Talk:Ductal carcinoma in situ

Confused use of terminology

There is a great deal of confusion regarding the use of terminology surrounding DCIS. I have restored this and moved to a section on terminology. Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:46, 19 June 2014 (UTC)

There is some ambiguity/uncertainty, I agree. But basically, I think it depends on what level one's talking: e.g. histopathologic vs. clinical vs. statistical. My understanding is that the cells are always abnormal (i.e. atypical/neoplastic, rather than just hyperplastic). Clinically, the lesions are considered precancerous, in that although currently non-invasive they may become invasive. Statistically, there is no consensus on whether reported cases of DCIS should be categorized as "cancers" or not. 86.128.169.211 (talk) 21:31, 19 June 2014 (UTC)

James, did you find a mention of "controversy" I missed? If not, I don't think we should really be creating one. I think the real differences in practice regard how the cases detected at mammography are counted (i.e. categorized) at a statistical level. The source you use to reference the "controversy" just says (unless I've missed something), "Some people include DCIS in breast cancer statistics." 86.128.169.211 (talk) 21:41, 19 June 2014 (UTC)

Yes good point. Have reworded. Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:07, 19 June 2014 (UTC)

This source [1] refers to the historical controversy, primarily surrounding the impact of mass mammographic screening and the clinical relevance of the lesions uncovered due to these mass public campaigns. All very relevant stuff, but we'd need (imo) to contextualize appropriately. 86.128.169.211 (talk) 22:23, 19 June 2014 (UTC)

Meant page 112. "Some oncologist refuse to classify them as breast cancer" Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:30, 19 June 2014 (UTC)

This is an interested bit on page 3 and 4 [2] Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:36, 19 June 2014 (UTC)

Yes, and that source highlights that this all has very real social and even political dimensions. I think a key question is how we're going to approach this matter editorially, within the framework of a WP article... I don't think the terminological differences here regarding what should and shouldn't be counted as cases of cancer stem from a basic disagreement in biological classification as such, as with, say, the historical confrontation between the Kiel classification and the Working Formulation in non-Hodgkin lymphoma. Rather, as with analagous prostate cancer controversies, this really hinges on well-founded concerns regarding overdiagnosis in mass screening -- a very real bone of contention here. I think we need to find a suitable editorial way of contextualizing this.
tl;dr: This highly relevant new page needs some tlc to develop. 86.128.169.211 (talk) 09:11, 20 June 2014 (UTC)

Clarification needed

Some refer to it as maliganant. Why is clarification needed? Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:28, 21 June 2014 (UTC)

Because that's not what the source actually says (I think). It says [3]:

This is a pre-invasive breast cancer and is characterized by malignant proliferation of breast epithelium that is confined to the ductal system and has not yet invaded through the basement membrane. ... This condition is pre-malignant and often multicentric in the breast.

In other words, the proliferating cells themselves are already neoplastic (i.e. biologically malignant), but clinically the condition (i.e. the single or multiple lesions) is premalignant. That's because the malignant cells haven't yet passed through the basement membrane to invade the surrounding tissues. And that's why it's sometimes called, as in this source, a pre-invasive cancer.

It's also true that some oncologists/institutions classify cases of DCIS as cases of "cancer" (e.g. [4]), whereas others are more cautious. This particular source chooses to define DCIS as "pre-invasive breast cancer".

My impression is that there's broad consensus that whereas the proliferative cells are "malignant", the lesion is clinically "premalignant" -- in the sense that it is potentially malignant (see [5]). However, there's still no general agreement as to whether cases of DCIS should be counted for statistical purposes as "cancers" or not. And I guess that's a legacy of the very real controversy surrounding the clinical significance of all those cases of DCIS that suddenly started to turn up after the introduction of mass screening mammography. 86.128.169.211 (talk) 09:23, 21 June 2014 (UTC)

• I've now done my best to clarify the text. 86.128.169.211 (talk) 19:20, 21 June 2014 (UTC)

The thing is that it is not clarifiable. Cancer is by definition invasive. Malignant is by definition cancer. Pre malignant / precancer / preinvasive is not cancer. Yet they call it cancer. No matter how you splice it it doesn't make sense. There are inconsistencies in the use of the language. The problem with the current version is that it does not convey this. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:39, 22 June 2014 (UTC)

Short reply: Do you have a reliable source specifically about DCIS that actually says that the two different uses of "malignant" (i.e. malignant cells/tissue vs. pre-malignant condition) are a contradiction in terms? Otherwise that seems to me to be OR.

Extended reply: The point is that since the malignant (i.e. neoplastic) cells are confined to the duct/lobule the growth is clinically considered to be "premalignant". If we look at the wording of the best written sources, I think we can see how the authors are careful to distinguish whether they're referring to the cellular level or the clinical level. That is certainly true of the source you chose to reference usage of the term "malignant" [6] (viz. "proliferation of malignant breast epithelium" -- cellular level; "This condition is premalignant" -- clinical level). I think other writers are careful in their choice of words so as not to confuse readers unnecessarily.

