When does breast cancer begin?

This debate reminds me of the emotional debate over when life begins.  If abnormal cells have the potential to become cancer, do we call it cancer, and more importantly, do we treat it like cancer?

When considering breast cancer, one step along the pathway can be abnormal cells confined to the breast ducts, or Ductal Carcinoma In Situ (DCIS).  But controversy has existed for years over whether this is indeed “breast cancer” and whether it should be treated as such.

After two and a half days, an NIH-convened panel tasked with summarizing the State-of-the-Science for DCIS concluded….drum roll please……we still don’t know much.

We do know DCIS is a risk for invasive cancer, but we still don’t know how much of a risk.   We don’t know the natural course of DCIS,  how often it would become invasive, who should be treated, and who can safely avoid the surgery/and or radiation.  Whew.  So much for the state-of-the-science.

There were two distinct camps at the panel proceedings in Bethesda, MD. – one strongly and passionately in favor of treating all DCIS, and the other camp just as strongly expressing concern about overdiagnosis and overtreatment of the disease.   And of course, they didn’t come up with any new recommendations in terms of diagnosis or treatment of DCIS.

But surprisingly, in the end, the panel did agree that the medical community should strongly consider eliminating the word “carcinoma” from the diagnosis.

“Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS,” the panel concludes in their final statement, released yesterday.

This is a good first step.  Changing the language of DCIS  will help facilitate a change in attitudes and approaches to treatment for this disease.  But what we still need is good evidence for making treatment decisions.   Treatment decisions that tens of thousands of women will face in the next year.

The incidence of DCIS has increased seven-fold as a result of widespread mammography with about one-half million women currently living with the disease.  This would be great news if it meant we were catching the serious breast cancers early – but the data just doesn’t show that.  Catching all of this DCIS, may just be catching a lot of abnormal cells that would never go on to cause any problem.  Unfortunately, the conference didn’t help to clarify the issues.  Time to call for more research.  <sigh>

The panel correctly concluded that the primary focus of research should be on developing methods for determining who can safely avoid treatment.  And they called for better collection of data on DCIS nationwide, suggesting that pathologists adopt standardized reporting of DCIS.

Some of their specific research recommendations:

Develop models for identifying which patients are candidates for (1) active surveillance only, (2) local excision only, (3) local excision with radiotherapy, and (4) mastectomy.

Who is at high risk for recurrence of DCIS or the development of invasive carcinoma?

What do comparative effectiveness analyses tell us about the role of current therapies in DCIS patients?

Read the full panel statement here.

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