Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 1!

Is There a Better Way to Treat DCIS?

A Review of the Literature

Vanessa Mendoza

Dominican University of California

Authors Note
This paper was prepared for English 3200: Advanced Writing & Research, taught by Pro-
fessor Cumings.
Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 2!

Within the past decade, routine mammograms and better imaging techniques have made

it easier to detect ductal carcinoma in situ (DCIS), which is also known as stage 0 breast cancer.

DCIS is not life-threatening, but in some cases it can spread and develop into an invasive cancer.

Experts have yet to find a reliable form of technology that tells doctors which cases will develop

into an invasive cancer. This leads many patients to have a mastectomy or lumpectomy to surgi-

cally remove the entire or part of the breast that contains the cells that could develop into cancer

and use radiotherapy to reduce risk. However, many experts are becoming skeptical about how to

go about treating DCIS because many believe that DCIS patients are being overdiagnosed and

overtreated. Some doctors still believe that aggressive treatment is the way to go, while others

believe that watchful waiting is the better option for patients. Esserman and Yau, N. Smith, Fran-

cis et al., Peres, Cheung, Booth, Kearins, and Dodwell, and J. Smith argue this matter. Their re-

search suggests that active surveillance is the appropriate treatment to some degree, but in other

cases aggressive treatment with surgery will benefit the patient more.

Laura Esserman, MD, MBA and Christina Yau, PhD argue in Rethinking the Standard

for Ductal Carcinoma In Situ Treatment that breast cancer behavior can range from aggressive

to inactive and the treatments of DCIS should emerge from activity in the patient. Esserman and

Yau (2015) looked at more than 100,000 women with DCIS and determined that aggressive

treatment does not decrease breast cancer mortality rates, but rather may increase them when

treated with radiation therapy (p. 881). Early removal and treatment of DCIS lesions have not

showed a reduction in recurrence of invasive breast cancers (Esserman and Yau, 2015, p. 881).

According to Teri Okita (2015), Esserman has treated some of her patients who have been diag-

nosed with low-risk DCIS with active surveillance by ordering addition screenings and prescrib-
Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 3!

ing medication (p. 881). Esserman and Yau (2015) go on to argue that in order to minimize the

risk of overdiagnosis and/or overtreatment (p. 881), we must not focus on the clustered amor-

phous calcifications found in the screenings of DCIS. Instead, we should shift our attention to the

lesions that are occur with invasive cancer or linked with hormone receptor-negative or HER2-

positive DCIS (p. 881). Overall, Esserman and Yau suggest that other alternatives for treatment

should be tested. Essermen and Yaus points are made credible by data and studies, which dis-

prove the arguments that early aggressive treatment on DCIS patients is the best procedure for

any case. They specifically pinpoint the areas in DCIS diagnosis that need to be addressed and

make a strong, well-documented argument against using surgery and radiation as the primary

procedure for treating DCIS.

According to Nancy F. Smiths (2011) article, A Breast Cancer You May Not Need to

Treat, patients feel pressured to make a decision about their course of treatment for DCIS.

Smith states that, time isn't the enemy (p. 5). Patients fear the question what if? so they de-

cide to aggressively treat their DCIS so they can go back to their lives, but many don't take into

account the possibility of recurrence. Dr. Shahla Masood, head of pathology at the University of

Florida College of Medicine explains that, by the time DCIS appears on a mammogram, its

been there for several years. If you spend two weeks or three weeks or a month to find the right

people to take care of it, thats not going to make any difference in the outcome" (N. Smith,

2011, p. 5). It is also pointed out that even with the amount of women being diagnosed early with

DCIS and using aggressive treatment to prevent it from developing into an invasive tumor, the

rate of invasive cancer has not declined; its actually gone up by 25% (N. Smith, 2011, p. 1).

Some patients diagnosed with DCIS are not taking the time to consider their options. N. Smith
Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 4!

discusses both sides of the controversial issue and explains why she favors the treatment of ac-

tive surveillance. She reports data and information from Dr. Brian J. Czerniecki, codirector of the

Rena Rowan Breast Center at the University of Pennsylvania, and Dr. Todd M. Tuttle, chief of

surgical oncology at the University of Minnesota in Minneapolis, regarding the aggressive course

of treatment and properly cites her sources, which validates the material and strengthens her ar-

gument further.

In Addressing Overtreatment of Screen Detected DCIS; The LORIS Trial Adele Fran-

cis et al. (2015), explains their clinical trial background and the development of treating low-risk

DCIS by active monitoring. The Swiss medical board reveals that at least 14 patients with DCIS

have been overtreated and overdiagnosed (Francis et al., 2015, p. 2297). Francis et al.s primary

objective is to evaluate whether active monitoring is a superior treatment to surgery for women

with DCIS and will be invasive cancer free. The trial protocol addresses several specific areas,

including eligibility (age, DCIS grade, and DCIS size), biopsy method, imaging criteria, surgery

arm , active monitoring arm, follow up in both arms, recall and investigation, and imaging tissue

banks and translation research (Francis et al., 2015, p. 2298-2301). Since the study began in De-

cember 2014, there has not been any data released. This paper is well thought out and considers a

lot when selecting women to be in the trial. However, because there is not any actual data to

prove that actively monitoring DCIS will prevent a recurrence of DCIS or the development of an

invasive cancer, it makes it difficult for the Francis et al.s argument to be evaluated.

