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DR MORROW: My fifth patient is something that I am increasingly seeing and finding increasingly troubling. This is a 44-year-old with no family history of breast cancer who had a screening mammogram that showed a 5-mm cluster of calcifications. Core biopsy showed that this was intermediate-grade DCIS, 90% ER-positive. The patient comes, announcing that she thinks she wants bilateral mastectomies because she doesn’t want to take tamoxifen. And so the question is: When did the decision to have breast-conserving surgery become conflated with the fact that you had to take endocrine therapy when there’s no survival benefit? If I tell you that in the last 2 weeks I have had 3 different patients tell me this, it must be out there on the Internet.

DR LOVE: Let me ask Bill. What are your thoughts?

DR GRADISHAR: I think you don’t have to take tamoxifen, number one. It’s not going to make you live longer. And, if anything, we’ve even had some patients — which we’ll get to later — saying, “Well, if, for DCIS, I’m taking it, do I have to take it for 10 years now, instead of 5,” which, of course, has nothing to do with anything. But I would agree. If anything, you’re making an argument based on NSABP data that there’s some benefit, which is largely going to potentially impact on a local recurrence in-breast problem and probably some issue about chemoprevention on the opposite side.

Taking all things into account, including potential side effects, I think for this kind of patient — five millimeters of tumor — the risk of a problem going forward is probably very modest. The impact of tamoxifen is equally modest. And I would call it a wash.

DR LOVE: What happened, Monica?

DR MORROW: We had a long discussion about what the actual risk of contralateral breast cancer is in the setting of DCIS, which even in a 44-year-old woman over the next 10 years is in the range of about 6% and tends to be grossly overestimated by most patients, as well as the fact that screening had been very successful in her case in terms of finding something early and favorable, and that while it’s true, if you have 2 breasts, the benefit of tamoxifen is greater, for the reasons that Bill said, it works on both in-breast recurrence and new contralateral primaries. It’s by no means at all a requirement, and she could undergo breast conservation without taking tamoxifen.

Unfortunately, like so many patients in our practice today, she had really made up her mind she wanted to have bilateral mastectomies and there was no talking her out of it with any data about the fact that her risk of dying of something other than breast cancer was higher than her risk of dying of breast cancer related to this DCIS. So, that’s what she did.

DR LOVE: You did the surgery?

DR MORROW: We did the surgery. Our current bilateral mastectomy rate in patients with unilateral cancer is sitting at around 29%.

DR LOVE: Wow! That’s Memorial?

DR MORROW: It’s incredibly high. At Memorial. That’s Memorial data.

DR LOVE: What about nationally? Do we know what it is?

DR MORROW: Nationally, the number is smaller than that. The last data I’ve seen, Todd Tuttle published in the JCO and they’re older now, the rate was up to I think around 10%. It certainly was substantially lower than ours. And you get to the point where, unfortunately, you can say, “You absolutely don’t need this. You’re subjecting yourself to a lot of morbidity,” but we have somehow made the cultural decision in breast cancer that it’s the patient’s right to have unnecessary surgery.

DR LOVE: It’s interesting, though, that we were talking about patients who refuse therapies that we want to do. You can also say, “We just don’t do this,” if you feel strongly enough about it.

DR MORROW: You can. Unfortunately, then you get into the problem that they walk across the street and somebody else does it.

DR LOVE: Hope, I’m kind of curious. We saw some data — it seems like so long ago, but I guess it was last year — looking at an Oncotype assay in DCIS. Where are we right now in terms of markers in DCIS?

DR RUGO: It could be that having a genomic index to help us decide on how aggressive to be with treatment would be useful. But in a disease where the mortality at 10 years is 2%, at most, I think it’s hard. We don’t know that that predictor is telling us who’s going to get metastatic breast cancer, for example. We’d all like to know that. We do know that maybe potentially it would help you understand who needs radiation after a lumpectomy. And if that is a use, which we tend to use not so much in medical oncology, since we’re not making those decisions, generally — we contribute to the discussion — but then I think it could be useful. So for a patient where that is a big decision, that may be an additional useful piece of information. But I think that it’s in a subset of patients with DCIS that that will be of value.