Extended content

- Looking at another good MEDRS [7]: Ductal carcinoma in situ (DCIS) is noninvasive breast cancer that encompasses a wide spectrum of diseases ranging from low-grade lesions that are not life threatening to high-grade lesions that may harbor foci of invasive breast cancer. DCIS is characterized histologically by the proliferation of malignant epithelial cells that are bounded by the basement membrane of the breast ducts. Here it's described as "non-invasive breast cancer" composed of "malignant epithelial cells". - In another publication that provides a general introduction to terminology and classification [8] (in a symposium): Ductal carcinoma in situ (DCIS) refers to breast epithelial cells that have become “cancerous” but still reside in their normal place in the ducts and lobules. In this setting, cancerous means that there is an abnormal increase in the growth of the epithelial cells, which accumulate within and greatly expand the ducts and lobules. The author is careful to distinguish the clinical and biological levels: DCIS is the most common (80%–90%) type of in situ carcinoma in the breast, it represents an advanced or late stage of premalignant tumor progression, and it is the direct precursor of most IBCs [= invasive breast cancers]... Progression of noninvasive to invasive cancer occurs in other organs where it is easier to observe, such as skin and cervix, so there is ample biological precedence... For the most part, nearly everything known about DCIS was studied first in IBC (4,33–36). Surprisingly, we learned that the tumor cells of DCIS and IBC are highly similar at the cellular and molecular levels, even though one is invasive and the other is not. In this article, the author does mention a genuine source of terminological confusion, but that regards contemporary use of different systems of grading: More recent methods of taxonomy and terminology attempt to convey the relative degree that tumor cells in DCIS resemble normal cells, referred to as differentiation, and how rapidly they are dividing. Numerical scoring and grading systems were developed to reflect differentiation and growth. There are several and the details vary somewhat... All of these methods of classifying DCIS are still in use today, often interchangeably, which can be confusing and which could be improved.

(Note: I think we agree from the sources that on the statistical level there are real differences on whether DCIS should be counted as cancer or not. But that's another question.)
86.128.169.211 (talk) 11:31, 22 June 2014 (UTC)

At our institution, as I believe is general practice, DCIS is considered a "non-invasive" + "cancer" in every context -- histologically, clinically, and statistically. While there is a lot of (fair) controversy about where to draw the line between lower-grade, atypical histological classification and DCIS, clearly-identified DCIS is not controversial. As mentioned above, it is analogous to any other non-invasive carcinoma. For example, cervical cancer is well-understood to progress from a malignant, non-invasive stage to a later, invasive stage of disease. Likewise, DCIS is an abnormal proliferation of malignant epithelial cells that are limited to intra-ductal involvement, thus they are "non-invasive." Even the reference cited in opening line of main article (Allred 2010) refer to DCIS as cancer and not "precancerous." It is not "pre-malignant" so much as "pre-invasive." Dr G (talk) 19:52, 6 September 2014 (UTC)

Use "DCIS" or "intraductal carcinoma"?

Any objection to using DCIS throughout the main text, per the page name? Although I think it's generally best to restrict use of acronyms, I think this is the more widely used term ([9] vs. [10]), and it is probably more reader-friendly. 86.128.169.211 (talk) 10:15, 23 June 2014 (UTC)

Sounds good. Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:03, 23 June 2014 (UTC)

Easily done. 86.128.169.211 (talk) 16:35, 23 June 2014 (UTC)

Agree. While both accurate & commonly used, "intraductal carcinoma" is easier to mis-interpret. Dr G (talk) 19:55, 6 September 2014 (UTC)

Addressing "Treatment" section by adding "Controversy" section

The entire first paragraph of the "Treatment" section is inappropriate as it is currently written. The standard-of-care treatment for DCIS is surgical excision of the mass. There would be grounds for lawsuit if surgery was not offered. Surgery is basically always recommended for treatment. That being said, there is a (small) growing movement of protest against this standard of practice because there is a relative dearth of hard data showing comparing surgical excision vs. observation for non-invasive breast cancer. The issue is raised here in the Prescrire article, however this one source is cited 3x separate times as justification for several statements in the lead paragraph suggesting that surgery is perhaps not proper treatment. To me, this is editorially improper and smells of significant bias. To be sure, the question of surgery vs. alternate treatments is valid and wonderful question to explore, but such discussion belongs in another (perhaps separate) section of the page and not as the lead under "Treatment." Dr G (talk) 03:31, 10 September 2014 (UTC)

Do we have refs that state it is always recommended? US practice is not universally accepted. Agree it is "always" recommended as treatment in the USA but the US also has more lawyers per capita than any other country in the world. Happy for you to adjust. You just need references. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:06, 10 September 2014 (UTC)

Have clarified this to US position. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:22, 10 September 2014 (UTC)

I am not as familiar with international practices, however this 2012 review article from the International Journal of Surgical Oncology suggests (under "Treatment" section) that the options for treatment of DCIS are the same as listed by NCI. That is, breast-conservation surgery + XRT vs. mastectomy, with optional adjuvants. I will keep my eye out for alternative standards, as well as ask some of my international colleagues. Dr G (talk) 05:00, 11 September 2014 (UTC)

