Today’s Managing Health Care Costs Number is 5
It’s been 5 days since JAMA Oncology published its landmark article on ductal carcinoma in situ (DCIS), thought to be a precursor to breast cancer. And the top five articles in the New York Times Healthsection this morning were all about this article. It’s a big deal – important to the treatment of women with breast calcifications on mammograms, and also important to health policy.
Researchers used the SEER (Surveillance, Epidemiology, and End Results) database to show that the 20 year likelihood of dying of breast cancer among the 110,000 women who had DCIS was a bit over 3% - very similar to the likelihood among women who were not diagnosed with DCIS. The likelihood of local recurrence went down with mastectomy or lumpectomy, but the likelihood of dying of breast cancer was unmoved. Radiation therapy with lumpectomy was not significantly better at decreasing mortality compared to lumpectomy alone; removal of the entire breast was associated with statistically significantly higher rate of breast cancer mortality than lumpectomy with or without radiation therapy.
DCIS is increasingly common; it represented 3% of all breast cancers found before mammography became widespread, and was usually diagnosed on autopsy only. It now represents 20-25% of all breast cancers detected – 50 to 60,000 women a year.
The accompanying editorial observes:
1. The risk of death from breast cancer in those with DCIS is low
2. The risk of dying from breast cancer in black women and women under 40 diagnosed with DCIS is substantially higher
3. Aggressive treatment doesn’t lower mortality
4. The risk of invasive breast cancer is almost the same in the other breast, making it likely that DCIS is an indicator of higher risk as opposed to a precursor lesion itself.
Screening for cancer makes intuitive sense. Find it early, remove it, and lengthen life. This works for at least two cancers – colon cancer, where death rates are falling in the era of colonoscopy, and cervical cancer, where pap smears decreased death rates dramatically.
But we’re increasingly finding that screening isn’t nearly as effective for many other cancers. Prostate cancer screening raised diagnosis dramatically, but few lives were saved, and many suffered from complications of therapy. I’ve written earlier about the epidemic of diagnosis of thyroid cancer, unaccompanied by any decrease in diagnosis of invasive cancer, or any decline in death from thyroid cancer.
We should look at population data before deploying population-wide screening. The goal of medical care is to give people more life and better quality life – not merely to make diagnoses that subject patients to potentially harmful therapy without benefit. We also need to recognize that there are subpopulations where screening and therapy recommendations can differ, as their risks are substantially higher.
JAMA Oncology, a journal that just began publishing this year, is offering access with no paywall to the original research and to the editorial.
