The Surgical Clinic’s, Mark E. Cooper, MD, breast surgeon, Nashville, TN, has responded to the controversy of the value of surgery for early-stage breast lesions discussed in an article published in THE NEW YORK TIMES entitled Doubt Is Raised Over Value of Surgery for Breast Lesion at Earliest Stage by Gina Kolata dated August 20, 2015.
If you or a loved one has been diagnosed with ductal carcinoma in-situ (DCIS), chances are you’ve gone to the internet for answers. That might even be how you stumbled upon this article. It is understandable that you want answers. Hearing that you have early-stage breast lesions can be alarming and confusing.
There is a lot of great information on the internet, but there is also a lot of misleading information floating around. There are many reasons for this.
People often have differing opinions (even medical professionals), and opinions aren’t necessarily facts. When it comes to studies, the findings of some research aren’t as trustworthy as most people believe, and often when trusted studies are cited, it is common that they are only partially cited or taken out of context. Furthermore, anyone can write an article or deem themselves an authority figure or “expert.”
A prime example is a controversial article published in The New York Times several years back entitled “Doubt Is Raised Over Value of Surgery for Breast Lesion at Earliest Stage.”
Since the subject matter in this article is such an important topic, we wanted to ask Dr. Mark E. Cooper, MD, one of our breast surgeons here at The Surgical Clinic in Nashville, TN, to weigh in on his thoughts about the information in this article and the value of surgery for early-stage breast lesions.
The Truth About Surgery For Early Stage Breast Lesions
by Dr. Mark Cooper
The conclusion in this New York Times article on the topic of early stage breast lesions is that the medical profession is “over treating” early stage breast lesions called ductal carcinoma in-situ (DCIS), which is often referred to as a pre-cancerous or pre-malignant disease of the breast.
Some might argue there is truth to this, but I believe you must have a forward approach and look at the entire context of the studies that were mentioned in the article. I find the proposed conclusion of this article interesting since it is not based on prospective (looking forward), long-term studies spanning several years or decades.
Let’s discuss what DCIS is and break down some discrepancies I found in the article. And as a veteran breast cancer and breast reconstruction surgeon, what I believe to be the truth about this early stage of breast cancer and the effectiveness of treating it with surgery.
WHAT IS DUCTAL CARCINOMA IN-SITU (DCIS)?
Ductal carcinoma in situ (DCIS) is usually found during a mammogram as part of breast cancer screening or to investigate a breast lump.
DCIS is abnormal cells inside a milk duct in the breast that has not metastasized (spread outside of that area) and has a low risk of becoming invasive. It is not staged breast cancer (I-IV); it is considered stage 0, which is the earliest form of breast cancer.
While DCIS is considered non-invasive, it is known to be a “proliferative” disease of the breast, meaning it can proliferate or turn into cancer. Therefore, I believe in taking a proactive approach to treating DCIS by performing local surgical excision.
To help you better understand the stages of cancer and why surgery for early-stage breast lesions is a viable treatment, it might help to understand what the word “metastatic” means.
METASTATIC MEANING: Metastatic refers to the spread of cancerous cells from one part of the body to another. When cancer cells metastasize, they break away from the original tumor and travel through the bloodstream or lymphatic system to other organs or tissues.
Metastasis is a serious complication of cancer because it can cause the disease to become more aggressive and difficult to treat. The most common sites of metastasis are the lungs, liver, and bone marrow. However, cancer cells can also metastasize to the brain, skin, and other parts of the body.
Metastatic cancer is often more difficult to treat than non-metastatic cancer because it has already spread beyond the primary tumor site. In some cases, surgery may be able to remove metastatic cancer cells; however, chemotherapy and radiation therapy are usually the only treatments available.
Again, DCIS is not considered a metastatic form of breast cancer. It is a non-invasive form of cancer that does not spread throughout the body (metastasize). However, DCIS can sometimes become invasive cancer, spreading into nearby tissue and, from there, metastasizing to other parts of the body.
Right now, there isn’t a way to know for sure which cells will become invasive cancer and which ones won’t. That is exactly why I believe those diagnosed with DCIS should be treated with surgery to decrease the risk of recurrence. For patients with DCIS that choose to have a lumpectomy with radiation, the risk of local recurrence ranges from only 5% to 15%.
HOW SHOULD DUCTAL CARCINOMA IN-SITU (DCIS) BE TREATED?
About 1 in 5 new breast cancers will be DCIS, and nearly all with this early stage of breast cancer can be cured if the right proactive approach is taken.
The New York Times article suggests surgery is not the answer in treating DCIS; rather, that doctors should be exploring the long-term use of hormonal manipulation drugs such as anti-estrogen drugs as a preventative measure for DCIS.
