DCIS Is Not Like a Rose

Words Affect Treatment Choice

Nick Mulcahy

August 26, 2013

A rose is a rose is a rose is a law of identity that apparently does not apply to ductal carcinoma in situ (DCIS).

The oft-quoted poetic phrase from American writer Gertrude Stein suggests that a thing is itself no matter what it is called or how it is described.

However, new research indicates that when DCIS is described as a high-risk condition, women make different treatment choices to some extent than when it is described as "noninvasive breast cancer."

When the word "cancer" was not used, 65% of the study participants choose nonsurgical management of the condition.

In short, the study suggests that DCIS is not like a rose because different descriptive terms seem to change the meaning of the condition for some women.

"These results suggest that many women may prefer nonsurgical options if allowed to weigh each choice and its attendant risks," write E. Shelley Hwang, MD, from Duke University in Durham, North Carolina, and colleagues in a letter published online today in JAMA Internal Medicine.

The researchers presented 394 healthy women with 3 clinical scenarios that described a diagnosis of DCIS using 1 of 3 terms: abnormal cells, breast lesion, or noninvasive breast cancer.

Each woman reviewed all 3 scenarios and the accompanying set of treatment options (surgery, medication, or active surveillance) and outcomes (chance of developing invasive breast cancer or dying). The information was identical — except for the terms used to describe DCIS.

When DCIS was described as noninvasive breast cancer, 53% (208 of 394) of participants preferred a nonsurgical option.

However, when the DCIS was described as a breast lesion, 66% (258 of 394) preferred a nonsurgical option, and when it was described as abnormal cells, 69% (270 of 394) preferred no surgery.

"We conclude that the terminology used to describe DCIS has a significant and important impact on patients' perceptions of treatment alternatives," the researchers write. "Healthcare providers who use 'cancer' to describe DCIS must be particularly assiduous in ensuring that patients understand the important distinctions between DCIS and invasive cancer."

Clinicians also commonly use terms such as carcinoma, stage 0 cancer, and noninvasive cancer to describe DCIS, they report.

This study comes on the heels of a controversial report by a National Cancer Institute (NCI) working group, which called for changing the term DCIS to something less threatening. "Use of the term 'cancer' should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated," the NCI panel explained.

However, some readers of Medscape Medical News dislike the proposed nomenclature change, which included the alternative term "indolent lesions of an epithelial origin."

"So what do I call an 'indolent lesion of epithelial origin' when it metastasizes to a regional lymph node? 'Metastatic indolent lesion of epithelial origin'? As a practicing pathologist I think this idea is full of hazards that can harm patients. It has a great feel good, 'don't worry, be happy,' tone to it, but does not represent reality for some patients," one reader wrote in the Comments section.

About 25% of all breast cancers diagnosed in the United States are considered DCIS, and there are more than 50,000 new cases each year. The numbers are going to continue to grow, according to some experts who spoke at the 2013 annual meeting of the Society of Surgical Oncology (SSO).

A driver behind the anticipated growth in cases is the use of advanced technologies in breast cancer screening — and their enhanced imaging — which increase the detection of abnormal cells in the breast, Dr. Hwang said at that meeting, where she discussed some of the new results.

Her presentation included a description of the outcome risks related to the DCIS treatment options that were presented to the study participants.

Table. Outcome Information Provided to the Women About DCIS

Outcome Surgery Medication Observation
Chance of developing invasive breast cancer in next 10 years 3.0% 17.0% 30.0%
Chance of dying from breast cancer in next 10 years 0.3% 1.7% 3.0%
Adverse effects various various none

 

Dr. Hwang encouraged clinicians to use decision aids with DCIS patients to help make treatment decisions.

In their letter, she and her collegues acknowledge that observation or active surveillance of DCIS places clinicians in uncharted territory. "How to implement such a strategy is unclear," they write.

The study was supported by the American Cancer Society. The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 26, 2013. Abstract

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