The emerging breast-cancer treatment: no surgery required
Women with a type of low-risk cancer might not have to rush aggressive treatment, some doctors say.
When a woman learns she has breast cancer, her reaction is often: take it out. Now doctors say that might not always be necessary.
Some women with the earliest stages of breast cancer could be carefully monitored, undergoing surgery and radiation only if the disease advances, new data suggests.
The strategy is akin to one already used in early prostate cancer, as doctors are increasingly looking at whether they can pull back on some cancer therapies, to spare patients side effects and costs.
“This is really the first study to confirm our suspicions that there’s a subset of low-risk patients that could do just as well without surgery,” said Dr Nancy Chan, a breast-cancer specialist at NYU Langone’s Perlmutter Cancer Centre, who wasn’t involved in the study. “It’s really encouraging.”
Some doctors said there wasn’t enough long-term data to prove that the practice is safe. How aggressively to treat this form of early-stage cancer — and whether to call it cancer at all — is controversial.
Some 300,000 women in the US are diagnosed with invasive breast cancer each year. But an additional 50,000 are diagnosed with “stage zero” breast cancer, also called ductal carcinoma in situ, or DCIS, which occurs when there are cancer cells in a woman’s milk duct but not in her breast tissue. The disease itself poses little risk but can turn into the more dangerous, invasive cancer.
Caught almost exclusively on routine mammograms, cases of DCIS became more common with the advent and expansion of breast-cancer screening. Because they don’t know who will go on to develop invasive breast cancer, oncologists in the US generally advise women with DCIS to get a combination of surgery, radiation and hormone therapy.
Some doctors suspect that DCIS might be overtreated.
“It was a data-free zone because we already treated it like a cancer,” said Dr E. Shelley Hwang, a breast-cancer surgeon at Duke Cancer Institute, who led the trial. “We didn’t know what we could dial back on.”
Hwang and her colleagues recruited some 950 women ages 40 and older with a type of low-risk DCIS that is sensitive to hormones. The women were split into two groups: One was recommended standard care — surgery with or without radiation — while the other was recommended mammograms every six months. The monitoring group could opt for surgery at any time and had to get surgery if the disease progressed.
Most women in both groups took hormone therapy to help keep cancer growth in check. Some 17 per cent of women in the monitoring group ended up getting surgery, and some assigned to the treatment group declined to get an operation.
Two years later, the rates of women who developed invasive breast cancer were similar between the groups, less than 10 per cent, the researchers found. The women also reported comparable rates of anxiety, a concern when doctors are considering dialling-back treatment.
Women who got standard care reported more arm problems and breast pain, but that resolved over time. The results were published in the academic journals JAMA and JAMA Oncology and presented at the San Antonio Breast Cancer Symposium last Thursday.
The findings might not apply to certain groups including younger women, who would likely have to live with the risk of invasive disease for a longer period. And some doctors said that it was too early to draw conclusions.
“With only two years of follow-up, we would expect the likelihood of problems to be low,” said Dr Monica Morrow, a breast-cancer surgeon at Memorial Sloan Kettering Cancer Center in New York, who wasn’t involved in the trial. “It’s just not long enough to say how safe this is or isn’t.”
The researchers will continue to follow the women over time. But the trial so far shows that women don’t need to rush into surgery because they hear the word “cancer,” they said.
“It’s not an emergency,” said Dr Ann Partridge, a senior researcher on the trial and a breast-cancer specialist at Dana-Farber Cancer Institute in Boston. “Women can really take a pause, take a deep breath, and make good decisions.”
When Tina Clark was told that she had DCIS in 2019 after a routine mammogram, her mind went to her husband and nephew. Her nephew had already lost his mother to breast cancer, and her husband’s health was failing and required regular tests and trips to the hospital.
Clark didn’t think her husband would be able to care for her if she got more intense treatment.
“It would have been a tremendous hardship,” said Clark, 63, who lives in Maine. “Even if it was going to put off more-aggressive treatment for a year, it was worth it to me, so I could be there for him and my nephew.”
Clark enrolled in the trial, travelling to Boston for mammograms every six months, using it as an occasion to get a good meal or see a show in the city. Her husband died later that year.
In 2023, a more-concerning cancer appeared in her other breast, and she got surgery and hormone therapy to treat it. Her original DCIS hasn’t progressed.
The Wall Street Journal
