Nine out of ten women don’t realize that some breast cancers would never have caused any problems or even become known in one’s lifetime. This is an issue ductal carcinoma in situ has brought to the forefront.
Overtreatment of Stage 0 Breast Cancer DCIS
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
The whole point of cancer screening is to “detect life-threatening disease at an earlier, more curable stage.” So, an “[e]ffective cancer-screening program…[would] therefore…increase the incidence of cancer detected at an early stage [because you’d find all these tiny cancers you would have missed before] and [therefore] decrease the incidence of cancer presenting at a late stage”—because you would have cut out all the little cancers you found, pulling them out of circulation.
But, that’s not what appeared to happen with mammograms. As mammography ramped up in the 80s, the first part happened: the diagnosis of early cancers shot up. And so, what we’d like to see is like a mirror image of this, going the other way, for late-stage cancers. If you caught it early, it wouldn’t be around for late. But, that didn’t happen. Late-stage cancer incidence didn’t seem to drop much at all.
Another way to look at this is to compare mammogram rates around the country. The more mammograms you do, the more heavily screened the population is, the more early cancers you pick up. Great. And late, advanced disease should go down too, right? But, it doesn’t. We’re taking all these early cancers out of circulation—surgery, radiation; and so, there should be about the same number fewer late-stage cancers found. But, that didn’t happen. Mammograms catch a lot of small cancers, but with no concomitant decline in the detection of larger cancers. That would explain this. The more mammograms you do, the more cancer you find. But, death from breast cancer doesn’t seem to change much.
Wait a second; you just cut out tens of thousands of cancers; why aren’t there that many fewer women dying? “Together, these findings suggest widespread overdiagnosis”—meaning cancer picked up on mammograms that would have never progressed to the point of presenting during the woman’s lifetime, and so, wouldn’t even have been noticed, or caused “any harm” had it never been picked up at all.
So, if removing all these early ones didn’t lead to that many fewer late ones, that suggests that most would have never progressed during that time, or even go away on their own. That “could explain almost all [that] increase in incidence.” And indeed, “many invasive breast cancers detected by repeated mammography screening do not persist to be detected later, suggesting that the natural course of many of the [mammogram]-detected invasive breast cancers is to spontaneously regress [spontaneously disappear].”
We’ve known for more than a century that even serious metastatic breast cancer can sometimes just spontaneously go away. The problem is that you can’t tell which is which. So, if you find it, the natural inclination is to treat it, which can be especially tricky for ductal carcinoma in situ: DCIS, so called stage zero breast cancer. This is what it looks like. “Ductal” means in the breast ducts, “carcinoma” means cancer, and “in situ” means in place, in position, not spreading outside of the duct. And, it can create these tiny calcifications that can be picked up on mammogram.
The whole point of mammograms was “to identify early invasive disease.” So, the large numbers of DCIS they found “were unexpected and unwelcome.” “Prior to the advent of [mammogram] screening,…DCIS…made up approximately 3% of breast cancers detected,” but now accounts for a significant chunk. The cells “look like invasive cancer…,and therefore the presumption was made that these lesions were the precursors of cancer” [stage zero cancer] and that early removal and treatment would reduce cancer incidence and mortality.”
“However, long-term [population] studies have demonstrated that the [surgical] removal of 50 000 to 60 000 DCIS lesions annually has not been accompanied by a reduction in the incidence of invasive breast cancers. This is in contrast to [our] experience with remov[ing]…colon…polyps” with colonoscopy or precancerous cervical lesions thanks to Pap smears, “in which the removal of precursor lesions has led to a decrease in the incidence of colon and cervical cancer….” Those are cancer screening programs that work.
Radiologists argue that “overdiagnosis” isn’t so much the problem as “overtreatment.” Yeah, it sucks to get a breast cancer diagnosis, even though it would never have hurt you. But, you don’t know that at the time. So, most women undergo aggressive surgical and radiation treatment. Yeah, but if you compare the 10-year breast cancer survival for women with low grade DCIS, among those who chose not to go to surgery at all? 1.2% of them died of breast cancer within a decade. But, in that same decade, those that went to surgery instead for a lumpectomy or a full mastectomy to cut it out—1.4% died from breast cancer. So, surgery appeared to make no difference.
That’s why there are currently randomized, controlled trials to put it to the test. But, it’s “incredibly difficult to convince a patient with…DCIS not to” just want to get it cut out. “The fear of cancer paralyzes patients,” who may resort to “drastic [excessive] measures,” like getting a double mastectomy. How can we prevent that? How about we change its name? A National Cancer Institute panel has recommended dropping the “carcinoma” part. Let’s just call it an “indolent lesion of epithelial origin”—”use language that engenders less fear.” How bad can an “IDLE” tumor be?
