Personalized treatment is key for Stage 0 breast cancer
October 23, 2015
An early form of breast cancer called ductal carcinoma in situ (DCIS) has stirred controversy in the medical community nationwide.
DCIS, also known as Stage 0 breast cancer, is abnormal cells that are confined to the milk ducts of the breast. The debate is whether all cases of DCIS should be treated immediately with surgery and additional therapy, or if patients should be monitored instead and treated only if the cancer spreads.
A New York Times article from August 2015 has fanned the flames of this controversy. The article features DCIS patients reacting with a mix of gratitude and outrage about their cancer treatment. Some felt their treatment was unnecessary or too severe; others were glad they received proactive care.
Both sides of the debate have a viable argument: of course we don’t want to perform surgeries that aren’t needed or expose women to radiation or hormonal therapy unnecessarily, and DCIS in some women will never spread beyond the milk ducts.
But this is our concern: DCIS has a significant chance of turning into invasive cancer. There is currently no way to know which cases will become invasive. Until we have a way to determine that, we can’t just sit back and watch women develop breast cancer. We favor a personalized, case-by-case approach to treating Stage 0 breast cancer over watching and waiting.
I’ve asked four of our breast cancer experts to explain our position and clear up some misconceptions about the treatment of DCIS.
Is DCIS always a sign of invasive breast cancer?
Roshni Rao, M.D.: Ductal carcinoma in situ is a Stage 0 cancer. That means in some women, there’s a potential for the cancer to become invasive – to spread beyond the breast to other parts of the body.
Phil Evans, M.D.: DCIS is the earliest indicator of potentially invasive breast cancer – 25 percent to 33 percent of screen-detected cancers are DCIS.
Barbara Haley, M.D.: There are different types of DCIS – it’s not one disease. Especially for a small subset of patients who died from pure DCIS without any recognized relapse (in reference to this JAMA-published study by Dr. Steven Narod), the malignancies may be more like a very small, invasive cancer.
How should DCIS be treated, and how is treatment personalized?
RR: If you come in with DCIS, we’re going to recommend treating it because we currently have no way to know whether your DCIS will stay put or become invasive cancer. You don’t have to rush right into treatment, so be sure to ask your physician questions so you understand the benefits and risks of treatment.
PE: If treated properly, the 10-year survival rate for DCIS is greater than 95 percent. We base treatment on how much of the breast is affected and how abnormal the cells have become. Treatment also depends on the nuclear grade and extent of the DCIS, and it varies with the pathology results. Treatment varies with individual cases, but can include:
- Lumpectomy: For small, localized areas of DCIS to prevent recurrence in the same breast.
- Total mastectomy: In patients with large areas of DCIS or invasive DCIS to stop the spread of cancer to other parts of the body.
- Radiation or hormonal therapy after surgery: Radiation therapy decreases the risk of recurrence by 50 percent. Hormonal therapy can decrease it by another 50 percent in some cases.
Agnes Witkiewicz, M.D.: While radiation therapy decreases risk of recurrence, it has no effect on overall survival. But there has been a substantial effort to identify DCIS patients who are at high risk of recurrence to determine who would benefit from therapy beyond surgery and who could be treated with surgery alone. Our research has identified the loss of certain tumor suppressors as potentially promising markers of aggressive DCIS, but more research is needed before we can apply those markers across all DCIS patients as a standard of clinical care.
Why are biopsies important when DCIS is diagnosed?
PE: The information obtained from a needle biopsy is very important – that’s how a DCIS diagnosis is typically made. From tissue specimens, we can tell how abnormal the cells have become and whether the cells have hormone receptors that will signal the cancer to grow. In many cases, the extent of DCIS within the breast can be estimated from imaging studies.
BH: A recent JAMA oncology study showed that you do have to look at the biopsy itself to diagnose DCIS. The very small, low-grade case in an older patient is not the same as a high-grade, receptor negative case in a younger patient. Those are two different diseases, and we expect them to have different outcomes.
AW: Evaluation of DCIS features in a biopsy sample (for example, its nuclear grade, its structure, and the presence of comedo type necrosis) also provides some insight into DCIS biology, which can help us determine proper treatment for individual patients.
What should a woman with a DCIS diagnosis do at this point?
RR: As many as 60,000 women are diagnosed with DCIS each year. That’s too many diagnoses for us to think it’s acceptable to simply watch and wait. Talk to your doctor about the treatment options available to you for your individual case of DCIS.
PE: The diagnosis and treatment of DCIS is complex. You may need to meet with several physicians including a diagnostic radiologist; surgical, medical, and radiation oncologists; and a plastic surgeon. The best treatment occurs when these experts work together with the latest technology to individualize your treatment plan.
BH: I hope women don’t think you don’t have to do anything at all. A lot of women are treated identically from patient to patient, which leads to overtreatment in some patients. Particularly as we get into the older age groups, we really have to think about the impact of the radiation. There probably are some women for whom waiting is a totally safe approach, but what we don’t know right now is how to identify that patient. That’s why you can’t just watch and wait.
AW: Find a center that specializes in DCIS diagnosis and treatment. It’s critical to the appropriate management of your disease, and it’s vital that the physicians can appropriately advise you about the risk of progression to invasive disease, side-effects of therapy, and treatment options.
Our final thoughts about the treatment of DCIS
We’re certain that treatment should not be the same for all patients, and that we should carefully consider each individual case before treating DCIS. One of our big concerns is that invasive cancer may potentially require additional therapies such as chemotherapy, which could have been avoided for some women if they had been treated when they were diagnosed with DCIS only. We must look at the patient characteristics and the tumor characteristics carefully to determine the best therapeutic approach.
It will be beneficial to patients and providers when, through continual research, we can clearly characterize genes in those cancers that never progress versus the genes of those that become aggressive. DCIS is a complex condition, and one thing is certain: DCIS is a type of breast cancer that needs to be evaluated in greater depth before we can say it’s acceptable to watch and wait.
Dr. Roshni Rao has been with UT Southwestern since 2005. She is a surgical oncologist who focuses on the surgical treatment of breast cancer.
Dr. Phil Evans is a radiation oncologist. He is the Director of the UT Southwestern Center for Breast Care, and he joined the UT faculty in March 2002.
Dr. Barbara Haley is a medical oncologist who focuses on emerging alternatives for treating breast cancer, including chemotherapy, hormonal therapy, and biologic therapy.
Dr. Agnieszka Witkiewicz is an Associate Professor of Pathology. Her work involves the evaluation of breast tissue for diagnosis and treatment plans.
Dr. James Willson has served as Director of the Harold C. Simmons Cancer Center at UT Southwestern Medical Center since 2004. Under his leadership, the center was recently named an NCI-designated comprehensive cancer center.