Alarming New Trend in Breast Cancer
Diagnoses — Should You Believe the Hype?
By Carol Parks, Contributing Editor
Imagine… you go in for your regular mammogram and are assured — happily — that you do not have breast cancer.
But — your doctor claims — you do have a kind of cancer referred to as ductal carcinoma in situ (DCIS)… also called "stage zero" cancer. Which means irregular cells are lodged in one or more of your breast ducts — the "highways" connecting the milk-producing lobes to your nipples. But they have not escaped to invade the other breast tissue. Yet.Will they ever? Maybe… maybe not. Read on…
Continued below. . .
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Being diagnosed with DCIS is complicated, annoying… and horribly frightening.
On the one hand, you're told not to fret; you don't have invasive cancer and most probably won't (the 10-year survival rate is 99 percent).
Then again, you're informed you must have the cells surgically removed, along with, in some instances, radiation and chemo… pretty much the same as if you had full-blown cancer.
Though DCIS is almost always treated, scientists agree that not all cases of DCIS will turn harmful. In fact, most won't. The words "in situ" literally mean "in place" — in other words, non-invasive.
DCIS comprises 30 percent of all breast cancer diagnoses, and is 99% curable. Breast cancer stages range from 0 to IV. The higher the stage, the worse the cancer… making stage zero seem pretty harmless.
So why all the hype — and the aggressive treatment? Is it all a hoax?
It all begins with a mammogram
DCIS is initially detected through mammography. But the trouble is, mammography is a very poor, inaccurate diagnostic tool.
Perhaps its most glaring problem is its unacceptably high rate of false positives, up to six percent. A false positive occurs when the test mistakenly indicates cancer is present.It should be noted that we here at Cancer Defeated suggest you avoid mammography and use thermography, which has better detection for all stages of breast cancer without the risks of spreading potential cancers via compression and radiation. Detailed information about thermography is available in our Special Report, Breast Cancer Cover-Up.
Getting back to conventional testing, if a mammogram detects an abnormal spot, the next step is usually biopsy — cutting a small amount of tissue from the breast to be examined under a microscope by a pathologist to see if cancer is present.
A 30-year history of confusion, differences of opinion,
and unnecessary treatment
and unnecessary treatment
There's a huge problem with conventional testing…
An estimated 17 percent of DCIS cases found through needle biopsy are misdiagnosed.1 Far from being the infallible "gold standard" claimed by conventional medicine… biopsy is fraught with errors and differences of opinion.
DCIS is notoriously tricky to diagnose, prone to outright mistakes and case by case disagreements over whether a cluster of cells is benign or malignant.2 Discerning these kinds of minute differences is a challenging area of pathology, the science of examining tissue samples for evidence of disease.
Plus, pathologists vary widely in level of experience and expertise. Some read as few as 50 breast biopsies per year — far less than the acknowledged 250 a biologist needs to perform before you can have confidence in his or her ability.
Add that to the fact that no diagnostic standards exist for DCIS, nor do any requirements of expertise levels in the pathologists who read them, and you have a real quagmire.
So maybe this statement by Dr. Shahla Masood, head of pathology at the University of Florida College of Medicine in Jacksonville is not so shocking…
He told the New York Times, "There are studies that show that diagnosing these borderline breast lesions occasionally comes down to the flip of a coin."3
Indeed, even where your pathology report is done can affect the diagnosis.
Many of the hundreds of thousands of biopsies performed each year are done in small community hospitals, where the pathologist may only read a few breast biopsies a year. Thus, they lack exposure to atypical breast lesions. The local pathologist might not even be board certified.
In larger hospitals, the diagnosis may be decided by a tumor board.
Beyond diagnostic errors, there's a difference of opinion as to what even constitutes DCIS.
Dr. Lagios, a San Francisco pathologist who reviews slides for second opinions, uses a criterion that does not classify some breast lesions smaller than 2 mm as DCIS, even if they possess other markers of it.
On the other hand, at Beth Israel Deaconess Medical Center in Boston — also a respected center for breast pathology — those same lesions are considered DCIS.4
"We have troubling news to tell you…"
In 2006, the Susan G. Komen for the Cure cancer group released a disturbing study.
In it, an estimated 90,000 cases of women who'd received a DCIS or invasive breast cancer diagnosis either (1) did not have the disease, or (2) their pathologist made another error resulting in incorrect treatment.This wasn't really a shock to the medical community, since this problem had been cited in the medical literature numerous times.
Take the illustrative stories of the women in the July 19, 2010 New York Times story as a case in point…
All of them began their troubling journey with mammography showing a spot… which led to biopsy… and a (mis)diagnosis of DCIS… which then progressed to painful, debilitating, and disfiguring breast surgery… and one even led to radiation therapy — only to be told later that they never had cancer at all.
Now imagine you've gone through that hellish series of events — and lived with the terrifying fear of invasive breast cancer — only to receive the troubling news that all the fear and pain was for nothing.
Not very reassuring, even though…
You've got plenty of company
An estimated one million women will be living with a DCIS diagnosis by 2020… and 50,000 new cases are diagnosed every year, just in the U.S.
DCIS incidence rose from 1.87 per 100,000 in 1973-75, to a staggering 32.5 per 100,000 in 2004. A more than seventeen times increase… according to a published report by Beth Vernig, PhD and colleagues, in the January 13, 2010 online issue of the Journal of the National Cancer Institute. Dr. Virnig is professor of public health at the University of Minnesota, School of Public Health.
