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Doctors Debate How to Treat Early, Noninvasive Breast Cancer

Studies Disclose Wide Variation in Techniques Across United States

Monday, April 05, 2004

Increasing use of screening mammography is uncovering more cases of ductal carcinoma in situ, or DCIS, an early form of breast cancer. But tremendous variations in care, variations that have been increasing, suggest a substantial lack of agreement over the best way to treat this disease, says a University of Rochester study.

Differences in the way physicians across geographic regions view DCIS peaked in the late 1990s, according to a UR analysis of 2,700 cases among elderly women between 1991 and 1996. But doctors tend to practice as their colleagues do, patients often make choices based on local behavior, and there are few randomized controlled clinical trials to compare strategies or guide treatment for DCIS, the study also concludes, as reported in the March 2004 journal Medical Care.

The study is authored by Heather Taffet Gold, Ph.D., a former UR doctoral student, now an assistant professor at Weill Medical College, Cornell University; and Andrew W. Dick, Ph.D, assistant professor, Community and Preventive Medicine at the UR. It was funded by the Centers for Medicare and Medicaid Services of the Department of Health and Human Services.

DCIS is gaining attention, with approximately 50,000 new cases expected this year. A review article in the April 1 New England Journal of Medicine discusses the cancer in detail and echoes the fact that treatment choices are complicated by many uncertainties. A third study reported in March in the Journal of the National Cancer Institute suggested the need for uniform guidelines.

 “When a woman hears she has cancer, it is absolutely overwhelming, even if it’s caught early and she has this noninvasive form,” says Dick, whose sister was diagnosed with DCIS as he was studying the treatment trends. “It’s crucial that physicians and others in the medical community provide accurate information to aid women in making decisions about their treatments.”

DCIS is considered a precursor to invasive breast cancer. But left untreated, or improperly treated, it can develop into invasive disease, with the same risks of metastasis and death. The goal of treatment, therefore, is to eliminate the cancer and prevent a recurrence, says Jennifer Griggs, M.D., M.P.H., medical director of the Comprehensive Breast Cancer Program at the James P. Wilmot Cancer Center at the UR, who is also working with Dick to study the natural history of the disease and risk factors. The National Cancer Institute is funding their research with a $1 million grant.

Twenty to 30 percent of new cases of breast cancer at the Wilmot Center each year are DCIS, Griggs says. Most women with DCIS undergo either breast-sparing surgery alone, breast-sparing surgery with radiation, or mastectomy, depending on the tumor grade and extent of disease. However, Dick’s study found that income and education level, urban/rural status, race, age, marital status and other variables play into how DCIS is treated.

For example, the trend toward breast-sparing surgery alone increased during the study period from 38 percent to 50 percent, and breast-sparing surgery with radiation was also used more often. But the use of mastectomy decreased from 49 percent to 29 percent.

The wide variations in treatment – especially the trend toward breast sparing surgery alone – contradicts the most recent scientific literature showing that an aggressive approach may be best way to prevent a recurrence for some women, the study says.

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