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No Easy Answers

Massachusetts General

Shelley Hwang, professor of surgery at Duke University in Durham, N.C., meanwhile, has found that words do make a difference: When she and her colleagues presented nearly 400 healthy women with fictitious DCIS scenarios and three treatment options—surgery, medication or watchful waiting—47 percent of them chose surgery when DCIS was described as a “noninvasive breast cancer.” But when the description was changed to “abnormal cells,” fewer than a third of the women said they’d opt to have the lesion removed.

It’s a scenario that’s becoming more common. A generation ago, an oncologist might have gone years without encountering DCIS. In the 1970s, DCIS represented fewer than 2 percent of breast cancer diagnoses, and the condition was usually discovered only after a breast lump, discharge or other symptom raised the alarm. But widespread mammography, able to detect smaller and smaller lesions, has led to a sevenfold increase in the number of new cases of DCIS. Today it accounts for about one in five breast cancer diagnoses, with some 64,000 women diagnosed with the condition last year.

That surge presents a quandary for physicians—and for their patients—because screening’s ability to find these precancerous lesions has outstripped knowledge about how to classify DCIS and how to treat it, says Khan. “We’re probably finding some DCIS lesions we don’t need to find, and then we’re faced with the conundrum of what to do,” she says.

Complicating the situation further is DCIS’s similarity to what might be considered a pre-precancerous condition—atypical ductal hyperplasia. The line between the two is “open to controversy,” according to Dennis Sgroi, director of breast pathology at MGH. Yet a pathologist’s decision about what to call the lesion may make a world of difference to a patient, because ADH gets treated much less aggressively than DCIS, which is handled pretty much like early stage breast cancer. The abnormal cells are cut out through a lumpectomy or mastectomy—the latter only if DCIS is diffuse throughout the breast (and a double mastectomy only if it’s in both breasts). Then the patient may receive radiation or the drug tamoxifen.

Yet for those 85 percent who have DCIS that will pose little threat, a mastectomy or a lumpectomy may make no sense. But so far, there’s no good way to distinguish the dangerous from the benign, says Kramer. Autopsy studies have examined the breast tissue of women who had never been diagnosed with breast cancer and found that many cases of DCIS had gone undetected. At least some of the lesions may go away on their own, though it’s not clear how or even whether that happens.

Originally published in Proto, focusing on the promise of biomedicine, published by Massachusetts General Hospital

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