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Study raises questions about treatment for early breast cancer

A new study has found that women who received lumpectomies and mastectomies for very early stage breast cancer had similar survival rates to those who had less radical treatments. Dr. Steven Narod of the Women's College Research Institute and Dr. Monica Morrow of Memorial Sloan Kettering Cancer Center discuss the findings with Judy Woodruff.

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    There was other big news today related to cancer.

    A study published in "The Journal of the American Medical Association Oncology" found that women given lumpectomies and mastectomies as treatment for very early-stage breast cancer had similar survival rates to those patients who had less radical cancer treatments. Those findings may call into question some of the standard assumptions on how to treat the disease.

    For a closer look at the study and its potential implications, we turn to two cancer specialists. Dr. Steven Narod is a researcher at the Women's College Research Institute in Toronto. He was the study's lead author. And Dr. Monica Morrow is chief breast cancer surgeon at Memorial Sloan Kettering Cancer Center in New York City.

    Dr. Morrow, Dr. Narod, welcome to you both.

    I'm going to start with you, Dr. Narod.

    On this study, we did read that it's the most extensive collection of data ever analyzed on this particular type of cancer. Boil down the findings for us.

  • DR. STEVEN NAROD, Women’s College Research Institute:

    We focused on 100,000 women with the earliest form of cancer. Some say it's not even cancer. It's a precursor lesion. We call it DCIS, or ductal carcinoma in situ.

    So, this, because it's a very good prognosis, we followed the 100,000 women for up to 20 years and we found that, at 20 years, about 3 percent of them had died of breast cancer. Roughly a third of the patients were treated with lumpectomy alone, which is removing the DCIS, the focus of cancer. One-third of the patients, probably, had a lumpectomy plus radiotherapy, and one-third of the patients approximately had the entire breast removed through mastectomy.

    And what we found, that there was no difference in the survival at 20 years between women treated with any of the three ways.


    What is the — you said one-third, one-third, one-third. What do these findings tell you that the treatment should be?


    Well, it tells us about — something about the early stages of breast cancer.

    The reason I say that is because, of those 3 percent of the women who died of breast cancer, most of them, 54 percent of them, between the time they had DCIS and the time they had a distant recurrence or a metastatic disease, never experienced another breast — cancer in the breast.

    So, that leads me to think that when that DCIS was removed by the surgeon, it had already spread around the breast and it took years, up to 20 years, in order for those cells that had spread to flourish and to be metastatic and to ultimately cause the breast cancer death.


    So, just to quickly interpret what you're saying and to turn to Dr. Morrow, it sounds as if what we're hearing and what the article says, Dr. Morrow, is that these findings would suggest that a minimal treatment is going to be just as effective as the maximal treatment. What's your interpretation?

  • DR. MONICA MORROW, Memorial Sloan Kettering Cancer Center:

    Well, I'm not necessarily sure the article says that.

    I think a critical finding of this study is how good the prognosis for DCIS is, and women should be reassured, because we know that women with DCIS estimate their risk of dying of breast cancer to be as high as 30 percent. And this study says that's just simply not true.

    I think what it does tell us is that, to date, physicians have been pretty good at selecting low-risk DCIS, which can be treated minimally with lumpectomy alone. I think it says we should think hard about expanding the indications for minimal treatment.

    But I think it's also important for women to be aware that we can only say there is nothing there but DCIS after we have removed the entire area. Thirty percent of women who are — or — sorry — 20 percent of women who are diagnosed as having DCIS on a needle biopsy will actually be found to have invasive cancer when you remove the entire area.

    So the idea that you can do nothing at all for DCIS and end up with the same extremely favorable outcomes that Dr. Narod reports remains to be proven and should be the subject of future research perhaps.


    And I just want to clarify again for our audience who is watching, we're throwing around the term DCIS, which, again, most — it stands for the least advanced stage of cancer, also known as stage zero.

    So, Dr. Narod, how — are you — you heard what Dr. Morrow said, that she doesn't believe the treatment should change as a result of this study. Are you saying something different should be done, that women should wait if they have a very early-stage breast cancer?


    No, and, certainly, I defer to Dr. Morrow, who is a practicing surgeon, of which I'm not.

    What I do say, though, is there are two clear goals of treatment for DCIS, and those are separate goals. The first goal, the one that we have been accustomed to and the one we have always prioritized, is to prevent a new breast cancer event or recurrence.

    If the goal is to prevent the breast cancer death, then we found no benefit from the radiotherapy and no benefit from the mastectomy, from the more extensive surgery.


    Now, let me just go back to Dr. Morrow.

    So, Dr. Morrow, what should a woman watching this who is — you know, has to make a decision, or a woman who has had the more radical treatment in the past and is now wondering if she should have had it, what are these women to think now?


    Well, I think women who have had radical treatment can be reassured that they have an extremely high probability of not dying of the DCIS that they have been treated for, and that's a very good position to be in. We can't always say that for radical treatment of invasive breast cancer.

    For women who are looking at treatment today, though, I think they have the opportunity to ask the surgeon who is counseling them, what are my options, what are the factors that suggest I might benefit from more aggressive treatment? If you're not given options, that's a good time to seek a second opinion.

    The other thing I say is that, although death was the primary end point of this story, for many women, recurrence in the breast, even if it's not associated with death, is a psychologically devastating complication that they would like to seek additional treatment to avoid.

    And there, I think a person's individual values is important in deciding what is right for her to do.


    Well, as you said at the outset, what every woman should do is to certainly have a very close conversation with her own physician. And we will leave it on that note.

    And we want to thank both of you, Dr. Monica Morrow and Dr. Steven Narod. We appreciate it.


    Thank you.


    Thank you very much.

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