The DCIS Dilemma

Will suspicious cells remain idle or become aggressive breast cancers?
Sandie Walters’ breast cancer was diagnosed in 2007 during a routine screening mammogram, and soon after, the 58-year-old Grand Rapids, Mich., woman was sitting in a surgeon’s office. His recommendation: a mastectomy, preferably immediately.

She says her doctor even seemed reluctant to postpone the surgery until after she and her husband had returned from their imminent two-week summer vacation. “He said, ‘It’s probably OK, but I can’t officially say that it would be OK.’ Well, if you think that’s not scary—that’s scary.”

It’s a story that sounds unsettlingly familiar to patients who undergo a routine test only to find themselves thrust into the frightening position of making a life-changing decision about cancer treatment. However, Walters’ story comes with a notable twist—one that’s affecting an increasing number of women with breast cancer. Her diagnosis was ductal carcinoma in situ (DCIS), also referred to as stage 0 cancer, a nonmalignant but potentially risky condition that’s creating stress and controversy for patients and physicians alike.

That news launched Walters on a seven-year quest. She first steeped herself in studies and second opinions before choosing more limited treatment followed by ongoing screening. It’s not an approach that she regrets, despite receiving unsettling test results in June. “When I think back on it, I don’t think I would have done anything differently,” says Walters, shortly after an imaging scan identified a stage 2 tumor in her healthy breast.

Time to Decide

The abnormal cells of DCIS are described as stage 0 because they’re confined to the milk ducts of the breast, where they could remain, perhaps forever, without causing additional problems. But DCIS also is considered a risk factor for invasive breast cancer, which occurs when those cells spread beyond the ducts to elsewhere in the breast and potentially, albeit rarely, much farther. “The problem is that it’s difficult to pick out the bad actors in terms of cancer,” says Ann Partridge, a medical oncologist at Boston’s Dana-Farber Cancer Institute.

The result is that some women decide to use the surgical equivalent of a sledgehammer on a not-quite-cancerous lesion. Getting a double mastectomy for a small area of DCIS is typically considered an excessive measure by clinicians, Partridge says. The comedian Wanda Sykes took this surgical route after her DCIS diagnosis in 2011, telling viewers of the “Ellen” show that she preferred to slash her worry and recurrence risk to near zero. Meanwhile, women like Walters pursue second opinions as they weigh not only the type of surgery, but whether to later undergo radiation treatments or take tamoxifen, a hormonal agent that blocks the cancer-promoting effects of estrogen. At the opposite end of the spectrum, still a small group, are those women who opt for “active surveillance,” which includes aggressive screening, sometimes combined with hormonal medications, instead of surgery.

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