{"id":3089,"date":"2015-10-09T22:11:24","date_gmt":"2015-10-10T05:11:24","guid":{"rendered":"http:\/\/andylee.pro\/wp\/?p=3089"},"modified":"2015-10-09T22:13:18","modified_gmt":"2015-10-10T05:13:18","slug":"time%ef%bc%9awhy-doctors-are-rethinking-breast-cancer-treatment-3","status":"publish","type":"post","link":"https:\/\/andylee.pro\/wp\/?p=3089","title":{"rendered":"TIME\uff1aWhy Doctors Are Rethinking Breast-Cancer Treatment"},"content":{"rendered":"

\"Screen<\/a><\/p>\n

http:\/\/time.com\/4057310\/breast-cancer-overtreatment\/<\/a><\/p>\n

Too much chemo. Too much radiation. And way too many mastectomies<\/h2>\n
\n

\u201cWhat if I decide to just do nothing?\u201d<\/p>\n

It was kind of a taunt, Desiree Basila admits. Not the sort of thing that usually comes out of the mouth of a woman who\u2019s just been diagnosed with breast cancer. For 20 minutes she\u2019d been grilling her breast surgeon. \u201cJust one more question,\u201d she kept saying, and her surgeon appeared to her to be growing weary. She was trying to figure out what to do about her ductal carcinoma in situ (DCIS), also known as Stage 0 breast cancer, and she was already on her second opinion. The first surgeon had slapped a photograph of her right breast onto a viewer, pointed to a spot about 5 cm long and 2.5 cm wide and told her there was a slot open the following week for a mastectomy.<\/p>\n

Basila\u2019s first reaction to her diagnosis was an animal-instinct panic that she registered as \u201c10,000 bricks\u201d crushing into her chest when she woke up in the morning. After that, Basila, who is now 60 and teaches high school science in San Francisco, did a little research. She learned that there were a lot of unknowns about the progression of DCIS, which is noninvasive\u2013it\u2019s confined to the milk ducts\u2013and is the earliest stage of breast cancer. She also learned there was some disagreement in the field about how to treat it.<\/p>\n

She knew she wasn\u2019t ready to have one or both of her breasts cut off. And she wasn\u2019t sure she wanted a lumpectomy either. That\u2019s why when Dr. Shelley Hwang, then a surgeon at the University of California, San Francisco (UCSF), recommended a lumpectomy, Basila grew frustrated. She was coat in hand and ready to walk out the door when she issued that half taunt. And when she did, Hwang said this: \u201cWell, some people are electing to do that.\u201d<\/p>\n

Basila sat back down, and as their meeting reached the hour mark, she made a choice that humans are practically hardwired not to make in the face of a cancer diagnosis: she decided to do nothing.<\/p>\n

Well, not nothing, exactly. She would start taking a drug called tamoxifen that blocks estrogen, which can fuel tumor growth, and she would enroll in a clinical trial involving active surveillance: twice-a-year visits in which she would get mammograms alternating with MRIs. As long as there were no worrisome changes, Basila would be spared the standard arsenal in breast-cancer treatment: surgery, radiation and chemotherapy.<\/p>\n

That conversation took place eight years ago. And if it sounds radical today, it was all but heresy back then. This was before the U.S. Preventive Services Task Force said in 2009 that women should start mammograms at 50, not the previous guideline of 40, because there\u2019s insufficient evidence that earlier screening does more good than harm. Before research showed that for some women with Stages 1 and 2 breast cancer, the absolute survival benefit from preventive double mastectomies is less than 1% after 20 years. Before the paper in August showing that no matter how a woman is treated for DCIS, the mortality risk is 3%\u2013similar to the average for the general population. And before the news that some women with early-stage breast cancer don\u2019t benefit from chemo and can skip it.<\/p>\n

