8/20/2015 NY Times article on surgery for DCIS

I agree. I looked at the JAMA article (http://oncology.jamanetwork.com/article.aspx?artic...) before reading the NYT article. The NYT Article (and possibly the authors who certainly seem to have their opinions) misinterpreted the findings:

"Yet it now appears that treatment may make no difference in their outcomes. Patients with this condition had close to the same likelihood of dying of breast cancer as women in the general population, and the few who died did so despite treatment, not for lack of it..."

From the JAMA article:

"For the entire cohort, at 20 years the breast cancer–specific mortality was 3.3% (95% CI, 3.0%-3.6%). The risk of death from breast cancer among all women who received a diagnosis of DCIS was 1.8 times greater than that of the US population (SMR, 1.8 [95% CI, 1.7-1.9])."

Because the 95%-confidence interval on the Standardized Mortality Ratio (SMR) falls above 1, those with a DCIS diagnosis have a higher mortality rate due to BC than women in the general population. Kolata's assertion that these numbers are "close" is not true statistically.

Also, Kolata: "Almost no women went untreated, so it is not clear if as a group they did worse." This is important. One cannot judge from these data whether or not a treatment is effective relative to no treatment. We cannot assume that "watch and wait" is appropriate from these data. One can only compare the treatments among all of the treated women.

Kolata doesn't discuss the specifics of DCIS grade other than some mentions of "tumors with ominous molecular markers." Grade is crucial in determining treatment. Fig. 6 in the JAMA article shows the significance of grade on mortality.

It's not unreasonble to me to consider that DCIS diagnosis is actually decreasing the incidence of invasive cancer but that the incidence of BC is increasing in the population which gives the impression that DCIS treatment is ineffective. Two significant but opposing effects can cancel each other at the population level.

It's not surprising that there is a subset of women who do not experience recurrence prior to metastasis. I have had BMX due to to multi-focal grade 3 DCIS and suspicious spots on contralateral breast (which were MRI false-positives). It's been challenging to find an oncologist to follow me and no one does any imaging because I've had flap reconstruction. I've been told to give them a call if my bones start hurting. If anything, I think these results indicate that DCIS is not well-understood and not taken seriously enough! Like ballet12, I shudder to think how many people will read this article and refuse treatment based on a poor summary of this research.

Thank you for your elegant review LAstar. I just keep the whole DCIS thing quiet. The few colleagues who knew my diagnosis at work thought it was breast cancer without an asterisk in front of it, as did many in my social community. That helped when I was going through radiation--as my side effects were the same as those with early IDC anyway. I was also treated at MSKCC, and the breast surgeon looked me in the eye after the third surgery and said--you know that you will need radiation. She is a published expert in DCIS, as is my radiation oncologist. No one there told me that my DCIS would eventually become invasive (as Dragonista's did), although I also had the large amount of multifocal high grade with necrosis, etc. etc....but there was certainly a good chance of it. The person who had the most trouble with the whole DCIS thing was a friend who had had inflammatory breast cancer as well as triple negative (and underwent a bone marrow transplant). She didn't understand why hormonal therapies would be recommended for someone who didn't really have breast cancer, although she did understand the notion of prevention with the surgery and the radiation. She's now fighting for her life, having one and possibly two new cancer diagnoses, so I understand where she's coming from.

I don't know if DCIS will ever be redeemed in the media, although there was an op-ed piece following Kolata's in the NYTimes, which did state that all the patients had received treatment, so we don't know much about "watch and wait" outcomes. We just have to privately be confident that what we did was the correct thing. I am certainly relieved that people rarely die of it. I might not even rush to a biopsy in the future, to be honest, unless there are really compelling reasons to do so, but I believe that the treatment was appropriate under the circumstances.

I'll just add that I was on the fence about Tamox as well. I'm 2 months in and really have no side effects. A little warm every once in a while. We'll see. I figured I could always stop if it got really bad.

Jennvo, I've heard of radiation after MX for DCIS when the mastectomy margins were very small or the DCIS was close to the chest wall. I'm in the high-risk category too based on tumor size, age at diagnosis, and grade. My BS told me about some imaging he'd seen where microscopic ducts containing DCIS had grown into the skin layer. He said it was a game changer to see this and wonders how much it contributes to the recurrence rate after MX for DCIS.