NY Times article on Dr. Laura Esserman and DCIS

Below is a comment by one of the New York Times readers (NLS--whom I believe is an MD) about the article. I like it a lot. I have a hard time with some of Dr. Esserman's views. There just isn't enough data in many cases, to say who should forego treatment. I'm sure that she would have said that I didn't need an excisional (surgical) biopsy when my core biopsy showed only ADH (atypia). Then the excisional biopsy showed extensive high grade, multifocal DCIS with comedonecrosis, which she does believe should be treated. So.....this process isn't so easy and predictable as she makes it out to be.

"Is this about improving patient outcomes? Or is it about an OCD, controlling surgeon? Medicine strives to claim it is 'patient-centered' and 'evidence-based' yet I see none of that in this approach. This is not the eclectic approach of a future-thinking genius, this is a doctor making unilateral decisions, based on little evidence, playing with a lethal disease.
Small does not mean less aggressive when it comes to tumors. DCIS often does not exist alone, but frequently pairs with more lethal forms of invasive disease. Until we have evidence to help stratify who we should say 'no' to as a 'low risk', valiant efforts such as this are careless and can result in expensive and more extensive interventions in the future (if we miss the early diagnosis of disease, catch it at a more advanced stage and have to throw multiple modalities at it rather than less intensive, less expensive early intervention) and, in fact, might risk lives.
Challenging the status quo when armed with evidence is noble, however when so many questions remain unanswered about appropriate selection of candidates for observation vs treatment, 'cowboy medicine' such as this has no place putting lives at risk. There may be a day when we can confidently identify low vs high risk DCIS, but this is not yet that day and no surgeon has the clairvoyance to know which patients are most aligned with benign disease." (from the New York Times website 9-28-15, a reader's comments)

The problem I have with her approach is that she doesn’t even recommend excising the DCIS ... so how in the heck can she be sure that is all that is in there? As one of the 10% cited in the article who have invasive cancer found alongside the DCIS (despite it being a tiny amount of intermediate grade DCIS so not particularly high risk) I am glad my surgeon insisted on removing it.

Advocating against radiation and tamoxifen in some cases is one thing, but advocating against removal and complete pathology is a very different thing in my opinion.

Maybe there is more information about this doctor elsewhere, but there is nothing in the article that says she never recommends surgery for DCIS, only that evidence shows that we are vastly overtreating it (which is correct).

I completely agree with Annette. I had a small cluster of calcifications, which Dr. Esserman would have probably said watch and wait, don't even biopsy. When I had the core biopsy it was found to be atypia only (ADH) and she would have likely said just leave things alone at that point. Then they found the extensive high grade DCIS on the surgical biopsy, which she actually does treat, but if she doesn't biopsy, it won't be found.

I'm all for Dr. Esserman doing clinical trials, and women signing up to be treated first with hormonals, but I just don't believe that the data is there for her to be making preemptive treatment decisions about women who aren't voluntarily participating in clinical trials, without, at least, biopsies to determine the extent of disease.

I'm going to ask my radiation oncologist about Dr. Esserman's perspective when I see her in a few months. The RO is a NCCN (National Comprehensive Cancer Network) panelist who develops the standard of care for DCIS (she works at MSKCC).

I wish the NY Times would sometimes publish articles on DCIS which are more balanced in terms of perspective, and in terms of the breadth of available factual information. Sigh.

Well, I have to chime in here. First of all, this piece in the Times doesn't share any new info, and focusses on Esserman's quirks and not her research initiatives. People, especially those who have lost loved ones to breast cancer or have it themselves, have understandably negative reactions to Esserman's views based on their particular set of circumstances. But she is not dangerous or practicing cowboy medicine. If you listen to this podcast, she explains her current trial, which is the kind of data collection that needs to take place in order to develop more appropriate treatments for DCIS. True, we don't have the data to support not treating DCIS across the board. Esserman does not suggest that we do. She's made a career of saying the data that we do have does not support current treatments. And given the heavy price to be paid physically, emotionally, professionally and financially by the millions of women treated for DCIS, why do we continue down this path? The Times writes about her because she is willing to question the status quo.

link to the podcast http://www.healthnewsreview.org/2015/09/dcis-dilem...

thanks dtad

To add to this, you should understand that I am supposed to get my 2-year-out mammo, and I have a real feeling to not do it. Because, if a tiny DCIS is found, I truly do not know what I would do about it, now.

