DCIS 411
What is DCIS Overdiagnosis?
Cancer Research UK states:
Overdiagnosis: when finding cancer can do more harm than good
“Research has shown that for each woman whose life is saved through breast cancer screening, around three will be diagnosed with a breast cancer that would have never caused them any harm.
Because breast screening and diagnostic tests can’t yet tell the dangerous cancers that need treating from the harmless ones that don’t, doctors recommend treatment to everyone who is diagnosed with cancer after screening.
Overdiagnosis, in turn, leads to overtreatment.
Experts Explain DCIS Overdiagnosis
Dr. H. Gilbert Welch
Known for his research into cancer screening. In 2012, Welch co-authored a study, Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence, which found that mammography was having little to no impact on breast cancer death rates. The study also concluded that substantial overdiagnosis was associated with mammographic screening, accounting for nearly a third of all newly diagnosed breast cancers.
Welch is the author of Overdiagnosed: Making People Sick in The Pursuit of Health
He also describes cancers as birds, rabbits, and turtles. DCIS is mostly found on screening and most are turtles. They do not need to be found or treated. This is known as the “Barnyard analogy.“
A quick explanation: Screening for cancer is like a farmer trying to build fences to keep in his animals. The farmer has birds, rabbits, and turtles.
Fences won’t stop the birds (aggressive cancers) that will simply fly over them.
If you build enough fences, you can catch the rabbits, but what we are really good at fencing in are turtles (technically cancers, but very slow growing, and less likely to cause death.) The problem is that our pathologists can’t tell by looking at cells under a microscope whether they are looking at a turtle or a rabbit, and we often over treat.
Below is an excellent presentation by H. Gilbert Welch on Cancer Screening and Overdiagnosis.
Mammography discussion starts at 32:27, but the entire video is extremely beneficial:
Dr. Otis Brawley
An American physician and the Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University. He served as Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society from July 2007 to November 2018.
“We’ve been doing a disservice to American women by considering all DCIS are cancers.”
An outspoken expert about the problem of breast cancer screening and overdiagnosis for many years. Here is his presentation from Preventing Overdiagnosis 2018
1 minute clip of Professor Michael Baum discussing breast cancer screening increasing DCIS and mastectomies, but not making a difference in later stage invasive cancers:
https://www.youtube.com/clip/Ugkx-yKMEfOCpJTPKPT70So8JujF3v_5NEre
Increase in mastectomies with mammography screening, – Professor Michael Baum presentation 2010:
“Estimates of benefit have been grossly overestimated,” he explains, “but none of the data shows that breast cancer screening reduces all-cause death. There was a modest effect on breast cancer death and no reduction in all-cause death, so you cannot say that breast screening saves lives.”
So how can screening reduce breast cancer deaths but not deaths of women overall?
“We now know that about 30% of breast cancers diagnosed by screening would never be life threatening, but the treatment can kill you,’ Michael explains. ‘Surgery, radiotherapy, chemotherapy and radiotherapy increases the risk of cardiovascular disease and even (rarely) lung cancer.
“For every breast cancer death avoided there is one death caused by over-diagnosis.”
Read full interview here.
Peter Gotzsche
A Danish physician, medical researcher, and former leader of the Nordic Cochrane Center in Copenhagen, Denmark. He is a co-founder of the Cochrane Collaboration
Gotzsche is the author of many “controversial” books including Mammography Screening: Truth, Lies and Controversy
“Screening saves probably one life for every 2,000 women who go for a mammogram. But it harms 10 others. Cancerous cells that will go away or never progress to disease in the woman’s lifetime are excised with surgery and sometimes (six times in 10) she will lose a breast. Treatments with radiotherapy and drugs, as well as the surgery itself, all have a heavy mental and physical cost. I believe the time has come to realize that breast cancer screening programs can no longer be justified.”
Dr Peter Gøtzsche talks about his views on prescreening for breast and prostate cancer:
“If we assume that screening reduces breast cancer mortality by 15% and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.
Mammography screening: The great hoax is free to download.
Vinay Prasad
A hematologist-oncologist and health researcher
“Huge overdiagnosis problem…”
Cancer Research UK states:
Overdiagnosis: when finding cancer can do more harm than good
“Research has shown that for each woman whose life is saved through breast cancer screening, around three will be diagnosed with a breast cancer that would have never caused them any harm.
Because breast screening and diagnostic tests can’t yet tell the dangerous cancers that need treating from the harmless ones that don’t, doctors recommend treatment to everyone who is diagnosed with cancer after screening.
Overdiagnosis, in turn, leads to overtreatment, which is the treatment of clinically insignificant disease, essentially giving too much treatment without benefit to the patient. Treating a cancer that is not life-threatening leads to significant harm for women. Accepting the Swiss Medical Board estimates, that means one in five women who was told she had breast cancer after her mammogram received unnecessary treatment for cancer. The result is that tens of thousands of women in the U.S. each year are treated unnecessarily for breast cancer and undergo surgery, radiation and chemotherapy for tumors that are not and never would be life threatening. – How Routine Mammography Screening Leads to Overdiagnosis & Overtreatment, Breast Cancer Action
“In some cases, overdiagnosis can occur because a patient will die of other causes, such as old age or existing health conditions, before even a progressive cancer can cause an issue.
