While we quote the life time risk of breast cancer as 1 in 9, it is important to remember that breast cancer is not one disease but a host of different diseases that share a common anatomical site of origin- the breast. As the authors in a new report in the Archives of Internal Medicine point out- ductal carcinoma in situ (DCIS) is a pre-invasive malignancy of the breast and is diagnosed in more than 50,000 women a year in the United States. The important adjective here is PRE INVASIVE.
In cases of low-grade DCIS, studies suggest that IF progression occurs to invasion, it does so within a time frame of 5 to 40 years, and possibly in only 20 per cent of DCIS cases. If one uses the comparison of prostate cancer, where many cases will not progress and so called watchful waiting is suggested, it raises the question as to whether or not watchful waiting is a reasonable strategy for many cases of DCIS.
While DCIS can be treated with lumpectomy and radiation or even mastectomy alone, are these treatments always the best choices?
DCIS is generally too small to be felt during a clinical breast exam (CBE) and is most commonly found by mammography, that often appears as microcalcifications.
For many women when given a diagnosis of DCIS all they hear is the word cancer and as the authors point out, “many women are unable to distinguish between preinvasive and invasive cancer and often overestimate the implications of a DCIS diagnosis. These misperceptions may drive patients’ willingness for invasive treatments. Health care providers ’communication with their patients about DCIS plays an important role in patients understanding the risks of their diagnosis. Terms such as carcinoma, stage-0 cancer, and noninvasive cancer are commonly used to describe DCIS and may further contribute to the confusion engendered in many patients.” The authors suggested that when DCIS is described without the term cancer, women would be more likely to opt for noninvasive approaches such as medication or watchful waiting in place of surgery.
The researchers studied 394 healthy women without a history of breast cancer. The women were presented with 3 scenarios that described a diagnosis of DCIS as noninvasive breast cancer, breast lesion, or abnormal cells. Each scenario and the treatment options and outcomes of treatment (chance of developing invasive breast cancer or death) were identical, with the only difference being the term used for DCIS.
After each scenario, participants chose among 3 treatment options (surgery, medication, or active surveillance). The order of scenarios was varied randomly across participants, with an equal distribution of each sequence.
Overall, nonsurgical options (medication and active surveillance) were more frequently selected over surgery. When DCIS was described using the term noninvasive cancer, 53 % preferred nonsurgical options, whereas 66 per cent preferred nonsurgical options when the term was breast lesion and 69 per cent preferred nonsurgical options when the term was abnormal cells. Significantly more women changed their preference from a surgical to a nonsurgical option than from a nonsurgical to a surgical option depending on terminology, according to the study results.
These results suggest that many women may prefer nonsurgical options if allowed to weigh each choice and its risks. Our survey specifically reminded the participants that risks and benefits were the same among all 3 scenarios; however, excluding the word cancer in the diagnosis shifted many participants to choose a less invasive option.
The study reminds us of what the term informed consent really means. In order to have an informed decision the words used to describe DCIS has a significant and important impact on patients’ perceptions of treatment alternatives.