In other words, that conversation took place before doctors and patients were faced with the evidence that in the U.S., many women with breast cancer are being massively overtreated. Thanks to advances in genomic testing and deeper insights into the biology of different kinds of breast cancer, doctors are learning that the one-size-fits-all approach isn\u2019t working. They\u2019re also learning that every woman brings with her a unique profile of biological risk\u2013as well as a unique appetite for risk. That means that while some women require urgent and aggressive treatment, there are many who can slow down and take a more sparing approach.<\/p>\n

Now those at the vanguard of breast-cancer treatment are calling for a major shift in the way doctors treat\u2013and talk about\u2013the disease, from the first few millimeters of suspicious-looking cells in milk ducts to the invasive masses found outside of them. That\u2019s making the tough conversations between a woman and her cancer doctor ever harder, but it also stands to make them more fruitful.<\/p>\n

Because as good as we have gotten at finding breast cancer\u2013and we\u2019ve gotten very good\u2013all this new data suggests there may be better ways to treat some breast cancers, particularly those at the early stages. Evidence is mounting that aggressive treatments, designed in earnest to save women\u2019s lives, can have unforeseen and sometimes devastating consequences.<\/p>\n

Call it collateral damage. It\u2019s the multiple follow-up surgeries after a mastectomy and the subsequent infections; the radiation that doesn\u2019t always improve survival and the cancer risk that can come with too much of it; the sometimes unnecessary chemotherapy and its life-sapping side effects. For some in the field, that collateral damage is getting harder and harder to justify.<\/p>\n

Now a small but influential chorus of leaders is calling for a radical\u2013measured but still radical\u2013shift in the way doctors are approaching the disease. \u201cAs a surgeon, to say we shouldn\u2019t be operating as much as we are is a very big deal,\u201d says Dr. Mehra Golshan, a surgical oncologist at the Dana-Farber\/Brigham and Women\u2019s Cancer Center. \u201cAnd that\u2019s what I\u2019m saying.\u201d<\/p>\n

Medicine is slow\u00a0<\/strong>to move, and that\u2019s especially true with breast cancer. Doctors are up against not only new data but also an accumulated mass of public opinion seeded by policymakers and advocacy groups with strong positions on how best to screen for and treat breast cancer. These measures were put into place for good reason, of course\u2013because experts thought they would save lives. But they didn\u2019t\u2013or at least not as many as anticipated.<\/p>\n

This year more than 40,000 women in the U.S. will die of breast cancer. That\u2019s the same, give or take, as last year, and the 13 years before that. At the same time, fear of the disease has led many to overestimate the risk it poses. The chance that a woman will die of breast cancer is 3%, and that\u2019s been the case since the early 2000s, when a blockbuster report demonstrated that hormone-replacement therapy (HRT), which women took during menopause to help with side effects, could unwittingly fuel the development of breast cancer. Once HRT fell out of vogue, the number of deaths dropped, and it\u2019s remained largely unchanged since.<\/p>\n

\u201cI hear people say that medicine is so important that we can\u2019t be too quick to change, and I would say the opposite: Because it\u2019s so important, we need to innovate,\u201d says Dr. Laura Esserman, a surgeon and the director of the Carol Franc Buck Breast Care Center at UCSF. \u201cIf we were doing so well and no one was dying, I would agree we don\u2019t need to change. But patients don\u2019t like the treatment options, and physicians don\u2019t like the outcomes.\u201d<\/p>\n

Esserman and Hwang, now chief of breast surgery at Duke University and Duke Cancer Institute in North Carolina, are leading a number of studies that they hope will fill in some of the knowledge gaps that make change such an uphill battle. DCIS now accounts for about 20% to 25% of breast cancers diagnosed through screening. Before routine screening, which went wide in the mid-1980s, it was 3%.<\/p>\n

\u201cOur two greatest challenges,\u201d says Dr. Eric Winer, director of breast oncology at Dana-Farber, \u201care figuring out better treatments for the 40,000 women who die of breast cancer every year, and at same time, figure out who, on the other end of the spectrum, is getting exposed to needless toxicity.\u201d<\/p>\n