Good points, NoCalMom. I look forward to the day that the treatment regimen is clear for those diagnosed with DCIS, and hope that a MX will one day be unneeded. I'm a statistician, but some days I am too close to this topic!

Hi Labelle, until they figure out a way to know for sure who will and who will not progress, I find popularizing wait-and-see approach to be potentially doing a lot of harm. Scanning technologies are getting better but are not there yet to be fully reliable and to catch that evasive moment when pure DCIS becomes invasive..

On a personal level, I was followed up by regular mammos for about 12 years. During those dozen years, always had BIRADS 2 and no further follow up required.  Regular mammos were alternated with diagnostic six month cycles. That's 'wait-and-see.' Until on year 13, regular mammo showed a change in calcification pattern. Was sent for biopsy. Scannings including MRI done before surgery showed a tiny tumor and clear lymph nodes. Surgical pathology results are in my profile below. I wish I were sent for biopsy and other tests much sooner than I was.

Speaking of mastectomy, nothing showed on pre-surgery scannings in my left breast that I decided to remove anyway. Surgical pathology showed very extensive LCIS in the left breast as well as in the right that were not observed in any scannings prior to surgery.

I also think we need to be completely open about the limits of screening. Every woman needs to know it is not fail safe. I had no idea. I did it for 20 years. I was sure it would be caught at stage 0 because I did all the blue ribbon screening - even MRI's like clockwork. I would say that the vast majority of women today would say "I had a mammogram, I'm good." In the same way as breast density is required to be disclosed in many states I think the effectiveness of screenings need to be disclosed too. Ok, stepping down from my soapbox.

Thanks, ladies. I may sound crazy, and, again, though with the knowledge I had at the time, I do feel I did the wise thing, I am still undecided about future screenings. What DO I do if a tiny, low-grade DCIS is found in the previously radiated breast? I cannot have rads again, there, and with these new schools of thought, I'm just not sure I would go right to mastectomy, which would, in the treated breast, be my only option. DCIS is now 25% of findings. Good; if it prevents it becoming worse. Bad; if it means severe over-treatment. I cannot know, but have a strong feeling, that, undetected (as in the past) my low-grade DCIS (and even the non-aggressive micro) may never have caused me any harm at all. But the radiation I had certainly can. Really, seriously, considering not getting future screenings. There is no breast cancer in my family, and, in fact, no cancer at all. Everyone has lived to be 100. It would be a big leap to forgo screening, but, really?

Hi all - In the interest of honesty and clarity, I feel I have to say that, even though the articles about DCIS, and maybe even very early invasive cancers (I did have a microinvasion) not progressing, or being gotten rid of by the immune system have concerned me about possible over-treatment, I WILL be getting my mammo. I'm just unhappy that the ability to know which cancers will progress and which will not is just not here, yet. That is REALLY too bad. Still; all in all, I think things in this area are better than they used to be. Just hate all of this!

Thank you, my Dear. Good thoughts, indeed. xx

I'm with Percy4. My journey started with LCIS. Constant monitoring every 3 months between BS and Onc. 2nd excisional biopsy for another papilloma resulted in DCIS finding which was not noticed on US or Mam. After MRI then another with biopsy, determined too large an area for lumpectormy so mastectomy was the outcome. After reading the article, I too wish that maybe just maybe this surgery was too aggressive a treatment. What if the dcis / lcis could have been managed with Tamoxifen rather than with mastectomy? I have since had hysterectomy and ovaries removed due to 9cm on ovary. If I didnt have the DCIS would they have been ok with just removing the ovary? maybe maybe not. So now, my female parts are few. And I am still taking tamoxifen to keep the LCIS/DCIS from turning up in my remaining breast.