DCIS - Rethinking Breast-Cancer Treatment Options

I completely agree with Ballet12’s post, and would add that one difficulty which didn’t seem to be addressed much in the article is that it is not always easy to tell which is “low risk” DCIS and which isn’t. Approximately 20% of DCIS diagnoses are upgraded to IDC after excision, and while some risk factors (size, high grade, comedo necrosis) are known, not every case fits into those so you could be watching and waiting an invasive cancer while thinking you are only dealing with DCIS.

In my opinion, everyone with DCIS should have it excised, and then if it is confirmed to be nothing but “low risk” DCIS, radiation and hormone blockers could be skipped, but I am not comfortable at all with leaving it in the breast unless and until our imaging techniques allow us to to better differentiate early invasive cancer from pure DCIS. Notice, I did not say that everyone should go out and get a BMX, either .... I think there is definitely a wide middle ground between active surveillance and bilateral mastectomy that should provide a range of options for patients.

Hi:

Thanks for posting YogaGirl.

I am glad that researchers are raising the question of possible over-treatment and initiating new studies. This is the kind of discussion and work that led to improved, more limited mastectomy techniques, lumpectomies, sentinel node biopsy, new radiation and chemotherapy regimens, and the like.

Observations that raise the question of over-treatment in certain patient sub-group(s) are not necessarily proof of it in any particular case and do not establish that more limited treatment regimens would be safe and effective compared with standard treatments. The flip side of this is that the features that consistently and reliably establish "low risk" remain to be characterized. That is why the "knowledge gaps" that make change "an uphill battle" still need to be addressed by new studies.

For various reasons, including these knowledge gaps, the number of DCIS patients today who elect to take the type of approach discussed by Dr. Esserman and others is probably pretty small, particularly outside of a clinical trial. The choice may be right for them, in light of their personal risk tolerance. Otherwise, the current consensus guidelines from the National Comprehensive Cancer Center (NCCN) regarding breast cancer treatment are available at NCCN.org.

I also agree that a truly effective "watch and wait" strategy seems to require better diagnostic methods than are available today (and currently are unable to reliably detect the debut of invasion, assuming it is not already present).

BarredOwl