Patients with stage 0 breast cancer may not need to rush into surgery

Watch and wait may be an alternative to surgery for some women with very early breast cancer.

A new study of 957 women evaluated whether it was safe to do active surveillance for a low-risk form of ductal carcinoma in situ, or DCIS—a noninvasive cancer, often called Stage 0 breast cancer, that has not spread. beyond the milk ducts. – as an alternative to surgery (SN: 8/30/24).

After two years of follow-up, women assigned to receive active monitoring had no more invasive breast cancer than women assigned to have surgery, researchers report Dec. 12 in JAMA. In fact, in the surgery group, there was a cumulative rate of invasive cancer of 8.7 percent, compared with a 3.1 percent rate in the monitoring group.

Of the cancers found in the monitoring group compared with those detected during surgery, “those cancers were not larger, they were no more likely to have spread,” says Shelley Hwang, a breast cancer surgeon at the University School of Medicine. Duke.

Active monitoring included mammograms every six months and hormone therapy for most participants. Of the 484 women in the monitoring group, 82 ended up having a lump or the entire breast removed. The 473 participants assigned to the surgery group often also received radiation and hormone therapy. A handful of volunteers in each group received chemotherapy.

The results suggest that a watch-and-wait approach is safe in the short term and may even be superior to surgery for low-risk DCIS because it helps women avoid treatments for a precancerous condition that can never be cured life-threatening, Hwang and colleagues say.

But “two years of follow-up is too short to draw that conclusion,” says Monica Morrow, a surgical oncologist and chief of breast cancer surgery at Memorial Sloan Kettering Cancer Center in New York City, who co-authored a editorial. about the study that also appeared on Dec. 12 in JAMA. She points out that while women in the monitoring group who underwent delayed surgery did not have statistically significant differences in the size of their tumors from the surgery group, the monitoring group had more cancers that were larger than one centimeter than in the group he received. surgery immediately.

“As the cancer gets bigger, the risk of spreading to women [lymph] the joints go up. The amount of drug therapy we give to treat them goes up,” says Morrow. “So if by delaying surgery, you end up getting more aggressive treatment than you would have gotten if you had done the surgery earlier, a is it really a good compensation?”

And the study is not representative of all women with DCIS, Morrow says.

As Hwang notes, the study examined DCIS in women age 40 and older, in whom the abnormal duct cells “didn’t seem particularly aggressive” and who had receptors for hormones such as estrogen or progesterone. These factors make the cells at low risk of becoming invasive and controllable with hormone therapy. About half of the more than 50,000 cases of DCIS diagnosed in the United States each year fall into the low-risk category, Hwang says. People with more aggressive forms of DCIS shouldn’t wait to have it removed, she says.

Another difference between the women who volunteered for the study and the general population diagnosed with stage 0 breast cancer is psychological, Morrow says. Often patients diagnosed with DCIS want it removed. But “the women who entered this study very clearly wanted to have No. surgery.” In fact, an unexpectedly large number of the 473 women who were randomly assigned to have the operation refused. Only 264 continued with their assigned treatment.

Patients and patient advocates who are concerned about overtreatment may be reassured by the study, Hwang says. “Patients [diagnosed with DCIS] they used to say, ‘You have to be in the operating room next week so we can get this out.’ They can take a lot of reassurance knowing that this is not an emergency, they don’t have to rush into anything.”

A companion study, published Dec. 12 in JAMA Oncologyexamined quality of life for patients in the monitoring and surgery groups. “Patients in the active monitoring group didn’t spend their entire days worrying about things,” Hwang says. “There was an equal amount of discomfort in both groups.”