COMMENTARY

'Cultural Change': Dialing Back the Discussion and Treatment of DCIS

E. Shelley Hwang, MD, MPH;  Kathy D. Miller, MD

Disclosures

January 17, 2018

Kathy D. Miller, MD: Hi. I am Dr Kathy Miller, professor of medicine at the Indiana University School of Medicine in Indianapolis. Welcome to Medscape Oncology Insights, coming to you today from the 2017 San Antonio Breast Cancer Symposium (SABCS).

Surgery and radiation remain the mainstays of treatment for ductal carcinoma in situ (DCIS), but there is a lot of change in treatment of DCIS and really critical questions that need answers. Here to talk about the emerging approach to DCIS is my next guest, Dr Shelley Hwang, professor of surgery and chief of breast surgical oncology at the Duke University School of Medicine in Durham, North Carolina. Welcome, Shelley.

E. Shelley Hwang, MD, MPH: Thank you, Kathy. it's very nice to be here.

Current Management of DCIS

Dr Miller: Remind us about how DCIS is currently treated.

Dr Hwang: DCIS is treated now as it has been for the past 40 years. Just as a reminder for everyone, the diagnosis of DCIS did not even really exist before we did mammographic screening. Once we started screening women for breast cancer, we started picking up more of this diagnosis of pre-cancer, or pre-invasive cancer, otherwise known as DCIS. It is one step before invasive cancer develops.

DCIS is treated now as it has been for the past 40 years.

In our, I guess, ignorance to know how else to treat it, we really ended up just treating it like a cancer, which would consist of surgery—either a lumpectomy or mastectomy—often together with radiation. The management of DCIS has not changed that much in the past 40 years. Hopefully, we are on the verge of making some changes now.

Do We Really Understand DCIS?

Dr Miller: Whenever I hear that we do the same thing now as we did 40 years ago, either that is because it works really well and there is no reason to change it, or we do not know what else to do. Which of those is it, in this case?

Dr Hwang: For DCIS it is a little bit of both. Because it is a pre-invasive or pre-cancerous lesion, it really does not have the ability to spread to any other part of the body. If you catch it at that stage, women are almost 100% cured, if you will. I think we can make the argument, and many of us do, that many women are cured of a diagnosis that would not have caused them any harm during their lifetime. As a result, we are incredibly successful, and we have a very high cure rate. So a little bit of this is that we are very successful in achieving great outcomes with the treatments we use now.

Dr Miller: This strikes me, though, as one question. Since we did not know about this diagnosis before mammograms, do we really understand the natural history of DCIS? Are we taking credit for something that maybe was successful 80 years ago, and we just did not know about it?

Dr Hwang: That is exactly where the controversy is with DCIS. Because we started treating it very aggressively from the very beginning, it is really hard to now dial back on the treatment and say, "Woops, we were really wrong, and we probably should have been treating you in a lot less aggressive form."

The concept of de-escalation is gaining more traction.

We are at that place with a lot of treatments. Not knowing any better and with the best of intentions, we started off with very aggressive therapy, were incredibly successful, and now it is really hard to start dialing back. The concept, de-escalation, is gaining more traction. As we start investing more in precision therapy, we will end up treating some patients a lot more aggressively than we do now, while some patients will be treated exactly the way we do now, and some patients will have de-escalation of therapy because what we are doing now is probably too much. That is really where most of the activity and interest are right now in DCIS.

'Dialing Back' Treatment for DCIS

Dr Miller: How will we get there in DCIS? There is almost a bit of a catch-22. To understand the natural history and to figure out who needs treatment as we currently give, who maybe needs more than we currently give, and who needs less, we actually cannot give everybody everything. If we are reluctant to do that, how do we ever get the data to help us do that?

Dr Hwang: That is the dilemma that we are all grappling with. Fundamentally, it is paramount that we start off with research that maintains patient safety and good outcomes. We are doing such a good job with possibly the two invasive approaches we have right now. To dial back, we need to make sure that we are able to maintain the really great outcomes that we have.

I think we are starting to whittle away at the edges. We are taking patients with the lowest risk condition, with DCIS that is the least likely to ever become invasive, and starting to de-escalate or dial back on some of the treatments for those best-prognosis patients. Once we understand that a little bit better, then we can extend that, possibly, to other groups of patients.

Dr Miller: How are you defining that best-prognosis group?

Dr Hwang: [Clinicians] did that 20 years ago by trying to define a low-risk group and recommending active surveillance [in men with prostate cancer]. When they first set out on that adventure, there was a lot of worry that we would actually be hurting patients by de-escalating. They spent a lot of time trying to identify the lowest-risk group. Now, about 40% of men with prostate cancer are managed with active surveillance.

