What’s In A Name? Cancer – or Indolent Lesions of Epithelial Origin

What’s in a name? In the case of cancer, there are myths, fears and misinformation – more than perhaps any other illness. 

Cancer encompasses hundreds of different diseases and each one is complex.  Even women diagnosed with exactly the same ‘type’ of breast cancer and who undergo the same treatment can have very different outcomes. 

Not all cancers are equal and not all cancers are lethal.

While early detection and treatment were once equated with improved survival, we now know that tumor biology (characteristics governing the behavior of spread and response to treatment) plays an extremely important role in the prognosis of an individual cancer. There is an increasing recognition that current screening tests, meant to diagnose cancer in the earliest stages, will often diagnose lesions that have minimal potential to become aggressive or lethal. As our screening technology improves, we are detecting more patients in early stages or with pre-cancerous conditions (such as atypical ductal hyperplasia), and we are treating those patients with surgery and other potentially toxic therapies.

In 2012, the National Cancer Institute convened a working group to “evaluate the problem of ‘overdiagnosis’ which occurs when tumors are detected that, if left unattended, would not become clinically apparent or cause death.” Unrecognized overdiagnosis, they stated, “generally leads to overtreatment” 1. 

The recommendations of this panel were recently published in the Journal of the American Medical Association: Overdiagnosis and Overtreatment in Cancer, An Opportunity for Improvement.  The authors provide five recommendations:

      1. Physicians and patients alike need to acknowledge that screening results in overdiagnosis – especially in breast, lung, prostate and thyroid tumors.

      2.  The term ‘cancer’ should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated.

      3.  Create observational registries for low malignant potential lesions in order to better understand prognosis and best treatment options.

      4. Mitigate overdiagnosis with an ultimate goal of preferential detection of consequential cancer while avoiding detection of inconsequential disease.

      5. Expand the concept of how to approach cancer progression by controlling the environment in which cancerous conditions arise.

While these are certainly laudable goals, some important points should be made, especially in regards to breast cancer and ductal carcinoma in-situ – the most important being that we do not currently have biomarkers or other indicators that can clearly distinguish a potentially lethal cancer from a more indolent one. The field of cancer genomics is rapidly changing, and today more than ever we can obtain very sophisticated prognostic information regarding an individual patient’s tumor. Despite that, Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center, stated “Which cases of DCIS will turn into an aggressive cancer and which ones won’t? I wish I knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer” 2.

Regarding the modern management of DCIS, there are three points to remember:

      1. When DCIS lesions diagnosed by needle core biopsy are surgically removed (which involves removal of substantially more tissue from the abnormal area), there is an approximately 15% rate of ‘upstaging’ to invasive ductal cancer 3. Put another way, one cannot always reliably predict the behavior of an entire lesion based on a core biopsy specimen.

      2. During surgery for DCIS, axillary lymph node metastases have been demonstrated up to 20% of the time, usually indicating missed microinvasion or invasion 4.

      3. Finally, if DCIS recurs, 50% of the time it is invasive 5.

What is important for the #BCSM community to be aware of is that any woman with breast disease, including DCIS, should be presented with the information necessary so that she may gain an understanding of where her diagnosis stands in the biological spectrum and the wide array of choices she has for treatment. DCIS is far from simple, and it is not to be taken lightly. Clearly there are cases where ‘watchful waiting’ is safe – but we cannot always reliably predict who will truly benefit from treatment. Moving forward, we need to be aware of the facts – what medical technology can provide the physician and patient now, and we need to ask how we can drive this conversation in the future.

Jody Schoger
Michael S. Cowher, M.D.
Deanna J. Attai, M.D., F.A.C.S.

