Are We Overtreating DCIS?

Cancer Is a Collection of Heterogeneous Diseases

Definition of Cancer

Patients Assume That Cancer, Left Untreated, Will Kill You: Physicians Do Too

Old Paradigm: Inexorable Progression

Pathways for Progression

March 2012 Workshop

Recommendations Working Group

Overdiagnosis Occurs and Is Common.

Overdiagnosis Is More Common With Screening

For Both Breast and Prostate: Incidence Rates Have Risen and Remain Higher

Chance Increases With Screening

Noninvasive Cancer

What Is the Problem With Diagnosing All of These Cancers?

Treatments Have Consequences

Recommendations to the NCI

Recommendation #1: Embrace the Development of New Terminology to Replace the Word “Cancer” Where Appropriate

Establish a New Naming Convention

DCIS Has Increased 500% Since the Advent of Mammographic Screening

Comparison

It Is Unlikely That the Majority of DCIS Detected Is Destined for Significant Cancers

Recommendation #2: Create Observational Registries Where There Is Uncertain Risk of Progression to “Metastatic” Cancer

DCIS Is an Excellent Example: No Emergency to Operate

Incorporate Disease Dynamics Into Pathology Paradigm

Time Can Be Used as the Discriminator of Who Needs Surgical Intervention

If We Continue on the Same Clinical Path, We Cannot Hope to See Change: If We Study an Alternative Approach, We May Be Surprised at What We Learn

Remarkable Variation in Approach to Management of “Risk”

Interesting Studies

DCIS Score: 10-Year Ipsilateral Breast Events (IBE) by Risk Group

Atypia and Chemoprevention

Probability of Cancer After Atypia Diagnosis With and Without Chemoprevention

Invasive Cancer Risk

The Evidence Supports Overdiagnosis and Overtreatment of DCIS

Recommendation #3: Mitigate Overdiagnosis by Testing Strategies That Lower the Chance of Detecting Unimportant Lesions

What Is the Magnitude of the Problem in Screening?

Embracing Learning and Change Going Forward

Changing the Threshold

ATHENA Reader Study

Ways to Find Less DCIS

Recommendation #4: Embrace New Concepts for How to Approach Cancer Progression and Prevention

Biology Determines the Type of Progression

What Can Clinicians Do Today?

The Evidence Supports Overdiagnosis and Overtreatment of DCIS