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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.

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.

Welcome to this DCIS Blog

Hi. As soon as I titled this blog, I had a good number of hits. Indeed, people are hungry for information on DCIS. Please be patient as I have just begun. I will start with an article titled Prone to Error published in the New York Times last year.

There are so many errors made trying to save women from breast cancer that it brings into question the validity of going on the investigation in the first place. What is the purpose of finding cancer early if diagnosis is full of holes? Most of the examples come from small communities where there are inexperienced pathologists, but even when one receives a DCIS diagnosis from the best pathologist in the world, the diagnosis is still an opinion.

My question is, why not wait? Why not wait to see if the tiny bits of calcification actually grow into something before engaging in last resort treatment, or any treatment at all? Why attempt to even diagnose DCIS if a woman is okay with watching and waiting? These are the questions I am asking, and I know that it is easy to say that a case of DCIS might grow into cancer, and while cure for DCIS is like 98 or 99%, the problem is that even if the DCIS never comes back, it may never have gone on to become invasive breast cancer in the first place. It is a conundrum. I get that. But what I don’t get is why women don’t have a choice in the matter, given the lack of knowledge on the subject. Why can’t the doctors say, “we don’t know what will happen. We don’t know whether these cells will kill you, or won’t do anything at all. Given that, what do you want to do?”