In Stage 0 Breast Cancer: When Should You Wait and See? Judy Peres (2015) claims

that the treatment of DCIS depends on the grade of it, whether it is low-risk, intermediate, or

high-risk for recurrence. By knowing which cases of DCIS will progress to invasive cancer, we
Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 5!

will be able to reduce overdiagnosis and overtreatment. Peres (2015) explains that doctors are

unwilling to change current practice [of surgically removing DCIS] without more evidence that

[active surveillance is] safe (p. 2). On the other hand she argues that some doctors have given

the option of active surveillance to their patients because they have the right to know all the pos-

sible courses of treatment and can make an informed decision. Apparently there is a new genom-

ic test that may make it easier to decide on a course of treatment by detecting which cases of

DCIS are low-risk, intermediate, or high-risk for recurrence or will progress to invasive cancer

(Peres, 2015, p. 3). Overall, Peres remains neutral by only stating the facts of both sides of the

debate and not imputing her own commentary. However, when she mentioned the new genomic

test, Peres did not provide any evidence or sources that it does indeed detect the DCIS grade,

which put into question the credibility of her other sources as well.

In Risk of Subsequent Invasive Breast Cancer After a Diagnosis of Ductal Carcinoma In

Situ (DCIS) by Cheung, Booth, Kerins, and Dodwell (2014) argue that rates of invasive cancer

recurrence are low after surgically treating DCIS when detected by a mammogram (p. 809).

Their study examined the risk of invasive recurrence when DCIS was treated with wide local ex-

cision (WLE) or a mastectomy, which are two types of surgeries used to remove DCIS lesions

(Cheung et al., 2014, p. 807). Since studies providing data on the subject of active surveillance

are lacking, the choice is up to the patient and their doctor. In this article the arguments support-

ing surgically treating DCIS are weak. They do not specify the grade of the DCIS in the results,

whether it was low-risk, intermediate, or high risk. The tables of patient and tumor characteristics

of the DCIS cases are difficult to understand and confusing. Cheung, Booth, Kerins, and Dod-

well do not even mention treating DCIS with active surveillance so there is no hard evidence that
Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 6!

aggressive treatment is indeed the best course of action for DCIS.

Julia A. Smith in Treatment of Ductal Carcinoma In Situ: New Data Refine the Risk Es-

timates Associated with Various Treatments makes many of the same claims as Cheung, Booth,

Kerins, and Dodwell. DCIS that is treated aggressively by a lumpectomy and radiation reduced

recurrence of invasive cancer by 52% compared to only being treated by a lumpectomy which

only reduced recurrence by 19.6% (J. Smith, 2011, p. 918). J. Smith explains that by treating

DCIS with more and more treatment the recurrence rate will continue to decrease. She argues

that she only examines aggressive treatment for DCIS no matter its grade because it is impossi-

ble to distinguish how aggressive and subclinically invasive the tumors are (J. Smith, 2011, p.

918) and the lack of markers makes it difficult to identify non-invasive tumors that can subse-

quently become invasive (J. Smith, 2011, p. 918). Until the genome and candidate studies can

figure out which markers can predict invasive cancer recurrence, Smith will continue to treat pa-

tients with DCIS aggressively. Smith provides clear and comprehensible data, which strengthens

her paper. The article is has credible sources that supports Smiths argument.

The treatment of DCIS has become a debated topic between patients with DCIS and

health care professionals. According to all of the articles analyzed here, there have been very

few scientific studies conducted that make a case for the advantages of active surveillance as a

treatment for DCIS. In fact, most articles explain that there is nothing that can detect the grade of

DCIS and if it could develop into an invasive cancer. Most likely, patients that are well-informed

of the studies and results of aggressive treatment versus active surveillance would choose to un-

dergo aggressive treatment.

Running head: IS THERE A BETTER WAY TO TREAT DCIS? Mendoza 7!

References

Cheung, S., Booth, M. E., Kearins, O., & Dodwell, D. (2014). Risk of subsequent invasive breast

cancer after a diagnosis of ductal carcinoma in situ (DCIS). The Breast, 23, 807-811. doi:

10.1016/j.breast.2014.08.013

Esserman, L., & Yau, C. (2015). Rethinking the standard for ductal carcinoma in situ treatment.

JAMA Oncology, 1, 881-883. doi:10.1001/jamaoncol.2015.2607

Francis, A., Thomas, J., Fallowfield, L., Wallis, M., Bartlett, J. M. S., Brookes, C., Rea, D.

(2015). Addressing overtreatment of screen detected DCIS; the LORIS trial. European

Journal of Cancer, 51, 2296-2303. doi:10.1016/j.ejca.2015.07.017

Okita, T. (2015, November 3). The debate over early breast cancer treatment. CBS News.

Retrieved from http://www.nbcnews.com/

Peres, J. (2015, October 1). Stage 0 breast cancer: When should you wait and see?. Chicago

Tribune. Retrieved from http://www.chicagotribune.com/

Smith, J. A., (2011). Treatment of ductal carcinoma in situ: New data refine the risk estimates

associated with various treatments. BMJ: British Medical Journal, 343, 917-918. doi:

10.1136/bmj.d5344

Smith, N. F. (2011, September 6). A breast cancer you may not need to treat. MORE Magazine.

Retrieved from http://www.more.com/