On Tuesday, I got an e-mail from JAMA Oncology, a leading medical journal, saying that it planned to publish a paper and editorial on ductal carcinoma in situ, or D.C.I.S., a condition that has become increasingly controversial over the years. As many as 60,000 women are told each year that they have it: tiny clusters of abnormal breast cells, confined to a milk duct and too small to be felt. It’s often called stage 0 cancer, and it almost never was detected before the early 1980s when mammograms came into widespread use.
I clicked on the paper and noticed that it and the accompanying editorial seemed to be raising some provocative issues. Was the usual brutal treatment — a mastectomy or a lumpectomy with or without radiation — excessive? Was Cindy Pearson, executive director of the National Women’s Health Network, correct when she told me treating D.C.I.S. this way “is like killing a mosquito with an elephant gun?”
To be honest, stories like this frighten me.
The article I wrote in today’s paper does not provide definitive answers but provokes questions about difficult treatments tens of thousands of women have had, hoping to save their lives. No one wants to make a person who already is terrified of cancer think perhaps she had her breast cut off for nothing.
It’s hard to know how you would react until something like that hits you, but it cannot be easy. I sometimes think of what it would be like to be the last woman to have had a radical mastectomy. Will the treatment of D.C.I.S. be so different in a decade that women who have undergone today’s procedures feel like they were born too soon?
Then I think about the women soon to receive a D.C.I.S. diagnosis. Shouldn’t they at least know that there are no definitive answers about treatment? Shouldn’t they know that the more cancer researchers learn about D.C.I.S., the more they wonder if the usual treatments are helping.
The problem lies in what to do with this information. Medical researchers, of course, say that more research is needed: They need more studies; they need to better understand the biology of breast cancer in general and D.C.I.S. in particular. The new data is the type “that justifies use of watchful waiting,” said Dr. Barnett Kramer, director of the division of cancer prevention at the National Cancer Institute.
But is anyone actually doing that now, I asked medical experts.
It’s big step, said Dr. Otis Brawley, chief medical officer for the American Cancer Society. It would be a big departure from decades of medical practice. He said he does not know anyone right now who is telling women with D.C.I.S. that they should just wait and be monitored. But, he said, “I anticipate that in the next decade or so people will be willing to make that leap.”