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Mon August 5, 2013

When Treating Abnormal Breast Cells, Sometimes Less Is More

Originally published on Tue August 6, 2013 10:39 am

When Sally O'Neill's doctor told her she had an early form of cancer in one of her breasts, she didn't agonize about what she wanted to.

The 42-year-old mother of two young girls wanted a double mastectomy.

"I decided at that moment that I wanted them both taken off," says O'Neill, who lives in a suburb of Boston. "There wasn't a real lot of thought process to it. I always thought, 'If this happens to me, this is what I'm going to do.' Because I'm not taking any chances. I want the best possible outcome. I don't want to do a wait-and-see."

Today, 10 years later, O'Neill has no regrets about what most people would consider a radical decision. And as it turns out, she was at the leading edge of a trend.

O'Neill had ductal carcinoma in situ, or DCIS. The number of women who get double mastectomies because of DCIS is small — around one in 16 women (see accompanying chart). But the rate has doubled in the past 10 years.

DCIS is an abnormality that most specialists call "stage zero" breast cancer — on a scale of 1 to 4. In many cases it doesn't ever progress to invasive cancer, the type that can be life-threatening.

These women are in a very different position than actress Angelina Jolie,who recently chose to have a double mastectomy. She has a gene mutation that gives her a very high risk of breast cancer. Research shows many of the women choosing double mastectomy have the same diagnosis as O'Neill, not Jolie.

The debate over appropriate treatment for DCIS is part of an even bigger debate about what many specialists call the "overdiagnosis" of cancer, especially cancers of the breast, prostate and thyroid.

This means the discovery of growths that look like cancer but are not destined to cause the patient a problem if they go untreated.

The National Cancer Institute recently convened a group to look at overdiagnosis and overtreatment of cancer. JAMA, a journal of the American Medical Association, last week published a summary of its conclusions.

Overdiagnosis is a product of widespread screening programs that look for cancers before they cause symptoms, on the assumption that early treatment will invariably reduce the chance that a cancer will kill. There's growing evidence that's not necessarily true.

Routine mammography and PSA screening for prostate cancer are thought to reveal many malignancies that wouldn't show up otherwise. And many doctors worry that a federal task force's new recommendation to increase screening with CT scans to look for early lung cancer will also lead to overdiagnosis.

Stepping back further, the issues of cancer overdiagnosis and overtreatment are part of an even bigger concern about unnecessary medical care. It's a problem NPR intends to explore in coming months as part of a series we're calling "Less Is More." The series will focus on situations when less treatment may actually be better for patients.

DCIS is a touch point of the overdiagnosis debate. Nearly 70,000 women are diagnosed with it each year. Before mammography screening, only about 3 percent of breast cancers were DCIS. Now the condition accounts for about a third of all "breast cancers."

The reason for those quote marks is that, while most cancer doctors view DCIS as a very early stage of breast cancer, a growing number say it really shouldn't be called "cancer" at all.

DCIS is an overgrowth of cells within the lining of a woman's milk ducts. Such growths are not dangerous unless and until they break through and invade other breast tissue and ultimately spread to lymph nodes and other organs.

"Many of these precancerous lesions are not going to go on to become cancer," says Dr. Laura Esserman, a breast cancer surgeon at the University of California, San Francisco. "I don't think we should label it as cancer. I think we should call it a 'ductal lesion.' I think people would be much more willing to be calm about it."

We'll come back to Esserman's ideas about how woman and their doctors should address DCIS. But first, let's go back to Sally O'Neill; her case capsulizes the dilemma.

Her decision to have a double mastectomy, even though she had DCIS in only one breast, was so radical that the first surgeon she consulted refused to do it without a letter from a psychiatrist. "His exact words were, 'You're cancer-phobic,'" she says.

So she found a different surgeon, Dr. Kevin Hughes at Massachusetts General Hospital. When it comes to treating DCIS, Hughes errs on the side of caution.

