Ductal Carcinoma-in-situ (DCIS): One Breast Surgeon’s Perspective on the Latest in Research and Treatment

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Dr. Elisa Port

The breast cancer cure rate is at an all-time high, and so is the information — and misinformation — available to patients and their families. Online searches can lead to unreliable sources, leaving even the most resilient patient feeling uneasy and uncertain about her diagnosis, treatment options, doctors, side effects and recovery. Elisa Port, M.D., FACS, chief of breast surgery at The Mount Sinai Hospital and co-director of the Dubin Breast Center in Manhattan, offers a valuable perspective on how to approach reports of new developments on screening, diagnosis, prognosis and treatment. In her book, The New Generation Breast Cancer Book: How to Navigate Your Diagnosis and Treatment Options—and Remain Optimistic—in an Age of Information Overload, she describes every possible test and every type of doctor visit, providing a comprehensive, empathetic guide that a newly diagnosed woman (and her family) will want to have at her side. —Ed.


Whenever big news in breast cancer is reported, those of us who are in the thick of it, the physicians actually taking care of women with breast cancer, brace ourselves for the flurry of phone calls, emails and texts from our patients wanting to know one thing: “How does this new development apply to me?”

The JAMA study released a few months ago, which was covered extensively in the media (The New York Times, Aug. 20, 2015) and the TIME magazine cover story were no exceptions. Both the study and the story involved patients with DCIS (ductal carcinoma-in-situ), the earliest form of breast cancer. The take-home message from reading both the study and these articles should be that for women with DCIS the overall long-term survival rate is excellent: 97 percent to 98 percent. This is good news, and all women with DCIS should keep this in mind.  

And there is more good news. Because there have been so many advances in the care and treatment of breast cancer in general, not just DCIS, there are more options than ever before. As a result there is no place anymore for the “one size fits all” approach in taking care of women with breast cancer. It’s critical to know that not all women will have all options, and that in each particular case, surgery and additional treatments are tailored and offered based on different factors specific to each individual case. As surgeons and oncologists, our job is to decide which options are medically appropriate, and then among the viable options in each case, help a patient decide which is best for her as an individual: Lumpectomy or mastectomy? Mastectomy or bilateral mastectomy? Chemotherapy or hormonal therapy? Or both?

Some of the factors that contribute to decision making about treatment on an individual basis include: age, overall health status, the amount of cancer in the breast, whether or not there is a concern for spread, and of course, what does the patient herself want? It’s not easy to navigate these pathways for any woman with a new diagnosis, but with the right guidance and the right team of doctors, the outcomes are usually very good, and the results from the JAMA study verify this fact.
But in reading these studies and the associated media coverage, many of the women who called my office recently did not get this message of optimism. Mostly, there was confusion and anxiety. I heard two specific concerns over and over again, and I believe they should be addressed with clear answers:

1) I had a mastectomy for DCIS. Does that mean I was “overtreated” and would have had the same outcome with lumpectomy?

breast-cancer-coverNot at all. One of the biggest sources of confusion about the JAMA study and the Time magazine article is that they didn’t clarify well enough that there is no one-size-fits-all treatment, and that eligibility for different approaches, everything from watchful waiting to bilateral mastectomy, can only be determined on a case-by-case basis. Patients in the JAMA study were not randomly assigned to different treatments all ending up with the same excellent outcomes. Many patients included in this study were advised to undergo particular treatments based on what their doctors felt was the best approach after considering the specifics of the particular case. For example, often women who have large areas of DCIS in their breasts that would be difficult to remove in a small operation are advised to undergo mastectomy. With mastectomy, a woman with DCIS has an extremely low risk of cancer coming back, and an extremely high likelihood of survival. To assume that you could take this same woman with a large area of cancer, perform a lumpectomy (thereby possibly not removing all the cancer) or do no treatment at all, and expect the same outcome would be completely wrong.  And in no way did this study show that this would be reasonable to expect.

There are also other mitigating circumstances that may lead us, the surgeons, to advise a woman to have a mastectomy. For example, women with the BRCA gene mutation are at much higher risk for cancer recurrence after lumpectomy, and mastectomy is frequently advised. For many women both lumpectomy and mastectomy would be associated with equal outcomes in their particular cases, and some of these women choose to have a mastectomy. For these women there are other factors that drive decision making beyond just equal survival rates, and in my experience, the choices my patients make are usually well thought out and made after careful consideration and consultation regarding the risks and benefits of all their options.
Women who choose a “watch and wait” or no treatment approach via various research protocols (described in detail in the Time magazine article) are also carefully selected to be the patients who are at lowest risk for having disease progression, and they are carefully monitored. In addition, it should be clarified that while many of these patients undergo no surgical treatment, they often take anti-hormonal therapy which is a form of treatment.

To reiterate, there is no one size fits all. And this holds true for women with DCIS as much as for any other scenario. Perhaps one reason why women with DCIS have such good outcomes is in part because we, the surgeons, are making reasonably good recommendations on a case-by-case basis as to whom should receive which type of surgery.

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