Hormonal manipulation is a cancer treatment that uses hormones or drugs to change how hormones work in the body. This type of treatment is most often used to treat metastasized breast cancer and prostate cancer and can be very effective for more invasive forms of these types of cancer.
For breast cancer, hormonal manipulation can be used to block the effects of estrogen. This can stop the growth of some types of breast cancer. For prostate cancer, hormonal manipulation can be used to lower the amount of testosterone in the body. This can stop the growth of some types of prostate cancer.
While hormonal manipulation can be great for these types of cancer, and even for short times, as part of a treatment plan for DCIS, I do not agree that these drugs should be the primary treatment for DCIS.
Anti-estrogen drugs such as tamoxifen or raloxifene are not life-long drugs and are only designed to be given for a finite period, such as 5-7 years. Using these drugs this way would require life-long use to reduce the risk of developing breast cancer from DCIS.
There is a big difference in the treatment and consequences of DCIS and more advanced staged cancer.
We know that DCIS is a precursor of breast cancer and is often considered the earliest form of breast cancer. Therefore, I firmly believe that a proactive approach should be taken with DCIS and treated with either a lumpectomy or, in some cases, a mastectomy.
Lumpectomy (Breast-conserving surgery)
Usually, the surgery performed for DCIS is a surgical excision called a lumpectomy, also called breast-conserving surgery (BCS.) This is a type of surgery where the lump is removed from the breast, typically when cancer is present but has not spread. We often suggest radiation in addition to a lumpectomy; however, if the lesion is small enough, radiation is unnecessary.
A mastectomy might also be considered based on the extent of the disease. A mastectomy is the surgical removal of one or both breasts, either partially or completely. Typically, a mastectomy is only performed to treat staged breast cancer. And in some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure.
In the case of DCIS, some women are not candidates for a lumpectomy and choose to have a mastectomy instead.
WHAT ABOUT CHEMOTHERAPY?
Chemotherapy is not given for DCIS since it is not an invasive process and has approximately a 3% chance of being metastatic to the lymph nodes. Chemotherapy is typically only used in later stages of breast cancer with a higher metastatic disease rate.
BOTTOM LINE: DCIS TREATMENT METHODS AREN’T BROKEN
I can’t entirely agree with the suggestion in this article that DCIS should only be treated with long-term anti-estrogen drugs. Other factors must be taken into account before a carte-blanche statement about treatment can be made, such as:
What Were The Margins Of The Specimens Reviewed?
We know that this has a tremendous impact on recurrence. There are three grades of DCIS, low, intermediate, and high grade.
What Was The Most Common Type Reviewed?
High-grade DCIS is closer to cancer than low-grade. This is why I do a sentinel node biopsy on high-grade DCIS.
When making a treatment plan for DCIS, these factors and others must be entertained. I do not feel that “watchful waiting” is a viable alternative treatment plan for DCIS.
Instead, I concur with Dr. Monica Morrow, the chief breast cancer surgeon at Memorial Sloan Kettering Cancer Center, who believes that the current treatment we use at The Surgical Clinic to treat DCIS, which is excision, whether a lumpectomy or mastectomy, should be the gold standard for those diagnosed with DCIS.
The underlying theme of this article is “less is more.” But this limited article is not realistic for my patients based on the knowledge we currently have about DCIS.
After 20 years of treating women with DCIS and breast cancer, I doubt that “let’s just watch it” will be an acceptable response once the patient is educated on DCIS. It is not the answer for my patients based on current medical research and literature.
I will say that this article raises some interesting and controversial points that need and demand further research before we, as a medical profession, could or should change our current treatment methods.
THE SURGICAL CLINIC SOUTHERN HILLS BREAST CANCER CENTER
The Surgical Clinic in Nashville, Tn, is a group of private practice surgeons representing various specialties, including breast surgery. Our state-of-the-art Southern Hills Breast Cancer Center is one of Middle Tennessee’s most respected establishments for those with any stage of breast cancer or other concerns surrounding breast health.
In addition to treating breast cancer, and breast surgeries such as a lumpectomy and mastectomy, we offer various other breast procedures such as:
- Mammosite Placement
- Sentinel Node Mapping
- Cyst Aspiration
- Lymph Node Biopsy/Dissection
- Lymph Node Mapping for Melanoma
- Breast Ultrasound
- Breast Ultrasound Guided Biopsy
- Ectopic Breast Tissue
- Nipple Discharge
Meet our Breast Cancer Surgical Providers
Brian Kendrick, MD, Mid-South Surgeons
Richard J. Greer, MD, FACS, Downtown Clinic
Robert F. Garza, MD, FACS, Garza Plastic Surgery
E. Dwayne Lett, MD, FACS, The Lett Center – Mt. Juliet, Lebanon