That’s a controversial notion. Most breast-cancer specialists, while conceding that DCIS is overtreated, say they have no choice but to proceed as if the disease could become dangerous. “There’s no scientific proof that there definitely is a group of DCIS cells that won’t progress to becoming invasive. I don’t think we’re there yet, though this is a hot topic of research,” says Brian J. Czerniecki, MD, PhD, codirector of the Rena Rowan Breast Center at the University of Pennsylvania and surgical director of the Immunotherapy Program for the Abramson Cancer Center. Christine Laronga, MD, head of the Comprehensive Breast Program at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, concurs. “We have no way of figuring out which cells are the bad players,” she says. But Esserman and similarly minded breast-cancer specialists disagree; they believe that the current technology is adequate for some doctors to distinguish between low- and high-risk DCIS cases.
Caught in the middle of this debate are the thousands of women with a DCIS diagnosis who face life-altering decisions about their treatment.
THE PATIENT'S DILEMMA
“We found an irregularity in your left breast,” the phone message from Cathy Hopf’s doctor said. “We need to find out what it is, and to do that, you’ll need a biopsy.” It was a heart-stopping moment for the 50-year-old mother of two, who lives in Rancho Santa Fe, California. She recalls, “Of course, I’m thinking, I can’t have breast cancer. No one in my family has had breast cancer. I’m a healthy person. I exercise. I eat right. I’m not overweight.” But still she worried. The word irregularity could not completely blot out the C-word that kept popping into her head.
It took two and a half years, eight specialists and two biopsies for Hopf to decide on a course of action. The first irregularity turned out to be benign, but a mammogram to confirm its presence revealed a second lesion in the same breast. When biopsied, that lesion was diagnosed as DCIS. Even though it was not, by definition, spreading outside her ducts, the treatment options laid out for Hopf weren’t all that different from those offered women with invasive breast cancer: lumpectomy (surgical extraction of the abnormal tissue and its surrounding area); lumpectomy followed by a regimen of radiation; or mastectomy (surgical removal of a breast), which does not require follow-up radiation.
The choice is presented as three levels of preventing recurrence—of making sure the cancer doesn’t come back, as either DCIS or invasive breast cancer. With a lumpectomy, the recurrence rate is about 25 percent in 10 years. Half of those recurrences will be DCIS, and the other half will be invasive breast cancer. Among those who choose lumpectomy and radiation, 10 percent will have a recurrence—5 percent DCIS and 5 percent invasive. With a mastectomy, about 2 percent of cancer cases will recur, and almost all of those will be invasive. Looked at another way, all these patients have at least a 70 percent chance of living out their lives without having any more brushes with DCIS or invasive breast cancer. What about the survival rate? “The 10-year survival rate of all three of the treatment options is the same: about 99 percent,” Tuttle says.
Today 97 percent of women with a DCIS diagnosis undergo a lumpectomy or mastectomy. Given that this is a precancerous condition, you’d expect that most would pursue the least aggressive treatment, yet mastectomy is the choice of 33 percent of DCIS patients, and that percentage is growing. Even more surprising, the number of DCIS patients who opt to have a healthy breast removed in a prophylactic double mastectomy is also on the rise, jumping almost 150 percent from 1998 to 2005, according to the Journal of Clinical Oncology.