2) If more extensive surgery and treatment does not lead to better survival does that imply that having no treatment at all (i.e., “watchful waiting”) is equally as acceptable?

Absolutely not. The women included in the JAMA study all underwent treatment of some sort, which ranged from lumpectomy alone, to lumpectomy with radiation, to mastectomy. And with appropriate treatment, excellent outcomes can be expected. The same cannot be said for doing nothing.

The comparison between DCIS and prostate cancer where the watchful waiting approach has been adopted to some extent has been offered as a model to follow for DCIS patients, but in truth, it is not a good comparison to make for many reasons. First, men with prostate cancer for whom watchful waiting is recommended are often elderly and infirm, with other concomitant illnesses that have a higher likelihood of causing death before their prostate cancer progresses. Second, surgical treatment for prostate cancer, a prostatectomy, is associated with a significantly higher risk of serious operative complications (compared to the operations we perform for breast cancer) and one might think twice before recommending this course of action for someone elderly or infirm.

There is no question that we, as breast surgeons, also think twice before recommending extensive or aggressive treatment for our older female patients, especially when they have other co-morbid conditions. But to assume that a 45-year-old otherwise healthy woman would have no progression of her DCIS over the ensuing 40 years (the current lifespan of the average woman in the United States is approximately 85 years old) is potentially dangerous.

Equally as concerning is the assumption that if no treatment is given, and disease progresses, there is a guarantee that it can be treated later with no compromise in cure or change in outcome. Progression of DCIS to spread throughout the breast or progression from DCIS to invasive cancer is a potentially catastrophic development that could lead to the need for even more aggressive treatment than what was originally feasible: women who were lumpectomy candidates may now require mastectomy. And women who would not have been recommended to have chemotherapy based on DCIS, may now require it for their invasive cancer. True, there may be cases, among the 60,000 women who receive a DCIS diagnosis each year where watching and waiting may be appropriate, where there is no progression, and the disease is stable for years and years. And many of my colleagues are actively engaged in research exploring the watchful waiting approach for some cases. But no one currently has the tools or tests to identify or accurately predict which cases fall into this category. This is an area of extensive research and we welcome the day where we can safely recommend this approach for a real number of patients.
 
There is another reason why a woman considering a  “no treatment” approach to DCIS needs to proceed with caution. When an abnormality is identified on a mammogram and a needle biopsy is done and shows “DCIS,” we ultimately remove this area in its entirety (with lumpectomy or mastectomy). When we examine the tissue that was removed at surgery, approximately 10 percent of the time there will actually be invasive cancer in and around the area of the original biopsy. In other words, the needle biopsy under-estimated and under-sampled the true extent of disease. So if 100 women went untreated for what was “DCIS” on the biopsy, approximately 10 of them might actually be undergoing no treatment for what is actually invasive cancer.

In this country, one of the most common cancer-related lawsuits is failure to diagnose or treat breast cancer. The hypocrisy here is undeniable: we can’t advocate for not treating what may be potentially life-threatening cancer on one hand, yet permit lawsuits for failing to diagnose and treat it on the other.  So when discussing the “watching and waiting” approach for DCIS, one very real question that first needs to be answered is, “How do we know for certain that it’s just DCIS?” And the answer is: we don’t.

For the millions of women who have been treated for DCIS and the approximately 60,000 that will be diagnosed this year and the years to come, DCIS is the most curable form of breast cancer with cure rates of approximately 97 percent, and with the right care, a woman with DCIS has every reason to be optimistic and expect an excellent long-term outcome. Through research, progress has been and will continue to be made, and more and more options will become available. Perhaps one day soon, with research leading the way, we will be able to confidently advise a large proportion of women with DCIS that “no treatment” is a safe and viable option.  Believe me, even those of us who make our living by performing breast surgery would welcome that day. But that day is not today.

For now, we who are on the front lines of cancer treatment taking care of women (and men) with breast cancer every day look at each case in detail and work with each person to decide jointly what is best for each particular case. In general, the data shows that the treatment choices that we and our patients make together are sound and should not be a continued source of anxiety, confusion, and second guessing. Let’s at least make that part clear because our patients deserve that.