"We don't know what percent are not deadly, and we have no idea which patients do or do not have a deadly form of cancer," Hughes says. "So as a surgeon I need to treat every cancer as if it might be deadly, because I don't know which ones are and which ones aren't."

Hughes does not advocate removing a healthy breast that doesn't have any DCIS. But he'll do it if he thinks a woman wants it for the right reasons.

"If they want to take the opposite breast off to never experience breast cancer again, that ... is a good reason to do it," Hughes says. "If they are taking their opposite breast off so they will live longer, that's not a good reason to take the opposite breast off."

This is a critical point. Many women — perhaps assuming all breast cancers are dangerous — may believe that removing the healthy breast after a diagnosis of DCIS improves their chances of survival.

But DCIS is nearly 100 percent curable. Typically, the treatment is a small operation called lumpectomy, often but not always followed by radiation to the area. (About a quarter of women with DCIS have a single mastectomy, usually because the abnormal growth occupies too great a percentage of the breast to make lumpectomy feasible.)

The chance of DCIS later appearing in the opposite breast is not precisely known, but is thought to be well under 1 percent per year. And Hughes points out that if DCIS does appear in the second breast – or even if invasive cancer turns up –it would likely be highly curable, too.

"We normally find it at a very early, very curable stage," Hughes says. "We very seldom have patients die from cancer in the opposite breast."

Some say concern about survival is not the only thing that's driving some women to seek a double mastectomy.

Patients may be distressed about the experience of breast cancer diagnosis and treatment and have a "very strong aversion" to going through it again, Seema Khan of Northwestern University writes in a commentary in the Journal of Clinical Oncology.

Whatever their reasons, some patients and some doctors are pushing back against what they consider too much treatment for DCIS.

Peggy MacDonald of Portland, Ore., is one of those patients. She was stunned after she recently got a diagnosis of DCIS and discovered that all the doctors she saw thought she should have surgery to remove it — right away.

"Quite honestly," she says, "I just didn't like the options being presented to me. It didn't ... make sense to me."

None of the surgeons recommended that MacDonald should remove her healthy breast, but all agreed she should have surgery. She was almost ready to give in when one of her sisters sent her an article quoting Esserman, the San Francisco breast surgeon.

MacDonald made an appointment to see Esserman and discovered a different approach.

"She said, 'OK, I've looked at your MRI, I've looked at your mammograms, I've looked at your blood tests. Here's what I will tell you — this is not an emergency and you have options,'" MacDonald says.

Esserman stresses there's no need for women to rush into surgery after a DCIS diagnosis.

"I think we all need to take a step back and not be so hysterical," Esserman says. "When I see people who've been told they've got to make a decision within two weeks, that's just crazy! No one has shown a progression [from DCIS] to invasive cancer in a two-week period of time — ever."

After seeing Esserman, MacDonald decided not to have surgery, at least for now. Instead, the doctor put her on hormone suppression therapy. McDonald now takes a drug that blocks estrogen. Because her DCIS cells are fueled by estrogen, the hope is that once they are starved of the hormone the cells will shrink and perhaps even disappear.

MacDonald says she realizes she may end up needing surgery anyway, but if so she'll be clearer about the decision.

She's hoping her case will turn out like another of Esserman's patients, Barbara Mann. Mann took an estrogen-blocking medication as well, for six months. Today, an MRI scan and biopsy show no trace of DCIS in her breast.

"It's amazing," Mann says. "It's not even a case of less-is-more. This is a case of less-is-best. I am just hugely relieved, absolutely thrilled. And what I would really like is for every other woman in my position to know this is an option."

But it's an option that will require lifelong vigilance. Anyone who chooses not to have surgery will have to be watched carefully and have routine mammograms and maybe even MRI scans and biopsies.

And women who choose this alternate route must be willing to live with the risk, however tiny, that DCIS might return, and might turn into invasive cancer.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

LINDA WERTHEIMER, HOST:

This is MORNING EDITION, from NPR News. I'm Linda Wertheimer.

RENEE MONTAGNE, HOST:

And I'm Renee Montagne.

