US surgeon calls for a rethink of DCIS

Leading US breast surgeon Dr Laura Esserman is urging a rethink of the name and management of ductal carcinoma in situ (DCIS).

Dr Esserman, Director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco, was in Australia recently to speak at the NBCF-sponsored Australian Breast Cancer Conference in Melbourne.

“DCIS is not cancer, so why are calling it cancer and always treating it like it is cancer?” Dr Esserman said.

In breast cancer, like other cancers, there are different types of the disease and not all types progress at the same rate.

“Some progress rapidly; some progress slowly and some don’t progress at all and are idle,” she told NBCF. “In fact, between 20% and 80% of cancers, depending on the organ site, grow so slowly that if you didn’t find the cancers on screening, they would never come to clinical attention.”

Dr Esserman said the original aim of breast screening was to find invasive breast cancer, but breast screening also identified DCIS – the diagnosis of DCIS had increased 500% since the start of breast screening.

“We thought that if we took out DCIS we would see a dramatic drop in breast cancer rates, just like removing polyps has led to a significant drop in bowel cancer rates,” Dr Esserman said. “This hasn’t happened with breast cancer. The invasive breast cancer rates have gone up, so it tells us the majority of DCIS cases we’re finding are not destined to progress to invasive breast cancer.”

Dr Esserman is a member of an expert US panel advising the National Cancer Institute which, in July this year, published recommendations in the Journal of theAnerican Medical Association that included a call to rename precancerous conditions such as DCIS.

They recommended that new terminology should be used that does not include the word cancer so that patients would be less fearful and less likely to have potentially unneeded and harmful treatments, including surgery and radiation.

Dr Esserman said there was clear evidence that a watch-and-wait approach, especially if combined with medicines that prevent hormone positive breast cancer, is appropriate for low-grade DCIS.

“DCIS is not an emergency,” she said. “It’s something that creates an environment where cancer may arise over the next 10-20 years, yet patients are being told they need surgery in the next fortnight.”

Dr Esserman said the breast cancer community could learn from a prostate cancer surveillance project in the US, which had adopted a watch-and-wait approach for a group of 1000 men with prostate cancer, rather than surgery and radiation treatment.

“The 10-year mortality rates for that group is about 3.0 per cent, without any treatment whatsoever, so extremely low,” she said. “These are men who all would otherwise have had their prostates out or had radiation treatment.”

She said that in January next year, the five University of California medical centres (the ATHENA Breast Health Network) would offer women a range of options that suited the grade of their DCIS. For low-grade DCIS, those options would include watching and waiting rather than immediate treatment. “We’re also going to try changing the name – not using the word cancer, so we’ll see if it makes a difference to what women choose to do.”

She said the impetus for the recent recommendations was to signal to the public that there is a scientific basis for watch-and-wait protocols. “There will be some people who say, ‘forget it, I don’t want to watch, I’d rather have it taken out’ – and that’s fine, but it is important to provide people with the facts so they can make informed decisions.”

Visit site: National Breast Cancer Foundation