Breast Cancer Watch and Wait:

Ductal Carcinoma In Situ (DCIS) has long been considered a “forerunner” to breast cancer. Therefore, conventional wisdom was, if a person has DCIS, treating it would mean we would save the patient from getting breast cancer in the future. Now that conventional wisdom is being challenged.

 Terminology:

Invasive Breast Cancer, or adenocarcinoma of the breast – this is true breast cancer for which the recommendations have not changed. People who have breast cancer need to undergo therapy. Usually surgery with radiation and sometimes chemotherapy with follow up hormone blocking therapy. While the treatments have long-lasting effects, they prolong life for most people.

Ductal Carcinoma In Situ, this is non-invasive cancer. There are various types of DCIS, but now studies are showing that treating these lesions does not prolong life, and the treatments have long-lasting effects that may not be worth it.

Bilateral Mastectomy:

Some women opt for bilateral mastectomy (surgically removing both breasts) but there is no evidence of improved survival for the majority of women with breast cancer. The exception is for those who have BRCA1 and 2 genetic mutations (like Angelina Jolie).

Bilateral mastectomy is a major surgery with risks of infection, bleeding, long-term scars, and psychological effects for many women. Bilateral mastectomy for most breast cancers offers no improvement in survival. Reconstructive surgery is not a guarantee that the new breasts will be beautiful and perfect. There are often multiple revision operations and even then are often not perfect.

DCIS – if you take a woman in her 30’s with DCIS the chances are it will never become invasive cancer and kill her. Contrast that with invasive cancer, which will kill the person and shorten life unless some intervention is done.

Two facts: we do not have randomized clinical trials of women who have been diagnosed with DCIS into treatment and survey arms. That “cuts” both ways. We cannot justify surgical treatment of all forms of DCIS as life saving, nor can we say that surveillance is optimal.

The Psychology of Disease:

When most women hear they have some breast disease they go into shock. They want surgery “right away,” and often will say that they want “everything done,” but surgeons have to step back.

Breast cancer and DCIS are not emergency operations. A fast operation is not a solution for “fear of cancer,” and will never completely eliminate fear of cancer. The danger of the “quick operation” is that it may not allow adequate information to be provided to the patient. The patient becoming psychologically committed to an operation, before having all the facts.

Our job now is to educate about the choices for breast disease. Relationships with our patients, education, allowing them to take control of their lives with our help is the best medicine.

To quote from the study below:

Important risk factors for death from breast cancer following a DCIS diagnosis include age at diagnosis and black ethnicity. The risk of death increases after a diagnosis of an ipsilateral second primary invasive breast cancer, but prevention of these recurrences by radiotherapy does not diminish breast cancer mortality at 10 years.

JAMA Oncol. 2015 Aug 20. doi: 10.1001/jamaoncol.2015.2510. [Epub ahead of print]
Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ.
Narod SA1, Iqbal J2, Giannakeas V1, Sopik V2, Sun P2.