Today in Your Health, we begin an occasional series called Less Is More. It explores the idea that more health care may not be better health care. And as part of this, our science team has been learning about a condition called DCIS.

WERTHEIMER: It stands for ductal carcinoma in situ. It's controversial. Most cancer doctors view DCIS as a very early stage of breast cancer. But some say it really is not cancer at all.

MONTAGNE: It's being diagnosed much more often these days, and treatment is getting more aggressive, perhaps too aggressive at times.

Here's NPR's Richard Knox and Patti Neighmond with a look at the hard choices patients are facing.

PATTI NEIGHMOND, BYLINE: Let's start our story with Sally O'Neill. She's a single parent raising two girls in a suburb of Boston.

RICHARD KNOX, BYLINE: When I went to see her, she told me that 10 years ago, life was good. She was happy and healthy. Then she went to the doctor for a routine visit, and everything changed.

SALLY O'NEILL: I had my yearly mammogram, and that's when they found the microcalcifications in a circle. And they said that usually when they're in a circle, that means that there's something inside of it.

KNOX: O'Neill had a second mammogram, then a biopsy. It showed she had ductal carcinoma in situ. DCIS is a collection of abnormal cells found only in the milk ducts of the breast.

NEIGHMOND: Now, doctors differ on whether these cells should be called cancer or pre-cancer. But they do agree that they're only dangerous when and if they invade surrounding tissue. There's only a 10 to 15 percent chance they'll ever do that.

KNOX: O'Neill told me her surgeon suggested a lumpectomy to remove the abnormal cells. But he couldn't guarantee he'd be able to get all of them. It might take several operations.

O'NEILL: That was too much, and I thought, I can't do that. I've got kids at home that are little that need, you know, my attention, and I can't be going in and out of the hospital, and going through surgeries and all the stuff that comes afterwards, how sick you are.

KNOX: So this is when Sally O'Neill made what most would consider a radical decision. She wanted the maximum treatment she could get. She asked the surgeon to remove both of her breasts - the one with the abnormal cells and the one without them - just in case.

NEIGHMOND: You might be thinking now about the high-profile decision that actress Angelina Jolie made to remove both of her healthy breasts. That was a very different situation. Her condition was not DCIS. She had a gene mutation that gave her an extremely high risk of developing invasive breast cancer.

KNOX: Sally O'Neill's risk was much, much smaller. But she's the kind of person who likes to make a decision and be done with it. She says she just couldn't live with any risk of her abnormal cells becoming cancer.

O'NEILL: People ask me all the time: How did you decide so easily? And it was just something I felt was right. It was right for me. It didn't matter what anybody else thought. I got a lot of negative input from people saying that, you know, oh, my God. Those are your breasts. And I thought oh, my God. This is my life.

KNOX: O'Neill's decision to have a double mastectomy was such a radical one that the first surgeon she consulted refused to do it without a letter from a psychiatrist. So she found a different surgeon, Dr. Kevin Hughes at Massachusetts General Hospital. When it comes to treating DCIS, Hughes errs on the side of caution.

DR. KEVIN HUGHES: We don't know what percent are not deadly. And we have no idea which patients do or do not have a deadly form of cancer. So, as a surgeon, I need to treat every cancer as if it might be deadly, because I don't know which ones are and are not.

NEIGHMOND: Now, Dr. Hughes does not advocate removing a healthy breast that doesn't have any DCIS. But he says he'll do it if he thinks a woman is doing it for the right reasons.

HUGHES: If they want to take the opposite breast off to never experience breast cancer again, that is a reasonable - it's a good reason to do it. If they are taking their opposite breast off so they will live longer, that's not a good reason to take the opposite breast off.

NEIGHMOND: Because any cancer in that breast would be caught early, when it's highly curable, since women with DCIS get more frequent mammograms.

KNOX: Sally O'Neill's story is about medicine-to-the-max. And, in fact, many women are choosing to remove both breasts when they're diagnosed with DCIS, and many surgeons are obliging. The rate has doubled over the past 10 years. But some patients and some doctors are pushing back against what they consider too much treatment.

