Stage 0 breast cancer, also known as ductal carcinoma in situ (DCIS) is considered a very early stage of breast cancer, in which cancer cells are confined to the milk ducts only. The incidence of DCIS has seen a dramatic increase in an era when technological advances make it possible to detect abnormalities that might have gone unnoticed in the past.
The vast majority of women with Stage 0 cancers undergo either a lumpectomy (tumour removal without removing the breast) or a mastectomy (removal of the entire breast). Especially in the case of a mastectomy, surgery can have far-reaching consequences for women beyond treatment, including scarring, disfigurement and complications such as lymphedema (swelling of the lymph nodes). The scars can also be emotional and psychological, affecting a woman’s relationships and self-esteem. Finally, a woman’s working life and career prospects may be adversely affected.
It is therefore not surprising that a recently published study has made headlines[i] suggesting that treatment might not have any impact on a woman’s risk of dying from breast cancer. The study[ii], published in the Journal of the American Medical Association followed100,000 women who had either undergone a lumpectomy or a mastectomy. After 20 years, the women were found to have the same rate of mortality (3.3%) as the rate among women in general.
Another key finding was that women who had undergone mastectomies had the same risk of developing invasive breast cancer as those who had only had lumpectomies. These findings raise questions not just about treatment but also about the nature of DCIS itself, leading many to wonder if DCIS is really an initial stage, or precursor, to cancer or simply one of the risk factors.
Within the medical community, reactions to the study have ranged from advocates of not treating DCIS at all to using medication instead, such as hormone therapy drug, to continuing to recommend lumpectomies and mastectomies.
Best Doctors spoke to two leading oncologists at University Medical Centre Utrecht in the Netherlands, Dr. Arjen J Witkamp and Prof. Inne Borel Rinkes about the findings.
The need for a personalised approach
Dr. Arjen J Witkamp, oncological surgeon and breast cancer advises caution yet sees potential for the future:
“The study shows that the probability of dying from breast cancer after treatment for DCIS is, fortunately, very low, and that is exactly what one might expect as it is, after all, the goal of treatment. However, one cannot conclude from this data that omitting any kind of treatment at all in DCIS patients will lead to a similar outcome. That said, the study does offer some interesting food for thought: should DCIS be considered a collective term for different types of cancer which require different types of treatment? Just as it is for invasive cancer, personalised treatment seems to be the answer. So for me, the next step is to carry out prospective studies in order to determine who needs treatment and who doesn’t. There are currently some randomised trials in progress, yet until we find these answers, we must not change our DCIS treatment strategies based on this one study.”
Head of Surgical Oncology at University Medical Centre Utrecht and member of the Best Doctors European Medical Advisory Board, Prof. Inne Borel Rinkes agrees.
“This study should encourage us, as oncologists, to look carefully at treatment options for our patients and weigh the risk of side effects and complications against overall effectiveness. At the same time, however, we cannot underestimate the importance of localised cancer control, especially for certain types of DCIS. Although the study focuses predominantly on breast cancer-related mortality, it also found, intriguingly, that more aggressive treatment (radiotherapy after lumpectomy, or mastectomy) did in fact reduce the recurrence of invasive cancer. We therefore need to consider the risk of cancer spreading to another part of the body.”
With so much debate, women facing a breast cancer diagnosis might feel understandably confused. That’s when having access to the right expert advice and support can make a real difference.
[ii] Narod, S et al (August 20th 2015) Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ. JAMA (Journal of the American Medical Association) Oncology. doi:10.1001/jamaoncol.2015.2510. Available at: http://oncology.jamanetwork.com