1 JAMA – Overdiagnosis and Overtreatment in Cancer – An Opportunity for Improvement

2 New York Times – Scientists Seek to Rein in Diagnoses of Cancer

3  Bruening W, et al.  Systematic Review:  Comparative Effectiveness of Core-needle and Open Surgical Biopsy to Diagnose Breast Lesions.  Ann Intern Med.  2010;152(4):238-246

 Journal of the National Cancer Institute (2004) – Ductal Carcinoma In-Situ: Complexities and Challenges

5  National Cancer Institute – Breast Cancer Treatment – Ductal Carcinoma In Situ 

CURE  Today Blog by Dr. Debu Tripathy: Redefining the Word “Cancer”

Ductal Carcinoma In-Situ Clinical Trials

Neoadjuvant Letrozole For DCIS (Clinical Trial)

Pink Ribbon Blues – Carcinoma: What’s In a Name?

Bloomberg News – Women with Pre-Cancer Tumors Urged to Reconsider Surgery


Breast Cancer Overdiagnosis and Overtreatment | Center For Breast Care

Date: 3 Aug, 2013

[...] What’s In A Name? Cancer – or Indolent Lesion of Epithelial Origin? [...]

Beth Gainer

Date: 3 Aug, 2013

Thank you for discussing this important topic. As a patient, it is scary to me to not know which cancers are lethal and which ones are indolent. I truly can understand why people diagnosed with DCIS want their lesions removed, though. If it's not known which DCIS lesions will eventually become lethal, as a patient, I would have it removed. I wish I could be at the tweet chat. I teach Monday nights this quarter and miss #BCSM. Thank you for such a great post!


Date: 3 Aug, 2013

Thanks for your comments, Beth - it is a difficult and challenging disease and there are clearly not one-size-fits-all answers. We will miss you on Monday but this is sure to be a topic discussed for quite some time!

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Date: 3 Aug, 2013

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Susan Zager

Date: 3 Aug, 2013

Thank you for helping explain this very complex issue. There's so many mixed messages when prominent studies are questioning whether there's been over treatment for DCIS or not. As you so clearly point out, there is no way to know which cases of DCIS will become invasive. With statistics showing that 50% of cases will, added with your information stating that "during surgery for DCIS, axillary lymph node metastases have been demonstrated up to 20% of the time, usually indicating missed microinvasion or invasion," clearly there are many factors that must be weighed out with one's Doctor when presented with DCIS. Thank you for giving us the facts and statistics involved.

Julie Goodale

Date: 3 Aug, 2013

Thank you for this very clear post. It's such a difficult issue - filled with fear and the fog of the unknown. I keep working very hard at separating my personal experience from the larger issue. Thanks for helping to bring a little clarity to the discussion. Looking forward to tonight's chat. Julie


Date: 3 Aug, 2013

Thank you for your comments, Julie.

Margaret Polaneczky, MD

Date: 3 Aug, 2013

Thanks for this info. It's important for women to know that not all DCIS is just DCIS, and that even within this diagnosis there are variables than warrant consideration. However, in my experience, treatment decisions about DCIS are usually not based on just a core biopsy. In my experience, the lesion is excised and often sentinal node biopsied. Now, with info in hand, a woman and her doctor can discuss management options that are right for her. Every woman's disease is different, and every woman can make her own decision as to how to proceed. I do think that a most important message for women to get is that mastectomy in DCIS, while most certainly reducing the risks for being diagnosed with breast cancer in the future, has not been shown to reduce breast cancer mortality. Thanks for keeping the discussion going....


Date: 3 Aug, 2013

Thanks so much for your comments, Margaret. I agree that most often the treatment decision is being made after surgical excision, but I am seeing (at least in my practice) more women who are wanting to make their decision based on the core biopsy information alone. No question that our consultations are becoming longer as the amount of information increases and the decision-making process becomes more individualized.


Date: 3 Aug, 2013

This is an excellent explanation and I'm sharing it. Thank you!! PS Awesome Tweet chat tonight!


Date: 3 Aug, 2013

For those of you that missed the tweetchat, here's the transcript: http://hashtags.symplur.com/healthcare-hashtag-transcript.php?hashtag=BCSM&fdate=08-05-2013&shour=18&smin=00&tdate=08-05-2013&thour=19&tmin=15&ssec=00&tsec=00&img=1

Should We Rename DCIS? - Breast Cancer Consortium

Date: 3 Aug, 2013

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Date: 3 Aug, 2013

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