Category Archives: biopsy

Is there a trend away from aggressive treatment?

13948I haven’t written in awhile on DCIS because I have not seen anything new lately, but recently, a well-publicized article caught my attention. While the article focused on the mammogram debate, it also noted that there is new thinking on the DCIS front.

I looked into this. There is nothing very new, but there is a seeming trend towards reconsidering extreme options for treating DCIS. I read another article in the Baltimore Sun titled Doctors Seek to Scale Back Treatment for Common Breast Cancer Diagnosis, which emphasizes the idea that DCIS rarely causes harm, but it can turn into breast cancer. The author notes that DCIS is sometimes referred to as stage-zero cancer, or pre-cancer, and again, this concept is nothing new. However, the subject of risk came up. Do we want to treat a pre-cancer as radically as a full-blown cancer? Studies are cited, and the article includes quotes from physicians, including Dr. Esserman. It is a good article that visits the nuances of decision-making, and why it is still so difficult to know what to do. But does it really point to a new way of thinking? The short answer is, not really. The topic is still very controversial, but with headlines like this, there is a suggestion that perhaps the community is looking into the difficulty in making decisions for those diagnosed with DCIS. It is a recognition that women aren’t just doing what they’re told. They are thinking about their options.

The article looks at choices, such as the one that Angelina Jolie made. At the time her situation became public, I co-authored a blog post titled Angelina Jolie’s Decision at Everything Noetic on why it was courageous for her to have made that choice. Personally, I would vie for watching and waiting as opposed to taking radical action. Of course, it is easy for me to say. When faced with a 5% chance of breast cancer, I decided to do a surgical, incisional biopsy, a procedure that my doctor assured would have removed the DCIS with clean margins had it turned out to be positive. Truthfully, I don’t know what I would do had things gone a different way. Plus, I didn’t watchfully wait, nor did I do the less invasive stereotactic biopsy. It is hard to know what you would really do in any given situation that has not yet occurred.

When it comes to treating DCIS or a suspicious mammogram, I do not think there are right and wrong answers. I do however hope that future research will support a trend away from aggressive treatment.

My Surgical Excisional Biopsy

So I decided to go for the surgical (excisional) biopsy, just to see, just in case it was DCIS, based on the conclusions I relayed in my last post. I was lucky. The results showed no sign of cancer.

The biopsy itself was not painful nor was the wire placement procedure I needed prior to the surgery. I am relaying this in case someone else needs to hear it. I read my share of horror stories before I went in. It’s probably nice to know that a surgical biopsy can be relatively easy.

While I waited for the results I did look at BC websites and discovered stories of women who did not biopsy microcalcifications. Either their doctors told them it was ok to wait, they never got the initial worrisome result, or the idea that they should have a biopsy was never revealed to them. And they ended up with invasive breast cancer. I’m sure these women only represent a small percentage of those who might have prevented cancer had they been biopsied, but still. Their stories are real. So while waiting for results, what I found supported my choice.

Now I am back to square one. After my breast is completely healed–it takes awhile– I will be back to normal. Now I wonder about things like soy, HRT, how breasts really should be monitored, and all that. While my risk of breast cancer is not higher than it was previously, I never really thought about risk factors much. I was more afraid of being overtreated than actually having a disease.

Objectively, I am one of the many women who have had what critics refer to as an unecessary biopsy, but I can’t help to feel that I’m glad I did.

It’s hard to escape the dilemma. Either you look for it (cancer) in the most accurate way possible, or you don’t and hope for the best. For me, I think I will continue to keep up to date on the latest research because as surely as I make a decision on how to proceed, a new study will come along to change my mind.

My Conclusions So Far…

When I cracked my eggs one morning last month I noticed they were stamped with pink ribbons (really), and then I caught part of the Giants game that was adorned with pink ribbons, and I thought, is there any industry that does not get on the pink ribbon bandwagon? I mean, we are aware.  I think we are very aware already, and it seems silly that the Giants were wearing pink socks that day.

So what does being aware really do? We are aware of the mammography guidelines, but we aren’t aware of a lot of things, which is why there are unnecessary biopsies and unnecessary surgeries, and why there are women who do not have the treatment they need in time. So we need to be aware of our choices and what we should be doing, but not that breast cancer exists. We know about breast cancer, but we don’t really know our options.

There are two sides to this issue: one is that there is hysteria, hyperawareness, a lack of real knowledge on the subject and overtreatment, but then there is the other side. What if we really are catching it early?

