Tuesday, December 6, 2011

Genomic testing can now guide DCIS treatment decisions

The only time I'd really seen my surgeon flummoxed was when I referred a mutual acquaintance who was diagnosed with what's often called 'early breast cancer.' The term means different things to many people.  For the woman newly diagnosed the operative word may be cancer;  for those who've been successfully treated congratulations may seem in order (YayYouDon'tNeedChemo); for women with aggressive or metastatic cancer it's the disease they wish they had. 
          "Is she a friend of yours," my surgeon stated, not asking. This was his not-so-subtle way of fishing asking for more information. "No," I told him in all honesty, "she came in under the transom."
          This happens in any community once you've had cancer and are here to tell about it. You automatically become an informal source of information on cancer, doctors, treatments, facilities, and how to cope with everything from infection to nausea to dizziness, and whether or not homeopathy, Dr. Mercola or  Dr. Oz are good sources of information. 
          I later found out what stumped my surgeon. The woman's 'early breast cancer' was in fact DCIS - ductal carcinoma in situ or Stage 0 cancer - and she wanted a double mastectomy so she wouldn't ever have to think about breast cancer again.  Period.  He thought a mastectomy, not to mention a double mastectomy, was like dropping an atomic bomb on an ant. This isn't a story of right or wrong, but an indication of how times have changed in seven years and how, at long last, a technology is now available that can predict when DCIS is more likely to recur.
          Results from a clinical validation study released at the San Antonio Breast Cancer Symposium yesterday represent a great step forward in the treatment of ductal carcinoma in situ, which affects up to 45,000 women every year. To date there haven't been any validated molecular markers to select those patients with a high risk of recurrence. 
           According to a news release issued by the American Association for Cancer Research, this is the first time a multigene test has been used to differentiate the aggressive forms of DCIS that require radiation, from lower risk disease. 
           The study, conducted by the Eastern Cooperative Oncology Group, validated the use of OncotypeDX in patients previously enrolled in a prior study (E5194) of breast conservation surgery. It clearly identified up to 75% of patients over a ten-year period who were at a low risk for recurrence and could consequently, forgo radiation therapy without any differences in overall survival.  
           "This is a big step forward in terms of treating women with DCIS," said Deanna Attai, MD, director, Center for Breast Care in Burbank, California. "With both invasive and non-invasive breast cancer, it is clear that some women are over-treated, and unfortunately we are also not always accurate in identifying which women have more aggressive disease requiring more aggressive treatment. The ability to really identify a cancer's biologic behavior, "what makes it tick" is going to help us be more selective in our therapy, sparing many women toxic treatment that will be of little or no benefit, and identifying women at higher risk of recurrence that should undergo more aggressive, and hopefully more targeted therapy."
          Biology, not pathology, is what ultimately determines the kind of treatment required. How a sample of tissue from a tumor looks under a microscope, said the American Cancer Society's Chief Medical Officer Otis Brawley, MD, in a recent NY Times article, "does not always predict." 
          Bingo. That's the million dollar question. How cancer looks under the microscope may not be the true story of what it does in your body. My cancer may be napping while yours is out to paint the town. Or vice versa.
          The test will be available for women diagnosed with DCIS by the end of this year, "If we can spare a woman from having to undergo adjuvant therapies then we can actually reduce overall cost when the test is  used correctly. The majority of patients are lower risk," said Lawrence Solin, MD, lead investigator. 
          At long last, the beginning of technology to help assist women with "weird cells" and how to help them decide other than repeating the oft-told tale of someone's Aunt Minnie.  Real data, for women who need it. 
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Nancy's Point said...

Jody, Such an important post and it's exciting to think we are finally inching our way along here and beginning to understand that it's the biology of each cancer that matters most when determining treatment, not the pathology. The ramifications are huge.

Jody said...

I'm excited, too, Nancy. Finally there's something that can help since more cases are now being diagnosed w/screening mammograms. If the 75% number (of those at low risk) continues to hold that is a LOT of women who can safely do without radiation therapy.

It was also interesting listening to a session this morning on molecular differences as possible predictors for early vs late recurrence in hormone positive breast cancer. From there, researchers from MD Anderson hope to begin design of novel targeted therapies. All good stuff.

Unknown said...

Hi, I read your post with interest; I took part in a clinical trial in March of this year, I was diagnosed with DCIS & IDC & a sample of my tumour was sent over to America where they did the 'Oncotype DX' test. I was given a score of 20 out of 100 which equates to a 13% chance of my cancer returning in the next 10 years. I was 38 at the time. I decided not to have chemo on the back of this result. I'm glad I never had chemo but some days I lose all faith in the test result; I just feel that either I will have a recurrence or I won't - which makes me think I have a 50/50 chance of recurrence. Ultimately though, I'm glad that I was given the chance to take part in the trial as some women have nothing else to back up their oncologists decision as to whether or not they have rads or chemo. So, now I'll be taking Tamoxifen for another 4 & a half years & Zoladex injections for the next 3 years & hoping that the test predicted correctly! xx

Annemieke said...


Thank you so much for educating me once again! This was a well written, informative blog, like all your blogs are. Very happy we seem to have made a small step forwards at least. Thanks again, you are a source of knowledge, wisdom and care so much for all affected by this disease. Big hug, Annemieke

skye said...

I appreciate the post. I had extensive DCIS, out of the blue since my last mammogram, & opted for a mastectomy (it was an avacado sized area & everyone was *strongly* pressing me to have a lumpectomy & radiation, which just sounded insane!)
No one ever offered genomic testing, just pressure to have radiation, do this drug or that.
It just, quite honestly, felt like a factory~~as before I even saw my breast surgeon, radiation oncology called to "confirm my appointment". I had to go "explain my choices" to the head of the breast cancer program at my facility, as if going to talk to the principal.
I am extremely grateful that this was caught, & for the mastectomy & reconstruction, but this experience has done NOTHING to increase my trust in the oncology industry.

Unknown said...

How is this different from the Genotype testing? My oncologist has been using the test regularly.

Jody said...

What's different is the application of the test for women with DCIS, or ductal cancer in situ. Before it's only been used for women with invasive cancers. This is something that can help guide women with this diagnoss and help them determine if additional treatment (usually radiation) will be necessary.

Gayle said...

Thank you for this great piece of information from the SABCS. The development of a multigene test to differentiate the aggressive forms of DCIS from those that have a significantly lower risk of developing an invasive form of breast cancer means that there is hope that we can stop overtreating women for something that will never have been life threatening. Wonderful, wonderful news!

Patricia Parker said...

Nicely explained about SABCS. Thanks for sharing all good insights about cancer. This will be helpful for so many women suffering from cancer.
breast cancer center