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Treatment of Earliest Stage Breast Cancer Varies Widely
Don't Be Afraid to Seek Second Opinion
Article date: 2004/04/16

Treatment of ductal carcinoma in situ (DCIS) varies widely across the United States, according to a study that examined treatment trends between 1992 and 1999. Researchers led by Nancy Baxter, MD, PhD, of the University of Minnesota, found that substantial numbers of women may be getting overly aggressive treatment or potentially inadequate treatment for this earliest stage of breast cancer.

In a report published in the Journal of the National Cancer Institute (Vol. 96, No. 6: 443-448), Baxter and her colleagues analyzed treatment data from 25,206 DCIS patients from across the country. The discrepancies they found point to a need for greater consensus on how best to manage the disease, said Baxter.

"Treatment guidelines would be very useful, if only because they would allow us to decide what we agree on and find areas of disagreement that require urgent study," she said. One area in particular need of clarification: which women can safely skip radiation after lumpectomy.

"The problem is there's such variation in terms of the disease," Baxter said.

Although DCIS is not invasive, it can form very large tumors or tumors that are spread throughout the breast. Women with large or widespread tumors may require mastectomy (surgical removal of the breast), while those with small tumors may be candidates for breast-conserving surgery, such as lumpectomy. DCIS has the potential to progress to invasive breast cancer, but there is currently no good way to predict which women face this risk, and which do not. And there are no data showing that one type of treatment is better than another.

Mastectomy Rate Dropping, Radiation Rates Low

Still, treatment has evolved in recent years. Baxter and colleagues found that rates of mastectomy for DCIS decreased from 43% in 1992 to 28% in 1999.

Yet 30% of women getting mastectomies in 1999 were also getting axillary dissection, a procedure to remove the lymph nodes under the arm. This operation can have serious side effects and many experts say it is rarely necessary for DCIS treatment. The fact that so many women received it anyway could indicate that some doctors are treating women with DCIS as they would women with invasive cancer, even though the two conditions are different and have very different prognoses, Baxter said.

Also worrisome was the number of women who did not receive radiation after lumpectomy, Baxter said. Radiation has been shown to reduce the risk of recurrence in women with DCIS, yet over the course of the study, about half the women treated with lumpectomy did not receive subsequent radiation (55% in 1992; 46% in 1999).

About 33% of women with adverse disease characteristics did not receive radiation after lumpectomy in 1999, even though they should have, Baxter said. Rates of radiation after lumpectomy ranged from about 39% in San Francisco, to 74% in Hawaii.

Patient, Physician Preferences at Work

Such variations in treatment don't necessarily mean that bad practice is rampant, said Monica Morrow, MD, who wrote an editorial accompanying the study.

"When you see wide variation in practice it means there is not a single right answer and patient and physician preferences come into play," said Morrow, professor of surgical oncology at Northwestern University's Feinberg School of Medicine, in Chicago.

It may be that local physicians who have strong opinions about some of these treatment issues are influencing practice in their area, she said. And women may be guiding some of the decisions themselves.

For instance, some women may choose a mastectomy because they want to lower their risk of recurrence as much as possible. In other cases, mastectomy may be the only treatment option because of the nature of the DCIS tumor. For other women, the benefit from radiation may not be worth its side effects. Studies that examine women's perceptions about their treatment experience could help doctors understand some of the existing treatment discrepancies, Morrow said.

DCIS Prognosis 'Excellent'

"What we need to be concerned about is, are women being offered the appropriate treatment option," she added. "We need to help women understand that their treatment is geared to the prevention of a life-threatening disease, invasive breast cancer. Women with DCIS think their risk of dying is the same as that of a woman with invasive breast cancer, but it's not."

Baxter agreed that educating patients about DCIS is difficult. Ten-year survival of DCIS is estimated at close to 98%, but many patients miss that message.

"When you tell someone they have DCIS, even though you try to explain it, you see the fear in their eyes," Baxter said. "We need to find better ways of communicating about the disease and the excellent prognosis."

Getting a second opinion on treatment may also be helpful for some patients, Baxter said.

"We have a high rate of variation in care," she said. "As professionals, we need to admit that and empower patients to get a second opinion about treatment. I think people perceive that as threatening their doctor, but if someone wants a second opinion, it's better for them to get it than to have lingering doubts about their treatment."


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