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'Watch-and-wait' puts women at risk of breast cancer

By Daily Pilot

October 3, 2016
Some in the medical field are trumpeting a "watch-and-wait" approach to early-stage breast cancer, leaving women with a misunderstanding of the best possible treatment options available.

Ductal carcinoma in situ is the presence of cancer cells inside the milk ducts of the breast, and is commonly referred to early-stage, or Stage 0, breast cancer.

Cancer at this stage is not invasive, but has the potential to become so when given enough time. Some are calling for a "watch-and-wait" approach, which means forgoing traditional cancer therapies, such as surgery and radiation, and instead using active imaging surveillance to monitor the tumor.

Although the trials to support this new theory are pending, a distorted message has gained traction in the media over the last two years, confusing women and clouding judgment of what might be the best treatment plan.

The "watch-and-wait" school of thought argues that we may be over-treating ductal carcinoma in some patients as the mortality rates are low with non-invasive breast cancer. While this may hold true for some women, we don't understand enough about the biology of the cancer to know which patients are being over-treated versus which patients' lives are being saved with standard treatment.

To help shed light on this complex question of whether there is a select group of patients with ductal carcinoma who may qualify for less treatment, me and Dr. Melvin J. Silverstein queried the database of pure DCIS patients and found 720 who were treated with excision alone.

A total of 596 of the women had the tumor removed with cancer-free margins of at least 1 millimeter of normal tissue around, which we considered adequate surgical excision. We compared those patients with 124 women who had tumors removed with less than 1 millimeter of cancer-free margin around.

This second group of women were considered inadequately treated, as per the current national cancer guideline recommendations, and therefore, considered a surrogate for no treatment in our study. These patients were recommended to undergo either re-excision for close margins or to go on to have whole breast radiation therapy, but refused any additional treatment.

We found that leaving even low-grade ductal carcinoma untreated led to local recurrence in more than half of patients at 10 years. And when patients did reoccur, half of the recurrences were invasive disease with the potential to spread elsewhere in the body. In high-grade DCIS the recurrence rate is 70% at 10 years. These numbers are simply too high to advocate for a "watch and wait" approach as a safe option for patients with ductal carcinoma.

While saving a life is of utmost importance, women also deserve to be saved from enduring the physical and emotional pain of battling cancer a second time.

Dr. SADIA KHAN is program advisor to Hoag Breast Care Program, Hoag Memorial Hospital Presbyterian, Newport Beach.