Here is what I have concluded after researching the various methods of tracking microcalcifications: there is no way to know if an aggressive form of DCIS lurks without biopsy. Although the chances of having an aggressive form of DCIS is miniscule when going by the percentages, a surgical biopsy can eliminate that “what if” entirely. On some level, it seems like overkill because no one will ever know if the bits of tissue would have gone on to become a cancer, but there really aren’t any protocols in place to watch and wait.

Those who call for active surveillance have not come up with a proper method. Thermography could be a good way to montior breasts, but it  is still rather controversial, and I think more research is needed–or at least more round table discussions so that all the experts can hash it out. Dr. Susan Love’s website says that microcalcifications can only be seen by mammogram. If that is the case, then following them with thermography that monitors breast changes  may not see a cancer until it has gotten too big. At least, that is Dr. Love’s conclusion.

I can see why there is controversy. Some doctors see thermography as a way to monitor breast health, claiming that it can detect breast cancers years before they arise, while other doctors claim that only mammogram can detect these early cancers. I don’t know the truth. In everything I have read, I can’t figure which side is correct. The conventional doctors claim that thermography has never been proven to find cancer early, while supporters say not only can thermography find early IBC, but it is much safer than the mammograms that can actually cause DCIS to spread.  Following up with mammograms is really the only option aside from biopsy, but most doctors will not condone that with a BIRADS 4 rating anyway. Plus, it’s not a great solution.

I have read that the aggressive type of DCIS can grow quickly. When doctors tell us not to wait six months, I’m thinking, maybe they know something I don’t. DCIS can change at any time, and we can’t be screened daily, weekly, or even monthly. Living with DCIS is kind of the same risk as keeping all your money in a 401K when you are very close to retirement. You just don’t know when the market will crash.  You just don’t know when a noninvasive cancer will become invasive. Not finding it by not looking for it is one solution by I think we don’t yet have the data to support that position.

In the end, the decision comes down to risk and it is a valid argument that we can live with the risk, but if the risk of biopsy is not great, why not eliminate the cancer risk completely?

Now, there are risks associated with biopsy too, and pain, and time off from work, and those are things that are important to keep in mind. If there is only a slight risk that you might have DCIS, and there is a slight risk of needle track seeding with the stereotactic biopsy, why even bother? It is a valid question. With microcalcifications, some of those types of biopsies fail and plus, you have the risk of actually spreading a cancer, so why do something that can actually harm your body?

That is why I see surgical biopsy as a good option. (Here is a wonderful page that goes through all biopsy options and provides a thorough explanation. This is from a site written by a nurse and survivor).

As far as the DCIS controversy is concerned, I don’t know if they are catching a cancer early, or they are doing too many biopsies. It is one or the other, or maybe something in between. I do know that there is controversy and confusion, but we still have decisions to make.  I do think we can agree that we are aware, aware of breast cancer, and aware of some treatments, but there is a lot we don’t know still.

In the end, no test can really discern what the microcalcifications are with the exception of biopsy. And with all the hysteria surrounding breast cancer, it is hard to ignore anything they find. As I have heard a number of critics say, if they find something, they have to biopsy it. So true. But I’m not sure that not looking is the answer. I am hoping current trials on DCIS/suspected DCIS will yield some real results that the mainstream medical community can live with. Until then, we really have very few options.

Can Suspected DCIS be treated by Watchful Waiting?

While most doctors do treat DCIS with surgery, there are some who see watchful waiting as an option.

Thanks to this month’s issue of More Magazine, an article by Nancy Smith entitled “A Breast Cancer You May Not Need to Treat” provides the latest information on DCIS. In it, a handful of doctors who advocate for the watchful waiting approach are interviewed and that part of the piece appears on page 4.

It  should be said that while some doctors believe that not taking drastic measures, or even having a biopsy, is possible, it does not seem to be typical. That is, most doctors who see something awry on the mammo will probably advocate for biopsy, and if something turns up there, well, the protocol says to treat it like invasive breast cancer.

It should be emphasized that when a doctor says that one should watch and wait, it should not be construed as “do nothing” and one should not get the impression that everything is fine. Monitoring is key to watchful waiting. It means that you have your mammograms or sonograms or whatever is recommended to make sure that everything is under control. In other words, what the doctors call active surveillance in the Smith article means that you take an active role in watching the cells. You don’t run the other way, terrified of getting the next mammogram. You wait with optimism, and reverence for the process. You listen to your doctors. It seems to be a non-invasive way of potentially saving your life.