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With DCIS, where does the real risk lie?

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Karen Titus

December 2015—When a pathologist makes a diagnosis of DCIS, few people greet the news happily. Not patients, not surgeons, not radiation oncologists. Depending on the particulars of the case, pathologists might also feel cheerless. Typically, the only winners are uncertainty and its sidekick, fear.

DCIS diagnosis is straightforward in most cases, but at either end of the spectrum it’s less so, says Dr. Stuart Schnitt. “There’s no substitute for having face-to-face, real-time conversations with clinicians related to the care of these patients with borderline or equivocal lesions.”

DCIS diagnosis is straightforward in most cases, but at either end of the spectrum it’s less so, says Dr. Stuart Schnitt. “There’s no substitute for having face-to-face, real-time conversations with clinicians related to the care of these patients with borderline or equivocal lesions.”

While it’s not difficult to distinguish between cases of high-grade and low-grade ductal carcinoma in situ, telling low-grade DCIS from atypical ductal hyperplasia often is. “The toughest distinction that I encounter is a borderline lesion between those two,” says David Hicks, MD, professor of pathology and laboratory medicine and director of surgical pathology, University of Rochester (NY) Medical Center.
There’s plenty at stake for everyone involved. In such cases, pathologists are asked to be seers as much as scientists, as they try to predict the future malignant potential of a lesion and help surgeons and radiation oncologists choose the best treatment. “They look to us to have all the answers, and we do the best we can. In some cases it’s clear; in others it’s murky,” says Dr. Hicks. “In one sense, we’re looking at cells as if they’re a crystal ball and we’re trying to predict the future.”

Given that, pathologists might be tempted to add to their reports lines from Robert Frost’s famous, slightly regretful poem about picking a path through the woods: “Both that morning equally lay…/I took the one less traveled by,/and that has made all the difference.”

The need to understand where DCIS might be headed has only grown more critical with the advent of screening mammography in recent decades. DCIS represents some 20 percent of breast cancers identified through screening. There has even been talk, off and on, about removing the word “carcinoma” from diagnoses, and concerns about overdiagnosis and overtreatment of DCIS run high.

“I talked with a radiation oncologist recently about this,” says Dennis Sgroi, MD, professor of pathology, Harvard Medical School, and co-director of breast pathology, Massachusetts General Hospital. “I said, ‘Would you not agree we are probably overtreating?’ He said, ‘Yes—but we just don’t know how to stratify patients. If we can come up with a way, that would be great.’ They would like to give less radiation.”

The question is clear, says Dr. Sgroi. “Can we come up with something that allows us to stratify patients into less aggressive treatment?”

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Dr. Simpson

“In current practice there’s a lot riding on getting the diagnosis of DCIS correct, because atypical ductal hyperplasia is excised and the patient is followed,” says Jean Simpson, MD, president, Breast Pathology Consultants, Nashville, Tenn., and adjunct professor of pathology, University of South Alabama, Mobile. “And if a diagnosis of DCIS is made, often patients will receive radiation.”

There are good reasons to steer patients away from unnecessary treatment. Many of them fall into the you-can-kill-a-fly-with-a-grenade-but-why-not-try-a-flyswatter-first? category.

But just as pathologists can find it difficult to make a diagnosis in borderline cases, clinicians and patients can find it hard to understand the risks of DCIS.

Stuart Schnitt, MD, explains why. Treating DCIS isn’t treating cancer—it’s prophylactic treatment. And even when clinicians try to downplay the cancer angle, by reminding patients DCIS means they have a type of precancer, the treatments they’re offered typically erase that notion. They’re basically the same options—radiation, surgery—given to patients with invasive cancer. Says Dr. Schnitt: “No wonder patients are confused.”

The term LCIS is not nearly as explosive, despite the common “carcinoma” denominator. Dr. Schnitt, director of the Division of Anatomic Pathology, Beth Israel Deaconess Medical Center, and professor of pathology at Harvard Medical School, attributes that to the fact that LCIS is managed by either observation or observation and chemoprevention, which are less doomful than DCIS treatments.

Even as physicians ponder drastic approaches to treating DCIS, another undercurrent remains: What about the case that looks harmless but then develops into an invasive cancer? It mirrors current debates about immigration and terrorists: Everyone fears the dangerous one that gets through.

Given the many possibilities in play, DCIS might be described by a faux Latin phrase: ductal est ductile.

The diagnosis is actually straightforward in most cases, says Dr. Schnitt, but at either end of the spectrum matters can get tricky. On the high end, it can be hard to tell pure, high-grade DCIS from a DCIS with foci of microinvasion. At the low end, as noted, it can be difficult to distinguish limited forms of low-grade DCIS from ADH.

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