If only doctors could agree on how to do that. Everyone says surgeons and radiologists need to know more about how to do less. And doctors don\u2019t want to be responsible for the patient who isn\u2019t treated aggressively and dies on their watch. That\u2019s where the two camps split: motivated by the same thing, some in the field are working to find even more proof the disease can be treated responsibly another way, while others say it\u2019s just too risky to pivot without proof.<\/p>\n

It used to\u00a0<\/strong>be accepted that tumors grow at a steady clip. Once they get big enough, they spread, and when they spread, you\u2019re in trouble. That was the reasoning behind the \u201cearly detection saves lives\u201d thinking and it did, in fact, help save many lives. But now experts know that many breast cancers are, in the apt medical term, indolent\u2013slow-growing tumors that may never cause symptoms, let alone hasten a woman\u2019s death. They also know there are a small number of breast cancers that spread very quickly, sometimes even before they are detected. They\u2019re working to figure out which ones are which\u2013and what to do in the meantime.<\/p>\n

\u201cMany doctors still say that any breast cancer is a failure of a patient to get a mammogram or failure of a doctor to detect it,\u201d says Dr. Otis Brawley, chief medical officer of the American Cancer Society. \u201cIf you look at the science, that is so clearly not the case.\u201d<\/p>\n

Indeed, the 2009 guideline that most women start screening at 50, which caused a national uproar, is still controversial today\u2013despite the fact that when mammograms went wide, the reduction in deaths didn\u2019t match what experts say was expected.<\/p>\n

Screening presents doctors and patients with a modern conundrum. If you have the technology to detect something, you are without a doubt going to find more of it. One doctor puts it this way: In a beachside tragedy, a shark attacks a swimmer and the swimmer dies. In the past, that would have been seen, perhaps, as a freak accident. But today we have flying robots with cameras and sensors that can patrol the waters. When we discover the area is teeming with creatures that may also have an appetite for humans, though we can\u2019t be sure, what do we do? Do we close the beach?<\/p>\n

No one is suggesting that women stop getting mammograms. But experts think it\u2019s important to be honest that it\u2019s an imperfect technology. \u201cMammograms are here to stay,\u201d says Hwang, who has about 20 patients at any given time who have chosen to do active surveillance instead of surgery and the treatments that follow it. \u201cIt\u2019s not the \u2018finding more\u2019 that we need to work on. It\u2019s what are we going to do with the more that we find?\u201d<\/p>\n

That\u2019s what\u2019s keeping cancer doctors up at night. That, and the growing concern that with all breast cancers being treated aggressively, some patients are getting hurt. With breast cancer, the burden of proof for not doing something is greater than it is for acting. And when doctors deviate from what\u2019s called the standard of care, they can face malpractice lawsuits.<\/p>\n

Some experts note that with other diseases, insurers would be the bad cops, denying payment for treatments that may be unnecessary. But with breast cancer, otherwise hard-nosed insurers will often pay for many of the approved therapies as long as they\u2019re in line with published guidelines. Since the guidelines for breast cancer tend to err on the side of caution, it means that regardless of the stage of her disease or her prognosis, a woman is likely to have insurance that will cover both mastectomy and reconstruction.<\/p>\n

\u201cThere is no check on what is a reasonable treatment for an anticipated outcome,\u201d says Hwang. \u201cIf we are going to accept that everyone, even those who have a 1% chance of mortality improvement, can get a treatment, that is not biologically a good way to approach the problem. It\u2019s also just incredibly expensive.\u201d<\/p>\n

The increase in women opting for a contralateral prophylactic mastectomy\u2013which doesn\u2019t improve survival for most patients\u2013worries a number of surgeons because it isn\u2019t clinically indicated for most of the patients who get one. (One exception is women with rare BRCA1 and 2 mutations, which greatly increase a woman\u2019s chance of developing breast and ovarian cancer. That\u2019s why Angelina Jolie famously had the procedure and why doctors continue to recommend the surgery in such cases.)<\/p>\n

