City.
Although it doesn’t spread outside the breast, recommended treatment includes surgery, radiation and hormone therapy.
Surgery is typically a lumpectomy, where the tumor and a small amount of tissue are removed from the breast, Iyengar said. The aesthetic result is “usually quite good;” there may not even be a scar.
Although surgery carries low risk, Iyengar said radiation can be taxing. Most protocols require patients to visit the treatment center daily for up to several weeks to complete treatment. Patients are also recommended to take hormone therapy for up to five years, which can cause menopausal symptoms, extreme tiredness, nausea and other side effects.
“There’s a mental health burden going through what feels like serious cancer therapy for a non-invasive diagnosis like DCIS,” Iyengar said.
Doctors recommend surgery because of two “worrisome” possibilities, he said. One possibility is that the DCIS cell turns into a cancer cell and spreads throughout the body. Another possibility is that invasive cancer “hides” behind DCIS, making it undetectable through a mammogram.
But many women wonder if this burdensome treatment protocol is necessary for low-risk pre-cancer, Hwang said. Her study’s results suggest maybe not.
Active monitoring vs. surgery and radiation
The standard of care for DCIS is surgery and radiation. Still, researchers have wondered if women truly benefit from this treatment, said Dr. Ann Partridge, interim chair of medical oncology at the Dana-Farber Cancer Institute and another lead author on the study.
“Not all breast cancer is the same,” she said. “There’s a whole interest in trying to do less than more.”
In Thursday’s study, researchers enrolled nearly 1,000 women ages 40 and up who received a confirmed diagnosis of DCIS after a biopsy. They were randomly selected to enter one of two groups: One that received the current standard of care, which included surgery and radiation, and the other did not.
The participants who did not undergo surgery were actively monitored for invasive cancer with routine mammograms conducted every six months on the breast where DCIS was detected and every 12 months on the unaffected breast.
After two years, the study found the rate of invasive cancer was not higher among those who opted out of radiation and surgery. It was slightly higher in the surgery group, at 5.9%, compared to the non-surgery group, at 4.2%.
This may be due to “upstaging,” Partridge said, when more advanced cancer is identified during surgery. Some women in the active monitoring group may develop more advanced cancers over time, so researchers plan to continue monitoring study participants.
Expanding treatment options
In addition to the study, participants were asked in surveys how they felt over time. Researchers found the quality of life, anxiety, depression, worries and symptoms were similar among participants regardless of treatment.
“Active monitoring – from both a disease and quality of life standpoint – appears to be safe and well tolerated in women with low-risk DCIS,” Partridge said. “It expands options for women if we continue to show safety.”
Iyengar argues the study may not accurately reflect the patient population in the clinical setting. For example, participants are probably less likely to be naturally anxious since they agreed to a study where they might not receive treatment.
The study results shouldn’t change the standard care for DCIS, he said, but it does help doctors inform patients of the risks and benefits of treatment when making that “very personal decision.”
“Ultimately, I caution against people making any conclusions that suggest that it’s safe to not do surgery for DCIS,” Iyengar said. “We need that long-term follow-up before we definitively say that it’s okay to not do surgery.”
Adrianna Rodriguez can be reached at [email protected].
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