But on a mammogram, a silent, indolent tumor looks the same as a deadly, progressive cancer that just hasn’t yet spread. If a clinician finds cancer on a mammogram, it often still triggers a slew of follow-up treatments possibly including biopsies, surgery, chemotherapy, and radiation — all unneeded and harmful interventions if the cancer was destined to remain silent.” – How often is breast cancer overdiagnosed? New research finds true cases far outweigh false alarms
Physical, Emotional, and Financial Harms of Overdiagnosis
“Women with DCIS are turned into ‘cancer patients’ with all the concomitant anxiety and implicit negative impact on family life that is almost certainly unwarranted for many. For example, in the United States it is estimated that almost 500,000 women have been treated for in situ cancers in the last 10 years with negligible impact on breast cancer mortality for up to 80% of these women.
Moreover, estimates suggest that mammographic screening has resulted in overdiagnosis and overtreatment in over 1 million women in the United States in the past 30 years. The majority of this is due to the overtreatment of DCIS.” – PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now), an international research project funded by Cancer Research UK
In this country, the huge jump in D.C.I.S. diagnoses potentially transforms some 50,000 healthy people a year into “cancer survivors” and contributes to the larger sense that breast cancer is “everywhere,” happening to “everyone.” That, in turn, stokes women’s anxiety about their personal vulnerability, increasing demand for screening — which, inevitably, results in even more diagnoses of D.C.I.S. Meanwhile, D.C.I.S. patients themselves are subject to the pain, mutilation, side effects and psychological trauma of anyone with cancer and may never think of themselves as fully healthy again. – Our Feel-Good War on Breast Cancer, NY Times, Peggy Orenstein
According to Dr. Laura Esserman, Director of the Carol Franc Buck Breast Care Center at UCSF stated, “DCIS is not cancer. It’s a risk factor. In Our Feel-Good War on Breast Cancer, Esserman states, “For many DCIS lesions, there is only a 5 percent chance of invasive cancer developing over 10 years. That’s like the average risk of a 62-year-old. We don’t do heart surgery when someone comes in with high cholesterol. What are we doing to these people?”
Research on Psychological Harm of Overdiagnosis
The Marmot Report in 2012 recognised the burden of overtreatment to women’s wellbeing.7 In effect, women with DCIS are labelled as ‘cancer patients’, with concomitant anxiety and negative impact on their lives, despite the fact that most DCIS lesions will probably never progress to invasive breast cancer.
Owing to the uncertainty regarding which lesions run the risk of progression to invasive cancer, current risk perceptions are misleading and consequently bias the dialogue between clinicians and women diagnosed with DCIS, resulting in overtreatment for some, and potentially many, women. – Ductal carcinoma in situ: to treat or not to treat, that is the question
More Research Concluding Serious Psychological Harm
What to do about Overdiagnosis?
“First and foremost, tell the truth: women really do have a choice. While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily. Women have to decide for themselves about the benefit and harms. But health care providers can also do better. They can look less hard for tiny cancers and pre-cancers and put more effort into differentiating between consequential and inconsequential cancers. We must redesign screening protocols to reduce overdiagnosis or stop population-wide screening completely. Screening could be targeted instead to those at the highest risk of dying from breast cancer — women with strong family histories or genetic predispositions to the disease. These are the women who are most likely to benefit and least likely to be overdiagnosed.” – Cancer Survivor or Victim of Overdiagnosis? , NY Times, H. Gilbert Welch
Education about Overdiagnosis is Critical
In Britain, where women are screened every three years beginning at 50, the government recently decided to revise its brochure on mammography to include a more thorough discussion of overdiagnosis, something it previously dispatched with in one sentence. That may or may not change anyone’s mind about screening, but at least there is a fuller explanation of the trade-offs. – Our Feel-Good War on Breast Cancer, NY Times, Peggy Orenstein
Patient Advocacy on DCIS Overdiagnosis
Read Donna Pinto’s Blog Post:
Overdiagnosis – “That’s Not Even a Word”
Join our BeWISE movement
BeWISE (Women Informed Supported Empowered) is a woman’s health initiative with an urgent public health mission — to ensure all women are properly informed about serious potential harms of breast cancer screening.
Conflicts of interest and well-funded marketing campaigns have created an imbalance of information — promoting a one-sided story of “life-saving” benefits of mammography while ignoring or downplaying serious harms.
Inspired by thousands of women’s personal experiences and shocking discoveries following a diagnosis of DCIS, also known as “Stage Zero” Breast Cancer, #BeWISE seeks to spare thousands of women world-wide annually from harm due to being uninformed or misinformed.
#BeWISE utilizes videos and info-graphics to break down real science into simple, no-nonsense chunks.
Must Watch Documentary Films Explain Breast Screening Isuues (Overdiagnosis and Underdiagnosis):
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- 3D Investigates: Breast screening – the truth (New Zealand)
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- Breast screening: some inconvenient truths by Professor Michael Baum (University College London School of Life and Medical Sciences) 2010 UCL Lunch Hour Lecture
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- Mammography – Does it save lives? | The USPSTF is incorrect | I review ALL the data by Vinay Prasad, MD MPH
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- Michael Greger, MD FACLM, is a physician, author, and internationally recognized speaker on a number of important public health issues created a video series on mammograms:
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- Michael Greger, MD FACLM, is a physician, author, and internationally recognized speaker on a number of important public health issues created a video series on mammograms:
Book Recommendations:
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- Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch, MD
- Opting Out is an Informed Choice; Experts Explain the Harms of Mammograms by Donna Pino
- Mammography screening: The great hoax by Peter C. Gøtzsche of the Institute for Scientific Freedom
- Mammography Screening: Truth, Lies and Controversy, by Peter Gotzsche
- Conspiracy of Hope: The Truth about Breast Cancer Screening, by Renée Pellerin
- Stop Breast Cancer Before it Starts, by Samuel S. Epstein MD