Yes we have [11] that acknowledges the controversy. Looking further agree surgery (either mastectomy or now more commonly lumpectomy) is the usual treatment globally. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:17, 11 September 2014 (UTC)

Conservatice management has not been studied [12] Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:22, 11 September 2014 (UTC)

JAMA Oncol 2015

Here's the JAMA Oncology study. Can we mention this in the entry, or do we have to treat it as a primary source and ignore it until it gets mentioned in a review article?

http://oncology.jamanetwork.com/article.aspx?articleid=2427491
Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ
Steven A. Narod, Javaid Iqbal, Vasily Giannakeas, Victoria Sopik, Ping Sun
JAMA Oncol. Published online August 20, 2015.
doi:10.1001/jamaoncol.2015.2510
At a Glance
-- The purpose of this study was to estimate the mortality from breast cancer following a diagnosis of ductal carcinoma in situ (DCIS) and to identify risk factors for death from breast cancer.
-- The 20-year breast cancer–specific mortality rate following a diagnosis of DCIS was 3.3%.
-- Young age at diagnosis and black ethnicity were significant predictors of breast cancer mortality.
-- Prevention of invasive in-breast recurrence with either radiotherapy or mastectomy did not prevent death from breast cancer.
-- The clinical course of women with DCIS is similar to that of women with small invasive breast cancers.

http://oncology.jamanetwork.com/article.aspx?articleid=2427488
Editorial | August 20, 2015
Rethinking the Standard for Ductal Carcinoma In Situ Treatment
Laura Esserman, MD, MBA1; Christina Yau, PhD1
JAMA Oncol. Published online August 20, 2015.
doi:10.1001/jamaoncol.2015.2607

Love it or hate it, Gina Kolata had a story in the NYT that explains the study pretty well -- or rather, quoted leading oncologists who explained the study pretty well:
http://www.nytimes.com/2015/08/21/health/breast-cancer-ductal-carcinoma-in-situ-study.html
Doubt Is Raised Over Value of Surgery for Breast Lesion at Earliest Stage
By GINA KOLATA
New York Times
AUG. 20, 2015

(Study in JAMA Oncology found no difference in cancer mortality in women with DCIS who had lumpectomies or mastectomies. Retrospective study of 100,000 patients found 3.3% mortality from breast cancer after 20 years, equivalent to general population. Almost no women were untreated. Model of DCIS colon cancer polyps. Widespread treatment of DCIS had no effect on invasive cancer in the general population.)
--Nbauman (talk) 16:53, 22 August 2015 (UTC)

Yes we have "While surgery reduces the risk of subsequent cancer, many people never develop cancer even without treatment and there are associated side effects.[21] There is no evidence comparing surgery with watchful waiting and some feel watchful waiting may be a reasonable option in certain cases.[21]" which is based on a review by Prescire. Doc James (talk · contribs · email) 17:09, 22 August 2015 (UTC)

I can't get access to Prescire (I've never seen it mentioned before), so I can't check their citations. But the JAMA Oncology article gives hard data based on SEER to reassure people that their 20-year mortality is no different with lumpectomy with or without radiation, or from the general public. That seems to be the kind of information that could affect a decision by a patient or doctor. --Nbauman (talk) 22:15, 22 August 2015 (UTC)

I assume it will be combined into secondary sources soon. I guess the question is should we include a summary now? We have this Cochrane review [13] Doc James (talk · contribs · email) 22:30, 22 August 2015 (UTC)

This source says " They found women undergoing mastectomy were less likely than women undergoing lumpectomy plus radiation to experience local DCIS or invasive recurrence. Women undergoing BCS alone were also more likely to experience a local recurrence than women treated with mastectomy. We found no study showing a mortality reduction associated with mastectomy over breast conserving surgery with or without radiation. This lack of benefit is particularly striking since clinically larger, multicentric, and more problematic tumors will be more likely to be treated with mastectomy than BCS with or without radiation."[14] So this simply confirms that statement from 2009 Doc James (talk · contribs · email) 22:36, 22 August 2015 (UTC)

Have added these details here [15]. Let me know what you think? Doc James (talk · contribs · email) 22:48, 22 August 2015 (UTC)

Rubin 2008

This cite seems too old, 2008. First, WP:MEDDATE says 5 years or so, and second, common sense says that there's been a lot of new work published since then which contradicts it. That's a particular problem since it's used to justify the statement that "About 20–30% of those who do not receive treatment develop breast cancer." More recent sources say 3%.

Rubin's Pathology: clinicopathologic foundations of medicine (5. ed.). Philadelphia [u.a.]: Wolters Kluwer/Lippincott Williams & Wilkins. 2008. p. 848. ISBN 9780781795166.
--Nbauman (talk) 17:05, 22 August 2015 (UTC)

Yes update it with the newer source. Doc James (talk · contribs · email) 17:07, 22 August 2015 (UTC)