Another option to avoid this dilemma is just not get screened in the first place, but women aren’t typically told about any of this. Less than one in 10 women were aware that mammograms carried any potential harms at all, and more than nine out of 10 were unaware that some breast cancers never cause problems. Few were told about DCIS, but when informed about it, most wished they were told before they signed up.
Once a cancer is detected, it is currently not possible to distinguish life-threatening from potentially harmless cases. “Therefore, overdiagnosis can only be avoided by abstaining from [routine mammograms] altogether.”
That’s how this researcher explained her own decision away from screening. “[W]orried by the possibility that [she] could be seriously harmed by the treatment of a cancer that would never have affected [her] health,” and given that the only way to avoid opening that Pandora’s box was by not getting mammograms, she decided to try improving her diet and lifestyle to prevent getting breast cancer in the first place.
Please consider volunteering to help out on the site.
- Costanza ME. Has screening mammography become obsolete?. Curr Oncol. 2015;22(5):e328-31.
- Zahl PH, Gøtzsche PC, Mæhlen J. Natural history of breast cancers detected in the Swedish mammography screening programme: a cohort study. Lancet Oncol. 2011;12(12):1118-24.
- Houssami N. Overdiagnosis of breast cancer in population screening: does it make breast screening worthless?. Cancer Biol Med. 2017;14(1):1-8.
- Morris E, Feig SA, Drexler M, Lehman C. Implications of Overdiagnosis: Impact on Screening Mammography Practices. Popul Health Manag. 2015;18 Suppl 1:S3-11.
- Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367(21):1998-2005.
- Barratt A. Perspective: The risks of overdiagnosis. Nature. 2015;527(7578):S104.
- Elmore JG, Fletcher SW. Overdiagnosis in breast cancer screening: time to tackle an underappreciated harm. Ann Intern Med. 2012;156(7):536-7.
- Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US women's attitudes to false-positive mammography results and detection of ductal carcinoma in situ: cross-sectional survey. West J Med. 2000;173(5):307-12.
- Masood S. A Call for Change in the Diagnosis and Treatment of Patients with Ductal Carcinoma In Situ: An Opportunity to Minimize Overdiagnosis and Overtreatment. Breast J. 2015;21(6):575-8.
- Harding C, Pompei F, Burmistrov D, Welch HG, Abebe R, Wilson R. Breast Cancer Screening, Incidence, and Mortality Across US Counties. JAMA Intern Med. 2015;175(9):1483-9.
- Esserman L, Thompson I. Solving the overdiagnosis dilemma. J Natl Cancer Inst. 2010;102(9):582-3.
- Keen JD, Jørgensen KJ. Four Principles to Consider Before Advising Women on Screening Mammography. J Womens Health (Larchmt). 2015;24(11):867-74.
- Osler W. An Address ON THE MEDICAL ASPECTS OF CARCINOMA OF THE BREAST. Br Med J. 1906;1(2349):1-4.
- Fallowfield L, Francis A. Overtreatment of Low-Grade Ductal Carcinoma In Situ. JAMA Oncol. 2016;2(3):382-3.
- Esserman L. When Less Is Better, but Physicians Are Afraid Not to Intervene. JAMA Intern Med. 2016;176(7):888-9.
- Esserman L, Yau C. Rethinking the Standard for Ductal Carcinoma In Situ Treatment. JAMA Oncol. 2015;1(7):881-3.
- Autier P, Boniol M. Effect of screening mammography on breast cancer incidence. N Engl J Med. 2013;368(7):677.
Motion graphics by Avocado Video
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
The whole point of cancer screening is to “detect life-threatening disease at an earlier, more curable stage.” So, an “[e]ffective cancer-screening program…[would] therefore…increase the incidence of cancer detected at an early stage [because you’d find all these tiny cancers you would have missed before] and [therefore] decrease the incidence of cancer presenting at a late stage”—because you would have cut out all the little cancers you found, pulling them out of circulation.
But, that’s not what appeared to happen with mammograms. As mammography ramped up in the 80s, the first part happened: the diagnosis of early cancers shot up. And so, what we’d like to see is like a mirror image of this, going the other way, for late-stage cancers. If you caught it early, it wouldn’t be around for late. But, that didn’t happen. Late-stage cancer incidence didn’t seem to drop much at all.
