By William J. Gradishar, MD
Health care providers in the United States have the luxury (and perhaps curse) of having endless diagnostic tools and therapeutic interventions to offer their patients. In many situations, little scrutiny is given to how these tools are used. Cancer care is particularly relevant to this issue because of the increasing number of imaging tools, diagnostic molecular tests, and novel therapeutics that are emerging from clinical development and available to ordering physicians. Additionally, direct marketing to patients amplify the problem, because patients may then pressure their caregivers to order tests or request therapies with questionable added benefit.
All of these interventions have a cost, both economically and potentially as direct toxicity to the patient. Mukhtar and colleagues provide a thought-provoking discussion of these issues as they apply to breast cancer care. The overdiagnosis of breast cancers that may have remained indolent and have little clinical relevance to patient outcome is one end of the spectrum discussed. The other consequence of a diagnosis is overtreatment of a disease for which therapy offers little benefit to the patient. A better understanding of these clinical scenarios is a formidable challenge that clinicians must come to grips with to make the right decisions for their patients.
Rather than denoting criticisms of breast cancer care, the terms overdiagnosis and overtreatment should represent opportunities to further refine the current state of the art. Overdiagnosis occurs when tumors that would otherwise not become symptomatic are identified. Overtreatment occurs when such a tumor is treated, often with surgery and adjuvant therapy in the case of breast cancer.1 As the ability to identify lesions of the breast improves, so must the ability to distinguish between lesions that require aggressive treatment and those that can be treated less aggressively. Breast cancer care has already undergone dramatic improvement, and this represents another step in its evolution.
In the past few decades, the surgical treatment of breast cancer has progressed from radical mastectomy to modified radical mastectomy, with the subsequent incorporation of breast conservation and oncoplastic techniques.2,3 These advances have occurred simultaneously with improvements in multimodality therapy. More recently, the use of molecular tests in breast cancer have become part of the standard of care, and are included in the NCCN Guidelines.4 Before 1980, most women with breast cancer were treated with radical mastectomy. In the 1990s, tumor size and stage essentially determined adjuvant therapy recommendations. Today, a wide array of patient and tumor features are used, including overall health status, and molecular tests, such as the 70-gene prognostic score and the 21-gene recurrence score, for determining optimal treatment strategies.5,6
This kind of evolution has also occurred in the management of other cancer types, in which what was once thought to be the standard of care is now considered unnecessary. In the 1960s, staging laparotomy and splenectomy were commonly performed in the treatment of lymphoma. These morbid procedures are now largely replaced with technology in the form of CT and PET scans.7,8 In the treatment of squamous cell cancer of the anus, chemoradiation has replaced the surgical removal of the anus and rectum, providing equivalent survival but preserved sphincter function.9 Epidemiologic data and advances in imaging, molecular subtyping, and genomics in breast cancer now present the opportunity to further evolve breast cancer care by preserving excellent outcomes while minimizing harms and unnecessary treatment.
The opportunities for change in current breast cancer care need to be identified in order to reduce unhelpful and potentially harmful treatment. Making these advances will require a multifaceted and multidisciplinary approach, with roles for radiologists, pathologists, surgeons, medical oncologists, radiation oncologists, and geneticists in optimizing treatment recommendations. The heterogeneity of breast cancer has allowed the tailoring of specific treatments to specific tumor types. This not only improves outcomes but also reduces morbidity for women who potentially derive little or no benefit from receiving treatments designed for other tumor types.10
Although tailored treatment has improved outcomes in breast cancer,10 the implementation of screening programs also bears some responsibility for increased survival.11 However, one must recognize that screening itself impacts the disease in ways that should be considered when making management recommendations. Before the advent of screening in the 1980s, only women with clinically apparent, usually palpable, disease came to clinical attention. Since the institution of screening programs, the spectrum of breast cancer that comes to clinical attention has expanded. A large group of women have disease identified by screening only. Analyses of these screen-detected cancers show them to be very different from clinically detected cancers, with different grade and molecular subtypes.12,13 Some may, in fact, be indolent lesions that would never impact a woman's life expectancy if left untreated, for which the authors have recommended the term indolent lesion of epithelial origin (IDLE).1,14 If treatments designed for aggressive cancers are applied to screen-detected cancers that were never going to become clinically significant, this introduces the risk of overtreating. This is not an insurmountable problem. In fact, recognition of the differences between screen-detected and clinically apparent breast cancers provides the opportunity to better understand breast cancer biology and to tailor treatments even more specifically.
Several areas in breast cancer management currently exist in which changes can be implemented to reduce overtreatment. Three of these areas are (1) reducing the use of adjuvant radiation in some invasive breast cancers, (2) decreasing the morbidity of treatment for low-risk ductal carcinoma in situ (DCIS), and (3) changing the approach to breast cancer screening.
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