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DCIS: What You Need to Know

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A diagnosis of DCIS often brings mixed messages. Is this a real breast cancer? What is the meaning of Stage 0? If this is not life threatening, why are the treatments similar to those recommended for an invasive cancer? Deborah Collyar, founder of Patient Advocates in Research, helps us interpret the new findings that will aid you in navigating this diagnosis.

Published in: Health & Medicine
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DCIS: What You Need to Know

  1. 1. DCIS: what you need to know SHARE webinar with Deborah Collyar March 22 2017
  2. 2. Deborah Collyar Thanks for joining us today! PAIR: Patient Advocates In Research HLM: Health Literacy Media* Author Computers & training Cancer survivor x 2+ Early patient advocacy movement Research projects & organizations Why? Connect researchers & patients Better treatments & decisions *Thanks for slide format!
  3. 3. Why is DCIS so confusing? DCIS details What do I need to know? DCIS decisions How can we find better answers?Research & you What we’ll cover
  4. 4. Normal Cells line up in breast ducts ADH Atypical Ductal Hyperplasia DCIS & LCIS Ductal Carcinoma In Situ Lobular Carcinoma In Situ IBC Invasive Breast Cancer ex: Infiltrating Ductal Carcinoma, Stages 1-4 Types of breast conditions http://breast-cancer.ca/dcis-grypes/
  5. 5. Find breast cancer early Lower death rates at first, but… Same death rates over time Found more breast conditions Why DCIS? Mammography Theory (1970s – 2000s)
  6. 6.                       1980 1983 1985 1987 1989 1991 0 5 10 15 20 25 Thousands DCIS MMG Machines 1 in 1300 screening MMG diagnose DCIS DCIS = unintended consequence of increased screening DCIS rise with mammogram machines Courtesy of Shelley Hwang, MD
  7. 7. DCIS and Invasive Cancer Incidence (1975-2008) Screening mammograms introduced WHI data published DCIS Invasive Cancer Courtesy of Shelley Hwang, MD
  8. 8.  Found more breast cancer  Found DCIS  No change in overall deaths This means Screening results? More DCIS diagnoses (~50,000 in US/year) Over-treatment for many (3 in 10 estimated)* * 2017 University of Oslo
  9. 9. Low or grade 1 Medium or grade 2 High or grade 3 Slow growth Cells look normal or like ADH Faster growth Cells look abnormal Rapid growth Cells in different sizes & shapes DCIS makes grades http://breast-cancer.ca/dcis-grypes/
  10. 10. Slow growth Cells look normal or like ADH Faster growth Cells look abnormal Rapid growth Cells in different sizes & shapes DCIS grades http://breast-cancer.ca/dcis-grypes/ Low risk DCIS High risk DCIS Low or grade 1 Medium or grade 2 High or grade 3
  11. 11. Surgery Radiation therapy Hormonal therapy http://www.mayoclinic.org/diseases-conditions/dcis/basics/treatment/con-20031842 Current treatments for DCIS Lumpectomy Mastectomy Double mastectomy (preventive) Whole breast (external) Partial breast (internal) Tamoxifen Aromatase inhibitors NOTE: for ER+ only
  12. 12. Monitor Surgery Radiation therapy Hormonal therapyActive Surveillance https://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=616060 What about Active Surveillance for low risk DCIS? Currently, less than 4 in 100 women (4%)
  13. 13. Complexity of the health care system How to find those at highest risk? The U.S. culture of medicine Do no harm?
  14. 14. Why is DCIS so confusing? DCIS details What do I need to know? DCIS decisions How can we find better answers?Research & you Questions?
  15. 15. You have TIME Treatment for DCIS depends on personal preference
  16. 16. You have TIME Treatment for DCIS depends on personal preference Survival higher than general population* Review your options 8 out of 10 won’t get a future DCIS or IBC High risk DCIS: all treatment options Low risk DCIS: Active Surveillance too
  17. 17. Surgery does not always give good results… Courtesy of Shelley Hwang, MD • Includes double mastectomies to “prevent” future DCIS or IBC • Long-term complications (pain, numbness, edema, multiple surgeries, etc.) • Women often don’t hear about problems when making decisions
  18. 18. The Worried Well after 2 years… From Shelley Hwang MD. Liu Y et. al. BCRT 2011 • 506 women in a quality-of-life (QOL) study • Completed interviews at baseline + 2 years after surgery • Fear of cancer “recurrence” • About 3 in 10 (30%) DCIS patients had medium/high levels of fear 2 years after surgery
  19. 19. Who is at risk for DCIS/IBC? What does that mean? How much can you handle? Fear = uncertainty Uncertainty = risk
