Compelling Case For Changing the Management of DCIS-Not So Fast

The New, Big Study

In a study of over 100,000 women published in the August issue of the Journal of the American Medical Association Oncology, Dr. Stephen Narod, the lead researcher, suggested that a change in the management of DCIS or ductal carcinoma in situ from lumpectomy and radiation to

Ask Questions about Your Best Treatment Options. Speak to your surgeon, medical oncologist and a radiation oncologist.

Ask Questions about Your Best Treatment Options. Speak to your surgeon, medical oncologist and a radiation oncologist.

endocrine therapy in some patients with low risk or even observation in others. The results were “confirmatory and surprising” according to Medscape Medical Oncology News.  Dr. Narod went on to say:

“If the goal is to prevent in-breast recurrence, then radiotherapy and mastectomy are good treatment options,” he said.

“If the goal is to prevent death from breast cancer, the best option might be watchful waiting followed by chemotherapy at the time of an invasive breast recurrence,” he explained.

So What Are the Problems with This Study?

Dr. Narod’s results fly in the face of level I evidence-the so-called gold standard prospective, randomized trials with long-term follow-up.  So as a physician scientist, I always want to look at the raw data myself, not just accept the authors’ conclusion.

The “blockbuster conclusion” in this study was that the risk of dying from breast cancer was exactly the same when Dr. Narod and co-workers compared women with DCIS to women in the general population.  So determining whether a person dies of breast cancer or from other causes seems to be simple, doesn’t it?  But nothing could be further from the truth.  It’s actually difficult in a “rearview mirror” or retrospective review of a patient database, like the SEER data base used in the study.

Let me give you a real-life example.  We all know that famous American, President Ronald Reagan, passed away from Alzheimer’s disease.  Yet nowhere on his death certificate was Alzheimer’s disease ever mentioned as the cause of death.  So looking at the SEER database and just accepting that a woman’s death was not from breast cancer is likely a gross underestimate.  Secondly, the follow-up in Dr. Narod’s the study was relatively short, only 7 1/2 years.  But it has been known for decades that the risk of recurrence from DCIS is much longer, as much as 8 years on average.  So a 7 ½ year follow-up is just not good enough.  So I’ll caution the authors of this study not to draw too many “blockbuster conclusions” based on these data.

So What Is a Woman with DCIS to Do?

For now, I think it’s best for a woman with DCIS to sit down with her surgeon, medical oncologist, and radiation oncologist to discuss her own particular clinical situation.  We’ve known for years about the high risk features of women with DCIS: younger age, high nuclear grade, size of the DCIS, comedo necrosis, estrogen receptor status, and even race.  So talk to your breast cancer specialists and decide how you’re going to choose wisely.

If you have any questions about your DCIS, please feel free to call me, Dr. Ed Hughes, at 855-Dayton 1.