Detecting, classifying (grading), treating, and managing ductal carcinoma in situ (DCIS), and other high-risk abnormalities (eg, atypical ductal hyperplasia [ADH]), of the breast remains an ever-evolving, complicated, extremely expensive, and controversial area of interest.
I recently attended a National Institutes of Health workshop on the topic of “Diagnosis and Management of Ductal Carcinoma In Situ (DCIS)” with the hope of gaining a new perspective mixed with a critical assessment through open discussion about the “big picture issues” we face, only to be surprised as to how little is known about the natural history of this disease (or better yet diseases) and as to the best course of treatment and management of DCIS. As far as I was concerned, this lack of knowledge regarding optimal management of DCIS (which I personally saw as the “huge white elephant in the room”) was briefly mentioned (and largely glanced over or completely ignored) by several speakers rather than being the clear and primary focus of the meeting.
In 11 single-spaced pages of the draft statement that came out of the meeting, there were several indirect comments about the lack of understanding as to how should DCIS be optimally managed, but there was only one clear recommendation (on page 10) that specifically mentioned the need to “develop and validate risk-stratification models to identify subsets of women who have DCIS who are candidates for (1) active surveillance only, (2) local excision only, (3) local excision with radiotherapy, and (4) mastectomy” . One could argue that the current diagnosis and management of DCIS is optimal because mortality from breast cancer is indeed declining and the general consensus is that early detection leads to a better chance for a cure. It is therefore understandable why we may not wish to challenge our current thinking and admit that we truly do not know if treating ADH and DCIS primarily as an invasive cancer has any effect on survival, and perhaps consider the possibility that the vast majority of those treated may have indeed been overtreated.
At the National Institutes of Health workshop, a score of highly respected experts in epidemiology, statistics, imaging, surgery, oncology, and pathology presented a substantial amount of data that, from my perspective, can be summarized by the naive observer as follows: All available retrospective reviews of pure DCIS (namely, no evidence of any invasiveness at any level) from very large studies suggest that for all DCIS grades, regardless of the treatment and management regime implemented at the time of detection, including but not limited to lumpectomy, mastectomy, radiotherapy, hormonal therapy, and a number combinations thereof, resulted in outstanding survival over a reasonable and wide range of time (between 5 and to as long as more than 10 years). Namely, all studies regardless of the treatment regime involved showed (and reported) survival at somewhere between 96% and 98% !
In general, excellent long-term survival rates among women diagnosed with DCIS regardless of the treatment regime is very telling and constitutes a simple indication of one of several possibilities. The most intriguing possibility is that because little is known about the natural history of these diseases/abnormalities, in at least some of these cases the “easy” route is taken and DCIS is overtreated at a great cost to the health care delivery system, society as a whole, and the patient. Although most of us do believe that these abnormalities should be considered as precursors to invasive cancer, and given enough time, eventually, some, if not all, ADH and DCIS would develop into an invasive cancer, the fact is that improving on an average of 97% long-term survival is cost prohibitive and scientifically extremely difficult in most other scenarios. Notably, it may very well be that those who ultimately died from “this disease” in the studies that have been reported, actually had had some undetected invasion at the time of diagnosis of DCIS during biopsy and the invasive part (micro or macro) was not specifically identified for a variety of technical, practical, and cost-related reasons. In lung cancer there are data demonstrating that left alone and untreated, most if not all patients will die from the disease. That all treatment regimes for DCIS resulted in the very same and extremely high survival rate suggest that perhaps we are simply “shooting from the hip” in the case of ADH and, at a minimum, lower grades of DCIS. Arguments of “so what, we are doing so well, hence we should continue this aggressive practice,” may ultimately prove to be the wrong approach.
To this naive observer, it is clear that we have to study ADH and DCIS in a randomized clinical trial with at least one arm that resorts to observation and close monitoring alone. To avoid unacceptable outcomes, this study could have strict rules as to when and how one steps in and performs an intervention, as needed (eg, the affected size as shown by dynamic magnetic resonance imaging is increasing by a factor of 2). If nothing else, the “observation and close monitoring alone arm”, with no immediate intervention, should include all ADH and DCIS grades 1 and 2, if not all three DCIS grades.
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References
1. NIH State-of-the-Science Conference. Diagnosis and Management of Ductal Carcinoma In Situ (DCIS). Program and Abstracts, September 22–24, 2009; William H. Natcher Conference Center National Institutes of Health Bethesda, MD. Available online at: http://consensus.nih.gov/2009/dcis.htm . Accessed November 23, 2009.
2. NIH State-of-the-Science Conference. Diagnosis and Management of Ductal Carcinoma In Situ (DCIS). Program and Abstracts, September 22–24, 2009; William H. Natcher Conference Center National Institutes of Health Bethesda, MD. Available online at: http://consensus.nih.gov/2009/DCIS%20images/dcis_draftstmt.pdf . Accessed November 23, 2009.
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