Introduction:
A newly published large study indicates the best treatment option for a common form of breast cancer may be no medical treatment. The study examined the results of treatment from over 100,000 women with ductal carcinoma in situ (DCIS), a type of breast cancer where abnormal cells have been found in the lining of the breast milk duct, but the cells are “in situ” meaning that they are in the original place and have not spread.
Women diagnosed with DCIS are routinely told they need to have surgery and begin radiation within two weeks. However, the surprising results from this new study question this conventional wisdom. Aggressive treatment (mastectomy plus radiation) did not lead to a reduction in breast cancer mortality compared to a simple lumpectomy (surgical removal of the small section affected) without radiation.
Treatment with more aggressive surgery and radiation is still appropriate in minority of cases based upon age, race, and/or specific tumor characteristics. In the remaining large majority of women with DCIS, strategies aimed at breast cancer prevention and close observation (also known as watchful waiting) may be the best course of action.
Background Data:
One of the reasons for the recommendation of a yearly screening mammogram has been the assumption that early detection would lead to better treatment outcomes. That recommendation has been challenged by considerable scientific investigation. For example, the Cochrane Collaboration concluded mammography screening overall did not reduce breast cancer mortality and women were ten times more likely to be treated unnecessarily and 200 times more likely to have a false positive finding, causing them undue stress and anxiety. Some reviews have also stated that mammography screening is “no longer effective.” Yet, the American College of Radiology and American Cancer Society recommend yearly screening mammography starting at age 40. So, it remains a controversial subject.
Early treatment of both DCIS as well as early stages of more invasive forms of breast cancer is based upon the thought that earlier treatment would prevent not only recurrence in the same breast, but also early death due to the cancer spreading. However, there are a lot of variables that influence the outcome. In general, results have not supported aggressive treatment for either early stage invasive breast cancer or DCIS. Lumpectomy without radiation is just as effective in terms of survival, as mastectomy with radiation in the overwhelming majority of women. There are exceptions, most notably age of diagnosis (women under 35 generally have more aggressive forms of breast cancer), presence of the breast cancer gene (BRCA), race (black women are at higher risk of having aggressive breast cancer), and the presence of various tumor markers indicative of more aggressive cancer (estrogen-receptor positive, larger tumor, higher replication rate, etc.).
New Data:
Researchers, led by lead investigator Steven Narod, MD, from the Women’s College Hospital in Toronto, identified 108,000 cases of DCIS diagnosed from 1988 to 2011 in the Epidemiology, and End Results (SEER) database. They then compared the risk of dying from breast cancer in women with DCIS and in women in the general population, and estimated the hazard ratio for death from DCIS using a variety of factors, including age and treatment.
Many of the results confirmed previous studies, however, there were several surprising findings. First, one of the surprising findings was the overall risk of dying from breast cancer at 20 years post diagnosis (3.3%) in the study group did not differ from the chance that the average woman will die of breast cancer given by the American Cancer Society. Hence, treatment did not show any benefit in the study population overall.
One of the findings confirmed in the new study was that the mortality rate with DCIS was higher in women younger than 35 years at diagnosis, black women, and tumor markers linked to more aggressive cancer. However, since about 20% of the women diagnosed with DCIS had one or more of these characteristics associated with a higher risk for breast cancer death, and based upon the overall results of the study the researchers concluded that 80% of the women with DICS are better served with less aggressive therapy.
One of the other surprising study results was that prevention of recurrence of DCIS in the affected breast with radiation did not prevent death from breast cancer. The dominant thought has been that if you prevent DCIS from recurring it will, in turn, reduce the risk for breast cancer death, but that is not what the study found. In patients who underwent lumpectomy, the addition of radiotherapy was associated with a 50% reduction in the risk for DCIS recurrence at 10 years, but had zero effect in reducing breast-cancer-specific mortality at 10 years. The takeaway conclusion is that radiation therapy should not be routinely added to lumpectomy in women who are not at high risk, because it is associated with some risk for side effects and offer no benefit in reducing the risk for dying of breast cancer.
Similar results were found in the women in the study who underwent more aggressive surgery, like a mastectomy. The more aggressive treatment was good for reducing a recurrence, but not did reduce the risk for dying of breast cancer.
The results of this study calls into question whether all women with DCIS should be treated with aggressive therapy (surgery + radiation).
Commentary:
Instead of the term “watchful waiting,” I prefer “aggressive focus.” In other words, if you have DCIS (or prostate cancer or other non-invasive cancer), it is not about sitting around idle waiting for the worst possible outcome, it is all about aggressively focusing on the preventive, even reversal measures, through diet, lifestyle, and other natural approaches.
How will conventional medicine respond to the findings of this study (and others) that question the use of aggressive surgery and radiation for DCIS? No question it will be to start recommending estrogen antagonists like tamoxifen/raloxifene or aromatase inhibitors. In my opinion the use of these drugs in breast cancer treatment or prevention including women with prior history of breast cancer is the wrong way to go (see my book, How to Prevent and Treat Cancer with Natural Medicine for more information). I don’t like these drugs at all, especially when there are dietary and supplement strategies that I feel are much more rational.
Medical science is in a little bit of a limbo in that there is more and more evidence that conventional approaches are not delivering the desired outcome, but the data and sophistication of understanding how to use food as medicine is not quite where it needs to be to get more doctors to jump on that bandwagon. I fear what will happen here is that they will use drugs instead of diet simply because there is some data to support their use. Patients feel that they are stuck in the middle of choosing to follow their doctor’s recommendation or simply take charge of their health on their own. Often they try a combination of conventional medicine along with diet or alternative therapies.
As it relates to this particular situation about DCIS, the picture is getting more and more clear. Here is what I recommend: Opt for lumpectomy without radiation unless you are black or have aggressive tumor markers in which case, I would recommend lumpectomy with radiation. If you are under 40 with a diagnosis of breast cancer including DCIS, I would recommend seeing a naturopathic physician for aggressive natural support. In all cases, please see my recommendations on Breast Cancer Prevention.
On another note, in talking to women (including my wife) about mammography, they always seem to bring up someone who they know that had their life “saved” because a mammogram discovered a breast cancer early on and that allowed them to go down the treatment path. Is that story true? According to the data, it is a rare occurrence if it happens at all. There are basically three types of cancers found by mammography:
-Very slow growing cancers where early detection offers no benefit to survivability.
-Fast growing, aggressive cancers where even early detection by mammography is too late and the woman will die from the cancer anyway.
-Cancers detected by screening mammography and whose treatment outcome may be better as a result of earlier detection.
According to various review articles, to find that 1 woman to possibly benefit from early detection it would require 1,000 healthy women screened every year for 10 years. It is simply not an effective tool. And what this new study illustrates, is that even if you find that 1 woman, unless she falls into the known higher risk categories, aggressive treatment may not be the best course of action.
Here is the takeaway message. Make breast cancer prevention the major focus and if you have a family or personal history of breast cancer, be even more aggressive in your breast cancer prevention plan. Again, for more information, see my recommendations on Breast Cancer Prevention.