  20. 20. Breast cancer survival - even better for DCIS! Seer.cancerlgov
  21. 21. DCIS in perspective: women live longer than general population* DCIS Dilemmas, 2015 DCIS: Ductal Carcinoma In Situ IBC: Invasive Breast Cancer * Netherlands Cancer Institute, 2017
  22. 22. Some risk factors are known Good news! Now we need to apply them
  23. 23. Age & hormones Periods, reproduction, density, DES Biology & self Genetics, history, biomarkers Diet & activity Alcohol, obesity, exercise, behavior Race & ethnicity Biology? Access? Bias? Risks for DCIS https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm Similar to breast cancer
  24. 24. Ex. Risk model before having DCIS or IBC https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm
  25. 25.  High grade DCIS  Unclear margins  Multiple lesions  Large lesions  Under 40 at diagnosis  African-American  Access to medical system Those with DCIS at highest future risk over 10 years have more: DCIS Dilemmas 2015
  26. 26. More 10 year risk factors after having DCIS Kerlikowske et al. JNCI 2010 Risk factor Future DCIS Future IBC Age 40-49 years Over 40 If original DCIS: • Lump could be felt (palpable) No Yes • Lesion was larger (>10mm) Yes No • High grade or dead center (necrosis) Yes No • Unclear or positive margins Yes No High levels of these biomarkers : • P16+ - Yes • P16+ and Ki67+ - Yes • P16+ and Ki67+ and Cox2+ - Yes Abnormal levels of these biomarkers: • ER- Yes No • ERRBB2+ or ERBB2+ Yes No • Ki67+ Yes No • ER- and ERBB2+ Yes No • ER- and Ki67+ Yes No • P16+ and Cox2- and Ki67+ Yes No Differences between future DCIS and future Invasive Breast Cancer (IBC)
  27. 27. Why is DCIS so confusing? DCIS details What do I need to know? DCIS decisions How can we find better answers? Research & you Questions?
  28. 28. What happens if you don’t “treat” DCIS? SEER 1988-2011 From Shelley Hwang MD. Sagara et al, JAMA Surgery 2015 10-year DSS: • Surgery: 98.8% • No surgery: 98.6%
  29. 29. Basic research Biological reasons for DCIS & risk Clinical trials Treatment options by DCIS type Other Tests: risk scores Health outcomes & quality of life Imaging (mammography, etc.) Population science (epidemiology) Research areas DCIS Dilemmas 2015
  30. 30. o Mammaprint, Oncotype DX, MSKCC Nomogram o Developed for invasive breast cancer (IBC), not DCIS o Not clear for DCIS: included combined DCIS+IBC in studies o Best use o Decide about radiation therapy with a breast cancer diagnosis o For DCIS? o Promising, but not widely used o Need research specifically for pure DCIS About predictive tests…
  31. 31. LORIS LORD COMET PRECISION UK EORTC US Biomarkers from all DCIS is global: clinical trials for low risk
  32. 32. Endpoints: • 2, 5, 7-year invasive cancer dx • 2, 5, 7-year OS, DSS • PRO endpoints (QOL, fear of cancer recurrence, body image) COMET (Comparison of Operative to Monitoring and Endocrine Therapy) trial for low risk DCIS Eligiblity criteria: • Age ≥ 40 • Grade I/II DCIS without invasive cancer • Diagnosed confirmed by core or surgical biopsy • ER(+) and/or PR(+), HER2(-) if tested • No mass on PE or imaging Registered and randomized (n=900) GROUP 1: Usual Treatment (n=450) Surgery, Radiation or both choice for endocrine therapy Mammogram every 12 months for 5 years GROUP 2: Close Monitoring (n=450) choice for endocrine therapy Mammogram every 6 months for 5 years Courtesy of Shelley Hwang, MD
  33. 33. Patients who are NOT candidates for COMET • High grade or extensive DCIS • Palpable disease, other breast signs or symptoms • Mass on imaging Courtesy of Shelley Hwang, MD
  34. 34. DCIS will be less confusing with new clinical trials & studies • Stay informed (dcisoptions.org, dcis411.com, etc.) • Give us feedback • Spread the word about COMET! If you have/get DCIS • You have TIME • It’s a trade-off between future risk v. treatment effects • COMET, LORIS and LORD will help us see if Active Surveillance is as good as Usual Treatment for women with LOW risk DCIS In summary
  35. 35. https://collyar.wordpress.com/ www.facebook.com/DeborahCollyarAutho r Twitter: @deborahcollyar Thank you! Get in touch with deborah@tumortime.com Deborah Collyar http://amzn.to/2mNz8CD
  36. 36. Discussion time
  37. 37. Trade-offs to treatment (from US data/year) 34,000 lumpectomy 23,000 radiation 10,000 mastectomy 4000 double mastectomy + 20,000 hormonal therapy ~$250M annually > = < USUAL CARE ~1% 10-year disease- specific mortality benefit ACTIVE SURVEILLANCE (AS) From Shelley Hwang MD. Ong and Mandl, Health Affairs 2014 USUAL CARE (UC)

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