When we started doing it for DCIS, we looked back at the retrospective literature of women who had had DCIS before and looked for the group that was least likely to have any invasive cancer outcomes. Those included women with very nonaggressive types of DCIS, the smaller ones, DCIS occurring in older women, and in those with lots of other comorbidities. If patients have lots of other medical conditions, then treating a pre-cancer is probably not going to make any difference in their long-term outcome. We are defining the lowest-risk group of patients to the best of our ability.

COMET Study

We launched [COMET], a prospective, randomized trial,[1] earlier this year. We have about 50 sites that are enrolling patients. Half of the patients will continue to get all of the standard treatment that we have been giving them all these years (ie, surgery, radiation; some women get double mastectomy for this diagnosis). The other group is just being monitored very, very closely. We will see which group of patients does better. And by "better," not only are we are looking at cancer outcomes, but we are also looking at quality of life. There is no question that the treatments have been very successful, but they are quite invasive and they result in long-term morbidities for patients. We need to understand that a lot better.

Dr Miller: Are you also looking at the patient's sense of anxiety, fear, worry? The language here gets tricky. We put "cancer" in the name of this condition, and that sounds very frightening. "Active surveillance" sounds better than doing nothing, which is another lesson that I think we learned from our prostate cancer colleagues. I wonder about that difference in that aspect of the patient experience.

Dr Hwang: There has been a lot of discussion about whether we need to change the name, but we have to call it something. It is not quite so much what we call it but the reaction that we have toward the patient and the diagnosis. That is where we need to institute some education and cultural change.

Leading this for the COMET study is our patient advocates. They are taking the bull by the horns and thinking of ways that physicians can introduce the concept of DCIS without automatically making it just sound like another cancer. There are clear distinctions between a pre-invasive condition and an invasive cancer. Our advocates have been instrumental in helping to shape the language around this diagnosis so that it is not quite so fearful for patients. We have a long way to go, but we made a terrific start.

A 'Cultural Change' for DCIS?

Dr Miller: I want to ask you a bit about the impact of first impressions. I would bet that even at Duke, someone newly diagnosed with DCIS hears about their diagnosis from someone else before they see you—maybe the radiologist who did an image-guided biopsy, or the primary care physician who ordered the screening imaging that led to the biopsy in the first place. It seems to me that we are often starting out in a hole if the patient heard about this condition from someone else. Even if someone else called it a pre-invasive cancer, they still called it a cancer. They may have said, "The next step is that you are going to see a surgeon and have surgery," which makes talking about a different surveillance approach feel like you are starting out in a hole. Expectations have been set as to what a proper course should be; you now have to walk [that] back a bit without trashing the well-meaning, accurate people who told them, "This is what we currently do."

The way we talk to patients now around their diagnosis...is very different than it was just a few years ago.

Dr Hwang: Absolutely. To reiterate, we do the things we do and we treat patients with the best tools that we have, all with good intentions. I do not think anyone sets out to overtreat anyone. It is a multidisciplinary approach and we start with one center at a time. When I first got to Duke, we had a very different language around how we described the diagnosis to patients. But our radiologists are such terrific collaborators now—they have drunk the Kool-Aid. The way we talk to patients now around their diagnosis, if it is not cancer, is very different than it was just a few years ago.

With the implementation of the study, we can at least start bringing about a cultural change from the medical community, and also from patients, about how they think about the diagnosis. The other big change now is that patients do not get all of their information from their doctors; they get it from the Internet. Even if they received a diagnosis of cancer, most of my patients have done plenty of research on their own before they come to see me, and they are curious. They hear that there may be alternatives to invasive treatments. There is a lot of hope there for patients to come armed with information and to not be derailed by what they think they may have heard at the point of first contact.

Dr Miller: This is another frontier in precision medicine—not just getting the right treatment to the right person, but actually figuring out who needs treatment. And maybe that is not everyone.

Dr Hwang: This is the canary in the coal mine. There are many other conditions in medicine where we can learn the lessons from prostate cancer, and hopefully DCIS, to really tailor the precise therapy for the right patient at the right time. That is what we are all aiming for.

Dr Miller: Good luck with the COMET study. It is an incredibly important study to help us make those next steps.

Dr Hwang: Thank you very much, Kathy. It is exciting, and I look forward to working together with the patients and advocates to really change how we think about DCIS.

Dr Miller: Thank you for joining us today to talk about this issue, and thank you for joining us as well. This is Dr Kathy Miller, reporting from SABCS.

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