\u201cWe are talking about major surgery,\u201d says Hwang. \u201cIt can involve revisions, prolonged pain, hernias. I think the best way to understand it is that it may require surgeries for the rest of your life. Some small, some major. But it\u2019s not like you\u2019re done and you can forget about it. It just doesn\u2019t work that way.\u201d<\/p>\n

There are psychological effects for some women, though not all. Some women say they struggle with feelings around femininity and sexuality after surgery. Some who have had nipple-sparing mastectomies\u2013a reconstruction that preserves the woman\u2019s own nipples\u2013wonder when the sensation will return. (The answer is often, never.) They\u2019re also at increased risk of depression and all that can come with it.<\/p>\n

\u201cIt\u2019s not my job to say that their decision is wrong,\u201d says the breast surgeon Golshan, who worries that patients are not adequately cautioned about\u2013or at least not fully aware of\u2013the potential risks. \u201cWomen may see end-result pictures, and it looks wonderful. But the vast majority of reconstruction requires multiple steps of revision.\u201d<\/p>\n

Cancer has a<\/strong>\u00a0language problem\u2013not just in the way we speak about it, as a war that drafts soldiers who never signed up for it, who do battle and win, or do battle and lose. There\u2019s also the problem of the word itself. A 57-year-old woman with low-grade DCIS that will almost certainly never become invasive hears the same word as the 34-year-old woman who has metastatic malignancies that will kill her. That\u2019s confusing to patients conditioned to treat every cancer diagnosis as an emergency, in a world that still reacts to cancer as though it\u2019s the beginning of the end and in a culture where we don\u2019t talk about death until we have to.<\/p>\n

\u201cWe think that word means the most aggressive thing,\u201d says Basila, recalling the shock when she first learned she had DCIS. \u201cI\u2019m not saying doctors should sugarcoat it. But we have to have the perspective that we can sometimes afford to not see it as a death sentence, de facto.\u201d That is hard to do in an hour, let alone in a 10-minute appointment.<\/p>\n

Dr. Steven J. Katz, a professor at the University of Michigan who studies patient and physician decisionmaking, points out that the vast majority of women feel healthy when they\u2019re diagnosed. And with most women diagnosed from ages 55 to 64, their own mortality is not, for good reason, top of mind. But now, inevitably, it will come up. This is not an easy conversation to have. \u201cThey\u2019re well and told they\u2019re sick,\u201d says Katz. \u201cAnd then they are told they will have to get really sick to get well.\u201d<\/p>\n

Talk to women about what that\u2019s like and you\u2019ll hear things like: \u201cI literally went into shock.\u201d \u201cI was blindsided.\u201d \u201cI got sort of dizzy.\u201d You may also hear: \u201cI don\u2019t really remember what we spoke about, but I remember it said 4:01 on the clock.\u201d<\/p>\n

That\u2019s a difficult position from which to make a life-changing decision, and most women make a decision within weeks of diagnosis, says Katz. It\u2019s not the right way to do things, says UCSF\u2019s Esserman. \u201cThe time has come to ask, What happens if I do nothing right away.\u201d The \u201cright away\u201d part of the question is important. \u201cLet\u2019s not make it a panic. There is no evidence to support getting surgery in two weeks.\u201d<\/p>\n

Katz\u2019s research has demonstrated that there\u2019s a natural instinct in patients, when faced with the C word, to outsource the decision to their doctors. That\u2019s why who your doctor is, what she tells you and how she tells it to you matter enormously. Because for many women, the strong inclination is to do whatever can be done\u2013and as quickly as possible\u2013to begin to feel like their normal selves again. That can get tricky when a patient\u2019s attempt to get back to normal as quickly as possible is at odds with the science of how best to do that.<\/p>\n

Some new tools\u00a0<\/strong>are pushing the field forward, though they\u2019re not perfect. A genomic test called Oncotype DX, for instance, can help doctors determine whether or not some patients will respond to chemo. It was part of a landmark study in the New England Journal of Medicine in September showing that some women with early-stage disease could be treated with hormone therapy alone.<\/p>\n