NEIGHMOND: And I talked to one of those patients. Peggy MacDonald lives in Portland, Oregon. She was recently diagnosed with DCIS and was stunned when the first thing she was told to do was see a breast surgeon.

PEGGY MACDONALD: And it didn't, at this point, make sense to me that I should rush into removing a part of my body that had some issue with it, but it wasn't showing, you know, this dramatic, invasive cancer.

NEIGHMOND: But, in fact, all the doctors MacDonald saw were treating it like it was invasive cancer. And the only two options she was given involved surgery: lumpectomy followed by radiation, or mastectomy.

MacDonald describes herself as a calm person who doesn't like making hasty decisions. And she felt like she was being railroaded.

MACDONALD: The second breast surgeon that we met with, for the first 10 minutes she spoke in such a canned manner, it was like she goes through this spiel on such a regular basis with exactly the same information that she's got it down to like, this weird canned speech.

KNOX: Now, none of the surgeons recommended removing her healthy breast. But all agreed she should have surgery to remove the abnormal cells.

MACDONALD: Basically, I felt beat down and by the end of May, I was sort of mentally prepared for a mastectomy.

NEIGHMOND: Then, one of her sisters sent her a news article about doctors overtreating DCIS. It quoted Dr. Laura Esserman, a breast surgeon at the University of California, San Francisco.

MacDonald went to San Francisco to see her. The office visit, she says, just felt right.

MACDONALD: It wasn't a canned thing. She says OK, I've looked at your MRI, I've looked at your mammograms, I've looked at your blood tests. Here's what I will tell you: this is not an emergency and you have options.

And time. Esserman stresses that there's no need to rush into surgery.

DR. LAURA ESSERMAN: I think we all need to take a step back and not be so hysterical. You know, when I see people who've been told they've got to make a decision in two weeks, that's just crazy. No one has shown a progression to invasive cancer in a two-week period of time - ever.

KNOX: Esserman even thinks the word carcinoma should be taken out of the disease name. She's insists it's not cancer.

ESSERMAN: It doesn't have the capacity to kill you, so that is not cancer, even though a lot of people call it and it has the word cancer in the name. I don't think that we should label it as cancer. I think it should be considered a ductal lesion. I think people would be much more willing to be calm about it.

KNOX: This point of view is very controversial among cancer specialists. Even so, after seeing Esserman, Peggy MacDonald decided not to have surgery, at least for now.

MACDONALD: I don't want to take it lightly. I don't want to say it's nothing, but I also don't want to treat it like it's invasive cancer when it's not.

NEIGHMOND: So, instead of surgery, Dr. Esserman has put MacDonald on hormone suppression therapy. She's taking a drug that blocks estrogen. Because her DCIS cells are fueled by estrogen, the hope is that without the hormone the cells will shrink and perhaps even go away.

MACDONALD: And I tell everybody now, I think my chances are 50/50; I may still end up needing to get surgery to take care of this. But I'll do that with a more of a clear conscience that I did more than the average person to come up with a decision that was a good decision for me.

KNOX: MacDonald's hoping her case will turn out like another of Dr. Esserman's patients, Barbara Mann. Mann took an estrogen-blocking medication as well, for six months. And, today an MRI scan and biopsy show no trace of DCIS in her breast.

BARBARA MANN: It's amazing; it's not even a case of less is more. This is a case of less is best. So, I am just hugely relieved, absolutely thrilled, and what I would really like is for every other woman in my position to know that this is an option for her.

NEIGHMOND: But it's an option that will require lifelong vigilance. Anyone who chooses not to have surgery will have to be watched carefully, have routine mammograms and maybe even MRI scans and biopsies.

KNOX: And be willing to live with the risk, however small, that DCIS might return and might turn into invasive cancer.

I'm Richard Knox.

NEIGHMOND: And I'm Patti Neighmond, NPR News.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

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