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Cancerous changes within the breast ducts are abnormal but not
uncommon. As indeed are cancerous changes in other sites. We know that
some progress to endanger life and some don't. Bodies commonly harbour
abnormalities of this and other kinds without compromise to health. It is
in this sense normal to be abnormal. So it is unclear whether DCIS,
usually detected through screening, is a "disease" at all (1,2). Hence it
is not clear whether such changes need - in some sense of need, which is a
value judgment - to be treated.
Knowledge gathered from the outcomes of various treatment regimes do
not answer these questions. What is clear is that the final decisions -
whether to treat, and how - belong to the woman diagnosed. To make those
decisions she needs adequate information. No conscientious doctor could
deny that the client must be adequately informed of facts material to her
condition which she can evaluate in light of her values and circumstances,
on which decisions ultimately turn and of which clinicians are ignorant.
In the case of DCIS, no amount of data on recurrence after various
treatment regimes changes the fact that, for an individual, treatment may
be unnecessary. Diagnosed women are made to gamble: to pre-empt or not, a
future unquantifiable possibility, rather than to deal with a real and
present threat. This is not a clinical decision. "Treatment" is not
therapy but a strategy to deal with uncertainty. Individuals differ in
response to uncertainty (3). It would not be irrational to decline
treatment particularly since most screen-detected cancers are slow-
growing, screening has not been definitively shown to reduce breast cancer
mortality and all-cause mortality appears unchanged (4,5,6,7). Her choice
is between panicking into life-changing, permanently damaging treatment
whose necessity she will always doubt combined with fear of recurrence; or
no treatment, combined with fear of occurrence. Many might think the
latter, on balance, less psychologically and physically damaging, and
given the uncertainties, not more risky than treatment. DCIS is not an
emergency and women should not be railroaded because of doctors' anxiety
about possible future blame - not a clinical reason for intervention.
It may be that whether DCIS, or indeed screen-detected invasive
cancer (in light of overdiagnosis that distinction is something of a red
herring (6,7).) will progress or not cannot be answered at time of
discovery because determined by factors outside those cells or outside the
host - factors which may not yet be in play. Cancers are known to remain
static without causing symptoms or to regress and such relative stability
may continue until something disturbs it. That thing may be inherently
unpredictable, and not something that can be seen by looking at the cells.
Pending answers, doctors must inform women of the unknowns
(8,9,10,11). Indeed women should have been informed before screening since
there are those who would rationally and safely prefer to avoid this
predicament altogether, given the uncertainty over whether there is any
benefit to screening and the obvious harms.
References
1) Should I be tested for cancer? Maybe not and here's why
H. Gilbert Welch, University of California Press, 2004
2) The Natural History of Invasive Breast Cancers Detected by
Screening Mammography
Per-Henrik Zahl, MD, PhD; Jan M?hlen, MD, PhD; H. Gilbert Welch, MD, MPH
Arch Intern Med. 2008;168(21):2311-2316
3) The art of medicine Decision making and fear in the midst of life
Aronowitz, R. www.thelancet.com Vol 375 April 24, 2010
4) Systematic review of screening for breast cancer with mammography
Ole Olsen, deputy director, senior researcher, MSc, Peter C. G?tzsche,
director, MD, MSc. The Nordic Cochrane Centre. Published October 20, 2001
5) Screening for breast cancer with mammography (Review)
G?tzsche PC, Nielsen M. The Cochrane Library 2009, Issue 4 http://www.thecochranelibrary.com
6) Effect of Screening Mammography on Breast Cancer Mortality in
Norway
Mette Kalager, M.D., Marvin Zelen, Ph.D., Fr?ydis Langmark, M.D., and Hans
-Olov Adami, M.D., Ph.D. N Engl J Med 2010;363:1203-10.
7) Breast cancer mortality in neighbouring European countries with
different levels of screening but similar access to treatment: trend
analysis of WHO mortality database
Philippe Autier, Mathieu Boniol, Anna Gavin, Lars J Vatten. BMJ 2011;
343:d4411
8) 'Well, have I got cancer or haven't I?' The psycho-social issues
for women diagnosed with ductal carcinoma in situ
Simone De Morgan, Sally Redman, Kate J White, Burcu Cakir, John Boyages
Health Expectations 5: Dec 2002: 310-318
9) Women need better information about routine mammography
Hazel Thornton, Adrian Edwards, Michael Baum BMJ 2003;327:101-3
10) Women's information needs about ductal carcinoma in situ before
mammographic screening and after diagnosis: a qualitative study.
Prinjha S, Evans J, Mcpherson A. J Med Screen 2006;13:110-114
11) 'A mastectomy for something that wasn't even truly invasive
cancer.' Women's understandings of having a mastectomy for screen-detected
DCIS: a qualitative study
S Prinjha, J Evans, S Ziebland and A McPherson. J Med Screen 2011;18:34-40
A question begged?