Another gene test, the Oncotype DX DCIS, can help indicate who is at low, intermediate and high risk of recurrence of DCIS, helping inform whether a woman needs radiation therapy following a lumpectomy. And while there aren\u2019t yet diagnostics to say precisely who is a good candidate for active surveillance, the doctors who partner with their patients on such a plan say they do so prudently.<\/p>\n

Many in the field still don\u2019t think there\u2019s enough evidence to support active surveillance for anyone, because the method hasn\u2019t been tested in a randomized prospective trial\u2013the gold standard for the widespread adoption of a medical treatment. That\u2019s something Hwang and Esserman are hoping to address in the U.S.<\/p>\n

Hwang was awarded $1.8 million in September to perform a retrospective study comparing active surveillance with standard care, and she\u2019s hoping she\u2019ll soon have the green light to do a prospective study looking at the same thing.<\/p>\n

Esserman is creating a DCIS registry at the five University of California medical centers. Women diagnosed with DCIS at any of the facilities will be offered options\u2013including active surveillance\u2013and be tracked over time. The hope: that the data will refine doctors\u2019 understanding of who, with DCIS, will go on to develop invasive breast cancers and who will not.<\/p>\n

Esserman has also launched something called the WISDOM study, which will randomize women to either annual screening or a more personalized screening approach. \u201cWe\u2019ll learn over time what works,\u201d says Esserman. \u201cHow wonderful if we can learn how to do less for women.\u201d<\/p>\n

In the U.K., meanwhile, where bilateral prophylactic mastectomies are rarely performed unless a patient has a gene defect or is at a very high risk of invasive breast cancer, a first-of-its-kind investigation is under way. Called LORIS, it\u2019s a 10-year randomized controlled prospective study, funded by the U.K.\u2019s National Institute for Health Research, that will include 900 women. Half will get the standard care, and half will be actively monitored.<\/p>\n

\u201cMy personal view is that enough time has been spent arguing about screening, and we now should be addressing the issue through well-run clinical trials that are long overdue,\u201d says Dr. Adele Francis, a breast surgeon at University Hospital Birmingham and the lead on the LORIS study. Some experts doubt that such a trial would fly in the U.S., given how risk-averse the field historically has been.<\/p>\n

There\u2019s another important piece of the puzzle: the women with the diagnosis. \u201cChange in medicine comes from patients,\u201d says Esserman. \u201cMy patients don\u2019t like the options we have. So I say, Get the facts. Find someone who will go through those options with you.\u201d<\/p>\n

For some women, like Basila, that\u2019s already happened. And just as some women choose to take a \u201cget it out of me\u201d approach, there are some\u2013not many, but some\u2013for whom the opposite is appropriate. As with all the hardest decisions we have to make about our health, it comes down to the impossible calculus of what level of uncertainty can I live with?<\/p>\n

\u201cWhat I am doing is not foolproof,\u201d says Basila. \u201cI know that. I also know life is finite and that death is unavoidable. For me it came down to the quality of the life I want to live. I don\u2019t want to be tired and bitchy if I can avoid it. And come what may, I think we really hurt ourselves by trying to just not be dead.\u201d<\/p>\n

\u8a55\u8ad6\uff1a<\/strong><\/p>\n

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http:\/\/time.com\/4057310\/breast-cancer-overtreatment\/ Too much chemo. Too much radiation. And way too many mastectomies \u201cWhat if I decide to just do nothing?\u201d It was kind of a taunt, Desiree Basila admits. Not the sort of thing that usually comes out […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[],"class_list":["post-3089","post","type-post","status-publish","format-standard","hentry","category-5","has_thumb"],"_links":{"self":[{"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/posts\/3089","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3089"}],"version-history":[{"count":5,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/posts\/3089\/revisions"}],"predecessor-version":[{"id":3094,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=\/wp\/v2\/posts\/3089\/revisions\/3094"}],"wp:attachment":[{"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3089"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3089"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/andylee.pro\/wp\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3089"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}