A State of Shock and Fear

"I went into a state of shock and fear [on the diagnosis of breast cancer]. It [mastectomy] takes away your feeling of attractiveness."
"Compared to women who really have cancer, it is nothing. But the mastectomy was for no reason, and that's why it bothers me."
Therese Taylor, Toronto

Therese Taylor of Mississauga, Ontario, had a mastectomy four years ago after a diagnosis of ductal carcinoma in situ. She now believes it was unnecessary. Credit Michelle Siu for The New York Times

"It's not an emergency. It's just not an emergency. We need to stop the urgency, be more thoughtful, start generating different approaches, think about it as prevention."
Dr. Laura Esserman, director, University of California, San Francisco breast care centre

"The surgeons cure 97 percent of it [cases of DCIS; ductal carcinoma in situ]. If you did nothing ... we don't know what would happen.
Dr. Steven Narod, breast cancer expert, Toronto

Dr. Narod is the lead author of a study undertaken by researchers at Women's College Hospital and the University of Toronto. The results of the study, called an observational study, one which visits medical records to assess whether treatments had an impact on patients are controversial. In the case of women diagnosed with ductal carcinoma in situ (DCIS), the purpose of the study was to identify whether treatment, resulting in single or double mastectomies or radiation effectively increased life expectancy.

The study's conclusion was published in the journal JAMA Oncology. And the conclusion is a matter of controversy. The very nature of the study -- observational -- is incapable of rendering proof that one course of action is superior in its end-result over the others. But the authors do argue that mastectomies don't appear to increase survival chances.

Almost 97 percent of the one hundred thousand women diagnosed with DCIS between 1988 and 2011 featured a 1.1 percent death rate ten years following treatment, a percentage that rose to 3.3 percent two decades following treatment. The study lent the impression to the researchers that while up to 3.3 percent of the women died, aggressive early treatments did not appear to impact on the disease course.

Cancerous cells are found in the milk ducts of the breast, in DCIS. The standard treatment is surgical removal of the affected portion of the breast, after which radiation treatment is recommended to minimize the risk of of the cancer returning or spreading. For some women the prospect of return or spread leads them to seek surgery removing the affected breast, or both breasts for complete peace of mind.

Clearly, Therese Taylor regrets her impulse to choose surgery. When she was 51 four years earlier, her doctor recommended a mammogram based on having felt a lump in her right breast. As things turned out, the right breast was fine, but DCIS was detected in her left breast; a surgeon informing her "it was consistent with cancer", recommending she have a mastectomy.

Because of the conclusion published by the researchers suggesting there seems to appear nothing is to be gained by aggressive proactive treatment, an editorial accompanying the article suggests that its findings indicate that a move to dial back treatment offered to women diagnosed with DCIS would seem to be appropriate. Dr. Esserman was the editorial's lead author.

She felt that the article's findings are fully supportive of the theory that some women diagnosed with DCIS may not need any surgery; she recommends ongoing monitoring of their condition, treatment being offered if the cancer is seen to be progressing. Emulating the manner in which many prostate cancer cases are now handled.

Her conclusion stands in contrast to the lead author of the research paper who believes the death rate might conceivably be higher than the 3.3 percent seen after two decades if women didn't undergo surgery to remove the cancerous cells. The controversy in this matter echoes what ensues in any scientific-medical situation where studies lead to polarizing theories. This is just yet another one.

The chief medical officer of the American Cancer Society, Dr. Otis W. Brawley, states he is not prepared to abandon treatment, preferring to wait for a large clinical trial which would select patients randomly for mastectomies, lumpectomies or no treatment of DCIS, often referred to as Stage 0 breast cancer, which might conclude from the resulting evidence that treatment is unnecessary for most patients.

That treatment tends to be excessive, however, is also a reality: "In medicine, we have a tendency to get too enthusiastic about a technique and overuse it. This has happened with the treatment of DCIS", he admitted.