When Laura Colletti was told that she had ductal carcinoma in situ (DCIS), or early-stage breast cancer, she dreaded what the diagnosis would mean for her life. Laura’s daughter had some straightforward advice: “Mom, if it was me I’d take it out. You just get rid of it.”
But Laura wasn’t ready for a mastectomy. She and her husband researched DCIS, which is known as stage 0 cancer, and found that at her stage, her lump was made of pre-cancerous cells fully contained inside the ducts of the breast. The cells might never break out of the duct and become an invasive cancer. Laura says she found that, “really we don’t have to have surgery. That it’s not life-threatening, and I’ll probably die from something else.”
Some doctors agree. Surgeon Shelley Hwang, Chief of Breast Surgery at Duke Medical Center, says it makes her sad when patients feel they have to undergo a major mastectomy surgery in order to rid themselves of the anxiety of breast cancer. Dr. Hwang explains that in ductal carcinoma in situ, the in situ phrase means that the abnormal cells are contained, and if they stay contained, they pose much less risk than having a preventative surgery.
Doctors are now finding breast cancer tumors at higher rates because of how detection technology has improved in recent years. But while early detection has improved, breast cancer death rates have stayed about the same from 2002 to 2015. Shouldn’t more detection, especially early detection, mean more lives saved?
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Cases of DCIS account for 20 to 25 percent of breast cancers detected by screening, whereas DCIS made up about 3 percent of detected cancers before screening became more popular in the 1980s. The reaction of many doctors and patients, understandably, is to want to remove any tumors regardless of stage. Even if a woman does have very early stage breast cancer, it may seem far better to undergo surgery than to worry over whether or not the cancer will become invasive.
But not all tumors are the same, and some are so slow-growing that they might not ever cause death, or even symptoms. They key is to know which ones are which. Cancer is the blanket term applied to low-risk DCIS and to stage IV metastatic cancer, but they don’t pose near the same amount of risk, though the terminology can cause an equal amount of fear in both cases.
But even stage 0 DCIS poses some risk of becoming invasive; isn’t it better to operate and be done with it? According to Dr. Hwang, not always: “There have been a couple of very important studies that have been published lately which have shown that for the really low risk DCIS, whether you ever operate on them, whether you do a lumpectomy or whether you do a mastectomy, the patients are equally likely to not die of breast cancer.”
This is a serious consideration, especially because treatment comes with its own set of risks. The side effects of chemotherapy and radiation are both short- and long-term, and even a double mastectomy is not a magic bullet. Aside from the emotional side effects, a mastectomy may involve revisions, prolonged pain, loss of sensation, or hernias.
Some doctors are beginning to think there are times when treatment risks outweigh the benefits, and they’re putting a new option on the table: active surveillance. Active surveillance involves screenings every six months and may include estrogen-blocking drugs. This is the route that Laura Colletti chose. Her daughter was, understandably, against the decision at first. But after talking to her mom about the research the the pros and cons of more aggressive treatment, she become supportive.
Laura was relieved that she wouldn’t have to, at least at this stage, undergo surgery. “I feel great about my decision. If options were given to women, more women would choose active surveillance. But because there’s no options out there, people don’t know to even ask.”
Dr. Hwang is not suggesting that people stop getting mammograms; she’s simply questioning the rapid-fire reaction to all types of cancer. If active surveillance can help women avoid surgery without sacrificing peace of mind, it may be a good option for those with very low-risk DCIS—at least it should be one of the options presented.Whizzco