Are We Overtreating Breast Cancer?

A Growing Trend

Patty Nersesian, an at-home mother of three in Manlius, New York, was 31 when she had a bilateral mastectomy last year, followed by reconstruction with saline implants.

Lee Mirrer, a 49-year-old office manager for a Santa Barbara, California, dental office, had three surgeries on her left breast in the past year before she and her doctor were both satisfied that she could safely forgo follow-up radiation therapy.

Marianne Wallis, a marketing manager in the Boston area, had just turned 40 in 2000 when she had the first of two surgeries on her left breast, followed by six weeks of daily radiation treatments. Her name has been changed for this story because a human-resources professional advised her to keep her medical history quiet for fear it might someday lead to subtle job discrimination.

What do these three women have in common? Not one of them had invasive breast cancer.

Instead, they all had something called ductal carcinoma in situ (DCIS), also known as intraductal cancer, preinvasive breast cancer or Stage 0 breast cancer. One of the most puzzling and controversial problems in breast-cancer treatment today, DCIS is treated like cancer, but it's not cancer in the way most people understand that disease. Because it is confined to the milk ducts, DCIS cannot metastasize, or spread outside the breast to other organs. In other words, as long as it remains DCIS, it can't kill you. For that reason, some specialists prefer to call it "precancer."

Once thought to be rare, the disease is being diagnosed in growing numbers of women each year-between 1973 and 1998, incidence rates of DCIS increased six times faster than incidence rates of invasive breast cancer. This year, the American Cancer Society (ACS) estimates that nearly 48,000 new cases will be identified. However, this doesn't mean that more women have the disease, only that we've gotten better at finding it.

Because it rarely forms a lump, DCIS is discovered almost exclusively by mammography, usually when the X ray shows a pattern of white dots called microcalcifications. According to the ACS, the increase in cases of DCIS is a direct result of more and more women getting mammograms.

Unfortunately, our ability to detect the condition has far outpaced our knowledge of how to handle it. "If you don't treat it at all, seventy percent of the time it would never do anything," says Susan Love, M.D., adjunct professor of surgery at UCLA, medical director of the nonprofit Susan Love MD Breast Cancer Foundation and author of Dr. Susan Love's Breast Book (Perseus Book Group, 2000). "But thirty percent of the time it will turn into [invasive] cancer."

"The problem is that right now we cannot predict which DCIS will remain DCIS and which will go on to become invasive," says Monica Morrow, M.D., professor of surgery at Northwestern University and director of the Lynn Sage Comprehensive Breast Center at Northwestern Memorial Hospital, in Chicago. As a result, thousands of women each year are undergoing mastectomies, lumpectomies or radiation therapy that may be completely unnecessary. On the other hand, some of those women are being spared a later diagnosis of invasive cancer that could have killed them.