2017-10-11 / News

Are doctors too aggressive on noninvasive breast cancer?


Alongside the red and gold of changing leaves, October brings another splash of color: the annual outbreak of pink ribbons.

Breast Cancer Awareness Month is upon us, with individuals and organizations raising funds and encouraging women to seek mammograms as a means of early detection. For those who do detect a cancerous lump, treatment has traditionally been swift and aggressive, including surgery, chemotherapy and radiation, but some doctors are now advocating for a different approach.

In certain cases, some doctors are now promoting “active surveillance.” Instead of more aggressive treatments, patients with a certain type of breast cancer receive regular mammograms and MRIs to monitor for concerning changes. At the same time, these patients take drugs that block estrogen, a fueler of cancer growth.

This new method of treatment is specific to ductal carcinoma in situ (DCIS), a non-invasive type of breast cancer that is confined to the milk ducts. Roughly 65,000 new cases of DCIS were diagnosed last year, making up nearly a quarter of all new breast cancer cases. DCIS can’t spread outside the breast, but can turn into invasive breast cancer, which can spread, necessitating the need to monitor.

Also known as Stage 0 breast cancer, DCIS is traditionally treated with surgery, but some patients are now taking the active surveillance route.

“This is really cutting edge and really new,” says Dr. James Pellicane, director of breast oncology at Bon Secours Cancer Institute Richmond and co-founder of Bon Secours Virginia Breast Center. “The word is not out to the general surgical populous.”

The concern over more aggressive treatments for DCIS is that doctors may be giving patients therapies they don’t need. Though Pellicane says the risks from breast cancer surgery are “quite low,” any surgery carries the risk of bleeding or infection. Radiation therapy has the potential to cause chest tenderness and scatter radiation through the heart and lungs, but again, Pellicane says the risks are low. “Sometimes, our treatments are worse than the disease,” Pellicane says. “As breast surgeons and breast cancer doctors, we’re painfully aware that we overtreat a lot of breast cancer patients. The move has been over the past decade to try to ID patients who don’t need that level of treatment.”

Presently, a randomized clinical trial of 1,200 women from across the U.S. is taking place that looks at the benefits and risks of active surveillance versus other methods of treating DCIS. Called the Comparison of Operative to Monitoring and Endocrine Therapy Trial for Low Risk DCIS – the COMET Trial for short – the study hopes to help doctors determine which patients can be monitored, and which require other treatments. There’s also DCISionRT, a genomic test doctors use to assess risks and determine if radiation will help.

“Within the next year, this is going to be a fairly well-known assay that is going to be known to most patients who are diagnosed with DCIS, and it’s going to save a lot of women [from] being overtreated,” says Pellicane of DCISionRT.

That said, this is a new method of treatment, and not all doctors are in agreement.

Dr. Ruth Felsen, medical director of breast cancer services at the Sarah Cannon Cancer Institute at Johnston-Willis Hospital, says that even in cases of low-grade, noninvasive breast cancer, most doctors would move to excise it.

“You sometimes find when you take it out that it’s a higher grade [of cancer] than you thought, and in the end, you just don’t know which [lesions] are going to progress,” says Felsen, who is also a breast surgeon with Surgical Associates of Richmond. “We don’t have good data about that, and you can’t pick it out ahead of time, so for the most part we want to excise it.”

Except for in the case of someone with complicating health issues, Felsen doesn’t advocate for the active surveillance method. Lumpectomies – surgeries to remove cancer or other abnormal tissue from the breast – are outpatient surgeries, she notes.

“It’s low risk, it has a short recovery time, and so it really doesn’t have a lot of downside to it, other than having the procedure done,” Felsen says. “It’s not major surgery, it’s not a major recovery time, and then it gives you all of that information to work with, [should] you need any additional treatment.” ¦

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