Another way to look at this is to compare mammogram rates around the country. The more mammograms you do, the more heavily screened the population is, the more early cancers you pick up. Great. And late, advanced disease should go down too, right? But, it doesn’t. We’re taking all these early cancers out of circulation—surgery, radiation; and so, there should be about the same number fewer late-stage cancers found. But, that didn’t happen. Mammograms catch a lot of small cancers, but with no concomitant decline in the detection of larger cancers. That would explain this. The more mammograms you do, the more cancer you find. But, death from breast cancer doesn’t seem to change much.
Wait a second; you just cut out tens of thousands of cancers; why aren’t there that many fewer women dying? “Together, these findings suggest widespread overdiagnosis”—meaning cancer picked up on mammograms that would have never progressed to the point of presenting during the woman’s lifetime, and so, wouldn’t even have been noticed, or caused “any harm” had it never been picked up at all.
So, if removing all these early ones didn’t lead to that many fewer late ones, that suggests that most would have never progressed during that time, or even go away on their own. That “could explain almost all [that] increase in incidence.” And indeed, “many invasive breast cancers detected by repeated mammography screening do not persist to be detected later, suggesting that the natural course of many of the [mammogram]-detected invasive breast cancers is to spontaneously regress [spontaneously disappear].”
We’ve known for more than a century that even serious metastatic breast cancer can sometimes just spontaneously go away. The problem is that you can’t tell which is which. So, if you find it, the natural inclination is to treat it, which can be especially tricky for ductal carcinoma in situ: DCIS, so called stage zero breast cancer. This is what it looks like. “Ductal” means in the breast ducts, “carcinoma” means cancer, and “in situ” means in place, in position, not spreading outside of the duct. And, it can create these tiny calcifications that can be picked up on mammogram.
The whole point of mammograms was “to identify early invasive disease.” So, the large numbers of DCIS they found “were unexpected and unwelcome.” “Prior to the advent of [mammogram] screening,…DCIS…made up approximately 3% of breast cancers detected,” but now accounts for a significant chunk. The cells “look like invasive cancer…,and therefore the presumption was made that these lesions were the precursors of cancer” [stage zero cancer] and that early removal and treatment would reduce cancer incidence and mortality.”
“However, long-term [population] studies have demonstrated that the [surgical] removal of 50 000 to 60 000 DCIS lesions annually has not been accompanied by a reduction in the incidence of invasive breast cancers. This is in contrast to [our] experience with remov[ing]…colon…polyps” with colonoscopy or precancerous cervical lesions thanks to Pap smears, “in which the removal of precursor lesions has led to a decrease in the incidence of colon and cervical cancer….” Those are cancer screening programs that work.
Radiologists argue that “overdiagnosis” isn’t so much the problem as “overtreatment.” Yeah, it sucks to get a breast cancer diagnosis, even though it would never have hurt you. But, you don’t know that at the time. So, most women undergo aggressive surgical and radiation treatment. Yeah, but if you compare the 10-year breast cancer survival for women with low grade DCIS, among those who chose not to go to surgery at all? 1.2% of them died of breast cancer within a decade. But, in that same decade, those that went to surgery instead for a lumpectomy or a full mastectomy to cut it out—1.4% died from breast cancer. So, surgery appeared to make no difference.
That’s why there are currently randomized, controlled trials to put it to the test. But, it’s “incredibly difficult to convince a patient with…DCIS not to” just want to get it cut out. “The fear of cancer paralyzes patients,” who may resort to “drastic [excessive] measures,” like getting a double mastectomy. How can we prevent that? How about we change its name? A National Cancer Institute panel has recommended dropping the “carcinoma” part. Let’s just call it an “indolent lesion of epithelial origin”—”use language that engenders less fear.” How bad can an “IDLE” tumor be?
Another option to avoid this dilemma is just not get screened in the first place, but women aren’t typically told about any of this. Less than one in 10 women were aware that mammograms carried any potential harms at all, and more than nine out of 10 were unaware that some breast cancers never cause problems. Few were told about DCIS, but when informed about it, most wished they were told before they signed up.
Once a cancer is detected, it is currently not possible to distinguish life-threatening from potentially harmless cases. “Therefore, overdiagnosis can only be avoided by abstaining from [routine mammograms] altogether.”
That’s how this researcher explained her own decision away from screening. “[W]orried by the possibility that [she] could be seriously harmed by the treatment of a cancer that would never have affected [her] health,” and given that the only way to avoid opening that Pandora’s box was by not getting mammograms, she decided to try improving her diet and lifestyle to prevent getting breast cancer in the first place.
Please consider volunteering to help out on the site.
