Study Prompts San Diego Doctors, Patients To Question Breast Cancer Treatment Strategy
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August 24, 2015 1:17 p.m.
Dr. Reema Batra, medical oncologist, Sharp Grossmont Hospital
Donna Pinto, diagnosed with DCIS
Related Story: Study Prompts San Diego Doctors, Patients To Question Breast Cancer Treatment Strategy
Our top story on Midday Edition, early intervention is key in the treatment of cancer. But how early is too early? And is early intervention helpful in so-called stages zero breast cancer? A new study by a team of Canadian researchers finds that surgery on this type of breast cancer had no effect on ultimate survival rates. The study as fuel to the contribution about whether the treatment of some cancers is overly aggressive and joining me to talk about the findings are Dr. Reema Batra, a medical oncologist at Sharp Grossmont hospital and Dr. Dr. Batra, welcome to the show.
Donna Pinto is from -- diagnosed with Stage 0 ductal carcinoma in situ or DCIS. Several years ago in Donna, welcome to the program.
Thank you so much for having me, it is great to be here.
Dr. Batra, what is DCIS?
We've been calling it a stages zero cancer for many years now, but I think there's a lot of controversy just surrounding the name cancer, the word cancer around DCIS. It is abnormal cancerous appearing sales that are still in the duct of the breast. The action haven't invaded and cancer typically invades the breast tissue and actually there's a concern that it is going to spread through out the rest the body. Because these cancer sales that we see DCIS are still within the duct, the chances of that spreading to the body are quite low so there's a lot of controversies surrounding the name, the word cancer with these DCIS.
How common is it?
If CNET about 20 to 25% of women so within a year we will see about 60,000 women? That knows with first cancer. They have DCIS.
What does stages zero mean?
The term is basically telling us that this is a precursor to invasive cancer. So all these years we have been treating it as if if you keep the DCIS lesion within your breast then you are definitely going to develop cancer down the road. So it is really a precursor to the base of form.
Dr. Batra, what's the current standard of care for DCIS?
Typically when you see a patient with DCIS the next recommendation is to surgically reset the lesion so either we do a lump it to me with radiation or a mastectomy.
This study that we are talking about today was of more than 1000 patients that found that survival rates over 20 years after diagnosis with the same for women who had surgery as for those who didn't. What doesthat information indicate about the current treatment methods that you just told us about?
I think this is kind of confirming what we are -- what we have been thinking for a while now is that we are probably over treating DCIS. One mammogram came in to play in the 80s we were only detecting a few hundred of these a year and once mammogram started we were seeing 20 to 25% of breast cancers be DCIS. So everyone was overenthusiastic in starting to treat the patients goes like we would treat an invasive cancer. With the studies telling us that we may need to rethink our treatment strategy with these -- with DCIS.
Donna Pinto, let me go to. When were you diagnosed with DCIS?
I was diagnosed January 19, 2010.
What kind of treatments have you undergone?
Initially when I had the diagnosis I had already had surgery because I had had a biopsy company-owned biopsy prior to that which showed a typical ductal hyperplasia which is a less of a concern, but still the search in situ wanted to get a bigger piece sample issue when you to do a wide excision. That is pretty typical -- it is the same as a lumpectomy. I had that done and that's what upstaged me to DCIS and at that point I was told that there were positive margins, there were still DCIS there that they would need to do a mastectomy or partial max up to me plus seven weeks of daily radiation. That's when I just was dumbfounded and shocked by -- was told me it was a precancer or noninvasive and great that it is early stage and nothing really to worry about but then the treatment didn't really match what I was being told. That's when I started investigating and I put the brakes on
As you are saying -- telling us here you decided to stop aggressive treatments. Why?
At that point I had a friend who is a holistic health practitioner, she found out that I put an e-mail out to all my printed family this is the good news and this is the bad news and the bad news was the treatment options and the good news was the founder early so that was the thought process at the time. My friend said no, you need to come see me and I will go through this whole detox with you and put off the MRI for a month and it will be clear and this is nothing and she counseled me on the fear part of it because the emotional aspect of that doses like this is something that you do not understand until app and to you. It takes you to hold the other source for especially when you've had a family member, I had a grandmother who died of breast cancer at a young age so you automatically go into the place of getting out, do everything you can, I understand why people do you want the aggressive treatment. However had my friend saying this is what we are going to do for a month and she calm my fears and she directed me to certain websites and books and I start getting educated and competent peers and a month later the MRI showed nothing. Sweat that point was very easy to say I'm not doing more surgery if you cannot see anything. It is that clear little bit of applied surgery anyway because they have to put a wire the woman's breast to localize the place where the cause of Kaizens are, it so microscopic they cannot really see when the surgeon goes and it is like a naked applied surgery so they are groping for the best area and that's why it leads off into the positive margins which happened to me three times.
So Donna, what are you doing instead of surgery or radiation?
So instead of the radiation or even tamoxifen was also an option five years of the drug tamoxifen as a prevention, I look at what can we do naturally to reduce estrogen are block estrogen in a similar fashion as something like tamoxifen and I studied what are those chemicals compounds in nature so --
Nutrition, I became a certified nutritionist, I studied nutrition so much that I thought I might as well get certified in it and help other people because at that point also that was the very beginning and I got very much into the nutrition part and I was already very healthy diet and exercising and running for 30 years and doing yoga for 10 years. I think all that played into when I was given the diagnosis I was also told to go see all these different oncologist, get an MRI, see this nurse to together and would you like a production for Xanax? That to me also was not the right with going about this. If you have stress, there's a lot of other ways to manage
Is your doctor supportive of the decisions you have made?
