Breast Cancer Treatment: Are you Overtreating Breast Cancer?
When it comes to breast cancer treatment less could be more, but when to pull back and when to turn it up to 11? As a doctor, you may be torn between your instinct and your patient’s expectations. The fact that October is Breast Cancer Awareness Month – during which your practice may receive an influx of women requesting screening tests – and many women opting to pull a Saint Agatha of Sicily and have both breasts removed at the first sign of cancer – following the example of certain celebrities – may put you at a crossroads when treating breast cancer.
Being at a loss for what to say to a patient is not a reason to hide your face in shame behind your surgical mask. You may be a doctor, but that doesn’t mean you’re omniscient. After all, it was only in 2009 that the U.S. Preventive Services Task Force recommended women to start mammograms at 50 instead of 40, because there is enough data to prove that earlier screening is better or worse. Since then research has shown that the absolute survival benefit from preventive double mastectomies is less than 1% after 20 years for some women with Stages 1 and 2 breast cancer. Furthermore, a paper in August showed that regardless of breast cancer treatment for ductal carcinoma in situ (DCIS) the mortality risk is similar to the average for the general population. Finally, we know now that some women with early-stage breast cancer may forgo chemotherapy since they won’t benefit from it.
All things considered, many women with breast cancer in the United States are being overtreated. Genomic testing and deeper insights into the biology of different forms of breast cancer have taught doctors that breast cancer treatment can be tailor-made to specific patients. Physicians have also learned that each patient has different biological and personal standards regarding the risk they should/are willing to take. Some require and/or demand swift and decisive breast cancer treatment, while others are more receptive to taking it easy and try more passive alternatives. The question is where do you stand as a doctor? Are you old-school, or do you agree with surgical oncologist at the Dana-Farber/Brigham and Women’s Cancer Center Dr. Mehra Golshan? “As a surgeon, to say we shouldn’t be operating as much as we are is a very big deal,” Dr. Golshan says. “And that’s what I’m saying.”
On the one hand, the evidence indicates that aggressive treatments can entail unexpected and even deadly complications (follow-up surgeries, potential infections, radiation-related cancer risk, side effects of chemotherapy, etc.). On the other, there may be better methods of early breast cancer treatment. Additionally, as a doctor you face not only new data but also a slew of public opinion spearheaded by policymakers and advocacy groups who feel very strongly for or against. “I hear people say that medicine is so important that we can’t be too quick to change, and I would say the opposite: Because it’s so important, we need to innovate,” says surgeon and the director of the Carol Franc Buck Breast Care Center at UCSF Dr. Laura Esserman. “If we were doing so well and no one was dying, I would agree we don’t need to change. But patients don’t like the treatment options, and physicians don’t like the outcomes.”
Together with chief of breast surgery at Duke University and Duke Cancer Institute in North Carolina Dr. Shelley Hwang, Esserman is leading research that will hopefully tie some loose ends that baffle some physicians such as director of breast oncology at Dana-Farber Dr. Eric Winer, who says that “our two greatest challenges are figuring out better treatments for the 40,000 women who die of breast cancer every year, and at same time, figure out who, on the other end of the spectrum, is getting exposed to needless toxicity.” Being a doctor yourself this dilemma may seem familiar. Understandably, you don’t want to be responsible for the patient who is not being treated aggressively and dies on your watch. Once again, there are two different schools of thought; some are working to find more evidence that breast cancer treatment can be achieved responsibly another way, while others claim the risk is too great to pivot without proof.
The 2009 guideline to start screening at 50 caused a national controversy that continues to this day, even though the decrease in deaths didn’t reflect what experts were expecting after mammograms became widespread. Moreover, no one is saying that mammograms should go. On the contrary, “mammograms are here to stay,” says Hwang. Screening technology allows doctors to find more of anything that is there, but “it’s not the ‘finding more’ that we need to work on,” Hwang adds. “It’s what are we going to do with the more that we find?” Doctors should keep in mind as well that screening is not an exact science. “Many doctors still say that any breast cancer is a failure of a patient to get a mammogram or failure of a doctor to detect it,” says Dr. Otis Brawley, chief medical officer of the American Cancer Society. “If you look at the science, that is so clearly not the case.”
And when cancer is indeed found – regardless of the stage – there is the dreaded doctor-patient conversation – probably as dreaded by you as by the patient. A woman is her late 50’s with low-grade DCIS that will almost certainly never become invasive hears the same word as a woman in her mid-30’s with metastatic malignancies that will kill her. Cancer carries such a stigma that the name of the condition alone is often construed as an immutable death sentence. Dr. Steven J. Katz, a professor at the University of Michigan has led research indicating there’s a natural tendency in patients faced with cancer to leave breast cancer treatment decisions up to their doctors. That’s why what you tell your patients is of the utmost importance.
Many women are strongly inclined to do whatever it takes as soon as possible to be healthy again, even if that contradicts the science. According to Katz, most women make a decision that can be life-changing in a matter of weeks after diagnosis. “The time has come to ask, What happens if I do nothing right away,” Esserman says. “Let’s not make it a panic. There is no evidence to support getting surgery in two weeks.” As a doctor, it just might be your responsibility to bring up that question, although many in the field still think there’s not enough evidence to support active surveillance for anyone, because the method hasn’t been tested in a randomized prospective trial.
In order to address that concern, Hwang was awarded $1.8 million in September to perform a retrospective study comparing active surveillance with standard care, and she’s waiting to get the green light to do a prospective study on the same subject. Meanwhile, Esserman is creating a DCIS registry at the five University of California medical centers to offer women options including active surveillance and monitor them over time, as well as the WISDOM study, an initiative that will randomize women with DCIS to either annual screening or a more personalized screening approach. “We’ll learn over time what works,” Esserman says. “How wonderful if we can learn how to do less for women.” Hopefully the resulting data will help doctors like you determine who will develop invasive breast cancer from DCIS.