Genomic Testing May Help Women Navigate DCIS Treatment Choices
This column was written by Julia White, MD, Director of Breast Radiation Oncology and William Farrar, MD, Interim Physician-in-Chief and Surgical Oncologist of The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute
In an era of improved early detection of breast cancer, we must constantly ask ourselves:
- Are we detecting more cancers that don’t need treatment?
- How are we going to help women make the right decisions for their futures?
These are particularly relevant questions when it comes to a very early-stage form of breast cancer commonly known as DCIS (or ductal cell carcinoma in situ). Rates of DCIS have risen dramatically over the past 20 years, representing 25 percent of all new breast cancer diagnoses in the United States. About 63,000 American women will be diagnosed with DCIS this year alone.
‘Low-Risk,’ but Still Frightening
In contrast to invasive breast cancer, DCIS is restricted to the insides of the milk ducts and does not spread to the nearby breast tissue or lymph nodes.
Increasingly, there is a form of DCIS diagnosed from screening mammography that is characterized by being small in size and responsive to the female hormone estrogen and by having an indolent, or slow-growing, course. It is therefore considered low risk.
But the response of a woman facing a new cancer diagnosis — even one considered low risk — is often fear for her future, and that fear is visceral and life-impacting. Such a woman is often at the peak of her career, juggling family and friends, and with many years of life yet to live. In the face of fear, scientific studies and statistical risk information become cold data to her. Instead, her response is to do anything she can do to ensure she survives and remains cancer-free.
Overdiagnosis and Overtreatment
Recent estimates suggest that as many as 1 in 4 patients are overdiagnosed as a result of screening mammography — meaning the abnormalities found during mammography would never have caused symptoms — and are therefore overtreated.
This doesn’t mean we shouldn’t be screening women for breast cancer: Mammography has dramatically changed overall survival for women diagnosed with breast cancer, and 40 percent of all the years of life saved by mammography are among women in their 40s.
Nonetheless, in this era of improved early detection of breast cancer, breast cancer physicians and scientists must be steadfast in their efforts to achieve a balance between detecting potentially life-threatening issues and providing the right level of treatment for each woman’s cancer.
The ‘Right’ DCIS Treatment Is Based on Individual Risk
There are many effective treatment options for DCIS: lumpectomy, lumpectomy with radiation therapy, or mastectomy, with or without oral hormone medication.
The million-dollar question is how much treatment women with DCIS should have, based on real future risk versus fear.
Every treatment approach and every surgical procedure also has an inherent risk and associated costs. As a breast cancer treatment community, we are seeking ways to help our patients make that decision, driven by individualized risk assessments and prediction models.
Scientific studies continue to show us there is truly no routine cancer. Each person’s cancer is a little different, based on genomic factors (a person’s genetic makeup), personal and family risk factors, environmental exposures, lifestyle choices, and so much more. This is where genomic testing can help guide patients toward the “right” amount of treatment for their disease.
Genomic Research Guiding Treatment Choice
Our team at the OSUCCC — James was recently part of a multicenter research team that conducted a comprehensive study looking at the feasibility of using a 12-gene test to predict future risk of cancer recurrence for patients with DCIS and the impact of the test results on whether physicians recommended patients choose to receive radiation therapy.
The study, published in Annals of Surgical Oncology in October 2016, showed us that the testing of DCIS provides meaningful information on a woman’s individual risk of recurrence that impacts treatment decisions.
This type of genomic testing transformed the way invasive breast cancer was treated in the past, and we hope it will do the same for DCIS.
The next step is to determine whether active surveillance is effective. That’s to say, women with very low-risk DCIS could be followed with a revised screening and medical checkup schedule to watch for signs of disease progression, possibly avoiding invasive surgical or medical treatments altogether.
The OSUCCC — James is part of new nationwide study to evaluate the risks and benefits of this approach in women with low-risk DCIS, while also tracking information about the impact of this treatment path on quality of life, coping mechanisms, depression, anxiety, and other psychosocial factors.
Take Action, Know Your Risk
We encourage everyone to take action and to inspire action.
Whether you work in oncology, have been personally affected by a cancer diagnosis, know someone affected by cancer, or are blessed to have no experience with the disease at all, take the time to understand your personal cancer risk, then reduce your risk for this and other diseases by making healthy lifestyle choices like regular exercise and a healthful diet, avoiding tobacco and excessive alcohol intake, and maintaining a healthy weight.
If you end up facing a cancer diagnosis, know there is hope — and resources — to help you navigate and succeed in your personal cancer journey.