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NEWS & VIEWS |
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She and her colleagues analyzed treatment data from 25,206 DCIS patients from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database. The discrepancies they found point to a need for greater consensus on how best to manage the disease, said Baxter, who is Assistant Professor of Colon and Rectal Surgery and Surgical Oncology at the University of Minnesota.
"The problem is there’s such variation in terms of the disease," Baxter said
Although DCIS is by definition not invasive, it can nonetheless manifest as a very large lesion or as multicentric tumors in different quadrants of the breast. Women with large or multicentric tumors may require mastectomy, while most with small lesions are candidates for breast-conserving surgery. 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.
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. Thirty percent of women treated by mastectomy in 1999 were also getting axillary dissection, a procedure rarely indicated for DCIS treatment, Baxter said.
More worrisome, though, 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 comedo histology did not receive radiation after lumpectomy in 1999, even though, Baxter said, "most people can agree that women with adverse risk factors should have radiation."
Baxter and colleagues reported substantial geographic variation in rates of radiation after lumpectomy, ranging from about 39% in San Francisco to 74% in Hawaii, and suggested that "... selection of patients for breast-conserving therapy without radiation therapy cannot be explained solely on the basis of unmeasured tumor characteristics."
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. "Local physician leaders do have an impact on issues where there’s not a clear-cut answer."
Because of the nature of DCIS, mastectomy may be the only treatment option for some women. In other cases, risk-averse women may choose mastectomy over lumpectomy.
For some women, the magnitude of 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.
"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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