Of course, that doesn't mean there's a sudden increase in this illness, or pre-illness, or whatever it is. It just means that testing has led to a massive increase in the number of cases diagnosed. Mammography may be responsible for the dramatic increase. Before widespread mammography use began in the 1980s, DCIS was rare. Now, since we assume early detection is the best way to "cure" cancer, we actively go looking for it.
In addition to finding cancer in earlier stages, doctors sometimes find cells in a twilight zone between normal breast cells and cancerous ones — a condition known as DCIS or "stage zero" cancer.
The standard treatment protocol
With few exceptions (notably elderly women with other health issues), standard practice is to treat DCIS as cancer, rather than monitor it to see if it progresses over time.
This means doctors are surely over-treating some (perhaps many) patients. Conventional medicine claims to lack the necessary tools to identify who should be treated and who should be watched. They may have a point, but…With a DCIS diagnosis, your current treatment is almost always surgery — either a lumpectomy or mastectomy, depending on how widespread the cells appear to be in the ducts. As Allegra says, "it's hard to imagine not doing any surgery."5 (Emphasis mine.)
If the cells are concentrated in one location, you'll get a lumpectomy followed by radiation… which conventional medicine says slashes the risk of recurrence in that breast (but not the other one) by half. But if abnormal cells are fairly widespread, they'll typically advise a mastectomy and skip the post-op radiation.
Some women, particularly young women with a family history of breast cancer or genetic mutation (placing them at higher risk) even opt for a double mastectomy.
The rate of double mastectomies for DCIS patients skyrocketed from 4.1 percent in 1998 to 13.5 percent in 2005 — well more than a three-fold increase — according to a study published in April 2009 in the Journal of Clinical Oncology.
Your doctor may sometimes recommend Tamoxifen (a chemotherapy drug) along with surgery.
So, what if YOU get a DCIS diagnosis?
First, take a deep breath and realize that mistakes are regularly made. There's no need to panic.
If you're diagnosed with DCIS or any type of early stage breast cancer, ALWAYS get a second — if not a third and fourth — opinion. False positive rates are so high, the diagnostic criteria so subjective, and the risks of surgery, radiation, and chemo too great to forgo this step.Before you make any treatment decisions, have your biopsy results reviewed specifically by a breast specialist.
As mentioned above, there are pathologists who specialize in rendering second opinions. I would certainly be willing to pay for it out of my own pocket, if necessary, before rushing into conventional medicine's slice and burn protocol.
Some doctors are increasingly urging the cautionary principle even with a clear DCIS diagnosis. A wait and see attitude. There seems to be a growing body of evidence suggesting that some breast cancers may spontaneously regress without treatment.6
Certainly a "wait and see" stance gives you a heads-up and an opportunity to engage in some of the strategies we discuss here and in our publications.
The controversy about over-treatment
Lawsuits from women who have been wrongly diagnosed -- and undergone radical disfiguring surgeries as a result -- may be affecting the treatment landscape and giving credence to a less aggressive approach.
Conventional medicine is quick to rush you into surgery. But researchers at the University of California-San Francisco see DCIS as part of a larger problem of cancer over-treatment.
Laura Esserman, director of the Carol Franc Buck Cancer Center and Professor of Surgery and Radiology, co-authored the 'controversial' analysis in the Journal of the American Medical Association in 2009… which calls for a new look at screening for both breast and prostate cancer.
Her argument: Mammography catches more early cancers, but the number caught at more advanced stages has not declined at a similar rate — which you'd expect if they were simply identifying early cases before they progress.
So screening may just be finding cases that don't need treatment.
What if we took the carcinoma out of ductal
carcinoma in situ -- DCIS --and eased up on treatments?
carcinoma in situ -- DCIS --and eased up on treatments?
There's growing pressure in the medical community for dropping the "carcinoma" from DCIS — saying it is troubling and misleading (which is impossible to disagree with).
These same proponents also suggest DCIS as an excellent candidate for "active surveillance" — a watching-waiting strategy that skips surgery and radiation unless the condition progresses to higher risk.So far, most of the drive for active surveillance seems to be coming from UC-San Francisco. Dr. Esserman has been especially forthright in demanding change in the naming and management of minimal risk cancers including DCIS.7
She advocates that minimal risk lesions should not be called cancer, and proposed a new term… saying the new name encourages a search for good outcomes without over-treating a rather benign condition.
With DCIS, "the bulk of what we find is not high grade… less than five percent of DCIS turns out to be 'something else' including invasive cancer," explained Dr. Esserman to Medscape Oncology in an interview.
Only high-grade DCIS tends to progress to invasive breast cancer. "If if doesn't look like high-grade DCIS, we should leave it alone. We would eliminate two-thirds of all biopsies if we did," says Dr. Esserman.
She states that there's sufficient data to rethink our entire approach to DCIS.
I'm sure eliminating two-thirds of all biopsies and practicing active surveillance will rattle those whose livelihoods depend on it. But that's exactly the route I'd choose.
Kindest regards,
Lee Euler,
Publisher
Footnotes from 1st article:
2http://www.nytimes.com/2010/
3http://www.nytimes.com/2010/
4http://www.nytimes.com/2010/
5http://health.usnews.com/
the-confusion-over-dcis-what-
6http://www.medscape.com/
7Journal of the American Medical Association (JAMA. 2009;302:1685-1692).
References from second article:
"Cancer Death Rates Continue to Decline," by Katie Moisse. http://abcnews.go.com/blogs/
"Cancer death rates continue to drop," by Amanda Gardner, HealthDay. http://yourlife.usatoday.com/
"Report: U.S. Cancer Death Rates Continue to Drop," by Dr. David B. Samadi. http://www.foxnews.com/health/
Fighting Cancer, ebook, by K.W.A. Jayawardana. http://www.nadula.info/
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