- Costanza ME. Has screening mammography become obsolete?. Curr Oncol. 2015;22(5):e328-31.
- Zahl PH, Gøtzsche PC, Mæhlen J. Natural history of breast cancers detected in the Swedish mammography screening programme: a cohort study. Lancet Oncol. 2011;12(12):1118-24.
- Houssami N. Overdiagnosis of breast cancer in population screening: does it make breast screening worthless?. Cancer Biol Med. 2017;14(1):1-8.
- Morris E, Feig SA, Drexler M, Lehman C. Implications of Overdiagnosis: Impact on Screening Mammography Practices. Popul Health Manag. 2015;18 Suppl 1:S3-11.
- Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367(21):1998-2005.
- Barratt A. Perspective: The risks of overdiagnosis. Nature. 2015;527(7578):S104.
- Elmore JG, Fletcher SW. Overdiagnosis in breast cancer screening: time to tackle an underappreciated harm. Ann Intern Med. 2012;156(7):536-7.
- Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US women's attitudes to false-positive mammography results and detection of ductal carcinoma in situ: cross-sectional survey. West J Med. 2000;173(5):307-12.
- Masood S. A Call for Change in the Diagnosis and Treatment of Patients with Ductal Carcinoma In Situ: An Opportunity to Minimize Overdiagnosis and Overtreatment. Breast J. 2015;21(6):575-8.
- Harding C, Pompei F, Burmistrov D, Welch HG, Abebe R, Wilson R. Breast Cancer Screening, Incidence, and Mortality Across US Counties. JAMA Intern Med. 2015;175(9):1483-9.
- Esserman L, Thompson I. Solving the overdiagnosis dilemma. J Natl Cancer Inst. 2010;102(9):582-3.
- Keen JD, Jørgensen KJ. Four Principles to Consider Before Advising Women on Screening Mammography. J Womens Health (Larchmt). 2015;24(11):867-74.
- Osler W. An Address ON THE MEDICAL ASPECTS OF CARCINOMA OF THE BREAST. Br Med J. 1906;1(2349):1-4.
- Fallowfield L, Francis A. Overtreatment of Low-Grade Ductal Carcinoma In Situ. JAMA Oncol. 2016;2(3):382-3.
- Esserman L. When Less Is Better, but Physicians Are Afraid Not to Intervene. JAMA Intern Med. 2016;176(7):888-9.
- Esserman L, Yau C. Rethinking the Standard for Ductal Carcinoma In Situ Treatment. JAMA Oncol. 2015;1(7):881-3.
- Autier P, Boniol M. Effect of screening mammography on breast cancer incidence. N Engl J Med. 2013;368(7):677.
Motion graphics by Avocado Video
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Title
Overtreatment of Stage 0 Breast Cancer DCIS
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
How might someone improve their diet and lifestyle to lower breast cancer risk? See, for example:
- Breast Cancer and Constipation
- Cholesterol Feeds Breast Cancer Cells
- Breast Cancer Survival Vegetable
- Breast Cancer and Alcohol: How Much Is Safe?
- Which Dietary Factors Affect Breast Cancer Most?
- Is Soy Healthy for Breast Cancer Survivors?
- How to Treat Endometriosis with Seaweed
- Tree Nuts or Peanuts for Breast Cancer Prevention?
This is the ninth in a 14-video series on mammograms. If you missed any of the first eight, see:
- Nine out of Ten Women Misinformed About Mammograms
- Mammogram Recommendations: Why the Conflicting Guidelines?
- Should Women Get Mammograms Starting at Age 40?
- Do Mammograms Save Lives?
- Consequences of False-Positive Mammogram Results
- Do Mammograms Hurt?
- Can Mammogram Radiation Cause Breast Cancer?
- Understanding the Mammogram Paradox
For the rest of the series, check out:
- Women Deserve to Know the Truth About Mammograms
- Breast Cancer and the Five-Year Survival Rate Myth
- Why Mammograms Don’t Appear to Save Lives
- Why Patients Aren’t Informed About Mammograms
- The Pros and Cons of Mammograms
If you want to watch the entire series right now, you can stream it for a donation to NutritionFacts.org by going here.
For more on breast cancer, see my videos Oxidized Cholesterol 27HC May Explain Three Breast Cancer Mysteriesand Eggs and Breast Cancer.
I was able to cover colon cancer screening in just one video. If you missed it, check out Should We All Get Colonoscopies Starting at Age 50?.
Also on the topic of medical screenings, see Is It Worth Getting Annual Health Check-Ups? and Is It Worth Getting an Annual Physical Exam?.
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