Cancerous changes within the breast ducts are abnormal but not
uncommon. As indeed are cancerous changes in other sites. We know that
some progress to endanger life and some don't. Bodies commonly harbour
abnormalities of this and other kinds without compromise to health. It is
in this sense normal to be abnormal. So it is unclear whether DCIS,
usually detected through screening, is a "disease" at all (1,2). Hence it
is not clear whether such changes need - in some sense of need, which is a
value judgment - to be treated.
Knowledge gathered from the outcomes of various treatment regimes do
not answer these questions. What is clear is that the final decisions -
whether to treat, and how - belong to the woman diagnosed. To make those
decisions she needs adequate information. No conscientious doctor could
deny that the client must be adequately informed of facts material to her
condition which she can evaluate in light of her values and circumstances,
on which decisions ultimately turn and of which clinicians are ignorant.
In the case of DCIS, no amount of data on recurrence after various
treatment regimes changes the fact that, for an individual, treatment may
be unnecessary. Diagnosed women are made to gamble: to pre-empt or not, a
future unquantifiable possibility, rather than to deal with a real and
present threat. This is not a clinical decision. "Treatment" is not
therapy but a strategy to deal with uncertainty. Individuals differ in
response to uncertainty (3). It would not be irrational to decline
treatment particularly since most screen-detected cancers are slow-
growing, screening has not been definitively shown to reduce breast cancer
mortality and all-cause mortality appears unchanged (4,5,6,7). Her choice
is between panicking into life-changing, permanently damaging treatment
whose necessity she will always doubt combined with fear of recurrence; or
no treatment, combined with fear of occurrence. Many might think the
latter, on balance, less psychologically and physically damaging, and
given the uncertainties, not more risky than treatment. DCIS is not an
emergency and women should not be railroaded because of doctors' anxiety
about possible future blame - not a clinical reason for intervention.
It may be that whether DCIS, or indeed screen-detected invasive
cancer (in light of overdiagnosis that distinction is something of a red
herring (6,7).) will progress or not cannot be answered at time of
discovery because determined by factors outside those cells or outside the
host - factors which may not yet be in play. Cancers are known to remain
static without causing symptoms or to regress and such relative stability
may continue until something disturbs it. That thing may be inherently
unpredictable, and not something that can be seen by looking at the cells.
Pending answers, doctors must inform women of the unknowns
(8,9,10,11). Indeed women should have been informed before screening since
there are those who would rationally and safely prefer to avoid this
predicament altogether, given the uncertainty over whether there is any
benefit to screening and the obvious harms.
References
1) Should I be tested for cancer? Maybe not and here's why
H. Gilbert Welch, University of California Press, 2004
2) The Natural History of Invasive Breast Cancers Detected by
Screening Mammography
Per-Henrik Zahl, MD, PhD; Jan M?hlen, MD, PhD; H. Gilbert Welch, MD, MPH
Arch Intern Med. 2008;168(21):2311-2316
3) The art of medicine Decision making and fear in the midst of life
Aronowitz, R. www.thelancet.com Vol 375 April 24, 2010
4) Systematic review of screening for breast cancer with mammography
Ole Olsen, deputy director, senior researcher, MSc, Peter C. G?tzsche,
director, MD, MSc. The Nordic Cochrane Centre. Published October 20, 2001
5) Screening for breast cancer with mammography (Review)
G?tzsche PC, Nielsen M. The Cochrane Library 2009, Issue 4
http://www.thecochranelibrary.com
6) Effect of Screening Mammography on Breast Cancer Mortality in
Norway
Mette Kalager, M.D., Marvin Zelen, Ph.D., Fr?ydis Langmark, M.D., and Hans
-Olov Adami, M.D., Ph.D. N Engl J Med 2010;363:1203-10.
7) Breast cancer mortality in neighbouring European countries with
different levels of screening but similar access to treatment: trend
analysis of WHO mortality database
Philippe Autier, Mathieu Boniol, Anna Gavin, Lars J Vatten. BMJ 2011;
343:d4411
8) 'Well, have I got cancer or haven't I?' The psycho-social issues
for women diagnosed with ductal carcinoma in situ
Simone De Morgan, Sally Redman, Kate J White, Burcu Cakir, John Boyages
Health Expectations 5: Dec 2002: 310-318
9) Women need better information about routine mammography
Hazel Thornton, Adrian Edwards, Michael Baum BMJ 2003;327:101-3
10) Women's information needs about ductal carcinoma in situ before
mammographic screening and after diagnosis: a qualitative study.
Prinjha S, Evans J, Mcpherson A. J Med Screen 2006;13:110-114
11) 'A mastectomy for something that wasn't even truly invasive
cancer.' Women's understandings of having a mastectomy for screen-detected
DCIS: a qualitative study
S Prinjha, J Evans, S Ziebland and A McPherson. J Med Screen 2011;18:34-40
Competing interests: Screen-diagnosed with DCIS