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October 2015

Rethinking the Standard for Ductal Carcinoma In Situ Treatment

Author Affiliations
  • 1Department of Surgery, University of California, San Francisco, California
JAMA Oncol. 2015;1(7):881-883. doi:10.1001/jamaoncol.2015.2607

The original goal of mammographic screening was to identify invasive cancers at the earliest stage, because of the superior prognosis of stage I cancers. Prior to the advent of screening, ductal carcinoma in situ (DCIS) made up approximately 3% of breast cancers detected. As we pushed to find smaller and smaller cancers, and targeted calcifications instead of just masses, we began to identify DCIS more frequently. Now DCIS accounts for approximately 20% to 25% of screen-detected breast cancers. The cells that make up DCIS look like invasive cancer both pathologically and molecularly, and therefore the presumption was made that these lesions were the precursors of cancer and that early removal and treatment would reduce cancer incidence and mortality. However, long-term epidemiology studies have demonstrated that the removal of 50 000 to 60 000 DCIS lesions annually has not been accompanied by a reduction in the incidence of invasive breast cancers.1 This is in contrast to the experience with removal of colonic polyps and intraepithelial neoplasia lesions of the cervix, in which the removal of precursor lesions has led to a decrease in the incidence of colon and cervical cancer, respectively.2 We now know that breast cancer encompasses a range of behaviors, from aggressive to indolent; the latter are more likely to surface with screening.3 The analysis of Narod et al4 fuels a growing concern that we should rethink our strategy for the detection and treatment of DCIS.

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2 Comments for this article
Another blow to routine mammogram screening
James Kolter, M.D. | Senior Attending, Paoli Hospital
The decision a woman should make about accepting mammogram screening requires a thoughtful risk/benefit analysis. Unfortunately, women usually are handed a request slip and without thinking, subject themselves to unnecessary radiation for a test that may create more harm than good. The discovery of DCIS only heightens a woman's anxiety and often leads to over treatment programs. Our study, available at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128895 , demonstrates that our profession uses an inflated risk assessment from SEER data. Would a woman choose this test if she knew the risk is lower than touted and the benefits less than advocated? We should educate our patients and find out!
Many progestins, not progesterone, increase the risk of breast cancer
Henry Lindner, MD | Private Practice
The authors' otherwise excellent commentary is marred by their advice to avoid progesterone-containing HRT regimens in menopause. Perhaps they meant to say \"progestins'\". Progesterone, unlike many progestins, has not been shown to increase the risk of breast cancer diagnosis. Progesterone has several known anti-estrogen actions in the breast, and high-dose progesterone should be studied as a possible preventative measure. It would not have the negative health and quality-of-life effects of current anti-estrogen treatments. A good review of the evidence regarding progesterone and breast cancer can be found here:

Campagnoli C, Clavel-Chapelon F, Kaaks R, Peris C, Berrino F. Progestins and progesterone
in hormone replacement therapy and the risk of breast cancer. J Steroid Biochem Mol Biol. 2005 Jul;96(2):95-108.