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.
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 “overtreating” 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 cancer with breast cancer stage I-IV. DCIS is stage 0.
How is DCIS (Ductal Carcinoma In-Situ) Treated?
DCIS is typically treated with a lumpectomy followed by radiation. But, 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 raloxifene.
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.
Hormonal Manipulation Meaning:
Hormonal manipulation is a cancer treatment that uses hormones or drugs to change the way hormones work in the body. This type of treatment is most often used to treat breast cancer and prostate 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. Hormonal manipulation is sometimes used with other treatments, such as surgery, radiation therapy, and chemotherapy.
DCIS and Anti-Estrogen Drugs For Breast Cancer
Breast cancer is typically treated with surgery and possibly chemotherapy since cancer has a higher rate of metastatic disease. Other possible treatments include radiation therapy with the addition of hormonal manipulation if appropriate.
However, this article suggests that Dr. Brawley wants to explore the long-term use of anti-estrogen drugs as a preventative measure for DCIS. Anti-estrogen drugs such as tamoxifen or raloxifene are not life-long drugs and are given for a finite period of time such as 5-7 years.
Using these drugs this way would require life-long use in order to reduce the risk of developing breast cancer from DCIS. There is a big difference in the treatment and consequences of DCIS and cancer. We know that DCIS is a precursor of breast cancer, and is often considered the earliest form of breast cancer.
DCIS Treatment Methods Aren’t Broken
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 alternative treatment plan for DCIS.
In conclusion, 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.
Meet our Breast Cancer Surgical Providers
Brian Kendrick, MD, Mid-South Surgeons
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E. Dwayne Lett, MD, FACS, The Lett Center – Mt. Juliet, Lebanon