This was the heading of the cover of the prestigious Time magazine for its October 12, 2015 issue and it was addressing “Breast cancer’s new frontier.” I would say that I was intrigued and concerned of such a title that made me shuffle the pages to get to this article which I read rapidly. My surprise turned into disappointment.
I found that this title was misleading since this was referring only to Ductal Carcinoma In Situ (DCIS). An early cancer of the breast confined to the ducts or, as I explain to my patients, “a crab without legs” unable to invade or go to other places. This type of tumor represent only 20 to 25% of the women with cancer of the breast.
The genesis of DCIS has two theories behind it. An old one that believes that this is a different tumor and it will be always DCIS. Therefore the risk is the same regardless how early or advanced it is; or the current one that most of us believe is an intraductal tumor that will eventually evolve in an invasive one, given the opportunity. Therefore, it should be taken care sooner rather than later.
The treatment of DCIS is also surrounded by controversy and confusion that includes the patient’s panic in trying to get rid of the disease as soon as possible and prevent any chance of similar event. That calls for double mastectomy, a procedure that definitely is overused with the excuse of “patient’s choice”.
While the majority of patients are treated with more conservative and more realistic procedures as lumpectomy, wide excision and partial mastectomy commonly followed by radiotherapy and anti-estrogen hormonotherapy. All of them carrying certain degree of toxicity from burning of the tissues in the area of radiation to the systemic side effects of hormonotherapy specially inducing menopausal symptoms in young women.
Now, “active surveillance” that must be reserved for certain post menopausal patients when specific favorable factors are present as patients age and comorbidities, size and tumor characteristics, type of DCIS, location, extension, presence of Estrogen receptors and others.
The majority of early cancer of the breast patients are referred to surgeons who properly advise the patients in most of the cases. When a patient has a concern that requires a second opinion, I usually recommend to be given by a medical oncologist keeping in mind the type of surgical indication already given.