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In a Ralph Moss article titled “The Great American Mammography Debate,” Ductal Carcinoma In-Situ is a topic of discussion. Questions that arise for me are whether or not Ductal Carcinoma In-Situ should be classified as cancer and whether or not it is included in the national survival statistics. I have addressed the statistics issue in another blog. Ralph Moss says the following about DCIS:
“Ductal carcinoma in situ [is] an amorphous category that sounds like cancer but may not be. What is the medical significance of DCIS? Will it surprise you to learn that, after decades of detecting and treating this condition, nobody seems to know? As the new USPSTF report states:
“Studies on overdiagnosis might also include long-term follow-up of women with probable missed cases of DCIS on the basis of microcalcifications that were missed in an earlier mammogram. Such studies could provide the percentage of these women who develop invasive breast cancer over the next 10 or more years” (Nelson 2009).
In other words, nobody knows how many of these DCIS lesions actually progress to invasive cancer. Since nobody really knows what DCIS means, nobody knows how best to treat it. Again, quoting the USPSTF report says:
“Although the standard treatments women receive for ductal carcinoma in situ (DCIS) include surgical approaches as well as radiation and hormonal therapy, considerable debate exists about the optimal treatment strategy for this condition” (Nelson 2009).
According to breastcancer.org, DCIS is not cancer and isn’t life-threatening. But DCIS is routinely treated as if it were full-blown cancer, possibly entailing a mastectomy (surgical removal of the breast). Meanwhile, thanks to mammography, DCIS’s growth has been astonishing. In 1983, there were 4,900 US cases of DCIS. By 2008, that number had increased to 67,770 (Nelson 2009). The over-treatment of DCIS has also swollen the ranks of “breast cancer survivors” and mightily improved the cure rate from the disease-because doctors are now “curing” a non-cancerous condition that in all likelihood would not have progressed to cancer.”
I believe Ralph Moss’s statement that DCIS is treated pretty much like invasive cancer is often true. As far as I know, most women are not yet offered chemotherapy, but they are commonly offered radiation and five years of Tamoxifen or other estrogen-blocking pills. Neither option is benign. My opinion is that this is often overtreatment, especially for very small singular focus DCIS that is not aggressive.
Every woman who is diagnosed with DCIS is going to be worried about the possible outcome. Hopefully, each person will have the time and ability to understand the situation and make a decision that is comfortable for them. This site contains other articles about DCIS that might be helpful.
I believe that saying Ductal Carcinoma In-Situ is breast cancer is sort of like saying a colon polyp is colon cancer. I do believe that some extensive or aggressive cases of DCIS are cause for alarm. I also believe that mammograms can save lives (including those lives from age 40-50 when breast cancers are commonly more aggressive than after menopause).
Moss says “meanwhile, thanks to mammography, DCIS’s growth has been astonishing.” I disagree with the way he puts that. Mammography is not to blame for the DCIS. It would have been there with or without mammography. It is only showing that the DCIS exists and can be easily detected with modern mammography. The problem is the aggressive overtreatment of what, statistically, is not likely to be life-threatening.
It is true that breastcancer.org say that DCIS “isn’t life-threatening.” But, Moss takes it a bit out of context. I can not find where breastcancer.org says that DCIS is not cancer. In fact, they call it cancer in the first sentence; non-invasive breast cancer.
To learn more about DCIS and the evidence-based therapies that can help you prevent its spread into invasive breast cancer, please watch the video below:
Mary Miller- Breast Cancer Profile in Courage
“Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means “in its original place.” DCIS is called “non-invasive” because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue. DCIS isn’t life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.
When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a recurrence are under 30%.
Women who have breast-conserving surgery (lumpectomy) for Ductal Carcinoma In-Situ without radiation therapy have about a 25% to 30% chance of having a recurrence at some point in the future. Including radiation therapy in the treatment plan after surgery drops the risk of recurrence to about 15%. If breast cancer does come back after earlier Ductal Carcinoma In-Situ treatment, the recurrence is non-invasive (DCIS again) about half the time and invasive about half the time. (DCIS itself is NOT invasive.)
According to the American Cancer Society, about 60,000 cases of Ductal Carcinoma In-Situ are diagnosed in the United States each year, accounting for about 1 out of every 5 new breast cancer cases.”
There are two main reasons this number is so large and has been increasing over time:
“Overdiagnosis refers to the phenomenon by which sophisticated methods of imaging and other methods of detection reveal cancers that in many cases would never have become evident clinically. This is a subject that Welch has long emphasized — for example, in a 2016 NEJM article on overdiagnosis of breast cancer from mammography screening.
Welch explores this issue once again, together with two colleagues, in a new study published in the October 3 issue of the New England Journal of Medicine.
This time, however, the authors have used a new approach to illustrate the issue: they looked at “epidemiologic signatures” for various cancer types.
“Cancer incidence is not a reliable measurement of cancer burden,” Welch said in a statement. “Rising incidence may not reflect rising true cancer occurrence but instead reflect overdiagnosis…
Undesirable epidemiologic signatures are those that show discordance between occurrence and mortality, or suggest overdiagnosis…
It is more likely that these signatures suggest overdiagnosis, in that cancers that were not “destined to cause death” were detected…
Mixed signals, the third category, is more complex and highlighted by changes in breast and prostate cancer incidence — both of these show rising incidence and declining mortality, but both are cancers where screening has played an intensive role…
The researchers point out that the introduction of widespread screening mammography led to a rapid increase in breast-cancer: the incidence increased rapidly and has apparently settled at a new, higher baseline. This could either be a true increase in occurrence, or overdiagnosis associated with widespread population based screening, they say.
Breast cancer associated mortality also began to drop in the 1990s, which could reflect either improved treatment or screening or a combination of both. “Other data suggest that improved treatment is the primary explanation,” they write.”