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 a recent 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.
I find the purposed conclusion of this article interesting since it is not based on prospective (looking forward), long term studies spanning several years or decades. The conclusion was that the medical profession is “over treating” ductal carcinoma in-situ (DCIS) which is often referred to as a pre-cancerous or pre-malignant disease of the breast. DCIS is known to be a “proliferative” disease of the breast meaning it will proliferate, or turn into, cancer. DCIS is not staged as a cancer with breast cancer stage I-IV. DCIS is stage 0.
DCIS is typically treated with a lumpectomy followed by radiation and in some instances, if the lesion is small enough, radiation is not needed. 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, unlike breast cancer. Therefore, DCIS, a pre-cancerous lesion, can be treated with local surgical excision with radiation with the addition of hormonal manipulation with drugs such as tamoxifen or raloxifine. While breast cancer is treated with surgery, possibly chemotherapy since cancer has a higher rate of metastatic disease and possibly radiation therapy with the addition of hormonal manipulation if appropriate. Anti-estrogen drugs such as tamoxifen or raloxifine are not life-long drugs and are given for a finite period of time such as 5-7 years. The risk of developing breast cancer from DCIS is and would be a life-long process! There is a big difference in the treatment and consequences of DCIS and cancer. We know that DCIS is a precursor of breast cancer.
I concur with Dr. Monica Morrow, the chief breast cancer surgeon at Memorial Sloan Kettering Cancer Center in our current treatment of DCIS. This is a cancer precursor that should be treated with excision whether a lumpectomy or mastectomy based on the extent of the disease. We know that a lumpectomy with radiation has equivalent long term outcomes when compared to mastectomy, but some women are not candidates for a lumpectomy. In a review such as this one, there are other factors that must be taken into account before a carte-blanch statement about treatment can be made. 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 and this is why I do a sentinel node biopsy on high grade DCIS. All these factors and others must be entertained when making a treatment plan for DCIS. I do not feel that “watchful waiting” is a viable alternate treatment plan for DCIS.
In conclusion, the underlying theme to this article is “less is more”. Not for my patients based on this limited article armed with 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 will not be the answer for my patients based on current medical research and literature. 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.