In the Oct 2015 issue of TIME Magazine, Dr. Shelley Hwang, chief of breast surgery at Duke Medical Center, and some of her patients are featured in a story along with a short must-watch video titled: Choosing to Wait: A New Approach to Treating Breast Cancer at It’s Earliest Stages.
The article states, “Dr. Shelley Hwang is one of a growing number of breast cancer experts in the U.S. who support Active Surveillance as a form of treatment for patients with low risk DCIS.” This new approach is “a paradigm shift in breast cancer treatment,” with a small but influential group of experts calling for a major shift in the way doctors treat and talk about different types of DCIS. The article continues, “Evidence is mounting that aggressive treatments, designed in earnest to save women’s lives, can have unforeseen and sometimes devastating consequences. It’s the multiple follow-up surgeries after a mastectomy and the subsequent infections; the radiation that doesn’t always improve survival and the cancer risk that can come with too much of it; the sometimes unnecessary chemotherapy and its life-sapping side effects. For some in the field, that collateral damage is getting harder and harder to justify.”
And then there is the extreme anxiety created by a DCIS diagnosis. For many women it can turn their lives upside down overnight — and this anxiety can be on-going. Too often women diagnosed with DCIS are offered aggressive treatments and psychiatric drugs, rather than counseling, support and life-style therapies.
Why are most women diagnosed with DCIS still not offered active surveillance or “watchful waiting” as a treatment option? Women are generally told “no one knows for sure which DCIS cases will go on to progress to invasive cancer. So the “standard of care” is to treat everyone with any type, size or grade of DCIS the same — as if it is invasive cancer. It’s a “one size fits all” approach that is harming thousands and thousands of women.
These studies, many experts agree are long overdue.
An article from Sept 2011 in More Magazine discusses the issue:
THE CASE FOR THE SURVEILLANCE OPTION
“Esserman is among the most outspoken of the voices for change. She and similarly minded breast-cancer specialists such as Hwang believe that it’s time to seriously look into what’s known as management by active surveillance. For DCIS, any lesion that doesn’t appear high grade would be left alone and not biopsied. Instead, if suspicious calcifications were discovered in mammography screening, patients would be given the option of forgoing treatment while doctors monitor them intensely to see what develops. This strategy is already used in treating low-risk prostate-cancer patients, who do not undergo surgery or radiation unless the lesion progresses to a higher risk level. “With early stages of prostate cancer, there is a lot of discussion about watchful waiting and active surveillance, about how cancers come in different types and how the patient has lots of options,” says Barron Lerner, MD, internist and medical historian at Columbia University Medical Center. “For DCIS, the conversation hasn’t moved so much in that direction.” And, he says, “to the degree that breast-cancer specialists consider close surveillance a reasonable option, women should be made aware of this choice.”
In a 2008 JNCI editorial, The Sea of Uncertainty Surrounding Ductal CarcinomaIn Situ — The Price of Screening Mammography H. Gilbert Welch states:
“It’s time to figure out whether they really need surgery or whether all they really need is repeat mammography (or magnetic resonance imaging). In other words, should they be treated for breast cancer or should they be managed as individuals with an elevated risk for disease? Because the prognosis for women who are treated for early-stage breast cancer is so good, it’s reasonable to test a strategy of active surveillance for DCIS. Active surveillance could help women whose DCIS does not progress avoid treatment and allow those whose DCIS does progress to invasive cancer be diagnosed and treated when the prognosis is still extremely favorable.”
A mathematical model developed by Duke researchers “suggests that active surveillance may be a rational trade-off for carefully selected patients with DCIS.”
So how do women best monitor calcifications, DCIS and/or close margins? Mammograms every 6 months? Alternate between mammograms and MRI? Thermography? Ultrasound? For a complete overview of imaging modalities, please click on imaging and monitoring.