Is surgery the right decision for women with DCIS?

Ligia Toro de Stefani, Ph.D., had just retired from a busy academic medical research career when a mammogram revealed a suspicious mass in her right breast. Her doctors in Brownsville, Texas, referred her to MD Anderson, where she was diagnosed with ductal carcinoma in situ, or DCIS, often called “stage 0” breast cancer – the very earliest stage.

Toro and her husband, Enrico Stefani, M.D., Ph.D., researched everything they could about the condition before meeting with MD Anderson surgeon Alastair Thompson, M.D., to discuss treatment options.

Investigating came naturally to the scientific couple. Toro is an emeritus professor of anesthesiology and molecular and medical pharmacology at the University of California, Los Angeles. Her husband is a former director of UCLA’s anesthesiology division of molecular medicine.

“We started reading a lot of papers, not just Googling the disease, but doing a serious literature search,” Toro de Stefani says.

DCIS is a cluster of cancer cells inside a milk duct. The cells are held in place by the duct’s wall, but they have the ability to break through the wall. That’s when they become invasive.

“That won’t happen to everyone,” Toro de Stefani says, “but there’s no predicting when cells will break through the duct and spread, and when they won’t.”

Studies show that about 75% of DCIS cases may never become invasive breast cancer.

Still, current guidelines for DCIS often recommend surgery, usually lumpectomy followed by radiation, to remove suspicious lesions.

“I didn’t relish the thought of having surgery at my age,” Toro de Stefani says, “especially since my doctor determined that I was at low risk for developing invasive cancer.” 

She decided to forego surgery and instead opted for active surveillance.

Now, Toro de Stefani returns to MD Anderson every six months for a routine mammogram to see if the abnormal cells have spread, and takes a daily hormone therapy pill to keep any growth in check. And she eats a low-carb diet and exercises to stay at a healthy weight and lower her cancer risk. A year has passed since her initial diagnosis, without any change.

“I just live a normal life without having to have surgery,” she says. “The only inconvenience is having a mammogram every six months, then waiting for the results to see if they’re the same or not.”    

Difficult decisions for patients

Toro de Stefani is one of 60,000 U.S. women diagnosed with DCIS each year. Each must decide on a treatment option.

Current guidelines that recommend lumpectomy and radiation are causing concerns that the condition may be overtreated, since most cases never become invasive.

“This gives medical professionals enormous uncertainty about how to advise women on an individual basis,” says Thompson, professor of Surgery at MD Anderson. “And therefore, historically the treatments have ranged from active surveillance on one end of the pectrum all the way to mastectomies on the other.”

Thompson says DCIS diagnoses have increased as breast imaging has become more accurate and frequent. The National Institutes of Health estimates that by 2020, more than 1 million women in the U.S. will be living with a DCIS diagnosis, compared to 500,000 in 2005.

Before mammograms became common, many women had the condition for years without being aware of it, because it grows so slowly and causes no symptoms.

“Perhaps, surprisingly, given that breast screening has been around for three or four decades, we’re only now really coming to grips with the fact that we often diagnose some conditions like DCIS as breast cancer even though they’re not conventional, invasive breast cancers,” Thompson says.

He’s participating in three DCIS research studies that he hopes will make treatment decisions easier.