Would you opt out of treating early breast cancer?
Women with early stage breast cancer have the same outcome if they are treated or if they elect to have no treatment, according to a 2015 study in JAMA Oncology.
The study followed 100,000 women for 20 years and revealed that the death rate from Stage 0 breast cancer (which affects as many as 60,000 women each year) was the same – 3.3 percent – whether the women underwent treatment or not.
The report caused a flurry of controversy when it was released, and doctors differed over whether they agreed with it. It also caused confusion for patients and a flurry of provocative headlines. A Time magazine cover last October showed a woman with her hand over her breast with the headline, “What if I decide to just do nothing?”
Is that really a safe choice?
Michael Fishbein, MD, the community outreach director of the Falmouth Hospital Cancer Committee doesn’t think so. He read the story in Time very carefully and found it misleading.
“If you didn’t read it all the way until the end, it gave the impression that the patient was electing to just wait and see what happens,” he said.
The patient in the story was diagnosed with ductal carcinoma in situ (DCIS) eight years ago. Even though she opted not to have surgery, she did in fact follow through with medical therapy – meaning her doctor did do something.
Rather than have surgery, the patient was treated with the estrogen blocking drug Tamoxifen. She was also monitored with alternate mammograms and MRIs every six months so that any progression of the cancer could be detected quickly and treated.
“I don’t think any doctor would say, do nothing,” Dr. Fishbein said. “In the spectrum of DCIS, I don’t think that eight years is a reasonable follow-up period to say that this woman will not develop invasive cancer. Plus, even though an estrogen blocker is an effective form of chemotherapy, I don’t think that alone is enough.”
Not all breast cancers are created equal, he added. The JAMA Oncology study was specifically designed to look at ductal carcinoma in situ. The words “in situ” mean that the abnormal cells are contained within the milk ducts and haven’t spread. As long as they stay confined, the patient is safe. But if it does spread beyond the walls of the duct it can quickly become invasive.
“We have patients who have a very minimal form of it and it may take decades to develop into breast cancer, if it does at all,” Dr. Fishbein said. “But we also have patients who have a very aggressive form of it that we know will develop breast cancer at some point. We just don’t know when.”
For that reason, most doctors are very reluctant to advise patients to do nothing when dealing with breast cancer. No one wants a patient to die when treatment is available and effective. Patients with DCIS who undergo a lumpectomy and radiation have a cure rate of close to 100 percent, according to Dr. Fishbein. DCIS is the earliest and most treatable kind of breast cancer, he added.
Even though he acknowledged that overtreatment is still an issue, techniques for breast imaging keep getting better. The result is that the treatment of breast cancer has vastly improved and the rate of women dying from the disease has gone down dramatically.
“If you go to the American Cancer Society website and look at breast cancer mortality in the United States, it has fallen about two percent per year for about the last 15 years,” he said. “That comes to about a 30 percent reduction over that time period.”