No, actually the doctors here actually said things to me like don't be stupid, Donna. I actually flew to San Francisco to consult with Dr. Astromen who I found her editorials and her writings and there was one article in Medscape in 2010.talk about this issue of overtreatment and she was at the forefront saying minimal risk lesion should not be called cancer. We are over treating this in 95% of the cases. I want to know was I one of the 95 cases if I am low risk, this is too much -- my gut feeling was right. So I went along her path. 20 months later after that first surgery that left the DCIS the positive margin I had a mammogram and again the alarms went off, that is highly suspicious and malignancy, you are sucked what you do now with the only way to know is to remove it. So we have a choice of needle biopsy again or surgically remove it so --
I want to ask Dr. Batra, you made this comment early on about whether DCIS is cancer or not, is there any consensus in the medical community about whether or not this abnormality is going to lead to invasive cancer?
I think we come I can it to something like a polyp that you see on a colonoscopy and those cases where just removing the public instead of going at it and doing the full colon cancer surgery. Where in this case I think when mammogram started and it there was all this enthusiasm we said that Street street alike in invasive breast cancer and I think what we're seeing now is the trend that that start rethinking our strategy. At this point there's no standard of care change, think this article is really eye-opening, but what we really need is a prospective trial comparing those surgical strategies doing observational Mike what Donna did. In order to really make a standard of care practice changing type thing. The consensus at this point and just in my small practice we pulled my colleagues and I don't think any of us are yet willing to say when we meet the patient like Donna we are going to suggest doing watchful waiting or something like that. I think we will still go along with the standard of care, but really the important take away point from what Donna is saying is treatment can certainly be individualized based on the type of DCIS you see in the patient.
As Donna was mentioning, there is this reaction especially if you have any kind of family history is if it is even the smallest chance it could become invasive, that's remove it. Are there downsides to that way of thinking?
Sure. I think fear can definitely play a big role in the management of this diagnosis. When I see patients with DCIS I see patients who range from Donna's reaction to maybe doing less as far as the medical strategy and we more observational and dietary changes to people who want to do a bilateral mastectomy. So there's definitely a various reaction that -- varied reactions I get from the patient community.
I would imagine that this most recent study that we are talking about Donna has affirmed your decisions what your thoughts about overtreatment. But is there a danger do you think that this study will swing the pendulum any other way from overtreatment to undertreatment?
That's always a concern, I know there's a lot of women I hear from that are concerned about that the insurance will not cover certain medical cost because it will not be medically necessary. I think it comes back to what we were talking about with individualized seeing the treatment to the specific case so rather than women reacting in fear and over reacting and watching the double mastectomies which receive is on the rise which is a big concern, then if we could utilize the risk assessment tools that are available that can show whether or not or the low risk or high risk such as Oncotype test which came out in 2012, which I had and which confirmed for me that mine was low risk as well. That should be covered by insurance. These tests and MRIs which have been shown to be better at finding high-grade ECAS or invasive cancer, we should be covering that with insurance and I was told you whenever get an MRI if you do not do another mammogram and I said but the mammogram is part of the problem in finding these low risk locales applications setting off the alarms, scaring the heck out of us and you have no choice but to do surgery. It is an ineffective tool. We doneed to be able to figure out better, have better screening, better test of molecular genetics and all that genomics and that's happening and that's available so really a few years ago they said we do not know which ones will become invasive and that is not true anymore.
I think that we have to look at this from every case is individual, everybody's situation is different and you cannot just do one-size-fits-all.
Dr. Batra, will this study is that of fact when you tell your patients? Who are diagnosed with DCIS?
I think I don't think it is going to change my recommendations as far as the surgical removal of the lesion. Of course there's exceptions to that, but generally, I do not think the standard of care approach is going to take as change as far as my practice. But I do think that having a conversation with the patient and really educating them for them to understand that this may be a bigger treatment than what you are thinking. If the patient comes to me with a small area of calcification and lots of do a bilateral facet be, this is something I will bring up. So in that way yes, I think this will help me change my strategy but overall, the standard of care remains the same. I think they are still a lots of taking we have to do.
Donna, finally, do you see you and your doctors continuing to monitor your condition well into the future?
Yes, but I'm not doing mammograms as a monitoring tool. I'm -- MRI and I feel that mammography is what caused a lot of harm for me and I think that I've done a lot of research on it and it is not the tool that we had all hoped it would be. I bought into the whole early detection saves lives, we all want that, there's no question about it and it is a hot topic but it will continue to monitor and I'm not living in fear of cancer. I feel like I know so much now. I am not afraid and I am on top of it and I know my body and I will continue in my own way and I will try to help other people to get the resources that I have found to be the most helpful and that's what I created my blog.
Exactly, tell us just where can people find your blog?
It is a DCIS 411, 411 this information and I created it to provide a place of support for women looking for less aggressive treatment and maybe opting out of radiation were tamoxifen.
We will have to leave there. I've been speaking with Dr. Reema Batra with Sharp Grossmont hospital and with nutritionist to do, thank you both very much.